High Concordance Between Nonalcoholic Fatty Liver Disease and Metabolic Dysfunction-Associated Steatotic Liver Disease in the TARGET-NASH Real-World Cohort

INTRODUCTION

This study investigates the applicability of the new metabolic dysfunction-associated steatotic liver disease (MASLD) nomenclature to the real-world TARGET-NASH US adult cohort.

METHODS

The new MASLD/metabolic steatohepatitis nomenclature was applied to patients enrolled with pragmatic diagnoses of nonalcoholic fatty liver and nonalcoholic steatohepatitis (NASH), and NASH cirrhosis and concordance were determined between the definitions.

RESULTS

Approximately 99% of TARGET-NASH participants met the new MASLD diagnostic criteria. Approximately 1,484/1,541 (96.3%, kappa 0.974) nonalcoholic fatty liver patients (metabolic dysfunction-associated steatotic liver), 2,195/2,201 (99.7%, kappa 0.998) NASH patients (metabolic steatohepatitis), and 1,999/2,003 (99.8%, kappa 0.999) NASH cirrhosis patients met the new criteria.

DISCUSSION

The new MASLD nomenclature is highly concordant with the previous TARGET-NASH pragmatic definitions.

Impact of Pruritus on Quality of Life and Current Treatment Patterns in Patients with Primary Biliary Cholangitis

BACKGROUND AND AIMS

Patients with primary biliary cholangitis (PBC) often suffer with pruritus. We describe the impact of pruritus on quality of life and how it is managed in a real-world cohort.

METHODS

TARGET-PBC is a longitudinal observational cohort of patients with PBC across the USA. Data include information from medical records for three years prior to the date of consent up to 5 years of follow-up. Enrolled patients were asked to complete patient-reported outcome surveys: PBC-40, 5-D itch, and the PROMIS fatigue survey. Kruskal-Wallis tests were used to compare differences in symptoms between groups.

RESULTS

A total of 211 patients with completed PRO surveys were included in the current study. PRO respondents were compared with non-respondents in the TARGET-PBC population and were broadly similar. Pruritus was reported in 170 patients (81%), with those reporting clinically significant pruritus (30%) scoring worse across each domain of the PBC-40 and 5-D itch, more frequently having cirrhosis, and having significantly greater levels of fatigue. Patients reporting clinically significant pruritus were more likely to receive treatment, but 33% had never received treatment (no itch = 43.9%, mild itch = 38.3%).

CONCLUSIONS

The prevalence of pruritus was high in this population, and those reporting clinically significant pruritus had a higher likelihood of having advanced disease and worse quality of life. However, this study found that pruritus in PBC is under-treated. This may be due in part to ineffectiveness of current treatments, poor tolerance, or the lack of FDA-approved medications for pruritus.

Variation in Alanine Aminotransferase in Children with Non-Alcoholic Fatty Liver Disease

Background: Pediatric non-alcoholic fatty liver disease (NAFLD) is a major public health concern. Aminotransferase (ALT) is frequently used for screening and monitoring, but few studies have reported typical patterns of ALT elevation in children. Methods: TARGET-NASH is a real-world longitudinal observational cohort of patients with NAFLD receiving care across the United States. Analyses included children enrolled between 1 August 2016, and 12 October 2020, with at least one ALT measurement after enrollment. Peak ALT was based on the first and last available record and categorized into clinical cut points: <70 IU/L, >70−<250 IU/L, and >250 IU/L. A chi-squared test was used to compare differences in proportions, and a Kruskal−Wallis test was used to compare the medians and distributions of continuous responses. Results: Analyses included 660 children with a median age of 13 years. Of the 660, a total of 187 had undergone a biopsy and were more likely to be Hispanic or Latino (67% vs. 57%, p = 0.02) and to have cirrhosis (10% vs. 1%, p < 0.001). The highest ALT scores ranged from 28 U/L to 929 U/L; however, these scores varied across time. The prevalence of cirrhosis or any liver fibrosis stage was most common among children with a peak ALT > 70 U/L. Conclusions: Large variability was seen in ALT among children, including many values > 250 U/L. Higher levels of ALT were associated with increased prevalence of comorbidities and more advanced stages of NAFLD. These findings support an increased need for therapeutics and disease severity assessment in children with peak ALT > 70 U/L.

Diabetes medication regimens and patient clinical characteristics in the national patient-centered clinical research network, PCORnet

We used electronic medical record (EMR) data in the National Patient-Centered Clinical Research Network (PCORnet) to characterize "real-world" prescription patterns of Type 2 diabetes (T2D) medications. We identified a retrospective cohort of 613,203 adult patients with T2D from 33 datamarts (median patient number: 12,711) from 2012 through 2017 using a validated computable phenotype. We characterized outpatient T2D prescriptions for each patient in the 90 days before and after cohort entry, as well as demographics, comorbidities, non-T2D prescriptions, and clinical and laboratory variables in the 730 days prior to cohort entry. Approximately half of the individuals in the cohort were females and 20% Black. Hypertension (60.3%) and hyperlipidemia (50.5%) were highly prevalent. Most patients were prescribed either a single T2D drug class (42.2%) or had no evidence of a T2D prescription in the EMR (42.4%). A smaller percentage was prescribed multiple T2D drug types (15.4%). Among patients prescribed a single T2D drug type, metformin was the most common (42.6%), followed by insulin (18.2%) and sulfonylureas (13.9%). Newer classes represented approximately 13% of single T2D drug type prescriptions (dipeptidyl peptidase-4 inhibitors [6.6%], glucagon-like peptide-1 receptor agonists [2.5%], thiazolidinediones [2.0%], and sodium-glucose cotransporter-2 inhibitors [1.6%]). Among patients prescribed multiple T2D drug types, the most common combination was metformin and sulfonylureas (63.5%). Metformin-based regimens were highly prevalent in PCORnet's T2D population, whereas newer agents were prescribed less frequently. PCORnet is a novel source for the potential conduct of observational studies among patients with T2D.

Real-world evidence in hepatocellular carcinoma

Real-world evidence includes all health-related information, such as electronic health records, insurance claims, pharmacy records and wearables that are obtained outside of clinical trials. These data can provide critical insights into the natural history of disease and evaluate the safety and effectiveness of treatment regimens used in clinical practice. Real-world data have been applied to varying degrees by global regulatory agencies to inform and expedite many phases of drug development and help refine the use of therapeutic regimens after marketing, especially in populations that are under-represented in registration trials. For the management of hepatocellular carcinoma, early detection provides the best chance for curative therapies, whose success has been evaluated in numerous cohorts. The availability of novel systemic therapies, including kinase inhibitors and immunotherapies, has provided new treatment options and improved survival in patients with advanced stage hepatocellular carcinoma. Real-world longitudinal observational studies can help understand the long-term safety and effectiveness of these agents.

Factors Associated With Readmission in the United States Following Hospitalization With Coronavirus Disease 2019

BACKGROUND

Patients hospitalized for coronavirus disease 2019 (COVID-19) may experience complications following hospitalization and require readmission. In this analysis, we estimated the rate and risk factors associated with COVID-19-related readmission and inpatient mortality.

METHODS

In this retrospective cohort study, we used deidentified chargemaster data from 297 hospitals across 40 US states on patients hospitalized with COVID-19 from 15 February 2020 through 9 June 2020. Demographics, comorbidities, acute conditions, and clinical characteristics of first hospitalization are summarized. Multivariable logistic regression was used to measure risk factor associations with 30-day readmission and in-hospital mortality.

RESULTS

Among 29 659 patients, 1070 (3.6%) were readmitted. Readmitted patients were more likely to have diabetes, hypertension, cardiovascular disease (CVD), or chronic kidney disease (CKD) vs those not readmitted (P < .0001) and to present on first admission with acute kidney injury (15.6% vs 9.2%), congestive heart failure (6.4% vs 2.4%), or cardiomyopathy (2.1% vs 0.8%) (P < .0001). Higher odds of readmission were observed in patients aged >60 vs 18-40 years (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.48-2.50) and those admitted in the Northeast vs West (OR, 1.43; 95% CI, 1.14-1.79) or South (OR, 1.28; 95% CI, 1.11-1.49). Comorbidities including diabetes (OR, 1.34; 95% CI, 1.12-1.60), CVD (OR, 1.46; 95% CI, 1.23-1.72), CKD stage 1-5 (OR, 1.51; 95% CI, 1.25-1.81), and CKD stage 5 (OR, 2.27; 95% CI, 1.81-2.86) were associated with higher odds of readmission; 12.3% of readmitted patients died during second hospitalization.

CONCLUSIONS

Among this large US population of patients hospitalized with COVID-19, readmission was associated with certain comorbidities and acute conditions during first hospitalization. These findings may inform strategies to mitigate risks of readmission due to COVID-19 complications.

Cost-Effectiveness of the Wellness Incentives and Navigation (WIN) Program

OBJECTIVES

Promoting patient involvement in managing co-occurring physical and mental health conditions is increasingly recognized as critical to improving outcomes and controlling costs in this growing chronically ill population. The main objective of this study was to conduct an economic evaluation of the Wellness Incentives and Navigation (WIN) intervention as part of a longitudinal randomized pragmatic clinical trial for chronically ill Texas Medicaid enrollees with co-occurring physical and mental health conditions.

METHODS

The WIN intervention used a personal navigator, motivational interviewing, and a flexible wellness expense account to increase patient activation, that is, the patient's knowledge, skills, and confidence in managing their self-care and co-occurring physical and mental health conditions. Regression models were fit to both participant-level quality-adjusted life years (QALYs) and total costs of care (including the intervention) controlling for demographics, health status, poverty, Medicaid managed care plan, intervention group, and baseline health utility and costs. Incremental costs and QALYs were calculated based on the difference in predicted costs and QALYs under intervention versus usual care and were used to calculate the incremental cost-effectiveness ratios (ICERs). Confidence intervals were calculated using Fieller's method, and sensitivity analyses were performed.

RESULTS

The mean ICER for the intervention compared with usual care was $12 511 (95% CI $8971-$16 842), with a sizable majority of participants (70%) having ICERs below $40 000. The WIN intervention also produced higher QALY increases for participants who were sicker at baseline compared to those who were healthier at baseline.

CONCLUSION

The WIN intervention shows considerable promise as a cost-effective intervention in this challenging chronically ill population.

Addressing health disparities in type 1 diabetes through peer mentorship

Pronounced health disparities exist in type 1 diabetes (T1D) based on socioeconomic status (SES) yet there are a lack of programs designed to promote health equity for vulnerable communities. The All for ONE (Outreach, Networks, and Education) mentoring program was piloted pairing college students and publicly insured teenagers with T1D to assess feasibility as a possible intervention. There were 22 mentors recruited (mean age 20 ± 2 years; 17 [77%] females; mean HbA1c 8.4 ± 1.5%) and matched with mentees based on gender. There were 42 teens randomized to treatment and control groups including 22 teens in the treatment group (age 14 ± 2 years; 17 [77%] females; HbA1c 9.8 ± 2.3%) and 20 teens in the control group (age 14 ± 2 years; 15 [75%] females; HbA1c 8.9 ± 2.0%) followed over 9 months. Outcome measures included HbA1c and the Children's Hope Scale. The intervention included automated text reminders for blood glucose monitoring, text exchanges, social events with education, and clinic visits with mentors/mentees. Mean change in HbA1c for teens was +0.09% in the intervention group, compared with +0.28% in the control group (P = .61); college students had a reduction in HbA1c of -0.22% (P = .38). Treatment group teens had marked improvement in their hope for the future compared to control group teens (P = .04) and were more likely to attend clinic visits (P = .02). This program established feasibility for a model that could be replicated and modified for other types of settings. Additional research is warranted to study the potential long-term benefits of participating in the All for ONE mentoring program.

Performance of a computable phenotype for identification of patients with diabetes within PCORnet: The Patient-Centered Clinical Research Network

PURPOSE

PCORnet, the National Patient-Centered Clinical Research Network, represents an innovative system for the conduct of observational and pragmatic studies. We describe the identification and validation of a retrospective cohort of patients with type 2 diabetes (T2DM) from four PCORnet sites.

METHODS

We adapted existing computable phenotypes (CP) for the identification of patients with T2DM and evaluated their performance across four PCORnet sites (2012-2016). Patients entered the cohort on the earliest date they met one of three CP categories: (CP1) coded T2DM diagnosis (ICD-9/ICD-10) and an antidiabetic prescription, (CP2) diagnosis and glycosylated hemoglobin (HbA1c) ≥6.5%, or (CP3) an antidiabetic prescription and HbA1c ≥6.5%. We required evidence of health care utilization in each of the 2 prior years for each patient, as we also developed an incident T2DM CP to identify the subset of patients without documentation of T2DM in the 365 days before t₀ . Among a systematic sample of patients, we calculated the positive predictive value (PPV) for the T2DM CP and incident-T2DM CP using electronic health record (EHR) review as reference.

RESULTS

The CP identified 50 657 patients with T2DM. The PPV of patients randomly selected for validation was 96.2% (n = 1572; CI:95.1-97.0) and was consistently high across sites. The PPV for the incident-T2DM CP was 5.8% (CI:4.5-7.5).

CONCLUSIONS

The T2DM CP accurately and efficiently identified patients with T2DM across multiple sites that participate in PCORnet, although the incident T2DM CP requires further study. PCORnet is a valuable data source for future epidemiological and comparative effectiveness research among patients with T2DM.

Development and validation of an instrument to measure collaborative goal setting in the care of patients with diabetes

OBJECTIVE

Despite known benefits of patient-perceived collaborative goal setting, we have a limited ability to monitor this process in practice. We developed the Patient Measure of Collaborative Goal Setting (PM-CGS) to evaluate the use of collaborative goal setting from the patient's perspective.

RESEARCH DESIGN AND METHODS

A random sample of 400 patients aged 40 years or older, receiving diabetes care from the Virginia Commonwealth University Health System between 8/2012 and 8/2013, were mailed a survey containing potential PM-CGS items (n=44) as well as measures of patient demographics, perceived self-management competence, trust in their physician, and self-management behaviors. Confirmatory factor analysis was used to evaluate construct validity. External validity was evaluated via a structural equation model (SEM) that tested the association of the PM-CGS with self-management behaviors. The direct and two mediated (via trust and self-efficacy) pathways were tested.

RESULTS

A total of 259 patients responded to the survey (64% response rate), of which 192 were eligible for inclusion. Results from the factor analysis supported a 37-item measure of patient-perceived CGS spanning five domains: listen and learn; share ideas; caring relationship; measurable objective; and goal achievement support (χ=4366.13, p<0.001; RMSEA=0.08). Results from the SEM supported the external validity of the PM-CGS. The relationship between CGS and self-management was partially mediated by perceived competence (p<0.05). The direct effect between the PM-CGS and self-management was significant (p<0.001).

CONCLUSIONS

CGS can be validly measured by the 37-item PM-CGS. Use of the PM-CGS can help illustrate actionable deficits in goal-setting discussions.

Adding the patient's voice to our understanding of collaborative goal setting: How do patients with diabetes define collaborative goal setting?

BACKGROUND

Patient reports of collaborative goal setting have repeatedly been associated with improved health outcomes, and the American Diabetes Association specifically encourages collaborative goal setting as a component of high quality care. Current limitations in our understanding of what needs to transpire for patients to denote goal setting as "collaborative", remain a barrier to fostering collaborative goal setting in practice.

METHODS

Four focus groups were conducted among 19 patients with diabetes. A semi-structured focus group guide was used to explore patient perceptions of collaborative goal setting and what needed to happen for goals to be considered collaboratively set. Focus group transcripts were coded using thematic analysis.

RESULTS

Collaborative goal setting was described by patients as occurring within the context of a caring relationship where patients and health care providers: (1) listen and learn from each other; (2) share ideas; (3) agree on a measurable objective; and (4) support goal achievement. Patients also articulated clear responsibilities for themselves and clinicians and described collaborative goal setting as a process that occurs over time.

CONCLUSIONS

Patients perceived collaborative goal setting as a multidimensional process that occurs over time within the context of a caring relationship and encompasses distinct patient and clinician responsibilities.

Patient-reported use of collaborative goal setting and glycemic control among patients with diabetes

OBJECTIVE

Little is known about how patient-clinician communication leads to better outcomes. Among patients with diabetes, we describe patient-reported use of collaborative goal setting and evaluate whether perceived competency and physician trust mediate the association between collaborative goal setting and glycemic control.

METHODS

Data from a patient survey administered in 2008 to a cohort of insured patients aged 18+ years with diabetes who initiated oral mono-therapy between 2000 and 2005 were joined with pharmaceutical claims data for the prior 12 months and laboratory data for the prior and subsequent 12 months (N=1065). A structural equation model (SEM) was used to test mediation models controlling for baseline HbA1c.

RESULTS

The hypothesized mediation model was supported. Patient-reported use of more collaborative goal setting was associated with greater perceived self-management competency and increased level of trust in the physician (p<0.05). In turn, both greater perceived competence and increased trust were associated with increased control (p<0.05).

CONCLUSIONS

Findings indicate that engaging patients in collaborative goal setting during clinical encounters has potential to foster a trusting patient-clinician relationship as well as enhance patient perceived competence, thereby improving clinical control.

PRACTICE IMPLICATIONS

Fostering collaborative goal setting may yield payoffs in improved clinical outcomes among patients with diabetes.

Mechanisms of fluid-flow-induced matrix production in bone tissue engineering

Matrix production by tissue-engineered bone is enhanced when the growing tissue is subjected to mechanical forces and/or fluid flow in bioreactor culture. Cells deposit collagen and mineral, depending upon the mechanical loading that they receive. However, the molecular mechanisms of flow-induced signal transduction in bone are poorly understood. The hyaluronan (HA) glycocalyx has been proposed as a potential mediator of mechanical forces in bone. Using a parallel-plate flow chamber the effects of removal of HA on flow-induced collagen production and NF-κB activation in MLO-A5 osteoid osteocytes were investigated. Short periods of fluid flow significantly increased collagen production and induced translocation of the NF-κB subunit p65 to the cell's nuclei in 65 per cent of the cell population. Enzymatic removal of the HA coat and antibody blocking of CD44 (a transmembrane protein that binds to HA) eliminated the fluid-flow-induced increase in collagen production but had no effect on the translocation of p65. HA and CD44 appear to play roles in transducing the flow signals that modulate collagen production over long-term culture but not in the short-term flow-induced activation of NF-κB, implying that multiple signalling events are initiated from the commencement of flow. Understanding the mechanotransduction events that enable fluid flow to stimulate bone matrix production will allow the optimization of bioreactor design and flow profiles for bone tissue engineering.

Science, medicine and the future: healing chronic wounds

Greater interest in wound healing is needed to ensure higher standards of basic care. Precise identification of the systemic, local, and molecular factors underlying the wound healing problem in individual patients should allow better tailored treatment. Allogeneic skin grafting and bioengineered skin equivalents are being used successfully in patients with venous leg ulcers and diabetic patients with foot ulcers.

Specific growth factors and the healing of chronic wounds

Part II of this two-part review focuses on the function of specific growth factors in wound healing and considers the results of clinical trials of their use in chronic wounds.

A dynamic regulator: the role of growth factors in tissue repair

Growth factors have the potential to improve wound healing during the three main phases of wound repair. This review, the first in a two-part series, explains how they do this.

Co-existing abdominal aortic aneurysm and intra-abdominal malignancy: reflections on the order of treatment

BACKGROUND

The management of simultaneously occurring abdominal aortic aneurysm and intra-abdominal malignancy is controversial. It is unclear whether to treat the aneurysm first or the malignancy, or both simultaneously. If the malignancy is resected first there is a risk of postoperative rupture of the aneurysm. If simultaneous surgery is performed there is a risk of prosthetic graft infection from contamination by gastrointestinal or urinary tract contents.

METHODS

Relevant papers from 1960 to 1996, identified from Medline and manual searching, were reviewed.

RESULTS AND CONCLUSION

The literature supports the conclusion that the lesion of greater priority is that posing the greater threat to the patient; this is usually the aneurysm, especially if it is over 6 cm in diameter. For renal malignancies simultaneous surgery is the treatment of choice, but for bladder cancer the best management is unclear. Large aneurysms should usually be resected in preference to colorectal cancer unless the cancer is locally advanced, perforated or likely to result in early intestinal obstruction. If both lesions are complicated there may be a case for simultaneous treatment.

Clinical results of pharyngeal flap surgery: the Iowa experience

Sixty-five patients with cleft palate, with or without cleft lip, who received previous pharyngeal flap surgery for chronic velopharyngeal dysfunction in our department, were examined for velopharyngeal status, speech production patterns, and evidence of nasal airway obstruction. Of the 65 subjects, 54 (83.1 percent) showed velopharyngeal function within normal limits, 43 (66.1 percent) showed normal or near-normal speech production, and 58 (89.2 percent) reported snoring sometimes or often. Of the 58 reporting snoring, electrocardiogram (ECG) data for 33 were examined for evidence of right ventricular hypertrophy. Only one (3 percent) of the 33 showed such possible indication. We conclude that by our methods, pharyngeal flap surgery is an effective treatment for velopharyngeal dysfunction. After surgery, patients may report symptoms of nasal airway obstruction during sleep but are not expected to show ECG changes in cardiac function resulting from oxygen deprivation.

Complication outcomes based on preoperative admission and length of stay for primary palatoplasty and cleft lip/palate revision in children aged 1 to 6 years

With increasing focus on outcome studies, there is continued need for data about whether same-day admission and reduced hospital stay have adverse effects on surgical treatment, including that for cleft lip and palate. In this study, medical records were inspected for all cleft lip and palate patients, aged 1 to 6 years, who had primary palatoplasty or cleft lip/palate revision in this treatment center between 1978 and 1992 (N = 329). Length of stay for 251 (96.5%) of the 260 subjects admitted the day before surgery was from 4 to 7 days; 9 remained in the hospital longer than 8 days. Length of stay for 67 (97.1%) of 69 patients admitted the day of surgery was from 2 to 3 days; 2 were in the hospital for 7 days, and none for 8 or more days. Thirty-seven instances of surgical complications were reported for the 260 patients admitted the day before surgery (14.2%). Twelve complications (17.4%) were recorded for the 69 patients admitted the day of surgery. There was no significant difference in the number of complications between the two groups of patients (Fisher's exact test, p = 0.5682). There was no significant difference in the types of complications observed between the two groups (Fisher's exact test). Surgery was performed at age 1 year for 61 of the 69 patients admitted on the day of surgery (88.4%). The mean age of this group was significantly younger than that of patients operated on earlier than 1989 and admitted on the day before surgery (Wilcoxon's test, p = .0001, Z = 4.48).(ABSTRACT TRUNCATED AT 250 WORDS)

Multidisciplinary treatment results for patients with isolated cleft palate

Fifty-eight patients with cleft palate only who had received treatment in the Department of Otolaryngology-Head and Neck Surgery at the University of Iowa were examined for treatment results. Forty-one (70.7 percent) of the 58 patients showed a syndrome or suggestive factors. An unusually high percentage (36 percent) of the 58 patients required secondary surgery for velopharyngeal dysfunction or showed indications for surgery at examination. Some but not all of the relatively low success rate appears related to surgical experience. Speech proficiency, hearing acuity, and dental status were within normal limits or nearly so. The 20 patients with pharyngeal flap surgery were doing well, with minimal indications of functional obstruction.

Long-term speech results of cleft palate patients with primary palatoplasty

This investigation examined the influence of cleft type, type of surgery, age at surgery, and gender on speech proficiency of 204 patients with cleft palate who required only primary palatoplasty. Speech measures were obtained for each subject from at least three annual examinations between the ages of 4 and 16 years. Neither age at surgery nor type of surgery were discriminating factors. The less extensive cleft type, i.e., soft palate only, was associated with greater rates of change in the performance variables than were the other three cleft types. Females showed greater rate changes than males.

Correspondence between nasalance scores and listener judgments of hypernasality and hyponasality

The relationship between nasalance scores and perceptual judgments of hypernasality and hyponasality was examined for 74 subjects (51 with cleft palate and 23 noncleft controls). Twenty-nine of the 51 subjects with cleft palate had received pharyngeal flap surgery. Predictive analyses were performed to assess the sensitivity, specificity, and efficiency of the Nasometer as a screening instrument. The overall relationship between perceptual judgments of hypernasality and nasalance scores was good for the nonflap subjects when a nasalance cutoff score of 26 was used. A sensitivity coefficient of 0.87 and a specificity coefficient of 0.93 were obtained. Ninety-one percent of the nasometry-based classifications accurately reflected listener judgments of hypernasality. The correspondence between nasalance scores and clinical judgments of hyponasality was also good for the nonflap subjects when a nasalance cutoff score of 50 was used. Ninety-one percent of these classifications were consistent with the listener judgments. Efficiency of nasometry was poorer for the flap subjects.

Communication status following laryngectomy: the Iowa experience 1984-1987

Data regarding treatment and outcome for a consecutive series of 73 total laryngectomy patients were collected from clinical records with a follow-up period of 30 to 78 months postoperatively. Notable findings were that 27% were women; 75% reported hoarseness or a voice change as an early symptom; and 22% reported combined heavy use of both cigarettes and alcohol. Of the 73 patients, 38 (52%) died during the follow-up period; 18 of the 38 died within 1 year postoperatively. Thirty-nine (53%) of the 73 had received a surgical tracheoesophageal fistula (TEF) for voice restoration, as either a primary or a secondary procedure. Of the 39, 75% were using the TEF at last examination, with no failures attributed to sphincter spasm. Of the total group, the primary communication modality was reported to be use of a TEF by 44% and use of an electrolarynx by 50%. Limitations of the study and directions for future investigations are discussed.

Results of multidisciplinary management of bilateral cleft lip and palate at the Iowa Cleft Palate Center

Bilateral cleft of the lip and palate is by many standards the most complex and severe form of the defect. The complexity and severity of the defect require an unusual degree of cooperation among all specialists and especially between the surgeon and the orthodontist. There are no published findings that we know about in which comprehensive data from a number of disciplines are reported for the same group of bilateral cleft patients. Fifty randomly selected patients with bilateral complete clefts were examined by the Iowa team and two orthodontists from other institutions. The evaluations revealed that a large number of patients over the age of 10 have multiple residual problems requiring further treatment. Only 23 percent of the older patients studied were judged to have had treatment completed by the surgeon, speech pathologist, and orthodontist. It is very difficult to state whether the results obtained by our team can be considered satisfactory because there are no comparable studies that have attempted to evaluate the same parameters in multidisciplinary management.

Velar-pharyngeal status in cleft palate patients with expected adenoidal involution

This study was designed to provide information about whether cleft palate patients with hypertrophied adenoids maintain velar-pharyngeal contact during the time of expected adenoidal atrophy. Thirty-nine subjects were selected from a large longitudinal study on the basis of availability of lateral still x-ray films taken in series from 5 to 16 years of age. Ratings of velar-pharyngeal contact and ratings of adenoid size were obtained from the films. The obtained data indicated the expected decrease in adenoid size but also, for the group, maintenance of velar-pharyngeal contact. However, three of the 39 subjects were judged to show loss of such contact during the period of study, and an additional four had surgery for velopharyngeal incompetence after the completion of the study. All seven appeared to show significant deterioration of velopharyngeal status in middle or late adolescence. Implications of these findings are discussed.

Cleft lip and palate and related disorders: issues for future research of high priority

On October 14 to 17, 1987, a meeting entitled "State of the Art Conference: Multidisciplinary Management of Cleft Lip and Palate" was held in Iowa City. The major purpose of the conference was to review the available knowledge concerning management of unilateral cleft lip and palate from the perspectives of surgery, speech-language pathology, and orthodontics. The closing feature of the conference was the identification of issues for future research. Participants identified issues of high priority that were then discussed by the entire conference faculty. This paper reports the summary of that discussion and the recommendations of the Conference.

Assessment of velopharyngeal competence: a long-term process

This study compared longitudinally perceptual ratings of articulation defectiveness, nasality, and velopharyngeal competency in 13 subjects who required secondary palatal management after age 10 with a second group. Perceptual data when examined longitudinally did not adequately discriminate between subjects who at one time achieved velopharyngeal closure but who ultimately required secondary management and those patients who needed no further treatment. A decrease in articulation scores and an increase in severity of nasality and articulation defectiveness over time indicate that patients are at risk for secondary management. Evaluation of lateral x-rays indicated that those in the group that required secondary operations demonstrated more variability in velopharyngeal closure than those in the comparison group, who required no secondary operations and that adenoidal involution did not appear to be a significant factor.

Contribution of selected variables to the prediction of speech proficiency for adolescents with cleft lip and palate

The purpose of this study was to examine the relative contribution of clinical data obtained during speech examinations at age 4 years and at each subsequent age through 13 years to the prediction of judged speech proficiency at age 14 years for children with unilateral cleft of the lip and palate. Psychological scale values of speech proficiency were obtained for 50 adolescents and used as the dependent variable in each analysis. The 16 independent variables used in the analysis at age 4 years included four nonspeech variables (gender, type and age of primary surgery, and pharyngeal flap surgery) and 12 speech measures obtained from speech examination. In subsequent analyses at ages 5 through 13 years, the rate of change between adjacent age levels for each of the 12 speech measures was also included, for a total of 28 independent variables. The data were analyzed using the MAXR stepwise regression procedure, first for the total group of subjects and then separately for males and females. The results of this investigation indicated that a large percentage of the variance in judged speech proficiency at age 14 years can be accounted for, using clinical data obtained for speech examinations at ages 4 through 13 years. When the regression analyses were performed for the total group of subjects at ages 4 through 13 years, the most efficient set of predictors accounted for 50 to 75 percent of the variance in the dependent variable. The variable of gender was identified as the single most important predictor in nine of the 10 regression analyses, alone accounting for at least 40 percent of the variance in judged speech proficiency. When the regression analyses were performed separately for males and females, approximately 50 to 80 percent of the variance was accounted for in judged speech proficiency for males and 50 to 90 percent for females using one, two, or three of the independent variables. The most efficient set of predictors varied across age levels for both groups. In addition, these predictors differed between males and females.

Multiview videoendoscopic evaluation of velopharyngeal physiology in 15 normal speakers

Oral and nasal videoendoscopic procedures, when used in tandem, could provide a more useful analysis of velopharyngeal physiology than either procedure used alone. The purposes of this research were to document observed differences between the two approaches when applied to the examination of velopharyngeal function and to determine the advantages and disadvantages of using oral and nasal endoscopy as tandem diagnostic tools. The results indicated that patterns of velopharyngeal closure as observed from both the oral and nasal views are in approximately 60% agreement. Differences between the two perspectives most frequently involve the relative contributions of the pharyngeal walls. These differences are attributed to important physiologic variations along the vertical plane of the velopharynx. The data indicate that using oral and nasal videoendoscopy as tandem diagnostic procedures can result in improved understanding of velopharyngeal physiology. The issues of interference with speech movements and patient compliance are discussed.

Late results of primary veloplasty: the Marburg Project

Forty-five randomly selected patients with unilateral cleft lip, alveolus, and palate, all operated upon by Dr. Wolfram Schweckendiek were evaluated by three American specialists to assess the validity of primary veloplasty. Examination revealed an unusually high incidence of short palate and poor mobility of the soft palate. Facial growth was found to be highly acceptable in the majority of the patients. Unusually high incidence of velopharyngeal incompetence was found in these patients.

Reliability of the nasopharyngeal fiberscope (NPF) for assessing velopharyngeal function: analysis by judgment

The reliability and validity of data about velopharyngeal function obtained with the nasopharyngeal fiberscope was assessed in normal subjects. The experimental design included data reduction procedures that are likely to have clinical utility (clinical ratings). The results indicated that relative velar movement and size of the velopharyngeal port may be reliably and validly estimated using the procedures. However NPF estimates of lateral pharyngeal wall movement were not reliable. Finally, the data indicated that velar movement and size of V-P port were consistent within subjects and tasks across data collection sessions. Data about consistency of lateral wall movement across sessions was inconclusive, however. Additional research involving similar procedures with subjects who have morphologic deficits is indicated.

Reliability of the nasopharyngeal fiberscope (NPF) for assessing velopharyngeal function

Simultaneous side-view nasopharyngeal fiberscopic (NPF) and lateral cinefluoroscopic (cine) recordings were taken for two normal subjects to determine the stability of NPF placement for the study of velopharyngeal function, and the reliability and validity of NPF findings. The results indicate that the NPF was highly stable during the several velopharyngeal activities examined, the NPF tip maintaining a relatively constant relationship within the vertebral complex. Therefore, it seems likely that similar NPF views are obtained on different occasions with a subject. The findings also indicate that measurements can be made from NPF still photos for several aspects of the velopharyngeal mechanism. However, measurements of the left lateral wall movement were not reliable. Measurement of velar movement from NPF correlated well with cine measures of velar movement, indicating validity of that NPF measure.

Indications of congenital palatal incompetence before diagnosis

By questionnaire, parents of 28 children with CPI were asked about pregnancy and delivery; speech, developmental, and health history; and the circumstances of the CPI diagnosis. A normal control group was used for comparison. CPI children had lower birth weights and, during early childhood, were more poorly understood by parents and more frequently had nasalized speech. In 50%, CPI diagnosis was made following adenoidectomy. Data and clinical findings indicate that possible predictors of CPI are unusually defective speech production, particularly characterized by nasalization, as a young child; a short or poorly mobile palate; anterior dimpling of the soft palate during elevation; radiographic abnormalities of the cervical vertebrae; neurologic abnormalities (developmental milestones or clinical examination); and nasal leakage of liquids as a very young infant. Temporary velopharyngeal incompetence and nasalized speech may occur in the normal patient following adenoidectomy but the disorder resolves in a day or two. Persistent nasalized speech following adenoidectomy indicates the likelihood of CPI; such a patient requires evaluation by a speech pathologist and possible surgical correction.

Verbal communication skills of six children wit craniofacial anomalies

The verbal communication skills of six children with craniofacial syndromes were examined. The subjects were four girls with Apert syndrome, a boy with Crouzon disease, and a fifth girl with Saethre-Chotzen Syndrome. They ranged in age from six to sixteen years. Each of the six subjects demonstrated oral structural anomalies and at least a mild communication problem. Sample size precluded the formation of judgments relative to the population as a whole or to particular subgroups.

Simultaneous assessment of pharyngeal wall and velar displacement for selected speech sounds

Velar and pharyngeal wall displacements were studied simultaneously by using conventional lateral-view radiography and frontal-view tomography. Twenty-five normal adult male and female subjects were utilized. Major results pertaining to lateral pharyngeal wall displacements during speech include the following. 1) At more superior levels of the pharynx, greater mesial displacements occurred for nonnasal compared to nasal speech sounds and no significant differences were noted among the nonnasal speech sounds studied. 2) At an inferior level of the pharynx, mesial displacements were greater for low vowels compared to the other speech sounds studied but some lateral (outward) movements were observed during high vowel production for some subjects. 3) Greatest mesial displacements for all subjects ad speech sounds studied occurred at the level of and just below the plane of the hard palate. Low correlations between velar and lateral pharyngeal wall displacements were obtained for most subjects. The results do not support the hypothesis that the levator veli palatini muscle is solely involved in both velar and lateral pharyngeal wall movements.

The structure and function of interdisciplinary health teams

A useful definition of the function of the interdisciplinary health team includes issues of goal identification, efficiency, effectiveness, practicality, and relevance. Criteria for determining the structure of the team involve the specific objectives to be met, administrative systems that are available, creating an atmosphere of mutual respect and professional esteem, and maintaining a proper arena for intellectual growth. Teamwork has certain disadvantages, however, and is probably not for everyone.

Patterns of articulation abilities in speakers with cleft palate

The purpose of this study was to report the articulation scores of 351 subjects with cleft palate from the ages of 2-6 to 18-0. Analysis of the data indicate that, as a group, subjects with cleft palate are retarded in articulation skills. However, they continue to improve in this regard past the age at which normal speakers have achieved articulation maturation. This information should be compared with that acquired from other centers in order to determine how typical these findings are.

Performance of children with good and poor articulation on tasks of tongue placement

This study determined whether children could learn to replicate four positions of lingual-palatal contact with and without topical anesthesia that eliminated touch-pressure sensations. First-grade boys, nine with good articulation skills and nine with poor articulation skills, were used as subjects. Results suggest that individuals are able to learn nonspeech tasks of tongue positioning by relying on muscle spindles or deep receptors within the tongue, or both, or by relying on lingual touch-pressure or other surface receptors within the tongue, or, by a combination of deep and surface receptors of the tongue. Further, tongue positioning need not be dependent on touch-pressure or superficial tactile mechanisms. Children with relatively severe articulation problems performed more poorly on the tasks of precise tongue placement than children with good articulation skills. And finally, children with relatively severe articulation problems may be able to improve their initially poor performance on tongue placement tasks with specific training on those tasks, implying that this group did receive the intraoral sensory feedback necessary to learn the task, but that more experience was needed for the learning to occur.

An assessment of informative-counseling procedures for cleft palate children

32 children with cleft palate and their mothers were interviewed for the purpose of learning what information they had about cleft and cleft management. Their responses were compared with standards specified by eight cleft palate specialists from four disciplines. The findings indicate that the specialists were somewhat inconsistent in what they expected the families to know about clefts and in their routine counseling procedures to provide the information. In general, the mothers had appropriate knowledge about clefts but predicted that their children knew more about clefts and cleft management than was actually the case. The children had less than adequate information about the general impact of a cleft, the etiology of clefts, the rationale for cleft management they had received, and future management of their problem. The results of the study indicate the need or more systematic procedures for providing information to the child with a cleft. The results also suggest the need for additional research about the general counseling process.

A preliminary study of the predictive value of the IPAT

Articulation test scores for 278 subjects with cleft palate were compared with the normative data of Templin and Darley on the Iowa Pressure Articulation Test and the Templin-Darley Screening test of Articulation. In addition the predictive value of the Iowa Pressure Articulation Test in relation to the need for secondary management was examined. The results indicate that, at no age level between four and ten years, do more than 9% of the subjects achieve the mean on the IPAT without secondary management. Examination of the data in regard to "risk rates" indicates that the IPAT is very useful in predicting the need for secondary management. Subjects who obtained scores of zero on the IPAT at four and one-half years of age had a 96% risk of requiring secondary palatal management.