Cost efficacy of routine screening for diabetes in pregnancy: 1-h versus 2-h specimen.

Undetected gestational diabetes mellitus (GDM) is associated with a two- to fivefold increase in perinatal morbidity and mortality. Widespread screening of the obstetric population (resulting in identification and treatment) should reduce these rates. Seven hundred ninety-eight women were examined during a 13-mo period of universal glucose challenge testing (GCT). A total of 2.8% of the population had an abnormal oral glucose tolerance test (OGTT). Thirty percent of those with an abnormal OGTT were less than 25 yr old. The specificity of a 1-h GCT (50-g carbohydrate load) using a threshold of either 140 or 150 mg/dl was compared with that of a 2-h specimen using a threshold of 118 mg/dl to determine whether the cost of screening could be reduced. One- and 2-h specimens were obtained in 347 of these women. A 34% reduction in the number of follow-up OGTTs required would have been achieved if a 2-h specimen had been used as the index instead of a 1-h specimen (P less than .05). As a result, the (direct and indirect) cost per patient identified with GDM would have declined 23.5%--from $866 to $662. No comment concerning the actual false-negative rate of either the 1- or 2-h GCT can be made because only select women underwent an OGTT. To assess the validity of the 2-h threshold, an OGTT was performed in an additional 190 women if either the 1- or 2-h screen was abnormal. The results were confirmatory: the 2-h screen would have reduced the cost per case identified by 32% in this small group. Screening on the basis of past medical history clearly lacked sensitivity and cost efficacy in comparison with the GCT and should be abandoned as a practice.

Frontonasal malformation and cloacal exstrophy: a previously unreported association.

We report on a child with frontonasal malformation (FNM) and cloacal exstrophy, a combination of findings that have not been reported previously. In FNM and cloacal exstrophy, associated malformations are rare. FNM and cloacal exstrophy both represent abnormalities of the development of the midline field; this combination of anomalies in this patient suggests an impairment of caudal and cranial midline development during blastogenesis.

TWIST gene mutation in a patient with radial aplasia and craniosynostosis: further evidence for heterogeneity of Baller-Gerold syndrome.

The term Baller-Gerold syndrome was coined by Cohen [1979: Birth Defects 15(5B): 13-63] to designate the phenotype of craniosynostosis and radial aplasia. It is thought to be a rare autosomal recessive condition, which, in some patients, presents with additional abnormalities, such as polymicrogyria, mental retardation or anal atresia. A phenotypic overlap of Baller-Gerold and Roberts-SC phocomelia syndrome was noted when a patient with bicoronal synostosis and bilateral radial hypoplasia was found to have premature centromere separation, a finding characteristic of Roberts syndrome [Huson et al.,1990: J Med Genet 27:371-375]. Other cases of presumed Baller-Gerold syndrome were rediagnosed as Fanconi pancytopenia, Rothmund-Thomson syndrome or VACTERL association. These reports led to a narrowed redefinition of Baller-Gerold syndrome based on the exclusion of cytogenetic and hematopoetic abnormalities and the absence of additional malformations in patients with craniosynostosis and preaxial upper limb abnormalities. Here we report on a patient with unilateral radial aplasia and bicoronal synostosis without additional malformations and without chromosome breakage, who fits this narrow definition of Baller-Gerold syndrome. We identified a novel TWIST gene mutation in this patient, a Glu181Stop mutation predicting a premature termination of the protein carboxy-terminal to the helix 2 domain. This report provides further evidence that Baller-Gerold is of heterogeneous cause, and a thorough evaluation is indicated to identify a possibly more specific diagnosis, including Saethre-Chotzen syndrome. This differential diagnosis is of particular importance, as it is an autosomal dominant trait. Therefore, the recurrence risk for parents of an affected child can be 50% if one parent carries the mutation, as opposed to the 25% recurrence risk for autosomal recessive inheritance. Offspring of the affected patient also have a 50% risk to inherit the mutation, while the risk to bear an affected offspring for an autosomal recessive trait is very low.

Ocular and adnexal complications of unilateral orbital advancement for plagiocephaly.

Strabismus, ptosis, lateral canthal dystopia, nasolacrimal obstruction, and cranial nerve palsy were noted preoperatively in 32%, 21%, 14%, 12%, and 9% of 34 patients, respectively, undergoing ophthalmologic evaluation prior to unilateral orbital advancement for plagiocephaly. Thirty-two percent of the patients had normal preoperative ocular and adnexal examination results. Ptosis, strabismus, and amblyopia were frequently acquired postoperative abnormalities in 29%, 18%, and 18% of the patients, respectively. Forty-four percent of the patients had no new abnormalities following craniofacial surgery.

Facial reconstruction consideration in rheumatic diseases.

In conclusion, the management of facial involvement in JRA, Romberg disease, and scleroderma is dictated by the degree of severity of the disease, age of onset, and length of activity. Functional occlusal abnormalities are best addressed through a team approach consisting of initial orthodontics followed by orthognathic surgery if needed. In all types of scleroderma, surgical facial reconstruction is best delayed until the disease is quiescent for at least a year. The ideal option for facial skeletal and soft-tissue augmentation has not yet been realized. Careful surgical planning and choice of grafts, flaps, or implants are critical to obtain the desired result.

Variations in extraocular muscle number and structure in craniofacial dysostosis.

Five of 12 patients with craniofacial dysostosis who needed strabismus surgery had anomalies of extraocular muscle structure and number. Two cul-de-sac incisions per eye are sufficient to investigate all muscles for anomalies and add little time or risk to the planned strabismus procedure. The origin of these anomalies and their frequency in craniofacial stenosis are unknown.

The psychology of cosmetic surgery: a review and reconceptualization.

This article discusses the psychology of cosmetic surgery. A review of the research on the psychological characteristics of individuals who seek cosmetic surgery yielded contradictory findings. Interview-based investigations revealed high levels of psychopathology in cosmetic surgery patients, whereas studies that used standardized measurements reported far less disturbance. It is difficult to fully resolve the discrepancy between these two sets of findings. We believe that investigating the construct of body image in cosmetic surgery patients will yield more useful findings. Thus, we propose a model of the relationship between body image dissatisfaction and cosmetic surgery and outline a research agenda based upon the model. Such research will generate information that is useful to the medical and mental health communities and, ultimately, the patients themselves.

Item analysis of a single response dichotic listening test.

Ten left-handed and eight right-handed subjects were tested on five replications of a single-response dichotic listening test. Nine CV dichotic pairings of the six stop consonants plus /a/ were used. Computer synthesis guaranteed that these pairs differed on only a single phonemic feature, thus permitting fusion. Mean laterality scores were significantly higher (greater right ear advantage) for right-handers than for left-handers. Selective attention instructions did not alter laterality scores. Test-retest correlation coefficients were consistently high (greater than .70 for all adjacent replication comparisons). Error rates were low (averaging 5.5%) and 39% of these were psychoacoustic confusions rather than true (guessing) errors. These confusions were found for only two of the nine pairs. Stimulus dominance, as opposed to ear dominance, was considered separately. Two dichotic pairs had such strong stimulus dominance for all subjects that little ear advantage information was available from those pairs. It was recommended that the three dichotic pairs prone to psychoacoustic confusions and/or overwhelming stimulus dominance be removed from the test.

Stimulus-response compatibility for left-right discriminations as a function of stimulus position.

In two experiments, choice response times to visual stimuli (word and arrow) were measured. The stimuli were presented briefly (180 msec) in left and right visual half-field (VHF). Each stimulus required a left-right discrimination; however, half the stimuli were positive (e.g., LEFT), and half were negative (e.g., NOT RIGHT). In Experiment 1, button-pressing responses in the midsagittal plane were used; in Experiment 2, vocal responses were used. There was a strong stimulus-response (S-R) compatibility effect, influenced by the interaction of negation (positive vs. negative) and stimulus position (VHF). Latencies were faster to positive stimuli whose direction and VHF matched than to positive stimuli whose direction and VHF did not correspond. Conversely, latencies were faster to negative stimuli when response direction and VHF did not match than when direction and VHF did correspond. These results replicate the S-R compatibility effect found by Whitaker (1980) using foveal stimuli. The results were analyzed with regard to a hemisphere activation model proposed by Cotton, Tzeng, and Hardyck (1980) but were found to fit Whitaker's (1980) model better.

Facial malformations and spinal anomalies. A predictable relationship.

Facial malformations have generally been associated with spinal anomalies, but this report reviews patients with specific facial abnormalities and attempts to document accompanying spinal anomalies. The results indicate that the most common types of facial malformations vary predictably in their influence on spinal or other musculoskeletal abnormalities. Apert and Goldenhaar syndromes are associated with significant spinal anomalies.

The skeletal treatment of orbital hypertelorism.

Orbital hypertelorism, strictly defined as an increase in bony interorbital distance, is not itself an isolated syndrome, but is instead an anomaly that may occur as either part of a syndrome or malformation sequence. Evaluation of orbital hypertelorism and the various anomalies that accompany it is best performed by a multidisciplinary craniofacial team. The timing of surgery involves considerations of multiple variables, but when performed can offer marked cosmetic improvements. Equally important as the skeletal surgery is correction of the associated soft-tissue problems.

Temporal and malar-zygomatic reduction and augmentation.

The temporal fossa, zygomatic arch, and malar-midface should be considered jointly when augmentation of the temporal area or reduction of the zygomatic arch are to be carried out. These anatomic areas relate so closely to one another that altering one affects the other. In addition, augmentation of the malar-midface area may be done if one of the other two procedures is to be considered, or if a brow lift, subperiosteal face lift, or other reason for using a coronal incision exists. Use of the coronal incision for malar augmentation is probably not justified because of the large amount of surgery required in spite of the lesser morbidity associated with this approach in terms of amount of infections, lip stiffness, and hypesthesia. Planning a surgical procedure must be done in the office, by examining the patient at eye level to determine the amount of zygomatic arch reduction and the amount of temporal fossa augmentation necessary. Similarly, the three zones of the malar-midface complex must be assessed, with the amount of augmentation of each zone determined prior to the day of surgery. The surgical procedure is then executed through a coronal incision, with the dissection extending down to the zygomatic arch. If the temporal muscle is to be elevated out of its fossa, it is cut on its anterior, superior, and posterior edges, elevating it out of its fossa so that a Proplast implant, typically 3 to 4 mm thick and finely tapered on its superior and posterior edges, with suturing done anteriorly, may be inserted. The muscle is then resutured to its aponeurosis on all three edges. If the zygomatic arch and malar-midface area are to be approached, the dissection is carried to the deep and superior edge of the zygomatic arch, and the periosteal elevator is used to elevate the soft tissue off the lateral and inferior edge. The arch and malar-midface are cleared of soft tissue, extending the tunnel to the upper buccal sulcus. The arch is then reduced with a contouring burr to the thinness desired. Alternatively, the malar-midface area may be augmented with synthetic material precisely positioned, with a suture around the zygomatic arch, holding it in position as measured from the lateral orbital rim. The incision in the temporal fascia is then resutured, and the coronal incision is closed.(ABSTRACT TRUNCATED AT 400 WORDS)

Biological boundaries: a concept in facial skeletal restructuring.

The concept of biological boundaries is based on observations of craniofacial restructuring. It describes the body's intrinsic sense of physical surface and how this knowledge can be used to determine when to use bone grafts, segment shifts, or synthetic material.

Aesthetic contouring of the facial support system.

The skeletal foundation and its attachments provide a basis for changing the basic structure of the face. Detailed preoperative evaluation and a clear understanding between the patient and surgeon of the aesthetic goals are essential prior to proceeding with surgery. Besides a knowledge of the normal aesthetic and arthropologic measurements, the surgeon must have an understanding of the range of methods available prior to proceeding with surgery. For minor alterations, contour reduction or augmentation should be considered. In the temporal fossa, augmentation with synthetic material is preferred. In the supraorbital ridge and chin autogenous tissue is generally the material of choice. An understanding of when and how to use these materials is the essence of achieving satisfactory results.

Psychosocial considerations in craniofacial deformity.

The authors evaluate the hypotheses that duration and severity of craniofacial malformations correlate with psychosocial adjustment. Reviewing data from congenital and traumatic craniofacial malformation patients of varying ages, they find partial support for the hypothesized associations; however, the relationship between psychosocial adjustment and craniofacial deformity is far from straightforward.

The craniofacial dysostoses: guidelines for management of the symmetric and asymmetric deformities.

Although great diversity marks the craniosynostoses, our experience related to that from other centers allows us to draw certain conclusions for their management. For the asymmetric synostoses, operative intervention should be carried out in infancy or early childhood. Although the unilateral approach is our preferred method, the bilateral approach can yield equally satisfactory results. Surgeons should, therefore, familiarize themselves with both methods and individualize for the given deformity. Mild symmetric (upper face) synostoses are best managed in infancy or early childhood, utilizing bilateral orbital advancement with the expectation that the need for additional major surgery will be at worst 50 per cent and likely significantly less. For moderate to severe synostoses, delaying major intervention to later childhood or adolescence maximizes the chance of obtaining a satisfactory result by a single procedure, either an extended LeFort III or monoblock advancement. Individualization of each case is essential, and the need for brain and eye protection or the psychologic needs of the patient may dictate a modification of the treatment guidelines. Patients and parents must be aware that growth and development subsequent to surgery is not entirely predictable, and there may be a need for a second major intervention at a subsequent time, despite these established guidelines.

Skeletal alterations as a basis for facial rejuvenation.

A slight decrease in overall facial bone bulk coupled with the increased soft-tissue expansion associated with aging produce effects that should be reversed in both the bone and soft tissue where possible. The changes are best done at the ledge areas: the supraorbital-temporal ridge areas, malar-midface, and chin mandible. However, the overall bone bulk may be increased in addition in the temporal fossae, in the infraorbital rim, at the lateral canthus, in the paranasal area, and at the alveolar ridges and dental areas. A combination of autogenous and synthetic materials is currently best, with synthetic materials most useful in the malar-midface, posterior mandibular, infraorbital, and paranasal areas. In the supraorbital ridge-temporal areas, it is a near equal choice between autogenous and synthetic materials. In the chin, the preferred method is by osteotomy using autogenous augmentation. The concept of increasing bone mass and decreasing expanded soft-tissue mass has application within the judgment of the surgeon coupled with the patient's desires. Subtle increases of bone mass to compensate for soft-tissue thinning as well as bone shrinkage, at the same time taking up lax soft tissue, can be done in conjunction with one another, effectively producing a three-layer face lift. The subperiosteal face lift is in reality an extended brow lift and can be used to enhance the brow-forehead area and the temporal, zygomatic, and paranasal areas. At the same time, the perioral, jowl, and submandibular regions must be treated by a combination of standard face lifting procedures and augmentation of the bone structures of the face.

Social and psychological effects of craniofacial deformity and surgical reconstruction.

Psychosocial evaluations of patients undergoing surgery for congenital craniofacial anomalies are being conducted preoperatively and postoperatively to document functioning prior to and following surgery. Our findings to date indicate that presurgically younger patients, those between 6 and 13, fare better than those 14 years and over. The former, for the most part, appear to be functioning adequately and test within normal range on standardized psychometric measures. The latter are more prone to social isolation and problems in self-concept and mood state. Postoperative evaluations are reported only for the younger group because of the small sample size of the older. Overall postoperative adjustment appears improved on several psychometric tests. The majority of patients and families are pleased with outcome. Improvement in appearance postoperatively as rated by independent judges has not reached statistical significance; however, there are significant correlations between changes in appearance and changes on several measures including self-concept and trait anxiety. This finding would tend to support the contention that improvement in appearance brought about by craniofacial surgery is associated with improvement in psychosocial adjustment.

Evaluation of facial skeletal aesthetics and surgical planning.

Proper surgical planning for aesthetic facial skeletal surgery requires of the surgeon not only intimate knowledge of available techniques but also an understanding of how and when to apply those techniques. To this end, proper facial form analysis is essential. In this introduction we have attempted to describe the elements of such an analysis, realizing that much remains to be learned about how the bone and soft tissue interact. In many ways the soft tissue--bone relations remain the unexplored area in aesthetic skeletal surgery. The further delineation of these relations by the use of anthropometry, laser light scanning, ultrasound, CT, and MRI remains an open area for investigation. The potential is enormous for using these data to study how bone and soft-tissue relationships combine to create facial form and how this form changes with both surgery and normal aging.

Avoiding pitfalls and managing complications of aesthetic contouring of the craniofacial skeleton.

Contouring of the facial skeleton has become applicable to a wide spectrum of patients. Although complications do occur, they now can be managed in a safe and predictable fashion. Moreover, it has been our experience that through increased use and attention to the tenets described in this article, the incidence of postoperative complications is significantly reduced.