Effets du stress sur l'évolution des représentations parentales au cours des 12 premiers mois de vie d'un enfant né avec une fente faciale = Stress influence on parental representations' development during the first year of a child born with a facial cleft

La venue au monde d'un enfant avec une fente faciale constitue un événement stressant, voire traumatique, pour les parents. Que ce soit à travers le risque de symptômes associés, la logistique d'alimentation ou par simples raisons d'esthétisme, de nombreuses personnes vivent l'annonce de la présence d'une fente faciale comme une intrusion brutale dans le vécu de la grossesse et une interruption momentanée de l'investissement représentationnel du foetus. À travers notre recherche, nous montrons qu'un haut stress n'influe pas forcément négativement sur le développement de la relation entre le parent et l'enfant et que, au contraire, dans le cas des pères, il peut contribuer à l'implication émotionnelle envers le bébé. Le moment de l'annonce de la malformation a aussi une importance dans les représentations à propos de l'enfant puisque si elle est faite durant la période prénatale, elle permet aux parents un réarrangement des représentations afin de mieux accueillir le bébé le jour de sa naissance. The birth of a child with a facial cleft is often seen as a very stressing event for both parents. Risks of comorbidity, difficulty in nutrition or just aesthetical reasons are frequently invoked while describing this moment. The announcement of the deformation is felt like a brutal intrusion in representations associated to pregnancy. Then, we can observe a kind of disinvestment of the coming baby. Through our study, we find that high stress has not always a bad issue on relationship between parents and infants. In contrary, this kind of chronic stress can preserve the well-being of the relationship, especially for fatherhood. The time of facial deformation announcement also plays its part in representations about the baby. Before birth, it opens room for reordering and modifying representations, then the baby will be accepted as it should be on his birthday.

Cost-effectiveness of surgery in low- and middle-income countries: a systematic review.

BACKGROUND: There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions. METHODS: PubMed and EMBASE were searched using single and combinations of the search terms "disability adjusted life year" (DALY), "quality adjusted life year," "cost-effectiveness," and "surgery." Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies. RESULTS: Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06-$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88-$78.18), male circumcision (cost/DALY averted range US$7.38-$319.29), emergency cesarean section (cost/DALY averted range US$18-$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44-$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78-$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00-$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00). CONCLUSIONS: Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.

Endoscopic laryngotracheal cleft repair without tracheotomy or intubation.

OBJECTIVES: The objectives of this study are to present the technique and results of endoscopic repair of laryngotracheoesophageal clefts (LTEC) extending caudally to the cricoid plate into the cervical trachea and to revisit the classification of LTEC. METHODS: The authors conducted a retrospective case analysis consisting of four infants with complete laryngeal clefts (extending through the cricoid plate in three cases and down into the cervical trachea in one case) treated endoscopically by CO2 laser incision of the mucosa and two-layer endoscopic closure of the cleft without postoperative intubation or tracheotomy. RESULTS: All four infants resumed spontaneous respiration without support after a mean postoperative period of 3 days with continuous positive airway pressure (CPAP). They accepted oral feeding within 5 postoperative days (range, 3-11 days). No breakdown of endoscopic repair was encountered. After a mean follow up of 48 months (range, 3 mos to 7 y), all children have a good voice, have no sign of residual aspiration, but experience a slight exertional dyspnea. CONCLUSION: This limited experience on the endoscopic repair of extrathoracic LTEC shows that a minimally invasive approach sparing the need for postoperative intubation or tracheotomy is feasible and safe if modern technology (ultrapulse CO2 laser, endoscopic suturing, and postoperative use of CPAP in the intensive care unit) is available.

Saimiri sciureus' hard palate morphology

Primate order includes around 180 species. Morphological aspects of New World non-human primates (NHP) have been extensively investigated since last century. General commonsense describes oral cavity adaptations according to diet and feeding, dentition, tongue projection and head shape. Morphological appearance and dimension of the hard palate have been outstanding as interest in many species including man. Six young Saimiri sciureus hard palate were investigated. We measured the hard palate distance (HL), intercanine distance (ICD), intermolar distance (IMD), and interpremolar distance (IPD). Complete and incomplete palatine crests were quantified. We believe that better understanding of the mouth roof morphology will contribute to improve the management of captive animal's diet in order to re-introduce the animals in its habitat.

Delleman syndrome in a Brazilian boy

We report on a Brazilian boy, born to normal and nonconsanguineous parents and presenting facial asymmetry, hypotonia, cerebral anomalies, bilateral anophthalmia, supraorbital cysts, skin tags, cleft lip and palate, micrognatia, glossoptosis, cryptorchidism, and genital hypoplasia.

MSX1 gene and nonsyndromic oral clefts in a Southern Brazilian population

Nonsyndromic oral clefts (NSOC) are the most common craniofacial birth defects in humans. The etiology of NSOC is complex, involving both genetic and environmental factors. Several genes that play a role in cellular proliferation, differentiation, and apoptosis have been associated with clefting. For example, variations in the homeobox gene family member MSX1, including a CA repeat located within its single intron, may play a role in clefting. The aim of this study was to investigate the association between MSX1CA repeat polymorphism and NSOC in a Southern Brazilian population using a case-parent triad design. We studied 182 nuclear families with NSOC recruited from the Hospital de Clínicas de Porto Alegre in Southern Brazil. The polymorphic region was amplified by the polymerase chain reaction and analyzed by using an automated sequencer. Among the 182 families studied, four different alleles were observed, at frequencies of 0.057 (175 bp), 0.169 (173 bp), 0.096 (171 bp) and 0.67 (169 bp). A transmission disequilibrium test with a family-based association test (FBAT) software program was used for analysis. FBAT analysis showed overtransmission of the 169 bp allele in NSOC (P=0.0005). These results suggest that the CA repeat polymorphism of theMSX1 gene may play a role in risk of NSOC in populations from Southern Brazil.

The effect of cleft lip on cognitive development in school-aged children: a paradigm for examining sensitive period effects

Background:  Our previous investigation showed that infants with cleft lip who had undergone late (three-month) surgical repair (but not those with early, neonatal, repair) had significantly poorer cognitive development at 18 months than a group of unaffected control children. These differences were mediated by the quality of early mother–infant interactions. The present study examined whether this pattern persisted into later childhood. Method:  At 7 years, 93 index (44 early, and 49 late repair) and 77 control children were followed up and their cognitive development assessed (IQ, language and school achievements). Results:  Index children (particularly those with late lip repair) scored significantly lower than controls on tests of cognitive development. Group differences in Verbal IQ were mediated by 2 months’ maternal sensitivity; this was associated with 7-year Verbal IQ, even after controlling for later mother–child interactions. Conclusions:  Social interactions in the first few months may be of especial importance for child cognitive development. Interventions for infants with cleft lip should be directed at fostering the best possible parental care in infancy.

The role of negative maternal affective states and infant temperament in early interactions between infants with cleft lip and their mothers

OBJECTIVES: The study examined the early interaction between mothers and their infants with cleft lip, assessing the role of maternal affective state and expressiveness and differences in infant temperament. METHODS: Mother-infant interactions were assessed in 25 2-month-old infants with cleft lip and 25 age-matched healthy infants. Self-report and behavioral observations were used to assess maternal depressive symptoms and expressions. Mothers rated infant temperament. RESULTS: Infants with cleft lip were less engaged and their mothers showed more difficulty in interaction than control group dyads. Mothers of infants with cleft lip displayed more negative affectivity, but did not report more self-rated depressive symptoms than control group mothers. No group differences were found in infant temperament. CONCLUSIONS: In order to support the mother's experience and facilitate her ongoing parental role, findings highlight the importance of identifying maternal negative affectivity during early interactions, even when they seem have little awareness of their depressive symptoms.

ESR and EISCAT observations of the response of the cusp and cleft to IMF orientation changes

We report observations of the cusp/cleft ionosphere made on December 16th 1998 by the EISCAT (European incoherent scatter) VHF radar at Tromso and the EISCAT Svalbard radar (ESR). We compare them with observations of the dayside auroral luminosity, as seen by meridian scanning photometers at Ny Alesund and of HF radar backscatter, as observed by the CUTLASS radar. We study the response to an interval of about one hour when the interplanetary magnetic field (IMF), monitored by the WIND and ACE spacecraft, was southward. The cusp/cleft aurora is shown to correspond to a spatially extended region of elevated electron temperatures in the VHF radar data. Initial conditions were characterised by a northward-directed IMF and cusp/cleft aurora poleward of the ESR. A strong southward turning then occurred, causing an equatorward motion of the cusp/cleft aurora. Within the equatorward expanding, southward-IMF cusp/cleft, the ESR observed structured and elevated plasma densities and ion and electron temperatures. Cleft ion fountain upflows were seen in association with elevated ion temperatures and rapid eastward convection, consistent with the magnetic curvature force on newly opened held lines for the observed negative IMF B-y. Subsequently, the ESR beam remained immediately poleward of the main cusp/cleft and a sequence of poleward-moving auroral transients passed over it. After the last of these, the ESR was in the polar cap and the radar observations were characterised by extremely low ionospheric densities and downward field-aligned flows. The IMF then turned northward again and the auroral oval contracted such that the ESR moved back into the cusp/cleft region. For the poleward-retreating northward-IMF cusp/cleft, the convection flows were slower, upflows were weaker and the electron density and temperature enhancements were less structured. Following the northward turning, the bands of high electron temperature and cusp/cleft aurora bifurcated, consistent with both subsolar and lobe reconnection taking place simultaneously. The present paper describes the large-scale behaviour of the ionosphere during this interval, as observed by a powerful combination of instruments. Two companion papers, by Lockwood et al. (2000) and Thorolfsson et al. (2000), both in this issue, describe the detailed behaviour of the poleward-moving transients observed during the interval of southward B-z, and explain their morphology in the context of previous theoretical work.

Plasma structure within poleward-moving cusp/cleft auroral transients: EISCAT Svalbard radar observations and an explanation in terms of large local time extent of events

We report high-resolution observations of the southward-IMF cusp/cleft ionosphere made on December 16th 1998 by the EISCAT (European incoherent scatter) Svalbard radar (ESR), and compare them with observations of dayside auroral luminosity, as seen at a wavelength of 630 nm by a meridian scanning photometer at Ny Alesund, and of plasma flows, as seen by the CUTLASS (co-operative UK twin location auroral sounding system) Finland HF radar. The optical data reveal a series of poleward-moving transient red-line (630 nm) enhancements, events that have been associated with bursts in the rate of magnetopause reconnection generating new open flux. The combined observations at this time have strong similarities to predictions of the effects of soft electron precipitation modulated by pulsed reconnection, as made by Davis and Lockwood (1996); however, the effects of rapid zonal flow in the ionosphere, caused by the magnetic curvature force on the newly opened field lines, are found to be a significant additional factor. In particular, it is shown how enhanced plasma loss rates induced by the rapid convection can explain two outstanding anomalies of the 630 nm transients, namely how minima in luminosity form between the poleward-moving events and how events can re-brighten as they move poleward. The observations show how cusp/cleft aurora and transient poleward-moving auroral forms appear in the ESR data and the conditions which cause enhanced 630 nm emission in the transients: they are an important first step in enabling the ESR to identify these features away from the winter solstice when supporting auroral observations are not available.

Coherent EISCAT Svalbard Radar spectra from the dayside cusp/cleft and their implications for transient field-aligned currents

Naturally enhanced incoherent scatter spectra from the vicinity of the dayside cusp/cleft, interpreted as being due to plasma turbulence driven by short bursts of intense field-aligned current, are compared with high-resolution narrow-angle auroral images and meridian scanning photometer data. Enhanced spectra have been observed on many occasions in association with nightside aurora, but there has been only one report of such spectra seen in the cusp/cleft region. Narrow-angle images show considerable change in the aurora on timescales shorter than the 10-s radar integration period, which could explain spectra observed with both ion lines simultaneously enhanced. Enhanced radar spectra are generally seen inside or beside regions of 630-nm auroral emission, indicative of sharp F region conductivity gradients, but there appears also to be a correlation with dynamic, small-scale auroral forms of order 100 m and less in width.

Reconfiguration and closure of lobe flux by reconnection during northward IMF: possible evidence for signatures in cusp/cleft auroral emissions

Observations are presented of the response of the dayside cusp/cleft aurora to changes in both the clock and elevation angles of the interplanetary magnetic field (IMF) vector, as monitored by the WIND spacecraft. The auroral observations are made in 630 nm light at the winter solstice near magnetic noon, using an all-sky camera and a meridian-scanning photometer on the island of Spitsbergen. The dominant change was the response to a northward turning of the IMF which caused a poleward retreat of the dayside aurora. A second, higher-latitude band of aurora was seen to form following the northward turning, which is interpreted as the effect of lobe reconnection which reconfigures open flux. We suggest that this was made possible in the winter hemisphere, despite the effect of the Earth's dipole tilt, by a relatively large negative X component of the IMF. A series of five events then formed in the poleward band and these propagated in a southwestward direction and faded at the equatorward edge of the lower-latitude band as it migrated poleward. It is shown that the auroral observations are consistent with overdraped lobe flux being generated by lobe reconnection in the winter hemisphere and subsequently being re-closed by lobe reconnection in the summer hemisphere. We propose that the balance between the reconnection rates at these two sites is modulated by the IMF elevation angle, such that when the IMF points more directly northward, the summer lobe reconnection site dominates, re-closing all overdraped lobe flux and eventually becoming disconnected from the Northern Hemisphere.

The source population for the cusp and cleft/LLBL for southward IMF

The distinction between plasma properties in different dayside regions in the Earth's magnetosphere is of strong interest as it is often indicative of specific physical processes. This is certainly true for the distinction between low latitude boundary layer (LLBL) and cusp plasma, which has been attributed to the effects of plasma diffusion across the magnetopause (LLBL) versus more direct entry of magnetosheath plasma(cusp). It is also the case, however, that quite different plasma regions can result more simply from a common source plasma, and from different stages of temporal evolution of the plasma associated with magnetospheric convection. In this paper, we show that, for southward interplanetary magnetic field (IMF) conditions, the distinction between the cusp and cleft/LLBL at low altitudes may result from;the single process of magnetosheath plasma entry into the magnetosphere on reconnected field lines. The different plasma characteristics of the two regions result from the properties of the source magnetosheath ion distribution and the effects of magnetic reconnection. Using well known properties of the magnetosheath, several predictions concerning the cusp and cleft/ LLBL precipitation are readily derived.

Variability of dayside convection and motions of the cusp/cleft aurora

We present measurements of the ionospheric plasma flow over the range of invariant latitudes 71–76°, observed at 10-second resolution using both the EISCAT radars, with simultaneous observations of the 630 nm cusp/cleft aurora made by a meridian-scanning photometer at Ny Ålesund, Svalbard. A major increase in the trans-auroral voltage from 5 to 40 kV (associated with sunward convection in the early afternoon sector) is found to follow a southward motion of the aurora and coincide with the onset of regular transient auroral breakup events. It is shown that these observations are consistent with recent theoretical work on how ionospheric flows are excited by time-dependent reconnection at the dayside magnetopause.