RESUMEN
BACKGROUND: Pre-surgical orthopedic (PSO) devices can be used in the management of patient with cleft lip/palate (CL/P) to narrow the alveolar gap (AG) prior to lip surgery. There are few studies comparing these 2 devices. The objective of this work was to compare the effects of active and passive PSO devices on facial growth in a single surgeon's cohort of patients with CL/P over a 10-year period. METHODS: A retrospective review of all patients with CL/P in a single surgeon's practice from 2002 to 2018 was performed. Preoperative measurements of AG size were done using electronic calipers on patient molds. Patient radiographs were taken at 5 and 10 years of age and cephalometric landmarks were plotted using specialized software. Independent sample t-tests were used to compare means for maxillary, mandibular, vertical, and dento-alveolar growth parameters. RESULTS: Twenty patients with an active device and 23 patients with a passive device were included. No differences were observed in the basic demographic information between the two groups. At the time of lip repair, patients with a passive device had significantly larger horizontal AGs (P < .01), but by the time of palate repair, there was no difference between the two groups (P = .94). There was no significant difference in any growth measurements between the active and passive device groups at 5 and 10 years. CONCLUSIONS: Despite closing the AG more quickly, patients treated with an active device have no significant difference in facial growth at 10 years compared to patients treated with a passive device.
Asunto(s)
Labio Leporino , Fisura del Paladar , Humanos , Fisura del Paladar/cirugía , Labio Leporino/diagnóstico por imagen , Labio Leporino/cirugía , Cefalometría , Maxilar/cirugía , Estudios RetrospectivosRESUMEN
Velopharyngeal insufficiency (VPI) is a complication that occurs following cleft palate (CP) repair, and the patient/surgical factors that contribute to the development of VPI have not been completely described. The objectives of this study were to identify patient and surgical factors that may increase the risk of development of VPI and to identify whether there are any factors that predispose patients to the development of VPI that requires surgery versus VPI that resolves with non-operative management. Data was prospectively collected for all non-syndromic patients with a CP undergoing primary CP repair by a single surgeon between 2002 and 2018. Patient factors were recorded from patient charts, and anatomic measurements were recorded by the primary surgeon at the time of palate repair. The rates of VPI requiring surgery were compared between (1) patients with cleft lip/palate versus isolated CP, (2) patient gender, (3) unilateral or bilateral cleft, (4) complete or incomplete cleft, (5) the type of primary palatoplasty performed, and (6) the presence of palatal fistula. Data were analyzed retrospectively using a combination of Chi-square tests, t-tests, and one-way ANOVA. Overall, 229 patients were identified in this study, and the total rate of VPI was identified as 30.1%. The risk of VPI development was associated with bilateral cleft lip/palate (p = 0.01), increased pre-operative cleft width (p = 0.03), and von Langenbeck palatoplasty (p<0.01). No factors were found to be associated with operative versus non-operative VPI. Moving forward, at-risk patients should be identified early and monitored closely for the development of VPI.
Asunto(s)
Labio Leporino , Fisura del Paladar , Insuficiencia Velofaríngea , Labio Leporino/complicaciones , Labio Leporino/cirugía , Fisura del Paladar/complicaciones , Fisura del Paladar/cirugía , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Insuficiencia Velofaríngea/etiología , Insuficiencia Velofaríngea/cirugíaRESUMEN
OBJECTIVE: To perform a systematic review of the literature to identify the long-term effects of presurgical orthopedic (PSO) device use on patient outcomes. DESIGN: A comprehensive literature review of Embase and Ovid databases was performed to identify all English-language publications related to unilateral cleft lip and palate, presurgical devices, and patient outcomes. Studies were excluded if they did not report patient outcomes beyond 2 years of age, did not describe the use of a PSO device, were case reports (n < 10), or were purely descriptive studies. MAIN OUTCOME MEASURES: Reported patient outcomes following the use of PSO devices. RESULTS: Following a review of all articles by 2 independent reviews, 30 articles were selected for inclusion. Overall, there was no reported consensus as to the long-term effects of PSO devices. Furthermore, this study identified that only 10% of published research controlled for confounding factors that could influence the reported results. Confounding factors that were identified included different operating surgeon, different surgical protocols, and different rates of revision surgeries. CONCLUSIONS: Overall, this systematic review identified 2 important conclusions. Firstly, there is no consensus in the literature about the long-term effects of PSO devices on long-term patient outcomes. Secondly, research in this domain is limited by confounding factors that influence the applicability of the reported results.
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Labio Leporino , Fisura del Paladar , Labio Leporino/cirugía , Fisura del Paladar/cirugía , HumanosRESUMEN
Initial assessment and triage of burns are guided by the American Burn Association criteria for referral to a burn center. These criteria are sensitive but not specific and can potentially lead to over-triage and "unnecessary" clinic visits. We are a Level 1 trauma center with burn subspecialty care, and due to the COVID-19 pandemic, referrals to our multidisciplinary outpatient burn clinic required triaging for virtual care appointments. In order to improve the triage process, we retrospectively reviewed our outpatient burn clinic referrals over a 2-year period, 2018 to 2019, for adherence to American Burn Association criteria. We collected data pertaining to patient and burn characteristics, as well as treatment outcome, to characterize referrals not requiring an in-person appointment. Of the 244 patients referred, 73% met the referral criteria, with 45% of these patients being healed at the first visit and 14.6% requiring surgical management. Mean time from injury to first visit was 9.7 days (mode 6), and the average number of visits was 2. Overall, mean burn size was 2%, with the majority of injuries being partial thickness (71%), located in the hand or extremity (77%). There was a fairly equal distribution of contact (36%), flame (21%), and scald (26%) burns. This study highlights the nonspecific nature of the American Burn Association referral criteria. We found that pediatric and hand burns in particular were over-triaged and lead to "unnecessary" appointments. This information is useful to help adjust referral criteria and to guide triaging of appointments with the evolution of telehealth and virtual care.
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Quemaduras/terapia , Continuidad de la Atención al Paciente/organización & administración , Derivación y Consulta/estadística & datos numéricos , Triaje/estadística & datos numéricos , Adulto , Unidades de Quemados , Quemaduras/epidemiología , COVID-19/epidemiología , Niño , Femenino , Humanos , Masculino , Estudios RetrospectivosRESUMEN
Summary: Ensuring adverse event (AE) recording is standardized and accurate is paramount for patient safety. In this discussion, we outline our comparison of AE data collected by orthopedic surgeons and independent clinical reviewers using the Spine Adverse Events Severity System (SAVES) and Orthopedic Surgical Adverse Events Severity System (OrthoSAVES) against AE data recorded by hospital administrative discharge abstract coders. In 164 spine, hip, knee and shoulder patients, reviewers recorded significantly more AEs than coders, and coders recorded significantly more AEs than surgeons. The AEs were recorded similarly by reviewers using SAVES and OrthoSAVES in 48 spine patients. Despite our small sample size and use of different AE tools, we believe it is important to highlight that coders, surgeons and reviewers recorded AEs differently. While further investigations on its utility and cost-effectiveness are necessary, we assert that it is feasible to use Ortho-SAVES to prospectively record AEs across all orthopedic subspecialties.
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Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Ortopédicos/efectos adversos , Evaluación de Procesos y Resultados en Atención de Salud , Canadá , Codificación Clínica/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Humanos , Auditoría Médica/estadística & datos numéricos , Procedimientos Ortopédicos/estadística & datos numéricos , Cirujanos Ortopédicos/estadística & datos numéricos , Evaluación de Procesos y Resultados en Atención de Salud/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricosRESUMEN
PURPOSE OF REVIEW: Cleft lip repair requires multidisciplinary follow-up throughout a child's life and often requires lip revision surgery in adolescence to restore function and symmetry of the lip. There is significant variability in the approaches taken for lip repair and therefore a review of current techniques and subsequent guidance to secondary cleft lip repair is warranted. RECENT FINDINGS: New methods of secondary reconstruction can be divided into superficial or muscle related. Recent suggestions for superficial reconstruction include botulinum toxin injection, silicone gel sheeting, local flap reconstruction, fat grafting, and CO2 laser ablation. Suggestions for muscular reconstruction include pedicled prolabial flaps, modified Abbe flap, and orbicularis oris eversion. SUMMARY: Secondary cleft lip deformities can be classified as superficial or muscle related. Superficial problems require relatively minor treatments such as laser, local scar revisions, small local flaps, mucosal excision, or fat grafting. Muscle deformities generally require total lip revision and rerepair as a first step to achieving longstanding improvements in lip esthetics and function. Cleft lip revision should only be considered in concert with the patient, be based on the patient's concerns and desires, and offered at the appropriate timeline to improve social integration and/or psychosocial wellbeing.
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Labio Leporino/cirugía , Procedimientos de Cirugía Plástica/métodos , Reoperación/métodos , Tejido Adiposo/trasplante , Toxinas Botulínicas/uso terapéutico , Humanos , Terapia por Láser , Fármacos Neuromusculares/uso terapéutico , Prótesis e Implantes , Colgajos QuirúrgicosRESUMEN
PROBLEM: A predicted shortage of surgeons and attrition among surgical residents has highlighted the need to attract well-suited medical students to surgical specialties. Literature suggests that early exposure may increase interest by addressing misconceptions and allowing students more time to make an informed career decision. APPROACH: The Surgical Exploration and Discovery (SEAD) program was created in 2012 with the goal of providing medical students with comprehensive and multifaceted exposure to surgical specialties to develop their knowledge and skills, and in turn positively influence their interest in pursuing a surgical career. The purpose of this innovation report is to describe the challenges, successes, and evolution of the SEAD program. OUTCOMES: Since its inception, SEAD has expanded to include 5 North American institutions and has educated nearly 400 participants in 5 y. Through a replication strategy, SEAD has maintained its basic curriculum, while accommodating the constraints and innovative approaches unique to each institution. Short-term results have demonstrated improved knowledge of curricular objectives, student perception of significant value of the program, and the generation of interest in a career in surgery. CONCLUSIONS: Future directions include the evaluation of long-term impact on pursuing a career in surgery and continuing further expansion using the current replication model, while maintaining a high-quality surgical education program.
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Educación de Pregrado en Medicina/organización & administración , Especialidades Quirúrgicas/educación , Educación de Pregrado en Medicina/economía , Especialidades Quirúrgicas/organización & administraciónRESUMEN
BACKGROUND: Physicians have consistently shown poor adverse-event reporting practices in the literature and yet they have the clinical acumen to properly stratify and appraise these events. The Spine Adverse Events Severity System (SAVES) and Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) are standardized assessment tools designed to record adverse events in orthopaedic patients. These tools provide a list of prespecified adverse events for users to choose from-an aid that may improve adverse-event reporting by physicians. QUESTIONS/PURPOSES: The primary objective was to compare surgeons' adverse-event reporting with reporting by independent clinical reviewers using SAVES Version 2 (SAVES V2) and OrthoSAVES in elective orthopaedic procedures. METHOD: This was a 10-week prospective study where SAVES V2 and OrthoSAVES were used by six orthopaedic surgeons and two independent, non-MD clinical reviewers to record adverse events after all elective procedures to the point of patient discharge. Neither surgeons nor reviewers received specific training on adverse-event reporting. Surgeons were aware of the ongoing study, and reported adverse events based on their clinical interactions with the patients. Reviewers recorded adverse events by reviewing clinical notes by surgeons and other healthcare professionals (such as nurses and physiotherapists). Adverse events were graded using the severity-grading system included in SAVES V2 and OrthoSAVES. At discharge, adverse events recorded by surgeons and reviewers were recorded in our database. RESULTS: Adverse-event data for 164 patients were collected (48 patients who had spine surgery, 51 who had hip surgery, 34 who had knee surgery, and 31 who had shoulder surgery). Overall, 99 adverse events were captured by the reviewers, compared with 14 captured by the surgeons (p < 0.001). Surgeons adequately captured major adverse events, but failed to record minor events that were captured by the reviewers. A total of 93 of 99 (94%) adverse events reported by reviewers required only simple or minor treatment and had no long-term adverse effect. Three patients experienced adverse events that resulted in use of invasive or complex treatment that had a temporary adverse effect on outcome. CONCLUSION: Using SAVES V2 and OrthoSAVES, independent reviewers reported more minor adverse events compared with surgeons. The value of third-party reviewers requires further investigation in a detailed cost-benefit analysis. LEVEL OF EVIDENCE: Level II, therapeutic study.
Asunto(s)
Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/etiología , Columna Vertebral/cirugía , Análisis Costo-Beneficio , Bases de Datos Factuales , Humanos , Estudios ProspectivosRESUMEN
BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) are acute events of worsened respiratory symptoms that may increase the risk of cardiovascular disease (CVD), a leading cause of mortality amongst COPD patients. The utility of lung-specific inflammatory mediators such as club cell protein-16 (CC-16) and surfactant protein D (SPD) and that of a novel marker of CV outcomes in COPD- RelB- in predicting adverse cardiovascular events during exacerbation is not known. METHODS: Thirty-eight subjects with COPD admitted to the hospital for severe exacerbation were included in this analysis. Clinical, physiological and arterial stiffness measurements were performed within 72 hours of admission; this was followed by measurements taken every 3 days until hospital discharge, then once a week until 30 days after discharge, and then again at 90 and 180 days. Plasma concentrations of inflammatory mediators were measured from peripheral venous blood taken at admission, and at days 15, 30, 90 and 180. RESULTS: CC-16 and RelB concentrations were increased at day 15 of exacerbations whereas SPD concentrations were decreased. The course of change in CC-16 and RelB levels over time was inversely associated with that of carotid-femoral pulse wave velocity, the gold-standard measure of arterial stiffness. Increases in CC-16 could predict a decreased number of subsequent exacerbations during follow-up. CONCLUSIONS: Lung-specific (CC-16) and novel (RelB) biomarkers are associated with systemic cardiovascular changes over time. CC-16 can predict subsequent exacerbations in subjects with severe COPD and may be an important biomarker of pulmonary and systemic stress in COPD.