FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

Psychometric Validation of the FACE-Q Craniofacial Module for Facial Nerve Paralysis

Background: Systematic reviews have identified the need for a patient-reported outcome measure for facial nerve paralysis (FNP). The aim of this study was to determine the psychometric properties of FACE-Q Craniofacial module scales when used in a combined sample of children and older adults with FNP. Methods: Data were collected between December 2016 and December 2019. We conducted qualitative interviews with children and adults with FNP. FACE-Q data were collected from patients aged 8 years and older with FNP. Rasch measurement theory analysis was used to examine the reliability and validity of the relevant scales in the FNP sample. Results: Twenty-five patients provided 2052 qualitative codes related to appearance, physical, psychological, and social function. Many patient concerns were common across age. The field-test sample included 235 patients aged 8-81 years. Of the 13 scales examined, all 122 items had ordered thresholds and good item fit to the Rasch model. For 12 scales, person separation index values were ≥0.79 and Cronbach's alpha values were ≥0.82. The 13th scale's reliability values were ≥0.71. Conclusion: The FACE-Q Craniofacial module scales described in this study can be used to collect and compare evidence-based outcome data from children and adults with FNP.

X-rays had little value in diagnosing children's abnormal skull shapes, and primary care clinicians should refer concerns to specialist teams

Aim

This study examined the consensus between the primary care radiological diagnosis and specialist clinical diagnosis of abnormal skull shapes in children.

Methods

We performed a retrospective review of children treated at the National Paediatric Craniofacial Centre at Children's Health Ireland, Dublin, Ireland. Group 1 were referred by primary care colleagues concerned about suspected abnormal skull shapes from 1 January 2015 to 30 May 2017. These included cases where they sought specialist confirmation that the skull shape was normal. Group 2 underwent surgery for craniosynostosis from 1 January 2011 to 25 October 2017. The primary care skull X‐ray reports were examined for both groups to see whether they matched the specialist diagnosis.

Results

Group 1 comprised 300 children, and 59 (20%) had pre‐referral skull X‐rays. The primary care X‐ray reports and specialist diagnoses agreed in 44 (75%) cases, including 19 (43%) who had a normal skull shape. Group 2 comprised 274 children, and 63 (23%) had pre‐referral skull X‐rays. In this group, there was agreement in 41 (65%) diagnoses; however, the primary care X‐ray reports did not diagnose craniosynostosis for the remaining 22 (35%) children.

Conclusion

X‐rays were of little value in diagnosing abnormal skull shapes, especially craniosynostosis, and primary care clinicians should refer concerns to specialist teams.

ESPRAS Survey on Breast Reconstruction in Europe

BACKGROUND

 The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access.

MATERIALS AND METHODS

 A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature.

RESULTS

 A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported.

CONCLUSION

 This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions

BACKGROUND

The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales.

METHODS

Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity.

RESULTS

1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores.

CONCLUSION

The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

Surgical management of an odontogenic cutaneous fistula

A patient presented to our unit with a long history of a discharging skin infection on his left cheek, which came and went. He had been seen by numerous healthcare practitioners including his general practitioner, general dental practitioner and dermatologist, with no resolution. He was eventually diagnosed with an odontogenic cutaneous fistula (OCF), for which he underwent surgical management. The purpose of the study is to describe the diagnosis and surgical management of an OCF, from initial assessment through to postoperative review and discharge. Following surgical management of the OCF and treatment of the source of infection by dental extraction, the patient is no longer experiencing purulent discharge through his left cheek. The extraoral skin site of drainage at his left cheek has resolved completely, with minimal residual scarring. OCF can be managed by a number of different treatment modalities. The treatment of an OCF by surgical excision is presented.

"The historical timeline of cranioplasty"

Cranioplasty, defined as the reconstruction of cranial defects, not only offers protective effects with an aesthetically pleasing outcome, but also reverses the altered physiology post craniotomy and craniectomy. The journey of cranioplasty from its roots to the neoteric armamentarium depicts how enormously the innovation of surgical techniques have changed the face of plastic surgery.

Accelerating bone healing in vivo by harnessing the age-altered activation of c-Jun N-terminal kinase 3

We have recently demonstrated that c-Jun N-terminal kinase 3 (JNK3) is a key modulator of the enhanced osteogenic potential of stem cells derived from children when compared to those derived from adults. In this study, we formulated a JNK3-activator nanoparticle (JNK3*) that recapitulates the immense osteogenic potential of juvenile cells in adult stem cells by facilitating JNK3 activation. Moreover, we aimed to functionalize a collagen-based scaffold by incorporating the JNK3* in order to develop an advanced platform capable of accelerating bone healing by recruitment of host stem cells. Our data, in vitro and in vivo, demonstrated that the immense osteogenic potential of juvenile cells could be recapitulated in adult stem cells by facilitating JNK3 activation. Moreover, our results revealed that the JNK3* functionalized 3D scaffold induced the fastest bone healing and greatest blood vessel infiltration when implanted in critical-size rat calvarial defects in vivo. JNK3*scaffold fastest bone healing in vivo was associated with its capacity to recruit host stem cells to the site of injury and promote angiogenic-osteogenic coupling (e.g. Vegfa, Tie1, Runx2, Alp and Igf2 upregulation). In summary, this study has demonstrated the potential of harnessing knowledge of age-altered stem cell mechanobiology in order to develop a materials-based functionalization approach for the repair of large tissue defects.

Strengthening Plastic Surgery in Europe – ESPRAS Survey at ESPRAS European Leadership Forum (ELF)

Hintergrund Das Exekutivkomitee (ExCo) der ESPRAS hat im Oktober 2020 das erste ESPRAS European Leadership Forum (ELF) initiiert, um den internationalen Austausch zwischen den verschiedenen nationalen plastisch-chirurgischen Gesellschaften zu fördern und eine Plattform für die Bewältigung gemeinsamer Herausforderung bereitzustellen. Das vorgelegte Manuskript präsentiert die wichtigsten Ergebnisse und Schlussfolgerungen dieses Treffens.

Materialien und Methoden Mitglieder des Vorstands (Präsidenten, Vize-Präsidenten, Generalsekretäre) und Delegierte der nationalen Gesellschaften für Plastische Chirurgie diskutierten aktuelle Themen der Plastischen Chirurgie über das virtuelle Konferenzsystem Zoom (Zoom Video Communications, Inc.). Über Zoom erfolgte zudem eine Umfrage zu verschiedenen international relevanten plastisch-chirurgischen Themen.

Ergebnisse Die Durchführung ästhetischer Eingriffe durch Ärzte ohne Facharztweiterbildung in der Plastischen Chirurgie, sowie das Brustimplantat-assoziierte anaplastische großzellige Lymphom (BIA-ALCL) wurden als die wichtigsten internationalen Herausforderungen der Plastischen Chirurgie erkannt, für deren Bewältigung auf europäischer Ebene ein standardisiertes Vorgehen diskutiert wurde. Weiterhin wurden aktuelle Entwicklungen in der Weiterbildung junger Plastischer Chirurgen eruiert, wobei die Etablierung eines europäischen Fellowship Programms von der Mehrheit der Befragten stark befürwortet wurde. Strategien zur Einführung von europäischen Registern für freie Lappenplastiken, Implantate und für die Brustrekonstruktion wurden erörtert.

Schlussfolgerung Das ESPRAS ELF stärkt den internationalen Austausch und die europäische Einheit in der Plastischen Chirurgie. Ein weiteres virtuelles Webinar mit dem Thema „Strategien zur Stärkung und Verteidigung der Plastischen Chirurgie gegenüber anderen“ wurde für das Frühjahr 2021 terminiert.

Efficacy of temporomandibular joint arthroplasty and insertion of a Matthews device as treatment for ankylosis of the joint: a case series

Temporomandibular joint (TMJ) ankylosis is a condition in which bony or fibrous adhesion of the anatomical joint components results in loss of function. This is particularly distressing and debilitating for patients who struggle to maintain good oral hygiene, which results in additional pain, oral disease, and ultimately, a poor aesthetic profile. A retrospective chart review was carried out to document the cases of three patients who attended a single centre for the management of ankylosis of the TMJ. Consent for chart review and use of photographs was gained from each one. Charts were obtained, records reviewed, and each of the cases written up for presentation in a case series. All three underwent arthroplasty of the TMJ and insertion of Matthews devices (two patients unilateral, one bilateral). All were followed up postoperatively. They experienced significant improvements in vertical mouth opening which have been maintained to the present. The Matthews device allows movement and physiotherapy postoperatively whilst maintaining the surgically created space. This prevents impingement on the tissues placed between the glenoid fossa and mandible, and appears to prevent relapse and further ankylosis. To our knowledge, few studies to date have documented the use of the Matthews device following interpositional arthroplasty of the TMJ.

Caput membranaceum: A novel clinical presentation of ZIC1 related skull malformation and craniosynostosis

We report clinical and radiological features of a patient born with an isolated skull malformation of caput membranaceum and partial bicoronal craniosynostosis with a novel, de novo heterozygous missense variant in ZIC1 [NM_003412.3:c.1183C>G, p.(Pro395Ala)]. Caput membranaceum, or boneless skull, is a rare manifestation of skull ossification defect. It can result from an isolated, enlarged parietal foramina or it can present as part of skeletal dysplasia syndromes associated with poor mineralization such as hypophosphatasia, osteogenesis imperfecta type II, and Saethre-Chotzen syndrome. Their causative genes are well described. ZIC1, Zinc Finger protein of the cerebellum 1 (OMIM #600470) belongs to ZIC family genes, each encoding a Cys2 His2-type zinc finger domain-containing transcription factors. Recent studies have shown that pathogenic variants in ZIC1 have deleterious effect in developing human central nerves system and skull bone. ZIC1 related clinical conditions are reported and include cerebellum malformation, Dandy-Walker malformation, spinal dysraphism, microcephaly, and craniosynostosis with associated intellectual disability. To-date, there is no report of pathogenic variant in ZIC1 causing isolated caput membranaceum. Our observation adds to the clinical spectrum of ZIC1 related skull malformation.

The COVID-19 Pandemic and its Impact on Plastic Surgery in Europe - An ESPRAS Survey

The present article provides an overview of the current and expected effects of plastic surgery in Europe. It presents the experience of departments for plastic and reconstructive surgery, as evaluated by interviews with members of the Executive Committee (ExCo) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). The objective of this overview is to summmarise current information in our area of work and to make this accessible to a broad group of readers. As our knowledge is rapidly increasing during the current pandemic, it is evident that we can only provide a snapshot and this will inevitably be incomplete.

A Review Of Referral Patterns For Sagittal Synostosis In Ireland: 2008-2013

Sagittal synostosis (SS) is the commonest form of craniosynostosis. Children with sagittal synostosis in Ireland are treated in the National Paediatric Craniofacial Centre (NPCC) in Temple Street Children's University Hospital. This retrospective study analysed the correlation between referral patterns to the unit and age at operation. The notes of 81 patients referred over a 5-year period (April 2008 - April 2013) to the NPCC with non-syndromic SS were reviewed and demographics and referral information were recorded. Of 81 patients reviewed, 60 (74%) were referred before 6 months of age, while 21 (26%) had late referrals. Neonatologists referred 100% of infants before 6 months, paediatricians referred 71%, and GPs 64%. Later referral was associated with a more complex referral pathway, including multiple-steps of referral and unnecessary investigations. Improved clinician knowledge and emphasis on the importance of early referral may lead to a reduction in late referrals.

Identification of the mechanisms by which age alters the mechanosensitivity of mesenchymal stromal cells on substrates of differing stiffness: Implications for osteogenesis and angiogenesis

In order to identify the mechanisms by which skeletal maturity alters the mechanosensitivity of mesenchymal stromal cells (MSCs) and, the implications for osteogenesis and angiogenesis during bone formation, we compared the response of MSCs derived from children and skeletally-mature healthy adults cultured on soft and stiff collagen-coated polyacrylamide substrates. MSCs from children were more mechanosensitive, showing enhanced angiogenesis and osteogenesis on stiff substrates as indicated by increased endothelial tubule formation, PGF production, nuclear-translocation of YAP, ALP activity and mineralisation. To examine these mechanisms in more detail, a customised PCR array identified an age-dependent, stiffness-induced upregulation of NOX1, VEGFR1, VEGFR2, WIF1 and, of particular interest, JNK3 in cells from children compared to adults. When JNK3 activity was inhibited, a reduction in stiffness-induced driven osteogenesis was observed - suggesting that JNK3 might serve as a novel target for recapitulating the enhanced regenerative potential of children in adults suffering from bone degeneration.

STATEMENT OF SIGNIFICANCE

We investigated the age-associated changes in the capacity of MSCs for bone regeneration involving the mechanosensitive signalling pathways, which reduce the ability of adult cells to respond to biophysical cues in comparison to cells from children, who are still undergoing bone development. Our results offer new insights into the mechanobiology of MSCs and sheds new light on age-altered mechanosensitivity and, on why children have such an immense capacity to regenerate their skeletal system. We have identified the mechanisms by which skeletal maturity alters the mechanosensitivity of mesenchymal stromal cells and an age-dependent, stiffness-induced upregulation of a number of prominent genes including, most notably, JNK3 in children cells, thus suggesting its potential to promote enhanced bone repair.

Possible toxicity following embolization of congenital giant vertex hemangioma: case report

The authors describe the case of a 3-year-old boy with a giant congenital vertex hemangioma who underwent presurgical embolization with Onyx (ethylene-vinyl alcohol copolymer dissolved in dimethyl sulfoxide) and Glubran ( N-butyl-2-cyanoacrylate). This vascular tumor had no intracranial vascular communication as assessed by pre-embolization MRI and catheter angiography. All embolizations were performed by direct percutaneous injection. One week following the last embolization procedure the child presented with a 24-hour history of ataxia and extrapyramidal tremor. He was diagnosed with a possible immune-mediated reaction to Onyx or Glubran, which was treated with an urgent surgical excision of the hemangioma followed by intravenous administration of immunoglobulin and steroids. To the authors' knowledge, this is the first case of possible immune-mediated toxicity secondary to either Onyx or Glubran administration. This case highlights the need for awareness of potential toxic reactions to these embolic agents in the treatment of hemangiomas in the pediatric patient.

Bicoronal and metopic craniosynostosis in association with a de novo unbalanced t(2;7) chromosomal translocation

We report the case of a developmentally appropriate infant male with a de novo unbalanced chromosome translocation involving bands 2q32.1 and 7p21.3. The child was noted to have metopic and bicoronal craniosynostosis with closely spaced eyes, turricephaly, and flattening of the forehead. © 2016 Wiley Periodicals, Inc.

Cranial fasciitis located at the temporal region in a 2-year-old girl

INTRODUCTION

Cranial fasciitis is an exceedingly rare, benign, fibroblastic tumour of the skull of young children. It was first described in 1980 by Lauer and Enzinger as a subset of nodular fasciitis. There are fewer than 55 cases described in the literature.

CASE REPORT

We describe the presentation of a 2-year-old girl with a rapidly growing left temporal lesion, initially treated as an intramuscular haemangioma with propanolol. Following failure of response to this management, radiological and histological investigations indicated cranial fasciitis, and multidisciplinary surgery was undertaken via a bicoronal incision. Gross total resection was carried out, and the lesion was found to be adherent to but not infiltrating the dura. The petrous bone and zygomatic arch appeared destroyed, leaving a large temporal bony defect. This was repaired with a split calvarial graft from the outer table of the right parietal bone.

DISCUSSION

Histology confirmed a diagnosis of cranial fasciitis. She had an uneventful post-operative course and was discharged home well. A CT scan 8 months post-operatively showed no residual lesion and it was noted that the reconstruction had fully integrated and the zygomatic arch had reformed.

Current trends in simulation training in anesthesia: a review

Anesthesiology as a specialty has made numerous prescient commitments to better patient care. Physicians entering residency are reaching the zenith of their educational odyssey and primarily acquire knowledge and skill through active involvement. Simulation training and associated assessment offers a chance for active involvement to the learner. The goal of the training is to accelerate skill acquisition, improve skill retention and reduce the extinction of skills. Simulation training programs have been shown to increase the skill of anesthesiologists. This increase in skill is expected to translate to evidence of improved patient care. Direct evidence that simulation directly improves patient care continues to be difficult to establish. In the future, the intuitive benefit of simulation as a means to improve the safety and quality of patient care is likely to become established by clinical research.

Complete spontaneous regression in Merkel cell carcinoma

Merkel cell carcinoma is a rare, aggressive, cutaneous malignancy of the elderly with a generally poor prognosis. Like all skin cancers, its incidence is rising. A few reports of spontaneous regression have been published. The case of a 67-year-old female patient who presented with a cheek Merkel cell carcinoma is described. Following biopsy it underwent complete regression with no evidence of residual tumour in the excision specimen taken seven weeks later. The current knowledge of Merkel cell carcinoma and the other cases of spontaneous regression described in the literature are reviewed.

Free tissue transfer and deep vein thrombosis

Reconstruction of the post-oncologic defect of the lower limb frequently requires free tissue transfer and these often extensive bone and soft tissue resections can occasionally be compounded by the presence of a deep venous thrombosis (DVT). We describe two patients in whom free tissue transfer was attempted, following extensive resection of a sarcoma in the thigh. Both patients had been diagnosed with DVT prior to surgery and received therapeutic low molecular weight heparin preoperatively. In the first patient, flap failure occurred due to venous congestion initially resulting from poor flow in the reconstructed femoral vein and then thrombosis and failure of the vascular reconstruction. In the second patient the superficial venous system was used for successful microvascular anastomosis leading to survival of the flap. Therefore, patients undergoing lower extremity free tissue transfer who are at high risk of DVT, or when there is a clinical suspicion of DVT, thorough preoperative assessment of the deep and superficial venous system is warranted for reconstruction planning.

Non-syndromic trigonocephaly: surgical decision making and long-term cosmetic results

BACKGROUND

Surgical correction is often required for cosmetic correction of trigonocephaly. The purpose of this paper was to report the long-term aesthetic outcome as appreciated by the parents/patients themselves. The self-evaluation of cosmetic outcome after trigonocephaly correction has not previously been reported. The management and different surgical techniques utilized over a 16-year period are discussed.

MATERIALS AND METHODS

An observational study was undertaken of the clinical outcome, operative data, complications and cosmetic satisfaction of these trigonocephaly patients. The parents/child were asked to rate their satisfaction with the cosmetic outcome both in terms of head shape and scar appearance, on a five-point scale (excellent-5, very good-4, good-3, fair-2 and poor-1).

RESULTS

Sixty-three patients presented with non-syndromic trigonocephaly over the 16 years. Nineteen of 63 had a mild form of trigonocephaly and were managed conservatively. The remainder underwent surgical correction. Forty-two of 44 (95%) underwent fronto-orbital advancement with either barrel staving (26/44) or frontal bone rotation/re-modelling (16/44), with 2 of 44 having burring of the metopic ridge. Head shape rating was regarded as excellent in 25 of 63 (40%), very good in 18 of 63 (28%), good in 18 of 63 (28%) and fair in 2 of 63 (4%). Of those that underwent surgery, the scar was zigzag in 32 of 44 and straight in 12 of 44. Scar was rated as being excellent in 21 of 44 (48%), very good in 12 of 44 (28%) good in 11 of 44 (24%).

CONCLUSIONS

Metopic synostosis can result in varying degrees of severity. Milder forms can be treated conservatively, with more severe forms requiring both frontal bone re-modelling and fronto-orbital advancement. Surgical correction results in a high level of patient/parent satisfaction.

Intraocular Pressure Variations during Zygomatic Fracture Reduction and Fixation: A Clinical Study

BACKGROUND

The reduction of midface fractures has been associated with the rare but devastating complication of blindness. An increase in intraocular pressure is important in the mechanism of blindness in this setting. In this study, the authors assessed the intraocular pressure in patients who underwent zygomatic fracture reduction (with or without fixation).

METHODS

Using applanation tonometry, 29 patients underwent intraocular pressure measurements before, during, and after fracture fixation. The contralateral pressures were measured and used as the control.

RESULTS

There were 29 patients with a mean age of 35 years, and the mean time to surgery was 5 days. Preoperatively, all patients had normal intraocular pressures and normal visual acuity. All patients underwent a Gillies lift and 18 patients required open reduction and fixation of the frontozygomatic suture (n = 4) or the infraorbital margin (n = 2), and the remainder (n = 12) required fixation of both points. There was no statistically significant increase in the intraocular pressures following the reduction of uncomplicated zygomatic fractures. Statistically significant pressure reductions were noted immediately after reduction and fixation.

CONCLUSIONS

The surgical reduction of uncomplicated zygomatic fractures has no adverse effect on the intraocular pressure. It is the authors' opinion that adjunctive measures to reduce the pressures are unnecessary.

Sagittal synostosis: A review of 53 cases of sagittal suturectomy in one unit

The role of sagittal suturectomy in the treatment of scaphocephaly remains controversial. The purpose of this study was to report the experience of the National Craniofacial Unit in Dublin. This unit is the referral centre for the Republic of Ireland and serves a population of approximately 3.5 million. Quantitative assessments were made using radiographs and the pre- and postoperative cephalic index (CI) was calculated. Patients were asked to score their head shapes in a questionnaire. The mean age at surgery for the 53 children was 4.9 months with a mean follow up of 8 years. Pre- and postoperative radiographs were available for analysis in 24 patients. The mean preoperative CI was 65.3. There was a statistically significant increase in the CI postoperatively to 73.7. Seventy five per cent of children achieved a 'normal' CI and 86% scored their head shapes as good to excellent. There was no correlation between the age at surgery and the CI achieved. Although only one child was not happy with the shape of the head, the impression was that the CI correlated poorly with the clinical assessment of the head shape. There were no significant complications. We therefore conclude that the sagittal suturectomy is a safe procedure that has a limited but definite potential to improve the CI. This procedure still has a place in the surgical repertoire of the craniofacial surgeon dealing with scaphocephaly.

Behavioral, developmental, and educational problems in children with nonsyndromic trigonocephaly

OBJECT

The neurobehavioral morbidity of nonsyndromic trigonocephaly is incompletely understood. The purpose of this study was twofold: first, to assess the degree of developmental, educational, and behavioral problems in patients with nonsyndromic trigonocephaly and second, to establish whether patients with mild degrees of trigonocephaly had a lower frequency of such problems.

METHODS

The authors performed an observational study of the frequency of developmental, educational, and behavioral problems in 63 children with trigonocephaly at the National Craniofacial Centre in the Republic of Ireland between 1989 and 2004. The parents of the children completed a follow-up questionnaire. Thirty percent of patients had a mild form of trigonocephaly and were treated conservatively. The remainder underwent surgical correction. Speech and/or language delay was reported in 34% of the children. Thirty-three percent of the children needed to be assessed by a school psychologist, and 47% were receiving remedial or resource hours within the school system. Twenty percent of children required a special needs classroom assistant because of behavioral issues, and 37% of parents expressed concerns about their child's behavior. There were no statistically significant differences between children treated with surgery and those who had a mild deformity and were treated conservatively.

CONCLUSIONS

Nonsyndromic trigonocephaly is associated with a high frequency of developmental, educational, and behavioral problems. The frequency of these problems is not related to the severity of the trigonocephaly.

The Internal Mammary Artery Perforator Flap

The anatomic basis for the internal artery mammary perforator (IMAP) flap is described in this cadaveric study, together with a clinical case report. The IMAP flap is based on a single or double perforator of the internal mammary artery that is included in the pedicle for added length. It provides a very useful source of local tissue with skin of good texture and color for head and neck reconstruction and, being muscle free, is thin. With preservation of the anterior cutaneous branch of the intercostal nerve, the flap has the potential to be sensate. A large area can be covered, particularly if bilateral flaps are raised. The donor site can be closed directly. In selected patients, it offers an excellent option for use in head and neck reconstruction and should be considered as an alternative to the deltopectoral and pectoralis major flaps.

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

BACKGROUND

This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube.

METHODS

The charts of 14 patients were reviewed. All patients who had reconstruction of a pharyngoesophageal defect using an anterolateral thigh flap with a salivary bypass tube between 2001 and 2005 were included.

RESULTS

There were 10 men and 4 women (mean age, 61 years). There were no fistulae reported, and the stricture rate was 14%. Eleven patients achieved oral diet sufficient to have the gastrostomy or jejunal tube removed. The patients who had tracheoesophageal puncture for voice developed functional speech. There were no flap losses. However, problems with salivary tube migration in the early cases have led to technique refinement.

CONCLUSIONS

The low complication rates and the excellent functional outcomes make the anterolateral thigh flap in combination with a salivary bypass tube a viable option for reconstruction of these difficult defects.

Charpentier (1891) on the size-weight illusion

This paper offers background for an English translation of an article originally published in 1891 by Augustin Charpentier (1852-1916), as well as a summary of it. The article is frequently described as providing the first experimental evidence for the size-weight illusion. A comparison of experiments on the judged heaviness of lifted weights carried out by Weber (1834) and by Charpentier (1891) supports the view that Charpentier's work deserves priority; review of other experimental studies on the size-weight illusion in the 1890s suggests that the idea that the illusion depended on "disappointed expectations," especially with respect to speed of lift, became dominant almost immediately following the publication of Charpentier's paper. The fate of this and other ideas, including "motor energy," in 20th-century research on the illusion is briefly described.

The free gingival graft combined with the frenectomy: a clinical review

Abnormal labial frena are capable of retracting gingival margins, creating diastemas, and limiting lip movement. When these frena are present, the traditional frenectomy alone generally is successful. However, when the frenulum is extensive, the possibility of coronal reformation exists. Several procedures have combined the frenectomy with either a lateral pedicle flap, free papilla graft, or free gingival (mucosal) graft taken from the palate. Three case reports demonstrate the continued efficacy of the traditional palatal free gingival graft when the patient has an extensive frenulum or an area of minimal esthetic concern is involved.

Herbart's mathematical psychology

J.F. Herbart (1824/1890b) provided a mathematical theory about how mental ideas (Vorstellungen) in consciousness at Time 1 (T1) could compete, possibly driving 1 or more Vorstellungen below a threshold of consciousness. At T1 a Vorstellung A could also fuse with another, B. If at a later T2, A resurfaced into consciousness, it could help B to re-resurface into consciousness. This article describes the historical and mathematical background of Herbart's theory, outlines the mathematical theory itself with the aid of computer graphics, and argues that the theory can be applied to the modern problem of predicting recognition latencies in short-term memory (Sternberg's task; Sternberg, 1966)

A grouping interpretation of the modality effect in immediate probed recognition

In a series of experiments on immediate probed recognition for eight 3-digit numbers, it was shown that if the target modality involved auditory components and the effect of the similarity of the modality of the probe to that of the targets was controlled, unequivocal evidence was obtained for an auditory superiority effect (modality effect) for hit rates for the final items of the list. Moreover, false-alarm rates were significantly lower following targets with an auditory component than they were following silently seen targets. It is argued that this pattern of hits and false alarms is consistent with the idea that targets that have an auditory component yield memory representations that are better grouped as units than are those for targets that are only silently seen; in particular, if a new probe has a first digit that accidentally matches the first digit of a target item, it is more likely that the subject will mistakenly identify this new probe as old (give a false alarm) if the target has only been partially encoded because it was only silently seen.

A partial matching theory of the mirror effect in immediate probed recognition

A set of experiments on immediate probed recognition of digit triples is reported in which the variables were list length (five, six, seven, or eight triples), the probability that a probe was old (.33, .5, or .67), and whether the digit triples were presented with an auditory component or articulatory suppression. Previous work had suggested that the false alarm (FA) rate in this paradigm was lower when auditory information was available than when it was not; this observation had led to the development of the partial matching theory of immediate probed recognition, according to which FAs could arise not only as a result of unlucky guesses but also when new probes shared a first digit in common with a partially retained target triple. It was argued that partial memory representations were less likely following auditory presentation than following articulatory suppression. Partial matching theory is contrasted with the rational response theory, according to which all FAs are unlucky guesses; partial matching theory gave a better account of the present experimental data than did rational response theory. However, a logical relationship between the two theories was suggested, a consequence of which was that rational response theory could be modified to include partial matching in such a way as to account for mirror effects, not only in unusually difficult immediate probed recognition tasks, but also in the more commonly studied mixed test list paradigm involving words of high or low frequency.

The psychophysics of J-R-L Delboeuf (1831-1896)

Delboeuf's writings on psychophysics are little known nowadays. The object of this paper is to describe the psychological contributions of this eminent Belgian psychologist of the second half of the 19th century. A true pioneer of experimental psychology, his work on psychophysics began in 1865 at the University of Gand (Ghent) but was not published until 1873 and following years. His work in this area is characterised on the one hand by the adoption of a logarithmic law relating sensation strength to stimulus strength, but which differed from that of Fechner; and on the other hand by the utilisation of a psychophysical technique based on brightness contrast (now called the 'bisection method'). Even though, Delboeuf was classified by Fechner in his later writings as an opponent of his beliefs. Delboeuf was nevertheless one of his least-virulent critics and the only psychologist of that era to have adopted a logarithmic law. Delboeuf's work is not only of historic interest; his original ideas possess sufficient interest for present-day psychophysicists to reexamine them.

Transfusion management in pediatric and adolescent scoliosis surgery. Efficacy of autologous blood

STUDY DESIGN

A retrospective review of consecutive pediatric and adolescent patients who required posterior spinal fusion to correct scoliosis.

OBJECTIVES

To 1) measure the participation of pediatric patients in predeposit programs for autologous and directed blood donation 2) to assess the success of autologous predonation in preventing allogeneic blood use, 3) to determine whether transfusion indications differed between patients who received allogeneic blood and those who received autologous blood, and 4) to assess factors that predict transfusion requirements during scoliosis surgery.

SUMMARY OF BACKGROUND DATA

Authors of recent studies in adults have questioned whether transfusion of autologous blood is a cost-effective therapy when compared with the less-expensive alternative--transfusion of allogeneic blood. In children, the efficacy of autologous blood has not been assessed in a large population of surgical patients. In adults, the frequency of patient participation, the success of autologous donors in avoiding allogeneic transfusion, and the proportion of collected autologous units used during the perioperative period are measures used to establish the efficacy of autologous predonation programs.

METHODS

Hospital and clinic records for each patient who underwent posterior spinal fusion from September 1, 1989 through September 1, 1994 were reviewed. Blood bank consultation, autologous donation records, anesthesia records, surgical reports, and hospital records were reviewed. Seventy percent of patients (164 of 243) participated in autologous donation.

RESULTS

More than 90% of autologous donors successfully avoided receiving allogeneic blood. Patients with idiopathic scoliosis (n = 168) were more likely to participate in autologous donation (n = 144) and to avoid allogeneic blood (n = 135). Patients with neurologic causes of scoliosis more commonly used allogeneic or directed donation (56 of 75 patients). Nineteen patients with neuromuscular causes of scoliosis participated in autologous donation, but more than one half of this group (10 of 19 patients) required allogeneic blood in addition to autologous units.

CONCLUSIONS

Using measures of efficacy similar to those reported in studies of adults, autologous blood was found to be more effective in meeting the transfusion needs of pediatric patients who required posterior spinal fusion than in meeting those needs in adult surgical patients in previous studies.

Heparin detection by the activated coagulation time: a comparison of the sensitivity of coagulation tests and heparin assays

OBJECTIVE

Laboratory and point-of-care coagulation tests are frequently obtained to determine the presence of heparin after surgical procedures. The objective of this study was (1) to compare the sensitivity of the activated coagulation time (ACT), activated partial thromboplastin time (aPTT), protamine titration (Hepcon; HMS Medtronic, Hemotec, Englewood, CO), and thromboelastography (TEG) with heparin anticoagulation and (2) to determine how frequently residual heparin is present in the 24-hour period after heparin neutralization in cardiopulmonary bypass (CPB) patients.

DESIGN

A prospective study.

SETTING

A tertiary care university teaching center that performs more than 15,000 surgical procedures per year.

PARTICIPANTS

Vascular surgical (n = 17) and CPB (n = 29).

INTERVENTIONS

In vascular surgical patients, coagulation tests (ACT, protamine titration [Hepcon], and TEG) were obtained before and 90 minutes after heparin (50 to 60 U/kg IV) and compared with heparin concentration determined by factor Xa inhibition assay. In cardiac surgical patients, ACT and heparin concentrations were measured after anesthesia induction, during CPB, after protamine neutralization, and 3 as well as 6 hours after CPB. In addition to heparin concentrations and ACT measures, platelet counts, fibrinogen levels, and bleeding times were determined before and 3 and 24 hours after CPB.

MEASUREMENTS AND MAIN RESULTS

Ninety minutes after heparin, significant heparin concentrations were present in all vascular surgical patients, but ACT was elevated in only 4 of 17 patients. Protamine titration (Hepcon) correlated with the factor Xa inhibitory assay for heparin (r2 = 0.76). All 17 patients had an abnormal TEG (mean "R" time = 81 +/- 39 minutes) and a marked elevation of aPTT (135 +/- 35 sec [normal 22 to 33 seconds]) 90 minutes after heparin. In CPB patients, ACT did not correlate with heparin assays. After protamine neutralization of heparin in CPB patients, ACT returned to baseline despite the presence of heparin in 3 of 29 patients (0.22, 0.18, and 0.33 U/mL).

CONCLUSIONS

ACT was less sensitive to residual heparin anticoagulation than aPTT, TEG, and whole blood heparin assay. The whole blood heparin assay (Hepcon) provided sensitive and specific data about the presence of residual heparin. Despite the limitation of ACT in detecting heparin, the investigators found that residual heparin was not common in the period after uncomplicated CPB.

Postoperative care following single-stage laryngotracheoplasty

Single-stage laryngotracheoplasty (SSLTP) provides a method of correcting mild-to-moderate laryngotracheal stenosis while avoiding the risks of prolonged laryngeal stenting. Pediatric patients are orally intubated for 5 to 7 days postoperatively to ensure an adequate airway while edema resolves and healing begins. During this period, continuous neuromuscular blockade has been advocated in infants and young children to avoid endotracheal tube trauma to the fresh graft and potentially life-threatening accidental decannulation. Pulmonary atelectasis is the most common morbidity associated with prolonged neuromuscular blockade. Neuromuscular weakness also may follow prolonged paralysis and prolong hospitalization. This paper compares the postoperative course of 17 patients who underwent 18 SSLTP procedures by the senior author. The first 8 patients received continuous neuromuscular blockade in the early postoperative period. To reduce perceived morbidity, the last 9 patients were managed with a protocol that incorporated daily 4- to 8-hour "interruptions" of paralysis. Seven patients tolerated this protocol modification. As a group, these patients had less postoperative pulmonary atelectasis prior to extubation (p < .05) and were extubated sooner than patients receiving continuous neuromuscular blockade (p<.05) without compromising the surgical success of the procedure. Intermittent paralysis permitted for more accurate assessment of pain control and protected against accidental drug accumulation. Although self-extubation did not occur, diligent nursing care with adequate sedation and analgesia is necessary to avoid the risk of accidental extubation.

Analysis of changes in coagulation factors after postoperative blood loss in burn and non-burn patients

A prospective study of the postoperative kinetics of coagulation factors was undertaken in 23 burn patients and in six non-burn patients. All procedures resulted in a large volume blood loss. Fibrinogen, platelets and factors V, VIII and IX were measured serially. Burn patients returned all parameters to preoperative levels by 48 h postoperation, while non-burn patients showed a slower rate of return of platelets and factor V. This study suggests that burn patients may safely undergo re-operation at 48 h intervals for successive wound debridements if clinically necessary.

Anesthesia for magnetic resonance imaging in children: a low incidence of protracted post-procedure vomiting

STUDY OBJECTIVE

To determine the incidence and severity of vomiting in pediatric patients who have had inhalation anesthesia for magnetic resonance imaging (MRI).

DESIGN

A retrospective study of consecutive pediatric patients who had anesthesia for MRI.

SETTING

A large university hospital with an integrated clinic facility.

PATIENTS

234 children who required an MRI under general anesthesia over a 30 month period (July 1989 to February 1992).

MEASUREMENTS AND MAIN RESULTS

The duration of inhalation anesthesia was 105 +/- 33 minutes. Following anesthesia, the time to oral intake was 92 +/- 69 minutes. Eighteen patients (9%) experienced one or more episodes or emesis. In 14 of the 18 patients, vomiting occurred once and did not delay the intake of oral fluids or the discharge time from clinic when compared with the rest of the patients. Only one patient had frequent vomiting (more than three episodes), and all vomiting resolved spontaneously without anti-emetic therapy in less than eight hours following anesthesia.

CONCLUSIONS

Protracted post-procedure vomiting is an infrequent complication of inhalation anesthesia for MRI. Inhalation anesthesia may be a less important cause of postoperative vomiting than factors such as the type of operative procedure, use of opioids, or presence of postoperative pain.

Ligation of CD38 suppresses human B lymphopoiesis

CD38 is a transmembrane glycoprotein expressed in many cell types, including lymphoid progenitors and activated lymphocytes. High levels of CD38 expression on immature lymphoid cells suggest its role in the regulation of cell growth and differentiation, but there is no evidence demonstrating a functional activity of CD38 on these cells. We used stroma-supported cultures of B cell progenitors and anti-CD38 monoclonal antibodies (T16 and IB4) to study CD38 function. In cultures of normal bone marrow CD19+ cells (n = 5), addition of anti-CD38 markedly reduced the number of cells recovered after 7 d. Cell loss was greatest among CD19+ sIg- B cell progenitors (mean cell recovery +/- SD = 7.2 +/- 11.7% of recovery in control cultures) and extended to CD19+CD34+ B cells (the most immature subset; 7.6 +/- 2.2%). In contrast, CD38 ligation did not substantially affect cell numbers in cultures of normal peripheral blood or tonsillar B cells. In stroma-supported cultures of 22 B-lineage acute lymphoblastic leukemia cases, anti-CD38 suppressed recovery of CD19+ sIg- leukemic cells. CD38 ligation also suppressed the growth of immature lymphoid cell lines cultured on stroma and, in some cases, in the presence of stroma-derived cytokines (interleukin [IL] 7, IL-3, and/or stem cell factor), but did not inhibit growth in stroma- or cytokine-free cultures. DNA content and DNA fragmentation studies showed that CD38 ligation of stroma-supported cells resulted in both inhibition of DNA synthesis and induction of apoptosis. It is known that CD38 catalyzes nicotinamide adenine dinucleotide (NAD+) hydrolysis into cyclic ADP-ribose (cADPR) and ADPR. However, no changes in NAD+ hydrolysis or cADPR and ADPR production after CD38 ligation were found by high-performance liquid chromatography; addition of NAD+, ADPR, or cADPR to cultures of lymphoid progenitors did not offset the inhibitory effects of anti-CD38. Thus, anti-CD38 does not suppress B lymphopoiesis by altering the enzymatic function of the molecule. In conclusion, these data show that CD38 ligation inhibits the growth of immature B lymphoid cells in the bone marrow microenvironment, and suggest that CD38 interaction with a putative ligand represents a novel regulatory mechanism of B lymphopoiesis.

Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding

The purpose of this study was: 1) to define coagulation abnormalities in patients who receive red cell concentrates rather than whole blood for large volume blood loss (greater than 0.5 blood volume); and 2) to determine when coagulation abnormalities lead to increased bleeding in the massively transfused surgical patient. We studied 32 ASA physical status I or II patients (mean age 15.6 +/- 2.3 yr) who lost more than 50% of their blood volume during elective posterior spinal stabilization. Crystalloid solutions and packed red cell concentrates were used to replace blood and fluid losses. Invasive hemodynamic measures, urinary output, and serial hematocrit determinations were used to help maintain a constant intravascular volume and confirm the estimates of blood loss. The quality of hemostasis was assessed during operation. In 15 of the 32 patients, surgical hemostasis remained effective throughout posterior spinal fusion. A coagulation profile (prothrombin time [PT] and activated partial thromboplastin time [aPTT], platelet count, and fibrinogen) was measured at the conclusion of operation in these patients. In 17 patients, increased surgical bleeding as a result of decreased clot formation and increased bleeding from the wound was present. In these 17 patients at the time increased bleeding was diagnosed, hemostatic tests (PT, aPTT, fibrinogen, platelet count, and coagulation factor assays V, VIII, and IX) were obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatic duct obstruction treated with percutaneous antegrade insertion of a metal stent: report of two cases

Expanding metal stents were used to treat symptomatic pancreatic duct obstruction in two patients with chronic pancreatitis. Both patients initially underwent percutaneous external pancreatic duct drainage and then had metal stents inserted for internal drainage. Both patients remained asymptomatic, and the stents were patent during short-term follow-up periods of 6 and 9 months, respectively. Percutaneous insertion of metal stents, which can be performed to treat pancreatic duct obstruction after a trial of external drainage has been shown to relieve the patient's symptoms, should be considered as an alternative to endoscopic stent placement or surgical drainage.

Comparative hemodynamic depression of halothane versus isoflurane in neonates and infants: an echocardiographic study

The purpose of this study was to measure and compare the relationship of cardiovascular depression and dose during equal potent levels of halothane and isoflurane anesthesia in neonates (n = 19) (16.7 +/- 6.9 days) and infants (n = 54) (6.1 +/- 3.1 mo). Seventy-three children had heart rate, arterial blood pressure, and pulsed Doppler pulmonary blood flow velocity as well as two-dimensional echocardiographic assessments of left ventricular area and length recorded just before anesthesia induction. Anesthesia was induced by inhalation of increasing inspired concentrations of halothane or isoflurane in oxygen using a pediatric circle system and mask. During controlled ventilation, halothane and isoflurane concentrations were adjusted to maintain 1.0 MAC and then 1.5 MAC (corrected for age), and echocardiographic and hemodynamic measurements were repeated. A final cardiovascular measurement was recorded after intravenous administration of 0.02 mg/kg of atropine. All measurements were completed before tracheal intubation and the start of elective surgery. In neonates, 1.0 MAC concentrations of halothane and isoflurane decreased cardiac output (74% +/- 16%), stroke volume (75% +/- 15%), and ejection fraction (76% +/- 15%) similarly from awake levels. Decreases in cardiac output, stroke volume, and ejection fraction with halothane and isoflurane were significantly larger at 1.5 MAC (approximately 35% decreases from awake values) than at 1.0 MAC. Heart rate decreased significantly during 1.5 MAC halothane anesthesia (94% +/- 4%) but remained unchanged during isoflurane anesthesia. In infants, 1.0 MAC halothane and isoflurane decreased cardiac output (83% +/- 12%), stroke volume (78% +/- 12%), and ejection fraction (74% +/- 12%) when compared with awake measures.(ABSTRACT TRUNCATED AT 250 WORDS)

Application of digital signal processing to hearing aids: a critical survey

An audiologic rationale for the application of digital signal processing techniques to hearing aids is developed. These techniques enable complex processing beyond that possible in presently available analog aids. A critical survey of algorithms for filtering, nonlinear processing, noise reduction, speech enhancement, and feedback reduction is presented. The paper concludes with a discussion of practical considerations for implementation.