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Inadequate nasal tip projection is the most common problem of primary and secondary rhinoplasty. Inadequate nasal tip projection with inadequate septal support requires an umbrella graft. The umbrella graft consists of a vertical cartilaginous strut between the medial crura and a horizontal onlay graft overlying the alar domes. The umbrella graft supports the nasal tip pyramid and reestablishes nasal tip projection. The statistics included in this report involve 1252 cases from 1986 to 1996, and it was discovered that 22 percent of the patients required an umbrella graft. Most of these patients had secondary rhinoplasties. The revision rate was 5 percent; the most common complication was cartilaginous show. Cartilage graft loss or significant absorption was not observed. A closed rhinoplasty approach with autologous tissue to reconstruct nasal tip projection was used. The umbrella graft technique is time proven, successful, and reproducible.

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The relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA) were investigated. One-hundred and forty-seven subjects who met DSM-III criteria for agoraphobia with panic attacks and who completed participation in one of two previously conducted treatment outcome studies were mailed packets containing measures to assess history of trauma, victimization and dissociation. Eighty-nine of these were returned and completed sufficiently to be included in the present study. It was hypothesized that a variety of trauma-related variables (e.g. history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 year longitudinal follow-up. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.

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The effects of self-directed in vivo exposure in the treatment of panic disorder with agoraphobia were examined. Seventy-four chronic and severe agoraphobic subjects were randomly assigned to Cognitive Therapy plus graded exposure. Relaxation Training plus graded exposure, or therapist-assisted graded exposure alone. Treatment consisted of 16 weekly 2.5-hour sessions. All subjects received programmed practice instructions for engaging in self-directed exposure as a concomitant strategy to their primary treatment. All subjects were instructed to keep systematic behavioral diary recordings of all self-directed exposure practice. The diary data were analyzed across and within treatments and assessment phases. Statistically significant findings were obtained across all diary measure domains with powerful repeated measures effects observed across all treatments. Significant between group effects and treatment x repeated measures interactions were obtained across the diary measure domains. Multiple linear regressions of in vivo anxiety levels and, to a lesser extent, frequency of self-directed exposure practice were found to be significantly associated with global assessment of severity at posttreatment and 3-month follow-up assessments. Furthermore, depression and marital satisfaction were significantly associated with in vivo anxiety. These and other findings are discussed with regard to their conceptual and clinical implications.

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The present study examined the relationship of attributional style, as measured with a revised version of the Attributional Style Questionnaire (ASQ) and measures of agoraphobia severity, depression, and treatment outcome in 73 Ss who met DSM-III criteria for agoraphobia with panic attacks and participated in one of three 13-week treatment conditions: paradoxical intention, graduated exposure, or progressive deep muscle relaxation training. Subjects completed assessments at four periods: pretreatment, midtreatment, posttreatment, and at 3 month follow-up. In addition to the three dimensions typically examined on the ASQ, this revised version also measured Ss' estimates of the perceived importance, and future likelihood for both positive and negative events. Congruent with previous research, moderate but somewhat inconsistent associations were observed between attributional style and depression both within and across assessment periods. Predictions about associations between attributional style and agoraphobic severity were not supported; however, an interaction was observed between depression and attributional style with respect to severity of agoraphobia. There was no evidence of group differences across treatment types, although there were several significant changes in attributional style across time. Attributions for health related events were also examined. Conceptual, clinical, and research issues related to the findings are discussed.

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The distribution of sebaceous glands in nasal skin is of interest because the presence of these adnexal structures significantly influences the outcome of healing. Using whole nasal skins dissected from cadavers, we prepared tissue sections from the nasal bridge to the nasal tip, both from the midline and lateral aspects. The sebaceous glands in these sections were analyzed for the following parameters: (1) size of the glands, (2) width of luminal cross-sections, and (3) depth of the glands. These parameters were studied using a Leitz Quantimet 500 Plus image analyzer and software to quantify the results. We found that the superior or proximal nasal skin contains fewer, smaller, more superficially located sebaceous glands. The inferior or distal nasal skin contains increased numbers of sebaceous glands which are markedly larger in size. The glands in the distal nose have larger lumina, are situated both superficially and deep in the dermis, and also occupy a greater percentage of the dermis. We identified an anatomical breakpoint on the nasal skin, marking the transition from superficial, small sebaceous glands to superficial-and-deep, enlarged glands. The columella was found to be similar to the proximal nasal skin.

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A comprehensive drug screening procedure for detecting drugs in the blood samples of car drivers suspected of driving under the influence of drugs, is presented. Amphetamines, cannabinoids, opioids, cocaine and benzodiazepines were screened by an immunological EMIT ETS system after acetone precipitation. Gas chromatographic methods were used to screen and quantitate basic, neutral and acidic drugs. The free amino groups of basic drugs were derivatized with heptafluorobutyric anhydride. Analysis was performed by a dual channel gas chromatograph combined with a nitrogen phosphorus and an electron capture detector. Phenyltrimethylammonium hydroxide was used as a methylathing agent for acidic substances before analysis with a gas chromatograph connected to a nitrogen phosphorus detector. A gas chromatograph/mass spectrometry was used as a common confirmation method. Tetrahydrocannabinol was quantitated after bis(trimethylsilyl)trifluoroacetamide derivatization, opiates after pentafluoropropionic anhydride derivatization and benzoylecgonine after pentafluoropropionic anhydride and pentafluoropropanol derivatization. Excluding benzodiazepines, which were confirmed with a gas chromatograph connected to a nitrogen phosphorus and an electron capture detector, the other basic drugs as well as the acidic drugs were confirmed after the same derivatization procedures as in the screening methods. Alcohols were quantitated in triplicate by gas chromatography using three different kinds of columns. Although urine is the most important specimen for screening abused drugs, it has only limited use in forensic toxicology. The described system is most useful for analyzing a wide range of substances, including illicit drugs, benzodiazepines, barbiturates, antidepressants and phenothiazenes in forensic samples when urine is not available.

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The extent of drug use among drivers suspected of driving under the influence of alcohol and/or drugs in Finland was studied. All blood samples submitted to the laboratory during 1 week in two study periods, in 1979 (n = 298) and 1993 (n = 332), were analyzed for alcohol and psychotropic drugs. Drugs classified as hazardous to traffic safety were detected in 7.0% of the samples in 1979 and 26.8% in 1993. Benzodiazepines were the most frequently found drugs in both years: 6.0% of the cases in 1979 and 22.9% in 1993. Illegal drugs were found in 4% of the cases in 1993. Of the samples tested, 296 in 1979 and 317 in 1993 were from drivers suspected of driving under the influence of alcohol only. In 1979 every fourteenth and in 1993 every fourth of these suspected drunken drivers had drugs in their blood. Drugs, other than alcohol, were found six times more often than expected by the police. The results indicate that the trend of drug use, multidrug use and drug abuse is increasing among cases suspected of driving under the influence of alcohol/drugs.

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External shaving is an accepted technique in the treatment of rhinophyma. The application of external shaving to aesthetic rhinoplasty is also valuable in the treatment of a thick, sebaceous nasal tip that does not respond to standard reduction rhinoplasty. External shaving will reduce the thickness of the nasal tip skin and enhance tip definition. Fifty consecutive patients undergoing external shaving were followed over a 5-year period. The majority of the cases were secondary rhinoplasties. The results reveal a very high success rate, with one significant complication, a hypertrophic scar, and two minor complications. Proper diagnosis, patient selection, and surgical technique produce predictable and favorable aesthetic results.

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OBJECTIVE: Factors associated with response to treatment for agoraphobia are as of yet poorly understood. The authors investigated the relationship between chronic forms of life stress and clinical improvement and recovery in subjects with agoraphobia. METHOD: Subjects meeting the DSM-III criteria for agoraphobia with panic attacks (N = 73) completed measures of life stress, agoraphobic symptoms, and depressive symptoms at the initiation and completion of the 12-week treatment protocol. Chronic stressors were assessed during intensive structured interviews 3-5 years after the completion of treatment and were rated by using a reliable, and previously validated, contextual rating system. The contextual life stress interview was completed by 54 subjects. The relationship of chronic forms of stress to treatment response was assessed by comparing symptomatic improvement in the subjects who had and had not experienced chronic stressors. RESULTS: Of the 54 subjects, 23 (43%) reported chronic stressors of marked or moderate severity. Subjects experiencing chronic stressors evidenced less improvement after treatment on both self-report and objective indexes of agoraphobic symptoms. Additionally, more subjects identified as nonrecovered experienced chronic stressors than did recovered subjects. CONCLUSIONS: Chronic stressors appear to predict a relatively unfavorable treatment outcome, as defined by higher levels of symptoms after treatment, less improvement, and less likelihood of recovery. These results have important implications for enhancing psychotherapeutic outcomes.

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Differences in response to behavioral and electroencephalographic parameters were delineated between two inbred rat strains, Lewis (LEW) and Fischer 344 (F344), upon acute exposure to IV administration of ethylketocyclazocine (EKC) at doses of 1.25, 2.5, and 5 mg/kg. Duration of EKC-induced EEG slow-wave bursts and associated behavioral stupor increased in a dose-related manner, and was greater in duration for the LEW animals; a less robust, quadratic trend was displayed by the F344 group. For both rat strains, latency to onset of slow-wave sleep increased proportionately with EKC dose. Duration of EKC-induced EEG bursts and interbursts were greater in duration for the F344 rats. Assessment of six power spectral parameters (peak frequency, complexity, mobility, mean frequency, edge frequency, and total power) revealed no differences between groups when EKC-induced burst and interburst periods were analyzed simultaneously. Separation of the phases revealed rat strain differences; overall, the LEW animals displayed a greater dose-related EEG response. Except for total power, the F344 group displayed little variation across the three doses tested in the burst phase; the interburst phase reflected more dose-related differences for this group but to a lesser degree than the LEW animals. These results may reflect differences in opioid-related receptor populations between Lewis and F344 inbred rat strains.

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The purpose of the present study was to examine and compare the effects of morphine at doses of 3, 10, and 30 mg/kg, IV, on EEG, EEG power spectra, and behavior in two inbred rat strains, Lewis and Fischer 344. Duration of morphine-induced EEG slow-wave bursts and associated behavioral stupor was greater in Lewis rats. Latency to slow-wave sleep increased in a dose-related manner for both strains; differences were not significant between the two groups. The analog EEG signal was transformed by fast Fourier analysis; six power spectral quantities were examined: peak frequency, complexity, mobility, mean frequency, edge frequency, and total power. With the exception of peak frequency and edge frequency, all differed as a function of inbred rat strain. Regarding morphine dose, all spectral parameters differed except peak frequency. Factor analysis on morphine-induced EEG revealed a unique factor for each strain that was bipolar in nature and may be associated with the burst and interburst periods that occur in EEG after opiate administration. Genetic variability appears to play a role in the behavioral, EEG, and derived power spectral responses of both LEW and F344 inbred rat strains following acute morphine administration. These results may reflect differences in neurosensitivity and/or opioid receptor populations between Lewis and Fischer 344 inbred rat strains.

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Utilizing behavioral and electroencephalographic (EEG) assessments, two inbred rat strains, Lewis (LEW) and Fischer 344 (F344), were exposed to morphine (IV) over a period of 7 days to discern differences in tolerance development. Following morphine injection, the LEW group demonstrated a greater mean total amount, as well as a greater rate of reduction, of stuporous behavior across the 7 days tested. Differences in patterns of latency to onset of slow-wave sleep between the two strains were also exposed. EEG analysis of spectral parameters utilizing an analysis of variance with repeated measures revealed that peak frequency, mean frequency, and edge frequency differed as a function of inbred rat strain. All spectral parameters differed as a function of duration of morphine injection; linear trends were indicated for both strains. Naloxone was administered (IV) following the 7 days of morphine to delineate dependence differences. LEW animals reflected a greater amount of behavioral responses, for example, wet-dog shakes, diarrhea, body stretch, and sluggish behavior. However, F344 rats demonstrated a greater alteration in two spectral parameters assessed: peak frequency and total power. Genetic variability appears to play a major role in both morphine tolerance and dependence as indicated by differences in EEG and behavioral responses.

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Motivating employees is a challenging and critical task for all managers--no matter what the field. Robert Barczewski, M.B.A., and Linda Michelson describe how a successful incentive program at the Washington University School of Medicine was developed.

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Theoretical, methodologic, and clinical research issues pertaining to these treatments are examined as are their strengths, limitations, and possible interactions. Attrition, outcome, and maintenance effects are compared. Composite indices of clinically significant improvement, endstate functioning, and longitudinal adjustment are presented. The article also highlights emerging models, theoretical advances, and promising interventions. Advantages and limitations of current treatments are discussed, with recommendations for future research. It is concluded that significant advances have been made in the conceptualization and treatment of panic disorder with agoraphobia.

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Psychophysiological process and outcome phenomena were analyzed to examine differential temporal patterns within and across cognitive, behavioral and physiologically-based treatments of agoraphobia. Eighty-eight severe and chronic agoraphobics with panic attacks (DSM-III) were randomly assigned to one of three treatments: Paradoxical Intention, Graduated Exposure or Progressive Deep Muscle Relaxation Training. Protocol therapists, whose treatment integrity was objectively monitored, conducted 12 two-hour weekly sessions. All subjects received programmed practice instructions concurrent with their primary treatment. Analyses revealed numerous significant reductions on in vivo psychophysiological measures for the relaxation condition, a few improvements for the exposure treatment and no effects for the paradoxical intention modality. The mediating role of pretreatment physiological reactivity in treatment outcome and follow-up status was examined and revealed no significant associations. Synchrony-desynchrony patterns were found to vary widely according to both treatment phase and the time interval between assessments. No between-group differences were observed on the proportion of synchronizers. However, synchronizers exhibited superior outcome and follow-up compared to desynchronizers on all domains except the physiological measures. Conceptual, methodological and clinical implications of these findings are discussed with recommendations for future research.

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The effectiveness of an integrated treatment program utilizing cognitive-behavioral therapies for Panic Disorder was examined. Treatment was comprised of Cognitive Model of Panic-derived procedures, Cognitive Therapy and Applied Relaxation Training. Subjects meeting DSM-III-R criteria for Panic Disorder received thirteen 2.5-hr sessions of outpatient therapy in small groups, over a 12-week period. Subjects were given an extensive rationale of the etiology, development and maintenance of Panic Disorder, within the framework of the Cognitive Model of Panic, and controlled behavioral experiments in panic evocation to internal panicogenic cues, cognitive reappraisal of somatic and ideational cues, breathing retraining, Applied Relaxation Training and Cognitive Therapy to identify and remediate maladaptive beliefs and dysfunctional cognitive schemas. A comprehensive assessment battery was given at pre-mid-post-treatment which included measures of tripartite functioning, global severity, panic, fear, anxiety, depression and psychiatric symptomatology. Analyses indicated statistically significant improvements across all outcome domains. All subjects were free of spontaneous (uncued) panic attacks at post-treatment, and all met operationalized criteria for high endstate functioning. These findings are discussed, with recommendations for future research.

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Assessing facial balance before attempting correction of nasal proportions is critical. Modifications of facial structures, which alter perception of the nose, even with seemingly minor disproportion, can do much to enhance final results. Many of these procedures are conceptually simple, rapidly executed, and overwhelmingly gratifying.

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Recent major developments in supercomputer technology are outlined. Areas of interest in biomedical supercomputing that are discussed are: (1) molecular modeling and dynamics; (2) medical imaging and signals processing; (3) modeling and simulation of complex physiological systems; (4) genetic engineering; (5) large-scale database design; and (6) artificial intelligence in medicine.