Monobloc Differential Distraction Osteogenesis.

ABSTRACT: Midface advancement at the monobloc level can be the seminal life event for patients with craniofacial dysostosis. Monobloc reconstruction, when planned appropriately, can simultaneously and definitively address multiple functional and aesthetic deficiencies in these patients. The application of distraction has reduced the morbidity experienced with traditional monobloc surgery. The purpose of this study is to report on the outcomes, stability, and growth in younger patients after monobloc advancement in syndromic craniosynostosis patients. The authors report a consecutive series of thirty patients with craniofacial dysostosis treated through monobloc differential distraction osteogenesis. Detailed history, photographic, and long-term radiographic data are reviewed, including a subset of patients who were skeletally immature at the time of their treatment. Differential distraction allows control of midface pitch, roll, and yaw, optimizing functional and aesthetic outcomes. There were no infectious complications requiring reoperation. The average surgical age for all patients was 12.5 years. For the 7 patients age <7 years, average age was 6 years. For all patients, the mean horizontal movement was 12 mm at nasion and 10 mm at A-point. At mean follow-up (4.8 years entire group and 6.2 years age <7 years group) a positive horizontal advancement of 1.1 mm at nasion and 0.8 mm at A-point was observed. More pronounced positive horizontal changes were seen in the age <7 years group. Monobloc differential distraction osteogenesis affords safe and precise repositioning of the midface. The advancement is skeletally stable and young patients show moderate continued growth.

Persistent Intracranial Hypertension in a Cranial Vault Remodeling Patient With Open Skull Fractures From Horse Kick.

A 4-year-old female with prior cranial vault remodeling for nonsyndromic bilateral coronal craniosynostosis sustained a severe traumatic brain injury with open skull fractures from a horse kick. Her post-traumatic course was complicated by persistently elevated intracranial pressure despite neurosurgical decompressions, maximum medical therapy, and trial of multiple pressure monitoring devices. She eventually had improvement in her intracranial pressures and made a full neurologic recovery. This case highlights the potential severity of horse kick injuries, the possible etiology of persistent intracranial hypertension in cranial vault remodeling patients following traumatic brain injury, the importance of a multi-team approach in the initial evaluation and postoperative follow-up of all craniosynostosis patients, and the necessity of helmet utilization.

Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate.

OBJECTIVE: To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P). DESIGN: This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound. SETTING: The study population was selected from an academic, tertiary care center between 2003 and 2011. PATIENTS/PARTICIPANTS: Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size. RESULTS: There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all). CONCLUSIONS: Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Pediatric Blood Management Protocol in Cranial Vault Surgery.

BACKGROUND: Cranial vault surgeries are invasive, extensive procedures with blood transfusions being frequently required. Previous interventions have been described to attempt to decrease the transfusion burden. The objective of this study is to determine if a Pediatric Blood Management (PBM) team can reduce transfusion requirements in children undergoing cranial vault surgery. METHODS: A protocol was developed which involved preoperative optimization of hemoglobin (Hb), intraoperative use of tranexamic acid, cell saver technology, and blood sparing operative techniques. Patients were preoperatively screened with basic laboratory testing. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior were used as controls. Prospective data on patients was collected. RESULTS: Groups were similar in age and weight. Postoperative Hb measurements were similar, with the control group 10.9 ±â€Š2.2 g/dL and the intervention arm 9.6 + 2.7 g/dL. Discharge Hb concentrations also were similar with 9.6 ±â€Š1.6 g/dL and 9.7 ±â€Š2.5 g/dL in the control and PBM group, respectively. The rate of transfusion decreased from 80% to 42% after protocol implementation (P = 0.007). During the last 6 months of data collection, the transfusion rate decreased further to 17%. Furthermore, 4 patients were found to have von Willebrand disease preoperatively with only 1 requiring a transfusion. CONCLUSIONS: The authors found that the institution of a PBM team reduced the transfusion burden of patients, including complex patients with von Willebrand disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications.

Trends in Enteral Access Placement Among Patients With Oral Clefts: Evaluation of 46 617 Patient Admissions.

OBJECTIVE: It is well known that patients with oral clefts have challenges with feeding. Enteral feeding access, in the form of gastrostomy, is often utilized to supplement or replace oral intake. Although commonly performed, these procedures have reported complication rates as high as 83%. We intend to discover rates of enteral access in patients with oral clefts and report-related outcomes. DESIGN: The Healthcare Cost Utilization Project Kids' Inpatient Database from 2000 to 2012 was analyzed using patients with oral clefts and enteral access procedures. The χ2 test was used for univariate analyses of proportions, and linear regression was used to analyze trends. Multivariate logistic regression was used to analyze odds ratios. RESULTS: Of the 46 617 patient admissions included, 14.6% had isolated cleft lip (CL), 51.7% cleft lip and palate (CLP), and 43.7% isolated cleft palate. The rates of enteral access in the oral cleft population increased from 3.7% in 2000 to 5.8% in 2012 ( P < .001). Increased rates were identified in patients with ( P = .019) and without ( P < .001) complex conditions. A significant increase in the rate of enteral access was seen in patients with CLP ( P < .001) and isolated cleft palate ( P < .001). No difference was seen in the isolated CL group ( P = .096). Patients with complex conditions were at a 4.4-fold increased risk and those admitted to urban, teaching hospitals were at a 4.7-fold risk of enteral access placement. CONCLUSIONS: The rates for enteral feeding access increased significantly from 2000 to 2012. The reasons for the increased incidence are unclear. Invasive enteral access procedures have been shown to have a multitude of complications. Careful patient selection should be done before placement of invasive enteral access.

Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.

The Evolution of Iliac Bone Graft Donor Site Analgesia in Cleft Patients: Transversus Abdominis Plane Block Is Safe and Efficacious.

BACKGROUND: The transversus abdominis plane (TAP) block has been increasingly used as a means of abdominal wall analgesia. This study aims to determine if TAP block analgesia provides a benefit in cleft patients undergoing alveolar bone grafting with iliac crest cancellous bone graft. METHODS: Two groups of 20 consecutive patients undergoing alveolar bone grafting with iliac crest cancellous bone with either TAP block or indwelling catheter pain pump were examined in a retrospective fashion. Demographic data, pharmacologic use, and hospital length of stay were examined. RESULTS: Mean lengths of stay were identical between both groups. Patients in both groups received similar cumulative doses of morphine equivalents, codeine, ibuprofen, and ondansetron at 6 and 24 hours postoperatively. Transversus abdominis plane block patients received greater amounts of Tylenol at both 6 and 24 hours (P = 0.0015 and P = 0.0106). Pain scores did not differ significantly across our groups at 6 or 24 hours postoperatively. No adverse events were reported with the TAP block procedure. CONCLUSIONS: Patients undergoing TAP blocks receive the benefit of a single stage procedure without an indwelling catheter and similar 6- and 24-hour morphine usage. Given the safety profile of the procedure, its effectiveness and comfort without indwelling catheter, we advocate for TAP block analgesia as an adjunct therapy in the management of postoperative pain in this population.

A Novel Treatment of Nasal Stenosis Using Steel Gauging Earrings.

Nasal stenosis is an uncommon and challenging deformity. Most common etiologies for nasal stenosis include congenital, iatrogenic, trauma, and infection. Repair techniques typically include tissue replacement with grafts or flaps with subsequent stent placement. These procedures often require general anesthesia and carry high rates of restenosis. We describe a case of a 10-year-old girl with Teebi syndrome and iatrogenic nasal stenosis who underwent successful nasal dilation with inexpensive, minimally invasive steel gauge earrings.

Repair of Oropharyngeal Stenosis With Bilateral Buccal Myomucosal Flaps.

Oropharyngeal stenosis (OPS) is a rare postoperative complication of adenotonsillectomy that can be a source of considerable patient distress and morbidity. Circumferential scarring of the soft palate and tonsillar pillars leads to narrowing of the oropharyngeal aperture. This case report describes the novel use of bilateral buccal myomucosal flaps for the repair of postoperative OPS in a 20-year-old woman presenting with dysphagia, odynophagia, dyspnea, and intermittent hypernasal speech. Postoperatively, the patient noted immediate improvement of her symptoms. At 1-month follow-up, she noted complete resolution of her symptoms with no dysphagia, nasal regurgitation, speaking difficulty, dyspnea, or gagging. The buccal flaps were well healed and completely intact, maintaining appropriate height of the tonsillar pillars. The buccal myomucosal flap is an effective tool for numerous palatal and oropharyngeal abnormalities and, as described in this case study, is a reliable, safe, and effective technique that can be considered for the reconstruction of postsurgical OPS.

Deep Venous Thrombosis in Teen With Crouzon Syndrome Post-Le Fort III Osteotomy With Rigid External Distraction.

Venous thromboembolic events are rare in pediatric patients. Risk factors associated with the development of venous thromboembolic events in pediatric patients include the use of central venous catheters, hospitalization, cancer, sepsis, trauma, surgery, and congenital prothrombotic disorders.The authors present the case of a 14-year-old man with Crouzon syndrome who required Le Fort III osteotomy with rigid external distraction for significant midface hypoplasia who presented postoperatively with an extensive deep venous thrombosis. This is the first reported case of symptomatic venous thrombosis post-Le Fort III osteotomy and rigid external distraction. Although rare, surgeons should be aware of this potential complication.

The Millard Rotation-Advancement Cleft Lip Repair: 50 Years of Modification.

Since its inception in 1955, Millard's rotation-advancement repair has been one of the most popular techniques used in the care of patients with a cleft lip. Over the past half century, Millard's repair has evolved and laid the foundation for many other repair techniques that have followed in its footsteps. This publication compares Millard's rotation-advancement technique to the various repairs used today. The purpose of this article is to lend perspective as to the impact of Millard repair over the past 50 years in the treatment of cleft lip.

Evolution of abdominal wall reconstruction: development of a unified algorithm with improved outcomes.

INTRODUCTION: Ventral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS) for large defects. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for repair. METHODS: One hundred five consecutive patients undergoing VHR for large midline hernias over 9 years were examined. Patients were divided into those operated on after (group 1) and before (group 2) the institution of our simplified algorithm. Our algorithm emphasizes careful patient selection and a stepwise approach including, but not limited to, bilateral CS if appropriate, preservation of large perforators, retrorectus mesh placement as appropriate, linea alba or midline fascial closure, and vertical panniculectomy. Primary outcomes evaluated included wound infection, dehiscence, and hernia recurrence. RESULTS: Seventy-eight (74.3%) patients underwent repair using our algorithm (group 1), whereas 27 (25.7%) underwent repair before utilization of this algorithm (group 2). Ninety-eight (93.3%) underwent CS, whereas 7 (6.7%) underwent another form of VHR. There was no significant difference in patient age or defect size. The mean follow-up period in days for patients in group 1 and group 2 were 184.02 and 526.06, respectively (P < 0.001). Hernia recurrence in group 1 was 2.6% versus 29.6% in group 2 (P < 0.001). The incidence of wound infection in group 1 was 10.3%, whereas that in group 2 was 33.3% (P < 0.001). The rate of wound dehiscence in group 1 was 17.9% versus 25.9% in group 2 (P < 0.001). CONCLUSIONS: Simplifying and unifying our algorithm for VHR, notably with utilization of CS, has yielded improved results. Recurrence and wound healing complications using this approach are favorable compared with published outcomes.

Treatment of plagiocephaly with helmet molding therapy: do actual results mimic perception?

PURPOSE: Actual and perceived improvements from helmet molding therapy for deformational plagiocephaly are demonstrated here. Effective communication of these data by craniofacial teams can help avoid unrealistic expectations and inform parents of expected outcomes. METHODS: Parents of 61 patients with plagiocephaly were asked to rate their children's head shape and ear position before and after helmet therapy (a score of 1 being abnormal and 10 being normal). Topographic laser head scans for an aged-matched cohort of 91 patients with deformational plagiocephaly were acquired. Cephalic ratio, overall symmetry ratio, radial symmetry index, ear offset, and left and right oblique were recorded before and after molding. The cranial vault asymmetry index (CVSI) score was calculated. RESULTS: Parent ratings before and after molding, respectively, were head shape 2.99 ± 1.50 (mean ± SD) versus 7.88 ± 1.64 (p < .0001) and ear position 3.75 ± 2.5 versus 7.73 ± 2.34 (p < 0.0001). Measurements before and after molding were cephalic ratio 0.89 ± 0.07 versus 0.87 ± 0.08 (p < .0001), overall symmetry index 0.87 ± 0.05 versus 0.90 ± 0.04 (p < .0001), radial symmetry index 59.9 ± 26.9 mm versus 46.3 ± 25.1 mm (p < .0001), CVSI 7.2 ± 3.75 versus 4.8 ± 2.8 (p < .0001), and ear offset 5.7 versus 5.5 mm (p  =  .58). CONCLUSIONS: Helmet molding produces reproducible changes in head shape. Despite relatively small actual changes on topographic laser imaging, parents perceive a large correction in head shape and ear position following helmet molding. Craniofacial teams can use these data and head scans before helmet molding to provide parents with realistic expectations for the outcome of their child's helmet molding therapy.

Continuous bupivacaine infusion in iliac bone graft donor sites to minimize pain and hospitalization.

PURPOSE: To assess the efficacy of continuous bupivacaine infusion at the iliac crest donor site in reducing postoperative pain and inpatient hospital stay. METHODS: Forty consecutive cleft lip/palate patients who underwent alveolar bone grafting at a single institution between 2003 and 2008 were identified, and their charts were retrospectively reviewed. Opioid analgesic use, self-reported pain indices, and length of hospital stay were analyzed. Comparisons were made between those patients who received a bupivacaine infusion pump at the iliac crest harvest site and those who did not. RESULTS: Twenty patients underwent iliac crest bone graft harvest followed by intraoperative placement of a continuous 0.25% bupivacaine infusion pump, and 20 were managed primarily with postoperative intravenous and parenteral analgesics. There were no statistically significant differences in demographics between the two cohorts. Those patients receiving continuous bupivacaine had a decreased length of hospital stay (mean, 2.9 versus 1.4 days; p = .0077), a statistical trend toward decreased opioid use (p = .032), and a lower average subjective pain score on the day of surgery (p = .0058). CONCLUSION: There is a significant decrease in the length of hospitalization when using a continuous local infusion pump to deliver bupivacaine to the iliac crest following bone graft harvest. The pump is tolerated by patients and carries little morbidity. As such, the benefit of reduced cost from a reduced hospital stay is worthwhile. Continuous bupivacaine infusion is recommended for the iliac crest donor site.

Incidence of use of acid suppression medications in infants with oral clefting.

OBJECTIVE: Less than 1% of the general pediatric population needs pharmacologic therapy for reflux symptoms; yet, the co-existence of gastroesophageal reflux disease (GERD) with oral clefting remains unclear. The purpose of this retrospective study was to appreciate the difference in the incidence of anti-GERD pharmacotherapy in a sample population of infants with oral clefting compared to the general pediatric population. MATERIALS AND METHODS: One hundred ninety-six consecutive patients diagnosed with cleft lip only, cleft lip and palate, and isolated cleft palate were analyzed through clinical record review. Demographic and clinical information including but not limited to the type of oral cleft present at birth, reported signs and symptoms of GERD, and anti-GERD medications used were compiled for all subjects. Collected data were analyzed using descriptive statistics. RESULTS: Sixty-four (33%) of 196 infants with oral clefts had documented signs and symptoms of GERD. Nine percent (18 of 196) of the subjects received anti-GERD medications. The infant subgroup with treated GERD consisted of 11 out of 62 (18%) patients with isolated cleft palate, 5 of 112 (4.5%) with cleft lip and palate, and 2 of 17 (11%) with cleft lip only. CONCLUSIONS: The incidence of anti-GERD pharmacologic therapy among infants with oral clefts (9%) is significantly higher than among the general pediatric population (<1%). Furthermore, palatal clefts impart a greater risk of GERD symptoms than clefts of the alveolus, lip, or nose. In order to minimize the long-term consequences of GERD, a standardized interdisciplinary clinical protocol is necessary for evaluating infants with oral clefts.

Pediatric Procedural Sedation in the Emergency Setting.

BACKGROUND: Pediatric emergency department (ED) visits are common. Many are due to injury, which require procedural treatments with sedation. There are many well researched independent predictors of adverse events for pediatric procedural sedation. The duration of sedation as a predictor of adverse events has not been well studied. This study aims to determine the complication rate and severity of procedural sedation as well as determine if the duration of sedation is correlated with an increased risk of complications. METHODS: After Institutional Review Board approval, a retrospective study was performed on all patients seen at Helen Devos Children's ED who received sedation from August 1, 2011, to August 15, 2016. Study variables included age, weight, type of procedure, American Society of Anesthesiologist (ASA) physical status class, Mallampati score, comorbidities, sedation medication, sedation time, and complication. A logistic regression was performed assessing risk factors for complications. Statistical significance was assessed at P < 0.05. RESULTS: There were 1,814 patients included in the study. Median sedation time was 20 minutes. There were 70 (3.9%) total complications. Controlling for age, weight, comorbidities, ASA class, Mallampati score, and total sedation medication, sedation time was a significant predictor of a complication (odds ratio: 1.021; 95% CI, 1.004-1.039). CONCLUSIONS: Pediatric patients can safely undergo procedural sedation in the ED. This study demonstrates a high safety profile for long procedural sedations with slight increases in risk as sedation time increases. There is no identifiable time where the duration of sedation significantly increases the risk of complication.

Performance on the Plastic Surgery In-Service Examination Can Predict Success on the American Board of Plastic Surgery Written Examination.

BACKGROUND: Originally developed for resident self-assessment, the Plastic Surgery In-Service Examination has been administered for over 45 years. The Accreditation Council for Graduate Medical Education requires that at least 70 percent of graduates pass the American Board of Plastic Surgery Written Examination on their first attempt. This study evaluates the role of In-Service Exam scores in predicting Written Exam success. METHODS: In-Service Exam scores from 2009 to 2015 were collected from the National Board of Medical Examiners. Data included residency training track, training year, and examination year. Written Exam data were gathered from the American Board of Plastic Surgery. Multivariate analysis was performed and receiver operating characteristic curves were used to identify optimal In-Service Exam score cut-points for Written Exam success. RESULTS: Data from 1364 residents were included. Residents who failed the Written Exam had significantly lower In-Service Exam scores than those who passed (p < 0.001). Independent residents were 7.0 times more likely to fail compared with integrated/combined residents (p < 0.001). Residents who scored above the optimal cut-points were significantly more likely to pass the Written Exam. The optimal cut-point score for independent residents was the thirty-sixth percentile and the twenty-second percentile for integrated/combined residents. CONCLUSIONS: Plastic Surgery In-Service Exam scores can predict success on the American Board of Plastic Surgery Written Exam. Residents who score below the cut-points are at an increased risk of failing. These data can help identify residents at risk for early intervention.

The impact of the repeal of Michigan's universal helmet law on traumatic brain injury: A statewide analysis.

BACKGROUND: In April of 2012, Michigan repealed its 35-year-old universal motorcycle helmet law in favor of a partial helmet law, which permits motorcyclists older than 21 years old with sufficient insurance and experience to drive un-helmeted. We evaluated the clinical impact of the repeal. METHODS: The Michigan Trauma Quality Improvement Program's trauma database was queried for motorcycle crash patients between 1/1/09-4/12/12 and between 4/13/12-12/31/14. RESULTS: There were 1970 patients in the pre-repeal analysis and 2673 patients in the post-repeal analysis. Following the repeal, patients were more likely to be un-helmeted (p < 0.001) and to have a traumatic brain injury (p < 0.001). Patients were also more likely to require neurosurgical interventions (relative risk 1.4, p = 0.011). CONCLUSION: Following the repeal of the universal helmet law, there has been a significant increase in traumatic brain injuries and neurosurgical interventions. This analysis highlights another detrimental impact of the repeal of the universal helmet law.

The Double Opposing Z-Plasty Plus or Minus Buccal Flap Approach for Repair of Cleft Palate: A Review of 505 Consecutive Cases.

BACKGROUND: Standard methods of cleft palate repair rely on existing palatal tissue to achieve closure. These procedures often require relaxing incisions, causing scars and growth restriction, and may result in insufficient palatal length and suboptimal positioning of the velar musculature. The Furlow double opposing Z-plasty improves palatal length and repositions the velar musculature; however, relaxing incisions may still be needed. The addition of buccal flaps to the Furlow repair obviates the need for relaxing incisions and allows the Furlow repair to be used in wide clefts. METHODS: A retrospective review was performed on 505 patients; all patients were treated with the double opposing Z-plasty plus or minus buccal flap approach. Outcomes included nasal resonance, secondary speech surgery, and postoperative complications. A comparison was made between patients treated with double opposing Z-plasty alone and those treated with double opposing Z-plasty plus buccal flaps. RESULTS: The average nasal resonance score was 1.38 and was equivalent in both the double opposing Z-plasty alone and with buccal flap groups, despite significantly more wide clefts in the buccal flap group (56 percent versus 8 percent). The secondary surgery rate for velopharyngeal insufficiency was 6.6 percent and the fistula rate was 6.1 percent. The large fistula rate (>2 mm) was 2.7 percent. CONCLUSIONS: The double opposing Z-plasty plus or minus buccal flap approach is a useful alternative to standard palate repairs. Speech outcomes were excellent, even in wider clefts, and postoperative complications were minimal. Buccal flaps allow the benefits of the Furlow repair to be applied to any size cleft, without the need for relaxing incisions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.