Barriers to Cleft Lip and Palate Repair Around the World

Perspectives on the state of cleft lip and cleft palate patient care in Africa

PURPOSE OF REVIEW

Patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa.

RECENT FINDINGS

To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources.

SUMMARY

The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.

Cleft Lip and Palate Surgery at a Rural African Hospital: A 13-Year Experience From Western Kenya

INTRODUCTION

Most studies on the treatment of cleft lip and palate (CLP) in low-income and middle-income countries have reported on the experience of urban centers or surgical mission trips to rural locations. There is a paucity of literature on the experience of local teams providing orofacial cleft surgery in rural Sub-Saharan Africa. This study reports the efficacy and cost-effectiveness of cleft surgery performed by an all-local team in rural Kenya.

METHODS

A retrospective chart review was performed on all patients who received CLP repair at Kapsowar Hospital between 2011 and 2023. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. For the most recent year of study (2023), the authors performed a financial audit of all costs related to the performance of unilateral cleft lip surgery. Descriptive statistics were performed.

RESULTS

The authors identified 381 CLP surgeries performed on 311 patients (197 male, 63.3%). The most common etiology of the cleft was left unilateral (28.3%). The average age of primary lip repair decreased from 46.3 months in 2008 to 2009 to 20.2 months in 2022 to 2023 ( P <0.001). The average age of primary cleft palate repair decreased from 38.0 months in 2008 to 2009 to 25.3 months in 2022 to 2023 ( P <0.001). Patients traveled from 23 districts to receive treatment. Age of treatment was not different when distinguished by sex, county poverty level, or travel time from the hospital. The total costs associated with cleft lip repair was $201.6.

CONCLUSIONS

Adequately staffed hospitals in rural locations can meaningfully address a regional CLP backlog more cost-effectively than surgical mission trips.

Otology and Audiology: Complications, Challenges, and Concerns in the Patient With Cleft Lip and/or Palate

Cleft lip and/or palate, a treatable congenital condition, affects around 1 in 700 births, placing a large burden of care on those affected. A multidisciplinary approach to treating the patient involves not only cleft surgery but also a wide array of treatments and preventative therapies to prevent further disease. In this review, the otolaryngology subspecialties, otology and audiology, are discussed in relation to orofacial clefts. As patients with clefts carry a higher risk of permanent hearing loss and speech complications caused by the pathology of their cleft, management of additional diseases such as otitis media with effusion, conductive hearing loss, or infections requires timely evaluation, treatment, and follow-up. The current practice in otology and audiology is discussed with the challenges faced in delivering timely care-in any setting, low or higher income. Lack of consensus and controversies surrounding the use and timing of tympanostomy tubes are reviewed, as well as the palatoplasty types that show significant benefit for otitis media with effusion, audiometry, and speech outcomes. Lastly, a call for further research in clefts and otology and the urgency for its awareness and advocacy in low and middle-income countries is imperative.

A Geospatial Analysis of Barriers to Cleft Lip and Palate Care in the United States

OBJECTIVE

This study evaluates the geospatial distribution of cleft lip and/or cleft palate (CL/P) care in the United States, assesses disparities between families with and without one-hour proximity to CL/P care, and recommends interventions for improving access.

DESIGN

We identified American Cleft Palate Craniofacial Association-approved CL/P teams and calculated a one-hour driving radius around each clinic. We then used census data to compare risk factors for developing cleft (i.e., incidence risk factors) and obstacles to care (i.e., access risk factors) between counties with and without one-hour proximity.

RESULTS

We identified 187 CL/P teams in 45 states. Most were in the South (n = 60, 32.0%), though children in the Middle Atlantic had the greatest access to care. Alabama, Mississippi, Tennessee, and Kentucky had the least access. Children without access were 39% more likely to have gestational tobacco exposure, 8% more likely to have gestational obesity exposure, and 28% less likely to have health insurance (p < 0.01). Children without access in the South were 29% more likely to have a low birth weight and 46% more likely to be living below the poverty line (p < 0.01). Children with access were twice as likely to live in immigrant families and 7-times more likely to speak English as a second language.

CONCLUSIONS

Pronounced disparities affect patients with and without one-hour access to CL/P care. Interventions should address care costs for patients living furthest without access and language barriers for patients with access that speak English as a second language.

A systematic review of barriers to accessing cleft care worldwide

PURPOSE

Patients with cleft lip/palate need an interdisciplinary approach. Delays in the care of these patients and difficulties in accessing health services have been reported in different low-, middle-, and high-income countries. This study aimed to characterize worldwide publications on access to cleft lip and palate health treatment.

METHODS

Databases were selected systematically and searched until July 2021. The review process followed standard methods for systematic reviews. The study quality was evaluated using the Strengthening the Reporting of Observational studies in Epidemiology guidelines for observational studies.

RESULTS

A total of 289 publications were identified using our search strategy. After reviewing the titles and reading the abstracts and full text, 16 studies met the inclusion criteria in the review. In one study, financial difficulties obtained the attention of the professionals who attended to cleft lip/palate patients. Ethnic disparities, problems in transportation, and long distances between users and health centers were found. Additionally, there was misinformation about treatment and follow-up among the caregivers of patients with cleft lip/palate.

CONCLUSION

When reviewing the literature on access to health services for patients with cleft lip/palate, barriers were reported in access to information, physical access to care centers, financial resources to cover expenses for treatment, and opportunities in care.

Age at primary surgery among orofacial cleft individuals in Indonesia

OBJECTIVES

To observe the age at primary cleft surgery among charity organizations such as Smile Train in helping Indonesia manage patients with OFC.

MATERIALS AND METHODS

A retrospective analysis of medical records was conducted to identify patients with orofacial clefts who underwent primary surgery between 2001 and 2021. The age at the time of surgery was recorded for each patient. Descriptive statistics were used to analyse the data and determine the average age at primary surgery.

RESULTS

In the period between 2001 and 2021, a total of 34 239 individuals in Indonesia underwent primary lip surgery, while 16 768 individuals received primary palatal surgery, as recorded in the Smile Train database. Notably, a significant proportion of these surgeries were classified as delayed primary repairs. Approximately 65.3% of primary lip surgeries were performed beyond the recommended timeline of 6 months of age, indicating a delay in the surgical intervention. Similarly, 67% of primary palatal surgeries were also delayed, occurring after the recommended timeline of 18 months of life.

CONCLUSIONS

This study provides insights into the age at primary surgery among individuals with orofacial clefts in Indonesia. The findings highlight the need for timely intervention and the importance of considering individualized treatment plans based on the specific type of orofacial cleft. Further research is warranted to explore factors influencing the age at primary surgery and their impact on treatment outcomes and long-term functional outcomes in this population.

Barriers in Cleft Service Access in Sub-Saharan Africa: A Thematic Analysis of Practical Needs of Rural Families

OBJECTIVE

To explore the experiences and perceptions of barriers of parents and family members of patients with cleft lip and palate in accessing cleft services in remote northwest Nigeria.

DESIGN

Face-to-face semi-structured audio recorded interviews were used to obtained qualitative textual data. Thematic analysis using interpretative descriptive techniques was employed to understand the participants' lived experiences with barriers and accessibility to cleft services.

SETTING

Participants were from Sokoto, Kebbi and Zamfara states in remote northwest, Nigeria.

PARTICIPANTS

Consisted of 22 caregivers (17 parents and 5 extended family members) were purposively sampled between 2017 and 2020.

MAIN OUTCOME MEASURES

Barriers experienced while accessing cleft services were identified during thematic analysis.

RESULT

Over three quarter of the respondents had patients with both cleft lip and palate and without any previous family history (n = 20). About two-thirds of the participants (n = 15) were females. Most of the interviews were conducted before the surgeries (n = 15).

FIVE THEMES EMERGED

lack of information, financial difficulty, misrepresentation from health workers, multiple transportation and previous disappointment.

CONCLUSIONS

Areas of poor awareness, misinformation from primary health care workers, financial hurdles, multiple transportation logistics and others were identified. Aggressive broadcasting of information through radio, timely treatment and collaboration with influential religious leaders were emphasized. Support, grants and subsidies from government and voluntary agencies are encouraged to mitigate the huge out of pocket cost of cleft care in the region.

Utilising massive open online courses to enhance global learning dissemination in cleft lip and palate: a case report of penta helix collaboration

BACKGROUND

Educating and raising awareness in cleft lip and palate future generations is one vital effort to ensure the improvement of cleft care and research in the future. This study reported the overview in organising and evaluating the Massive Open Online Course (MOOC) in Cleft Lip and Palate as the alternative way for students' capacity building outside their study program whilst also earning credits towards their studies.

METHODS

Smile Train cleft charity generously donated recorded lectures from cleft experts around the world in which each of the experts agreed to provide one-hour live discussion sessions. The learning activities ranging from lectures, pre- and post-course evaluation, forum, live discussion sessions, virtual visits to Indonesian Cleft Centre, self-reflection assignments and final project. A survey was released to the participants to collect their feedback.

RESULTS

The course mainly attracted dental students, and several allied health professional students. In total, 414 out of 717 participants registered for this MOOC managed to finish the course and received a certificate of completion which was run between August-October 2021. In general, participants positively received the course.

CONCLUSIONS

The MOOC model and its objective of disseminating widespread information across geographical boundaries to enhance learning about cleft lip and palate treatment was achieved. This report serves as an example for other educational institutions and stakeholders who plan to use online educational engagement platforms to provide high-quality education and capacity building to participants in lower-middle income countries.

A novel technique predicting velopharyngeal insufficiency risk in newborns following primary cleft repair. A randomized clinical trial comparing buccinator flap and Bardach two-flap palatoplasty

The study aimed to assess the efficacy of buccinator myomucosal flap (BMF) compared to Bardach two-flap use in primary cleft palatoplasty on palatal length and fistulation rate. Palatal length in relation to the pharynx is a critical factor regarding velopharyngeal function. The goal was to predict the risk of velopharyngeal insufficiency by comparing the potential of two different techniques in lengthening the palate and to decrease the fistulation rate. A total of 46 patients with complete wide cleft palate were randomly divided into two equal groups: a study group, in which the cleft palate defect was repaired by BMF; and a control group, in which patients' clefts were repaired by Bardach (two-flap) palatoplasty during primary repair. All patients were evaluated at 1-, 3- and 6-month intervals to detect the fistulation rate and to measure the palatal length by taking impressions, pouring casts to measure the palatal length from anterior reference point (incisive foramen) to the posterior reference point(uvula) and calculating the change of palatal length. There was a significant increase in the palatal length measurements in the study (BMF) group (immediate postoperatively and at 3 and 6 months) compared to the control group (p < 0.001). Regarding the fistulation rate, there was no statistically significant difference (p = 0.346). The use of the buccinator flap during primary repair of cleft palate decreased the fistulation rate.

Gender inequality and burden of orofacial clefts in the Eastern Mediterranean region: findings from global burden of disease study 1990-2019

BACKGROUND

Gender inequality may be associated with the burden of orofacial clefts (OFCs), particularly in low-and middle-income countries (LMICs). To investigate the OFCs' burden and its association with gender inequality in the Eastern Mediterranean region (EMR).

METHODS

Country-specific data on the OFCs' prevalence and Disability-Adjusted Life Years (DALYs) from 1990 to 2019 were gathered from the Global Burden of Disease database by age and gender. Estimated annual percentage change (EAPCs) was used to investigate the OFCs' trends. The association of the Gender Inequality Index (GII) with prevalence and DALY rates was determined using multiple linear regression. Human Development Index (HDI), Socio-Demographic Index (SDI), and Gross Domestic Product (GDP) were also considered as potential confounders.

RESULTS

In 2019, the overall regional OFCs' prevalence and DALYs (per 100,000 person-years) were 93.84 and 9.68, respectively. During the 1990-2019 period, there was a decrease in prevalence (EAPC = -0.05%), demonstrating a consistent trend across genders. Moreover, within the same timeframe, DALYs also declined (EAPC = -2.10%), with a more pronounced reduction observed among females. Gender differences were observed in age-specific prevalence rates (p-value = 0.015). GII was associated with DALYs (βmale= -0.42, p-value = 0.1; βfemale = 0.48, p-value = 0.036) and prevalence (βmale= -1.86, p-value < 0.001, βfemale= -2.07, p-value < 0.001).

CONCLUSIONS

Despite a declining prevalence, the burden of OFCs remained notably significant in the EMR. Gender inequality is associated with the burden of OFCs in the Eastern Mediterranean region. Countries in the region should establish comprehensive public policies to mitigate gender inequalities in healthcare services available for OFCs.

Abbe Flap Division Before Two Weeks' Time: Harmful or Advantageous?

INTRODUCTION

The Abbe flap is a standard intervention to treat upper lip deformities in patients with bilateral cleft lip. This two-stage procedure requires a 2 to 3-week period in which the superior and inferior lips remain connected. This study evaluates the safety of Abbe flap division and inset prior to 14 days' time.

MATERIALS AND METHODS

A single institution, 8-year review of all patients with a bilateral cleft lip who underwent Abbe flap reconstruction was performed. Patients were classified into two groups: those whom division was performed 14 days or later and those with division earlier than 14 days.

RESULTS

A total of 26 patients were identified. Patients who underwent Abbe flap division in less than 14 days (n = 10) demonstrated an average time to division of 9.7 days (range 7-13 days) with no evidence of flap loss, wound breakdown or infection. Patients who underwent Abbe flap division within 14 days or more (n = 16) demonstrated an average time to division of 15 days with four minor complications and no flap loss.

CONCLUSION

Dividing the Abbe flap after the first postoperative week appears to be safe and without additional risk to flap loss or wound breakdown. A shorter time to Abbe flap division may decrease the burden of care on patients and their caregivers.

How are people with orofacial clefts attended in northwest region of São Paulo state, Brazil?

Characterization of specific birth defects is essential for conducting scientific investigations, care and therapeutic strategies. This article describes demographic, clinical and genetic aspects, risk factors and access to treatment of Brazilian patients with orofacial clefts registered in a specialized collaborative center of the Brazilian Database on Craniofacial Anomalies (BDCA). We interviewed 70 individuals with typical orofacial clefts using a standard instrument from the database and subjected them to genetic testing. The patients were grouped as syndromic and non-syndromic. The majority of individuals were of lower middle class, native ancestry and syndromic. There was a significant difference in the type of clefts regarding gender. There was no significant difference between bilateral and unilateral, between the side affected, right and left, or familial recurrence related to type of oral cleft. The risk factor familial recurrence was significantly higher among non-syndromic cases. Etiological factors were identified or suggested in 62.5% of the syndromic cases. There was a delay in diagnosis and in access to treatment in most cases. We concluded that gender, native ancestry and low family income represent risk factors. Furthermore, the distribution by cleft types and gender is similar to previous studies. The results can guide scientific investigations and care policies.

Situational analysis of nutritional status among 1899 children presenting with cleft lip and/or palate in Indonesia

Background

Given the increased risk of malnutrition in children with cleft lip and/or palate (CLP), determining their nutritional status is critical for preventing adverse surgical risks. However, no such disaggregated, national-level data are available in Indonesia. We aimed to determine the nutritional status of patients with clefts in Indonesia and to identify problems and solutions for malnutrition cases within the population.

Methods

In this cross-sectional study, we considered records of individuals who underwent primary surgery for CLP in Smile Train-sponsored facilities in Indonesia between 1 January 2016 and 31 December 2021 (n = 18 480). We only included children under the age of five with an evaluation date prior to admission date and excluded subjects with invalid data values. We classified their nutritional status by z-scores according to the World Health Organization Child Growth Standard (2006). Malnutrition cases cover four indicators - stunting, wasting, underweight, and overweight. We compared the prevalence for malnutrition cases in children under the age of five using national health survey data.

Results

We included 1899 records following data validation. The national prevalence of stunting (24.4%), wasting (12.5%), and overweight cases (12.9%) was high, while underweight cases (6.8%) were comparatively low. Statistical analyses showed significant differences in nutritional status based on length/height-for-age between girls and boys aged 0-5 months (P = 0.008) and 48-60 months (P = 0.001), and based on body mass index-for-age (P = 0.000) between girls and boys aged 0-5 months. Girls in different age groups exhibited a statistically significant difference in nutritional status based on length/height-for-age (P = 0.002) and weight-for-age (P = 0.017). Concurrent stunting and overweight were the most common forms of concurrent malnutrition (8.7%). We found a significant difference in the prevalence of underweight (P = 0.001) and overweight (P = 0.000) cases between children with CLP and those without CLP.

Conclusions

Our findings highlight the importance of nutritional interventions for children with orofacial clefts in Indonesia, and the importance of age and gender in their design and implementation. Further investigation is necessary to explore the risks of overweight and concurrent malnutrition among this population.

The First Hybrid International Educational Comprehensive Cleft Care Workshop

OBJECTIVE

Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance.

DESIGN

Cross-sectional survey-based evaluation.

SETTING

International comprehensive cleft care workshop.

PARTICIPANTS

Total of 489 participants.

INTERVENTIONS

Three-day simulation-based hybrid comprehensive cleft care workshop.

MAIN OUTCOME MEASURES

Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance.

RESULTS

The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01).

CONCLUSION

Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

The burden, prevention and care of infants and children with congenital anomalies in sub-Saharan Africa: A scoping review

The aim of this scoping review was to determine the scope, objectives and methodology of contemporary published research on congenital anomalies (CAs) in sub-Saharan Africa (SSA), to inform activities of the newly established sub-Saharan African Congenital Anomaly Network (sSCAN). MEDLINE was searched for CA-related articles published between January 2016 and June 2021. Articles were classified into four main areas (public health burden, surveillance, prevention, care) and their objectives and methodologies summarized. Of the 532 articles identified, 255 were included. The articles originated from 22 of the 49 SSA countries, with four countries contributing 60% of the articles: Nigeria (22.0%), Ethiopia (14.1%), Uganda (11.7%) and South Africa (11.7%). Only 5.5% of studies involved multiple countries within the region. Most articles included CA as their primary focus (85%), investigated a single CA (88%), focused on CA burden (56.9%) and care (54.1%), with less coverage of surveillance (3.5%) and prevention (13.3%). The most common study designs were case studies/case series (26.6%), followed by cross-sectional surveys (17.6%), retrospective record reviews (17.3%), and cohort studies (17.2%). Studies were mainly derived from single hospitals (60.4%), with only 9% being population-based studies. Most data were obtained from retrospective review of clinical records (56.1%) or via caregiver interviews (34.9%). Few papers included stillbirths (7.5%), prenatally diagnosed CAs (3.5%) or terminations of pregnancy for CA (2.4%).This first-of-a-kind-scoping review on CA in SSA demonstrated an increasing level of awareness and recognition among researchers in SSA of the contribution of CAs to under-5 mortality and morbidity in the region. The review also highlighted the need to address diagnosis, prevention, surveillance and care to meet Sustainable Development Goals 3.2 and 3.8. The SSA sub-region faces unique challenges, including fragmentation of efforts that we hope to surmount through sSCAN via a multidisciplinary and multi-stakeholder approach.

Global Cleft Lip and Palate Outreach: A Google Trends Analysis

Understanding patient awareness of cleft lip and/or palate (CL/P) and evaluating demand for necessary procedures may serve to better target future efforts in global outreach.

We utilized internet search query data from Google Trends for the terms: "cleft lip," "cleft palate," "cleft lip and palate," "cleft surgery," and "cleft repair" from January 2004 to January 2021. Relative search volumes (RSV) recorded for the top 5 highest displaying countries and top 3 available regions within those countries were compared against global outreach by Operation Smile and Smile Train, as measured by the number of patients treated. World Health Organization (WHO) indicators were used to validate the RSV values for each country and better understand the current infrastructure and need for cleft care in those countries.

Globally, there was an increase in RSV for the terms "cleft lip," "cleft palate," "cleft repair," and "cleft surgery" between 2004 and 2021. For "cleft lip," the countries with the highest displaying RSVs included: Ghana (100%), Zimbabwe (97%), Nepal (78%), the Philippines (64%), and Kenya (52%). Countries with high RSVs and moderate to high WHO indicators included Ghana, Kenya, India, Nigeria, and Zimbabwe. Countries with high RSVs and poor WHO indicators included Nepal and Pakistan. Some countries had specific regions with high search demand that are not currently targeted for global outreach.

Using Google Trends' data may help find more feasible locations and targeted care for efforts in global outreach with better patient awareness and turnout where demand for CL/P is increasing.

Evidence of the folate-mediated one-carbon metabolism pathway genes in controlling the non-syndromic oral clefts risks

The folate-mediated one-carbon metabolism pathway is thought to play an important role in the etiology of non-syndromic oral clefts (NSOFC), although none of the genes in this pathway has shown significant signals in genome-wide association studies (GWAS). Recent evidence indicated that enhanced understanding could be gained by aggregating multiple SNPs effect simultaneously into polygenic risk score (PRS) to assess its association with disease risks. This study is aimed to assess the association between the genetic effect of folate-mediated one-carbon metabolism pathway and NSOFC risks using PRS based on a case-parent trio design. A total of 297 SNPs mapped from 18 genes in the folate-mediated one-carbon metabolism pathway were aggregated from a GWAS of 2458 case-parent trios recruited from an international consortium. We found a PRS based on the folate-mediated one-carbon metabolism pathway was significant among all NSOFC trios (OR = 1.95, 95% CI: 1.66-2.28, p = 2.39 × 10^-16 ), as well as two major subtypes, non-syndromic cleft lip with or without cleft palate (NSCL/P) trios (OR = 1.71, 95% CI: 1.50-1.96, p = 7.66 × 10^-15 ) and non-syndromic cleft palate only (NSCPO) trios (OR = 1.51, 95% CI: 1.36-1.68, p = 2.1 × 10^-14 ). Similar results were also observed in further subgroup analyses stratified into Asian and European trios. The averaged PRS of the folate-mediated one-carbon metabolism pathway varied between the NSOFC case group and its comparison group (p < 0.05) with higher average PRS in the cases. Moreover, the top 5% pathway PRS group had 2.25 (95% CI: 1.85-2.73) times increased NSOFC risk, also 3.09 (95% CI: 2.50-3.81) and 2.06 (95% CI: 1.39-3.02) times increased risk of NSCL/P and NSCPO compared to the remainder of the distribution. The results of our study confirmed the folate-mediated one-carbon metabolism pathway was important in controlling risk to NSOFC and this study enhanced evidence towards understanding the genetic risks of NSOFC.

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.

Application of Safety Protocols for International Cleft Outreach Programs During the COVID-19 Pandemic: Global Smile Foundation Precaution Guidelines and Implications

BACKGROUND

Since COVID-19 was declared a worldwide pandemic by the World Health Organization (WHO) in March of 2020, foundation-based cleft outreach programs to Low- and Middle-Income Countries (LMICs) were halted considering global public health challenges, scarcity of capacity and resources, and travel restrictions. This led to an increase in the backlog of untreated patients with cleft lip and/or palate, with new challenges to providing comprehensive care in those regions. Resumption of international outreach programs requires an updated course of action to incorporate necessary safety measures in the face of the ongoing pandemic. In this manuscript, the authors outline safety protocols, guidelines, and recommendations implemented in Global Smile Foundation's (GSF) most recent outreach trip to Beirut, Lebanon.

METHODS

COVID-19 safety protocols for outreach cleft care and an Action Response Plan were developed by the GSF team based on the published literature and recommendations from leading international organizations.

RESULTS

GSF conducted a 1-week surgical outreach program in Beirut, Lebanon, performing 13 primary cleft lip repairs, 7 cleft palate repairs, and 1 alveolar bone grafting procedure. Safety protocols were implemented at all stages of the outreach program, including patient preselection and education, hospital admission and screening, intraoperative care, and postoperative monitoring and follow-up.

CONCLUSIONS

Organizing outreach programs in the setting of infectious diseases outbreaks should prioritize the safety and welfare of patients and team members within the program's local community. The COVID-19 protocols and guidelines described may represent a reproducible framework for planning future similar outreach initiatives in high-risk conditions.

Sociodemographic Disparities in Access to Cleft Rhinoplasty

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Follow-Up Care Barriers for Patients with Orofacial Clefts

OBJECTIVE

The aim of this study was to evaluate whether a patient with a cleft's age, associated syndrome, cleft phenotype or travel distance affects their follow-up rate.

DESIGN

This study is a retrospective review of patients with CL/P treated by a craniofacial clinic.

SETTING

The setting was a craniofacial clinic at a tertiary care university hospital.

PATIENTS, PARTICIPANTS

Candidates were patients seen by the craniofacial clinic between January 2007 and December 2019. An initial pool of 589 patients was then reduced to 440 due to exclusion criteria.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The outcome measure was actual patient attendance to the craniofacial team compared to the team goal expectation of annual return visits.

RESULTS

The mean age of participants at the end of the study was 9.0 ±  5.4 years with a mean follow-up period (total possible follow-up period length based on patient age at presentation and study window) of 5.5 ±  3.6 years. There was no association between cleft phenotype, type of syndrome, or distance to the clinic with attendance. Children with syndromes had an 11% decrease in the odds of attending follow-up visits with each 1-year increase in age compared to a 4% decrease in children without syndromes.

CONCLUSIONS

The only significant factors determining patient attendance were the presence of a syndrome and increasing age.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Association of Patient Factors and Follow-Up in an International Volunteer Cleft Lip and Palate Repair Clinic in El Salvador

BACKGROUND

In countries which lack robust health care systems, congenital conditions such as cleft lip and/or palate deformities are often untreated in certain individuals. Many volunteer organizations have stepped in to fill this gap but certain factors, such as continuity of care, are yet to be studied for these clinics.

METHODS

This is a retrospective cohort study of 167 pediatric patients with cleft lip and/or palate residing in El Salvador treated by a nongovernmental organizations between 2011 and 2020. This data was used in univariate and multivariable models to associate particular patient factors to their likelihood of following up to their annual clinic visits.

RESULTS

Each 1-year increase in duration of follow-up was associated with a 27% decrease in the odds of attending a visit. In addition, 33.7% of cleft lip and 49.7% of cleft palate/cleft lip and palate patients returned at least once. Males had 36% higher odds of attending a return visit compared with females but this difference was not statistically significant. Time spent travelling to the clinic had no effect on follow-up rates.

CONCLUSION

Nongovernmental organizations utilizing a diagonal care model should consider using more strategies to maximize continuity of care by increasing communication with patients and emphasizing the need of following up during clinic visits. Continued and increased collaboration with the local team is also of great importance.

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.

METHOD

A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.

RESULTS

Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP (p = .003) and CLP (p =  .002) patients but higher frequency than OSMCP (p = .002) and non-CP (p =  .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).

CONCLUSIONS

CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.

Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving?

Background

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

Methods

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

Results

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

Conclusions

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06630-w.

Barriers and Resources to Cleft Lip and Palate Speech Services Globally: A Descriptive Study

BACKGROUND

Although a number of international cleft organizations and cleft professionals in low- and middle-income countries (LMICs) have built and supported comprehensive cleft care and speech therapy models to address the shortage of speech services in LMICs, the specific speech needs of individuals with cleft lip and palate (CLP) in such countries remain unknown. The objective of this study was to evaluate the barriers to accessing speech services for patients with CLP as well as the resources and models of speech services that are currently available for individuals with CLP in LMICs, with the goal of better understanding the needs of this population.

METHODS

Qualitative and quantitative methods consisted of Smile Train partner surveys that were distributed June 25th to July 31st, 2018 worldwide. Surveys were distributed through Smile Train's online medical database, Smile Train Express, which every Smile Train partner uses to report their Smile Train sponsored treatment outcomes. A total of 658 Smile Train partners responded to the surveys. Respondents included surgeons, speech therapists, orthodontists, administrators and nurses who represented non-governmental organizations, hospitals (private or public), hospital groups, and private clinics.

RESULTS

Results indicated that lack of resources, including access to local speech providers and language materials, as well as financial constraints such as patient travel and speech treatment costs, are the most commonly reported barriers to accessing speech services across all geographic regions surveyed.

CONCLUSIONS

Improving access to CLP speech services in LMICs may require strategies that address lack of speech providers, language materials, and financial constraints.

Global Burden of Orofacial Clefts and the World Surgical Workforce

BACKGROUND

Orofacial clefts are one of the most common congenital anomalies, but this disease burden is unevenly distributed worldwide. The authors hypothesize that this burden falls disproportionately on the countries with the smallest surgical workforce or lowest Socio-Demographic Index, rather than those with the highest prevalence of disease.

METHODS

The authors estimated the prevalence and disease burden of orofacial clefting from 1990 to 2017 in 195 countries using the Global Burden of Disease methodology. Prevalence and disability-adjusted life-years were compared geographically, temporally, and against the size of the national surgical workforce, Socio-Demographic Index, and income status. Linear and logarithmic regressions were performed.

RESULTS

In 2017, the prevalence of orofacial clefting was estimated to be 10.8 million people, representing a disease burden of 652,084 disability-adjusted life-years, with most of this disease burden experienced by low- and middle-income countries (94.1%). From 1990 to 2017, there was a decrease in disease burden (-70.2%) and prevalence (-4.9%). There was negative logarithmic association between surgical workforce size and disease burden, with a surgical workforce of greater than six providers per 100,000 population (3.6 disability-adjusted life-years versus 22.4 disability-adjusted life-years per 100,000 population; p < 0.0001).

CONCLUSIONS

Burden of orofacial clefting has a strong negative association with the size of the surgical workforce, suggesting that strengthening the surgical workforce will help alleviate this burden. Epidemiologic data on countries and regions with inadequate surgical workforces and high disease burden should guide future research efforts and allocation of resources, and guide the treatment and educational goals of international charitable organizations.

Comprehensive Cleft Care Delivery in Developing Countries: Impact of Geographic and Demographic Factors

INTRODUCTION

The authors analyzed the insights of participants and faculty members of Global Smile Foundation's Comprehensive Cleft Care Workshops concerning the barriers and interventions to multidisciplinary cleft care delivery, after stratification based on demographic and geographic factors.

METHODS

During 2 simulation-based Comprehensive Cleft Care Workshops organized by Global Smile Foundation, participants and faculty members filled a survey. Surveys included demographic and geographic data and investigated the most relevant barrier to multidisciplinary cleft care and the most significant intervention to deliver comprehensive cleft care in outreach settings, as perceived by participants.

RESULTS

The total response rate was 57.8%. Respondents reported that the greatest barrier to comprehensive cleft care was financial, and the most relevant intervention to deliver multidisciplinary cleft care was building multidisciplinary teams. Stratification by age, gender, and geographical area showed no statistical difference in reporting that the greatest barrier to cleft care was financial. However, lack of multidisciplinary teams was the most important barrier according to respondents with less than 5 years of experience (P = 0.03). Stratification by gender, years in practice, specialty, and geographical area showed no statistical difference, with building multidisciplinary teams reported as the most significant intervention. However, increased training was reported as the main intervention to cleft care for those aged less than 30 years old (P = 0.04).

CONCLUSIONS

Our study delivers an assessment for barriers facing multidisciplinary cleft care delivery and interventions required to improve cleft care delivery. The authors are hoping that stratification by demographic and geographic factors will help them delineate community-specific road maps to refine cleft care delivery.

Mobile Surgical Scouts Increase Surgical Access for Patients with Cleft Lip and Palate in Nepal

Background: In Nepal's remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care. Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal. Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed. Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries. Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepal.

The Current State of Cleft Care in Sub-Saharan Africa: A Narrative Review

OBJECTIVE

To identify practices and limitations of cleft care in sub-Saharan Africa (SSA).

DESIGN

A retrospective narrative nonsystematic literature review was performed.

SETTING

Literature exploring the management practices of cleft lip and/or palate across regions in SSA was included.

PARTICIPANTS

Full text case reports, retrospective studies, prospective studies, clinical trials, and review articles written and published in English between 1966 and February 1, 2021, were included in this analysis utilizing PubMed, MEDLINE, EMBASE, and Google scholar databases.

MAIN OUTCOME MEASURES

Qualitative themes identified in analysis were clinical practice patterns, current infrastructure and limitations of cleft repair, training and interdisciplinary teams, economic analyses, and international partnerships.

RESULTS

Significant barriers to care identified in SSA include lack of hospital resources, craniofacial training, access to multidisciplinary specialists, and public awareness. These problems make the entire care journey difficult for patients. Increasing public education has the power to diminish late presentations to hospitals. Providing adequate hospital resources and craniofacial training through international and organizational partnerships can ensure that more patients will receive care. Increasing the availability and number of multidisciplinary specialists is crucial to follow up care which aims at improving functional outcomes.

CONCLUSION

This narrative review highlights current practices and limitations in cleft care, emphasizing the importance of effective and timely repair of clefts in SSA. Targeted efforts aimed at establishing sustainable infrastructure for cleft care in SSA can have significant individual and community health and economic benefits.

Perceived Barriers to Comprehensive Cleft Care Delivery: Results From A Capacity-Building Educational Initiative and Implications

INTRODUCTION

We analyzed the perceptions of participants and faculty members in simulation-based comprehensive cleft care workshops regarding comprehensive cleft care delivery in developing countries.

METHODS

Data were collected from participants and faculty members in 2 simulation-based comprehensive cleft care workshops organized by Global Smile Foundation. We collected demographic data and surveyed what they believed was the most significant barrier to comprehensive cleft care delivery and the most important intervention to deliver comprehensive cleft care in developing countries. We also compared participant and faculty responses.

RESULTS

The total number of participants and faculty members was 313 from 44 countries. The response rate was 57.8%. The majority reported that the most significant barrier facing the delivery of comprehensive cleft care in developing countries was financial (35.0%), followed by the absence of multidisciplinary cleft teams (30.8%). The majority reported that the most important intervention to deliver comprehensive cleft care was creating multidisciplinary cleft teams (32.2%), followed by providing cleft training (22.6%). We found no significant differences in what participants and faculty perceived as the greatest barrier to comprehensive cleft care delivery (P = 0.46), or most important intervention to deliver comprehensive cleft care in developing countries (P = 0.38).

CONCLUSIONS

Our study provides an appraisal of barriers facing comprehensive cleft care delivery and interventions required to overcome these barriers in developing countries. Future studies will be critical to validate or refute our findings, as well as determine country-specific roadmaps for delivering comprehensive cleft care to those who need it the most.

Engineered mucoperiosteal scaffold for cleft palate regeneration towards the non-immunogenic transplantation

Cleft lip and palate (CL/P) is the most prevalent craniofacial birth defect in humans. None of the surgical procedures currently used for CL/P repair lead to definitive correction of hard palate bone interruption. Advances in tissue engineering and regenerative medicine aim to develop new strategies to restore palatal bone interruption by using tissue or organ-decellularized bioscaffolds seeded with host cells. Aim of this study was to set up a new natural scaffold deriving from a decellularized porcine mucoperiosteum, engineered by an innovative micro-perforation procedure based on Quantum Molecular Resonance (QMR) and then subjected to in vitro recellularization with human bone marrow-derived mesenchymal stem cells (hBM-MSCs). Our results demonstrated the efficiency of decellularization treatment gaining a natural, non-immunogenic scaffold with preserved collagen microenvironment that displays a favorable support to hMSC engraftment, spreading and differentiation. Ultrastructural analysis showed that the micro-perforation procedure preserved the collagen mesh, increasing the osteoinductive potential for mesenchymal precursor cells. In conclusion, we developed a novel tissue engineering protocol to obtain a non-immunogenic mucoperiosteal scaffold suitable for allogenic transplantation and CL/P repair. The innovative micro-perforation procedure improving hMSC osteogenic differentiation potentially impacts for enhanced palatal bone regeneration leading to future clinical applications in humans.

Care Barriers for Patients With Nonsyndromic Orofacial Clefts in Saudi Arabia: A Cross-Sectional Study

OBJECTIVE

To evaluate the barriers faced by patients with nonsyndromic orofacial clefts (NSOFC) throughout their treatment course in Saudi Arabia.

DESIGN

A cross-sectional study.

SETTING

Eleven different governmental health care centers across Saudi Arabia. Patients: Records of pediatric patients with NSOFC.

INTERVENTIONS

A questionnaire with multiple validation stages was designed to assess the barriers in care of these patients through telephonic interviews with the parents or guardians of patients with NSOFC.

MAIN OUTCOME MEASURES

We identified 3 care-barrier-related factors: (1) geographic accessibility, (2) appointment availability and accessibility, and (3) scheduling-related barriers.

RESULTS

Overall, 240 participants of both sexes, with orofacial cleft of various types and with various demographic characteristics (residence, family monthly income, and caregiver level of education) were included. The highest mean score of care barriers was reported for scheduling-related barriers. Overall, 186 individuals reported sometimes/often not receiving the required medical care for the following reasons: scheduling difficulties (89%; 37.1%), prolonged waiting room time (40%; 16.7%), and transportation difficulties (36%; 15.0%). A linear regression showed that parents cited late appointments as the main reason for patients with NSOFC not receiving adequate medical care. Care-barrier factors were significantly related to gender (P = .035), patient age (P < .001), place of residency (P < .001), and caregiver's level of education (P = .015).

CONCLUSIONS

Gaps in the health care system directly related to common care barriers need to be addressed to ensure adequate care for patients with NSOFC.

Treatment of Cleft Lip and Palate in the Amazon Region in Brazil: Speech Results and Sociodemographic Aspects

OBJECTIVE

To investigate the speech outcomes in individuals with cleft lip and palate (CLP) from the Amazon region and determine their correlation with sociodemographic factors.

DESIGN

Cross-sectional, prospective, single-blind study.

SETTING

Tertiary care institute in Manaus, Amazonas, Brazil.

PATIENTS

Four hundred twenty individuals with CLP, aged 4 to 57 years.

MAIN OUTCOME MEASURES

The samples were judged by 3 speech pathologists experienced in the speech assessment of individuals with CLP. Hypernasality was scored using a 4-point scale, being 1 = absent, 2 = mild, 3 = moderate, and 4 = severe, and the active speech symptoms were classified as absent or present. The final score for each speech symptom was reached by consensus among the 3 examiners Descriptive analysis of sociodemographic data included origin, socioeconomic status, type of cleft, surgical technique employed, the age they underwent primary and secondary palatoplasty, and palatal fistula.

RESULTS

Absence of hypernasality was observed in 41% of the individuals, 18% had mild, 28% moderate, and 13% severe hypernasality. Active speech symptoms were observed in 57% of the individuals. Significant correlations were found between speech outcomes and the variables such as origin, socioeconomic status, age at primary and secondary palatoplasty, and presence of fistula.

CONCLUSIONS

Most individuals with repaired CLP from the Amazon region presented speech disorders, characterized by hypernasality and active errors. Patients living outside the state capital, of low socioeconomic level, underwent palatoplasty late and with presence of palatal fistula tended to have the worst speech outcomes.

A Novel IRF6 Frameshift Mutation in a Large Chinese Pedigree With Van der Woude syndrome

AIMS

Van der Woude syndrome (VWS) is one of the most common craniofacial anomalies, causing significant functional and psychological burden to the patients. This study aimed to identify the genetic cause of VWS in a Chinese family.

METHODS

Whole genome sequencing (WGS) was performed to screen for pathogenic mutations. Various Bioinformatics tools were used to assess the pathogenicity of the variants. Cosegregation analysis of the candidate variant was carried out. Interpretation of variants was performed according to the American College of Medical Genetics and Genomics guidelines.

RESULTS

A novel frameshift duplication c.373_374dupAA (p.Asn125Lys fs*43) was identified in exon 4 of the interferon regulatory factor 6 (IRF6) gene in all 3 affected members, which were not found in unaffected family members. The novel mutation leads to a frameshift and a premature stop codon which caused putative truncated protein. Protein alignment indicated high evolutionary conservation of the p.N125 residue, and this mutation was predicted by online tools to be damaging and deleterious.

CONCLUSIONS

This study demonstrates that the novel mutation c.373_374dupAA (p.Asn125Lysfs*43) in the IRF6 gene corresponds to the VWS in this family. The discovery of this pathogenic variant enriches the genotypic spectrum of IRF6 gene and contributes to genetic diagnosis and counseling of families with VWS.

The Geographic Availability of Certified Cleft Care in the United States: A National Geospatial Analysis of 1-Hour Access to Care

PURPOSE

Children with cleft lip and/or palate (CLP) require longitudinal multidisciplinary care. Travel distance to comprehensive cleft centers may be a barrier for some families. This study evaluated the geospatial availability of certified cleft teams across the United States.

MATERIALS AND METHODS

A geographic catchment area within a 1-hour travel radius of each American Cleft Palate-Craniofacial Association-certified cleft center was mapped using TravelTime distance matrix programming. The proportion of children located within each catchment area was calculated using county-level data from the National Kids Count Data Center, with aggregate estimates of patients with CLP based on state-level data from the Centers for Disease Control and Prevention. One-hour access was compared across regions and based on urbanization data collected from the US Census.

RESULTS

There were 182 American Cleft Palate-Craniofacial Association-certified centers identified. As per study estimates, 28,331 (27.3%) children with CLP did not live within 1-hour travel distance to any center. One-hour access was highest in the Northeast (84.2% of children, P < .001) and lowest in the South (65.7%) and higher in states with the greatest urbanization in comparison with more rural states (85.1 vs 37.4%, P < .001). Similar patterns were seen for access to 2 or more cleft centers. The number of CLP children-per-center was highest in the West (775) and lowest in the Northeast (452).

CONCLUSIONS

Travel distances of more than 1 hour may affect more than 25,000 (1 of 4) CLP children in the US, with significant variation across geographic regions. Future studies should seek to understand the impact of and provide strategies for overcoming geographic barriers.

Factors Associated With Delay in Cleft Surgery at a Tertiary Children's Hospital in a Major US Metropolitan City

OBJECTIVE

To identify factors associated with late cleft repair at a US tertiary children's hospital.

DESIGN

Retrospective study of children with CL/P using Children's Hospital Los Angeles (CHLA) records.

SETTING

US tertiary children's hospital.

PATIENTS/PARTICIPANTS

Patients undergoing primary CL or CP repair at CHLA from 2009 to 2018.

MAIN OUTCOME MEASURES

Proportion of children who had delayed primary CL repair or CP repair using CHLA and American Cleft Palate-Craniofacial Association (ACPA) guidelines and factors associated with late surgery.

RESULTS

In total, 805 patients-503 (62.5%) who had CL repair, 302 (37.5%) CP repair-were included. Using CHLA protocol, 14.3% of patients seeking CL repair had delayed surgery. Delay was significantly associated with female gender, non-Hispanic ethnicity, Spanish primary language, government insurance, bilateral cleft, cleft lip and palate (CLP), and syndromic diagnosis. Using ACPA guidelines, 5.4% had delayed surgery. Female gender and syndromic diagnosis were significantly associated with delay and remained significant after adjustment for confounders in multivariate models. For CP repair, 60.3% of patients had delayed surgery using CHLA protocol. Cleft lip and palate diagnosis, complete cleft, syndromic diagnosis, and longer travel distance were significantly associated with delay. Using ACPA guidelines, 28.5% had delayed surgery; however, significant association with patient variables was not consistently observed.

CONCLUSIONS

Delay in cleft surgery occurs most often for patients seeking CP repair and is associated with female gender, non-Hispanic ethnicity, Spanish language, government insurance, and bilateral CL, CLP, or syndromic diagnoses. Initiatives should aim to optimize cleft surgery delivery for these subpopulations.

The use of glutathione to reduce oxidative stress status and its potential for modifying the extracellular matrix organization in cleft lip

OBJECTIVE

Cleft lip (CL) is a common congenital anomaly that can be syndromic or non-syndromic. It can be triggered by the mutation of gene or environmental factors. The incidence of CL is about 1 out of 700 live births. Facial development is a complex process, and there is no existing therapy to prevent the disease development. One of the characteristics in this facial malformation is the increased presence of reactive oxygen species (ROS). In this study, we hypothesize that the antioxidant glutathione (GSH) could help to attenuate the oxidative stress in this disease.

METHODS

Bioinformatics network pharmacology was applied to determine pharmacological targets and molecular mechanisms of GSH treatment for CL. Moreover, RNA-sequencing of the POLR1C knockdown osteoblast CL model was applied to validate the in silico data of using GSH in CL.

RESULTS

Twenty-two core targets of GSH and CL were identified via various bioinformatics tools. The GO and KEGG analysis indicated that GSH could modulate two major families (matrix metalloproteinase and integrins), which are related to extracellular matrix modification and composition for facial development in CL. The findings from POLR1C knockdown model further supported the rescue response of GSH in CL.

CONCLUSIONS

The study uncovered the possible pharmacological mechanism of GSH for treating CL. The data helps research group to focus on the specific pathways for understanding the biological action of GSH for treating the CL in the future.

The Local Mission: Improving Access to Surgical Care in Middle-Income Countries

BACKGROUND

Billions of people lack access to quality surgical care. Short-term missions are used to supplement the delivery of surgical care in regions with poor access to care. Traditionally known for using international teams, Operation Smile has transitioned to using a local mission model, where surgical service is delivered to areas of need by teams originating within that country. This study investigates the proportion and location of Operation Smile missions that use the local mission model.

METHODS

A retrospective review was performed of the Operation Smile mission database for fiscal years 2014 to 2019. Missions were classified into local or international missions. Countries were also classified by their income levels as well as their specialist surgical workforce (SAO) density. As no individual patient or provider data was recorded, ethics board approval was not warranted.

RESULTS

Between 2014 and 2019, Operation Smile held an average of 144.8 (range 135-154) surgical missions per year. Local missions accounted for 97 ± 5.6 (67%) of the missions. Of the 34 program countries, 26 (76%) used local missions. Of the countries that had only international missions, six (75%) were low-income countries and the average SAO density was 1.54 (range 0.19-5.88) providers per 100,000 people. Of the countries with local missions, 24 (92%) were middle-income, and the average SAO density was 30.9 (range 3.4-142.4).

CONCLUSION

International investments may assist in the creation of local surgical teams. Once teams are established, local missions are a valuable way to provide specialized surgical care within a country's own borders.

Orofacial clefts in low- and middle-income countries: A scoping review of quality and quantity of research based on literature between 2010-2019

This paper assesses the research literature on OFC in LMIC over the last decade across various geographical settings and project focus of the indexed literature. A scoping review of the indexed literature was performed using a set of predefined keywords. The articles were filtered by a ten-year time frame (2010-2019) and a strict inclusive-exclusive criterion. Two authors screened the titles/abstracts/full text of the final included papers and input the desired data (year of publication, type of publication, geographical country/region and project focus to a coded spreadsheet). Six hundred and twenty publications were inventoried from the indexed literature on OFC in LMIC settings over the 10-year period. Five hundred and eighty-three derived from single LMIC countries and 37 from multi-settings. More than half of the articles were reported from Asia (57%), then from Americas (22.8%), Africa (15.4%) and the rest from cross-regional, Europe and Oceania (4.9%). The top 3 LMIC contributors towards OFC publications were China (21.5%), Brazil (13.1%) and India (11.6%). The most discussed OFC project themes were prevalence, surgical repair, aetiology and genetics. This study helps OFC researchers, humanitarian missions and research grant funders to identify gaps in the literature on issues impacting on children and adults born with OFC, in which issues were subjected to research and which were less explored in which LMIC regions. In addition, this study offers recommendations for established OFC researchers and international research bodies to identify areas of deficiency in the literature and what information is required to support LMIC governments achieve SDGs by 2030.

A Qualitative Analysis of Factors Impacting Comprehensive Cleft Lip and Palate Care in Ghana

OBJECTIVE

The objective of this study was to examine practices regarding cleft lip and palate (CLP) among medical professionals and caregivers of children with CLP and to identify barriers and facilitators to comprehensive CLP care at a hospital in West Africa.

DESIGN

Qualitative methods used consisted of individual semistructured interviews with caregivers of children with CLP and one focus group with CLP team members.

SETTING

A majority of the interviews took place in the hospital, with some occurring during home visits. The focus group was conducted in the same hospital.

PARTICIPANTS

Forty-five caregivers of children with CLP and 1 adult with CLP completed an interview. Additionally, 2 of the caregivers had CLP and completed an interview from their perspective. The focus group consisted of 13 CLP team members from a comprehensive CLP team in Ghana.

INTERVENTIONS

Interviews consisted of semistructured, open-ended questions, and the focus group relied on a discussion guide. Line-by-line coding was used to identify common themes regarding barriers and facilitators to CLP care.

RESULTS

Barriers to CLP care that were consistent across caregiver interviews and the focus group were lack of knowledge regarding CLP, stigma and cultural beliefs surrounding CLP, transportation, financial, and feeding/nutrition issues. Barriers to care identified in the interviews and focus group were similar; however, facilitators to care varied greatly between the 2.

CONCLUSIONS

Two different qualitative methods provided unique perspectives on barriers and facilitators to CLP care. However, patients and caregivers continue to face substantial barriers to obtaining care.

Sustainable Cleft Care: A Comprehensive Model Based on the Global Smile Foundation Experience

INTRODUCTION

Clefts of the lip and palate are leading congenital facial anomalies. Underserved patients with these facial differences lack access to medical care, surgical expertise, prenatal care, or psychological support. Moreover, the disease results in significant economic strains on patients and their families. While surgical outreach programs have attempted to fill this void, significant challenges facing international comprehensive cleft care persist.

OBJECTIVE

Propose a path toward international sustainable cleft care based on the Global Smile Foundation experience.

RESULTS

International sustainable comprehensive cleft care can be achieved by regulating surgical outreach programs. Regulation of these missions would ensure standardized care and encourage stakeholders to cooperate and adequately allocate funding and resources. Capacity building can be achieved through "diagonal" cleft care delivery models, multidisciplinary workshops, fellowship programs, research and quality assurance, as well as leveraging emerging technologies such as Augmented Reality.

CONCLUSION

International comprehensive cleft care requires continuous collaborative efforts between visiting and local teams as well as international and national organizations. Standardizing and regulating current practices as well as promoting capacity building initiatives can contribute to sustainable cleft care.

[Association between platelet-derived growth factor-C single nucleotide polymorphisms and nonsyndromic cleft lip with or without cleft palate in Western Chinese population]

OBJECTIVE

To explore the association between two single nucleotide polymorphisms (SNPs), namely, rs4691383 and rs7667857, in the platelet-derived growth factor-C (PDGF-C) gene, the genotypes, environmental exposure factors, and nonsyndromic cleft lip with or without cleft palate (NSCL/P) in Western Chinese population.

METHODS

A total of 268 case-parent trios were selected, and two SNPs (rs4691383 andrs7667857) were genotyped by using polymerase chain reaction and restriction enzyme fragment length polymorphic method and direct sequencing method. Hardy-Weinberg equilibrium, linkage disequilibrium test, transmission disequilibrium test, and haplotype analysis were conducted to analyze the data. Meanwhile, the questionnaires on the epidemiology of cleft lip and palate filled by the included samples were collected, and the interaction between the genotypes of the two SNPs and environmental exposure factors was assessed by conditional logistic regression.

RESULTS

The A allele at rs4691383 and the G allele at rs7667857 of PDGF-C gene were over-transmitted for NSCL/P (P<0.05). No interaction effect was observed between the three environmental exposure factors (history of smoking/passive smoking, folic acid supplementation, and long-term inhalation of harmful environmental gases) and the PDGF-C genotypes among NSCL/P (P>0.05).

CONCLUSIONS

The rs4691383 and rs7667857 at PDGF-C gene are closely related to the occurrence of NSCL/P in Western Chinese population. However, the interaction between environmental exposure factors and PDGF-C genotypes is not obvious in the occurrence of NSCL/P.

Simulation-Based Comprehensive Cleft Care Workshops: A Reproducible Model for Sustainable Education

OBJECTIVE

Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact.

DESIGN

Cross-sectional survey-based evaluation.

SETTING

Simulation-based comprehensive cleft care workshop.

PARTICIPANTS

Total of 180 participants.

INTERVENTIONS

Three-day simulation-based comprehensive cleft care workshop.

MAIN OUTCOME MEASURES

Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice.

RESULTS

The workshop included 180 participants from 5 continents. The response rate was 54.5%, with participants reporting high satisfaction with all aspects of the workshop and with simulation-based workshops as educational tools. Participants reported a significant improvement in cleft lip (33.3 ± 5.7 vs 25.7 ± 7.6; P < .001) and palate (32.4 ± 7.1 vs 23.7 ± 6.6; P < .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices.

CONCLUSION

Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

A task-shifted speech therapy program for cleft palate patients in rural Nepal: Evaluating impact and associated healthcare barriers

INTRODUCTION

Though access to surgical care for cleft lip/palate has expanded in low- and middle-income countries (LMICs), post-palatoplasty speech therapy is often lacking due to limited healthcare infrastructure and personnel. This mixed-methods study seeks to: 1) evaluate the impact of task-shifted speech therapy on a standardized speech score; 2) describe the experiences of families with post-operative cleft care and associated barriers; and 3) understand how to optimize cleft care by exploring the experiences of children who had nominal improvements after task-shifted speech therapy.

METHODS

A convergent parallel mixed-methods study was conducted in Nepal. Standardized speech scores were compared by a blinded speech-language pathologist before and after the speech intervention. Semi-structured interviews (SSIs) and focus groups with families evaluated cleft care experiences and barriers. Qualitative and quantitative data were merged and analyzed.

RESULTS

Thirty-nine post-palatoplasty children with speech deficits (ages 3-18) underwent task-shifted speech therapy, and demonstrated significant improvements in composite speech scores targeted by exercises (p<0.0001) and weakness (p=0.0002), with improvements in misarticulation (p=0.07) and glottal stop (p=0.05) that trended towards significance. Forty-seven SSIs demonstrated that the greatest barriers to follow-up were family responsibilities (62%), travel/distance (53%), and work (34%). In five focus groups, families expressed a desire to improve their child's speech and seek formal speech therapy. The speech intervention was found to be beneficial because of the compassionate staff, free lodging/food, and ability to socialize with other cleft patients and families. After merging quantitative and qualitative data, we noted that younger children between 3 and 5 years old and families who traveled greater distances for healthcare access benefited less from the speech therapy intervention.

CONCLUSIONS

Task-shifted speech therapy has the potential to improve cleft lip/palate speech in LMICs. Multiple biosocial issues limit access to appropriate post-operative care.

The History and Mission of Smile Train, a Global Cleft Charity

Cleft lip and/or palate (CLP) is a common congenital anomaly with a global impact. One organization attempting to decrease global burden of CLPs is Smile Train. Since 1999, Smile Train has empowered local medical providers to provide comprehensive and sustainable cleft care. Partner surgeons have performed more than 1.5 million operations for patients with CLPs in more than 90 countries. This article outlines the history and mission of Smile Train and details the organization's efforts to increase hospital-wide safety, provide education and training opportunities for partners, and use technology to improve the delivery of cleft care on a global scale.