Gastrointestinal parasites in captive olive baboons in a UK safari park

From the safety inside vehicles, Knowsley Safari offers visitors a close-up encounter with captive olive baboons. As exiting vehicles may be contaminated with baboon stool, a comprehensive coprological inspection was conducted to address public health concerns. Baboon stools were obtained from vehicles, and sleeping areas, inclusive of video analysis of baboon–vehicle interactions. A purposely selected 4-day sampling period enabled comparative inspections of 2662 vehicles, with a total of 669 baboon stools examined (371 from vehicles and 298 from sleeping areas). As informed by our pilot study, front-line diagnostic methods were: QUIK-CHEK rapid diagnostic test (RDT) (Giardia and Cryptosporidium), Kato–Katz coproscopy (Trichuris) and charcoal culture (Strongyloides). Some 13.9% of vehicles were contaminated with baboon stool. Prevalence of giardiasis was 37.4% while cryptosporidiosis was <0.01%, however, an absence of faecal cysts by quality control coproscopy, alongside lower than the expected levels of Giardia-specific DNA, judged RDT results as misleading, grossly overestimating prevalence. Prevalence of trichuriasis was 48.0% and strongyloidiasis was 13.7%, a first report of Strongyloides fuelleborni in UK. We advise regular blanket administration(s) of anthelminthics to the colony, exploring pour-on formulations, thereafter, smaller-scale indicator surveys would be adequate.

Timing of Primary Surgery for Cleft Palate

BACKGROUND

Among infants with isolated cleft palate, whether primary surgery at 6 months of age is more beneficial than surgery at 12 months of age with respect to speech outcomes, hearing outcomes, dentofacial development, and safety is unknown.

METHODS

We randomly assigned infants with nonsyndromic isolated cleft palate, in a 1:1 ratio, to undergo standardized primary surgery at 6 months of age (6-month group) or at 12 months of age (12-month group) for closure of the cleft. Standardized assessments of quality-checked video and audio recordings at 1, 3, and 5 years of age were performed independently by speech and language therapists who were unaware of the trial-group assignments. The primary outcome was velopharyngeal insufficiency at 5 years of age, defined as a velopharyngeal composite summary score of at least 4 (scores range from 0 to 6, with higher scores indicating greater severity). Secondary outcomes included speech development, postoperative complications, hearing sensitivity, dentofacial development, and growth.

RESULTS

We randomly assigned 558 infants at 23 centers across Europe and South America to undergo surgery at 6 months of age (281 infants) or at 12 months of age (277 infants). Speech recordings from 235 infants (83.6%) in the 6-month group and 226 (81.6%) in the 12-month group were analyzable. Insufficient velopharyngeal function at 5 years of age was observed in 21 of 235 infants (8.9%) in the 6-month group as compared with 34 of 226 (15.0%) in the 12-month group (risk ratio, 0.59; 95% confidence interval, 0.36 to 0.99; P = 0.04). Postoperative complications were infrequent and similar in the 6-month and 12-month groups. Four serious adverse events were reported (three in the 6-month group and one in the 12-month group) and had resolved at follow-up.

CONCLUSIONS

Medically fit infants who underwent primary surgery for isolated cleft palate in adequately resourced settings at 6 months of age were less likely to have velopharyngeal insufficiency at the age of 5 years than those who had surgery at 12 months of age. (Funded by the National Institute of Dental and Craniofacial Research; TOPS ClinicalTrials.gov number, NCT00993551.).

Preventing Pain and Stress-Related Ill-Health in Employees: A 6-Months Follow-Up of a Psychosocial Program in a Cluster Randomized Controlled Trial

Purpose Pain and stress-related ill-health are major causes of long-term disability and sick leave. This study evaluated the effects of a brief psychosocial program, which previously has been tested for an at-risk population of employees. Methods The Effective Communication within the Organization (ECO) program, where supervisors and employees were trained in communication and problem solving, was compared to an active control consisting of psychoeducative lectures (PE) about pain and stress in a cluster randomized controlled trial. First-line supervisors were randomized to ECO or PE, and a total of 191 mainly female employees with self-reported pain and/or stress-related ill-health were included. The hybrid format programs consisted of 2-3 group sessions. Sick leave data was collected from social insurance registers, before and 6-months after the program. Secondary outcomes (work ability, work limitations, pain-disability risk, exhaustion symptoms, perceived stress, perceived health, quality of life, perceived communication and support from supervisors) were assessed at baseline, post intervention, and at 6-months follow-up. Results No effects were observed on primary or secondary outcome variables. Pain symptoms were common (89%), however a lower proportion (30%) were identified as at risk for long-term pain disability, which might explain the lack of evident effects. The Covid-19 pandemic affected participation rates and delivery of intervention. Conclusion In this study, preventive effects of the ECO program were not supported. Altogether, the findings point at the importance of selecting participants for prevention based on screening of psychosocial risk. Further research on workplace communication and support, and impact on employee health is warranted.

Inhibition of the Beta-oxidation Pathway of Fatty Acids and Dopamine- Beta-hydroxylase by Phenyl Derivatives of Short- Chain Fatty Acids from Gastrointestinal Clostridia Bacteria is a (the) Major Cause of Autism

Background

A The author's comprehensive evaluation of the biochemical metabolomic literature over more than 40 years discusses multiple studies documenting abnormal elevations of the neurotransmitter dopamine and its metabolites as well as inhibitors of dopamine beta hydroxylase (DBH) from Clostridia bacteria in urine samples and cerebrospinal fluid samples of children with autism.

Aims of Review

The evaluation intends to elucidate the reasons for the elevation of dopamine and its metabolites in urine and their relationship to increased Clostridia colonization of the gastrointestinal tract in children with autism. In addition, to the evaluation of Clostridia metabolism and its effects on abnormal dopamine metabolism in autism, a secondary aim intends to demonstrate as a hypothesis that one particular metabolite of Clostridia bacteria-3-hydroxy-(3-hydroxyphenyl)- 3-hydroxypropionic acid (HPHPA)-may cause even more severe effects on in autism than other metabolites by leading to depletion of free coenzyme A (CoASH). This depletion of free Coenzyme A leads to a deficiency of cholesterol and activated palmitic acid needed for activation of the key brain developmental protein sonic hedgehog, which has recently been research has shown to be severely abnormal in severe autism.

Key Scientific Concepts of Review

Laboratories throughout the world have consistently found high quantities of HPHPA and 4-cresol in high percentages of urine samples of children with autism. Those inhibitors, which intestinal Clostridia bacteria produce, cause an elevation in dopamine and its metabolites, which affect the brain's and the sympathetic nervous system's key enzyme dopamine-beta-hydroxylase (DBH). Excessive dopamine and its toxic metabolites due to these DBH inhibitors may cause brain damage due to excessive unstable dopamine quinones, toxic adducts of dopamine disrupting brain mitochondrial energy production, and oxygen superoxide. HPHPA, a short chain phenyl compound, may have additional biochemical effects on the brain in autism, causing a reduction in free CoASH needed to produce the CoA palmitic acid derivative necessary to activate the key brain developmental protein sonic hedgehog. The depletion of CoASH appears to be a new therapeutic target to reverse the adverse effects of the HPHPA metabolite on the beta oxidation of fatty acids and cholesterol synthesis that are prevalent in autism.

Conclusions

Variations in the severity of autism could be based on the types and concentrations of the Clostridia markers produced and the extent to which these markers, such as HPHPA, have depleted critical lipids, such as cholesterol and CoA palmitic acid derivative. Patients need those lipids for the activation of the developmental protein sonic hedgehog. In addition, the sequestration of coenzyme A by short chain adducts of Clostridia leads to the depletion of critical free CoASH, needed throughout intermediary metabolism, and creates a biochemical storm that especially affects brain function.

Inter-rater reliability in classification of canonical babbling status based on canonical babbling ratio in infants with isolated cleft palate randomised to Timing of Primary Surgery for Cleft Palate (TOPS)

Canonical babbling (CB) is commonly defined as present when at least 15% of all syllables produced are canonical, in other words a canonical babbling ratio (CBR) ≥0.15. However, there is limited knowledge about inter-rater reliability in classification of CB status based on CBR and inter-rater differences in assessment of CBR. We investigated inter-rater reliability of experienced Speech Language Therapists (SLTs) on: classification of CB status based on CBR ≥ 0.15, CBRs and the total number of syllables per infant used to calculate CBR.Each infant (n = 484) was video-recorded at a clinical site in play interaction with their parent as part of the randomised controlled trial Timing of Primary Surgery for Cleft Palate. Each recording was subsequently assessed by three independent SLTs, from a pool of 29 SLTs. They assessed the recordings in real time.The three assessing SLTs agreed in classification of CB status in 423 (87.4%) infants, with higher complete agreement for canonical (91%; 326/358) than non-canonical (77%; 97/126). The average difference in CBR and total number of syllables identified between the SLT assessments of each infant was 0.12 and 95, respectively.This study provided new evidence that one trained SLT can reliably classify CB status (CBR ≥ 0.15) in real time when there is clear distinction between the observed CBR and the boundary (0.15); however, when the observed CBR approaches the boundary multiple SLT assessments are beneficial. Thus, we recommend to include assessment of inter-rater reliability, if the purpose is to compare CBR and total syllable count across infants or studies.Trial registration number here: www.clinicaltrials.gov, identifier NCT00993551.

Clinical acceptability of fully automated external beam radiotherapy for cervical cancer with three different beam delivery techniques

Purpose

To fully automate CT‐based cervical cancer radiotherapy by automating contouring and planning for three different treatment techniques.

Methods

We automated three different radiotherapy planning techniques for locally advanced cervical cancer: 2D 4‐field‐box (4‐field‐box), 3D conformal radiotherapy (3D‐CRT), and volumetric modulated arc therapy (VMAT). These auto‐planning algorithms were combined with a previously developed auto‐contouring system. To improve the quality of the 4‐field‐box and 3D‐CRT plans, we used an in‐house, field‐in‐field (FIF) automation program. Thirty‐five plans were generated for each technique on CT scans from multiple institutions and evaluated by five experienced radiation oncologists from three different countries. Every plan was reviewed by two of the five radiation oncologists and scored using a 5‐point Likert scale.

Results

Overall, 87%, 99%, and 94% of the automatically generated plans were found to be clinically acceptable without modification for the 4‐field‐box, 3D‐CRT, and VMAT plans, respectively. Some customizations of the FIF configuration were necessary on the basis of radiation oncologist preference. Additionally, in some cases, it was necessary to renormalize the plan after it was generated to satisfy radiation oncologist preference.

Conclusion

Approximately, 90% of the automatically generated plans were clinically acceptable for all three planning techniques. This fully automated planning system has been implemented into the radiation planning assistant for further testing in resource‐constrained radiotherapy departments in low‐ and middle‐income countries.

Automatic contouring QA method using a deep learning-based autocontouring system

Purpose

To determine the most accurate similarity metric when using an independent system to verify automatically generated contours.

Methods

A reference autocontouring system (primary system to create clinical contours) and a verification autocontouring system (secondary system to test the primary contours) were used to generate a pair of 6 female pelvic structures (UteroCervix [uterus + cervix], CTVn [nodal clinical target volume (CTV)], PAN [para‐aortic lymph nodes], bladder, rectum, and kidneys) on 49 CT scans from our institution and 38 from other institutions. Additionally, clinically acceptable and unacceptable contours were manually generated using the 49 internal CT scans. Eleven similarity metrics (volumetric Dice similarity coefficient (DSC), Hausdorff distance, 95% Hausdorff distance, mean surface distance, and surface DSC with tolerances from 1 to 10 mm) were calculated between the reference and the verification autocontours, and between the manually generated and the verification autocontours. A support vector machine (SVM) was used to determine the threshold that separates clinically acceptable and unacceptable contours for each structure. The 11 metrics were investigated individually and in certain combinations. Linear, radial basis function, sigmoid, and polynomial kernels were tested using the combinations of metrics as inputs for the SVM.

Results

The highest contouring error detection accuracies were 0.91 for the UteroCervix, 0.90 for the CTVn, 0.89 for the PAN, 0.92 for the bladder, 0.95 for the rectum, and 0.97 for the kidneys and were achieved using surface DSCs with a thickness of 1, 2, or 3 mm. The linear kernel was the most accurate and consistent when a combination of metrics was used as an input for the SVM. However, the best model accuracy from the combinations of metrics was not better than the best model accuracy from a surface DSC as an input.

Conclusions

We distinguished clinically acceptable contours from clinically unacceptable contours with an accuracy higher than 0.9 for the targets and critical structures in patients with cervical cancer; the most accurate similarity metric was surface DSC with a thickness of 1, 2, or 3 mm.

Barriers and Facilitators of Implementing Automated Radiotherapy Planning: A Multisite Survey of Low- and Middle-Income Country Radiation Oncology Providers

PURPOSE

Global access to radiotherapy (RT) is inequitable, with obstacles to implementing modern technologies in low- and middle- income countries (LMICs). The Radiation Planning Assistant (RPA) is a web-based automated RT planning software package intended to increase accessibility of high-quality RT planning. We surveyed LMIC RT providers to identify barriers and facilitators of future RPA deployment and uptake.

METHODS

RT providers underwent a pilot RPA teaching session in sub-Saharan Africa (Botswana, South Africa, and Tanzania) and Central America (Guatemala). Thirty providers (30 of 33, 90.9% response rate) participated in a postsession survey.

RESULTS

Respondents included physicians (n = 10, 33%), physicists (n = 9, 30%), dosimetrists (n = 8, 27%), residents/registrars (n = 1, 3.3%), radiation therapists (n = 1, 3.3%), and administrators (n = 1, 3.3%). Overall, 86.7% expressed interest in RPA; more respondents expected that RPA would be usable in 2 years (80%) compared with now (60%). Anticipated barriers were lack of reliable internet (80%), potential subscription fees (60%), and need for functionality in additional disease sites (48%). Expected facilitators included decreased workload (80%), decreased planning time (72%), and ability to treat more patients (64%). Forty-four percent anticipated that RPA would help transition from 2-dimensional to 3-dimensional techniques and 48% from 3-dimensional to intensity-modulated radiation treatment. Of a maximum acceptability/feasibility score of 60, physicians (45.6, standard deviation [SD] = 7.5) and dosimetrists (44.3, SD = 9.1) had lower scores than the mean for all respondents (48.3, SD = 7.7) although variation in scores by roles was not significantly different (P = .21).

CONCLUSION

These data provide an early assessment and create an initial framework to identify stakeholder needs and establish priorities to address barriers and promote facilitators of RPA deployment and uptake across global sites, as well as to tailor to needs in LMICs.

Does Sleep Position Influence Sleep-Disordered Breathing in Infants With Cleft Palate: A Feasibility Study?

OBJECTIVE

Cleft palate (CP) can affect breathing, leading to sleep-disordered breathing (SDB). Sleep position can affect SDB, but the optimum sleep position for infants with CP is unknown. We aimed to determine the design of a pragmatic study to investigate the effect of the 2 routinely advised sleep positions in infants with CP on oxygen saturations.

DESIGN

A multicentered observational cohort.

SETTING

Four UK-based cleft centers, 2 advising supine- and 2 side-lying sleep positions for infants with CP.

PARTICIPANTS

Infants with isolated CP born July 1, 2015, and December 31, 2016. Of 48 eligible infants, 30 consented (17 side-lying; 13 supine).

INTERVENTIONS

Oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2) home monitoring at age 1 and 3 months. Qualitative interviews of parents.

OUTCOME MEASURES

Willingness to participate, recruitment, retention, and acceptability/success (>90 minutes recording) of SpO2 and ETCO2 monitoring.

RESULTS

SpO2 recordings were obtained during 50 sleep sessions on 24 babies (13 side-lying) at 1 month (34 sessions >90 minutes) and 50 sessions on 19 babies (10 side-lying) at 3 months (27 sessions >90 minutes). The ETCO2 monitoring was only achieved in 12 sessions at 1 month and 6 at 3 months; only 1 was >90 minutes long. The ETCO2 monitoring was reported by the majority as unacceptable. Parents consistently reported the topic of sleep position in CP to be of importance.

CONCLUSIONS

This study has demonstrated that it is feasible to perform domiciliary oxygen saturation studies in a research setting and has suggested that there may be a difference in the effects of sleep position that requires further investigation. We propose a study with randomization is indicated, comparing side-lying with supine-lying sleep position, representing an important step toward better understanding of SDB in infants with CP.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: comparison of dental arch relationships and dental indices at 5, 8, and 10 years

Background and trial design

The Scandcleft intercentre study evaluates the outcomes of four surgical protocols (common method Arm A, and methods B, C, and D) for treatment of children with unilateral cleft lip and palate (UCLP) in a set of three randomized trials of primary surgery (Trials 1, 2, and 3).

Objectives

To evaluate and compare dental arch relationships of 5-, 8-, and 10-year-old children with UCLP after four different protocols of primary surgery and to compare three dental indices. The results are secondary outcomes of the overall trial.

Methods

Study models taken at the ages of 5 (n = 418), 8 (n = 411), and 10 years (n = 410) were analysed by a blinded panel of orthodontists using the Eurocran index, the 5-year-olds’ (5YO) index, and the GOSLON Yardstick. Student’s t-test, Pearson’s correlation, chi-square test, and kappa statistics were used in statistical analyses.

Results

The reliability of the dental indices varied between moderate and very good, and those of the Eurocran palatal index varied between fair and very good. Significant correlations existed between the dental indices at all ages. No differences were found in the mean 5-, 8-, and 10-year index scores or their distributions within surgical trials. Comparisons between trials detected significantly better mean index scores in Trial 2 Arm C (at all ages) and in Trial 1 Arm B (at 5 and 10 years of age) than in Trial 3 Arm D. The mean Eurocran dental index scores of the total material at 5, 8, and 10 years of age were 2.50, 2.60, and 2.26, and those of the 5YO index and GOSLON Yardstick were 2.77, 2.90, and 2.54, respectively. At age 10 years, 75.8% of the patients had had orthodontic treatment.

Conclusions

The results of these three trials do not provide evidence that one surgical method is superior to the others. The reliabilities of the dental indices were acceptable, and significant correlations existed between the indices at all ages. The reliability of the Eurocran palatal index was questionable.

Trial registration

ISRCTN29932826.

Pain psychology in the 21st century: lessons learned and moving forward

Background and aims In the spring of 2019, Professor Steven J. Linton, the founder of the Center for Health and Medical Psychology (CHAMP) at Örebro University, Sweden, formally retired. As a tribute to his scholarly work covering decades of influence and inspiration to the field of pain psychology, the research center organized a topical conference titled "Pain in the 21st century: Where do we come from and where are we going?", which resulted in this state-of the-art synthesis. The aim of this declaration is to highlight lessons learned but not in the least is meant to inspire and guide our continued journey forward, developing pain psychology into the 21st century. Methods Several collaborators of Professor Linton have summarized and reflected on the current state-of-the-art of pain psychology from the perspective of his input to the field, as well as on developments from the last years of advancements in pain psychology. Results The topics have been divided into six themed sections covering the fear avoidance model, transdiagnostics, secondary prevention, risk- and protective factors, communication and contextual factors. The sections cover a broad spectrum, from basic experimental studies, integrating emotion and motivational theories into current theoretical models, to applied research on the effect of early interventions as well as sophisticated emotion-focused treatment models for pain patients with concurrent emotional ill-health. Conclusions There have been major advancements within pain psychology research during the last decades, moving the field towards a more comprehensive picture, taking emotional and motivational aspects into account to understand pain sufferers. Although psychologically informed interventions in general mainly focus on the individual, it has been put forward that pain management is highly influenced by the surrounding environment, including communication with health care providers, and the occupational and social context. Implications Professor Steven J. Linton has been at the forefront of pain psychology research during the last decades, and inspired by his work this journey will continue into the 21st century, with the ultimate goal of enhancing the understanding and treatment for all people suffering from persistent and disabling pain.

Development of intra-oral automated landmark recognition (ALR) for dental and occlusal outcome measurements

Background

Previous studies embracing digital technology and automated methods of scoring dental arch relationships have shown that such technology is valid and accurate. To date, however there is no published literature on artificial intelligence and machine learning to completely automate the process of dental landmark recognition.

Objectives

This study aimed to develop and evaluate a fully automated system and software tool for the identification of landmarks on human teeth using geometric computing, image segmenting, and machine learning technology.

Methods

Two hundred and thirty-nine digital models were used in the automated landmark recognition (ALR) validation phase, 161 of which were digital models from cleft palate subjects aged 5 years. These were manually annotated to facilitate qualitative validation. Additionally, landmarks were placed on 20 adult digital models manually by 3 independent observers. The same models were subjected to scoring using the ALR software and the differences (in mm) were calculated. All the teeth from the 239 models were evaluated for correct recognition by the ALR with a breakdown to find which stages of the process caused the errors.

Results

The results revealed that 1526 out of 1915 teeth (79.7%) were correctly identified, and the accuracy validation gave 95% confidence intervals for the geometric mean error of [0.285, 0.317] for the humans and [0.269, 0.325] for ALR—a negligible difference.

Conclusions/implications

It is anticipated that ALR software tool will have applications throughout clinical dentistry and anthropology, and in research will constitute an accurate and objective tool for handling large datasets without the need for time intensive employment of experts to place landmarks manually.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: impact of maxillary dental agenesis on craniofacial growth and dental arch relationship in 8 year olds

BACKGROUND

It is suggested that dental agenesis affects maxillary protrusion and dental arch relationship in children with unilateral cleft lip and palate (UCLP). In addition, an association between the need for orthognathic surgery and dental agenesis is reported.

AIM

The aim was to study the impact of maxillary dental agenesis on craniofacial growth and dental arch relationship in 8-year-old children with UCLP.

SUBJECTS AND METHODS

The sample consisted of individuals with UCLP from Scandcleft randomized trials. The participants had available data from diagnosis of maxillary dental agenesis as well as cephalometric measurements (n = 399) and GOSLON assessment (n = 408) at 8 years of age.

RESULTS

A statistically significant difference was found for ANB between individuals with agenesis of two or more maxillary teeth (mean 1.52°) in comparison with those with no or only one missing maxillary tooth (mean 3.30° and 2.70°, respectively). Mean NSL/NL was lower among individuals with agenesis of two or more maxillary teeth (mean 9.90°), in comparison with individuals with no or one missing maxillary tooth (mean 11.46° and 11.45°, respectively). The number of individuals with GOSLON score 4-5 was 47.2% in the group with two or more missing maxillary teeth and 26.1% respectively 26.3% in the groups with no or one missing maxillary tooth. No statistically significant difference was found in the comparison between individuals with no agenesis or with agenesis solely of the cleft-side lateral.

CONCLUSION

Maxillary dental agenesis impacts on craniofacial growth as well as dental arch relationship and should be considered in orthodontic treatment planning.

Exploring pain phenotypes in workers with chronic low back pain: Application of IMMPACT recommendations

Background: Chronic low back pain (CLBP) is a major cause of disability globally. Stratified care has been proposed as a means to improve prognosis and treatment but is generally based on limited aspects of pain, including biopsychosocial drivers.

Aims: Following Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations, the present study explored pain phenotypes with a sample of workers with CLBP, a population for which no pain phenotypes have been derived to date.

Methods: A cross-sectional design was used with a sample of 154 workers with CLBP attending a rehabilitation clinic, recruited in person and from social media. Latent class analysis was used to identify subgroups of patients with different pain profiles based on ten pain indicators (pain variability, pain intensity, pain quality, somatization, sleep quality, depression, fatigue, pain catastrophizing, neuropathic pain, and central sensitization).

Results: The majority of the sample (85%) were recruited through social media. Both the two-class and three-class solutions were found to be satisfactory in distinguishing phenotypes of workers with CLBP. Three variables proved particularly important in distinguishing between the pain phenotypes—pain quality, fatigue, and central sensitization—with higher scores on these indicators associated with pain phenotypes with higher pain burden. Increased chronic pain self-efficacy, work-related support, and perceived work abilities were protective risk factors for being in a higher pain burden class.

Conclusions: The present study is the first to explore IMMPACT recommendations for pain phenotyping with workers with CLBP. Future prospective research will be needed to validate the proposed pain phenotypes.

Adding a fourth rater to three had little impact in pre-linguistic outcome classification

The consequence of differing levels of agreement across raters is rarely studied. Subsequently, knowledge is limited on how number of raters affects the outcome. The present study aimed to examine the impact on pre-linguistic outcome classifications of 12-month-old infants when using four raters compared to three. Thirty experienced Speech and Language Therapists (SLTs) from five countries assessed 20 minute video recordings of four 12-month-old infants during a play session with a parent. One recording was assessed twice. A naturalistic listening method in real time was used. This involved: (1) assessing, each syllable as canonical or non-canonical, and (2) following the recording, assessing if the infant was babbling canonically and listing the syllables the infant produced with command. The impact that four raters had on outcome, compared to three, was explored by classifying the outcome based on all possible combinations of three raters and determining the frequency that the outcome assessment changed when a fourth assessor was added. Results revealed that adding a fourth rater had a minimal impact on canonical babbling ratio assessment. Presence/absence of canonical babbling and size of consonant inventory showed a negligible impact on three out of four recordings, whereas the size of syllable inventory and presence/absence of canonical babbling was minimally affected in one recording by adding a fourth rater. In conclusion, adding a forth rater in assessment of pre-linguistic utterances in 12-month-old infants with naturalistic assessment in real time does not affect outcome classifications considerably. Thus, using three raters, as opposed to four, is recommended.

A randomised controlled trial comparing palate surgery at 6 months versus 12 months of age (the TOPS trial): a statistical analysis plan

Background

Cleft palate is among the most common birth abnormalities. The success of primary surgery in the early months of life is crucial for successful feeding, hearing, dental development, and facial growth. Over recent decades, age at palatal surgery in infancy has reduced. The Timing Of Primary Surgery for cleft palate (TOPS) trial aims to determine whether, in infants with cleft palate, it is better to perform primary surgery at age 6 or 12 months (corrected for gestational age).

Methods/design

The TOPS trial is an international, two-arm, parallel group, randomised controlled trial. The primary outcome is insufficient velopharyngeal function at 5 years of age. Secondary outcomes, measured at 12 months, 3 years, and 5 years of age, include measures of speech development, safety of the procedure, hearing level, middle ear function, dentofacial development, and growth. The analysis approaches for primary and secondary outcomes are described here, as are the descriptive statistics which will be reported. The TOPS protocol has been published previously.

Discussion

This paper provides details of the planned statistical analyses for the TOPS trial and will reduce the risk of outcome reporting bias and data-driven results.

Trial registration

ClinicalTrials.gov NCT00993551. Registered on 9 October 2009.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04886-y.

Scandcleft trial of primary surgery for unilateral cleft lip and palate: Craniofacial cephalometrics at 8 years

BACKGROUND

The Scandcleft trial is a randomized controlled trial that includes children with unilateral cleft lip and palate where registrations are standardized and therefore provides the opportunity to describe craniofacial characteristics in a very large sample of patients.

OBJECTIVES

The aim of this study was to describe craniofacial growth and morphology in a large study sample of 8-year-old children with unilateral cleft lip and palate (UCLP); before orthodontic treatment and before secondary alveolar bone grafting; and to compare the cephalometric values with age-matched non-cleft children from previous growth studies to identify the differences between untreated cleft- and non-cleft children.

MATERIALS

There are 429 eight-year-old UCLP patients in the Scandcleft study group. A total of 408 lateral cephalograms with a mean age of 8.1 years were analysed. Cephalometric analyses were performed digitally. The results from three previously published growth studies on non-cleft children were used for comparison.

RESULTS

Cephalometric analyses showed a large variation in craniofacial morphology among the UCLP group. In general, they present with significant maxillary retrusion and reduced intermaxillary relationships compared to the age-matched non-cleft children. In addition, the vertical jaw relationship was decreased, mainly due to decreased maxillary inclination. The upper and lower incisors were retroclined. It can be expected that these differences will increase in significance as the children age.

CONCLUSION

Results from this study provide proposed norms for the young UCLP before any orthodontic treatment and can be valuable for the clinician in future treatment planning.

TRIAL REGISTRATION

ISRCTN29932826.

Automatic contouring system for cervical cancer using convolutional neural networks

PURPOSE

To develop a tool for the automatic contouring of clinical treatment volumes (CTVs) and normal tissues for radiotherapy treatment planning in cervical cancer patients.

METHODS

An auto-contouring tool based on convolutional neural networks (CNN) was developed to delineate three cervical CTVs and 11 normal structures (seven OARs, four bony structures) in cervical cancer treatment for use with the Radiation Planning Assistant, a web-based automatic plan generation system. A total of 2254 retrospective clinical computed tomography (CT) scans from a single cancer center and 210 CT scans from a segmentation challenge were used to train and validate the CNN-based auto-contouring tool. The accuracy of the tool was evaluated by calculating the Sørensen-dice similarity coefficient (DSC) and mean surface and Hausdorff distances between the automatically generated contours and physician-drawn contours on 140 internal CT scans. A radiation oncologist scored the automatically generated contours on 30 external CT scans from three South African hospitals.

RESULTS

The average DSC, mean surface distance, and Hausdorff distance of our CNN-based tool were 0.86/0.19 cm/2.02 cm for the primary CTV, 0.81/0.21 cm/2.09 cm for the nodal CTV, 0.76/0.27 cm/2.00 cm for the PAN CTV, 0.89/0.11 cm/1.07 cm for the bladder, 0.81/0.18 cm/1.66 cm for the rectum, 0.90/0.06 cm/0.65 cm for the spinal cord, 0.94/0.06 cm/0.60 cm for the left femur, 0.93/0.07 cm/0.66 cm for the right femur, 0.94/0.08 cm/0.76 cm for the left kidney, 0.95/0.07 cm/0.84 cm for the right kidney, 0.93/0.05 cm/1.06 cm for the pelvic bone, 0.91/0.07 cm/1.25 cm for the sacrum, 0.91/0.07 cm/0.53 cm for the L4 vertebral body, and 0.90/0.08 cm/0.68 cm for the L5 vertebral bodies. On average, 80% of the CTVs, 97% of the organ at risk, and 98% of the bony structure contours in the external test dataset were clinically acceptable based on physician review.

CONCLUSIONS

Our CNN-based auto-contouring tool performed well on both internal and external datasets and had a high rate of clinical acceptability.

Validity of the Work Assessment Triage Tool for Selecting Rehabilitation Interventions for Workers' Compensation Claimants with Musculoskeletal Conditions

Purpose The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions for patients with musculoskeletal disorders. The WATT categorizes patients based on individual characteristics according to likelihood of successful return to work following rehabilitation. A previous validation showed acceptable classification accuracy, but we re-examined accuracy using a new dataset drawn from the same system 2 years later. Methods A population-based cohort design was used, with data extracted from a Canadian compensation database on workers considered for rehabilitation between January 2013 and December 2016. Data were obtained on demographic, clinical, and occupational characteristics, type of rehabilitation undertaken, and return to work outcomes. Analysis included classification accuracy statistics of WATT recommendations. Results The sample included 28,919 workers (mean age 43.9 years, median duration 56 days), of whom 23,124 experienced a positive outcome within 30 days following return to work assessment. Sensitivity of the WATT for selecting successful programs was 0.13 while specificity was 0.87. Overall accuracy was 0.60 while human recommendations were higher at 0.72. Conclusions Overall accuracy of the WATT for selecting successful rehabilitation programs declined in a more recent cohort and proved less accurate than human clinical recommendations. Algorithm revision and further validation is needed.

Computer-Aided Whole-Cell Design: Taking a Holistic Approach by Integrating Synthetic With Systems Biology

Computer-aided design (CAD) for synthetic biology promises to accelerate the rational and robust engineering of biological systems. It requires both detailed and quantitative mathematical and experimental models of the processes to (re)design biology, and software and tools for genetic engineering and DNA assembly. Ultimately, the increased precision in the design phase will have a dramatic impact on the production of designer cells and organisms with bespoke functions and increased modularity. CAD strategies require quantitative models of cells that can capture multiscale processes and link genotypes to phenotypes. Here, we present a perspective on how whole-cell, multiscale models could transform design-build-test-learn cycles in synthetic biology. We show how these models could significantly aid in the design and learn phases while reducing experimental testing by presenting case studies spanning from genome minimization to cell-free systems. We also discuss several challenges for the realization of our vision. The possibility to describe and build whole-cells in silico offers an opportunity to develop increasingly automatized, precise and accessible CAD tools and strategies.

Case Study: Rapid Complete Recovery From An Autism Spectrum Disorder After Treatment of Aspergillus With The Antifungal Drugs Itraconazole And Sporanox

CONTEXT

A child with symptoms placing him within the autism spectrum and with urine biochemical markers consistent with fungal (Aspergillus) colonization of the gastrointestinal tract was first treated with the antifungal probiotic Saccharomyces boulardii. A dramatic Herxheimer reaction provided strong clinical indications that mold colonization might be a factor in causing autism in this child.

OBJECTIVE

The child's physician (Baker) wished to try a more potent antifungal therapy, itraconazole, in an attempt to reverse the child's autism since itraconazole is an especially effective agent against Aspergillus species.

SETTING

The child was treated as an outpatient by the physician who had first diagnosed the child with an autism spectrum disorder.

PARTICIPANT

A child with an autism spectrum disorder.

INTERVENTION

The major intervention was increasing doses of the antifungal drug itraconazole. However, the Sporanox^® brand of itraconazole gave the best results. The child was monitored twice weekly with liver function tests which remained normal throughout the therapy.

RESULTS

The child had a complete recovery from all the symptoms of autism and in addition developed excellent academic, athletic, and musical skills. The recovery coincided with a marked reduction of urine markers of Aspergillus colonization.

CONCLUSIONS

Escalation of the dose of itraconazole resulted in a complete loss of all symptoms of autism over the course of three months. This rapid complete reversal of autism is consistent with several articles proposing mold in general and Aspergillus specifically as a potential major cause of autism.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: maxillary growth at eight years of age

OBJECTIVES

To assess differences in craniofacial growth at 8 years of age according to the different protocols for primary cleft surgery in the Scandcleft project.

DESIGN AND SETTING

Prospective, randomized, controlled clinical trial (RCT) involving 10 centres, including non-syndromic Caucasians with unilateral cleft lip and palate (UCLP). In Trial 1, a common surgical method (1a) with soft palate closure at 3-4 months of age and hard palate closure at 12 months of age was tested against similar surgery but with hard palate repair at 36 months (delayed hard palate closure) (1b). In Trial 2, the common method (2a) was tested against simultaneous closure of both hard and soft palate at 1 year (2c). In Trial 3, the common method (3a) was tested against hard palate closure together with lip closure at 3 months of age and soft palate closure at 1 year of age (3d). Participants were randomly allocated by use of a dice. Operator blinding was not possible but all raters of all outcomes were blinded.

SUBJECTS AND METHODS

The total number of participating patients at 8 years of age was 429. Lateral cephalograms (n = 408) were analysed. The cephalometric angles SNA and ANB were chosen for assessing maxillary growth for this part of the presentation.

RESULTS

Within each trial (Trial 1a/1b, Trial 2a/2c, and Trial 3a/3d), there was no difference in cephalometric values between the common and the local arm. There were no statistically significant differences in the SNA and ANB angles between the common arm in Trial 1a (mean SNA 77.8, mean ANB 2.6) and Trial 2a (mean SNA 79.8, mean ANB 3.6) and no difference between Trial 1a and Trial 3a, but a statistical difference could be seen between Trial 2a and Trial 3a (mean SNA 76.9, mean ANB 1.7). However, the confidence interval was rather large. Intra- and inter-rater reliability were within acceptable range.

CONCLUSIONS

The timing and the surgical method is not of major importance as far as growth outcomes (SNA and ANB) in UCLP are concerned.

REGISTRATION

ISRCTN29932826.

PROTOCOL

The protocol was not published before trial commencement.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: dental anomalies in 8-year olds

BACKGROUND

Children born with unilateral cleft lip and palate (UCLP) are reported to display several dental anomalies including agenesis, supernumeraries, as well as variations in dental size, shape, and path of eruption. The extensive sample of individuals with UCLP included in the Scandcleft randomized control trials offers the opportunity to study more rare conditions, which is seldom possible with limited samples.

OBJECTIVES

The aim was to study dental anomalies at 8 years of age in children born with UCLP included in the Scandcleft randomized control trials.

METHODS

Panoramic and intraoral radiographs from 425 individuals (279 males and 146 females) with a mean age of 8.1 years were assessed by four orthodontists regarding dental anomalies.

RESULTS

Agenesis was found in 52.5 per cent and supernumerary teeth in 16.9 per cent of the participants. The cleft lateral was missing in 43.8 per cent and was found peg shaped in 44.7 per cent. The distribution of ectopic eruption was 14.6 per cent, mainly affecting maxillary first molars, while transposition was found in 3.4 per cent of the individuals. In addition, infraocclusion of one or several primary molars was registered in 7.2 per cent of the participants.

CONCLUSION

We conclude that 8-year-old children born with UCLP display multiple dental anomalies. The Scandcleft sample allowed rarely studied conditions such as infraocclusion of primary molars and transposition to be studied in children born with UCLP.

TRIAL REGISTRATION

ISRCTN29932826.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate. Dental arch relationships in 8 year-olds

BACKGROUND AND TRIAL DESIGN

The Scandcleft intercentre study evaluates the outcomes of four surgical protocols for treatment of children with unilateral cleft lip and palate (UCLP). Originally 10 cleft centres in Denmark, Finland, Norway, Sweden, and the UK participated in a set of three randomized trials of primary surgery. Three groups of centres (Trials 1, 2, and 3) tested their traditional local surgical protocols (Arms B, C, and D) against a common protocol (Arm A).

OBJECTIVES

To evaluate dental arch relationships at age 8 years after four different protocols of primary surgery for UCLP. These results are secondary outcomes of the overall trial.

METHODS

Study models of 411 children (270 boys, 141 girls) with non-syndromic UCLP at a mean age of 8.1 (range 7.0-10.0) years were available. Dental arch relationships were analysed using the GOSLON Yardstick by a blinded panel of 11 orthodontists. To assess reliability, Kappa statistics were calculated. The trials were tested statistically with t-tests.

RESULTS

Comparisons within each trial showed no statistically significant differences in the mean 8-year index scores or their distributions between the common protocol and the local team protocol. The mean index scores were Trial 1: Arm A 3.03, Arm B 2.82, Trial 2: Arm A 2.78, Arm C 2.64, and Trial 3: Arm A 3.06, Arm D 3.08. Comparisons between the trials detected a significantly (P < 0.005) better mean index score Trial 2 Arm C than in Trial 3 Arm D. The intra- and inter-rater reliabilities were acceptable.

CONCLUSION

The results of these three trials do not provide evidence that one surgical protocol is better than the others.

TRIAL REGISTRATION

ISRCTN29932826.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: occlusion in 8-year-olds according to the Modified Huddart and Bodenham index

BACKGROUND

The Scandcleft international multicenter study is a prospective clinical trial of the long-term outcome after four different surgical protocols for palatal closure in patients born with unilateral cleft lip and palate (UCLP). This paper is one of a series of follow-up studies in 8-year olds.

OBJECTIVES

To evaluate the dental occlusion of 8-year-old patients after four different protocols of primary surgery for UCLP.

TRIAL DESIGN

Ten cleft centres in five countries tested three different surgical procedures for primary palatal repair in three parallel trials (Arms B, C, and D) against a common procedure (Arm A).

METHODS

Initially 448 children born with non-syndromic UCLP were included in the project. At 8 years of age, 428 children remained in the study. Dental casts of 411 patients (270 boys, 141 girls), mean age 8.1 years (range 7.0-10.0) were taken. The casts were blindly assessed with the Modified Huddart and Bodenham (MHB) index by four orthodontists. The main outcome measures were anterior (+2 to -6) and posterior (0 to -8) mean scores. Comparisons were made with previous data in 5-year-olds.

RESULTS

The inter- and intra-examiner reliability was good to excellent (0.75-0.90; 0.73-0.97), respectively. The mean total scores varied from -7.09 (Trial 2C) to -10.13 (Trial 3D). The mean anterior scores varied from -1.75 (Trial 2C) to -3.18 (Trial 1A). The mean posterior cleft-side scores varied from -4.32 (Trial 1B) to -5.21 (Trial 3D) and the mean non-cleft-side scores varied from -0.88 (Trial 2C) to -2.40 (Trial 3A). No significant differences were found within the trials. A significant difference was found between Trials 2 and 3 (Arm C/D) for the total score (P = 0.004).

CONCLUSIONS

There was no evidence of clinically significant differences in occlusion between the two surgical methods in each trial or between the trials. All mean scores showed more negative values in 8-year-olds compared with previously reported values in 5-year-olds.

TRIAL REGISTRATION

ISRCTN29932826.

Considerations for the verification of volumetric modulated arc therapy-planned dose distributions

Background: Volumetric modulated arc therapy (VMAT) is the standard of care for many clinical indications, but should only be considered with proper technical support and quality assurance (QA) in place. Despite the high accuracy of VMAT systems, errors can be present and adequate verification is required. Dosimetric VMAT verification systems have a broadly similar analysis philosophy. However, many factors influence the analyses and the subsequent QA outcome, based on which the plan will pass or fail.Aim: This study investigated various factors that influence the dosimetric impact and detectability of known linac component deviations on VMAT QA, including geometries, tissue densities, gamma criteria and dose–volume differences.Setting: Universitas Hospital (Annex), Bloemfontein, South Africa.Methods: Deliberate multi-leaf collimator (MLC)-bank offsets were introduced on four different VMAT plans of the prostate, nasopharynx and brain. Measured reference dose sets were compared to measured QA results, using the IBA Dolphin© detector and Compass© software for three dosimetric scenarios. Gamma pass rates over a range of criteria from 1%/2-mm to 4%/4-mm in the total volumes and per structure, as well as dose–volume differences were studied.Results: Gamma tests in the total patient/phantom did not sufficiently detect errors. The calculation media did not influence the QA outcome greatly. However, the detection geometry affected the results. Per structure gamma analyses provided superior error detection, although still missed some clinically relevant differences. The addition of dose–volume analyses highlighted several important errors.Conclusion: Volumetric modulated arc therapy using only total volume gamma analyses can easily overlook clinically relevant errors. The choice of gamma criterion is crucial. Verification with at least a per structure gamma test in combination with dose–volume checks is recommended, especially in small target volume cases.

Timing Of Primary Surgery for cleft palate (TOPS): protocol for a randomised trial of palate surgery at 6 months versus 12 months of age

INTRODUCTION

Cleft palate is among the most common birth abnormalities. The success of primary surgery in the early months of life is crucial for successful feeding, speech, hearing, dental development and facial growth. Over recent decades, age at palatal surgery in infancy has reduced. This has led to palatal closure in one-stage procedures being carried out around the age of 12 months, but in some cases as early as 6 months. The primary objective of the Timing Of Primary Surgery for Cleft Palate (TOPS)trial is to determine whether surgery for cleft palate performed at 6 or 12 months of age is most beneficial for speech outcomes.

METHODS AND ANALYSIS

Infants with a diagnosis of non-syndromic isolated cleft palate will be randomised to receive standardised primary surgery (Sommerlad technique) for closure of the cleft at either 6 months or 12 months, corrected for gestational age. The primary outcome will be perceived insufficient velopharyngeal function at 5 years of age. Secondary outcomes measured across 12 months, 3 years and 5 years will include growth, safety of the procedure, dentofacial development, speech, hearing level and middle ear function. Video and audio recordings of speech will be collected in a standardised age-appropriate manner and analysed independently by multiple speech and language therapists. The trial aims to recruit and follow-up 300 participants per arm. Data will be analysed according to the intention-to-treat principle using a 5% significance level. All analyses will be prespecified within a full and detailed statistical analysis plan.

ETHICS AND DISSEMINATION

Ethical approval has been sought in each participating country according to country-specific procedures. Trial results will be presented at conferences, published in peer-reviewed journals and disseminated through relevant patient support groups.

TRIAL REGISTRATION NUMBER

NCT00993551; Pre-results.

A risk assessment of automated treatment planning and recommendations for clinical deployment

Purpose

To assess the risk of failure of a recently developed automated treatment planning tool, the radiation planning assistant (RPA), and to determine the reduction in these risks with implementation of a quality assurance (QA) program specifically designed for the RPA.

Methods

We used failure mode and effects analysis (FMEA) to assess the risk of the RPA. The steps involved in the workflow of planning a four‐field box treatment of cervical cancer with the RPA were identified. Then, the potential failure modes at each step and their causes were identified and scored according to their likelihood of occurrence, severity, and likelihood of going undetected. Additionally, the impact of the components of the QA program on the detectability of the failure modes was assessed. The QA program was designed to supplement a clinic's standard QA processes and consisted of three components: (a) automatic, independent verification of the results of automated planning; (b) automatic comparison of treatment parameters to expected values; and (c) guided manual checks of the treatment plan. A risk priority number (RPN) was calculated for each potential failure mode with and without use of the QA program.

Results

In the RPA automated treatment planning workflow, we identified 68 potential failure modes with 113 causes. The average RPN was 91 without the QA program and 68 with the QA program (maximum RPNs were 504 and 315, respectively). The reduction in RPN was due to an improvement in the likelihood of detecting failures, resulting in lower detectability scores. The top‐ranked failure modes included incorrect identification of the marked isocenter, inappropriate beam aperture definition, incorrect entry of the prescription into the RPA plan directive, and lack of a comprehensive plan review by the physician.

Conclusions

Using FMEA, we assessed the risks in the clinical deployment of an automated treatment planning workflow and showed that a specialized QA program for the RPA, which included automatic QA techniques, improved the detectability of failures, reducing this risk. However, some residual risks persisted, which were similar to those found in manual treatment planning, and human error remained a major cause of potential failures. Through the risk analysis process, we identified three key aspects of safe deployment of automated planning: (a) user training on potential failure modes; (b) comprehensive manual plan review by physicians and physicists; and (c) automated QA of the treatment plan.

Large Scale Synthetic Site Saturation GPCR Libraries Reveal Novel Mutations That Alter Glucose Signaling

Site saturation mutagenesis (SSM) is a powerful mutagenesis strategy for protein engineering and directed evolution experiments. However, limiting factors using this method are either biased representation of variants, or limiting library size. To overcome these hurdles, we generated large scale targeted synthetic SSM libraries using massively parallel oligonucleotide synthesis and benchmarked this against an error-prone (epPCR) library. The yeast glucose activated GPCR-Gpr1 was chosen as a prototype to evolve novel glucose sensors. We demonstrate superior variant representation and several unique hits in the synthetic library compared to the PCR generated library. Application of this mutational approach further builds the possibilities of synthetic biology in tuning of a response to known ligands and in generating biosensors for novel ligands.

Reserve stem cell population in intestinal crypts found to be consistently small by analysis of in vivo clonogenic assays with a biomathematical dynamic model

BACKGROUND AND PURPOSE

The high plasticity of the intestinal epithelium is maintained by a resilient reserve stem cell population, whose extent and biology are a matter of ongoing debate. The in vivo clonogenic assay (IVCA), presents a well established and efficient analysis of radiation insult to the intestinal crypts. However, we found that inadequate mathematical analysis over the last four decades led to systematic errors and contradictory results in estimates of radio-sensitivity and size of the reserve stem cell pool.

MATERIAL AND METHODS

We devised a refinement of the IVCA via development of a biomathematical model that delivers a full statistical dynamic description of epithelial radiation injury and subsequent regeneration. We validated the model against cellular and crypt distribution statistics obtained from IVCA experiments and through systematic re-analysis of experimental data from 27 publications.

RESULTS

A full dynamic description of the evolution of stem cell niche population statistics is obtained. A systematic re-analysis reveals a consistent clonogenic content of the crypt of 31±6 cells. The stem cell reserve manifests to be, contrary to prior predictions, radio-resistant: α=(0.22±0.04) Gy^-1.

CONCLUSION

We established a precision tool for the quantitative analysis of radiation insult to the intestinal crypts, which we employ to show that the reserve stem cell population is small, radio-resistant, and remarkably immutable against a large variety of interventions. The increased resolution of the model allows not only a reduction of the number of animals by about 75%, but also to quantify experimentally the influence of additional agents on damage and on regeneration of the stem cell niche.

An Intercenter Comparison of Dental Arch Relationships and Craniofacial Form Including a Center Using Nasoalveolar Molding

Objective:

To compare dental arch relationship and craniofacial morphology of patients with CUCLP in pre-adolescence from five cleft centers including a center using NAM.

Design:

Retrospective cohort study.

Setting:

Five cleft centers in North America.

Patients:

One hundred eighty-two subjects with repaired CUCLP from the five cleft centers participated in the craniofacial form study. One hundred forty-eight subjects from four of the five centers participated in the dental arch relationship study.

Methods:

Digital dental models were assessed using the GOSLON Yardstick. Eighteen cephalometric measurements were performed. Measurement means, by center, were compared. Analysis of variance and Tukey-Kramer analysis were used to compare GOSLON scores and cephalometric measurements.

Results:

The center that performed neither PSOT (including NAM) nor primary bone grafting exhibited the most favorable mean GOSLON score. The same center also showed the highest mean SNA, ANB, and ANS-N-Pg angles. However, the mean ANB and ANS-N-Pg angles were not significantly different from those of the center using NAM. No statistically significant differences were seen for mandibular prominence, vertical dimensions, or dental inclinations. The center with NAM also showed a significantly smaller nasoform angle than two of the four other centers.

Conclusion:

The centers that used NAM and other forms of PSOT did not have better dental arch relationships or craniofacial morphology compared with the centers that performed only primary lip repair. However, this study was not designed to investigate the cause-and-effect relationship between specific outcomes and particular features of those protocols.

An Intercenter Comparison of Nasolabial Appearance Including a Center Using Nasoalveolar Molding

OBJECTIVE

To compare nasolabial appearance outcomes of patients with complete unilateral cleft lip and palate (CUCLP) in preadolescence from 4 cleft centers including a center using nasoalveolar molding (NAM) and primary nasal reconstruction.

DESIGN

Retrospective cohort study.

SETTING

Four cleft centers in North America.

PATIENTS

135 subjects with repaired CUCLP.

METHODS

Frontal and profile facial pictures were assessed using the Asher-McDade rating scale. Intra- and interrater reliability were tested using weighted Kappa statistics. Median scores by center were compared with Kruskal-Wallis statistics.

RESULTS

Intrarater reliability scores were moderate to good. Interrater reliability scores were moderate. Significant differences ( P < .05) among centers were found. For nasal form, center G (median = 2.83) had better scores than centers C and D (C median = 3.33, D median = 3.17). For nose symmetry, center G had better scores (median = 2.33) than all other centers (B median = 2.67, C median = 2.83, D median = 2.83). For vermillion border, center G had better scores (median = 2.58) than centers B and C (B median = 3.17, C median = 3.17). For nasolabial profile, center G (median score = 2.67) had better scores than center C (median = 3.00). For total nasolabial score, center G (median = 2.67) had better scores than all other centers (B median = 2.83, C median = 3, D median = 2.83).

CONCLUSION

The protocol followed by center G, the only center that performed NAM and primary nasal reconstruction, produced better results in all categories when compared to center C, the only center that did not perform presurgical orthopedics or lip/nose revisions. When compared to centers that performed traditional presurgical orthopedics and surgical revisions (B and D), center G was not consistently better in all categories. As with other uncontrolled, retrospective intercenter studies, it is not possible to attribute the outcomes to a specific protocol component.

Reliability and Validity of a Medicine Ball-Contained Accelerometer for Measuring Upper-Body Neuromuscular Performance

Roe, G, Shaw, W, Darrall-Jones, J, Phibbs, PJ, Read, D, Weakley, JJ, Till, K, and Jones, B. Reliability and validity of a medicine ball-contained accelerometer for measuring upper-body neuromuscular performance. J Strength Cond Res 32(7): 1915-1918, 2018-The aim of the study was to assess the between-day reliability and validity of a medicine ball-contained accelerometer (MBA) for assessing upper-body neuromuscular performance during a throwing task. Ten professional rugby union players partook in the study. Between-day reliability was assessed from the best score attained during 2 sets of 3 throws, on 2 testing occasions separated by 7 days. Validity was assessed against a criterion measure (Optioelectronic system) during 75 throws from a subgroup of 3 participants. The MBA exhibited a small between-day error of 2.2% (90% confidence intervals; 2.0-4.6%) and an almost perfect relationship with a criterion measure (r = 0.91 [90% CIs; 0.87-0.94]). However, the mean bias and standard error were moderate (7.9% [90% CIs; 6.6-9.2%] and 4.9% [90% CIs; 4.2-5.7%], respectively). Practitioners using an MBA to assess neuromuscular performance of the upper body must take into account the overestimation and error associated with such assessment with respect to a criterion measure. However, as the error associated with between-day testing was small and testing is easy to implement in applied practice, an MBA may provide a useful tool for monitoring upper-body neuromuscular performance over time.

A Multicenter Study Using the SWAG Scale to Compare Secondary Alveolar Bone Graft Outcomes for Patients with Cleft Lip and Palate

Objective

To assess secondary alveolar bone graft (ABG) outcomes using the standardized way to assess grafts, or SWAG scale, for patients with cleft lip and palate (CLP).

Design

Retrospective cohort study.

Setting

Four cleft centers with different protocols.

Methods

One hundred sixty maxillary occlusal radiographs taken 3 to 18 months after secondary ABG for sequentially treated patients with CLP were assessed using the SWAG scale. Radiographs were scanned, standardized, blinded, and rated by six orthodontists using the SWAG scale. Randomized radiographs were rated twice, 24 hours apart, by the same raters.

Main Outcomes

Intrarater and interrater reliabilities were assessed. Means and SDs were calculated for ABG ratings using analysis of variance and Tukey tests (P < .05).

Result

The mean ABG age was 9.1 years (range = 7 to 10.1 years) and the mean follow-up age was 12.4 years (range = 8.2 to 20.4 years). Intrarater and interrater reliabilities were good (intrarater = 0.788, interrater = 0.705), and higher than published methods. Mean ABG ratings for the cleft centers were 4.53, 2.9, 3.63, and 5.0 and differed significantly. The two centers with the highest ABG ratings showed higher ratings for all thirds decreasing from apical to coronal. The two centers with lower ABG ratings showed poorer ABG ratings for all thirds, and the middle third received the highest ratings.

Conclusions

The SWAG scale overcomes the challenges of age and bone location. The SWAG method was validated for showing intercenter differences for overall bone fill as well as in vertical thirds. Surgical technique, timing, and expertise/volume were identified as possible factors related to outcome.

The Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 11. What next?

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for unilateral cleft lip and palate (UCLP), and randomised trials have only occasionally been performed. The Scandcleft Project consists of three trials initiated in 1997. The results at age 5 have been published in the series of reports that precede this manuscript, which aims to distill some of the issues that future trialists may need to address.

METHOD

The shared experience of this group of trials is reviewed with reference to the current literature on trial management and, more specifically, trials of surgical technique and timing.

RESULTS

The main discussion points relate to the challenges associated with research bureaucracy, learning curve, individuality of skill, and ethics.

CONCLUSIONS

Compliance with current regulatory requirements for clinical trials and recruitment rates for cleft sub-types represent substantial challenges. Mastery of new surgical techniques prior to trials raises important ethical issues, although recent reports in the wider surgical literature suggest that learning may be hastened with the assistance of anonymised peer review ratings of intraoperative performance. The three Scandcleft Trials succeeded in meeting the planned recruitment targets, and completed follow-up with remarkably high retention rates (99.3%). The design of the study required the majority of participating surgeons to master a new technique and, although overall outcomes were comparable with those in the literature, the associated learning curve increased postoperative complications in two of the trials.

TRIAL REGISTRATION

ISRCTN29932826.

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 8. Assessing naso-labial appearance in 5-year-olds - a preliminary study

BACKGROUND AND AIM

Facial appearance is one of the most relevant measures of success in cleft lip and palate treatment. The aim was to assess nasolabial appearance at 5 years of age in all children in the project. In this part of the project the local protocol for lip closure continued to be used because the primary lip and nose operations were not part of the randomisation. The great majority of the surgeons used Millard's technique together with McComb's technique for the nose. One center used Tennison-Randalls technique and in one center the centers own technique as well as nose plugs were used.

METHODS

Three hundred and fifty-nine children participated in this part of the project. Standardised photos according to a specific protocol developed for the Scandcleft project were taken. Only the nasolabial area was shown, the surrounding facial features were masked. Three components were scored using a 5-point ordinal scale. A new developed Scandcleft Yardstick was used.

RESULTS

The reliability of the method was tested using the weighted kappa statistics. Both the interrater and intrarater reliability scores were good to very good. There were statistically significant differences between the three trials.

CONCLUSION

The Millard procedure combined with McComb technique had been used in the majority of the cases in all three trials. There were statistically significant differences between the three trials concerning upper lip, nasal form, and cleft side profile.

TRIAL REGISTRATION

ISRCTN29932826.

A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project.

METHOD

Ten established national or regional cleft centres participated. Lip and soft palate closure at 3-4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3-4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3-4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes.

RESULTS

Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years.

CONCLUSION

The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series.

TRIAL REGISTRATION

ISRCTN29932826.

Pharyngeal Flap and Sphincterplasty for Velopharyngeal Insufficiency Have Equal Outcome at 1 Year Postoperatively: Results of a Randomized Trial

Objective

The aim of this trial was to compare the relative effectiveness (efficacy and morbidity) of two surgical procedures for correcting velopharyngeal insufficiency (VPI).

Design

This was an international multicenter randomized trial to study the outcome of two surgical procedures (flap and sphincter pharyngoplasty) for speech, incidence of sleep apnea, and surgical complications.

Method

Ninety-seven patients 3 to 25 years old with repaired cleft palate and previously identified VPI were enrolled from five centers in the United States, Norway, and the U.K. Data were collected at presurgery, 3 months postsurgery, and 12 months postsurgery for subsequent analysis blind to the procedure. Main outcome measures included perceptual speech parameters, sleep apnea, nasalance measures, endoscopic features, and surgical complications.

Results

Groups for both surgical procedures achieved a high level of clinical improvement. At 3 months postsurgery, elimination of hypernasal resonance was achieved in twice as many patients after the flap procedure. This reached significance. However, at 12 months postsurgery, no statistically significant difference in outcomes remained between the two procedures for resonance, nasalance, endoscopic outcomes, or surgical complications. Flap and sphincter pharyngoplasty rarely resulted in clinically significant sleep apnea, and no difference was detected between the two procedures in the long-term incidence of sleep apnea.

Conclusions

Despite strongly held views in the literature concerning the relative effectiveness and safety of flap and sphincter pharyngoplasty, no significant differences were detected 1 year postoperatively.

Reliability of the SWAG—The Standardized Way to Assess Grafts Method for Alveolar Bone Grafting in Patients with Cleft Lip and Palate

Objective

The objective of this study was to test a new method, a Standardized Way to Assess Grafts (SWAG), to rate alveolar bone graft (ABG) outcomes for patients with cleft lip and palate.

Design

This was a retrospective comparison using the SWAG scale.

Setting

This study took place in four cleft palate centers with different treatment protocols.

Methods

A total of 160 maxillary occlusal radiographs taken 3 to 18 months post-ABG for sequentially treated patients with cleft lip and palate were assessed using the SWAG scale. Radiographs were scanned, standardized, blinded, and rated by 6 calibrated orthodontists to assess vertical thirds, bony root coverage, and complete bony fill. All radiographs were rated twice, 24 hours apart, by the same raters.

Main Outcomes

Intra- and interrater reliabilities were assessed.

Results

Intrarater reliability was good to very good (.760; .652–.834), and interrater reliability was moderate to good (.606; .569–.681), comparable to previously published methods.

Conclusions

Rater reliabilities were shown to be comparable to or better than existing methods. The SWAG method was validated for ABG assessments in the mixed and permanent dentitions based on reliabilities in an intercenter outcome comparison.

Supervisors' perceptions of organizational policies are associated with their likelihood to accommodate back-injured workers

Background Low back pain (LBP) is a major concern among North American workplaces and little is known regarding a supervisor's decision to support job accommodation for workers with LBP. The extent to which supervisors are included in a company's effort to institute disability management policies and practices and workplace safety climate are two factors that may influence a supervisor's decision to accommodate workers with LBP. Objective Determine the association between supervisors' perceptions of disability management policies, corporate safety culture and their likelihood of supporting job accommodations for workers with LBP. Methods We conducted a cross-sectional study of supervisors (N=796) recruited from a non-random, convenience sample of 19 Canadian and US employers. The outcome was supervisors' likeliness to support job accommodation and the exposure was global work safety culture and disability management policies and practices. A multivariable generalized linear modelling strategy was used and final models for each exposure were obtained after assessing potential effect modifiers and confounders. Results In the study, 796 eligible supervisors from 19 employers participated. Disability management policies and practices were positively associated with supervisors' likeliness to accommodate (β=0.19; 95% CI: 0.13; 0.24) while no significant association was found between corporate safety culture (β= -0.084; 95% CI: -0.19; 0.027) and supervisors' likeliness to accommodate. Conclusions Employers should ensure that proactive disability management policies and practices are clearly communicated to supervisors in order to improve job modification and return to work efforts. Implications for Rehabilitation Low back pain (LBP) is a major workplace concern and little is known regarding what factors are associated with a supervisor's likelihood to support job accommodation for workers with LBP. The objective of this article was to determine the association between supervisors' perceptions of disability management policies and practices, corporate safety culture and their likelihood of support job accommodations for workers with LBP. Results suggest that disability management policies and practices are positively associated with supervisors' likelihood to accommodate while corporate safety culture is not. These results are important for employers as it suggests that employers should ensure that their disability management policies and practices are clearly communicated to supervisors in order to improve job accommodation and return to work efforts.

Elevated Urinary Glyphosate and Clostridia Metabolites With Altered Dopamine Metabolism in Triplets With Autistic Spectrum Disorder or Suspected Seizure Disorder: A Case Study

CONTEXT

Autism is a neurodevelopmental disorder for which a number of genetic, environmental, and nutritional causes have been proposed. Glyphosate is used widely as a crop desiccant and as an herbicide in fields of genetically modified foods that are glyphosate resistant. Several researchers have proposed that it may be a cause of autism, based on epidemiological data that correlates increased usage of glyphosate with an increased autism rate.

OBJECTIVE

The current study was intended to determine if excessive glyphosate was present in the triplets and their parents and to evaluate biochemical findings for the family to determine the potential effects of its presence.

DESIGN

The author performed a case study with the cooperation of the parents and the attending physician.

SETTING

The study took place at The Great Plains Laboratory, Inc (Lenexa, KS, USA).

PARTICIPANTS

Participants were triplets, 2 male children and 1 female, and their parents. The 2 male children had autism, whereas the female had a possible seizure disorder. All 3 had elevated urinary glyphosate, and all of the triplets and their mother had elevated values of succinic acid or tiglylglycine, which are indicators of mitochondrial dysfunction.

INTERVENTION

The participants received a diet of organic food only.

OUTCOME MEASURES

The study performed organic acids, glyphosate, toxic chemicals and tiglylglycine, and creatinine testing of the participants' urine.

RESULTS

The 2 male triplets with autism had abnormalities on at least 1 organic acids test, including elevated phenolic compounds such as 4-cresol, 3-[3-hydroxyphenyl]-3-hydroxypropionic acid and 4-hydroxyphenylacetic acid, which have been previously associated with Clostridia bacteria and autism. The female, who was suspected of having a seizure disorder but not autism, did not have elevated phenolic compounds but did have a significantly elevated value of the metabolite tiglylglycine, a marker for mitochondrial dysfunction and/or mutations. One male triplet was retested postintervention and was found to have a markedly lower amount of glyphosate in his urine.

CONCLUSIONS

The pattern of metabolites in the urine samples of the males with autism are consistent with a recent theory of autism that connects widespread glyphosate use with alteration of animal and human gastrointestinal flora. That theory is that the normally beneficial bacteria species that are sensitive to glyphosate are diminished and harmful bacteria species, such as Clostridia, that are insensitive to glyphosate, are increased following exposure to glyphosate. Excessive dopamine, caused by inhibition of dopamine-beta-hydroxylase by Clostridia metabolites, in turn, produces oxidative species that damage neuronal Krebs cycle enzymes, neuronal mitochondria, and neuronal structural elements such as the neurofibrils.