Atmospheric Chemistry of Perfluorinated Aldehyde Hydrates (n-CxF2x+1CH(OH)2, x = 1, 3, 4): Hydration, Dehydration, and Kinetics and Mechanism of Cl Atom and OH Radical Initiated Oxidation

Smog chamber/Fourier transform infrared (FTIR) techniques were used to measure k(Cl+C(x)F(2x+1)CH(OH)(2)) (x = 1, 3, 4) = (5.84 +/- 0.92) x 10(-13) and k(OH+C(x)F(2x+1)CH(OH)(2)) = (1.22 +/- 0.26) x 10(-13) cm(3) molecule(-1) s(-1) in 700 Torr of N(2) or air at 296 +/- 2 K. The Cl initiated oxidation of CF(3)CH(OH)(2) in 700 Torr of air gave CF(3)COOH in a molar yield of 101 +/- 6%. IR spectra of C(x)F(2x+1)CH(OH)(2) (x = 1, 3, 4) were recorded and are presented. An upper limit of k(CF(3)CHO+H(2)O) < 2 x 10(-23) cm(3) molecule(-1) s(-1) was established for the gas-phase hydration of CF(3)CHO. Bubbling CF(3)CHO/air mixtures through liquid water led to >80% conversion of CF(3)CHO into the hydrate within the approximately 2 s taken for passage through the bubbler. These results suggest that OH radical initiated oxidation of C(x)F(2x+1)CH(OH)(2) hydrates could be a significant source of perfluorinated carboxylic acids in the environment.

Family Mediators and Moderators of Treatment Outcomes Among Youths with Poorly Controlled Type 1 Diabetes: Results From a Randomized Controlled Trial

OBJECTIVE

To determine whether multisystemic therapy (MST) improved family relationships among youths with poorly controlled type 1 diabetes and whether these changes mediated MST effects on health outcomes. The moderating effect of family demographics on study outcomes was also assessed.

METHODS

A randomized controlled trial was conducted with 127 youths. Changes in general family relationships and caregiver support for diabetes care from baseline to treatment completion were assessed. Structural equation modeling (SEM) was used to test whether changes in family relations mediated improvements in frequency of blood glucose testing (BGT) and metabolic control.

RESULTS

MST increased support for diabetes care from both primary and secondary caregivers in two-parent but not in single-parent families. However, MST had the strongest effects on BGT and metabolic control in single-parent families. SEM did not support family relations as the mediator of improved BGT or metabolic control. Rather, MST had a direct effect on BGT for all participants. BGT mediated improvements in metabolic control among single-parent families.

CONCLUSIONS

MST improved family relationships for youths with diabetes in two-parent but not in single-parent families. Objective outcomes related to diabetes were strongest for single-parent families. Other processes such as increased parental monitoring may have been responsible for improved health outcomes among these families.

Use of multisystemic therapy to improve antiretroviral adherence and health outcomes in HIV-infected pediatric patients: evaluation of a pilot program

The purpose of the current study was to evaluate a clinical program that used multisystemic therapy (MST) to improve regimen adherence and health outcomes among children with perinatally acquired HIV who exhibited high viral loads in the absence of viral resistance. MST is an intensive, home-based family therapy previously used for the treatment of serious antisocial behavior. Goals of the study were to assess the feasibility of the MST program and its effectiveness for improving health outcomes among children who were treated. The study was conducted by retrospective chart review. Ninety percent of children and families referred to the program accepted the referral and 95% received a full dose of treatment, suggesting high program feasibility. Nineteen children participated in the program. General HIV knowledge on the part of caregivers improved significantly over the course of treatment. Although caregiver-reported adherence did not change, viral loads were found to significantly decrease from referral to the end of MST treatment, with the mean change reflecting a greater than 1 log10 decrease. The majority of children maintained these improvements during the 3 months after treatment termination. Results suggest that MST holds promise as an intervention for improving health outcomes among pediatric patients with HIV.

Achieving adherence to antiretroviral medications for pediatric HIV disease using an empirically supported treatment: a case report

Adherence to antiretroviral medication regimens among human immunodeficiency virus positive-children is influenced by a number of psychosocial factors including characteristics of the child, the caregiver, the medical team, and the medications. To address these factors requires treatment approaches that are flexible and comprehensive. One such treatment approach is multisystemic therapy (MST), an empirically supported intensive home-based treatment approach that has been proven effective with other chronic pediatric conditions. This case report describes the use of MST with a poorly adherent, perinatally infected adolescent.

Formation of C7F15COOH (PFOA) and other perfluorocarboxylic acids during the atmospheric oxidation of 8:2 fluorotelomer alcohol

Calculations using a three-dimensional global atmospheric chemistry model (IMPACT) indicate that n-C8F17CH2CH2OH (widely used in industrial and consumer products) degrades in the atmosphere to give perfluorooctanoic acid (PFOA) and other perfluorocarboxylic acids (PFCAs). PFOA is persistent, bioaccumulative, and potentially toxic. Molar yields of PFOA depend on location and season, are in the range of 1-10%, and are of the correct order of magnitude to explain the observed levels in Arctic fauna. Fluorotelomer alcohols such as n-C8F17CH2CH2OH appear to be a significant global source of persistent bioaccumulative perfluorocarboxylic acid pollution. This is the first modeling study of the atmospheric chemistry of a fluorotelomer alcohol.

Atmospheric chemistry of perfluoroalkanesulfonamides: kinetic and product studies of the OH radical and Cl atom initiated oxidation of N-ethyl perfluorobutanesulfonamide

Perfluorooctanesulfonamides [C8F17SO2N(R1)(R2)] are present in the atmosphere and may, via atmospheric transport and oxidation, contribute to perfluorocarboxylates (PFCA) and perfluorooctanesulfonate (PFOS) pollution in remote locations. Smog chamber experiments with the perfluorobutanesulfonyl analogue N-ethyl perfluorobutanesulfonamide [NEtFBSA; C4F9SO2N(H)CH2CH3] were performed to assess this possibility. By use of relative rate methods, rate constants for reactions of NEtFBSA with chlorine atoms (296 K) and OH radicals (301 K) were determined to be kCL) = (8.37 +/- 1.44) x 10(-12) and kOH = (3.74 +/- 0.77) x 10(-13) cm3 molecule(-1) s(-1), indicating OH reactions will be dominant in the troposphere. Simple modeling exercises suggestthat reaction with OH radicals will dominate removal of perfluoroalkanesulfonamides from the gas phase (wet and dry deposition will not be important) and that the atmospheric lifetime of NEtFBSA in the gas phase will be 20-50 days, thus allowing substantial long-range atmospheric transport. Liquid chromatography/tandem mass spectrometry (LC/MS/MS) analysis showed that the primary products of chlorine atom initiated oxidation were the ketone C4F9SO2N(H)COCH3; aldehyde 1, C4F9SO2N(H)CH2CHO; and a product identified as C4F9SO2N(C2H5O)- by high-resolution MS but whose structure remains tentative. Another reaction product, aldehyde 2, C4F9SO2N(H)CHO, was also observed and was presumed to be a secondary oxidation product of aldehyde 1. Perfluorobutanesulfonate was not detected above the level of the blank in any sample; however, three perfluoroalkanecarboxylates (C3F7CO2-, C2F5CO2-, and CF3CO2-) were detected in all samples. Taken together, results suggest a plausible route by which perfluorooctanesulfonamides may serve as atmospheric sources of PFCAs, including perfluorooctanoic acid.

Social ecological model of illness management in high-risk youths with type 1 diabetes

In this study, the authors tested a social ecological model of illness management in high-risk, urban adolescents with Type 1 diabetes. It was hypothesized that management behaviors would be associated with individual adolescent characteristics as well as family, peer, and provider relationships. Questionnaires were collected from 96 adolescents in poor metabolic control and their primary caregivers. Variables in each system were correlated with illness management. Multiple regression demonstrated that higher externalizing symptoms, poorer family relationships, lower satisfaction with providers, and greater age contributed to the variance in illness management. Internalizing symptoms and peer relationships were no longer significant in the model. Results support a social ecological model of illness management in high-risk youths. Interventions grounded in social ecological theory are discussed.

The effects of multisystemic therapy on diabetes stress among adolescents with chronically poorly controlled type 1 diabetes: findings from a randomized, controlled trial

OBJECTIVE

The goal of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Stress was also evaluated as a mediator of the effect of MST on adherence and metabolic control.

METHODS

A randomized, controlled trial was conducted with 127 adolescents with type 1 diabetes mellitus and chronically poor metabolic control (hemoglobin A1c levels of > or =8% at study enrollment and for the past 1 year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for approximately 6 months. Data were collected at baseline and at a 7-month posttest (ie, treatment termination). Changes in diabetes-related stress, as measured with a self-report questionnaire, were assessed. Structural equation models were used to test the degree to which changes in stress levels mediated the ability of the MST intervention to improve adherence and metabolic control.

RESULTS

In intent-to-treat analyses, participation in MST was associated with significant reductions in diabetes-related stress. Tests for moderation found no significant effects of age, gender, or ethnicity, which suggests that the intervention was equally effective in reducing diabetes stress for all participants. However, structural equation modeling did not provide support for diabetes stress as the mechanism through which MST improved health outcomes. Rather, the final model suggested that MST improved metabolic control through increased regimen adherence.

CONCLUSIONS

Intensive, home-based psychotherapy reduces diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Such stress reductions are important for the psychological wellbeing of a subset of youths with diabetes who are at high risk for future health complications.

Atmospheric Chemistry of CF3CH2CH2OH: Kinetics, Mechanisms and Products of Cl Atom and OH Radical Initiated Oxidation in the Presence and Absence of NOX

Relative rate techniques were used to study the kinetics of the reactions of Cl atoms and OH radicals with CF(3)CH(2)C(O)H and CF(3)CH(2)CH(2)OH in 700 Torr of N(2) or air diluent at 296 +/- 2 K. The rate constants determined were k(Cl+CF(3)CH(2)C(O)H) = (1.81 +/- 0.27) x 10(-11), k(OH+CF(3)CH(2)C(O)H) = (2.57 +/- 0.44) x 10(-12), k(Cl+CF(3)CH(2)CH(2)OH) = (1.59 +/- 0.20) x 10(-11), and k(OH+CF(3)CH(2)CH(2)OH) = (6.91 +/- 0.91) x 10(-13) cm(3) molecule(-1) s(-1). Product studies of the chlorine initiated oxidation of CF(3)CH(2)CH(2)OH in the absence of NO show the sole primary product to be CF(3)CH(2)C(O)H. Product studies of the chlorine initiated oxidation of CF(3)CH(2)CH(2)OH in the presence of NO show the primary products to be CF(3)CH(2)C(O)H (81%), HC(O)OH (10%), and CF(3)C(O)H. Product studies of the chlorine initiated oxidation of CF(3)CH(2)C(O)H in the absence of NO show the primary products to be CF(3)C(O)H (76%), CF(3)CH(2)C(O)OH (14%), and CF(3)CH(2)C(O)OOH (< or =10%). As part of this work, an upper limit of k(O(3)+CF(3)CH(2)CH(2)OH) < 2 x 10(-21) cm(3) molecule(-1) s(-1) was established. Results are discussed with respect to the atmospheric chemistry of fluorinated alcohols.

Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: a randomized controlled trial

OBJECTIVE

The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes.

RESEARCH DESIGN AND METHODS

A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA(1c) [A1C] > or =8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for approximately 6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed.

RESULTS

In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] = 16.75, P = 0.001) and 24-h recall interviews (F[1,125] = 6.70, P = 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] = 6.25, P = 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] = 4.03, P = 0.047).

CONCLUSIONS

Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes.

Multisystemic treatment of poorly controlled type 1 diabetes: effects on medical resource utilization

OBJECTIVE

To determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease rates of hospital utilization and related costs of care among adolescents with poorly controlled type diabetes.

METHODS

Thirty-one adolescents were randomly assigned to receive either MST or standard care. MST lasted approximately 6 months, and all participants were followed for 9 months. Rates of inpatient admissions and emergency room (ER) visits were calculated for a 9-month prestudy period and during the 9 months of study participation. The relationship between changes in inpatient admissions and changes in metabolic control was also investigated.

RESULTS

Intervention participants had a decreasing number of inpatient admissions from the baseline period to the end of the study, whereas the number of inpatient admissions increased for controls. Use of the emergency room did not differ. Related medical charges and direct care costs were significantly lower for adolescents receiving MST. Correlational analyses conducted with a subset of participants indicated that decreases in inpatient admissions were associated with improved metabolic control for MST but not control participants.

CONCLUSIONS

Findings suggest that MST has the potential to decrease inpatient admissions among adolescents with poorly controlled type 1 diabetes.

Atmospheric lifetime of fluorotelomer alcohols

Relative rate techniques were used to study the kinetics of the reactions of Cl atoms and OH radicals with a series of fluorotelomer alcohols, F(CF2CF2)nCH2CH2OH (n = 2, 3, 4), in 700 Torr of N2 or air, diluent at 296 +/- 2K. The length of the F(CF2CF2)n- group had no discernible impact on the reactivity of the molecule. For n = 2, 3, or 4, k(Cl + F(CF2CF2)nCH2CH2OH) = (1.61 +/- 0.49) x 10(-11) and k(OH + F(CF2CF2)nCH2CH2OH) = (1.07 +/- 0.22) x 10(-12) cm3 molecule(-1) s(-1). Consideration of the likely rates of other possible atmospheric loss mechanisms leads to the conclusion that the atmospheric lifetime of F(CF2CF2)nCH2CH2OH (n > or = 2) is determined by reaction with OH radicals and is approximately 20 d.

Case study: feasibility of multisystemic therapy as a treatment for urban adolescents with poorly controlled type 1 diabetes

OBJECTIVE

To determine the feasibility of using multisystemic therapy (MST), an intensive, home-based psychotherapy, to improve poor metabolic control among four adolescents with type 1 diabetes.

METHOD

A multiple baseline, repeated measures design was used. Blood glucose readings were obtained every 2 weeks during a baseline period, a 7-month intervention, and a month-long postintervention period. Glycosylated hemoglobin (GHb) was measured at baseline and follow-up and was contrasted between two participants who received MST and two participants who did not receive the intervention.

RESULTS

Intervention participants showed improvements in health status, as well as fewer hospitalizations and emergency room visits.

CONCLUSIONS

Findings from this case study suggest that MST has the potential to improve treatment adherence and metabolic control among teens with poorly controlled type 1 diabetes.

Metal cation complexation and activation of reversed CPyI analogues of CC-1065 and duocarmycin SA: partitioning the effects of binding and catalysis

The synthesis and examination of a novel class of reversed CPyI analogues of CC-1065 and the duocarmycins are described. Capable of a unique metal cation activation of DNA alkylation, these agents allowed the effects of the DNA binding domain (10(4)-fold increase in DNA alkylation rate and efficiency) to be partitioned into two components: that derived from enhanced DNA binding affinity and selectivity (10-80-fold) and that derived from a contribution to catalysis (250-5000-fold). In addition, the reversed enantiomeric selectivity of these sequence selective DNA alkylating agents provides further strong support for a previously disclosed model where it is the noncovalent binding selectivity of the compounds, and not the alkylation subunit or the source of catalysis, that controls the DNA alkylation selectivity.

Survey of future injectables

There has been an explosion in the technology of injectable filler materials for soft tissue augmentation of the face in the past decade. As a result, this is an exciting field and has provided surgeons who treat the aging face with newer, minimally invasive tools and techniques to augment the soft tissues of the face. In general, there are four classes of materials available for soft-tissue augmentation: synthetic, xenogeneic, homogeneic, and autogeneic. Moreover, within each class, these materials can be further divided, according to their longevity, into permanent materials, materials that last an undefined prolonged time, and temporary fillers. These products allow the surgeon and the patient to make choices that will give the best cosmetic results.

Thermolysis of fluoropolymers as a potential source of halogenated organic acids in the environment

Following the introduction of hydrochlorofluorocarbon (HCFCs) and hydrofluorocarbon (HFCs) gases as replacements for the ozone-destroying chlorofluorocarbons (CFCs), it has been discovered that HCFCs/HFCs can degrade in the atmosphere to produce trifluoroacetic acid, a compound with no known loss mechanisms in the environment, and higher concentrations in natural waters have been shown to be mildly phytotoxic. Present environmental levels of trifluooracetic acid are not accounted by HCFC/HFC degradation alone. Here we report that thermolysis of fluorinated polymers, such as the commercial polymers Teflon and Kel-F, can also produce trifluoroacetate and the similar compound chlorodifluoroacetate. This can occur either directly, or indirectly via products that are known to degrade to these haloacetates in the atmosphere. The environmental significance of these findings is confirmed by modelling, which indicates that the thermolysis of fluoropolymers in industrial and consumer high-temperature applications (ovens, non-stick cooking utensils and combustion engines) is likely to be a significant source of trifluoroacetate in urban rain water ( approximately 25 ng l-1, as estimated for Toronto). Thermolysis also leads to longer chain polyfluoro- and/or polychlorofluoro- (C3-C14) carboxylic acids which may be equally persistent. Some of these products have recently been linked with possible adverse health and environmental impacts and are being phased out of the US market. Furthermore, we detected CFCs and fluorocarbons-groups that can destroy ozone and act as greenhouse gases, respectively-among the other thermal degradation products, suggesting that continued use of fluoropolymers may also exacerbate stratospheric ozone-depletion and global warming.

The fate and persistence of trifluoroacetic and chloroacetic acids in pond waters

The environmental fate of trichloro-, dichloro-, and monochloroacetic acids, and trifluoroacetic acid was investigated using field aquatic microcosms and laboratory sediment-water systems. Trifluoroacetic acid was extremely persistent and showed no degradation during a one-year field study, though it appeared to undergo transient partitioning within an unknown pond phase as the temperature of the surroundings was reduced. Of the three chloroacetic acids, trichloro had the longest residence time (induction and decay) (approximately 40 d), dichloro the shortest (approximately 4 d), and monochloro an intermediate residence time (approximately 14 d). Laboratory studies suggest that the biodegradation of trichloro-, dichloro-, and monochloroacetic acids leads primarily to the formation of chloride and oxalic, glyoxalic, and glycolic acids, respectively.

Laser facial resurfacing: patient survey of recovery and results

OBJECTIVE

To determine patient satisfaction with the postoperative recovery period and surgical outcome after facial laser resurfacing.

DESIGN

Survey.

PATIENTS

Patients who underwent facial laser resurfacing by two of the authors (PAA or DAFE) between 1995 and 1996. Questionnaires were completed by 47 of 100 patients.

INTERVENTIONS

Facial laser resurfacing with the Sharplan CO2 laser and SilkTouch Scanner.

MAIN OUTCOME MEASURES

Questionnaire. Statistical analysis was generated from a 5-point analogue scale.

RESULTS

The overall side effects were moderate in severity, were well tolerated, and met the expectations of our patients. Redness was the most frequent side effect with an average duration of 3 months. Most patients returned to occupational and social activities at 2.5 weeks. Moderate lifestyle disruption was more frequent after full-face laser resurfacing than partial-face laser resurfacing. Excellent improvement was achieved for removal of fine wrinkles, improvement of skin quality, and sun-damaged skin. Good improvement was obtained for acne scarring and deep rhytids. Overall goals were attained in 89% of patients.

CONCLUSIONS

Laser resurfacing produced excellent results for fine rhytids, skin quality, and sun-damaged skin. Return to social and occupational activities may occur early in recovery with the use of camouflage make-up. Patient education and close follow-up are necessary in the postoperative period.

Intellectual, cognitive, and academic performance among sons of alcoholics, during the early school years: differences related to subtypes of familial alcoholism

BACKGROUND

Research on intellectual and cognitive functioning of children of alcoholics has been marked by inconsistency, with some studies unable to document deficits. This discrepancy may reflect the substantial heterogeneity found in the alcoholic population and among families of alcoholics. The current study sought to examine the effects of familial alcoholism subtypes on intellectual, cognitive, and academic performance in early school-aged sons of alcoholics.

METHODS

Subjects for the present study were 198 elementary-age boys who were participants in the larger MSU-UM Longitudinal Study. Familial alcoholism subtypes were determined based on fathers' alcoholism and antisocial personality disorder diagnoses. Intellectual functioning was measured with the Wechsler Intelligence Scale for Children-Revised (WISC-R); academic achievement was measured with the Wide Range Achievement Test-Revised. In addition, Mazes and Freedom from Distractability factor scores of the WISC-R were used to assess abstract planning and attention abilities.

RESULTS

Children of antisocial alcoholics (AALs) displayed the worst IQ and academic achievement compared with children of nonantisocial alcoholics (NAALs) and controls. In addition, children of AALs displayed relatively poorer abstract planning and attention abilities compared with children from control families. Regression analyses revealed that familial alcoholism subtype continued to account for variance in child intellectual ability even when other factors were excluded.

CONCLUSIONS

Findings indicate that children from AAL families are most susceptible to relative intellectual, cognitive, and academic deficits. The study further supports the proposition that familial risk characteristics (i.e., paternal alcoholism and antisociality) may serve as effective indicators of family risk for poor intellectual outcome among offspring as early as the elementary school years.

Laser facial skin resurfacing: discussion on erbium:YAG and CO2 lasers

There are two lasers for resurfacing. The erbium:YAG laser and the CO2 laser both have different physical and physiologic differences when striking the skin. Therefore, each laser gives a different result. This article reviews the use of the Sharplan Silktouch CO2 laser for 4 years and the erbium:YAG laser for 1 year. In the last year, we have performed 40 laser procedures with the erbium:YAG laser. Discussion ensues regarding the differences and similarities of the two lasers as well as the difficulties and complications.

Development of an 19F NMR method for the analysis of fluorinated acids in environmental water samples

This investigation was carried out to evaluate 19F NMR as an analytical tool for the measurement of trifluoroacetic acid (TFA) and other fluorinated acids in the aquatic environment. A method based upon strong anionic exchange (SAX) chromatography was also optimized for the concentration of the fluoro acids prior to NMR analysis. Extraction of the analyte from the SAX column was carried out directly in the NMR solvent in the presence of the strong organic base, DBU. The method allowed the analysis of the acid without any prior cleanup steps being involved. Optimal NMR sensitivity based upon T1 relaxation times was investigated for seven fluorinated compounds in four different NMR solvents. The use of the relaxation agent chromium acetylacetonate, Cr(acac)3, within these solvent systems was also evaluated. Results show that the optimal NMR solvent differs for each fluorinated analyte. Cr(acac)3 was shown to have pronounced effects on the limits of detection of the analyte. Generally, the optimal sensitivity condition appears to be methanol-d4/2M DBU in the presence of 4 mg/mL of Cr-(acac)3. The method was validated through spike and recovery for five fluoro acids from environmentally relevant waters. Results are presented for the analysis of TFA in Toronto rainwater, which ranged from < 16 to 850 ng/L. The NMR results were confirmed by GC-MS selected-ion monitoring of the fluoroanalide derivative.

Augmentation of the nasal spine area with tissue bone matrix sponge

OBJECTIVE

High-density tissue bone matrix (TBM) sponge is a homograft derived from human cadaver. It is reported to be osteoinductive. The objective of this paper is to measure the bone formation and cosmetic effect of TBM sponge implanted in the nasal spine area of patients undergoing rhinoplasty with retraction of this region and loss of nasal tip support.

DESIGN

The study was designed as a prospective trial.

SETTING

Patients were selected from private facial cosmetic practice and from public otolaryngology practice.

PATIENTS

Six patients were selected who had retraction of the nasal spine area and loss of tip support.

INTERVENTION

Patients had implantation of the TBM sponge in the nasal spine area either as a sole procedure or in conjunction with other rhinoplasty maneuvers.

MAIN OUTCOME MEASURES

Palpation was used to assess position, size and consistency of the implant. Cosmetic effect was assessed by computer imaging, which was used to measure nasolabial angle and tip projection. Bone formation was assessed by computed tomography scanning.

RESULTS

The implant could be palpated in all six patients at 1 month postoperatively, but at 3 months was either smaller or could not be felt. Nasolabial angle and tip projection were improved in all patients initially, but 3 months following surgery this cosmetic improvement was maintained in only two patients. At 3 months, CT scanning showed no evidence of bone formation.

CONCLUSION

The TBM sponge was not found to be osteoinductive or permanent when implanted in the nasal spine area and therefore is not a good implant in that region.

Chlamydia trachomatis infections in female military recruits

BACKGROUND

Asymptomatic genital Chlamydia trachomatis infections in women can lead to pelvic inflammatory disease, infertility, and ectopic pregnancy. To design a chlamydia-control program, we conducted a large survey of women in the U.S. military.

METHODS

From January 1996 through December 1997, urine samples from 13,204 new female U.S. Army recruits from 50 states were screened by ligase chain reaction for C. trachomatis infection. Information on potential risk factors was obtained by questionnaire. With multivariate analysis, we identified criteria for a screening program.

RESULTS

The overall prevalence of chlamydial infection was 9.2 percent, with a peak of 12.2 percent among the 17-year-old recruits. The prevalence was 15 percent or more among the recruits from five southern states. The following risk factors were independently associated with chlamydial infection: having ever had vaginal sex (odds ratio for infection, 5.9), being 25 years of age or less (odds ratio, 3.0), being black (odds ratio, 3.4), having had more than one sex partner in the previous 90 days (odds ratio, 1.4), having had a new partner in the previous 90 days (odds ratio, 1.3), having had a partner in the previous 90 days who did not always use condoms (odds ratio, 1.4), and having ever had a sexually transmitted disease (odds ratio, 1.2). A screening program for subjects 25 years of age or less (87.9 percent of our sample) would have identified 95.3 percent of the infected women.

CONCLUSIONS

Among female military recruits, the prevalence of chlamydial infection is high. A control program that screens female recruits who are 25 years old or younger with urine DNA-amplification assays has the potential to reduce infection, transmission, and the sequelae of chlamydial infection.

Anatomy of the motor innervation of the corrugator supercilii muscle: clinical significance and development of a new surgical technique for frowning

OBJECTIVE

This study was conducted to determine the motor innervation of the corrugator supercilii muscle and, based on this information, develop a new surgical technique to treat patients with hyperfunctional corrugator muscles with deep vertical glabellar creases.

METHOD

Microdissection of five fresh-frozen cadaveric heads was performed. Following this, patients presenting with a complaint of vertical glabellar creases (frown lines) due to hyperfunctional corrugator supercilii muscles were offered a new surgical technique to divide the nerve lateral to its entry into the corrugator supercilii muscle.

RESULTS

The motor innervation of the corrugator supercilii muscle is constant and predictable in its course. Patients treated with motor nerve neurotomy showed considerable weakening of the corrugator supercilii muscle function as determined by clinical testing; however, the nerve lysis did not affect the glabellar depressor muscles.

CONCLUSIONS

The anatomy of the motor nerve supply to the corrugator supercilii muscle is described. Lysis of the nerve appears to be safe, reliable, and effective in weakening the strength of the corrugator supercilii muscles and improving the appearance of vertical glabellar creases.

Facial rejuvenation with botulinum

Botulinum toxin type A (Botox) blocks the release of neurotransmitter acetylcholine at the presynaptic neuromuscular junction leading to an irreversible, but temporary muscular paralysis and weakness. This can produce a significant improvement of wrinkling in the upper face caused by the actions of the facial muscles. A prospective clinical study representing a 15-month experience with this new technique is presented. Patient selection and evaluation, classification of animation lines, techniques, results, and complications are discussed.

The carbon dioxide laser. An alternative for the treatment of actinically damaged skin

BACKGROUND

The treatment of complex and diffuse actinic keratoses involving the face presents a problem in that they frequently recur despite traditional treatment modalities. The carbon dioxide (CO2) laser is an effective method for resurfacing actinically damaged facial skin.

OBJECTIVE

The purpose of this study is to show the usefulness of the CO2 laser for the treatment of actinically damaged skin in patients with proven actinic keratoses and squamous cell carcinoma in situ of the face.

METHODS

In an office surgery setting, the Sharplan 1030 or 40C CO2 laser with the SilkTouch flashscanner attachment was utilized to treat various regions of the face in 14 patients.

RESULTS

All patients were satisfied with the aesthetic outcome of their laser procedures and no clinical evidence of residual or recurrent lesions have been noted. There were no long-term complications reported.

CONCLUSIONS

Based on this preliminary report, the CO2 laser appears to be an excellent alternative for the surgical treatment of premalignant lesions of the face and can be used effectively without significant complications.

Cosmetic upper-facial rejuvenation with botulinum

OBJECTIVE

This study was conducted to evaluate the cosmetic use of botulinum toxin type A (Botox), which blocks the release of acetylcholine at the presynaptic neuromuscular junction leading to an irreversible, but temporary chemical denervation muscular paralysis and weakness. This produces a significant cosmetic improvement of wrinkling in the upper face due to hyperfunctional animation.

METHOD

A prospective clinical study representing our experience with this new technique is presented. Patient selection and evaluation, classification of animation lines, techniques, results and complications are discussed. In a 15-month period, 23 patients with seven anatomic sites were injected. Twenty-three patients had the lateral aspect and the inferior aspect of their squint lines injected, and 26 patients had their glabellar frownlines injected.

RESULTS

Significant improvement occurred to the average depth and length of the glabellar frownlines. The subjective improvement by the patients was also significant. Regarding the crow's feet, the lateral canthal lines showed more improvement than the inferior lateral canthal lines because the latter has a greater component of zygomaticus major and minor muscle, which contributes to the inferior lateral squint line.

CONCLUSION

Botox is a safe, easy-to-use, effective modality for the temporary elimination of hyperfunctioning upper-facial muscles.

The role of family influences in development and risk

Various influences in the family environment contribute to children of alcoholics' (COAs') risk of developing alcoholism and other mental health problems. These risk factors include alcohol-specific influences, which selectively predict alcohol problems, and alcohol-nonspecific influences, which predict a variety of mental health problems. Alcohol-specific family influences include modeling of parental drinking behavior, development of alcohol expectancies, and the family's ethnic background. Parental psychopathology, the family's socioeconomic status, and general family psychopathology are examples of alcohol-nonspecific risk factors, which increase the COA's risk of behavior disorders as well as of alcoholism. The families of COA's who are at highest risk for alcoholism and other mental health problems are characterized by the aggregation of numerous alcohol-specific and alcohol-nonspecific risk factors.

The Development of Alcoholic Subtypes: Risk Variation Among Alcoholic Families During the Early Childhood Years

Lifetime differences in antisocial behavior among alcoholic men historically have been useful in distinguishing alcoholic subtypes. However, the usefulness of this subtyping strategy for identifying differences in families that may put offspring at risk for developing later alcoholism has not been previously documented. Findings from a prospective study on the development of vulnerability for alcoholism among (initially) preschool-age children showed that children from families with antisocial alcoholism differ on a number of indicators of child risk, including measures of risky temperament, externalizing behavior problems, and hyperactivity. Risk differences among children from these family subtypes appear to be sustained into middle childhood. Differences between nonantisocial alcoholic families and nonalcoholic control families were less distinguishable in both early and middle childhood.

Expanded pectoralis major myocutaneous flaps in head and neck surgery

The use of tissue expanders in head and neck surgery has been popularized since the early 1980s. Tissue expanders are currently used in nasal reconstruction, alopecia, and other head and neck defects when there is inadequate tissue or when transposition of a local flap would create a significant donor-site deformity. Occasionally, situations in head and neck reconstruction arise where local, regional, or free flaps are not available or sufficient for head and neck reconstruction. In these situations, the use of controlled tissue expansion can be employed for enlarging myocutaneous flaps for head and neck reconstructive surgery. Two cases illustrated here present the principles and techniques of this means of reconstruction.

A simplified approach to otoplasty

Outstanding or protruding ears are relatively common in the pediatric otolaryngology population. We propose a method of otoplasty that is simple to use and provides safe and predictable results. The technique of otoplasty is outlined in detail with emphasis on creation of a desired antehelical fold with the use of modified Mustarde sutures as well as modifications of the lobule and the need for conchal set-back.

Survival of patients with acquired immune deficiency syndrome and disseminated Mycobacterium avium complex infection with and without antimycobacterial chemotherapy

The contribution of disseminated Mycobacterium avium complex (DMAC) infection to the morbidity and mortality of patients with acquired immune deficiency syndrome (AIDS) is unclear. Previous studies that suggested the decreased survival of patients with AIDS and DMAC had incomplete information on patient immunologic status and follow-up. We studied patients with AIDS and DMAC and compared their survival with that of AIDS patients without DMAC but with other comparable risk factors for survival. Case and control subjects were similar in terms of CD4 cell count, prior AIDS status, history of antiretroviral therapy, history of Pneumocystis carinii prophylaxis, and year of diagnosis. A group of 39 patients with untreated DMAC had significantly shorter survival, mean of 5.6 +/- 1.1 months (median 4 months), than 39 matched patients with AIDS but without DMAC, mean 10.8 +/- 1.3 months (median 11 months, p less than 0.0001). The survival of 16 additional patients with DMAC who received antimycobacterial therapy, mean of 9.5 +/- 1.4 months (median 8 months), was not significantly shorter than that of an additional 16 matched control subjects, mean 11.7 +/- 1.9 months (median 11 months, p = 0.58). Patients with treated DMAC survived significantly longer than those with untreated DMAC (p less than 0.01). We conclude that untreated DMAC significantly shortens survival. Moreover, these results indicate that patients with DMAC who receive antimycobacterial therapy do not experience the shortened survival seen in untreated DMAC.

Evaluation of conscious sedation in facial plastic surgery

Local anesthesia and conscious sedation are important aspects of facial plastic surgery. The safe and effective application of these techniques is important to produce happy, satisfied patients as well as good surgical results. Local anesthetic and sedative drugs will be discussed with respect to their mechanisms of action, doses, toxicities and appropriate selection. We will discuss the techniques we have developed using fentanyl and Versed and our evaluation of their effectiveness. Twenty sequential facial plastic surgical patients undergoing a total of 30 procedures will be reviewed. The average dose of fentanyl was 70 mcg and Versed was 3.1 mg. Significant amnesia occurred in 60% of patients, 80% experienced little or no discomfort and 90% would have no hesitation to undergo another procedure with similar anesthesia and sedation.

The ideal tissue adhesive in facial plastic and reconstructive surgery

In this paper we have reviewed cutaneous wound closure in facial plastic and reconstructive surgery using two different tissue adhesives: (1) Fibrin glue (Tisseel), and (2) N-butyl-2-Cyanoacrylate (Histoacryl Blue). Fibrin glue was used on 23 patients: eight lower blepharoplasties, eight hemi-facelifts, five mid browlifts and seven facial reconstructive procedures. Histoacryl glue was used in 108 blepharoplasty incisions, 30 facelift incisions, 21 submental incisions for liposuction, and 19 local flaps for facial reconstructive procedures. Comparison was made of the adequacy of bonding, cosmetic result of the incision, ease of use and cost. The results of our experience with tissue adhesives indicate the use of fibrin glue mainly on the undersurface of flaps. We think histoacryl glue is the ideal tissue adhesive for surface cutaneous wound closure in regards to safety, reliability, tensile strength and cost effectiveness.

A prospective study of genital infections in a family-planning clinic. 2. Chlamydia infection--the identification of a high-risk group

During a study of genital infection in inner-city family-planning patients we examined 452 women for Chlamydia trachomatis. The prevalence of infection was 7.3%. There was no significant difference between patients attending because of genital symptoms and those who were attending for routine family-planning advice. Infection was found to be correlated with five main demographic parameters; age less than 25, no stable partnership, hormonal contraception, nulliparity and West Indian Ethnic origin. Using these parameters a simple scoring system was devised which allowed a high-risk population to be defined in whom screening would be economically justified.

The effect of facial animation on the aging upper half of the face

Sixty patients, ranging in age from 29 to 74 years, were studied for the effect of animation of the upper half of the face on the aging features. Patients were divided into three categories according to the dominant behavioral pattern: brow lifters, frowners, and squinters. Brow ptosis was accentuated laterally in the squinters and medially in the frowners. The brow-lifter group showed more uniform displacement of the eyebrow. The coarse wrinkles or the animation lines also correlated well with the animation pattern. These patterns are acquired in childhood and remain subconsciously in effect throughout adult life and therefore have a significant effect on brow ptosis.

Fibrin glue in facial plastic and reconstructive surgery

Fibrin glue has gained extensive use in Europe in the past decade but remains fairly new to North America. Fibrin glue physiology, its historical background, experimental findings, its present uses and the question of safety are addressed. Results of its use in facial plastic and reconstructive surgery at the Toronto Western Hospital are presented. The authors conclude that fibrin glue is a safe bioadhesive and sealant. It is an excellent adjunct but not a substitute for good surgical techniques.

Use of radionuclide scanning in the preoperative estimation of pulmonary function after pneumonectomy

Twenty eight patients with bronchial carcinoma were studied before pneumonectomy. Measurement of spirometric indices, static lung volumes, transfer factor (TLCO), and transfer coefficient (KCO) was undertaken before and four months after pneumonectomy. Fourteen of the patients also performed a symptom limited progressive exercise test on a cycle ergometer before and four months after pneumonectomy. All patients had standard xenon-133 ventilation and technetium-99m perfusion scans performed before operation. Eleven patients had krypton-81m ventilation scans in addition. Significant correlations were seen between changes in FEV1, TLCO and KCO and the preoperative function of the resected lung as determined by percentage preoperative perfusion to that lung (p less than 0.001). There were mean decreases in FEV1 of 22% and in vital capacity (VC) of 28.7% predicted. Estimation of postoperative FEV1 from the preoperative values showed equally good agreement with measured postoperative values whether 99mTc perfusion or 81mKr ventilation scans were used in the 11 patients in whom both scans were available. Significant correlations were seen between change in maximum exercise ventilation (VEmax) or maximum oxygen uptake (VO2max) after pneumonectomy and percentage preoperative perfusion to the resected lung (p less than 0.001). Estimation of postoperative maximum ventilation and maximum oxygen uptake from the postoperative values on the basis of 99mTc perfusion scans showed good agreement with observed values. Perfusion scans are useful in estimating not only the changes in spirometric indices that follow pneumonectomy for bronchial carcinoma but also changes in carbon monoxide transfer and exercise capacity.

Surgical treatment of acne scarring: non-linear scar revision

Non-linear scar revision techniques involve levelling facial skin. Classification as to the nature of the pitting allows the surgeon to select techniques to improve the facial cosmetic appearance. The types of intradermal pitting and subcutaneous atrophy along with nodular scarring produce the lack of levelling and the depression that the patients want corrected. The useful modalities available to level facial skin are dermal levelling, injectable substances, dermal punch grafting, excision and facelifting. The selection of these techniques is dependent on the above classification and the patient's desire for improvement.