Factors Associated with Receipt of Adjuvant Chemotherapy in Stage II Colon Cancer.

BACKGROUND: The benefits of chemotherapy in stage II colon cancer remain unclear, but it is recommended for high-risk stage II disease. Which patients receive chemotherapy and its impact on survival remains undetermined. METHODS: The National Cancer Database was surveyed between 2004 and 2016 for stage II colon cancer patients. Patients were categorized as high- or average-risk as defined by the National Comprehensive Cancer Network. The demographic characteristics of high- and average-risk patients who did and did not receive chemotherapy were compared using univariate and multivariable analyses. The survival of high- and average-risk patients was compared based on receipt of chemotherapy with Cox hazard ratios and Kaplan-Meier curves. RESULTS: Overall, 84,424 patients met the inclusion criteria. A total of 34,868 patients were high-risk and 49,556 were average-risk. In high-risk patients, the risk factors for not receiving chemotherapy included increasing age, distance from the treatment facility, Charlson-Deyo score, and lack of insurance. In average-risk patients, factors associated with receipt of chemotherapy were decreasing age, distance from the treatment facility, Charlson-Deyo score, and non-academic association of the treatment facility. In both, chemotherapy was significantly associated with increased survival on the Kaplan-Meier curve. In the Cox hazard ratio, only high-risk patients benefited from chemotherapy (hazard ratio 1.183, confidence interval 1.116-1.254). CONCLUSIONS: Factors associated with not receiving chemotherapy in high-risk stage II colon cancers included increasing age, medical comorbidities, increasing distance from the treatment facility, and lack of insurance. Chemotherapy is associated with improved overall survival in high-risk patients.

An analysis of publications originating from abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting.

BACKGROUND: Research presentation has benefits, including CV building, networking, and collaboration. A measurable standard for achievement is publication in a peer-reviewed journal. Expectations regarding the likelihood of publication are unknown for studies presented at a national surgical scientific meeting. This study aims to evaluate predictors of manuscript publication arising from abstracts presented at a national surgical scientific meeting. METHODS: Abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting 2019 were reviewed. Identification of published manuscripts was completed using MedLine, Embase, and Google Scholar 28 months after the presentation to allow for time for publication. Factors evaluated for association with publication included author and abstract measures. Descriptive analyses and multivariable statistics were performed. RESULTS: 724 abstracts (160 podiums, 564 posters) were included. Of the podium presentations, 128 (80%) were published in a median of 4 months after the presentation. On univariable and multivariable analyses, there was no association between publication and abstract topic, gender, degree, number of publications, or H-indices of first and senior authors. 154 (27.3%) poster presentations were published with a median of 13 months. On univariable analysis, there was a statistically significant difference regarding the abstract topic (p = 0.015) and senior author degree (p = 0.01) between published and unpublished posters. Multivariable analysis demonstrated that colorectal surgery (OR 2.52; CI 1.02-6.23) and metabolic/obesity (OR 2.53; CI 1.09-5.84) are associated with an increased odd of publication. There was an inverse association with female senior authors (OR 0.53; CI 0.29-0.98), while additional degrees (e.g., doctorate and/or master's degree) of the senior authors were associated with an increased publication rate (OR 1.80; CI 1.00-3.22). CONCLUSION: 80% of podiums but only 27% of posters were ultimately published. While some predictors of poster publication were noted, it is unclear if these are why these projects fail to publish. Future research is warranted to determine if there are effective strategies to increase poster publication rates.

The Incidence of Thromboembolic Events During Hospitalizations Following Surgical Resection of Lower Extremity Sarcomas in Children: Utilizing the Pediatric Health Information System Database.

BACKGROUND: Venous thromboembolism (VTE) is a frequent occurrence during treatment for adults with sarcoma. The incidence and underlying risk factors of postsurgical VTE in children and adolescents undergoing resection of sarcoma are unknown. METHODS: Using International Classification of Disease revision-9 diagnostic and procedure codes, the Pediatric Health Information System database was queried for patients aged 18 years and younger, discharged from 2004 to 2015 with a diagnosis of lower extremity malignant neoplasm who had a tumor resection or amputation performed during the encounter. Malignant neoplasms of the pelvic bones and soft tissues were categorized as "pelvis tumors", whereas malignant neoplasms of bone and soft tissues of the lower limbs were categorized as "lower limb tumors". Hospitalizations were evaluated for the occurrence of VTE. Demographic characteristics (age at admission, sex, race, and race/ethnicity) and incidence of VTE were reported. RESULTS: There were 2400 patients identified. Of these, 19 experienced VTE (0.79%) during their surgical hospitalization encounter. By anatomic group, the rate of VTE was 1.4% (CI: 0.5%-3.2%) for tumors in the pelvis and 0.6% (CI: 0.3%-1.0%) in lower limb tumors. Categorizing by age, the incidence of VTE was 1.2% in patients aged zero to 5, 0.3% in patients 6 to 13, and 1.2% in patients 14 to 18 years old. (Table 1). The extremely low rate of VTE occurrence precluded further analysis of risk factors. CONCLUSIONS: In this analysis, postsurgical VTE during hospitalization after pelvic and lower extremity sarcoma resection was an uncommon event in children and adolescents. There seemed to be an increased incidence of postsurgical VTE in pelvic tumors when compared with lower limb tumors, however, the rarity of all events precluded formal statistical analysis. A more robust data set would be required to determine if there are subsets of children and adolescents with sarcoma at higher risk of VTE that could benefit from thromboprophylaxis in the postoperative setting. LEVEL OF EVIDENCE: Level II.

Determination of Ethnic Variation in Infant Nasolabial Anthropometry Using 3D Photographs: Implications for Bilateral Cleft Lip Nasal Correction.

OBJECTIVE: We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients. METHODS: Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P < .05. RESULTS: Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P = .9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P = .02]; ac-ac [C-AA; P = .00; H-AA; P = .04]; al-al [C-AA; P = .00; H-AA; P = .001]) and labial length (sn-ls [C-AA; P = .041]; sn-sto [C-AA; P = .005]; Cphs-Cphi L [C-AA; P = .013]; Cphs-Cphi R [C-AA; P = .015]). Interrater reliability was good to excellent and significantly correlated for all measures. CONCLUSIONS: African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction.

Degree of Asymmetry Between Patients With Complete and Incomplete Cleft Lips.

INTRODUCTION: Surgical outcomes for patients with complete cleft lips are not as ideal as those achieved for milder phenotypes. We hypothesized that in addition to the greater width of the cleft, patients with complete cleft lip and palate exhibit a greater degree of hypoplasia and asymmetry. METHODS: Stereophotographs of 14 infants with unrepaired unilateral complete and 14 with incomplete cleft lips were measured using Vectra imaging software (Canfield Imaging). Unpaired t tests were used to compare measured asymmetry between groups. Measurements included nasion to endocathion, sn-sbal, subnasale to alare (sn-al), subnasale to crista philtra, subalare to crista philtra (sbal-cphi), chelion to crista philtra, lateral lip element fullness, medial lip element fullness (mef), and non-cleft lip fullness. Duplicate measurements allowed Pearson correlation to be used to determine intra-rater reliability. Statistical significance was set at P < .05. RESULTS: Degree of asymmetry of the nasal base, sn-al, and sn-sbal was significantly greater for patients with complete clefts (P = .0001, P = .0001). Hypoplasia of the lateral lip element was seen when comparing lateral and mef (P = .04, P = .004) and lateral lip height (sbal-cphi''; P = .002). The degree of cupid's bow asymmetry did not differ between groups (P = .23). Intrarater reliability was high for all facial measures, ranging from 0.70 to 0.99. CONCLUSIONS: More severe, complete cleft lips demonstrate statistically significant greater asymmetry in surgically relevant dimensions. There was greater width of the nasal base. Vertical asymmetry of cupid's bow was unaffected by cleft severity, but that asymmetry was greater in patients with complete clefts due to hypoplasia of the lateral lip element. This may contribute to the less favorable results in these patients.

Patients With a History of Oronasal Fistula Repair Exhibit Lower Oral Health Measured With Patient-Centric Outcomes Measures.

INTRODUCTION: Oronasal fistulae following palatoplasty may affect patients' quality of life by impacting their ability to eat, speak, and maintain oral hygiene. We aimed to quantify the impact of previous oronasal fistula repair on patients' quality of life using patient-reported outcome psychometric tools. METHODS: A cross-sectional study of 8- to 9-year-old patients with cleft palate and/or lip was completed. Patients who had a cleft team clinic between September 2018 and August 2019 were recruited. Participants were divided into 2 groups (no fistula, prior fistula repair). Differences in the individual CLEFT-Q and Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) Oral Health scores between the 2 groups were evaluated using a multivariate analysis controlling for Veau classification and syndromic diagnosis. RESULTS: Sixty patients with a history of cleft palate were included. Forty-two (70%) patients had an associated cleft lip. Thirty-two (53.3%) patients had no history of fistula and 28 (46.7%) patients had undergone a fistula repair. CLEFT-Q Dental, Jaw, and Speech Function were all higher in patients without a history of a fistula repair; however, none of these differences were statistically significant. The COHIP-SF 19 Oral Health score demonstrated a significantly lower score in the fistula group, indicating poorer oral health (P = .05). CONCLUSIONS: One would expect that successful repair of a fistula would result in improved function and patient satisfaction, but the consistent trend toward lower CLEFT-Q scores and significantly increased COHIP-SF 19 Oral Health scores in our study group suggests that residual effects linger and that the morbidity of a fistula may not be completely treated with a secondary correction.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. DESIGN: Retrospective cohort analysis. SETTING: Three tertiary care institutions. PATIENTS: Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. MAIN OUTCOME MEASURES: The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. RESULTS: Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). CONCLUSION: Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Le Fort 1 and Bimaxillary Osteotomies Increase the Length of Stay but not Postoperative Morbidity Compared to Mandibular Osteotomies and Single Jaw Procedures.

PURPOSE: The purpose of this study is to examine the association between type of facial osteotomies performed during orthognathic surgery and postoperative outcomes including complications, length of stay, and readmission. METHODS: A retrospective review of orthognathic surgery cases from the Pediatric Health Information System (PHIS) database from 2004 to 2014 was undertaken. Osteotomy procedures were classified as Le Fort 1 (LF 1), Mandibular osteotomy, Genioplasty or their combinations. Primary outcome variable was major complications. Secondary outcomes included postoperative LOS > 1 day and 90-day readmission. Random-intercept logistic regression models were utilized to assess the association between the type of osteotomy performed and the outcomes. Bonferroni approach was used to account for multiple comparisons. RESULTS: The sample included 5413 patients, with a mean age of 17.1 ±â€Š1.68 years and 60.65% were female. The most common procedures were LF1 (39.4%), followed by bimaxillary surgery (23%). Major complications occurred in 8.57% of patients, postoperative LOS > 1 day in 52.4% and 90-day all-cause readmission in 11.16%. In adjusted analyses comparing LF1 compared to mandibular osteotomies, there were no significant differences for major complications (OR = 0.78), 90-day readmission rate (OR = 0.98). However, LF1 was associated with an increased odds for LOS compared to mandibular osteotomies (OR = 1.42). Addition of osteotomies is associated with a significant increase in LOS (P < 0.001). CONCLUSIONS: Patients undergoing orthognathic surgery demonstrated increased length of stay for LF1 or bimaxillary osteotomies. Osteotomy type did not impact the odds of readmission or complications. The trends revealed should be helpful for patient counseling.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion.

BACKGROUND: Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies. METHODS: A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20. RESULTS: A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups. CONCLUSIONS: While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.

Factors Influencing Timely Preparation of Alveolar Bone Grafting: A Survey of the ACPA.

OBJECTIVE: To identify factors that are commonly felt to impact a team's ability to ensure patients are orthodontically and dentally prepared for alveolar bone grafting at the appropriate time. DESIGN: Cross-sectional survey. SETTING: American Cleft Palate-Craniofacial Association (ACPA)-approved multidisciplinary cleft teams. PARTICIPANTS: Cleft team coordinators. INTERVENTIONS: Cleft team coordinators were asked to complete the survey. RESULTS: Fifty-three team coordinators from the 167 ACPA-certified cleft teams completed the survey (response rate = 32%). The majority (83.02%) of cleft teams feel having a case manager increases or would increase the rate of timely bone graft preparation. Orthodontic and dental coverage varied greatly between teams with university/hospital employed dentists and volunteer private practice orthodontists representing the most frequent models. The reported percentage of patients seeking regular dental and orthodontic care with providers affiliated with the team did not correlate with the likelihood of timely bone graft preparation (P = .17; P = .43). Great variability was noted in the manner and frequency of team communication with families during orthodontic bone graft preparation. The presence of a designated case manager on the team was not significantly associated with the percentage of patients who were reported to be orthodontically prepared for bone graft surgery (P = .25). CONCLUSION: Within our survey data, there is great variability noted in factors that may potentially impact orthodontic bone graft preparation. The majority of teams felt that a case manager did or would help with this process, however, our study does not support this fact. Significant recall bias concerning the success of bone graft preparation may affect these results.

Laser ablation of embryonic veins in children.

BACKGROUND: Klippel-Trenaunay syndrome (KTS) and related overgrowth syndromes are rare conditions that often present to academic pediatric units and multidisciplinary vascular anomaly clinics. These conditions are commonly associated with abnormalities of the superficial and deep venous structures and carry an increased risk of venous thromboembolism. METHODS: A retrospective chart review was completed of all patients treated at Johns Hopkins All Children's Hospital with endovenous laser ablation therapy (EVLT) for management of dilated embryonic veins in the setting of limb overgrowth. RESULTS: Three patients with limb overgrowth underwent EVLT between 2015 and 2017. All patients had successful occlusion of the targeted veins on post-procedure imaging. One patient developed a cellulitis successfully treated with oral antibiotics. CONCLUSIONS: Endovenous laser ablation therapy is a well-tolerated and safe procedure for prophylactic closure of abnormal superficial embryonic veins. This study supports the use of this technique in managing increased thromboembolic risk in this unique patient population and recognizes the need for a long-term study to determine its efficacy.

Alveolar soft-part sarcoma: Case demonstrating principles for uncommon vascular lesions.

BACKGROUND: Alveolar soft-part sarcoma (ASPS) is an uncommon malignancy that may present in a manner similar to benign vascular tumors. METHODS: A 6-year-old boy with autism spectrum disorder was referred to the Johns Hopkins All Children's Hospital vascular anomalies clinic for the evaluation of a tongue mass. RESULTS: Prior to the presentation, at 5 years of age, neck computed tomography (CT) was performed. This showed a well circumscribed, enhancing mass at the anterior aspect of the tongue. The radiologic impression was that this lesion was most likely a hemangioma. Two years later, the patient was evaluated in the vascular anomalies clinic. At that examination a 2-3 cm swelling was noted on the dorsal aspect of the tongue. The mass was fleshy and firm with discrete borders. Handheld Doppler examination indicated a high-flow lesion. The patient underwent an excisional biopsy. The lesion was identified as an alveolar soft-part sarcoma based on pathologic characteristics. CONCLUSION: Familiarity with common vascular tumors and malformations allows providers to diagnose the majority of these lesions on a combination of clinical history and physical examination. Atypical and combined lesions do benefit from imaging to help characterize and aid in the differential diagnosis. Biopsy enables definitive diagnosis but is necessary in the minority of cases. When in doubt, referral to a specialized, multidisciplinary vascular anomalies clinic will ensure that these patients receive management for this challenging collection of conditions.

Adding Depth to Cephalometric Analysis: Comparing Two- and Three-Dimensional Angular Cephalometric Measurements.

INTRODUCTION: Lateral cephalometric radiographs (LCR) have been the standard tool used for cephalometric analysis in craniofacial surgery. Over the past decade, a three-dimensional (3D) revolution in cephalometric analysis and surgical planning has been underway. To date, research has not validated whether cephalometric measurements taken from two-dimensional (2D) and 3D data sources are equivalent and interchangeable. The authors sought to compare angular cephalometric measurements taken with 2D and 3D modalities. METHODS: Sixty-two head CT scans (36 females, 26 males) with an average age of 63 ±â€Š20 years were studied. Twelve cephalometric angular measurements were taken from 3D reconstructed skulls using the software package Mimics 19.0 (Materialize; Leuven, Belgium). These same facial angles were measured from 2D lateral cephalograms reconstructed from the original CT scans using Dolphin 11.9. Measurements taken with both techniques were compared for agreement using a paired t test. Intra-class correlation coefficient assessment was used to determine inter-rater reliability. Statistical significance was set at P < 0.05. RESULTS: Five of the 12 angular measurements (SNA, SNB, MP-FH, U1-SN, and U1-L1) demonstrated statistically significant differences (P < 0.05) between the 2D and 3D analyses. All of these differences were less than the standard deviations for the respective measure. CONCLUSION: The differences between angular cephalometric values obtained from 2D LCRs and 3D CT reconstructions are small. This supports the practices of using 2D and 3D cephalometric data interchangeably in most applications. Clinicians must be selective in which measures they employ to maximize accuracy and care must be taken when measuring dental inclination with lateral cephalograms.

High-Fidelity Anthropometric Facial Measurements Can Be Obtained From a Single Stereophotograph From the Vectra H1 3-Dimensional Camera.

BACKGROUND: Anthropometry is a well-established means of measuring facial morphology. Although reliable, direct anthropometry can be time-consuming and not conducive to a busy clinical practice. The Vectra H1 handheld stereophotogrammetric system requires 3 stereophotographs taken from different perspectives to generate a three-dimensional (3D) surface. The time needed to take the 3 stereophotographs can increase the possibility of involuntary movements, precluding its use to assess young patients. To overcome this limitation, we evaluated if accurate linear facial measurements can be obtained from a single stereophotograph and compare these to the measurements taken by direct anthropometry. METHODS: Twenty pediatric patients, aged 0 to 10 years, who were undergoing minor surgical procedures at Johns Hopkins All Children's Hospital were recruited. Fourteen linear facial distances were obtained from each participant using direct anthropometry under general anesthesia. These same distances were measured using Mirror 3D analysis. Intraclass correlation was used to determine intrarater reliability on duplicate 3D images. RESULTS: Correlation coefficients between 3D imaging in frontal view and direct anthropometric measurements were excellent for 13 measures taken, ranging from 0.8 (subnasale to columella and subnasale to stomion superius) to 0.98 (nasion to subnasale and subnasale to labiale superius). Correlation coefficients between submental view and direct anthropometric measurements were excellent for 13 measures as well, ranging from 0.77 (subnasale to columella) to 0.98 (nasion to subnasale). CONCLUSIONS: Linear anthropometric measurements taken from 3D surfaces generated from a single stereophotograph correlate closely with direct anthropometric measures. This improves workflow and applicability of anthropometric studies to our youngest patients.

The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis.

BACKGROUND: Presurgical infant orthopedics (PSIO) techniques were introduced to improve the outcomes achieved when treating children with complete cleft lip and palate. The effect of PSIO on the incidence of postoperative fistulae has never been reliably demonstrated. We conducted a meta-analysis to assess the effectiveness of PSIO in reducing postoperative fistulas in patients with complete cleft lip and palate. METHODS: A search of the PubMed and Embase databases was performed to identify relevant articles that included primary palate repairs of patients with unilateral or bilateral complete clefts, reported the incidence of postoperative fistulae, and explicitly stated if PSIO was used. Details including author, number of subjects, use of PSIO, and fistula rate were cataloged. RESULTS: A review of the PubMed database yielded 1135 unique citations, and Embase yielded 507 articles. Review of these yielded 15 studies, comprising 1241 children, which met inclusion criteria. The overall rate of oronasal fistula development was 7.09%. The average fistula rate for studies using PSIO was 5.93% versus 9.71% in the non-PSIO group. This difference was not statistically significant ( P = .34). CONCLUSIONS: The use of PSIO prior to cleft lip and palate repair provides multiple benefits related to facial and nasal form and is supported by a body of literature. The effect of PSIO on the incidence of postoperative fistulae has received less attention in the literature. Our meta-analysis of the available literature does not provide evidence to support the premise that the use of PSIO affects the incidence of fistulae after cleft palate repair.

Comprehension of Online Educational Material Regarding Orofacial Clefts.

BACKGROUND: Cleft lip and palate are among the common birth defects in the United States. Management is complex and may be difficult for parents and patients to understand. The goal of this study was to evaluate the readability of online educational material provided by the American Society of Plastic Surgeons (ASPS) and the American Cleft Palate-Craniofacial Association (ACPA) websites regarding cleft lip and palate and to assess parents' comprehension. METHODS: Parents of children younger than 10 years of age presenting to the plastic and reconstructive surgery clinic at Johns Hopkins All Children's Hospital for conditions other than cleft lip and palate were recruited for participation. Parents were given the literature published on the ASPS and ACPA web sites to review and were asked to complete a 5-question test specifically targeted to the content of the passage they reviewed. We tested the readability of the 2 online passages using Readability Studio software (Oleander Software Solutions Ltd). RESULTS: Sixty parents completed the study. Across all groups, the mean score was 4.35 of a possible 5. The mean score was 4.4 for the ASPS web site and 4.29 for the ACPA web site. Fifty-three percent of participants answered all questions correctly. No significant difference in scores was noted between web sites (P = .48). CONCLUSIONS: Despite containing content of varying reading-level difficulty, the literature posted on the ACPA and ASPS web sites concerning cleft lip and palate conveyed information equally well to the target parent demographic with high levels of comprehension.

Clinical Outcomes Utilizing a "Modified Latham" Appliance for Presurgical Infant Orthopedics in Patients With Unilateral Complete Cleft Lip and Palate.

Presurgical infant orthopedic manipulation is utilized prior to cleft lip/nasal repair to facilitate a gingivoperiosteoplasty (GPP) and primary nasolabial repairs. The Latham dentomaxillary advancement appliance uses a screw that must be tightened daily to approximate the cleft segments in unilateral complete clefts. Our cleft center has been utilizing a "modified Latham" appliance since 1987, including an orthodontic elastic power chain to close the gap in a shorter amount of time. We performed a retrospective chart review of all patients undergoing treatment at Johns Hopkins All Children's Hospital (JHACH) with a unilateral complete cleft lip and palate between 1987 and 2017. Patients were identified by the International Classification of Diseases, Ninth Revision code (749.21). The majority of the patients represent the experience of the senior authors (E.R. and R.F.). Two hundred and eighty-one patients with unilateral complete cleft lip/palate were identified. Seventy-five patients were treated with a "modified Latham" appliance prior to their lip repair. The "modified Latham" appliance remained in place on average 20.6 days (range: 4-82), and average hospital stay after placement was 1.18 days. Nearly 96% of patients underwent a successful GPP at the time of nasolabial repair. Modification of the Latham appliance by utilizing an elastic power chain and eliminating the screw allows rapid closure of the alveolar cleft with limited need for adjustments and outpatient visits. Direct approximation of the palatal segments allows successful completion of a GPP in 95.9% of patients with limited dissection.

Postoperative Drain Use in Cranial Vault Remodeling: A Survey of Craniofacial Surgeon Practices and a Review of the Literature.

BACKGROUND: The use of subgaleal drains following primary cranioplasty for craniosynostosis has undergone limited investigation. Proposed benefits include prevention of seroma, detection of postoperative bleeding, and cerebrospinal fluid leak. We conducted a systematic review of the literature and surveyed craniofacial surgeons to ascertain the current evidence pertaining to drain use following primary cranioplasty for craniosynostosis and to determine surgical practice patterns. METHODS: PubMed and Embase databases were searched to identify relevant articles. Abstracts were reviewed by 2 investigators, and a Cohen κ statistic was calculated. Patient demographic and outcome data were extracted and compared. A 9-question survey was e-mailed to active and associate members of the American Society of Craniofacial Surgeons. RESULTS: A total of 7395 unique citations were identified. Only 2 retrospective chart reviews met inclusion criteria. All objective parameters demonstrated no difference between patients with and without drains. A subjective benefit of limiting facial swelling was proposed without objective analysis. Fifty (32.5%) of the 154 craniofacial surgeons responded to the survey. Forty-two percent used postoperative drains. A significant association (P = .01) was found between the belief that drains limited facial swelling and their use. CONCLUSIONS: The literature examining postoperative drain use in primary cranioplasty for craniosynostosis is restricted. The current studies show no definite benefit to drain use but are limited in their assessment of key outcomes. There is wide variability among surgeons regarding drain use, and this seems to be motivated by belief and tradition.

Cleft and Craniofacial Team Orthodontic Care in the United States: A Survey of the ACPA.

OBJECTIVE: To better understand the capacity for orthodontic care, service features, and finances among members of the American Cleft Palate-Craniofacial Association (ACPA). DESIGN: Cross-sectional survey. SETTING: ACPA-approved multidisciplinary cleft teams. PARTICIPANTS: Cleft team coordinators. INTERVENTIONS: Coordinators were asked to complete the survey working together with their orthodontists. MAIN OUTCOME MEASURE: Model for orthodontic care. RESULTS: Coordinators from 82 out of 167 teams certified by ACPA completed the survey (response rate = 49.1%). Most orthodontists were private practice volunteers (48%) followed by university/hospital employed (22.8%). Care was often delivered in community private practice facilities (44.2%) or combination of university and private practice facilities (39.0%). Half of teams reported offering presurgical infant orthopedics (PSIO), with nasoalveolar molding being the most common. Cleft/craniofacial patients typically comprise 25% or less of the orthodontists' practices. The presence of a university/hospital-based orthodontist was associated with higher rates of offering PSIO (P < .001) and an increased percentage dedication of their practice to cleft/craniofacial care (P < .001). CONCLUSION: Orthodontic models across ACPA-certified teams are highly varied. The employment of full-time craniofacial orthodontists is less common but is highly correlated with a practice with a high percentage of cleft care and the offering of advanced services such as PSIO. Future work should focus on how to effectively promote such roles for orthodontists to ensure high-level care for cleft/craniofacial patients requiring treatment from infancy through skeletal maturity.