Effect of Erythropoietin on Transfusion Requirements for Craniosynostosis Surgery in Children.

BACKGROUND: Pediatric craniosynostosis surgery is associated with significant blood loss often requiring allogenic blood transfusion (ABT). This study explores the clinical effectiveness of preoperative erythropoietin (EPO) administration in pediatric craniosynostosis surgery in reducing transfusion requirements. METHODS: A systematic review and meta-analysis of the literature was performed for studies published in English language between 1946 and 2015. Inclusion criteria included original studies in the pediatric population (0-8 years of age) involving preoperative use of EPO in craniofacial procedures with quantitative reporting of perioperative blood transfusion. Extracted data included demographics, hematocrit, hemoglobin, estimated blood loss, number of patients transfused, and amount of ABT. RESULTS: Four studies met the inclusion criteria with a total of 117 patients. Patients were divided into 2 groups: EPO versus control. No statistical differences were found in the demographics between the 2 groups. Mean preoperative hematocrit level was higher in the EPO group compared with control (43% vs 35%). The percentage of patients who required ABT and the volume of transfused blood were less in the EPO group (54% vs 98% and 84 vs 283 mL, respectively). Meta-analysis of 3 comparable studies showed a lower proportion of patients who needed blood transfusion in the EPO group. CONCLUSIONS: The present meta-analysis demonstrated that preoperative administration of EPO in pediatric craniosynostosis surgery decreased the proportion of patients requiring ABT. In addition, the volume of transfusion was reduced in patients who received EPO. Future randomized studies are needed to establish the cost-effectiveness of routine preoperative EPO administration in craniosynostosis surgery.

Constructing a question bank based on script concordance approach as a novel assessment methodology in surgical education.

BACKGROUND: Script Concordance Test (SCT) is a new assessment tool that reliably assesses clinical reasoning skills. Previous descriptions of developing SCT-question banks were merely subjective. This study addresses two gaps in the literature: 1) conducting the first phase of a multistep validation process of SCT in Plastic Surgery, and 2) providing an objective methodology to construct a question bank based on SCT. METHODS: After developing a test blueprint, 52 test items were written. Five validation questions were developed and a validation survey was established online. Seven reviewers were asked to answer this survey. They were recruited from two countries, Saudi Arabia and Canada, to improve the test's external validity. Their ratings were transformed into percentages. Analysis was performed to compare reviewers' ratings by looking at correlations, ranges, means, medians, and overall scores. RESULTS: Scores of reviewers' ratings were between 76% and 95% (mean 86% ± 5). We found poor correlations between reviewers (Pearson's: +0.38 to -0.22). Ratings of individual validation questions ranged between 0 and 4 (on a scale 1-5). Means and medians of these ranges were computed for each test item (mean: 0.8 to 2.4; median: 1 to 3). A subset of test items comprising 27 items was generated based on a set of inclusion and exclusion criteria. CONCLUSION: This study proposes an objective methodology for validation of SCT-question bank. Analysis of validation survey is done from all angles, i.e., reviewers, validation questions, and test items. Finally, a subset of test items is generated based on a set of criteria.

Acellular dermal matrix in cleft palate repair: an evidence-based review.

BACKGROUND: The repair of wide cleft palates and secondary palatal fistulas remains a challenge for pediatric plastic surgeons. To reduce the incidence of fistulization, use of acellular dermal matrix to facilitate closure has been reported in the literature. A review of the literature was performed to assess whether sufficient evidence exists to recommend the routine use of acellular dermal matrix for either primary palatoplasty or secondary palatal fistula repair. METHODS: A literature search for the period between 1970 and 2011 was performed. All articles with clinical application of acellular dermal matrix in primary palatoplasty or palatal fistula repair were included. Data were analyzed using weighted averages to compare fistula rates between repairs performed with and without acellular dermal matrix (historical controls) for each repair type (primary versus secondary fistula repairs). RESULTS: Four studies examined the use of acellular dermal matrix in primary palatoplasty (n = 92) with a mean cleft width of 14.2 mm. The overall fistula rate was 5.4 percent compared with 10.6 percent in the non-acellular dermal matrix historical control group. Five studies used acellular dermal matrix in palatal fistula repair (n = 74). The overall recurrent fistula rate was 8.1 percent compared with 12.9 percent in the historical control group. CONCLUSIONS: Based on the available data, the results imply that acellular dermal matrix may have a potential benefit in reducing fistula formation/persistence in palate surgery. However, the authors did not find sufficient prospective randomized (level II or better) evidence to recommend the routine use of acellular dermal matrix for cleft palate repair.

Ambulatory cleft lip repair.

BACKGROUND: Ambulatory cleft lip repair has been practiced in developed countries, but its safety has never been examined in developing countries. This study compares the outcomes of ambulatory cleft lip repair with the inpatient setting. METHODS: A retrospective cohort study of 122 patients who underwent repair between 2000 and 2008 was conducted. All patients underwent primary cleft lip repair performed by the same surgeon. Patients were divided into two groups: ambulatory (n = 58) and inpatient (n = 64). Demographics, surgical parameters, and outcomes were obtained. The main outcome measure examined was the overall readmission rate. RESULTS: Mean patient age was 133 days in the ambulatory group and 154 days in the inpatient group. Six patients (10.3 percent) in the ambulatory group and 15 (23.4 percent) in the inpatient group had associated medical problems. Both groups were homogeneous for other parameters. Three patients (5.2 percent) in the ambulatory group and two (3.1 percent) in the inpatient group were readmitted. There were no significant differences in the readmission rate, intraoperative or postoperative complications, or rate of return to the emergency room (p > 0.05). However, the reason for readmission was different in the two groups, consisting of respiratory problems in the ambulatory group and late wound dehiscence in the inpatient group. CONCLUSIONS: This study confirms the safety of ambulatory cleft lip repair in a developing country. However, the authors suggest hospital admission for patients with preexisting cardiac problems and those who experience any respiratory problems in the immediate postoperative period in the ambulatory group.