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Item does not contain fulltext OBJECTIVE: : To evaluate long-term results after protocoled treatment of supination-external rotation (SER) Type II-IV ankle injuries. DESIGN: : Retrospective cohort study. SETTING: : Level I trauma center. PATIENTS: : Two hundred seventy-six adult patients with an SER Type II-IV ankle fracture between January 1, 1985, and January 1, 1990. All patients were approached to participate in this study. INTERVENTION: : Fractures with tibiotalar congruity were treated nonoperative and unstable fractures with joint incongruity were treated operatively. MEAN OUTCOME MEASUREMENTS:: 1) a functional outcome questionnaire (Olerud score); 2) range of motion; 3) functional impairment (American Medical Association guidelines); and 4) radiologic anatomic result (medial clear space widening; osteoarthritis; Cedell score). RESULTS: : After a median of 21 years in 54% (n = 148) of patients, follow-up was achieved. Seventy-six patients (51%) had a SER Type II injury, four patients (3%) a SER Type III injury, and 68 (46%) had sustained a SER Type IV. Excellent or good results were found in 92% (Olerud score), 97% (loaded dorsal range of motion), 92% (medial clear space widening), 97% (osteoarthritis), and 76% (Cedell score) of patients. Functional impairment expressed as percentage of whole person impairment varied between 0% and 16%. The various fracture types performed statistically equal on all outcome parameters. There was no difference between operative and nonoperative treatment. There was no correlation between the Olerud score and other parameters. CONCLUSIONS: : The very long-term overall results of the stratified surgical treatment of SER Type II-IV ankle fractures is 'excellent' or 'good' in the majority of patients and therefore seems justified. Although additional soft tissue damage is unavoidable in case of operative treatment, it does not negatively affect outcome in the long term. LEVEL OF EVIDENCE: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. 01 augustus 2012

Item does not contain fulltext OBJECTIVE: To investigate differences in effects of 270 degrees (270 degrees LPF) and 360 degrees laparoscopic posterior fundoplication (360 degrees LPF) on reflux characteristics and belching. BACKGROUND: Three hundred sixty degrees LPF greatly reduces the ability of the stomach to vent ingested air by gastric belching. This frequently leads to postoperative symptoms including inability to belch, gas bloating and increased flatulence. Two hundred seventy degrees LPF allegedly provides less effective reflux control compared with 360 degrees LPF, but theoretically may allow for gastric belches (GBs) with a limitation of gas-related symptoms. METHODS: Endoscopy, stationary esophageal manometry, and 24-hour impedance-pH monitoring off PPIs was performed before and 6 months after fundoplication for PPI-refractory gastroesophageal reflux disease (n = 14 270 degrees LPF vs. n = 28 360 degrees LPF). GBs were defined as gas components of pure gas and mixed reflux episodes reaching the proximal esophagus. Absolute reductions (Delta) were compared. RESULTS: Reflux symptoms and the 24-hour incidence of acid (Delta -77.6 vs. -76.7), weakly acidic (Delta -9.4 vs. -6.6), liquid (Delta -59.0 vs. -49.8) and mixed reflux episodes (Delta -28.0 vs. -33.5) were reduced to a similar extent after 270 degrees LPF and 360 degrees LPF, respectively. The reduction in proximal, mid-esophageal and distal reflux episodes were similar in both groups as well. Persistent symptoms were not related to acid or weakly acidic reflux. Two hundred seventy degrees LPF had no significant impact on the number of gas reflux episodes (Delta -3.6; P = 0.363), whereas 360 degrees LPF significantly reduced gas reflux episodes (Delta -17.0; P = 0.002). After 270 degrees LPF, GBs (Delta -29.3 vs. -50.6; P = 0.026) were significantly less reduced and the prevalence of gas bloating (7.1% vs. 21.4%; P = 0.242) and increased flatulence (7.1% vs. 42.9%; P = 0.018) was lower compared to 360 degrees LPF. Twenty-eight patients (67%) showed supragastric belches (SGBs) before and after surgery. The increase in SGBs without reflux (Delta +32.4 vs. +25.5) and the decrease in reflux-associated SGBs (Delta -12.1 vs. -14.0) were similar after 270 degrees LPF and 360 degrees LPF. CONCLUSIONS: Two hundred seventy degrees LPF and 360 degrees LPF alter the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). However, gas reflux and GBs are reduced less after 270 degrees LPF than after 360 degrees LPF, resulting in more air venting from the stomach and less gas bloating and flatulence, whereas reflux is reduced to a similar extent in the short-term. 01 januari 2012

Item does not contain fulltext OBJECTIVE: To report the 4-year follow-up quality-of-life data of a randomized controlled trial between abdominal and laparoscopic hysterectomy and to investigate whether any difference in quality of life would remain long-term. METHODS: Patients scheduled for hysterectomy for benign indications were randomized and received the Dutch version of the Short Form 36 questionnaire. The Short Form 36 consists of eight domains in which 100 points can be obtained. Higher scores denote a higher quality of life. A linear mixed model was used to study the differences between the two groups up to 4 years after surgery for each of the domains and the total Short Form 36 score separately. RESULTS: Fifty-nine patients were randomized (27 to laparoscopic hysterectomy and 32 to abdominal hysterectomy). Median follow-up after surgery was 243 weeks (range, 188-303 weeks). The overall response rate on the Short Form 36 questionnaire after 4 years was 83% (49 of 59 patients). Total Short Form 36 questionnaire scores were significantly higher in patients after laparoscopic compared with abdominal hysterectomy up to 4 years after surgery (overall mean difference 50.4 points [95% confidence interval 1.0-99.7] in favor of laparoscopic hysterectomy). Higher scores were also found on the domains physical role functioning, social role functioning, and vitality. CONCLUSION: With a follow-up of 4 years, patients who underwent laparoscopic hysterectomy reported a better quality of life compared with abdominal hysterectomy. Therefore, patients in whom vaginal hysterectomy is not possible should be able to have a laparoscopic hysterectomy, if feasible, in terms of uterine size. CLINICAL TRIAL REGISTRATION: ISRCTN Register, www.controlled-trials.com/isrctn, ISRCTN15214439. 01 januari 2012

Item does not contain fulltext OBJECTIVE: : To assess the attributable mortality of ventilator-associated pneumonia using results from randomized controlled trials on ventilator-associated pneumonia prevention. DATA SOURCES: : A systematic search was performed in PubMed, Embase, Web of Science, and Cochrane Library from their inception until July 2010. In addition, a reference and related article search was performed. STUDY SELECTION: : Randomized ventilator-associated pneumonia prevention studies in which all patients were mechanically ventilated and from which ventilator-associated pneumonia and mortality rates of intervention and control group could be extracted were included. DATA EXTRACTION/SYNTHESIS: : Fifty-three papers were identified describing 58 comparisons. Statistical significant reductions in ventilator-associated pneumonia incidences were reported in 20 of the 58 comparisons, whereas none of these trials reported a significant reduction of mortality. Pooled estimates of the relative risk reductions of both ventilator-associated pneumonia and mortality were calculated and the attributable mortality was estimated as the ratio between the relative risk reductions of mortality and ventilator-associated pneumonia. Effects of study quality, diagnostic methods used, and effectiveness of preventing ventilator-associated pneumonia on the mortality rate of ventilator-associated pneumonia were assessed in subgroup analyses. The overall attributable mortality of ventilator-associated pneumonia was estimated as 9%. In subgroup analyses, the attributable mortality varied between 3% and 17%. CONCLUSION: : Based on the results of 58 randomized studies on ventilator-associated pneumonia prevention, the attributable mortality rate of ventilator-associated pneumonia was estimated to be 9% and ranged between 3% and 17% in subgroup analyses. Together with the results of other recent studies, there is cumulative evidence that the attributable mortality resulting from ventilator-associated pneumonia is approximately 10%. 01 december 2011

Contains fulltext : 97762.pdf (Publisher’s version ) (Closed access) BACKGROUND: Coping strategies may be important factors influencing quality of life (QOL), depression, and hopelessness. However, most studies on this issue were performed in patients still undergoing anticancer treatment. Unknown is which coping strategies are of importance for palliative-cancer patients who no longer receive treatment. OBJECTIVE: The objectives of this study were to assess coping strategies in curatively treated and palliative-cancer patients no longer receiving anticancer treatment and to examine the relation of these coping strategies with QOL, depression, and hopelessness. METHODS: A descriptive research design was used. Ninety-two curative and 59 palliative patients filled out the COPE-Easy abbreviated version, the European Organisation for Research-and-Treatment of Cancer QOL-Questionnaire version 2.0, Beck Depression Inventory for Primary Care, and Beck Hopelessness Scale. RESULTS: In both curative and palliative patients, active coping strategies and acceptance were beneficial in terms of QOL, depression, and hopelessness, unlike avoidant coping strategies and venting of emotions. Palliative patients scored higher on the coping strategy, seeking moral support. For the outcome variable, emotional functioning, significant interactions were observed between the variable, curative/palliative care setting, and the coping strategy, seeking moral support. For the outcome variable, role functioning, significant interactions were observed between the variable, curative/palliative care setting, and the coping strategy, waiting. CONCLUSIONS: Coping strategies were significantly correlated to QOL, depression, and hopelessness. However, this correlation differed in the curative and palliative, end-of-life care setting. IMPLICATIONS FOR PRACTICE: The observed relations between coping strategies, QOL, depression, and hopelessness give room to cognitive-behavioral nursing interventions. Specific attention is needed for differences in coping strategies between curative and palliative patients.

Contains fulltext : 89868.pdf (Publisher’s version ) (Closed access) Overlap in the clinical presentation of pediatric granulomatous inflammatory bowel disease may be substantial, depending on the mode of presentation. Chronic granulomatous disease (CGD) may present with granulomatous colitis, perianal abscesses, hepatic abscesses or granulomas, failure to thrive, and obstruction of the gastrointestinal tract (including esophageal strictures and dysmotility, delayed gastric emptying, and small bowel obstruction). Anemia, thrombocytosis, elevated C-reactive protein and erythrocyte sedimentation rate, and hypoalbuminemia are nonspecific and may occur in any of the granulomatous inflammatory bowel diseases. In histology, macrophages with cytoplasmic inclusions will be rather specific for CGD. Sarcoidosis may present with abdominal pain or discomfort, diarrhea, weight loss, growth failure, delayed puberty, erythema nodosum, arthritis, uveitis, and hepatic granulomata. Only in 55% of the patients will angiotensin-converting enzyme be elevated. The noncaseating epithelioid granulomata will be unspecific. Bronchoalveolar lymphocytosis and abnormalities in pulmonary function are reported in sarcoidosis and in Crohn disease (CD) and CGD. Importantly, patients with CD may present with granulomatous lung disease, fibrosing alveolitis, and drug-induced pneumonitis. Sarcoidosis and concomitant gastrointestinal CD have been reported in patients, as well as coexistence of CD and sarcoidosis in siblings. Common susceptibility loci have been identified in CD and sarcoidosis. CD and CGD share defects in the defense mechanisms against different microbes. In the present review, common features and essential differences are discussed in clinical presentation and diagnostics--including histology--in CGD, sarcoidosis, and CD, together with 2 other granulomatous inflammatory bowel diseases, namely abdominal tuberculosis and Hermansky-Pudlak syndrome. Instructions for specific diagnosis and respective treatments are provided. 01 december 2010

Contains fulltext : 87936.pdf (Publisher’s version ) (Closed access) PURPOSE: The purpose of this study was to determine the effect of radial optic neurotomy and retinal endovascular surgery on retinal blood flow velocity in patients with central retinal vein occlusion. METHODS: A prospective interventional case series. RESULTS: Six patients with a central retinal vein occlusion of

Contains fulltext : 89093.pdf (Publisher’s version ) (Closed access) This study was performed to obtain a comprehensive overview of the benefits and risks of second-line irinotecan monotherapy for advanced colorectal cancer. The literature was systematically reviewed to identify phase II and phase III trials that investigated the effect of second-line monotherapy with irinotecan. Thirty studies were included in this review: 25 phase II studies including 32 samples and five phase III studies including six samples. A disease control rate of greater than or equal to 50% was found in 23 out of 32 phase II samples, and one out of two phase III samples that reported disease control rate. Median time to progression was 2.7-6.0 months in phase II samples and 3.0-4.3 months in phase III samples. Median overall survival ranged from 6.6 to 16.1 months in phase II samples and 9.1-10.8 months in phase III samples. The most important severe adverse event in both phase II and phase III trials was diarrhea (5-39 and 15-36%, respectively), followed by nausea (1-24 and 5-14%), vomiting (2-22 and 6-14%), and asthenia (0-31 and 4-21%). Treatment-related mortality was 0-2% in phase II samples and 0-5% in phase III samples. Quality-of-life scores in phase II studies were associated with tumor response. In phase III studies, the quality of life while on treatment with irinotecan was similar to that of 5-fluorouracil, but better than supportive care alone. The quality of life on the weekly schedule was similar to the 3-weekly schedule. This study provides a comprehensive overview of the benefits and risks of second-line irinotecan. In general, second-line treatment with irinotecan is beneficial to patients. 01 september 2010

Contains fulltext : 89910.pdf (Publisher’s version ) (Closed access) BACKGROUND: The incision design for correcting a unilateral cleft lip is important because all subsequent stages of surgery depend on the access and maneuverability of the incision. This prospective cohort study compares the aesthetic and functional outcomes of three different skin incisions for primary unilateral cleft lip repair. METHODS: Patients with complete unilateral cleft lips (n = 1200) were enrolled and divided into three groups of 400 patients. Each group of patients was operated on with the Millard incision, Pfeifer wave line incision, or Afroze incision. Outcome assessments were performed 2 years postoperatively and consisted of assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, nostril symmetry, and appearance of alar dome and base. RESULTS: With regard to white roll, vermilion border, scar, Cupid's bow, and lip length, the Afroze incision always gave superior results compared with the Millard or Pfeifer incision. Depending on the cut-off for treatment success, the Afroze incision also showed better results regarding nostril symmetry. With respect to the alar base and alar dome, all three incisions showed comparable outcomes. CONCLUSION: The Afroze incision is superior regarding a broad spectrum of outcomes in a heterogeneous population of patients with unilateral cleft lip. 01 april 2010

Contains fulltext : 89655.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To select parameters that can predict which patients should receive abdominal computed tomography (CT) after high-energy blunt trauma. SUMMARY BACKGROUND DATA: Abdominal CT accurately detects injuries of the abdomen, pelvis, and lumbar spine, but has important disadvantages. More evidence for an appropriate patient selection for CT is required. METHODS: A prospective observational study was performed on consecutive adult high-energy blunt trauma patients. All patients received primary and secondary surveys according to the advanced trauma life support, sonography (focused assessment with sonography for trauma [FAST]), conventional radiography (CR) of the chest, pelvis, and spine and routine abdominal CT. Parameters from prehospital information, physical examination, laboratory investigations, FAST, and CR were prospectively recorded for all patients. Independent predictors for the presence of > or =1 injuries on abdominal CT were determined using a multivariate logistic regression analysis. RESULTS: A total of 1040 patients were included, 309 had injuries on abdominal CT. Nine parameters were independent predictors for injuries on CT: abnormal CR of the pelvis (odds ratio [OR], 46.8), lumbar spine (OR, 16.2), and chest (OR, 2.37), abnormal FAST (OR, 26.7), abnormalities in physical examination of the abdomen/pelvis (OR, 2.41) or lumbar spine (OR 2.53), base excess

Contains fulltext : 52572.pdf (Publisher’s version ) (Closed access) BACKGROUND: Particularly in clinical studies, it has been found that rapid swelling of tissue expanders leads to high-pressure peaks that can cause hypoxia in the tissue and thus also skin damage. For this reason, the present study in animals investigated whether an osmotic expander with silicone shell is capable of expanding in tissue and bringing about useful tissue expansion without complications. It was also examined whether and what quantitative and qualitative differences there are between conventional osmotic expanders and the new expanders with silicone shell. METHODS: The expansion of osmotic expanders with silicone shell was compared with that of osmotic expanders without silicone shell in four mini pigs. The expander type used was an M1 rectangle with an initial volume of 6 ml. Five expanders were implanted in each pig, meaning that 20 expanders were measured. The volume of the expanders was measured directly after explantation. Indirect volume determination was performed by producing plaster casts for subsequent laser optical measurement. RESULTS: Comparison of the two curve profiles showed a much flatter profile for the expanders with silicone shell. The absolute values for the volumes of the expanders with silicone shell were likewise substantially lower. CONCLUSIONS: Controlled skin expansion is a technique of providing localized donor tissue for reconstructive surgery. The new expanders could be in a position to lower the rate of complications in tissue expansion.

Contains fulltext : 50298.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To investigate the diagnostic value of transforming growth factor beta(1) (TGFbeta(1)), vascular endothelial growth factor (VEGF), urokinase-type plasminogen activator (uPA), and tissue-type plasminogen activator (tPA) in CSF for leptomeningeal metastasis (LM). METHODS: The authors measured concentrations of biomarkers by ELISA in matched samples of CSF and serum, collected from 132 patients with a solid malignancy with LM (n = 19) and without LM (n = 54) and patients with viral (n = 16) and bacterial (n = 16) meningitis and a variety of nonmalignant, noninfectious neurologic disorders (n = 27). Indexes of the biomarkers (CSF/serum value relative to CSF/serum albumin ratios) were calculated to correct for the serum contribution to the CSF marker concentration. RESULTS: CSF VEGF concentration was significantly higher in LM than in all other groups. VEGF indexes were also higher, although not significant. In contrast, the tPA index was significantly decreased in LM compared with all other groups. The combination of the VEGF and tPA indexes resulted in a sensitivity of 100% for LM and a specificity of 73% for the patient group with a primary tumor but without LM. CONCLUSION: Patients with leptomeningeal metastasis have high vascular endothelial growth factor (VEGF) indexes and low tissue-type plasminogen activator (tPA) indexes. As cytologic examination of CSF lacks 100% sensitivity for the diagnosis of leptomeningeal metastasis (LM), the combination VEGF and tPA index analysis may be of additional value in the diagnostic workup of patients suspected of having LM.

Contains fulltext : 50690.pdf (Publisher’s version ) (Closed access) PURPOSE: Yoked prism spectacles (eccentric viewing spectacles [EVS]) facilitate eccentric viewing in patients with bilateral central scotomas. This study was conducted to evaluate the long-term success and patient satisfaction of this type of low-vision aid. METHODS. In this retrospective cross-sectional study, we reviewed the low-vision rehabilitation records of all patients who received EVS since 1993. With an 18-item survey, 191 patients were questioned about the wearing characteristics, advantages, and disadvantages of the EVS. Descriptive and nonparametric statistics were applied to compare regular users with those persons who no longer use the EVS. RESULTS: The response rate was 83.2% and the average follow-up time was 4.5 years. Forty percent of all patients still used the EVS. The main disadvantages of these spectacles, mentioned mainly by the nonusers, included the heavy weight (41%), perception of curved lines (46%), dizziness during walking (46%), and poor cosmetic appearance (25%). Many successful long-term users considered the EVS suitable for home activities (86%) and walking in the street (70%) and reported that this device reduced eccentric viewing (77%), created better vision in the center of their visual field (67%), and helped with recognition of objects and faces (64%). CONCLUSIONS: The prescription of EVS aids eccentric viewing in patients with dense central scotomas. Although associated with a number of disadvantages and side effects, 40% of the patients continued to use EVS. The results of this study indicate that patients who experience difficulties with eccentric fixation are most likely to benefit from these low-vision aids. A thorough explanation of the advantages and disadvantages of the EVS is important to prevent unnecessary disappointments.

Contains fulltext : 48595.pdf (Publisher’s version ) (Closed access) PURPOSE: The strength of the uninjured and anastomosed intestinal wall is determined by its submucosal connective tissue. Matrix degradation by matrix metalloproteinases may result in loss of strength. It is known that anastomotic construction leads to up-regulation of matrix metalloproteinase activity in the wound area, but no quantitative data are available as to the extent of this effect throughout the intestinal wall. This study was designed to quantitate changes in gelatinolytic activity in the intestine after anastomotic construction in the ileum or colon. METHODS: An anastomosis was constructed in the distal ileum or distal colon of rats, and animals were killed after one or three days. Tissue samples (5 mm) were collected containing the suture line, its adjacent segments (2- x 5-mm in both directions) and at nine other, more distant, sites throughout the gastrointestinal tract. Similar samples were collected from nonoperated control rats. All samples were analyzed by quantitative gelatin zymography. RESULTS: In control rats, the most prominent gelatinolytic activities were found at 80 kDa, thought to represent a nonspecific proteolytic activity, 60 kDa and 50 kDa, representing the proform and active form of matrix metalloproteinase-2, respectively. Activities were higher in the small bowel than in the large bowel. Anastomotic construction led to massive up-regulation of an activity at 105 kDa, and its dimer, believed to represent promatrix metalloproteinase-9. Matrix metalloproteinase-2 remained unaffected, whereas the activity of the 80 kDa protein was significantly (P < 0.05) reduced. Significantly increased matrix metalloproteinase-9 activity was found in the actual anastomotic segments and in the immediately adjacent tissue. Matrix metalloproteinase-9 activities in the anastomotic segments were highest at Day 1 in the ileum and at Day 3 in the colon. Anastomotic construction in the ileum or colon did not lead to any significant changes of any gelatinolytic activity at the more distant sites in the bowel wall. CONCLUSIONS: Up-regulation of gelatinase activity after anastomotic construction in the intestine is caused by matrix metalloproteinase-9. Because the effect is local and not systemic, unwanted matrix degradation at distant sites seems unlikely.

Contains fulltext : 49232.pdf (Publisher’s version ) (Closed access) BACKGROUND: The goal of this study was to assess determinants for treatment outcome in unilateral cleft lip and palate, evaluated according to the Great Ormond Street London and Oslo (GOSLON) Yardstick and 5-year-index ratings by means of a meta-analysis. METHODS: Multiple databases were searched for publications in which patient groups were evaluated by GOSLON ranking or the GOSLON-like 5-year index. From the 15 selected publications, the following background variables could be extracted and were evaluated as determinants for treatment outcome in unilateral cleft lip and palate: year of birth, average age of the patient at the time of GOSLON classification, racial background, presence of Simonart's band, infant orthopedics, palatal closure before the age of 3 versus palatal closure at a later age, bone graft, and number of surgeons. RESULTS: The total number of patients included in the meta-analysis was 1236. Patients whose soft and hard palate were closed before the age of 3 presented significantly poorer (p = 0.003) GOSLON scores (mean score, 2.9; SD 0.4) than patients whose palate was closed at a later age (mean GOSLON score, 2.3; SD 0.2). CONCLUSIONS: Delayed palatal closure generally results in better dental arch relationships than early palatal closure. Well-designed, randomized clinical trials are required for further investigation of the optimal timing for palatal closure.

Item does not contain fulltext BACKGROUND: A later menopause has been associated with a decreased cardiovascular risk but with an increased risk for breast and endometrial cancer. The net effect on mortality is unclear. We determined the association of age at menopause with longevity and with the balance between cardiovascular and cancer mortality. METHODS: We analyzed data from a breast cancer screening cohort comprising 12,134 postmenopausal women followed for an average of 17 years. We used Cox proportional hazards models and life tables to calculate the life expectancy of an average Dutch woman at age 50. RESULTS: During 204,024 person-years, there were 2607 deaths, of which 963 were due to cardiovascular diseases and 812 due to cancer. Ischemic heart disease risk decreased with a later menopause (hazard ratio [HR] = 0.98 per year; 95% confidence interval = 0.96-0.99), but the risk of fatal uterine or ovarian cancer increased (1.07 per year; 1.01-1.12). A later menopause was associated with longer overall survival; HR for total mortality was 0.98 per year (0.97-0.99). Life expectancy in women with menopause after age 55 was 2.0 years longer than those with menopause before age 40. Adjustment for potential confounders did not materially change the results. CONCLUSIONS: Age-adjusted mortality is reduced 2% with each increasing year of age at menopause. In particular, ischemic heart disease mortality is 2% lower. Although the risk of death from uterine or ovarian cancer is increased by 5%, the net effect of a later menopause is an increased lifespan.

Contains fulltext : 47696.pdf (Publisher’s version ) (Closed access) BACKGROUND: Retrospective and prospective serial spatiotemporal investigations were carried out primarily to determine whether the ratio of the size of the posterior cleft space relative to the palatal surface area limited laterally by the alveolar ridges can be used to select the appropriate time for surgical closure of the palatal cleft space. Two subsamples were compared to determine whether the size of the palate and velocity of palatal development in well growing cases differ from those in cases treated by vomer flap surgery. The prospective investigation asked whether presurgical orthopedics increases the rate of palatal growth and palatal size. METHODS: Using the palatal casts of 242 male and female individuals from eight institutions in the United States and Western Europe that followed a variety of treatment protocols, separate serial analyses were conducted of well growing cases with excellent aesthetics, dental occlusion, and speech and a control series of 17 cases of various clefts of the lip and alveolus and/or soft palate but no clefts in the hard palate. Twelve groupings of cases were established depending on their institutional location and type of cleft. RESULTS: Among the various institutions in the study, palatal growth rates and size were statistically similar. Growth in the various clinical series (size, mm2) was less than that of the control series. The ratio of cleft space size to palatal surface area medial to the alveolar ridges was 10 percent or less at 18 months of age in most cases. There was no statistical difference in total surface size between groups, except for one series whose total growth size was least of all. Right and left lateral palatal segments, whether large or small, grew at the same rate. The sample of bilateral cases was too small for statistical comparisons. Presurgical orthopedics did not stimulate palatal growth. The coefficient of variance was less than 10 percent in all measurements. CONCLUSIONS: Delaying all cleft closure surgery until 5 years of age and older is unnecessary to maximize palatal growth. The best time to close the palatal cleft space is when the palatal cleft size is 10 percent or less of the total palatal surface area bounded laterally by the alveolar ridges. The 10 percent ratio generally occurs between 18 and 24 months but can occur earlier or later. There is more than one good type of palatal cleft closure surgery.

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