Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: Speech proficiency at 10 years of age

BACKGROUND & AIM

To assess consonant proficiency and velopharyngeal function in 10-year-old children born with unilateral cleft lip and palate (UCLP) within the Scandcleft project.

METHODS & PROCEDURES

Three parallel group, randomized, clinical trials were undertaken as an international multicentre study by nine cleft teams in five countries. Three different surgical protocols for primary palate repair (Arm B-Lip and soft palate closure at 3-4 months, hard palate closure at 36 months, Arm C-Lip closure at 3-4 months, hard and soft palate closure at 12 months, and Arm D-Lip closure at 3-4 months combined with a single-layer closure of the hard palate using a vomer flap, soft palate closure at 12 months) were tested against a common procedure (Arm A-Lip and soft palate closure at 3-4 months followed by hard palate closure at 12 months) in the total cohort of 431 children born with a non-syndromic UCLP. Speech audio and video recordings of 399 children were available and perceptually analysed. Percentage of consonants correct (PCC) from a naming test, an overall rating of velopharyngeal competence (VPC) (VPC-Rate), and a composite measure (VPC-Sum) were reported.

OUTCOMES & RESULTS

The mean levels of consonant proficiency (PCC score) in the trial arms were 86-92% and between 58% and 83% of the children had VPC (VPC-Sum). Only 50-73% of the participants had a consonant proficiency level with their peers. Girls performed better throughout. Long delay of the hard palate repair (Arm B) indicated lower PCC and simultaneous hard and soft palate closure higher (Arm C). However, the proportion of participants with primary VPC (not including velopharyngeal surgeries) was highest in Arm B (68%) and lowest in Arm C (47%).

CONCLUSIONS & IMPLICATIONS

The speech outcome in terms of PCC and VPC was low across the trials. The different protocols had their pros and cons and there is no obvious evidence to recommend any of the protocols as superior. Aspects other than primary surgical method, such as time after velopharyngeal surgery, surgical experience, hearing level, language difficulties and speech therapy, need to be thoroughly reviewed for a better understanding of what has affected speech outcome at 10 years.

WHAT THIS PAPER ADDS

What is already known on the subject Speech outcomes at 10 years of age in children treated for UCLP are sparse and contradictory. Previous studies have examined speech outcomes and the relationship with surgical intervention in 5-year-olds. What this study adds to the existing knowledge Speech outcomes based on standardized assessment in a large group of 10-year-old children born with UCLP and surgically treated according to different protocols are presented. While speech therapy had been provided, a large proportion of the children across treatment protocols still needed further speech therapy. What are the potential or actual clinical implications of this work? Aspects other than surgery and speech function might add to the understanding of what affects speech outcome. Effective speech therapy should be available for children in addition to primary surgical repair of the cleft and secondary surgeries if needed.

The Americleft Project: A Comparison of Short- and Longer-Term Secondary Alveolar Bone Graft Outcomes in Two Centers Using the Standardized Way to Assess Grafts Scale

Objective

To compare length of follow-up and cleft site dental management on bone graft ratings from two centers.

Design

Blind retrospective analysis of cleft site radiographs and chart reviews for determination of cleft-site lateral incisor management.

Patients

A total of 78 consecutively grafted patients with complete clefts from two major cleft/craniofacial centers (43 from Center 1 and 35 from Center 2).

Interventions

Secondary iliac crest alveolar bone grafting, at a mean age of 9 years 9 months (Center 1: 9 years 7 months; Center 2: 10 years 0 month).

Main Outcome Measures

The Americleft Standardized Way to Assess Grafts scale from 0 ( failed graft) to 6 ( ideal) was used to rate graft outcome at two time points (T1, T2). Average T1 was 11 years 1 month of age, 1 year 3 months postgraft. Average T2 was 17 years 11 months of age, 8 years 0 months postgraft. Six trained and calibrated raters scored each radiograph twice. Reliability was calculated at T1 and T2 using weighted kappa. A paired Wilcoxon signed rank test ( P < .05) tested T1 and T2 differences for each center. A Kruskal-Wallis test was used to determine the significance of differences between centers at T1 and T2. Correlation tested whether T1 ratings predicted T2. Linear regression determined possible factors that might contribute to graft rating changes over time.

Results

Reliability was good at T1 and T2 (interrater = .713 and .701, respectively; intrarater = .790 and .805, respectively). Center 1 scores were significantly better than those from Center 2 at both T1 (5.21 versus 3.29) and T2 (5.18 versus 3.44). There was no statistical difference between T1 and T2 scores for either center; although, there was a greater chance of bone graft score improving with completion of canine eruption and substitution for missing lateral incisors.

Conclusions

Short-term ratings of graft outcomes identified significant differences between centers that persisted over time. Dental cleft-site management influenced final graft outcome.

The Americleft Project: A Proposed Expanded Nasolabial Appearance Yardstick for 5- to 7-Year-Old Patients with Complete Unilateral Cleft Lip and Palate (CUCLP)

Objective

To develop a yardstick of reference photographs for nasolabial appearance assessments of 5- to 7-year-old patients with complete unilateral cleft lip and palate (CUCLP).

Design

Blind retrospective analysis of clinical records and comparison to historical controls.

Patients

Subjects were two groups of 6- to 12-year-olds (n = 124 and n = 135) and one group of 5- to 7-year-olds (n = 149) with nonsyndromic CUCLP from three previous Americleft studies, including cohorts from seven different cleft/craniofacial centers.

Interventions

All patients received the infant management protocols of their respective centers. Eleven trained and calibrated judges (five participated in all three studies) did blind ratings of nasolabial appearance using the Asher-McDade method.

Main Outcome Measures

Patients receiving the most consistent ratings between judges, selected first from the groups of 6- to 12-year-olds, were used to create a pilot yardstick for eventual use in the third study of 5- to 7-year-olds. For each of the Asher-McDade categories, 8 of the 5- to 7-year-old patients receiving the most consistent scores between raters were ranked by 10 judges for a final elimination to leave three per category.

Results

Using this method of successive changes in rating methods, a new reference yardstick for nasolabial appearance rating was established and linked to the original Asher-McDade method as well as the single examples in a previously published yardstick for patients with CUCLP. Pilot testing using the yardstick improved reliabilities.

Conclusions

Use of an expanded nasolabial yardstick of reference photographs representative of the range of possibilities of each of the five Asher-McDade categories is now available to see if reliability of these ratings can be improved.

Photographs of dental casts or digital models: rating dental arch relationships in bilateral cleft lip and palate

Yardsticks have been developed to measure dental arch relations in cleft lip and palate (CLP) patients as diagnostic proxies for the underlying skeletal relationship. Travelling with plaster casts to compare results between CLP centres is inefficient so the aim of this study was to investigate the reliability of using digital models or photographs of dental casts instead of plaster casts for rating dental arch relationships in children with complete bilateral cleft lip and palate (CBCLP). Dental casts of children with CBCLP (n=20) were included. Plaster casts, digital models and photographs of the plaster casts were available for all the children at 6, 9, and 12 years of age. All three record formats were scored using the bilateral cleft lip and palate (BCLP) yardstick by four observers in random order. No significant differences were found for the BCLP yardstick scores among the three formats. The interobserver weighted kappa scores were between 0.672 and 0.934. Comparison between the formats per observer resulted in weighted kappa scores between 0.692 and 0.885. It is concluded that digital models and photographs of dental casts can be used for rating dental arch relationships in patients with CBCLP. These formats are a reliable alternative for BCLP yardstick assessments on conventional plaster casts.

The effects of mastery criteria and assignment length on college student test performance

This study analyzed the function of two components of a personalized instruction course -mastery criteria for passing a test and assignment length. A high mastery criterion (100% correct) and short assignments produced better test performance than either a low mastery criterion (60% correct) or long assignments (four short assignments combined) on both study question items that students had in their possession and probe items that were not available to students in advance.

The effects of study questions and grades on student test performance in a college course

Two experiments demonstrated the effects of study questions on student test performance in an introductory college course. Students in both experiments correctly answered study question items 20 to 30% more frequently than non-study question probes. Furthermore, mean performance on study question items was better than 90% during all phases of both experiments. The present experiments were also designed to study the effects of grades on test performance, and the relationship between long and short sets of study questions. The results of Experiment I clearly illustrated the importance of using grades to maintain high levels of student test performance. The results of Experiment II suggested that long sets of study questions may produce better performance on probe items than do short sets of study questions, but the effect was small.

A cephalometric inter-centre comparison of growth in children with cleft lip and palate

AIM

To examine whether the treatment provided by the Mount Vernon Cleft Team produces craniofacial growth outcomes comparable with that of the Oslo Team.

LOCATION

Mount Vernon Hospital, Middlesex, UK.

DESIGN

A retrospective cephalometric investigation.

SUBJECTS

Seventy-five Mount Vernon children and 150 Oslo children with complete unilateral or bilateral clefts of the lip and palate

METHOD

The subjects were matched for age, gender, and cleft type, and their radiographs were digitized. The radiographs from each site were grouped according to patient age (9-11 or 14-16) and cleft classification (bilateral/unilateral). Patients with associated craniofacial anomalies were excluded from the study.

RESULTS

Of the four variables studied (SNA, SNPg, NGn, sNANsPG) significant differences in maxillary growth were noted for bilateral and unilateral cleft groups at 14-16 years of age. The soft tissue profile was significantly flatter in bilateral and unilateral Mount Vernon cases at 14-16 years. The craniofacial growth exhibited by the Mount Vernon patients demonstrated 3.9-5.1 degrees reduction in maxillary prominence with respect to the Oslo sample. The bilateral cases from Mount Vernon had greater anterior face heights at 14-16 years.

CONCLUSION

The treatment provided by the Mount Vernon Cleft team leads to a reduced maxillary prominence in children aged 14-16 years compared with the Oslo sample. This reduction is statistically significant in unilateral cleft lip and palate.

The prevalence of anomalies of the upper cervical vertebrae in subjects with cleft lip, cleft palate, or both

OBJECTIVE

The purpose of this study was to examine the prevalence of cervical vertebral anomalies in individuals with cleft palate only (CPO) and bilateral (BCLP) and unilateral (UCLP) complete cleft lip and palate and make a comparison with a group without cleft.

SETTING

This retrospective comparison was performed at the Dental Unit, Department of Plastic Surgery, National Hospital and at the Department of Orthodontics, Faculty of Dentistry, University of Oslo, Oslo, Norway.

MATERIAL AND METHODS

Six hundred eleven subjects (334 boys, 277 girls) with three different cleft subtypes at age 6 years or older and 264 children (121 boys, 143 girls) without clefts were included in this study. Their lateral cephalometric radiographs were studied for cervical vertebral anomalies and categorized into posterior arch deficiencies or fusions.

RESULTS

In the total cleft sample, 111 subjects (18.2%) had cervical vertebral anomalies; of these, 10 subjects had more than one anomaly. Posterior arch deficiency was found in 7.7% and fusions in 12.1%. In the sample without cleft, 9.1% had cervical vertebral anomalies, 5% posterior arch deficiency, and 4.1% fusions. When the cleft sample was divided into the three cleft subtypes, the prevalence of cervical vertebral anomalies was 25.6% in the CPO group, 16.3% in the BCLP group, and 11.1% in the UCLP group. Differences were statistically significant between the CPO and the group without cleft for both posterior arch deficiency and fusion anomalies (p <.01).

CONCLUSION

Cervical vertebral anomalies occur more frequently in individuals with clefts as compared with those without clefts. This was statistically significant for the CPO group.

The Eurocleft project 1996-2000: overview

INTRODUCTION

The original Eurocleft project, a European intercentre comparison study, revealed dramatic differences in outcome, which were a powerful stimulus for improvement in the services of respective teams. The study developed a preliminary methodology to compare practices and the potential for wider European collaboration including opportunities for the promotion of clinical trials and intercentre comparison was recognized by the European Commission. Therefore, the project: 'Standards of Care for Cleft Lip and Palate in Europe: Eurocleft' ran between 1996 and 2000 and aimed to promote a broad uplift in the quality of care and research in the area of cleft lip and palate.

RESULTS

The results of the 1996-2000 project include: a register of services in Europe, with details of professionals and teams involved in cleft care, service organization, clinical protocols and special facilities for research; a set of common Policy Statements governing clinical practice for European cleft teams, Practice Guidelines describing minimum recommendations for care that all European children with clefts should be entitled to and recommendations for Documentation governing minimum records that cleft teams should maintain; encouraging initial efforts to compare outcomes (results) of care between centres. A survey showed a wide diversity in models of care and national policies as well as clinical practices in Europe. Of the 201 centres that registered with the network, the survey showed 194 different protocols being followed for only unilateral clefts.

CONCLUSION

Cleft services, treatment and research have undoubtedly suffered from haphazard development across Europe. Attainment of even minimum standards of care remains a major challenge in some communities and both the will to reform and a basic strategy to follow are overdue. It is hoped that the Eurocleft Consensus Recommendations reached during the present project will assist in improving the opportunities for tomorrow's patients. It is also hoped that the collaborative research now beginning under the European Commission's Framework V Programme will provide a focus for European researchers wishing to improve understanding, treatment and prevention of clefts of the lip, alveolus and palate in the years ahead.

Outcomes of cleft care in Western Australia: A pilot study

The purpose of this study was to compare outcomes and delivery of cleft care in Western Australia with the average standard of care in the United Kingdom (UK). This was achieved through a cross-sectional study involving children born with unilateral cleft lip and palate between April 1983 and March 1985 (12 year olds) or between April 1990 and March 1992 (5 year olds). A total of 38 children born with unilateral cleft lip and palate were under the care of the cleft team based at Perth's Princess Margaret Hospital. Dental arch relations, facial skeletal pattern, speech, hearing, success of alveolar bone grafting and dental health were measured. It was found that fewer Princess Margaret Hospital children in both age cohorts had revision surgery and speech therapy compared with the UK average. The facial skeletal pattern, speech, hearing and alveolar bone grafting outcomes from Princess Margaret Hospital were similar to the UK at age 12. Seventeen per cent of the Princess Margaret Hospital 12 year olds had a poor dental arch relationship compared with 39 per cent in the UK. In the 5 year olds, most outcomes in Princess Margaret Hospital patients appeared better than the UK with lower residual treatment needs. While it is difficult to draw firm conclusions because of the small numbers involved, this study indicates standards need to be set and determined for Australia.

Asymmetry of left versus right unilateral cleft impairments: an experimental study of face perception

OBJECTIVE

Previous psychosocial studies of adults born with cleft lip and palate have provided circumstantial evidence that surgically repaired right-sided unilateral clefts may be more disfiguring than left-sided clefts. The present study asked if such asymmetries are physiognomic asymmetries or arise "in the eye of the beholder," representing perceptual processes in face recognition.

DESIGN

Color slides of 160 children (6 years of age) and young teenagers (16 years of age) were rated by subjects for perceived disfigurement. Sixty of the subjects had unilateral complete cleft lip and palate (30 had a right-sided cleft and 30 had a left-sided cleft), 60 had unilateral cleft lip/alveolus (30 right-sided and 30 left-sided clefts), 32 children had bilateral cleft lip and palate, and 8 children had cleft palate only. Faces were shown in normal and in mirror-reversed versions; the order in which faces were shown was randomized, as were other stimulus factors such as cleft type, age, and gender.

SETTING

The study was conducted as a classroom-type experiment at the Vision Laboratory, Department of Psychology, Oslo, Norway.

PARTICIPANTS

Thirty-seven students of psychology at the University of Oslo, who were ignorant of the purpose of the study, acted as subjects.

MAIN OUTCOME MEASURE

Subjects rated perceived disfigurement using a visual analog scale.

RESULTS

Modest but highly consistent hemifacial asymmetries in judged disfigurement were found, with left-sided unilateral clefts rated as less disfiguring than right-sided unilateral clefts. Unilateral clefts were judged as being less disfiguring than the bilateral clefts, and cleft lip/alveolus was judged as being less disfiguring than cleft lip and palate. The patterns of facial judgments were almost identical in the normal and reversed-slides conditions.

CONCLUSIONS

Asymmetries between left- and right-sided clefts reside in physiognomic factors rather than in hemispheric asymmetries controlling the perceptual process of face judgment.

The influence of alveolar bone grafting on the orthodontic and prosthodontic treatment of patients with cleft lip and palate

The introduction of mixed dentition bone grafting of alveolar clefts means that the alveolar process can be fully restored, permitting adjacent teeth to migrate or be orthodontically moved into the grafted bone. Thus a complete dental arch can be obtained without prosthodontics in the great majority of patients. In addition, oral-nasal fistulae are closed, mucosal recesses eliminated (facilitating oral hygiene) and the long-term periodontal health of the teeth adjacent to the former cleft is improved. Alveolar bone grafting with subsequent orthodontic treatment, together with advances in dental materials, have contributed substantially to the care of patients with alveolar clefts, reducing the need for prosthodontic procedures and allowing completion of the dental treatment at an earlier age.

Facial growth after different methods of surgical intervention in patients with cleft lip and palate

Studies of the influence of surgery on facial growth in cleft lip and palate must take into account inherent variations in craniofacial form independent of surgery. Primary surgery, the most important iatrogenic influence on facial form, can differ in technique, timing, and sequence, and one of the major challenges in researching the topic is the remarkably varied clinical protocols in current use. Unfortunately, systematic attempts to compare dentofacial outcomes reported in the literature are unlikely to be reliable, as methodologic biases cannot be overcome. Rigorous intercenter studies can improve the dependability of data and provide evidence of the success of cleft services as a whole, but they are still subject to biases introduced by differences in surgical skills and underlying craniofacial form. These shortcomings are finally being overcome through multicenter randomized control trials.

Early detection of differences in surgical outcome for cleft lip and palate

This study examined the dento-alveolar relationships of 5-year-old children born with a unilateral cleft lip and palate with primary surgical repair performed in one of two centres (Bristol or Oslo). The Bristol sample comprised 46 sets of study models and the Oslo CLP Growth Archive provided 54 cases with a very similar sex distribution. We used a recently developed 5-year-old index to measure differences in outcome between the two centres. The Oslo sample were assessed as having up to 57 per cent in the ideal groupings (1 and 2), in the Bristol group this was only 35 per cent. Bristol had up to 46 per cent of cases assessed in the worst groups (4 and 5). The comparative figure from the Oslo group was 15 per cent. These results suggest that it is possible to detect differences in surgical outcome at 5 years of age.

Craniofacial morphology in adult patients with unoperated complete bilateral cleft lip and palate

OBJECTIVE

This report is a retrospective study that compares the craniofacial morphology of adult subjects with unoperated bilateral complete cleft lip and palate (BCLP) with that of a noncleft group.

METHODS

The study was performed on standardized lateral cephalograms obtained at the Hospital for Research and Rehabilitation of Cleft Lip and Palate, University of São Paulo, Brazil. The research group consisted of 28 subjects (20 males, 8 females) with unoperated BCLP, ranging in age from 15 to 41 years. The control group was matched to the cleft group with regard to gender and age. The findings were analyzed on the basis of the two-way analysis of variance (ANOVA) for cleft and gender.

RESULTS

The most striking difference between the groups was the extremely prominent premaxilla in the cleft group that gave the BCLP face a very convex profile. The mandible exhibited a vertical growth pattern that resulted in a steep mandibular plane, an obtuse gonial angle and a long lower face height. The posterior face height was reduced. The cranial base dimensions were smaller, but there was no difference in cranial base angulation.

CONCLUSIONS

These findings confirm that in subjects with unoperated BCLP, the initial characteristics of the cleft malformation persist during growth.

A new index for assessing surgical outcome in unilateral cleft lip and palate subjects aged five: reproducibility and validity

OBJECTIVE

This study assessed the reproducibility, reliability, and predictive validity of a previously developed index by the authors for assessing surgical outcome in unilateral cleft lip and palate (UCLP) children aged 5.

METHODS

Sixty randomly selected study models of 5- to 6-year-old complete UCLP subjects were obtained and the index was used to assess their surgical outcomes.

RESULTS

Assessment of these study models using the new index demonstrated excellent intra-examiner agreement. The inter-examiner agreement was shown to be good. The corresponding longitudinal models at 16 to 18 years of 54 of the initial 5- to 6-year-old sample were also acquired. These subjects had undergone orthodontic treatment but not orthognathic surgery. The need for osteotomy amongst these models was assessed. Between 13% and 18% (depending on examiner) of 5-year-olds' models were scored in the groups likely to require orthognathic surgery. In the corresponding 16- to 18-year-olds' models, 9% were assessed as likely to benefit from an osteotomy. However, on an individual basis, it was not possible to predict future growth from study models at age 5.

CONCLUSIONS

This study has provided a reliable and reproducible index for assessing the outcome of surgery in UCLP subjects earlier than indices already available. True validation of the index was not possible but it appears that it relies on face validity.

The effect of alveolar bone grafting on the prosthodontic/reconstructive treatment of patients with unilateral complete cleft lip and palate

This study compared the effect that the introduction of mixed dentition alveolar bone grafting and subsequent orthodontic treatment has had on the prosthodontic/reconstructive habilitation of patients with unilateral cleft lip and palate. Two groups, each consisting of 40 consecutive patients with unilateral cleft lip and palate, were compared at the end of their dental treatment. In the group treated prior to the advent of bone grafting, all subjects received a fixed partial prosthesis in the cleft area, and a total of 87 abutment teeth were prepared for complete coverage crowns. In contrast, in the group of patients for whom the alveolus was restored by bone grafting, it was possible to obtain a complete dental arch without prosthodontic intervention in 36 patients (90%). Thirteen subjects in the bone grafting group had the crown anatomy of anterior teeth modified using resin composite or resin-bonded porcelain veneers. Two patients had a premolar transplanted to the anterior region of the dental arch. On average the dental treatment was completed 3 years earlier in the bone grafting group. Thus, alveolar bone grafting with subsequent orthodontic treatment, together with advances in dental materials, have markedly reduced the need for prosthodontic procedures and have also allowed the completion of the dental treatment at an earlier age.

Facial growth in patients with unilateral clefts of the lip and palate: a two-center study

Two groups of 10-year-old patients with complete unilateral clefts of the lip and palate were examined in this study. Two centers; Bristol, U.K. and Oslo, Norway, who had different treatment regimens were used. The groups comprised 40 patients from Oslo and 32 from Bristol. The groups were matched, in proportion to the size of the groups, for age, sex, and presence of Simonart's bands. In Oslo, a Millard lip repaired was performed at 3 months of age with a von Langenbeck palatal repair at 18 months, no presurgical orthopedics was employed and there was no primary nasal correction. The Bristol center also repaired the lip at 3 months with a Millard type repair but also performed a radical nasal correction at the same time. The palate was repaired at 6 months with a Veau repair, and presurgical orthopedics using a pinned arch orthopedic plate was carried out. In addition, the volume of primary repairs per surgeon was much higher in Oslo, and a much stricter treatment protocol was used compared with Bristol. Lateral cephalograms obtained within 1 year of the child's tenth birthday were digitized, and the craniofacial morphology of the two groups was compared. Significant differences in maxillary growth and soft tissue profile were noted with a much more retruded mid-face and flatter nasiolabial angle in the Bristol group. The main factors for the better results in Oslo are suggested to be the absence of presurgical orthopedics, no radical nasal correction, the high volume of operations performed per surgeon, and the stricter protocol.

[Long term results of the use of Björk-Shiley convex-concave heart valves. Ullevol hospital 1978-83]

In recent years, Björk-Shiley CC-valves have become the object of suspicion after several reports of strut fracture with embolization of the tilting disk and acute heart failure. At Ullevål Hospital Björk-Shiley CC-valves were used in 341 patients during the period October 1978 to March 1983. Strut fracture occurred in four cases, three of the patients died and one survived an emergency heart operation with replacement of the valve. In four patients, prophylactic replacement of the valves was performed. During the observation period concluded in September 1995 a total of 187 patients died. These included 26 operative deaths (7.6%). Of the late deaths, 40% were due to heart failure and 21% were sudden deaths. Strut fracture was the cause of death in 2% of the late deaths.

Dentofacial form in the five-year-old child with unilateral cleft lip and palate

It is generally believed that studies of outcome for children with clefts of the lip and palate should be based on patients who are in their teens. This means that health care workers who look after these children would have to wait many years until the quality of treatment could be evaluated. In this study, significant differences between two centers, Oslo and Manchester, in facial form at the age of 5 years were detected. Based on cephalometric analysis, children from Manchester were more likely to have a retrognathic maxilla with the upper lip significantly behind the esthetic plane. An important future step may be the setting up of "reference centers" with a large archive of database information for each racial group. This would assist smaller centers in comparing their outcomes.

Reduced complement and granulocyte activation with heparin-coated cardiopulmonary bypass

Plasma concentrations of the complement activation products C3b, iC3b, and C3c; the terminal C5b-9 complement complex; and the granulocyte proteins calprotectin, myeloperoxidase, and lactoferrin were assessed in two groups of patients undergoing aortocoronary bypass procedures. In 10 patients operated on, the bypass circuits were coated by the Carmeda Bio-Active Surface and systemic heparinization was reduced to 1.5 mg/kg; in another 10, the systems were uncoated and the dosage of systemic heparinization was 4 mg/kg. In both groups, significant complement activation was observed after the onset of cardiopulmonary bypass, but the maximum levels of C3b, iC3b, and C3c and the terminal C5b-9 complement complex were significantly lower in the heparin-coated group. In both groups, a significant increase in calprotectin, myeloperoxidase, and lactoferrin release was observed by the end of operation. The maximum myeloperoxidase levels were significantly lower in the heparin-coated group than those in the uncoated group (p = 0.03). There was a correlation of borderline significance between the formation of terminal C5b-9 complement complex and lactoferrin release, as well as between the formation of terminal C5b-9 complement complex and myeloperoxidase release (p = 0.05). The postoperative blood loss did not differ significantly between the two groups. We conclude that coating by end point-attached and functionally active heparin allows a significant reduction in the amount of systemic heparinization, and significantly reduces complement and granulocyte activation.

Prevalence of a soft tissue bridge in a sample of 2014 patients with complete unilateral clefts of the lip and palate

This study examines the prevalence of a soft tissue bridge (Simonart's band) on 2014 Brazilian Caucasian patients with unilateral complete cleft lip and palate (UCLP). A soft tissue bridge occurred in 19.6% of the subjects; 94.9% of the soft tissue bands had skin coverage. The presence of soft tissue bridges was unrelated to gender and the laterality of the cleft.

A multicentre comparison of treatment regimens for unilateral cleft lip and palate using a multiple regression model

The European Cleft Lip and Palate Research Group consists of specialists in orthodontics from six centres for the treatment of cleft palate in northern Europe. The purpose of this part of the multicentre study was to investigate whether differences in outcomes could be explained by specific treatment regimens. Three regimens that were assumed to influence the outcome of treatment were selected: Presurgical orthopaedics, closure of the palate, and primary bone grafting. The sample comprised 151 children with complete unilateral cleft lip and palate from the six centres. The result of multiple regression analysis showed that within that sample it was not possible to reach definite conclusions as to which factors exerted the most favourable influence on facial growth, but primary bone grafting was associated with reduced maxillary inclination and presurgical orthopedics with increased mandibular inclination.

Lip and nose morphology in patients with unilateral cleft lip and palate from four Scandinavian centres

Sixty patients with unilateral cleft lip and palate were compared for lip and nose appearance. All patients were photographed from an anteroposterior and a basal view at 7-10 years of age. The photographic registration method was tested for validity and accuracy. Although the four groups of 15 patients each were treated according to different protocols, many similarities were found with shorter lip heights at the cleft side and inclination of the rima oris. Asymmetry of nose and retropositioning at the cleft side naris were generally seen. Significantly straighter noses were demonstrated in the group treated with a two-stage lip nose operation combined with nose plugs, and the two groups where vomer flaps were used showed the greatest deviation of the nose.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: evaluation of maxillary asymmetry

This investigation was carried out by the European Cleft Lip and Palate Research Group. The purpose of this part of the investigation was to compare and evaluate maxillary asymmetry in children born with complete unilateral cleft lip and palate treated at cleft palate centers with different surgical management. Posteroanterior radiographs from three of the six participating centers were included in the investigation. Statistically significant differences were found in the symmetry of the anterior part of the maxillary complex. Children with a primary bonegrafting procedure involved in their primary treatment procedure had a more symmetric dentoalveolar development. Children from centers with primary surgical procedures including a vomer plasty and no involvement of the alveolar process had a more asymmetric development with a tilted premaxilla and a deviating inclination of the central incisors.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 3. Dental arch relationships

One hundred and forty-nine dental casts of subjects with complete unilateral clefts of the lip and palate from six European cleft palate centers were assessed by means of the Goslon Yardstick. The Yardstick proved capable of discriminating between the quality of the dental arch relationships between the six centers. Two centers showed especially poor results. Three centers obtained satisfactory results although differing surgical techniques were used in these centers. One of the centers showing satisfactory dental arch relationships employed a more complex and expensive treatment program than the other two centers, which both used simpler centralized treatment regimens.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 2. Craniofacial form and soft tissue profile

The craniofacial morphology and the soft tissue profile were evaluated in this part of the intercenter study of the European Cleft Lip and Palate Research Group. The sample was comprised of cephalometric x-rays of the full cohort of 151 cases from the six European cleft palate centers. The facial morphology in complete unilateral cleft lip and palate patients was evaluated by means of roentgen cephalometry. Approximately 25 consecutive cases from each of six European cleft palate centers were compared. Only one center showed notable and consistent differences from the others. A contributing factor for these differences may be an inconsistent treatment regimen with many surgeons involved. Analysis of the soft tissue profile between the centers showed more pronounced differences than analysis of the skeletal profile. The treatment outcome in centers with more complex or expensive programs was no better than those centers using simpler management approaches.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 1. Principles and study design

This article describes the design of an intercenter comparative study of treatment outcome in the treatment of children with a unilateral complete cleft of the lip and palate. The rationale and aims of this study are defined and treatment schemes of the participating centers are described. The findings are presented in a series of three papers (Parts 2, 3, and 4) dealing with the comparison of craniofacial form, dental arch relationships, and nasolabial appearance. In Part 5, conclusions and general recommendations regarding future research are discussed.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 4. Assessment of nasolabial appearance

One hundred and fifteen frontal and profile photographs of the nasolabial area of subjects with complete unilateral clefts of the lip and palate from six European centers were assessed. Four components of the nasolabial area were rated separately by a panel of judges using a five-point scale of attractiveness. The Tukey multiple comparison test showed significant differences between the centers. The relative position of the six centers in this study followed a similar pattern to their respective positions in the cephalometric and dental cast studies.

Reduced complement activation with heparin-coated oxygenator and tubings in coronary bypass operations

Complement activation after cardiopulmonary bypass is correlated with postoperative organ dysfunction. Heparin coating of the entire blood-contact surface of the cardiopulmonary bypass circuit has proved to reduce complement activation in vitro. A membrane oxygenator and tubing setup coated with functionally active heparin was compared with an uncoated, otherwise identical setup in 20 patients undergoing routine coronary bypass operations. The concentrations of C3 activation products and the terminal complement complex were measured in sensitive and specific enzyme immunoassays. Peak concentrations of C3 activation products were 90.1 (74.7 to 107.4) AU/ml (medians and 95% confidence intervals) and 52.4 (35.7 to 76.4) AU/ml with the uncoated and coated setups, respectively (p = 0.02). The corresponding concentrations of the terminal complement complex were 26.2 (20.1 to 37.5) AU/ml and 13.7 (11.1 to 25.1) AU/ml (p = 0.03). Blood loss from the mediastinal drains during the first 12 postoperative hours was 533 (416 to 975) ml in patients treated with the uncoated setup and 388 (313 to 579) ml in the coated treatment group (p = 0.06) and was significantly correlated with peak concentrations of the terminal complement complex (p = 0.01). There were no differences in neutrophil counts nor platelet numbers between the treatment groups. The approximate 45% reduction in complement activation with the heparin-coated cardiopulmonary bypass device indicates a substantial improvement of biocompatibility.

Results of multidisciplinary management of bilateral cleft lip and palate at the Iowa Cleft Palate Center

Bilateral cleft of the lip and palate is by many standards the most complex and severe form of the defect. The complexity and severity of the defect require an unusual degree of cooperation among all specialists and especially between the surgeon and the orthodontist. There are no published findings that we know about in which comprehensive data from a number of disciplines are reported for the same group of bilateral cleft patients. Fifty randomly selected patients with bilateral complete clefts were examined by the Iowa team and two orthodontists from other institutions. The evaluations revealed that a large number of patients over the age of 10 have multiple residual problems requiring further treatment. Only 23 percent of the older patients studied were judged to have had treatment completed by the surgeon, speech pathologist, and orthodontist. It is very difficult to state whether the results obtained by our team can be considered satisfactory because there are no comparable studies that have attempted to evaluate the same parameters in multidisciplinary management.

Strut fracture with Björk-Shiley 70 degrees convexo-concave valve. An international multi-institutional follow-up study

Between 1980 and 1983, 831 Björk-Shiley 70 degrees convexo-concave prosthetic heart valves were implanted at five institutions in Sweden, Germany. The Netherlands, and Canada. As of January 1991, there were 34 outlet strut fractures occurring from 0.2 to 10.1 years (median = 4.6 years) after implantation. In addition, there were 28 sudden, unexplained deaths. The mortality after strut fracture was 84%. The mortality after emergency valve replacement for strut fracture was 50%. The 10-year actuarial fracture rate (standard error) was 10.5 (2.4)% for large (29-33 mm) valves vs. 3.3 (1.2)% for 21-27 mm valves (P less than 0.001). Within valve size groups, fracture rates for aortic and mitral valves were similar. Cox regression analysis found only valve size to be significantly associated with strut fracture. There is a further subgrouping of the valves according to the manufacturer: group I are the earlier large 29-33 mm) valves; group II are the later large valves; group III are the small size (21-27 mm) valves. The risk of strut fracture was highest in group I (12.3% at 10 years) with an approximatively constant hazard (1.4% per year). A comparison was made with a statistical model incorporating all cases reported to the manufacturer. This model estimates fracture rates approximately 63%-73% of those found in the present study. These findings lead us to recommend that group I patients should be considered for elective reoperation on an individual basis, giving careful attention to risk factors and contraindications.

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes. II. Mandibular and vertical development

Lateral skull radiographs of 85 patients with unilateral clefts of the lip, alveolus and palate treated according to four different regimes were compared longitudinally, at three different ages, regarding mandibular and vertical facial development. It was found that there were no lasting differences in mandibular morphology resulting from regimes including primary or early secondary bone grafting. The non grafted group, however, showed increased mandibular length and anterior height. The jaw angle was increased and there was a more favourable sagittal jaw relationship. Regimes that included primary bone grafting were associated with reduced upper anterior facial height, which resulted in less harmonious facial proportions compared with treatment regimes including early secondary bone grafting done during the mixed dentition, or no bone grafting at all. Vertical development was greatest where bone grafting was excluded.

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to three different regimes. Assessment of nasolabial appearance

From extraoral photographs taken from the front and in profile of 61 16-year old children with unilateral cleft lip, alveolus, and palate (UCLAP) who had been treated by three different treatment regimes, the nasolabial appearances were assessed by a panel. The photographs were masked, leaving only the mid face including the nose and lips. The following features were assessed using a five point scale: nasal form, symmetry of the nose, vermilion of the upper lip, shape of the vermilion border, total symmetry of upper lip, and nasal profile including the upper lip. The number and type of secondary operations required were recorded. Intraobserver reliability was good but interobserver agreement was poor, some observers systematically scoring more severely than others. A panel of six was therefore set up to establish an acceptable mean assessment. The treatment regime that included secondary bone grafting, and the one that included primary bone grafting and presurgical orthopaedic-T-traction, scored better on all features assessed compared with the group that underwent primary bone grafting but no T-traction. The latter group required fewer secondary revisionary procedures, however, which could explain these results.

Five-year results after valve replacement with the Björk-Shiley 70 degrees convexo-concave prosthesis

In the 18 months up to July 1983, 120 Björk-Shiley convexo-concave prostheses with 70 degrees opening angle were implanted in 47 women and 61 men aged 19-78 (mean 58.6) years. The prosthetic valves were aortic in 65 cases, mitral in 23 and both aortic and mitral in 20 cases. Emergency operation was required in ten cases, and concomitant surgery was performed in 43 (39.8%). The early mortality was 5.5%. A follow-up study, comprising 498 patient years, revealed 73.1% 5-year survival. There were three mechanical failures of prosthesis, in one of which re-replacement was successful. Elective prosthesis replacement was performed in four other cases judged to be at high risk of strut fracture.

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes. III. The soft tissue profile at 16-18 years of age

The soft tissue profiles of 85 16-18 year old children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes were studied using lateral skull radiographs. Regimes that included secondary bone grafting to the alveolus in the mixed dentition gave better convexity of the soft tissue profile (excluding the nose) and better soft tissue sagittal jaw relationships compared with treatment regimens that included primary bone grafting. The soft tissue profile in regimes that excluded bone grafting was almost as favourable as those in regimes in which bone grafting was done during the mixed dentition.

Cephalometric scaling methodology in limited samples

In longitudinal or cross-sectional cephalometric evaluation there are many factors which make analysis difficult. Samples are often limited in number and include both sexes. Registration may be done at different ages, using different equipment and techniques. By linear scaling size differences between sub-groups may be calibrated. Angular variables may still differ, however, suggesting differences in shape. If not, such sub-groups can be pooled, thus increasing the number of cases in each group and allowing more meaningful comparisons to be made with other groups. Calibration of biological size differences and/or technical effects of image enlargement may also be used to create a suitable baseline independent of growth, from which to study treatment effects.

Strategies for the advancement of surgical methods in cleft lip and palate

This paper examines the clinical research methodologies used for the evaluation of cleft lip and palate therapies. A survey of clinical reports in the Cleft Palate Journal between 1964 and 1988 revealed that almost all used retrospective methods (96%). The authors examine the merits and biases associated with retrospective evaluation of therapies and compared these to prospective randomized clinical trials. The strengths and weaknesses of clinical trials are discussed in relation to the long-term evaluation of primary surgery in cleft patients. For these to be successful, further work is needed to investigate questions such as sample size, possible predictors of long-term outcome, and improved methods of presurgical assessment. The authors conclude that if the uncertainties associated with the choice of primary cleft surgery are to be resolved, the challenge of multicenter prospective clinical trials must be faced by the various disciplines involved in cleft palate clinical research.

[Accidental hypothermia. Risk factors in 29 patients with body temperature of 30 degrees C and below]

29 patients with a body temperature below 30 degrees C (mean 26.4 degrees C) were treated during the period 1982-88, both years inclusive. Eight patients were severely hypotensive (systolic blood pressure less than 60 mm Hg) and two had ventricular fibrillation on admission. Bradycardia (less than 60 beats per minute) was noted in ten patients. 12 patients were rewarmed by surface warming, 17 by extracorporeal circulation with femoral cannulation. 22 patients (76%) were discharged alive. Age, sex, body temperature, method and rate of rewarming, serum electrolytes, acidosis and the use of blood components did not influence the outcome. Renal failure was the only complication associated with a fatal outcome. Severe hypotension on admission tended to increase mortality, but logistic regression analysis identified the mode of cooling as the only independent risk factor for death. A patient cooled indoors had an odd risk of 10.6 of hospital mortality compared to one found outdoors. For the sake of convenience, in hospitals with the available resources rewarming by extracorporeal circulation may be used in patients with circulatory arrest, since this is the easiest way to control and support failing circulation. In all other cases carefully monitored surface rewarming should be used as this necessitates less use of hospital resources and produces equally good results.

A study of facial growth in patients with bilateral cleft lip and palate treated by the Oslo CLP Team

Lateral and frontal cephalometric analysis of a mixed longitudinal survey of 90 individuals with complete bilateral clefts of the lip and palate from the Oslo Growth Archive is described. All subjects were treated and followed-up by the Olso CLP Team according to strictly defined protocols for treatment and documentation. Craniofacial form in this sample is generally similar to that reported for Caucasian subjects treated for this condition elsewhere.

Craniofacial development in children with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes. I. Maxillary development

Lateral skull radiographs of 85 patients with unilateral clefts of the lip, alveolus, and palate treated according to four different regimes were compared at three different ages regarding maxillary development. Regimes that included primary bone grafting to the alveolus at six months of age resulted in inhibited anterior maxillary growth and reduced maxillary inclination. Regimes that included secondary bone grafting after eruption of the incisors but before the eruption of the canines, resulted in better maxillary development, but were not as good as regimes that omitted bone grafting altogether.

Craniofacial and occlusal characteristics in unilateral cleft lip and palate patients from four Scandinavian centres

Craniofacial morphology and dental occlusion were studied at early school age in 15 consecutive patients with unilateral cleft lip and palate from each of four Scandinavian cleft centres. Treatment differed mainly in the techniques of palatal repair. Push-back closure of the palate particularly impaired maxillary development, which resulted in an increased incidence of crossbite and reduced intercanine distance when compared with patients who had been operated on by the von Langenbeck method or in whom the anterior palate had not yet been closed.

Simonart's band and facial growth in unilateral clefts of the lip and palate

A cephalometric analysis was carried out to see if the presence of a Simonart's band at birth was associated with a detectable difference in subsequent craniofacial form. Mixed longitudinal data from 5 through 18 years of age was analyzed for 257 individuals with complete UCLP included in the Oslo CLP Growth Archive, 80 with a Simonart's band and 177 without. No major differences were detected between individuals with or without Simonart's band, though the presence of a Simonart's band was associated with a larger cranial base angle and a slightly more favorable maxillomandibular relationship. The findings are discussed in relation to embryogenesis, primary surgery, and secondary surgery. It is recommended that cephalometric studies of UCLP involving group comparisons should avoid major imbalance with respect to the proportion of individuals with a Simonart's band at birth.

A study of facial growth in patients with unilateral cleft lip and palate treated by the Oslo CLP Team

Lateral and frontal cephalometric analysis of a mixed longitudinal survey of 257 individuals with complete unilateral cleft lip and palate from the Oslo CLP Growth Archive is described. All subjects were treated and followed up by the Oslo CLP Team according to strictly defined protocols for treatment and documentation. Craniofacial form for this sample is generally similar to that reported for Caucasian children treated for this condition elsewhere.

Effects of nimodipine on cerebral blood flow and neuropsychological outcome after cardiac surgery

Thirty-five patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) were allocated randomly in a prospective double-blind study to receive either nimodipine 0.5 micrograms kg-1 min-1 or placebo. Cerebral blood flow (CBF) was measured during and immediately after CPB. Neuropsychological tests were performed 6 months after surgery to determine any relationship between ischaemic damage and CBF and administration of nimodipine. There were no differences in CBF between the nimodipine (n = 18) and placebo groups (n = 17). Significant changes in neuropsychological tests were found in six patients tested 6 months after surgery but there were no conclusive signs of ischaemic damage. The nimodipine-treated group performed better in tests of verbal fluency and visual retention, suggesting that some memory functions were preserved better in this group.