Lessons Learned From Two Consecutive Cleft Lip and Palate Missions and the Impact of Patient Education

Cleft Lip Surgery in Sudan: Clinical Presentations, Early Outcomes, and Patient and Professional Satisfaction: A sub-Saharan African experience

Background

Cleft lip and palate are the most common congenital craniofacial anomalies. They account for approximately 13% of all congenital anomalies.

Objectives

To study the presentation of cleft lip and the early results of surgical repair among patients who presented to our centers.

Methods

This was a hospital-based prospective cohort study of 72 patients who underwent cleft lip repair in Sudan.

Results

The commonest age group was between 10-18 months. The male-to-female ratio was 2:1, and a family history of cleft lip was found in 2.8% of patients. The cleft lip was complete in 81.9%, incomplete in 12.5%, and hybrid in 5.6% of patients. Associated cleft palate was observed in 54 patients. Associated syndromes were found in 10 patients. The surgery was carried out in most patients at 9 months or less; in 4 patients, it was more than 18 months. Achievement of reasonable lip repair was moderate (50% collectively). High achievement was observed for criteria, such as accurate union (90.3%), and sub-moderate achievement in even vermillion border and cupid's bow (44%), low nose symmetry (30.6%), and quality of scar (18.1%). Early complications were reported at the rate of 13.9%. Patient satisfaction was 59.7%; however, the professionals showed higher satisfaction levels (66.7%). The anthropometric measurements of normal infants were moderately similar to those of the infants who underwent surgery.

Conclusion

The patients with cleft lip showed early presentation, with a predominance of the male gender and left side pattern. The preliminary outcome of cleft lip repair was moderate, with variations in different criteria. Patient and professional satisfaction were above average.

FATE: The Effect of Fetal Antenatal Testing Education on Patient Knowledge and Satisfaction

OBJECTIVE

This study aimed to evaluate the effect of a physician-created educational infographic on the knowledge and attitudes of patients undergoing antenatal fetal surveillance.

STUDY DESIGN

This single-center prospective cohort study evaluated the impact of implementing an electronic educational infographic about antenatal fetal surveillance. English-speaking women receiving antenatal surveillance between the ages of 18 to 50 years were approached for inclusion. The preimplementation group enrolled women receiving antenatal surveillance between March 8, 2021, and April 2, 2021, who received usual care. Postimplementation, from April 5 to May 6, 2021, patients at our site received the infographic about antenatal fetal surveillance at their first antenatal testing appointment. Both pre- and postimplementation groups received a 5-question multiple-choice knowledge and 12-question attitude survey between 320/7 to 336/7 weeks at baseline (prior to receipt of infographic in postimplementation group) and again between 350/7 to 366/7 weeks. Patients were included in the analysis only if they completed both surveys. Differences from initial to final survey were compared between groups.

RESULTS

Of 106 patients who completed the initial survey, 74 (69.8%) participants finished both surveys (preimplementation = 39 and postimplementation = 35). There were no significant differences in demographics between the two groups, including in baseline knowledge (p = 0.58) or attitude tests (p = 0.57). There was no significant difference in knowledge on final surveys between groups (p = 0.79). However, utilization of the infographic was associated with a significant increase in attitude survey score from initial to final survey in the postimplementation group as compared with usual care (median difference: pre = 0, interquartile rang [IQR]: [-1 to +4] vs. post = +3, IQR: [+1 to +6], p = 0.016).

CONCLUSION

A physician-created infographic on antepartum fetal testing was associated with overall improved patient attitude toward fetal testing, showing that small education interventions can increase patient satisfaction with care.

KEY POINTS

· A physician-created, readable, and patient-oriented education resource is feasible.. · Infographic patient-education materials do not change patient knowledge about antenatal testing.. · Infographic patient-education materials can improve patient attitude toward antenatal testing..

Prophylactic Antibiotics After Cleft Lip and Palate Reconstruction: A Review From a Global Health Perspective

Orofacial clefts are common congenital deformities. Global initiatives have increased access to cleft care and reconstruction surgeries for cleft lip with or without cleft palate (CL/P), but there is no consensus on the use of postoperative prophylactic antibiotics. We conducted a narrative review using PubMed on the use of postoperative prophylactic antibiotics in CL/P surgery. A search of PubMed identified 30 potentially relevant articles, of which 15 were reviewed. There was no consensus among surgeons on prescribing patterns, but there was limited evidence that postoperative antibiotics reduce palatal fistulas. Notably, microbiological screening is not used to guide the choice of antimicrobial or to predict postoperative complications. Based on limited available data, we cannot make any strong evidence-based recommendations on prescribing postoperative antibiotics; however, we recommend that each cleft surgeon performing these procedures in lower-income countries without access to tertiary care centers consider the cost-benefit analysis of prescribing antimicrobials postoperatively, without antimicrobial screening, which showed no benefit.

Patient understanding of and participation in infection-related care across surgical pathways: a scoping review

OBJECTIVE

To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties.

METHOD

A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies.

RESULTS

The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs.

CONCLUSION

Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.

Development of Patient Education Materials for Total Joint Replacement During an International Surgical Brigade

Temporary brigade trips to deliver international surgical care are increasingly common. For the purposes of this work, we use the term brigade to describe self-contained short-term medical or surgical mission trips where healthcare professionals are brought in from foreign regions to provide care to an underserved population. Many brigade programs have begun to collect and publish data on outcomes and complications, but few have examined their own patient education practices.

Implementation strategies to reduce surgical site infections: A systematic review

BACKGROUND

Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence.

OBJECTIVE

To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs.

DESIGN

Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate).

RESULTS

In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers.

CONCLUSIONS

Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

What Is the Role of Plastic Surgery in Global Health? A Review

There is growing awareness of the substantial global burden of surgical disease. Conditions treated effectively by plastic and reconstructive procedures make a large proportion of the global surgical diseases, and disproportionately affect individuals at the lower end of the economic spectrum. This article reviews the role of plastic surgery in global health, highlights the ongoing need for plastic and reconstructive surgery globally, and increasing efforts that have been made to meet these needs. There global shortage of plastic surgeons in low and middle income countries, but plastic surgery has a long tradition of humanitarian aid, has been a leader in global surgery development. Plastic and reconstructive surgical care has increasingly been shown to be cost effective and to have an immense impact on the economy of a region, delivering a substantial return on investment. More sustainable global surgical care is essential in future, requiring ongoing efforts from the plastic surgery community, greater recognition of the problems that can be addressed at policy level, and research to help guide policy-makers when facing the decision of allocating scarce resources. There is a fundamental role of plastic surgery in global health.

Improved Early Cleft Lip and Palate Complications at a Surgery Specialty Center in the Developing World

OBJECTIVE

To evaluate complication rates following cleft lip and cleft palate repairs during the transition from mission-based care to center-based care in a developing region.

PATIENTS AND DESIGN

We performed a retrospective review of 3419 patients who underwent cleft lip repair and 1728 patients who underwent cleft palate repair in Guwahati, India between December 2010 and February 2014. Of those who underwent cleft lip repair, 654 were treated during a surgical mission and 2765 were treated at a permanent center. Of those who underwent cleft palate repair, 236 were treated during a surgical mission and 1491 were treated at a permanent center.

SETTING

Two large surgical missions to Guwahati, India, and the Guwahati Comprehensive Cleft Care Center (GCCCC) in Assam, India.

MAIN OUTCOME MEASURE

Overall complication rates following cleft lip and cleft palate repair.

RESULTS

Overall complication rates following cleft lip repair were 13.2% for the first mission, 6.7% for the second mission, and 4.0% at GCCCC. Overall complication rates following cleft palate repair were 28.0% for the first mission, 30.0% for the second mission, and 15.8% at GCCCC. Complication rates following cleft palate repair by the subset of surgeons permanently based at GCCCC (7.2%) were lower than visiting surgeons ( P < .05).

CONCLUSIONS

Our findings support the notion that transitioning from a mission-based model to a permanent facility-based model of cleft care delivery in the developing world can lead to decreased complication rates.

Early Surgical Complications after Primary Cleft Lip Repair: A Report of 3108 Consecutive Cases

Objective

To analyze short term surgical complications after primary cleft lip repair.

Patients and Design

A total of 3108 consecutive lip repairs with 2062 follow-ups were reviewed retrospectively through medical records. Patients were aged 3 months to 75 years at the time of surgery, with a median of 7 years.

Setting

Guwahati Comprehensive Cleft Care Center, Assam, India.

Intervention

Primary cleft lip repair.

Main Outcome Measures

Documented complications in terms of dehiscence, necrosis, infection, and suture granuloma were compiled. Logistic regression was used with dehiscence (yes/no) or infection (yes/no) as binary dependant variables. Age, cleft type, and surgeon (visiting/long term) were used as covariates.

Results

Among the 2062 patients who returned for early follow-up, 90 (4.4%) had one or more complications. Dehiscence (3.2%) and infection (1.1%) were the most common types of complication. Visiting surgeon, complete cleft, and bilateral cleft were significantly associated with wound dehiscence, and complete cleft was associated with wound infection according to the logistic regression analysis. Of patients with bilateral complete clefts, 6.9% suffered from some degree of wound dehiscence.

Conclusion

In a setting where presurgical molding is unavailable and patients present at all ages, lip wound dehiscence is a relatively common complication in patients with bilateral complete clefts. The risk of dehiscence, however, is reduced when these cases are assigned to surgeons with experience with these types of clefts. We also found that the incidence of wound infection can be kept relatively low, even without the use of postoperative antibiotics.

Role of Postoperative Antimicrobials in Cleft Palate Surgery: Prospective, Double-Blind, Randomized, Placebo-Controlled Clinical Study in India

BACKGROUND

The purpose of this study was to determine whether administration of postoperative antibiotics affects the incidence of complications after primary cleft palate repair in a developing area.

METHODS

This study was a prospective, double-blind, randomized, placebo-controlled trial composed of 518 consecutive patients who underwent primary cleft palate repair at a single institution. Patients were aged 1 to 43 years at the time of surgery (median, 9 years). The patients were divided randomly into two groups. One group received a 5-day regimen of oral amoxicillin (50 mg/kg/day) postoperatively and the other group received placebo medication. Both groups received a single dose of cefuroxime (30 mg/kg) before incision. Patients and providers were blinded to the randomization. Patients were followed postoperatively for early complications (infection and wound breakdown) and for late complications (palatal fistulas).

RESULTS

The incidence of early complications was 13.8 percent among the patients in the placebo group and 8.7 percent among the patients in the antibiotic group (p = 0.175). Fistulas were noted in 17.1 percent in the placebo group and in 10.7 percent in the antibiotic group (p = 0.085). Logistic regression analysis identified visiting surgeons as the only covariate related to early complications (OR, 3.71; p < 0.001). However, the use of placebo (OR, 2.09; p = 0.037), female sex (OR, 2.04; p = 0.047), and Veau III and IV (OR, 3.31; p = 0.004) were observed as factors associated with the incidence of fistulas.

CONCLUSION

The authors' results indicate that postoperative antibiotic prophylaxis can reduce the incidence of fistulas after primary cleft palate repair in a developing area.