“The Stork Lift”: A Circumoccipital Extended Neck-Lift

Background  The goal of the lower face- and neck-lift is restoration of a sharp cervicomental angle. However, standard cervical rhytidectomy for the patient with extensive excess skin of the neck often leaves the patient with objectionable vertical or diagonal skin folds of the lateral neck, a large hair-step deformity, or both. To remove extensive excess skin of the neck and to avoid vertical/diagonal folds and a stepped hairline, the authors “walk” the excess skin posteriorly along the hairline, often from ear to ear along the inferior posterior hairline. Methods  Patients with extensive excess skin of the neck underwent neck-lift procedures using the circumocciput incision technique during a 1-year period. With the patient in a sitting position, a postauricular face-lift incision is extended along the inferior hairline from ear to ear. The flap is “walked” posteriorly to and along the occiput on either side of the midline. It is closed using a divide and close technique. Flaps are created, and the wound is closed in a multilayered fashion with a posterior midline A-to-T flap. Results  During a 1-year period, 25 patients (22 women and 3 men) underwent a cheek/neck-lift, and 2 patients (1 man and 1 woman) underwent isolated neck-lift procedures using the circumocciput incision technique. The average patient age was 64.8 years (range, 49–79 years). There were no instances of obvious lateral neck folds. Complications included hematoma (1 patient), Candida wound infection (1 patient), and a widened scar revised secondarily (1 patient). All the patients were satisfied with their cosmetic result 6 months after the operation. None of the patients stated that their final scar was noticeable or objectionable. Conclusions  The patients in this study who presented with excessive redundant skin of the neck were treated with the “stork lift,” which provided excellent lifting of the anterior, lateral, and posterior neck as well as excellent cervicomental angles without postoperative sequelae of lateral neck folds or stepped hairlines.     

The dilemma of DCIS

The increasingly frequent diagnosis of ductal carcinoma in situ (DCIS) presents a major clinical dilemma. Our inability to predict which DCIS will progress to invasive cancer or the time interval in which recurrent DCIS or invasive cancer will occur has resulted in treatments ranging from mastectomy to excision and observation being offered to patients. Four randomized trials have demonstrated that the use of radiation reduces the risk of local recurrence by about 50% in women with DCIS. Prospective attempts to duplicate retrospective findings that wide excision results in high rates of local control have been unsuccessful. Patient attitudes towards risks and benefits of treatment are an important component of treatment choice in the absence of predictors of biologic behavior.     

A population-based study of geriatric trauma in a rural state

BACKGROUND: Urban geriatric trauma patients are known to die more often than their younger counterparts. Little is known of the fate of geriatric trauma patients in a rural environment where delays to definitive treatment are frequent. We hypothesized that rural trauma patients would do worse than their urban counterparts because of prolonged delays to definitive care. METHODS: Five-year retrospective analysis of all trauma deaths occurring within a rural state and retrospective outcome analysis of trauma patients admitted to a tertiary care facility who were less than 55 years old (defined as young) and 55 or more years old (defined as old). Outcome analysis was performed comparing old and young rural hospitalized patients to the Major Trauma Outcome Study data set collected in major urban trauma centers. RESULTS: Of the total trauma deaths in the state, 32.5% were old. Old patients were less likely to die at the scene of the injury than were their younger counterparts (R2 = 0.84, p < 0.001). Hospitalized old patients had a significantly higher mean Revised Trauma Score and a significantly lower Injury Severity Score, a higher complication rate, and a higher mortality rate than did hospitalized young patients. The young group had a significantly better survival (W = 0.59, Z = -3.49, p = 0.0001) than the MTOS data set, but the old group had a significantly worse survival (W = -1.8, Z = -3.49, p = 0.001). CONCLUSION: In a rural environment, old trauma patients die more commonly in the hospital than their younger counterparts, who die more commonly at the scene. Old trauma patients who die in the hospital were less severely injured than their younger counterparts who died in the hospital. Old patients admitted to this rural trauma center have a significantly worse survival than their urban counterparts despite the fact that young rural trauma patients do significantly better than their urban counterparts. Understanding the demographics of rural geriatric trauma may be useful in allocating resources in rural trauma system design. It must be understood that despite relatively low injury severity and physiologic stability, there is a significant potential for rural geriatric trauma patients to do poorly.     

Cognitive Impairment in Multiple Sclerosis: Clinical,Radiologic and Pathologic Insights

Cognitive impairment is a common and debilitating feature of multiple sclerosis (MS) that has only recent gained considerable attention. Clinical neuropsychological studies have made apparent the multifaceted nature of cognitive troubles often encountered in MS and continue to broaden our understanding of its complexity. Radiographic studies have started to decipher the neuroanatomic substrate of MS‐related cognitive impairment and have shed light onto its pathogenesis. Where radiographic studies have been limited by inadequate resolution or non‐specificity, pathological studies have come to the fore. This review aims to provide an overview of the nature of cognitive impairment typically seen in MS and to explore the literature on imaging and pathological studies relevant to its evolution. In particular, the relative contributions of gray (ie, cerebral cortex, hippocampus, thalamus and basal ganglia) and white matter to MS‐related cognitive impairment will be discussed and the importance of interconnectivity between structures highlighted. The pressing need for longitudinal studies combining standardized neuropsychometric, paraclinical and radiographic outcomes obtained during life with post‐mortem tissue analysis after death is presented.     

Assisted autogenic drainage in infants and young children hospitalized with uncomplicated pneumonia,a pilot study

Background and purpose

Pneumonia is the most important respiratory problem in low‐to‐middle income countries. Airway clearance therapy continues to be used in children with pneumonia and secretion retention; however, there is lack of evidence to support or reject this treatment. This study aimed to investigate the feasibility of a randomized controlled trial (RCT) on the efficacy and safety of assisted autogenic drainage (AAD) compared to standard nursing care in children hospitalized with uncomplicated pneumonia.

Methods

A single‐blinded pilot RCT was conducted on 29 children (median age 3.5 months, IQR 1.5–9.4) hospitalized with uncomplicated pneumonia. The intervention group received standard nursing care with additional bi‐daily AAD, for 10 to 30 min. The control group only received standard nursing care, unless otherwise deemed necessary by the physician or physiotherapist. The primary outcome measure was duration of hospitalization. The secondary outcome measures included days of fever and supplemental oxygen support; respiratory rate (RR) and heart rate adjusted for age; RR and oxygen saturation pre‐, post‐, and 1‐hr post‐treatment; oxygen saturation; adverse events; and mortality.

Results

No difference was found for duration of hospitalization (median 7.5 and 7.0 days for the control and intervention groups, respectively); however, Kaplan–Meier analysis revealed a strong tendency towards a shorter time to discharge in the intervention group (p = .06). No significant differences were found for the other outcome measures at time of discharge. No adverse events were reported. Within the intervention group, a significant reduction in RR adjusted for age was found.

Discussion

As no adverse events were reported, and AAD did not prolong hospitalization; AAD might be considered as safe and effective in young children with uncomplicated pneumonia. However, a larger multicentred RCT is warranted to determine the efficacy of AAD compared to standard nursing care.