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Published standards for the management of open extremity fractures have improved limb salvage, fracture union, and deep infection rates, but the aesthetic and functional importance of our flap choices has been overlooked. Thin and superthin free flaps exhibit advantages over traditional free flaps in some situations but have seldom been reported in children. The aim of this paper is to present our experience of thin and superthin free flaps in pediatric extremity reconstruction. Children (≤13 years) who underwent soft tissue reconstruction using a thin and superthin free flap following major extremity trauma are presented. Five patients (5 flaps) met the inclusion criteria. The median age was 9 (range 6–13). There were 3 Gustilo IIIB open fractures and 2 multiplanar degloving injuries. The median mangled extremity severity score (MESS) was 4 (range 2–6). The median time from injury to definitive soft tissue closure was 72 h (range 28–120 h). Four anterolateral thigh (ALT) flaps were raised as thin flaps, and 1 superficial circumflex iliac artery perforator (SCIP) was raised as a superthin flap. There was one re-exploration owing to venous congestion, and a second venous anastomosis was performed to enhance flap drainage. The same ALT flap exhibited necrosis at one margin, which was debrided and grafted before discharge. There were no other flap complications. No flap-related secondary surgeries were required. Thin and superthin free flaps are viable options in pediatric extremity reconstruction. They exhibit excellent aesthetic and functional contouring when a slender fasciocutaneous flap is needed, especially when body habitus renders traditional options unfavorable. [ABSTRACT FROM AUTHOR]

Limited data are available regarding observers' visual attention to faces with congenital difference. We implemented eye tracking technology to examine this issue, as it pertains particularly to faces with cleft deformity. Four hundred three observers assessed 273 clinical images, while their eye movements were unobtrusively tracked using an infrared sensor. Forty-one facial images of the repaired cleft lip, 137 images of other facial conditions, and 95 images of matched controls were assessed. Twenty facial regions of interest ("lookzones") were considered for all images observed. A separate cohort of 720 raters evaluated the images for attractiveness. Observer and image demographic information was collected. Visual fixation counts and durations were computed across all 20 lookzones for all images. The effect of a variety of variables on lookzone fixation was analyzed using factorial ANOVA testing. Cleft-repaired faces were rated as less attractive and drew observers' attention preferentially to the affected upper lip lookzone (p<.001). Images rated as less attractive garnered greater visual attention in the cleft-affected lookzones (p<.001). The eye tracking methodology demonstrated exquisite sensitivity to laterality of cleft deformity (p<.001). Individuals reporting a personal or a family history of facial deformity fixated more on the perioral region of cleft-repaired faces than did naïve observers (p<.001). These findings highlight the utility of eye tracking measures for understanding critical variables that influence the visual processing of faces with cleft deformity. The data may provide analytical tools for assessing surgical outcome and direct priority setting during surgeons' conversations with patients. [ABSTRACT FROM AUTHOR]

Every pregnant woman in the United States is exposed to many and varied environmental chemicals. Rapidly accumulating scientific evidence documents that widespread exposure to environmental chemicals at levels that are encountered in daily life can impact reproductive and developmental health adversely. Preconception and prenatal exposure to environmental chemicals are of particular importance because they may have a profound and lasting impact on health across the life course. Thus, prevention of developmental exposures to environmental chemicals would benefit greatly from the active participation of reproductive health professionals in clinical and policy arenas. [ABSTRACT FROM AUTHOR]

Given the increasing incidence and prevalence of skin cancer, dermatologists are more frequently recommending sunscreens to their patients. However, the safety of titanium dioxide and zinc oxide nanosized particles in the majority of sunscreens has come under scrutiny from governments and the general public. We sought to characterize the use, safety, and regulatory state of nanosized particles in titanium dioxide and zinc oxide in sunscreens based on studies and position statements from 1980 to 2008. Although we found no evidence of significant penetration of titanium dioxide and zinc oxide nanosized particles beyond the stratum corneum, further studies must be done to simulate real-world conditions particularly in sunburned skin and under ultraviolet exposure. [Copyright &y& Elsevier]

Abstract: Background:: Research shows that tight glycemic control is a major factor in forestalling the microvascular and macrovascular complications that accompany diabetes mellitus (DM). Recent evidence shows that earlier use of insulin therapy is beneficial for people who are at higher risk for these complications because it provides more effective glycemic control. Yet, some patients either do not adhere to their insulin therapy or they modify their regimens in an unprescribed way. Objective:: The goal of this article was to examine the psychological barriers some patients with DM have to insulin therapy. Also discussed are strategies to overcome these barriers. Methods:: A literature search of MEDLINE was conducted for the period 1992 through 2005, using search word combinations including psychological barriers in people with diabetes, insulin therapy, needle phobia, injection anxiety, weight gain, and fear of hypoglycemia. Relevant articles relating to the topic of overcoming psychological barriers in insulin therapy were studied and summarized. Results:: The primary reasons why some patients alter their insulin intake are injection-related anxiety, concern about weight gain, and fear of hypoglycemia. Injection-related anxiety, or needle phobia, is associated with higher levels of anxiety, depression, and phobic symptoms; it can result in poor glycemic control. Such patients should be identified early in therapy so that attention can be directed to address this anxiety. Weight gain can become a circuitous problem; the patient may be overweight at the time of DM diagnosis and then fear a weight gain after the initiation of insulin therapy. This may lead to a patient''s decision to skip doses of insulin therapy and sacrifice glycemic control in the process. Fear of hypoglycemia can be avoided through awareness of the causes of low blood glucose and prescribing newer insulin analogues that have lesser serum peaks and troughs over a 24-hour period. Conclusions:: Good communication between patient and clinician is the key in overcoming any psychological barriers to insulin therapy that some patients may have. The optimal use of insulin therapy is dependent on the patient''s intentions to use it as prescribed. [Copyright &y& Elsevier]

Objective: The purpose of this study was to determine whether rates of hypertensive disorders of pregnancy increase beyond 37 weeks of gestation and to address how best to analyze these rates.Study Design: This was a retrospective cohort study of all women delivered beyond 37 weeks' gestational age from 1995 to 1999 at all Kaiser Permanente Medical Care Program delivery hospitals in Northern California. Rates of gestational hypertension, preeclampsia, and eclampsia were calculated by use of both pregnancy delivered (PD) and ongoing pregnancy (OP) as the denominator. Bivariate and multivariate analyses were conducted with use of P<.05 to indicate statistical significance.Results: Among the 135,560 women in this cohort, the rates of gestational hypertension, preeclampsia, and eclampsia were the same or decreased from 37 to 43 weeks' gestation using PD, but all three increased when calculated according to OP (P<.01).Conclusion: We found that among complications of pregnancy that are diagnosed ante partum, use of a different denominator led to contradictory conclusions. When hypertensive disorders of pregnancy are analyzed, ongoing pregnancies should be used as the denominator. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The study was undertaken to assess attitudes and behavior of newer obstetricians/gynecologists in depression care. STUDY DESIGN: One thousand randomly selected physicians in their final year of training or recent practice received a survey about depression: training; related attitudes, responsibility, confidence; and self-reported care for the last depressed patient. RESULTS: Of those eligible, 437 (64%) returned the survey. Current residents reported more didactic mental health training, but practice patterns were similar to recent graduates. Overall, 94% felt responsible for recognition, whereas about half indicated asking about substance abuse, sexual abuse, or physical abuse, 37% expressed confidence in their ability to treat with medications, and 22% felt confident in their ability to manage depression overall. CONCLUSION: Residents are receiving more didactic mental health training, yet changes in training are not yet reflected in reported practice patterns or confidence. The use of antidepressant medications and assessment of contributing conditions such as abuse deserve more emphasis in training. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The purpose of this study was to compare four strategies for treating patients with a previous classic cesarean delivery by medical outcomes and quality-adjusted life years. STUDY DESIGN: A decision tree was designed that compared four strategies for a hypothetical cohort of 10,000 women with a previous classic cesarean delivery: (1) delivery at 39 weeks of gestation, (2) delivery at 36 weeks of gestation without amniocentesis, (3) amniocentesis at 36 weeks of gestation with delivery if the fetus was mature and antenatal corticosteroids if the fetus was immature, and (4) weekly amniocentesis starting at 36 weeks of gestation with delivery when mature. RESULTS: Strategy 2 provided the greatest maternal quality-adjusted life years. Comparing strategy 1 with strategy 2, it was determined that 27 cesarean deliveries must be performed at 36 weeks of gestation with one associated case of respiratory distress syndrome to prevent one case of uterine rupture. Sensitivity analysis revealed that the uterine rupture rate must be below 0.36% for any strategy to surpass strategy 2 (elective cesarean delivery at 36 weeks of gestation without amniocentesis). CONCLUSION: A 36-week delivery may be preferable because it provides a lower risk of severe adverse outcomes and higher maternal quality of life. [ABSTRACT FROM AUTHOR]

Summary Insufficient responses to hypocaloric diets have been attributed to hormonal adaptations that override self-control of food intake. We tested this hypothesis by measuring circulating energy-balance hormones and brain functional magnetic resonance imaging reactivity to food cues in 24 overweight/obese participants before, and 1 and 3 months after starting a calorie restriction diet. Increased activity and functional connectivity in prefrontal regions at month 1 correlated with weight loss at months 1 and 3. Weight loss was also correlated with increased plasma ghrelin and decreased leptin, and these changes were associated with food cue reactivity in reward-related brain regions. However, the reduction in leptin did not counteract weight loss; indeed, it was correlated with further weight loss at month 3. Activation in prefrontal regions associated with self-control could contribute to successful weight loss and maintenance. This work supports the role of higher-level cognitive brain function in body-weight regulation in humans. Graphical Abstract Highlights • We performed functional MRI in individuals who undertook a weight-loss regimen • Calorie restriction led to weight loss and leptin and ghrelin adaptations • We uncovered a neural signature of successful weight loss • The best predictor of success was activation in prefrontal cortex during the regime Dagher et al. tested the hypothesis that hormonal adaptations during dieting override eating self-control in 24 overweight participants on a 1,200 kcal/day diet. They found that brain activity in cognitive control regions, rather than hormones associated with energy balance, plays a critical role in weight loss. [ABSTRACT FROM AUTHOR]

To estimate when rates of maternal pregnancy complications increase beyond 37 weeks' gestation, investigators examined rates of mode of delivery and maternal complications of labor and delivery by gestational age in a 5-year retrospective cohort study of low-risk women. [ABSTRACT FROM AUTHOR]

Mercury exposure during pregnancy can have serious health effects for a developing fetus including impacting the child's neurologic and cognitive development. Through biomonitoring in a low-income Latina population in California, we identified a patient with high levels of mercury and traced the source to face creams purchased in a pharmacy in Mexico. [Copyright &y& Elsevier]

Objective: The objective of the study was to examine the rates of gestational diabetes mellitus (GDM) associated with both maternal and paternal race/ethnicity. Study Design: This was a retrospective cohort study of all women delivered within a managed care network. Rates of GDM were calculated for maternal, paternal, and combined race/ethnicity. Results: Among the 139,848 women with identified race/ethnicity, Asians had the highest rate (P < .001) of GDM (6.8%) as compared with whites (3.4%), African Americans (3.2%), and Hispanics (4.9%). When examining race/ethnicity controlling for potential confounders, we found that the rates of GDM were higher among Asian (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.4–1.6) and Hispanic (aOR, 1.2; 95% CI, 1.1–1.4) women as well as Asian (aOR, 1.4; 95% CI, 1.3–1.5) and Hispanic (aOR, 1.3; 95% CI, 1.2–1.4) men as compared with their white counterparts. Conclusion: We found that rates of GDM are affected by both maternal and paternal race/ethnicity. In both Asians and Hispanics, maternal and paternal race are equally associated with an increase in GDM. These differences may inform further investigation of the pathophysiology of GDM. [Copyright &y& Elsevier]

Objective: The objective of the study was to examine risk factors for postterm (gestational age ≥ 42 weeks) or prolonged (gestational age ≥ 41 weeks) pregnancy. Study Design: We conducted a retrospective cohort study of all term, singleton pregnancies delivered at a mature, managed care organization. The primary outcome measures were the rates of pregnancies greater than 41 or 42 weeks'' gestation. Multivariable logistic regression models were used to control for potential confounding and interaction. Results: Specific risk factors for pregnancy beyond 41 weeks of gestation include obesity (adjusted odds ratio [aOR], 1.26; 95% confidence interval [CI], 1.16-1.37), nulliparity (aOR, 1.46; 95% CI 1.42-1.51), and maternal age 30-39 years (aOR, 1.06; 95% CI, 1.02-1.10) and 40 years or older (aOR, 1.07; 95% CI, 1.02-1.12). Additionally, African American, Latina, and Asian race/ethnicity were all associated with a lower risk of reaching 41 or 42 weeks of gestation. Conclusion: Our findings suggest that there may be biological differences that underlie the risk for women to progress to 41 or 42 weeks of gestation. In particular, obesity is a modifiable risk factor and could potentially be prevented with prepregnancy or interpregnancy interventions. [Copyright &y& Elsevier]

Objective: The purpose of this study was to examine the relationship between prepregnancy body mass index (BMI) and length of gestation at term. Study Design: This was a retrospective study of 9336 births at the University of California, San Francisco, at ≥37 weeks’ gestation. We performed univariate and multivariable analyses of the associations between prepregnancy BMI and length of gestation (≥40, ≥41, and ≥42 weeks’ gestation). Results: Overweight women were more likely to deliver at ≥40, ≥41, and ≥42 weeks’ gestation than were women who were underweight or normal weight. In multivariable analyses, higher prepregnancy BMI was associated with higher risk of progressing past 40 weeks. Obese women had 69% higher adjusted odds of reaching 42 weeks’ gestation, compared with women of normal prepregnancy BMI (adjusted odds ratio, 1.69; 95% confidence interval, 1.23-2.31). Conclusion: Higher BMI is associated with prolonged gestation at term. Achieving optimal BMI before conception may reduce the risk of postterm pregnancy and its associated complications. [Copyright &y& Elsevier]