Anesthetic Exposure in Staged Versus Single-Stage Cleft Lip and Palate Repair: Can We Reduce Risk of Anesthesia-Induced Developmental Neurotoxicity?

ABSTRACT: Cleft lip and palate (CLP) repair is typically performed in a staged fashion, which requires multiple instances of anesthetic exposure during a critical period of infant neurodevelopment. One solution to this concern includes the implementation of a single-stage CLP repair performed between 6 and 12 months of age. This study aimed to compare total anesthetic exposure between single-stage and staged CLP repairs. A retrospective review of unilateral CLP repairs between 2013 and 2018 conducted at a single institution was performed. Patients underwent either traditional, staged lip and palate repair, or single-stage complete cleft repair, where palate, lip, alveolus, and nasal repair was performed simultaneously. Primary endpoints included: total surgical time and total anesthetic exposure. Secondary endpoints included: excess anesthesia time, recovery room time, length of stay, and type of anesthetic administered. Two hundred twenty-five (n = 225) unilateral CLP repairs were conducted at the Loma Linda University. Detailed anesthetic data for eighty-six (n = 86) single-stage and twenty-eight (n = 28) staged operations were available. There was a statistically significant decrease in anesthetic exposure in single-stage versus staged repairs (316 minutes versus 345 minutes, P = 0.017), despite similar procedure times (260 minutes versus 246 minutes, P = 0.224). This resulted in near double excess anesthetic exposure time in the staged group (98 minutes versus 56 minutes, P < 0.001), primarily occurring during induction. This analysis suggests that single-stage CLP repair can reduce wasted time under general anesthesia and potentially reduce harmful neuronal toxicity in the developmental period in this at-risk population.

Cost Utility Analysis of Staged Versus Single-Stage Cleft Lip and Palate Repair.

PURPOSE: As one of the most common congenital craniofacial deformities, cleft lip and palate repair is a complex and much published topic. Proper treatment can require a multitude of appointments and operations and can place a significant burden on both the patients' families and the health care system itself. One proposed solution has been to combine multiple cleft procedures. However, these more complex operations have drawn concerns from institutions and providers regarding increased cost. This study provides a cost utility analysis between single-stage and staged unilateral cleft lip and palate repairs. METHODS: A retrospective review was conducted via current procedural terminology code identification of all cleft-related operations performed between 2013 and 2018. Patients were screened according to diagnosis, and only analysis on unilateral cleft lip and palate patients was performed. Patients were split into 2 cohorts: those that underwent a single-stage complete cleft repair, which includes palate, lip, alveolus, and nasal repair-termed "PLAN" at our institution, and those that underwent more traditional staged lip and palate repairs. Demographic and billing data were collected for any procedure performed between patient ages 0 and 24 months. χ, t-tests, and parametric regression analyses were performed to compare the cohorts. RESULTS: Between 2013 and 2018, 968 (n = 968) cleft-related operations were conducted at Loma Linda University Children's Hospital. Seven hundred ninety-six (n = 796) noncleft lip/palate repairs and 38 (n = 38) bilateral cleft lip repairs were excluded. Of the remaining 135 (n = 135) patients with unilateral cleft lip and palate, detailed cost data were available for 86 single-stage and 28 staged repairs. The average combined total cost for single-stage repairs was US $80,405 compared with US $109,473 for staged repairs (P < 0.001). The average total intraoperative cost for single-stage repairs was US $60,683 versus US $79,739 for staged repairs (P < 0.001), and the average total postoperative cost for single-stage repairs versus staged repairs was US $19,776 and US $29,703, respectively (P < 0.001). CONCLUSIONS: This analysis suggests that single-stage PLAN repair, provides an effective, cost-efficient solution to unilateral cleft lip and palate care, reducing burden on patients' families and the health care system at large.

The Effect of Modified Ultrafiltration on Serum Vancomycin Levels During Cardiopulmonary Bypass in Cardiac Surgery.

OBJECTIVE: The aim of this study was to investigate whether the use of modified ultrafiltration at the end of cardiopulmonary bypass for cardiac surgical procedures significantly changes vancomycin serum concentrations. DESIGN: Prospective study. SETTING: Single tertiary cardiac center. PARTICIPANTS: Twenty-six elective adult patients undergoing cardiac surgery with cardiopulmonary bypass from April 2014 to April 2015. INTERVENTIONS: Serum vancomycin concentrations were measured just before cardiopulmonary bypass; during cardiopulmonary bypass at 5, 30, 60 minutes and then every 60 minutes; after completion of cardiopulmonary bypass before initiation of modified ultrafiltration; and at the end of modified ultrafiltration. MEASUREMENTS AND MAIN RESULTS: Seventeen patients received modified ultrafiltration at the end of cardiopulmonary bypass. Serum vancomycin concentrations prior to cardiopulmonary bypass (45.9 ± 17.3 µg/mL) were significantly higher (P < 0.0001) than each time point following cardiopulmonary bypass (5 min 20.4 ± 6.4 µg/mL, 30 min 18.8 ± 5.4 µg/mL, 60 min 16.6 ± 4.9 µg/mL, and 120 min 14.3 ± 4.7 µg/mL). In the modified ultrafiltration group, serum vancomycin concentrations were 14.7 ± 4.6 µg/mL prior to modified ultrafiltration and 13.9 ± 4.3 µg/mL after ultrafiltration; this difference was statistically significant (P  =  0.0288). The mean modified ultrafiltration volume was 465 ± 158 mL. CONCLUSIONS: Using modified ultrafiltration at the end of cardiopulmonary bypass significantly decreases serum vancomycin levels, but not by a clinically relevant amount. The decrease is to a concentration that is still significantly higher than the minimum inhibitory concentration for Staphylococcus epidermidis and Staphylococcus aureus; thus additional vancomycin administration is not recommended.

Comparison of satellite reflectance algorithms for estimating turbidity and cyanobacterial concentrations in productive freshwaters using hyperspectral aircraft imagery and dense coincident surface observations.

We analyzed 37 satellite reflectance algorithms and 321 variants for five satellites for estimating turbidity in a freshwater inland lake in Ohio using coincident real hyperspectral aircraft imagery converted to relative reflectance and dense coincident surface observations. This study is part of an effort to develop simple proxies for turbidity and algal blooms and to evaluate their performance and portability between satellite imagers for regional operational turbidity and algal bloom monitoring. Turbidity algorithms were then applied to synthetic satellite images and compared to in situ measurements of turbidity, chlorophyll-a (Chl-a), total suspended solids (TSS) and phycocyanin as an indicator of cyanobacterial/blue green algal (BGA) abundance. Several turbidity algorithms worked well with real Compact Airborne Spectrographic Imager (CASI) and synthetic WorldView-2, Sentinel-2 and Sentinel-3/MERIS/OLCI imagery. A simple red band algorithm for MODIS imagery and a new fluorescence line height algorithm for Landsat-8 imagery had limited performance with regard to turbidity estimation. Blue-Green Algae/Phycocyanin (BGA/PC) and Chl-a algorithms were the most widely applicable algorithms for turbidity estimation because strong co-variance of turbidity, TSS, Chl-a, and BGA made them mutual proxies in this experiment.

Upper Eyelid Approach for the Reconstruction of Isolated Fractures of the Anterior Wall of the Frontal Sinus.

The management of frontal sinus fractures can vary widely depending on involvement of the anterior wall, the posterior wall, and the frontonasal duct. The main morbidity associated with isolated anterior wall fractures is an aesthetic deformity. Treatment includes coronal, endoscopic, and transcutaneous approaches. However, each has reported limitations and associated risks of iatrogenic injuries. In this paper, the authors discuss a novel approach through the upper eyelid crease and examine 4 cases where it is utilized for anterior frontal sinus wall, superior orbital rim, and orbital roof fracture repair.

Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study.

BACKGROUND: Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. METHODS: (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. RESULTS: (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. CONCLUSIONS: Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

Reconstruction of Extended Orbitomaxillectomy and Hemimandibulectomy Defects With Fibula Flaps and Patient-Specific Implants.

An extended orbitomaxillectomy and hemimandibulectomy for polyostotic juvenile ossifying fibroma resection were performed with the assistance of patient-specific cutting guides. The resulting defects were reconstructed in stages. First, a patient-specific mandibular reconstruction plate was fixed to the hemimandibulectomy defect in the same operation as the resection. After margins were proven to be free of tumor on histologic analysis, a free fibula flap contoured to the reconstruction plate was used to reconstruct the mandible. Reconstruction of the maxilla, alveolus, and orbit were performed with a second free fibula flap and patient-specific implants. The lining of the total nasal vault cavity was reconstructed with septal flaps. At 7 months postoperatively, the patient had an excellent esthetic result and resolved diplopia.

Polyostotic Juvenile Ossifying Fibroma: An Exceptionally Rare Case.

Accurate and early diagnosis of benign fibroosseous lesions is important because the treatment and resulting outcomes of each differ. Juvenile ossifying fibromas typically occur in young patients and grow rapidly with a high recurrence rate. Their monostotic nature has previously differentiated these tumors from other fibroosseous lesions. We describe an interesting and extremely rare case of polyostotic juvenile ossifying fibromas in a 14-year-old boy with involvement of the maxilla and mandible. The available literature on juvenile ossifying fibromas is also briefly reviewed. When diagnosing a polyostotic fibroosseous lesion, it is important to not exclude the possibility of juvenile ossifying fibromas because this may warrant a different treatment.

A True Single-Stage Reconstruction of a Projected Auricle for Concha-Type Microtia Incorporating Endoscopically Harvested Temporoparietal Fascia.

Reconstruction of microtia with autogenous costal cartilage that produces a well-projected ear in a single stage is a challenging endeavor. In this case report, we describe a single-stage, projected costal cartilage-based reconstruction of concha type mitoria. Due to the patient's low hairline, his hair-bearing scalp would encroach on the ear framework if placed subcutaneously in the standard fashion. Thus, a large TPF flap harvested with endoscopic assistance was planned to achieve both a color-matched hairless skin envelope and a well-projected ear in single stage.

The reconstructive challenges and approach to patients with excoriation disorder.

Many mental and emotional disorders have some variations of physical manifestations that are often the first definitive sign of disease. One such disorder is excoriation (skin-picking) disorder, also known as dermatillomania, acne excoriée, neurotic excoriation, or psychogenic excoriation. First identified in the dermatologic literature in 1920, excoriation disorder involves repetitive scratching behavior that sometimes accompanies pruritus and is often associated with depression, anxiety, and obsessive-compulsive disorder. In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the Diagnostic and Statistical Manual of Mental Disorders fifth edition, excoriation or skin-picking disorder is listed as a stand-alone disorder associated with obsessive-compulsive disorder. In certain patients, the skin lesions are shallow and have adherent crusts that can be mistaken for acne. These lesions, once healed, may appear white and partially atrophic. Because these patients often initially present to dermatologists or plastic surgeons for their skin conditions rather than to psychiatric professionals, it is important to recognize the salient diagnostic features and to acknowledge the importance of a multidisciplinary approach to patient care and management. We present a case of a 51-year-old woman with excoriation disorder who required medical management by dermatology, neurosurgery, psychiatry, and plastic surgery for a definitive surgical treatment.

Casting a long shadow in the classroom: an educator's perspective of the contributions of Carl Woese.

"What does one do when the giants pass away?" remarked a very famous microbiologist to me, soon after the death of Carl Woese in late 2012. I teach microbiology and introductory cell and molecular biology at a small undergraduate institution; Woese's example and contributions have long been part of every class I teach, and with good reason. Thus, I didn't know quite what to say to my colleague at first; I was still mentally processing the event.

Analgesic effectiveness of acetaminophen for primary cleft palate repair in young children: a randomized placebo controlled trial.

BACKGROUND: Clefting of the lip, palate, or both is a common congenital abnormality. Inadequate treatment for pain in children may result from concerns over opioid-related adverse effects. Providing adequate pain control with minimal adverse effects remains challenging in children. OBJECTIVES: To assess opioid-sparing effects of oral or intravenous acetaminophen following primary cleft palate repair in children. METHODS: Prospective randomized controlled trial in 45 healthy children, ages 5 months to 5 years, using standardized general anesthesia and lidocaine infiltration of the operative field. Patients were allocated to groups: intravenous acetaminophen/oral placebo (intravenous), oral acetaminophen/intravenous placebo (oral), or intravenous/oral placebo (control). Groups were compared for differences in opioid administration during the 24-h study period (morphine equivalents µg·kg(-1) ; 95% confidence interval). RESULTS: Intravenous acetaminophen decreased opioid requirement after surgery (P = 0.003). Patients in the intravenous group received less opioid (272.9; 202.9-342.8 µg·kg(-1) ) than control patients (454.2; 384.3-524.2 µg·kg(-1) ; P < 0.002). Opioid requirement in oral patients (376.5; 304.1-448.9 µg·kg(-1) ) was intermediate and not significantly different from either intravenous (P = 0.11) or control (P = 0.27). During the ward phase of care, intravenous had better analgesia than control (P = 0.002), and both intravenous and oral group patients received less opioid than control (P = 0.01). CONCLUSION: Intravenous acetaminophen given to young children undergoing primary cleft palate repair was associated with opioid-sparing effects compared to placebo. The fewer morphine doses during ward stay in both intravenous and oral may be important clinically in some settings.

Use of two cleft lip and palate classification systems by nonsubspecialized health care providers.

Objective : The purpose of this experiment was to evaluate the use of RPL and LAHSHAL coding systems by individuals not specialized in craniofacial abnormalities to code cleft lip and palate (CLP). The effectiveness of system use by referring services and the electronic medical record (EMR) applicability of other CLP systems was evaluated by literature review and testing data. Design and Participants : The RPL and LAHSHAL systems were presented together to a sample of medical students (n = 28) and neonatal intensive care unit nurses (n = 24) from Loma Linda University. Following the presentation, a test assessing the application of each system was administered. A second assessment of the medical students (n = 23) 2 weeks after the initial presentation evaluated system retention. Scores were compared using t test (P ≤ .05). Results : Both the medical students and nurses used RPL more accurately than LAHSHAL in the first assessment (76.9% versus 45.2%, P < .001; 46.6% versus 22.5%, P < .001). Medical students again used RPL more accurately at the 2-week assessment (72.2% versus 43.7%, P < .001). Accuracy of use within each system was not significantly different between the two assessments. Conclusion : Our test results and literature review indicate that, when compared with LAHSHAL, RPL is more easily and accurately used by representatives not specialized in abnormalities in CLP; therefore, RPL may be a more effective system for nonspecialist health care providers to improve the accuracy of referrals and simple EMR documentation.

A Method for Efficient De-identification of DICOM Metadata and Burned-in Pixel Text.

De-identification of DICOM images is an essential component of medical image research. While many established methods exist for the safe removal of protected health information (PHI) in DICOM metadata, approaches for the removal of PHI "burned-in" to image pixel data are typically manual, and automated high-throughput approaches are not well validated. Emerging optical character recognition (OCR) models can potentially detect and remove PHI-bearing text from medical images but are very time-consuming to run on the high volume of images found in typical research studies. We present a data processing method that performs metadata de-identification for all images combined with a targeted approach to only apply OCR to images with a high likelihood of burned-in text. The method was validated on a dataset of 415,182 images across ten modalities representative of the de-identification requests submitted at our institution over a 20-year span. Of the 12,578 images in this dataset with burned-in text of any kind, only 10 passed undetected with the method. OCR was only required for 6050 images (1.5% of the dataset).

Indirect cerebral revascularization with a temporoparietal fascial flap in pediatric moyamoya patients: a novel technique and review of current surgical options.

Moyamoya syndrome is a progressive occlusive disease of the cerebral vessels. There are a variety of surgical treatments directed at revascularizing the ischemic brain in pediatric moyamoya disease. Many reports of varying success with both direct and indirect type of procedures can be found in medical literature. We present a novel technique, encephalo-TPF-synangiosis (ETS) with a pedicled bone flap, for indirect moyamoya revascularization in pediatric patients. A three-quarters osteoplastic temporal craniotomy was created. A pedicled temporoparietal fascial flap was passed intracranially through the temporalis muscle and placed into contact with the pial surface. The bone flap was the reaffixed to the skull. We performed 8 ETS in 6 patients. This is a well-vascularized, highly reliable method that offers broad-based surface area for revascularization. We also offer a composite overview of current surgical indirect revascularization techniques.

A unique case of tessier 30 and bilateral cleft lip and palate: a new clinical syndrome?

Background : Tessier 30 cleft is rare and sparsely reported in the literature. A unique case of an infant with a Tessier 30 cleft, bilateral cleft lip and palate, and other anomalies is presented. In addition to craniofacial anomalies, he had cardiac, gastrointestinal, and genitourinal defects. The constellation of these findings suggests the possibility of a new clinical syndrome. We present these findings and postoperative results following surgical treatment. Patient and Methods : A 37-week gestational male infant with multiple congenital anomalies is presented. Findings on clinical exam were notable for Tessier 30 median mandibular cleft, bilateral cleft of the lip and palate, and bifid tongue. Further workup revealed levocardia, perimembranous moderate-to-large ventricular septal defect, patent foramen ovale, double outlet right ventricle, intestinal malrotation, and bilateral undescended testicles. There were no extremity anomalies, and cytogenetic studies for 22q deletion were negative. Results : The preoperative, intraoperative, and postoperative findings and images are discussed. Conclusion : We present a unique case of a child with a Tessier 30 cleft associated with bilateral cleft lip and palate in the absence of intraoral masses or limb anomalies. Previous reports of median facial clefts have occurred either in the presence of intraoral hamartomas, suggesting the palatal defects are a result of sequence abnormalities, or in association with extremity findings consistent with the spectrum of orofaciodigital syndrome. The case we present is distinct and may represent a new clinical syndrome.

Myo/Nog Cells Give Rise to Myofibroblasts During Epiretinal Membrane Formation in a Mouse Model of Proliferative Vitreoretinopathy.

Purpose: Myo/Nog cells are the source of myofibroblasts in the lens and synthesize muscle proteins in human epiretinal membranes (ERMs). In the current study, we examined the response of Myo/Nog cells during ERM formation in a mouse model of proliferative vitreoretinopathy (PVR). Methods: PVR was induced by intravitreal injections of gas and ARPE-19 cells. PVR grade was scored by fundus imaging, optical coherence tomography, and histology. Double label immunofluorescence localization was performed to quantify Myo/Nog cells, myofibroblasts, and leukocytes. Results: Myo/Nog cells, identified by co-labeling with antibodies to brain-specific angiogenesis inhibitor 1 (BAI1) and Noggin, increased throughout the eye with induction of PVR and disease progression. They were present on the inner surface of the retina in grades 1/2 PVR and were the largest subpopulation of cells in grades 3 to 6 ERMs. All α-SMA-positive (+) cells and all but one striated myosin+ cell expressed BAI1 in grades 1 to 6 PVR. Folds and areas of retinal detachment were overlain by Myo/Nog cells containing muscle proteins. Low numbers of CD18, CD68, and CD45+ leukocytes were detected throughout the eye. Small subpopulations of BAI1+ cells expressed leukocyte markers. ARPE-19 cells were found in the vitreous but were rare in ERMs. Pigmented cells lacking Myo/Nog and muscle cell markers were present in ERMs and abundant within the retina by grade 5/6. Conclusions: Myo/Nog cells differentiate into myofibroblasts that appear to contract and produce retinal folds and detachment. Targeting BAI1 for Myo/Nog cell depletion may be a pharmacological approach to preventing and treating PVR.

Genome sequences of four agarolytic bacteria from the Bacteroidia and Gammaproteobacteria.

Here we present the genomes of four marine agarolytic bacteria belonging to the Bacteroidota and Proteobacteria. Two genomes are closed and two are in draft form, but all are at least 99% complete and offer new opportunities to study agar-degradation in marine bacteria.

Demographics of cleft care providers in Africa and reported experience in training and practice: direct analysis of continent-based practitioners.

OBJECTIVE: To elucidate the impact of several geographic, cultural, and socioeconomic variables on cleft care delivery in Africa, and to investigate the current status of cleft care delivery in Africa. DESIGN: Survey of practitioners attending the second Pan-African Congress on Cleft Lip and Palate (PACCLIP). SETTING: The annual PACCLIP conference in Ibadan, Nigeria, West Africa, February 2007. MAIN OUTCOME MEASURE: To provide an analysis of the demographics and training experience of cleft care providers in Africa by collating information directly from the continent-based practitioners. RESULTS: Plastic surgeons and oral and maxillofacial surgeons provide the majority of cleft care. Most of the participants reported availability of formal training programs in their respective countries. The predominant practice settings were university and government-based. During training, half of the providers had encountered up to 30 cleft cases, and a quarter had managed more than 100 cases. Representation of visiting surgeons were equally distributed between African and non-African countries. CONCLUSIONS: This study provides initial and detailed analysis crucial to understanding the underlying framework of cleft care composition teams, demographics of providers, and training and practice experience. This awareness will further enable North American and other non-African plastic surgeons to effectively partner with African cleft care providers to have a further reaching impact in the region.

Exploring the impact of a mindfulness meditation class on college student stress levels and quality of life.

Objective: This study explored the differences in perceptions of stress levels and quality of life amongst college students enrolled in mindfulness meditation classes and those enrolled in an introductory holistic health class. Participants: 236 undergraduate students at a mid-sized university completed coursework and surveys. Methods: One-credit mindfulness meditation classes and an introductory holistic health class, serving as the control group, were offered over the course of one semester. Pre- and posttest questionnaires on stress and quality of life were administered to the participants. Results: Students enrolled in mindfulness meditation classes began with higher stress levels and lower perceptions of their quality of life compared to the control group. The mindfulness meditation class participants ended with both significantly lower stress levels and higher quality of life scores then the control group. Conclusions: Offering mindfulness meditation classes for credit may help promote positive mental health and well-being for students on a college campus.