ABSTRACT
OBJECTIVE: Identification of patient factors influencing velopharyngeal function for speech following initial cleft palate repair. DESIGN: A literature search of relevant databases from inception until 2018 was performed using medical subject headings and keywords related to cleft palate, palatoplasty and speech assessment. Following three stage screening data extraction was performed. SETTING: Systematic review and meta-analysis of relevant literature. PATIENTS/PARTICIPANTS: Three hundred and eighty-three studies met the inclusion criteria, comprising data on 47â 658 participants. INTERVENTIONS: Individuals undergoing initial palatoplasty. MAIN OUTCOME MEASURES: Studies including participants undergoing initial cleft palate repair where the frequency of secondary speech surgery and/or velopharyngeal function for speech was recorded. RESULTS: Patient factors reported included cleft phenotype (95% studies), biological sex (64%), syndrome diagnosis (44%), hearing loss (28%), developmental delay (16%), Robin Sequence (16%) and 22q11.2 microdeletion syndrome (11%). Meta-analysis provided strong evidence that rates of secondary surgery and velopharyngeal dysfunction varied according to cleft phenotype (Veau I best outcomes, Veau IV worst outcomes), Robin Sequence and syndrome diagnosis. There was no evidence that biological sex was associated with worse outcomes. Many studies were poor quality with minimal follow-up. CONCLUSIONS: Meta-analysis demonstrated the association of certain patient factors with speech outcome, however the quality of the evidence was low. Uniform, prospective, multi-centre documentation of preoperative characteristics and speech outcomes is required to characterise risk factors for post-palatoplasty velopharyngeal insufficiency for speech. SYSTEMATIC REVIEW REGISTRATION: Registered with PROSPERO CRD42017051624.
ABSTRACT
BACKGROUND: This systematic review aims to inform the development of a screening tool which pre-operatively predicts which children are likely to develop velopharyngeal insufficiency, one of the causes of poor speech outcomes, following cleft palate repair. This would be highly beneficial as it would inform pre-operative counselling of parents, allow targeted speech and language therapy, and enable meaningful comparison of outcomes between surgeons, techniques, and institutions. Currently, it is unclear which factors influence speech outcomes. A systematic review investigating the non-interventional factors which potentially influence speech outcomes following cleft palate repair is warranted. This may be illuminating in itself or provide foundations for future studies. METHODS: A systematic review will be carried out according to Cochrane methodology and reported according to PRISMA guidelines (PLoS Med 6: e1000097, 2009). Systematic review software will be used to facilitate three-stage screening by two independent reviewers experienced in cleft lip and palate. Thereafter, data extraction and GRADE assessment will be performed in duplicate by five independent reviewers experienced in cleft lip and palate. Studies reporting the proportion of patients who were recommended or underwent secondary speech surgery for velopharyngeal insufficiency following primary surgery for cleft palate will be included. The study findings will be tabulated and summarised. The primary outcome measure will be further speech surgery (either recommended or performed). The secondary outcome measure will be perceptual speech assessment for the presence of velopharyngeal insufficiency. A meta-analysis is planned. However, if this is not possible, due to the anticipated marked heterogeneity of study characteristics, pre-operative assessment, and the recorded outcome measures, a narrative synthesis will be undertaken. DISCUSSION: This systematic review may provide sufficient data to inform the development of a screening tool to predict the risk of velopharyngeal insufficiency prior to cleft palate repair. However, it is anticipated that these findings will provide the foundation for future studies in this area. SYSTEMATIC REVIEW REGISTRATION: Registered on 19 December 2016 with PROSPERO CRD42017051624.
Subject(s)
Cleft Palate/complications , Speech , Velopharyngeal Insufficiency/diagnosis , Child , Cleft Palate/surgery , Humans , Speech Disorders/etiology , Speech Disorders/surgery , Velopharyngeal Insufficiency/etiology , Systematic Reviews as TopicABSTRACT
BACKGROUND: Many studies that have reported decreases in human immunodeficiency virus (HIV)-related mortality since the advent of highly active antiretroviral therapy (HAART) have also reported steady increases in non-HIV-related mortality over the same time periods. We examined temporal trends and risk factors for accident- and injury-related mortality among HIV-infected and -uninfected participants in the Women's Interagency HIV Study (WIHS) and the Multicenter AIDS Cohort Study (MACS). METHODS: Information on causes of death was recorded for all participants in the MACS and WIHS cohort studies who died, and causes of death were categorized as accident- or injury-related deaths or not. Mortality rates were calculated by time periods, prior to the widespread use of HAART (before 1997) and after (1997-2002), and risk factors. RESULTS: Cause of death information was available for 619 women in the WIHS who died (during the period 1994-2002) and 1830 men in the MACS who died (during the period 1984-2002). The death rates were higher for accident- or injury-related mortality in the WIHS (2.96 deaths per 1000 person-years for the HIV-infected group and 2.96 per 1000 person-years for the HIV-uninfected group), compared with the participants in MACS (0.79 deaths per 1000 person-years for the HIV-infected group and 0.63 per 1000 person-years for the HIV-uninfected group). In the final multivariate analysis, the following factors were associated with significantly higher risk in men: higher education, depressive symptoms, and a greater number of sex partners. Among women, the significant risk factors for death were decreased CD4+ T cell count, unemployment, higher alcohol use, and injection drug use. CONCLUSION: The characteristics of the men in the MACS who died and women in the WIHS who died differ, as do the risk factors for mortality. These results characterize important target groups for interventions to reduce accident- and injury-related deaths.
