Comparison of personality styles between students enrolled in osteopathic medical, pharmacy, physical therapy, physician assistant, and occupational therapy programs.
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Adult↗
Biomedical subjects
S R Cohen
Publications and source records attributed to S R Cohen.
Endoscopic pediatric plastic surgery.
Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been to date no reports of its use in the pediatric population. Because of its minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal in this age group. Herein we present our initial experience with endoscopic pediatric plastic surgery. From February 1995 to December 1995, 41 patients were treated utilizing 5-mm and 10-mm endoscopes at Scottish Rite Children's Medical Center, Atlanta, GA. There were 19 males and 22 females. The mean age at surgery was 5.6 years (range, 7 months-15 years). The most common types of procedures performed were insertion of tissue expanders (N = 19), excision of facial dermoids (N = 7), torticollis release (N = 5), and excision of vascular lesions (N = 4). The remaining 6 patients underwent a variety of reconstructive procedures. The complication rate in the tissue expander group was 3 out of 39 expanders inserted (9.5%), and consisted of infection (N = 2) and rupture (N = 1). In the dermoid group, complications consisted of wound infection requiring reoperation (N = 1), and transient frontal paresis (N = 1). One patient in the hemangioma group had an incomplete resection necessitating open excision. The remaining patients all had satisfactory outcomes with no complications. The majority of the procedures were done on an outpatient basis. These results suggest that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds with complication rates that are comparable to those of conventional surgical treatment.
Adolescent↗
Age-related outcomes of sleep apnea surgery in infants and children.
This study was designed to determine whether age at the time of surgery is an important influencing factor on outcomes following surgical correction of severe refractory obstructive sleep apnea (OSA) in infants and children. Data were collected prospectively on 55 children, all with severe OSA refractory to conservative medical and surgical measures, who underwent combinations of soft-tissue and skeletal procedures aimed at relieving their airway obstruction. The study population was subdivided for analysis into three groups based on age at the time of surgery (> 36 months, > 12 to < 36 months, and < or = 12 months). Each child was assessed for clinical outcomes, polysomnography results, and complications. Children in the > 36 months group demonstrated a significant improvement in respiratory disturbance index (RDI), apnea index, and lowest overnight oxygen saturation postoperatively. Only RDI improved significantly in the > 12 to < 36 months group. Although there was a trend toward improvement in the respiratory indices for the children < or = 12 months of age, they had a significantly longer intensive care and hospital stay, a greater mean number of extubation attempts, and the highest surgical failure rate (29%). Other complications such as infection, atelectasis, or temporary postoperative nasopharyngeal tube dependence occurred most frequently in the > 36 months group. Surgical management of severe refractory OSA in children age < or = 12 months is more difficult and less likely to succeed. The reasons for this are discussed and recommendations for management are given.
Adolescent↗
Down syndrome: identification and surgical management of obstructive sleep apnea.
To date, a paucity of information is available on the optimal management of obstructive sleep apnea in Down syndrome, which may have particularly important implications in this already vulnerable patient population. The objective of this study was to evaluate prospectively the results of a new surgical approach for the treatment of obstructive sleep apnea. Patients with Down syndrome and obstructive sleep apnea underwent preoperative and postoperative polysomnography and clinical and radiologic evaluation to determine prospectively the efficacy of sleep apnea surgery. Statistical testing of apnea index, respiratory disturbance index, and lowest oxygen saturation were compared by means of paired t tests. Seven children (five boys, two girls) from 3 to 12 years of age were subjected to a management protocol that included an aggressive surgical approach to the treatment of obstructive sleep apnea. Clinical symptoms and signs of obstructive sleep apnea, apnea index, respiratory disturbance index, lowest oxygen saturation, and surgical morbidity were the main outcome measures. Surgical treatment consisted of a combination of soft-tissue and skeletal alterations including tongue reduction (n = 6), tongue hyoid advancement (n = 4), uvulopalatopharyngoplasty (n = 7), and maxillary or midface advancement (n = 2). Polysomnography was obtained preoperatively and postoperatively in six patients. One patient was intubated preoperatively. Mean preoperative apnea index and respiratory disturbance index were 34.00 and 52.46 compared with mean postoperative values of 1.62 and 6.46, respectively. Clinically, all patients were improved symptomatically in terms of snoring, noisy breathing, and oxygen requirements. The one patient who had been intubated preoperatively for respiratory failure was extubated successfully but later developed recurrent tricuspid regurgitation and was found to have fixed pulmonary hypertension with cor pulmonale. This patient represented the only treatment failure and underwent tracheostomy. An aggressive surgical approach aimed at correcting all anatomic abnormalities associated with upper airway obstruction was applied successfully to the treatment of obstructive sleep apnea in Down syndrome. We suggest periodic polysomnography in patients with Down syndrome, especially if there is unexplained deterioration in mental capacity or other signs and symptoms of obstructive sleep apnea. Surgical treatment should address both the soft-tissue abnormalities and the skeletal deformities such as midface retrusion. Preoperative cardiac ultrasonography is important to determine the presence of right-sided heart failure, which may be an indication for cardiac catheterization to determine pulmonary venous pressures.
Child↗
Surgical treatment of obstructive sleep apnea in neurologically compromised patients.
Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.
Adenoidectomy↗
Maxillary-midface distraction in children with cleft lip and palate: a preliminary report.
A miniature system of distraction devices has been employed for maxillary-midface advancement in two children with cleft lip and palate, class III malocclusion, and associated midfacial hypoplasia. The devices are made with commercially available palatal expansion screws linked to rigid fixation plates. A midfacial osteotomy is used, and distraction is begun on the third postoperative day. In the first child, a 7-year-old boy, the midface was distracted 11 mm sagittally and 4 mm inferiorly. In the second patient, a 4 1/2-year-old girl with unilateral cleft lip and palate and midfacial retrusion, an 11-mm distraction was carried out in the vertical and sagittal direction. There were no complications, and none of the devices failed. Maxillary-midfacial distraction osteogenesis to correct severe maxillary-midfacial hypoplasia in children with clefts and other craniofacial disorders permits early intervention with potentially less invasive techniques than are currently available.
Bone Lengthening↗
A longitudinal, statistical study of reoperation rates in craniosynostosis.
A prospective, statistical study of reoperation rates was done in the treatment of 167 consecutive children with nonsyndromic and syndromic craniosynostosis over a 6-year period at Scottish Rite Children's Medical Center in Atlanta, Georgia. Mean length of follow-up was 2.8 years, with a range of 3 months to 6 years. Reoperation equal to or exceeding the magnitude of the original procedure occurred in 7 percent of cases. Multiple regression analysis revealed several factors associated with reoperation: Females and children with syndromic synostoses were more likely to require reoperation. Total reoperation rates for syndromic and nonsyndromic synostoses were 27.3 and 5.9 percent, respectively. Age at initial surgery, length of operation, and estimated blood loss did not predict a higher reoperation rate.
Child↗
History of the American Society of Maxillofacial Surgeons: 1947-1997.
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History, 20th Century↗
The use of porous granular hydroxyapatite in secondary orbitocranial reconstruction.
The search for the ideal bone-graft substitute has been the focus of many research and clinical studies. Hydroxyapatite is one such material that combines osseointegration with maintenance of implant volume and excellent durability. We present our experience in 29 patients ranging in age from 3 to 22 years (mean age 10.5 years) who underwent secondary orbitocranial reconstruction of large contour defects utilizing porous granular hydroxyapatite. Follow-up ranges from 6 to 72 months (mean 30 months). Indications for secondary surgery included residual bony contour defects of the frontal bone, temporal areas, and superior orbital rims that were present 12 months or more after initial surgery. There was one infection secondary to a chronic seroma necessitating removal of the porous hydroxyapatite, and one patient required revision for underfilling and another for overfilling. Excellent permanent contour improvement was obtained with a smooth skin surface in the remainder of our patients. The contour corrections have been long lasting, without evidence of porous hydroxyapatite resorption or migration.
Biocompatible Materials↗
Adult Still's disease presenting as serum sickness.
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Adult↗
Validity of the McGill Quality of Life Questionnaire in the palliative care setting: a multi-centre Canadian study demonstrating the importance of the existential domain.
This study was carried out in eight palliative care services in four Canadian cities. A revised version of The McGill Quality of Life Questionnaire (MQOL) is compared to a single-item scale measuring overall quality of life (SIS), and the self-administered version of the Spitzer Quality of Life Index (SA-QLI), to obtain evidence of validity. MQOL total score predicts SIS better than does SA-QLI, although much of the variance remains to be explained. The results of principal components analysis of data using this revised version of MQOL are similar to those from previous MQOL studies with different patient populations. The MQOL subscales, constructed on the basis of principal components analysis, demonstrate acceptable internal consistency reliability. The MQOL measures reflecting physical well-being and existential well-being are important for predicting SIS.
Humans↗
Velopharyngeal incompetence as the presenting symptom of malignant brainstem tumor.
OBJECTIVE: When a patient presents with velopharyngeal incompetence (VPI) without an obvious structural or neurologic cause, the clinician is faced with a diagnostic challenge. We present an 11-year-old male with a long history of VPI who had been referred to our institution for evaluation and treatment. RESULTS: Detailed clinical examination and work-up revealed a malignant brainstem tumor. The presenting symptoms of breathiness associated with VPI had been overlooked by several different clinicians in the past. The patient successfully underwent a sphincter pharyngoplasty. CONCLUSIONS: A careful neurologic examination with special attention to the cranial nerves is necessary to identify subtle neurologic deficits and avoid delay in diagnosis. Differential diagnosis of neurogenic VPI is discussed.
Brain Neoplasms↗
Acitretin therapy is effective for psoriasis associated with human immunodeficiency virus infection.
OBJECTIVE: To determine the safety, tolerability, and effectiveness of a newer retinoid, acitretin, as monotherapy for psoriasis associated with human immunodeficiency virus infection (PS-HIV). DESIGN: Pilot investigation. SETTING: An academic medical center. PATIENTS: Eleven patients selected from volunteers with PS-HIV were enrolled in a 20-week treatment protocol. Two patients discontinued participation in the study because of worsening psoriasis; a third patient was unable to continue treatment after having a myocardial infarction, presumably unrelated to acitretin therapy. INTERVENTION: Each patient received an optimized dose of acitretin during the period of observation. Clinical and laboratory assessments were performed every 2 weeks during the trial. MAIN OUTCOME MEASURES: The Psoriasis Area and Severity Index was used to assess the clinical response to treatment. To monitor for toxic drug effects, a panel of laboratory parameters, including complete blood cell count, biochemistry profile, urinalysis, HLA typing, skin biopsy for histological examination, and T-cell counts, was performed. RESULTS: Six (54%) of 11 patients with PS-HIV achieved good to excellent responses using acitretin monotherapy. Four patients (36%) achieved complete clearing. There was no evidence of a correlation between the pretreatment measures of immunosuppression and the therapeutic response. Parameters of immunosuppression were not exacerbated by acitretin therapy. CONCLUSIONS: Acitretin is a safe and effective treatment for PS-HIV. Both skin and joint manifestations of PS-HIV responded to acitretin therapy in most patients. Optimal results were achieved with a dose of 75 mg/d. The adverse effects were moderate and well tolerated. Acitretin does not appear to have immunosuppressive properties. A formal randomized clinical trial is warranted.
Acitretin↗
Secondary management of congenital and acquired craniomaxillofacial deformities. Individualized treatment planning.
Late treatment of craniofacial disorders with concomitant abnormalities of the jaw are the most challenging cases a craniofacial surgeon faces. This article details the principles of preoperative, individualized treatment planning using anthropometric guidelines in a simple but systematic scheme for facial analysis. Seventeen skeletally mature patients without cleft lip and palate or hemifacial microsomia, aged 15 to 65 years, underwent simultaneous orthognathic and craniofacial surgery for a variety of complex craniofacial disorders. The basic clinical approaches outlined in this article permit the surgeon to develop a flexible but accurate treatment plan and proceed with confidence in the management of patients with widespread craniomaxillofacial deformities.
Adolescent↗
Well-being at the end of life: Part 1. A research agenda for psychosocial and spiritual aspects of care from the patient's perspective.
This article reviews the scientific literature concerning psychosocial and spiritual aspects of palliative care for the patient with cancer. It discusses 4 separate areas: the continuum of care, communication, spiritual and psychological issues, and psychotherapeutic and behavioural management of physical symptoms. Most of the research could be classified as fundamental according to the Cancer Control Framework of the National Cancer Institute of Canada. In some areas, even fundamental research was lacking. There is a need for clearer and more relevant definitions of the desired outcomes of interventions and also for the development of appropriate quantitative and qualitative methods. We must determine which interventions can be initiated earlier in the disease trajectory and can provide benefit at the palliative phase. Given the burden of suffering that palliative care aims to address, relatively little research in this area has been conducted.
Humans↗
Well-being at the end of life: Part 2. A research agenda for the delivery of care from the patient's perspective.
This article reviews the scientific literature in several areas important to the delivery of palliative care: multicultural issues, education, comprehensive outcome measures and ethics. Most of the research can be classified as fundamental rather than intervention research according to the Cancer Control Framework of the National Cancer Institute of Canada. Desired outcomes of interventions are most often defined from the health care professional's perspective but need to be defined from the patient's perspective. In areas such as multicultural issues and the effect of the volunteer on the patient, there is almost no research. The complexity of studying the best way to deliver palliative care would benefit from the input of colleagues who have experience addressing these issues in other patient populations.
Ethics, Medical↗
Existential well-being is an important determinant of quality of life. Evidence from the McGill Quality of Life Questionnaire.
BACKGROUND: The McGill Quality of Life Questionnaire (MQOL) is being developed to correct what we perceive to be a flaw in existing quality of life instruments: neglect of the existential domain. METHODS: This study reports the first use of MQOL for people with cancer at all phases of the disease, including those with no evidence of disease after therapy. RESULTS: The data suggest that MQOL is comprised of an item measuring physical well-being and four subscales: physical symptoms, psychological symptoms, existential well-being, and support. MQOL is acceptable to oncology outpatients. Correlation of the MQOL total and subscale scores with a single item scale measuring overall quality of life and with the Spitzer Quality of Life Index suggests that MQOL has construct and concurrent validity. CONCLUSIONS: The hypothesis that the existential domain is important, especially to those patients with a life-threatening illness, is supported because multiple regression showed that the existential subscale is at least as important as any other subscale in predicting a single item scale measuring the overall quality of life and plays a greater role in determining the quality of life of patients with local or metastatic disease than in patients with no evidence of disease.
Adult↗
Defining quality of life.
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Health Status Indicators↗