Cleft Palate Repair Postoperative Management: Current Practices in the United States

OBJECTIVE

To describe current postoperative management practices following cleft palate repair.

DESIGN

A survey was administered to cleft surgeons to collect information on their demographic characteristics, surgical training, surgical practice, and postoperative management preferences.

SETTING

Eighteen tertiary referral hospitals across the United States.Participants: Surgeons (n = 67) performing primary cleft palate repair.

RESULTS

Postoperative diet restrictions were imposed by 92% of surgeons; pureed foods were allowed at one week after surgery by 90% of surgeons; a regular diet was allowed at one month by 80% of surgeons. Elbow immobilizers and/or mittens were used by 85% of surgeons, for a median duration of two weeks. There was significant disagreement about postoperative use of bottles (61% allow), sippy cups (68% allow), pacifiers (29% allow), and antibiotics (45% prescribe). Surgeon specialty was not associated with any aspect of postoperative management (p > 0.05 for all comparisons). Surgeon years in practice, a measure of surgeon experience, was associated only with sippy cup use (p < 0.01). The hospital at which the surgeon practiced was associated with diet restrictions (p < 0.01), bottle use (p < 0.01), and use of elbow immobilizers or mittens (p < 0.01); however, many hospitals still had disagreement among their surgeons.

CONCLUSIONS

Surgeons broadly agree on diet restrictions and the use of elbow immobilizers or mittens following palate repair. Almost all other aspects of postoperative management, including the type and duration of diet restriction as well as the duration of immobilizer use, are highly individualized.

Correspondence between consonant inventories obtained using modified naturalistic listening in real time (NLRT) and parent report

OBJECTIVE

The current study examined the correspondence between consonant inventories obtained using the modified NLRT approach and parent report.

DESIGN

Prospective comparative study.

SETTING

Multisite institutional.

PARTICIPANTS

Participants included 70 children with repaired CP + L (mean age = 16 months) who were participating in the multicenter study.

PROCEDURES

Parents of participants were asked to record approximately two hours of their child's vocalizations/words at home using a Language ENvironmental Analysis (LENATM) recorder. Four ten-minute audio-recorded samples of vocalizations were extracted from the original recording for each participant and analyzed for size of consonant inventory. Parent reported consonant inventory was compared to coder identified consonant inventory. Coders identified an in-inventory consonant using two different criteria: 2+ tokens of each consonant were required in the first analysis and 10+ tokens of each consonant were required in the second analysis.

RESULTS

Coder identified consonant inventory was larger (mean = 7.90) than that reported by parents (mean = 6.06) when a minimum of two tokens per consonant was required for inclusion of a consonant in inventory, while the inventory transcribed by coders was smaller (mean = 4.46) than that reported by parents when inclusion criteria required a minimum of ten tokens per consonant.

CONCLUSIONS

Although the mean number of consonants in inventory between coders and parents was slightly closer using the 10+ versus 2+ criterion for consonant inclusion, the difference was not significant enough to recommend one protocol over the other.

Factors Associated with Delayed Palatoplasty Before, During, and After the COVID-19 Pandemic

BACKGROUND

Cleft palatoplasty is typically performed around 10 to 12 months of age in the US, and delays can negatively affect speech development. Early during COVID-19, elective surgeries were canceled. The aims of this study were to (1) identify overall risk factors for greater age at palatoplasty and (2) analyze delays in palatoplasty during COVID-19.

METHODS

This study was part of a larger prospective, multicenter comparative study of speech outcomes in palatoplasty. Participants underwent palatoplasty between March 2019 and September 2022 at 18 pediatric hospitals in the United States. Ages were corrected for prematurity. Dates of palatoplasty were divided into 4 periods corresponding to different phases of the pandemic. Factors analyzed included region, language, adoption status, sex, ethnicity, race, rurality, health insurance type, and cleft type. Analyses were performed using ANOVA, Student's test, and multivariable linear regression, with a P value of ≤0.05 being significant.

RESULTS

Nine hundred twenty-eight participants were included. Average corrected age at palatoplasty was 374 days. In univariable analysis, palatoplasty was performed later in children who were Hispanic (P=0.003), of a race other than White, Black, or Asian (P<0.001), and without private insurance (P<0.001). On multivariable regression, predictors of delayed palatoplasty were Hispanic ethnicity (P=0.015), from other race (P<0.001), and without private insurance (P<0.001). During COVID-19, disproportionate delays occurred in patients who were female, of other races, from nonrural areas, and on Medicaid.

CONCLUSIONS

Palatoplasty was performed later in vulnerable populations. Some of these populations were also disproportionately affected by COVID-19 delays. Providers should be aware of these differences as they pertain to equitable access to craniofacial care.

LEVEL OF EVIDENCE

III.

Standardization of Videorecorded Speech Samples for Children with Cleft Palate: Methods to Facilitate High-Quality Speech Outcomes Data Collection

BACKGROUND

Collection of high-quality videorecorded speech samples is essential for speech outcomes research.

SOLUTION

Cleft palate team SLPs were trained to collect standard videorecorded speech samples in the clinic setting across 20 sites in North America. Standard training and equipment was provided.

WHAT WE DID THAT IS NEW

Quality management procedures were developed and utilized to verify video quality and protocol adherence. Over 97% of speech samples collected by trained SLPs met defined quality standards.

Stop Consonant Production in Children with Cleft Palate After Palatoplasty

The current study examined stop consonant production in children with cleft lip and/or palate (CP ± L) 2-6 months following palatal surgery.

Prospective comparative study.

Multisite institutional.

Participants included 113 children with repaired CP ± L (mean age = 16 months) who were participating in the multicenter CORNET study.

Parents of participants were asked to record approximately two hours of their child's vocalizations/words at home using a Language ENvironmental Analysis (LENATM) recorder. Four ten-minute audio-recorded samples of vocalizations were extracted from the original recording for each participant and analyzed for presence of oral stop consonants. A minimum of 100 vocalizations were required for analysis.

Preliminary findings indicate that at least one oral stop was evident in the consonant inventory for 95 of the 113 children (84%) at the time of their post-surgery 16-month recording, and 80 of these children (71%) were producing two or more different stops. Approximately 50% of the children (57/113) produced the three voiced stops, and eight of the children (7%) were producing all six stop consonants.

The findings of this study suggest that the majority of children with repaired CP ± L from English-speaking homes are producing oral stops within six months following palatal surgery. Similar to same-age children without CL ± P, voiced stops were more frequently evident in the children's inventories than voiceless stops. In contrast to findings of previous reports suggesting place of articulation differences, a somewhat comparable percentage of children in this study produced voiced bilabial, alveolar, and velar stops.

Transcribing toddler vocalizations: comparison of a modified naturalistic listening approach with phonetic transcription

Previous investigations have demonstrated that naturalistic listening in real time (NLRT) can be used reliability to assess prelinguistic vocalizations and is less time-consuming than phonetic transcription. The current investigation was performed to examine the correspondence of syllable and consonant information obtained using a modified naturalistic listening in real time (NLRT) methodology compared to broad phonetic transcription for 20 toddlers with repaired cleft palate. A forty-minute vocalization sample was obtained for each toddler. Two listeners listened to each recording independently and coded the number of syllables and consonant types produced by each toddler using NLRT. Each recording was phonetically transcribed by each listener 2 to 16 months following the NLRT analysis. High reliability was evident between the modified NSRT method and phonetic transcription for identification of both syllables and consonants. Differences were evident in the actual number of syllables and consonants identified between the two types of assessment across the 20 participants. Possible explanations for those differences are addressed. The results of this investigation indicate that the modified NLRT procedure is a reliable method for determining consonant/inventories of young children. It is less labor intensive than traditional phonetic transcription and may be useful clinically when documentation of early sound development is needed to support early intervention decisions.

Non-Oral Compensatory Misarticulations Revisited

Non-oral compensatory misarticulation patterns are often associated with the speech of children with cleft palate. Despite their saliency, the etiology, frequency, and treatment of these misarticulations have not been studied extensively. The purpose of this commentary is to review what we know about these atypical patterns of articulation and address clinical assumptions regarding their etiology and treatment.

The Implications of Nasal Substitutions in the Early Phonology of Toddlers With Repaired Cleft Palate

OBJECTIVE

To examine the implications of nasal substitutions in the early words of toddlers with cleft palate.

DESIGN

Retrospective.

PATIENTS

Thirty-four toddlers with nonsyndromic cleft palate and 20 noncleft toddlers, followed from ages 13 to 39 months.

MAIN OUTCOME MEASURES

The groups were compared for the percentage of toddlers who produced nasal substitutions in their early words. The percentage of toddlers with repaired cleft palate who produced nasal substitutions and were later suspected of having velopharyngeal dysfunction (VPD) was also examined.

RESULTS

Seventy-six percent of the toddlers in the cleft group (n = 26) and 35% of toddlers in the noncleft group (n = 7) produced nasal substitutions on one or more of their early words. Only 38% (10/26) of the toddlers with cleft palate who produced nasal substitutions in their early words were later diagnosed as having moderate-severe hypernasality and suspected VPD.

CONCLUSIONS

The presence of nasal substitutions following palatal surgery was not always an early sign of VPD. These substitutions were present in the early lexicon of children with and without cleft palate.

Conversational Skills of Children with Cleft Lip and Palate: A Replication and Extension

Objective

To replicate and to extend a previous study examining the conversational skills of children with cleft lip and palate.

Participants

Thirty-four children (33 to 44 months) participated: 17 children with cleft lip and palate and 17 noncleft children.

Methods

The children were observed during an interaction with caregivers in their homes. Samples of caregiver-child interactions were coded as assertive or responsive, for type of conversational act, and for discourse level categories. Profiles of conversational activity were determined for each child based on the coding. Correlations were performed to examine the relationship between assertiveness and speech variables (articulation and resonance) for the children with cleft lip and palate.

Results

Group comparisons revealed that the children with cleft lip and palate produced fewer assertive utterances, were less likely to respond adequately to comments by caregivers, and produced more topic maintaining and fewer topic extending utterances than did their noncleft peers during conversational interactions. Examination of individual child data indicated that 35% of the children with cleft lip and palate exhibited conversational profiles characterized by either low assertiveness or low responsiveness. Finally, a significant positive correlation was noted between conversational assertiveness and speech production skills.

Conclusion

These findings suggested that the children with cleft lip and palate were less conversationally assertive than their noncleft peers. Further, there appeared to be a relationship between speech production skills and conversational skills, suggesting that poor speech may be impacting language performance for these children.

Multipoint genome-wide linkage scan for nonword repetition in a multigenerational family further supports chromosome 13q as a locus for verbal trait disorders

Verbal trait disorders encompass a wide range of conditions and are marked by deficits in five domains that impair a person's ability to communicate: speech, language, reading, spelling, and writing. Nonword repetition is a robust endophenotype for verbal trait disorders that is sensitive to cognitive processes critical to verbal development, including auditory processing, phonological working memory, and motor planning and programming. In the present study, we present a six-generation extended pedigree with a history of verbal trait disorders. Using genome-wide multipoint variance component linkage analysis of nonword repetition, we identified a region spanning chromosome 13q14-q21 with LOD = 4.45 between 52 and 55 cM, spanning approximately 5.5 Mb on chromosome 13. This region overlaps with SLI3, a locus implicated in reading disability in families with a history of specific language impairment. Our study of a large multigenerational family with verbal trait disorders further implicates the SLI3 region in verbal trait disorders. Future studies will further refine the specific causal genetic factors in this locus on chromosome 13q that contribute to language traits.

The Americleft Speech Project: A Training and Reliability Study

OBJECTIVE

To describe the results of two reliability studies and to assess the effect of training on interrater reliability scores.

DESIGN

The first study (1) examined interrater and intrarater reliability scores (weighted and unweighted kappas) and (2) compared interrater reliability scores before and after training on the use of the Cleft Audit Protocol for Speech-Augmented (CAPS-A) with British English-speaking children. The second study examined interrater and intrarater reliability on a modified version of the CAPS-A (CAPS-A Americleft Modification) with American and Canadian English-speaking children. Finally, comparisons were made between the interrater and intrarater reliability scores obtained for Study 1 and Study 2.

PARTICIPANTS

The participants were speech-language pathologists from the Americleft Speech Project.

RESULTS

In Study 1, interrater reliability scores improved for 6 of the 13 parameters following training on the CAPS-A protocol. Comparison of the reliability results for the two studies indicated lower scores for Study 2 compared with Study 1. However, this appeared to be an artifact of the kappa statistic that occurred due to insufficient variability in the reliability samples for Study 2. When percent agreement scores were also calculated, the ratings appeared similar across Study 1 and Study 2.

CONCLUSION

The findings of this study suggested that improvements in interrater reliability could be obtained following a program of systematic training. However, improvements were not uniform across all parameters. Acceptable levels of reliability were achieved for those parameters most important for evaluation of velopharyngeal function.

Early Lexical Characteristics of Toddlers with Cleft Lip and Palate

Objective

To examine development of early expressive lexicons in toddlers with cleft palate to determine whether they differ from those of noncleft toddlers in terms of size and lexical selectivity.

Design

Retrospective.

Patients

A total of 37 toddlers with cleft palate and 22 noncleft toddlers.

Main Outcome Measures

The groups were compared for size of expressive lexicon reported on the MacArthur Communicative Development Inventory and the percentage of words beginning with obstruents and sonorants produced in a language sample. Differences between groups in the percentage of word initial consonants correct on the language sample were also examined.

Results

Although expressive vocabulary was comparable at 13 months of age for both groups, size of the lexicon for the cleft group was significantly smaller than that for the noncleft group at 21 and 27 months of age. Toddlers with cleft palate produced significantly more words beginning with sonorants and fewer words beginning with obstruents in their spontaneous speech samples. They were also less accurate when producing word initial obstruents compared with the noncleft group.

Conclusions

Toddlers with cleft palate demonstrate a slower rate of lexical development compared with their noncleft peers. The preference that toddlers with cleft palate demonstrate for words beginning with sonorants could suggest they are selecting words that begin with consonants that are easier for them to produce. An alternative explanation might be that because these children are less accurate in the production of obstruent consonants, listeners may not always identify obstruents when they occur.

An analysis of the frame-content theory in babble of 9-month-old babies with cleft lip and palate

The aim of this study was to examine the consonant-vowel co-occurrence patterns predicted by the Frame-Content theory in 16 nine-month-old babies with unrepaired cleft palate (±cleft lip) and 16 age-matched non-cleft babies. Babble from these babies was phonetically transcribed and grouped according to the intrasyllabic predictions of the theory (labial-central, alveolar-front, and velar-back). Both groups demonstrated the three consonant-vowel co-occurrence patterns predicted by the Frame-Content theory. Other patterns not predicted by the Frame-Content theory emerged as strong patterns as well.

LEARNING OUTCOMES

The reader will be able to: • Describe consonant-vowel co-occurrence patterns produced by babies with and without cleft palate. • Describe vowel inventories of babies with cleft palate. • Identify possible therapy targets for babies with cleft palate.

The Relationship between Early Reading Skills and Speech and Language Performance in Young Children with Cleft Lip and Palate

Objective

To examine the early reading skills of young children with cleft lip and palate and to examine the relationship between early reading skills and speech and language performance.

Participants

A total of 56 children participated in the study: 28 children with cleft lip and palate and 28 noncleft children matched for age (mean age, 5 years 7 months), gender, and months of formal schooling.

Main Outcome Measures

The two groups of children were compared ( t tests) on the Test of Early Reading-3. Pearson product moment correlations were performed to examine separately the relationship between early reading skills speech production abilities and between early reading skills and receptive and expressive language abilities for the two groups.

Results

Statistically significant group differences were noted on the Test of Early Reading-3. The mean score of 99 obtained by the group of children with cleft lip and palate was within normal limits compared with the norms for the Test of Early Reading-3; however, 14% of the children with cleft lip and palate scored outside the normal range on the Test of Early Reading-3. Statistically significant correlations were obtained between early reading skills and speech production abilities and between early reading skills and language abilities.

Conclusions

Children with cleft lip and palate differed from noncleft peers in speech and early reading skills. Children with the most severe speech problems were the children with the poorest performance on the Test of Early Reading-3. Management of children with cleft lip and palate should include early identification of and intervention for delays in speech, language, and reading.

Speech-language characteristics of children with neurofibromatosis type 1

Delays in speech and articulation development have been found in school-aged children and adolescents with neurofibromatosis type 1 (NF1). This report examines speech and language skills of preschool children with NF1. Nineteen 3- to 5-year-old children diagnosed with NF1 were assessed using measures of articulation (GFTA-2), and receptive and expressive language (CELF-P2). Significant differences were observed between mean scores obtained by the group of children with NF1 compared to the validated controls from the speech and language instruments (P < or = 0.009). Sixty-eight percent of the children exhibited delays in speech and/or language. Thirty-two percent demonstrated delays in articulation, 37% percent demonstrated delays in receptive language, and 37% exhibited delays in expressive language. Sixteen percent of the children exhibited a voice disorder and 42% were judged to have a resonance problem. No significant differences were observed on any of the measures of speech and language for children with non-familial versus familial NF1. Results of this study support the need for early assessment of speech and language problems for children diagnosed with NF1 and implementation of appropriate timely intervention as needed.

Timing of Palatal Surgery and Speech Outcome

Objective:

To examine the impact of age and lexical status at the time of primary palatal surgery on speech outcome of preschoolers with cleft palate.

Participants:

Forty children (33 to 42 months) with nonsyndromic cleft palate participated in the study. Twenty children (Group 1) were less lexically advanced and younger (mean age  =  11 months) and 20 children (Group 2) were more lexically advanced and older (mean age  =  15 months) when palatal surgery was performed.

Main Outcome Measures:

Samples of the children's spontaneous speech were compared on 11 speech production measures (e.g., size of consonant inventory, total consonants correct, % correct for manner of articulation categories, compensatory articulation usage, etc.). Next, listeners rated a 30-second sample of each child's connected speech for articulation proficiency and hypernasality, separately, using direct magnitude estimation (DME).

Results:

Group differences were noted for 4 of the 11 speech production measures. Children in Group 1 exhibited larger consonant inventories (and true consonant inventories) and more accurate production of nasals and liquids compared to children in Group 2. On the DME task, significant group differences were found for ratings of articulation proficiency and hypernasality. Children in Group 1 exhibited better articulation and less hypernasality than children in Group 2.

Conclusions:

The findings suggested that children who were less lexically advanced and younger at the time of palatal surgery exhibited better articulation and resonance outcomes at 3 years of age.

The Impact of Early Intervention on Speech and Lexical Development for Toddlers With Cleft Palate: A Retrospective Look at Outcome

Purpose

The purpose of the present investigation was to examine the impact of early intervention on speech and lexical measures for toddlers with cleft palate.

Method

Speech measures of ten 27-month-old toddlers with cleft palate who had been referred for therapy at 17 months of age were compared to those of 10 toddlers with cleft palate who had been referred but did not receive therapy. Both groups were compared to 2 other groups of children who had never been referred for therapy.

Results

Multivariate analysis of variance revealed only 1 significant difference between the children who received therapy and those who did not receive therapy. Children who received therapy produced a significantly greater percentage of glides ( p < .001) than did children who did not receive therapy.

Conclusion

The findings of this study indicated that early intervention as conducted by the speech-language pathologists in this study was not as effective as expected for this group of toddlers with cleft palate.

Is presurgery and early postsurgery performance related to speech and language outcomes at 3 years of age for children with cleft palate?

This study examined the relationship between presurgery speech measures and speech and language performance at 39 months as well as the relationship between early postsurgery speech measures and speech and language performance at 39 months of age. Fifteen children with cleft lip and palate participated in the study. Spontaneous speech samples were obtained in the children's homes at presurgery/ 9 months, postsurgery/13 months and again at 39 months of age. Correlational analyses revealed a lack of association between speech measures presurgery and early postsurgery and speech outcome measures at 39 months. Significant negative correlations were noted for true canonical babbling ratio presurgery and mean length of utterance (MLU) at 39 months, as well as for size of true consonant inventory presurgery, and both language outcome measures at 39 months (MLU and number of different words). Significant positive correlations were noted for percentage of true stops produced postsurgery and both language measures at 39 months. Variables that may have influenced speech and language development from presurgery to 39 months are discussed.

The impact of cleft type on early vocal development in babies with cleft palate

OBJECTIVE

The purpose of the present investigation was to examine the impact of cleft type on early sound development in children with cleft palate (with or without cleft lip).

PARTICIPANTS

The participants included 53 babies with unrepaired cleft palate aged 8 to 10 months. Thirty-five babies had cleft lip and palate (CLP) and 18 had cleft palate only (CPO).

MAIN OUTCOME MEASURES

Spontaneous vocalizations of the CLP and CPO groups were compared to determine whether differences were evident in canonical babbling, size of consonant inventory as well as place and manner of consonant production, and frequency of vocalization.

RESULTS

Student's t tests revealed no significant differences between the groups in canonical babbling, size of consonant inventory, place and manner of consonant production, or frequency of vocalization. However, there was a trend for babies in the CPO group to produce fewer compensatory stop consonants and more anterior place features. In addition, a larger percentage of children in the CPO group had entered the canonical babbling stage at the time of this study.

CONCLUSIONS

In general, the findings of this study suggested that cleft type does not appear to play a significant role in early consonant development for babies with cleft palate. Additional study using a larger CPO group is recommended to further investigate the trend toward better performance noted in this group.

The relationship between early speech and later speech and language performance for children with cleft lip and palate

This study examined the relationship between speech measures at presurgery/9 months and postsurgery/13 months and speech and language performance at 21 months for children with cleft lip and palate and their noncleft peers. Comparisons were also made between the speech and lexical development of children with cleft lip and palate and noncleft children at 21 months of age. The participants included 30 children; 15 with cleft lip and palate and 15 noncleft children. Results revealed differences between the groups for several measures of speech and lexical development at 21 months. For the children with cleft palate, correlational analyses suggested that true stop production, both immediately before and after palatal surgery, was positively correlated with a majority of the speech production measures at 21 months. At postsurgery/13 months, true stop production was related to later vocabulary development, and size of true consonant inventory was related to all measure of speech production and one measure of lexical development at 21 months. For the noncleft group, true canonical babbling ratio at 13 months was the only measure that was significantly correlated with any of the speech and/or language measures at 21 months. The impact of clefting on prelinguistic and later speech and language skills is discussed.

Speech development of children with cleft palate before and after palatal surgery

OBJECTIVE

This study examined the speech production abilities of children with cleft palate before and after palate repair.

PARTICIPANTS

Twenty-eight children participated in the study, 14 with cleft palate and 14 without clefts matched for age, gender, and mothers' educational level.

MAIN OUTCOME MEASURES

Comparisons were made between the children with cleft palate before and after surgery for canonical babbling ratios, size of consonant inventories, place and manner characteristics, and early developing sounds [p, b, t, d, k, g, m, n, eta]. Also, comparisons were made between the children with cleft palate and their peers without clefts at postsurgery/17 months for the measures described above.

RESULTS

Paired t tests revealed differences in pre- and postsurgery performance of the children with cleft palate for production of canonical syllables and size of consonant inventories. Although no significant differences were noted for place and manner features, production of oral stops doubled from the time before surgery to that after surgery. Specifically, production of the bilabial stop [b] showed significant change over time. Results of independent t tests indicated no difference between groups for production of canonical syllables and size of consonant inventories at 17 months. However, significant group differences were noted for production of stops, oral stops, nasals, glides, and alveolars. The children without clefts produced more stops, oral stops, and alveolars. In contrast, more nasals and glides were seen in the vocalizations of the children with cleft palate.

CONCLUSIONS

Children with cleft palate made gains in production of canonical syllables and size of consonant inventories postsurgery; however, they continued to show deficits in production of stops and alveolar place features.

The impact of early palatal obturation on consonant development in babies with unrepaired cleft palate

OBJECTIVE

The purpose of this investigation was to determine whether palatal obturators enhance consonant development during babbling for babies with unrepaired cleft palate.

PARTICIPANTS

Fourteen babies with cleft palate who had worn anterior palatal obturators prior to palatal surgery were matched to 14 unobturated babies according to cleft type, sex, and age at time of presurgical evaluation.

MAIN OUTCOME MEASURES

Spontaneous vocalizations of the obturated and unobturated groups were compared to determine whether differences were evident in size of consonant inventory as well as place and manner of consonant production.

RESULTS

Paired t tests revealed no significant differences between the groups in size of consonant inventory or place and manner of consonant production. There was a trend for babies in the obturated group to produce more glottal consonants.

CONCLUSIONS

In general, the findings of this study suggested that palatal obturators do not appear to facilitate production of anterior palatal consonants during babbling.

Vocal development of 9-month-old babies with cleft palate

This study compared the prelinguistic vocal development of 9-month-old babies with unrepaired cleft palate (n = 30) and age-matched peers (n = 15). Samples of the babies' spontaneous vocalizations were obtained while they interacted with their primary caregiver during play. The groups were compared on a number of variables including (a) canonical babbling ratios, (b) percentage of babies who reached the canonical babbling stage by 9 months, (c) syllable and segmental aspects of babbling, and (d) vocal frequency. Results indicated that the babies with cleft palate had smaller canonical babbling ratios than their age-matched peers, with just 57% of the babies with cleft palate reaching the canonical babbling stage by 9 months compared to 93% of the noncleft babies. Although syllable types and length were similar for the two groups, differences were noted for consonant characteristics. The babies with cleft palate had smaller consonant inventories, with fewer stops, glides, and velars noted. Glottals occurred more frequently in the vocalizations of the babies with cleft palate. Finally, no statistically significant difference was noted in the number of vocalizations produced by the two groups. Some possible explanations for why babies with cleft palate are delayed in babbling are explored.

Mutations in the region encoding the von Willebrand factor A domain of matrilin-3 are associated with multiple epiphyseal dysplasia

Multiple epiphyseal dysplasia (MED) is a relatively mild and clinically variable osteochondrodysplasia, primarily characterized by delayed and irregular ossification of the epiphyses and early-onset osteoarthritis. Mutations in the genes encoding cartilage oligomeric matrix protein (COMP) and type IX collagen (COL9A2 and COL9A3) have previously been shown to cause different forms of MED (refs. 4-13). These dominant forms of MED (EDM1-3) are caused by mutations in the genes encoding structural proteins of the cartilage extracellular matrix (ECM); these proteins interact with high affinity in vitro. A recessive form of MED (EDM4) has also been reported; it is caused by a mutation in the diastrophic dysplasia sulfate transporter gene (SLC26A). A genomewide screen of family with autosomal-dominant MED not linked to the EDM1-3 genes provides significant genetic evidence for a MED locus on the short arm of chromosome 2 (2p24-p23), and a search for candidate genes identified MATN3 (ref. 18), encoding matrilin-3, within the critical region. Matrilin-3 is an oligomeric protein that is present in the cartilage ECM. We have identified two different missense mutations in the exon encoding the von Willebrand factor A (vWFA) domain of matrilin-3 in two unrelated families with MED (EDM5). These are the first mutations to be identified in any of the genes encoding the matrilin family of proteins and confirm a role for matrilin-3 in the development and homeostasis of cartilage and bone.

Surgical correction of blepharoptosis in patients with myasthenia gravis

PURPOSE

To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis (MG).

METHODS

In this retrospective case series, we reviewed the medical records of all patients with MG who did not respond to medical therapy and underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height.

RESULTS

Sixteen blepharoptosis procedures were performed on 10 patients with MG. Eight of the 10 patients had ocular MG. Two of the 10 patients had systemic MG. Of the 16 procedures performed, 9 were external levator advancements (ELA), six were frontalis slings, and one was a tarsomyectomy. Patients were followed postoperatively for an average of 34 months (range, 14-126 months). The amount of ptosis was quantified pre- and postoperatively for seven of the nine eyelids that underwent ELA. For these seven eyelids (five patients), there was a statistically significant improvement in the mean interpalpebral eyelid fissure height from 3.7 mm preoperatively to 7.8 mm postoperatively, with a mean difference of 4.1 mm (95% confidence interval 1.9 mm to 6.25 mm, p = 0.0038). Postoperative complications included worsened diplopia in one patient with ELA and exposure keratopathy in one patient with frontalis sling. Two of the ELA eyelids developed recurrent ptosis requiring additional surgery more than 2 years after the initial procedure.

CONCLUSIONS

Blepharoptosis surgery can achieve eyelid elevation in patients who have failed to respond to medical therapy for MG. Potential complications include worsened diplopia and exposure keratopathy.

Cartilage oligomeric matrix protein interacts with type IX collagen, and disruptions to these interactions identify a pathogenetic mechanism in a bone dysplasia family

Cartilage oligomeric matrix protein (COMP) and type IX collagen are key structural components of the cartilage extracellular matrix and have important roles in tissue development and homeostasis. Mutations in the genes encoding these glycoproteins result in two related human bone dysplasias, pseudoachondroplasia and multiple epiphyseal dysplasia, which together comprise a "bone dysplasia family." It has been proposed that these diseases have a similar pathophysiology, which is highlighted by the fact that mutations in either the COMP or the type IX collagen genes produce multiple epiphyseal dysplasia, suggesting that their gene products interact. To investigate the interactions between COMP and type IX collagen, we have used rotary shadowing electron microscopy and real time biomolecular (BIAcore) analysis. Analysis of COMP-type IX collagen complexes demonstrated that COMP interacts with type IX collagen through the noncollagenous domains of type IX collagen and the C-terminal domain of COMP. Furthermore, peptide mapping identified a putative collagen-binding site that is associated with known human mutations. These data provide evidence that disruptions to COMP-type IX collagen interactions define a pathogenetic mechanism in a bone dysplasia family.

Reliability of listener transcriptions of compensatory articulations

OBJECTIVE

This study examined the ability of speech-language pathologists to transcribe compensatory articulation errors.

DESIGN

Speech-language pathologists phonetically transcribed audiorecordings of 130 monosyllabic words, 70 of which contained compensatory articulations.

PARTICIPANTS

The participants for this study were two groups of 10 speech-language pathologists. Group I included speech-language pathologists who were experienced in evaluating children with cleft palate, and group II speech-language pathologists were not.

RESULTS

Marked variability was evident across listeners, with percentages of agreement ranging from 19 to 71 (mean agreement = 41%). The experienced listeners performed significantly better on the transcription task than the inexperienced listeners, but poor interjudge agreement was evident across both groups.

CONCLUSIONS

The results of this study suggest that speech-language pathologists may differ in their understanding of the auditory perceptual characteristics of compensatory articulations. The results underscore the need for increased training and standardization of transcription procedures.

Surgical correction of blepharoptosis in patients with myasthenia gravis

PURPOSE

To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis.

METHODS

We reviewed the medical records of all patients with myasthenia gravis who underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height.

RESULTS

Eighteen blepharoptosis procedures were performed on 11 patients with myasthenia gravis. Eight of the 11 patients had ocular myasthenia gravis, and 3 had systemic myasthenia gravis. Of the 18 procedures performed, 11 were external levator advancements (ELA), 6 were frontalis slings, and 1 was a tarsomyectomy. Patients were followed up postoperatively for an average of 34 months (range, 9 to 126 months). The amount of ptosis was quantified preoperatively and postoperatively for 9 of the 11 eyelids that underwent ELA. For these eyelids, there was a statistically significant improvement in the mean interpalpebral eyelid fissure height, from 4.2 mm preoperatively to 8.1 mm postoperatively, with a mean difference of 3.9 mm (95% confidence interval, 2.3 to 5.5 mm; P = .0005). Postoperative complications included worsened diplopia in 1 patient who underwent ELA and exposure keratopathy in 1 patient who underwent a frontalis sling procedure. Two of the eyelids that underwent ELA developed recurrent ptosis, requiring additional surgery more than 2 years after the initial procedure.

CONCLUSION

Surgical correction of blepharoptosis is an appropriate treatment option in patients with myasthenia gravis who fail medical therapy. Potential complications include worsened diplopia and exposure keratopathy.

Lacrimal bypass surgery in patients with sarcoidosis

PURPOSE

To examine the results of lacrimal bypass surgery in patients with sarcoidosis.

METHODS

Patients with sarcoidosis who underwent dacryocystorhinostomy (DCR) or conjunctivodacryocystorhinostomy (CDCR) in two practice settings from 1986 through 1995 were identified and their medical records reviewed.

RESULTS

Twelve patients, of whom eight were women, underwent bilateral DCR or CDCR to treat nasolacrimal duct obstruction associated with sarcoidosis. The initial diagnosis of sarcoidosis was established in four patients from a biopsy specimen obtained during DCR. The ages of the patients at diagnosis of sarcoidosis ranged from 39 to 64 years (mean, 49.6 years; median, 45.5 years), whereas their ages at the time of surgery ranged from 42 to 72 years (mean and median, 55 years). The average duration of postoperative follow-up evaluation was 44 months (median, 38.5 months; range, 10 to 82 months). All patients received local corticosteroids postoperatively, and nine patients (75%) were treated with prednisone. Of the 24 lacrimal procedures, 23 (95.8%) were patent to irrigation at the last follow-up examination, and all patients were asymptomatic.

CONCLUSION

Lacrimal drainage obstruction may be the initial manifestation of sarcoidosis, and tissue obtained during DCR may help to establish the diagnosis. A successful surgical outcome may require intensive and occasionally long-term therapy with local and systemic corticosteroids.

Follow-up of patients with essential blepharospasm who underwent eyelid protractor myectomy at the Mayo Clinic from 1980 through 1995

PURPOSE

To determine the efficacy of eyelid protractor myectomy (subtotal excision of the orbicularis oculi, the corrugator supercilii, and the procerus muscles) for the treatment of essential blepharospasm, and to evaluate the need for and the effectiveness of botulinum toxin (BT) injections in these patients.

METHODS

The medical records of all patients who underwent eyelid protractor myectomy at the Mayo Clinic (Rochester, MN) from 1980 through 1995 were reviewed. The Health Status Questionnaire was used to assess overall medical and mental health, and a questionnaire specific to eyelid spasms was developed.

RESULTS

Fifty-four white patients, of whom 32 (59%) were women, underwent myectomy. The average age at diagnosis of essential blepharospasm was 64 years (median, 65 years; range, 43 to 84 years), whereas the average age at the time of myectomy was 66 years (median, 66 years; range, 51 to 85 years). Of the 14 patients who were treated with BT injections before myectomy, the average interval between the initial injection and surgery was 21 months (median, 20 months; range, 2 to 51 months). Patients who had been treated with BT injections before myectomy were more likely to receive injections postoperatively than were those patients who had not been treated with BT (p < 0.001). Twenty patients were treated with BT injections after myectomy; the overall probability of receiving BT five years after surgery was 46%. Time from myectomy to treatment with BT varied considerably; mean, 880 days; median, 659 days; range, 3 to 4221 days. Postoperative follow-up for those patients who did not receive BT after myectomy ranged from 2 to 5935 days (mean, 2354 days; median, 1722 days). Although the probability of receiving BT injections after myectomy was not associated with age or sex, there was a significant association with the time interval during which the myectomy had been performed (related to the availability of BT as an adjunctive therapy). Of the 41 patients who were alive when the study was conducted, 32 (78%) completed a follow-up survey. Thirty of those (94%) said myectomy provided short-term and long-term benefits. Of the 11 patients who received BT injections before and after myectomy, six (55%) said the toxin was more effective in ameliorating eyelid spasms after surgery and four (36%) required injections less frequently after myectomy. Results from the Health Status Questionnaire showed no significant differences between patients who underwent myectomy and control subjects.

CONCLUSIONS

Eyelid protractor myectomy provides subjective benefit to patients with essential blepharospasm and decreases the long-term need for BT injections in approximately 50% of these patients. Although the probability of receiving postoperative BT paralleled its availability, patients who received both preoperative and postoperative BT perceived either increased efficacy of the toxin injections, longer-lasting effects, or both, after myectomy. Patients with severe disability from blepharospasm benefited more from myectomy than did patients with relatively mild symptoms.

Conversational skills of preschool and school-age children with cleft lip and palate

OBJECTIVE

The purpose of this study was to examine the conversational skills of preschool and school-age children with cleft lip and palate.

DESIGN

The children were audio- and videotaped during interactions with an unfamiliar adult. In addition, standardized measures of speech and language were administered, and ratings of resonance were obtained. Comparisons were made between the children with cleft lip and palate and their same-age peers on measures of conversational participation and a standardized test of pragmatic skills.

PARTICIPANTS

Participants were 20 children with unilateral cleft lip and palate (10 preschoolers and 10 school-age children) recruited from the Craniofacial Team at Rainbow Babies and Children's Hospital, Cleveland (OH) and 20 noncleft peers matched for gender, age, and socioeconomic status.

MAIN OUTCOME MEASURES

Separate comparisons were made for the preschool children with cleft lip and palate and their noncleft peers, and the school-age children with cleft lip and palate and their noncleft peers on eight measures of conversational assertiveness/responsiveness and the standardized tests of pragmatics. Next, each child with cleft lip and palate was classified for level of conversational participation.

RESULTS

Paired t tests revealed no significant differences between the preschool and school-age children with cleft lip and palate and their noncleft peers in level of conversational participation. However, individual child comparisons revealed less assertive profiles of conversational participation for 50% of the preschool and 20% of the school-age children with cleft lip and palate.

CONCLUSIONS

Children with cleft lip and palate may show a less assertive style of conversational participation, at least during the preschool years. Therefore, craniofacial team evaluations should include examination of conversational competency, particularly for children who are demonstrating difficulty with other aspects of speech, language, or social development.

Substituted pyrazoles as novel selective ligands for the human dopamine D4 receptor

Two novel series of 3-(heterocyclylmethyl)pyrazoles have been synthesised and evaluated as ligands for the human dopamine D4 receptor. Compounds in series I (exemplified by 8k) have a phenyl ring joined to the 4-position of the pyrazole while those in series II (exemplified by 15j) have a 5-phenyl ring linked by a saturated chain to the 4-position of the pyrazole. Both series supplied compounds with excellent affinity for the human D4 and good selectivity over other dopamine receptors. Excellent selectivity over calcium, sodium, and potassium ion channels was also achieved.

Biological profile of L-745,870, a selective antagonist with high affinity for the dopamine D4 receptor

L-745,870,(3-([4-(4-chlorophenyl)piperazin-1-yl]methyl)-1H- pyrollo[2,3-b] pyridine, was identified as a selective dopamine D4 receptor antagonist with excellent oral bioavailability and brain penetration. L-745,870 displaced specific binding of 0.2 nM [3H] spiperone to cloned human dopamine D4 receptors with a binding affinity (Ki) of 0. 43 nM which was 5- and 20-fold higher than that of the standard antipsychotics haloperidol and clozapine, respectively. L-745,870 exhibited high selectivity for the dopamine D4 receptor (>2000 fold) compared to other dopamine receptor subtypes and had moderate affinity for 5HT2, sigma and alpha adrenergic receptors(IC50 < 300 nM). In vitro, L-745,870 (0.1-1 microM) exhibited D4 receptor antagonist activity, reversing dopamine (1 microM) mediated 1) inhibition of adenylate cyclase in hD4HEK and hD4CHO cells; 2) stimulation of [35S] GTPgammaS binding and 3) stimulation of extracellular acidification rate, but did not exhibit any significant intrinsic activity in these assays. Although standard antipsychotics increase dopamine metabolism or plasma prolactin levels in rodents, L-745,870 (</=30 mg/kg p.o.) had no effect in these assays. The lack of a suitable in vivo assay for D4 receptor activation prompted the use of in vivo surrogate marker assays which confirmed that doses of 5-60 microg/kg L-745,870 would be sufficient to occupy 50% D4 receptors in the brain. These results show that dopamine D4 receptor antagonism in the brain does not result in the same neurochemical consequences (increased dopamine metabolism or hyperprolactinemia) observed with typical neuroleptics.

5-(Piperidin-2-yl)- and 5-(homopiperidin-2-yl)-1,4-benzodiazepines: high-affinity, basic ligands for the cholecystokinin-B receptor

The design, synthesis, and biological activity of a series of high-affinity, basic ligands for the cholecystokinin-B receptor are described. The compounds, which incorporate a piperidin-2-yl or a homopiperidin-2-yl group attached to C5 of a benzodiazepine core structure, are substantially more basic (e.g., 9d, pKa = 9.48) than previously reported antagonists based on 5-amino-1,4-benzodiazepines (e.g., 5, pKa = 7.1) and have improved aqueous solubility. In view of their basicity, it would be tempting to speculate that the present series of compounds might be binding to the CCK-B receptor in their protonated form. Compounds such as 9d, e and 10d showed high affinity for this receptor (IC50 < 2.5 nM) and very good selectivity over CCK-A (CCK-A/CCK-B > 2000), even as the racemates. Additionally, a significantly improved in vivo half-life was observed for a selection of compounds compared to the clinical candidate L-365, -260 (1).

Are radioligand antagonist/agonist binding ratios in rat pancreas predictive of functional efficacy of cholecystokinin receptor agonists and antagonists?

Radioligand binding assays have been previously used to predict the relative efficacy of novel ligands. In the present study we have investigated whether for the cholecystokinin CCK-A receptors in the rat pancreas, the ratio of binding affinities for compounds for antagonist and agonist radioligands are predictive of functional activity. A number of classical cholecystokinin agonists, such as CCK-8S, caerulein, CCK-8DS, pentagastrin and CCK-4 had antagonist/agonist binding ratios of 4-fold or greater. All compounds behaved as full agonists in the stimulation of phosphatidylinositol (PI) turnover and increase in amylase secretion in rat pancreas. In contrast, compounds such as the benzodiazepine derivatives devazepide and L-365,260 had binding ratios of less than one and lacked agonist activity in either functional assay. Interestingly, the dipeptide derivative CI-988, which has been described as a selective CCK-B antagonist, was found to have an antagonist/agonist binding ratio of 1.5 for the CCK-A receptors in rat pancreas which was sufficiently high for this compound to behave as a full agonist in the amylase assay, although CI-988 did not exhibit agonist activity in the PI assay. These results suggest that the effective receptor reserve in the amylase assay is greater than that required to stimulate PI turnover, and that the selective peptoid CCK-B antagonist CI-988 has weak agonist activity at CCK-A receptors.

Controlled modification of acidity in cholecystokinin B receptor antagonists: N-(1,4-benzodiazepin-3-yl)-N'-[3-(tetrazol-5-ylamino) phenyl]ureas

The design, synthesis, and biological activity of a novel series of CCK-B receptor antagonists (1) which incorporate a tetrazol-5-ylamino functionality attached to the phenyl ring of the arylurea moiety of L-365,260 are described. In these compounds, the acidity of the tetrazole was gradually modified by utilization of simple conformational constraints, and X-ray crystallographic data were obtained to support the conformational depenence of the pK(a) of the aminotetrazoles. Compounds to emerge from the present work such as 1f and 2c,d are among the highest affinity and, in the case of 1f, most selective (CCK-A/CCK-B, 37 000) antagonists so far reported for this receptor. The C(5)-cyclohexyl compound 2c (L-736,380) dose-dependently inhibited gastric acid secretion in anesthetized rats (ID(50), 0.064 mg/kg) and ex vivo binding of [(125)I]CCK-8S in BKTO mice brain membranes (ED(50), 1.7 mg/kg) and is one of the most potent acidic CCK-B receptor antagonists yet described.

Biological properties of the benzodiazepine amidine derivative L-740,093, a cholecystokinin-B/gastrin receptor antagonist with high affinity in vitro and high potency in vivo

A novel series of 5-amino-1,4-benzodiazepin-2-one derivatives (amidines), which contain a cationic solubilizing group and which are antagonists for the cholecystokinin (CCK)-B receptor, have been identified. Optimization of this series led to the identification of an azabicyclononane amidine, L-740,093 [N-[(3R)-5-(3-azabicyclo[3.2.2]nonan-3-yl)-2,3-dihydro-1-methyl-2- oxo- 1H-1,4-benzodiazepin-3-yl]-N'-(3-methylphenyl)urea], that bound with high affinity of CCK-B receptors from guinea pig cerebral cortex (IC50 of 0.1 nM) and had a CCK-B/CCK-A receptor selectivity of 16,000. In comparison, L-365,260 had 85-fold lower affinity (8.5 nM) and was only 87-fold selective for CCK-B over CCK-A receptors. L-740,093 bound with high affinity to guinea pig gastrin receptors in vitro (IC50 of 0.04 nM). Electrophysiological studies on slices of rat ventromedial hypothalamic nucleus showed that L-740,093 produced rightward shifts of the concentration-response curve for the CCK-B receptor agonist pentagastrin (Kb of 0.06 nM). L-740,093 blocked pentagastrin-induced gastric acid secretion in anesthetized rats with a 50% inhibitory dose of 0.01 mg/kg, intraperitoneally, showing 100-fold greater activity, compared with L-365,260 (50% inhibitory dose of 1 mg/kg, intraperitoneally). An ex vivo binding assay in mice was used to investigate the interaction of L-740,093 with central CCK binding sites. After intravenous administration, L-740,093 inhibited ex vivo binding dose dependently, with a 50% effective dose of 0.2 mg/kg. These studies demonstrate that L-740,093 is the most potent and selective CCK-B antagonist yet described and that it has excellent central nervous system penetration.

Selective non-peptide ligands for an accommodating peptide receptor. Imidazobenzodiazepines as potent cholecystokinin type B receptor antagonists

A series of imidazobenzodiazepines, non-peptide antagonists of the peptide hormone cholecystokinin (CCK), are described. Derived by chemical modification of the benzodiazepine ring system embedded within the CCK-B antagonist L-365,260, these compounds display CCK-B/CCK-A selectivity and some analogs have receptor binding affinities in the subnanomolar range. This group of novel imidazobenzodiazepines, among which N-[(2S,4R)-methyl-6-phenyl-2,4-dihydro-1H-imidazo[1,2- alpha][1,4]benzodiazepin-4-yl]-N'-[3-methylphenyl]-urea (12) is the principal compound, expands the structural diversity of the collection of non-peptide CCK-B antagonists and will be useful in further delineating the function of CCK in the central nervous system.

Measurement of central nervous system activity of systemically administered CCKB receptor antagonists by ex vivo binding

In the present study we have described an ex vivo binding assay in mice to measure the central nervous system (CNS) activity of systemically administered CCKB receptor antagonists. This assay incorporated a transcardiac perfusion step to remove the residual blood from the brain, which otherwise may result in an overestimation of CNS activity. The benzodiazepine CCKB receptor antagonist L-365,260 had marked CNS activity in this assay following i.v. (ED50 12.0 mg/kg) and p.o. (ED50 20.0 mg/kg) administration, whereas the dipeptoid CCKB receptor antagonist, CI988 exhibited relatively weak CNS activity following i.v. injection (ED50 > 30.0 mg/kg). In contrast, following i.c.v. administration, CI988 potently inhibited ex vivo binding of [125I]Bolton Hunter-CCK-8S to mouse brain. The recently described acidic tetrazole CCKB receptor antagonist, L-368,935 had potent CNS activity with an ED50 of 5.6 mg/kg i.v. and an ED50 of 1.9 micrograms/kg i.c.v. These studies suggest that the weak CNS activity of CI988 following systemic injection may, in part, be due to poor brain penetration and that the ex vivo binding assay is a useful way of assessing the brain penetration of CCKB receptor antagonists.

Identification of children with and without cleft palate from tape-recorded samples of early vocalizations and speech

Thirty judges (5 speech pathologists, 10 mothers of children with cleft palate, and 15 mothers of noncleft children) listened to 90 tape-recorded samples of early vocalizations/speech obtained from noncleft babies and babies with cleft palate. Each sample was classified by the judges as normal or abnormal. As a group, the speech pathologists classified only 60% of the cleft samples as abnormal and 59% of the normal samples as normal. The cleft and noncleft mother groups, on the other hand, classified 37% and 25% of the cleft samples as abnormal and 59% and 73% of the normal samples as normal. Poor interjudge agreement was evident within and across the three groups of judges. The poor reliability demonstrated by the speech pathologists in identifying babies with unrepaired clefts appeared related more to a difference in interpretation of the perceptual data than an inability to hear salient information.

Phonologic processes in children with cleft palate

This study examined the phonologic process usage of 3-, 4- and 5-year-old children with cleft palate. Sixty children served as subjects: 30 children with cleft palate (with or without cleft lip) and 30 noncleft palate children. The children's whole word productions were analyzed for frequency and type of phonologic process usage. Results indicated that the 3- and 4-year old children with cleft palate exhibited more instances of process usage, compared to their noncleft peers. The 5-year-old cleft and noncleft groups were similar in total instances of process usage. Further, the children with cleft palate employed common phonologic processes; however, some processes were noted more frequently in the speech of the 3-year-old children with cleft palate.