Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study.

Objective: To qualitatively assess surgeons decision making for lip surgery in patients with cleft lip/palate (CL/P). Design: Prospective, non-randomized, clinical trial. Setting: Clinical data institutional laboratory setting. Patients Participants: The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the Standardized Assessment for Facial Surgery (SAFS) for systematic viewing by the surgeons. Interventions: The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either in person or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method. Results: Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. For diagnoses/treatments, surgeons agreed, and level of surgical experience was not a factor. Conclusions: The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study.

Objective: To qualitatively assess surgeons' decision making for lip surgery in patients with cleft lip/palate (CL/P). Design: Prospective, non-randomized, clinical trial. Setting: Clinical data institutional laboratory setting. Patients Participants: The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the 'Standardized Assessment for Facial Surgery (SAFS)' for systematic viewing by the surgeons. Interventions: The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either 'in person' or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method. Results: Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. In general, there was surgeon agreement for the diagnoses/treatments. Conclusions: The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

Characterizing the orthodontic patient's purchase decision: A novel approach using netnography.

INTRODUCTION: A deeper and more thorough characterization of why patients do or do not seek orthodontic treatment is needed for effective shared decision making about receiving treatment. Previous orthodontic qualitative research has identified important dimensions that influence treatment decisions, but our understanding of patients' decisions and how they interpret benefits and barriers of treatment are lacking. The objectives of this study were to expand our current list of decision-making dimensions and to create a conceptual framework to describe the decision-making process. METHODS: Discussion boards, rich in orthodontic decision-making data, were identified and analyzed with qualitative methods. An iterative process of data collection, dimension identification, and dimension refinement were performed to saturation. A conceptual framework was created to describe the decision-making process. RESULTS: Fifty-four dimensions captured the ideas discussed in regard to a patient's decision to receive orthodontic treatment. Ten domains were identified: function, esthetics, psychosocial benefits, diagnosis, finances, inconveniences, risks of treatment, individual aspects, societal attitudes, and child-specific influences, each containing specific descriptive and conceptual dimensions. A person's desires, self-perceptions, and viewpoints, the public's views on esthetics and orthodontics, and parenting philosophies impacted perceptions of benefits and barriers associated with orthodontic treatment. CONCLUSIONS: We identified an expanded list of dimensions, created a conceptual framework describing the orthodontic patient's decision-making process, and identified dimensions associated with yes and no decisions, giving doctors a better understanding of patient attitudes and expectations.

Anaphylaxis Triggers and Treatments by Grade Level and Staff Training: Findings from the EPIPEN4SCHOOLS Pilot Survey.

This pilot survey was designed to evaluate the characteristics of anaphylactic events and epinephrine autoinjector (EAI) use in children in U.S. schools. A cross-sectional, web-based, pilot survey of schools participating in the EPIPEN4SCHOOLS® program (Mylan Specialty L.P., Canonsburg, PA) assessed characteristics of anaphylactic events and EAI use during the 2013-2014 academic year. Respondents reported 757 anaphylactic events experienced by students; student grade level was noted for 724 events. Of these events, 32.3% (234/724) were experienced by students in grade school, 18.6% (135/724) by students in middle school, and 49.0% (355/724) by students in high school. Frequency of food-related triggers was consistently high across grade levels. However, many events experienced by students in high school (22.3%, 79/355), middle school (15.0%, 20/135), and grade school (14.1%, 33/234) had an unknown trigger. In 36.0% of schools (2008/5579), only the school nurse and select staff received training to recognize anaphylaxis; most staff or all staff received training in 28.9% (1610/5579) and 30.9% (1722/5579) of schools, respectively. In a majority of schools (54.2%, 3003/5544), only the school nurse and select staff were permitted to administer epinephrine, whereas most staff or all staff were permitted to administer epinephrine in 15.8% (876/5544) and 21.9% (1212/5544) of schools, respectively. Risk of anaphylaxis may be particularly high during adolescence, and some students encounter staff members who are untrained in anaphylaxis recognition or management, or both. These findings support the need for continued anaphylaxis training for the protection of all students, staff, and visitors.

EpiPen4Schools pilot survey: Occurrence of anaphylaxis, triggers, and epinephrine administration in a U.S. school setting.

BACKGROUND: Although epinephrine is the treatment of choice for anaphylaxis, it remains underused. OBJECTIVE: This study was designed to describe anaphylactic events and epinephrine autoinjector (EAI) use in U.S. schools enrolled in the EpiPen4Schools program. METHODS: This exploratory, cross-sectional, Web-based survey of 6019 schools that participated in the EpiPen4Schools program assessed anaphylactic events and EAI use at responding schools during the 2013-2014 school year. RESULTS: A total of 919 anaphylactic events were reported in 607 schools. Of the 852 anaphylactic events with data on those who experienced an event, most 88.8% (n = 757) occurred in students, and 21.9% of events (n = 187) occurred in individuals with no known allergies. Of the 851 events with data on EAI use, 74.7% (n = 636) were treated with EAIs and 8.5% (n = 54) received a second epinephrine injection. Of the 204 individuals not treated with an EAI, 77.0% (n = 157) received antihistamines, 12.7% (n = 26) received another treatment, and 8.3% (n = 17) received no treatment. Of the 850 events with data on hospital transport, 79.6% of individuals (n = 677) were transported to the hospital. Common triggers varied seasonally, with food listed most frequently overall (62.5%). CONCLUSION: More than one in ten schools that participated in the EpiPen4Schools survey reported an anaphylactic event. Approximately 25% of individuals with anaphylactic events were not treated with EAIs, and 20.4% of patients were not taken to the hospital after an anaphylactic event. Analysis of these data supports the value of stocking EAIs and of providing continuing education regarding the recognition and proper treatment of anaphylaxis for school personnel.