Assessing housing exposures and interventions that impact healthy cities: a systematic overview of reviews.

AIM: There are direct links between housing and health. However, there is a lack of systematic reviews that bring together the evidence to outline the health impacts of exposures in housing and housing interventions. This article aims to address this gap by synthesising systematic reviews on the themes of housing exposures and interventions. METHODS: We searched four databases: Scopus (Elsevier), PsycINFO (OvidSP), Science Citation Index and Social Science Citation Index (Web of Science Core Collection), and the Sociology Collection (Proquest). We used keywords related to 'health' and 'city*' and included all types of reviews. We extracted data into a predesigned extraction form and synthesised information narratively. RESULTS: 745 articles were identified and screened, of which 256 reviews were included and 16 (6%) related to housing. All reviews related to housing exposures found that poor housing, including crowding, coldness, dampness, mould, and indoor air pollution had a negative impact on health. Most reviews found that housing interventions such as housing refurbishment, heating, and energy efficiency interventions positively impacted health outcomes. An online toolkit was developed to disseminate and communicate this research: https://www.healthycitiescommission.org/toolkit/. CONCLUSION: Governments have a pivotal role in addressing health issues related to housing interventions and exposures in housing. This includes interventions through building regulations following international guidance and financial assistance to encourage housing modifications that will improve health.

Case report series: revisiting third and fourth pharyngeal arch anomalies, - are they thymopharyngeal duct remnants?

BACKGROUND: Pharyngeal arch anomalies are the second most common form of head and neck congenital defect. The second arch anomalies are the most common, and compromise 95% of cases. Little is known about the 3rd and 4th arch anomalies as they are extremely rare. They most commonly present in childhood with sudden severe left lateral neck infection and abscess formation with considerable tendency to recur, contributing to significant mortality and morbidity in those patients. CASE PRESENTATION: Here we present four cases finally diagnosed as third or fourth pharyngeal arch anomalies, with more than 20 years of follow-up following their definitive surgery. The possibility that they are thymopharyngeal duct remnants is discussed. CONCLUSION: Meticulous open radical surgical excision of all involved paralaryngeal, parapharyngeal and thyroid tissue, with preservation of the superior and recurrent laryngeal nerves, is required for cure of recurrent cases.

Sinonasal malignant melanoma: an analysis of 115 cases assessing outcomes of surgery, postoperative radiotherapy and endoscopic resection.

BACKGROUND: Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection. METHODOLOGY: Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome. RESULTS: 115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome. CONCLUSIONS: Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.

Single nucleotide polymorphisms in the imprinted bovine insulin-like growth factor 2 receptor gene (IGF2R) are associated with body size traits in Irish Holstein-Friesian cattle.

The regulation of the bioavailability of insulin-like growth factors (IGFs) is critical for normal mammalian growth and development. The imprinted insulin-like growth factor 2 receptor gene (IGF2R) encodes a transmembrane protein receptor that acts to sequester and degrade excess circulating insulin-like growth factor 2 (IGF-II) - a potent foetal mitogen - and is considered an important inhibitor of growth. Consequently, IGF2R may serve as a candidate gene underlying important growth- and body-related quantitative traits in domestic mammalian livestock. In this study, we have quantified genotype-phenotype associations between three previously validated intronic bovine IGF2R single nucleotide polymorphisms (SNPs) (IGF2R:g.64614T>C, IGF2R:g.65037T>C and IGF2R:g.86262C>T) and a range of performance traits in 848 progeny-tested Irish Holstein-Friesian artificial insemination sires. Notably, all three polymorphisms analysed were associated (P ≤ 0.05) with at least one of a number of performance traits related to animal body size: angularity, body depth, chest width, rump width, and animal stature. In addition, the C-to-T transition at the IGF2R:g.65037T>C polymorphism was positively associated with cow carcass weight and angularity. Correction for multiple testing resulted in the retention of two genotype-phenotype associations (animal stature and rump width). None of the SNPs analysed were associated with any of the milk traits examined. Analysis of pairwise r(2) measures of linkage disequilibrium between all three assayed SNPs ranged between 0.41 and 0.79, suggesting that some of the observed SNP associations with performance may be independent. To our knowledge, this is one of the first studies demonstrating associations between IGF2R polymorphisms and growth- and body-related traits in cattle. These results also support the increasing body of evidence that imprinted genes harbour polymorphisms that contribute to heritable variation in phenotypic traits in domestic livestock species.

Single nucleotide polymorphisms in the growth hormone and insulin-like growth factor-1 genes are associated with milk production, body condition score and fertility traits in dairy cows.

The somatotrophic axis (GH-IGF) is a key regulator of animal growth and development, affecting performance traits that include milk production, growth rate, body composition, and fertility. The aim of this study was to quantify the association of previously identified SNPs in bovine growth hormone (GH1) and insulin-like growth factor 1 (IGF-1) genes with direct performance trait measurements of lactation and fertility in Holstein-Friesian lactating dairy cows. Sixteen SNPs in both IGF-1 and GH1 were genotyped across 610 cows and association analyses were carried out with traits of economic importance including calving interval, pregnancy rate to first service and 305-day milk production, using animal linear mixed models accounting for additive genetic effects. Two IGF-1 SNPs, IGF1i1 and IGF1i2, were significantly associated with body condition score at calving, while a single IGF-1 SNP, IGF1i3, was significantly associated with milk production, including milk yield (means ± SEM; 751.3 ± 262.0 kg), fat yield (21.3 ± 10.2 kg) and protein yield (16.5 ± 8.0 kg) per lactation. Only one GH1 SNP, GH33, was significantly associated with milk protein yield in the second lactation (allele substitution effect of 9.8 ± 5.0 kg). Several GH1 SNPs were significantly associated with fertility, including GH32, GH35 and GH38 with calving to third parity (22.4 ± 11.3 days) (GH32 and GH38 only), pregnancy rate to first service (0.1%) and overall pregnancy rate (0.05%). The results of this study demonstrate the effects of variants of the somatotrophic axis on milk production and fertility traits in commercial dairy cattle.

Associations between newly discovered polymorphisms in the Bos taurus growth hormone receptor gene and performance traits in Holstein-Friesian dairy cattle.

Variations in the growth hormone receptor (GHR) gene sequence are associated with performance traits in cattle. For example, the single nucleotide polymorphism (SNP) F279Y in transmembrane exon 8 has a strong association with milk yield. In this study, 32 previously unreported, putative novel SNPs (31 in the 5' non-coding region) were identified by resequencing ∼19 kb of the GHR gene in genomic DNA from 22 cattle of multiple breeds. A population of 848 Holstein-Friesian AI sires was subsequently genotyped for the 32 putative novel SNPs and seven published SNPs (including F279Y, one in exon 1A promoter and five in exon 10). Associations between each segregating SNP and genetic merit for performance were quantified in the 848 Holstein-Friesians using weighted animal linear mixed models. Six of the published SNPs and seven of the novel SNPs were associated with at least one of the traits--milk yield, fat yield, protein yield, fat percentage, protein percentage, somatic cell score, calving interval, survival and growth and size traits. Even when the allelic substitution effect (P < 0.001) of F279Y was accounted for, the allelic substitution effect of one of the novel SNPs (GHR4.2) in the 5' non-coding region of GHR was associated with a lactation milk yield of 37.46 kg (P < 0.001). GHR4.2 and F279Y were not in linkage disequilibrium (r(2) = 0.00, D' = 0.04) in the 848 Holstein-Friesians, indicating that their association with milk yield was independent.

Associations between novel single nucleotide polymorphisms in the Bos taurus growth hormone gene and performance traits in Holstein-Friesian dairy cattle.

Growth hormone, produced in the anterior pituitary gland, stimulates the release of insulin-like growth factor-I from the liver and is of critical importance in the control of nutrient utilization and partitioning for lactogenesis, fertility, growth, and development in cattle. The aim of this study was to discover novel polymorphisms in the bovine growth hormone gene (GH1) and to quantify their association with performance using estimates of genetic merit on 848 Holstein-Friesian AI (artificial insemination) dairy sires. Associations with previously reported polymorphisms in the bovine GH1 gene were also undertaken. A total of 38 novel single nucleotide polymorphisms (SNP) were identified across a panel of 22 beef and dairy cattle by sequence analysis of the 5' promoter, intronic, exonic, and 3' regulatory regions, encompassing approximately 7 kb of the GH1 gene. Following multiple regression analysis on all SNP, associations were identified between 11 SNP (2 novel and 9 previously identified) and milk fat and protein yield, milk composition, somatic cell score, survival, body condition score, and body size. The G allele of a previously identified SNP in exon 5 at position 2141 of the GH1 sequence, resulting in a nonsynonymous substitution, was associated with decreased milk protein yield. The C allele of a novel SNP, GH32, was associated with inferior carcass conformation. In addition, the T allele of a previously characterized SNP, GH35, was associated with decreased survival. Both GH24 (novel) and GH35 were independently associated with somatic cell count, and 3 SNP, GH21, 2291, and GH35, were independently associated with body depth. Furthermore, 2 SNP, GH24 and GH63, were independently associated with carcass fat. Results of this study further demonstrate the multifaceted influences of GH1 on milk production, fertility, and growth-related traits in cattle.

Polymorphisms in the bovine lactoferrin promoter are associated with reproductive performance and somatic cell count.

Lactoferrin plays an important role in the innate immune system, with well-characterized antibacterial, antiviral, and immune modulatory properties. The objective of this study was to determine the allele and haplotype frequency of polymorphisms at positions -586, -190, and -28 of the bovine lactoferrin promoter in Holstein-Friesians and to quantify their association with performance using phenotypic data on progeny from 848 sires. Associations between genotypes and performance were quantified using weighted mixed models with genotyped individuals included as a random effect, and average expected relationships among individuals accounted for through a numerator relationship matrix. The dependent variables were daughter yield deviation for production traits and deregressed predicted transmitting ability for calving interval and functional survival. The C to T polymorphism at -586, which distorts a putative activating protein 2 (AP-2) binding site, was associated with a shorter calving interval and higher somatic cell score. The G to A polymorphism at -190, located in a putative selective promoter factor 1 (SP-1) binding site, was associated with a longer calving interval and decreased functional survival. A third polymorphism (A to C) at position -28, found within the noncanonical TATA box, had a tendency to associate with functional survival. On the basis of the data we proposed a haplotype combination that was associated with improved reproductive performance in the Holstein-Friesian breed. We hypothesized that the observable phenotypic associations with lactoferrin promoter polymorphisms can potentially be explained by allele-specific differences in constitutive or inducible levels of gene expression. The lack of a pleiotropic effect of the single nucleotide polymorphisms studied on both fertility and milk production traits strengthens the importance of these polymorphisms, or at least the lactoferrin promoter, in selection for improved fertility.

Validation of the Clinical COPD Questionnaire as a psychophysical outcome measure in adult laryngotracheal stenosis.

OBJECTIVES: To validate the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ), a patient-administered instrument developed for bronchopulmonary disease as a disease-specific psychophysical outcome measure for adult laryngotracheal stenosis. DESIGN: Prospective observational study. SETTINGS: Tertiary/National referral airway reconstruction centre. PARTICIPANTS: Thirty-three tracheostomy-free patients undergoing endoscopic laryngotracheoplasty. MAIN OUTCOME MEASURES: CCQ and the Medical Research Council (MRC) Dyspnoea scale, a previously validated but more limited scale, were administered to patients 2 weeks before surgery, preoperatively, and 2 weeks after endoscopic laryngotracheoplasty. Pulmonary function was assessed preoperatively. Internal consistency was assessed with Cronbach alpha statistics and test-retest reliability was determined using intraclass correlation. Correlations between CCQ and MRC scale, and pulmonary function were used to assess convergent and divergent validity respectively. Instrument responsiveness was assessed by correlating total and domain-specific CCQ scores with anatomical disease severity and post-treatment effect size. RESULTS: There were 12 males and 21 females. Mean age was 44 +/- 15 years. Cronbach alpha coefficient and intraclass correlation coefficient were 0.88 and 0.95 respectively. Total and domain-specific CCQ scores significantly correlated with the MRC scores (P < 0.001) and significant correlations between CCQ and peak expiratory flow rate and FEV(1) were identified (P < 0.03). There were statistically significant changes in total and domain-specific CCQ scores when different stenosis severities were compared. Clinical COPD Questionnaire scores also changed significantly and congruently following surgery (P < 0.05 in both cases). DISCUSSION: Clinical COPD Questionnaire is a valid and sensitive instrument for assessing symptom severity and levels of function and well-being in adult patients with laryngotracheal stenosis and can be used as a patient-centred disease-specific outcome measure for this condition.

Physiological comparison of spontaneous and positive-pressure ventilation in laryngotracheal stenosis.

BACKGROUND: We compared spontaneous and positive-pressure ventilation in patients undergoing general anaesthesia for the treatment of extrathoracic, intralumenal laryngotracheal stenosis to assess the best method of ventilation in this patient group. METHODS: Records of 30 patients with laryngotracheal stenosis, but not with a tracheostomy, undergoing lumen-restoring surgery were prospectively reviewed. Awake spirometry and flow-volume loops were recorded before the procedure. Patients received i.v. anaesthesia induction, muscle paralysis, and positive-pressure ventilation through a laryngeal mask airway (LMA). Anaesthetized tidal volume (TV) and flow-volume loop measurements were obtained. RESULTS: We studied 19 males and 11 females [mean age 47 (SD 19) yr], ASA Grade III or IV, with lesions at 31 (10) mm below the vocal cords. Peak inspiratory flow (PIF) and peak expiratory flow (PEF) rates were 2.0 (1.2) litre s(-1) and 3.2 (1.7) litre s(-1) when awake. Tidal volumes were 657 (193) ml [9.2 (3.6) ml kg(-1)] and 586 (158) ml [8.3 (3.1) ml kg(-1)], respectively, when anaesthetized. There was a significant reduction in the PEF/PIF ratio, from a mean of 2.4 (1.3) awake to 1.0 (0.1) when anaesthetized (P<0.0001). A significant correlation was noted between awake PEF and anaesthetized expiratory TV (r=0.57; P<0.001) but not between awake PIF and anaesthetized inspiratory TV. DISCUSSION: Positive-pressure ventilation through an LMA is an effective method of ventilating patients with laryngotracheal stenosis. Spontaneous ventilation creates negative inspiratory intratracheal pressure that exacerbates an extrathoracic lesion, whereas positive-pressure ventilation generates positive intratracheal pressure that improves ventilation. This helps explain the apparent resolution of airway obstruction after positive-pressure ventilation.

Total laryngopharyngoesophagectomy with gastric transposition reconstruction: review of long-term swallowing outcomes.

AIM: The aim of this review was to examine long-term swallowing and eating outcomes following laryngopharyngoesophagectomy with gastric pull-up reconstruction. METHODS: Ten patients underwent clinical examination and completed the performance status scale for head and neck questionnaire and also a gastric pull-up swallowing questionnaire designed for this review. Nine of the 10 patients underwent videofluoroscopic examination of swallowing. RESULTS: One patient had a stricture at the orogastric anastomosis, and one patient had bilateral tongue immobility secondary to XIIth nerve palsies. Eight participants reported eating a normal diet, and five reported not limiting their eating environment. Regurgitation, slower eating and reduced capacity were the most common functional limitations. CONCLUSIONS: These results support previous opinions that the gastric pull-up procedure has good swallowing outcomes, and indicate that such outcomes continue in the long term.

Sensitivity and responsiveness of the Medical Research Council dyspnoea scale to the presence and treatment of adult laryngotracheal stenosis.

OBJECTIVES: To assess the sensitivity and responsiveness of the Medical Research Council (MRC) scale, a psychophysical dyspnoea assessment instrument to the presence and treatment of adult laryngotracheal stenosis. DESIGN: Prospective observational study. SETTINGS: Tertiary/National referral airway reconstruction centre. PARTICIPANTS: Fourty tracheostomy-free patients undergoing endoscopic airway examination/laryngotracheoplasty. MAIN OUTCOME MEASURES: Demographic and clinical information, obtained from patient records, lesion severity, which was recorded intraoperatively, standard spirometry, which was measured preoperatively, and the MRC dyspnoea scale, which was administered preoperatively and at the first outpatient visit 4-6 weeks later. RESULTS: There were 16 males and 24 females. Mean age at presentation was 44 +/- 14 years (+/- SD). Postintubation stenosis was the commonest aetiology (73%) followed by idiopathic subglottic stenosis and Wegener's Granulomatosis. Six patients were examined post-treatment and had minimal residual stenosis and the remaining patients had glottic stenosis (n = 11) or Myer-Cotton Grade I (n = 8), II (n = 7) or III (n = 8) tracheal stenoses. Pre-treatment MRC dyspnoea scores and the degree of change in the MRC score following treatment strongly correlated with pre-treatment stenosis severity (r = 0.75 and r = -0.71 respectively; P < .001). Moreover statistically significant correlations existed between preoperative peak expiratory flow and forced expiratory volume in 1 s and preoperative MRC dyspnoea scores (r = -0.34 and r = -0.35 respectively; P < 0.05). DISCUSSION: Exertional dyspnoea is the hallmark symptom of laryngotracheal stenosis and for many patients it is the primary cause of disability. These findings confirm that the MRC dyspnoea scale is an appropriate outcome instrument for assessing dyspnoea associated with this condition.

Results of endoscopic surgery and intralesional steroid therapy for airway compromise due to tracheobronchial Wegener's granulomatosis.

BACKGROUND: Upper airway compromise due to tracheobronchial stenosis commonly occurs in patients with Wegener's granulomatosis (WG). There is at present no consensus on the optimal management of this life threatening condition. OBJECTIVE: To assess the results of laryngo-tracheo-bronchoscopy, intralesional steroid therapy, laser surgery and dilatation in managing obstructive tracheobronchial WG. METHODS: Records of 18 previously untreated stridulous patients with obstructive tracheobronchial WG, treated between 2004 and 2006, were prospectively recorded on an airway database and retrospectively reviewed. Information about patient and lesion characteristics and treatment details were recorded. Treatment progress was illustrated using a timeline plot, and intervention-free intervals were calculated with actuarial analysis. RESULTS: There were nine males and the average age at presentation was 40 (16) years (range 13-74). There were 13 patients with tracheal and five with tracheal and bronchial lesions. The average tracheal lesion height was 8 (3) mm, located 23 (9) mm below the glottis. There were 1, 10 and 7 Myer-Cotton grade I, II and III lesions, respectively. Mean intervention-free interval following minimally invasive treatment was 26 (2.8) months. Following endobronchial therapy, the median intervention-free interval was 22 months (p>0.8 vs tracheal lesions). No patient required a tracheostomy or endoluminal stenting. CONCLUSIONS: Intralesional steroid therapy and conservative endoluminal surgery is an effective strategy for treating airway compromise due to active tracheal and bronchial WG, obviating the need for airway bypass or stenting. We recommend the combination of endotracheal dilatation, conservative laser surgery and steroid therapy as the standard of care for treating airway compromise due to obstructive tracheobronchial WG.

Results of endoscopic tracheoplasty for treating tracheostomy-related airway stenosis.

Post-tracheostomy 'lambdoid' deformity of the trachea is a specific and uncommon variant of adult post-intubation laryngotracheal stenosis, in which airway obstruction is caused by inward collapse of over-resected tracheal cartilage as a result of post-decannulation stomal contracture. We evaluated the results of endoscopic tracheoplasty as an alternative to open tracheal resection in 11 patients treated for this condition between 2004 and 2006. Patients were treated with endoscopic CO(2) laser resection, dilatation and endotracheal mitomycin C application. Suspension micro-laryngo-tracheoscopy and high-frequency supraglottic jet ventilation were used. Eleven patients with an average age of 56 years and lesion height and distance from glottis respectively of 11 +/- 5 mm and 35 +/- 12 mm were treated. The median number of treatments fell from four at the start of the series to two at the end (P = 0.08). The average follow-up was 17 +/- 8 months and all patients were cured with no cases of dysphagia or dysphonia. Almost all patients achieved and maintained a Medical Research Council Dyspnoea Scale of I or II. Endoscopic tracheoplasty is an effective treatment for this condition. It achieves a successful outcome while avoiding the operative risks, prolonged hospitalisation, and morbidity that is associated with tracheal resection. We recommend it as the standard of care for treating patients with this injury.

Are the demographics for squamous cell cancer in the head and neck changing in the United Kingdom?

Head and neck squamous cell carcinoma is well known to be more common in men than women. Smoking and alcohol are the key risk factors causing such malignancies and there are several publications which have suggested that the prevalence of these diseases is increasing more in women than in men in western countries due to increased smoking and alcohol use. We collected our data at the Institute of Laryngology and Otology from the last 45 years and analysed the disease ratios in male to female patients in different sites within the head and neck. Our results revealed a decreasing male to female ratio, though this was not statistically significant. However, it draws attention to the increasing number of women with head and neck cancer, which may reflect their increasing use of cigarettes and alcohol.

Objective sizing of upper airway stenosis: a quantitative endoscopic approach.

OBJECTIVE: In patients with airway stenosis, anatomy of the lesion determines the magnitude of the biomechanical ventilatory disturbance and thus the nature and severity of symptoms. It also gives information about biology, likelihood of response to treatment, and prognosis of laryngotracheal lesions. Accurate airway sizing throughout treatment is therefore central to managing this condition. We developed a method for objective assessment of airway lesions during endoscopy. METHODS: We used airway simulations to investigate the effects of endoscope tilt and lens distortions on measurement accuracy, devising and validating clinical rules for quantitative airway endoscopy. A calibrator was designed to assess lesion length, location, and cross-section during tracheoscopy. RESULTS: It proved possible to calculate the length and location of the stenosis using simple mathematics. Cross-section measurements were more than 95% accurate, independent of endoscope tilt and without making assumptions about endoscope optics and visuospatial distortion, for both pediatric and adult airway dimensions. The technique was used to characterize airway lesions in 10 adult patients with an average age of 48 years undergoing therapeutic laryngotracheoscopy. Lesions occurred on average 36 mm below the glottis (range, 21-54 mm) and were 9.3 mm long (5-17 mm). The average pretreatment airway cross-section was 48.3 mm, increasing to 141.1 mm after laser therapy. Two independent observers calculated airway cross-sections, achieving an interobserver concordance of 0.98. CONCLUSIONS: This method can be used to objectively and precisely determine the anatomy of airway lesions, allowing accurate documentation of lesion characteristics and surgical results, serial monitoring throughout treatment, and comparison of outcomes between different centers.

How we do it: transnasal fibreoptic oesophagoscopy.

KEYPOINTS: Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation. This permits patients with symptoms of upper aerodigestive pathology to be investigated at the initial consultation without the need for inpatient endoscopy or swallow studies. The technique is easily learned, and is statistically comparable with standard flexible nasoendoscopy in respect of procedural pain and discomfort. It is highly cost-efficient, paying for itself within 1 year, and thereafter leading to cost savings of over 80%. Its role can be expanded to encompass investigating patients with potentially malignant disease processes, as well as outpatients "panendoscopy" and biopsy, and a number of therapeutic interventions.

Quality of life of patients undergoing surgical treatment of head and neck malignancy.

This study prospectively follows changes in quality of life (QoL) of 40 patients undergoing surgical treatment for head and neck malignancy over a 1-year period, using the University of Washington QoL questionnaire version 4.0. The tumour types included oral, oropharyngeal, hypopharyngeal, oesophageal, laryngeal, sinonasal and thyroid carcinomas. Mean overall QoL scores were significantly worse at 3 and 6 months (P < 0.05) and returned to around preoperative scores at 12 months (P = 0.11). Oropharyngeal, laryngeal, sinonasal and thyroid subsites all maintained QoL scores at each time point. QoL scores for hypopharyngeal and oral subsites dropped markedly at 3 and 6 months but returned to around preoperative levels at 12 months. The domains most affected by treatment varied depending on tumour subsite. For the population as a whole, their appearance, activity, speech, shoulder and saliva domains were all significantly less at 12 months. Anxiety scores were significantly better at 12 months.