We studied the effect of insurance coverage on the use of emergency department services, using data from a national trial of cost sharing in health insurance. A total of 3973 persons below the age of 62 years were randomly assigned to fee-for-service health insurance plans with coinsurance rates of 0, 25, 50, or 95 per cent, subject to an income-related upper limit on out-of-pocket expenses. Persons with no cost sharing had emergency department expenses that were 42 per cent higher than those for persons on the 95 per cent plan (P less than 0.01) and about 16 per cent higher than those for persons with smaller amounts of cost sharing. Without cost sharing, emergency department visits for less serious diagnoses (e.g., abrasions) increased three times as much as did visits for more serious diagnoses (e.g., lacerations). After control for insurance, persons in the lower third of the income distribution had emergency department expenses that were 64 per cent higher than those in the upper third (P less than 0.001) and received a greater proportion of their ambulatory care in the emergency department. We conclude that the absence of cost sharing results in significantly greater emergency department use than does insurance with cost sharing. A disproportionate amount of the increased use involves less serious conditions.

This study evaluates six different techniques with respect to their ability to quantitatively describe facial asymmetry in three dimensions. Three-dimensional facial images were acquired using a Cyberware 3030RGB laser surface scanner. Image processing was performed on a Silicon Graphics Indigo computer workstation. The following techniques for facial asymmetry analysis were developed: asymmetry in the location of anthropometric landmarks, Euclidean distance matrix analysis (EDMA), scalar measurement of the lower ciliary margin and palpebral fissure area, clearance vector mapping, and determination of the volume of asymmetry. Techniques were applied and validated in three anthropometric models: a perfectly symmetrical plastic head model and a plaster head model with and without a unilateral cheek augmentation. In each of the anthropometric test models, each analytical technique was validated by means of static anthropometric facial models and was evaluated for intraobserver and interobserver reliability. Asymmetries in the location of anthropometric landmarks can be accurately determined to within 2 mm in x, y, and z directions of the Cartesian space. EDMA is a useful technique in describing both size and shape changes of discrete areas of the face. Measurement of the lower ciliary margin and palpebral fissure area is reliable. Clearance vector mapping is especially useful in quantifying facial surface asymmetries in facial areas where anthropometric landmarks are scarce. Volume of asymmetry is potentially useful in those patients for whom the use of injections or implants of known volume may be helpful in correcting unilateral facial deficiencies.

A 5-week premature infant boy with tumorous malformations underwent biopsy of two truncal masses and exenteration of the left orbit. Specimens were examined histologically. Histologic reports, slides, and clinical photographs were reviewed. A diagnosis of malignant rhabdoid tumor was made. Malignant rhabdoid tumors can present as local or disseminated neoplastic disease involving the orbit and should be considered in the differential diagnosis of rapidly progressing orbital lesions presenting in early infancy. We review the current classification of rhabdoid tumors and the previous literature on orbital rhabdoid tumors.

At physiologic airflow rates in a cadaveric model, medialization laryngoplasty implants of 11 mm or less seem to have no obvious effect on airway resistance.