Association of autoimmune blistering disease, and specifically, pemphigus vulgaris, with cardiovascular disease and its risk factors: a systematic review and meta-analysis.

Previous studies have found conflicting results about the association of autoimmune blistering disease (AIBD) with cardiovascular disease (CVD) risk. The objective of the study was to systematically review the relationship of AIBD, including pemphigus vulgaris (PV), and its treatment with CVD and CVD risk factors. MEDLINE, EMBASE, Cochrane, LILACS, SCOPUS, and Web of Science were searched. We included all studies of CVD and CVD risk factors in AIBD patients. Two reviewers performed title and/or abstract review and data extraction. Pooled random-effects meta-analysis was performed. Forty papers met inclusion criteria. AIBD was associated with higher odds of diabetes (DM) (odds ratio [95% confidence interval]: 1.809 [1.258-2.601]), hypertension (HTN) (1.393 [1.088-1.784]), dyslipidemia (2.177 [1.163-4.073]) and heart failure (1.919 [1.603-2.298]), but was not associated with obesity, stroke, angina, heart attack, or arrhythmia. The pooled random-effects prevalence for treatment-related adverse events (AEs) in AIBD was 13.7% for DM, 10.7% for HTN, and 17.1% for CVD. Sensitivity analysis of high-quality studies revealed similar results. AIBD patients have increased CVD risk factors and heart failure. Systemic corticosteroid treatment results in CVD-related AEs in AIBD. Increased CVD screening and prevention strategies are warranted in AIBD.

The Accreditation Council for Graduate Medical Education Milestones in Integrated Plastic Surgery Programs: How Competency-Based Assessment Has Been Implemented.

BACKGROUND: The plastic surgery milestones are a central component of resident assessment. The authors performed a survey to evaluate how milestones have been implemented across integrated plastic surgery programs and how faculty perceive the Milestones Project has impacted their program. METHODS: A 25-question survey was directed to the head of the clinical competency committee of all 82 integrated plastic surgery programs through the American Council of Academic Plastic Surgeons. The survey queried the composition of the committee, how ratings are generated, and the data used in generating these ratings. RESULTS: Committee leaders from 57 programs (69.5 percent) responded to the survey. For most programs (73 percent), one faculty member completed milestone ratings for each resident and reviewed them with the residents. To determine milestone ratings, 92 percent utilized resident assessment after every rotation, and 63 percent utilized in-service examination scores. For documented resident assessment overall, 96 percent of programs assess residents after every rotation; 37 percent asses after every procedure. Feedback is most frequently provided to residents after every rotation (52 percent), rather than only during committee reviews (32 percent) or after every documented assessment (16 percent). Sixty-four percent of respondents did not believe that milestones have helped in the mentorship role. CONCLUSIONS: Implementation of the milestones has varied among integrated plastic surgery programs. Structured training for core faculty directed to methods of assessment will make milestones a more effective a tool by which to improve resident evaluation and education. These findings provide a key data set by which to revise the milestones for their second iteration.

Ultrasound Diagnosis of Prenatal Cleft Lip: How Does Its Accuracy Affect the Family?

ABSTRACT: Factors impacting the accuracy of ultrasound (US) diagnosis of cleft lip (CL) and its subsequent effect on parents are not well understood. Our objectives were to evaluate how the type of CL (complete versus incomplete) and associated cleft palate affect the accuracy of CL's prenatal diagnosis and to evaluate differences between parents' perception of prenatal US in cases of true-positive versus false-negative results. The authors performed a retrospective review of all patients who underwent repair for nonsyndromic CL following prenatal US. Patients were stratified by type of CL and associated cleft palate. Parents were called to determine if their child's CL was diagnosed via US and their perception of the results. Forty-seven children with complete and 40 with incomplete CL responded to phone calls. The presence of a complete CL (P = 0.001) and an associated cleft palate (P = 0.014) were independently associated with an increased likelihood of prenatal diagnosis. Parents who received a true-positive prenatal diagnosis of CL were more satisfied than those who received a false-negative diagnosis (P = 0.0063). True-positives perceived knowing of their child's diagnosis in advance to be more helpful than false-negatives believed it would have been. These results afford an improved context to interpret US studies and help physicians provide more informed prenatal counseling.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: A 14-Year Review of Maintenance of Certification Tracer Data From the American Board of Plastic Surgery.

OBJECTIVE: To evaluate evolving practice patterns in secondary cleft rhinoplasty. DESIGN: Retrospective review of data submitted during Maintenance of Certification (MOC). SETTING: Evaluation of MOC data from the American Board of Plastic Surgery. PARTICIPANTS: Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns. INTERVENTIONS: Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period. MAIN OUTCOME MEASURES: Practice patterns were compared to EBM trends during the study period. RESULTS: A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007). CONCLUSIONS: These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

Efficacy and Safety in Combining Primary Palatoplasty and Myringotomy in Patients with Cleft Palate.

Patients born with a cleft lip and palate undergo multiple surgical procedures, increasing the infants' exposure to anesthesia and potential risk of neurocognitive delays. In addition, these numerous procedures lead to greater use of hospital resources. This study analyzes the differences in anesthetic exposure and perioperative characteristics between performing combined versus separate primary palatoplasty (PP) and placement of bilateral myringotomy tubes (BMT). METHODS: We reviewed patients younger than 2 years who underwent PP and BMT at our institution from June 2014 to January 2019. Patients who underwent PP and BMT during the same admission (combined group = 74) and during separate admissions (separate group = 26) were studied. Due to the small sample size in the separate group, additional data for this group were gathered by propensity score matching by gender, race, and American Society of Anesthesiology class. Statistical analyses were carried out to identify significant differences between the 2 groups. Linear regression was performed to compare perioperative variables. RESULTS: One hundred patients met the inclusion criteria. There were no significant differences in demographic characteristics or American Society of Anesthesiology class, surgery and anesthesia duration, dosage of intraoperative dexmedetomidine, hospital length of stay, and perioperative complications (P > 0.05). Per contra, combined group had significantly lower intraoperative dosages of fentanyl (P = 0.01) and shorter postoperative care unit stay (P = 0.047). CONCLUSIONS: This study documents decreased postoperative care unit time and anesthesia drug exposure without increased length of stay or perioperative complications in patients undergoing combined PP and BMT. These results support combining PP and BMT to reduce exposure to potentially neurotoxic medications and to increase efficient utilization of hospital resources.

Current Trends in Surgical Airway Management of Neonates with Robin Sequence.

BACKGROUND: Robin sequence is defined by the clinical triad of micrognathia, glossoptosis, and upper airway obstruction, and is frequently associated with cleft palate and failure to thrive. Though the efficacy of certain surgical interventions to relieve airway obstruction has been well established, algorithms dictating decision making and perioperative protocols are poorly defined. METHODS: A 22-question survey was sent via e-mail to members of the American Cleft Palate-Craniofacial Association and International Society of Craniofacial Surgeons. Questions were related to surgeon experience in treating neonates with Robin sequence, and specific perioperative protocols. RESULTS: One hundred fifty-one responses were collected. Most respondents were surgeons practicing in North America(82.8%), in a university hospital setting (81.5%) and had completed a fellowship in pediatric plastic surgery or craniofacial surgery (76.2%). Preoperative protocols varied widely by years in training and location of practice. Although 78.8% of respondents always performed direct laryngoscopy, only 49.7% of respondents routinely obtained preoperative polysomnography. Mandibular distraction osteogenesis was the most common primary surgical airway intervention reported by 74.2%, with only 12.6% primarily utilizing tongue-lip adhesion. Slightly less than half of respondents ever performed tongue-lip adhesion. Operative selection was influenced by surgeon experience, with 80% of those in practice 0-5 years primarily utilizing mandibular distraction, compared with 56% of respondents in practice >15 years. CONCLUSIONS: This study documents wide variations in preoperative, operative, and postoperative protocols for the surgical airway management of neonates with severe Robin sequence. These results underscore the need to acquire more objective data, to compare different protocols and outcome measures.