Patient Factors Influencing Speech Outcomes in Velopharyngeal Function Following Initial Cleft Palate Repair: A Systematic Review and Meta-Analysis.

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 47 658 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.

The Use of Eye-tracking Technology in Cleft Lip: A Literature Review.

Eye-tracking has become an increasingly popular research tool within the field of cleft lip and/or palate (CL+/-P). Despite this, there are no standardized protocols for conducting research. Our objective was to conduct a literature review of the methodology and outcomes of previous publications using eye-tracking in CL+/-P. Methods: The PubMed, Google Scholar, and Cochrane databases were searched to identify all articles published up to August 2022. All articles were screened by two independent reviewers. Inclusion criteria included using eye-tracking, image stimuli of CL+/-P, and outcome reporting using areas of interest (AOIs). Exclusion criteria included non-English studies, conference articles, and image stimuli of conditions other than CL+/-P. Results: Forty articles were identified, and 16 met the inclusion/exclusion criteria. Thirteen studies only displayed images of individuals following cleft lip surgery with three only displaying unrepaired cleft lips. Significant variation was found in study design, particularly in the AOIs used to report gaze outcomes. Ten studies asked participants to provide an outcome score alongside eye-tracking; however, only four compared outcome data to eye-tracking data. This review is primarily limited by the minimal number of publications in this area. Conclusions: Eye-tracking can be a powerful tool in evaluating appearance outcomes following CL+/-P surgery. It is currently limited by the lack of standardized research methodology and varied study design. Before future work, a replicable protocol should be developed to maximize the potential of this technology.

Evolution of Cleft Lip and Palate Surgical Training in the UK: A Qualitative Study.

BACKGROUND: Although the United Kingdom (UK) cleft surgeons follow a similar training pathway, and cleft centers adhere to similar protocols regarding the timing of palate surgery and surgical technique, speech outcomes still vary between centers. OBJECTIVE: To explore the training experiences of consultant cleft lip and palate (CL/P) surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP) and their approach to teaching others. DESIGN: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP and discuss what was important during training and upon qualifying as a consultant. METHOD: A semi-structured interview schedule was designed, interviews were conducted in-person or via videoconferencing, depending on preference and availability, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. RESULTS: Fourteen cleft consultants from the UK participated (3F:11M). Seven of the consultants were trained in plastic surgery and four in maxillofacial surgery. Seven themes were identified from the thematic analysis. Three themes, namely Learning to perform palate repair, Teaching others to perform palate repair, and Ongoing learning as a consultant are discussed. CONCLUSIONS: Cleft palate repair is clearly a technically challenging procedure to learn and teach with the potential to cause harm if performed incorrectly. Positive changes have been made to improve exposure to palate surgery, encourage practice away from the patient, and increase supervised practical experience. The role of colleagues in providing mentorship and support appears invaluable. We provide some simple recommendations that may improve the training experience and ensure parity for all trainees.

Defatted silkworm pupae meal as an alternative protein source for cattle.

Silkworm pupae meal (SWP) is a protein-rich by-product of the silk reeling industry, available in a significant quantity. However, there has been little and insignificant research into the use of SWP in ruminants to date. In this view, the present study was conducted in two phases to evaluate the effect of different inclusion levels of defatted silkworm pupae meal (DSWP) on rumen fermentation, microbial protein synthesis and nutrient utilisation in cattle fed on finger millet straw (FMS)-based diet. Four isonitrogenous concentrate mixtures (CM) were prepared with DSWP replacing soybean meal (SBM) protein at 0 (T0), 10 (T1), 20 (T2) and 30% (T3). In phase I, a rumen fermentation experiment was conducted in a 4 × 4 Latin square design using four crossbred steers to study the effect of different levels of DSWP on rumen fermentation. No significant difference (P > 0.05) was observed in rumen fermentation parameters such as pH, ammonia nitrogen (NH3-N) and total volatile fatty acids (VFA) among the experimental groups. In phase II, the digestibility trial was conducted in 20 crossbred cattle (311.2 ± 4.81 kg), which were divided into four experimental groups of five animals each in a completely randomised design to study the effect of different rations (T0, T1, T2, T3) on microbial protein synthesis and nutrient utilisation. The intake and digestibility of nutrients, excretion of urinary purine derivatives and microbial protein synthesis were not significantly different among the experimental groups. In addition, feeding DSWP revealed no significant (P > 0.05) change in the blood biochemical parameters of animals. Furthermore, at the same price as SBM, DSWP provides two units more crude protein. Therefore, the results of the present study indicated that DSWP can be incorporated into the ration of cattle up to 30% by replacing SBM without affecting rumen fermentation pattern and nutrient utilisation.

Vaccine mandates in the time of Omicron.

Nil.

Extubation strategies after esophageal atresia repair.

BACKGROUND/PURPOSE: Early extubation following repair of esophageal atresia (EA) is desirable unless the anastomosis is under tension, in which case paralysis and post-operative ventilation may reduce the risk of anastomotic leakage. However, complications from emergency reintubations do occur with either strategy. We aim to examine the risk/benefit balance of early and delayed extubation following EA repair. METHODS: A seven-year retrospective review of all babies that underwent EA repair was performed. Babies extubated within 24 h of surgery were classified as early extubation (EE). Babies intubated beyond the first 24 h were classified as delayed extubation (DE). The EE group was subdivided into babies extubated in operating room (EIOR), and babies who returned to the neonatal intensive care unit (NICU) intubated but extubated within 24 h (EW24). RESULTS: Forty-six babies were analyzed, and overall 15 (32.6%) required 24 reintubation episodes. Eight (28.6%) babies in the EE group required reintubation. The EIOR group (n = 12) had significantly increased risk of requiring reintubation (OR:7, 95%CI:1.08 to 45.16:p = 0.04) compared to the EW24 group (n = 16). Seven (38.9%) babies in the DE group required reintubation. The complication rate from reintubation after EA repair was 17%. CONCLUSIONS: Extubation on the NICU within 24 h of surgery carried the lowest risk of reintubation. For babies with a tight anastomosis, elective postoperative ventilation appeared to confer a protective benefit without incurring a high risk of complications from reintubation.

Outcomes of supraventricular tachycardia ablation: Results from the Singapore ablation and cardiac devices registry.

BACKGROUND: The Singapore Cardiac Databank was designed to monitor the performance and outcomes of catheter ablation. We investigated the outcomes of paroxysmal supraventricular tachycardia (PSVT)-ablation in a prospective, nationwide, cohort study. METHODS: Atrioventricular nodal re-entrant tachycardia (AVNRT), atrioventricular re-entry tachycardia (AVRT), or atrial tachycardia (AT)-ablations in Singapore from 2010 to 2018 were studied. Outcomes include acute success, periprocedural-complications, postoperative pacing requirement, arrhythmic recurrence and 1-year all-cause mortality. RESULTS: Among 2260 patients (mean age 45 ± 18 years, 50% female, 57% AVNRT, 37% AVRT, 6% AT), overall acute success rates of PSVT-ablation was 98.4% and increased in order of AT, AVRT, and AVNRT (p < .001). Periprocedural cardiac tamponade occurred in two AVRT patients. A total of 15 pacemakers (6 within first 30-days, 9 after 30-days) were implanted (seven AV block, eight sinus node dysfunction [SND]), with the highest incidence of pacemaker implantation after AT-ablation (5% vs. 0.6% AVNRT vs. 0.1% AVRT, p < .001). Repeat ablations (0.9% AVNRT, 7% AVRT, 4% AT, p < .001) were performed in 78 (3.5%) patients and 13 (0.6%) patients died within a year of ablation. Among outcomes considered adjusting for age, sex, PSVT-type and procedure-time, AT was independently associated with 6-fold increased odds of total (adjusted odds ratio [AOR] 6.32, 95% confidence interval [CI] 1.95-20.53) and late (AOR 6.38, 95% CI 1.39-29.29) pacemaker implantation, while AVRT was associated with higher arrhythmic recurrence with repeat ablations (AOR 4.72, 95% CI 2.36-9.44) compared to AVNRT. CONCLUSIONS: Contemporary PSVT ablation is safe with high acute success rates. Long-term outcomes differed by nature of the PSVT.

Surgical Variation Between Consultant Surgeons Performing a Sommerlad Radical Intravelar Veloplasty.

BACKGROUND: Although cleft surgeons in the United Kingdom follow a similar training pathway, and cleft centers adhere to similar protocols regarding timing of palate surgery and surgical technique, speech outcomes still vary significantly between centers. OBJECTIVE: To explore if differences in technique exist between individual surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP). DESIGN: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP for primary cleft palate repair and to discuss what was important in the adoption, adaptation, and evolution of this technique within their own practice. METHOD: A semistructured interview schedule was designed. Interviews were conducted in person or via videoconferencing, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. RESULTS: Fourteen cleft consultants from the United Kingdom participated (3 females and 11 males). Seven of the consultants were trained in plastic surgery and 4 in oral and maxillofacial surgery. Eight themes were identified from the thematic analysis. One theme-Surgical Variation-is discussed. CONCLUSIONS: The findings provide insight into areas of variation seen within one surgical technique of cleft palate repair. These variations may have arisen to accommodate heterogeneity in the patient population or may have evolved in relation to different experiences of training or influences of colleagues. Further work is needed to explore the reasons for these differences in technique and to identify if any of these subtle differences contributed to variability in outcomes.

Enabling Global Clinical Collaborations on Identifiable Patient Data: The Minerva Initiative.

The clinical utility of computational phenotyping for both genetic and rare diseases is increasingly appreciated; however, its true potential is yet to be fully realized. Alongside the growing clinical and research availability of sequencing technologies, precise deep and scalable phenotyping is required to serve unmet need in genetic and rare diseases. To improve the lives of individuals affected with rare diseases through deep phenotyping, global big data interrogation is necessary to aid our understanding of disease biology, assist diagnosis, and develop targeted treatment strategies. This includes the application of cutting-edge machine learning methods to image data. As with most digital tools employed in health care, there are ethical and data governance challenges associated with using identifiable personal image data. There are also risks with failing to deliver on the patient benefits of these new technologies, the biggest of which is posed by data siloing. The Minerva Initiative has been designed to enable the public good of deep phenotyping while mitigating these ethical risks. Its open structure, enabling collaboration and data sharing between individuals, clinicians, researchers and private enterprise, is key for delivering precision public health.

The Cleft Multidisciplinary Collaborative: Establishing a Network to Support Cleft Lip and Palate Research in the United Kingdom.

BACKGROUND: As a growing paradigm of health research, trainee collaboratives can influence clinical practice through the generation of cost-effective multicenter audit and research projects. The aims of the present article are to outline and discuss the establishment of a multidisciplinary collaborative in the context of cleft lip and/or palate (CL/P). METHODS: The Cleft Multidisciplinary Collaborative (CMC) was formed in April 2016 under the overarching supervision of the National Institute for Health Research. Membership of the CMC is open to all members of the CL/P multidisciplinary team, who are encouraged to submit ideas for new research projects that will benefit clinical practice. RESULTS: To date, 48 clinical participants are involved in the CMC. These participants represent all 17 cleft teams from the United Kingdom and encompass a wide range of disciplines. The CMC has undertaken 2 major projects so far. The first involved collection of phenotype data to support a national cohort study. The second, still in progress, is a systematic review investigating factors associated with outcomes for velopharyngeal competence following cleft palate repair. CONCLUSIONS: The concept of a multidisciplinary collaborative in CL/P has been demonstrated through the generation of a United Kingdom-wide network of committed clinicians and researchers and the effective undertaking of 2 large research projects. As the CMC gathers momentum, it hopes to attract funding to support its activities, to promote more involvement from the allied health and nursing professions, to encourage a more ingrained research culture within the CL/P community, and to promote the wider ambition of a global collaborative.

Prenatally diagnosed congenital lung malformations-A long-term outcome study.

AIM: To report the natural history of a cohort of children with prenatally diagnosed congenital lung malformations (CLM) which we set out to manage expectantly. METHODS: Retrospective review of children born between 1995 and 2013 with a CLM identified on prenatal ultrasound. Prenatal ultrasound data were analyzed along with patient medical records, radiology, and pathology. RESULTS: One hundred fifty-nine newborns with a fetal lung lesion were identified during the study period. All infants were live born. Twenty-eight (18%) newborns were symptomatic, 17 with transient symptoms, and 11 with persistent symptoms. The latter all underwent lobectomy in the neonatal period with two postoperative deaths. One hundred thirty-one asymptomatic newborns plus the 17 babies with transient symptoms (148 total) were followed during childhood for a median of 6.0 years (0.1-19.2 years). Twenty-one children (13% of the original cohort of 159) became symptomatic at a median age of 2.5 years (9 months-5 years 8 months) with infection and underwent CLM resection. No child became symptomatic after the age of 5 years 8 months. One hundred twenty-seven children remained symptom free during follow-up for a median of 5.75 years (1 month-19 years). We saw no instance of malignancy in the resected specimens. CONCLUSIONS: This study adds further evidence that most children born with CLM identified prenatally are asymptomatic at birth and the majority will remain asymptomatic during childhood. We recommend follow-up to the age of 10 years.

Response of in ovo administration of zinc on egg hatchability and immune response of commercial broiler chicken.

An experiment was conducted to determine the effect of in ovo administration of different forms of zinc with respect to hatchability and performance of commercial broiler chicken. In trial 1, the fertile eggs on day 18 were divided into six treatment groups: Group I as control without any supplementation of zinc, group II to IV were supplemented with 0.5 mg zinc per egg as zinc sulphate, zinc methionine or nano zinc, respectively, and Group V with nano zinc at 0.25 mg zinc per egg. Sixth group received 0.5 ml citric acid per egg as sham control. The results of the first trial indicated that in ovo administration of nano zinc at both levels and zinc methionine resulted in complete failure of hatchability. A second trial to validate the result of trial 1 consisted of Group I control (no administration). Group II and Group III were supplemented with zinc sulphate and zinc methionine, respectively, at 0.5 mg zinc per egg. Group IV and Group V were supplemented with nano zinc at 0.04 and 0.08 mg per egg. In the second trial, again there was a similar pattern for zinc sulphate and zinc methionine. Administration of Zn by nano form had around 80% hatchability on fertile eggs in comparison with the unadministered control eggs (92%). There was no difference (p > .05) in body weight gain, feed intake and FCR. No difference (p > .05) was observed between treatments for cell-mediated immune response and humoral immune response. Nano Zn-administered group showed a non-significant downregulation of MUC2 gene. It could be concluded that in ovo administration of higher levels of zinc has to be with caution for the developing embryo of commercial broiler chicken.

Bilateral Malar Reconstruction Using Patient-Specific Polyether Ether Ketone Implants in Treacher-Collins Syndrome Patients With Absent Zygomas.

The authors performed bilateral malar reconstruction using polyether ether ketone implants in 3 patients with Treacher-Collins syndrome with absent, as opposed to hypoplastic, zygomata. These patient-specific implants were fabricated using computed-aided design software reformatted from three-dimensional bony preoperative computed tomography images. The first time the authors performed this procedure the implant compressed the globe resulting in temporary anisocoria that was quickly recognized intraoperatively. The implant was immediately removed and the patient made a full-recovery with no ocular disturbance. The computer-aided design and manufacturing process was adjusted to include periorbital soft-tissue boundaries to aid in contouring the new implants. The same patient, and 2 further patients, subsequently underwent malar reconstruction using this soft tissue periorbital boundary fabrication process with an additional 2 mm relief removed from the implant's orbital surface. These subsequent procedures were performed without complication and with pleasing aesthetic results. The authors describe their experience and the salutary lessons learnt.

Adaptive capability as indicated by behavioral and physiological responses, plasma HSP70 level, and PBMC HSP70 mRNA expression in Osmanabadi goats subjected to combined (heat and nutritional) stressors.

A study was conducted to assess the impact of heat and nutritional stress simultaneously on the adaptive capability as indicated by behavioral and physiological responses, plasma heat shock protein 70 (HSP70) level, and peripheral blood mononuclear cells (PBMC) HSP70 gene expression in goats. Twenty-four adult Osmanabadi bucks (average body weight (BW) 16.0 kg) were used in the present study. The bucks were divided into four groups viz., C (n = 6; control), HS (n = 6; heat stress), NS (n = 6; nutritional stress), and CS (n = 6; combined stress). The study was conducted for a period of 45 days. C and HS bucks had ad libitum access to their feed while NS and CS bucks were under restricted feed (30 % intake of C bucks) to induce nutritional stress. The HS and CS bucks were exposed to solar radiation for 6 h a day between 10:00 a.m. and 4:00 p.m. to induce heat stress. The data was analyzed using repeated measures analysis of variance. The standing time differed significantly (P < 0.01) between ad libitum fed groups (C and HS) and restricted feeding groups (NS and CS). The highest (P < 0.01) lying time was recorded in the CS group while the lowest in the C and HS groups. The highest (P < 0.01) drinking frequency was also recorded in the CS group. Water intake recorded was significantly (P < 0.01) higher in both the HS and CS groups. The highest respiration rate (RR), pulse rate (PR), and rectal temperature (RT) during the afternoon were also recorded in the CS group. Further, skin temperature of the head, flank, and scrotum during the afternoon was also higher (P < 0.01) in the CS group. In addition, both plasma HSP70 concentration and PBMC HSP70 messenger RNA (mRNA) transcript expression were also significantly (P < 0.01) higher in the CS group. It can be concluded from this study that when two stressors occur simultaneously, they may have severe impact on adaptive capabilities of Osmanabadi bucks as compared to that would occur individually. Further, the study indicated that lying time, drinking frequency, RR, RT, plasma HSP70, and PBMC HSP70 gene expression may act as ideal biological markers for assessing the impact of CS on adaptive capabilities in bucks.

Hippocampal, amygdala and nucleus accumbens volume in first-episode schizophrenia patients and individuals at high familial risk: A cross-sectional comparison.

It is unknown whether brain changes occur prior to onset of schizophrenia or after it develops. Prospective familial high risk studies provide a good method to investigate this. In the Edinburgh High Risk Study, structural MRI scans of 150 young individuals at familial high risk of schizophrenia, 34 patients with first-episode schizophrenia and 36 matched controls were obtained. Of the high risk participants with scans suitable for analysis, 17 developed schizophrenia after the scans were taken, whilst 57 experienced isolated or sub-clinical psychotic symptoms, and 70 remained well. We used Freesurfer to extract volumetric measurements of the hippocampus, amygdala and nucleus accumbens with the aim of assessing whether any alterations found were present in all those at high risk, or selectively in the high risk cohort based on future clinical outcome, or only in those experiencing their first-episode of psychosis. We found no significant differences in any examined regions between controls and those at high risk, or between those at high risk who later developed schizophrenia and those who remained well. However, patients with first-episode schizophrenia demonstrated significant volumetric reductions in the bilateral hippocampus, left amygdala, and right nucleus accumbens compared to high risk individuals and healthy controls, which were not significantly associated with the intake of anti-psychotic medication or duration of illness. We found that patients had significantly smaller left amygdalae and bilateral hippocampus compared to HR[ill]. Our findings suggest that volumetric reductions of the hippocampus, amygdala and nucleus accumbens occur early in the first-episode of psychosis. The apparent absence of high risk versus control differences we found using Freesurfer is at odds with our previous studies conducted on the same sample, and possible methodological reasons for these apparent discrepancies are discussed.

The great debate: open or thoracoscopic repair for oesophageal atresia or diaphragmatic hernia.

Controversy exists over the best method and technique of repair of oesophageal atresia and diaphragmatic hernia. Open surgical repairs have a long established history of over 60 years of experience. Set against this has been a series of successful thoracoscopic repairs of both congenital anomalies reported over the past decade. This review was based upon a four-handed debate on the merits and weaknesses of the two contrasting surgical philosophies and reviews existing literature, techniques, complications, and importantly outcome and results.