Prevalence of feeding disorders in children with cleft palate only: a retrospective study

OBJECTIVES

The purpose of this study in children with cleft palate only (CPO) is to (1) explore the prevalence of feeding problems on a retrospective basis, (2) investigate rates of nasogastric (NG) feeding, (3) examine the prevalence of associated disorders and/or syndromes (AssD/S), (4) investigate if there are certain risk factors associated with feeding difficulties, NG feeding, and failure of breastfeeding, and (5) investigate the effect of palatoplasty on feeding difficulties.

MATERIALS AND METHODS

In total, 90 questionnaires were included in this study. The medical records were reviewed.

RESULTS

Feeding difficulties were reported in 67% (n = 60) of all cases. NG feeding was given in 32% (n = 28) of all children. Forty-nine children (54%) have associated malformations. There is no significant relation for gender, gestational age, and birth weight as risk factors for feeding difficulties, NG feeding, and failure of breastfeeding. The severity of the cleft is significantly related to the prevalence of AssD/S. After palatoplasty, feeding difficulties improved in 79% of the CPO children.

CONCLUSIONS AND CLINICAL RELEVANCE

First, our results clearly indicate that children with CPO are at high risk of developing feeding difficulties (67%); NG feeding is often necessary (32%). Second, our results also indicate that the more severe the cleft, the more likely the chance for AssD/S. Third, the severity of the cleft is significantly related to the prevalence of AssD/S. Fourth, there is no significant relation for gender, gestational age, and birth weight as risk factors for feeding difficulties, NG feeding, and failure of breastfeeding. Fifth, improvement of feeding difficulties after surgery supports the importance of the soft palate closure in relation to sucking patterns and feeding skills.

Inflammatory mediators in posttraumatic radiocarpal osteoarthritis

PURPOSE

To identify the mediator profile in healthy, pre-osteoarthritis (OA) and end-stage OA radiocarpal joints. We hypothesized that there would be an increase in soluble mediators in posttraumatic wrist OA.

METHODS

We obtained radiocarpal synovial fluid samples from 3 groups of patients: healthy control (n = 12) samples were collected during wrist ganglion resection; pre-osteoarthritic (n = 16) samples, during a 3-ligament tenodesis procedure for complete scapholunate dissociation; and end-stage OA (n = 20) samples in patients with proven radiological OA changes. Using a multiplex enzyme-linked immunosorbent assay, we measured 12 mediators: interleukin (IL)-1β, tumor necrosis factor-α, oncostatin-M, interferon-γ, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13, IL-1RA, and osteoprotegerin. Statistical analysis was performed using analysis of variance and Bonferroni-corrected post hoc tests.

RESULTS

Mediators IL-6, IL-10, and interferon-γ were increased in OA wrists compared to healthy and pre-OA samples. Tumor necrosis factor-α, oncostatin-M, osteoprotegerin, IL-8, and IL-1RA were detected but not at increased levels in OA wrists. We found no differences between healthy and pre-OA joints in all 12 mediators. Mediators IL-4, IL-7, IL-13, and IL-1β were not detected in either healthy, pre-OA or end-stage OA samples.

CONCLUSIONS

We identified no differences between healthy and pre-OA samples, suggesting no alteration in inflammatory status at the time of the 3-ligament tenodesis procedure. Consequently, mechanical disturbance seems to be the driving force toward OA and OA-associated inflammation in this stage of scapholunate dissociation. Increased levels of interferon-γ, IL-6, and IL-10 confirm inflammatory changes in the mechanically disturbed posttraumatic radiocarpal joint.

Oncological safety of autologous lipoaspirate grafting in breast cancer patients: a systematic review

BACKGROUND

Autologous lipoaspirate grafting (ALAG) has become a widely used treatment in breast reconstruction after mastectomy (MST) or breast-conserving treatment (BCT), although there is an ongoing debate about its oncological safety. The aim of this systematic review was to identify, evaluate, and synthesize all clinical evidence examining the oncological risks associated with the procedure.

METHODS

An extensive electronic search was performed in PubMed, Embase, and the Cochrane Library using the keywords "breast" and "autologous lipoaspirate grafting" and synonyms.

RESULTS

The search yielded a total of 269 unique hits. Twenty clinical trials investigated ALAG in breast reconstruction after cancer. Although nine of them provided oncological follow-up data, only one retrospective cohort and four case series were suitable for analysis. The former reported no significant differences in the locoregional recurrence (LRR) incidence rates between the intervention and control groups for patients with MST as well as BCT. A large multicenter case series reported LRR incidence rates of 1.35 and 2.19 for MST and BCT patients, respectively. The remaining two series were far smaller trials with shorter follow-up and reported no recurrences. No randomized, controlled trials were identified. Most of the available studies consisted of cohorts and case series with short follow-up and no control subjects.

CONCLUSIONS

Although the first reports on cancer recurrence after ALAG are inconclusive, they show promising results. Whether lipoaspirate grafting promotes LRR in breast cancer patients is still unclear. To be able to answer this question, larger prospective trials with longer follow-up are needed.

Velopharyngeal Dysfunction and 22q11.2 Deletion Syndrome: A Longitudinal Study of Functional Outcome and Preoperative Prognostic Factors

Objective

To describe the effect of time after velopharyngoplasty on outcome and to search for preoperative prognostic factors for residual hypernasality in patients with 22q11.2 deletion syndrome.

Design

Retrospective chart review.

Setting

Tertiary hospital.

Patients

Patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction who underwent a primary (modified) Honig velopharyngoplasty between 1989 and 2009.

Main Outcome Measures

Clinically obtained perceptual and instrumental measurements of resonance, nasalance, and understandability before and after velopharyngoplasty.

Results

Data were available for 44 of 54 patients (81% follow-up), with a mean follow-up time of 7.0 years (range, 1.0 to 19.4 years). During follow-up, 24 (55%) patients attained normal resonance and 20 (45%) had residual hypernasality or underwent revision surgery. Mean postoperative nasalance and understandability scores were closer to the norm than mean preoperative scores were (2.0 versus 5.5 standard deviations for the normal passage, 1.3 versus 8.1 standard deviations for the nonnasal passage, and score 2.3 versus 4.1 understandability). Serial measurements revealed that hypernasality only resolved an average of 5 years after surgery, and three patients whose resonance initially normalized later relapsed to hypernasality. Gender, age at surgery, lateral pharyngeal wall adduction, velar elevation, presence of a palatal defect, previous intravelar veloplasty, nasalance, understandability, adenoidectomy, hearing loss, and IQ were not able to predict poor outcome following primary velopharyngoplasty (all p > .05).

Conclusions

In this chart review of patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction, residual hypernasality persisted in many patients after velopharyngoplasty. None of the preoperative factors that were studied had prognostic value for the outcome.

Prenatal ultrasound screening for orofacial clefts

OBJECTIVES

To evaluate the sensitivity and specificity of ultrasound for detecting prenatal facial clefts in low-risk and high-risk populations.

METHODS

This study prospectively followed up a non-selected population, namely all pregnant women who underwent routine second-trimester prenatal ultrasound screening in the Utrecht region during the 2-year period from January 2007 to December 2008.

RESULTS

A total of 35 924 low-risk and 2836 high-risk pregnant women underwent ultrasound screening. Orofacial clefts were present in 62 cases, an incidence of 1:624. The distribution of clefts was as follows: 18 (29%) cleft lip, 25 (40%) cleft lip with cleft palate, 17 (27%) cleft palate only, one median cleft and one atypical cleft. Of these, 38 (61%) were unilateral and 23 (37%) were bilateral. Thirty-nine per cent (24/62) had associated anomalies, with most chromosomal defects found in the cleft lip with cleft palate and cleft palate only groups. Cleft lip with or without cleft palate was detected prenatally in 38/43 cases, a sensitivity of 88%. No case of cleft palate only was detected prenatally. There were three false-positive cases, of which two were fetuses with multiple congenital deformities.

CONCLUSIONS

Ultrasound screening has a high sensitivity for the detection of cleft lip with and without cleft palate in high-risk and low-risk pregnancies in our region, where well-trained sonographers carry out primary screening. The key to a high sensitivity of prenatal ultrasound is likely to be a combination of excellent training of sonographers, referral to specialized centers when a cleft is suspected, routine visualization of the fetal face and advances in ultrasound techniques.

A prospective study on non-surgical correction of protruding ears: the importance of early treatment

OBJECTIVES

Splinting is an elegant method to correct ear deformities in the newborn. However evidence is lacking on the relation between age and efficacy and duration of the treatment. We prospectively studied these questions on protruding ears in 132 babies.

METHODS

A splint in the scaphal hollow was used in combination with tape (Earbuddies(®)). Treatment continued until the desired shape persisted. Results were judged from photographs and mastoid-helical distance was measured.

RESULTS

In 132 babies 209 ears were treated. Twenty-four patients had no follow-up, 27 stopped therapy for skin irritation and fixation problems. In the remaining patients results were good in 28%, fair in 36%, poor in 36%. Efficacy deteriorates with age; with fair or good results in 66.7% if therapy started before the sixth week. Older children needed to be splinted longer. The anti-helical fold was easier corrected than a deep concha (correction in 69.8% versus 26.8%).

CONCLUSIONS

Considering splinting therapy for protruding ears, a reasonable chance of success can only be offered to parents of children up to six weeks of age. It is favorable if the deformity is mainly due to a flat antihelix.

Gastric tumor from metastasis of breast cancer

Metastatic tumours of the stomach have been reported to result from various types of cancer. Among them, gastric metastasis from breast cancer has been recognised in 0.3-18% patients (1-4). Here, a rare case of metastatic gastric tumour derived from breast carcinoma is reported. Gastric endoscopy confirmed a large, friable mass (approximately 5 cm in diameter) in the upper part of the gastric body. The mass within the stomach was difficult to distinguish from primary gastric cancer, although biopsies of this lesion revealed the characteristics of adenocarcinoma. In addition, immunohistochemistry showed the positive expression of mammaglobin. Taken together, the evidence pointed to metastasis of breast cancer to the stomach. The patient was treated with hormonal therapy (letrozole), and the size of the metastasis in the stomach was markedly reduced. Therefore, a gastric metastasis from breast cancer was diagnosed successfully using immunohistochemistry and unnecessary surgery was avoided. In conclusion, although gastric metastatic tumours derived from breast carcinoma are rare, their accurate pre-operative diagnosis and appropriate systemic treatment is essential.

Diagnostic accuracy of transabdominal ultrasound in detecting prenatal cleft lip and palate: a systematic review

OBJECTIVES

To systematically review the diagnostic accuracy of second-trimester transabdominal ultrasound in detecting orofacial clefts in low- and high-risk populations and to compare two-dimensional (2D) with three-dimensional (3D) ultrasound techniques.

METHODS

MEDLINE and EMBASE were searched for articles published in English, Dutch, French or German using the keywords 'cleft' and 'ultrasound' or 'screening' or 'sonogram' and 'prenatal' or 'antenatal' or 'fetus' to identify cohort studies and randomized trials in order to assess the detection rate by prenatal ultrasound of cleft lip and palate in high-risk and low-risk pregnant women.

RESULTS

Of 451 citations identified, 27 met the criteria for the systematic review, 21 involving unselected low-risk populations and six involving high-risk populations. In the selected studies there was diversity in the gestational age at which the ultrasound examination was performed and there was considerable variety in the diagnostic accuracy of 2D ultrasound in the low-risk women, with prenatal detection rates ranging from 9% to 100% for cleft lip with or without cleft palate, 0% to 22% for cleft palate only and 0% to 73% for all types of cleft. 3D ultrasound in high-risk women resulted in a detection rate of 100% for cleft lip, 86% to 90% for cleft lip with palate and 0% to 89% for cleft palate only.

CONCLUSIONS

2D ultrasound screening for cleft lip and palate in a low-risk population has a relatively low detection rate but is associated with few false-positive results. 3D ultrasound can achieve a reliable diagnosis, but not of cleft palate only.

Contractile and morphological properties of hamster retractor muscle following 16 h of cold preservation

INTRODUCTION

Cold hypoxia is a common factor in cold tissue preservation and mammalian hibernation. The purpose of this study was to determine the effects of cold preservation on the function of the retractor (RET) muscle of the hamster in the non-hibernating state and compare these with previously published data (van der Heijden et al., 2000) on the rat cutaneus trunci (CT) muscle.

MATERIALS AND METHODS

After cold storage (16 h at 4 degrees C), muscles were stimulated electrically to measure maximum tetanus tension (P(0)) and histologically analyzed. The protective effects of addition of the antioxidants trolox and deferiprone and the calcium release inhibitor BDM to the storage fluid were determined.

RESULTS

After storage, the twitch threshold current was increased (from 60 to 500 microA) and P(0) was decreased to 27% of control. RET morphology remained unaffected. RET muscle function was protected by trolox and deferiprone (P(0), resp., 43% and 59% of control). Addition of BDM had no effect on the RET.

CONCLUSIONS

The observed effects of cold preservation and of trolox and deferiprone on the RET were comparable to those on CT muscle function, as reported in a previously published study (van der Heijden et al., 2000). Both hamster RET and rat CT muscles show considerable functional damage due to actions of reactive oxygen species. In contrast to the CT, in the RET cold preservation-induced functional injury could not be prevented by BDM and was not accompanied by morphological damage such as necrosis and edema. This suggests that the RET myocytes possess a specific adaptation to withstand the Ca(2+) overload induced by cold ischemia.

Different models of training and certification in plastic surgery

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Hammering versus drilling of sharp and obtuse trocar-point k-wires

Kirschner wire characteristics affect the heating of bone during insertion and the subsequent strength of fixation. We inserted 90 sharp and 90 obtuse trocar-tip K-wires into 90 fresh frozen human cadaver metacarpals using either a drill or a pneumatic hammer. The temperature elevation, insertion time and extraction force were measured for four K-wire insertion combinations: drilling sharp; drilling obtuse; hammering sharp; hammering obtuse. Hammering resulted in significantly lower temperature elevations than drilling. Hammering sharp K-wires resulted in the highest extraction forces. The first and fifth metacarpals showed significantly lower temperature elevations than the other metacarpals, while the insertion time was significantly higher in the second and third metacarpal than in the other metacarpals. Hammering sharp trocar-tip K-wires minimises thermal damage to bone and gives the strongest fixation.

Vascular anatomy of the hamster retractor muscle with regard to its microvascular transfer

BACKGROUND

The hamster retractor muscle (RET) is used as an in vivo model in studies of skeletal muscle ischemia-reperfusion injury. The RET is unique in that the muscle can be isolated while preserving the primary vascular supply so that its contractile function can be measured simultaneously with local microvascular responses to experimental interventions. The goal of this study was to understand the anatomical origin of the vascular supply to the RET and determine whether the RET can be used as a free flap after surgical isolation of the thoracodorsal vessels.

METHODS

Microdissection was performed to determine the anatomy of the vasculature that supplies and drains the RET.

RESULTS

Distinct numbers and patterns of feed arteries (2-4) and collecting veins (1-3) were identified (n = 26 animals). Dye injection (n = 8) of the thoracodorsal artery demonstrated that the RET remains perfused following its isolation on the thoracodorsal pedicle. Heterotopic allograft transplantation of the RET (n = 2) was performed by anastomosing the thoracodorsal vessels to the femoral vessels using the end-to-side technique.

CONCLUSIONS

The anatomical relationships indicate that the RET can be used as a free flap model for evaluating the effect of preservation strategies and transplantation on skeletal muscle microcirculation and contractile function.

A rat model of saliva secretory immunoglobulin: a suppression caused by intense exercise

We aimed to develop a valid model of immunosuppression induced by intense exercise in rats. Rats were divided into three groups. In the rest (Rest) group, saliva was collected from resting rats on 4 consecutive days. In the exercise (Ex) group, rats ran on a treadmill until exhaustion (exercise time: 60.0 +/- 3.7 min), and their saliva was collected before and after exercise; the salivary glands were removed after exercise. In the control (Con) group, saliva collection and gland removal were also performed, but the rats did not exercise. Secretory immunoglobulin A (SIgA) concentrations in saliva and polymeric immunoglobulin receptor (pIgR) mRNA expression in the glands were measured. There was no significant change in SIgA concentration in the Rest group over 4 days. In the Ex group, SIgA concentration decreased significantly after exercise compared with before, whereas there was no significant change in the Con group. The expression of pIgR mRNA was significantly lower in the Ex group post-exercise than in the Con group. Our procedure for saliva collection appeared suitable, and the exercise-induced SIgA suppression was probably caused by a decline in pIgR mRNA expression. We propose to use this reproducible and reliable rat model of exercise-induced SIgA suppression in future studies.

Keeping osteocytes alive: a comparison of drilling and hammering k-wires into bone

In this study, the insertion time and histological effects of drilling and hammering K-wires into bone are described. The insertion time was measured while drilling or hammering K-wires into the femurs and tibias of ten rabbits. Four K-wires, inserted into one hind limb, were used for histological examination directly after insertion and four K-wires inserted into the contralateral hind limb were used for the same measurements 4 weeks later. The specimens were scored for presence, or absence, of osteocytes, fragmentation of the bone edges, haemorrhage, microfractures, cortical reaction and callus formation around the pin track. The insertion time needed for drilling in K-wires was significantly longer than that of hammering. Drilling also resulted in the disappearance of the osteocytes in almost all sections while hammering did not have this effect but did result in more microfractures. Hammering K-wires may be a superior technique because it prevents osteonecrosis and requires a shorter insertion time.

Spawning behavior of the kissing loach (Leptobotia curta) in temporary waters

The natural spawning behavior of the kissing loach, an endangered species of Botiidae, was investigated in the wild in early June for two years in relation to several environmental factors. Kissing loaches spawned in temporary waters after elevation in water level. All spawnings observed (n=163) occurred within 3-5.5 hours from late afternoon to night after formation of the temporary water. These spawnings were performed by one female and one (71%) or two (29%) males in densely vegetated lentic waters. The female and following male(s) swam into dense grasses, where they vibrated to spawn intermittently. After the vibration continuing for 3-20 seconds, they moved to other parts of the dense grassy area and began vibration again. This sequence of spawning behavior was usually repeated several times, and the eggs were thus scattered widely. The spawning behavior and the rapid larval development of this species appear to be adaptations for the use of temporary waters as a spawning ground. The rise in water level and the consequent formation of temporary waters appear to be crucial triggers for reproduction of the kissing loach.

Ear piercing techniques and their effect on cartilage, a histologic study

BACKGROUND

The popularity of high ear piercing has led to an increased incidence of perichondritis. Damage to the relatively avascular cartilage will make the ear prone to infection. The literature suggests that a piercing gun, mainly used by jewellers to pierce the lobule, may give excessive cartilaginous damage. Therefore some authors favour the piercing needle, as used in piercing studios. But until now, no comparative histological studies have been performed.

PURPOSE OF STUDY

To evaluate the extent of damage to ear cartilage using different piercing techniques.

METHODS

Twenty-two fresh human cadaver ears were pierced using two spring loaded piercing guns (Caflon and Blomdahl), one hand force system (Studex) and a piercing needle (16G i.v. catheter). Extent of damage to the perichondrium and cartilage was quantified using a transverse section along the pin tract and compared between the different methods.

RESULTS

The pattern of injury was similar in all techniques, showing perichondrium stripped from the cartilage around the pin tract, with most damage present on the exit site (mean length of 0.43 mm). Cartilage fractures and loose fragments were present over a mean length of 0.21 mm. No significant difference in the amount of injury between the different techniques was observed.

CONCLUSIONS

In contradiction with assumptions in the literature, all piercing methods give the same extent of damage to cartilage and perichondrium. Each method is expected to have the same risk for perichondritis, thus in the prevention of post-piercing perichondritis focus should be on other factors such as hygiene and after-care.

The prognostic value of abnormal findings on radiographic swallowing studies after total laryngectomy

Pharyngocutaneous fistulae are a common complication after total laryngectomy. Our study evaluates the correlation of postoperative radiographic swallowing studies and clinical symptoms. We also propose a grading system to classify leaks radiographically. The records of 45 patients who underwent total laryngectomy were retrospectively reviewed. All patients had a radiographic swallowing study (RSS) on or around the tenth postoperative day. A grading system was developed to classify radiographic findings (grade 0-5). Twenty-two patients had an abnormal RSS (grade 2-5). Three patients (13.6%) had clinical signs of impending fistula whereas radiography showed moderate leakage (grade 3) in one patient and a pharyngocutaneous fistula (grade 5) in two. The other 19 patients with radiographically demonstrated leakage had no clinical signs of anastomotic complications. After total laryngectomy, radiography may reveal anastomotic complications of varying severity. The grading system used in this study enabled us to objectively classify the radiological abnormalities on swallowing studies. Because most radiographic leakages were clinically silent and not all clinically apparent fistula were radiographically visible in our study, the role of routine postoperative radiographic swallowing studies in the absence of clinical signs or fistula remains unclear.