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Clefts involving the mandible and lower lip are very rare, with less than 80 cases having been reported worldwide. The objective of this case report is to highlight this unusual type of facial cleft, and to present the principle features and management typically associated with it. We carefully describe our surgical planning and management of the patient alongside a compilation and comparison of different surgical techniques described in the literature thus far. In this report, we discuss a patient with a cleft of the lower lip, true cleft mandible with independent movements of his mandibular segments, ankyloglossia, and a fistula extending from the mandible to the suprasternal notch complicated with congenital heart abnormalities. We explore the different approaches of when to close the hard and soft tissues, however, there is still no clear surgical protocol for treating cleft mandibles but with more cases and their management and outcomes being reported, this is something which will be useful to develop.

Introduction and Aims: Difficult laryngoscopy [poor visualisation of larynx] is a surrogate indicator of difficult intubation and inability to manage difficult visualisation of larynx (DVL) can be life threatening. This study is performed to assess the ability of new index –Acromio -Axillo-Suprasternal Notch Index to predict difficult laryngoscopy in patient undergoing general anaesthesia in addition to other common predictors. Material and Methods: 100 patients with ASA class I and II candidate for general anaesthesia with endotracheal intubation were enrolled to this study. The four usual tests Modified MallampatiTest[MMT], Ratio Of Height to Thyromental Distance[RHTMD], Neck Circumference/ Thyromental distance, Sternomental distance difference were assessed before induction of anaesthesia. The new test AASI is calculated as follow: 1) Using a ruler a line is drawn vertically from the top of the acromion process to the superior border of the axilla at the pectoralismajor muscle named as line A. 2) A second line is drawn perpendicular to line A from the suprasternal notch (line B) and 3)That portion of line A that lies above where line B bisects line A is line C. AASI is calculated from the length of line C divided by line A[AASI = C/A]. By a skilled anaesthesiologist with more than 5 years of experience & who was unaware of the study, A laryngoscopy was done and based on Cormack-Lehane classification, grading of laryngoscopy was recorded. Sensitivity, specificity, positive predictive value and negative predictive value with 95% Confidence Interval for each airway predictor in isolation was studied. Results: DVL observed in 12% patients. We observed that sensitivity,specificity,PPV,NPV,AUC of Roc[95% confidence interval] of AASI was 80%[44.4-97.5%], 95.56%[89-98.8%],66.67%[42.22-84.6%],97.7%[92.6-99.33%},0.985[0.898-0.988]respectively & these results are better than other conventional methods of difficult airway predictors. Conclusion: AASI more than or equal to 0.5 is a good predictor of difficult visualisation of larynx (DVL) at direct laryngoscopy.

Purpose. Echocardiography assessment from apical five-chamber view (A5CV) is the standard technique for aortic stenosis (AS) grading. Data on non-apical views, such as right parasternal (RPV), subcostal (SCV) and suprasternal notch (SSNV), is scarce and constitutes the aim of our study. Methods. We designed an observational study that included patients with AS recruited prospectively in whom the stenosis was graded by echocardiography from A5CV and non-apical view. The value of non-apical views in up-grading the stenosis severity (primary objective), the prognostic relevance of such reclassification and the feasibility and reproducibility of non-apical views assessment (secondary objectives) was evaluated. Results. Feasibility of AS appraisal from RPV, SCV and SSNV was 78%, 81% and 56%, respectively (SCV vs SSNV, p = .009). AS were up-graded from non-apical views according to peak gradient, mean gradient, area and indexed area by 24%, 17%, 24% and 22%, respectively (p < .0001). Non-apical views reclassified from non-severe to severe AS, from low gradient severe to high gradient severe AS and from non-critical to critical AS 19%, 23% and 3% of cases (p < .0001). The 4-years hard cardiac events rate was 41% in patients with non-severe AS, 67% in patients with severe AS from non-apical views, 68% in patients with severe AS from A5CV and 80% in patients with severe AS from A5CV and non-apical views (p < .001). Reproducibility of AS evaluation from non-apical views was fair to excellent (intraclass correlation coefficients: SSNV = 0.44, RPV = 0.61, SCV = 0.92). Conclusion. Assessment of AS from non-apical views is feasible, reproducible and valuable over A5CV; its use is encouraged.

Background: The outstretched arm span and measurement of components of the upper limb are a reliable predictors of stature when fragmentary remains of the human body are found. However, this relationship can be affected by age, sex, diet, racial and geographical differences, etc. Hence, a regional database is necessary to be more accurate. Materilas and Methods: This cross-sectional, prospective analytical study included 200 students pursuing MBBS (Male = 100, Female = 100), natives of Gujarat, aged between 18 - 24 years with normal developmental history. Rich bells stature meter, Anthropometric metal rods (scaled), and Vernier caliper were used for taking measurements. SPSS software version 26 was used for statistical analysis. Results: The findings showed a positive correlation between stature and the outstretched arm span as well as stature and various components of the upper limb. Except for the correlation between stature and the length of the shoulder to mid suprasternal notch in males, all of the results were statistically significant (p Conclusion: Outstretched arm span is the most reliable indicator of stature whereas the length of the shoulder to mid suprasternal notch is the least reliable indicator of stature in both sexes in the natives of Gujarat. This study can be used as a reference in the future for medico-legal purposes. Keywords: Arm span, Personal identification, Regression equation, Stature, Upper limb.

Emergency front-of-neck airway rescue is recommended in a can't intubate, can't oxygenate clinical scenario. Cannula cricothyroidotomy has been reported as having a high failure rate. Our primary aim was to estimate the angle of the trachea in relation to the horizontal axis in a simulated emergency front-of-neck airway rescue position. Our secondary aims were to estimate the optimal cannula angle of approach and evaluate the anatomical relationship of the cricothyroid membrane (CTM) to adjacent structures. We also assessed whether the CTM lies above or below the neck midpoint, a point equidistant from the suprasternal notch (SSN), and the chin surface landmarks. All measurements were compared between the male and female subjects.Subjects having elective computed tomography of their thorax were consented to have extension of the computed tomography to include their neck. A preliminary radiation dose and risk assessment deemed the additional radiation to be of very low risk (level IIa). Subjects were positioned supinely on the computed tomography table. Standard neck extension was achieved by placing a pillow under the scapulae and a rolled towel under the neck to simulate emergency front-of-neck airway rescue positioning.Fifty-two subjects were included in this study: 31 men and 21 women. The mean angle of the trachea in relation to the horizontal axis was 25.5° (95% confidence interval [CI], 21.8-29.1) in men and 14.0° (95% CI, 11.5-16.5) in women. The mean minimum angles required for hypothetical cannula cricothyroidotomy for men and women were 55.2° (95% CI, 51.8-58.7) and 50.5° (95% CI, 45.4-55.6), respectively. The CTM was located lower in the neck in men compared to women. The CTM was located below the neck midpoint in 30 of 30 (100%) male subjects and 11 of 20 (55%) female subjects (P.001).The trachea angulates posteriorly in a simulated emergency front-of-neck airway rescue position in supine subjects and to a greater degree in men compared to women (P.001). The minimum angle required for hypothetical cannula cricothyroidotomy was45° in the majority (75%) of subjects studied. A steeper cannula angle of approach may be more reliable and warrants further clinical study. If airway anatomy is indistinct and performing a vertical scalpel cricothyroidotomy, consideration should be given to performing this incision lower in the neck in men compared to women.

Mediastinal ectopic goiter is a thyroid tumor that lies entirely below a plane extending from the superior surface of the first thoracic vertebra to the suprasternal notch, and commonly lies in the vicinity of the thymus. Intrapericardial ectopic goiter is extremely rare. We present an extremely rare case of a 63-year-old woman with an intrapericardial ectopic goiter and review the pertinent literature.

One of the most important signals to assess respiratory function, especially in patients with sleep apnea, is airflow. A convenient method to estimate airflow is based on analyzing tracheal sounds and movements. However, this method requires accurate identification of respiratory phases. Our goal is to develop an automatic algorithm to analyze tracheal sounds and movements to identify respiratory phases during sleep. Data from adults with suspected sleep apnea who were referred for in-laboratory sleep studies were included. Simultaneously with polysomnography, tracheal sounds and movements were recorded with a small wearable device attached to the suprasternal notch. First, an adaptive detection algorithm was developed to localize the respiratory phases in tracheal sounds. Then, for each phase, a set of morphological features from sound energy and tracheal movement were extracted to classify the localized phases into inspirations or expirations. The average error and time delay of detecting respiratory phases were 7.62% and 181 ms during normal breathing, 8.95% and 194 ms during snoring, and 13.19% and 220 ms during respiratory events, respectively. The average classification accuracy was 83.7% for inspirations and 75.0% for expirations. Respiratory phases were accurately identified from tracheal sounds and movements during sleep.

Objective: Controlling the spread of the COVID-19 pandemic largely depends on scaling up the testing infrastructure for identifying infected individuals. Consumer-grade wearables may present a solution to detect the presence of infections in the population, but the current paradigm requires collecting physiological data continuously and for long periods of time on each individual, which poses limitations in the context of rapid screening. Technology: Here, we propose a novel paradigm based on recording the physiological responses elicited by a short (~2 minutes) sequence of activities (i.e. “snapshot”), to detect symptoms associated with COVID-19. We employed a novel body-conforming soft wearable sensor placed on the suprasternal notch to capture data on physical activity, cardio-respiratory function, and cough sounds. Results: We performed a pilot study in a cohort of individuals (n=14) who tested positive for COVID-19 and detected altered heart rate, respiration rate and heart rate variability, relative to a group of healthy individuals (n=14) with no known exposure. Logistic regression classifiers were trained on individual and combined sets of physiological features (heartbeat and respiration dynamics, walking cadence, and cough frequency spectrum) at discriminating COVID-positive participants from the healthy group. Combining features yielded an AUC of 0.94 (95% CI=[0.92, 0.96]) using a leave-one-subject-out cross validation scheme. Conclusions and Clinical Impact: These results, although preliminary, suggest that a sensor-based snapshot paradigm may be a promising approach for non-invasive and repeatable testing to alert individuals that need further screening.

BACKGROUND Subfascial placement of breast implants has the advantages of subglandular and submuscular placement without the adverse outcomes. There are few large series with longitudinal follow-up and outcome measures. METHODS Seven hundred eighty-three patients underwent subfascial breast augmentation and were followed up for 10 years. Adverse outcomes, changes in breast morphometry, and patient satisfaction were outcome measures. RESULTS All morphometry increased except soft-tissue thickness at the lateral sternal margin. The distance from the nipple-areola complex to the inframammary crease increased by 40 percent, with a concomitant 6.2 percent increase in the distance from the suprasternal notch to the nipple-areola complex. The capsular contracture rate was 6.48 percent, and correlates with a lateral sternal margin of less than 20 mm (r = 0.57, p < 0.001). Ripples occurred in patients with less than 10 mm of soft tissue at the lateral sternal margin; 11.6 percent of patients would choose a larger implant and 2.7 percent would choose a smaller implant. CONCLUSIONS Subfascial placement of breast implants provides a reliable technique. It can be used in patients with at least 20 mm of soft tissue at the lateral sternal margin. Those with 10 to 20 mm should be counseled that ripples may occur if they lose body fat. The technique is unsuitable for individuals with less than 10 mm measurable at the lateral sternal margin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Background Emergency front of neck airway access by anaesthetists carries a high failure rate and it is recommended to identify the cricothyroid membrane before induction of anaesthesia in patients with a predicted difficult airway. We have investigated whether a marking of the cricothyroid membrane done in the extended neck position remains correct after the patient’s neck has been manipulated and subsequently repositioned Methods The subject was first placed in the extended head and neck position and had the cricothyroid membrane identified and marked with three methods, palpation, ‘laryngeal handshake’ and ultrasonography and the distance from the suprasternal notch to the cricothyroid membrane was measured. The subject then moved off the table and sat on a chair and subsequently returned to the extended neck position and examinations were repeated. Results Skin markings of all 11 subjects lay within the boundaries of the cricothyroid membrane when the subject was repositioned back to the extended neck position and the median difference between the two measurements of the distance from the suprasternal notch was 0 mm (range 0‐2 mm). Conclusion The cricothyroid membrane can be identified and marked with the subject in the extended neck position. Then the patient’s position can be changed as needed, for example to the ‘sniffing’ neck position for conventional intubation. If a front of neck airway access is required during subsequent airway management, the patient can be returned expediently to the extended‐neck position, and the marking of the centre of the membrane will still be in the correct place. Postprint

Background and aims Large osteochondroma arising from chest wall and sternum is uncommon and presentation with airway compression is further uncommon. Methods Here we present a case of large chest wall osteochondroma as a part of hereditary multiple exostoses in a 9-year-old boy presented with a history of stridor and shortness of breath. The bony mass of the right chest wall was extending up to a suprasternal notch and compressing the trachea. Results The case was successfully managed by initial femoro-femoral cardiopulmonary bypass under local anesthesia before the induction of anesthesia to prevent respiratory collapse, followed by debulking surgery was done.

Background The accuracy of clinical N staging of esophageal squamous cell carcinoma is suboptimal. As an important station of lymph node metastasis, station C201 (right recurrent laryngeal nerve nodes) has rarely been evaluated alone. We aimed to explore an effective way to evaluate the right recurrent laryngeal nerve nodes in thoracic esophageal squamous cell carcinoma. Methods We retrospectively analyzed 628 thoracic esophageal squamous cell carcinoma patients who underwent radical resection without neoadjuvant therapy from two Chinese cancer centers. The diameter of the short axis of the largest right recurrent laryngeal nerve node (DC201) was measured on contrast-enhanced multi-slice computed tomography (MSCT). Right recurrent laryngeal nerve nodes were examined by postoperative pathologic results. The receiver operating characteristic (ROC) curve was generated to assess the diagnostic capabilities of DC201 to determine the right recurrent laryngeal nerve nodes status. Results ROC curve analysis revealed that the optimal cut-off point of DC201 was 6 mm, with an area under curve (AUC), sensitivity, specificity, and Youden index of 0.896, 71.9%, 88.8%, and 0.607 respectively. When the cut-off point of DC201 was set to 10 mm, sensitivity, specificity and the Youden index were 14.1%, 99.6% and 0.137 respectively. Among 128 patients with right recurrent laryngeal nerve node metastasis, 71 and 108 patients had the largest right recurrent laryngeal nerve node located above the suprasternal notch level and in the tracheoesophageal groove respectively. Conclusions When DC201 ≥6.0 mm instead of DC201 ≥10 mm was used to dictate the right recurrent laryngeal nerve nodes metastasis, contrast-enhanced MSCT could evaluate the status of right recurrent laryngeal nerve nodes with high sensitivity and specificity. The largest right recurrent laryngeal nerve nodes were mainly located in the tracheoesophageal groove and/or above the suprasternal notch.

Central pulse wave velocity (PWV) is a marker of arterial stiffness and is calculated by dividing the pulse wave travel distance by the transit time. However, there is no consensus as to the ideal distance measurement in children. The aim of our study was to identify the more reliable method to assess the distance measurement in the pediatric age.Carotid-femoral PWV was measured by applanation tonometry in 988 healthy children aged 6.5-19.9 years. Two different surface distances were assessed: the subtraction method, representing the distance from the suprasternal notch to the femoral artery minus the distance from the carotid artery to the suprasternal notch, and the direct method, consisting of 80% of the distance from the carotid artery to the femoral artery. Both these methods were compared with the actual path length determined by magnetic resonance imaging (MRI) in 31 children.Subtraction and direct methods were significantly correlated in patients aged14 years and the corresponding PWV values showed a good agreement. In children aged ≥14 years, a significant difference between the two methods was found: subtraction - direct distance = -45 ± 28 mm, with a significant difference in the resulting PWV values = -0.57 ± 0.35 m/s (p 0.0001). This result was confirmed by MRI, showing a 10% overestimation in distance measurement by the direct method in subjects aged ≥14 years, resulting in a significantly higher PWV.These data suggest a greater reliability of the subtractive method of distance measurement compared to the direct method in children.

Study objective To develop an algorithm for improving apnea hypopnea index (AHI) estimation which includes event by event validation and event duration estimation. The algorithm uses breathing sounds, respiratory related movements and blood oxygen saturation (SaO2). Methods Adults with suspected sleep apnea underwent overnight polysomnography (PSG) at Toronto Rehabilitations Institute. Simultaneously with PSG, breathing sounds and respiratory related movements were recorded over the suprasternal notch using the Patch. The Patch had a microphone and an accelerometer to record respiratory sounds and movement, respectively. First, we calculated the amount of drops in SaO2 from pulse oximeter. Subsequently, energy of breaths and accelerometer were extracted. Features were normalized, weighted, summed and passed through a threshold to estimate PatchAHI. PatchAHI was compared to the AHI obtained from PSG (PSGAHI). Furthermore, performance of event detection was evaluated using F1-score. Moreover, event duration difference between estimated and PSG-based events was compared. Results Data from 69 subjects were investigated. PatchAHI had high correlation with PSGAHI (r2 = 0.88). Considering a diagnostic AHI cut-off of ≥15, sensitivity and specificity were 91.42 ± 11.92% and 89.29 ± 7.62%, respectively. F1-score for individual event detection increased from 0.22 ± 0.10 for AHI≤5 to 0.72 ± 0.09 for AHI >30. Moreover, event duration difference between estimated events and PSG-based events was 5.33 ± 8.17 sec. Conclusion Our proposed algorithm had high accuracy in estimating individual respiratory events during sleep. The algorithm can increase reliability of acoustic methods for diagnosis of sleep apnea at home.

Background: In this study, we present our technique ofthe septum-based superomedial pedicle reduction mammoplastyusing an inverted T scar pattern. It is based on theWuringer's horizontal breast septum, through which run themain neurovascular supply to the nipple-areola complex(NAC).Patients and Methods: The study included 35 cases withbilateral breast hypertrophy. The mean suprasternal notch tonipple (SSN-N) distance in our cases was 39.7±5.6cm. Themean nipple elevation in our cases was 17.9±4.6cm. Our meanresection weight was 764±160 grams per side. We had 6 caseswith resection weight exceeding 1500 grams per side.Results: We had no cases of partial or total necrosis ofthe NAC. Immediate postoperative breast sensation waspreserved in 26 cases and was impaired in 9 cases but it wasregained spontaneously within 6 months.Conclusion: The septum-based superomedial pedicletechnique of reduction mammoplasty is safe technique withimproved NAC vascularity and sensation, even in cases ofgigantomastia, owing to the preservation of the importantneurovascular structures related to the breast septum.

Objectives To determine if a saline-filled cuff seen at the suprasternal notch on ultrasound corresponds to correct endotracheal tube depth on a chest radiograph (tip at/below clavicle AND ≥ 1 cm above carina). Design Prospective observational study. Setting Tertiary Care Pediatric hospital. Patients Patients between the ages of 0-18 years requiring nonemergent cardiac catheterizations and endotracheal intubation with a cuffed endotracheal tube were included in the study. Children with anticipated or known difficult airways were excluded. Interventions Ultrasound evaluation of the neck following saline inflation of the endotracheal tube cuff. Measurements and main results Ultrasonography of the patient's neck was performed following intubation by a pediatric anesthesiologist. A linear probe was used in transverse axis to identify the saline-filled cuff starting at the suprasternal notch and moving cephalad. A cine-fluoroscopic image, similar to a chest radiograph, was obtained to ascertain the endotracheal tube depth after the cuff was identified sonographically. Endotracheal tube cuffs seen on ultrasound at the suprasternal notch were compared with the endotracheal tube depth on the cine-fluoroscopic image. A total of 75 children were enrolled in the study. The endotracheal tube was seen sonographically at the suprasternal notch in 70 patients of which 60 had complete data (an adequate chest radiograph available for review). Patient ages ranged from 2 months to 18 years with a median age of 4 years. The median endotracheal tube tip to carina distance was 2.4 cm (interquartile range, 1.75-3.3 cm.) The endotracheal tube tip to carina distance was greater than or equal to 1 cm in 57 out of the 60 patients. Endotracheal tube cuff at the suprasternal notch on ultrasound corresponded with correct endotracheal tube depth on chest radiograph with an accuracy of 95% (CI, 86-98%). Conclusions Visualization of the cuff at the suprasternal notch by ultrasound demonstrates potential as a means of confirming correct depth of the endotracheal tube following endotracheal intubation.

A 30-year-old female patient with past medical history of supraventricular tachycardia presented with shortness of breath and underwent a transthoracic echocardiogram (TTE). The TTE noted a concerning partially mobile linear echo density, with positive Doppler color flow across it along the aortic arch, which was concerning for a dissection flap. The patient accordingly underwent a cardiac MRI which revealed that the anomaly seen on echocardiogram was in the setting of a prominent left brachiocephalic (innominate) vein and without evidence of aortic dissection. While this is a relatively common phenomenon, there is no literature on prominent brachiocephalic vein masquerading as an aortic dissection flap on TTE.

Objective: Sleep apnea is a chronic respiratory disorder and its standard assessment requires full night in-laboratory polysomnography (PSG). However, PSG is expensive, time-consuming, and inconvenient. Thus, there is a need to monitor sleep apnea with more convenient wearable devices. The objective of this study was to implement deep learning algorithms to monitor sleep apnea severity based on respiratory movements that can be easily recorded over the trachea. Methods: Adult individuals referred to the sleep laboratory at the Toronto Rehabilitation Institute for overnight sleep studies were included (N=69). Simultaneously with the PSG, an accelerometer was attached to the participant's suprasternal notch to record tracheal respiratory movements. Twenty-one features were extracted from the tracheal movements and used in a deep learning classifier to detect respiratory events. The apnea hypopnea index (AHI) was estimated as the number of events per hour of sleep. Results: The F1 score of the event-by-event detection algorithm was between 12% and 71% for different groups of sleep apnea severity. There was a strong correlation between the estimated and the PSG-derived AHI (r=0.86, p

Teratomas have been reported to occur in multiple organ regions, and are less common in non-gonadal regions, such as the neck and chest, than in gonadal and midline regions of the body, such as ovaries and testis. Cases have been reported of a large teratoma of the anterior mediastinum extending to the neck, causing symptoms such as dyspnea, which can be quickly detected by Ultrasound, and patients can be quickly treated. In adults, primary teratoma at the suprasternal foss that not accumulate thyroid gland upward and not invade the mediastinum are rare, usually have no obvious clinical symptoms and are found in most patients by chance. In this literature, we report a rare case of mature cystic teratoma in the suprasternal fossa of a 33-year-old male. Preoperative ultrasonography showed a superior sternal fossa tumor with less calcification and more adipose tissue. The final pathologic diagnosis was mature cystic teratoma through open surgery of the suprasternal neck incision. The patient was followed up for 9 months and there was no recurrence. We believe that the suprasternal notch approach is a safe and effective method for the treatment of mature teratoma without protruding into the superior mediastinum.

BACKGROUND Emergency front of neck access in a "can't intubate can't oxygenate" scenario in pediatrics is rare. Ideally airway rescue would involve the presence of an ear, nose, and throat surgeon. If unavailable however, responsibility lies with the anesthesiologist and accurate identification of anterior neck structures is essential for success. AIM We assessed anesthesiologists' accuracy in identification of the pediatric cricothyroid membrane by digital palpation in three predefined age groups (37 weeks to

We present a comparative study on flexible capacitive sensors using three different mechanisms for vital sign monitoring. To record arterial pulse and respiration rate, sensors with a parallel-plate structure and engineered dielectrics with piezoelectric (BTO, PVDF - TrFE) fillers, polyurethane foam or triboelectric frictional layers are explored in this work. The sensitivity of the sensors with alternative mechanisms are compared by placing them on different locations on the body (wrist, neck and suprasternal notch). It is found that PU foam-based sensor is most sensitive option in terms of location and spectral content. Collectively, these sensors can be used in a multimodal patch developed for monitoring respiratory health as well as other abnormalities via sensor fusion.

BackgroundBrachiocephalic trunk (BCT) variants may have a clinical impact during surgical procedures, some of which could be fatal. The objective of this study was to classify height positions of the BCT and report their prevalence in a Mexican population.MethodsPatients: A retrospective, descriptive, observational, and cross-sectional was performed using computed tomography angiography (CTA) of adult (> 18 years of age) patients, without gender distinction, of Mexican origin. Measuring techniques were standardized using the suprasternal notch to analyze linear and maximum heights, linear and curved lengths, and the vertebral origin and bifurcation levels of the BCT.ResultsA total of 270 CTA were obtained (66.7% men and 33.3% women). A high position of BCT was present in 64.81% (n 175/270). The mean linear medial height was 0.58 ± 1.91 cm, the maximum height of the free edge was 3.85 ± 2.04 cm, side length of the midline at the maximum height of the free edge was 1.46 ± 2.59, linear length 3.72 ± 0.70, and a curve length 3.99 ± 0.79. The BCT origin was most predominant at the T3 (57.9%) and T4 (27.0%) vertebral levels, with the bifurcation at T2 (57.9%) and T1 (36.2%).ConclusionsThere is a high prevalence of high position BCT in our population. Patients should be assessed before any procedures in the area, due to the potential risk of complications.

Objectives: To evaluate effect of supporting superior pedicle by central glandular pedicle in reduction mammoplasty in improving aesthetic outcome and reducing the incidence of nipple areola necrosis and postoperative NAC loss of sensation.Background: Superior pedicle reduction mammoplasty provides good aesthetic outcome, but has high possibility of nipple areola complex loss of sensation, therefor keeping the central glandular portion as support to superior pedicle ensures good blood and sensory supply to NAC Methods: This study included 37 patients presented by breasts hypertrophy from March 2019 to March 2021. All patients’ breasts were examined for suprasternal notch to nipple distance, areolar diameter, nipple to infra mammary fold distance. Postoperative assessment included: Nipple areola complex vascularity, nipple areola complex sensitivity and patients’ satisfaction about breast contour, projection, symmetry, scars and overall aesthetic outcome using a score out of 4. Patients underwent marking using wise pattern for skin incision. Intraoperative; excision of skin, fat and glandular tissue inferior to NAC, starting from skin and went directly to chest wall keeping central breast mound with the superior pedicle. Finally closure was in vertical or inverted T pattern according to skin excess to be removed. Results: In this study we operated upon 37 patients who were asking for breast reduction aged between 20 and 57 years with mean age 39.6 years. The overall complication percentage 14.8% excluding poor scarring. We had no cases of total Nipple areola complex loss, low incidence of nipple areola complex persistent reduced sensation after 1 year of follow up (2.7%) and no complete loss of sensation in any patient. Aesthetic outcome accepted by 97.3% of patients. Conclusion: Superior pedicle reduction mammoplasty supported by central glandular pedicle helps in ensuring reliable blood perfusion and sensory nerve supply to nipple areola complex which reduces possibility of post-operative nipple areola complex necrosis and loss of sensation, while patient gets pleasant and long standing aesthetic outcome. Key words: superior pedicle - reduction- mammoplasty- supported by – central – glandular - pedicle

Wearable electronics with dual-sensing modalities enable artifact-free health monitoring through differential detection., Soft, skin-integrated electronic sensors can provide continuous measurements of diverse physiological parameters, with broad relevance to the future of human health care. Motion artifacts can, however, corrupt the recorded signals, particularly those associated with mechanical signatures of cardiopulmonary processes. Design strategies introduced here address this limitation through differential operation of a matched, time-synchronized pair of high-bandwidth accelerometers located on parts of the anatomy that exhibit strong spatial gradients in motion characteristics. When mounted at a location that spans the suprasternal notch and the sternal manubrium, these dual-sensing devices allow measurements of heart rate and sounds, respiratory activities, body temperature, body orientation, and activity level, along with swallowing, coughing, talking, and related processes, without sensitivity to ambient conditions during routine daily activities, vigorous exercises, intense manual labor, and even swimming. Deployments on patients with COVID-19 allow clinical-grade ambulatory monitoring of the key symptoms of the disease even during rehabilitation protocols.

Video 1. Click here to view the video. What findings are seen on this video? Suprasternal pulsations are pulsations that occur in the midline region above the suprasternal notch; in Video 2, these pulsations are observed below the infant’s neck. They can be found in a neonate with hyperdynamic circulation or a dilated aortic arch. Both of these findings are seen in an infant with a patent ductus arteriosus with a large left-to-right shunt causing volume overload of the …

Background Do plastic surgeons really know what happens to the breast after surgery? We often think that we do, but we have very few measurements to show whether we are on the right track. Objectives Only when the surgeon can predict the changes can she or he achieve consistent outcomes. Measurements lead to understanding; understanding what the measurements show allows us to refine our approach. Methods Consecutive patients in 4 categories were analyzed: breast reduction, mastopexy, augmentation, and mastopexy-augmentation. All procedures were performed by a single surgeon and all measurements were performed by the same surgeon. A standard measuring tape was utilized, and data were collected immediately preoperatively and at each follow-up visit. Only those patients with preoperative and complete 1-year postoperative measurements were included in this review. The parameters measured were clavicle to upper breast border (UBB), UBB to nipple, suprasternal notch (SSN) to nipple, SSN to inframammary fold (IMF), and chest midline to nipple. Results The changes were consistent. The borders of the breast footprint were expanded with the addition of an implant (UBB and IMF) and reduced with the removal of parenchyma (IMF). The existing SSN to nipple position was stretched when volume was added to the breast mound and it remained unchanged from the preoperatively marked position in a breast reduction. Conclusions Although measurements are not necessary to achieve good aesthetic results in breast surgery, surgeons should understand what the measurements show and what happens to the different breast parameters. Level of Evidence: 3

BackgroundEndotracheal tube (ETT) tip position is determined on chest X-ray (CXR) and should lie between the upper border of the first thoracic vertebra (T1) and the lower border of second thoracic vertebra (T2). Infant weight is commonly used to estimate how far the ETT should be inserted but frequently results in malpositioned ETT tips. Palpation of the ETT tip at the suprasternal notch has been recommended as an alternative.ObjectiveTo determine whether estimating ETT insertion depth using suprasternal palpation of the ETT tip rather than weight results in more correctly positioned ETT tips.DesignSingle-centre randomised controlled trial.SettingLevel III neonatal intensive care unit (NICU) at a university maternity hospital.PatientsNewborn infants without congenital anomalies intubated in the NICU.InterventionsParticipants were randomised to have ETT insertion depth estimated using palpation of the ETT tip at the suprasternal notch or weight [insertion depth (cm)=6 + wt (kg)].Main outcome measureCorrect ETT position, that is, between the upper border of T1 and lower border of T2 on CXR, determined by one consultant paediatric radiologist masked to group assignment.ResultsThere was no difference in the proportion of correctly placed ETT tips between the groups (suprasternal palpation 27/58 (47%) vs weight 23/60 (38%), p=0.456). Most incorrectly positioned ETTs were too low (56/68 (82%)).ConclusionEstimating ETT insertion depth using suprasternal palpation did not result in more correctly positioned ETTs.Trial registration numberISRCTN13570106.

Background: The aim of reduction mammoplasty is to reposition the NAC with adequate projection by basing the NAC on a reliable pedicle that provides good vascularity, preserves sensory innervation and enables post-operative breastfeeding.Aim of Study: The purpose of this study is to introduce a breast reduction technique designed to reduce the incidence of post-operative nipple-areola complex ischemia and necrosis following reduction mammoplasty by using handheld doppler in detection of perforators and compare it's finding with complementary color duplex ultrasonography.Subjects and Methods: The study included 10 patients that underwent reduction mammoplasty. The average body mass index of our patients was 33.4. The average suprasternal notch to nipple distance was 41.3cm. The average resection weight per side was 1324.6g.Results: None of the cases experienced NAC necrosis.Conclusion: The pedicle constructed with the aid of preoperative perforator identification with a Doppler and compare it's finding with complimentary color duplex ultra-sonography is an effective technique for breast reduction that results in a very low rate of post-operative ischemia and necrosis of the nipple-areola complex.

Background Ventral lesions of upper thoracic spinal cord due to degenerative diseases are rare and often have poor operative outcomes. Anterior decompression of the lesion is difficult because of the local anatomy. This retrospective study aimed to evaluate reproducible anatomic measurements for selecting the best surgical approach for anterior decompression of ventral lesions of upper thoracic spinal cord. Methods Cases of anterior decompression of ventral lesions of upper thoracic spinal cord due to degenerative diseases at our institution from 2004 to 2015 were assessed. Several lines were drawn on magnetic resonance imaging and computed tomography scans of midsagittal sections of the upper thoracic spine to evaluate the most optimal approach for treating upper thoracic lesions. A line from the suprasternal notch to the vertebral body (suprasternal notch to vertebral body [SV] line) was accepted as baseline. Results The caudal edge of the lesion was above the SV line in 10 cases, each of which was treated via an anterior approach without sternotomy. The caudal edge was below the SV line in 7 cases, 5 of which underwent surgery with the sternum-splitting or transthoracic approach. The other 2 lesions were approached via an obliquely deviated route without sternotomy. The SV line sometimes changed with patients' posture alterations. Conclusions The SV line, a useful landmark for upper thoracic lesions, is not sufficiently reliable because it changes according to the patient's posture. By leaning in the direction of the surgical microscope, more caudal upper thoracic lesions can be reached than when using the SV line as a surgical landmark.

Reduction mammoplasty using the inferior pedicle technique has been used for more than five decades. Without doubt, it has many advantages, especially in patients with moderate to severe macromastia. Although the esthetic outcome of reduction mammoplasty in the early postoperative period is usually satisfactory, typical esthetic drawbacks appear during the first year. These drawbacks include bottoming out, loss of superior fullness, box-shaped breasts, poor definition of the infra-mammary fold (IMF), elongation of the vertical scar, star gazing of the nipple-areola complex (NAC) and, of course, the scar burden. Parenchymal reshaping and suspension have been introduced as an additional step to eliminate the drawbacks of the inferior pedicle procedure. This is a prospective study done in a period from March 2016 to March 2018 in Kasr Al-Ainy Hospital (Cairo University hospitals) by the senior author and his team of co-authors. Reduction mammoplasty (Wise pattern) with the inferior pedicle and dermal wrap technique (using two dermal wings) was performed in 20 patients. The distance from the suprasternal notch (SSN) to the NAC was > 30 cm. The patients’ ages ranged from 28 to 55 years (average age, 39 years). Body mass index (BMI) ranged from 27 to 35 kg/m2 (average BMI, 33.3 kg/m2). The distance between the SSN and NAC ranged from 33 to 45 cm (average distance, 40 cm). The nipples were lifted by 11 to 19.5 cm. The distance from the nipple to the IMF ranged from 18 to 24 cm. This distance was reduced postoperatively to between 9 and 11.5 cm (p value