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Salinero LK, Romeo DJ, Pontell ME, Friedman L, Ahluwalia VS, Wagner CS, Barrero CE, Napoli J, Jackson OA, Low DW, Bartlett SP, Swanson J, Magee L, Taylor JA. Psychosocial Status and Self-Perception in Patients with Cleft Lip and/or Palate. Cleft Palate Craniofac J 2024:10556656241236369. [PMID: 38436069 DOI: 10.1177/10556656241236369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVE To describe how the psychosocial status of patients with cleft lip and/or palate (CL/P) relates to patient-reported outcomes (PROs). DESIGN Cross-sectional retrospective chart review. SETTING Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS Patients aged 8 to 29 years attending cleft team evaluations during a 1-year period. MAIN OUTCOME MEASURES CLEFT-Q. RESULTS Patients (N = 158) with isolated or syndromic CL/P and mean age 13.4 ± 3.0 years were included. Fifteen (9%) patients had siblings who also had CL/P. Of 104 patients who met with the team psychologist, psychosocial concerns were identified in 49 (47%) patients, including 25 (24%) with Attention-Deficit/Hyperactivity Disorder or behavior concerns, 28 (27%) with anxiety, and 14 (13%) with depression or mood concerns. Younger age and having siblings with cleft were associated with better PROs, while psychosocial concerns were associated with worse PROs on Speech, Psychosocial, and Face Appearance scales. CONCLUSIONS Patient perception of cleft outcomes is linked to psychosocial factors.
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Affiliation(s)
- Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dominic J Romeo
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew E Pontell
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Leigh Friedman
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vinayak S Ahluwalia
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connor S Wagner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Napoli
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Leanne Magee
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Card EB, Morales CE, Kimia R, Ramirez JM, Billingslea M, Marroquín A, Masaya I, Arteaga V, Marazita ML, Friedland LR, Low DW, Schwartz AJ, Scott M, Jackson OA. A Retrospective and Prospective Cohort Study Comparing Pediatric Patients With Cleft Lip and Palate From the United States and Guatemala. J Craniofac Surg 2023; 34:1978-1984. [PMID: 37449578 DOI: 10.1097/scs.0000000000009539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/19/2023] [Indexed: 07/18/2023] Open
Abstract
Orofacial clefts (OFC) remain among the most prevalent congenital abnormalities worldwide. In the United States in 2010 to 2014, 16.2 of 10,000 live births are born with OFC compared with 23.6 of 10,000 in Alta Verapaz, Guatemala in 2012. Demographics and cleft severity scores were retrospectively gathered from 514 patients with isolated OFC at the Children's Hospital of Philadelphia scheduled for surgery from 2012 to 2019 and from 115 patients seen during surgical mission trips to Guatemala City from 2017 to 2020. Risk factors were also gathered prospectively from Guatemalan families. The Guatemalan cohort had a significantly lower prevalence of cleft palate only compared with the US cohort, which may be a result of greater cleft severity in the population or poor screening and subsequent increased mortality of untreated cleft palate. Of those with lip involvement, Guatemalan patients were significantly more likely to have complete cleft lip, associated cleft palate, and right-sided and bilateral clefts, demonstrating an increased severity of Guatemalan cleft phenotype. Primary palate and lip repair for the Guatemalan cohort occurred at a significantly older age than that of the US cohort, placing Guatemalan patients at increased risk for long-term complications such as communication difficulties. Potential OFC risk factors identified in the Guatemalan cohort included maternal cooking-fire and agricultural chemical exposure, poor prenatal vitamin intake, poverty, and risk factors related to primarily corn-based diets. OFC patients who primarily rely on surgical missions for cleft care would likely benefit from more comprehensive screening and investigation into risk factors for more severe OFC phenotypes.
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Affiliation(s)
- Elizabeth B Card
- Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Carrie E Morales
- Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Rotem Kimia
- Division of Plastic and Reconstructive Surgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | | | | | | | - Irina Masaya
- Facultad de Ciencias de la Salud, Departamento de Medicina, Universidad Rafael Landívar
| | - Vilma Arteaga
- Guatemalan Functional Occlusion Association, Functional Maxillary Orthopedics and Craniofacial Orthodontics Specialist, Juan Pablo II Children's Hospital, Operation Smile Guatemala, Guatemala
| | - Mary L Marazita
- Center for Craniofacial and Dental Genetics
- Department of Oral and Craniofacial Sciences, School of Dental Medicine
- Department of Human Genetics, Graduate School of Public Health
- Clinical and Translation Sciences
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Leonard R Friedland
- Scientific Affairs and Public Health GSK Vaccines, Research and Development Department, GlaxoSmithKline
| | - David W Low
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Alan Jay Schwartz
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania
| | - Michelle Scott
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia
| | - Oksana A Jackson
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System
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Salinero LK, Wagner CS, Barrero CE, Valenzuela ZD, McCormack SM, Solot C, Cohen M, Kirschner RE, Low DW, Jackson OA. Speech Outcomes and Rates of Secondary Speech Surgery from Childhood to Skeletal Maturity Following Modified-Furlow Palatoplasty. Plast Reconstr Surg 2023:00006534-990000000-02111. [PMID: 37699109 DOI: 10.1097/prs.0000000000011056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This study updates our institutional experience with modified Furlow palatoplasty, evaluating speech outcomes and incidence of secondary speech surgery throughout development and at skeletal maturity. METHODS Nonsyndromic patients undergoing primary modified Furlow palatoplasty between 1985 and 2005 with post-operative speech evaluations were retrospectively reviewed. Secondary speech surgery and Pittsburgh Weighted Speech Scale (PWSS) scores prior to secondary speech or orthognathic surgeries were assessed in the 5-7, 8-11, 12-14, and 15+ age groups and analyzed by Veau cleft type. RESULTS Five hundred fifty-one patients with 895 total speech assessments were analyzed. Of 364 patients followed to age 15 or older, 19.8% underwent secondary speech surgery. Speech assessment of patients aged 15 or older without prior secondary speech surgery showed competent velopharyngeal mechanisms in 77% of patients. PWSS nasal emission scores were worse in the 5-7 age range (p=0.02), while resonance scores remained stable throughout development (p=0.2). Patients with Veau type I or II clefts had worse overall PWSS classifications in the age 5-7 and 8-11 age groups (p=0.01, p=0.03), with greater odds of secondary speech surgery relative to those with Veau type III (OR 2.9, p<0.001) or IV clefts (OR 3.6, p=0.001). CONCLUSIONS Most patients undergoing primary modified Furlow palatoplasty do not require secondary speech surgery and achieve socially acceptable speech at skeletal maturity. However, Veau type I and II clefts are associated with increased risk for early velopharyngeal dysfunction and secondary speech surgery. Incidence of secondary speech surgery was 19.8%, an increase from our previously reported rate of 8%.
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Affiliation(s)
- Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Connor S Wagner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Zachary D Valenzuela
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Susan M McCormack
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cynthia Solot
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Marilyn Cohen
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard E Kirschner
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH
| | - David W Low
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Oksana A Jackson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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Salinero LK, Cheung L, Villavisanis DF, Wagner CS, Barrero CE, Pontell ME, Jackson OA, Taylor JA, Low DW, Swanson JW. How does CLEFT-Q change the way we practice? A prospective study integrating patient-reported outcomes. Plast Reconstr Surg 2023:00006534-990000000-02104. [PMID: 37678808 DOI: 10.1097/prs.0000000000011036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The CLEFT-Q is a validated instrument designed to elicit patient-reported outcomes among people affected by cleft lip and/or palate. However, it has not been reported how use of CLEFT-Q data alters routine cleft care. This study analyzed the impact of CLEFT-Q data integration on patient care and clinical decision making. METHODS Patients were sequentially, prospectively evaluated during scheduled cleft team visits. The CLEFT-Q was completed prior to the clinic encounter but results were initially masked from the surgeon and family. In the encounter, a study observer characterized patients' verbalized attitudes across seven specific domains of appearance and function and the provisional assessment and plan was noted. CLEFT-Q data was then introduced in the clinical encounter and discussed. Discordance between patients' initially verbalized attitudes and their self-reported scores on the CLEFT-Q was documented along with any resultant modifications to their care plan. RESULTS Seventy patient visits were observed; mean patient age was 12.7 years (range 8-19). Forty-one patients (59%) had cleft lip and palate/alveolus and 29 (41%) had isolated cleft palate. Discordance was observed in 36% of visits and in 9.2% of specific domains assessed. Highest discordance rates were observed in domains of psychosocial function (12.5%,) speech function/distress (11.6%,) and lips/lip scar appearance (11.6%). No age group or gender was associated with increased discordance. Integration of CLEFT-Q results altered the assessment and plan in 11 (16%) visits. CONCLUSIONS The CLEFT-Q provides clinically-relevant insight into patient perspectives that are not captured by routine interview and examination alone, and regularly leads to a change in the management plan.
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Affiliation(s)
- Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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Salinero LK, Ahluwalia VS, Barrero CE, Wagner CS, Pontell ME, Magee L, Low DW, Jackson OA, Napoli JA, Bartlett SP, Swanson J, Taylor JA. Long-Term Patient-Reported Outcomes in Internationally Adopted Children with Cleft Lip and Palate. Cleft Palate Craniofac J 2023:10556656231198647. [PMID: 37649261 DOI: 10.1177/10556656231198647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE To compare patient-reported outcomes (PROs) in internationally adopted patients with cleft lip and palate to those in non-adopted peers. DESIGN Cross-sectional study. SETTING Multidisciplinary cleft team at tertiary care hospital. PATIENTS Patients aged ≥ 8 with cleft lip and palate attending routine cleft team evaluations September 2021 - September 2022. MAIN OUTCOME MEASURE CLEFT-Q PRO scores. RESULTS Sixty-four internationally adopted patients and 113 non-adopted patients with a mean age of 13 years were included. Compared to non-adopted peers, adopted patients demonstrated worse satisfaction with face appearance (mean 59 vs. 66, p = .044), speech function (mean 69 vs. 78, p = .005), and speech distress (mean 80 vs. 84, p = .032). No significant differences were observed on the nose, nostrils, teeth, lips, lip scar, jaws, psychological function, or social function scales (p > .05). Objective clinical evaluation corroborated these findings, with adopted patients demonstrating worse Pittsburgh Weighted Speech scores (mean 3.0 vs 1.9, p = .027) and greater incidence of articulation errors (64% vs 46%, p = .021). No significant differences were observed in rates of mood, anxiety, or behavior concerns identified on psychosocial assessment (p = .764). Among adopted patients, undergoing palatoplasty prior to adoption was associated with worse satisfaction with speech, appearance, school, and social function (p < .05). CONCLUSIONS Patient-reported outcomes among internationally adopted adolescents and young adults with cleft lip and palate show slightly lower satisfaction with facial appearance and speech but otherwise demonstrate similar results to non-adopted peers on most appearance and psychosocial measures. PRO data correlated well with objective speech assessment and did not portend worse psychosocial function.
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Affiliation(s)
- Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vinayak S Ahluwalia
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connor S Wagner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew E Pontell
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Leanne Magee
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph A Napoli
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Tse RW, Sie KC, Tollefson TT, Jackson OA, Kirshner R, Fisher DM, Bly R, Arneja JS, Dahl JP, Soldanska M, Sitzman TJ. Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations. Cleft Palate Craniofac J 2023:10556656231181359. [PMID: 37441787 PMCID: PMC10787042 DOI: 10.1177/10556656231181359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique. RESULTS Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation. CONCLUSIONS A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.
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Affiliation(s)
- Raymond W Tse
- Craniofacial and Pediatric Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Plastic Surgery, University of Washington, Seattle, WA, USA
| | - Kathleen C Sie
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Travis T Tollefson
- Otolaryngology Head and Neck Surgery, University of California, Davis, Sacramento, CA, USA
| | - Oksana A Jackson
- Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard Kirshner
- Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
- Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David M Fisher
- Plastic Surgery, The Hospital for Sick Children, Toronto, ON, USA
- Plastic Surgery, University of Toronto, Toronto, ON, USA
| | - Randall Bly
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Jugpal S Arneja
- Plastic Surgery, BC Children's Hospital, Vancouver, BC, USA
- Plastic Surgery, University of British Columbia, Vancouver, BC, USA
| | - John P Dahl
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | | | - Thomas J Sitzman
- Plastic Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Sadri BS, Low DW, Jackson OA, Jackson BM, Belkin N. Subclavian to carotid artery bypass for a case of ocular ischemic syndrome. Vascular 2023:17085381231164015. [PMID: 36917226 DOI: 10.1177/17085381231164015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND Ocular Ischemic Syndrome (OIS) is a rare, vision threatening condition associated with severe carotid artery disease. There are few cases of OIS reported in the literature. METHODS We present the case of a 54-year-old male with history of multiple previous carotid interventions including a right carotid stent, who presented with right-sided OIS. RESULTS CTA and angiogram showed a severe calcific plaque causing restenosis of the right carotid stent, with a patent right internal carotid artery (ICA) in the very distal neck. The right common carotid artery (CCA) was patent but diseased with ulcerated plaque extending proximally to below the level of the clavicle. The left CCA was chronically occluded from its origin all the way to the bifurcation. Given our patient's surgical history, the imperative to revascularize the ipsilateral carotid, and a diffusely diseased ipsilateral CCA, he was successfully treated with an ipsilateral subclavian to internal carotid bypass. CONCLUSION There is paucity of data regarding the best approach for carotid revascularization in OIS. This case report discusses our unique perioperative decision making as well as relevant literature.
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Affiliation(s)
- Babak S Sadri
- Department of Surgery, 1147Lehigh Valley Hospital, Allentown, PA, USA
| | - David W Low
- Division of Plastic Surgery, 21798Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Oksana A Jackson
- Department of Surgery, Division of Plastic, Reconstructive and Oral Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Nathan Belkin
- Division of Plastic Surgery, 21798Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Óskarsdóttir S, Boot E, Crowley TB, Loo JCY, Arganbright JM, Armando M, Baylis AL, Breetvelt EJ, Castelein RM, Chadehumbe M, Cielo CM, de Reuver S, Eliez S, Fiksinski AM, Forbes BJ, Gallagher E, Hopkins SE, Jackson OA, Levitz-Katz L, Klingberg G, Lambert MP, Marino B, Mascarenhas MR, Moldenhauer J, Moss EM, Nowakowska BA, Orchanian-Cheff A, Putotto C, Repetto GM, Schindewolf E, Schneider M, Solot CB, Sullivan KE, Swillen A, Unolt M, Van Batavia JP, Vingerhoets C, Vorstman J, Bassett AS, McDonald-McGinn DM. Updated clinical practice recommendations for managing children with 22q11.2 deletion syndrome. Genet Med 2023; 25:100338. [PMID: 36729053 DOI: 10.1016/j.gim.2022.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/03/2023] Open
Abstract
This review aimed to update the clinical practice guidelines for managing children and adolescents with 22q11.2 deletion syndrome (22q11.2DS). The 22q11.2 Society, the international scientific organization studying chromosome 22q11.2 differences and related conditions, recruited expert clinicians worldwide to revise the original 2011 pediatric clinical practice guidelines in a stepwise process: (1) a systematic literature search (1992-2021), (2) study selection and data extraction by clinical experts from 9 different countries, covering 24 subspecialties, and (3) creation of a draft consensus document based on the literature and expert opinion, which was further shaped by survey results from family support organizations regarding perceived needs. Of 2441 22q11.2DS-relevant publications initially identified, 2344 received full-text reviews, including 1545 meeting criteria for potential relevance to clinical care of children and adolescents. Informed by the available literature, recommendations were formulated. Given evidence base limitations, multidisciplinary recommendations represent consensus statements of good practice for this evolving field. These recommendations provide contemporary guidance for evaluation, surveillance, and management of the many 22q11.2DS-associated physical, cognitive, behavioral, and psychiatric morbidities while addressing important genetic counseling and psychosocial issues.
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Affiliation(s)
- Sólveig Óskarsdóttir
- Department of Pediatric Rheumatology and Immunology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Erik Boot
- Advisium, 's Heeren Loo Zorggroep, Amersfoort, The Netherlands; The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.
| | - Terrence Blaine Crowley
- The 22q and You Center, Clinical Genetics Center, and Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joanne C Y Loo
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
| | - Jill M Arganbright
- Department of Otorhinolaryngology, Children's Mercy Hospital and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Marco Armando
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Adriane L Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Elemi J Breetvelt
- Department of Psychiatry, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Genetics & Genome Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - René M Castelein
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Madeline Chadehumbe
- Division of Neurology, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christopher M Cielo
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pulmonary and Sleep Medicine, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Steven de Reuver
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stephan Eliez
- Fondation Pôle Autisme, Department of Psychiatry, Geneva University School of Medecine, Geneva, Switzerland
| | - Ania M Fiksinski
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands; Department of Pediatric Psychology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Brian J Forbes
- Division of Ophthalmology, The 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Emily Gallagher
- Division of Craniofacial Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Sarah E Hopkins
- Division of Neurology, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Oksana A Jackson
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cleft Lip and Palate Program, Division of Plastic, Reconstructive and Oral Surgery, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lorraine Levitz-Katz
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Endocrinology and Diabetes, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Michele P Lambert
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Hematology, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bruno Marino
- Pediatric Cardiology Unit, Department of Pediatrics, Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Maria R Mascarenhas
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Gastroenterology, Hepatology and Nutrition, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie Moldenhauer
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, 22q and You Center, The Children's Hospital of Philadelphia, Philadelphia, PA; Departments of Obstetrics and Gynecology and Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Ani Orchanian-Cheff
- Library and Information Services and The Institute of Education Research (TIER), University Health Network, Toronto, Ontario, Canada
| | - Carolina Putotto
- Pediatric Cardiology Unit, Department of Pediatrics, Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Gabriela M Repetto
- Rare Diseases Program, Institute for Sciences and Innovation in Medicine, Facultad de Medicina Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Erica Schindewolf
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, 22q and You Center, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maude Schneider
- Clinical Psychology Unit for Intellectual and Developmental Disabilities, Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Cynthia B Solot
- Department of Speech-Language Pathology and Center for Childhood Communication, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathleen E Sullivan
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Allergy and Immunology, 22q and You Center, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ann Swillen
- Center for Human Genetics, University Hospital UZ Leuven, and Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Marta Unolt
- Pediatric Cardiology Unit, Department of Pediatrics, Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy; Department of Pediatric Cardiology and Cardiac Surgery, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Jason P Van Batavia
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Urology, 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Claudia Vingerhoets
- Advisium, 's Heeren Loo Zorggroep, Amersfoort, The Netherlands; Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Jacob Vorstman
- Department of Psychiatry, Hospital for Sick Children, Toronto, Ontario, Canada; Genetics & Genome Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne S Bassett
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Genetics & Genome Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; Clinical Genetics Research Program and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
| | - Donna M McDonald-McGinn
- The 22q and You Center, Clinical Genetics Center, and Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Human Biology and Medical Genetics, Sapienza University, Rome, Italy.
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Kimia R, Solot CB, McCormack SM, Cohen M, Blum JD, Villavisanis DF, Vora N, Valenzuela Z, Taylor JA, Low DW, Jackson OA. Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients. Cleft Palate Craniofac J 2023:10556656231154808. [PMID: 36749038 DOI: 10.1177/10556656231154808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients. SETTING An academic tertiary pediatric care center. METHODS Retrospective cohort study. PATIENTS Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL). OUTCOME MEASURES The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS). RESULTS 97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05). CONCLUSION Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.
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Affiliation(s)
- Rotem Kimia
- Division of Plastic and Reconstructive Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Cynthia B Solot
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan M McCormack
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marilyn Cohen
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jessica D Blum
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dillan F Villavisanis
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nisha Vora
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary Valenzuela
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Reconstructive and Plastic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Card EB, Morales CE, Ramirez JM, Billingslea M, Marroquín A, Trueblood E, Javia LR, McCormack SM, Friedland LR, Low DW, Schwartz AJ, Scott M, Jackson OA. Impact of Illustrated Postoperative Instructions on Knowledge and Retention During a Cleft Lip and Palate Surgical Mission. Cleft Palate Craniofac J 2022:10556656221100052. [PMID: 35711155 DOI: 10.1177/10556656221100052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention. DESIGN Prospective study with all participants receiving an educational intervention. SETTING Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020. PARTICIPANTS A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery. INTERVENTION Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points. MAIN OUTCOME MEASURE Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up. RESULTS Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based. CONCLUSIONS In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.
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Affiliation(s)
- Elizabeth B Card
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Carrie E Morales
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Juan M Ramirez
- Partner for Surgery, Guatemala City, Guatemala, Guatemala
| | | | | | - Eo Trueblood
- Stream Studios, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luv R Javia
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, PA, USA
| | - Susan M McCormack
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Leonard R Friedland
- Research and Development Department, 33139GlaxoSmithKline, Philadelphia, PA, USA
| | - David W Low
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Alan Jay Schwartz
- The Children's Hospital of Philadelphia, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Scott
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
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Vu GH, Warden C, Zimmerman CE, Kalmar CL, Humphries LS, McDonald-McGinn DM, Jackson OA, Low DW, Taylor JA, Swanson JW. Poverty and Risk of Cleft Lip and Palate: An Analysis of United States Birth Data. Plast Reconstr Surg 2022; 149:169-182. [PMID: 34936619 PMCID: PMC8691162 DOI: 10.1097/prs.0000000000008636] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The relationship between poverty and incidence of cleft lip and cleft palate remains unclear. The authors investigated the association between socioeconomic status and cleft lip with or without cleft palate and cleft palate only in the United States after controlling for demographic and environmental risk factors. METHODS The U.S. 2016 and 2017 natality data were utilized. Proxies for socioeconomic status included maternal education, use of the Special Supplemental Nutrition Program for Women, Infants, and Children, and payment source for delivery. Multiple logistic regression controlled for household demographics, prenatal care, maternal health, and infant characteristics. RESULTS Of 6,251,308 live births included, 2984 (0.05 percent) had cleft lip with or without cleft palate and 1180 (0.02 percent) had cleft palate only. Maternal education of bachelor's degree or higher was protective against, and delayed prenatal care associated with, cleft lip with or without cleft palate (adjusted ORs = 0.73 and 1.14 to 1.23, respectively; p < 0.02). Receiving assistance under the Special Supplemental Nutrition Program for Women, Infants, and Children was associated with cleft palate only (adjusted OR = 1.25; p = 0.003). Male sex, first-trimester tobacco smoking, and maternal gestational diabetes were also associated with cleft lip with or without cleft palate (adjusted ORs = 1.60, 1.01, and 1.19, respectively; p < 0.05). Female sex, prepregnancy tobacco smoking, and maternal infections during pregnancy were associated with cleft palate only (adjusted ORs = 0.74, 1.02, and 1.60, respectively; p < 0.05). CONCLUSIONS Increased incidence of orofacial clefts was associated with indicators of lower socioeconomic status, with different indicators associated with different cleft phenotypes. Notably, early prenatal care was protective against the development of cleft lip with or without cleft palate. CLIINCAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Giap H Vu
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Clara Warden
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Carrie E Zimmerman
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Christopher L Kalmar
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Laura S Humphries
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Donna M McDonald-McGinn
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Oksana A Jackson
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - David W Low
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Jesse A Taylor
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Jordan W Swanson
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
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12
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Morales CZ, Barrette LX, Vu GH, Kalmar CL, Oliver E, Gebb J, Feygin T, Howell LJ, Javia L, Hedrick HL, Adzick NS, Jackson OA. Postnatal outcomes and risk factor analysis for patients with prenatally diagnosed oropharyngeal masses. Int J Pediatr Otorhinolaryngol 2022; 152:110982. [PMID: 34794813 DOI: 10.1016/j.ijporl.2021.110982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/26/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe our experience treating prenatally diagnosed oropharyngeal masses in a novel, multidisciplinary collaboration. To identifying outcomes and risk factors associated with adverse postnatal outcomes. METHODS This is a sixty-two patient case series at an academic referral center. Patients with prenatally diagnosed oropharyngeal masses were identified through a programmatic database and confirmed in the electronic health record. RESULTS Sixty-two patient with prenatally diagnosed oropharyngeal mass were identified, with prenatal imaging at our institution confirming this diagnosis in fifty-seven patients, short term outcomes analysis conducted on forty-four patients, and long-term outcomes analysis conducted on seventeen patients. The most common pathology was lymphatic malformations (n = 27, 47.4%), followed by teratomas (n = 22, 38.6%). The median mass volume from all available patient imaging (n = 57) was 60.54 cm3 (range 1.73-742.5 cm3). Thirteen pregnancies were interrupted, six infants expired, and thirteen cases had an unknown fetal outcome. Confirmed mortality was 6/57 patients with imaging-confirmed oropharyngeal masses (10.5%). Fourteen (56%) of the surviving patients (n = 25) were delivered by Ex Utero Intrapartum Treatment (EXIT) procedure and the median NICU stay was thirty-six days (range: 3-215 days). There was no association between airway compression/deviation/displacement, stomach size, polyhydramnios, or mass size and mortality. Seventeen patients had more than one year of follow-up (mean 5.3 ± 2.4 years). These seventeen patients underwent general anesthesia a total of ninety-two times (mean 5.4 ± 4.3) and had a total of twenty-three mass-related surgeries. The great majority of patients required an artificial airway at birth, feeding support, and speech/swallow therapy. CONCLUSIONS Oropharyngeal mass involvement of key anatomic structures-the neck, upper thorax, orbit, and ear, has a greater association with mortality than mass size. Regardless of the size and involved structures, oropharyngeal masses are associated with a high burden of intensive medical care and surgical care beginning at or before birth.
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Affiliation(s)
- Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Louis-Xavier Barrette
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Giap H Vu
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Edward Oliver
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Juliana Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Tamara Feygin
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Luv Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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13
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Card EB, Zimmerman CE, Kalmar CL, Trueblood E, Low DW, Ramirez JM, Friedland LR, Schwartz AJ, Jackson OA. Visual Resources for Postoperative Care to Overcome Language and Cultural Barriers. Plast Reconstr Surg 2021; 148:1075e-1079e. [PMID: 34705801 DOI: 10.1097/prs.0000000000008561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Elizabeth B Card
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Carrie E Zimmerman
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Eo Trueblood
- The Children's Hospital of Philadelphia Stream Studios, Philadelphia, Pa
| | - David W Low
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Juan M Ramirez
- Asociación Compañero Para Cirugía, Guatemala City, Guatemala
| | | | - Alan Jay Schwartz
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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14
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Barrette LX, Morales CZ, Oliver ER, Gebb JS, Feygin T, Lioy J, Howell LJ, Hedrick HL, Jackson OA, Adzick NS, Javia LR. Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses. Int J Pediatr Otorhinolaryngol 2021; 149:110851. [PMID: 34311168 DOI: 10.1016/j.ijporl.2021.110851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/01/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. STUDY DESIGN A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. RESULTS Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. CONCLUSION This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.
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Affiliation(s)
- Louis-Xavier Barrette
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Tamara Feygin
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Luv R Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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15
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Kimia R, Elden L, Dailey J, Kodavatiganti M, Crowley TB, McGinn DE, Bailey A, Zackai EH, McDonald-McGinn DM, Jackson OA. Magnetic resonance angiography (MRA) in preoperative planning for patients with 22q11.2 deletion syndrome undergoing craniofacial and otorhinolaryngologic procedures. Int J Pediatr Otorhinolaryngol 2020; 138:110236. [PMID: 32890936 DOI: 10.1016/j.ijporl.2020.110236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/28/2020] [Accepted: 06/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with 22q11.2 deletion syndrome (22q11.2DS) have a variety of anatomic anomalies. For surgeons operating in proximity to the retropharynx, the most pertinent is medial displacement of the internal carotid arteries. The purpose of this study is to describe the preoperative use of magnetic resonance angiography (MRA) in surgical planning and update the incidence rate of medial carotid displacement in patients with 22q11.2DS. METHODS This is a retrospective cohort study of patients with a confirmed diagnosis of 22q11.2 deletion and preoperative MRA <18 years old who underwent tonsillectomy, adenoidectomy, Furlow palatoplasty (FPP), posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), or submucosal cleft palate (SMCP) repair between January 1st, 2008 and December 31st, 2019. RESULTS Ninety patients who met the inclusion criteria underwent 133 procedures. The majority identified as Caucasian (84.4%); 52.2% were female. Cervical MRA was more likely to be ordered before a PPF (80.9%) and tonsillectomy (72.7%) over a FPP (47.6%) or adenoidectomy (11.1%). Carotid medialization was visualized in 23 patients (25.6%) and was mild in 11 cases, moderate in 7 cases, and significant in 5 cases. There was no association between sex, race/ethnicity, or genetic diagnosis with carotid medialization. Flap shortening was necessary in 20% of PPF cases to avoid injuring the medialized vessel. CONCLUSION Patients with 22q11.2DS may have higher rates of medialization of the carotid arteries than previously thought. Given the risk for complications in these patients during pharyngeal operations, there may be a critical place for MRA in surgical planning for patients with 22q11.2DS.
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Affiliation(s)
- Rotem Kimia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julia Dailey
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mallika Kodavatiganti
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - T Blaine Crowley
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel E McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alice Bailey
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elaine H Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Donna M McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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16
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Kimia R, Butler PD, Guajardo I, Magee L, Lowe K, Scott M, Wes A, Jackson OA. Sociodemographic Factors That Influence the Choice to Pursue Nasoalveolar Molding: One Pediatric Hospital's Experience. Cleft Palate Craniofac J 2020; 57:1069-1077. [PMID: 32618203 DOI: 10.1177/1055665620936056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To identify demographic factors that influence choosing nasoalveolar molding (NAM) in the treatment of cleft lip with or without cleft palate (CL±P), and NAM treatment compliance. DESIGN This work is a retrospective cohort study. SETTING Tertiary pediatric hospital. PATIENTS, PARTICIPANTS One hundred forty-nine patients with a diagnosis of unilateral complete CL±P receiving treatment when NAM was offered (January 1, 2008-July 26, 2016). MAIN OUTCOME MEASURE(S) Demographic variables collected included race, ethnicity, ZIP code, number of caregivers, caregiver employment status, and health insurance status. Medical variables collected included diagnosis, treatment pursued, compliance with NAM, completion of NAM, and the treating cleft surgeon and orthodontist. Data were analyzed via Fisher exact tests, χ2 tests, and multivariate logistic regression to identify factors that influence the decision to pursue NAM and treatment compliance. RESULTS Univariate analyses identified the following significant factors predicting the pursuit of NAM: race and insurance type (both P < .001), surgeon (P = .005), income level (P = .009), comorbidities (P = .015), and syndromic diagnosis (P = .033). Driving distance trended toward significance (P = .078). Multivariate regression analyses indicated that Asian race (P = .047), insurance type (P = .046), driving distance (P = .019), and surgeon (P = .017) were significant predictors of pursuit of NAM. CONCLUSIONS There are disparities in patient choice of NAM at our center for children with complete cleft lip. African American patient families were less likely to pursue this intervention. A stronger understanding of the barriers that lower income and minority patients face is needed in order to better characterize disparities in cleft care.
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Affiliation(s)
- Rotem Kimia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Paris D Butler
- Division of Plastic and Reconstructive Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Isabella Guajardo
- Department of Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Leanne Magee
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
| | - Kristen Lowe
- Division of Plastic and Reconstructive Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Michelle Scott
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
| | - Ari Wes
- Division of Plastic and Reconstructive Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
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17
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Fairman AS, Fairman RM, Foley PJ, Etkin Y, Jackson OA, Jackson BM. Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome? Ann Vasc Surg 2020; 69:217-223. [PMID: 32497616 DOI: 10.1016/j.avsg.2020.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/26/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. METHODS Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. RESULTS Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. CONCLUSIONS This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.
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Affiliation(s)
- Alexander S Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Ronald M Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul J Foley
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Benjamin M Jackson
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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18
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Lee A, Chang BL, Solot C, Crowley TB, Vemulapalli V, McDonald-McGinn DM, Maguire MA, Mason TBA, Elden L, Cielo CM, Jackson OA. Defining Risk of Postoperative Obstructive Sleep Apnea in Patients With 22q11.2DS Undergoing Pharyngeal Flap Surgery for Velopharyngeal Dysfunction Using Polysomnographic Evaluation. Cleft Palate Craniofac J 2020; 57:808-818. [PMID: 31973553 DOI: 10.1177/1055665619900871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine pre- and postoperative prevalence of obstructive sleep apnea (OSA) in patients with 22q11.2 deletion syndrome (DS) undergoing wide posterior pharyngeal flap (PPF) surgery for velopharyngeal dysfunction (VPD). DESIGN Retrospective study using pre- and postoperative polysomnography (PSG) to determine prevalence of OSA. Medical records were reviewed for patients' medical comorbidities. Parents were surveyed about snoring. SETTING Academic tertiary care pediatric hospital. PATIENTS Forty patients with laboratory confirmed 22q11.2DS followed over a 6-year period. INTERVENTIONS Pre- and postoperative PSG, speech evaluation, and parent surveys. MAIN OUTCOME MEASURE Severity and prevalence of OSA, defined by obstructive apnea hypopnea index (OAHI), before and after PPF surgery to determine whether PPF is associated with increased risk of OSA. RESULTS Mean OAHI did not change significantly after PPF surgery (1.1/h vs 2.1/h, P = .330). Prevalence of clinically significant OSA (OAHI ≥ 5) was identical pre- and postoperatively (2 of 40), with both cases having severe-range OSA requiring positive airway pressure therapy. All other patients had mild-range OSA. Nasal resonance was graded as severe preoperatively in 85% of patients. None were graded as severe postoperatively. No single patient factor or parent-reported concern predicted risk of OSA (OAHI ≥ 1.5). CONCLUSIONS Patients with 22q11.2DS are medically complex and are at increased risk of OSA at baseline. Wide PPF surgery for severe VPD does not significantly increase risk of OSA. Careful perioperative planning is essential to optimize both speech and sleep outcomes.
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Affiliation(s)
- Alfred Lee
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
| | - Brian L Chang
- Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Cynthia Solot
- Velopharyngeal Dysfunction Program, Center for Childhood Communication, Children's Hospital of Philadelphia, PA, USA
| | - Terrence B Crowley
- Division of Human Genetics, Children's Hospital of Philadelphia, PA, USA
| | - Vamsee Vemulapalli
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
| | | | - Meg Ann Maguire
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
| | | | - Lisa Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, PA, USA
| | - Christopher M Cielo
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, PA, USA
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19
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Sequera-Ramos L, Ruby JM, Jackson OA, Ganesh A, Gurnaney H, Kraemer FW, Muhly WT. Continuous Transversalis Fascia Plane Catheter Infusion in a Pediatric Patient Undergoing Alveolar Cleft Repair With Iliac Crest Bone Graft: A Case Report. A A Pract 2020; 13:162-165. [PMID: 30973349 DOI: 10.1213/xaa.0000000000001013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Harvesting of iliac crest bone graft for alveolar cleft repair in children is associated with significant postoperative pain. Transversalis fascia plane block has emerged as an alternative to local wound infiltration for iliac crest bone graft harvesting and has been used with good effect in adult patients requiring bone graft for orthopedic surgery. Little is known about the use of the transversalis fascia plane block in children or the feasibility of placing a continuous infusion catheter. In this report, we describe our experience using a continuous transversalis fascia plane infusion catheter in the management of a 6-year-old girl undergoing alveolar cleft repair with iliac crest bone graft.
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Affiliation(s)
- Luis Sequera-Ramos
- From the Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan M Ruby
- From the Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana A Jackson
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arjunan Ganesh
- From the Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harshad Gurnaney
- From the Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis W Kraemer
- From the Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wallis T Muhly
- From the Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Campbell IM, Sheppard SE, Crowley TB, McGinn DE, Bailey A, McGinn MJ, Unolt M, Homans JF, Chen EY, Salmons HI, Gaynor JW, Goldmuntz E, Jackson OA, Katz LE, Mascarenhas MR, Deeney VFX, Castelein RM, Zur KB, Elden L, Kallish S, Kolon TF, Hopkins SE, Chadehumbe MA, Lambert MP, Forbes BJ, Moldenhauer JS, Schindewolf EM, Solot CB, Moss EM, Gur RE, Sullivan KE, Emanuel BS, Zackai EH, McDonald-McGinn DM. What is new with 22q? An update from the 22q and You Center at the Children's Hospital of Philadelphia. Am J Med Genet A 2019; 176:2058-2069. [PMID: 30380191 DOI: 10.1002/ajmg.a.40637] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/23/2018] [Indexed: 12/26/2022]
Abstract
22q11.2 deletion syndrome (22q11.2DS) is a disorder caused by recurrent, chromosome-specific, low copy repeat (LCR)-mediated copy-number losses of chromosome 22q11. The Children's Hospital of Philadelphia has been involved in the clinical care of individuals with what is now known as 22q11.2DS since our initial report of the association with DiGeorge syndrome in 1982. We reviewed the medical records on our continuously growing longitudinal cohort of 1,421 patients with molecularly confirmed 22q11.2DS from 1992 to 2018. Most individuals are Caucasian and older than 8 years. The mean age at diagnosis was 3.9 years. The majority of patients (85%) had typical LCR22A-LCR22D deletions, and only 7% of these typical deletions were inherited from a parent harboring the deletion constitutionally. However, 6% of individuals harbored other nested deletions that would not be identified by traditional 22q11.2 FISH, thus requiring an orthogonal technology to diagnose. Major medical problems included immune dysfunction or allergies (77%), palatal abnormalities (67%), congenital heart disease (64%), gastrointestinal difficulties (65%), endocrine dysfunction (>50%), scoliosis (50%), renal anomalies (16%), and airway abnormalities. Median full-scale intelligence quotient was 76, with no significant difference between individuals with and without congenital heart disease or hypocalcemia. Characteristic dysmorphic facial features were present in most individuals, but dermatoglyphic patterns of our cohort are similar to normal controls. This is the largest longitudinal study of patients with 22q11.2DS, helping to further describe the condition and aid in diagnosis and management. Further surveillance will likely elucidate additional clinically relevant findings as they age.
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Affiliation(s)
- Ian M Campbell
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sarah E Sheppard
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - T Blaine Crowley
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel E McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Davidson College, Davidson, North Carolina
| | - Alice Bailey
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marta Unolt
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Cardiology, Bambino Gesu Hospital, Rome, Italy
| | - Jelle F Homans
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erin Y Chen
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Johns Hopkins University, Baltimore, Maryland
| | - Harold I Salmons
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana A Jackson
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Plastic Surgery, Department of Pediatric Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lorraine E Katz
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maria R Mascarenhas
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Gastroenterology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vincent F X Deeney
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - René M Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karen B Zur
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Staci Kallish
- Department of Medicine, Division of Translational Medicine and Human Genetics, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas F Kolon
- Division of Pediatric Urology, Department of Pediatric Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Surgery (Urology), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Madeline A Chadehumbe
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michele P Lambert
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian J Forbes
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie S Moldenhauer
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erica M Schindewolf
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia B Solot
- Center for Childhood Communication, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edward M Moss
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Malamut and Moss, Bryn Mawr, Pennsylvania
| | - Raquel E Gur
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen E Sullivan
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Beverly S Emanuel
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elaine H Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Jackson OA, Lee A, Nikovina E, Kaye AE. Precision Dermal Fat Grafting for Vermillion Deficiencies in Patients With Unilateral and Bilateral Cleft Lip. Cleft Palate Craniofac J 2019; 57:127-131. [DOI: 10.1177/1055665619864221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: Deficiencies of the upper lip vermilion occur with some frequency following repair of unilateral and bilateral clefts of the lip and can compromise the aesthetic outcome. The presence of dense scar tissue within the lip at the cleft site as well as intrinsic vermillion deficiencies can make long-lasting correction of this deformity challenging. We describe a technique to address vermillion deficiencies after cleft lip repair. Design: A novel lip augmentation technique for correction of residual vermilion deficiencies after unilateral and bilateral cleft lip repair is presented. This technique combines precise placement of a contoured dermal fat graft with local tissue (V-Y) rearrangement. Conclusion: In our experience, this method of lip augmentation following either unilateral or bilateral cleft lip repair can restore upper lip vermillion symmetry and provide predictable and durable results in patients with mild to severe vermillion deficiency.
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Affiliation(s)
- Oksana A. Jackson
- Division of Plastic and Reconstructive Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alfred Lee
- Division of Plastic and Reconstructive Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elena Nikovina
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison E. Kaye
- Division of Plastic Surgery, Children’s Mercy Hospital, Kansas City, MO, USA
- University of Missouri–Kansas City School of Medicine, Kansas City, MO, USA
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22
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Jackson OA, Paine K, Magee L, Maguire MA, Zackai E, McDonald-McGinn DM, McCormack S, Solot C. Management of velopharyngeal dysfunction in patients with 22q11.2 deletion syndrome: A survey of practice patterns. Int J Pediatr Otorhinolaryngol 2019; 116:43-48. [PMID: 30554706 DOI: 10.1016/j.ijporl.2018.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine demographics and practice patterns of surgeons treating velopharyngeal dysfunction (VPD) in patients with 22q11.2 deletion syndrome (22q11.2DS). METHODS An anonymous electronic survey study was administered to the surgical membership of the American Cleft Palate-Craniofacial Association and the Society for Ear Nose and Throat Advances in Children. The survey queried surgeon demographics and differences in management practices for submucous cleft palate (SMCP), pharyngoplasty algorithms, and self-reported complications for nonsyndromic versus 22q11.2DS patients. RESULTS 126 surveys were returned from 9 international regions with the majority from the United States (73%), followed by Western Europe (9.5%) and Canada (7.9%). Plastic surgery was the most common specialty (61.9%), followed by otolaryngology (27.8%). 88.1% reported fellowship training, and 33% completed multiple fellowships. Prior to proceeding with pharyngoplasty in 22q11.2DS patients, surgeons required the following assessments: speech evaluation (79.4%), velopharyngeal imaging (51.6%), cardiac evaluation (50.0%), carotid artery MRI (29.4%), and cervical spine x-rays (11.1%). Nasoendoscopy was the most common modality used for imaging the velopharynx. Overall, providers managed patients with 22q11.2DS similarly to nonsyndromic patients, with several significant exceptions including that they were more likely to perform SMCP repair alone as a first approach in nonsyndromic patients (p = 0.031) and posterior pharyngeal flap without SMCP repair in those with 22q11.2DS (p = 0.017). CONCLUSIONS Practice patterns for the management of VPD in patients with 22q11.2DS vary across providers. Further collaborative studies are needed to develop optimal treatment paradigms for VPD in patients with 22q11.2 DS.
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Affiliation(s)
- Oksana A Jackson
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; The Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Kaitlyn Paine
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; The Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Leanne Magee
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; The Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Meg Ann Maguire
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Elaine Zackai
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; The Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Donna M McDonald-McGinn
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; The Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Susan McCormack
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Cynthia Solot
- The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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23
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Liu T, Wan J, McKenna RA, Jackson OA, Treat JR. Allergic contact dermatitis caused by Dermabond in a paediatric patient undergoing skin surgery. Contact Dermatitis 2018; 80:61-62. [DOI: 10.1111/cod.13125] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 08/16/2018] [Accepted: 08/19/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Tianyu Liu
- Section of Dermatology, Department of Pediatrics; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Joy Wan
- Section of Dermatology, Department of Pediatrics; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Rachel A. McKenna
- Division of Plastic and Reconstructive Surgery; Department of Surgery, Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Oksana A. Jackson
- Division of Plastic and Reconstructive Surgery; Department of Surgery, Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - James R. Treat
- Section of Dermatology, Department of Pediatrics; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
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24
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Campbell IM, Sheppard SE, Crowley TB, McGinn DE, Bailey A, McGinn MJ, Unolt M, Homans JF, Chen EY, Salmons HI, Gaynor JW, Goldmuntz E, Jackson OA, Katz LE, Mascarenhas MR, Deeney VFX, Castelein RM, Zur KB, Elden L, Kallish S, Kolon TF, Hopkins SE, Chadehumbe MA, Lambert MP, Forbes BJ, Moldenhauer JS, Schindewolf EM, Solot CB, Moss EM, Gur RE, Sullivan KE, Emanuel BS, Zackai EH, McDonald-McGinn DM. Cover Image, Volume 176A, Number 10, October 2018. Am J Med Genet A 2018. [DOI: 10.1002/ajmg.a.60697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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Zhang RS, Lin LO, Hoppe IC, Jackson OA, Low DW, Bartlett SP, Swanson JW, Taylor JA. Nasal Obstruction in Children With Cleft Lip and Palate: Results of a Cross-Sectional Study Utilizing the NOSE Scale. Cleft Palate Craniofac J 2018; 56:177-186. [PMID: 29698113 DOI: 10.1177/1055665618772400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To characterize the epidemiology and risk factors for nasal obstruction among subjects with cleft lip and/or cleft palate (CL/P) utilizing the well-validated Nasal Obstruction Symptom Evaluation (NOSE) survey. DESIGN Retrospective cross-sectional study. SETTING Cleft Lip and Palate Program, Children's Hospital of Philadelphia. PATIENTS, SUBJECTS One thousand twenty-eight surveys obtained from 456 subjects (mean age: 10.10 (4.48) years) with CL/P evaluated between January 2015 and August 2017 with at least 1 completed NOSE survey. INTERVENTIONS Nasal Obstruction Symptom Evaluation surveys completed at each annual visit. MAIN OUTCOME MEASURES Composite NOSE and individual symptom scores. RESULTS Sixty-seven percent of subjects had nasal obstruction at some point during the study period, with 49% reporting nasal obstruction at latest follow-up. subjects aged 14 years and older reported the most severe symptoms ( P = .002). Subjects with cleft lip and alveolus (CL+A) and unilateral cleft lip and palate (CLP) reported more severe nasal blockage than other phenotypes ( P = .021). subjects with a history of either posterior pharyngeal flap (PPF) or sphincter pharyngoplasty (SP) had significantly higher NOSE scores than subjects with no history of speech surgery ( P = .006). There was no significant difference ( P > .050) in NOSE scores with regard to history of primary tip rhinoplasty, nasal stent use, or nasoalveolar molding. CONCLUSIONS There are more severe nasal obstructive symptoms among subjects older than 14 years of age, with CL+A or unilateral CLP, and with a history of PPF or SP. Future studies utilizing the NOSE are needed to evaluate and address this prevalent morbidity in the CLP population.
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Affiliation(s)
- Rosaline S Zhang
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lawrence O Lin
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ian C Hoppe
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- 1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Basta MN, Fiadjoe JE, Woo AS, Peeples KN, Jackson OA. Predicting Adverse Perioperative Events in Patients Undergoing Primary Cleft Palate Repair. Cleft Palate Craniofac J 2018; 55:574-581. [DOI: 10.1177/1055665617744065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: This study aimed to identify risk factors for adverse perioperative events (APEs) after cleft palatoplasty to develop an individualized risk assessment tool. Design: Retrospective cohort. Setting: Tertiary institutional. Patients: Patients younger than 2 years with cleft palate. Interventions: Primary Furlow palatoplasty between 2008 and 2011. Main Outcome Measure(s): Adverse perioperative event, defined as laryngo- or bronchospasm, accidental extubation, reintubation, obstruction, hypoxia, or unplanned intensive care unit admission. Results: Three hundred patients averaging 12.3 months old were included. Cleft distribution included submucous, 1%; Veau 1, 17.3%; Veau 2, 38.3%; Veau 3, 30.3%; and Veau 4, 13.0%. Pierre Robin (n = 43) was the most prevalent syndrome/anomaly. Eighty-three percent of patients received reversal of neuromuscular blockade, and total morphine equivalent narcotic dose averaged 0.19 mg/kg. Sixty-nine patients (23.0%) had an APE, most commonly hypoventilation (10%) and airway obstruction (8%). Other APEs included reintubation (4.7%) and laryngobronchospasm (3.3%). APE was associated with multiple intubation attempts (odds ratio [OR] = 6.6, P = .001), structural or functional airway anomaly (OR = 4.5, P < .001), operation >160 minutes (OR = 2.2, P = .04), narcotic dose >0.3 mg/kg (OR = 2.3, P = .03), inexperienced provider (OR = 2.1, P = .02), and no paralytic reversal administration (OR = 2.0, P = .049); weight between 9 and 13 kg was protective (OR = 0.5, P = .04). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (APE 2.5%-91.7%) with excellent risk discrimination (C-statistic = 0.79). Conclusions: APE incidence was 23.0% after palatoplasty, with a 37-fold higher incidence in extreme-risk patients. Individualized risk assessment tools may enhance perioperative clinical decision making to mitigate complications.
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Affiliation(s)
- Marten N. Basta
- Brown University, Rhode Island Hospital, Providence, RI, USA
| | | | - Albert S. Woo
- Brown University, Rhode Island Hospital, Providence, RI, USA
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Chang BL, Wilson AJ, Chin BC, Friedman C, Jackson OA. Influence of Standardized Orientation on Patient Perception of Perioperative Care following Alveolar Cleft Repair: A Survey Based Study of Patients Treated in a Large Academic Medical Center. Cleft Palate Craniofac J 2017; 54:287-294. [DOI: 10.1597/15-234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective This study aims to better understand patient-reported outcomes for iliac bone grafting surgery for alveolar cleft repair and to determine how standardizing perioperative patient instruction affects patient-reported outcomes. Design Retrospective survey-based assessment of patients undergoing iliac bone grafting with and without hospital-based systems standardization. Setting Academic tertiary care hospital. Patients Of the 195 identified patients, 127 participated. Interventions Survey on pain and satisfaction regarding iliac bone grafting surgery. Main Outcome Measures Survey answers measured patient opinions about the surgery. Answers of the pre- and poststandardization patients were compared to determine the effect of standardizing patient instructions. Results Patients rated their satisfaction with the surgery and recovery a 4.5 and 4.4 out of 5, respectively. They rated their overall pain in the hospital a 5.5 out of 10 (4.9 in the mouth, 5.7 in the hip). Patients were discharged an average of 1.2 days after surgery and could return to normal daily activity in 6.1 days. Poststandardization patients were more likely to adhere to instructions regarding use of an antibacterial mouthrinse and a protective oral splint. Conclusions Patients were highly satisfied with the iliac bone grafting procedure and the recovery and reported only moderate levels of postoperative pain. Implementing standardized patient instructions may not affect patient satisfaction or pain severity, but it significantly increased patient adherence to physician instructions.
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Affiliation(s)
- Brian L. Chang
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anthony J. Wilson
- Plastic Surgery Resident, University of Pennsylvania, Perelman School of Medicine, Department of Plastic Surgery, Philadelphia, Pennsylvania
| | - Bianca C. Chin
- Plastic Surgery Resident, University of Pennsylvania, Perelman School of Medicine, Department of Plastic Surgery, Philadelphia, Pennsylvania
| | | | - Oksana A. Jackson
- Division of Plastic Surgery, University of Pennsylvania, Perelman School of Medicine, and Attending Physician, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Shay PL, Goldstein JA, Paliga JT, Wink J, Jackson OA, Low D, Bartlett SP, Taylor JA. A Comparative Cost Analysis of Cleft Lip Adhesion and Nasoalveolar Molding before Formal Cleft Lip Repair. Plast Reconstr Surg 2016; 136:1264-1271. [PMID: 26595019 DOI: 10.1097/prs.0b013e31829b69fe] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with complete cleft lip and palate may benefit from cleft lip adhesion or nasoalveolar molding before formal cleft lip repair. The authors compared the relative costs to insurers of these two treatment modalities and the burden of care to families. METHODS A retrospective analysis was performed of cleft lip and palate patients treated with nasoalveolar molding or cleft lip adhesion at The Children's Hospital of Philadelphia between January of 2007 and June of 2012. Demographic, appointment, and surgical data were reviewed; surgical, inpatient hospital, and orthodontic charges and costs were obtained. Multivariate linear regression and two-sample, two-tailed independent t tests were performed to compare cost and appointment data between groups. RESULTS Forty-two cleft adhesion and 35 nasoalveolar molding patients met inclusion criteria. Mean costs for nasoalveolar molding were $3550.24 ± $667.27. Cleft adhesion costs, consisting of both hospital and surgical costs, were $9370.55 ± $1691.79. Analysis of log costs demonstrated a significant difference between the groups, with the mean total cost for nasoalveolar molding significantly lower than that for adhesion (p < 0.0001). Nasoalveolar molding patients had significantly more made, cancelled, no-show, and missed visits and a higher missed percentage than adhesion patients (p < 0.0001) for all except no-show appointments, (p = 0.0199), indicating a higher burden of care to families. CONCLUSIONS Nasoalveolar molding may cost less before formal cleft lip repair treatment than cleft lip adhesion. Third-party payers who cover adhesion and not nasoalveolar molding may not be acting in their own best interest. Nasoalveolar molding places a higher burden of care on families, and this fact should be considered in planning treatment.
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Affiliation(s)
- Paul L Shay
- Philadelphia, Pa. From the Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia
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Pasick CM, Shay PL, Stransky CA, Solot CB, Cohen MA, Jackson OA. Long term speech outcomes following late cleft palate repair using the modified Furlow technique. Int J Pediatr Otorhinolaryngol 2014; 78:2275-80. [PMID: 25468463 DOI: 10.1016/j.ijporl.2014.10.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Published reports and previous studies from our institution have reported worse overall speech results, including significantly higher rates of persistent articulation errors, in patients undergoing palatoplasty at age >18 months. This study further investigates the effects of late repair on long term speech outcomes. METHODS A retrospective review was performed of non-syndromic patients undergoing primary palatoplasty at age >18 months between 1980 and 2006 at our institution. Longitudinal speech results were compared based on reason for late repair and age at repair. RESULTS Forty-one patients were greater than 18 months of age at the time of palatoplasty, and 24 fit criteria for longitudinal data analysis. There was a statistically significant improvement in nasality scores at Time Point 1 for international adoptees compared to the non-adopted population (p=0.04). Patients with submucosal clefts were found to have significantly less severe nasal emission scores at Time Point 1 compared to those with overt clefts (p=0.04), but not at Time Point 2. There were no significant differences between scores if repair was performed between 18 and 36 months or >36 months, nor any difference in incidence of articulation errors between subgroups of patients with late repair at either Time Point. CONCLUSION Our experience demonstrates that cleft palate repair after 18 months of age is associated with a significantly increased incidence of articulation errors associated with VPI, irrespective of reason for late repair, highlighting the persistence of learned compensatory behaviors in speech and the importance of proceeding with early repair.
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Affiliation(s)
- Christina M Pasick
- Mount Sinai Hospital's Division of Plastic and Reconstructive Surgery, New York City, NY, United States
| | - Paul L Shay
- The Children's Hospital of Philadelphia's Division of Plastic and Reconstructive Surgery, Philadelphia, PA, United States
| | - Carrie A Stransky
- Johns Hopkins Department of Plastic and Reconstructive Surgery, Baltimore, MD, United States
| | - Cynthia B Solot
- The Children's Hospital of Philadelphia's Division of Plastic and Reconstructive Surgery, Philadelphia, PA, United States
| | - Marilyn A Cohen
- The Children's Hospital of Philadelphia's Division of Plastic and Reconstructive Surgery, Philadelphia, PA, United States
| | - Oksana A Jackson
- The Children's Hospital of Philadelphia's Division of Plastic and Reconstructive Surgery, Philadelphia, PA, United States.
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Abstract
Angiolymphoid hyperplasia with eosinophilia is a rare, benign vascular lesion characterized by discrete, painful papules. Although the exact etiology is unknown, trauma precedes many cases. We present a case of angiolymphoid hyperplasia with eosinophilia in the earlobes of a 15-year-old girl after ear piercing.
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Affiliation(s)
- Jonathan S Okman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Kennedy WP, Mudd PA, Maguire MA, Souders MC, McDonald-McGinn DM, Marcus CL, Zackai EH, Solot CB, Mason TBA, Jackson OA, Elden LM. 22q11.2 Deletion syndrome and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2014; 78:1360-4. [PMID: 24958162 DOI: 10.1016/j.ijporl.2014.05.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/23/2014] [Accepted: 05/25/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Otolaryngologic problems are common in the 22q11.2 deletion syndrome (DS) population. Structural anomalies and retrognathia may predispose these patients to obstructive sleep apnea (OSA). The current association of OSA in this population is not defined. OBJECTIVE (1) Define the frequency of OSA in 22q11.2 DS patients referred for polysomnography (PSG). (2) Determine if OSA is present before and/or after surgery to correct velopharyngeal insufficiency (VPI). (3) Determine effect of prior adenotonsillectomy on OSA following VPI surgery. METHODS Retrospective review of children treated from 2006 to 2013 in a tertiary care setting identified by ICD-9 758.32 (velocardiofacial syndrome) and 279.11 (DiGeorge syndrome). Surgical history and PSG data were abstracted from the identified records. RESULTS We identified 323 patients with 22q11.2 DS; 57 (18%) were screened at any point in care using PSG and 15 patients had PSG at multiple time points in care. In most cases, indication for PSG was sleep disordered breathing or pre-operative planning. Overall, 33 patients met criteria for OSA on PSG, accounting for 10.2% of our study population; however, the percentage of patients with OSA was significantly higher within the group of 57 patients (58%) who were screened with PSG. Twenty-one of the screened patients (54%) had PSG prior to any pharyngeal surgery and had mild to severe OSA (obstructive apnea/hypopnea index (AHI): median 5.1/h, range 1.9-25.6). Eighteen patients had PSG after adenotonsillectomy; 8 of these patients (44%) had mild to moderate OSA (median AHI 2.95/h, range 1.9-5.4). Seventeen patients had PSG after VPI surgery (palatopharyngeal flap (PPF) n=16, sphincteroplasty n=1). Nine of these patients (53%) had mild to severe OSA (median AHI 3/h, range 1.9-15). Patients who underwent adenotonsillectomy prior to VPI surgery had similar prevalence of OSA (50%, n=12) than those who did not (OSA: 60%, n=5, p=0.70). Most children had mild OSA. CONCLUSION Prevalence of OSA in this population of 22q11.2 DS patients is higher than expected in the general population. OSA risk is highest after VPI surgery, and may be decreased by adenotonsillectomy. Providers should have awareness of increased prevalence of OSA in patients with 22q11.2 DS. Close monitoring for OSA is warranted given the likelihood of subsequent surgical intervention that can worsen OSA.
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Affiliation(s)
- William P Kennedy
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Pamela A Mudd
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Meg A Maguire
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Margaret C Souders
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Donna M McDonald-McGinn
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Carole L Marcus
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Elaine H Zackai
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Cynthia B Solot
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Oksana A Jackson
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lisa M Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Jackson BM, Bartlett EK, Jackson OA, Fairman RM, Foley PJ, Fraker DL, Karakousis GC. Isolated Limb Infusion For Melanoma and Sarcoma Performed in the Endovascular Operating Room. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.07.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Jackson OA. Making INROADS into cultural diversity. Interview by Richard L. Clarke. Healthc Financ Manage 1995; 49:26-8, 30. [PMID: 10146147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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