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The goal of this study was to describe the 10-year evolution of the authors' surgical technique and institutional perioperative outcomes using posterior vault distraction osteogenesis (PVDO) in patients with syndromic and multisuture craniosynostosis.The authors performed a retrospective cohort study of patients who underwent PVDO for treatment of syndromic and multisuture craniosynostosis at a single institution over a 10-year period. Demographic data, perioperative outcomes, distraction patterns, and complications were analyzed. Outcomes of patients in the first 5 years (early cohort) were compared with those of the latter 5 years (late cohort).One hundred ten patients underwent a total of 118 PVDO procedures. Patients with a syndromic diagnosis represented 83.6 percent of the cohort ( n = 92) and were significantly younger than patients with a nonsyndromic diagnosis at the time of first PVDO (median [25th percentile, 75th percentile] 14.1 [6.6, 40.1] versus 42.7 [15.2, 59.6] months; p = 0.014). Mean distraction distance in the anterior-posterior direction was 30.8 mm (SD, 7.4). Compared with the early cohort, PVDO in the late cohort had faster median operative times (144.0 [123.0, 189.0] minutes versus 161.0 [138.0, 199.0] minutes; p = 0.038), lower estimated blood loss as a percentage of blood volume (28.5 [20.6, 45.3] versus 50.0 [31.1, 95.8]; p0.001), and lower blood replacement as percentage of blood volume (39.5 [23.8, 59.1] versus 56.3 [37.8, 110.1]; p = 0.009).This 10-year experience with PVDO demonstrates continued overall safety and efficacy with improved perioperative outcomes over time. Although PVDO has become the authors' first line of expansion in syndromic craniosynostosis, shortcomings such as need for device removal, infection concerns, and potential for cerebrospinal fluid leak merit attention by the craniofacial community.Therapeutic, III.

Craniosynostosis may lead to elevated intracranial pressure, which may be implicated with impaired neurocognitive development. However, accurately measuring intracranial pressure is challenging, and patterns in craniosynostosis patients are poorly characterized. Spectral-domain optical coherence tomography may enable noninvasive assessment of intracranial pressure in pediatric patients with craniosynostosis.Pediatric patients with craniosynostosis undergoing surgical intervention between 2014 and 2019 prospectively underwent optical coherence tomographic evaluation. Intracranial pressure was directly measured intraoperatively in a subset of cases. Optical coherence tomographic parameters were compared to directly measured intracranial pressure and used for pattern assessment.Optical coherence tomography was performed in 158 subjects, among which 42 underwent direct intracranial pressure measurement during an initial cranial procedure. Maximal retinal nerve fiber layer thickness, maximal retinal thickness, and maximal anterior projection optical coherence tomographic parameters were positively correlated with intracranial pressure (p ≤ 0.001), with all parameters showing significantly higher values in patients with intracranial pressure thresholds of 15 mmHg (p0.001) and 20 mmHg (p ≤ 0.007). Patients with maximal retinal nerve fiber layer thickness and maximal anterior projection exceeding set thresholds in optical coherence tomography of either eye demonstrated 77.3 percent sensitivity and 95.0 percent specificity for detecting intracranial pressure above 15 mmHg, and 90.0 percent sensitivity and 81.3 percent specificity for detecting intracranial pressure above 20 mmHg. Patients with associated syndromes or multiple suture involvement and patients aged 9 months or older were significantly more likely to have elevated intracranial pressure above 15 mmHg (p ≤ 0.030) and above 20 mmHg (p ≤ 0.035).Spectral-domain optical coherence tomography can noninvasively detect elevated intracranial pressure in patients with craniosynostosis with reliable sensitivity and specificity. This technology may help guide decisions about the appropriate type and timing of surgical treatment.Diagnostic, I.

The relationship between poverty and incidence of cleft lip and cleft palate remains unclear. The authors investigated the association between socioeconomic status and cleft lip with or without cleft palate and cleft palate only in the United States after controlling for demographic and environmental risk factors.The U.S. 2016 and 2017 natality data were utilized. Proxies for socioeconomic status included maternal education, use of the Special Supplemental Nutrition Program for Women, Infants, and Children, and payment source for delivery. Multiple logistic regression controlled for household demographics, prenatal care, maternal health, and infant characteristics.Of 6,251,308 live births included, 2984 (0.05 percent) had cleft lip with or without cleft palate and 1180 (0.02 percent) had cleft palate only. Maternal education of bachelor's degree or higher was protective against, and delayed prenatal care associated with, cleft lip with or without cleft palate (adjusted ORs = 0.73 and 1.14 to 1.23, respectively; p0.02). Receiving assistance under the Special Supplemental Nutrition Program for Women, Infants, and Children was associated with cleft palate only (adjusted OR = 1.25; p = 0.003). Male sex, first-trimester tobacco smoking, and maternal gestational diabetes were also associated with cleft lip with or without cleft palate (adjusted ORs = 1.60, 1.01, and 1.19, respectively; p0.05). Female sex, prepregnancy tobacco smoking, and maternal infections during pregnancy were associated with cleft palate only (adjusted ORs = 0.74, 1.02, and 1.60, respectively; p0.05).Increased incidence of orofacial clefts was associated with indicators of lower socioeconomic status, with different indicators associated with different cleft phenotypes. Notably, early prenatal care was protective against the development of cleft lip with or without cleft palate.Risk, III.

SummaryManual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol generating procedure. This designation is based on a single epidemiological study suggesting an association between facemask ventilation and transmission from the SARS 2003 outbreak. There is no direct evidence to indicate whether facemask ventilation is a high-risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation, and facemask ventilation with an intentionally generated leak, in anaesthetised patients with neuromuscular blockade. Recordings were made in ultraclean theatres and compared against the aerosol generated by the patient’s own tidal breathing and coughs. Respiratory aerosol from tidal breathing was reliably detected above the very low background particle concentrations (191 (77-486 [3.8-1313]) versus 2.1 (0.7-4.6 [0-12.9] particles.l-1 median(IQR)[range], n=11, p=0.002). The average aerosol concentration detected during facemask ventilation both without a leak (3.0 particles.l-1 (0 – 9 [0-43])) and with an intentional leak (11 particles.l-1 (7.0 – 26 [1-62])) was 64-fold and 17-fold lower than that of tidal breathing (p=0.001 and p=0.002 respectively). The peak particle concentration during facemask ventilation both without a leak (60 particles.l-1 (0 – 60 [0-120])) and with a leak (120 particles.l-1 (60 – 180 [60-480]) were respectively 20-fold and 10-fold lower than a cough (1260 particles (800 – 3242 [100-3682]), p=0.002 and p=0.001 respectively). This study demonstrates that facemask ventilation, even performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, facemask ventilation should not be considered an aerosol generating procedure.

The purpose of this study was to compare perioperative safety and efficacy of posterior vault distraction osteogenesis (PVDO) in patients with primary nonsynostotic cephalo-cranial disproportion, namely slit ventricle syndrome and idiopathic intracranial hypertension (IIH), to a cohort of patients with craniosynostosis (CS). A retrospective review of patients undergoing PVDO from 2009 to 2019 at our institution was performed. Craniosynostosis patients were matched by sex and age at PVDO to the nonsynostotic cohort. Operative details, perioperative outcomes, and distraction patterns were analyzed with appropriate statistics. Nine patients met inclusion criteria for the non-CS cohort. Six patients (67%) underwent PVDO for slit ventricle and the remaining 3 patients (33%) underwent PVDO for IIH. The majority of CS patients were syndromic (n = 6, 67%) and had multisuture synostosis (n = 7, 78%). The non-CS cohort underwent PVDO at a median 56.1 months old [Q1 41.1, Q3 86.6] versus the CS cohort at 55.7 months [Q1 39.6, Q3 76.0] (P = 0.931). Total hospital length of stay was longer in the non-CS patients (median days 5 [Q1 4, Q3 6] versus 3 [Q1 3, Q3 4], P = 0.021). Non-CS patients with ventriculoperitoneal shunts had significantly less shunt operations for ICP concerns post-PVDO (median rate: 1.74/year [Q1 1.30, Q3 3.00] versus median: 0.18/year [Q1 0.0, Q3 0.7]; P = 0.046). In this pilot study using PVDO to treat slit ventricle syndrome and IIH, safety appears similar to PVDO in the synostotic setting. The cohort lacks adequate follow-up to assess long term efficacy, although short-midterm follow-up demonstrates promising results with less need for shunt revision and symptomatic relief. Future studies are warranted to identify the preferred surgical approach in these complex patients.

Fronto-orbital advancement (FOA) of the anterior skull and orbital bandeau is standard of care for craniosynostosis with anterior morphology. Fronto-orbital retrusion, temporal hollowing, and bony contour irregularities are commonly seen in long-term follow-up. In this study, we report several technical adaptations of a new FOA technique described in Fearon et al that help facilitate adaptation of the single-segment neo-bandeau FOA technique in preparation of use in younger patients, and perform a craniometric analysis of the technique. Five consecutive patients who underwent the single-segment neo-bandeau FOA in 2020 with available pre- and post-operative three-dimensional head computed tomography scans were studied. Using Materialise Mimics (Materialise, Ghent, Belgium), cranial length, cranial height, cranial widths, and intracranial volume were measured. Two (40%) patients were male and all were non-Hispanic White with a median age at surgery of 18.6 months (interquartile range 10.4-45.7). Three patients (60%) had bicoronal or other multi-suture craniosynostosis, and 1 each had metopic and sagittal craniosynostosis. Intraoperatively measured intracranial pressure decreased from 17.8 mmHg (R 13.0-20.0) before craniectomy to 4.8 mmHg (R 2.0-11.0; P = 0.038) after craniectomy. Anterior cranial width increased postoperatively (mean 92.6 mm; R 74.9-111.5 versus 117.6 mm; R 109.8-135.2, P = 0.005). Intracranial volume increased from preoperative (mean 1211 cm3; R 782-1949 cm3) to postoperative (1387 cm3; R 1022-2108 cm3; P = 0.009). The authors find in this small sample that a single-segment neo-bandeau FOA demonstrates volumetric expansion similar to conventional FOA techniques and is feasible in infants under 1 year of age.

Objective:To study the airflow, transmission, and clearance of aerosols in the clinical spaces of a hospital ward that had been used to care for patients with coronavirus disease 2019 (COVID-19) and to examine the impact of portable air cleaners on aerosol clearance.Design:Observational study.Setting:A single ward of a tertiary-care public hospital in Melbourne, Australia.Intervention:Glycerin-based aerosol was used as a surrogate for respiratory aerosols. The transmission of aerosols from a single patient room into corridors and a nurses’ station in the ward was measured. The rate of clearance of aerosols was measured over time from the patient room, nurses’ station and ward corridors with and without air cleaners [ie, portable high-efficiency particulate air (HEPA) filters].Results:Aerosols rapidly travelled from the patient room into other parts of the ward. Air cleaners were effective in increasing the clearance of aerosols from the air in clinical spaces and reducing their spread to other areas. With 2 small domestic air cleaners in a single patient room of a hospital ward, 99% of aerosols could be cleared within 5.5 minutes.Conclusions:Air cleaners may be useful in clinical spaces to help reduce the risk of acquisition of respiratory viruses that are transmitted via aerosols. They are easy to deploy and are likely to be cost-effective in a variety of healthcare settings.

Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single-institution experience with pediatric SWIs.Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival.Of the 14 patients, 8 (57%) were diagnosed with culture-positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities.The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.

Objective: This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics—cost-to-charge ratio (RCC) and case volume of cleft palate repair. Design: Retrospective cohort study. Setting: This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. Patients and Participants: Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. Main Outcome Measure(s): The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. Results: Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). Conclusions: Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

In the pediatric general surgery literature, it has been shown that prenatal diagnosis of a congenital anomaly is an independent predictor of parental psychological distress. Surgical prenatal counseling can decrease parental anxiety by helping families understand the surgical needs and potential outcomes of their infant. In this retrospective analysis (n = 440), the authors sought to present our care pathway for prenatally diagnosed cleft lip and palate (CL/P) and explore the impact of cleft lip and palate-specific prenatal counseling on patient care by comparing the timing of clinical and surgical care between a cohort of patients who received prenatal CL/P consultation and a cohort of patients only seen postnatally. The authors hypothesize that our multidisciplinary prenatal care intervention is associated with earlier postnatal clinic visits and surgical repair. The care of all patients whose mother's presented for prenatal CL/P consultation (prenatal cohort, n = 118) was compared to all new CL/P patients without prenatal consultation at our institution (postnatal cohort, n = 322) from January 2015 through August 2019. 81.4% (n = 96) of the prenatal cohort returned for care postnatally while 2 pregnancies were interrupted, four neonates died, and 15 patients did not return for care. Prenatal consultation was associated with earlier postnatal clinic appointments (P

Purpose To determine the particle size, concentration, airborne duration and spread during endoscopic endonasal pituitary surgery in actual patients in a theatre setting. Methods This observational study recruited a convenience sample of three patients. Procedures were performed in a positive pressure operating room. Particle image velocimetry and spectrometry with air sampling were used for aerosol detection. Results Intubation and extubation generated small particles ( 75 µm), remained airborne for up to 10 s and travelled up to 1.1 m. Use of a microdebrider generated mean aerosol concentrations 18 times above baseline (p = 0.005). High-speed drilling did not produce aerosols greater than baseline. Pituitary tumour resection generated mean aerosol concentrations less than background (p = 0.18). Surgical drape removal generated small and large particles in mean concentrations 6.4 times greater than background (p

INTRODUCTION While the use of virtual surgical planning (VSP) has been well described in the adult craniofacial literature, there has been little written about pediatric uses or trends. The purpose of this study is to evaluate the evolving utilization of VSP for pediatric craniofacial procedures. METHODS The authors' prospective institutional review board-approved craniofacial registry was queried for index craniofacial procedures from January 2011 through December 2018. Data was collected regarding utilization of traditional surgical planning versus VSP, as well as the extent of VSP's influence on the operative procedure. These data were analyzed for trends over time and compared using appropriate statistics. RESULTS During the study period, a total of 1131 index craniofacial cases were performed, of which 160 cases (14.1%) utilized VSP. Utilization of VSP collectively increased over time, from 2.0% in 2011 to 18.6% in 2018 (P

PURPOSE How different from "normal" are the cranial base and vault of infants with nonsyndromic, single-suture sagittal synostosis (NSSS)? This study quantitatively addresses this question utilizing computed tomography (CT) analytic technology. METHOD Head CT scans of infants with NSSS and normocephalic controls were analyzed using Mimics to calculate craniometric angles, distances, and segmented volumes. Craniometric measurements and asymmetry indices were compared between NSSS and control groups using linear regressions controlling for age. Ratios of anterior-, middle-, and posterior-to-total cranial vault volume were compared between groups using beta regressions controlling for age. RESULTS Seventeen patients with NSSS and 19 controls were identified. Cranial index and interoccipital angle were significantly smaller in NSSS compared with controls (P = 0.003 and

Otoplasty remains an overlapping clinical domain of plastic surgery and otolaryngology. The purpose of this study is to objectively analyze the safety of otoplasty and determine if there are any risk factors, such as surgical training, associated with increased patient morbidity.Retrospective cohort study was conducted of otoplasty procedures performed in North America by plastic surgeons and otolaryngologists between 2012 and 2017 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric dataset. Statistical analysis was performed to analyze the relationships between comorbidities, congenital malformations, and postoperative complications.There were 777 otoplasty procedures performed during the study period. Median age at time of surgery was 8.3 years (95% CI 7.9-8.7 years). Plastic surgeons performed 75.8% (n = 589) procedures and otolaryngologists performed 23.4% (n = 182). No significant (P = 0.952) difference in the occurrence of postoperative complications between surgical specialties was appreciated despite the fact that operative time was significantly longer in procedures performed by otolaryngologists (121 minutes versus 94 minutes, P 0.001). Overall, 1.3% (n = 10 of 777) children experienced a complication, with the most common complication being superficial surgical site infection, occurring in 0.9% (n = 7 of 777) patients. There was no association of comorbidities (P all 0.324) or congenital malformations (P all 0.382) contributing to postoperative complications. Reoperation (0.8%, n = 6 of 777) and readmission (0.4%, n = 3 of 777) were uncommon; nevertheless, these adverse events were significantly associated with multiple inherent patient risk factors on multivariate regression.Otoplasty is a relatively safe surgical procedure with similarly low complication and readmission rates when performed by plastic surgeons and otolaryngologists. Surgical site infection remains the most prevalent complication after otoplasty. Readmission and reoperation after otoplasty were significantly correlated to prematurity, structural pulmonary abnormality, alimentary tract disease, and seizure disorder.

Prenatal diagnosis of congenital anomalies is associated with increased parental stress. Surgical prenatal counseling for parents expecting a child with an orofacial cleft has been shown to reduce parental anxiety through education and expectation setting. Despite the prevalence and significance of these conditions throughout the world, little is known of international counseling practices as they pertain to clefts and other craniofacial conditions, specifically regarding topics of counseling and discussions of ethical issues including interruption of pregnancy (IOP).In this study, 50 members of the International Society of Craniofacial Surgery, representing 18 countries, were surveyed. The questionnaire included questions about the number of consultations performed, for which conditions, setting of practice, and regional regulations pertaining to IOP. The authors report that the most frequent topics of discussion included initial treatment of clefts (89%), future surgeries (89%), and speech/language difficulties (85%). North American surgeons more frequently discussed cleft appearance (100%) thansurgeons from Central/SouthAmerica (64%) or Europe (64%, P = 0.019). Overall, 46% of surgeons surveyed believe it is ethical to give parents their opinion on IOP when asked. European surgeons were more likely to report that parents want to receive information about IOP at prenatal consultations (82%), compared to 25% from North America and 8% from Central/South America ( P0.001). The authors conclude that despite a lack of standard guidelines on conducting prenatal counseling appointments for cleft and craniofacial conditions, discussion topics were similar across country, practice type, and surgeon experience.

OBJECTIVES Spring-mediated cranial vault expansion (SMC) may enable less invasive treatment of sagittal craniosynostosis than conventional methods. The influence of spring characteristics such as force, length, and quantity on cranial vault outcomes are not well understood. Using in vivo and ex vivo models, we evaluate the interaction between spring force, length, and quantity on correction of scaphocephalic deformity in patients undergoing SMC. METHODS The authors retrospectively studied subjects with isolated sagittal craniosynostosis who underwent SMC between 2011 and 2019. The primary outcome measure of in vivo analysis was head shape determined by cephalic index (CI). Ex vivo experimentation analyzed the impact of spring length, bend, and thickness on resultant force. RESULTS Eighty-nine subjects underwent SMC at median 3.4 months with median preoperative CI 69% (interquartile range: 66, 71%). Twenty-six and 63 subjects underwent SMC with 2 and 3 springs, with mean total force 20.1 and 27.6 N, respectively (P < 0.001).Postoperative CI increased from 71% to 74% and 68% to 77% in subjects undergoing 2- and 3-spring cranioplasty at the 6-month timepoint, respectively (P < 0.001). Total spring force correlated to increased change in CI (P < 0.002). Spring length was inversely related to transverse cranial expansion at Postoperative day 1, however, directly related at 1 and 3 months (P < 0.001). Ex vivo modeling of spring length was inversely related to spring force regardless of spring number (P < 0.0001). Ex vivo analysis demonstrated greater resultant force when utilizing wider, thicker springs independent of spring arm length and degree of compression. CONCLUSIONS A dynamic relationship among spring characteristics including length, bend, thickness, and quantity appear to influence SMC outcomes.

BACKGROUND Patients with hemifacial microsomia (HFM) may undergo unilateral mandibular distraction osteogenesis (MDO) before skeletal maturity in an effort to improve facial symmetry. Mandibular distraction osteogenesis's effect on airway volumes have been studied in the past, though to our knowledge, none have accounted for the effect of head and neck posture on airway morphology. This study aimed to tackle this shortcoming, using imaging to analyze the upper airway of patients with HFM before and after surgical intervention with MDO. METHODS/DESCRIPTION The authors retrospectively reviewed patients with a diagnosis of unilateral HFM whom underwent unilateral MDO with an oblique vector at age 4 to 14 years at a single institution from 2004 to 2019. Patients with pre- and post-MDO three-dimensional computed tomography scans of the upper airway within 12 months of distractor placement and removal, respectively, were included. Head and neck postures were determined by craniocervical, pitch, roll, and yaw angles. Pre- and post-operative pharyngeal airway volumes, pharyngeal surface area, minimum retropalatal cross-sectional areas (RP CSA) and retroglossal (RG) CSA and associated anteroposterior distances were measured using Mimics 22.0 (Materialise; Leuven, Belgium). Comparison was done using Kruskal-Wallis tests and linear mixed-effects models controlling for head and neck postures. RESULTS Ten patients met inclusion criteria. Mean age at pre-distractor placement computed tomography scan was 99 ± 35 months, and mean duration between pre- and post-surgery scans was 220 ± 90 days. Head and neck posture were found to be significant predictors of all airway dimensions. After controlling for significant factors with fixed effects linear modeling, surface area was found to be significantly smaller in patients after MDO by 189.48 mm2 (F[10.8] = -3.47, P = 0.0053), compared to their preoperative measurements. Surgery was not a significant predictor of changes in airway volume (F[11.6] = 0.52, P = 0.61), minimum RP CSA (F[12.2] = -0.64, P = 0.53), minimum RG CSA (F[12.6] = -1.64, P = 0.13), RP anteroposterior distance (F[14.0] = 0.30, P = 0.77), or RG anteroposterior distance (F[20.0] = -0.04, P = 0.97). CONCLUSIONS Oblique vector MDO in patients with HFM is associated only with statistically significant changes in the surface area of the upper airway, and is not associated with statistically significant changes in dimensions like volume, CSA, or anteroposterior dimension. This is an important finding, as it may guide discussions surrounding risk/benefit ratio for MDO in childhood.

BACKGROUND Fusion of cranial-base sutures/synchondroses presents a clinical conundrum, given their often unclear "normal" timing of closure. This study investigates the physiologic fusion timelines of cranial-base sutures/synchondroses. METHODS Twenty-three age intervals were analyzed in subjects aged 0 to 18 years. For each age interval, 10 head computed tomographic scans of healthy subjects were assessed. Thirteen cranial-base sutures/synchondroses were evaluated for patency. Partial closure in greater than or equal to 50 percent of subjects and complete bilateral closure in less than 50 percent of subjects defined the fusion "midpoint." Factor analysis identified clusters of related fusion patterns. RESULTS Two hundred thirty scans met inclusion criteria. The sutures' fusion midpoints and completion ages, respectively, were as follows: frontoethmoidal, 0 to 2 months and 4 years; frontosphenoidal, 6 to 8 months and 12 years; and sphenoparietal, 6 to 8 months and 4 years. Sphenosquamosal, sphenopetrosal, parietosquamosal, and parietomastoid sutures reached the midpoint at 6 to 8 months, 8 years, 9 to 11 months, and 12 years, respectively, but rarely completed fusion. The occipitomastoid suture partially closed in less than or equal to 30 percent of subjects. The synchondroses' fusion midpoints and completion ages, respectively, were as follows: sphenoethmoidal, 3 to 5 months and 5 years; spheno-occipital, 9 years and 17 years; anterior intraoccipital, 4 years and 10 years; and posterior intraoccipital, 18 to 23 months and 4 years. The petro-occipital synchondrosis reached the midpoint at 11 years and completely fused in less than 50 percent of subjects. Order of fusion of the sutures, but not the synchondroses, followed the anterior-to-posterior direction. Factor analysis suggested three separate fusion patterns. CONCLUSIONS The fusion timelines of cranial-base sutures/synchondroses may help providers interpret computed tomographic data of patients with head-shape abnormalities. Future work should elucidate the mechanisms and sequelae of cranial-base suture fusion that deviates from normal timelines.

Posterior cranial vault distraction osteogenesis is a powerful, reliable, low-morbidity method to achieve intracranial expansion. It is particularly useful in treating turribrachycephaly seen in syndromic craniosynostosis, allowing for gradual expansion of the bone while stretching the soft tissues over several weeks allowing greater volumetric expansion than conventional techniques. Posterior cranial vault distraction osteogenesis constitutes a more gradual remodeling modality, with infrequent complications. As a first step in intracranial expansion, it preserves the frontal cranium for future frontofacial procedures. A drawback is the need for a second surgery to remove the device, and this must be taken into account during counseling.

DDT remains in use for malaria control in South Africa. We quantified DDTs in aquatic bird eggs from the highly biodiverse northern KwaZulu-Natal, a province of South Africa where DDT has been used for more than 80 years for malaria control. Pelican eggs had the highest ΣDDT concentration (7200 ng/g lipid mass; lm), Little Egret eggs had 6900 ΣDDT lm, African Openbill eggs had 3400 ng/g lm ΣDDT, and White-breasted Cormorant had 2400 ng/g lm. All species had non-significantly different mean concentrations of o,p’-DDT, p,p’-DDT, and ΣDDT, but with significant differences for p,p-DDE, o,p’-DDD, p,p’-DDD, %DDT, %DDD, and %lipid. The thinnest pelican eggshell (0.40 mm) had a ΣDDT concentration of 3300 ng/g lm.; the thickest shell (0.96 mm) had the lowest ΣDDT concentration at 29 ng/g lm; a 58% difference. Linear regressions of concentrations with shell thickness for the pelican eggs were significant for p,p’-DDE and p,p’-DDD, indicating risk of reproductive impairment. Compositional profiles indicate different food webs for the different species. DDT concentrations were lower than from another DDT-sprayed locality in South Africa, possible linked to differences in hydrology and rainfall. We conclude that significant ecotoxic threats associated with DDT remain in this area, and possibly threatens birds from less polluted areas. Our findings suggest continued negative human health and environmental impacts from DDT. There is an urgency to move away from DDT as quickly as possible; alternatively, to implement practices that prevent emissions of DDT to the environment while protecting human life.

BACKGROUND AND OBJECTIVES: Sleep during hospitalization is important, but data on children’s sleep quality during hospitalization are lacking. We sought to document sleep duration and awakenings in hospitalized children and explore associations between sleep and chronic care complexity, home sleep quality, and late-night food consumption. METHODS: Children aged 2 to 17 years admitted to a hospitalist service for at least 24 hours were approached for participation. Children were video recorded from 20:00 to 08:00. Paired investigators reviewed recordings and extracted data. Investigators blinded to sleep data separately extracted clinical and demographic information. Analyses included Spearman correlations and linear and generalized linear regression models with t and Wald χ2 tests. RESULTS: The mean time subjects (n = 57) initiated sleep was 22:35 (range: 20:00–02:47), with a mean sleep duration of 475 minutes (89–719 minutes). Subjects awakened 2.2 times (0–7 times, SD: 1.9) per night, on average, with the average total time awake during those awakenings of 55.7 minutes (2–352 minutes, SD: 75 minutes). In multivariate analysis, children with private insurance had longer sleep duration. Additionally, subjects who ate a snack after 21:00 went to sleep much later (odds ratio: 9.5; confidence interval: 2.6 to 34.9) and had 64 minutes less total sleep time and spent less time in bed than patients who did not eat late (P = .007). CONCLUSIONS: Hospitalized children sleep less than recommended and experience frequent awakenings. Some demographic variables are related to sleep. Many hospitalized children also consume food at night, which is associated with later bedtime and less sleep. Future efforts to improve sleep in hospitalized children are needed.

Dietary intake of contaminated food is a major route of human exposure to organochlorine pesticides (OCPs). Despite the prevalence of OCP usage in southern Africa for several decades, their impact on socioeconomically vulnerable communities remains largely overlooked. We investigated the accumulation of OCPs in crops commonly cultivated by rural communities surrounding iSimangaliso Wetland Park, South Africa. All samples analysed were found to be contaminated, with total OCP concentrations ranging between 190 and 240 ng g−1 ww. Elevated levels of OCP residues were detected in all products, with the majority of samples exceeding European Commission’s maximum residue limits (MRLs). We combine these results with local OCP fish tissue estimates to assess potential dietary risks. Cumulative risk assessment indicated potential non-cancer risks associated with heptachlor epoxide, while a cancer risk as high as 1 in 10 was found to be associated with aldrin and dieldrin. This far exceeds USEPA guidelines and indicates that OCP residues in crops and fish from the study area pose a high risk to human health. The results of this study call for further attention to be given to the health implications of continued OCP use not only within the study area but also in Southern Africa in general.

Background Composite mandibular reconstruction requires multiple tissue components inset in different planes. Intrinsic chimeric flap design provides this, and may be best suited for these reconstructions. Methods A retrospective review of mandible reconstructions with composite, intrinsic chimeric, or 2 free flaps was performed. Patient and flap characteristics and complications were analyzed. Results Seventy-five patients were reviewed. Defects reconstructed with intrinsic chimeric flaps had significantly more soft tissue needs than composite reconstructions. However, intrinsic chimeric bony defects were less complex. Despite significantly longer operative times for intrinsic chimeric flaps, there were no differences in complications or hospital stays. Intrinsic chimeric reconstruction resulted in significantly lower complication rates requiring an additional flap. This benefit was pronounced in through-and-through defects. Conclusion Intrinsic chimeric flaps are a better option than composite flaps for reconstruction of mandibular defects with large soft tissue needs with no increased complication risk despite longer operative time.

The treatment of patients with multisuture craniosynostosis is complex and patient-dependent. Cranial distraction osteogenesis is a relatively new procedure for treatment of these patients, with its use increasing in many centers. With this increased use comes an expanding range of indications. Surgical management of multisuture craniosynostosis in therapeutically immunosuppressed patients following a solid organ transplant presents unique challenges. We describe our experience with posterior cranial vault distraction in two patients with multisuture craniosynostosis that had previously undergone organ transplantation.Two solid-organ transplant recipient patients with multisuture craniosynostosis were identified. A detailed examination of their medical/transplant history and perioperative details were recorded.The first patient was a 3-year-old girl who received a kidney transplantation in infancy and subsequently presented with a symptomatic Chiari malformation and papilledema. Imaging revealed pansynostosis. She underwent posterior cranial vault distraction extending into a Chiari decompression. Her postoperative course was complicated by distractor site infection at the beginning of consolidation, necessitating early removal of distractors. The second patient was a 2-year-old boy who received a heart transplantation at the age of 3 months and subsequently presented with head shape concerns. Imaging revealed bicoronal and sagittal craniosynostosis. He underwent a posterior cranial vault distraction without complication. Following removal of the distractors, he developed an infection at one of the distractor sites with associated fever and leukocytosis, necessitating washout and drain placement. Both patients achieved successful cranial vault expansion with distraction osteogenesis and at a 2-year follow-up do not have evidence of elevated intracranial pressure.Immunosuppressive therapy has the potential to inhibit wound healing and place patients at risk for wound infection. Although we have demonstrated successful cranial vault expansion with distraction in two immunosuppressed children, extra care must be taken with these patients when placing semi-buried hardware. Specifically, prompt identification and proactive management of potential infectious complications is critical to applying this technique safely in these patients.

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.

Although use of organochlorine pesticides (OCPs) has been banned or severely limited on a global basis, concerning concentrations continue to be reported in many tropical and subtropical regions of the world. These habitats often support high levels of unique biodiversity and vulnerable communities that depend on the environment for their survival. We investigated threats associated with OCP contamination at Lake St Lucia, a global hotspot for biodiversity and a UNESCO World Heritage Site in South Africa. Lake St Lucia is sustained largely by surface runoff from catchment areas where significant quantities of OCPs have historically been used in agriculture and where DDT continues to be used for disease control. Sediments (n = 40) collected from the two largest fluvial inputs to Lake St Lucia showed that these rivers represent important sources of contaminants, with ∑OCP concentrations ranging between 74 and 510 ng g−1. Measured HCH, dieldrin, ∑DDT and ∑chlor concentrations exceeded NOAA sediment toxicity guidelines in the majority of samples analysed. Bioaccumulation was assessed by examining residue concentrations in muscle tissues from two abundant fish species from Lake St Lucia. OCPs were detected in all samples analysed, with total concentrations ranging 860–5000 ng g−1 lw and 390–3200 ng g−1 lw for Oreochromis mossambicus (n = 17) and Clarias gariepinus (n = 41), respectively. A health risk assessment indicated potential dietary risk associated with exposure to aldrin, dieldrin and heptachlor, although the cumulative effect of OCPs on human health, ecosystem biodiversity and long-term ecotourism sustainability remains unknown.

The purpose of this study was to delineate optimal age to perform unilateral or bilateral cleft lip repair in premature patients. The American College of Surgeons National Surgical Quality Improvement Program Pediatric data set was queried for unilateral and bilateral cleft lip repairs performed between 2012 and 2017. Complications, readmissions, and reoperations were analyzed in the context of prematurity with appropriate statistics. Degree of prematurity was significantly associated with adverse events (p = 0.001, rs = 0.44). Premature patients with unilateral cleft lip had a significantly decreased risk of adverse events when performing cleft lip repair after 150 days of age [OR, 18.1; p = 0.004; before cutoff, n = 10 of 140 (7.1 percent); after cutoff, n = 0 of 112 (0.0 percent)] in the absence of other risk factors. Premature patients with bilateral cleft lip had a significantly decreased risk of adverse events when performing cleft lip repair after 175 days of age (OR, 16.1; p = 0.010; before cutoff, n = 7 of 33 (21.2 percent); after cutoff, n = 0 of 28 (0.0 percent)] in the absence of other risk factors. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Risk, II.

To quantify aerosol generation from respiratory interventions and the effectiveness of their removal by a personal ventilation hood.Determination of the aerosol particle generation (in a single, healthy volunteer in a clean room) associated with breathing, speaking, wet coughing, oxygen (OAerosol generation was measured with two particle sizer and counter devices, focusing on aerosols 0.5-5 μm (human-generated aerosols), with and without the hood. An increase from baseline of less than 0.3 particles per mL was considered a low level of generation.Comparisons of aerosol generation between different respiratory interventions. Effectiveness of aerosol reduction by a personal ventilation hood.Results for the 0.5-5 μm aerosol range. Quiet breathing and talking demonstrated very low increase in aerosols (0.1 particles/mL). Aerosol generation was low for wet coughing (0.1 particles/mL), OIn this human volunteer study, the administration of O

BACKGROUND Patients undergoing cranial expansion including spring-mediated cranioplasty (SMC) and cranial vault remodeling (CVR) receive costly and high acuity post-operative intensive care (ICU) given concerns over neurologic and hemodynamic vulnerability. The authors analyzed perioperative and post-operative events for patients presenting with sagittal craniosynostosis (CS) undergoing SMC and CVR in order to compare complication profiles. METHODS The authors performed a single center retrospective cohort study of patients undergoing SMC and CVR for the treatment of nonsyndromic, isolated sagittal CS from 2011 to 2018. Perioperative and post-operative factors were collected, focusing on hemodynamic instability and events necessitating ICU care. Mann-Whitney U and Fisher exact tests were used to compare data with significance defined as P

BACKGROUND Patients undergoing orthognathic skeletal correction present with a variety of comorbidities that may affect surgical outcomes. The purpose of this study was to determine how patient risk factors and operative technique contribute to complication rates after orthognathic surgery in the era of patient-specific implants. METHODS Retrospective cohort analysis was conducted of pediatric patients undergoing Le Fort I osteotomy, bilateral sagittal split osteotomy, and/or genioplasty from 2014 to 2018. Patient risk factors, operative characteristics, and postoperative outcomes were gathered and compared with appropriate statistics. RESULTS Ninety-four patients met inclusion criteria, with an overall 1-year complication rate of 11.7 percent (11 of 94). Patient-specific mandibular plates are significantly associated with infection (p = 0.009; OR, 8.8), occurrence of any complication (p = 0.003; OR, 8.3), readmission (p < 0.001; OR, 11.1), and reoperation (p < 0.001; OR, 11.4). In patients with syndromes or history of cleft lip/palate, patient-specific mandibular plates are associated with infection (p = 0.006; OR, 10.3), readmission (p < 0.001; OR, 21.6), and reoperation (p < 0.001; OR, 22.9). In multivariate regression controlling for age, sex, syndrome status, and orofacial cleft history, use of patient-specific mandibular plates was associated with infection (p = 0.017; adjusted OR, 12.5), any complication (p = 0.007; adjusted OR, 11.8), readmission (p = 0.001; adjusted OR, 17.9), and reoperation (p = 0.001; adjusted OR, 18.9). CONCLUSIONS In the era of patient-specific orthognathic surgery, syndromic status and use of patient-specific mandibular plates are associated with increased infection, readmission, and reoperation because of hardware-related complications. The authors' data support increased caution and counseling with use of patient-specific mandibular implants in patients with syndromic status, history of orofacial cleft, and history of previous maxillomandibular surgery given increased risk of hardware-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Spring-mediated cranial vault expansion (SMC) has become a primary treatment modality at our institution to correct scaphocephalic head shape in the setting of isolated sagittal craniosynostosis (CS). Spring-mediated cranioplasty is associated with minimal procedural morbidity and reliable clinical efficacy, although long-term outcomes are not well elucidated. Herein we describe our institutional experience and lessons learned with SMC. We hypothesize that SMC performed in young infants offers durable scaphocephalic correction as measured by cephalic index (CI) at the 1, 3, and 5-year postoperative timepoints.Patients with isolated sagittal CS who underwent SMC at our institution during an 8-year period were retrospectively studied. The primary outcome measure was long-term head shape determined by CI at the 1, 3, and 5-year postoperative timepoints. Secondary outcomes included patient and spring factors associated with change in CI, including age and spring force. All statistical tests were 2-tailed with P < 0.05 denoting significance.In total, 88 patients underwent SMC at a median age of 3.3 months with a median preoperative CI 69 (interquartile range: [66, 71]). The postoperative CI increased to 73 [71, 76] at postoperative day 1. At 1 month, the CI increased by 8.6 to 77 (P < 0.0001) and appeared to reach a plateau at 3 months (76, [74, 78]) without further improvement (P < 0.10). At 5 years, CI remained stable without relapse (76, [75, 81], demonstrating an 8.9 increase from preoperative CI. Age at time of spring placement and change in CI were inversely related (P < 0.005). Total spring force directly correlated with increased change in postoperative CI at the 6-month postoperative timepoint (P < 0.02).In summary, SMC offers durable correction of scaphocephaly as measured by CI for patients with isolated sagittal CS at the 5-year postoperative timepoint. The cranial expansion observed 1-month post-spring implantation may serve as a proxy for long-term CI.

Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the management of end-stage TMJ disease. However, its use in congenital TMJ deformities is limited. Here, the authors present initial outcomes of skeletally mature patients who underwent custom alloplastic TMJ reconstruction and simultaneous orthognathic surgery.A retrospective case series of patients who underwent custom alloplastic TMJ reconstruction concurrent with orthognathic surgery between 2014 and 2019 was completed. Functional, aesthetic and orthodontic outcomes as well as complications were recorded.Seven TMJs in 5 skeletally mature patients (4 female, 1 male, ages 16-30) (2 bilateral, 3 unilateral) were replaced. All but 1 patient had previous attempts at reconstructive surgery with poor results. All cases were prepared using virtual surgical planning and underwent concomitant maxillomandibular orthognathic surgery. All patients demonstrated improved post-operative occlusions. Four of 5 patients achieved >30 millimeters of post-operative MIO. Complications included ear canal perforation and facial nerve dysfunction.There were no infections or other implant-related complications. Mean follow up was 2 years and 15 days. Alloplastic TMJ reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects is an alternative to existing management options. Further long-term prospective outcomes studies are ongoing.

Midface advancement by distraction osteogenesis (DO) is commonly performed in patients with craniosynostosis for indications including midface hypoplasia, exorbitism, obstructive sleep apnea, class III malocclusion, and overall aesthetic facial deficiency. There is evidence to suggest that maxillary LeFort I advancement increases the risk of velopharyngeal dysfunction in the cleft palate population, yet few studies have investigated changes in speech following LeFort III or monobloc midface advancement in patients with syndromic craniosynostosis. The purpose of this study was to examine the effect of midface DO on speech as indicated by the Pittsburgh Weighted Speech Score in patients with Apert, Crouzon, and Pfeiffer Syndrome. Among 73 midface advancement cases performed during the study period, 19 cases met inclusion criteria. Overall, the highest post-advancement Pittsburgh Weighted Speech Score (PWSS) was significantly higher than the pre-advancement PWSS (0.52 versus 2.42, P = 0.01), indicating an acute worsening of VPI post-advancement. Specifically, the PWSS components nasal emission and nasality were significantly higher post-advancement than pre-advancement (nasal emission: 1.16 versus 0.21, P = 0.02) (nasality: 0.68 versus 0.05, P = 0.04). However, there was no significant difference between pre-advancement PWSS and the latest post-advancement PWSS (P = 0.31). Midface distraction is associated with an acute worsening of VPI post-operatively that is followed by improvement, and often resolution over time. Future work with additional patient accrual is needed to determine the effect of different advancement procedures and syndromes on VPI rates and profundity.

BACKGROUND Uncertain clinical evidence for treating positional plagiocephaly, especially with helmet therapy, creates difficulties in counseling parents of patients. This study investigates layperson perceptions and treatment preferences for positional plagiocephaly to provide patient-oriented evidence for management. METHODS Adult laypersons were recruited through crowdsourcing to view digitally-modified images of normal, mildly, moderately, or severely plagiocephalic infant heads. Participants provided demographic information and rated the infant's head shape and potential related social difficulties, likelihood of consulting a physician for treatment options, and likelihood of seeking helmeting treatment for the infant. RESULTS Nine hundred forty-five individuals participated in the study. Perception of head shape, prediction of future embarrassment and social difficulties, likelihood of seeking physician evaluation, likelihood of choosing helmet therapy, and willingness-to-pay for helmet therapy were pairwise-different between 4 plagiocephaly severities (corrected-P

Background In orthognathic surgery, virtual surgical planning (VSP) is gaining popularity over traditional surgical planning (TSP); however, concerns about cost of VSP have slowed adoption of this technology. This study investigates the clinical value of VSP versus TSP over the entire clinical care continuum. Methods Retrospective cohort study was conducted for patients undergoing maxillomandibular surgery between 2005 and 2016 at a tertiary pediatric hospital. Clinical value, defined as patient outcomes per unit cost, was analyzed between the 2 groups with appropriate statistics. Results The VSP (n = 19) and TSP (n = 10) cohorts had statistically similar hospital lengths of stay, rates of complications, readmissions, and duration of postoperative orthodontic treatment (P = 0.518, P > 0.999, P > 0.999, P = 0.812, respectively). VSP maxillomandibular procedures trended towards shorter operative times (P = 0.052). Total hospital charges were statistically similar between the TSP and VSP cohorts (P = 0.160). Medication, laboratory and testing, and room charges were also statistically similar between the TSP and VSP cohorts (P = 0.169, P = 0.953, and P = 0.196 respectively). Conclusions Indexed patient outcomes and costs incurred for maxillomandibular procedures were statistically similar between those utilizing TSP or VSP leading us to conclude that these 2 methods are associated with similar clinical value. This retrospective analysis should be followed with prospective data to give patients and insurers the best estimate of clinical value utilizing TSP and VSP.

Objective:To investigate airway morphology changes in patients with Pierre Robin sequence (PRS) pre–/post–mandibular distraction osteogenesis (MDO) and to compare morphologic changes to age-matched controls.Design:Retrospective case–control study.Setting:Urban, academic, tertiary medical center.Patients, Participants:Fifteen patients with PRS after MDO to relieve upper airway obstruction (UAO) (2008-2018); age-matched controls for post-MDO patients.Interventions:Mandibular distraction osteogenesis, curvilinear internal mandibular distractors.Main Outcome Measures:(1) Physiologic improvement after MDO (apnea–hypopnea index; minimum oxygen saturation); (2) airway size (volume, surface area, length, mean/minimum cross-sectional area), shape (lateral:anterior–posterior ratio, cross-sectional area ratios, uniformity, sphericity), and changes with MDO; and (3) post-MDO airway size, shape versus age-matched controls.Results:Airway size increased after MDO (volume, P = .01; surface area, P = .02; length, P = .01), as did cross-sectional area (mean, P = .02; minimum, P = .02; minimum retropalatal, P = .05, mid-retroglossal, P = .02). Post-MDO PRS airways were larger than controls (volume, P < .01; surface area, P < .01; length, P < .01, cross-sectional area, P = .03). Airway shape remained nonuniform and flat post-MDO; control airways were round. Two syndromic patients required repeat MDO and had subphysiologic post-MDO airway cross-sectional area. Post-MDO PRS patients with supraphysiologic cross-sectional area along the entire airway had no UAO recurrence.Conclusions:In this small, heterogenous patient sample, MDO increases airway size, may preferentially affect the retropalatal airway, and often results in supraphysiologic airway dimensions. These retropalatal changes may be important in relieving severe UAO in patients with PRS. Generalizability of our results is limited by small cohort size and patient heterogeneity.

Organochlorine pesticides (OCPs) have been used extensively in the eastern regions of South Africa for agricultural and malaria control purposes, yet few data exist on the local environmental and social impacts of these compounds. Such issues have become of increasing concern in the iSimangaliso World Heritage Site, where the continued use of OCPs may pose risks to several sensitive and protected species. This study was designed to examine the bioaccumulation of OCPs in two common fish species, Oreochromis mossambicus (Mozambique tilapia) and Clarias gariepinus (African sharptooth catfish) from iSimangaliso Wetland Park. These species are targeted by local subsistence fishermen and sustain substantial bird and crocodile populations. Our findings indicate widespread contamination of the aquatic environment, with ΣOCP fish tissue concentrations in the range of 6907–8740 ng g− 1 lw and 2953–5874 ng g− 1 lw for C. gariepinus and O. mossambicus, respectively. HCHs (471–1570 ng g− 1 lw), DDTs (645–2399 ng g− 1 lw), drin-related residues (589–1960 ng g− 1 lw), chlor-related residues (455–2162 ng g− 1 lw) and endosulfans (457–1495 ng g− 1 lw) were detected in all tissue samples. Concentrations detected in the majority of samples exceeded European Commission maximum residue limits and a health risk assessment indicated potential dietary risk associated with exposure to heptachlor, heptachlor epoxide and dieldrin. This study represents the first investigation into OCP bioaccumulation in fish species from iSimangaliso Wetland Park. Our findings highlight the need for more detailed investigations into the bioaccumulation and ecotoxicological effects of these contaminants in the food web and the associated risks to local ecosystems and human health. Capsule High levels of OCPs detected in two common fish species at iSimangaliso Wetland Park highlight potential human health and ecotoxicological threats to a globally important biodiversity conservation hotspot.

Background A thorough understanding of attitudes toward and program policies for parenthood in graduate medical education (GME) is essential for establishing fair and achievable parental leave policies and fostering a culture of support for trainees during GME. Methods A systematic review of the literature was completed. Non-cohort studies, studies completed or published outside of the United States, and studies not published in English were excluded. Studies that addressed the existence of parental leave policies in GME were identified and were the focus of this study. Results Twenty-eight studies addressed the topic of the existence of formal parental leave policies in GME, which was found to vary across time and ranged between 22 and 90%. Support for such policies persisted across time. Conclusions Attention to formal leave policies in GME has traditionally been lacking, but may be increasing. Negative attitudes towards parenthood in GME persist. Active awareness of the challenges faced by parent-trainees combined with formal parental leave policy implementation is important in supporting parenthood in GME.

Background Ablation of locally advanced or recurrent head and neck cancer often results in large composite orofacial defects with limited recipient vessels. These complex defects lend well to intrinsic chimeric flap reconstruction, which allows greater ability to inset various flap component tissue types than composite flaps and requires only one set of microvascular anastomoses. Methods A retrospective chart review was performed on all patients who underwent orofacial reconstruction with an intrinsic chimeric free flap from 2002 to 2015. Flaps with only one tissue type, such as two separate skin paddles with no additional component, were not considered chimeric flaps and therefore not included in this report. Patient demographic data, defect, and flap characteristics, as well as complications and outcomes were analyzed to create a guide for flap selection. Univariate and multivariate analysis was performed to determine risk factors for flap take-back and failure. Results Seventy-five patients underwent orofacial intrinsic chimeric free flap reconstruction. Results were organized based on defect characteristics to create a guide for flap selection. The number of chimeric flap components and operation duration were independently statistically associated with flap take-backs ( p Conclusions Intrinsic chimeric flaps provide a versatile and elegant reconstructive option for a variety of complex orofacial defects. We provide a guide to facilitate decision making in flap selection for these challenging reconstructions and report factors associated with flap take-backs and losses.

BACKGROUND This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States. METHODS Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics. RESULTS Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all). CONCLUSIONS Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Biologically significant concentrations of organochlorine pesticides (OCPs) continue to be reported in wildlife populations and are of particular concern in species that occupy the highest trophic levels. Nile crocodiles (Crocodylus niloticus) are important apex predators occurring throughout much of tropical and subtropical sub-Saharan Africa, where they inhabit estuarine and freshwater habitats often impacted by contamination. In this study we examined pesticide residue accumulation in fat tissue from Nile crocodiles at Lake St Lucia, South Africa, where historically large quantities of OCPs have been used for agriculture and disease control. During 2019, we collected tail fat samples from wild (n = 21) and captive (n = 3) individuals to examine the influence of habitat, body size and sex on variations in bioaccumulation. The principal contaminant found was p,p′-DDE, a major persistent metabolite of DDT, which continues to be used in the region for combating malaria. Tissue p,p′-DDE concentrations in wild crocodiles (95–1200 ng g−1 ww) were significantly (p 0.70) to body length. Male (n = 14) and female (n = 7) wild crocodiles exhibited similar contaminant body burdens, however, total concentrations were substantially lower than those measured in the same population during 2016/2017. Marked differences in residue levels and profiles appear to reflect changes in food availability and dietary exposure associated with a shift in environmental conditions. These findings suggest that periods of environmental stress may be associated with enhanced toxicological risk in crocodiles. Additional work is needed to better understand contaminant accumulation and elimination mechanisms in crocodiles, and their potential effects on reproductive health.

A series of novel carbazole-containing sulfonamides and sulfamides were synthesized. A structure-activity relationship study of these compounds led to the identification of potent cryptochrome modulators. Based on the results of efficacy studies in diet-induced obese (DIO) mice, and the desired pharmacokinetic parameters, compound 41 was selected for further profiling.

Background Successful free tissue transfer requires tension-free microvascular anastomosis. Vein grafts are used when this cannot be obtained, which increases microsurgical complexity and the chance of vessel thrombosis. Previous studies on vein grafts are limited to low numbers and selected techniques, making it difficult to draw conclusions. Methods A retrospective chart review was performed for all patients who underwent vein grafts in free flap reconstruction from 1995 to 2015. Information on patient and flap characteristics, returns to the operating room, and flap loss was analyzed. Results Seventy-two free flap reconstructions requiring 122 vein grafts were performed in the genitourinary/perineal (49 percent) and head and neck (38 percent) regions. The majority were performed in the initial operation (82 percent) and, of those, the majority were planned (71 percent). The most common vein graft types used were transposition arteriovenous loops (57 percent) and interpositions (26 percent). Of the initial cases, 22 percent returned to the operating room, resulting in a 7 percent total flap loss rate and a 7 percent partial flap loss rate. On univariate analysis, graft timing/planning, gap type, vein graft type, and reconstruction location were significantly associated with take-backs and flap loss. However, gap type and location seem to be strongly associated with graft timing/planning and vein graft type. Graft type and planning/timing do not have as strong a relationship and seem to independently relate to flap loss. Conclusions Vein grafts are more successful when planned and when performing transpositions and arteriovenous loops over interpositions. These graft types should be considered over interpositions when possible. Clinical question/level of evidence Therapeutic, IV.