A double dissociation between savings and long-term memory in motor learning.

Memories are easier to relearn than learn from scratch. This advantage, known as savings, has been widely assumed to result from the reemergence of stable long-term memories. In fact, the presence of savings has often been used as a marker for whether a memory has been consolidated. However, recent findings have demonstrated that motor learning rates can be systematically controlled, providing a mechanistic alternative to the reemergence of a stable long-term memory. Moreover, recent work has reported conflicting results about whether implicit contributions to savings in motor learning are present, absent, or inverted, suggesting a limited understanding of the underlying mechanisms. To elucidate these mechanisms, we investigate the relationship between savings and long-term memory by experimentally dissecting the underlying memories based on short-term (60-s) temporal persistence. Components of motor memory that are temporally-persistent at 60 s might go on to contribute to stable, consolidated long-term memory, whereas temporally-volatile components that have already decayed away by 60 s cannot. Surprisingly, we find that temporally-volatile implicit learning leads to savings, whereas temporally-persistent learning does not, but that temporally-persistent learning leads to long-term memory at 24 h, whereas temporally-volatile learning does not. This double dissociation between the mechanisms for savings and long-term memory formation challenges widespread assumptions about the connection between savings and memory consolidation. Moreover, we find that temporally-persistent implicit learning not only fails to contribute to savings, but also that it produces an opposite, anti-savings effect, and that the interplay between this temporally-persistent anti-savings and temporally-volatile savings provides an explanation for several seemingly conflicting recent reports about whether implicit contributions to savings are present, absent, or inverted. Finally, the learning curves we observed for the acquisition of temporally-volatile and temporally-persistent implicit memories demonstrate the coexistence of implicit memories with distinct time courses, challenging the assertion that models of context-based learning and estimation should supplant models of adaptive processes with different learning rates. Together, these findings provide new insight into the mechanisms for savings and long-term memory formation.

Implicit Adaptation Is Modulated by the Relevance of Feedback.

Given that informative and relevant feedback in the real world is often intertwined with distracting and irrelevant feedback, we asked how the relevancy of visual feedback impacts implicit sensorimotor adaptation. To tackle this question, we presented multiple cursors as visual feedback in a center-out reaching task and varied the task relevance of these cursors. In other words, participants were instructed to hit a target with a specific task-relevant cursor, while ignoring the other cursors. In Experiment 1, we found that reach aftereffects were attenuated by the mere presence of distracting cursors, compared with reach aftereffects in response to a single task-relevant cursor. The degree of attenuation did not depend on the position of the distracting cursors. In Experiment 2, we examined the interaction between task relevance and attention. Participants were asked to adapt to a task-relevant cursor/target pair, while ignoring the task-irrelevant cursor/target pair. Critically, we jittered the location of the relevant and irrelevant target in an uncorrelated manner, allowing us to index attention via how well participants tracked the position of target. We found that participants who were better at tracking the task-relevant target/cursor pair showed greater aftereffects, and interestingly, the same correlation applied to the task-irrelevant target/cursor pair. Together, these results highlight a novel role of task relevancy on modulating implicit adaptation, perhaps by giving greater attention to informative sources of feedback, increasing the saliency of the sensory prediction error.

Reexposure to a sensorimotor perturbation produces opposite effects on explicit and implicit learning processes.

The motor system demonstrates an exquisite ability to adapt to changes in the environment and to quickly reset when these changes prove transient. If similar environmental changes are encountered in the future, learning may be faster, a phenomenon known as savings. In studies of sensorimotor learning, a central component of savings is attributed to the explicit recall of the task structure and appropriate compensatory strategies. Whether implicit adaptation also contributes to savings remains subject to debate. We tackled this question by measuring, in parallel, explicit and implicit adaptive responses in a visuomotor rotation task, employing a protocol that typically elicits savings. While the initial rate of learning was faster in the second exposure to the perturbation, an analysis decomposing the 2 processes showed the benefit to be solely associated with explicit re-aiming. Surprisingly, we found a significant decrease after relearning in aftereffect magnitudes during no-feedback trials, a direct measure of implicit adaptation. In a second experiment, we isolated implicit adaptation using clamped visual feedback, a method known to eliminate the contribution of explicit learning processes. Consistent with the results of the first experiment, participants exhibited a marked reduction in the adaptation function, as well as an attenuated aftereffect when relearning from the clamped feedback. Motivated by these results, we reanalyzed data from prior studies and observed a consistent, yet unappreciated pattern of attenuation of implicit adaptation during relearning. These results indicate that explicit and implicit sensorimotor processes exhibit opposite effects upon relearning: Explicit learning shows savings, while implicit adaptation becomes attenuated.

Measuring motion-to-photon latency for sensorimotor experiments with virtual reality systems.

Consumer virtual reality (VR) systems are increasingly being deployed in research to study sensorimotor behaviors, but properties of such systems require verification before being used as scientific tools. The 'motion-to-photon' latency (the lag between a user making a movement and the movement being displayed within the display) is a particularly important metric as temporal delays can degrade sensorimotor performance. Extant approaches to quantifying this measure have involved the use of bespoke software and hardware and produce a single measure of latency and ignore the effect of the motion prediction algorithms used in modern VR systems. This reduces confidence in the generalizability of the results. We developed a novel, system-independent, high-speed camera-based latency measurement technique to co-register real and virtual controller movements, allowing assessment of how latencies change through a movement. We applied this technique to measure the motion-to-photon latency of controller movements in the HTC Vive, Oculus Rift, Oculus Rift S, and Valve Index, using the Unity game engine and SteamVR. For the start of a sudden movement, all measured headsets had mean latencies between 21 and 42 ms. Once motion prediction could account for the inherent delays, the latency was functionally reduced to 2-13 ms, and our technique revealed that this reduction occurs within ~25-58 ms of movement onset. Our findings indicate that sudden accelerations (e.g., movement onset, impacts, and direction changes) will increase latencies and lower spatial accuracy. Our technique allows researchers to measure these factors and determine the impact on their experimental design before collecting sensorimotor data from VR systems.

Sensorimotor ability and inhibitory control independently predict attainment in mathematics in children and adolescents.

We previously linked interceptive timing performance to mathematics attainment in 5- to 11-yr-old children, which we attributed to the neural overlap between spatiotemporal and numerical operations. This explanation implies that the relationship should persist through the teenage years. Here, we replicated this finding in adolescents (n = 200, 11-15 yr). However, an alternative explanation is that sensorimotor proficiency and academic attainment are both consequences of executive function. To assess this competing hypothesis, we developed a measure of a core executive function, inhibitory control, from the kinematic data. We combined our new adolescent data with the original children's data (total n = 568), performing a novel analysis controlling for our marker of executive function. We found that the relationship between mathematics and interceptive timing persisted at all ages. These results suggest a distinct functional link between interceptive timing and mathematics that operates independently of our measure of executive function.NEW & NOTEWORTHY Previous research downplays the role of sensorimotor skills in the development of higher-order cognitive domains such as mathematics: using inadequate sensorimotor measures, differences in "executive function" account for any shared variance. Utilizing a high-resolution, kinematic measure of a sensorimotor skill previously linked to mathematics attainment, we show that inhibitory control alone cannot account for this relationship. The practical implication is that the development of children's sensorimotor skills must be considered in their intellectual development.

Characteristics of Implicit Sensorimotor Adaptation Revealed by Task-irrelevant Clamped Feedback.

Sensorimotor adaptation occurs when there is a discrepancy between the expected and actual sensory consequences of a movement. This learning can be precisely measured, but its source has been hard to pin down because standard adaptation tasks introduce two potential learning signals: task performance errors and sensory prediction errors. Here we employed a new method that induces sensory prediction errors without task performance errors. This method combines the use of clamped visual feedback that is angularly offset from the target and independent of the direction of motion, along with instructions to ignore this feedback while reaching to targets. Despite these instructions, participants unknowingly showed robust adaptation of their movements. This adaptation was similar to that observed with standard methods, showing sign dependence, local generalization, and cerebellar dependency. Surprisingly, adaptation rate and magnitude were invariant across a large range of offsets. Collectively, our results challenge current models of adaptation and demonstrate that behavior observed in many studies of adaptation reflect the composite effects of task performance and sensory prediction errors.

Savings upon Re-Aiming in Visuomotor Adaptation.

Sensorimotor adaptation has traditionally been viewed as a purely error-based process. There is, however, growing appreciation for the idea that performance changes in these tasks can arise from the interplay of error-based adaptation with other learning processes. The challenge is to specify constraints on these different processes, elucidating their respective contributions to performance, as well as the manner in which they interact. We address this question by exploring constraints on savings, the phenomenon in which people show faster performance gains when the same learning task is repeated. In a series of five experiments, we demonstrate that error-based learning associated with sensorimotor adaptation does not contribute to savings. Instead, savings reflects improvements in action selection, rather than motor execution. SIGNIFICANCE STATEMENT: Savings is the phenomenon in which people show faster relearning of a previously forgotten memory. In the motor learning domain, this phenomenon has been a puzzle for learning models that operate exclusively on error-based learning processes. We demonstrate, in a series of experiments, that savings selectively reflects improvements in action selection: Participants are more adept in invoking an appropriate aiming strategy when presented with a previously experienced perturbation. Indeed, improvements in action selection appear to be the sole source of savings in visuomotor adaptation tasks. We observe no evidence of savings in implicit error-based adaptation.

Kinematic markers of skill in first-person shooter video games.

Video games present a unique opportunity to study motor skill. First-person shooter (FPS) games have particular utility because they require visually guided hand movements that are similar to widely studied planar reaching tasks. However, there is a need to ensure the tasks are equivalent if FPS games are to yield their potential as a powerful scientific tool for investigating sensorimotor control. Specifically, research is needed to ensure that differences in visual feedback of a movement do not affect motor learning between the two contexts. In traditional tasks, a movement will translate a cursor across a static background, whereas FPS games use movements to pan and tilt the view of the environment. To this end, we designed an online experiment where participants used their mouse or trackpad to shoot targets in both visual contexts. Kinematic analysis showed player movements were nearly identical between contexts, with highly correlated spatial and temporal metrics. This similarity suggests a shared internal model based on comparing predicted and observed displacement vectors rather than primary sensory feedback. A second experiment, modeled on FPS-style aim-trainer games, found movements exhibited classic invariant features described within the sensorimotor literature. We found the spatial metrics tested were significant predictors of overall task performance. More broadly, these results show that FPS games offer a novel, engaging, and compelling environment to study sensorimotor skill, providing the same precise kinematic metrics as traditional planar reaching tasks.

Synaptotagmin VII regulates Ca(2+)-dependent exocytosis of lysosomes in fibroblasts.

Synaptotagmins (Syts) are transmembrane proteins with two Ca(2+)-binding C(2) domains in their cytosolic region. Syt I, the most widely studied isoform, has been proposed to function as a Ca(2+) sensor in synaptic vesicle exocytosis. Several of the twelve known Syts are expressed primarily in brain, while a few are ubiquitous (Sudhof, T.C., and J. Rizo. 1996. Neuron. 17: 379-388; Butz, S., R. Fernandez-Chacon, F. Schmitz, R. Jahn, and T.C. Sudhof. 1999. J. Biol. Chem. 274:18290-18296). The ubiquitously expressed Syt VII binds syntaxin at free Ca(2+) concentrations ([Ca(2+)]) below 10 microM, whereas other isoforms require 200-500 microM [Ca(2+)] or show no Ca(2+)-dependent syntaxin binding (Li, C., B. Ullrich, Z. Zhang, R.G.W. Anderson, N. Brose, and T.C. Sudhof. 1995. Nature. 375:594-599). We investigated the involvement of Syt VII in the exocytosis of lysosomes, which is triggered in several cell types at 1-5 microM [Ca(2+)] (Rodríguez, A., P. Webster, J. Ortego, and N.W. Andrews. 1997. J. Cell Biol. 137:93-104). Here, we show that Syt VII is localized on dense lysosomes in normal rat kidney (NRK) fibroblasts, and that GFP-tagged Syt VII is targeted to lysosomes after transfection. Recombinant fragments containing the C(2)A domain of Syt VII inhibit Ca(2+)-triggered secretion of beta-hexosaminidase and surface translocation of Lgp120, whereas the C(2)A domain of the neuronal- specific isoform, Syt I, has no effect. Antibodies against the Syt VII C(2)A domain are also inhibitory in both assays, indicating that Syt VII plays a key role in the regulation of Ca(2+)-dependent lysosome exocytosis.

Invariant errors reveal limitations in motor correction rather than constraints on error sensitivity.

Implicit sensorimotor adaptation is traditionally described as a process of error reduction, whereby a fraction of the error is corrected for with each movement. Here, in our study of healthy human participants, we characterize two constraints on this learning process: the size of adaptive corrections is only related to error size when errors are smaller than 6°, and learning functions converge to a similar level of asymptotic learning over a wide range of error sizes. These findings are problematic for current models of sensorimotor adaptation, and point to a new theoretical perspective in which learning is constrained by the size of the error correction, rather than sensitivity to error.

Carpal and fetlock conformation of the juvenile Thoroughbred from birth to yearling auction age.

REASONS FOR PERFORMING STUDY: There is little information available about conformational changes in the forelimbs of growing foals. OBJECTIVES: To describe the conformation of the carpus and fetlock of Thoroughbred foals from birth to yearling sale age. METHODS: Subjective assessments of the fetlock and carpal conformation of 119 Thoroughbred foals were made within the first month of life and then at 30 day intervals until at least age 120 days. At least 70 subjects were examined further at 60 day intervals until September of their second year. Conformation grades are reported for 5 age groups: first 7 days and at a mean of 46, 176, 362 and 525 days. The conformation of all available sires and dams of subjects was also graded. RESULTS: All subjects demonstrated carpal deviations, such as valgus, outward rotation and offset, and approximately 30% had fetlock deviations. Heavier birth weights were associated with carpal offset and fetlock inward conformation at most ages, and heavier yearlings were more likely to be carpal valgus. The carpal conformation of the sire (offset and outward rotation) was associated with similar yearling carpal conformation. During the study period, the carpal conformation of Thoroughbred foals became less valgus and more offset. Fetlock conformation became more inwardly deviated during the first 6 months of the study. CONCLUSIONS: Carpal and fetlock conformation change greatly in Thoroughbred foals up to age 18 months. The phenotype of the sire can be associated with yearling carpal conformation and bodyweight, particularly at birth and as yearlings, is associated with yearling fetlock and carpal conformation. POTENTIAL RELEVANCE: New factors associated with forelimb conformational deviations have been identified that may help breeders better to manage young racing stock.

Maxillary sinus hypoplasia: classification and description of associated uncinate process hypoplasia.

Maxillary sinus hypoplasia is an anomaly of the paranasal sinuses occasionally encountered by otolaryngologists. Although this entity has been previously reported, an association between maxillary sinus hypoplasia and anomalies of other paranasal sinus structures, such as the uncinate process, has not yet been described. Additionally, the literature lacks a system by which the various types of maxillary sinus hypoplasia can be classified using computerized tomographic (CT) imaging. Two hundred and two consecutive coronal sinus computerized tomographic scans from patients undergoing evaluation at our institution were analyzed to determine the prevalence of MSH and associated paranasal sinus anomalies. The overall prevalence of maxillary sinus hypoplasia was 10.4%. Three distinct patterns of hypoplasia were evident. Type I, characterized by a normal uncinate process, a well-defined infundibular passage, and mild sinus hypoplasia, occurred in 14 patients (6.9%). Type II, characterized by absence or hypoplasia of the uncinate process, an ill-defined infundibular passage, and soft-tissue density opacification of a significantly hypoplastic sinus occurred in 6 patients (3.0%). Type III, characterized by absence of the uncinate process and a profoundly hypoplastic, cleft-like sinus, occurred in 1 patient (0.5%). Recognition of associated anomalies of the uncinate process in patients with maxillary sinus hypoplasia undergoing sinus surgery is of utmost clinical significance because the uncinate process serves as a key landmark during functional endoscopic sinus surgery. Failure to recognize hypoplasia or absence of the uncinate process could lead to inadvertent intraoperative damage to the adjacent medial orbital wall.

Comparative IUD study: Lippes Loop D, Dalkon Shield and TCu-200.

A study was undertaken to look at the clinical behavior of the Dalkon Shield, the Lippes Loop D and the TCu-200 inserted by physicians and midwives. Differences among the three devices were not statistically significant, although lower expulsion rates and higher pregnancy rates were reported for the Dalkon Shield. No differences were observed between insertions performed by physicians and those performed by midwives; this emphasizes the efficiency of using paramedical personnel in the field of intrauterine contraception.

Soft-tissue response to synthetic biomaterials.

The soft-tissue response to an implanted synthetic material is an inflammatory reaction to foreign body; factors that minimize this inflammation will maximize biocompatibility. The ideal implant is selected from a material that is non-toxic, nonantigenic and in chemical proximity to calcium or carbon on the periodic table. If it is porous, the pores should be large enough to admit immune and phagocytic cells and ideally, to allow native tissue ingrowth. The implant should be of appropriate size and shape and should be implanted in the correct location. The material should be nonparticulate, should resist fragmentation, and should be secured in the selected location after gentle insertion. All these factors help decrease the body's natural response to an implanted foreign body, but inflammation and foreign body reaction are the common threads in all responses to all implanted synthetic materials. Optimum soft-tissue biocompatibility, characterized either by thin fibrous encapsulation or by mesenchymal ingrowth into pores and interstices, is achieved by avoiding or containing this response.

Tracheobronchomalacia in Hunter's syndrome.

Hunter's syndrome is one of a group of heritable metabolic disorders caused by decreased activity of one or more of the lysosomal enzymes responsible for mucopolysaccharide catabolism, resulting in excessive deposition of mucopolysaccharides in skeletal and soft tissues. Pulmonary conditions, such as airway obstruction, sleep apnea syndrome, atalectasis, recurrent pneumonia and difficult endotracheal intubation are known to be associated with these rare disorders and have been reported. We report the findings at laryngotracheobronchoscopy of a patient with Hunter's syndrome with airway symptoms and, supported by analysis of previously reported cases of airway problems associated with the syndrome, suggest that tracheobronchomalacia with classifiable major airway collapse (MAC) may be the pathological correlate for this clinical picture. The endoscopic technique and characteristic findings of tracheobronchomalacia/MAC are discussed, as well as the natural history and pathophysiology of this condition, which is characterized by weakness of the tracheal wall due to softening of the supporting cartilage and hypotonia of the myoelastic elements with reduction in the tracheal lumen.

Squamous cell carcinoma of the tongue occurring as a subsequent malignancy in a 12-year-old acute leukemia survivor.

Squamous cell carcinoma of the tongue is rare in children and previously unreported as a second malignancy after survival of acute leukemia. Usual etiologic associations such as smoking and alcohol use are not commonly seen in this population, and exposure to immunosuppressive and antineoplastic agents including radiation therapy may contribute to the occurrence of these tumors. A review of the literature reveals only 21 previously reported cases of squamous cell carcinoma of the tongue in children less than 15 years old, and in only two cases was it a second malignancy; none were in leukemia survivors. Small numbers prevent accurate conclusions with regard to tumor behavior, but prognosis appears to be poor with aggressive invasion and early metastasis common. Follow-up of survivors of leukemia and its therapy with immunosuppressive and cytotoxic drugs and radiation should include regular careful head and neck examinations.

Radiographic changes in Thoroughbred yearlings. Part 1: Prevalence at the time of the yearling sales.

REASONS FOR PERFORMING STUDY: Radiography in presale examinations of TB yearlings has become standard practice in recent years. OBJECTIVES: To describe the prevalence and distribution of radiographic changes in the fetlocks, carpi, tarsi, stifles and fore feet of Thoroughbred yearlings in central Kentucky when these joints were examined as part of routine pre- and post sale evaluations. METHODS: Horses subjected to radiographs included the fore (n = 1127) and hind (n = 1102) fetlocks, carpi (n = 1130), tarsi (n = 1101), stifles (n = 660) and fore feet (n = 300). Radiographic changes were categorised by location and type of change present (e.g. lucency, fragment) for each series. RESULTS: In the fore fetlocks 1.6% had fragmentation of the proximal dorsal first phalanx and 0.5% fragmentation of the proximal palmar aspect. In the hind fetlocks 5.9% had fragmentation at the plantar aspect and 3.3% fragmentation dorsally. Lucencies, fragments or loose bodies were detected at the dorsal aspect of the distal third metacarpus in 2.8% and, at the same location on the third metatarsus, 3.2%. Most yearlings (98%) had vascular channels in the proximal sesamoid bones and irregular vascular channels (> 2 mm wide or with nonparallel sides) were more common (79%) than regular vascular channels (56%). The intermediate ridge of the distal tibia was the most common location for fragmentation in the tarsus (4.4%). CONCLUSIONS: While some radiographic changes, e.g. vascular channels in proximal sesamoid bones, are very common in Thoroughbred yearlings, others, e.g. fragmentation or subchondral lucency within joints are quite rare usually affecting less than 5% of the population. POTENTIAL RELEVANCE: Veterinarians should expect to find radiographic changes in Thoroughbreds presented for examination prior to the yearling sales. The rarity of some changes thought to affect soundness or racing performance will make further invesigation of these conditions in horses without clinical signs more difficult.

Radiographic changes in Thoroughbred yearlings. Part 2: Associations with racing performance.

REASONS FOR PERFORMING STUDY: Although the radiographic examination of yearlings has become commonplace at some large Thoroughbred sales, there are few data to support the decisions facing veterinarians who are asked to evaluate future racing potential. OBJECTIVES: To identify radiographic changes in the fetlocks, proximal sesamoid bones, carpi, tarsi, stifles and fore feet of Thoroughbred yearlings associated with future racing performance during ages 2 and 3 years. METHODS: Radiographs from routine pre- and post sale examinations of 1162 yearlings were used to identify individual radiographic changes in sale yearlings. Starting a race, the percent of starts placed, money earned and earnings per start were used to assess racing performanceand examined for associations with the radiographic changes observed. RESULTS: Overall 946 (81%) yearlings started at least one race during ages 2 or 3 years. Fourteen of 24 (58%) yearlings with moderate or extreme palmar supracondylar lysis of the third metacarpus, 8 of 14 (57%) of those with enthesophyte formation on the proximal sesamoid bones and 19 of 30 (63%) of those with dorsal medial intercarpal joint disease started a race. The odds of starting a race when age 2 or 3 years were 3 times lower for yearlings with these changes (P < 0.01) compared with yearlings that did not have these changes. Twenty-five of 36 (69%) yearlings with proximal dorsal fragmentation of the first phalanx in the hind fetlock started a race and these yearlings were also less likely (OR = 0.51, P = 0.07) to start a race. Yearlings with enthesophyte formation on hind proximal sesamoid bones placed in a smaller percentage of starts (16%, P = 0.01) earned less money (987 US dollars, P = 0.02) and had lower earnings per start (252 US dollars, P = 0.03) compared to starters without this change. CONCLUSIONS: Although many of the changes observed on radiographs of sale yearlings do not appear to influence future racing performance, some are associated with reduced performance. POTENTIAL RELEVANCE: The results of this study are best applied in parallel with the clinical impressions of veterinarians experienced in examining radiographs of sale yearlings. Some findings support those established in the literature as incidental findings and others suggest new areas for concern not previously reported as a problem in Thoroughbred sale yearlings.

Endoscopic assessment of airway function as a predictor of racing performance in Thoroughbred yearlings: 427 cases (1997-2000).

OBJECTIVE: To compare endoscopic findings of the upper portion of the respiratory tract in Thoroughbred yearlings with their subsequent race records to determine whether subjective assessment of airway function may be used as a predictor of future racing performance. DESIGN: Retrospective study. ANIMALS: 427 Thoroughbred yearlings. PROCEDURES: Endoscopic examination findings were obtained from the medical records and the videoendoscopic repository of the Keeneland 1996 September yearling sales. Racing records were requested for the yearlings through the end of their 4-year-old racing season (1997-2000). Twenty-nine measures of racing performance were correlated with endoscopic findings. Subjective arytenoid cartilage movement grades were determined, using a 4-point grading scale (grade 1 = symmetrical synchronous abduction of the arytenoid cartilages; grade 4 = no substantial movement of the left arytenoid cartilage). RESULTS: Of the 427 Thoroughbred yearlings included in this study, 364 established race records, and 63 did not. Opinions regarding suitability for purchase, meeting conditions of the sale, and the presence of epiglottic abnormalities had no significant association with racing performance. Arytenoid cartilage movement grades were significantly associated with many of the dependent variables. However, palatine abnormalities were not predictive of inferior racing performance. CONCLUSIONS AND CLINICAL RELEVANCE: Thoroughbred yearlings with grade-1 and -2 arytenoid cartilage movements had significantly better racing performance as adults, compared with yearlings with grade-3 arytenoid cartilage movements. In contrast, epiglottic and palatine abnormalities were not predictive of inferior racing performance. Therefore, evaluation of laryngeal function, but not epiglottic or palatine abnormalities, using the 4-point grading system, should be the major factor in developing recommendations for prospective buyers.