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Rapid eye movement (REM) sleep behavior disorder (RBD) classically presents with repetitive complex motor behavior during sleep with associated dream mentation. The diagnosis requires a history of repetitive complex motor behaviors and polysomnographic demonstration of REM sleep without atonia (RSWA) or capturing dream enactment behaviors. RSWA is best evaluated in the chin or flexor digitorum superficialis muscles. The anterior tibialis muscle is insufficiently accurate to be relied upon solely for RBD diagnosis. RBD may present with parkinsonism or cognitive impairment or may present in isolation. Patients should be monitored for parkinsonism, autonomic failure, or cognitive impairment., Competing Interests: Disclosure Dr Jones and Dr McCarter report no disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: For childhood sexual abuse survivors, cancer care can be retraumatizing because of perceived similarities to the original sexual violence. The authors' group designed and implemented a sensitive practice tool (SPT) and evaluated the feasibility of the tool in female patients receiving breast radiation., Methods: The SPT was offered as a "universal precaution" to patients with breast cancer as part of standard clinical care. Patients were given the SPT, which included an instructional video about radiotherapy and a survey about triggers and preferences. The survey results were provided to radiation therapists and used to personalize patients' care. A retrospective chart review and quality improvement survey of therapists were performed., Results: Of 739 eligible patients, 493 (66.7%) completed the SPT from November 2013 to June 2019. Among respondents, 281 (57.0%) reported potential triggers, 395 (80.1%) reported distress management preferences, and 59 (12.0%) requested psychosocial referrals. Mean patient satisfaction was high, and a majority of patients were likely to recommend the SPT to other patients (85.3%). Among radiation therapists (n = 13), 100% reported that the SPT made it easier to customize or individualize patient care. Trauma disclosure was not significantly associated with increased frequency of trigger endorsement (P = .07) but was associated with increased endorsement of distress management preferences (P = .02) and psychosocial referral requests (P < .001)., Conclusions: The reported experience with the SPT in the breast radiotherapy setting demonstrated that potential triggers and distress management preferences among patients are common and that patient satisfaction with the SPT is high, yielding clinically meaningful and actionable sensitive practice information., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Pharmacy residency recruitment and interviews have been significantly impacted by the COVID-19 pandemic. Many traditional recruitment events and interviews were transitioned from in-person to virtual, and new approaches to recruitment, such as virtual open houses, were developed. There are limited data on how these changes impacted pharmacy residency applicants and programs, and the future of virtual events is currently unknown. We highlight recommendations for virtual recruitment and interviews and provide suggestions for residency programs and national organizations to improve virtual processes in the future., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Partial breast irradiation (PBI) and ultra-hypofractionated whole breast irradiation (uWBI) are contemporary alternatives to conventional and standard hypofractionated whole breast irradiation (WBI), which shorten treatment from 3 to 6 weeks to 1-2 weeks for select patients. PBI and accelerated PBI (APBI) can be delivered with external beam radiation (3D conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT)), intraoperative radiation (IORT), or brachytherapy. These new radiation techniques offer the advantage of convenience and lower cost, which ultimately improves access to care. Globally, the COVID 19 pandemic has accelerated APBI/PBI and ultra-hypofractionated regimens into routine practice for carefully selected patients. Recent long-term data from randomized controlled trials (RCTs) have demonstrated these techniques are safe and effective in suitable patients demonstrating equivalent or improved local recurrence, acute/late toxicity, and cosmesis. PBI and APBI should be limited to low risk unifocal invasive ductal carcinoma and ductal carcinoma in situ with tumor size < 2 cm, clear margins (≥2 mm), ER+, and negative nodes. Based on the results from UK Fast-Forward and UK FAST ultra-hypofractionated breast radiation can be safely employed for early stage node negative patients, but is not yet considered an international standard of care. In this review, authors will appraise recent data for these shorter course radiation treatment regimens, as well as, considerations for breast radiologists including surveillance imaging and radiographic findings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Subclavian/axillary (TAx) access has become the most frequently used alternative access route for transcatheter aortic valve replacement (TAVR). Transcarotid (TC) TAVR has grown in popularity recently. Comparative data between these 2 contemporary access methods is lacking., Methods: Data were extracted from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry™ (June 2015 to October 2019) for patients undergoing TAVR by TC or TAx access with the SAPIEN 3 and SAPIEN 3 Ultra (Edwards Lifesciences, Irvine, CA) transcatheter heart valves. Procedural, index hospitalization, and 30-day outcomes were analyzed for TC vs TAx groups after 1:2 propensity matching of patient baseline characteristics., Results: The study included 3903 cases, of which 801 TC and 3102 TAx procedures were compared. After 1:2 propensity matching, TC TAVR was associated with similar 30-day mortality (4.3% vs 5.2%, P = .34) but a significantly lower risk of stroke (4.2% vs 7.4%; hazard ratio, 0.56; 95% confidence interval, 0.38-0.83; P = .003) compared with TAx access. Other outcomes that favored TC over TAx included shorter procedure time (117.0 vs 132.4 minutes; P < .001) and fluoroscopy time (16.6 vs 21.6 min; P < .001), lower contrast volume (78.5 vs 96.7 mL; P < .001), shorter length of stay in the intensive care unit (24.3 vs 25.0 hours; P = .02) and hospital (2.0 vs 3.0 days; P = .002), and more patients discharged to home (82.9% vs 74.6%; P < .001)., Conclusions: TC TAVR is associated with similar mortality and a significant reduction in stroke compared with the TAx approach. If femoral access is precluded, TC may be a safe, or at times, preferred avenue of transcatheter valve delivery., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Knowledge in infectious diseases (ID) pharmacotherapy and antimicrobial stewardship is becoming increasingly important for pharmacists. Pharmacy schools utilize multiple methods to teach ID pharmacotherapy including advanced pharmacy practice experiences (APPEs)., Methods: An internet-based survey was sent to students currently on APPEs at four colleges/schools of pharmacy. The primary study objective was a comparison of self-perceived ID knowledge and confidence prior to starting and during APPEs. The secondary objectives were to determine the level of self-perceived knowledge and confidence of students who have completed an ID APPE to those who have not, as well as the level of interest in postgraduate year 1 (PGY-1) and ID-specific postgraduate year 2 (PGY-2) residencies., Results: All statements revealed a statistically significant increase in self-perceived ID knowledge and confidence for students during APPEs compared to before starting rotations (p-values < 0.001). Students who completed an ID APPE had an overall increase in both self-perceived knowledge and confidence for all aspects. Completion of an ID APPE enhanced self-perceived knowledge in basic microbiology fundamentals, antimicrobial stewardship principles, and overall ID knowledge. Completion of an ID APPE created a higher level of confidence regarding selecting appropriate antimicrobial therapy, interpreting cultures and susceptibilities to de-escalate, and communicating with other healthcare professionals., Conclusions: Students who completed an ID APPE had a higher level of self-perceived knowledge and confidence than those who had not. Recent increases in demand for antimicrobial stewardship positions warrants maximization of ID and non-ID APPEs to enhance students' knowledge and confidence in infectious diseases., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This report describes the treatment of a 35-year-old male who presented to the emergency department with an empyema, and who had a long hospital course complicated by a catheter-related bloodstream infection and a history of intravenous drug use. Blood culture results confirmed Enterococcus faecalis. He was not a candidate for outpatient intravenous therapy and needed 14days of treatment, but was able to be discharged with a 3-day supply of oral levofloxacin to complete treatment for his empyema and 1 dose of dalbavancin at an outpatient infusion center to treat his bacteremia. Due to the unique properties of dalbavancin, off-label use in specific populations may help facilitate transitions of care. This report outlines the successful use of dalbavancin and removal of the central catheter in the treatment of E. faecalis bacteremia., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The prevalence of bovine trichomonosis (BT) in TN bulls was estimated through both active screening of bulls and review of previous laboratory records. During the active bull screening, preputial smegma specimens were collected from 458 TN beef bulls at 2 cattle slaughterhouses and 2 stockyards, which serve most beef bulls in TN, between March 2014 and June 2015. Each specimen was cultured for Tritrichomonas foetus (T. foetus) as well as evaluated microscopically every other day for seven days for any protozoa resembling T. foetus. An aliquot of the culture media from each specimen was used for DNA extraction and subsequent qPCR testing. Two specimens were considered suspect on microscopic evaluation, but all specimens were negative for T. foetus on qPCR. This suggests that the 2 specimens were most likely contaminated by fecal trichomonads. Retrospectively, 1979 T. foetus test records from 2 major TN diagnostic laboratories were reviewed between October 2013 and September 2016. True prevalence of BT in TN beef bulls was estimated at <0.01% from the laboratory records, although the county prevalence differed in 2 TN counties (Marshal: 0.09% and Bedford: 0.5%). Overall, the prevalence of BT in TN is low, and the current screening efforts to help control BT disease in TN are acceptable. Future efforts should focus on educating cattle stakeholders on the importance of optimal specimen collection and handling as well as routine testing for BT before cattle movement. In addition, cattle producers should be reminded of leading risk factors associated with BT in cattle., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) governs antioxidant, innate immune and cytoprotective responses and its deregulation is prominent in chronic inflammatory conditions. To examine the hypothesis that Nrf2 might be implicated in systemic sclerosis (SSc), we investigated its expression, activity, and mechanism of action in SSc patient samples and mouse models of fibrosis and evaluated the effects of a novel pharmacologic Nrf2 agonist. We found that both expression and activity of Nrf2 were significantly reduced in SSc patient skin biopsies and showed negative correlation with inflammatory gene expression. In skin fibroblasts, Nrf2 mitigated fibrotic responses by blocking canonical transforming growth factor-β (TGF-β)-Smad signaling, whereas silencing Nrf2 resulted in constitutively elevated collagen synthesis, spontaneous myofibroblast differentiation, and enhanced TGF-ß responses. Bleomycin treatment of Nrf2-null mice resulted in exaggerated fibrosis. In wild-type mice, treatment with a novel pharmacologic Nrf2 agonist 2-trifluoromethyl-2'-methoxychalcone prevented dermal fibrosis induced by TGF-β. These findings are the first to identify Nrf2 as a cell-intrinsic antifibrotic factor with key roles in maintaining extracellular matrix homeostasis and a pathogenic role in SSc. Pharmacologic reactivation of Nrf2, therefore, represents a novel therapeutic strategy toward effective treatment of fibrosis in SSc., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Honey bee colonies function as a superorganism, where facultatively sterile female workers perform various tasks that support the hive. Nurse workers undergo numerous anatomical and physiological changes in preparation for brood rearing, including the growth of hypopharyngeal glands (HGs). These glands produce the major protein fraction of a protein- and lipid-rich jelly used to sustain developing larvae. Pollen intake is positively correlated with HG growth, but growth in the first three days is similar regardless of diet, suggesting that initial growth is a pre-determined process while later HG development depends on nutrient availability during a critical window in early adulthood (>3 d). It is unclear whether the resultant size differences in nurse HG are simply due to growth arrest or active degradation of the tissue. To determine what processes cause such differences in HG size, we catalogued the differential expression of both gene transcripts and proteins in the HGs of 8 d old bees that were fed diets containing pollen or no pollen. 3438 genes and 367 proteins were differentially regulated due to nutrition. Of the genes and proteins differentially expressed, undernourished bees exhibited more gene and protein up-regulation compared to well-nourished bees, with the affected processes including salivary gland apoptosis, oogenesis, and hormone signaling. Protein secretion was virtually the only process up-regulated in well-nourished bees. Further assays demonstrated that inhibition of ultraspiracle, one component of the ecdysteroid receptor, in the fat body caused larger HGs. Undernourished bees also had higher acid phosphatase activity, a physiological marker of cell death, compared to well-nourished bees. These results support a connection between poor nutrition, hormonal signaling, and HG degradation., (Published by Elsevier Ltd.)

Irritability is an aspect of the negative affectivity domain of temperament, but in severe and dysregulated forms is a symptom of a range of psychopathologies. Better understanding of the neural underpinnings of irritability, outside the context of specific disorders, can help to understand normative variation but also characterize its clinical salience in psychopathology diagnosis. This study assessed brain activation during reward and frustration, domains of behavioral deficits in childhood irritability. Children (age 6-9) presenting in mental health clinics for extreme and impairing irritability (n = 26) were compared to healthy children (n = 28). Using developmentally sensitive methods, neural activation was measured via a negative mood induction paradigm during fMRI scanning. The clinical group displayed more activation of the anterior cingulate and middle frontal gyrus during reward, but less activation during frustration, than healthy comparison children. The opposite pattern was found in the posterior cingulate. Further, in clinical subjects, parent report of irritability was dimensionally related to decreased activation of the anterior cingulate and striatum during frustration. The results of this study indicate neural dysfunction within brain regions related to reward processing, error monitoring, and emotion regulation underlying clinically impairing irritability. Results are discussed in the context of a growing field of neuroimaging research investigating irritable children., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Early trials involving transcatheter aortic valve replacement raised concerns for an elevated risk of neurologic events compared to surgical AVR. Contemporary studies suggest declining rates with better patient selection, improved operator experience, and newer generation devices. Events are usually embolic in nature, occur in the periprocedural period, and can lead to increased morbidity and mortality. Current investigations are focused on developing embolic protection devices for intraprocedural use and optimizing antiplatelet and anticoagulant regimens. These efforts aim to further reduce the incidence of stroke, which is particularly important as the technology expands to include intermediate and possibly low surgical risk populations., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Matching-to-sample (MTS) is often used to teach symbolic relationships between spoken or printed words and their referents to children with intellectual and developmental disabilities. However, many children have difficulty learning symbolic matching, even though they may demonstrate generalized identity matching. The current study investigated whether training on symbolic MTS tasks in which the stimuli are physically dissimilar but members of familiar categories (i.e., thematic matching) can remediate an individual's difficulty learning symbolic MTS tasks involving non-representative stimuli. Three adolescent males diagnosed with autism spectrum disorder were first trained on symbolic MTS tasks with unfamiliar, non-representative form stimuli. Thematic matching was introduced after the participants failed to learn 0, 2 or 4 symbolic MTS tasks and before additional symbolic MTS tasks were introduced. After exposure to thematic matching, accuracy on symbolic MTS tasks with novel stimuli increased to above chance for all participants. For two participants, high accuracy (> 90%) was achieved on a majority of these sessions. Thus, thematic matching may be an effective intervention for students with limited verbal repertoires and who have difficulty learning symbolic MTS tasks. Possible explanations for the facilitative effect of thematic matching are considered and warrant further investigation.

A 10 year old, 25 kg girl, who was formerly a conjoined twin at the heart, diaphragm, liver, duodenum, bile ducts, and intestine, was admitted for a repeat liver, small bowel, pancreas, and kidney multivisceral transplant after having intestinal and liver failure. Intraoperatively, the patient had excessive bleeding, coagulopathy, and acidosis. Pulse co-oximetry was used for continuous monitoring of hemoglobin (Hb) during the procedure. Although noninvasive Hb appeared to follow a trend that correlated with arterial Hb concentration, it did not show accurate agreement with measured values from intermittent blood gas analysis. It may not be reliable during cases with abnormal physiology, rapid blood loss, and massive transfusion., (Published by Elsevier Inc.)

One of the key classical pathological features of Alzheimer's disease (AD) is the progressive accumulation of amyloid beta (Aβ42) peptides and their coalescence into highly insoluble senile plaque cores. A major factor driving Aβ42 peptide accumulation is the inability of brain cells to effectively clear excessive amounts of Aβ42 via phagocytosis. The trans-membrane spanning, sensor-receptor known as the "triggering receptor expressed in myeloid cells 2" (TREM2; chr6p21) is essential in the sensing, recognition, phagocytosis and clearance of noxious cellular debris from brain cells, including neurotoxic Aβ42 peptides. Recently, mutations in the TREM2 gene have been associated with amyloidogenesis in neurodegenerative diseases including AD. In this report, we provide evidence that aluminum-sulfate, when incubated with microglial cells, induces the up-regulation of an NF-кB-sensitive micro RNA-34a (miRNA-34a; chr1p36) that is known to target the TREM2 mRNA 3'-untranslated region (3'-UTR), significantly down-regulating TREM2 expression. The aluminum-induced up-regulation of miRNA-34a and down-regulation of TREM2 expression were effectively quenched using the natural phenolic compound and NF-kB inhibitor CAPE [2-phenylethyl-(2E)-3-(3,4-dihydroxyphenyl) acrylate; caffeic-acid phenethyl ester]. These results suggest, for the first time, that an epigenetic mechanism involving an aluminum-triggered, NF-kB-sensitive, miRNA-34a-mediated down-regulation of TREM2 expression may impair phagocytic responses that ultimately contribute to Aβ42 peptide accumulation, aggregation, amyloidogenesis and inflammatory degeneration in the brain., (Published by Elsevier Inc.)

Background: Ecchymosis, oedema, haematoma and pain after SMAS-based facelift surgery are all the direct result of the physical trauma of surgery and subsequent inflammatory response. Hilotherapy is a novel form of cryotherapy that purports to minimise these events through single-use face masks circulating cooled, sterile water. This study was performed to assess the validity of Hilotherapy in this population of patients., Methods: Over 14 weeks fifty consecutive patients were randomised to post-operative facial cooling with Hilotherapy or management with standard dressings alone, while fifteen subsequent, consecutive patients were randomised to cooling of one side of the face but not the other. Assessment of ecchymosis, oedema, haematoma and pain was performed independently by clinical staff and patients. The second analysis was undertaken to better delineate pain relief using each individual patient as their own control., Results: The Hilotherapy mask produced a statistically significant difference in facial skin temperature (p = 0.01). In the second limb of the study patients reported a statistically significant increase in facial swelling 6-8 days post surgery in the half of the face that was treated with the mask (p = 0.05) but there was no significant difference in ecchymosis, haematoma and pain between comparison groups (p > 0.10) in either limb of the study. Subjectively the majority of patients found the cooling masks to be comforting., Conclusion: In this randomised, controlled trial the Hilotherapy mask produced significant facial skin cooling after SMAS-based facelift surgery at the expense of a statistically significant increase in patient reported post-operative swelling. No objective benefits were derived in terms of reducing ecchymosis, haematoma or pain., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Macrolane™, an injectable compound composed of hyaluronic acid, has recently been marketed for breast enhancement. Three patients who presented to the authors with complications soon after treatment elsewhere are reported. One had severe infection and two had grade 3 capsular contracture. All three patients underwent a surgical procedure to treat their complication. The use of Macrolane™ for breast enhancement is reviewed together with previously published data., (Crown Copyright © 2010. Published by Elsevier Ltd. All rights reserved.)

Synostotic frontal plagiocephaly is most commonly caused by frontoparietal (unicoronal) synostosis, but may be caused by other fusions along the coronal hemiring. Frontosphenoidal synostosis is a rare cause of frontal plagiocephaly, with only five previously reported cases. We present the case of an 8-month-old male infant with frontal plagiocephaly caused by unilateral isolated frontosphenoidal synostosis mimicking frontoparietal (unicoronal) synostosis. The clinical and radiological features included flattened ipsilateral forehead, retruded ipsilateral maxilla, a midline chin, contralateral deviation of the nasal root and endocranial base, and anomalies of the bony orbit. Unilateral isolated frontosphenoidal synostosis may be misdiagnosed as unicoronal synostosis. Careful physical and radiological assessment is necessary to recognise this synostotic disorder of the coronal hemiring.

Background: Procedures combining a short scar with superficial musculoaponeurotic system (SMAS) manipulation are increasingly popular for patients with early signs of mid- and lower-facial laxity seeking rhytidectomy. We present the senior author's experience with a short scar volumetric malar imbrication rhytidectomy, which avoids post-auricular incisions and sub-SMAS dissection., Patients and Methods: Between January 2004 and April 2007, 54 patients underwent a short scar volumetric rhytidectomy (9.6% of all facelifts). These procedures were primary in 38 and secondary in 16 patients, at a mean age of 49 years (range 35-77 years). Average operating time was 90 min. Resultant vertical and horizontal skin movement at the helical root was recorded. Concurrent procedures included blepharoplasty, canthoplasty, endoscopic forehead rejuvenation and fat grafting. Minimum follow up was 3 months. Pre- and 3 month postoperative photographs of 25 randomly selected patients were rated by three independent surgeons. A seven-point scale was used to grade the improvement in the malar eminence, melolabial fold, jowls and cervicomental angle. The overall aesthetic result was assessed using the MDACS grading system. Statistical analysis was performed using Student's t-tests and general estimation equations where appropriate., Results: There were no significant complications. Three patients developed minor cheek swellings which all settled with antibiotics. Mean postoperative aesthetic outcomes were rated as 'Good' using the MDACS scale (mean score 0.64), with no 'Poor' results. Vertical skin lifting was significantly greater than the horizontal skin lifting (P<0.001). Mild postoperative improvements were noted in the malar eminence soft tissue volume, nasolabial fold diminishment, jowl diminishment and cervicomental angle., Conclusion: In the appropriately selected face, short scar volumetric malar imbrication rhytidectomy is a straightforward, safe and effective procedure for improving the early signs of ageing.

Bodylifting is often considered a high-risk surgical procedure. There is a widely held perception is that the operation is both time consuming and physically demanding for the surgeon, with, potentially, a long recovery and high complication rate for the patient. The senior author's experience of 16 consecutive bodylift procedures does not reflect this. Fourteen female patients and two male patients underwent Lockwood-type bodylifting procedures at two different hospitals over a 5 year period. Patients studied were unsuitable for a standard abdominoplasty either because of excess lateral abdominal tissue, or had undergone significant weight loss and developed redundant folds of skin in a circumferential pattern around the waistline. The average Body Mass Index (BMI) prior to surgery was 26.7. Mean surgical time and hospital stay was 4.2 hrs and 3.5 days respectively. No patient required blood transfusion. The follow up period was between 3 and 24 months. Levels of patient satisfaction were high and complications few. Only one patient required minor revisional surgery. No major complications were recorded. The commonest problem, seroma, developed in 4 out of 16 patients and was managed by simple aspiration. This study supports the effectiveness of the lower body lift as a procedure with the potential to produce an outcome unachievable by other means with a low incidence of minor complications.

The case notes of 278 consecutive patients who underwent abdominoplasty, during a five-year period, in one institution under the care of four surgeons were reviewed. Patient details, early and late complications and revision procedures were noted. Seventy-five percent of patients had a 'full' abdominoplasty with undermining to costal cartilage and repositioning of the umbilicus and 23% had 'mini abdominoplasties', 2% were revision operations. Eighteen percent of patients suffered from early complications the most common of which were seroma (5%), haematoma (3%), infection (3%), skin or fat necrosis (2.5%) and delayed healing (2%). Twenty-five percent of patients had late complications which were often relatively minor. These included 'dog ears' (12%), localised fatty excess (10%) and unsatisfactory scars (8%). Twenty-four percent of patients underwent revision surgery. Most commonly further liposuction (12%), dog ear revision (10%) and scar revision (5%). Analysis failed to reveal significant risk factors. Despite an apparently high complication and revision rate the subjective impression is of a satisfied patient cohort.

The chin is an important and often neglected feature of facial balance. Genioplasty is a useful procedure in aesthetic surgery and often can be combined with other procedures to obtain an optimal aesthetic outcome. A retrospective case note review of the senior author's (BMJ) experience of aesthetic genioplasty over an 11-year period was undertaken. Cases with non-aesthetic indications for genioplasty were excluded and overall 64 patients were included in this study. Our technique of intraoral osseous genioplasty is described and discussed. A total of 54 patients underwent osseous genioplasty, eight underwent alloplastic genioplasty and two underwent removal of a chin prosthesis only. Most of the patients who had an osseous genioplasty had a sliding advancement correction. Four of these patients required secondary surgery, five had additional minor complications and there were seven cases of transient numbness. Nine patients had a genioplasty alone, 26 had one additional procedure and 19 had more than one, with an average of 2.9 additional procedures. Twenty-four patients had a simultaneous rhinoplasty and 18 had a facelift. Osseous genioplasty is our preferred technique for its versatility and long-term stability compared to alloplastic methods. If performed correctly it provides excellent results with a high degree of patient satisfaction and few long-term complications.

This study set out to detect specific classes of potentially genotoxic aldehydes resulting from soybean-oil peroxidation in oil samples from 51 Trilucent implants in 26 patients and two factory-retained prostheses. The chemical analysis was performed independently of AEI inc. All of the implants showed evidence of shell deterioration suggestive of lipid absorption, and of lipid bleed throughout the implant shell. The mean implant weight loss was found to be almost 2% per year. Although none of the implants had actually ruptured in-situ, we identified specific problems with anterior and posterior patch delaminations, making the implant prone to rupture. Our data suggest that the soybean oil in all the explanted Trilucent implants and the two factory-retained prostheses had undergone peroxidation, yielding aldehyde by-products in millimolar concentrations. These concentrations are over 1000 times that thought to be potentially genotoxic. The clinical implications of these findings remain unclear. Capsular tissue was submitted to AEI Inc for histological and chemical analysis, but the data have not been forthcoming, which is disappointing as this may provide further evidence for the risks of long-term complications in these patients.

Steroids are often administered to paediatric craniomaxillofacial patients perioperatively to reduce postoperative facial swelling, although there is little evidence of their efficacy. Preoperative tumescent infiltration using 7 ml x kg(-1) of a solution consisting of 0.1 mg x ml(-1) triamcinolone acetate, 0.0125% bupivacaine, 0.025% lignocaine, 3 units x ml(-1) hyaluronidase and 1:1000000 adrenaline in Hartmann's solution was evaluated from a retrospective case controlled study of patients undergoing standard fronto-orbital remodelling for simple craniosynostosis (n = 20). Eye closure (i.e. inability to open the eyes) was used as a marker for severe facial swelling. Patients receiving the tumescent infiltration demonstrated significantly less eye closure (P < 0.005), implying that the tumescent infiltration had a significant effect on facial swelling. The avoidance of eye closure allowed more effective monitoring for neurological and ophthalmological complications, which is a significant clinical benefit. The infiltration solution has the advantage of a lower corticosteroid dose than previously reported dexamethasone-based perioperative regimens, thereby minimising any unwanted metabolic effects. The technique is advocated for the reduction of postoperative facial swelling in craniomaxillofacial surgical patients., (Copyright 2001 The British Association of Plastic Surgeons.)

Haematoma remains the most common complication of rhytidectomy and can lead to prolonged facial oedema or skin necrosis. The factors leading to haematoma formation remain unclear, and studies establishing causal relationships are lacking. The aim of this study was to determine which parameters were significantly associated with haematoma formation in a consecutive series of facelifts performed by two high-volume operators. The records of 1078 patients who underwent facelifting between 1994 and 1999 were reviewed and the parameters associated with haematoma formation were investigated using multivariate statistical analysis. In this series of 1078 patients, 45 haematomas occurred (4.2%). Analysis revealed significant associations between haematoma formation and anterior platysmaplasty (P= 0.009), systolic pressure (P= 0.02), gender (P= 0.03), aspirin or non-steroidal anti-inflammatory intake (P= 0.04) and smoking (P= 0.049). In addition the relative risk of each parameter was calculated. This allowed the haematoma risk for individual patients to be calculated and haematoma-prone patients were identified preoperatively. This is the first study to establish independent statistical risk factors for haematoma after rhytidectomy and to present a scoring system that calculates the haematoma risk preoperatively. The implications of these findings and possible measures for the prevention of haematoma are also presented., (Copyright 2001 The British Association of Plastic Surgeons.)

We report our findings in a retrospective study of patient satisfaction with soybean oil-filled mammary implants. Sixty-two women who had breast augmentation with Trilucent breast implants were sent a questionnaire to assess their satisfaction with implant placement; 19 of the 62 attended for clinical examination. Overall satisfaction with triglyceride implant placement was high: very pleased 45% (18/40), pleased 32.5% (13/40), content 12.5% (5/40). The majority of women felt that it had enhanced their body image and lifestyle (82.5%).

Distraction osteogenesis is increasingly recognised as a potentially useful technique to achieve the co-ordinated augmentation of craniofacial skeletal and soft tissue. A case is presented where bilateral maxillary distraction was successfully used to advance the midface in the treatment of recurrent ocular dislocation, in a 10-month-old boy with Pfeiffer's syndrome.

We report two children and a young adult who developed unilateral facial palsy shortly after injury to the external ear. In two instances the paralysis followed a prominent ear correction and in the other a laceration to the concha. The trauma-triggered facial palsy was most likely idiopathic although the anatomy of the facial nerve near the ear leads one to speculate on a possible pathway of a virally induced palsy (Bell's palsy). Each patient recovered over a period of 6 months.

A retrospective analysis of facelifting experience during the author's initial 8 years of consultant practice is presented. 137 procedures are reviewed and the surgical technique described. 70% were SMAS-platysma lifts, 24% skin only lifts and 6% subperiosteal (mask) lifts. Particular attention was paid to complications, most common of which was haematoma requiring surgical evacuation in 3.6% of patients.

Premature fusion of cranial sutures in craniosynostosis has been thought to lead to craniostenosis, which in turn may lead to increased intracranial pressures. In 41 consecutive patients with craniosynostosis, intracranial pressure and intracranial volume were measured. Of the 41 patients, 38 (92.6%) had raised intracranial pressure but only 4 (9.7%) had a decreased skull volume. In the present study, there is no correlation between intracranial volume and intracranial pressure. This study confirms that the measurement of intracranial volume, a non invasive procedure, cannot be used to assess intracranial pressure and to avoid an invasive procedure.

107 children undergoing transcranial craniofacial surgery in a paediatric hospital have been reviewed to assess the incidence and type of complications which arose. This represents the first 4 years' experience of the craniofacial team. There were no deaths or permanent adverse sequelae of surgery. A total of 53 complications were seen in 42 patients. In 9.3% of patients they were potentially life-threatening, serious in 12.1% and of a minor nature in 28%. The more serious complications were related either to haemorrhage and/or vasovagal shock at operation or to infection post-operatively. Infants undergoing monoblock frontofacial advancements and those with tracheostomies were at particular risk.

This paper describes a new method, with high specificity and sensitivity, for evaluating cell surface markes such as differentiation antigens and cytokine receptors on immunoglobulin-secreting cells. Mononuclear cells, freshly derived from peripheral blood or following stimulation in vitro with pokeweed mitogen or Staphylococcus aureus Cowan I, are partially depleted of T cells and monocytes using immunomagnetic beads (Dynabeads) coated with anti-CD2. The cells are incubated with Dynabeads coated with monoclonal antibody against the cell marker under investigation and then used in a protein A haemolytic plaque assay. Plaque-forming cells (PFC) with (marker-positive) and without (marker-negative) attached beads can be readily enumerated. Values are given for percentages of IgG-, IgA- and IgM-PFC bearing CD19, CD38, CD25 and CD5.

An experimental investigation is presented into the use of pulsed ultrasound Doppler flowmetry with a percutaneously implanted probe as a monitor of microvascular anastomotic patency. The method accurately indicated and distinguished between experimental arterial and venous occlusion in epigastric island flaps. In free flaps it had advantages over manipulative, intraoperative tests of anastomotic patency and was a reliable post-operative monitor of flap circulation in the experimental model. The technique appears to have great potential as a post-operative monitor for free flaps, including those without a visible surface.

Some malignant tissues and cell lines contain acidic isoferritins and it has been suggested that the assay of such isoferritins in serum may be of value in the diagnosis of malignancy. This paper describes a radioimmunoassay for acidic ferrtin purified from HeLa cells. Examiniation of purified heart, kidney, liver and spleen ferritin showed that the assay was highly specific for acidic isoferritins. Ferritin concentrations have been measured with antibodies to HeLa cell and spleen ferritin in extracts of normal and tumour tissue. Although the tumours contained more HeLa type ferritin than the corresponding normal tissue the HeLa/spleen type ferritin ratio was low. HeLa-type ferritin concentrations have been compared with values obtained with anti-spleen ferritin in over 1000 sera from normal subjects and patients with cancer and leukaemia. HeLa-type ferritin as not detected ( less than 2 micrograms/l) in most normal sera. Concentrations of up to 53 micrograms/l were found in sera from patients with malignant disease but the HeLa/spleen type ferritin ratio was always very low. There appears to be little application for antibodies to HeLa cell or heart ferritin in the diagnosis or monitoring of cancer.

Intradermal interstitial fluid pressure (IFP) in the rat epigastric flap has been measured under varying conditions of blood flow. Pressure changes were not as expected. An attempt has been made to explain these anomalous results using radiolabelled isotopes.

A preliminary report is presented of a free-flap monitoring technique using the Doppler shift of Laser light. It has provided useful information in five patients with free flaps. The technique is non-invasive and the apparatus is compact, portable and simple to use. Although a long term evaluation with a larger number of patients is required the technique has many advantages over others currently available and is sufficiently promising to warrant further investigation.

Two cases are reported in which the smoking of a cigarette on the 5th day after revascularisation of the thumb produced immediate vascular insufficiency in a previously viable digit.

Acute ischaemia of the hand following the elevation of a radial forearm flap despite a satisfactory preoperative Allen's test is reported. Circulation to the hand was restored by a vein graft. The importance of ensuring that peripheral circulation is adequate after raising such a flap is stressed.

The scapular flap is a medium-sized flap combining many of the good qualities of others, such as thinness and minimal donor site deficit, with the potentialities of a consistently long pedicle that allows combination with other adjacent flaps. The anatomy of the flap and its application in nine clinical cases is described.

A simple timed lysis assay is described for quantifying haemolytic complement activity in human serum. Classical pathway complement function was determined by measuring the time taken to lyse 50% of a standard suspension of antibody-coated sheep erythrocytes; the time required for 50% lysis of a standard rabbit erythrocyte suspension was similarly used to evaluate alternative pathway function. Because target erythrocytes prepared on different days gave slightly different 50% lysis times, it was necessary first to construct a series of calibration curves for converting 50% lysis times into CH50 U/ml. For this purpose, a range of dilutions of the standard human serum, of known haemolytic activity, was tested against erythrocytes prepared on 10 separate occasions. The standard serum was subsequently included with each batch of unknown sera and used to select the appropriate calibration curve for direct conversion of the 50% lysis time into CH50 U/ml. Eleven samples of normal human serum were tested by both the timed lysis assay and by the dilution methods of Mayer (1971) (classical) and Platts-Mills and Ishizaka (1974) (alternative pathway). Comparable results were obtained in all cases.

The effectiveness of the "floating forehead" operation for treating brachycephaly in infants has been assessed. All children who had undergone this procedure at the Hôpital des Enfants Malades between 1977 and 1984 were reviewed retrospectively by an independent observer. Particular attention was paid to the effects on cranial growth, facial growth and morphology.