Body Contouring Surgery After Bariatric Surgery Improves Long-Term Health-Related Quality of Life and Satisfaction With Appearance: An International Longitudinal Cohort Study Using the BODY-Q

OBJECTIVE

To examine health-related quality of life (HRQL) and satisfaction with appearance in patients who have undergone bariatric surgery (BS) with or without subsequent body contouring surgery (BCS) in relation to the general population normative for the BODY-Q.

BACKGROUND

The long-term impact of BS with or without BCS has not been established using rigorously developed and validated patient-reported outcome measures. The BODY-Q is a patient-reported outcome measure developed to measure changes in HRQL and satisfaction with appearance in patients with BS and BCS.

METHODS

Prospective BODY-Q data were collected from 6 European countries (Denmark, the Netherlands, Finland, Germany, Italy, and Poland) from June 2015 to February 2022 in a cohort of patients who underwent BS. Mixed-effects regression models were used to analyze changes in HRQL and appearance over time between patients who did and did not receive BCS and to examine the impact of patient-level covariates on outcomes.

RESULTS

This study included 24,604 assessments from 5620 patients. BS initially led to improved HRQL and appearance scores throughout the first postbariatric year, followed by a gradual decrease. Patients who underwent subsequent BCS after BS experienced a sustained improvement in HRQL and appearance or remained relatively stable for up to 10 years postoperatively.

CONCLUSIONS

Patients who underwent BCS maintained an improvement in HRQL and satisfaction with appearance in contrast to patients who only underwent BS, who reported a decline in scores 1 to 2 years postoperatively. Our results emphasize the pivotal role that BCS plays in the completion of the weight loss trajectory.

The Development of a European Multidisciplinary Cleft Lip and Palate Registry by the European Reference Network CRANIO: Experiences, Barriers, And Facilitators

The European Reference Network for Rare Craniofacial Aanomalies and Ear-Nose-Throat disorders aims to improve care for patients with such afflictions, including cleft lip and palate (CL/P) across Europe. Cleft treatment remains varied throughout European centers, inhibiting meaningful comparison of treatment outcomes. To overcome these issues, a European-wide common CL/P dataset and registry was developed, facilitating standardized treatment endpoints and outcome measures for international comparison and benchmarking of CL/P centers. Questionnaires and semi-structured interviews were used to determine the set-up of the registry. Previous CL/P initiatives were analyzed to create an initial dataset, refined through consensus meetings. In total, 87 cleft specialists working in specialized CL/P centers from 16 European nations participated. Consensus on a common dataset was reached. A "Level 1" dataset, with mandatory clinical and patient-reported outcome measures, and "Level 2" dataset with additional outcome measures. Finally, 2 dashboards were developed for data dissemination. The development of the European CL/P common dataset and registry tackled challenges with resource disparities, variations in specialists within CL/P teams, regulatory differences in patient data usage, patient-reported outcome measures availability in European languages, and use of assessment tools. This study described the successful development of the European Reference Network for Rare Craniofacial Aanomalies and Ear-Nose-Throat disorders CL/P common dataset and registry. This achievement will help improve patient care and outcomes for patients with CL/P in Europe. Furthermore, this study provides useful information for initiatives with similar aims.

Effect of Subnormothermic Machine Perfusion on the Preservation of Vascularized Composite Allografts After Prolonged Warm Ischemia

BACKGROUND

Warm ischemia time (WIT) and ischemia-reperfusion injury are limiting factors for vascularized composite allograft (VCA) transplantation. Subnormothermic machine perfusion (SNMP) has demonstrated the potential to extend WIT in organ transplantation. This study evaluates the effect of SNMP on VCA viability after prolonged WIT.

METHODS

Rat hindlimbs underwent WIT for 30, 45, 60, 120, 150, or 210 min, followed by 3-h SNMP. Monitoring of perfusion parameters and outflow determined the maximum WIT compatible with limb viability after SNMP. Thereafter, 2 groups were assessed: a control group with inbred transplantation (Txp) after 120 min of WIT and an experimental group that underwent WIT + SNMP + Txp. Graft appearance, blood gas, cytokine levels, and histology were assessed for 21 d.

RESULTS

Based on potassium levels, the limit of WIT compatible with limb viability after SNMP is 120 min. Before this limit, SNMP reduces potassium and lactate levels of WIT grafts to the same level as fresh grafts. In vivo, the control group presented 80% graft necrosis, whereas the experimental group showed no necrosis, had better healing (P = 0.0004), and reduced histological muscle injury (P = 0.012). Results of blood analysis revealed lower lactate, potassium levels, and calcium levels (P = 0.048) in the experimental group. Both groups presented an increase in interleukin (IL)-10 and IL-1b/IL-1F2 with a return to baseline after 7 to 14 d.

CONCLUSIONS

Our study establishes the limit of WIT compatible with VCA viability and demonstrates the effectiveness of SNMP in restoring a graft after WIT ex vivo and in vivo, locally and systemically.

Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis

OBJECTIVES

In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome.

MATERIALS AND METHODS

A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model.

RESULTS

One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11).

CONCLUSIONS

A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair.

CLINICAL RELEVANCE

Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.

What is the optimal assessment of speech? A multicentre, international evaluation of speech assessment in 2500 patients with a cleft

OBJECTIVES

Speech problems in patients with a cleft palate are often complex and multifactorial. Finding the optimal way of monitoring these problems is challenging. The International Consortium of Health Outcomes Measurement (ICHOM) has developed a set of standardised outcome measures at specific ages for patients with a cleft lip and/or palate, including measures of speech assessment. This study evaluates the type and timing of speech outcome measures currently included in this ICHOM Standard Set. Additionally, speech assessments in other cleft protocols and initiatives are discussed.

DESIGN, SETTING AND PARTICIPANTS

An international, multicentre study was set up including centres from the USA and the Netherlands. Outcomes of clinical measures and Patient Reported Outcome Measures (PROMs) were collected retrospectively according to the ICHOM set. PROM data from a field test of the CLEFT-Q, a questionnaire developed and validated for patients with a cleft, were collected, including participants from countries with all sorts of income statuses, to examine the value of additional moments of measurement that are used in other cleft initiatives.Data from 2500 patients were included. Measured outcomes contained univariate regression analyses, trend analyses, t-tests, correlations and floor and ceiling effects.

RESULTS

PROMs correlated low to moderate with clinical outcome measures. Clinical outcome measures correlated low to moderate with each other too. In contrast, two CLEFT-Q Scales correlated strongly with each other. All PROMs and the Percent Consonants Correct (PCC) showed an effect of age. In patients with an isolated cleft palate, a ceiling effect was found in the Intelligibility in Context Scale.

CONCLUSION

Recommendations for an optimal speech outcome assessment in cleft patients are made. Measurement moments of different cleft protocols and initiatives are considered in this proposition. Concerning the type of measures, adjustment of the current PCC score outcome seems appropriate. For centres with adequate resources and specific interest in research, translation and validation of an upcoming tool, the Cleft Audit Protocol for Speech Augmented, is recommended.

Sub-Zero Non-Freezing of Vascularized Composite Allografts Preservation in Rodents

Ischemia is a major limiting factor in Vascularized Composite Allotransplantation (VCA) as irreversible muscular injury can occur after as early as 4-6 hours of static cold storage (SCS). Organ preservation technologies have led to the development of storage protocols extending rat liver ex vivo preservation up to 4 days. Development of such a protocol for VCAs has the added challenge of inherent ice nucleating factors of the graft, therefore this study focused on developing a robust protocol for VCA supercooling. Rodent partial hindlimbs underwent subnormothermic machine perfusion (SNMP) with several loading solutions, followed by cryoprotective agent (CPA) cocktail developed for VCAs. Storage occurred in suspended animation for 24h and VCAs were recovered using SNMP with modified Steen. This study shows a robust VCA supercooling preservation protocol in a rodent model. Further optimization is expected to allow for its application in a transplantation model, which would be a breakthrough in the field of VCA preservation.

Core outcomes for orofacial clefts: reconciling traditional and ICHOM minimum datasets

OBJECTIVE/DESIGN/SETTING

This retrospective study sought voluntary participation from leading cleft centres from Europe and Brazil regarding core outcome measures. The results of this study would inform the debate on core outcome consensus pertaining to the European Reference Network for rare diseases (ERN CRANIO) and achieve a core outcome set for cleft care providers worldwide.

INTERVENTION/METHOD

Five orofacial cleft (OFC) disciplines were identified, within which all of the International Consortium of Health Outcomes Measurement (ICHOM) outcomes fall. One questionnaire was designed for each discipline and comprised 1. the relevant ICHOM's outcomes within that discipline, and 2. a series of questions targeted to clinicians. What core outcomes are currently measured and when, did these align with the ICHOM minimum, if not how did they differ, and would they recommend modified or additional outcomes?.

RESULTS

For some disciplines participants agreed with the ICHOM minimums but urged for earlier and more frequent intervention. Some clinicians felt that some of the ICHOM standards were compatible but that different ages were preferred and for others the ICHOM standards were acceptable but developmental stages should be preferred to absolute time points.

CONCLUSION/IMPLICATIONS

Core outcomes for OFC were supported in principle but there are differences between the ICHOM recommendations and the 2002 WHO global consensus. The latter are established in many centres with historical archives of OFC outcome data, and it was concluded that with some modifications ICHOM could be moulded into useful core outcomes data for inter-centre comparisons worldwide.

Body Image and Weight Loss Outcome After Bariatric Metabolic Surgery: a Mixed Model Analysis

PURPOSE

As in nonsurgical weight loss populations, body image may partly explain differences in weight loss outcomes after surgery. The aim of this study was to determine the prospective association between body image and weight loss in a longitudinal cohort of patients up to 3 years after bariatric metabolic surgery.

MATERIALS AND METHODS

The BODY-Q self-report questionnaire was used to assess body image. Linear mixed models evaluated associations of baseline body image with weight loss in the first year as well as associations of body image at 12 months and first-year change in body image with weight loss 12 to 36 months after surgery.

RESULTS

Available body image data included 400 (100%), 371 (93%), 306 (77%), 289 (72%), and 218 (55%) patients at baseline and 4, 12, 24, and 36 months, respectively. Body image scores improved significantly until 12 months, followed by a gradual decline. Scores remained improved in comparison to baseline (β = 31.49, 95% CI [27.8, 35.2], p < .001). Higher baseline body image was associated with less weight loss during the first year, and the effect size was trivial (ß = -0.05, 95% CI [-0.09, -0.01], p = .009). Body image and change in body image were not associated with weight loss 12 to 36 months after surgery.

CONCLUSION

Body image improved after bariatric metabolic surgery. Although no clinically relevant associations of body image with weight loss were demonstrated, the gradual decline in body image scores underlines the importance of long-term follow-up with regular assessment of this aspect of quality of life.

The relationship of body image and weight: A cross-sectional observational study of a Dutch female sample

Body image concerns may play a role in weight changing behaviour. The objective of this study was to assess body image in different weight groups. Participants reported satisfaction with (AE) and investment in (AO) appearance, and the discrepancy between current and ideal body size (BS). These scores were compared between weight groups based on body-mass index (BMI) using analysis of variance. One-sample t-tests and Cohen's d effect sizes examined the magnitude of differences within each weight group relative to neutral midpoints of the scales; cluster analysis identified body image profiles. A total of 27 896 women were included in this study. AE scores were highest for people with underweight and normal weight, AO scores were highest for the underweight group and lowest in class III obesity, and BS scores were largest in the obese groups (all p < .001) Cluster analysis identified eight body image profiles. In people with obesity, the most prevalent profiles included a preference for a smaller body and low satisfaction with appearance, but differed in investment in appearance (low vs. high). Most people with underweight were allocated to profiles showing high investment in their appearance, preference of a larger body, but differences in satisfaction with appearance (neutral vs. high). While people with a higher BMI have on average more body image concerns, different body image profiles exist in all weight groups. Future research should examine whether and which individuals in terms of body image profile may benefit more from weight interventions.

Validation of the Dutch Version of the BODY-Q Measuring Appearance, Health-related Quality of Life, and Experience of Healthcare in Patients Undergoing Bariatric and Body Contouring Surgery

Background

The BODY-Q is a patient-reported outcome measure (PROM) developed for use in bariatric and body contouring surgery.

Objectives

The objective of this study was to examine the validity and reliability of the Dutch version of the BODY-Q.

Methods

The BODY-Q consists of 163 items in 21 independently functioning scales that measure appearance, health-related quality of life (HRQL) and experience of care. The data used to validate the Dutch BODY-Q were provided by two prospective multicenter cohort studies across three hospitals in the Netherlands. The BODY-Q was administered before and after surgery at 3 or 4 months and 12 months. Rasch Measurement Theory (RMT) analysis was used to evaluate the BODY-Q for targeting, category threshold order, Rasch model fit, Person Separation Index (PSI), and differential item functioning (DIF) by language (original English data versus Dutch data).

Results

Data were collected between January 2016 and May 2019. A total of 876 participants were included in the study who provided 1614 assessments. Validity was supported by three RMT findings: most scales showed good targeting, 160/163 (98.2%) items evidenced ordered thresholds, and 142/163 (87.1%) items fit to the RMT model. Reliability was high with PSI values &gt;0.70 for 19/21 scales. There was negligible influence of DIF by language on person item locations and the scales scoring.

Conclusions

This study provides evidence for the reliability and validity of the Dutch BODY-Q for use in bariatric and body contouring patients in the Netherlands. The Dutch BODY-Q can be used in (inter)national research and clinical practice.

Patient-Level Factors Associated with Health-Related Quality of Life and Satisfaction with Body After Bariatric Surgery: a Multicenter, Cross-Sectional Study

BACKGROUND

Health-Related Quality of Life (HRQL) is a key outcome of success after bariatric surgery. Not all patients report improved HRQL scores postoperatively, which may be due to patient-level factors. It is unknown which factors influence HRQL after surgery. Our objective was to assess patient-level factors associated with HRQL after surgery.

METHODS

This international cross-sectional study included 730 patients who had bariatric surgery. Participants completed BODY-Q scales pertaining to HRQL and satisfaction with body, and demographic characteristics were obtained. The sample was divided into three groups based on time since surgery: 0 - 1 year, 1 - 3 years and more than 3 years. Uni- and multivariable linear regression analyses were conducted to identify variables associated with the BODY-Q scales per group.

RESULTS

The 0 - 1 year postoperative group included 377 patients (50.9%), the 1 - 3 years postoperative group 218 (29.4%) and the more than 3 years postoperative group 135 patients (18.2%). Lower current body-mass index (BMI), more weight loss (%TWL), being employed, having no comorbidities, higher age and shorter time since surgery were significantly associated with improved HRQL outcomes postoperatively. None of these factors influenced all BODY-Q scales. The effect of current BMI increased with longer time since surgery.

CONCLUSION

Factors including current BMI, %TWL, employment status, presence of comorbidities, age and time since surgery were associated with HRQL postoperatively. This information may be used to optimize patient-tailored care, improve patient education and underline the importance of long-term follow-up with special attention to weight regain to ensure lasting improvement in HRQL.

Surgeons Attitude toward Psychosocial Aspects of Trapeziometacarpal Osteoarthritis

Background There is notable evidence that unhelpful thoughts (symptoms of anxiety and depression) increase symptom intensity among patients with trapeziometacarpal osteoarthritis (TMC OA). Surgeons may or may not be mindful of this line of evidence when interacting with patients. In a survey-based experiment, we randomized surgeons to be prompted about the psychosocial aspects of TMC OA. We aimed to measure the influence of mindfulness of mental health on treatment recommendations and willingness to discuss mental health interventions.

Methods We randomized 121 hand surgeons to read one of two paragraphs: (A) about biomedical treatment options for TMC OA, or (B) about the impact of mental and social aspects on TMC OA. Thereafter, surgeons were asked several questions about their opinions and treatment recommendations.

Results We found that prompting surgeons with information about the psychosocial aspects of TMC OA did not influence their attitudes or treatment recommendations. Most surgeons were willing to offer patients a workbook (92%) or psychologist referral (84%). Among the few surgeons declining to refer, their reasoning was “it would not be of any help” and “stigmatization.”

Conclusion The observation that a paragraph to encourage mindfulness about the psychosocial aspects of TMC OA, which had no influence on surgeon opinions, suggests that awareness may not be a major factor accounting the relatively limited implementation of this evidence in practice to date. Surgeons seem aware of the importance of psychological influence and barriers may include availability, stigma, and a sense of futility. This is a diagnostic study that reflects level of evidence III.

Joint Distraction for Thumb Carpometacarpal Osteoarthritis: 2-Year Follow-up Results of 20 Patients

Background  Joint distraction is a fairly new treatment for patients with symptomatic thumb carpometacarpal osteoarthritis (CMC1 OA). A previous pilot study of five patients showed that CMC1 joint distraction is technically feasible. The current study presents the results of CMC1 joint distraction in 20 patients with a 2-year follow-up period. Purposes  The primary study aim was to assess if patients with CMC1 OA have better physical function and less pain 2 years after CMC1 joint distraction. Second, we assessed the number of patients who achieved a minimal clinically important difference (MCID) in patient-reported outcome measures at each follow-up time point. Furthermore, this study sought differences on magnetic resonance imaging (MRI) of the CMC1 joint before and after distraction. Adverse events were noted and reported. Methods  Twenty patients (median age of 54 years) with symptomatic CMC1 OA and an established indication for a trapeziectomy were enrolled. An external distractor device was placed over the CMC1 joint and left in situ for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), visual analogue scale (VAS), and grip strength were recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. Results  Two years after joint distraction, physical function and pain scores had improved significantly compared with baseline: DASH from 48 to 17, MHQ from 56 to 83, and VAS for pain from 50 to 18 mm. Fourteen of 19 patients (74%) reached an MCID in DASH and MHQ scores. One patient was not satisfied with treatment outcome and chose to proceed with a trapeziectomy 14 months after initial distraction therapy. Conclusions  This study demonstrates that CMC1 joint distraction can postpone more invasive surgical interventions (e.g., trapeziectomy) for at least 2 years. Larger comparative studies are needed to assess the value of CMC1 joint distraction in the treatment of CMC1 OA. Level of Evidence  This is a Level IV, prospective case series study.

Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.

Can we decrease the duration of basal thumb joint distraction for early osteoarthritis from 8 to 6 weeks? Study protocol for a non-inferiority randomized controlled trial

BACKGROUND

To our knowledge, to date, 52 patients with thumb carpometacarpal osteoarthritis (CMC1 OA) were treated with joint distraction. So far, most patients experienced improved physical function and less pain. After 2 years, only 1 patient proceeded to trapeziectomy. This study assesses if we can safely lower the distraction duration from 8 to 6 weeks for CMC1 joint distraction, maintaining the improvement in physical function and pain.

METHODS

This is a monocenter randomized controlled non-inferiority trial that includes patients younger than 65 years of age with ongoing symptoms of CMC1 OA and an established indication for surgery. All patients will be treated with CMC1 joint distraction. The primary outcome is to assess whether 6 weeks of joint distraction is not inferior to 8 weeks in terms of physical function at 1 year after surgery. Secondary outcomes will identify differences between groups at 1 year in pain intensity, patient satisfaction, hand health status, adverse event rates, treatment failure, differences in thumb strength and range of motion, and radiographic changes.

DISCUSSION

If safe, the duration of basal thumb joint distraction can be reduced to 6 weeks, reducing patient burden. Because this is a relatively new treatment, this trial will provide greater knowledge of potential adverse events. This knowledge allows for more informed decision making for patients considering CMC1 distraction treatment. Future studies can directly compare joint distraction to other treatments of CMC1 joint arthritis like splinting and trapeziectomy.

TRIAL REGISTRATION

Central Committee on Research Involving Human Subjects (CCMO), NL68225.100.18; registered on 9 August 2019. Medical Research Ethics Committees United (MEC-U), R19.003; registered on 9 August 2019. Netherlands Trial Register, NL8016 ; registered on 15 September 2019.

Incidence of complications in secondary alveolar bone grafting of bilateral clefts with premaxillary osteotomy: a retrospective cohort study

OBJECTIVE

To evaluate factors affecting incidence of complications after secondary alveolar bone grafting with premaxillary osteotomy (SABG + PO) in children with complete bilateral cleft of lip and palate (BCLP).

MATERIALS AND METHODS

Data were collected from children with BCLP treated with SABG + PO from 2004 to 2014 at our institute. Preoperative parameters included age, donor site, race, gingival health, bone quality around cleft-related teeth, premaxilla position, graft timing, presence of canines in the cleft, and presence of deciduous teeth around the cleft area. Logistic regression and the chi-squared test were used to assess correlations and the incidence of complications.

RESULTS

In the 64 patients, a significant correlation was found between complication rate and timing of bone grafting with respect to early versus late SABG + PO (p = 0.041), age > 12 years (p = 0.011; odds ratio (OR) 5.9; 95% confidence interval (CI) 1.49-23.93), malposition of the premaxilla (p = 0.042; OR 3.3; 95% CI 1.04-10.13), and preoperative bone quality around cleft-related teeth (p = 0.005; OR 5.3; 95% CI 1.6-17.2).

CONCLUSIONS

The timing of SABG + PO is essential, as early SABG + PO is associated with fewer complications. A malpositioned premaxilla and poor bone quality around cleft-related teeth are associated with more complications. Therefore, preoperative orthodontic repositioning of the malpositioned premaxilla before SABG + PO should be considered.

CLINICAL RELEVANCE

Analysis of treatment protocols and complications for BCLP patients underscores that proper timing of SABG + PO and correct premaxilla repositioning help reduce complications.

Quality of Life and Patient Satisfaction in Adults Treated for a Cleft Lip and Palate: A Qualitative Analysis

Objective:

Long-term outcomes of patients born with a cleft lip and palate (CLP) are scarcely investigated. Yet, this patient group is of particular interest, as they can provide a valuable retrospective view upon their treatment experiences and psychological adjustment. Qualitative accounts may be especially useful in understanding the patient journey.

Design:

The present study set out to evaluate quality of life and satisfaction with treatment in adult patients previously treated for CLP at the Wilhelmina Children’s Hospital. Semistructured interviews were performed.

Patients:

A total of 22 patients aged 17 to 35 years (mean: 25 years) were interviewed about their experiences of growing up with CLP and of the treatment they received. Interviews were audio-recorded and factors thought to influence psychological adjustment were identified.

Results:

Four main themes were identified: background factors, support systems, treatment factors, and coping/internal factors. Each theme was described with illustrative quotes.

Conclusion:

This study underlines that psychological adjustment can fluctuate over time and greatly differs between individuals, even during adulthood. Psychological support should therefore be available beyond the finalization of the treatment course. Furthermore, the majority of participants stated they had wanted more psychological support as a child to facilitate resilience and to help them cope with challenges.

Body image dissatisfaction and depression in postbariatric patients is associated with less weight loss and a desire for body contouring surgery

BACKGROUND

Overhanging skin in postbariatric patients leads to a negative body image. In patients with obesity, negative body image is related to more depressive symptoms and a higher weight. This relationship might also be important in postbariatric patients, because improvement of body image via body contouring surgery (BCS) could lead to better weight loss results.

OBJECTIVES

To evaluate the relationship between body image, depressive symptoms, and weight loss in a postbariatric population, focusing on desire for BCS.

SETTING

Outpatient clinic.

METHODS

One thousand twenty-four primary bariatric surgery patients were contacted, and 590 patients agreed to participate and filled in online questionnaires regarding body image (Body Shape Questionnaire and Multidimensional Body-Self Relations Questionnaire-Appearance Scales) and depression (Beck Depression Inventory-II). Differences between patients who had BCS, patients who desired BCS, and patients who did not desire BCS were studied. The mediating role of body image in the association between percentage total weight loss and depressive symptoms was assessed via a 2-mediator model.

RESULTS

There was a desire for BCS in 368 patients (62.4%); these patients had significantly lower scores on appearance evaluation and body image satisfaction scales and showed more depressive symptoms. Patients without a desire (n = 157, 26.6%) had lowest rates of depressive symptoms and a more positive body image. Sixty-five patients (11.0%) had undergone BCS. In the patients who desired BCS, percentage total weight loss was negatively affected by depressive symptoms via appearance evaluation and body-area satisfaction.

CONCLUSIONS

There are striking differences regarding body image satisfaction and depressive symptoms when comparing postbariatric patients and without desire for BCS. Body image satisfaction is associated with less depressive symptoms in all postbariatric patients. In patients who desired BCS, body image is one of the mediators of the relationship between percentage total weight loss and depressive symptoms. Therefore, body image should be taken seriously and be part of outcome assessment in postbariatric patients.

Congenital respiratory tract disorders in 22q11.2 deletion syndrome

OBJECTIVE

Respiratory tract disorders have been reported in patients with 22q11.2 deletion syndrome, however infrequently. This study describes the respiratory tract disorders encountered in a cohort of 278 patients with 22q11.2 deletion syndrome.

METHODS

We conducted a retrospective, cross-sectional, study at a single tertiary referral center. We identified the patients with 22q11.2 deletion syndrome and with an upper and/or lower respiratory tract disorder at our otorhinolaryngologic department. The different disorders were described.

RESULTS

Out of 278 patients referred to the otorhinolaryngologic department, we identified 14 patients with a laryngeal and/or tracheal disorder. Nine patients had more than one congenital disorder in this anatomical area. Disorders included a choanal stenosis (n = 1), laryngeal web (n = 5), laryngeal cleft (n = 2), subglottic stenosis (n = 3), pharyngo-, laryngo-, tracheo- and/or bronchomalacia (n = 11) and tracheal stenosis (n = 1).

CONCLUSION

Different types of respiratory tract disorders can be present in patients with 22q11.2 deletion syndrome. Clinicians should be aware of this clinical association for timely and accurate diagnosis and treatment. In addition, the diagnosis 22q11.2 deletion syndrome should be considered in patients presenting with a congenital respiratory tract disorder.

Parental Attitude Toward the Prenatal Diagnosis of Oral Cleft: A Prospective Cohort Study

OBJECTIVES

The prenatal diagnosis of oral clefts (OCs) by ultrasound can pose an ethical dilemma. The purpose of this study was to obtain insight into the psychosocial and moral considerations of prospective parents concerning OCs, the burden of OCs and parents' attitude toward possible termination of pregnancy (TOP) in order to improve counseling in the future.

DESIGN

Between August 2011 and August 2014, a prospective cohort questionnaire study was administered.

SETTING

Prenatal care clinic of the Wilhelmina's Children hospital, a Tertiary Care Centre.

PARTICIPANTS

Parents expecting a child with an OC.

MAIN OUTCOME MEASURES

Expectation of OCs in general and attitudes toward the impact and expected burden of the OC of their child. Furthermore, parents were asked if they had considered TOP.

RESULTS

Most of the parents described an OC as a cosmetic disability (50.6%) or as "just a little different" (29.4%). These parents expected that the OC would not affect their own happiness and have only minor influence on the happiness of their future child. Health professionals had a considerable influence on parental opinion. A minority (6.4%, 5/85) of the respondents considered TOP, and none of the responders chose to terminate the pregnancy.

CONCLUSIONS

This study suggests that future parents have very few negative perceptions of OC after prenatal counseling. Caregivers should be aware that their counseling is important for decision-making of parents.

Mortality in Robin sequence: identification of risk factors

Although Robin sequence (RS) is a well-known phenomenon, it is still associated with considerable morbidity and even mortality. The purposes of this study were to gain greater insight into the mortality rate and identify risk factors associated with mortality in RS. We retrospectively reviewed all RS infants followed at the Wilhelmina Children's Hospital from 1995 to 2016. Outcome measurements were death and causes of death. The authors identified 103 consecutive RS infants with a median follow-up of 8.6 years (range 0.1-21.9 years). Ten of the 103 infants (10%) died at a median age of 0.8 years (range 0.1-5.9 years). Nine of these ten infants (90%) were diagnosed with an associated syndrome. Of these, seven infants died of respiratory insufficiency due to various causes (two related to upper airway obstruction). The other two syndromic RS infants died of arrhythmia due to hypernatremia and of West syndrome with status epilepticus. One isolated RS infant died of brain ischemia after MDO surgery. Cardiac anomalies were observed in 41% and neurological anomalies in 36%. The presence of a neurological anomaly was associated with a mortality rate of 40% versus 7% in infants with no neurological anomaly (p = 0.016), with an odds ratio of 8.3 (95% CI 1.4-49.0) for neurological anomaly versus no neurological anomaly. Mortality was 15% in infants with syndromic RS versus 2% in infants with isolated RS (p = 0.044). Mortality was not significantly associated with the presence of a cardiac anomaly, surgical treatment for severe respiratory distress in the neonatal period, or prematurity.

CONCLUSION

RS represents a heterogeneous patient population and is associated with a high level of underlying syndromes. The present study reports a mortality rate of 10% significantly associated with syndromic RS and the presence of neurological anomalies. A multidisciplinary approach in all infants born with RS, including genetic testing and examination of neurological anomalies in a standardized way, is crucial to identify infants with underlying syndromes potentially associated with increased mortality. What is Known: • Reported mortality rates in Robin sequence vary from 2% to 26%. • Clinicians mainly focus on the morbidity of Robin sequence that includes respiratory complications due to upper airway obstruction in the period after birth. • Robin sequence represents a heterogeneous patient population and is associated with a high level of underlying syndromes. What is New: • The present study reports a mortality rate of 10% significantly associated with syndromic Robin sequence and the presence of neurological anomalies. • A multidisciplinary approach in all infants born with Robin sequence, including genetic evaluation and standardized workup for neurological anomalies, is crucial to identify infants with underlying syndromes potentially associated with increased mortality.

Different properties of skin of different body sites: The root of keloid formation?

The purpose of this study was to examine extracellular matrix composition, vascularization, and immune cell population of skin sites prone to keloid formation. Keloids remain a complex problem, posing esthetical as well as functional difficulties for those affected. These scars tend to develop at anatomic sites of preference. Mechanical properties of skin vary with anatomic location and depend largely on extracellular matrix composition. These differences in extracellular matrix composition, but also vascularization and resident immune cell populations might play a role in the mechanism of keloid formation. To examine this hypothesis, skin samples of several anatomic locations were taken from 24 human donors within zero to 36 hours after they had deceased. Collagen content and cross-links were determined through high-performance liquid chromatography. The expression of several genes, involved in extracellular matrix production and degradation, was measured by means of real-time PCR. (Immuno)histochemistry was performed to detect fibroblasts, collagen, elastin, blood vessels, Langerhans cells, and macrophages. Properties of skin of keloid predilections sites were compared to properties of skin from other locations (nonpredilection sites [NPS]). The results indicated that there are site specific variations in extracellular matrix properties (collagen and cross-links) as well as macrophage numbers. Moreover, predilection sites (PS) for keloid formation contain larger amounts of collagen compared to NPS, but decreased numbers of macrophages, in particular classically activated CD40 positive macrophages. In conclusion, the altered (histological, protein, and genetic) properties of skin of keloid PS may cause a predisposition for and contribute to keloid formation.

Joint distraction for thumb carpometacarpal osteoarthritis: a feasibility study with 1-year follow-up

OBJECTIVE

The purpose of this pilot study was to evaluate the feasibility of joint distraction of the first carpometacarpal (CMC1) joint in patients with CMC1 osteoarthritis (OA).

METHODS

An external joint distractor was placed over the CMC1 joint by K-wire fixation in the trapezium and the metacarpal. The joint was distracted 3 mm during surgery. The device was then kept in place for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), Visual Analogue Scale (VAS), and grip strength were recorded preoperatively and at set postoperative intervals.

RESULTS

Five female patients with an average age of 53 years (range = 41-61) were included. One year postoperatively, average DASH, MHQ, and VAS scores improved compared to preoperative values; DASH 53 to 27, MHQ 48 to 76, and VAS pain 48 to 14. There were no technical problems associated with the device. One patient had a local pin site infection treated successfully with oral antibiotics.

CONCLUSIONS

This study concludes that joint distraction of the osteoarthritic CMC1 joint is technically feasible. In this small, prospective pilot study the majority of the results were favourable during short-term follow-up.

Compound heterozygous NEK1 variants in two siblings with oral-facial-digital syndrome type II (Mohr syndrome)

The oral-facial-digital (OFD) syndromes comprise a group of related disorders with a combination of oral, facial and digital anomalies. Variants in several ciliary genes have been associated with subtypes of OFD syndrome, yet in most OFD patients the underlying cause remains unknown. We investigated the molecular basis of disease in two brothers with OFD type II, Mohr syndrome, by performing single-nucleotide polymorphism (SNP)-array analysis on the brothers and their healthy parents to identify homozygous regions and candidate genes. Subsequently, we performed whole-exome sequencing (WES) on the family. Using WES, we identified compound heterozygous variants c.[464G>C];[1226G>A] in NIMA (Never in Mitosis Gene A)-Related Kinase 1 (NEK1). The novel variant c.464G>C disturbs normal splicing in an essential region of the kinase domain. The nonsense variant c.1226G>A, p.(Trp409*), results in nonsense-associated alternative splicing, removing the first coiled-coil domain of NEK1. Candidate variants were confirmed with Sanger sequencing and alternative splicing assessed with cDNA analysis. Immunocytochemistry was used to assess cilia number and length. Patient-derived fibroblasts showed severely reduced ciliation compared with control fibroblasts (18.0 vs 48.9%, P<0.0001), but showed no significant difference in cilia length. In conclusion, we identified compound heterozygous deleterious variants in NEK1 in two brothers with Mohr syndrome. Ciliation in patient fibroblasts is drastically reduced, consistent with a ciliary defect pathogenesis. Our results establish NEK1 variants involved in the etiology of a subset of patients with OFD syndrome type II and support the consideration of including (routine) NEK1 analysis in patients suspected of OFD.

Retrospective Study of a Series of 20 Ivory Prostheses in the Treatment of Trapeziometacarpal Osteoarthritis

Background Many surgical treatment options for osteoarthritis (OA) of the trapeziometacarpal (TMC) joint exist. However, no procedure has been proven superior. Good results have been described for TMC joint replacement. Purpose To analyze the results of the Ivory prosthesis in the treatment of symptomatic TMC OA. Patients and Methods A retrospective single-center follow-up study was performed. Visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Michigan Hand Outcomes Questionnaire (MHQ), active range of motion, strength, and radiological outcomes were assessed and analyzed. Differences between the operated and nonoperated hand were analyzed using paired t-tests. Twenty patients were included with a mean follow-up duration of 37.0 months. Results Patients experienced minimal pain with a mean VAS pain score of 1.9. DASH and MHQ scores indicated mild to moderate impairments. Eighty-five percent of patients assessed the operation excellent or good. Significant differences were found in measurements of extension and palmar thumb abduction in favor of the contralateral hand. No significant differences in strength between both hands were found. Two patients had a dislocation of the prosthesis; one patient required open reduction and tightening of the joint capsule. The other dislocation was treated with trapeziectomy and interposition of a fascia lata allograft. One patient had a collapse of the trapezium requiring a revision procedure. Conclusion Ivory prosthesis TMC arthroplasty can achieve good results in patients with symptomatic isolated TMC OA. In this series, however, revision surgery was required in 3 of 20 cases.

A pragmatic approach to infants with Robin sequence: a retrospective cohort study and presence of a treatment algorithm

Objectives

Initial approaches to and treatments of infants with Robin sequence (RS) is diverse and inconsistent. The care of these sometimes critically ill infants involves many different medical specialties, which can make the decision process complex and difficult. To optimize the care of infants with RS, we present our institution’s approach and a review of the current literature.

Material and methods

A retrospective cohort study was conducted among 75 infants diagnosed with RS and managed at our institution in the 1996–2012 period. Additionally, the conducted treatment regimen in this paper was discussed with recent literature describing the approach of infants with RS.

Results

Forty-four infants (59 %) were found to have been treated conservatively. A significant larger proportion of nonisolated RS infants than isolated RS infants needed surgical intervention (53 vs. 25 %, p = .014). A mandibular distraction was conducted in 24 % (n = 18) of cases, a tracheotomy in 9 % (n = 7), and a tongue–lip adhesion in 8 % (n = 6). Seventy-seven percent of all infants had received temporary nasogastric tube feeding. The literature review of 31 studies showed that initial examinations and the indications to perform a surgical intervention varied and were often not clearly described.

Conclusions

RS is a heterogenic group with a wide spectrum of associated anomalies. As a result, the decisional process is challenging, and a multidisciplinary approach to treatment is desirable. Current treatment options in literature vary, and a more uniform approach is recommended.

Clinical Relevance

We provide a comprehensive and pragmatic approach to the analysis and treatment of infants with RS, which could serve as useful guidance in other clinics.

Professional opinion on oral cleft during pregnancy: a comparison between Israel and The Netherlands

OBJECTIVE

The aim of this study was to assess the opinion of obstetric care providers who perform prenatal ultrasounds to screen for anomalies and who advise women about their options, including termination of pregnancy, when an oral cleft is detected. We compared providers' opinions about pregnancy termination for isolated oral cleft in The Netherlands, where the number of terminations is low, and in Israel, where the number is high.

METHODS

Online questionnaires were used. The questions assessed the providers' views regarding the estimated burden of treatment, the functioning ability, and the level of happiness of children with an oral cleft and their parents. Additionally, we assessed providers' opinions on pregnancy termination for isolated oral cleft.

RESULTS

In The Netherlands, more professionals considered oral cleft a disability (rate differences 17.8%, 95% confidence interval: 0.5-33.1%) than in Israel. In the Netherlands, 10.6% of respondents (compared with 11.1% in Israel) thought that an isolated cleft was a reason for terminations of pregnancy (TOP) (rate differences 0.6%, 95% confidence interval: -12% to 10.9%).

CONCLUSIONS

Prenatal care providers in The Netherlands and Israel do not differ in their opinions about the severity of oral cleft and the acceptability of TOP for an isolated oral cleft. This study shows that prenatal care providers' attitudes do therefore not explain the dramatic difference between these countries in the number of TOP for isolated oral cleft.

Exploring a neurogenic basis of velopharyngeal dysfunction in Tbx1 mutant mice: no difference in volumes of the nucleus ambiguus

OBJECTIVE

Velopharyngeal hypotonia seems to be an important factor in velopharyngeal dysfunction in 22q11.2 deletion syndrome, but the etiology is not understood. Because TBX1 maps within the typical 22q11.2 deletion and Tbx1-deficient mice phenocopy many findings in patients with the 22q11.2 deletion syndrome, TBX1 is considered the major candidate gene in the etiology of these defects. Tbx1 heterozygosity in mice results in abnormal vocalization 7 days postnatally, suggestive of velopharyngeal dysfunction. Previous case-control studies on muscle specimens from patients and mice revealed no evidence for a myogenic cause of velopharyngeal dysfunction. Velopharyngeal muscles are innervated by cranial nerves that receive signals from the nucleus ambiguus in the brainstem. In this study, a possible neurogenic cause underlying velopharyngeal dysfunction in Tbx1 heterozygous mice was explored by determining the size of the nucleus ambiguus in Tbx1 heterozygous and wild type mice.

METHODS

The cranial motor nuclei in the brainstems of postnatal day 7 wild type (n=4) and Tbx1 heterozygous (n=4) mice were visualized by in situ hybridization on transverse sections to detect Islet-1 mRNA, a transcription factor known to be expressed in motor neurons. The volumes of the nucleus ambiguus were calculated.

RESULTS

No substantial histological differences were noted between the nucleus ambiguus of the two groups. Tbx1 mutant mice had mean nucleus ambiguus volumes of 4.6 million μm(3) (standard error of the mean 0.9 million μm(3)) and wild type mice had mean volumes of 3.4 million μm(3) (standard error of the mean 0.6 million μm(3)). Neither the difference nor the variance between the means were statistically significant (t-test p=0.30, Levene's test p=0.47, respectively).

CONCLUSIONS

Based on the histology, there is no difference or variability between the volumes of the nucleus ambiguus of Tbx1 heterozygous and wild type mice. The etiology of velopharyngeal hypotonia and variable speech in children with 22q11.2 deletion syndrome warrants further investigation.

In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review

BACKGROUND

Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity.

METHODOLOGY/ PRINCIPAL FINDINGS

A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11-18% versus 44-62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7-13%, p = 0.03).

CONCLUSIONS/ SIGNIFICANCE

In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty.

Bioresorbable distraction device for the treatment of airway problems for infants with Robin sequence

Pierre Robin sequence is a well known craniofacial entity. There are numerous ways to treat the respiratory insufficiency, but sometimes surgical intervention is needed. Tracheotomy could be associated with morbidity, and distraction osteogenesis has been established as a stable method to obtain a safe airway. Distraction osteogenesis has traditionally been performed with an external device. In this manuscript we describe the feasibility of an internal bioresorbable device. Retrospective descriptive study was performed in a tertiary academic children’s hospital. After multidisciplinary team consultation, 12 consecutive patients with Robin sequence were treated with this internal distraction device. The mean age at surgery was 32 days, and the average amount of mandibular distraction was 18 mm. All patients were extubated after an average of 7.5 days after the surgery. The average length of stay in the hospital was 17 days after surgery. There were no major surgical complications. A tracheotomy was prevented in all our patients, and complications were limited. Long-term studies are needed to evaluate the influence that internal distraction has on the growth of the mandible and teeth. The internal distraction system seems safe for infants with micrognathia and has certain benefits when compared to the external distractor.

Histology of the pharyngeal constrictor muscle in 22q11.2 deletion syndrome and non-syndromic children with velopharyngeal insufficiency

Plastic surgeons aim to correct velopharyngeal insufficiency manifest by hypernasal speech with a velopharyngoplasty. The functional outcome has been reported to be worse in patients with 22q11.2 deletion syndrome than in patients without the syndrome. A possible explanation is the hypotonia that is often present as part of the syndrome. To confirm a myogenic component of the etiology of velopharyngeal insufficiency in children with 22q11.2 deletion syndrome, specimens of the pharyngeal constrictor muscle were taken from children with and without the syndrome. Histologic properties were compared between the groups. Specimens from the two groups did not differ regarding the presence of increased perimysial or endomysial space, fiber grouping by size or type, internalized nuclei, the percentage type I fibers, or the diameters of type I and type II fibers. In conclusion, a myogenic component of the etiology of velopharyngeal insufficiency in children with 22q11.2 deletion syndrome could not be confirmed.

Reconstruction of the alveolar cleft: can growth factor-aided tissue engineering replace autologous bone grafting? A literature review and systematic review of results obtained with bone morphogenetic protein-2

The alveolar cleft in patients with clefts of lip, alveolus and palate (CLAP) is usually reconstructed with an autologous bone graft. Harvesting of autologous bone grafts is associated with more or less donor site morbidity. Donor site morbidity could be eliminated if bone is fabricated by growth factor-aided tissue engineering. The objective of this review was to provide an oversight on the current state of the art in growth factor-aided tissue engineering with regard to reconstruction of the alveolar cleft in CLAP. Medline, Embase and Central databases were searched for articles on bone morphogenetic protein 2 (BMP-2), bone morphogenetic protein 7, transforming growth factor beta, platelet-derived growth factor, insulin-like growth factor, fibroblast growth factor, vascular endothelial growth factor and platelet-rich plasma for the reconstruction of the alveolar cleft in CLAP. Two-hundred ninety-one unique search results were found. Three articles met our selection criteria. These three selected articles compared BMP-2-aided bone tissue engineering with iliac crest bone grafting by clinical and radiographic examinations. Bone quantity appeared comparable between the two methods in patients treated during the stage of mixed dentition, whereas bone quantity appeared superior in the BMP-2 group in skeletally mature patients. Favourable results with BMP-2-aided bone tissue engineering have been reported for the reconstruction of the alveolar cleft in CLAP. More studies are necessary to assess the quality of bone. Advantages are shortening of the operation time, absence of donor site morbidity, shorter hospital stay and reduction of overall cost.

The modified Honig velopharyngoplasty - a new technique to treat hypernasality by palatal lengthening

BACKGROUND

Palatal lengthening by pushback with a pharyngeal flap is a commonly used operative technique for the treatment of velopharyngeal insufficiency. The conventional Honig velopharyngoplasty uses full thickness mucoperiosteal flaps for the oral lining of the defect.

PURPOSE

A modification is described using only mucosal flaps, thus preserving the periosteum and the palatine arteries. Vascularisation of the hard palate is preserved and bone is not exposed, avoiding potential detrimental scar formation overlying the hard palate, which may affect normal outgrowth of the maxilla.

STUDY DESIGN

Eight patients with persisting hypernasality were included. Velopharyngeal closure was evaluated by nasendoscopy, nasometry and a Dutch speech test for cleft patients.

RESULTS

Hypernasality was corrected in all cases. One patient developed a light hyponasality. In four patients the overall speech normalised and in the remaining four cases small errors persisted, but speech was well understandable.

CONCLUSION

The procedure yields satisfactory speech results in this preliminary study, comparable to the conventional Honig velopharyngeaplasty. Long term follow up regarding maxillary growth and comparative studies with other operative techniques are now warranted.

Periconceptional health and lifestyle factors of both parents affect the risk of live-born children with orofacial clefts

BACKGROUND

Nonsyndromic cleft lip with or without cleft palate (CL/P) or cleft palate only (CPO) are orofacial clefts and have a multifactorial etiology. The identification of amendable parental risk factors may contribute to a reduced occurrence of these malformations in the future.

METHODS

Standardized demographic and periconceptional exposure data from 284 parents of a child with CL/P, 66 parents of a child with a CPO and 222 parents of a child without congenital malformations were collected at approximately 24 months after the periconceptional period of the index child. Univariate and multivariate logistic regression analyses were used to estimate relative risks by odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Univariate results suggest that low parental education, periconceptional maternal medication use and illnesses, paternal smoking, and first-trimester maternal common cold increased CL/P risk. Pregnancy planning and periconceptional folic acid supplementation, however, reduced CL/P risk by approximately 50% (OR, 0.5; 95% CI, 0.3-0.8) and 40% (OR, 0.6; 95% CI, 0.4-0.9), respectively. Mostly comparable results were obtained for CPO. Being a boy (OR, 2.0; 95% CI, 1.4-3.0), folic acid supplementation (OR, 0.6; 95% CI, 0.4-0.9), and low paternal education (OR, 1.6; 95% CI, 1.0-2.3) mainly determined CL/P in the multivariate analyses, compared to low paternal (OR, 4.5; 95% CI, 2.1-9.4) and maternal medication use (OR, 2.0; 95% CI, 1.0-4.0) for CPO.

CONCLUSIONS

Preconceptional counseling for orofacial cleft risk assessment should pay attention to maternal medication use, periconceptional folic acid supplementation, and exposures of the father. These determinants can be amended, thereby modifying orofacial cleft risk.