Safety and Benefits of Intraoperative Enteral Nutrition in Critically Ill Pediatric Burn Patients: A Systematic Review and Pooled Analysis.

Burn injuries significantly increase a patient's metabolic demand. Adequate nutrition is essential as an adjunct to recovery and reducing morbidity and mortality. In contrast to adults, this is especially important for pediatric patients who have limited reserves and are in a period of growth. Burn patients often require multiple anesthetic procedures that are accompanied by standard perioperative fasting periods that result in substantial nutritional interruptions. Continuous intraoperative feeding has been proposed as a solution, but there is no current consensus on its role and safety, particularly in the pediatric population. Thus, the goal of this study was to examine the safety and benefits of intraoperative nutrition in critically ill pediatric burn injured patients. A systematic review of MEDLINE, PubMed, Scopus, and Web of Science was conducted using the following terms: feeding or enteral or nutrition or fasting and adolescent or youth or pediatric or child or teen and burn or thermal injury or fire. The primary outcome was incidence of aspiration. Secondary outcomes included patient nutritional status (caloric deficit and weight), wound healing, days spent in the intensive care unit, ventilator days, pneumonia, number of surgeries, length of hospital stay, and mortality. Pooled analyses of binary outcomes were computed. Four studies consisting of 496 patients, met inclusion criteria. All studies were level IV evidence, but had high methodological quality. The median burn TBSA was 43.8% (interquartile range 33.4%-58.8%), with a median of 30% of patients having an inhalational injury. Patients underwent a median of 4.2 surgeries (interquartile range 1.8-7.4). Intraoperative feeding was conducted through nasoduodenal tubes. There were no aspiration events. Pooled analysis demonstrated that there were no differences in rates of aspiration, pneumonia, or wound infection (P > .05) between patients who were intraoperatively fed and those who were not. Those fed intraoperatively had significantly more surgeries, ventilator days, longer hospital stays, but lower mortality (P < .05). There was large heterogeneity in nutritional assessment methods. Intraoperatively fed patients had an average gain of 144.4 kcal/kg, 1.7 days of exclusive enteral nutrition (vs loss of -119.1 kcal/kg and -1.4 days), and a cumulative positive caloric balance of +2673 kcal ± 2147 (vs loss of -7899 kcal ± 3123) compared to those with interrupted feeding. Continuous intraoperative duodenal feeding during burn surgery appears to be safe in the pediatric burn population, with no reported episodes of aspiration. Uninterrupted feeding was also associated with weight maintenance and reduced caloric deficit. It may also have a survival benefit, as continuously fed patients needed more surgeries and intensive/hospital care, but had decreased mortality.

What makes global healthcare partnerships successful? A systematic review.

Academic communities are increasingly involved in efforts to address the overwhelming burden of disease in low-middle income countries. There is, however, little research dedicated to understanding the best approach to creating a successful and sustainable global healthcare project. Our objective was to review the shared characteristics of successful healthcare partnerships between high- and low-middle income countries. Two independent reviewers conducted a systematic review. Articles, describing collaborative, healthcare partnerships between a high- and low-middle income countries between 1910 and September 2018, were included. Twenty-six articles were included. The majority of collaborations were initiated by either the host institution or as a joint decision between institutions. The primary goal of these collaborations revolved around medical education/training and curriculum development. Two partnerships, after more than a decade of collaboration, had achieved a self-sustaining programme. Lack of funding was identified as a major barrier to sustainability. Successful global healthcare partnerships require true collaboration and equal participation of all partners. Funding should be secured prior to programme development in anticipation of a minimum 10-year project. A minimum list of guidelines has been proposed to improve the chances of both a successful and sustainable collaboration.

Reduction Mammaplasty for Macromastia in Adolescents: A Systematic Review and Pooled Analysis.

BACKGROUND: Reduction mammaplasty for macromastia is one of the most common operations performed by plastic surgeons. There remains hesitancy in operating on adolescents, as there is ongoing debate about breast regrowth and potential impact on breastfeeding. The goal of this study was to analyze these concerns by reviewing the current literature. METHODS: A systematic review of MEDLINE, Scopus, and Google Scholar was conducted using the following terms: "breast reduction" or "mammaplasty" or "breast reconstruction" and "adolescent" or "youth" or "pediatric" or "child" or "teen." Primary outcomes were success of breastfeeding after the procedure and procedure-related complications. RESULTS: Twenty-three studies (87 percent retrospective), consisting of 2926 patients with preoperative cup sizes of C to KK (mean, DDD), met inclusion criteria. Mean age at the time of surgery ranged from 16 to 21 years, with the youngest patient being 12 years old. The overall complication rate was 27.3 percent (95 percent CI, 14.4 to 42.5 percent). Minor complications (22.8 percent; 95 percent CI, 10.2 to 38.5 percent) were more common than major (4.2 percent; 95 percent CI, 1.6 to 7.9 percent). Eighteen percent of patients (95 percent CI, 2.2 to 43.8 percent) reported regrowth of their breast tissue postoperatively, with 2.7 percent (95 percent CI, 0.9 to 5.5 percent) undergoing a second revision mammaplasty. Fifty-three percent of patients (95 percent CI, 36.0 to 69.3 percent) did not attempt breastfeeding. Of those who attempted, 55.1 percent (95 percent CI, 34.4 to 74.9 percent) were successful. CONCLUSIONS: Prospective data are lacking. Patient counseling should focus on encouraging a trial of breastfeeding, despite surgical history. One-fifth of adolescent patients may notice breast regrowth postoperatively; however, the amount of regrowth is likely small and unlikely to reexacerbate symptoms, as the rate of revision surgery is small.

#Cleftlip/Palate: What Is the World Talking About?

OBJECTIVE: Studies have begun analyzing how the world converses on social media platforms about medical/surgical topics. This study's objective was to examine how cleft lip and palate, two of the most common birth defects in the world, are discussed on the social media platform Twitter. No study to date has analyzed this topic. METHODS: Tweets were identified using any of the following: cleft, cleft lip, cleft palate, #cleft, #cleftlip, #cleftpalate. Eight months between 2017 and 2018 were analyzed. MAIN OUTCOME MEASURES: The primary outcome was the tweet subject matter. Secondary outcomes were author characteristics, tweet engagement, multimedia, and tweet accuracy. RESULTS: A total of 1222 tweets were included. #Cleft was the most common hashtag (71%), and it was significantly associated with more retweets (P = .03). Twenty-seven countries tweeted, with the United States (34%) and India (27%) producing the most. Charities (36%), hospitals (14%), and physicians (13%) were the most common authors. Over three-quarters of tweets were self-promotional. The top content included charity information (22%) and patients' cleft stories (14%). Tweets about patient safety/care and surgical service trips generated the most engagement. The accuracy of educational tweets was 38% low accuracy and 1% inaccurate. One hundred forty-nine tweets (12%) discussed a published research article, but 41 tweets did not share a link. CONCLUSIONS: Charities dominate the cleft lip/palate "Twitterverse." Most tweets were self-promotional, and over a third of educational tweets were low accuracy. As the cleft social media community continues to grow, we recommend using the hashtag #cleft to reach a wider audience.

Discrepancies between Registered and Published Primary and Secondary Outcomes in Randomized Controlled Trials within the Plastic Surgery Literature: A Systematic Review.

BACKGROUND: Recent studies have identified a high incidence of discrepancy between registered and published outcomes in registered medical and surgical randomized controlled trials. This has not yet been studied in the plastic surgery literature. METHODS: The authors systematically assessed plastic surgery randomized controlled trials published between 2012 and 2016 in seven high-impact plastic surgery journals. Data were collected from the registration website and published articles using a standardized data extraction form. RESULTS: A total of 145 randomized controlled trials were identified, with a 39 percent trial registration rate (n = 57). Forty-nine trials were included in the final analysis. Forty-three (88 percent) had a discrepancy between registered and published outcomes: 26 (53 percent) for primary outcome(s), and 39 (80 percent) for secondary outcome(s). The number of discrepancies in an individual trial ranged from one to seven for primary outcomes and one to 12 for secondary outcomes. Aesthetic surgery had the largest number of trials with outcome discrepancies (n = 15). The prevalence of unreported registered outcomes was 13 percent for primary outcomes and 38 percent for secondary outcomes. Registered nonsignificant primary outcomes were published as nonsignificant secondary outcomes in 30 percent of trials. Publishing new nonregistered secondary outcomes (65 percent) and changing the assessment timing of published primary outcomes (61 percent) were the most common types of discrepancies. Discrepancies favored a statistically significant positive outcome in 19 (44 percent) of the 43 trials with an outcome discrepancy. Discrepancies that resulted in published outcomes with improved patient relevance were found in eight trials (16 percent) for primary outcome discrepancies and 14 trials (29 percent) for secondary outcome discrepancies. CONCLUSIONS: The plastic surgery literature has high rates of discrepancies between registered and published trial outcomes. Outcome reporting discrepancy is even more problematic for secondary outcomes, an area of analysis that has previously been poorly studied. The high rate of discrepancy change favoring a statistically significant outcome and more patient-relevant outcomes may indicate the pressure to demonstrate significant results to be accepted for publication in high-impact journals.

Reporting Adverse Events in Plastic Surgery: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Accurate knowledge of adverse events is critical for evaluation of the safety of interventions. Historically, adverse events in surgical trials have been poorly reported. The objective of this study was to systematically evaluate the reporting of adverse events in randomized controlled trials in the plastic surgery literature. METHODS: Two independent reviewers conducted a systematic search using MEDLINE, Embase, and Scopus of the top seven plastic surgery journals with the highest impact factors. Randomized controlled trials describing a potentially invasive treatment, published between January of 2012 and December of 2016, were included. RESULTS: One hundred forty-five randomized controlled trials involving 10,266 patients were included, of which 30 percent were registered. Anticipated adverse events were clearly defined in 15 percent of trials, and in 70 percent it was not clear who would be documenting adverse events. Furthermore, 72 percent of randomized controlled trials reported the occurrence of adverse events, of which 61 percent failed to report events occurring in the intrainterventional period. Binary logistic regression revealed that funded randomized controlled trials were 4.04 times more likely to report adverse events compared with nonfunded randomized controlled trials (95 percent CI, 1.41 to 10.83; p = 0.009). CONCLUSIONS: The authors' findings suggest the need for reporting standards for adverse events in the plastic surgery literature, as such reporting remains heterogeneous and is lacking rigor. Improved quality and transparency are needed to strengthen evidence-based practice and permit a balanced intervention assessment. This study provides a set of recommendations aimed at improving adverse event reporting.