Mark S. Lloyd

Review of quantitative outcome analysis of cranial morphology in craniosynostosis

Outcome measures in craniosynostosis surgery have progressed from those based on the need for surgical revision to linear anthropometric measurements, 2D CT vector analysis and 3D CT vector analysis. However, finding an objective means to assess postoperative cranial morphological improvement remains challenging. A critical review of previous studies used to measure craniosynostosis surgery outcomes is presented. We also introduce and briefly discuss the key features of the computational algorithm that is being utilized in our center for evaluating craniosynostosis surgical outcomes. This has addressed a number of the previous challenges encountered in quantitative measurement of cranial morphological change. Point cloud representation and 3D stereophotogrammetry have made it possible to compare pre and post-operative images of children undergoing surgical correction for craniosynostosis. These pre- and post-operative images can also be compared to age, sex and race-matched controls throughout the patients lifetime allowing longitudinal changes to be measured on follow up.

Microtia and Social Media: Patient Versus Physician Perspective of Quality of Information

Introduction: Previous research demonstrates that patients seek high-quality information on the World Wide Web, especially in rare conditions such as microtia. Social media has overtaken other sources of patient information but quality remains untested. This study quantifies the quality of information for patients with Microtia on social media compared with nonsocial media websites and compares physician and patient scoring on quality using the DISCERN tool. Methods: In phase 1, quality of the top 100 websites featuring information “Microtia” was ranked according to quality score and position on Google showing the position of social media websites among other nonsocial media websites. Phase 2 involved independent scoring of websites on microtia compared with a patient group with microtia to test whether physicians score differently to patients with t test comparison. Results: Social media websites account for 2% of the scored websites with health providers linking to social media. Social media websites were among the highest ranked on Google. No correlation was found between the quality of information and Google rank. Social media scored higher than nonsocial media websites regarding quality of information on microtia. No significant difference existed between physician and patient quality of information scores on social media and nonsocial media websites (p 1.033). Conclusion: Physicians and patients objectively score microtia websites alike. Social media websites have higher use despite being few in number compared with nonsocial media websites. Physicians providing links to social media on information websites on rare conditions such as microtia are engaging in current information-seeking trends.

Surrogate Outcome Measures for Corneal Neurotization in Infants and Children

Background: Corneal anesthesia is a rare and challenging condition, particularly in young children. The insensate cornea leads to abnormal epithelial cell metabolism and loss of trophic influences supplied by the corneal nerve fibers. This results in recurrent spontaneous epithelia erosion and eventual loss of sight. Corneal reinnervation is a definitive treatment option for neuropathic keratitis. The outcome measures in young children following corneal sensitization are different to adults as esthesiometry is unachievable. Methods: The authors have undertaken corneal reinnervation in a young patient using a sural nerve graft. Surrogate measures suitable for pediatric patients were used for assessment of the outcome. Results: Postoperatively there was evidence of improved corneal healing and function after 8 weeks. At 10 months postprocedure, the cornea was completely free of vascularization. Conclusion: Resensitization of the cornea using nerve grafts has previously been reported in older children and adults. This is the first time the procedure has been undertaken in a young child. Although the technique is still in its infancy with only 4 patients reported worldwide including our report, it seems to hold promise of improvement to this challenging cohort of patients.

Empowerment of Parents of Children With Craniosynostosis by Objective Scoring of Patient Information Websites.

Introduction:Parental anxiety may be caused by inappropriate information on the world wide web regarding craniosynostosis. The aim of this study was to study the correlation between the first 100 websites ranked on the Google search engine and those ranked based on objective scoring with patient information scoring tool. The results of these findings can then be used to recommend websites based on the quality of information that may not initially appear first on a search engine. Methods:The DISCERN patient information scoring tool was chosen as a scientific way of measuring the quality of patient information based on previous research by the Picker Institute in Oxford. The word “craniosynostosis” was entered into the Google internet search engine. Patient information provided by the first 100 websites was studied and scored using the DISCERN scoring tool. From this score, each website was ranked with the highest scoring website at the top and worse scoring website at the bottom. This ranking based on the DISCERN tool score was correlated against the ranking of the website by Google. Positive correlation between DISCERN and Google ranking would be demonstrated if a website high in the ranking using DISCERN was also at the top of the first 100 websites on Google. Results:No correlation could be found between those websites ranked highly for patient information on craniosynostosis using the DISCERN tool to the ranking provided by Google. DISCERN scores ranged from 17 to 72 (the lowest possible DISCERN tool score being 15 and the highest 85). The website ranking highest in terms of quality appeared only 50th in the Google rank. Conclusion:High-quality patient information on craniosynostosis does exist on the world wide web but may be difficult to find due to the complexity of factors used to rank websites on internet search engines. This results in some high-quality websites not appearing at the top of an internet search. Therefore, parents risk missing useful information relevant to their childs diagnosis. Healthcare professionals can use objective scoring of patient information websites to empower their patients to seek higher quality information.

Isolated Unilateral Frontosphenoidal Suture Synostosis in Six Patients: Lessons Learned in Diagnosis and Treatment.

Introduction:Due to the rarity of isolated frontosphenoidal suture synostosis clinical diagnosis can be challenging. This study of 6 patients aims to review the clinical, radiological findings, and operative techniques used to correct the underlying pathology. Methods:Patients with isolated frontosphenoidal suture craniosynostosis were selected from a retrospective review of 88 patients with unicoronal synostosis treated during a 3-year period. Two-dimensional photography of patients’ soft tissue morphology from the vertex view allowed assessment of the following morphology: frontal bossing, brow depression, nasal tip deviation, and ear position. Quantitative measure of the extent of bony deformity was measured using various angles measured from two-dimensional axial views of computerized tomography scans. Last, technical variations in correction of isolated frontosphenoidal craniosynostosis were collected from operative notes. Results:On the side of isolated frontosphenoidal craniosynostosis, contralateral bossing and ipsilateral brow depression was present in all 6 patients. Ipsilateral nasal tip deviation was seen in 3 out of the 6 patients. Ear position was symmetrical in the cranial-caudal and anterior-posterior axes. No radiological evidence of harlequin deformity was seen on skull X-ray in all 6 patients, but computerized tomography scans demonstrated isolated frontosphenoidal suture craniosynostosis. The angle drawn between the foramen magnum, sella turcica, and anterior cribriform plate in 3 of 6 patients showed deflection of the anterior cranial fossa opposite to the side of isolated frontosphenoidal suture craniosysnotosis. There was no difference in the angle between the petrosal pyramid and the midline. In all patients, operative technique involved taking a deeper fronto-orbital bandeau to capture and reshape the pathological suture. Conclusions:In isolated frontosphenoidal suture craniosynostosis, contralateral bossing and ipsilateral flattening of the forehead were the most consistent clinical features with nasal tip deviation away from the side of pathology less consistent. Ear position is unaffected. Measurements of various angles of the skull base were not consistent. A deeper vertical osteotomy at the site of isolated frontosphenoidal suture craniosysnotosis on removing the fronto-orbital bandeau was 1 operative technical variation.

Cranial Fasciitis: A Systematic Review and Diagnostic Approach to a Pediatric Scalp Mass.

AbstractCranial fasciitis is an uncommon, benign fibroproliferative condition of the scalp or skull that arises in children. Clinically, it manifests as a firm, nontender, subcutaneous, enlarging mass. The purpose of our study was to review the literature on cranial fasciitis to create a diagnostic algorithm using the latest patient at our institution as an example. The authors conducted a systematic review examining all published cases of cranial fasciitis in English literature. The authors then created a diagnostic algorithm to help distinguish cranial fasciitis from other similarly presenting cranial masses. To demonstrate this algorithm, the authors detailed the latest patient with cranial fasciitis at our institution. The authors extracted data from 53 published reports documenting 72 patients of cranial fasciitis. Our patient presented similarly to what was reported in the literature. A 7-week-old boy presented with 2 small parietal scalp masses that were noted shortly after birth. After noncontrast computed tomography imaging, the enlarging masses were resected and found to have eroded the outer cranial vault cortex. Histological analysis revealed cranial fasciitis. The differential diagnosis for an enlarging scalp mass in an infant or child is broad. Cranial fasciitis cannot be diagnosed based on clinical presentation alone. Imaging is usually employed to further characterize lesions after initial examination but histopathological analysis is essential for diagnosis. The locally invasive nature of cranial fasciitis makes it difficult to distinguish from malignant conditions such as sarcomas. However, if the diagnosis of cranial fasciitis is considered early, patients can achieve prompt clinical resolution following simple resection.

Bioinformatics Associated With Conjoined Twin Separation

Abstract The separation of conjoined twins is a rare event in the medical field and presents many unique challenges to overcome. With the complexities of todays interconnected healthcare technology and electronic medical record, there are many intricate details that need significant attention to guarantee proper care and accurate record keeping for conjoined twins. Items that require attention are how to digitally represent the twins—as 1 patient or 2, how to incorporate the physiological monitors into the medical record, and how to ensure the proper amount of infrastructure, equipment, and space. With careful planning and consideration, technology can be used as an aid in separating conjoined twins at any institution.

Tissue Engineering Strategies for Auricular Reconstruction

Abstract Simulating natural characteristics and aesthetics in reconstructed ears has provided a complex 3-dimensional puzzle for those treating patients with microtia. Costochondral grafts remain the gold standard for autologous reconstruction. However, other options such as Medpor and prosthetics are indicated depending on patient circumstances and personal choice. Research into tissue engineering offers an alternative method to a traditional surgical approach that may reduce donor-site morbidity. However, tissue engineering for microtia reconstruction brings new challenges such as cell sourcing, promotion of chondrogenesis, scaffold vascularization, and prevention of scaffold contraction. Advancements in 3D printing, nanofiber utilization, stem cell technologies, and decellularization techniques have played significant roles in overcoming these challenges. These recent advancements and reports of a successful clinical-scale study in an immunocompetent animal suggest a promising outlook for future clinical application of tissue engineering for auricular reconstruction.

Response to article, The median artery: its potential complications for the radial forearm flap by Varley et al, JPRAS 61:693–695

1. Mori H, Hata Y. Modified C-V flap in nipple reconstruction. J Plast Reconstr Aesthet Surg 2008;61:1109e10. 2. Alfano C, Tenna S, Caggiati A, et al. Nipple reconstruction by local flaps: A long-term comparative study between star and skate techniques. Acta Chir Plast 2004;46:127e31. 3. Schoeller T, Schubert HM, Pulzl P, et al. Nipple reconstruction usinga modified arrow flap technique. Breast2006 Dec;15:762e8. 4. Thomas SV, Gellis MB, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg 1996;97:1053e6.