Translation, Validation, and Cultural Adaptation of CLEFT-Q© for use in Indonesia

OBJECTIVE

To translate and validate CLEFT-Q©, patient-reported outcome measure for patients with cleft lip and/or palate (CL and/or P), into Indonesian. CLEFT-Q© covers the domains of appearance, facial function, health-related quality of life and consists of scales describing outcomes after cleft surgery.

DESIGN

The CLEFT-Q© instrument was translated according to the International Society of Pharmacoeconomics and Outcomes Research guidelines, including translation, cognitive debriefing, and field-testing.

SETTING

Dr. Cipto Mangunkusumo Hospital, Indonesia; independent CL and/or P support groups.

PATIENTS

Patients ages 8-29 with a history of repaired CL and/or P were grouped based on age. Those unable to complete the questionnaire independently were excluded.

INTERVENTIONS

The primary objective was reliable translation of the CLEFT-Q® instrument. Each scale was assessed for its internal consistency (Cronbach's alpha) and validity (inter-item correlation), and sub-group analyses were performed based on age group.

RESULTS

Forward and back translation revealed 25(13.3%) and 12(6.3%) of items were difficult to translate. Cognitive debriefing revealed 10(5.3%) items were difficult to understand, with the lowest reliability on the facial appearance scale (α=0.27). Other scales demonstrated acceptable to excellent reliability (α=0.53-0.68). Field testing revealed acceptable reliability and validity of the translation (α = 0.74-0.92; 69% ideal range of inter-item correlation). Sub-group analyses revealed patients in the <11y.o. and >18y.o. groups had the lowest scores on the "cleft lip scar" scale while those 11-18y.o. had the lowest scores on the "nostrils" scale.

CONCLUSION

Iterative translation and cultural adaptation of CLEFT-Q© into Indonesian demonstrated reliability and validity of the tool, supported by acceptable to excellent internal consistency and ideal inter-item correlation.

Finnish Translation and Linguistic Validation of the CLEFT-Q Questionnaire

OBJECTIVE

Cleft lip and/or palate (CL/P) can have long-lasting effects on the appearance, function, and psychosocial wellbeing of patients. The CLEFT-Q questionnaire is a patient-reported outcomes instrument specifically designed to assess the health-related quality of life of patients with CL/P. The aim of this study was to produce and linguistically validate a Finnish version of the CLEFT-Q questionnaire.

DESIGN

The CLEFT-Q questionnaire was translated into Finnish following guidelines of the International Society for Pharmacoeconomics and Outcomes Research. Pilot testing with cognitive debriefing interviews was conducted on patients of the target age range of the questionnaire, 8-29, and with various cleft types.

RESULTS

The CLEFT-Q questionnaire translated readily into Finnish. A review of the backward translation led to two words being changed. Thirteen patients - ten females and three males - with a median age of 14 years, participated in the cognitive debriefing interviews. The interviews led to further nine word changes. The pilot study data suggested that the performance of the Finnish version of the instrument is in line with the original CLEFT-Q questionnaire.

CONCLUSIONS

The Finnish version of CLEFT-Q produced here is linguistically valid and ready for use in the evaluation of the health-related quality of life of patients with CL/P. However, future work is needed to further assess the validity and the reliability of the CLEFT-Q in the Finnish patient population.

Self-perceived oral health and orofacial aesthetics of cleft patients

PURPOSE

To evaluate the self-perceived oral health and aesthetics of the dentition and jaw in patients with different types of oral cleft, measured by patient-reported outcome measures (PROMs). Additionally, to compare the results of the PROMs between cleft lip and or/palate (CL/P) patients and non-affected controls.

METHODS

420 CL/P patients treated at the cleft team of the Erasmus Medical Center, Rotterdam, The Netherlands, were included, and 138 non-cleft patients were recruited as control-group. Patient's perceptions were retrospectively evaluated using the CLEFT-Q Teeth for dental aesthetics at ages 8, 12 and 22, CLEFT-Q Jaw for jaw aesthetics at ages 12 and 22, and the Child Oral Health Impact Profile-Oral Symptoms Subscale (COHIP-OSS) for oral health at ages 8 and 12. One-way ANOVA was used to compare differences in oral health and aesthetic perceptions among age-groups, cleft types, as well as between cases and controls.

RESULTS

CL/P patients were significantly less satisfied than controls with their dental aesthetics (p = 0.001). CL/P patients reported significantly lower satisfaction on CLEFT-Q Teeth scores at ages 8 and 12, than at 22 years (p < 0.001). Patients with the most extensive cleft phenotype, Cleft Lip and Palate (CLAP), reported lowest satisfaction on the CLEFT-Q Teeth. No differences in perceptions of oral health nor in aesthetics of the jaw were found in the different cleft types, ages, nor in study versus control group.

CONCLUSION

This study found differences in self-perceived dental aesthetics: CL/P patients are less satisfied than non-affected controls. CLAP patients are least satisfied, but satisfaction increases with age.

Psychosocial Status and Self-Perception in Patients with Cleft Lip and/or Palate

OBJECTIVE

To describe how the psychosocial status of patients with cleft lip and/or palate (CL/P) relates to patient-reported outcomes (PROs).

DESIGN

Cross-sectional retrospective chart review.

SETTING

Tertiary care pediatric hospital.

PATIENTS/PARTICIPANTS

Patients aged 8 to 29 years attending cleft team evaluations during a 1-year period.

MAIN OUTCOME MEASURES

CLEFT-Q.

RESULTS

Patients (N = 158) with isolated or syndromic CL/P and mean age 13.4 ± 3.0 years were included. Fifteen (9%) patients had siblings who also had CL/P. Of 104 patients who met with the team psychologist, psychosocial concerns were identified in 49 (47%) patients, including 25 (24%) with Attention-Deficit/Hyperactivity Disorder or behavior concerns, 28 (27%) with anxiety, and 14 (13%) with depression or mood concerns. Younger age and having siblings with cleft were associated with better PROs, while psychosocial concerns were associated with worse PROs on Speech, Psychosocial, and Face Appearance scales.

CONCLUSIONS

Patient perception of cleft outcomes is linked to psychosocial factors.

Thai CLEFT-Q: Phase 1-A Pilot Study of Translation and Cultural Adaptation in Thailand

To translate and culturally adapt the original English version of the CLEFT-Q into Thai (Thai CLEFT-Q).

A pilot study.

A single tertiary referral hospital in Thailand.

Patients with cleft lip or palate (CL/P) aged between 8 and 29 years.

The CLEFT-Q was translated and culturally adapted from English into Thai using the good practice guidelines developed by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Two forward translations and reconciliation, 1 back translation, and 2 sets of cognitive debriefing interviews with patients were performed to develop the Thai CLEFT-Q.

The English version of the CLEFT-Q consists of 13 scales (119 items) assessing appearance, health-related quality of life (HRQOL), and facial function. The forward translations revealed 33.6% inconsistencies. They were related to narrow meaning (2.5%) and improper (16.8%) or incorrect (14.3%) wording or phrasing of the items. After reconciliation, the back translation showed 5 inconsistencies (4.2%) with the original version. However, no changes were needed because the reconciliation version was consistent with the source version. Sixteen participants underwent cognitive debriefing interviews, which revealed a comprehensive interpretation of the Thai CLEFT-Q. Interim reports revealed fair facial appearance scores, albeit with HRQOL and facial function outcomes.

Translation and cultural adaptation of the Thai CLEFT-Q provided evidence of its transferability and equivalence with the original English version. Feasible comprehension of the Thai version was also achieved.

Secondary Cleft Rhinoplasty

Secondary cleft rhinoplasty remains a challenging operation that requires an understanding of the aberrant anatomy in cleft lip nasal deformity as well as the ability to adapt various techniques suited to the needs of each patient. In this article, we review some of the classically described approaches in cleft rhinoplasty and different strategies to address the nasal subunits. Presurgical adjuncts, surgical interventions before facial skeletal maturity, and patient reported outcome measures are also discussed.

Most Efficient and Meaningful Patient-Reported Appearance Assessment in Different Cleft Types and Age Groups with CLEFT-Q

BACKGROUND

The CLEFT-Q, a questionnaire developed and validated specifically for cleft patients, contains seven appearance scales. The International Consortium of Health Outcomes Measurement (ICHOM) has incorporated only some CLEFT-Q appearance scales in the Standard Set to minimize burden. This study evaluates which appearance scales provide the most meaningful information in the different cleft types at specific ages, for the most efficient cleft appearance outcome assessment.

METHODS

Within this international multicenter study, outcomes of the seven appearance scales were collected, either as part of the ICHOM Standard Set, or as part of the field test study performed to validate the CLEFT-Q. Analyses were performed in separate age groups and cleft types, and involved univariate regression analyses, trend analyses, t tests, correlations, and floor and ceiling effects.

RESULTS

A total of 3116 patients were included. Scores for most appearance scales showed a downward trend by age group, with the exception of the Teeth and Jaw scales. In all cleft types, several scales correlated strongly with each other. No floor effects were observed, but ceiling effects were found in several scales in different age groups, most often in the CLEFT-Q Jaw scale.

CONCLUSIONS

A proposition for the most meaningful and efficient appearance outcome assessment in cleft patients is made. It was composed so that recommendations are of value for different cleft protocols and initiatives. Suggestions for the use of scales in the ICHOM Standard Set at different ages are given, and also from a clinical perspective. Use of the CLEFT-Q Scar, Lips, and Nose scales will provide additional relevant information.

What is the optimal assessment of speech? A multicentre, international evaluation of speech assessment in 2500 patients with a cleft

OBJECTIVES

Speech problems in patients with a cleft palate are often complex and multifactorial. Finding the optimal way of monitoring these problems is challenging. The International Consortium of Health Outcomes Measurement (ICHOM) has developed a set of standardised outcome measures at specific ages for patients with a cleft lip and/or palate, including measures of speech assessment. This study evaluates the type and timing of speech outcome measures currently included in this ICHOM Standard Set. Additionally, speech assessments in other cleft protocols and initiatives are discussed.

DESIGN, SETTING AND PARTICIPANTS

An international, multicentre study was set up including centres from the USA and the Netherlands. Outcomes of clinical measures and Patient Reported Outcome Measures (PROMs) were collected retrospectively according to the ICHOM set. PROM data from a field test of the CLEFT-Q, a questionnaire developed and validated for patients with a cleft, were collected, including participants from countries with all sorts of income statuses, to examine the value of additional moments of measurement that are used in other cleft initiatives.Data from 2500 patients were included. Measured outcomes contained univariate regression analyses, trend analyses, t-tests, correlations and floor and ceiling effects.

RESULTS

PROMs correlated low to moderate with clinical outcome measures. Clinical outcome measures correlated low to moderate with each other too. In contrast, two CLEFT-Q Scales correlated strongly with each other. All PROMs and the Percent Consonants Correct (PCC) showed an effect of age. In patients with an isolated cleft palate, a ceiling effect was found in the Intelligibility in Context Scale.

CONCLUSION

Recommendations for an optimal speech outcome assessment in cleft patients are made. Measurement moments of different cleft protocols and initiatives are considered in this proposition. Concerning the type of measures, adjustment of the current PCC score outcome seems appropriate. For centres with adequate resources and specific interest in research, translation and validation of an upcoming tool, the Cleft Audit Protocol for Speech Augmented, is recommended.

Treatment Outcomes of Interdisciplinary Care on Speech and Health-Related Quality of Life Outcomes in Adults With Cleft Palate

PURPOSE

Individuals born with a cleft palate with or without a cleft lip (CP ± L) often experience functional, aesthetic, and psychosocial consequences well into adulthood. This study aimed to investigate outcomes of speech and health-related quality of life (HRQoL) in adults with a CP ± L who received interdisciplinary cleft care at the Ghent University Hospital using valid, reliable, and condition-specific instruments.

METHOD

Thirteen Belgian Dutch-speaking participants with a CP ± L with a mean age of 25.4 years (SD = 5.1, range: 20-33 years) and an age- and gender-matched control group of 13 participants without a CP ± L with a mean age of 25.2 years (SD = 4.8, range: 20-32 years) were included in this study. Speech characteristics were evaluated perceptually and instrumentally. HRQoL was assessed through standardized patient-reported outcome measures. Outcomes were compared with those of the control group and to normative data where available.

RESULTS

Participants with a CP ± L in this sample demonstrated significantly lower speech acceptability (p < .001) and higher rates of hypernasality (p = .015) and nasal turbulence (p = .005) than the control group. They showed significantly higher satisfaction with appearance of the cleft scar compared with norms of adults with a CP ± L (p = .047). No other differences in speech characteristics, sociodemographics, or HRQoL were found between participants with and without a CP ± L.

CONCLUSIONS

The reduced speech acceptability and the presence of resonance and nasal airflow disorders may indicate the need for standardized long-term outcome measurement and interdisciplinary follow-up for speech characteristics and velopharyngeal insufficiency in young and middle adulthood in future clinical practice. Additional research is necessary to further substantiate these findings and to determine predictors for these continuing complications in adults with a CP ± L.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24243901.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network

OBJECTIVE

To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings.

DESIGN

Cross-sectional analysis of prospectively collected data from 2019-2022.

SETTING

Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol.

PARTICIPANTS

714 English-speaking children and adolescents with non-syndromic cleft lip/palate.

INTERVENTION

Routine multidisciplinary care and systematic outcomes measurement by cleft teams.

OUTCOME MEASURES

Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress.

RESULTS

12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes.

CONCLUSIONS

This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Articulating the issues: speech assessment and intervention in cleft lip and palate

This paper describes the impact of cleft lip and palate on speech. It provides an overview for the dental clinician of the key issues affecting speech development and clarity. The paper summarises the complex speech mechanism and cleft-related factors that affect speech, including palatal, dental and occlusal anomalies. It outlines the framework for speech assessment throughout the cleft pathway and provides a description of cleft speech disorder, as well as describing treatment approaches for cleft speech and velopharyngeal dysfunction.This is followed by a spotlight on speech prosthetics for treating nasal speech, with an emphasis on joint management by the Speech and Language Therapist and Consultant in Restorative Dentistry. This includes the core multidisciplinary approach, clinician and patient-reported outcome measures, and brief discussion of national developments in this area.The importance of multidisciplinary cleft care is highlighted and, within this, the essential interaction between speech and dental clinicians in providing routine care, as well as in delivering a highly specialist speech prosthetics service.

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program

OBJECTIVE

Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision.

DESIGN

The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community.

RESULTS

Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community.

CONCLUSIONS

The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

HOW PRO'S CAN CONTRIBUTE TO WHAT MATTERS MOST TO PATIENTS WITH OROFACIAL CLEFTS

An orofacial cleft (OC) is a congenital cleft that may affect the lip, alveolus, hard and soft palate. An OC impacts the individuals' appearance, psychosocial well-being and causes functional problems including feeding, dentition, growth of jaws, hearing and speech. The treatment of an orofacial cleft usually reaches from birth until 22 years of age or later. To understand and listen in an objective manner, OC specific Patient reported Outcome (PRO) and experience (PRE) measures are imperative. In patients with OCs many shared decision making moments exist from birth until adulthood. The aim is to understand what knowledge exists on PROs and PREs in patients with OCs, to formulate challenges to improve care to OC patients and how research on OCs needs to adapt. PROs and PREs need to be tailored to the individual with an OC. A framework with specific OC key domains including appearance, facial function and Health related Quality of Life exists. The current framework does not include the social network around the OC patients yet. However attention should be put on including family and community support into the framework. Also at an individual level more attention should be paid to enhancing experiences compared to impeding experiences. To create a better understanding traditional indicators and outcomes are combined with PROMs in a structured way. Challenges were identified that seek to improve our complete set of (PRO and PRE) instruments to provide better care to the individual with an OC and provide a voice so that good shared decision making is enabled. Thereby the individual with an OC is further empowered.

Comparison of the psychosocial impact on patients affected by cranio facial anomalies between traditional orthodontic brackets and aligners

OBJECTIVES

Malocclusion affects the psychological wellness and social interaction, impacting negatively on adolescents' quality of life and self-esteem. Facial attractiveness is mostly based on the esthetics of the smile and patients seek orthodontic treatment mainly to improve aesthetics. The aim of this prospective clinical study is to compare the psychosocial impact of aligners (AL) and fixed appliances (FA) as orthodontic treatments in patients affected by craniofacial anomalies (CFA).

METHODS

100 syndromic Caucasian patients with CFA followed in two different hospitals were divided in two groups: 50 patients treated with AL and 50 patients treated with FA. The two groups were matched for gender, age and CFA and filled out a modified psychosocial impact of dental aesthetics questionnaire (mPIDAQ).

RESULTS

Patients affected by CFA treated with AL reported a better psychosocial impact than patients treated with FA, showing higher esthetic self-perception and self-esteem, lower social interaction impairments, and lower physical/practical disturbances.

CONCLUSIONS

The results of this study suggest that AL could be a valid alternative, especially in complex patients with CFA. Since AL application requires more cooperative patients the orthodontist should dedicate more time to motivate the patient to adhere to the treatment schedule.

Neurodevelopmental trajectories in children with cleft lip and palate: A longitudinal study based on the Japan Environment and Children's Study

Cleft lip and/or palate (CL/P), the most prevalent congenital anomaly, is understood to negatively affect a wide range of child development. Since the concept remains controversial, because most published work is from cross-sectional studies, we examined the neurodevelopmental trajectories in participants with CL/P through a longitudinal comparison with the general population during early childhood using data from a nationwide birth cohort study in Japan. The linear mixed models for each domain of the Ages and Stages Questionnaire, third edition (ASQ-3), were used to detect differences in standardised mean scores between groups. The ASQ-3 is a general neurodevelopmental screening tool comprising communication, gross motor, fine motor, problem-solving, and personal-social domains. Participants' neurodevelopment was determined semi-annually from 6 to 36 months of age. The trajectories of standardised mean scores in each domain showed several significant differences between the control and CL/P groups, with the maximum difference at 24 months of age in the communication domain. Indeed, CL/P was associated with significantly lower scores in the communication (coefficient: -3.31, 95% CI: -5.09 to -1.14), problem-solving (coefficient: -3.13, 95% CI: -5.07 to -1.18), and personal-social domains (coefficient: -1.99, 95% CI: -3.87 to -0.11). Trajectories of ASQ-3 scores suggest neurodevelopmental delays in children with CL/P.

Childhood Experiences and Perspectives of Individuals With Orofacial Clefts: A Qualitative Systematic Review

OBJECTIVE

Children and adolescents with orofacial clefts may experience ongoing psychosocial impacts due to the continuous nature of cleft treatments, facial and dental differences, and speech and hearing difficulties. The aim of this qualitative systematic review was to better understand the experiences of children and adolescents with orofacial clefts.

DESIGN

A systematic search strategy using PubMed, Embase, Emcare, Scopus, and Web of Science databases was performed to identify relevant qualitative studies evaluating the lived experience of children and adolescents with orofacial clefts from inception through to June 2021. Eligible studies were critically appraised using the Joanna Briggs methodology and a meta-aggregative approach.

RESULTS

The search identified 2466 studies, with 13 found to meet the inclusion criteria. Extraction of 155 findings resulted in 27 categories, which were meta-aggregated into 7 overarching synthesized findings. These 7 core findings included aspects of child experience and findings that enhanced or impeded child experience at the individual, family, and community levels.

CONCLUSIONS

Factors that impeded child experience at the individual, family, and community levels were more pronounced than factors that enhanced their experience among children and adolescents with orofacial clefts. Further initiatives are needed to provide support to individuals, families, and school communities to enhance children's experience of orofacial cleft during the formative childhood and adolescent years.

The Impact of Fan-Type Rapid Palatal Expanders on Speech in Patients With Unilateral Cleft Lip and Palate

Rapid palatal expanders (RPEs) are commonly used in patients with cleft lip and palate (CLP) prior to secondary alveolar bone grafting (SABG). Their position and size can impede tongue movement and affect speech. This study assessed changes in perception and production of speech over the course of RPE treatment.

Prospective longitudinal.

Tertiary university-affiliated hospital.

Twenty-five patients with unilateral CLP treated with Fan-type RPEs, and their parents.

Patient and parent speech questionnaires and patient speech recordings were collected at baseline before RPE insertion (T1), directly after RPE insertion (T2), during RPE expansion (T3), during RPE retention (T4), directly after RPE removal but before SABG (T5), and at short-term follow-up after RPE removal and SABG (T6).

Ratings for patient and parent questionnaires, first (F1) and second (F2) formants for vowels /a/, /i/, and /u/, and nasalance scores for non-nasal and nasal sentences, were obtained and analyzed using mixed model analyses of variance.

Ratings worsened at T2. For the vowel /a/, F1 and F2 were unchanged at T2. For the vowel /i/, F1 increased and F2 decreased at T2. For the vowel /u/, F1 was unchanged and F2 decreased at T2. Nasalance was unchanged at T2. All outcome measures returned to T1 levels by T4.

RPE insertion resulted in initial adverse effects on speech perception and production, which decreased to baseline prior to removal. Information regarding transient speech dysfunction and distress may help prepare patients for treatment.

Speech diagnosis and intervention in children with a repaired cleft palate: A qualitative study of Flemish private community speech-language pathologists' practices

Purpose: This study investigated the practice patterns of private community speech-language pathologists (SLPs) when treating children with a repaired cleft of the palate with or without a cleft of the lip (CP ± L). Practices were explored in terms of diagnostics and treatment focus, treatment dosage and experienced difficulties when treating children with a CP ± L.Method: Eleven female private community SLPs, who lived in Flanders (i.e. the northern part of Belgium) and were aged between 23 and 62 years participated in this study. Data were collected from semi-structured face-to-face interviews. The qualitative software program NVivo 12 was used for data analysis. The interviews were analysed using an inductive thematic approach.Result: SLPs reported a lack of available information on speech-related cleft care. SLPs expressed the need to receive a referral letter from the hospital in order to make an adequate speech diagnosis. Most therapists reported that they performed an articulatory assessment combined with a language assessment. Most SLPs used a hybrid treatment model including a variety of intervention techniques. These techniques were not always in line with available scientific evidence. SLPs reported the desire to receive practical step-by-step guidelines on how to provide speech intervention to children with a CP ± L. In contrast, there was a strong consensus among the therapists that an individualised treatment plan is necessary.Conclusion: The results of this study have revealed gaps in the dissemination and implementation of scientific evidence relevant to speech services for children with a CP ± L (i.e. a research-practice gap) in Flanders. Research evidence needs to be adequately translated into clinical practice by providing concrete and practical guidelines.

Farsi version of the CLEFT-Q: translation, cultural adaptation process and reliability

Background

The purpose of this study was the translation and cultural adaptation of the CLEFT-Q to Farsi and evaluating the reliability of it.

Methods

The English version of the CLEFT-Q was translated to Farsi following the guidelines set forth by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). To calculate the reliability, 50 participants filled out the Farsi version of the questionnaire twice at 2-week intervals.

Results

The difficulties during the translation and cultural adaptation process were as follows: 7.56% of items from the independent forward translations, 62.18% of items from the comparison between two forward translations, and 21% of items from the comparison between post-back translation and the original version. The internal consistency and stability of the Farsi version of the CLEFT-Q were 0.979 and 0.997, which both were categorized as excellent.

Conclusion

The Farsi version of the CLEFT-Q is a valid and reliable tool currently available for Farsi-speaking families around the world.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01957-7.

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions

BACKGROUND

There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective.

METHODS

Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties.

RESULTS

Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales.

INTERPRETATION

The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

Core Outcome Set for Reporting Outcomes of Interventions for Velopharyngeal Dysfunction: Final Results of the COS-VPD Initiative

OBJECTIVE

To date, the recording of outcomes of interventions for velopharyngeal dysfunction (VPD) has not been standardized. This makes a comparison of results between studies challenging. The aim of this study was to develop a core outcome set (COS) for reporting outcomes in studies examining the management of VPD.

DESIGN

A two-round Delphi consensus process was used to develop the COS.

PATIENTS, PARTICIPANTS

The expert Delphi panel comprised patients and caregivers of patients with VPD, surgeons and speech and language therapists specializing in cleft palate, and researchers with expertise in VPD.

INTERVENTIONS

A long list of outcomes was derived from the published literature. In each round of a Delphi survey, participants were asked to score outcomes using the Grading of Recommendations, Assessment, Development, and Evaluations scale of 1 to 9, with 1 to 3 labeled "not important," 4 to 6 labeled "important but not critical," and 7 to 9 labeled "critical."

MAIN OUTCOME MEASURE

Consensus criteria were specified a priori. Outcomes with a rating of 75% or more of the panel rating 7 to 9 and 25% or fewer rating 1 to 3 were included in the COS.

RESULTS

A total of 31 core outcomes were identified from the Delphi process. This list was condensed to combine topic areas to produce a final COS of 10 outcomes, including both processes of care and patient-reported outcomes that should be considered for reporting in future studies of VPD.

CONCLUSIONS

Implementation of the COS-VPD will facilitate consistency of outcomes data collection and comparison of results across studies.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

Comparison of Corresponding Scores From the Cleft Hearing Appearance and Speech Questionnaire (CHASQ) and CLEFT-Q in Swedish Patients With Cleft Lip and/or Palate

OBJECTIVE

The primary aim of this study was to compare corresponding scores between 2 existing cleft-specific patient-reported outcome measures (PROMs)-Cleft Hearing Appearance and Speech Questionnaire (CHASQ) and CLEFT-Q. The second aim of the study was to investigate patient opinion on the 2 PROMs.

DESIGN

Cross-sectional questionnaire study.

SETTING

Participants were recruited from a University Hospital. They answered CHASQ and CLEFT-Q either in the hospital or at home.

PARTICIPANTS

Thirty-three participants with cleft lip and/or palate, aged 10 to 19 years.

MAIN OUTCOME MEASURE

CHASQ and CLEFT-Q.

RESULTS

The CHASQ scores and the corresponding CLEFT-Q scores on appearance correlated significantly. Corresponding scores regarding speech did not correlate significantly. A majority, 15 (58%) participants, answered that they liked CLEFT-Q more than CHASQ, 18 participants (69%) thought CHASQ was easier to complete, and 19 (76%) thought CLEFT-Q would better inform health care professionals.

CONCLUSION

Both instruments showed strengths and limitations. Clinicians will have to consider each instrument's respective qualities when choosing to implement either PROM.

Engaging the Voices of Children: A Scoping Review of How Children and Adolescents Are Involved in the Development of Quality-of-Life-Related Measures

OBJECTIVES

Patient-reported outcomes are increasingly recommended to guide patient care, develop and evaluate interventions, and modify health systems. However, not enough is known about whether and how children and adolescents, as "experts" in their own health and quality of life (QoL), are being engaged in the development of instruments. Our goals in this review were (1) to identify all QoL-related instruments that have included children and/or adolescents in the development of questionnaire content, including identification of themes and items; and (2) to report how this was done; and (3) to highlight those that used qualitative methods.

METHODS

MEDLINE and Embase were searched for child- or adolescent-completed QoL-related instruments, supplemented by hand-searching of relevant reviews until 2020. Original development papers were identified and retrieved when possible, from which instrument characteristics and details of qualitative development methods were extracted.

RESULTS

We identified 445 instruments, of which 88 used qualitative methods for content development. Interviews and focus groups were the most common methods. A variety of play techniques were used to engage the child and adolescent participants. The specific criteria for the inclusion of children and adolescents (age, developmental stage, duration, and nonclinical location) varied considerably.

CONCLUSIONS

Researchers frequently involve children and adolescents in qualitative methods when developing QoL-related measures; however, there is little information about the methods used. Better reporting of methodology, improved dissemination of methods guidelines, and research into optimal ways of including children and adolescents in the process of instrument development would be useful.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions

BACKGROUND

The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales.

METHODS

Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity.

RESULTS

1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores.

CONCLUSION

The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

Establishing content validity of an orthodontic subset of the FACE-Q Craniofacial Module in children and young adults with malocclusion

OBJECTIVE

The FACE-Q Craniofacial Module for children and young adults is a patient-reported outcome measure (PROM) designed to measure outcomes for patients aged 8 to 29 years with facial conditions. The aim of this study was to establish content validity of a relevant subset of the module for its use in orthodontic patients with malocclusion.

SETTING AND SAMPLE POPULATION

Experts in orthodontics were emailed and invited to provide feedback through a Research Electronic Data Capture survey. Patient feedback was obtained through cognitive interviews with patients aged 8 to 29 years recruited from a university-based orthodontic clinic in Canada.

MATERIALS AND METHODS

Expert opinion and patient interviews were used to obtain feedback on the content of 4 appearance (face, smile, teeth and jaws) and 1 function (eating and drinking) scales hypothesized to be relevant to orthodontic malocclusions, and to elicit new concepts. Interviews were audio-recorded, transcribed, and coded using a line-by-line approach.

RESULTS

Twenty-one experts and 15 patients participated. Expert feedback led us to drop 9, retain 40, revise 4 and add 16 new items. At the conclusion of cognitive interviews no items were dropped, 55 were retained, 5 were revised and 8 new items were added. The final set of 68 items demonstrated content validity for orthodontic patients.

CONCLUSION

Expert feedback and cognitive interviews enabled us to revise and refine 5 scales as part of the FACE-Q Craniofacial Module for use in orthodontic patients. These scales were included in the internationalfield-test of the FACE-Q Craniofacial Module.

Atypical Outcomes of Nasal and Lip Appearance After Unilateral Cleft Lip Repair: Judgment by Professionals, Patients, and Laypeople

Objective:

To gain more insight into the assessment of “atypical” nasal and lip appearance outcomes compared to “typical” appearance outcomes after unilateral cleft lip and palate (UCLP) repair, when judged by professionals, patients with repaired UCLP, and laypeople.

Design:

An online survey containing 3 series of photographs with various degrees of “typical” and “atypical” nasal and lip appearance outcomes after UCLP repair was sent to 30 professionals, 30 patients with repaired UCLP, and 50 laypeople in 2 countries. Participants were instructed to rank the photographs from excellent to poor based on overall appearance. Mean rank positions of photographs were analyzed and differences in mean rank score between “typical” and “atypical” results were assessed using a T-test. Agreement of ranking between the 3 groups was assessed with an analysis of variance analysis.

Setting:

Amsterdam UMC, location VUmc, Netherlands and Boston Children’s Hospital, Boston, USA.

Patients:

Photographs of 6- to 18-year-old patients with repaired UCLP.

Results:

“Atypical” appearance outcomes were ranked significantly less favorably (small nostril: P = 0.00; low vermillion border: P = 0.02; whistling deformity: P = 0.00) compared to “typical” outcomes. Difference between professionals, patients and laypeople in rank positioning the photographs was not statistically significant (P = 0.89).

Conclusions:

Noses with a smaller nostril and lips containing a whistling deformity were perceived as poorer outcome compared to the “typical” results. Professionals, patients, and laypeople are in agreement when assessing these outcomes.

Self-Consciousness of Appearance in Chinese Patients With Cleft Lip: Validation of the Chinese Derriford Appearance Scale 59 (DAS 59) Instrument

OBJECTIVE

To develop a reliable and valid Chinese version of the Derriford Appearance Scale 59 (DAS 59) instrument for assessing the self-consciousness of appearance in Chinese patients with cleft lip.

METHODS

The original DAS 59 instrument was translated into Mandarin, back-translated, and culturally adapted among the Chinese population, following the protocol of the original DAS 59. The validation of the Chinese DAS 59 instrument was estimated on 443 adult participants including 213 subjects with a history of cleft lip with/without palate (CL/P, study group) and 230 normal subjects without facial appearance concern (control group). The reliability was estimated by Cronbach's α coefficient and Guttman's split-half coefficient. Content validity was tested using the Spearman correlation coefficient, while discriminant validity was tested by the Mann-Whitney U test.

RESULTS

The overall internal consistency of Chinese DAS 59 was excellent; Cronbach's α was 0.951 (α = 0.965 and 0.959 in the study and control groups, respectively). Further, Guttman's split-half coefficient was excellent in the study group (0.935) and control group (0.901). The validity of content was good with an acceptable correlation between all the items and domains. The construct validity through the discrimination was good with a statistically significant difference in most domains between the two groups. Patients with CL/P had more concern about the general self-consciousness and social self-consciousness of appearance. They also showed a good self-concept score.

CONCLUSION

The Chinese version of DAS 59 demonstrated acceptable reliability and good construct and discriminant validity. It can be used for the research and assessment of the psychological state and quality of life for Chinese patients with cleft lip as well as other appearance problems and concerns.

Effectiveness of Speech Intervention in Patients With a Cleft Palate: Comparison of Motor-Phonetic Versus Linguistic-Phonological Speech Approaches

Purpose The purpose of this study was to compare the effect of two different speech therapy approaches, a traditional motor-phonetic approach and a linguistic-phonological approach, on the speech and health-related quality of life in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years old. Method A block-randomized, sham-controlled design was used. Fourteen children with a CP ± L (M _age = 7.71 years) were divided into two groups using block randomization stratified by age and gender: one receiving motor-phonetic intervention (n = 7) and one receiving linguistic-phonological intervention (n = 7). Each group received 10 hr of speech therapy divided over 2 weeks. Perceptual speech assessments were performed on several baseline and posttreatment data points. The psychosocial effects of the intervention were assessed using the patient-reported Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire. Both groups were compared over time using (generalized) linear mixed models. Within-group effects of time were determined using pairwise comparisons with post hoc Bonferroni correction. Results Significant Time × Group interactions with large effect sizes were revealed in terms of consonant proficiency, indicating significant differences in evolution over time among the two groups. Only in the group receiving linguistic-phonological intervention, percentage of correctly produced consonants and places significantly improved after the treatment. Total Velopharyngeal Insufficiency Effects on Life Outcomes scores of the parents significantly improved in both groups after the intervention. Conclusions Both motor-phonetic and linguistic-phonological speech interventions can have a positive impact on the occurrence of cleft speech characteristics and consonant proficiency in children with a CP ± L. A linguistic-phonological approach, however, was observed to be more effective in terms of improving these speech outcomes compared with a motor-phonetic approach. Speech intervention, irrespective of the used approach, significantly improved the participant's health-related quality of life.

Concepts Important to Patients With Facial Differences: A Qualitative Study Informing a New Module of the FACE-Q for Children and Young Adults

Objective:

The concepts important to children and young adults who undergo treatments for facial differences are not well-defined. Measurement of treatment outcomes from the patient’s perspective is necessary to ensure goals of treatment are met. We aimed to identify concepts important to children and young adults with facial differences through a qualitative study.

Design:

An interpretive description qualitative approach was followed. Semistructured interviews were conducted, transcribed verbatim, and coded using a line-by-line approach. Qualitative analysis led to the development of a conceptual framework of outcomes important to patients.

Setting:

Interviews were conducted in Canada and the United Kingdom at home, by telephone, or in the hospital.

Participants:

Participants (N = 72) were recruited between May and June 2014 from craniofacial clinics at the Hospital for Sick Children (Toronto) and Great Ormond Street Hospital (London). Participants included anyone with a visible and/or functional facial difference aged 8 to 29 years and fluent in English, excluding patients with a cleft. The sample included 38 females and 34 males, with a mean age of 13.9 years, and included 28 facial conditions (11 facial paralysis, 18 ear anomalies, 26 skeletal conditions, and 17 soft tissue conditions).

Results:

Analysis led to identification of important concepts within 4 overarching domains: facial appearance, facial function, adverse effects of treatment, and health-related quality of life (psychological, social, and school function).

Conclusions:

Our study provides an understanding of concepts important to children and young adults with facial differences.

Public Perception of a Normal Head Shape in Children With Sagittal Craniosynostosis

: A question that remains unanswered is at what level of surgical correction does the public perceive a head shape to be "normal" or "acceptable?" For most cases of non-syndromic asymptomatic craniosynostosis, the parents desire for surgical correction is to improve the cosmetic appearance of head shape. At the time of this writing, the intraoperative surgeons' perspective of what constitutes an acceptable head shape is the target for surgical correction. In introducing an improved objectively cosmetic goal, an appropriate outcome measure would be to assess what the general public considers a normal or acceptable head shape in children with craniosynostosis.

METHOD

Twenty-two unique images were presented via an online crowdsourcing survey of a severe case of non-syndromic sagittal craniosynosis gradually corrected to an age and gender matched normalized head shape. Participants were recruited via the Sick Kids Twitter account. Participants were invited to rate the head shapes as "normal" or "abnormal."

RESULTS

The 538 participants completed the online survey. Participants were able to reliably and consistently identify normal and abnormal head shapes with a Kappa Score >0.775. Furthermore, participants indicated that a correction of 70% is required in order for the cranial deformity to be regarded as "normal." This threshold closely reflects a normal Cranial Index, which is a widely used morphometric outcome in craniosynostosis.

CONCLUSION

Crowdsourcing provides an ideal method for capturing the general population's perspective on what constitutes a normal and acceptable head shape in children with sagittal craniosynostosis. Laypersons are able to reliably and consistently distinguish cranial deformities from a "normal" head shape. The public indicates a threshold correction of 70% in sagittal craniosynosis to regard it as a "normal" head shape.

The Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Validation Study

Objective:

To reassess reliability and validity of the Submental Nasal Appearance Scale (SNAS) compared to the preliminary pilot study, for assessment of patient photographs with repaired unilateral cleft lip and palate (UCLP). When utilizing the SNAS, 3 nasal features (1. nasal outline; 2. alar base position; 3. nostril axis) must be graded according to symmetry between the cleft and noncleft side using a 5-point scale with reference photographs for each feature. The mean score calculated from the graded features reflects the overall degree of nasal symmetry, which is considered an important goal when repairing UCLP.

Design:

Fifty patient photographs were selected and cropped, displaying the submental view. Six raters assessed these photographs using the SNAS and a separate 5-point scale to assess the overall submental appearance. Interrater reliability was determined for both methods and correlation was calculated between these as an indication of construct validity.

Setting:

Amsterdam UMC, location VUmc, Amsterdam, The Netherlands.

Patients:

Six- to 9-year-old patients with repaired UCLP.

Results:

Interrater reliability of 0.73 and 0.48 was found for the SNAS and overall appearance assessment, respectively, while in the pilot study values of 0.79 and 0.69 were found. Correlation of 0.59 and 0.74 was found in the current and pilot study, respectively, between the SNAS and overall appearance assessment.

Conclusions:

The SNAS is a reliable tool to assess nasal symmetry from the submental perspective. Reliability of the SNAS is higher compared to grading overall appearance, but validity of the SNAS was less well supported.

Three-Dimensional Computer-Assisted Single-Splint 2-Jaw Cleft Orthognathic Surgery: Toward Patient-Centered Surgical Rationale

Skeletally mature patients with cleft lip and palate commonly present with skeletofacial deformities characterized by varying degrees of intrinsic and acquired dentoskeletal and soft tissue abnormalities. These abnormalities are associated with scarring from previous surgeries and the asymmetric midline and facial contour that impose challenges for adequate reconstruction. These patients frequently require 2-jaw orthognathic surgery to improve occlusal function and for correction of facial deformities. In this article, we have detailed a 3-dimensional computer-assisted single-splint 2-jaw orthognathic surgery technique as a surgical approach for cleft skeletofacial reconstruction, allowing for the surgery to be tailored according to the specific needs and requests of the patients. Further, we have addressed the multidimensionality and specificities of cleft treatment, the wide versatility, adaptability, and applicability of this technique, and the patient-centered rationale for the adoption of this method.

Identifying Factors Most Important to Lower Extremity Trauma Patients: Key Concepts from the Development of a Patient-Reported Outcome Instrument for Lower Extremity Trauma, The LIMB-Q

BACKGROUND

Severe lower extremity injuries are challenging to treat. The aspects of limb salvage and amputation most important to patients are not well-defined. This study's aim is to develop a conceptual framework for a patient-reported outcome instrument for lower extremity trauma patients, by defining issues and concepts most important to this patient population.

METHODS

This is an interpretative description of transcripts collected from semistructured qualitative interviews at a single institution. High-energy lower extremity trauma patients were recruited by means of purposeful sampling to maximize variability. Thirty-three participant interviews were needed to reach content saturation. These participants were aged 19 to 79 years; 21 were men (63.6 percent); participation was after reconstruction [n= 15 (45.5 percent)], after amputation [n = 11 (33.3 percent)], or after amputation after failed reconstruction [n = 7 (21.2 percent)]. Interviews were recorded, transcribed, and coded line-by-line. Concepts were labeled with major and minor themes and refined through a process of constant comparison. Analysis led to the development of a conceptual framework and item pool to inform the development of a patient-reported outcome measure.

RESULTS

In total, 2430 unique codes were identified and used to generate the conceptual framework covering 10 major themes: appearance, environment, finances, physical, process of care, prosthesis, psychological, sexual, social, and treatment.

CONCLUSIONS

This study establishes a comprehensive set of concepts, identifying what is most important to severe lower extremity trauma patients. These findings can be used to inform and focus research and clinical care, and provides the framework to develop a lower extremity trauma-specific patient-reported outcome instrument: the LIMB-Q.

Measuring psychological outcomes in paediatric settings: Making outcomes meaningful using client-defined perspectives

There is a growing drive to develop and implement patient-reported outcome measures within paediatric health services, particularly for young people living with chronic health conditions; however, there is little consensus on how best to do this in meaningful ways within psychological services working alongside medical teams. This reflective commentary considers some of the challenges of collecting psychological outcome measures in paediatric services and considers alternative approaches to making outcome measurement meaningful. All measures have their limitations; however, they become meaningless if they are not used in meaningful and considered ways with young people. Client-defined outcome measurement, such as goal-based outcome measures, alongside other types of measurement, can capture outcomes of meaning to young people living with chronic health conditions, and can enable them to feed into a shared decision-making process.

World Cleft Coalition International Treatment Program Standards

OBJECTIVE

To present preliminary efforts to establish an internationally agreed set of minimum core practice and best practice guidelines, along with overarching principles to promote safe and comprehensive cleft care globally.

DESIGN

Representatives from 6 national and international organizations collaborated to form a World Cleft Coalition. Representatives met monthly/bimonthly to compile standards for safe, comprehensive, and sustainable cleft care. Outcomes were circulated within each organization and to a small subset of external constituents for feedback.

RESULTS

A series of overarching principles were established for those involved in International Cleft Treatment Programs, based on the experience of participating organizations. The overarching principles are followed by a structured and detailed Recommended Practice for Ensuring Safe, Comprehensive and Sustainable Cleft Care, which includes minimum core and best practice for the following areas: surgical safety, quality control, patient education, patient selection, patient follow-up, comprehensive care, partnership with the host nations and professionals, training and exchanges for sustainability, and local capacity building.

CONCLUSIONS

Outcomes aimed to provide a working document to define core principles for safe comprehensive cleft care, while balancing various levels of resources, geographic locations, appropriately trained health care professional specialists, and training limitations. The study highlights the process and benefits to a collaborative international working group not only to establish best practice but also to solicit and engage others in discussion of their experiences with building and supporting safe, high-quality, comprehensive, sustainable, worldwide cleft care.

"I smile, but Without Showing My Teeth": The Lived Experience of Cleft, Lip, and Palate in Adults

Objective:

To explore and describe the experience of growing up with unilateral cleft lip and palate (CLP) in adults.

Design:

Face-to-face interviews. Giorgi’s phenomenological method was used for analysis.

Participants:

Twenty-one (mean age: 40.8 years) adults treated for unilateral CLP during childhood and adolescence participated in the study.

Results:

Growing up with CLP meant to become aware of bodily otherness. The possible reactions from peers early in life complicated the striving for inclusion outside the close family. Being self-confident, clever in school, physically fit, and having trusted friends represented barriers against teasing and bullying. Nevertheless, the reflected image, in mirrors, windows, and photos, reminded the participants of the objectifying looks from others and often led to bodily adjustments that persisted into adulthood. The trajectory of treatment was not questioned during childhood, and the participants accepted the decisions on care made by experts and parents. Although problems related to the cleft could persist or return after the termination of ordinary treatment, a more hesitant view on the possible benefits of additional surgery was typical in adulthood.

Conclusions:

In retrospect, growing up with a unilateral CLP was found to have been an unquestioned part of the adult participants’ childhood, a burden that they feared would, to some extent, also be passed to their own children. However, the CLP had not prevented them from achieving goals and satisfaction in life. The occurrence of persisting psychological, functional, and esthetic challenges in adults suggests the need for an individualized, lifelong, and multidisciplinary perspective on CLP follow-up.

Outcomes of Surgical Management of Palatal Fistulae in Patients With Repaired Cleft Palate

BACKGROUND

The palatal fistula is an important surgical challenge within the longitudinal follow-up of patients with repaired cleft palate as the success rate of palatal fistula reconstruction by adopting several surgical techniques is variable and often unsatisfactory. The purpose of this retrospective study was to report the clinical outcomes of an algorithm for the surgical management of palatal fistulae in patients with repaired cleft palate.

METHODS

Consecutive patients (n = 101) with repaired cleft palate and palatal fistula-related symptoms who were treated according to a specific algorithm between 2009 and 2017 were included. Based on the anatomical location (Pittsburgh fistula types II-V), amount of scarring (minimal or severe scarred palate), and diameter of the fistula (≤5 mm or >5 mm), 1 of 3 approaches (local flaps [62.4%], buccinator myomucosal flaps [20.8%], or tongue flaps [16.8%]) was performed. For clinical outcome assessment, symptomatic and anatomical parameters (fistula-reported symptoms and residual fistula, respectively) were combined as follows: complete fistula closure with no symptoms; asymptomatic narrow fistula remained; or failure to repair the fistula ("good," "fair," or "poor" outcomes, respectively). Surgical-related complication data were also collected.

RESULTS

Most patients (91.1%) presented "good" clinical outcomes, ranging from 86.2% to 100% (86.2%, 100%, and 100% for local flaps, buccinator flaps, and tongue flaps, respectively). All (8.9%) "fair" and "poor" outcomes were observed in fistulae reconstructed by local flaps. All "poor" (5%) outcomes were observed in borderline fistulae (4-5 mm). No surgical-related complications (dehiscence, infections, or necrosis) were observed, except for an episode of bleeding after the 1st stage of tongue flap-based reconstruction (1.0%).

CONCLUSION

A high rate of fistula resolution was achieved using this algorithm for surgical management of palatal fistulae in patients with repaired cleft palate.

The Psychosocial Patient-Reported Outcomes of End of Pathway Cleft Surgery: A Systematic Review

OBJECTIVE

To identify and review the literature on the psychosocial patient-reported outcomes (PROs) of surgery at the end of the cleft treatment pathway.

DESIGN

A systematic literature search was performed using electronic databases (Medline, PubMed, EMBASE, PsycInfo, Web of Science, and Science Direct) from database inception to September 2017, to identify studies measuring and reporting the psychosocial PROs of end of pathway cleft surgery.

RESULTS

Of 263 identified papers, 22 studies were eligible for inclusion. Apart from one randomized controlled study, studies were largely observational and adopted a cross-sectional or retrospective design. The majority (n = 16) were small-scale studies. The methodological quality was variable in terms of what, how, and when psychosocial outcomes were measured and reported. None of the studies utilized a psychosocial PRO measure validated in the cleft population, and few studies measured outcomes prospectively. A high proportion of studies utilized bespoke measures of patient satisfaction. Taken together, findings from the included studies are tentative but seem to suggest patients derive some benefit from undergoing end of pathway cleft surgery, in terms of increased satisfaction, quality of life, social interactions, and decreased appearance-related distress.

CONCLUSIONS

Due to methodological challenges and the heterogeneity of what, how, and when outcomes are measured and currently reported, it is difficult to determine the psychosocial PROs of end of pathway cleft surgeries. Consequently, this review advocates the conduct of well-designed, longitudinal studies using cleft-sensitive tool/s to capture the psychosocial PROs of end of pathway cleft surgery at various time points.

Impact of Completing CLEFT-Q Scales That Ask About Appearance on Children and Young Adults: An International Study

OBJECTIVE

To describe the impact of completing the CLEFT-Q appearance scales on patients with cleft lip and/or palate and to identify demographic and clinical characteristics and CLEFT-Q scores associated with reporting a negative impact.

DESIGN

International cross-sectional survey.

SETTING

Recruitment took place between October 2014 and November 2016 at 30 craniofacial clinics located in 12 countries.

PATIENTS

Aged 8 to 29 years with cleft lip and/or palate.

MAIN OUTCOME MEASURE(S)

Participants were asked 4 questions to evaluate the impact of completing the field test version of a patient-reported outcome measure (the CLEFT-Q) that included 154 items, of which 79 (51%) asked about appearance (of the face, nose, nostrils, teeth, lips, jaws, and cleft lip scar).

RESULTS

The sample included 2056 participants. Most participants liked answering the CLEFT-Q (88%) and the appearance questions (82%). After completing the appearance scales, most participants (77%) did not feel upset or unhappy about how they look, and they felt the same (67%) or better (23%) about their appearance after completing the questionnaire. Demographic and clinical variables associated with feeling unhappy/upset or worse about how they look included country of residence, female gender, more severe cleft, anticipating future cleft-specific surgeries, and reporting lower (ie, worse) scores on CLEFT-Q appearance and health-related quality-of-life scales.

CONCLUSION

Most participants liked completing the CLEFT-Q, but a small minority reported a negative impact. When used in clinical practice, CLEFT-Q scale scores should be examined as soon as possible after completion in order that the clinical team might identify patients who might require additional support.

Patient-Centered Satisfaction After Secondary Correction of the Cleft Lip and Nasal Defect

OBJECTIVE

To evaluate patient-reported aesthetic and psychosocial outcomes of secondary cleft lip and nose revision procedures.

DESIGN

Single-center cohort study.

SETTING

Tertiary care pediatric hospital.

PATIENTS/PARTICIPANTS

Patients who underwent secondary revision procedures for cleft lip and nasal defect (N = 42).

INTERVENTIONS

Patients were administered a survey during a routine postoperative clinic visit.

MAIN OUTCOME MEASURE(S)

Outcome measures were planned prior to data collection and included improvement in appearance seen in lip and nose, satisfaction with revision procedure, changes in self-confidence, likelihood to participate in social activities, and effect on teasing by peers.

RESULTS

Patients agreed that an improvement was seen in the appearance of their lip (1.93) and nose (1.98) following surgery. Overall, patients felt satisfied with the results of their revision procedure (1.76). An improvement in confidence and decrease in feelings of self-consciousness was reported. Patients were teased less by their peers and more likely to participate in social activities.

CONCLUSIONS

Secondary revision procedures of the cleft lip and nasal defect provide a patient-reported improvement in appearance and a positive psychosocial impact on patient's lives.

Achieving Consensus in the Measurement of Psychological Adjustment to Cleft Lip and/or Palate at Age 8+ Years

BACKGROUND

Consensus regarding optimal outcome measurement has been identified as one of the most important, yet most challenging developments for the future of cleft lip and/or palate (CL/P) services. In 2011, a process began to adopt a shared conceptual framework and to identify a set of core outcome measures for the comprehensive assessment of psychological adjustment.

OBJECTIVES

The aim of the current article is to outline the collaborative process used to achieve consensus in the academic and clinical measurement of psychological adjustment to CL/P from the age of 8 years onward.

RESULTS

A conceptual framework and corresponding parent- and self-reported outcome measures for use at ages 8, 10, 12, 15, 18, 20, and 25 years have been agreed upon by clinicians, researchers, and patient and parent representatives. All measures have been evaluated according to their psychometric properties, clinical utility, ability to produce meaningful longitudinal data, and a range of pragmatic considerations.

CONCLUSIONS

Although the collaborative process has been challenging and has required ongoing dedication from multiple stakeholders, consistency in data collection over time will allow for key research questions in CL/P to be addressed, both in the United Kingdom (UK) and internationally. The process has also demonstrated the clinical utility of the measures and the potential for the gradual integration of the measures into clinical practice. UK progress has sparked global interest, and the adaptation of the framework and its corresponding measures for worldwide use is now a prominent focus.

One Multidisciplinary Cleft and Craniofacial Team's Experience in Shifting to Family-Centered Care

Family-centered care is a high-priority focus area in health care and is associated with increased family satisfaction and quality of life, better health outcomes and family follow-up, decreased burden of care, and improved efficiency of resource utilization. Motivated by our aim to improve clinic efficiency and patient retention, our multidisciplinary cleft palate and craniofacial center has been undergoing a complex family-centered reorganization over the past 3 years. We seek to share our experience in hope the information will be a useful starting point to other teams in structuring their own family-centered improvements. We suggest the following stepwise method to achieve a more family-centered process: (1) gathering preintervention data, (2) brainstorming challenges with stakeholders, (3) brainstorming solutions with stakeholders, (4) implementation, (5) follow-up and troubleshooting, (6) further implementation, and (7) gathering postintervention data. Additionally, we found the use of institutional resources added substantial value to our efforts.

CLEFT-Q: Detecting Differences in Outcomes among 2434 Patients with Varying Cleft Types

BACKGROUND

Measuring the patient perspective is important in evaluating outcomes of cleft care. Understanding how treatment outcomes vary depending on cleft type may allow for better planning of treatments, setting of expectations, and more accurate benchmarking efforts. The CLEFT-Q is a patient-reported outcome measure for patients with cleft lip and/or palate.

METHODS

The 12 CLEFT-Q scales measuring appearance (i.e., face, nose, nostrils, lips, cleft lip scar, teeth, and jaws), function (i.e., speech), and health-related quality of life (i.e., psychological, school, social, and speech-related distress) were field tested in a cross-sectional study in 30 centers in 12 countries. Patients with cleft lip and/or cleft palate aged 8 to 29 years were recruited from clinical settings. Differences in CLEFT-Q scores by cleft subtypes were evaluated using one-way analysis of variance or Kruskal-Wallis H tests, with Tukey or Dunn procedure with Bonferroni corrections post hoc analyses, respectively. Scores are presented using radar charts to visualize all outcomes simultaneously.

RESULTS

The field test included 2434 patients. Scores on all CLEFT-Q scales varied significantly with cleft subtype. Patients with unilateral or bilateral cleft lip and/or palate scored lower on all appearance scales compared with patients with cleft palate or unilateral incomplete cleft lip. Scores on the speech function and speech-related distress scales decreased with each progressive group in the Veau classification. Patients with complete bilateral cleft lip and palate scored lowest on the social, school, and psychological scales.

CONCLUSIONS

Patient-reported outcomes measured with the CLEFT-Q vary significantly with cleft type. Visualizing multiple outcomes simultaneously with radar charts allows for an understanding of a patient's overall status in a single graph.

Assessing health-related quality of life in patients with cleft palate in resource-limited countries: A preliminary evaluation of the VELO questionnaire in Uganda

BACKGROUND AND AIMS

Studies evaluating health-related quality of life (HRQoL) in patients with cleft palate living in resource-limited countries such as Uganda are scarce. The VELO questionnaire evaluates the impact of speech (and swallowing) difficulties on the patient's HRQoL. The aim was to evaluate an adapted English version of the VELO questionnaire with reduced response options in Ugandan patients with a cleft lip and palate in order to identify influencing factors and future perspectives to implement HRQoL assessement in this population.

METHODS

Based on the responses of 16 parents of patients with cleft palate, 6 adolescent/adult patients with cleft palate and 12 control participants without cleft palate, observations regarding linguistic and cultural difficulties were noted and the discriminant validity and internal consistency of this adapted version of the questionnaire were evaluated. Additionally, the relationship between these responses and perceptually assessed speech parameters was assessed.

RESULTS

Half of the participants (11/22) completed the questionnaire independently, frequently resulting in incomplete responses (8/11). Difficulties with wording and cultural aspects influencing the responses were identified. The subscales showed excellent internal consistency, with the exception of the subscale 'swallowing problems'. The score on the subscale 'perception by others' of the parent report showed no significant difference with the score of the control group. The total score on the parent report and the youth report was (borderline) significantly related to the speech variables speech understandability, speech acceptability and the VPC-SUM.

DISCUSSION AND CONCLUSION

Promising results regarding the validity and internal consistency of the adapted instrument were found, indicating the potential of the VELO questionnaire for HRQoL assessment at the CoRSU hospital in Uganda. However, results should be interpreted cautiously, given that all participants had a primary language other than English, the small sample size with skewed distribution of speech characteristics, and the bias induced by socially desirable responses. In future studies, adaptations based on qualitative research to account for linguistic and cultural aspects, followed by a rigorous forward-backward translation of the questionnaire to English and Luganda are needed.