Changing Patterns in Demography of Cleft Lip–Cleft Palate Deformities in a Developing Country: The Smile Train Effect—What Lies Ahead?:

The Pattern and Profile of Orofacial Clefts in Somaliland: A Review of 40 Consecutive Cleft Lip and Palate Surgical Camps

INTRODUCTION

Somaliland is an autonomously run country that is not internationally recognized. As such, it has been largely excluded by global health development programs despite being the world's fourth poorest country. The purpose of this study was to provide the first known description of the pattern and clinical profile of patients with cleft lip and palate from this nation.

METHODS

The authors performed a retrospective chart review on all patients who received cleft lip and palate repair by a single surgeon in 40 separate surgical camps at Edna Adan University Hospital in Hargeisa, Somaliland, between 2011 and 2024. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. Descriptive statistical analysis was performed.

RESULTS

A total of 767 patients (495 male, 64.5%) received 787 surgical procedures. The average age of primary surgery was 73.7 months. The most common chief complaint was left cleft lip with cleft palate (316, 41.2%). Males received primary surgery 19.2 months later than did females (73.7 and 54.6 mo, respectively, P <0.001). Patients residing in Hargeisa received their initial procedure an average of 17.8 months younger than those who lived elsewhere in Somaliland (62.9 and 80.7 mo, respectively, P =0.004).

CONCLUSIONS

In this severely economically depressed region, patients received treatment at ages that lagged far beyond recommended guidelines. Our finding of earlier treatment for females than males is rare in the literature and likely relates to cultural sex expectations. Patients from rural locations were especially vulnerable to receiving delayed treatment. Further efforts to decrease the burden of craniofacial deformities in Somaliland should be pursued in earnest.

Global Smile Foundation's Cleft Surgical Outreach Program: Clinical and Economic Impact During the Past 14 Years

Clefts of the lip and/or palate can result in significant morbidity as well as economic and psychosocial distress for patients and families. Global Smile Foundation is a non-profit organization committed to providing comprehensive cleft care to patients with cleft of the lip/palate around the world. Primary cleft lip and primary cleft palate repairs performed by the Global Smile Foundation in the last decade were reviewed. Averted disability-adjusted life years were estimated and assessed for their economic value. A total of 15,310 disability-adjusted life years were averted. The financial gain was estimated between $78,323,624 and $152,906,604, with an average financial benefit of $48,021 to $93,750 per patient.

A Preliminary Dynamic Investigation on Velopharyngeal Movements During Blowing: A New Approach for Evaluation

PURPOSE

To explore an alternative approach to evaluate velopharyngeal function on those speakers with compensatory misarticulation.

METHOD

Nasopharyngeal endoscopy was used to observe the velopharyngeal movement on 26 adult Mandarin speakers during articulation and different nonverbal state, including SCPS, DCPS, and ABS.

RESULTS

There were significant differences for the rate of velopharyngeal incompetence (RVPI) among the 4 different states. The RVPI was least for the Articulation State, followed by the Air Blowing and DCPS. The RVPI was largest for the SCPS.

CONCLUSION

The result indicated that the ABS may be used as an alternative approach to evaluate the velopharyngeal function instead of the articulation samples while patients cannot make clear articulation due to compensatory misarticulation habits. It merits further study on nonverbal activities, which could lay a foundation for exploring more effective approach for evaluation of the velopharyngeal function.

Innovate Global Plastic and Reconstructive Surgery: Cleft Lip and Palate Charity Database

BACKGROUND

There is an emerging interest in global surgery. The Lancet Commission on Global Surgery recognizes the important role that nongovernmental organizations (NGOs) play in the delivery of cleft lip and/or palate (CLP) surgical care. To better address the unmet burden of surgical disease, the commissioners propose the use of a centralized registry to maximize coordination of global surgical volunteerism efforts. This study aims to create a comprehensive database of CLP organizations.

METHODS

A systematic search of the following resources was conducted: The Plastic Surgery Foundation, Smile Train, Wikipedia, Google, and lists of surgical NGOs. A secondary review of each organization's website was performed to verify inclusion criteria and to extract data. Organizations were classified as providing surgical or nonsurgical care.

RESULTS

Thirty-one organizations providing CLP care were reviewed, with 30 that met inclusion criteria. Of the 20 surgical NGOs, 50% use a diagonal approach of international outreach, 40% a vertical one-way approach, and 10% a horizontal approach. All 10 of the nonsurgical NGOs provide care through a horizontal approach. Their offices are distributed across North America (43%), Asia (27%), Europe (23%), and Australia (7%). Forty-three percent of the organizations provide CLP surgeries or services in more than 1 country; 93% do so with a multidisciplinary team. A majority of the organizations established collaborations with host institutions (80%).

CONCLUSION

To the authors' best knowledge, this database includes the largest collection of CLP organizations. This list will be made publicly available to inform surgical care planning, facilitate collaboration, and promote further research.

Burden of Orofacial Clefting in India, 2016: A Global Burden of Disease Approach

Background:

In the recent past, there have been inconsistent reports of India witnessing a decreasing trend in the incidence of orofacial clefts (OFC). To date, little comprehensive evidence has been published. To identify the prevalence, associated burden in terms of epidemiological parameters and to estimate the “unmet” OFC treatment needs, the present study was undertaken.

Materials and Methods:

Using the Global Burden of Diseases 2016 approach and its assumptions, an attempt was made to estimate the prevalence to quantify the burden of OFC in India as disability-adjusted life years (DALYs), years of life lost (YLL), and years lived with disability (YLD) as well as death due to OFC. The results from such an approach are presented. Using previous estimates of “unmet” OFC treatment needs, an attempt was made to estimate the current volume of “unmet” OFC treatment needs.

Results:

In the present study, it was estimated that a total of 0.033% of all Indian population suffers from OFC. In 2016, the estimated prevalence rate/100,000 was 33.27 for males, 31.01 for females, and 32.18 combined for both genders. It was estimated that for all ages, the DALYs lost were 2.05 for 100,000 males, 2.66 for females and 2.34 for both sexes. The OFC birth prevalence model revealed that the birth prevalence (as a proportion) in 2016 in India showed an odds ratio of 0.48 (1.56–1.65) and fixed factor of nonrecording 0.83 (0.15–6.63), underreporting 0.97 (0.88–1), gender 1.09 (1.02–1.16), chromosomal diagnoses included 1.22 (1.22–1.22), and stillbirth 1.22 (1.22–1.22). The total unmet cleft treatment need was estimated at 79,430 or 18.76% of the total Indian cleft population with OFC.

Conclusions:

Within the constraints of the mathematical modeling and based on all available surveys, literature, and reported data, the overall birth prevalence and the prevalence of OFC in India are presented. Till reliable data emerges, the present estimates could serve as a robust estimate of the prevalence and burden of OFC in India. The present enterprise highlights the need for well-designed, high-quality Pan-India, community-based, observational studies to accurately estimate the burden of OFC in India.

Smile Train: Making the Grade in Global Cleft Care

The global medical and psychological burden of cleft lip and palate is large, especially in low- and middle-income countries. For decades, medical missions have sought to alleviate this burden; however, there are significant barriers to providing sustainable, high-quality cleft care using the mission model. Smile Train, an international children's charity founded in 1999, has developed a scalable model which provides support to local partner hospitals and surgeons around the world. Smile Train partners with hospitals to support cleft care treatment across the developing world. Partner hospitals are held to strict safety and quality standards. Local or regional providers are primarily used to train medical personnel. A quality assurance process developed by the Smile Train's Medical Advisory Board is used to assess cleft surgery cases and suggest additional review and training as needed. Surgical candidates are systematically evaluated and must meet specific medical criteria to ensure safety. Experienced anesthetists adhere to Smile Train's safety and quality protocols including anesthesia guidelines. Smile Train and its partners have provided more than 1.2 million safe, high-quality cleft surgical treatments since 1999. Smile Train has sponsored more than 3,000 hands-on training opportunities, 30,000 opportunities to participate in cleft conferences, and 40,000 virtual cleft training opportunities. Through rigorous self-governance and its sustainable, scalable model, this organization has elevated the standard of cleft care in the developing world.

The impact and cost-effectiveness of the Amref Health Africa-Smile Train Cleft Lip and Palate Surgical Repair Programme in Eastern and Central Africa

Introduction

Cleft lip with or without cleft palate (CLP) is a congenital malformation that causes significant morbidity in low and middle income countries. Amref Health Africa has partnered with Smile Train to provide CLP surgeries since 2006.

Methods

We analyzed anonymized data of 37,274 CLP patients from the Smile Train database operated on in eastern and central Africa between 2006 and 2014. Cases were analyzed by age, gender, country and surgery type. The impact of cleft surgery was determined by measuring averted Disability-Adjusted Life Years (DALYs) and delayed averted DALYs. We used mean Smile Train costs to calculate cost-effectiveness. We calculated economic benefit using the human capital approach and Value of Statistical Life (VSL) methods.

Results

The median age at time of primary surgery was 5.4 years. A total of 207,879 DALYs were averted at a total estimated cost of US$13 million. Mean averted DALYs per patient were 5.6, and mean cost per averted DALY was $62.8. Total delayed burden of disease from late age at surgery was 36,352 DALYs. Surgical correction resulted in $292 million in economic gain using the human capital approach and $2.4 billion using VSL methods.

Conclusion

Cleft surgery is a cost-effective intervention to reduce disability and increase economic productivity in eastern and central Africa. Dedicated programs that provide essential CLP surgery can produce substantial clinical and economic benefits.

The Role for International Outreach in Hand Surgery

Internationally, surgery is making its mark as a necessary priority in Low and Middle Income Countries (LMICs). In 2013, Paul Farmer, MD, and international leaders from 14 countries founded the Lancet Commission of Global Surgery to develop and assemble the best evidence on the state of surgery worldwide, to study the economics of surgical and anesthesia care delivery, and to develop strategies for improving access. Concurrently, there is growing interest in hand surgery. The Journal of Hand Surgery (European Volume) recently called for LMIC research with the goal of using their resources to improve the end product. International outreach was further prioritized at the American Society for Surgery of the Hand, with Scott Kozin, MD, and colleagues subsequently launching the Touching Hands Program (THP). Insight into current models, proven benefits, emphasis on quality, and research in international hand surgery will help invested volunteers provide high-quality, safe, and innovative solutions in the global hand surgery landscape.

Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery

Since the inception of the Lancet Commission in 2013 and consequent prioritization of Global Surgery at the World Health Assembly, international surgical outreach efforts have increased and become more synergistic. Plastic surgeons have been involved in international outreach for decades, and there is now a demand to collaborate and address local need in an innovative way. The aim of this article was to summarize new developments in plastic and reconstructive surgery in global health, to unify our approach to international outreach. Specifically, 5 topics are explored: current models in international outreach, benefits and concerns, the value of research, the value of international surgical outreach education, and the value of technology. A “Let’s Reconstruct Global Surgery” network has been formed using Facebook as a platform to unite plastic and reconstructive surgeons worldwide who are interested in international outreach. The article concludes with actionable recommendations from each topic.

Time trend of incidence rates of cleft lip/palate in Taiwan from 1994 to 2013

Background

This study was to estimate the incidence rate of cleft lip and/or cleft palate (CL/P) in Taiwan from 1994 to 2013, and to assess the time trend over these years.

Methods

Retrospective data analysis was performed on records of all newborns with CL/P treated at Chang Gung Craniofacial Center, the only treatment center for CL/P in Taiwan, from 1994 to 2013. Three-year moving average rates were computed and linear regression was used to explore the annual average percentage change.

Results

From 1994 to 2013, 7282 newborns with CL/P were identified, corresponding to an annual rate of 1.48‰ (95% confidence interval (CI) = 1.45‰–1.52‰). There was a significant decline of rate of cleft lip with or without cleft palate (CL ± P) (−2.9% ± 0.2%, p < 0.0001) but slightly increase of rate of cleft palate (CP) only (+0.2% ± 0.07%, p = 0.004).

Conclusion

From 1994 to 2013, the annual rate of incidence of CL/P was 1.48‰ in Taiwan. The 2.9% annual decline of the rate was mainly from the CL ± P group, not the CP group.

Nostril Morphometry Evaluation before and after Cleft Lip Surgical Correction: Clinical Evidence

Introduction The purpose to this work is to review systematically the morphological changes of the nostrils of patients undergoing surgery for correction of cleft lip and identify in the literature the issues involved in the evaluation of surgical results in this population.

Review of Literature A review was conducted, searching for clinical evidence from MEDLINE. The search occurred in January 2012. Selection criteria included original articles and research articles on individual subjects with cleft lip or cleft palate with unilateral nostril anthropometric measurements before and after surgical correction of cleft lip and measurements of soft tissues. There were 1,343 articles from the search descriptors and free terms. Of these, five articles were selected.

Discussion Most studies in this review evaluated children in Eastern countries, using different measurement techniques but with the aid of computers, and showed improved nostril asymmetry postoperatively compared with preoperatively.

Conclusion There is a reduction of the total nasal width postoperatively compared with preoperative measurements in patients with cleft lip.

Population-based study of birth prevalence and factors associated with cleft lip and/or palate in Taiwan 2002-2009

Background

Facial cleft deformities, including cleft lip with or without cleft palate (CL/P) and cleft palate (CP), are common congenital birth anomalies, especially in Asia. This study aimed to analyze the prevalence of CL/P and CP and to identify associated factors in Taiwan.

Methods

This population-based epidemiological study retrospectively analyzed birth data obtained from the Department of Health in Taiwan for years 2002–2009. Frequency distribution, percentages and related predictors were investigated, and findings were presented by types of cleft deformities. Logistic regression analysis was performed to identify factors associated with cleft deformities.

Results

Overall prevalence of cleft deformities among 1,705,192 births was 0.1% for CL/P and 0.04% for CP over the 8-year study period. Higher prevalence of CL/P or CP was observed with multiple pregnancies, being male for CL/P, being female for CP, gestational age ≤37 weeks and lower birth weight (<1.5 kg). Both CL/P and CP were significantly associated with gestational age <37 weeks and birth weight<1.5 kg (all P <0.0001). CL/P was significantly associated with multiple parities (P = 0.0004–0.002). Male newborns and female newborns were significantly associated with CL/P and CP, respectively (both P<0.0001).

Conclusions

Overall prevalence for congenital cleft deformities in study subjects was 0.1%, in keeping with high rates in Asia. Results suggest the need for awareness and early identification of those at high risk for cleft deformities, including newborns with gestational age <37 weeks, weighing <1.5 kg at birth and women with multiple parities, as a potential strategy to counter long-term adverse effects on speech and language in this population.

A clinical and demographic profile of the cleft lip and palate in Sub-Himalayan India: A hospital-based study

Objectives:

To study the cleft lip and cleft palate in the poverty stricken Sub-Himalayan Garhwal region of India, being a commonly seen congenital abnormality and scarcity of studies about the demography of cleft in this region.

Design:

A prospective cohort observational case series was performed on 4657 cleft patients at a Tertiary care Hospital in Dehradun, India, over a period of 5 years.

Outcome measures:

The authors investigated the differences between age and sex with cleft status and family history of clefts, birth order, religion, socioeconomic status, parent literacy, source of information for treatment, haematological investigations showing the status of infection and coagulation in such children and satisfaction after treatment.

Results:

Seventy-two percent parents of cleft lip patients were illiterate, and only 8% were graduates, the majority of patients were from the low socioeconomic class. The siblings of 1.1% of the cleft patients had similar deformity. Anemia was seen in 83.16% cases which was commonly microcytic hypochromic type and eosinophilia was seen in 25.50% of cases. In the coagulation profile, International Nationalized Ratio was found to be raised in 52.12%. Almost 95% of the families were fully satisfied by the treatment and results.

Conclusion:

This study will provide baseline information on the status of these less privileged cleft patients in this mountainous region for future reference to health workers.