Association of Perioperative Antibiotics with the Prevention of Postoperative Fistula after Cleft Palate Repair.

Background: There is debate amongst surgeons regarding the use of antibiotics to prevent fistulae after palatoplasty. Prescribing should be evidence based, as antibiotic stewardship is integral to reducing antibiotic resistance. Our aim was to determine whether differing perioperative regimens affect the prevalence of postoperative fistulae. Methods: The sample comprised participants from the Cleft Collective who had undergone palatoplasty. Participants were recruited across all 16 UK cleft centers between 2013 and 2021. The exposure was perioperative antibiotic regimen prescribed at the time of palatoplasty. The primary outcome was the presence of palatal fistula. Results: Fistula data were available for 167 participants when exploring antibiotic regimen and for 159 when exploring antibiotic agent. There was no evidence to suggest a difference in fistula rate between those receiving antibiotics on induction only versus as an inpatient or up to 7 days postoperatively (χ2 = 4.57; P = 0.10). There was no evidence to suggest a difference in fistula rate between those who received co-amoxiclav and those who had an alternative antibiotic (χ2 = 0.16; P = 0.69). Postoperative fistulae increased with the extent of the cleft (χ2 = 20.39; P < 0.001). When adjusting for cleft type, no evidence of an association between antibiotic regimen and fistulae was found (inpatient antibiotics: OR 1.36; 95% confidence interval, 0.53-3.51; antibiotics up to 7 days postoperatively: OR 0.68; 95% confidence interval, 0.26-1.80). Conclusions: The choice of antibiotic and dosing regimen does not influence the formation of postoperative fistulae. These results should be supported by interventional trials.

Syndromes associated with Robin sequence: a national prospective cohort study.

OBJECTIVES: To determine the prevalence of syndromic Robin sequence (RS) in the UK and if this group of patients had an increased need for airway and feeding management compared with a non-syndromic RS cohort. DESIGN: A prospective national multicentre study of cases submitted to the Cleft Collective cohort studies. SETTING: Specialist cleft services in the UK. PATIENTS: 259 participants who fulfilled the diagnosis of RS. This group was compared with 548 participants with cleft palate only (CPO). MAIN OUTCOME MEASURES: The primary outcome measure was the presence of a syndrome in patients with RS and CPO. Secondary outcome measures included the use of airway and feeding adjuncts. RESULTS: An associated syndrome was seen in 28% of patients with RS and 14% of patients with CPO. The most common syndrome for the RS group was Stickler syndrome (27%). Syndromic status was significantly higher among patients with RS compared with those with CPO (OR 2.36, 95% CI 1.65 to 3.39; p<0.001). Patients with syndromic RS have an increased reliance on airway adjuncts compared with the patients without syndromic RS (OR 2.02, 95% CI 1.13 to 3.64; p=0.018). There was no evidence of a difference in the use of feeding adjuncts between syndromic and non-syndromic RS groups (OR 2.43, 95% CI 0.78 to 7.58; p=0.126). CONCLUSION: The presence of a syndrome has implications for management of patients with RS. Early identification of a syndrome may help prevent the consequences of a missed syndromic diagnosis. Routine ophthalmological and genetic screening for Stickler syndrome should be mandatory for all patients with RS.

Fake News, Defamation, Online Reviews, and Their Potential Devastating Consequences for Aesthetic Plastic Surgeons.

BACKGROUND: Anecdotal evidence of the exposure and vulnerability of aesthetic plastic surgeons to fake news and online defamation by a minority of vociferous patients has been accruing over the past 10 to 20 years and lurks, hidden like an iceberg, beneath our specialty. Because of acute embarrassment, it is rarely, if ever, discussed in public, and the true extent of the underlying problem remains unknown. OBJECTIVES: The authors sought to accurately document the true magnitude of defamation in British aesthetic plastic surgery. METHODS: An anonymous online survey was distributed to all full members of the British Association of Aesthetic Plastic Surgeons in the summer of 2020. RESULTS: Forty-six percent of full British Association of Aesthetic Plastic Surgeons members responded. Over one-half had experienced denigration of their professional reputation; the most common medium reported was digital defamation. Over three-quarters of the respondents had been the subject of patient blackmail in an attempt to refund professional fees, and, most distressingly, almost one-third stated that the incident had significantly impacted their mental well-being. The majority had found help from their professional bodies to be significantly lacking. CONCLUSIONS: These findings reveal a torment among aesthetic plastic surgeons that has not, to the authors' knowledge, been previously recognized and requires urgent attention by professional organizations.

Bilateral musculus sternalis - An anatomical and clinical review.

The musculus sternalis is an extremely rare anatomical variant of the anterior chest wall. A detailed review of the anatomy, historical background and prevalence of the sternalis muscle is presented, with both the significant radiological and surgical implications of this variant specifically discussed.

The Role of Tranexamic Acid in Aesthetic Plastic Surgery: A Survey of the British Association of Aesthetic Plastic Surgeons.

BACKGROUND: Tranexamic acid (TXA) can reduce intra- and postoperative bleeding as well as minimizing postoperative swelling and ecchymosis. It can be administered both intravenously and topically during surgery with minimal side effects. OBJECTIVES: To assess the evidence of TXA use in aesthetic surgery and to complete a survey of current practice of full British Association of Aesthetic Plastic Surgeons members. METHODS: The authors performed a literature review and online survey of full British Association of Aesthetic Plastic Surgeons members. RESULTS: There is an increased indication of TXA utilization in aesthetic surgery. It provides multiple surgeon and patient benefits. CONCLUSIONS: TXA is a useful adjunct in aesthetic surgery.

A systematic review of psychological interventions in total hip and knee arthroplasty.

BACKGROUND: The current practice in elective orthopaedics does not routinely include psychological interventions despite evidence that psychological factors such as personality, anxiety, depression and negative thinking styles can influence outcomes and recovery from surgery. The objective of this paper was to review the effectiveness of psychological interventions used in conjunction with total hip (THA) and knee arthroplasty (TKA), in improving patient reported joint outcomes. METHODS: An extensive literature search was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Search terms included psychology, interventions, and orthopaedics. Articles were included if they were randomised controlled trials (RCTs) of psychological interventions involving active patient participation measured with patient reported joint outcomes in patients undergoing hip or knee arthroplasty. RESULTS: A total of 19,489 titles were screened. Seven studies met the inclusion criteria and were included. Five of seven studies did not show improvements in patient reported outcomes after surgery. Specifically, psycho-education alone was not effective at improving patient reported joint outcomes in two out of two studies. CONCLUSION: The current literature does not support routine psychological interventions for TKA and THA. However, it should be noted that the literature for psychological interventions in conjunction with TKA and THA is still in its infancy. This gap in the literature is surprising, considering the importance of the role of psychological factors in recovery. Further RCTs with long term follow ups, multidisciplinary involvement, and more comprehensive and focused interventions that go beyond educating patients are needed. Future studies should account for the demand effect, include measures of psychological variables to determine whether psychological interventions are more beneficial for some patients compared to others, and compare the different modes of delivery and timing of interventions to determine the optimal nature and duration of psychological interventions for TKA and THA.

The Craniofacial and Upper Limb Management of Nager Syndrome.

INTRODUCTION: Nager syndrome is a rare condition characterized by craniofacial and upper limb abnormalities. It is commonly mistaken for Treacher Collins syndrome, with which it shares the same craniofacial phenotype. However, patients with Treacher Collins do not exhibit hand anomalies, which are seen in patients with Nager syndrome. This paper reviews the multidisciplinary management of patients with Nager syndrome who were treated at the Australian Craniofacial Unit, Adelaide and the Erasmus Medical Centre, Rotterdam. METHODS: The database of both units was scrutinized and the case-notes of the patients with Nager syndrome were reviewed. Data was collected on patient demographics, surgical management, complications, and outcome. RESULTS: Nine patients (6 M:3 F) were identified with Nager syndrome, with a mean age at presentation of 3.7 years (range 8 days to 11.8 years). The mean follow-up time was 2.2 years (2 months to 19 years). SF3B4 mutation was noted in 2 patients and 1 patient had an X:9 translocation. Seven (77.8%) had obstructive sleep apnoea, with 5 patients diagnosed as severe obstructive sleep apnoea. Four patients had pollicization of their index, 2 patients had excision of extra radial digits and 1 patient underwent thumb duplication correction. Craniofacial surgery included mandibular advancement in 5 patients, temporo-mandibular joint reconstruction in 2 patients, and a genioplasty in 1 patient. CONCLUSION: Nager syndrome is a rare acrofacial dysostosis syndrome that is best managed within the realms of a multidisciplinary team. The authors would advocate early pollicization in patients with thumb anomalies to prevent any impairment in manual dexterity.

The Management of Nonsyndromic, Isolated Sagittal Synostosis.

AIM: Isolated sagittal synostosis is the commonest form of craniosynostosis. The reasons for surgery are to normalize the head shape and to increase the cranial volume, thus reducing the risk of raised intracranial pressure and allowing for normal brain development. It has been suggested that sagittal synostosis may impair neuropsychological development. This systematic review appraised the literature on the management of sagittal synostosis. METHODS: A literature search was performed with the assistance of a professional librarian. Studies selected had to satisfy the criteria set by PICO (patients, intervention, comparison, and outcome). Cranial index and neuropsychological outcome were used as outcome measures. MINORS was used to assess the methodological quality of the selected articles. A score of 75% was deemed to be of satisfactory quality, and the quality of the evidence from the selected studies was graded using the GRADE system. RESULTS: One hundred forty-eight articles were initially identified. Only 6 articles fulfilled the PICO criteria and scored a minimum of 75% on MINORS. Four studies compared 1 technique to another with documented cranial indices. Two studies compared 1 group to another and assessed the neuropsychological development. According to GRADE, the quality of evidence was deemed to be very low. CONCLUSIONS: This systematic review assessed cranial index and neuropsychological outcome following surgery for isolated, nonsyndromic sagittal synostosis. The quality of the evidence in the published literature was noted to be of very low quality. There is a need for better-designed, prospective studies to guide surgeons involved in management of sagittal synostosis.

Older maternal age is associated with depression, anxiety, and stress symptoms in young adult female offspring.

The evidence regarding older parental age and incidence of mood disorder symptoms in offspring is limited, and that which exists is mixed. We sought to clarify these relationships by using data from the Western Australian Pregnancy Cohort (Raine) Study. The Raine Study provided comprehensive data from 2,900 pregnancies, resulting in 2,868 live born children. A total of 1,220 participants completed the short form of the Depression Anxiety Stress Scale (DASS-21) at the 20-year cohort follow-up. We used negative binomial regression analyses with log link and with adjustment for known perinatal risk factors to examine the extent to which maternal and paternal age at childbirth predicted continuous DASS-21 index scores. In the final multivariate models, a maternal age of 30-34 years was associated with significant increases in stress DASS-21 scores in female offspring relative to female offspring of 25- to 29-year-old mothers. A maternal age of 35 years and over was associated with increased scores on all DASS-21 scales in female offspring. Our results indicate that older maternal age is associated with depression, anxiety, and stress symptoms in young adult females. Further research into the mechanisms underpinning this relationship is needed.

Does late childbearing increase the risk for behavioural problems in children? A longitudinal cohort study.

BACKGROUND: This study aimed to examine the relationship between advanced parental age and behavioural outcomes in offspring in a longitudinal cohort of children in Western Australia. METHODS: The Western Australian Pregnancy Cohort (Raine) is a prospective study of 2900 pregnancies. Offspring were followed up at ages 2, 5, 8, 10, 14, and 17 years, and 1754 adolescents were available for follow-up at 17 years. The Child Behaviour Checklist was used to measure child behaviour, including internalising (e.g. anxious/withdrawn) and externalising (e.g. aggressive/destructive) behaviours. RESULTS: There was a significant linear relationship between maternal age and total internalising and externalising behaviour outcomes, but not paternal age. Increasing maternal age was associated with decreasing risk for problem behaviours in offspring. In the categorical models, young maternal age (20-24 years) was associated with significantly increased risk for problem behaviours in offspring relative to offspring of parents in the reference group (25-29 years), and a paternal age of 35-39 years was associated with decreased risk for total behaviour morbidity in offspring. CONCLUSIONS: This study showed no evidence that late fatherhood is associated with adverse behavioural outcomes in offspring. Increasing maternal age was found to be a protective factor for child behaviour morbidity.

Maternal and family factors and child eating pathology: risk and protective relationships.

BACKGROUND: Previous studies have found associations between maternal and family factors and child eating disorder symptoms. However, it is not clear whether family factors predict eating disorder symptoms specifically, or relate to more general child psychopathology, of which eating disorder symptoms may be one component. This study aimed to identify maternal and family factors that may predict increases or decreases in child eating disorder symptoms over time, accounting for children's body mass index z-scores and levels of general psychological distress. METHODS: Participants were 221 mother-child dyads from the Childhood Growth and Development Study, a prospective cohort study in Western Australia. Participants were assessed at baseline, 1-year follow-up and 2-year follow-up using interview and self-report measures. Children had a mean age of 10 years at baseline and 46% were male. Linear mixed models and generalised estimating equations were used to identify predictors of children's eating disorder symptoms, with outcome variables including a global index of eating disorder psychopathology, levels of dietary restraint, levels of emotional eating, and the presence of loss of control ('binge') eating. RESULTS: Children of mothers with a current or past eating disorder reported significantly higher levels of global eating disorder symptoms and emotional eating than other children, and mothers with a current or past eating disorder reported significantly more concern about their children's weight than other mothers. Maternal concern about child weight, rather than maternal eating disorder symptoms, was significant in predicting child eating disorder symptoms over time. Family exposure to stress and low maternal education were additional risk factors for eating disorder symptoms, whilst child-reported family satisfaction was a protective factor. CONCLUSIONS: After adjusting for relevant confounding variables, maternal concern about child weight, children's level of family satisfaction, family exposure to stress, and maternal education are unique predictors of child eating disorder symptoms.

A long-term evaluation of 150 costochondral nasal grafts.

INTRODUCTION: This paper reviewed the outcome of cantilevered costochondral grafts used for dorsal nasal augmentation in the management of patients treated at the Australian Craniofacial Unit (ACFU), Adelaide over a 29-year period. MATERIALS AND METHODS: All patients undergoing dorsal nasal augmentation with costochondral grafts as part of their craniofacial management between 1981 and 2009 were identified using the ACFU database, and their medical notes were reviewed. RESULTS: 107 patients (50 M, 57 F), with a mean age of 12.3 years (range: 2-62 years) and requiring a total of 150 costochondral grafts, were identified from the departmental database. Mean follow-up after nasal augmentation was 5.6 years (1 month-31.5 years). 46% of the patients were diagnosed with Binder syndrome/Chondrodysplasia punctata; other diagnoses included Tessier midline clefts, cleft lip and palate and frontonasal dysplasia. A dorsal midline incision (49%) was the commonest method of access, with 84% of patients having mini-screw fixation for graft stabilisation. Complications included screw palpability, infection, skin necrosis and graft fracture. The commonest reasons for a replacement graft were graft atrophy and fracture, infection and persistent deformity. CONCLUSION: Cantilevered nasal costochondral grafting is an excellent technique for improving nasal contour and function in a wide variety of clinical situations.

Poly implant prothèse (PIP) breast implants: our experience.

INTRODUCTION: This study describes our experience on the management of patients with PIP (Poly Implant Prothèse) breast implants between 2000 and 2008. MATERIALS AND METHODS: The medical records of patients were reviewed. Data was collected on clinical presentation, investigations, management and outcome. RESULTS: 44 patients, with bilateral breast implants, and a median age of 33 years (18-54 years), were reviewed, and of these, 31 patients were asymptomatic. Symptoms at presentation included lymphadenopathy, capsule formation, breast lump, seroma and breast pain. Patients underwent mammography, ultrasound and MRI scanning of the breasts as part of the imaging investigations. 5 patients declined explantation. Reasons for explantation included patient anxiety, silent rupture, aesthetic breast change, palpable nodes and breast lump. 17 out of a total of 78 implants (21.8%) were noted to have ruptured; 2 had a simple tear and 15 were totally disintegrated. 1 patient underwent removal of the implants, 18 underwent exchange of implants, and 20 patients had a capsulotomy and exchange of implants. Postoperative complications included wound infection, seroma, axillary lymphadenopathy, hypersensitive scar and overgranulation of the wound. CONCLUSION: Our series confirms the high rate of PIP implant rupture (21.8%), the majority of which were asymptomatic. The main reasons for explantation were patient anxiety and silent rupture of implants. It is imperative that patients should be appropriately counselled, prior to surgery with regards to removal of the implants, given the increased rupture rates noted.

Hypertensive diseases of pregnancy predict parent-reported difficult temperament in infancy.

OBJECTIVE: Recent research has linked hypertensive diseases of pregnancy with adverse neurodevelopmental outcomes in childhood and adulthood. This study aimed to establish whether such effects are observed in infancy. METHODS: This was a prospective pregnancy cohort study of 2,785 pregnancies with complete data on hypertensive diseases of pregnancy. Mothers completed a validated Australian adaptation of the Toddler Temperament Scale when the children were 1 year of age (n = 2,384). Algorithms were used to classify children as difficult, slow to warm up, intermediate high, intermediate low, or easy, on the basis of their temperament scores. We then grouped difficult and intermediate-high infants together and compared them with easy, intermediate-low, and slow-to-warm-up infants. We used a multivariable logistic regression model and adjusted for known biomedical, sociodemographic, and psychological factors from the pre- and postnatal period that may influence child behavioral development. RESULTS: After adjusting for confounders, mothers who were diagnosed with gestational hypertension (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.06-1.75) or preeclampsia (OR, 2.23; 95% CI, 1.18-4.23) were more likely to report that their infants were in the difficult or intermediate-high classifications in the first year of life compared with infants born to mothers without gestational hypertension or preeclampsia. CONCLUSION: These data suggest that the link between maternal hypertensive diseases of pregnancy and child behavioral development begins in the first year of life.

Delivery at 37 weeks' gestation is associated with a higher risk for child behavioural problems.

BACKGROUND: Advances in obstetric care have been accompanied by increasing rates of intervention which often involve elective delivery at 37 weeks, soon after term gestation has been achieved. AIM: The aim of this study was to examine the behavioural sequelae for children born at this early term gestational age compared with those born at later weeks. METHODS: The Western Australian Pregnancy Cohort (Raine) Study provided comprehensive obstetric data from 2900 pregnancies. Offspring were followed up at ages two, five, eight, 10, 14 and 17 years using the parent report Child Behaviour Checklist (CBCL) with clinical cutoffs for overall, internalising (withdrawn, somatic complaints, anxious/depressed) and externalising (delinquent, aggressive) behaviour (T-score ≥ 60). We used longitudinal logistic regression models incorporating generalised estimating equations (GEE) with step-wise adjustment for ante-, peri- and postnatal confounding factors. RESULTS: Approximately 9% of our cohort was born within the range of 37(0/7) and 37(6/7)  weeks. Those born at 37 weeks' gestation were at increased risk for overall (OR = 1.43, 95% CI = 1.02, 2.01) and externalising (OR = 1.42, 95% CI = 1.01, 2.01) behavioural problems in the fully adjusted model when compared with infants born from 39 weeks onwards. Infants born late preterm (34-36 weeks) and at 38 weeks did not show a significantly increased risk for behavioural problems. CONCLUSION: Infants born at 37 weeks' gestation are at increased risk for behavioural problems over childhood and adolescence compared with those born later in gestation. We suggest that 37 weeks' gestation may not be the optimal cutoff for defining perinatal risk as it applies to behavioural development.

Evaluation of a new measure of mood intolerance, the Tolerance of Mood States Scale (TOMS): psychometric properties and associations with eating disorder symptoms.

OBJECTIVE: This research aimed to (i) validate a new measure of mood intolerance, the Tolerance of Mood States (TOMS) scale, and (ii) to examine associations between TOMS scores and eating pathology. METHODS: The original TOMS was developed and evaluated using the data from 258 adult participants. The measure consisted of two separate scales, initially with a total of 64 items, with this reduced to 34 items through exploratory factor analyses. The 34-item TOMS was administered to a new sample of adult participants recruited from a university setting (N=227), along with the Distress Tolerance Scale (DTS-C; Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007) and other measures of psychological distress and eating disorder symptoms. The reliability and validity of the 34-item TOMS scales were examined through confirmatory factor analysis, inspection of alpha coefficients, and inspection of correlations between TOMS scores and those on other relevant measures. Associations between TOMS scores and eating disorder symptoms were considered using continuous and categorical analyses. RESULTS: Analyses provided support for the reliability and validity of the scale two of the TOMS. This scale consists of 11 items on two subscales, and assesses the tendency to engage in maladaptive behaviours when confronted with intense moods. Scores on this scale were significantly higher amongst participants who reported binge eating and purging than amongst participants who did not, and they correlated significantly with a global index of eating disorder symptoms. The 11-item scale was retained as the final version of the TOMS. CONCLUSIONS: Preliminary support is provided for the validity of a new measure of mood intolerance, the TOMS. Scores on the TOMS subscales were significantly associated with eating disorder symptoms in this non-clinical sample.

The Eating Disorder Inventory-2 Perfectionism scale: factor structure and associations with dietary restraint and weight and shape concern in eating disorders.

The Eating Disorder Inventory-2 Perfectionism subscale (EDI-P) was originally construed as a unidimensional measure of perfectionism. However, research in non-clinical samples suggests that the EDI-P measures two dimensions of perfectionism: self-oriented and socially prescribed perfectionism. This study aimed to investigate the factor structure of the EDI-P in a transdiagnostic sample of females seeking treatment for an eating disorder, and to determine the unique association between EDI-P dimensions, weight and shape concern, and dietary restraint in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified. Two hundred and ninety nine females seeking treatment for an eating disorder at an outpatient eating disorder service completed the Eating Disorder Examination and the EDI-P. Confirmatory factor analysis supported a two-factor model of the EDI-P comprising self-oriented and socially prescribed perfectionism. Self-oriented perfectionism, but not socially prescribed perfectionism, accounted for unique variance in weight and shape concern and dietary restraint in both AN and BN. Results highlight the potential importance of self-oriented perfectionism in eating disorders and support the argument that self-imposed standards are central to perfectionism in eating disorders.

The nasopharynx in infants with cleft lip and palate.

OBJECTIVE: The purpose of this study was to use three-dimensional computed tomography data and computer imaging technology to assess the skeletal components of the naso-pharyngeal area in patients with cleft lip and palate and to quantify anatomical variations. METHODS: CT scans were obtained from 29 patients of Malay origin with cleft lip and palate aged between 0 and 12 months and 12 noncleft patients in the same age group, using a GE Lightspeed Plus Scanner housed in Hospital Universiti Sains Malaysia. Measurements were obtained using the 'Persona' three-dimensional software package, developed at Australian Craniofacial Unit, Adelaide. RESULTS: The results of the present study show that there is an increased nasopharyngeal space in cleft lip and palate that may lead to compression of the nasopharyngeal structures, including the Eustachian tube. Alterations of the medial pterygoid plate and the hamulus may lead to an alteration in the origin and orientation of the tensor veli palatini muscle leading to alteration in its function. CONCLUSIONS: These anatomical variations may compromise the dilatory mechanism of the Eustachian tube, thus leading to recurrent middle ear infections in cleft children and subsequent loss of hearing.

The dual-pathway and cognitive-behavioural models of binge eating: prospective evaluation and comparison.

To evaluate and compare the dual-pathway, original cognitive-behavioural, and enhanced "transdiagnostic" cognitive-behavioural models of binge eating, using prospective data from a pre-adolescent sample. Models were tested using multilevel longitudinal structural equation modelling. Participants were 236 children (48% male) aged between 8 and 13 years at baseline, who were interviewed annually over a 2-year period. Binge eating was assessed using the Child Eating Disorder Examination. The dual-pathway and enhanced cognitive-behavioural models provided an acceptable fit to the data, whereas the original cognitive-behavioural model did not. Partial support is provided for the prospective validity of the dual-pathway and enhanced cognitive-behavioural models of binge eating in childhood. Results suggest that body dissatisfaction and weight and shape over-evaluation may both contribute to dieting behaviour in youth, and that dieting and affect-related difficulties both require consideration in theories of binge eating development.

An evaluation of the enhanced cognitive-behavioural model of bulimia nervosa.

The original cognitive-behavioural model of bulimia nervosa (BN) has been enhanced to include four additional maintaining mechanisms: low self esteem, clinical perfectionism, interpersonal problems, and mood intolerance. These models have been used to guide cognitive-behavioural treatment for BN, but the enhanced model has yet to be directly evaluated as a whole in a clinical sample. This study aimed to compare and evaluate the original and the enhanced cognitive-behavioural models of BN using structural equation modelling. The Eating Disorder Examination and self-report questionnaires were completed by 162 patients seeking treatment for BN (N = 129) or atypical BN (N = 33). Fit indices suggested that both the original and enhanced models provided a good fit to the data, but the enhanced model accounted for more variance in dietary restraint and binge eating. In the enhanced model, low self esteem was associated with greater overevaluation of weight and shape, which, in turn, was associated with increased dietary restraint. Interpersonal problems were also directly associated with dietary restraint, and binge eating was associated with increased purging. While the current study provides support for some aspects of the enhanced cognitive-behavioural model of BN, some key relationships in the model were not supported, including the important conceptual relationship between dietary restraint and binge eating.