Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

OBJECTIVE

The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'.

DESIGN AND MAIN OUTCOME MEASURES

Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field.

RESULTS

Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH.

CONCLUSIONS

The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.

Disease severity impacts perceived quality of life in congenital diaphragmatic hernia: a prospective observational study

BACKGROUND

While research indicates comparable quality of life (QOL) in congenital diaphragmatic hernia (CDH) and healthy populations, the effect of CDH severity on patients' health perceptions remains unexplored. We aimed to assess QOL perception in CDH, hypothesising a decline correlated with increased disease severity.

METHODS

In this prospective observational study, we analysed patients with CDH aged 5 years and above participating in a longitudinal outpatient programme. We excluded bilateral CDH, genetic/syndromic conditions, prematurity and late diagnosis. Participants self-administered the age-adapted Pediatric Quality of Life Inventory (PedsQL) survey, covering four domains (physical, emotional, social, school). After enrolment, data were collected blind to severity status (larger defects denoting significant/'severe' disease). Repeated measurements were managed using a random mixed-effects model.

RESULTS

Of 34 participants (50% males) who completed the PedsQL, 10 provided measurements at two visits. Eight required a patch (type C), while 26 had primary repairs (type A=8; type B=18). Age at first evaluation was comparable across groups (no patch: median 11 (7-16), patch: 13 (8-15) years, p=0.78). Severe CDH correlated significantly with lower PedsQL scores (adjusted β: -18%, 95% CI -28%; -7%, adjusted for age at visit and sex). Lower scores specifically occurred in walking, exercising, social and academic functioning.

CONCLUSION

Severe CDH significantly lowers QOL. This finding is crucial for resource allocation in long-term CDH health surveillance and advocates for regular inclusion of patient experiences in quality improvement efforts.

Role of practice standardization in outcome optimization for CDH

Standardization of care seeks to improve patient outcomes and healthcare delivery by reducing unwanted variations in care as well as promoting the efficient and effective use of healthcare resources. There are many types of standardization, with clinical practice guidelines (CPGs), based on a stringent assessment of evidence and expert consensus, being the hallmark of high-quality care. This article outlines the history of CPGs, their benefits and shortcomings, with a specific focus on standardization efforts as it relates to congenital diaphragmatic hernia management.

Percutaneous extraction of metallic foreign body from pyogenic liver abscess

We report a case of a 35-year-old male who developed a pyogenic liver abscess (PLA) secondary to a foreign body that migrated from the transverse colon into the liver. The mainstay of treatment of PLA requires removal of the foreign body, most frequently performed surgically. Few case reports exist of percutaneous removal. As our patient was hemodynamically stable at time of presentation, he underwent successful percutaneous transhepatic removal of the foreign body, avoiding any need for surgical operation.

The sequential modular curriculum for oral health personnel: an evaluation of the Fijian experience after five years

In 1993 a new sequential modular curriculum was introduced for the training and education of oral health personnel in Pacific Island countries. The five-year model provided a multi-stage course with the opportunity to exist at the level of dental hygienist after two years, dental therapist or dental technologist after three years and dental surgeon after five years. After five years' experience the principles involved in the introduction of such a curriculum have been confirmed as educationally sound. The model may also be useful for introduction in other countries providing its structure and the details of individual modules are tailored to local social, cultural and demographic needs.

Incisor spacing: a sequential orthodontic restorative treatment approach

For those patients presenting with one or more missing incisors, a sequential technique utilizing specific arch wires to level and align the irregular incisor teeth may be used. Auxiliary coil springs are then fitted to redistribute the space prior to the preparation of a prosthesis, the fabrication of which is facilitated by parallel and upright abutments. The space obtained allows esthetically proportioned pontics. Two cases that illustrate this technique are presented.

The use of role-play and psychodrama in the education of the dental undergraduate

The delivery of effective information flow through self learning, critical thinking and problem solving is one of the objectives of current curriculum development within the Dental Faculty of the University of Hong Kong. These objectives reflect a desire to encourage skills related to 'comprehension learning' and 'meaning orientation' rather than 'rote' learning and 'surface' approaches. This paper explains the way in which role-play and psychodrama are used in an effort to achieve these objectives.

A clinical evaluation of conventional bridgework

The present study evaluated the incidence and causes of failure of conventional bridgework provided in the Prince Philip Dental Hospital, Hong Kong. Any bridge that utilized resin-bonded (Maryland) retainers was excluded from this study. All patients with bridges fitted between 1981 and 1987 were recalled for review, and 143 patients attended, a response rate of 77%. A total of 169 bridges were examined, their mean length of service being 35 months. Thirty-five bridges were deemed to have failed. The most frequent cause was endodontic, followed by loss of retention, then persistent pain and sensitivity. Failures of endodontic origin affected mostly anterior bridges, which could be attributed to the over-sized pulp of anterior teeth and the amount of tooth reduction required for the ceramometal retainer. All of the bridges that failed because of endodontic problems had had ceramometal retainers. Taking posterior bridges alone, the failure rate was 4.4% per year. From the evidence of this study, the replacement of the maxillary canine with a cantilever bridge appears to be contra-indicated.

Management of worn dentition with resin-bonded cast metal lingual veneering

The treatment of excessive tooth wear with limited interocclusal space is complicated. Nonprecious alloys may be cast into thin sections and bonded to the tooth surface with an adhesive cement. The technique may be applied to the provision of veneers to restore and protect worn tooth surfaces. This article describes the conservative management of excessively worn maxillary anterior teeth by use of this technique.

Establishment of a large collection of extracted teeth for research

A collection of over 14,000 teeth extracted at the Prince Philip Dental Hospital since 1982 has been organized and catalogued on a computerized database management system. The computer catalogue provides, for each tooth in the collection, information on the age and sex of the patient, and the date of extraction and condition of the tooth. The catalogue can be searched according to any combination of the descriptive variables in the database record. Researchers, including visiting scientists, can borrow teeth from the central "tooth library" on a temporary or permanent basis. Further information on particular teeth (e.g. patient's medical and dental histories, dental radiographs) can be obtained from patients' charts. Establishment of this collection has greatly facilitated the work of researchers in clinical dentistry, dental anatomy, and dental anthropology.