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Wagner CS, Barrero CE, Kumar SL, Pontell ME, Salinero LK, Bartlett SP, Taylor JA, Folsom N, Swanson JW. Characterizing Interventions and Family Assistance of a Nurse Navigation Program in Orofacial Cleft Care. Cleft Palate Craniofac J 2024; 61:1164-1171. [PMID: 36895093 DOI: 10.1177/10556656231163397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Characterize the interventions and assistance employed by a cleft nurse navigator (CNN) which have mediated improvement in care equity at our institution. DESIGN Retrospective study. SETTING Academic tertiary care center. PATIENTS, PARTICIPANTS Patients presenting with cleft lip and/or cleft palate presenting between August 2020 and August 2021 with exclusions for syndromic diagnosis, Pierre-Robin sequence, late (> 6 months) presentation, and prior cleft surgery at outside institutions. INTERVENTIONS Multidisciplinary cleft nurse navigator program. MAIN OUTCOME MEASURE(S) Family interactions with the CNN by phone, text, and email across the first year of life including feeding support, nasoalveolar molding (NAM) assistance, appointment scheduling, financial assistance, addressing perioperative concerns, and facilitating physician consults. Patient weight and surgical timing were also recorded. RESULTS Sixty-nine patients were included with a total of 639 interactions between the CNN and families. Scheduling support (30%), addressing perioperative concerns (22%), and feeding support (20%) were the most common interactions. Feeding support and NAM assistance were heavily distributed in the first 3 months of life compared to after 3 months (P < .001). Median age at first contact was 1 week (range: 22 weeks gestation-14 weeks). There was no difference in the proportion of families receiving feeding support, NAM assistance, or scheduling assistance based on insurance status or race (P > .05 for all). CONCLUSIONS Scheduling assistance, addressing perioperative concerns, and feeding support are the predominant methods by which the CNN interacts with and assists families of patients with cleft conditions. CNN service distribution is largely equitable between demographic groups.
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Affiliation(s)
- Connor S Wagner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Satvika L Kumar
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew E Pontell
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nancy Folsom
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Heron MJ, Rezwan SK, Zhu KJ, Gornitsky J, Redett RJ, Yang R. A Geospatial Analysis of Barriers to Cleft Lip and Palate Care in the United States. Cleft Palate Craniofac J 2024:10556656241259883. [PMID: 38836317 DOI: 10.1177/10556656241259883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
OBJECTIVE This study evaluates the geospatial distribution of cleft lip and/or cleft palate (CL/P) care in the United States, assesses disparities between families with and without one-hour proximity to CL/P care, and recommends interventions for improving access. DESIGN We identified American Cleft Palate Craniofacial Association-approved CL/P teams and calculated a one-hour driving radius around each clinic. We then used census data to compare risk factors for developing cleft (i.e., incidence risk factors) and obstacles to care (i.e., access risk factors) between counties with and without one-hour proximity. RESULTS We identified 187 CL/P teams in 45 states. Most were in the South (n = 60, 32.0%), though children in the Middle Atlantic had the greatest access to care. Alabama, Mississippi, Tennessee, and Kentucky had the least access. Children without access were 39% more likely to have gestational tobacco exposure, 8% more likely to have gestational obesity exposure, and 28% less likely to have health insurance (p < 0.01). Children without access in the South were 29% more likely to have a low birth weight and 46% more likely to be living below the poverty line (p < 0.01). Children with access were twice as likely to live in immigrant families and 7-times more likely to speak English as a second language. CONCLUSIONS Pronounced disparities affect patients with and without one-hour access to CL/P care. Interventions should address care costs for patients living furthest without access and language barriers for patients with access that speak English as a second language.
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Affiliation(s)
- Matthew J Heron
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Siam K Rezwan
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine J Zhu
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jordan Gornitsky
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robin Yang
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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Brown MI, McCandless MG, Hopper SJ, Lucas ED, Corder BN, Galarza LI, Hoppe IC, Humphries LS. Epidemiologic Trends of Cleft Lip and Palate in a Southern State: A 30-Year Follow-Up. South Med J 2024; 117:316-322. [PMID: 38830585 DOI: 10.14423/smj.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Children's of Mississippi at the University of Mississippi Medical Center serves as the state's only American Cleft Palate-Craniofacial Association-approved cleft team at the only pediatric hospital in the state. The goal of this study is to report geographic and demographic patterns of patients with orofacial cleft (OFC) treated at Children's of Mississippi, which are lacking. METHODS Patients with OFC treated at Children's of Mississippi from 2015 to 2020 were included. Demographic data were collected, including birth county and total live births from state data. Significant differences between incidence of OFC among public health regions of Mississippi were examined using analysis of variance (P < 0.05). Cases were compared with historical data from 1980 to 1989. RESULTS There were 184 patients who presented with OFC, with a statewide incidence of 0.83 per 1000 live births among 222,819 live births in the state across 6 years. The incidence of OFC was 0.83/1000 for Whites and 0.82/1000 for non-Whites versus a historical rate of 1.36 and 0.54, respectively. Significantly fewer children in the northern region (0.25/1000) were born with OFC than in central (1.21; P < 0.001) and southern (0.86; P < 0.001) regions. CONCLUSIONS Results from this study suggest changing regional patterns of OFC in Mississippi. Although rates increased among non-White infants, the overall incidence of OFC has decreased compared with historical data. The findings may reflect actual incidence patterns in the state or the proximity of certain regions to Children's of Mississippi. Further study may reveal regional differences in risk factors underlying OFC incidence, and/or issues with access to cleft care for different regions in the state.
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Affiliation(s)
- Madyson I Brown
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson
| | - Martin G McCandless
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson
| | - Samuel J Hopper
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson
| | - Eric D Lucas
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson
| | - Brittany N Corder
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson
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4
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Loomis-Goltl E, Briley P, Kotlarek KJ. Impact of Prenatal Care on Newborn Complications for Infants with Cleft Lip with or Without Cleft Palate. Cleft Palate Craniofac J 2024; 61:1041-1051. [PMID: 36718491 PMCID: PMC10387128 DOI: 10.1177/10556656231153453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To determine the association between prenatal care and cleft lip with or without cleft palate (CL ± P) and examine differences in newborn complications among infants diagnosed with CL ± P as a function of prenatal care. DESIGN Population-based retrospective cohort study. SETTING 2018 United States National Vital Statistics System-Natality component (NVSS-N) was used to examine nationwide birth certificate data. PARTICIPANTS 3,414,338 infants from the 2018 National Vital Statistics System, of which 1,699 had CL ± P. MAIN OUTCOME MEASURE Diagnosis of CL ± P and presence of newborn complications as a function of prenatal care. RESULTS Significant differences were found among various infant- and mother-specific variables when baseline comparisons were made between infants with and without CL ± P. After controlling for baseline differences, results indicated decreased odds of a diagnosis of CL ± P in cases where overall adequate prenatal care was obtained (OR = .841; 95% CI .757, .934), including prenatal care beginning in the 1st trimester (OR = .839; 95% CI .750, .939) and an adequate number of prenatal visits received (OR = .864; 95% CI .764, .976). Of infants with CL ± P, reduced odds of the infant admitted to the neonatal intensive care unit (OR = .777; 95% CI .613, .985) or transferred (OR = .601; 95% CI .407, .888) were apparent when adequate prenatal care was received. CONCLUSION Results suggest adequate prenatal care not only reduces the likelihood of CL ± P in infants but may also decrease the severity of negative outcomes in infants diagnosed with CL ± P. These findings emphasize necessity for adequate prenatal care.
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Affiliation(s)
- Evy Loomis-Goltl
- Department of Zoology and Physiology, University of
Wyoming, Laramie, WY, USA
| | - Patrick Briley
- Department of Communication Sciences and Disorders, East
Carolina University, Greenville, NC, USA
| | - Katelyn J. Kotlarek
- Division of Communication Disorders, University of Wyoming,
Laramie, WY, USA
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5
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Ács L, Nemes B, Nagy K, Ács M, Bánhidy F, Rózsa N. Maternal factors in the origin of cleft lip/cleft palate: A population-based case-control study. Orthod Craniofac Res 2024; 27 Suppl 1:6-13. [PMID: 38010849 DOI: 10.1111/ocr.12738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES Orofacial clefts are among the most common birth defects, with an estimated worldwide incidence of around 1.5-1.7 per 1000 live-born babies. The most frequent form of orofacial clefts is cleft lip with or without cleft palate (CL ± CP). The role of environmental factors in the development of clefts is unclear in most patients, thus the aim of this study was to estimate possible maternal risk factors in the origin of CL ± CP. MATERIALS AND METHODS 1648 CL ± CP cases, 2654 matched controls and 57 231 population controls were evaluated from The Hungarian Case-Control Surveillance of Congenital Abnormalities. Maternal factors during the critical period in cases and controls were compared. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were estimated in a multivariable conditional logistic regression model. RESULTS Among socio-demographic data, we have found significant differences between maternal employment. The proportion of unskilled mothers (6.5%) were higher in the CL ± CP group than in controls (3.5%). Medically recorded maternal anaemia, excessive vomiting and threatened abortion were associated with a higher risk of CL ± CP. An elevated risk was also found in various acute illnesses such as influenza (OR: 2.4, 95% CI: 3.0-5.8), acute bronchitis (OR: 4.5, 95% CI: 1.6-12.6) and urinary tract infections (OR: 3.5, 95% CI: 2.0-6.0). Maternal migraine and essential hypertension occurred more frequently in the mothers of cases than in controls. CONCLUSION The findings of this study suggest that maternal diseases and lifestyle factors during the first trimester play a significant role in the development of CL ± CP.
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Affiliation(s)
- Lili Ács
- Department of Paediatric Dentistry and Orthodontics, Semmelweis University Faculty of Dentistry, Budapest, Hungary
| | - Bálint Nemes
- Department of Paediatric Dentistry and Orthodontics, Semmelweis University Faculty of Dentistry, Budapest, Hungary
| | - Krisztián Nagy
- Department of Paediatrics, Semmelweis University School of Medicine, Budapest, Hungary
- OMFS-IMPATH KU Research Group, Leuven, Belgium
| | - Márton Ács
- Department of Oro-Maxillofacial Surgery and Stomatology, Semmelweis University Faculty of Dentistry, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Ferenc Bánhidy
- Department of Obstetrics and Gynaecology, Semmelweis University School of Medicine, Budapest, Hungary
| | - Noémi Rózsa
- Department of Paediatric Dentistry and Orthodontics, Semmelweis University Faculty of Dentistry, Budapest, Hungary
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Wagner CS, Hitchner MK, Plana NM, Morales CZ, Salinero LK, Barrero CE, Pontell ME, Bartlett SP, Taylor JA, Swanson JW. Incomes to Outcomes: A Global Assessment of Disparities in Cleft and Craniofacial Treatment. Cleft Palate Craniofac J 2024:10556656241249821. [PMID: 38700320 DOI: 10.1177/10556656241249821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVE Recent investigations focused on health equity have enumerated widespread disparities in cleft and craniofacial care. This review introduces a structured framework to aggregate findings and direct future research. DESIGN Systematic review was performed to identify studies assessing health disparities based on race/ethnicity, payor type, income, geography, and education in cleft and craniofacial surgery in high-income countries (HICs) and low/middle-income countries (LMICs). Case reports and systematic reviews were excluded. Meta-analysis was conducted using fixed-effect models for disparities described in three or more studies. SETTING N/A. PATIENTS Patients with cleft lip/palate, craniosynostosis, craniofacial syndromes, and craniofacial trauma. INTERVENTIONS N/A. RESULTS One hundred forty-seven articles were included (80% cleft, 20% craniofacial; 48% HIC-based). Studies in HICs predominantly described disparities (77%,) and in LMICs focused on reducing disparities (42%). Level II-IV evidence replicated delays in cleft repair, alveolar bone grafting, and cranial vault remodeling for non-White and publicly insured patients in HICs (Grades A-B). Grade B-D evidence from LMICs suggested efficacy of community-based speech therapy and remote patient navigation programs. Meta-analysis demonstrated that Black patients underwent craniosynostosis surgery 2.8 months later than White patients (P < .001) and were less likely to undergo minimally-invasive surgery (OR 0.36, P = .002). CONCLUSIONS Delays in cleft and craniofacial surgical treatment are consistently identified with high-level evidence among non-White and publicly-insured families in HICs. Multiple tactics to facilitate patient access and adapt multi-disciplinary case in austere settings are reported from LMICs. Future efforts including those sharing tactics among HICs and LMICs hold promise to help mitigate barriers to care.
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Affiliation(s)
- Connor S Wagner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Michaela K Hitchner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Natalie M Plana
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Carrie Z Morales
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
- Center for Surgical Health, Department of Surgery, Penn Medicine, USA
| | - Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Matthew E Pontell
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
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7
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Applebaum SA, Aronson S, Termanini KM, Gosain AK. Evidence-Based Practices in Cleft Palate Surgery. Plast Reconstr Surg 2024; 153:448e-461e. [PMID: 38266141 DOI: 10.1097/prs.0000000000011035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.
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Affiliation(s)
- Sarah A Applebaum
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Sofia Aronson
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Kareem M Termanini
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Arun K Gosain
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
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Varagur K, Murphy J, Skolnick GB, Naidoo SD, Grames LM, Dunsky KA, Menezes M, Snyder-Warwick AK, Patel KB. Impact of Neighborhood Deprivation and Social Vulnerability on Outcomes and Interventions in Patients with Cleft Palate. Cleft Palate Craniofac J 2024:10556656231226070. [PMID: 38196266 DOI: 10.1177/10556656231226070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVE To examine whether neighborhood disadvantage impacts length of follow-up, interventions, and outcomes for patients with cleft palate. DESIGN Retrospective cohort. SETTING Cleft Palate Craniofacial Institute Database at St. Louis Children's Hospital. PATIENTS/PARTICIPANTS Patients with cleft palate following in St. Louis Children's Hospital Cleft Palate Multidisciplinary Team Clinic. INTERVENTIONS Primary palatoplasty between 2012-2017. Patients were divided into quartiles across area deprivation index (ADI) and social vulnerability index (SVI), two validated, composite metrics of neighborhood disadvantage, to examine whether living in neighborhoods from different deprivation quartiles impacts outcomes of interest. MAIN OUTCOME MEASURE Follow-up through age 5, surgeries and surgical complications, speech, developmental, and behavioral outcomes. RESULTS 205 patients were included. 39% of patients belonged to the most deprived ADI quartile, while 15% belonged to the most vulnerable SVI quartile. There were no differences between ADI or SVI quartiles in number of operations received (p ≥ 0.40). Patients in the most deprived ADI quartile were significantly more likely to have speech/language concerns (OR 2.32, 95% CI [1.20-4.89], p = 0.01). Being in a more vulnerable SVI quartile was associated with developmental delay (OR 2.29, 95% CI [1.04-5.15], p = 0.04). ADI and SVI quartile did not impact risk of loss to follow-up in the isolated and combined cleft lip and palate subgroups (p ≥ 0.21). CONCLUSIONS Neighborhood disadvantage impacts speech and developmental outcomes in patients with cleft palate despite comparable length of follow-up in multidisciplinary team clinic.
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Affiliation(s)
- Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - John Murphy
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Lynn M Grames
- The Cleft Palate-Craniofacial Institute, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Katherine A Dunsky
- Department of Otolaryngology, Washington University in St. Louis, St. Louis, MO, USA
| | - Maithilee Menezes
- Department of Otolaryngology, Washington University in St. Louis, St. Louis, MO, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
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Krakauer KN, Cevallos PC, Amakiri UO, Saldana GM, Lipman KJ, Howell LK, Wan DC, Khosla RK, Nazerali R, Sheckter CC. US air pollution is associated with increased incidence of non-syndromic cleft lip/palate. J Plast Reconstr Aesthet Surg 2024; 88:344-351. [PMID: 38064913 DOI: 10.1016/j.bjps.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 01/02/2024]
Abstract
Maternal cigarette use is associated with the fetal development of orofacial clefts. Air pollution should be investigated for similar causation. We hypothesize that the incidence of non-syndromic cleft lip with or without palate (NSCLP) and non-syndromic cleft palate (NSCP) would be positively correlated with air pollution concentration. METHODS The incidence of NSCLP and NSCP per 1000 live births from 2016 to 2020 was extracted from the Centers for Disease Control and Prevention Vital Statistics Database and merged with national reports on air pollution using the Environmental Protection Agency Air Quality Systems annual data. The most commonly reported pollutants were analyzed including benzene, sulfur dioxide (SO2), particulate matter (PM) 2.5, PM 10, ozone (O3), and carbon monoxide (CO). Multivariable negative binomial and Poisson log-linear regression models evaluated the incidence of NSCLP and NSCP as a function of the pollutants, adjusting for race. All p-values are reported with Bonferroni correction. RESULTS The median NSCLP incidence was 0.22/1000 births, and isolated NSCP incidence was 0.18/1000 births. For NSCLP, SO2 had a coefficient estimate (CE) of 0.60 (95% CI [0.23, 0.98], p < 0.007) and PM 2.5 had a CE of 0.20 (95% CI [0.10, 0.31], p < 0.005). Among isolated NSCP, no pollutants were found to be significantly associated. CONCLUSION SO2 and PM 2.5 were significantly correlated with increased incidence of NSCLP. The American people and perinatal practitioners should be aware of the connection to allow for risk reduction and in utero screening.
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Affiliation(s)
- Kelsi N Krakauer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Priscila C Cevallos
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA
| | - Uche O Amakiri
- Icahn School of Medicine at Mt. Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA
| | - Golddy M Saldana
- University of California Davis School of Medicine, 4610 X Street, Sacramento, CA 95817, USA
| | - Kelsey J Lipman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Lori K Howell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Derrick C Wan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Rohit K Khosla
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Clifford C Sheckter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94305, USA.
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10
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Huang Z, Wu J, Qiu Y, Lin J, Huang W, Ma X, Zhang H, Yang X. Association between gestational exposure and risk of orofacial clefts: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:829. [PMID: 38041018 PMCID: PMC10691060 DOI: 10.1186/s12884-023-06104-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/02/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND The occurrence of orofacial Clefts (OFCs) is a congenital disease caused by many factors. According to recent studies, air pollution has a strong correlation with the occurrence of OFCs. However, there are still some controversies about the current research results, and there is no relevant research to review the latest results in recent years. OBJECTIVE In this paper, the authors conducted a systematic review and meta-analysis to explore the correlation between ambient air pollution and the occurrence of neonatal OFCs deformity. METHODS We searched Pubmed, Web of science, and Embase databases from the establishment of the database to May 2023. We included observational studies on the relationship between prenatal exposure to fine particulate matter 2.5 (PM2.5), fine particulate matter 10 (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), ozone (O3), carbon monoxide (CO) and the risk of cleft lip (CL), cleft palate (CP), cleft lip with or without palate (CL/P). the Newcastle-Ottawa quality assessment scale (NOS) was used to evaluate the quality of the literature. Funnel plot and Egger's regression were used to verify the publication bias. Random effect model or fixed effect model was used to estimate the combined relative risk (RR) and 95% confidence interval (95%CI). RESULTS A total of eleven studies were included in this study, including four cohort studies and seven case-control studies, including 22,453 cases of OFCs. Ten studies had low risk of bias and only one study had high risk of bias. Three studies reported that PM2.5 was positively correlated with CL and CP, with a combined RR and 95%CI of 1.287(1.174,1.411) and 1.267 (1.105,1.454). Two studies reported a positive correlation between O3 and CL, with a combined RR and 95%CI of 1.132(1.047,1.225). Two studies reported a positive correlation between PM10 and CL, with a combined RR and 95%CI of 1.108 (1.017,1.206). No association was found between SO2, CO, NO2 exposure during pregnancy and the risk of OFCs. CONCLUSION The results of this study showed that there was a significant statistical correlation between exposure to PM10, PM2.5, O3 and the risk of OFCs in the second month of pregnancy. Exposure assessment, research methods and mechanisms need to be further explored.
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Affiliation(s)
- ZhiMeng Huang
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China
| | - JinZhun Wu
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China
| | - Yue Qiu
- Key Laboratory of Urban Environment and Health, Institute of Urban Environment, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Fujian Province, 361000, China
| | - Jiayan Lin
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China
| | - Wanting Huang
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China
| | - Xiaohui Ma
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China
| | - Huifen Zhang
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China
| | - Xiaoqing Yang
- Department Pediatrics, Women and Children's Hospital, School of Medicine, Xiamen University, Fujian Province, 361000, China.
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Cho Y, Jeong HH, Shin H, Pak CJ, Cho J, Kim Y, Kim D, Kim T, Kim H, Kim S, Kwon S, Hong JP, Suh HP, Lee S. Hybrid Bionic Nerve Interface for Application in Bionic Limbs. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2303728. [PMID: 37840396 PMCID: PMC10724394 DOI: 10.1002/advs.202303728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/28/2023] [Indexed: 10/17/2023]
Abstract
Intuitive and perceptual neuroprosthetic systems require a high degree of neural control and a variety of sensory feedback, but reliable neural interfaces for long-term use that maintain their functionality are limited. Here, a novel hybrid bionic interface is presented, fabricated by integrating a biological interface (regenerative peripheral nerve interface (RPNI)) and a peripheral neural interface to enhance the neural interface performance between a nerve and bionic limbs. This interface utilizes a shape memory polymer buckle that can be easily implanted on a severed nerve and make contact with both the nerve and the muscle graft after RPNI formation. It is demonstrated that this interface can simultaneously record different signal information via the RPNI and the nerve, as well as stimulate them separately, inducing different responses. Furthermore, it is shown that this interface can record naturally evoked signals from a walking rabbit and use them to control a robotic leg. The long-term functionality and biocompatibility of this interface in rabbits are evaluated for up to 29 weeks, confirming its promising potential for enhancing prosthetic control.
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Affiliation(s)
- Youngjun Cho
- Department of Robotics and Mechatronics EngineeringDaegu Gyeongbuk Institute of Science and Technology (DGIST)Daegu42899South Korea
| | - Hyung Hwa Jeong
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Heejae Shin
- Department of Robotics and Mechatronics EngineeringDaegu Gyeongbuk Institute of Science and Technology (DGIST)Daegu42899South Korea
| | - Changsik John Pak
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Jeongmok Cho
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Yongwoo Kim
- Department of Robotics and Mechatronics EngineeringDaegu Gyeongbuk Institute of Science and Technology (DGIST)Daegu42899South Korea
| | - Donggeon Kim
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Taehyeon Kim
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Hoijun Kim
- Graduate School of Smart ConvergenceKwangwoon UniversitySeoul01897South Korea
| | - Sohee Kim
- Department of Robotics and Mechatronics EngineeringDaegu Gyeongbuk Institute of Science and Technology (DGIST)Daegu42899South Korea
| | - Soonchul Kwon
- Graduate School of Smart ConvergenceKwangwoon UniversitySeoul01897South Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Hyunsuk Peter Suh
- Department of Plastic and Reconstructive SurgeryAsan Medical Center, University of Ulsan College of Medicine05505SeoulSouth Korea
| | - Sanghoon Lee
- Department of Robotics and Mechatronics EngineeringDaegu Gyeongbuk Institute of Science and Technology (DGIST)Daegu42899South Korea
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Linkugel AD, Trivedi PB, Varagur K, Skolnick GB, Menezes MD, Dunsky KA, Grames LM, Locke LC, Naidoo SD, Snyder-Warwick AK, Patel KB. Multidisciplinary Optimal Outcomes Reporting and Team Clinic Retention in Isolated Nonsyndromic Cleft Palate. Cleft Palate Craniofac J 2023:10556656231205974. [PMID: 37801491 DOI: 10.1177/10556656231205974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE Optimal Outcomes Reporting was recently introduced to categorize outcomes after cleft palate repair. We seek to propose an expanded version of Optimal Outcomes Reporting and to determine if correlation exists between the expanded outcomes and persistence with team care follow-up through age 9. DESIGN Retrospective cohort study. SETTING Cleft team at large pediatric hospital. PATIENTS Patients with isolated nonsyndromic cleft palate (n = 83) born from 2001-2012. MAIN OUTCOME MEASURES Patients who continued to present at age 5 or greater were assessed for optimal outcomes. Optimal outcomes were: surgery - no fistula or velopharyngeal insufficiency; otolaryngology - no obstructive sleep apnea or signs of chronic middle ear disease; audiology - no hearing loss; speech-language pathology - no assessed need for speech therapy. RESULTS Of the 83 patients identified, 41 were assessed for optimal outcomes. Optimal outcome in any discipline was not associated with follow-up through age 9 (0.112 ≤ p ≤ 0.999). For all disciplines, the group with suboptimal outcomes had a higher proportion of patients from geographic areas in the most disadvantaged quartile of social vulnerability index, with the strongest association in the group with suboptimal speech outcome (OR 6.75, 95% CI 0.841-81.1). CONCLUSIONS Optimal outcomes and retention in team clinic were not statistically significantly associated, but clinically relevant associations were found between patients in the most disadvantaged quartile of social vulnerability and their outcomes. A patient-centered approach, including caregiver education about long-term care for patients with cleft palate, would allow for enhanced resource utilization to improve retention for patients of concern.
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Affiliation(s)
- Andrew D Linkugel
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Prerak B Trivedi
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Maithilee D Menezes
- Department of Otolaryngology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Katherine A Dunsky
- Department of Otolaryngology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lynn M Grames
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | | | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Limited Access to Alveolar Bone Graft Surgery Following Primary Cleft Lip and Palate Repair in Indonesia: A Questionnaire-Based Qualitative Study. J Craniofac Surg 2023; 34:544-547. [PMID: 36217224 DOI: 10.1097/scs.0000000000009063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cleft Lip and Palate is the most common craniofacial anomaly, and cleft lip and palate repair is widely performed. Alveolar cleft accompanies 75% of cleft lip cases and requires alveolar bone graft (ABG) surgery at mixed dentition age. However, studies on rates of ABG surgery are scarce. OBJECTIVE This study aims to investigate the low popularity of ABG and orthodontic care among patients with ABG history at Cleft and Craniofacial Centre, Cipto Mangunkusumo Hospital, Jakarta. METHOD A total of 771 patients had orofacial cleft surgeries throughout 2015 to 2021. A descriptive analysis of labioplasty, palatoplasty, and ABG surgeries was presented. Questionnaire-based qualitative analysis of ABG was obtained from the patient's guardians to evaluate the limitation and experience of conducting the surgery at our institution. RESULTS We distributed questionnaires to 13 patients with a history of ABG. ABG accounted for only 5% of total orofacial cleft surgeries. The average age of ABG surgery and orthodontic care initiation was 11 and 11.8 years old, respectively. About 82% had access to preoperative and postoperative orthodontic care; however, only 11% received PSO before 9 years old. The satisfaction rate was 100% and 75% in ABG patients with and without orthodontic care, respectively, reporting improved feeding, speech, teeth alignment, and esthetic result. CONCLUSION Orofacial cleft management requires a multistage, comprehensive, and multidisciplinary approach. The number of ABG surgeries is low in developing countries, attributed to unequal access to ABG and orthodontic care, suggesting that limitations of knowledge, geography, and economy play a big role in Indonesian healthcare.
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A Cross-Sectional Study of the Nutritional Status of Infants with Orofacial Clefts in the First 6 Months of Life. J Pediatr 2022; 255:181-189.e3. [PMID: 36462686 DOI: 10.1016/j.jpeds.2022.11.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE(S) To estimate nutritional status in a large cohort of infants with orofacial clefts in the US, overall and by cleft type from birth to 6 months of age. STUDY DESIGN We conducted a cross-sectional study in infants with orofacial clefts by examining growth by month between birth and 6 months of age. Infants with at least one weight measurement at a single US regional tertiary care pediatric hospital with an interdisciplinary cleft team between 2010 and 2020 were included. We calculated the average weight-for-age z scores and weight-for-length z scores. We calculated the proportion of infants underweight and wasting with z scores below -2 SDs monthly from birth to 6 months of age. We used t tests to compare the distribution of weight for age z-score and weight for length z-score among children with orofacial clefts to a normal distribution. RESULTS We included 883 infants with orofacial clefts. Compared with expected proportion of underweight infants (2.3%), a larger proportion of infants with orofacial clefts were underweight between birth and 1 month (10.6%), peaking between 2 and 3 months (27.1%), and remaining high between 5 and 6 months (16.3%). Compared with the expected proportion of infants with wasting (2.3%), a higher proportion of infants with orofacial clefts experienced wasting between birth and 1 month (7.3%), peaking between 2 and 3 months (12.8%), and remaining high between 5 and 6 months (5.3%). Similar findings were observed for all cleft types and regardless of comorbidities. CONCLUSION(S) A substantial proportion of infants with orofacial clefts compared with normative peers have malnutrition in the first 6 months of life in the US.
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Kancherla V, Roos N, Walani SR. Relationship between achieving Sustainable Development Goals and promoting optimal care and prevention of birth defects globally. Birth Defects Res 2022; 114:773-784. [PMID: 35776686 DOI: 10.1002/bdr2.2055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 02/27/2022] [Accepted: 03/16/2022] [Indexed: 11/09/2022]
Abstract
Birth defects affect eight million newborns annually worldwide. About 8% of global under-5 mortality is attributable to birth defects. The United Nations (UN) Sustainable Development Goals (SDGs) have set 17 global goals for human growth and development to be achieved by 2030 using multi-sectorial approaches. The third goal (SDG-3) focuses on ensuring healthy lives and promoting well-being; achieving SDG-3 improves birth defects care and prevention. However, we aimed to show how achieving other SDGs also influence optimal care and prevention of birth defects. SDGs focused on poverty reduction, access to nutritious food, universal health coverage, equitable education, gender equality, environment, inclusivity through infrastructure innovation, and strengthening social justice is crucial to addressing social determinants of health for individuals and families affected by birth defects. Understanding birth defects in the context of several relevant SDGs will allow practitioners, researchers, and policymakers to leverage the momentum generated by SDGs and make a case for commitment and allocation of funding and resources for advancing birth defects surveillance, care, and prevention. SDGs are built on principles of equity and social justice and we urge policy-makers to approach birth defects using various SDGs as a catalyst. The synergy between several SDGs helps to optimize birth defect outcomes and prevention. Our effort to present a more comprehensive look at various SDGs and their relationship with birth defects is parallel to several other health advocacy groups conducting a similar mapping exercise, thus bringing to the forefront millions of lives that are impacted by birth defects worldwide.
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Affiliation(s)
- Vijaya Kancherla
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nathalie Roos
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Klintö K, Eriksson M, Abdiu A, Brunnegård K, Cajander J, Hagberg E, Hakelius M, Havstam C, Mark H, Okhiria Å, Peterson P, Svensson K, Becker M. Inter-centre comparison of data on surgery and speech outcomes at 5 years of age based on the Swedish quality registry for patients born with cleft palate with or without cleft lip. BMC Pediatr 2022; 22:303. [PMID: 35606744 PMCID: PMC9125901 DOI: 10.1186/s12887-022-03367-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The objective of the Swedish cleft lip and palate registry (CLP registry) is to promote quality control, research and improvement of treatment, by the comparison of long-term results. The aim was to compare data from the CLP registry among the six treatment centres, regarding data on surgery and speech outcomes at 5 years of age. METHODS The participants were 430 children born in Sweden from 2009 to 2014, with cleft palate with or without cleft lip and without known syndromes and/or additional malformations. The number of primary and secondary palatal surgeries up to 5 years of age, timing of the last primary palatal surgery, percentage consonants correct, percentage non-oral speech errors and perceived velopharyngeal competence at 5 years were assessed. Multivariable binary logistic regression adjusted for sex and cleft type was used to compare results between the six centres. RESULTS At one centre (centre 4), the palate was closed in one to three stages, and at the remaining centres in one or two stages. At centre 4, more children underwent a higher number of palatal surgeries, and the last primary palatal surgery was performed at a higher age. Children in centre 4 were also less likely to achieve ≥86% correct consonants (OR = 0.169, P = < 0.001), have no non-oral speech errors (OR = 0.347, P = < 0.001), or have competent or marginally incompetent velopharyngeal competence (OR = 0.244, P = < 0.001), compared to the average results of the other centres. No clear association between patient volume and speech outcome was observed. CONCLUSIONS The results indicated the risk of a negative speech result if the last primary palatal surgery was performed after 25 months of age. Whether the cleft in the palate was closed in one or two stages did not affect speech outcome. The Swedish CLP registry can be used for open comparisons of treatment results to provide the basis for improvements of treatment methods. If deviating negative results are seen consistently at one centre, this information should be acted upon by further investigation and analysis, making changes to the treatment protocol as needed.
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Affiliation(s)
- Kristina Klintö
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.
| | - Marie Eriksson
- Department of Statistics, USBE, Umeå University, Umeå, Sweden
| | - Avni Abdiu
- Department of Hand Surgery, Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Karin Brunnegård
- Department of Clinical Sciences, Speech and Language Pathology, Umeå University, Umeå, Sweden
| | - Jenny Cajander
- Department for Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Emilie Hagberg
- Medical Unit Speech and Language Pathology and Department of Plastic Surgery and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Hakelius
- Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Christina Havstam
- Department of Otorhinolaryngology, Division of Speech and Language Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Mark
- Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Åsa Okhiria
- Department of Speech-Language Pathology, Uppsala University Hospital, Uppsala, Sweden
| | - Petra Peterson
- Department of Plastic Surgery and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Svensson
- Speech and Language Therapy Unit, Linköping University Hospital, Linköping, Sweden
| | - Magnus Becker
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
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