Long-Term Orthognathic Considerations in the Pierre Robin Sequence Patient.

BACKGROUND: One of the arguments against early intervention for micrognathia in Pierre Robin sequence is the concept that the growth of the mandible will eventually "catch up." Long-term growth of the mandible and occlusal relationships of conservatively managed Pierre Robin sequence patients remain unknown. In this study, the authors evaluated the orthognathic surgery requirements for Pierre Robin sequence patients at skeletal maturity. METHODS: Orthognathic surgical requirements of conservatively managed Pierre Robin sequence and isolated cleft patients (aged ≥13 years) at two institutions were reviewed and analyzed using t test, chi-square test, and Fisher's exact test. Values of p < 0.05 were considered statistically significant. RESULTS: Of the Pierre Robin sequence patients (n = 64; mean age ± SD, 17.9 ± 2.9 years), 65.6 percent were syndromic (primarily Stickler and velocardiofacial syndrome), 96.9 percent had a cleft palate, and 39.1 percent required orthognathic surgery at skeletal maturity. Nonsyndromic and syndromic Pierre Robin sequence patients demonstrated no differences in occlusal relationships or mandibular surgery frequency. The majority of Pierre Robin sequence patients requiring mandibular advancement had a class II occlusion. Comparison of Pierre Robin sequence patients to isolated cleft palate patients (n = 17) revealed a comparable frequency of orthognathic surgery between the two; however, Pierre Robin sequence patients did require mandibular advancement surgery at a greater frequency than cleft palate patients (p = 0.006). CONCLUSIONS: The present study found that 39.1 percent of conservatively managed Pierre Robin sequence patients required orthognathic surgery at skeletal maturity, of which the vast majority required mandibular advancement for class II malocclusion. These data suggest that mandibular micrognathia in conservatively managed Pierre Robin sequence patients may not resolve over time and may require surgical intervention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Effect of Parental English Proficiency on Psychosocial Functioning in Children with Craniofacial Anomalies.

BACKGROUND: Psychosocial distress in children with craniofacial anomalies is multifactorial. A known cause of childhood psychosocial distress is parental limited English proficiency; however, its role as a psychosocial stressor in the craniofacial anomaly population remains unknown. The current study aimed to understand the potential influence of parental English proficiency in children with craniofacial anomalies. METHODS: Two hundred ninety-six children were prospectively evaluated at the University of California, Los Angels and the Orthopaedic Institute for Children using the Pediatric Patient-Reported Outcomes Measurement Information System to assess anger, anxiety, depression, and peer relationships. Children were grouped by parental English proficiency based on the requirement or lack thereof for interpreting services during clinic appointments. Independent t tests, analyses of variance, and linear regressions were performed to compare groups and identify predictors for psychosocial functioning. RESULTS: Although comparison children did not exhibit any differences in psychosocial scores with respect to parental English proficiency, craniofacial anomaly children with parents who have limited English proficiency demonstrated higher anger, anxiety, depression, and lower peer relationships compared with those with parents who are English proficient. Linear regression analyses demonstrated that limited English proficiency in parents was a significant predictor for anger (p = 0.005), anxiety (p = 0.002), depression (p < 0.001), and poor peer relationships (p < 0.001) in children with craniofacial anomalies. CONCLUSIONS: Parental English proficiency is associated with increased psychosocial distress in children with craniofacial anomalies. Future efforts toward identification of and assistance for parents with limited English proficiency to address barriers to care may improve psychosocial function in children with craniofacial anomalies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Discrepancies in Parent Perceptions and Patient-Reported Psychosocial Function in Children with Craniofacial Anomalies.

BACKGROUND: Understanding and optimizing psychosocial functioning in children with craniofacial anomalies are essential components of their reconstructive care. This work compared parental perceptions to pediatric self-reported psychosocial functioning in children with craniofacial anomalies. METHODS: Two hundred twenty-one children with craniofacial anomalies (aged 8 to 17 years) and their parents were prospectively evaluated at two institutions using the parent-proxy and pediatric Patient-Reported Outcomes Measurement Information System to assess anger, anxiety, depression, and peer relationships. Children were stratified into three age groups: group A, 8 to 10 years; group B, 11 to 13 years; and group C, 14 to 17 years. Pearson correlations, analyses of variance with post hoc comparisons under the Tukey criterion, and paired samples t tests were performed. RESULTS: When stratified by age, no correlations between parent and child reports were found in anxiety for group A and anger, anxiety, and peer relationships for group C. Whereas group A reported the worst psychosocial functioning, group C parents perceived their children to have the worst psychosocial functioning. Group A parents perceived lower depression and better peer relationships, whereas group C parents perceived higher anxiety and depression compared to self-reports. CONCLUSIONS: Parents perceived an inverse relationship between age and psychosocial functioning compared to self-reports by children with craniofacial anomalies. These discrepancies in the current work highlight the importance of child self-report and suggest incorporating longitudinal patient-reported and parent-proxy-reported outcomes measures for psychosocial functioning as part of standard clinical care for patients with craniofacial anomalies.

The contributions of socioeconomic status, perceived stress, and depression to disability in adults with systemic lupus erythematosus.

Purpose: Psychological and sociodemographic factors contribute to disability in systemic lupus erythematosus. Yet the pathways by which these factors influence disability remain unclear. The objective of this study was to evaluate a model examining socioeconomic status (SES), perceived stress, and depressive symptoms as determinants of lupus-related disability.Methods: The sample included 134 patients receiving treatment at an academic hospital. Structural equation modeling examined the direct and indirect effects of SES (income, education, and subjective social status), perceived stress (Perceived Stress Scale), and depressive symptoms (Hospital Depression Anxiety Scale depression subscale) on disability (Lupus Patient-Reported Outcome measure Physical Health and Pain-Vitality subscales).Results: Structural equation modeling confirmed that the model fit the data well. The SES exerted a direct negative effect on perceived stress (ß = -0.40, p < 0.001). In turn, perceived stress predicted higher levels of depression (ß = 0.72, p < 0.001), which ultimately contributed to greater disability (ß = 0.53, p < 0.001). The influence of SES on disability was indirect (mediated by perceived stress and depression).Conclusions: Findings support the socioeconomic gradient in disability as mediated by perceived stress and depression, such that lower SES contributed to lupus-related disability via perceived stress and depressive symptoms.Implications for RehabilitationLow socioeconomic status, perceived stress, and depression are prognostic factors for the disability in systemic lupus erythematosus.Study findings indicate that perceived stress and depression fully mediate (account for) the negative impact of low socioeconomic status on lupus-related disability.Screening for and addressing psychological distress may enhance management of disability in lupus patients.This research demonstrates the value of a conceptual framework for identifying potentially modifiable risk factors for disability in lupus and other chronic disabling diseases.

Component Restoration in the Unilateral Intermediate Cleft Tip Rhinoplasty: Technique and Long-Term Outcomes.

BACKGROUND: The intermediate cleft tip rhinoplasty is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. The authors describe and evaluate long-term outcomes of that approach for the unilateral cleft lip and palate patient based on the concept of individual restoration of each abnormal anatomical component. METHODS: Photomorphometric analyses of unilateral cleft lip and palate patients (n = 50) who underwent intermediate cleft tip rhinoplasty using the component restoration technique were evaluated preoperatively (time 0) and postoperatively at less than 1 year (time 1), 1 to 3 years (time 2), and more than 3 years (time 3) and compared to age-matched unilateral cleft lip and palate control patients. Nasal relationships (alar symmetry, nasal tip protrusion-to-alar base width ratio, and height-to-width dimensions for the cleft and noncleft nostrils) were compared over time using a linear mixed-effect model. RESULTS: At time 0, both groups demonstrated similar nasal relationships, with the exception of a wider cleft-side nostril in relationship to height in the rhinoplasty group. The component restoration technique improved all four nasal relationships at all postoperative time points compared with time 0 in a statistically significant manner, whereas control patients did not demonstrate significant changes at the corresponding ages. Long-term differences at time 3 revealed a trend toward improved alar symmetry and cleft-side and non-cleft-side nostril dimensions, and a significant improvement in the nasal tip protrusion-to-alar base width ratio in intermediate cleft tip rhinoplasty-treated versus control patients (p = 0.002). CONCLUSION: The component restoration technique for the unilateral intermediate cleft tip rhinoplasty improves nasal relationships toward normal immediately and in a sustained manner for at least 3 years. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Management of the Cleft Nasal Tip: An Overview of Classic Techniques and Strategies.

The challenges of cleft reconstruction have been present for centuries. However, understanding of the cleft nasal tip and the evolution of techniques decidedly began in the 20th century and refinement continues into the present day. Although a multitude of technical descriptions and case series have been published, a compendium of seminal techniques, which have shaped modern thought, has not been compiled in the literature. In this review, we discuss the anatomical disturbances in the cleft nasal tip anomaly, the timing and strategy of tip correction, and the major classic techniques for management of the cleft nasal tip. In addition, we have categorized the classic techniques into concepts that they embody.

Psychological Factors that Link Socioeconomic Status to Depression/Anxiety in Patients with Systemic Lupus Erythematosus.

Our analyses examined whether reserve capacity factors would explain the relationship between socioeconomic status (SES) and symptoms of depression/anxiety in patients with systemic lupus erythematosus (SLE). We assessed disease activity, depression/anxiety symptoms, and intrapersonal and interpersonal reserve capacity measures in 128 patients with SLE. Multiple meditational analyses revealed that intrapersonal and interpersonal psychosocial aspects of reserve capacity fully mediated the relationship between SES and depression/anxiety. Lower SES was indirectly associated with higher symptoms of depression and anxiety through the effects of psychosocial resilience. Interventions aimed at improving modifiable reserve capacity variables, such as self-esteem and optimism, may improve anxious/depressive symptomatology in patients with SLE.