Acceptability of the Cognition Test Battery in Astronaut and Astronaut-Surrogate Populations

BACKGROUND

Sustained high levels of astronaut cognitive performance are a prerequisite for mission success. A neuropsychological battery of 10 brief cognitive tests (Cognition) covering a range of cognitive domains was specifically developed for high performing astronauts to objectively assess cognitive performance. Extended mission durations require repeated cognitive testing and thus high acceptability of the Cognition software to the astronaut population. The aim of this qualitative study was to evaluate acceptability of Cognition to astronauts and astronaut surrogate populations.

METHODS

Cognition was administered repeatedly to N=87 subjects (mean age ±SD 35.1 ±8.7 years, 52.8% male) on a laptop or iPad across five individual studies on the International Space Station or in space analog environments on Earth. Following completion of each study, participants were interviewed regarding their experience using Cognition in a semi-structured debrief. Participant comments were analyzed using a qualitative conventional content analysis approach.

RESULTS

The majority of participants' comments (86.1%) were coded as positive or neutral in valence, with most positive comments relating to software usability, engagement, and overall design. Among the 10 Cognition tests, subjects liked the Visual Object Learning Test most (28 likes, 32.2% of participants), while the Emotion Recognition Test was liked least (44 dislikes, 50.6% of participants). Some subjects (36.8%) were frustrated with the level of difficulty of some of the 10 Cognition tests, especially during early administrations, which was by design to avoid ceiling effects in repeated administrations of high-performers. Technical difficulties were rare (20.7% of participants), and most often observed in environments with restricted internet access. Most participants (82.3% of those who commented) liked the feedback provided by Cognition after each test, which includes a graph showing performance history.

CONCLUSION

Cognition was found to be acceptable to astronaut and astronaut-surrogate populations across a variety of settings and mission durations. Participant feedback provided was used to further improve Cognition and increase its acceptability during sustained space missions.

Facial growth in patients with isolated cleft palate treated with minimal incision technique compared to a normal population-a cephalometric study at 10 and 16 years of age

OBJECTIVE

To evaluate the result of a novel palatoplasty (minimal incision technique) for closure of an isolated cleft palate (ICP) at 10 and 16 years of age, concerning facial growth, compared to a normal population.

SUBJECTS

Treated group: 55 non-syndromic Caucasian children born with an ICP between 1987 and 2001. The children were treated surgically with a one-stage palatoplasty at a mean age of 13 months. Control group: 110 Caucasian children with normal occlusion with no history of clefts or orthodontic intervention.

METHOD

The treated children (25 boys, 30 girls) were matched (gender and age) with the children in the control group. A retrospective evaluation at 10 (mean 10.5) and 16 (mean 16.0) years of age was performed by analysis of lateral cephalograms. Fifteen variables were evaluated. Ninety-nine per cent confidence intervals were calculated. Two-way factorial ANOVA and mixed-model analysis were performed.

RESULTS

Treated patients compared to the control group showed: at 10 years of age, smaller mandible (P = 0.001) and reduced posterior upper and total face heights (P ≤ 0.001); at 10 and 16 years of age, a retrognathic (P ≤ 0.001), smaller (P ≤ 0.006) and with an increased posterior inclination of the maxilla (P < 0.001), as well as a retrognathic mandible (P ≤ 0.006).

CONCLUSION

The craniofacial morphology at 10 and 16 years of age in patients born with an ICP and treated with the minimal incision technique differs compared to the morphology of a normal control group born without a cleft. Retrognathic maxillas and a smaller and posteriorly inclined maxilla were found in the treated group.

Minimal incision palatoplasty with or without muscle reconstruction in patients with isolated cleft palate-a cephalometric study at 5 and 10 years

OBJECTIVE

To compare differences in facial growth in patients with isolated clefts of the hard and/or soft palate treated with the minimal incision technique without (MI) or with muscle reconstruction (MMI).

SUBJECTS AND METHOD

A consecutive series of 170 Caucasian children born with isolated cleft palate were studied. Individuals with other craniofacial malformations, apart from Pierre Robin sequence (PRS), were excluded. The patients were treated surgically with MI (n = 85) or MMI (n = 85) palatoplasty (mean age: 13 months) and divided further into two subgroups: clefts within the soft palate only (small cleft, n = 51) and within the hard and soft palate (big cleft, n = 119). A retrospective evaluation at 5 (mean 5.4) and 10 (mean 10.3) years was performed using lateral cephalograms. Twelve skeletal and one soft tissue measurement was evaluated. Both 95% and 99% confidence intervals were calculated, two-way ANOVA and mixed model analysis was performed including/excluding PRS.

RESULTS

At 5 years, statistically significant increased inclination of the palatal plane in the big MMI cleft group (P < 0.01), increased posterior upper face height (P < 0.01), and longer mandibular length (P < 0.001) in the small MI cleft group was observed. At 10 years, statistically significant increased inclination of the palatal plane (P < 0.001), decreased posterior upper face height (P < 0.001), and longer palatal length (P < 0.01) was seen in the big MMI group.

LIMITATIONS

Retrospective single centre study, limited sample size, three surgeons.

CONCLUSION

Minor differences in craniofacial morphology were found between patients with isolated clefts treated with MI or MMI technique and between small and big cleft lengths.

Minimal incision palatoplasty with or without muscle reconstruction in patients with isolated cleft palate: a cast and medical records analysis

Objectives

To compare the minimal incision (MI) technique with the minimal incision including muscle reconstruction (MMI) technique regarding surgical complications and dentoalveolar status at 5 years of age.

Subjects and method

A consecutive series of 202 Caucasian non-syndromic children (apart from Pierre Robin Sequence) born with isolated cleft palate between 1987 and 2007 and treated with MI (n = 78) or MMI (n = 102) palatoplasty at a mean age of 12.7 (SD = 1.43) months in Stockholm. Twenty-two patients did not fulfill the inclusion criteria. The patients were divided into two subgroups: clefts within the soft palate only (small cleft, n = 50) and clefts within the hard and soft palate (big cleft, n = 130). Dental relations, structure of the palatal mucosa, and height of the palatal vault at 5 (mean age 5.3, range: 4.4-6.9) years of age were studied using plaster models. Time for surgery, blood loss, complications in the immediate postoperative period, frequency of fistulas, and additional pharyngeal flap surgery were evaluated. Student's t-test, chi-square test and 95 per cent confidence intervals were calculated.

Results

MMI compared to MI technique result in statistically significant increased operation time, less need for pharyngeal flap surgery, and to shallower palatal vault. Big clefts result in statistically significant increased operation time and need for pharyngeal flap surgery. Dental relations were the same in all groups.

Limitations

Retrospective single centre study, limited sample size, more than one surgeon.

Conclusions

The muscle reconstruction results in a reduced subsequent need for pharyngeal flap surgery, but to shallower palatal vault and demand for almost double operation time. The dental relations were the same in all groups.

Mean GOSLON Yardstick Scores After 3 Different Treatment Protocols—A Long-term Study of Patients With Unilateral Cleft Lip and Palate

Objectives:

(1) To evaluate dental arch relationships, with the Great Ormond Street, London and Oslo (GOSLON) Yardstick, of participants with Unilateral cleft lip and palate (UCLP) and treated with 1-stage palatal closure with 3 different surgical protocols (2) to compare the mean GOSLON ratings with other CLP centers.

Design:

Retrospective study of medical charts and dental models.

Setting:

Karolinska University Hospital, Stockholm, Sweden.

Participants:

Eighty-seven patients with UCLP operated with 1-stage palatal repair. Thirty-five were operated with Veau-Wardill-Kilner (VWK) technique 1975 to 1986, 31 with minimal incision technique (MIT) from 1987 to 1997, and 21 according to MIT with muscle reconstruction (MITmr) 1998 to 2004.

Interventions:

Dental casts at ages 5 (n = 87), 7 to 8 (n = 27), 10 (n = 81), 16 (n = 61), and 19 (n = 35) years were rated by 10 assessors with the GOSLON Yardstick. Information of other interventions was retrieved from patients’ charts.

Main outcome measures:

Mean GOSLON ratings.

Results:

A total of 82% of the participants were rated as having excellent to satisfactory outcome. Weighted κ statistics for the 10 assessors was good for inter-rater agreement and good/very good for intra-rater agreement.

Conclusions:

The mean GOSLON score in the Stockholm overall material at age 10 was 2.67. The VWK technique resulted in a greater need of orthognathic surgery than the MIT ( P < .01). The MITmr did not produce better dental arch relationships than MIT at age 5 ( P < .05). The best dental arch relationships were found in the MIT group at 10 years, mean 2.58, which is not significantly different from other centers with excellent outcome except Gothenburg and Vienna.

Facial Growth at 5 and 10 Years After Veau-Wardill-Kilner Versus Minimal-Incision Technique Repair of Isolated Cleft Palate

OBJECTIVE

To compare the Veau-Wardill-Kilner technique with the Minimal-Incision technique repair of isolated clefts of the hard and soft palate regarding facial growth at 5 and 10 years of age.

DESIGN

Retrospective study of lateral cephalograms.

SETTING

Hospital and university based.

PATIENTS

A consecutive series of 145 Caucasian nonsyndromic children born with isolated cleft palate between 1980 and 1996 were studied. Children with Pierre Robin sequence (PRS) were included in the study. The patients were divided into 4 groups: 2 groups regarding surgical technique and 2 groups regarding cleft length.

INTERVENTION

Veau-Wardill-Kilner or Minimal-Incision palatoplasty.

MAIN OUTCOME MEASURES

Eleven skeletal and 1 soft tissue measurement were evaluated from lateral cephalograms taken at 5 and 10 years of age.

RESULTS

Only minor differences in cephalometric morphology were found between the Veau-Wardill-Kilner technique group and the Minimal-Incision technique group. Similar results were found independent of cleft length or the inclusion of PRS in the sample.

CONCLUSION

The craniofacial cephalometric morphology at 5 and 10 years of age in patients with isolated cleft palate is similar between the Veau-Wardill-Kilner and the Minimal-Incision technique group.

A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project.

METHOD

Ten established national or regional cleft centres participated. Lip and soft palate closure at 3-4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3-4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3-4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes.

RESULTS

Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years.

CONCLUSION

The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series.

TRIAL REGISTRATION

ISRCTN29932826.

Orthognathic bimaxillary surgery in two patients with osteogenesis imperfecta and a review of the literature

Orthognathic surgery in patients with osteogenesis imperfecta is rare. Most cases result in a successful outcome with stable and good occlusion. Two patients with, probably severe types III and IV, and malocclusion class III with retrognathic maxilla and prognathic mandible, were treated with orthodontic treatment and bimaxillary surgical correction. The surgical outcome and follow up are presented together with a review of published cases of orthognathic surgery in patients with different types of osteogenesis imperfecta. The authors conclude that it is possible to perform combined orthodontic and orthognathic surgery in patients with osteogenesis imperfecta despite the greater risk of complications. The treatments were successful with follow up times of 5-6 years.

Speech Results after One-Stage Palatoplasty with or without Muscle Reconstruction for Isolated Cleft Palate

Objective

To investigate speech outcome between children with isolated cleft palate undergoing palatoplasty with and without muscle reconstruction and to compare speech outcomes between cleft and noncleft children. The number of subsequent velopharyngeal flaps was compared with respect to surgical techniques and cleft extent.

Design

Cross-sectional retrospective study.

Participants

One hundred four children aged 4 years, 0 months to 6 years, 0 months, 33 with isolated cleft of the soft palate, 53 with isolated cleft of the hard and soft palate, and 18 noncleft children.

Interventions

Two primary palate repair techniques: minimal incision technique (MIT) and minimal incision technique including muscle reconstruction (MITmr).

Main Outcome Measures

Perceptual judgment of seven speech parameters assessed on a five-point scale.

Results

No significant differences in speech outcomes were found between MIT and MITmr surgery groups. The number of velopharyngeal flaps was significantly lower after MITmr surgery compared to MIT surgery. The number of flaps was also significantly lower in children with cleft of the soft palate compared to children with cleft of the hard and soft palate. Children with cleft of the soft palate had significantly less glottal articulation and weak pressure consonants compared to children with cleft of the hard and soft palate.

Conclusions

The MITmr surgery technique was not significantly superior to the MIT technique regarding speech outcomes related to velopharyngeal competence, but had fewer velopharyngeal flaps, which is contradictory. Until a larger sample can be studied, we will continue to use MITmr for primary palate repair.

Length of the cleft in relation to the incidence of hypodontia of the second premolar and to inheritance of cleft lip and palate in children with isolated cleft palate

We studied severity of the isolated cleft palate expressed as the length of the cleft in relation to hypodontia in the second premolar regions and known inheritance of any type of cleft lip and palate. The material consisted of 47 children at 10 years of age born with non-syndromic isolated cleft palate of varying extent, who all had hypodontia of at least one second premolar, and had panoramic radiographs taken at 10 years of age. Information about length of cleft and inheritance of cleft lip and palate was collected from surgical files initiated at birth. The higher the number of missing second premolars, the more extended was the length of the cleft. More children had hypodontia of the second premolar in the mandible than in the maxilla. The family history had little influence on the length of the cleft.

Novel and de novo mutations of the IRF6 gene detected in patients with Van der Woude or popliteal pterygium syndrome

The interferon regulatory factor 6 gene (IRF6) has been identified as the major Van der Woude (VWS) syndrome and popliteal pterygium (PPS) syndrome gene with mutations in the majority of the kindreds. We have studied altogether 17 kindreds from Sweden, Finland, Norway, Thailand and Singapore, and report here 10 mutations, six of them previously unseen. In two kindreds, we could document de novo mutations, both of them changing a codon for a glutamine residue to a stop. No mutation could be detected in the four VWS kindreds from Finland, suggesting a founder effect for a mutation in an atypical noncoding position. Our findings demonstrate that several distinct mutations occur in the Swedish population, and confirm the general notion of a broad spectrum of IRF6 mutations underlying the VWS/PPS phenotypes.

Dental occlusion after Veau-Wardill-Kilner versus minimal incision technique repair of isolated clefts of the hard and soft palate

OBJECTIVE

To compare the Veau-Wardill-Kilner technique with a technique similar to the minimal incision technique described by Mendosa et al. on the basis of surgical complications and dentoalveolar status in the deciduous dentition.

DESIGN

Retrospective study of medical and dental records and casts.

PATIENTS

A consecutive series of 129 Caucasian children born with isolated cleft palate between 1980 and 1992.

MAIN OUTCOME MEASURES

From medical records, the variables of time for surgery, blood loss, complications in the immediate postoperative period, and frequency of fistulas were evaluated. On dental casts, the variables of sagittal, transversal, and vertical relations; structure of the palatal mucosa; and height of the palatal vault were studied.

RESULTS

Time for surgery was shorter in the extensive clefts repaired with a Veau-Wardill-Kilner technique. Blood loss was higher using the Veau-Wardill-Kilner technique. The width of the upper jaw was significantly narrower in the Veau-Wardill-Kilner group, compared with the minimal incision group. Scar tissue and pits of the palate were more frequently found in the Veau-Wardill-Kilner group.

CONCLUSIONS

The minimal incision technique in this study has been shown to result in better development of the upper jaw with a better dental occlusion and palatal mucosa with significantly less scar tissue.

Mapping of the second locus for the Van der Woude syndrome to chromosome 1p34

The Van der Woude syndrome (VWS) is a dominantly inherited developmental disorder characterized by pits and/or sinuses of the lower lip, cleft lip and/or cleft palate. It is the most common cleft syndrome. VWS has shown remarkable genetic homogeneity in all populations, and so far, all families reported have been linked to 1q32-q41. A large Finnish pedigree with VWS was recently found to be unlinked to 1q32-q41. In order to map the disease locus in this family, a genome wide linkage scan was performed. A maximum lod score of 3.18 was obtained with the marker D1S2797, thus assigning the disease locus to chromosomal region 1p34. By analyses of meiotic recombinants an approximately 30 cM region of shared haplotypes was identified. The results confirm the heterogeneity of the VWS syndrome, and they place the second disease locus in 1p34. This finding has a special interest because the phenotype in VWS closely resembles the phenotype in non-syndromic forms of cleft lip and palate.

Linkage analysis of candidate regions in Swedish nonsyndromic cleft lip with or without cleft palate families

OBJECTIVE

To analyze linkage of five candidate regions for nonsyndromic cleft lip with or without palate (CLP) on chromosome 2p13, 4q, 6p23, and 19q13; in addition chromosome 1q32, the locus for van der Woude syndrome, on Swedish CLP families.

DESIGN

Three to five linked microsatellite markers were selected from each candidate region. Polymerase chain reaction (PCR) with fluorescent-labeled microsatellite markers was performed on DNA samples from the participating families. Electrophoresis of the PCR products was performed on a laser-fluorescent DNA sequencer. The genotype data were analyzed with multipoint linkage analysis. Modes of inheritance tested included two autosomal dominant, an autosomal recessive, and a nonparametric model. Multipoint logarithm of odds (LOD) scores were also calculated by assuming genetic heterogeneity.

PARTICIPANTS

Nineteen Swedish multigenerational families with at least two first-degree relatives affected with CLP. Greater than 50% of the families studied show vertical transmission of the clefting phenotype and both inter- and intrafamilial variability were noted.

RESULTS

Cumulative multipoint LOD scores for the whole group of families calculated under autosomal dominant modes of inheritance were negative in all regions and less than -2 except chromosome 6p23. LOD scores calculated under recessive inheritance and the nonparametric model were inconclusive. There was no significant evidence of genetic heterogeneity among the sample group.

CONCLUSIONS

The group of Swedish CLP families did not demonstrate significant linkage to any of the five candidate regions examined. This might suggest a new but yet unknown CLP locus or loci in this family group. However, because linkage could not be excluded in some individual families, they should still be tested with candidate genes from these regions.

Clinical and genetic studies of Van der Woude syndrome in Sweden

Van der Woude syndrome (VWS) is an autosomal dominant craniofacial disorder characterized by pits of the lower lip, hypodontia and cleft lip and/or cleft palate. It has been reported as the most common form of syndromic orofacial clefting with very high penetrance and varied expressivity. The disease locus for VWS has been mapped to chomosome 1q32, but the gene is yet to be cloned. Here we report a total of 11 Swedish VWS patients: 9 familial cases from two families and two isolated cases. Clinical examination of these patients showed phenotypic variability, even between patients from the same family. Genetic studies were performed using four microsatellite markers from chromosome 1q32. Constitutional deletion in this region was not demonstrated in any of the familial or isolated cases. However, in the two VWS families, linkage analysis using these markers showed positive LOD (logarithm of the odds) scores ranging from 2.56 to 2.88 to all individual markers. The highest LOD score of 3.75 was obtained with the combined haplotypes of D1S491 and D1S205, thus confirming linkage of VWS in these two families to 1q32. We conclude that there is varied expressivity but no evidence of genetic heterogeneity in VWS.

Comparison between two types of pharyngeal flap with regard to configuration at rest and function and speech outcome

OBJECTIVE

In management of hypernasality, wide pharyngeal flaps have been advocated when pharyngeal wall adduction is limited. Pharyngeal flaps merged into a transversely split velum (TS flaps) are reported to be wider than if the velum is split in the midline (MS flaps). The hypothesis to be tested was that TS flaps are wider than MS flaps and are more caudally based.

DESIGN

In this prospective study, MS flaps were videoradiographically and nasopharyngoscopically compared with TS flaps at both rest and function. Pharyngoplasty was randomly performed by one of three surgeons and the radiographic examinations were carried out by one radiologist. The speech was assessed pre- and postoperatively.

SETTING

The Stockholm Cleft Palate Team, Sweden, treated all patients.

PATIENTS

After strict selection of the patients to avoid any uncontrolled impact on velopharyngeal sphincter function, 22 patients with limited pharyngeal adduction received TS flaps and 20 patients with good adduction received MS flaps.

RESULTS

The data failed to show any difference in location of flap base and in flap width at rest. During function, TS flaps demonstrated statistically significant widening of the flap base. TS flaps, but not MS flaps, often had a bulge that appeared to assist velopharyngeal closure in some patients. Speech evaluation revealed that both flap types corrected velopharyngeal insufficiency equally well.

CONCLUSIONS

TS flaps were not wider than MS flaps, and functional plasticity of the TS flap appeared essential for elimination of velopharyngeal insufficiency. Contribution of postoperative adaptation of the pharyngeal wall adduction remains to be clarified.

Adaptation of pharyngeal wall adduction after pharyngeal flap surgery

OBJECTIVE

The purpose of this investigation was to study lateral pharyngeal wall adduction relative to pharyngeal flaps of different widths. The hypothesis to be tested was that pharyngeal wall adduction does not increase postoperatively but may decrease due to the mechanical hindrance of a wide flap.

DESIGN

In this prospective study, adaptation of lateral pharyngeal wall adduction during speech was studied relative to pharyngeal flaps of different widths utilizing videoradiography. Flap width was determined nasopharyngoscopically.

SETTING

All patients were treated by the Stockholm Cleft Palate Team, Sweden.

PATIENTS

Fifty-three patients were strictly selected by discarding conditions known to exert uncontrolled influence on velopharyngeal sphincter function.

RESULTS

The results revealed a potential for adaptation of pharyngeal wall adduction to different flap widths. The magnitude and character (increase or decrease) of change in adduction was significantly correlated with the degree of preoperative adduction and with the width of the flap. In patients with limited preoperative adduction, pharyngeal wall activity increased, more in the presence of a narrow flap while less if the flap was wide. When preoperative adduction was pronounced, the postoperative activity decreased because of mechanical hindrance by the flap, and the degree of impediment was correlated to the width of the flap.

CONCLUSION

A potential for increased lateral pharyngeal wall adduction after pharyngeal flap surgery was verified, but the result cannot be interpreted as generally applicable because of the strict selection of patients.

MR imaging of lipoma and liposarcoma

PURPOSE

To evaluate whether lipoma, atypical lipomatous tumors, and liposarcomas can be differentiated by MR images.

MATERIAL AND METHODS

The MR images of 59 lipomatous lesions and liposarcomas were retrospectively reviewed. Apart from size, surgical site, location and margins, the percentage of fat of the tumor volume was assessed as none, 1-75%, 75-95%, or 95-100%.

RESULTS

None of the 18 liposarcomas contained fat that could be recognized by MR imaging. The 3 atypical lipomatous tumors all contained fat but less than 75% of the tumor volume. In 32 of 38 ordinary lipomas, the percentage of fat was 95-100%, and in 4 less than 95% of the tumor volume. Two lipomas did not contain fat that could be recognized by MR imaging.

CONCLUSION

A lesion which predominantly has a fat signal is, in all probability, an ordinary lipoma. Lesions with less fat, but still mostly fatty, may either be lipoma or atypical lipomatous tumor. In this group, the discrimination between these two entities cannot be based upon imaging features. In the absence of a fat signal, liposarcoma or lipoma cannot be differentiated from other soft tissue tumors.

Incidence of cleft lip and palate and risks of additional malformations

OBJECTIVE AND METHODS

Children with cleft lip and/or palate (n = 251) born between 1991 and 1995 in the county of Stockholm, Sweden, were studied with reference to incidence and rate ratios (RRs) of different types of clefts, gender, birth weight, mother's age, and length of pregnancy. Children who had clefts and additional malformations were compared with children who had clefts but no additional malformations.

RESULTS

The incidence of clefts was 2.0/1000 live births, and it was higher among males than among females. The RR, an index of relative risk, was 1.58. The main groups, children with isolated cleft lip, children with cleft lip and palate, and children with isolated cleft palate, showed similar incidence values (0.6-0.7/1000 live births). Children with bilateral clefts had an incidence of 0.3/1000 live births. Additional malformations were found in approximately every sixth newborn with a cleft when children with Robin sequence were excluded. There was a tendency for newborns with bilateral clefts to have additional malformations (RR = 1.36; confidence interval = 0.74-2.49). Children with clefts and additional malformations had lower birth weight and were born earlier than children with clefts only.

CONCLUSION

Preterm cleft children with low birth weight should be screened for the presence of other birth defects.

Associated malformations in infants with cleft lip and palate: a prospective, population-based study

OBJECTIVE

Infants with cleft lip and palate may often have other associated congenital defects although the reported incidence and the types of associated malformations vary between different studies. The purpose of this investigation was to assess the prevalence of associated malformations in a geographically defined population.

METHODS

The prevalence of associated malformations in infants with clefts were collected prospectively between 1975 to 1992 on all infants born in greater Stockholm, Sweden. The patient records were also compared with data from the National Malformation Registry and other hospital records if any.

RESULTS

Of the 616 cleft infants (367 boys, 249 girls) born during this period, 21% had associated malformations that either required follow-up or treatment. Associated malformations were more frequent in infants who had both cleft lip and palate (28%) than in infants with isolated cleft palate (22%) or infants with isolated cleft lip (8%). Malformations of the upper or lower limbs or the vertebral column were the most common other anomalies and accounted for 33% of all associated defects. Twenty-four percent of associated malformations were in the cardiovascular system and congenital heart disease was the most common isolated associated malformation. Fifteen percent of all associated malformations were multiple and they were frequently associated with mental retardation or chromosomal anomalies. Twenty-two percent of infants with associated malformations were born preterm, compared with an expected 5% incidence of preterm delivery in Sweden.

CONCLUSION

A more extensive cleft seems to be associated with a higher risk for associated malformations. Although many associated congenital defects can be detected at a physical examination, the high prevalence of congenital heart disease (16 times that of general population) may justify a routine echocardiographic screening.

Time to B. cereus about hot chocolate

OBJECTIVE

To determine the cause of illnesses experienced by employees of a Minneapolis manufacturing plant after drinking hot chocolate bought from a vending machine and to explore the prevalence of similar vending machine-related illnesses.

METHODS

The authors inspected the vending machines at the manufacturing plant where employees reported illnesses and at other locations in the city where hot chocolate beverages were sold in machines. Tests were performed on dry mix, water, and beverage samples and on machine parts.

RESULTS

Laboratory analyses confirmed the presence of B. cereus in dispensed beverages at a concentration capable of causing illness (170,000 count/gm). In citywide testing of vending machines dispensing hot chocolate, 7 of the 39 licensed machines were found to be contaminated, with two contaminated machines having B. cereus levels capable of causing illness.

CONCLUSIONS

Hot chocolate sold in vending machines may contain organisms capable of producing toxins that under favorable conditions, can induce illness. Such illnesses are likely to be underreported. Even low concentrations of B. cereus may be dangerous for vulnerable populations such as the aged or immunosuppressed. Periodic testing of vending machines is thus warranted. The relationship between cleaning practices and B. cereus contamination is an issue for further study.

Oronasal fistulas in cleft palate patients and their influence on speech

The size, site, and influence on speech of oronasal fistulas were studied in 12 patients with unilateral and 32 with bilateral cleft lip and palate. There were more and larger fistulas in the bilateral group. The series was divided into: those with fistulas that affected speech (group A, n = 18) and those with fistulas that did not affect their speech (group B, n = 26). Group A had significantly larger fistulas than group B, but there were no differences in the sites of the fistulas, either between the bilateral and unilateral groups or between groups A and B. Most fistulas were located in the region of the incisive foramen or in the hard palate. Judgements by listeners and analyses by the NORAM instrument were made of the speech of 12 of the patients in group A before and after temporary covering of the fistulas. Significant differences in hypernasality, according to both listener's judgments and instrumental analyses were found. This finding is further evidence that an oronasal fistula can influence and contribute to velopharyngeal dysfunction.

NORAM--an instrument used in the assessment of hypernasality: a clinical investigation

The speech of 102 patients with complete unilateral and bilateral cleft lip and palate and 40 noncleft subjects was analysed using the NORAM (Nasal Oral Ratio Meter) instrument. The results obtained were compared with the perceptual judgments made by experienced listeners. A significant correlation was found between the NORAM values and the listener judgments. The NORAM instrument can thus be used as a complement to listener judgments in assessing hypernasality. A discussion of the acoustic and phonetic aspects of the differences between the instrumental and perceptual results is presented.

Morphologic effect of preoperative maxillofacial orthopedics (T-traction) on the maxilla in unilateral cleft lip and palate patients

Sixty-eight children born with complete unilateral cleft lip and palate were studied using dental casts taken at ages 0-0.1; 0.2-0.4; and 0.5-0.6 years of age. They were all treated with preoperative maxillofacial orthopedics using an external device (T-traction). The treatment was started after the first model was taken. Dental casts were analyzed regarding the morphology of the cleft region and the maxillary segments before and after treatment. The measurements were compared with measurements on dental casts of nontreated cleft children of similar age. The results suggest that a more normal anatomy of the cleft region occurs during the first 6 months of life whether preoperative maxillofacial orthopedics (T-traction) is used or not. However, this normalized growth seems to occur faster with the T-traction.

Speech in unilateral and bilateral cleft palate patients from Stockholm

The speech of 84 patients with complete unilateral cleft lip and palate and 19 patients with complete bilateral cleft lip and palate was judged by professional listeners and compared with a control group of 40 noncleft subjects. The unilateral cleft group consisted of two subgroups: one group of 45 patients, who were treated with presurgical orthopedics before primary surgery, and one group of 39 patients, who were not. The speech of the patients and the noncleft subjects was tape recorded and randomly mixed prior to listener judgments. No significant differences in articulation or resonance were found between the subgroups of unilateral cleft patients. The results also indicated that the bilateral cleft patients had poorer speech and needed more speech therapy than the unilateral cleft patients. All cleft patients were found to have poorer speech than the noncleft subjects in spite of considerable speech therapy and complementary surgical treatment. This has resulted in a change in the Stockholm approach toward earlier palatal surgery, tailor-made pharyngeal flap operations, and earlier parental information and treatment of articulatory deviations.

Middle ear disease in cleft palate children at three years of age

Fourty-four cleft palate children consecutively referred to a plastic surgery unit were treated with palate repair at one year of age by one surgeon. The children were not routinely treated with ventilating tubes for middle ear disease. At 3 years of age they were investigated for aural pathology. Also specific antipneumococcal antibody activity was measured and was found to be compatible with the activity found in healthy age-matched control children. In the cleft palate children with no immaturity of the immune system only a slight increase in frequency of acute otitis media was evident. One third of the children had however suffered from long-standing secretory otitis media which can be regarded to be more common than what has been found in the normal population in several epidemiologic studies. At 3-4 years of age 82% of the children had a normal hearing indicating an improvement of the condition.

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.

Tongue posture in cleft palate patients with a pharyngeal flap

Position of the tongue was studied in lateral cineradiographic pictures of 15 patients with cleft palate and velopharyngeal incompetence, and from ten unaffected reference subjects. The patients were examined before and after pharyngoplasty. Before operation there was no difference in the degree of tongue/velum contact between the patients and the reference subjects, but after the operation, contact was lost in 13 of the 15 patients because the tongue was lowered and the velum raised by the pharyngeal flap. This contradicts the previous theory that the position of the tongue should be expected to be higher to maintain the posterior oral seal. The tongue was in a more posterior position in the patients than in the reference subjects both before and after operation. After operation the tip of the tongue retracted into the anterior oral cavity. The posterior and downward change in position of the tongue may account for part of the posterior and downward growth pattern of the lower third of the face which occurs in children after pharyngoplasty. A loss of tongue-lip balance around the premaxilla may be one of the factors that causes the maxillary retrusion that has been reported after pharyngoplasty in patients with cleft palates.

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.

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.

The effect of palatoplasty on airway patency and growth in infants with clefts and failure to thrive

We monitored respiratory patterns, transcutaneous PO2 (tcPO2) and transcutaneous PCO2 (tcPO2) in three infants with clefts and severe failure to thrive. Unexplained dysphagia, muscular weakness and cardiac enlargement were other prominent symptoms. During sleep, repeated obstructive apneas accompanied by significant hypoxemia (tcPO2 less than 6 kPa) were recorded in all infants. Relief of the respiratory obstructions by means of nasopharyngeal intubation led to rapid growth catch-up and disappearance of the cardiac and gastrointestinal symptoms. This improvement in clinical condition was paralleled by an increase in transcutaneous PO2. Palatal closure according to Veau-Wardill-Killner led to a marked decrease in the number of airway obstructions and a significant improvement in blood gas homeostasis. The clinical condition of the infants was equally improved. We suggest that a respiratory investigation should be performed in infants with clefts and poor growth in spite of adequate caloric intake. Early closure of the palate should be considered in infants with signs of a respiratory failure.

Treatment of keloids with surgical excision and postoperative X-ray radiation

124 patients with keloids were treated with surgical excision followed by postoperative X-ray radiation, begun within 24 hours after surgery. Only patients with a two-year keloid history were included in this study. The treatment results were evaluated 6 and 24 months after treatment. There was good correlation agreement between subjective and objective evaluations. Good or excellent results were observed in 92% of the patients. Side effects were moderate. Slight hyperpigmentation was found in 31% of the patients and telangiectasis in 15%. It was concluded that excision and early postoperative irradiation constitute effective keloid treatment.