Search

A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need. A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care. Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention. A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Purpose: The purpose of this study was to examine parent/caregiver perspectives and experiences of speech-language pathology provision during the COVID-19 pandemic for children born with cleft palate. Method: An online questionnaire to parents of children born with cleft palate asked about delays and changes to speech-language pathology provision during the first U.K. national lockdown. Parents were also asked their views on the effectiveness of online speech-language pathology provision. Analysis considered variation in speech-language pathology provision by region. Chi-square and Mann–Whitney U tests examined associations between speech-language pathology provision and socioeconomic status and child age. Free text responses were analyzed using qualitative content analysis. Results: Three hundred fifty-six (39.3%) children were receiving speech-language pathology intervention before the first national lockdown. A further 49 (9.0%) were due to start speech-language pathology intervention during the lockdown. Speech-language pathology provision varied both nationally and within smaller geographical regions. Overall, 146 (42.6%) children continued to receive speech-language pathology and 197 (57.4%) had intervention delayed. There was no association between delayed speech-language pathology and socioeconomic status. Older children were more likely to experience delayed speech-language pathology provision ( p = .004). Qualitative analysis revealed concerns about access to speech-language pathology, challenges with adequate devices to access online provision, technological problems, and child engagement in online provision. Parents reported online provision as being “better than nothing.” Conclusions: Parents/caregivers reported delays to speech-language pathology provision during the first lockdown, but this varied geographically and was more prevalent for older children. Concerns about access to speech-language pathology provision were raised, including challenges regarding online provision. Follow-on work will consider the impact of the delays experienced on longer term outcomes.

Plastic Surgery is consistently ranked as one of the most competitive for higher surgical training in the United Kingdom. With falling rates of undergraduate Plastic Surgery education there is a danger that potentially excellent candidates will be deterred from applying for training positions. We sought to investigate a cohort of UK medical students with an established interest in Plastic Surgery regarding the factors that influence their interest in the specialty. A cross-sectional study design was used with questionnaires distributed to medical students attending the BAPRAS Undergraduate Day in London and Glasgow University Plastics Undergraduate National Conference in 2019. The questionnaire included factors attracting and deterring them from a career in Plastic Surgery, alongside their undergraduate exposure to the specialty and suggestions on how it could be improved. The most common factors attracting students to a career in Plastic Surgery were variety (25%), surgical intricacy (15%) and immediate effect on patient quality of life (12%). The most common factors deterring students from a Plastic Surgery career were a competitive national selection process (41%), work-life balance (15%) and length of training (12%). As 47% of students had not received undergraduate education in Plastic Surgery, their perceptions of the specialty will be likely be influenced from external, often negative, sources such as television and other media. To safeguard the future Plastic Surgery workforce, universities should collaborate with local departments and professional bodies to meet the needs of medical students for undergraduate exposure through mentorship, workshops, taster days and clinical placements.

Neurodevelopmental delays can interfere with children’s engagement with the world and further development, and may have negative consequences into adulthood. Mercury is highly toxic and may negatively influence neurodevelopment because it can freely cross the placenta and accumulate in the fetal brain. We searched four publication databases (Embase, PsycINFO, PubMed/MEDLINE, Scopus) for studies examining the relationship between early life mercury exposure and scores on neurodevelopmental performance measures in children aged 0 to 5 years old. Study quality was assessed using the National Institutes of Health (NIH) Quality Assessment Tool. Thirty-two prospective studies were included in the review. Neurodevelopmental performance was measured using 23 different scales, most commonly the Bayley Scales of Infant and Toddler Development (BSID). In most cases, the evidence for an association between mercury and neurodevelopment was weak. There did not appear to be exceptions for particular childhood ages, outcome scales, or mercury levels. The small number of results to the contrary were more likely to be studies which did not meet our high-quality criteria, and could be a consequence of multiple testing, selection bias, or incomplete confounder adjustment. Based on current evidence, dietary mercury exposure during pregnancy is unlikely to be a risk factor for low neurodevelopmental functioning in early childhood.

ObjectiveA consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptions to cleft care protocols during and after COVID as a priority learning area of need.DesignA multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptions to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organisations involved in comprehensive cleft care.ResultsFoundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinised and COVID adaptions, specifically in the pre and peri-operative periods, were highlighted. Second, surgical operations and access to services were prioritized according to their relationship to functional outcomes and time-sensitivity. The operations assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft services assigned the highest priority were new-born assessments, paediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.ConclusionsA collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Objective This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate (CL ± P) in the United Kingdom (UK). Design Data forms completed at the time of surgery included details on timing, technique, and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires. Setting Data were obtained from the Cleft Collective, a national longitudinal cohort study. Patients Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children. Results The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips (UCL) were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips (BCL) were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bimodal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties ( P Conclusions This study contributes to our understanding of current cleft surgical pathways in the UK and will provide a baseline for analysis of the effectiveness of utilized protocols.

ObjectivesA systematic review and meta-analysis to determine the association between active maternal smoking and cleft lip and palate etiology.Data SourcesMedline, Embase, Web of Science and the Cochrane database from inception to November 2020.Study selectionObservational studies of cigarette smoking habits in pregnant women. Outcomes included cleft lip and/or palate, cleft lip ± palate and cleft palate only.Data analysisPublication bias analyses were performed and the Newcastle Ottawa scales were used to assess study quality. Fixed or random effect models were used in the meta-analysis, dependent on risk of statistical heterogeneity.ResultsForty-five studies were eligible for inclusion of which 11 were cohort and 34 were case-control studies. Sixteen studies were of sufficient standard for inclusion in the meta-analysis. The summary odds ratio for the association between smoking and cleft lip and/or palate was 1.42 (95%CI 1.27 to 1.59) with a population attributable fraction of 4% (95%CI 3% - 5%). There was limited evidence to show a dose-response effect of smoking.ConclusionsThis review reports a moderate association between maternal smoking and orofacial cleft but the overall quality of the conventional observational studies included was poor. There is a need for high quality and novel research strategies to further define the role of smoking in the etiology of cleft lip and palate.

The intrauterine environment is critical for healthy prenatal growth and affects neonatal survival and later health. Mercury is a toxic metal which can freely cross the placenta and disrupt a wide range of cellular processes. Many observational studies have investigated mercury exposure and prenatal growth, but no prior review has synthesised this evidence. Four relevant publication databases (Embase, MEDLINE/PubMed, PsycINFO, and Scopus) were systematically searched to identify studies of prenatal mercury exposure and birth weight, birth length, or head circumference. Study quality was assessed using the NIH Quality Assessment Tool, and results synthesised in a narrative review. Twenty-seven studies met the review criteria, these were in 17 countries and used 8 types of mercury biomarker. Studies of birth weight (total = 27) involving populations with high levels of mercury exposure, non-linear methods, or identified as high quality were more likely to report an association with mercury, but overall results were inconsistent. Most studies reported no strong evidence of association between mercury and birth length (n = 14) or head circumference (n = 14). Overall, our review did not identify strong evidence that mercury exposure leads to impaired prenatal growth, although there was some evidence of a negative association of mercury with birth weight.

ObjectivesTo analyse the association between active and passive cigarette smoking and the incidence of children born with a cleft lip and/or palate within the United Kingdom.DesignFirst, a longitudinal time-series study was conducted with routinely collected smoking prevalence data for females over 16 years of age. Second, an interrupted time-series design was used as a natural experiment to assess the impact of smoke-free legislation using segmented Poisson regression.SettingUnited Kingdom.PopulationAll children born between 2000 and 2018 and their mothers.Main outcome measuresOrofacial cleft incidence, reported annually for England, Wales and Northern Ireland and separately for Scotland.ResultsOver the study period, the annual incidence of orofacial cleft per 10,000 live births ranged from 14.2-16.2 in England, Wales and Northern Ireland and 13.4-18.8 in Scotland. The proportion of active smokers amongst females in the United Kingdom declined by 37% during the study period. Adjusted regression analysis did not show a correlation between the proportion of active smokers and orofacial cleft incidence in either dataset, although we were unable to exclude a modest effect of the magnitude seen in individual-level observational studies. The data in England, Wales and Northern Ireland suggested an 8% reduction in orofacial cleft incidence (95%CI 1% to 14%; P=0.026) following the implementation of smoke-free legislation. In Scotland, there was weak evidence for an increase in orofacial cleft incidence following smoke-free legislation.ConclusionThese two ecological studies offer a novel insight into the influence of smoking in orofacial cleft aetiology, adding to the evidence base from individual-level studies. Our results suggest that smoke-free legislation may have reduced orofacial cleft incidence in England, Wales and Northern Ireland.SUMMARY BOXSection 1: What is already known on this topicAn association between maternal active and passive smoking and orofacial cleft has been previously reported in conventional individual-level observational studiesEcological and natural experiment time-series designs have been successfully used to demonstrate the association between population-level exposures and other non-cleft health outcomesSection 2: What this study addsEcological studies within a single country with complete cleft registration data are unlikely to be sufficiently powered to detect a relationship between time-series population level trends in active smoking and the number of children born with orofacial cleft each year.In England, Wales and Northern Ireland our natural experiment study showed a reduction in the proportion of children born with an orofacial cleft following the implementation of smoke-free legislation, but this was not replicated in Scotland.This study exploits the systematic collection of population data in the UK and adds to our understanding of the role of smoking in orofacial clefting as well as demonstrating the impact of public health interventions.

BackgroundBoth active and passive cigarette smoking have previously been associated with orofacial cleft aetiology. We aimed to analyse the impact of declining active smoking prevalence and the implementation of smoke-free legislation on the incidence of children born with a cleft lip and/or palate within the United Kingdom.Methods and findingsWe conducted regression analysis using national administrative data in the United Kingdom between 2000–2018. The main outcome measure was orofacial cleft incidence, reported annually for England, Wales and Northern Ireland and separately for Scotland. First, we conducted an ecological study with longitudinal time-series analysis using smoking prevalence data for females over 16 years of age. Second, we used a natural experiment design with interrupted time-series analysis to assess the impact of smoke-free legislation. Over the study period, the annual incidence of orofacial cleft per 10,000 live births ranged from 14.2–16.2 in England, Wales and Northern Ireland and 13.4–18.8 in Scotland. The proportion of active smokers amongst females in the United Kingdom declined by 37% during the study period. Adjusted regression analysis did not show a correlation between the proportion of active smokers and orofacial cleft incidence in either dataset, although we were unable to exclude a modest effect of the magnitude seen in individual-level observational studies. The data in England, Wales and Northern Ireland suggested an 8% reduction in orofacial cleft incidence (RR 0.92, 95%CI 0.85 to 0.99; P = 0.024) following the implementation of smoke-free legislation. In Scotland, there was weak evidence for an increase in orofacial cleft incidence following smoke-free legislation (RR 1.16, 95%CI 0.94 to 1.44; P = 0.173).ConclusionsThese two ecological studies offer a novel insight into the influence of smoking in orofacial cleft aetiology, adding to the evidence base from individual-level studies. Our results suggest that smoke-free legislation may have reduced orofacial cleft incidence in England, Wales and Northern Ireland.

A lack of high-level evidence exists on the outcomes of different cleft palate repair techniques. A critical appreciation for the complication rates of common repair techniques is paramount to optimize cleft palate care.A literature search was conducted for articles on the measurement of fistula and velopharyngeal insufficiency (VPI) rates following cleft palate repair. Study quality was determined using validated scales. The heterogeneity between studies was evaluated using the IOf 2386 studies retrieved, 852 underwent screening and 227 met inclusion criteria (130 studies (57%) on fistulas and 122 studies (54%) on VPI). Meta-analyses were performed using 32 studies. The Furlow technique was associated with less postoperative fistulae than the von Langenbeck and Veau/Wardill/Kilner techniques (RR = 0.56 [0.39-0.79], p 0.01 and RR = 0.25 [0.12-0.52], p 0.01, respectively). One-stage repair was associated with less fistulae compared to two-stage repair (RR = 0.42 [0.19-0.96], p = 0.04). The Furlow repair was also associated with a less VPI than the Bardach palatoplasty (RR = 0.41 [0.23, 0.71], p 0.01), and the one-stage repair was associated with a reduction in VPI rates compared to two-stage repair (RR = 0.55 [0.32, 0.95], p = 0.03).The Furlow repair is associated with less risk of fistula formation than the von Langenbeck and Veau/Wardill/Kilner techniques and less VPI compared to the Bardach repair. One-stage repair is associated with less risk of fistula formation and VPI than two-stage repair.

The aim of effective healing is to restore comparable structure and function to tissues. In some circumstances, this is not achieved, resulting in fibrotic scar tissue formation. Although this may have offered survival advantages in the past, fibrosis leads to functional disruption, organ failure and even death. Fibrosis affects many tissues types, but its ramifications are arguably most conspicuous in the skin. Dermal fibrosis impacts millions of people worldwide, and currently, treatment is not directed against a given molecular abnormality. Research demonstrates a complex picture of cellular and molecular interaction culminating in the deposition of fibrotic tissue. This article discusses key molecular mechanisms of fibrosis within tissues and highlights the similarities and differences amongst key pathways. There is compelling evidence for the involvement of toll-like receptor-4 and transforming growth factor β within fibrosis throughout all tissue types. With regards to other molecules, although there are similarities between tissues, evidence is inconsistent. In order to gain therapeutic advances in the prevention or treatment of fibrosis, research should strive to understand specific molecular mechanisms in models that closely replicate human disease. Further, there should be a healthy scepticism regarding the applicability of given molecular targets between settings. This review highlights a number of prime movers to fibrosis that are the focus of current research.

In April 2013 I had the opportunity to assist with a facial reconstruction project in Ethiopia. Project Harar is a British charity that provides access to treatment for patients with facial deformities living in rural areas of Ethiopia. Patients with a cleft of the lip and/or palate are the most common group encountered. They are treated by a team of Ethiopian plastic surgeons and health staff throughout the year in the capital, Addis Ababa. Each year, however, the Project Harar community staff are presented with a number of patients with complex facial deformities, the management of which exceeds the level of experience and resources available in Ethiopia. An international surgical team comprising plastic and maxillofacial surgeons, anaesthetists and specialist nurses travels to Ethiopia annually for a two-month period to provide assistance with these complex cases. My role as a junior doctor was to assess the patients in preparation for surgery, organise the necessary investigations and assist in theatre where needed.

Symptomatic beta blocker overdose is a relatively uncommon, but potentially life-threatening condition ( Sheppard, 2006 ; Health Protection Agency, 2010 ). Current definitive treatment for these patients involves intravenous glucagon therapy, and as such, glucagon is considered both a first-line treatment and an antidote in cases of symptomatic beta blocker overdose ( Joint Formulary Committee, 2011 ; National Poisons Information Service, 2011a ; 2011b ). This case report examines an intentional overdose of propranolol, including paramedic prehospital management, and subsequent in-hospital definitive treatment involving intravenous glucagon therapy. Paramedics have experience and knowledge of administering intramuscular glucagon as part of their formulary, and possess the necessary skills for obtaining intravenous access. Therefore, could intravenous glucagon be considered appropriate for administration by paramedics as a prehospital intervention in cases of symptomatic beta blocker overdose?

The U.S. Environmental Protection Agency, FHWA, and California Department of Transportation have initiated a demonstration in California called Partnership for Integrated Planning. The purpose of this program is to obtain early involvement from local, state, and federal agency staff to help in planning for transportation infrastructure, urban growth, and resource protection together, rather than just to negotiate over permits for major infrastructure at the project stage. A report on this demonstration project is provided. The project applies a simple urban growth model based on a geographic information system to evaluate a transportation plan and projects in Merced County (population 211,000 in 2000). Interviews with agency participants show that, in general, resource agency personnel have limited involvement with transportation planning and transportation planners have limited knowledge of environmental planning; they therefore need to develop methods for identifying their concerns for 20-year planning purposes. Planning for resource protection for a whole county is quite different from arguing for maximum protection of resources at the project scale. The early steps in building the model and acquiring data sets are reviewed.