Access Deficit Research Articles

Cognitive advantages and disadvantages in early and late bilinguals.

Previous research has documented advantages and disadvantages of early bilinguals, defined as learning a 2nd language by school age and using both languages since that time. Relative to monolinguals, early bilinguals manifest deficits in lexical access but benefits in executive function. We investigated whether becoming bilingual after childhood (late bilinguals) can produce the cognitive advantages and disadvantages typical of early bilinguals. Participants were 30 monolingual English speakers, 30 late English-Spanish bilinguals, and 30 early Spanish-English bilinguals who completed a picture naming task (lexical access) and an attentional network task (executive function). Late and early bilinguals manifested equivalent cognitive effects in both tasks, demonstrating lexical access deficits and executive function benefits. These findings provide support for the hypothesis that cognitive effects associated with bilingualism arise as the result of proficient, habitual use of 2 languages and not of developmental changes associated with becoming bilingual during childhood.

Verb processing in Basque and French agrammatic aphasia: A “post-lexical access” deficit

Background: Verb processing is largely described across languages as being impaired in agrammatic aphasia, i.e., non-fluent aphasia with so-called “telegraphic style”. Although both lexical and morphosyntactic errors have been reported in the literature, this paper questions the claim that impaired access to verbs is a hallmark of this clinical syndrome.Aims: The present study aims to assess how agrammatic verb processing is impaired in two languages with distinct grammatical properties: Basque and French, and to test hypotheses that suggested an access deficit to verbs on this new database. Moreover, the nature of agrammatic verb errors is analysed from an interdisciplinary neuropsycholinguistic perspective according to which aphasic symptoms should be interpretable at different levels of organisation of language processing involving neural, cognitive and linguistic aspects.Methods & Procedures: A protocol built on Basque and French grammatical properties was designed in order to assess whether errors are specific to verbs, whether they are lexical or morphosyntactic and whether the verb argument structure complexity increases lexical and morphosyntactic processing difficulties, in both production and comprehension. One Basque-speaking and one French-speaking patient with agrammatism and matched controls were assessed on various oral tasks (object and action naming; sentence production and comprehension; prepositional phrase production), each of them containing 20 pictures displayed on a computer. Data were collected using a digital recorder.Outcomes & Results: Results show that agrammatic speakers produced many lexical verbs of every argument structure type. Errors were specifically morphosyntactic and increased with the verb argument structure complexity. However, verb errors were different in Basque and French due to their distinct morphosyntactic properties. In addition, whereas errors appeared in French in the use of prepositions, case morphology was well preserved in Basque, raising the issue of considering distinct neurocognitive mechanisms underlying different morphological systems.Conclusions: This paper supports the view that Basque and French agrammatic data collected from this study do not result from a lexical-access deficit. However, this interpretation depends on how one considers inflected verbs to be processed (endolexicon or exolexicon), as addressed in the discussion. In conclusion, a “post-lexical access” deficit is rather suggested, that is prior to morphophonological encoding, and affects abstract morphosyntactic operations required to implement the verb argument structure.

Déficit de acesso a serviços de saneamento ambiental: evidências de uma Curva Ambiental de Kuznets para o caso dos municípios brasileiros?

O presente estudo avaliou a existência de uma Curva Ambiental de Kuznets (CAK) para o caso dos déficits municipais de acesso a serviços de saneamento ambiental, que podem ser considerados como medidas indiretas de degradação ambiental. Os resultados obtidos sinalizam, de uma maneira geral, a existência de uma relação entre os déficits de acesso e o desenvolvimento econômico no formato de um "N" e não no tradicional formato de um "U invertido" da CAK. Portanto, para o caso específico dos serviços de saneamento ambiental nos municípios brasileiros, a hipótese de que o desenvolvimento econômico seria a melhor solução para a preservação ambiental não é verdadeira, uma vez que, ao longo do tempo, o desenvolvimento econômico voltaria a gerar degradação ambiental.

Suburbia under an Energy Transition: A Socio-technical Perspective

This paper assesses the effects on suburbia of an energy transition to less carbon- or petroleum-intensive energy urban forms using a socio-technical theoretical perspective. The paper argues that while suburbia is the predominant form of urbanisation in advanced nations, especially North America and Australia, its socio-technical composition is insufficiently understood by urban scholars. Using a socio-technical theoretical perspective, the paper argues that suburbia should be seen a complex ‘assemblage’ that is configured through socio-material relations of land use, transport technology, energy and money credit. This system is also differentiated by social status and infrastructure access deficits. The paper argues that suburbia faces a number of socio-technical challenges from an energy transition principally due to heavy mobility reliance on motor vehicles. The paper sets out some potential trajectories of transformation for suburbia under an energy transition.

Using mixed methods to analyse barriers to primary paediatric health access

This paper describes the way in which a mixed methods approach might provide a knowledge base to understand some of the factors involved in access to paediatric healthcare. The paper addresses the potential for this approach to start to build an evidence-informed understanding of a public policy issue. Our research tracked the increase in paediatric presentations at the Woman's and Children's Health Service Emergency Department (ED) in South Australia for primary care illness events. The use of ED for primary care services is an increasing issue for emergency service provision. The mixed methods used the Hospital Admission Status (HAS), Paediatric ED data, analysis of the South Australian Social Health Atlas for demographic and epidemiological data, and triage priority information. This quantitative analysis informed the use of interviews with parents, community health providers and emergency health professionals. Sequencing allowed the researchers to integrate the question over time and revealed policy deficits in health access in Australia.

Numerical matching judgments in children with mathematical learning disabilities

Both deficits in the innate magnitude representation (i.e. representation deficit hypothesis) and deficits in accessing the magnitude representation from symbols (i.e. access deficit hypotheses) have been proposed to explain mathematical learning disabilities (MLD). Evidence for these hypotheses has mainly been accumulated through the use of numerical magnitude comparison tasks. It has been argued that the comparison distance effect might reflect decision processes on activated magnitude representations rather than number processing per se. One way to avoid such decisional processes confounding the numerical distance effect is by using a numerical matching task, in which children have to indicate whether two dot-arrays or a dot-array and a digit are numerically the same or different. Against this background, we used a numerical matching task to examined the representation deficit and access deficit hypotheses in a group children with MLD and controls matched on age, gender and IQ. The results revealed that children with MLD were slower than controls on the mixed notation trials, whereas no difference was found for the non-symbolic trials. This might be in line with the access deficit hypothesis, showing that children with MLD have difficulties in linking a symbol with its quantity representation. However, further investigation is required to exclude the possibility that children with MLD have a deficit in integrating the information from different input notations.

Effects of phonological and semantic deficits on facilitative and inhibitory consequences of item repetition in spoken word comprehension

Repeating a word can have both facilitative and inhibitory effects on subsequent processing. The present study investigated these dynamics by examining the facilitative and inhibitory consequences of different kinds of item repetition in two individuals with aphasia and a group of neurologically intact control participants. The two individuals with aphasia were matched on overall aphasia severity, but had deficits at different levels of processing: one with a phonological deficit and spared semantic processing, the other with a semantic deficit and spared phonological processing. Participants completed a spoken word-to-picture matching task in which they had to pick which of four object images matched the spoken word. The trials were grouped into pairs such that exactly two objects from the first trial in a pair were present on screen during the second trial in the pair. When the second trial's target was the same as the first trial's target, compared to control participants, both participants with aphasia exhibited equally larger repetition priming effects. When the second trial's target was one of the new items, the participant with a phonological deficit exhibited a significantly more negative effect (i.e., second trial response slower than first trial response) than the control participants and the participant with a semantic deficit. Simulations of a computational model confirmed that this pattern of results could arise from (1) normal residual activation being functionally more significant when overall lexical processing is slower and (2) residual phonological activation of the previous trial's target having a particularly strong inhibitory effect specifically when phonological processing is impaired because the task was phonologically-driven (the spoken input specified the target). These results provide new insights into perseveration errors and lexical access deficits in aphasia.

Masked repetition priming effects on naming in aphasia: A Phase I treatment study

Background: It has been suggested that lexical access deficits in aphasia may be the result of impaired automatic activation of the networks that support language processing, a system that operates implicitly, outside conscious awareness. This raises the question of whether there might be a way to address rebuilding these implicit networks directly, rather than through the explicit treatment protocols that are typical of aphasia therapy. Masked priming is one method by which the language system can be automatically activated, while limiting or preventing the influence of conscious, explicit processing. Aims: This Phase I study was undertaken to investigate the potential effectiveness of masked repetition priming as a treatment for anomia. Methods & Procedures: This study used a single-participant, ABA, multiple-baseline repeated-probe design. A total of 22 training sessions were completed across 4 weeks. Training involved repeated presentation of masked repetition primes paired with target pictures prior to attempts at naming those pictures. Untrained items were presented an equal number of times, but without prime words. Repeated naming probes administered before, during, and after treatment were used to measure effects of training (naming trained stimuli) and generalisation (naming within and across semantic categories). Pre- and post-training assessment with broader tests of language function and conversation were also completed. Outcomes & Results: Results revealed a small effect of training on naming of trained items in one category, as well as a pattern of improvement in the other category that did not quite meet the criterion for a small effect. There was also a medium cross- category generalisation effect, although no generalisation effect was seen to untrained items within semantic categories. Improvements were seen on some measures of general language function. Conclusions: Masked priming can elicit changes in naming ability over time, and may have potential as a tool for improving word retrieval in individuals with anomia. Results warrant further investigation.

Cogenerating electricity from charcoaling: A promising new advanced technology

This article presents a technical review of the status of the charcoal cogeneration technologies. Cogeneration of electricity from charcoal production is an emerging technology, with promising worldwide application. When charcoal is produced through traditional slow pyrolysis batch cycle processes, about 50% of the original firewood energy is lost through the pyrolysis gases. These gases are made of condensable and non-condensable portions. The condensable fraction consists of an energy-rich mix of compounds that can be extracted through condensation. The non-condensable fractions consist of flammable gases such as CO, H2 and CH4, which can used to produce heat and power, either using steam cycle systems, or other technologies such as Stirling engines or even ECGT (External Combustion Gas Turbines). Several companies in Brazil, France, Denmark and Australia are currently pursuing the development of charcoal cogeneration. To overcome the usual instability in the availability of energy from pyrolysis gases when charcoaling in batch cycles, most companies are developing charcoal production units that cluster several charcoal kilns together, operating them in a staggered sequence, in order to stabilize the energy output from the system. Furthermore the usage of complementary fuels such as biomass residues or other petroleum fuels is investigated, to help stabilize cogeneration and increase power output. As this technology develops, it could offer several benefits including entrepreneurial opportunities, livelihood diversification and increased incomes in rural areas for charcoal entrepreneurs, as well as reduction of greenhouse gases emissions and additional renewable energy capacity. Sub-Saharan Africa, the leading charcoal production region in the world, suffers acute deficits in electricity access, and could benefit from this technology. However to enable such technology to flourish in the future, an appropriate legal framework and business model should be specifically developed for each country.

Symbolic and Non-Symbolic Number Magnitude Processing in Children with Developmental Dyscalculia

The aim of this study was to evaluate if children with Developmental Dyscalculia (DD) exhibit a general deficit in magnitude representations or a specific deficit in the connection of symbolic representations with the corresponding analogous magnitudes. DD was diagnosed using a timed arithmetic task. The experimental magnitude comparison tasks were presented in non-symbolic and symbolic formats. DD and typically developing (TD) children showed similar numerical distance and size congruity effects. However, DD children performed significantly slower in the symbolic task. These results are consistent with the access deficit hypothesis, according to which DD children's deficits are caused by difficulties accessing magnitude information from numerical symbols rather than in processing numerosities per se.

National health policy, the need of the hour: an analysis in Indian perspective

PurposeThe national health policy should strive towards achieving the concept of “healthcare for all” conceptualized by the World Health Organization (WHO) through health insurance scheme. The purpose of this paper is to identify and discuss the various gaps affecting the health care systems and to evolve strategic issues in health care in India through an exploratory survey.Design/methodology/approachThe main thrust is to analyze the problems of India's health care system and review of related literature, to identify the areas in the field of healthcare and health insurance which are unexplored or need to be tapped. This evaluation would give ample data to reinforce these areas and would lead us ultimately to the pre‐set target of WHO.FindingsIndia's march to prosperity faces a serious risk of slowing down due to the main reason – lack of proper access to health care due to the absence of a well laid out public policy. Therefore, the key stakeholders of the health insurance industry jointly need to build a robust health insurance system and help to bridge the gap that exists in reaching quality healthcare in India. A review of the health policy for modifications and to implement it successfully through health insurance without road blocks is called for.Practical implicationsThe results of this study, it is hoped, will outline equity in health care, which matters to every Indian citizen and how it can be achieved in India.Originality/valueThis paper suggests the adoption of an approach of management science called the gaps model of service quality in dealing with India's healthcare system problems, a new indicator aimed at assessment of the deficit in access to health services through a structured integrated way. The strategy takes account of the significant gaps identified to suggest new pragmatic methods to close the gaps.

Number magnitude processing and basic cognitive functions in children with mathematical learning disabilities

The study sought out to extend our knowledge regarding the origin of mathematical learning disabilities (MLD) in children by testing different hypotheses in the same samples of children. Different aspects of cognitive functions and number processing were assessed in fifth- and sixth-graders (11–13years old) with MLD and compared to controls. The MLD group displayed weaknesses with most aspects of number processing (e.g., subitizing, symbolic number comparison, number-line estimation) and two cognitive functions (e.g., visual–spatial working memory). These findings favor the defective approximate number system (ANS) hypothesis, but do not fit well with the access deficit hypothesis. Support is also provided for the defective object-tracking system (OTS) hypothesis, the domain general cognitive deficit hypothesis and to some extent the defective numerosity-coding hypothesis. The study suggests that MLD might be caused by multiple deficits and not a single core deficit.

Access regulation with asymmetric termination costs

In many telecommunications markets incumbent providers enjoy a demand-side advantage over any entrant. However, market entrants may enjoy a supply-side advantage over the incumbent, since they are more efficient or operate on innovative technologies. Considering both a supply-side and a demand-side asymmetry, the present model analyzes the effect of two regulatory regimes: an access markup for a low cost network and reciprocal charges below the costs of a high cost network. Both regimes may have adverse effects on subscribers, market shares, and profits. It can be shown that an access markup is not generally beneficial and an access deficit not generally detrimental for the respective networks.

Die Klagebefugnis von Umweltverbänden unter Anpassungsdruck des Völker- und Europarechts

The Access to Court for Environmental Organisations under the Impact of Public International Law and European Union Law The Aarhus Convention requires its parties, among them the EU and almost all of its Member States, to facilitate access to justice for NGOs promoting environmental protection. However, both the conditions under German law for bringing a claim to the German administrative courts and the prerequisites under primary EU law for taking a case to the Union judicature fall short of this requirement. This is all the more astonishing since the CJEU is traditionally perceived as being more prone to admitting individual claims than the German jurisprudence. The current article seeks to explore the background of the access deficits established for the respective legal order. In the EU part, it offers for the first time a comprehensive analysis of the effects, with respect of NGOs promoting environmental protection, of the widening of direct access to Union courts for natural and legal persons brought about by the Treaty of Lisbon.

“Acute concerns”: is the mental health workforce equipped and supported to meet complex needs?

PurposeThe focus of this paper is to consider the findings of a survey, which aims to identify the types of training that acute mental health staff could access, in relation to workforce development and substance misuse issues in acute mental health care.Design/methodology/approachAn electronic survey was developed and distributed using work email lists to all clinicians who worked in acute mental health services across a region in England. Not all NHS organisations agreed to participate.FindingsA total of 89 clinicians responded to the survey, some failed to indicate their consent, therefore the results of the 77 that did are presented. The main finding was that most acute care staff had only accessed mandatory training such as risk assessment. Many staff had not been trained in the use of psychosocial approaches. Drug and alcohol specific activities were performed on the whole only “sometimes”.Research limitations/implicationsIt was not possible to determine the total number of potentially eligible staff who were sent the survey, therefore, response rates cannot be calculated. It is possible that the findings may not be generalisable to other services. There may be bias in those who choose to respond to an electronic email, in terms of those who had access to a computer or who were more IT literate. In addition, the survey did not specifically set out to examine substance misuse issues as its main focus.Practical implicationsAcute care staff work with service users with increasingly complex needs. Creative and cost effective ways of facilitating access to training and support must be found as a priority to ensure that staff have the competencies to identify and manage substance users effectively in acute mental health settings.Originality/valueThe findings reinforce previous studies highlighting the deficit in access to psychosocial interventions training for acute care staff.

Different patterns of spoken and written word comprehension deficit in aphasic stroke patients

This study presents neuropsychological evidence for differences in the semantic representations underpinning spoken and written word comprehension. Potential modality-based discrepancies in the semantic system were examined by testing whether spoken word (auditory–verbal input) and written word (visual–verbal input) comprehension exhibited the same effect profile on variables typically used to distinguish so-called access and storage disorders (e.g., response consistency, sensitivity to item frequency). The study was based on the premise that damage to a common set of semantic representations should have an equivalent impact upon comprehension performance irrespective of input modality, whereas damage to partially dissociable semantic representations may give rise to different qualities of deficit (access/storage) in the comprehension of stimuli presented in different input modalities (spoken/written). The study involved two patients with global aphasia following left middle cerebral artery stroke (F.B.I. and H.O.P.). The two patients showed matched performance on conventional tests of single word comprehension with clear evidence of semantic impairment for stimuli presented in both the spoken and written input modalities. However, in H.O.P., spoken and written word comprehension was affected in the same way by variations in stimulus category, frequency, and multiple stimulus presentations, whilst in F.B.I., there were clear differences between input modalities with all three variables. More specifically, F.B.I.'s written word comprehension was significantly affected by category (living > nonliving) and frequency (high > low) but not multiple presentations (single = multiple), more consistent with degradation of stored representations (storage deficit). By contrast, his spoken word comprehension was unaffected by category (living = nonliving) and frequency (high = low) but was affected by multiple presentations (single > multiple; serial position effects), more consistent with impaired access to stored representations (access deficit). These spoken/written input modality differences were observed on tasks matched closely for output modality, stimulus identity, and executive control requirements. It is argued that subtle differences in comprehension performance for stimuli presented in different input modalities may reflect damage to multimodal representations, which are intermediate between unimodal and amodal representations on a continuum of convergence within the semantic system. These ideas are discussed in the context of existing “distributed-only”, “distributed-plus-convergence”, or “distributed-plus-hub” models of conceptual knowledge.

Network Alterations Supporting Word Retrieval in Patients with Medial Temporal Lobe Epilepsy

Although the hippocampus is not considered a key structure in semantic memory, patients with medial-temporal lobe epilepsy (mTLE) have deficits in semantic access on some word retrieval tasks. We hypothesized that these deficits reflect the negative impact of focal epilepsy on remote cerebral structures. Thus, we expected that the networks that support word retrieval tasks would be altered in left mTLE patients. We measured brain activity with fMRI while participants (13 controls, 13 left mTLE, and 13 right mTLE) performed a verb generation task. We examined functional connectivity during this task in relation to language performance on an off-line clinical test of lexical access (Boston Naming Test, BNT). Using task-seed-behavior partial least squares, we identified a canonical language network that was more active during verb generation than the baseline condition, but this network did not correlate with variability in BNT performance in either controls or patients. Instead, additional networks were identified for each group, with more anterior temporal and prefrontal regions recruited for controls and more posterior temporal regions for both left and right mTLE patients. Our findings go beyond the literature emphasizing differences in laterality of language processes in mTLE patients and, critically, highlight how network changes can be used to account for performance variation among patients on clinically relevant measures. This strategy of correlating network changes and off-line behavior may provide a powerful tool for predicting a postoperative decline in language performance.

Lack of semantic priming effects in famous person recognition in Mild Cognitive Impairment

IntroductionGrowing evidence indicates that individuals with Mild Cognitive Impairment (MCI) manifest semantic deficits that are often more severe for items that are characterized by a unique semantic and lexical association, such as famous people and famous buildings, than common concepts, such as objects. However, it is still controversial whether the semantic deficits observed in MCI are determined by a degradation of semantic information or by a deficit in intentional access to semantic knowledge. Here we used a semantic priming task in order to assess the integrity of the semantic system without requiring explicit access to this system. This paradigm may provide new insights in clarifying the nature of the semantic deficits in MCI. MethodsWe assessed the semantic and repetition priming effect in 13 individuals with MCI and 13 age-matched controls who engaged in a familiarity judgment task of famous names. In the semantic priming condition, the prime was the name of a member of the same occupation category as the target (Tom Cruise–Brad Pitt), while in the repetition priming condition the prime was the same name as the target (Charlie Chaplin–Charlie Chaplin). ResultsThe results showed a defective priming effect in MCI in the semantic but not in the repetition priming condition. Specifically, when compared to controls, MCI patients did not show a facilitation effect in responding to the same occupation prime-target pairs, but they showed an equivalent facilitation effect when the target was the same name as the prime. ConclusionThe present results provide support to the hypothesis that the semantic impairments observed in MCI cannot be uniquely ascribed to a deficit in intentional access to semantic information. Instead, these findings point to the semantic nature of these deficits and, in particular, to a degraded representation of semantic information concerning famous people.

'It's risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan.

BackgroundDespite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs).MethodsSemi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors.ResultsStigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included:criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers.ConclusionsApproaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.

Psychological care for maxillofacial trauma patients: A preliminary survey of oral and maxillofacial surgeons

Introduction Psychological morbidities are major complications following maxillofacial injuries. The aim of this study was to assess self-evaluation of oral and maxillofacial surgeons on posttraumatic psychological care. Methods Using a cross-sectional study design, we enrolled a sample of surgeons in 261 oral and maxillofacial surgery (OMFS) departments in the United States, United Kingdom and France. A self-administered e-mail questionnaire was used to evaluate knowledge, attitude and practice of the surgeons regarding psychological problems in maxillofacial injury patients, and their collaboration with psychological personnel. Appropriate descriptive and univariate statistics were computed, and P < 0.05 was considered statistically significant. Results The response rate was 28.1% (112 of 398), but we included only 100 respondents from 107 OMS units. 60% of the surgeons disclosed a moderate or high level of relevant knowledge. Only 28 OMS departments (26.2%) had intra-service psychological staff (commonly in France [ P < 0.05]), and five surgeons revealed considerable deficits in access to psychological care. Frequent reasons for patient referral to psychological staff were depression, body dysmorphic disorder, posttraumatic stress disorder, suicidal idea, anxiety and behavioural changes. Eighty-eight surgeons linked patient’s non-compliance with changes or difficulties in practice, and 58 surgeons experienced it already. Conclusions Despite several limitations, the results of this study suggest that oral and maxillofacial surgeons have a great interest and experience in posttraumatic psychological problems. Psychological professionals in charge will improve surgical care quality. Well-designed studies with larger sample size are desirable to confirm our results. Ethical issues of maxillofacial trauma care are also discussed.