Sidedness in Unilateral Orofacial Clefts: A Systematic Scoping Review

OBJECTIVE

An overview of the literature relating to the sidedness of unilateral cleft lip with or without cleft palate to map current knowledge on the cause and impact of directional asymmetry.

DESIGN

Scoping review with a systematic search of Medline and Embase from inception to May 2023.

PATIENTS, PARTICIPANTS

Humans born with a left or right unilateral cleft lip with or without a cleft palate.

MAIN OUTCOME MEASURES

Cleft sidedness as a co-occurrence, an outcome or an exposure.

RESULTS

Forty studies were eligible for inclusion and confirmed the predilection for the occurrence of left sided cleft lips; 12 studies reported cleft sidedness co-occurring with another phenotype, 11 studies report sidedness as an outcome and 17 studies as an exposure. Phenotypes which were reported to co-occur with either left or right sided clefts included congenital dental anomalies, handedness and additional congenital anomalies. Variables investigated as a potential cause of left or right sided clefts as an outcome included chromosomal anomalies, genetic variants and environmental factors. Outcomes investigated in relation to cleft sidedness as an exposure included facial anatomical features, facial growth, educational attainment, functional and psychological characteristics. More studies showed worse outcomes in right sided clefts versus left sided clefts than vice versa, although studies were inconsistent, and a quality assessment was not performed.

CONCLUSIONS

The field of cleft sidedness research is expanding and there are promising early findings to differentiate cause and outcome by sidedness of the cleft.

The Implications of Laterality in Unilateral Cleft Lip Reconstruction: A Global Survey of Cleft Surgeons

OBJECTIVE

To explore the impact of directional laterality in complete Unilateral Cleft Lip (UCL) amongst the global cleft surgeon community.

DESIGN

Cross-sectional survey study.

SETTING

Global distribution of online survey distributed in English and Spanish.

PARTICIPANTS

Cleft surgeons from around the world.

MAIN OUTCOME MEASURES

Survey participant perception of the impact of laterality on: (1) cleft presentation (2) surgical challenge and (3) surgical outcomes.

RESULTS

Responses were received from 453 cleft surgeons located in 54 countries around the world. 221 (49%) had previously considered differences in patients presenting with a left- versus right-sided UCL. 95 (21%) considered right-sided clefts more difficult to reconstruct, 37 (8%) reported left-sided clefts to be more difficult and 321 (71%) reported no difference in difficulty between the cleft sides. Higher volume cleft surgeons, characterised by those reporting cleft as their principal area of practice and performing >20 cleft operations per year, were more likely to have both previously considered differences in laterality in cleft and to report right-sided unilateral cleft lip to be more difficult to primarily reconstruct. 395 (87%) did not consider surgical outcomes to be influenced by cleft laterality.

CONCLUSIONS

This survey reports perceptions on cleft laterality from a large body of global surgeons and suggests a trend for increased difficulty in right-sided compared to left-sided cleft lip reconstruction, where such laterality-associated difficulty is perceived.

A 2-4 keV multilayer mirrored channel for the NIF Dante system

During inertial confinement fusion experiments at the National Ignition Facility (NIF), a capsule filled with deuterium and tritium (DT) gas, surrounded by a DT ice layer and a high-density carbon ablator, is driven to the temperature and densities required to initiate fusion. In the indirect method, 2 MJ of NIF laser light heats the inside of a gold hohlraum to a radiation temperature of 300 eV; thermal x rays from the hohlraum interior couple to the capsule and create a central hotspot at tens of millions degrees Kelvin and a density of 100-200 g/cm³. During the laser interaction with the gold wall, m-band x rays are produced at ∼2.5 keV; these can penetrate into the capsule and preheat the ablator and DT fuel. Preheat can impact instability growth rates in the ablation front and at the fuel-ablator interface. Monitoring the hohlraum x-ray spectrum throughout the implosion is, therefore, critical; for this purpose, a Multilayer Mirror (MLM) with flat response in the 2-4 keV range has been installed in the NIF 37° Dante calorimeter. Precision engineering and x-ray calibration of components mean the channel will report 2-4 keV spectral power with an uncertainty of ±8.7%.

Hot Spot Evolution Measured by High-Resolution X-Ray Spectroscopy at the National Ignition Facility

Evolution of the hot spot plasma conditions was measured using high-resolution x-ray spectroscopy at the National Ignition Facility. The capsules were filled with DD gas with trace levels of Kr and had either a high-density-carbon (HDC) ablator or a tungsten (W)-doped HDC ablator. Time-resolved measurement of the Kr Heβ spectra, absolutely calibrated by a simultaneous time-integrated measurement, allows inference of the electron density and temperature through observing Stark broadening and the relative intensities of dielectronic satellites. By matching the calculated hot spot emission using a collisional-radiative code to experimental observations, the hot spot size and areal density are determined. These advanced spectroscopy techniques further reveal the effect of W dopant in the ablator on the hot spot parameters for their improved implosion performance.

Outcomes of microsurgical free tissue transfer performed on international surgical collaborations in low-income and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Microsurgical free tissue transfer is the gold standard for reconstruction of significant soft tissue and bony defects following cancer resection and trauma. Many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources or training required to perform microsurgical procedures. Long-term international collaborations have been formed with annual reconstructive programmes conducting microsurgery.

AIMS

To critically analyze outcomes of microsurgical free tissue transfer performed on international reconstructive collaborations in LMICs.

METHODS

PRISMA-compliant systematic review and meta-analysis of outcomes for free tissue transfer performed during international collaborations in LMICs using an inverse variance model. The study protocol was published prospectively and registered with PROSPERO (ID: CRD42021225613).

RESULTS

Seven studies, included 290 flaps on 284 patients. The most common sites requiring reconstruction were Head and neck (53% (n = 153)) and lower limb (7.9% (n = 23)) were lower limb reconstruction. The most common free flaps were radial forearm (22%; n = 64) and anterolateral thigh (18%; n = 51). Total Flap Failure rate was 3.8% (n = 13; 95% confidence interval (CI) = 1.9-6.3%) Overall complication rate was 38% (95% CI =27-48%), with 19% of flaps requiring emergency return to theatre (95% CI =14-26%). Flap salvage was successful in 52% of take-backs (95% CI =15% - 88%).

CONCLUSIONS

Free flaps performed during international surgical collaborations in LMICs have comparable failure rates to those performed in higher-income settings. However, there are higher complication and take-back rates. This should be taken into account when planning international collaborations. These results should help preoperative counselling and the consent process.

59 Burns in Low- and Middle-income Countries: A Scientometric Analysis of Peer-reviewed Research

Introduction

Low- and middle-income countries (LMICs) account for 70% of all global burns. Due to this significantly disproportionate burden, it’s critical we identify barriers to burn care and prevention in LMICs. As a result, this study aimed to elucidate trends in LMIC-related burn research to create focused strategies for burn care training, research, and innovation. Accomplishing meaningful change from the study’s findings will be guided by the first 4 steps of Dr. John Kotter’s “8-Step Process for Leading Change” – 1) create urgency for change, 2) build a guiding team, 3) develop a vision and plan, 4) communicate with key stakeholders to obtain buy-in.

Methods

Web of Science’s 7 citation databases were searched through March 2, 2021 using synonyms of “burns” and “low- and middle-income countries.” After screening articles, metadata were uploaded to VOSviewer (Leiden, Netherlands) where citation and network metrics were generated. The Kruskal-Wallis test and linear regression were used for bivariable and multivariable analysis of factors influencing publications, citations, and total link strength (TLS) – the strength of association between a given research article, other articles, and additional institutions.

Results

Bibliometric analysis identified 2,027 articles by 8,602 authors in 692 journals. Two-thirds of journals published a single article (n=453, 65.5%) whereas only 3.6% published ≥10 articles. One-quarter of LMIC burn research was published in ISBI’s Burns (n=417 articles, 20.6%) and ABA’s Journal of Burn Care & Research (n=89 articles, 4.4%). Most authors published < 5 articles (n=8521, 99.1%) but 19 (0.2%) had published ≥10. Authors were affiliated with 2,519 organizations in 132 countries. There was a strong positive correlation between total publications and citations (R=0.87, P< 0.001). In addition, there was a significant difference in the number of publications (P=0.003, 0.07), citations (P=0.005, 0.03), and TLS (P=0.009, 0.008) by geographic and economic categories - North America had the highest while Latin American and the Caribbean had the lowest. The USA (n = 563), India (n = 161), and China (n = 154) published the most articles.

Conclusions

Given the disproportionate representation of high-income countries and authors in the current LMIC burn research landscape, there must be a sense of urgency to develop pathways for facilitating change. Local and regional candidates for mentors and leaders were identified using bibliometric findings. Assembling teams with these individuals and prolific authors using a well-defined vision for change will facilitate sustainable communication and collaboration within LMIC research.

231 ESTABLISHING AN INTERVENTIONS BUNDLE TO IMPROVE INPATIENT CARE FOR PATIENTS WITH PARKINSON’S DISEASE: A MULTIDISCIPLINARY QUALITY IMPROVEMENT PROJECT

Background

Patients with Parkinson’s (PwP) are at a higher risk of complications once admited to hospital compared to their age-matched peers. Medication mismanagement is a well-known obstacle, which puts PwP at risk of sub-optimal treatment leading to an unnecessary deterioration of baseline and potentially increases risk of adverse sequelae.

Methods

Retrospective electronic patient records (EPR)/chart review of 47 admissions was conducted, across three hospital sites.

Data attaining to correct prescribing of medication on admission and discharge, prescribing of contraindicated medications, reasons for medication lapses and complications of inpatient stay were collected. EPR of 17 patients’ were reviewed to assess if Parkinson’s disease (PD) medication administrations occurred within 30 minutes of patient schedule, as recommended by NICE guidelines. Key areas for improvement were identified based on the results.

Results

47 charts (30 Males, 17 Females) with mean age 72 (range:57–90), were reviewed. Average number of co-morbidities:4.5 and Clinical Frailty Scale ranged 5–9 (n = 30). LOS averaged 12.4 days and 43% of patients had ≥2 hospital admissions in the preceeding year.

38% (17/44) of admissions correctly documented patient specific medication times. Only 48% of patients (n = 638) received their medications within 30 minutes of the scheduled time. 47% (22/47) experienced complications attributable to PD. Contraindicated medications were noted in 5 cases. 84% of discharging prescriptions did not mention timing of PD medication and 3 prescriptions had errors with regards to dosage/omission of medication.

Conclusion

We implemented across two sites: 1) Care protocol flag in patient’s chart highlighting simple avoidable complications. 2) Laminated over the bed signpost alerting ‘time critical medication’. 3) ‘Time critical medication’ stickers in drug kardex 4) Education sessions for Medical, Nursing and Ward staff. 6) Establishing out of hours access to PD medications and protocols for NPO/poor swallow. We plan to reassess significance of efforts post intervention.

Protocol for a systematic review of outcomes from microsurgical free-tissue transfer performed on short-term collaborative surgical trips in low-income and middle-income countries

BACKGROUND

In many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services.

METHODS

A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the 'Revised Cochrane risk of bias tool for randomized trials' (Rob2), the 'Risk of bias in non-randomized studies of interventions' (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

DISCUSSION

To-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 225613.

Urethrographic examinations: Patient and staff exposures and associated radiobiological risks

Medical exposure of the general population due to radiological investigations is the foremost source of all artificial ionising radiation. Here, we focus on a particular diagnostic radiological procedure, as only limited data are published with regard to radiation measurements during urethrograpic imaging. Specifically, this work seeks to estimate patient and occupational effective doses during urethrographic procedures at three radiology hospitals. Both staff and patient X-ray exposure levels were calculated in terms of entrance surface air kerma (ESAK), obtained by means of lithium fluoride thermoluminescent dosimeters (TLD-100(LiF:Mg:Cu.P)) for 243 urethrographic examinations. Patient radiation effective doses per procedure were estimated using conversion factors obtained from the use of Public Health England computer software. In units of mGy, the median and range of ESAK per examination were found to be 10.8 (3.6-26.2), 7.0 (0.2-32.3), and 24.3 (9.0-32.0) in Hospitals A, B, and C, respectively. The overall mean and range of staff doses (in µGy) were found to be 310 (4.0-1750) per procedure. With the exception of hospital C, the present evaluations of radiation dose have been found to be similar to those of previously published research. The wide range of patient and staff doses illustrate the need for radiation dose optimisation.

Adjuvant Alendronic Acid in the Management of Severe Cherubism: A Case Report and Literature Review

Cherubism is a rare disease of the jaws characterized by bilateral symmetrical painless expansion of the mandible and maxilla. In extreme cases, larger lesions can become exophytic and have profound functional and esthetic implications. Several pharmacologic agents have been trialed in the treatment of cherubism with variable success reported. Bisphosphonates have not been significantly studied in this setting. We present a case where oral alendronic acid was used as an adjuvant treatment after surgical debulking of the maxilla in a 13-year-old boy with a severe case of cherubism.

Searching for meaning in sound: Learning and interpreting alarm signals in visual environments

Given the ease with which the diverse array of environmental sounds can be understood, the difficulties encountered in using auditory alarm signals on medical devices are surprising. In two experiments, with nonclinical participants, alarm sets which relied on similarities to environmental sounds (concrete alarms, such as a heartbeat sound to indicate "check cardiovascular function") were compared to alarms using abstract tones to represent functions on medical devices. The extent to which alarms were acoustically diverse was also examined: alarm sets were either acoustically different or acoustically similar within each set. In Experiment 1, concrete alarm sets, which were also acoustically different, were learned more quickly than abstract alarms which were acoustically similar. Importantly, the abstract similar alarms were devised using guidelines from the current global medical device standard (International Electrotechnical Commission 60601-1-8, 2012). Experiment 2 replicated these findings. In addition, eye tracking data showed that participants were most likely to fixate first on the correct medical devices in an operating theater scene when presented with concrete acoustically different alarms using real world sounds. A new set of alarms which are related to environmental sounds and differ acoustically have therefore been proposed as a replacement for the current medical device standard. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Recurrent Rathke's Cleft Cysts: Incidence and Surgical Management in a Tertiary Pituitary Center over 2 Decades

BACKGROUND

Limited data exist pertaining to outcomes following surgery for recurrent Rathke's cleft cysts (RCC).

OBJECTIVE

To determine treatment outcomes in patients undergoing reoperation for recurrent or residual RCCs.

METHODS

A retrospective analysis of 112 consecutive RCC operations in 109 patients between 1995 and 2017 was conducted.

RESULTS

Eighteen patients underwent 21 RCC reoperations with a mean follow-up of 58 mo. Patient symptoms prior to reoperation included headaches (14, 66.7%) and vision loss (12, 57.1%). Thirteen of 18 patients (72.2%) required hormone supplementation prior to reoperation including 5 with diabetes insipidus (DI). Mean RCC diameter was 16 mm and 76% had suprasellar extension. Compared to index RCC cases, intraoperative cerebrospinal fluid leak repair was more common in reoperation cases (15/21, 71% vs 43/91, 47%, P = .05). There was 1 carotid artery injury without neurological sequelae, and 2 postoperative cerebrospinal fluid (CSF) leaks (9.5%). Rates of transient hyponatremia (3/10, 30% vs 4/91, 4.4%, P = .04) and transient DI (5/10, 50% vs 17/91, 18.7%, P = .04) were higher in the reoperation vs index group. Improved headaches and vision were reported in 4/12 (33%) and 8/12 (61.5%) of RCC reoperation patients, respectively. Two patients developed new permanent DI. A higher proportion of reoperation patients had RCC squamous metaplasia (24% vs 5.4%, P = .02) or wall inflammation (42.9% vs 2.2%, P < .001) on pathological examination.

CONCLUSION

Reoperation for RCCs is generally safe at tertiary pituitary centers and often results in improved vision. Hypopituitarism is less likely to improve following reoperation for recurrent RCCs. Several histopathological features may help characterize "atypical RCCs" with a higher likelihood of recurrence/progression.

Evaluation of aldosterone antagonist utilization in heart failure with reduced and preserved ejection fraction at an academic medical center

Background:

Objective:

Methods:

Results:

Conclusions:

Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke's cleft cysts

OBJECTIVE

Rathke's cleft cysts (RCCs) are benign epithelial lesions of the sellar region typically treated via a transsphenoidal approach with cyst fenestration and drainage. At present, there is limited evidence to guide patient selection for operative treatment. Furthermore, there is minimal literature describing factors contributing to cyst recurrence.

METHODS

The authors conducted a retrospective analysis of 109 consecutive cases of pathology-confirmed RCCs treated via a transsphenoidal approach at a single center from 1995 to 2016. The majority of cases (86.2%) involved cyst fenestration, drainage, and partial wall resection. Long-term outcomes were analyzed.

RESULTS

A total of 109 surgeries in 100 patients were included, with a mean follow-up duration of 67 months (range 3-220 months). The mean patient age was 44.6 years (range 12-82 years), and 73% were women. The mean maximal cyst diameter was 14.7 mm. Eighty-eight cases (80.7%) were primary operations, and 21 (19.3%) were reoperations. Intraoperative CSF leak repair was performed in 53% of cases and was more common in reoperation cases (71% vs 48%, p < 0.001). There were no new neurological deficits or perioperative deaths. Two patients (1.8%) developed postoperative CSF leaks. Transient diabetes insipidus (DI) developed in 24 cases (22%) and permanent DI developed in 6 (5.5%). Seven cases (6.4%) developed delayed postoperative hyponatremia. Of the 66 patients with preoperative headache, 27 (44.3%) of 61 reported postoperative improvement and 31 (50.8%) reported no change. Of 31 patients with preoperative vision loss, 13 (48.1%) reported subjective improvement and 12 (44.4%) reported unchanged vision. Initial postoperative MRI showed a residual cyst in 25% of cases and no evidence of RCC in 75% of cases. Imaging revealed evidence of RCC recurrence or progression in 29 cases (26.6%), with an average latency of 28.8 months. Of these, only 10 (9.2% of the total 109 cases) were symptomatic and underwent reoperation.

CONCLUSIONS

Transsphenoidal fenestration and drainage of RCCs is a safe and effective intervention for symptomatic lesions, with many patients experiencing improvement of headaches and vision. RCCs show an appreciable (although usually asymptomatic) recurrence rate, thereby mandating serial follow-up. Despite this, full RCC excision is typically not recommended due to risk of hypopituitarism, DI, and CSF leaks.

Non-invasive imaging of disrupted protein homeostasis induced by proteasome inhibitor treatment using chemical exchange saturation transfer MRI

Proteasome inhibitors (PIs) are now standard of care for several cancers, and noninvasive biomarkers of treatment response are critically required for early patient stratification and treatment personalization. The present study evaluated whether chemical exchange (CEST) magnetic resonance imaging (MRI) can provide measurements that can be used as the noninvasive biomarkers of proteasome inhibition, alongside diffusion MRI and relaxometry. The sensitivity of human colorectal carcinoma cells to the PI Ixazomib was assessed via in vitro and in vivo dose-response experiments. Acute in vivo response to Ixazomib was assessed at three dosing concentrations, using CEST MRI (amide, amine, hydroxyl signals), diffusion MRI (ADC) and relaxometry (T1, T2). These responses were further evaluated with the known histological markers for Ixazomib and Bradford assay ex vivo. The CEST signal from amides and amines increased in proportion to Ixazomib dose in colorectal cancer xenografts. The cell lines differed in their sensitivity to Ixazomib, which was reflected in the MRI measurements. A mild stimulation in tumor growth was observed at low Ixazomib doses. Our results identify CEST MRI as a promising method for safely and noninvasively monitoring disrupted tumor protein homeostasis induced by proteasome inhibitor treatment, and for stratifying sensitivity between tumor types.

Design and raytrace simulations of a multilayer-coated Wolter x-ray optic for the Z machine at Sandia National Laboratories

Recent breakthroughs in the fabrication of small-radii Wolter optics for astrophysics allow high energy density facilities to consider such optics as novel x-ray diagnostics at photon energies of 15-50 keV. Recently, the Lawrence Livermore National Laboratory, Sandia National Laboratories (SNL), the Smithsonian Astrophysical Observatory, and the NASA Marshall Space Flight Center jointly developed and fabricated the first custom Wolter microscope for implementation in SNL's Z machine with optimized sensitivity at 17.5 keV. To achieve spatial resolution of order 100-200 microns over a field of view of 5 × 5 × 5 mm³ with high throughput and narrow energy bandpass, the geometry of the optic and its multilayer required careful design and optimization. While the geometry mainly influences resolution and the field of view of the diagnostic, the mirror coating determines the spectral response and throughput. Here we outline the details of the design and fabrication process for the first multilayer-coated Wolter I optic for SNL's Z machine (Z Wolter), including its W/Si multilayer, and present results of raytrace simulations completed to predict and verify the performance of the optic.