University Hospital Limerick

OBJECTIVE: To achieve consistency and uniformity in reporting speech outcomes in individuals born with cleft palate with or without cleft lip using perceptual parameters that characterize their speech production behavior regardless of the language or languages spoken. DESIGN: A working group of six individuals experienced in speech and cleft palate was formed to develop a system of universal parameters for reporting speech outcomes in individuals born with cleft palate. The system was adopted in conjunction with a workshop held in Washington, D.C., that was devoted to developing the universal system. The system, which was refined further following the workshop, involves a three-stage plan consisting of (1) evaluation, (2) mapping, and (3) reporting. The current report focuses primarily on the third stage, reporting speech outcomes. RESULTS: A set of five universal speech parameters has been devised for the reporting stage. These consist of (1) hypernasality, (2) hyponasality, (3) audible nasal air emission and/or nasal turbulence, (4) consonant production errors, and (5) voice disorder. Also included are speech understandability and speech acceptability, global parameters that can be reported for any type of speech disorder. The parameters are described in detail, and guidelines for speech-sampling content and scoring procedures in relation to the parameters are presented. CONCLUSION: A plan has been developed to document speech outcomes in individuals with cleft palate, regardless of the spoken language, using a set of five universal reporting parameters and two global speech parameters.

BACKGROUND: To date, delirium prevalence and incidence in acute hospitals has been estimated from pooled findings of studies performed in distinct patient populations. OBJECTIVE: To determine delirium prevalence across an acute care facility. DESIGN: A point prevalence study. SETTING: A large tertiary care, teaching hospital. PATIENTS: 311 general hospital adult inpatients were assessed over a single day. Of those, 280 had full data collected within the study's time frame (90%). MEASUREMENTS: Initial screening for inattention was performed using the spatial span forwards and months backwards tests by junior medical staff, followed by two independent formal delirium assessments: first the Confusion Assessment Method (CAM) by trained geriatric medicine consultants and registrars, and, subsequently, the Delirium Rating Scale-Revised-98 (DRS-R98) by experienced psychiatrists. The diagnosis of delirium was ultimately made using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria. RESULTS: Using DSM-IV criteria, 55 of 280 patients (19.6%) had delirium versus 17.6% using the CAM. Using the DRS-R98 total score for independent diagnosis, 20.7% had full delirium, and 8.6% had subsyndromal delirium. Prevalence was higher in older patients (4.7% if <50 years and 34.8% if >80 years) and particularly in those with prior dementia (OR=15.33, p<0.001), even when adjusted for potential confounders. Although 50.9% of delirious patients had pre-existing dementia, it was poorly documented in the medical notes. Delirium symptoms detected by medical notes, nurse interview and patient reports did not overlap much, with inattention noted by professional staff, and acute change and sleep-wake disturbance noted by patients. CONCLUSIONS: Our point prevalence study confirms that delirium occurs in about 1/5 of general hospital inpatients and particularly in those with prior cognitive impairment. Recognition strategies may need to be tailored to the symptoms most noticed by the detector (patient, nurse or primary physician) if formal assessments are not available.

Fibrodysplasia ossificans progressiva (FOP) is an autosomal dominant human disorder of bone formation that causes developmental skeletal defects and extensive debilitating bone formation within soft connective tissues (heterotopic ossification) during childhood. All patients with classic clinical features of FOP (great toe malformations and progressive heterotopic ossification) have previously been found to carry the same heterozygous mutation (c.617G>A; p.R206H) in the glycine and serine residue (GS) activation domain of activin A type I receptor/activin-like kinase 2 (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor. Among patients with FOP-like heterotopic ossification and/or toe malformations, we identified patients with clinical features unusual for FOP. These atypical FOP patients form two classes: FOP-plus (classic defining features of FOP plus one or more atypical features) and FOP variants (major variations in one or both of the two classic defining features of FOP). All patients examined have heterozygous ACVR1 missense mutations in conserved amino acids. While the recurrent c.617G>A; p.R206H mutation was found in all cases of classic FOP and most cases of FOP-plus, novel ACVR1 mutations occur in the FOP variants and two cases of FOP-plus. Protein structure homology modeling predicts that each of the amino acid substitutions activates the ACVR1 protein to enhance receptor signaling. We observed genotype-phenotype correlation between some ACVR1 mutations and the age of onset of heterotopic ossification or on embryonic skeletal development.

I wish to describe what I believe to be a novel approach to abdominal field block. The technique, as originally described, entails multiple injections and administration of potentially toxic doses of local anaesthetic agent [1]. This new approach involves identifying the neurovascular plane of the abdominal musculature and injecting a local anaesthetic agent therein. The only area of the abdominal wall where the internal oblique muscle can be localised directly is the ‘lumbar triangle of Petit’ where it forms the floor of this triangle. In most people, the lumbar triangle is situated just behind the highest point of the iliac crest. Local anaesthetic agent deposited in the area of the lumbar triangle will block the lower intercostal nerves, the iliohypogastric and the ilioinguinal nerves as they traverse between subcostal margin and the iliac crest. The iliac crest [2] has ventral and dorsal segments. The ventral segment has external and internal lips and a rough intermediate zone. The crest's summit is level with the L3−4 intervertebral space. The lower fibres of the external oblique and the latissimus dorsi muscles are attached to the external lip. A variable interval exists between the most posterior attachment of external oblique and the most anterior attachment of latissimus dorsi. Here, the crest forms the base of the ‘lumbar triangle of Petit’. The floor of the triangle is the internal oblique muscle, which is attached to the crest's intermediate area. The transversus abdominis muscle is attached to the anterior two-thirds of the crest's inner lip. The lumbar triangle is bounded anteriorly by the free posterior border of external oblique, posteriorly by the lower, lateral margin of latissimus dorsi and inferiorly by the iliac crest. The seventh to eleventh intercostals nerves, subcostal nerve, iliohypogastric and ilioinguinal nerves, all run a variable part of their courses between internal oblique and transversus abdominis muscles. With the patient in the supine position, a finger is walked posteriorly from the anterior superior iliac spine along the top of the iliac crest until it dips slightly inward. On further posterior movement, the finger-tip is felt to slip over the edge of a muscle. At this point, the finger is assumed to be abutting on the lateral border of latissimus dorsi where it is attached to the external lip of the iliac crest (Fig. 8). Without moving the hand, the skin is pierced anterior to the finger-tip with an 18G cutting needle at the level of the external lip. A 24G, blunt-tipped, 2-inch needle (1Plexufix®, Ref: 0489 1562, B. Braun.) is inserted perpendicular to the skin until it touches bone of the external lip (Fig. 9). Thereafter, the needle is slowly advanced over the intermediate zone of the iliac crest until a definite ‘pop’ or ‘sensation of giving way’ is felt. At this juncture, the needle has reached the plane between the internal oblique and the transversus abdominis muscles. After negative aspiration, 20 ml of a local anaesthetic agent is injected. Only one injection is required for a unilateral incision, e.g. in appendicectomy, while bilateral injections are administered for midline or transverse abdominal incisions. For a successful block, the injectate must disappear between the muscle layers without any apparent swelling of the abdominal wall. I have used this technique for more than 2 years and performed the abdominal field block via the lumbar triangle on more than 200 patients without any untoward sequelae. For bilateral injections, the maximum dose limit of the local anaesthetic agent is carefully observed. If the needle is advanced too far, a second ‘pop’ is felt. This indicates that the needle has passed through the transversus abdominis muscle attached to the internal lip of the iliac crest and must be withdrawn and re-inserted. Even after the second ‘pop’, the needle would have to pass through the transversalis fascia and parietal peritoneum before reaching the peritoneal cavity. The use of a fine-gauged, blunt-tipped needle helps to minimise the possibility of visceral damage if the needle is advanced too far inadvertently. The block may not be easy in obese patients because of difficulty in identifying landmarks. In these subjects, the point of needle insertion is chosen 2.5 cm behind the highest point of the iliac crest, a landmark easily palpable in most people. In elderly patients, the whole thickness of the iliac crest can be grasped between two fingers due to the loss of muscle mass and tone. It makes block easier to perform, bearing in mind that the needle tip must not be advanced beyond the inner lip of the crest. In small children, the lumbar triangle is felt like a tiny hole in the abdominal wall just behind the highest point of the iliac crest. I recommended a 24G 1-inch needle (1Plexufix®, Ref: 0489 152, B. Braun) for use in children. If extraordinary resistance is felt during injection, the needle may have lifted the periosteum in which case it should be withdrawn and re-sited. Finally, I would emphasise that this new approach of abdominal field block via the lumbar triangle should be avoided in patients with a lumbar hernia in which the hernial sac protrudes through the lumbar triangle.

BACKGROUND AND AIMS: Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease. METHODS: Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells. RESULTS: Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes. CONCLUSIONS: Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

Recent technological developments have led to the production of inexpensive, miniature accelerometer sensors with potential for use in a clinical setting. These sensors can provide reliable information on mobility and objective measurement of gait. They are currently used mainly in a research setting; however, with recent advances, incorporation into clinical practice is possible. For illustrative purposes this paper describes some current applications of accelerometers in gait and balance evaluation, falls risk assessment and mobility monitoring. Accelerometers provide quantitative measures of gait, they are capable of identifying specific gait changes in older adults and in fallers and can be used to objectively quantify ambulatory activity levels. Accelerometers have many potential uses in monitoring of patients in rehabilitation. They provide an added objective and quantitative dimension to gait analysis when combined with clinical assessment. They have the potential in the future to stratify falls risk facilitating early initiation of appropriate therapeutic intervention, thus reducing further falls. The challenge facing clinicians and biomedical engineers is to further harness this technology making it part of everyday clinical practice.

OBJECTIVES: To develop an assessment tool for use in intercenter audit studies of cleft speech and to test its acceptability, validity, and reliability. The tool is to be used systematically to record and report speech outcomes, providing an indication of treatment needs and continuing burden of care. SETTING: Regional Cleft Center, U.K. METHODS: The Cleft Audit Protocol for Speech-Augmented (CAPS-A) was developed by three cleft speech experts who identified the key features required from existing assessment measures. Criterion validity was assessed by comparing the Cleft Audit Protocol for Speech-Augmented outcomes reported for 20 cases with clinical assessment results and other investigations. Intra- and interrater reliability were tested following the training of specialist speech and language therapists who used the Cleft Audit Protocol for Speech-Augmented on two occasions to assess 10 cases. The raters evaluated acceptability and ease of using a questionnaire. RESULTS: The mean percentage agreement for criterion validity in each section was 87% (range 70% to 100%). Both intra- and interexaminer reliability were rated as good/very good (Kappa 0.61 to 1.00) for seven sections and moderate (Kappa 0.41 to 0.60) for three sections. Raters reported that the Cleft Audit Protocol for Speech-Augmented was acceptable and easy to use with appropriate training. CONCLUSION: An acceptable, valid, and reliable cleft speech audit tool has been developed based on a small sample. The Cleft Audit Protocol for Speech-Augmented is recommended for use in intercenter audit studies in the U.K. and Ireland and could be used in other English-speaking countries. In addition, it has wider applicability for use in reporting speech outcomes of surgical procedures.

Guidelines are presented for safe practice in the use of intravenous drug infusions for general anaesthesia. When maintenance of general anaesthesia is by intravenous infusion, this is referred to as total intravenous anaesthesia. Although total intravenous anaesthesia has advantages for some patients, the commonest technique used for maintenance of anaesthesia in the UK and Ireland remains the administration of an inhaled volatile anaesthetic. However, the use of an inhalational technique is sometimes not possible, and in some situations, inhalational anaesthesia is contraindicated. Therefore, all anaesthetists should be able to deliver total intravenous anaesthesia competently and safely. For the purposes of simplicity, these guidelines will use the term total intravenous anaesthesia but also encompass techniques involving a combination of intravenous infusion and inhalational anaesthesia. This document is intended as a guideline for safe practice when total intravenous anaesthesia is being used, and not as a review of the pros and cons of total intravenous anaesthesia vs. inhalational anaesthesia in situations where both techniques are possible.

BACKGROUND: Aetiology of births involving very low birthweight (VLBW) and extremely low birthweight (ELBW) infants is heterogeneous and preventive strategies remain elusive. Socioenvironmental measures implemented as Ireland's response to the SARS-CoV-2 virus (COVID-19) pandemic represented a national lockdown, and have possibly influenced the health and well-being of pregnant women and unborn infants. METHODS: Regional trends of VLBW and ELBW infants in one designated health area of Ireland over two decades were analysed. Poisson regression and rate ratio analyses with 95% CI were conducted. Regional data covering most of the lockdown period of 2020 were compared with historical regional and national data and forecasted national figures for 2020. RESULTS: Poisson regression analysis found that the regional historical VLBW rate per 1000 live births for January to April, 2001-2019 was 8.18 (95% CI 7.21 to 9.29). During January to April 2020, an unusually low VLBW rate of just 2.17 per 1000 live births was observed, reflecting a rate ratio of 3.77 (95% CI 1.21 to 11.75), p=0.022, representing a 73% reduction of VLBW during the first 4 months of 2020 compared with same period for the preceding two decades. There were no ELBW infants admitted to the regional neonatal intensive care unit. National Irish VLBW rate for 2020 is forecasted to be reduced to approximate 400 per 60 000 births compared with the historical 500-600 range. CONCLUSION: An unprecedented reduction in regional births of VLBW and ELBW infants was observed in Ireland coinciding with the COVID-19 lockdown. Potential determinants of this unique temporal trend possibly reside in the summative socioenvironmental impact of the COVID-19 lockdown. Our findings, if mirrored in other regions that have adopted a lockdown, demonstrate the potential to evaluate these implicated behavioural and socioenvironmental modifiers to positively influence VLBW and ELBW rates globally.

Abstract Rationale The impact of coronavirus disease (COVID-19) on patients with interstitial lung disease (ILD) has not been established. Objectives To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age-, sex-, and comorbidity-matched population. Methods An international multicenter audit of patients with a prior diagnosis of ILD admitted to the hospital with COVID-19 between March 1 and May 1, 2020, was undertaken and compared with patients without ILD, obtained from the ISARIC4C (International Severe Acute Respiratory and Emerging Infection Consortium Coronavirus Clinical Characterisation Consortium) cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished idiopathic pulmonary fibrosis from non–idiopathic pulmonary fibrosis ILD and used lung function to determine the greatest risks of death. Measurements and Main Results Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to the hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching, patients with ILD with COVID-19 had significantly poorer survival (hazard ratio [HR], 1.60; confidence interval, 1.17–2.18; P = 0.003) than age-, sex-, and comorbidity-matched controls without ILD. Patients with an FVC of &amp;lt;80% had an increased risk of death versus patients with FVC ≥80% (HR, 1.72; 1.05–2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR, 2.27; 1.39−3.71). Conclusions Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD.

Syndesmosis screws have significant problems including loosening, breakage, the need for removal, and late diastasis. A new technique of syndesmosis fixation is proposed in this study, in which a heavy suture is placed across the syndesmosis, which has been looped and tightened through cortical button anchors on either side of the ankle. Indirect placement of the medial button avoids a medial incision. Sixteen patients had this suture-button fixation in a prospective clinical study. Mean American Orthopaedic Foot and Ankle Society ankle scores were significantly better in patients who had suture-button fixation than in a comparative group of 16 patients who had syndesmosis screw fixation at 3 months (91 versus 80, respectively) and at 12 months postoperatively (93 versus 83, respectively). Return to work was faster (2.8 months in patients who had suture-button fixation versus 4.6 months who had syndesmosis screw fixation), and no patients who had suture-buttons required secondary surgery for implant removal. Axial computed tomography scanning at 3 months showed maintenance of reduction. Suture-button fixation is simple, safe, and effective. Patients have had improved outcomes and faster rehabilitation, without needing routine implant removal. It may become the treatment of choice in patients with a syndesmosis injury.

BACKGROUND: Establishing intravenous access is often vital in an acute hospital setting but can be difficult. Ultrasound-guided cannulation increases success rates in prospective studies. However, these studies have often lacked a comparative group. This systematic review and meta-analysis aimed to determine the clinical effectiveness of Ultrasound-guided peripheral intravenous cannulation compared with the standard technique in patients known to have difficult access. METHODS: Electronic abstract databases, trial registries, article reference lists and internet repositories were searched using the following search terms: 'peripheral venous cannulation', 'peripheral venous access'. Studies meeting the following criteria were included: randomised controlled trial patients of all ages who required peripheral intravenous access; interventions were Ultrasound-guided versus standard cannulation technique; patients were identified as having difficult venous access; inclusion of at least one defined outcome (procedural success time to cannula placement; number of attempts). RESULTS: 7 trials were identified (289 participants). Ultrasound guidance increases the likelihood of successful cannulation (pooled OR 2.42; 95% CI 1.26 to 4.68; p=0.008). There were no differences in time to successful cannulation, or number of percutaneous skin punctures. CONCLUSION: Ultrasound guidance increases the likelihood of successful peripheral cannulation in difficult access patients. We recommend its use in patients who have difficult venous access, and have failed venous cannulation by standard methods. Further randomised controlled trials (RCTs) with larger sample sizes would be of benefit to investigate if Ultrasound has any additional advantages in terms of reducing the procedure time and the number of skin punctures required for successful venous cannulation.

Clinical subtyping of delirium according to motor-activity profile has considerable potential to account for the heterogeneity of this complex and multifactorial syndrome. Previous work has identified a range of clinically important differences between motor subtypes in relation to detection, causation, treatment experience and prognosis, but studies have been hampered by inconsistent methodology, especially in relation to definition of subtypes. This article considers research to date, including a number of recent studies that have attempted to address these issues and identify a means of achieving greater consistency in approaches to subtyping. Possibilities for future work are discussed and a research plan for the field is outlined.

Accurate monitoring of the mobility status of older adults, over the long-term, is important in rehabilitation medicine, as regular physical activity is central to maintaining both physical and mental health, as well as evaluating quality of life. This technical note describes an accelerometer-based mobility monitoring technique, which can distinguish between static and dynamic activities and can detect the basic postures of sitting, standing and lying. The technique allows thresholds for these postures to be set and two different posture threshold methods are described: mid-point and "best estimate". Preliminary results from using these methods are presented. This preliminary evaluation of the technique was carried out over the long-term (>29 h) in an uncontrolled environment and the method used to carry out the evaluation is described in detail. The two different posture thresholding methods were tested on long-term mobility data from one older adult subject. The subject did not have to follow a specific activity protocol during the recording period (4 days) and was shadowed by an observer in order to evaluate the accuracy of this technique. The monitoring hardware consisted of two accelerometer devices, one on the trunk and the other on the thigh and a pocket-sized ambulatory data-logger. Applying 'best estimate' thresholding, as opposed to mid-point thresholding, improved sitting detection accuracy by 18%, to 93% and lying detection accuracy by 5%, to 84%. Thus, based on these preliminary data, an accurate mobility monitoring system for older adults is described and it was observed that the actual posture threshold limits applied have a high impact on the mobility monitoring system's accuracy and are particularly important for accurately detecting postures when used over the long-term, in an uncontrolled environment.

OBJECTIVE: Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection. METHODS: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. RESULTS: Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall. CONCLUSIONS: The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO REGISTRATION NUMBER: CRD42019133702.

Adipose tissue is present in close proximity to various organs in the human body. One prominent example is fat contained in the mesentery that is contiguous with all abdominal digestive organs including the intestine. Despite the fact that mesenteric fat-wrapping around the inflamed gut (so called "creeping fat") was described as a characteristic feature of Crohn's disease (CD) in the early 1930s, the functional implications of creeping fat have received only recent attention. As a potent producer of fatty acids, cytokines, growth factors, and adipokines, creeping fat plays an important role in regulation of immunity and inflammation. Increasing evidence points to a link between creeping fat and intestinal inflammation in CD, where histopathologic evaluation shows a significant association between creeping fat and connective tissue changes in the bowel wall, such as muscular hypertrophy, fibrosis, and stricture formation. In addition, emerging mechanistic data indicate a link between creeping fat, muscularis propria hyperplasia, and stricturing disease. Information on fat-mesenchymal interactions in other organs could provide clues to fill the fundamental knowledge gap on the role of distinct components of creeping fat in intestinal fibrosis and stricture formation. Future studies will provide important new information that in turn could lead to novel therapeutic agents aimed at prevention or treatment of CD-associated fibrosis and stricture formation.

Arterial occlusive disease remains a major health issue in the developed world and a rapidly growing problem in the developing world. Although a growing number of patients are now being effectively treated with minimally invasive techniques, there remains a tremendous pressure on the vascular community to develop a synthetic small-diameter vascular graft with improved long-term patency rates. The field of tissue engineering offers an exciting alternative in the search for living organ replacement structures. Several methodologies have emerged for constructing blood vessel replacements with biological functionality. Common strategies include cell-seeded biodegradable synthetic scaffolds, cell self-assembly, cell-seeded gels and xenogeneic acellular materials. A wide range of materials are being investigated as potential scaffolds for vascular tissue engineering applications. Some are commercialised and others are still in development. Recently, researchers have studied the role of fibrin gel as a three-dimensional scaffold in vascular tissue engineering. This overview describes the properties of fibrin gel in vascular tissue engineering and highlights some recent progress and difficulties encountered in the development of cell fibrin scaffold technology.

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.

OBJECTIVE: To determine whether obstetric complications occur to excess in the early histories of individuals who go on to develop schizophrenia when compared with controls, and to seek clinical correlates of any such excess. DESIGN: Contemporaneous maternity hospital records were identified and extracted verbatim, and these extracts evaluated for obstetric complications by two independent assessors who were blind to subjects' status. SUBJECTS: 65 patients having an ICD-9 diagnosis of schizophrenia, the records of the previous same sex live birth being deemed to be those of a control subject. MAIN OUTCOME MEASURE: Presence of one or more obstetric complications recorded in maternity notes of patients and controls. RESULTS: When two recognised scales for specifying obstetric complications were used the patients with schizophrenia were significantly more likely than controls to have experienced at least one obstetric complication (odds ratio 2.44, 95% confidence interval 1.08 to 6.03). Patients also showed a greater number and severity of and total score for obstetric complications, fetal distress being the only complication to occur to significant individual excess (present in five (8%) patients, absent in controls). There was a marked sex effect, male patients being more vulnerable (odds ratio 4.24, 1.39 to 12.90) to such complications. Obstetric complications in patients were unrelated to family history or season of birth but were associated with a significantly younger age at onset of illness (mean difference--4.5 years,--1.2 to--7.8 years). CONCLUSIONS: Patients with schizophrenia, particularly males, have an excess of obstetric complications in their early developmental histories, and such complications are associated with a younger age at onset of their disease. Though the data are not conclusive, they also suggest that obstetric complications may be secondary to yet earlier events.

PURPOSE: YouTube is a global medium used predominantly by young adults (aged 18-49 years). This study examined the quality of YouTube information regarding ACL injury and reconstruction. METHODS: YouTube was searched on the 13th of June 2015 for "ACL" and "anterior cruciate ligament" with/without associated terms of "injury", "reconstruction", and "surgery". Videos were evaluated by two independent reviewers [EF (Reviewer 1), (Reviewer 2)] using two recognized information scoring systems (Modified DISCERN (MD) 0-5 and JAMA Benchmark 0-4) and an adaptation of a score designed for written ACL information [ACL Specific Score (ASS) 0-25]. The ASS categorized scores as very good (21-25), good (16-20), moderate (11-15), poor (6-10), and very poor (0-5). Number of views/likes/dislikes, animation, and continent of origin and source (e.g., corporate/educational) were recorded. Correlation of video characteristics with number of views was examined using the analysis of variance (ANOVA) model. Agreement between reviewers was assessed by Interclass Correlation Co-efficient (ICC). RESULTS: Following a filtering process of the 964,770 identified videos, 39 videos were retained. The mean MD score was 2.3 (standard deviation (SD) ±0.9) for Reviewer 1 and 2.2 (SD ±0.9) for Reviewer 2 (ICC = 0.7). The mean JAMA score was 2.5(SD ±0.7) for Reviewer 1 and 2.3 (SD ±0.7) for Reviewer 2 (ICC = 0.8). The mean ASS was 6.3 (SD ±3.5) for Reviewer 1 and 4.6 (SD ±2.9) for Reviewer 2 (ICC = 0.9). Five videos achieved moderate score (13%), while 15 (38%) and 19 (49%) scored as poor and very poor, respectively. There was no correlation between number of views and video quality/video source for any scoring system. CONCLUSION: The majority of videos viewed on YouTube regarding ACL injury and treatment are of low quality.