Lip symmetry following rotation advancement cleft lip repair in 5-year-old children treated by Ralph Millard and Ron Pigott

Objective

To compare the symmetry of the lip following Rotation-Advancement cleft lip repair by Millard and Pigott and to investigate the effect on the symmetry of cleft side and gender by using different surgical protocols. Symmetry following cleft surgery was compared to that of non-cleft children.

Design

Retrospective study of photographs of children aged 5 years.

Setting

Three decades of post-operative photographs of children treated by Millard and Pigott.

Patients

Eighty-nine children treated by Millard, 87 by Pigott and 91 non-cleft children.

Interventions

Photographs were assessed using the Symnose Computer program, a rapid semi-objective quantitative assessment of lip symmetry.

Main Outcome Measure(s)

Asymmetry score for each surgeon, and non-cleft children.

Results

There was no significant difference in the median lip % mismatch score of Millard, 36.65% and Pigott, 38.52%. Right-sided clefts showed better symmetry than left-sided clefts for Millard (p<.001). This was reversed for Pigott (P=.0121). There was a difference (P<.001) between the symmetry of the two cleft cohorts and the non-cleft children (asymmetry 19.9%), and between Millard's outcomes following different lip surgical protocols (P < .0001), but no difference between Pigott's outcomes using different palate surgical protocols (P = 0.59).

Conclusions

Cleft lip repair by Millard and Pigott resulted in similar lip asymmetry (37% and 39% symmetry mismatch, respectively). Lip surgical protocol and cleft side may affect lip asymmetry. Palate surgery did not affect lip asymmetry. Following cleft surgery, children were more asymmetric than non-cleft children.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Structural outcomes in the Cleft Care UK study. Part 2: dento-facial outcomes

OBJECTIVES

To compare facial appearance and dento-alveolar relationship outcomes from the CSAG (1998) and CCUK (2013) studies.

SETTING AND SAMPLE POPULATION

Five-year-olds born with non-syndromic unilateral cleft lip and palate. Those in the original CSAG were treated in a dispersed model of care with low-volume operators. Those in CCUK were treated in a more centralized, high-volume operator model.

MATERIALS AND METHODS

We compared facial appearance using frontal view photographs (252 CCUK, 239 CSAG) and dental relationships using study models (198 CCUK, 223 CSAG). Facial appearance was scored by a panel of six assessors using a standardized and validated outcome tool. Dento-alveolar relationships were scored by two assessors using the 5-Year-Olds' Index. Ordinal regression was used to compare results between surveys.

RESULTS

Excellent or good facial appearance was seen in 36.2% of CCUK compared with 31.9% in CSAG. In CCUK, 21.6% were rated as having poor or very poor facial appearance compared with 27.6% in CSAG. The percentage rated as having excellent or good dento-alveolar relationships was 53.0% in CCUK compared with 29.6% in CSAG. In CCUK, 19.2% were rated as having poor or very poor dento-alveolar relationships compared to 36.3% in CSAG. The odds ratios for improved outcome in CCUK compared to CSAG were 1.43 (95% CI 1.03, 1.97) for facial appearance and 2.29 (95% CI 1.47, 3.55) for dento-alveolar relationships.

CONCLUSIONS

Facial and dento-alveolar outcomes were better in CCUK children compared to those in CSAG.

Development of a sink-source interaction model for the growth of short-rotation coppice willow and in silico exploration of genotype×environment effects

Identifying key performance traits is essential for elucidating crop growth processes and breeding. In Salix spp., genotypic diversity is being exploited to tailor new varieties to overcome environmental yield constraints. Process-based models can assist these efforts by identifying key parameters of yield formation for different genotype×environment (G×E) combinations. Here, four commercial willow varieties grown in contrasting environments (west and south-east UK) were intensively sampled for growth traits over two 2-year rotations. A sink-source interaction model was developed to parameterize the balance of source (carbon capture/mobilization) and sink formation (morphogenesis, carbon allocation) during growth. Global sensitivity analysis consistently identified day length for the onset of stem elongation as most important factor for yield formation, followed by various 'sink>source' controlling parameters. In coastal climates, the chilling control of budburst ranked higher compared with the more eastern climate. Sensitivity to drought, including canopy size and rooting depth, was potentially growth limiting in the south-east and west of the UK. Potential yields increased from the first to the second rotation, but less so for broad- than for narrow-leaved varieties (20 and 47%, respectively), which had established less well initially (-19%). The establishment was confounded by drought during the first rotation, affecting broad- more than narrow-leaved canopy phenotypes (-29%). The analysis emphasized quantum efficiency at low light intensity as key to assimilation; however, on average, sink parameters were more important than source parameters. The G×E pairings described with this new process model will help to identify parameters of sink-source control for future willow breeding.

External validation of structure-biodegradation relationship (SBR) models for predicting the biodegradability of xenobiotics

Biodegradation is an important mechanism for eliminating xenobiotics by biotransforming them into simple organic and inorganic products. Faced with the ever growing number of chemicals available on the market, structure-biodegradation relationship (SBR) and quantitative structure-biodegradation relationship (QSBR) models are increasingly used as surrogates of the biodegradation tests. Such models have great potential for a quick and cheap estimation of the biodegradation potential of chemicals. The Estimation Programs Interface (EPI) Suite™ includes different models for predicting the potential aerobic biodegradability of organic substances. They are based on different endpoints, methodologies and/or statistical approaches. Among them, Biowin 5 and 6 appeared the most robust, being derived from the largest biodegradation database with results obtained only from the Ministry of International Trade and Industry (MITI) test. The aim of this study was to assess the predictive performances of these two models from a set of 356 chemicals extracted from notification dossiers including compatible biodegradation data. Another set of molecules with no more than four carbon atoms and substituted by various heteroatoms and/or functional groups was also embodied in the validation exercise. Comparisons were made with the predictions obtained with START (Structural Alerts for Reactivity in Toxtree). Biowin 5 and Biowin 6 gave satisfactorily prediction results except for the prediction of readily degradable chemicals. A consensus model built with Biowin 1 allowed the diminution of this tendency.

[Biology of primary hyperparathyroidism: selective venous sampling]

The diagnosis of primary hyperparathyroidism (PHP) is chemical: high level of Parathormone (PTH) in conjunction with hypercalcaemia. In borderline cases with sub-normal plasma PTH and calcium, an oral calcium load test could allow a differential diagnosis from other causes of high PTH. Imaging is required only for PHP. Selective venous sampling can help in localizing a parathyroid adenoma in difficult cases by PTH cartography in the following situations: imaging in favour of an ectopic mediastinal gland or a deep cervical adenoma, persistent or recurrent PHP after first failed surgery with negative neck exploration or unsatisfactory in case of another hypersecreting gland, PHP well diagnosed with indeterminate imaging, symptomatic PHP with normal PTH and negative imaging. Venous blood sampling performed in a vascular radiological department with a quick PTH assay can reveal an area of maximum secretion potentially linked to a nodule localized by previous ultrasound coupled to scintigraphy, giving thus a "biological imaging" study. The association of imaging and biology is an efficient procedure enabling localization of an area of abnormal PTH secretion and characterization of the level of PTH secretion. The area with the highest gradient of PTH concentration can help to protocol CT and MR examination.

[Primary hyperparathyroidism: ultrasonography and scintigraphy]

Primary hyperparathyroidism is nowadays frequently diagnosed from screening biological work-up: it is due to a single parathyroid adenoma in nearly 90% of cases. There is increasing interest in the minimally invasive surgical approach with unilateral neck exploration. For such approaches preoperative localizing studies are mandatory. Ultrasound and radionuclide imaging are the most widely used procedures for this purpose. Ultrasound offers detailed anatomic imaging of the adenoma but may not be not able to detect some ectopic glands. Sonographic imaging features, as well as pitfalls and diagnostic difficulties are described. Radionuclide scanning using Tc-99m-Sestamibi is able to localize parathyroid adenomas even in the case of ectopic localization with the help of SPECT-CT.

A Comparison of Shepard's Osteotome versus Trapdoor Flap Technique to Harvest Iliac Crest Bone for Secondary Alveolar Bone Grafting

Objective:

To compare the postoperative donor site morbidity and alveolar bone graft results following two different techniques for iliac crest bone graft harvest: a closed (Shepard's osteotome) and an open (trapdoor flap) technique.

Design:

A retrospective review of two cohorts of alveolar bone grafts performed from 1998 to 2004 in Birmingham Children's Hospital by two surgeons using different harvest techniques. Medical and nursing anesthetic notes and medication charts were reviewed. Alveolar bone graft results were assessed using preoperative and postoperative radiographic studies.

Patients:

A total of 137 patients underwent an operation. Of these, 109 patients were compatible with the inclusion criteria (data available, first operation, no multiple comorbidities). Sixty-four patients had iliac bone harvested using the open trapdoor technique, while 45 had the same procedure using the closed osteotomy technique.

Results:

Maximum bone graft volumes harvested were similar with both techniques. The mean length of hospital stay was 50.9 hours for the osteotome and 75.5 hours for the open technique group (p < .0001). The postoperative analgesia requirement was higher and the postoperative mobilization was delayed and more difficult for the open technique patients (p < .0005). Kindelan scores performed by two independent orthodontists were similar for both techniques.

Conclusion:

The findings demonstrate that harvesting bone from the iliac crest using an osteotome technique reduces time in hospital, analgesia requirements, and postoperative donor site morbidity with no detrimental outcome.

Scintigraphic imaging of paediatric thyroid dysfunction

Imaging of thyroid dysfunction is safe and clinically relevant in children. In congenital hypothyroidism (CH), thyroid imaging permits a precise characterization of the aetiology, which is important for genetic counselling and clinical management. CH may be due to thyroid dysgenesis (ectopia, hypoplasia and athyrosis) or occurs in eutopic glands. In the latter, hypothyroidism may be either transient, especially after iodine overload, or due to permanent autosomal recessive dyshormonogenesis. Thyroid scintigraphy (TS) with either 99mTcO4 or 123I will identify ectopic thyroid tissue, which is the commonest cause of CH. However, recent reports favour the use of 123I, which enhances the accuracy of the aetiological classification. In cases of eutopic thyroid, the measurement of 123I uptake before and after perchlorate administration evaluates the organification process. At all ages, colour Doppler ultrasound scanning (CDU) is helpful in assessing thyroid volume, in identifying nodules and in characterizing tissue vascularization. TS and CDU images of most paediatric thyroid dysfunctions are presented.