Search

The mortality rate from firearm injuries in the United States has decreased from 30.3 per 100,000 people in 1990 to 20.6 in 2010, likely because of improvement in treatments. However, the incidence of gunshot wounds continues to increase, including the number of mass shootings, even though the definition of which is still unclear. According to Gun Violence Archives, there were 346 mass shootings in the United States, defined as 4 or more injuries in a single incident, in 2017, with 437 deaths and 1803 injured. This article briefly reviews the ballistics of firearms pertinent for maxillofacial surgeons and summarizes the lessons learned from caring for patients with ballistic injuries to the craniofacial region based on the available peer-reviewed publications and the authors' combined experience of more than six decades. Specifically, we discuss in details the roles of plastic surgeons as a member of the multidisciplinary trauma team in the following three phases: damage control, definitive treatment, and long-term rehabilitation.

White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are attributed to the tendency of younger bone to break and reapproximate owing to greater elasticity. This phenomenon, commonly referred to as the greenstick fracture, increases the risk of entrapment of surrounding soft tissue structures in orbital floor fractures. Further concern arises in the presence of an oculocardiac reflex, which requires urgent intervention to prevent serious bradycardia. Prolonged entrapment can go unnoticed and result in irreversible ischemic damage to entrapped tissues. This case discusses the presentation 16-year-old female who sustained a left sided, white-eyed blowout fracture from a face-first ground level fall. On admission, she displayed restrictive strabismus and mild periorbital edema around the left eye. Vertical gaze was restricted when looking inferiorly on the affected side. With sustained upward gaze, her heart rate decreased from 99 to 81 beats per minute. High-resolution non-contrast computed tomography scans of the head showed entrapment of the inferior rectus muscle and periorbital fat. Liberation of entrapped tissues with reduction of bony segments was performed urgently, utilizing a MEDPOR® Titan 3D orbital floor plate and secured with two screws. The patient had an uneventful postoperative period and showed considerable improvements in periorbital edema, duction, and ophthalmalgia on the affected side. In addition, the oculocardiac reflex could no longer be elicited on prolonged upward gaze. Mild and improving paresthesia was noted in the maxillary distribution of the left trigeminal nerve. Sensory deficits like this are the result of fracture communication with the infraorbital canal, which may cause irritation of the infraorbital nerve responsible for sensation by the maxillary division. By postoperative week 7, she had complete resolution of periorbital edema, indiscernible duction abnormalities, and complete healing of surgical incision sites, and an oculocardiac reflex could not be elicited.

This case involves a 32-year-old pregnant patient with a preexisting ventriculoperitoneal shunt. At term, she had a vaginal delivery with vacuum assistance, an epidural, and prophylactic antibiotics. Although there are [...]

Shoulder dislocations and their treatment have been written about and discussed since at least the 5th century BC, when Hippocrates described a number of methods of reduction.[1] During the Greek [...], The glenohumeral joint of the shoulder is the most commonly dislocated joint in the body. When dislocation occurs, it is usually anterior. The primary care physician usually sees the patient after reduction has been performed. Thus, treatment is directed at recovery of function and preventing recurrences. The prognosis and likelihood of recurrence in a first-time anterior dislocation depends on the mechanism of injury, treatment, rehabilitation, sex, age, and complications. Non-operative treatment after reduction usually involves immobilization and rehabilitation. Studies to date seem to indicate that age and activity level are more important factors for recurrence than length of immobilization. Traditionally, if there are recurrences after conservative treatment, then surgery is contemplated. Key words. Shoulder dislocation; recurrence; immobilization; clinical protocols. J Fam Pract 1992; 35:567-576.

The smile is an important part of the individual’s facial expression, it allows the communication of emotions and ideas. However, its aesthetics can be severely compromised in patients with cleft lip and palate due to multiple missing, malformed and malposed teeth, abnormal soft tissue morphology, upper lip scar tissue, and altered anatomy in the lower third of the face. This clinical case reports the interdisciplinary treatment approach of a young male patient with complete bilateral cleft lip and palate and missing premaxilla. Prosthodontic rehabilitation included a zirconia-based fixed dental prosthesis, with pink porcelain to camouflage the bony defect and restore the facial and dental aesthetics. Maxillary second premolars received lithium disilicate crowns to obtain a more harmonious smile line and adequate occlusion. A resin-bonded fixed partial denture restored a missing mandibular central incisor. Tooth proportions, gingival contours and facial ratios routinely used in noncleft patients, were used to achieve a consonant smile. The final restorations satisfied the patient’s expectations, restored an aesthetically pleasant smile, and provided an adequate occlusion.

Breast milk is considered the ideal and preferred feeding for all infants through the first 4–6 months of life. It provides many short and long-term benefits to the infant and mother. In the absence of breastfeeding, expressed breast milk is the best way to provide nutrition. In the United States, the majority of breastfeeding mothers express milk at some point during the course of lactation. Breast milk is a dynamic fluid and its content changes with duration of lactation and varies between and among women. Many factors such as maternal diet and medications affect the constituents of breast milk. In addition, method of breast milk expression, handling, and storage can also influence its contents.

An innovative chemical-affinity filtration process helped Anadarko to discharge water with a stringent 10-ppm oil content standard. Vol. 230 No. 12 Produced Water ReportDeoiling for discharge-quality waterAn innovative chemical-affinity filtration [...]

Representing 68% of firearm-related injuries, nonfatal firearm injuries cause substantial morbidity and are associated with high costs to patients and the health care system. A retrospective analysis was performed to evaluate 359 adults in the Southeastern United States from 2019 to 2021. IBM SPSS was used for descriptive and parametric statistical analysis. The mean total cost of stay (TCOS) was $36,639.12, length of stay (LOS) was 8.61 days, number of times to the operating room was 1.88, and number of follow-ups was 3.21. Vascular and traumatic brain injuries were associated with higher TCOS and LOS. Vascular injuries were associated with more operating room visits. Bony injuries and non-TBI neurological injuries were associated with more follow-up appointments. In this brief report, we aim to understand the effect injury types have on these factors to help inform trauma protocol development with the goal of decreasing financial burdens.

Whole-body vibration (WBV) has gained attention as a potential exercise mimetic, but direct comparisons with the metabolic effects of exercise are scarce. To determine whether WBV recapitulates the metabolic and osteogenic effects of physical activity, we exposed male wild-type (WT) and leptin receptor-deficient (db/db) mice to daily treadmill exercise (TE) or WBV for 3 months. Body weights were analyzed and compared with WT and db/db mice that remained sedentary. Glucose and insulin tolerance testing revealed comparable attenuation of hyperglycemia and insulin resistance in db/db mice following TE or WBV. Both interventions reduced body weight in db/db mice and normalized muscle fiber diameter. TE or WBV also attenuated adipocyte hypertrophy in visceral adipose tissue and reduced hepatic lipid content in db/db mice. Although the effects of leptin receptor deficiency on cortical bone structure were not eliminated by either intervention, exercise and WBV increased circulating levels of osteocalcin in db/db mice. In the context of increased serum osteocalcin, the modest effects of TE and WBV on bone geometry, mineralization, and biomechanics may reflect subtle increases in osteoblast activity in multiple areas of the skeleton. Taken together, these observations indicate that WBV recapitulates the effects of exercise on metabolism in type 2 diabetes.

Disc tube (DT) and spiral wound (SW) configurations of nanofiltration (NF) and reverse osmosis (RO) processes were tested at pilot-scale using a two-pass configuration to treat produced water obtained from natural gas wells. First pass NF membranes were used to remove divalent cations from produced water. Permeate from the first pass NF membranes were used as feed to second pass RO membranes after increasing the pH to 10.0 to enhance silica solubility. To reduce the fouling potential on NF and RO membranes dissolved air floatation (DAF), ceramic ultrafiltration (UF), MYCELX cartridges, and organoclay filters were tested as pretreatment alternatives. Pretreatment processes were effective for turbidity and oil and grease removal but were not efficient in retaining organic matter, primarily protein-like and polysaccharide-like material, which eventually fouled the first pass NF membranes. The second pass RO membranes were scaled predominantly by silica. The overall feed water recovery of the two-pass NF-RO system was limited to less than 70%. Although the application of a two-pass configuration met the discharge limits for most of the contaminants in produced water, a more stringent pretreatment process for selective removal of organics and silica is essential to operate the membrane systems at recoveries greater than 85%. If treated appropriately, produced water can be employed as a true water resource to augment existing surface water streams and creeks.

Pediatric craniofacial structures differ from those of adults in many ways. Because of these differences, management of pediatric craniofacial fractures is not the same as those in adults. The most important differences that have clinical relevance are the mechanical properties, craniofacial anatomy, healing capacity, and dental morphology. This article will review these key differences and the management of pediatric maxillary fractures. From the mechanical properties' perspective, pediatric bones are much more resilient than adult bones; as such, they undergo plastic deformation and ductile failure. From the gross anatomic perspective, the relative proportion of the cranial to facial structures is much larger for the pediatric patients and the sinuses are not yet developed. The differences related to dentition and dental development are more conical crowns, larger interdental spaces, and presence of permanent tooth buds in the pediatric population. The fracture pattern, as a result of all the above, does not follow the classic Le Fort types. The maxillomandibular fixation may require circum-mandibular wires, drop wires, or Ivy loops. Interfragmentary ligatures using absorbable sutures play a much greater role in these patients. The use of plates and screws should take into consideration the future development with respect to growth centers and the location of the permanent tooth buds. Pediatric maxillary fractures are not common, require different treatments, and enjoy better long-term outcomes.

In this article, the authors present a microeconomic analysis of the effects of the administrative status on plastic surgery units within academic medical centers, comparing the departmental versus subdepartmental status. The objectives are to introduce decision-making tools of microeconomics and use them to explore the potential effects of administrative status on academic plastic surgery services.

This is a mini-review of the etiopathogenesis and management of Pierre Robin Sequence (PRS). PRS is the combination of intermittent upper airway obstruction, glossoptosis, microgenia, and retrognathia, with or without cleft palate. 70 to 75 of PRS babies can be managed by prone positioning. Failing conservative measures, classified as Caouette-Laberge Group III PRS patients, surgical airway management is necessary and includes tongue-lip adhesion, mandibular distraction, or tracheostomy. The objectives are to provide a comprehensive, practical, and updated synopsis for health care professionals involved in the care of this group of patients, so that accurate diagnosis can be made, logical treatment plan can be formulated, and effective therapy can be carried out. Particular emphasis is placed on the management for Group III patients with focus on the technical aspects of the tongue-lip adhesion and distraction osteogenesis in this review.

Primary osteosarcoma of the calvarium is rare. A 22-year-old female patient was admitted for a progressively enlarging, indurated mass under her scalp for 6 months. A computed tomographic scan revealed a 4 × 3 × 2-cm3osteolytic lesion over the right parietal cortex with a sunburst appearance. The patient underwent en bloc tumor resection using bicortical parietal craniectomy with a 2-cm margin of normal bone, including the tightly adherent periosteum over the tumor. Immediate cranioplasty was performed with split-thickness autogenous calvarial bone grafts. Histopathologic examination showed the tumor to be a primary high-grade osteosarcoma of the skull. She received postoperative chemotherapy. She has recovered well and remains without any evidence of disease at her most recent, 8-year follow-up. The key to disease-free survival in treating primary osteosarcoma of the calvarium is complete surgical resection with immediate reconstruction followed by adjuvant chemotherapy.

Computed tomographic scan evaluation is the current standard of care for diagnosing craniosynostosis. Recent publications, and the National Cancer Institute, have raised concerns about ionizing radiation associated with computed tomographic scans in children (e.g., developmental delays, tumor induction). The authors sought to ascertain the diagnostic accuracy of the physical examination in evaluating single-sutural craniosynostosis and assess the need for computed tomographic scans in surgical correction.

Objective: To evaluate the complexity of human sagittal suture patterns and to investigate whether the suture complexity correlates with age.Design: Geometric patterns of the sagittal sutures from 104 dry human skulls from the Terry Collection and 16 computed tomography images from the Bosma Collection, aged 2 months to 60 years, were digitized. The complexity of the patterns was presented by suture length, curved suture (or skull) length, and length ratio and the frequency and amplitude contents by the discrete Fourier transform (DFT) analysis.Results: The suture length along the skull showed a positive correlation with age from 2 months to 10 years, reflecting the growth of the skull. The suture length ratio, R, a measure of the complexity of the suture pattern, had a similar trend to suture length (i.e., increased with age to about 10 years and leveled off afterward, accompanied by a large scatter). The major frequency from the DFT analysis indicated an age-related development in suture complexity from infants to about 10 years and no further change for individuals older than 10 years.Conclusions: Quantitative analyses of human sagittal suture using length, length ratio, and DFT indicated that there is a progressive increase in the complexity of sagittal sutural waveform with age, especially in the early ages. These findings agree with the observations from animal experiments that sagittal sutural waveform is the result of intrinsic tissue response to extrinsic forces such as those generated by the temporalis.

Signal transduction pathways play a crucial role in breast cancer development, progression, and response to different therapies. A major problem in breast cancer therapy is the heterogeneity among different tumor types and cell lines commonly used in preclinical studies. To characterize the signaling pathways of some of the commonly used breast cancer cell lines and dissect the relationship among a number of pathways and some key genetic and molecular events in breast cancer development, such as p53 mutation, ErbB2 expression, and estrogen receptor (ER)/progesterone receptor (PR) status, we performed pathway profiling of 14 breast cancer cell lines by measuring the expression and phosphorylation status of 40 different cell signaling proteins with 53 specific antibodies using a protein lysate array. Cluster analysis of the expression data showed that there was close clustering of phosphatidylinositol 3-kinase, Akt, mammalian target of rapamycin (mTOR), Src, and platelet-derived growth factor receptor β (PDGFRβ) in all of the cell lines. The most differentially expressed proteins between ER- and PR-positive and ER- and PR-negative breast cells were mTOR, Akt (pThr308), PDGFRβ, PDGFRβ (pTyr751), panSrc, Akt (pSer473), insulin-like growth factor-binding protein 5 (IGFBP5), Src (pTyr418), mTOR (pSer2448), and IGFBP2. Many apoptotic proteins, such as apoptosis-inducing factor, IGFBP3, bad, bax, and cleaved caspase 9, were overexpressed in mutant p53-carrying breast cancer cells. Hexokinase isoenzyme 1, ND2, and c-kit were the most differentially expressed proteins in high and low ErbB2-expressing breast cancer cells. This study demonstrated that ER/PR status, ErbB2 expression, and p53 status are major molecules that impact downstream signaling pathways.

Identifying the primary site in patients with metastatic carcinoma of unknown primary origin can enable more specific therapeutic regimens and may prolong survival. Twenty-three putative tissue-specific markers for lung, colon, pancreatic, breast, prostate, and ovarian carcinomas were nominated by querying a gene expression profile database and by performing a literature search. Ten of these marker candidates were then selected based on validation by reverse transcriptase-polymerase chain reaction (RT-PCR) on 205 formalin-fixed, paraffin-embedded metastatic carcinoma specimens originating from these six and from other cancer types. Next, we optimized the RNA isolation and quantitative RT-PCR methods for these 10 markers and applied the quantitative RT-PCR assay to a set of 260 metastatic tumors. We then built a gene-based algorithm that predicted the tissue of origin of metastatic carcinomas with an overall leave-one-out cross-validation accuracy of 78%. Lastly, our assay demonstrated an accuracy of 76% when tested on an independent set of 48 metastatic samples, 37 of which were either a known primary or initially presented as carcinoma of unknown primary but were subsequently resolved.

Gene expression signatures have the ability to serve in both prognostic and predictive capacities in patient management. The use of RNA as the starting material and the lability of this analyte, however, dictate that tissues must be snap-frozen or stored in a solution that can maintain the integrity of the RNA. We compared pairs of snap-frozen and RNAlater preservative-suspended tissue from 30 such paired lymph node-negative breast tumors and 21 such paired Dukes' B colon tumors. We assessed the correlation of gene expression profiles and prediction of recurrence based on two prognostic algorithms. Tissues stored in RNAlater preservative generated expression profiles with excellent correlation (average Pearson correlation coefficients of 0.97 and 0.94 for the breast and colon tumor pairs, respectively) compared to those produced by tissues that were snap-frozen. The correlation in the prediction of recurrence was 97% and 95% for the breast and colon tumor pairs, respectively, between these two types of tissue handling protocols. This novel finding demonstrates that prognostic signatures can be obtained from RNAlater preservative-suspended tissues, an important step in bringing gene expression signatures to the clinic.

Background Genome-wide measures of gene expression can identify patterns of gene activity that subclassify tumours and might provide a better means than is currently available for individual risk assessment in patients with lymph-node-negative breast cancer.Methods We analysed, with Affymetrix Human U133a GeneChips, the expression of 22 000 transcripts from total RNA of frozen tumour samples from 286 lymph-node-negative patients who had not received adjuvant systemic treatment.Findings In a training set of 115 tumours, we identified a 76-gene signature consisting of 60 genes for patients positive for oestrogen receptors (ER) and 16 genes for ER-negative patients. This signature showed 93% sensitivity and 48% specificity in a subsequent independent testing set of 171 lymph-node-negative patients. The gene profile was highly informative in identifying patients who developed distant metastases within 5 years (hazard ratio 5·67 [95% CI 2·59–12·4]), even when corrected for traditional prognostic factors in multivariate analysis (5·55 [2·46–12·5]). The 76-gene profile also represented a strong prognostic factor for the development of metastasis in the subgroups of 84 premenopausal patients (9·60 [2·28–40·5]), 87 postmenopausal patients (4·04 [1·57–10·4]), and 79 patients with tumours of 10–20 mm (14·1 [3·34–59·2]), a group of patients for whom prediction of prognosis is especially difficult.Interpretation The identified signature provides a powerful tool for identification of patients at high risk of distant recurrence. The ability to identify patients who have a favourable prognosis could, after independent confirmation, allow clinicians to avoid adjuvant systemic therapy or to choose less aggressive therapeutic options.

After studying this article, the participant should be able to 1. Review the biomechanical principles and pertinent cellular and molecular biology of distraction osteogenesis of the craniofacial skeleton. 2. Describe the clinical indications and applications of distraction osteogenesis of the craniofacial skeleton. 3. Describe maxillary, mandibular, midface, and calvarial procedures in distraction osteogenesis. 4. Discuss the clinical outcomes and complications of distraction osteogenesis of the craniofacial skeleton.

The purpose of this study is to test predicted form–function relationships between cranial suture complexity and masticatory muscle mass and biomechanics in a mouse model. Specifically, to test the hypothesis that increased masticatory muscle mass increases sagittal suture complexity, we measured the fractal dimension (FD), temporalis mass, and temporalis bite force in myostatin-deficient (GDF8-/-) mice and wild-type CD-1 mice (all male, 6 months old). Myostatin is a negative regulator of muscle mass, and myostatin-deficient mice show a marked increase in muscle mass compared to normal mice. We predicted that increased sagittal suture complexity would decrease suture stiffness. The data presented here demonstrate that increased suture complexity (measured as FD) was observed in a hypermuscular mouse model (GDF8-/-) with significantly increased temporalis muscle mass and bite forces. Hypermuscular mice were also found to possess suture connective tissue that was less stiff (i.e., underwent more displacement before failure occurred) when loaded in tension. By decreasing stiffness, suture complexity apparently helps to dissipate mechanical loads within the cranium that are related to chewing. These results suggest that cranial suture connective tissue locally adapts to functional demands of the biomechanical suture environment. As such, cranial sutures provide a novel model for studies in connective tissue mechanotransduction. © 2004 Wiley-Liss, Inc.

Objectives Many biological structures are products of repeated iteration functions. As such, they demonstrate characteristic, scale-invariant features. Fractal analysis of these features elucidates the mechanism of their formation. The objectives of this project were to determine whether human cranial sutures demonstrate self-similarity and measure their exponents of similarity (fractal dimensions).Design One hundred three documented human skulls from the Terry Collection of the Smithsonian Institution were used. Their sagittal sutures were digitized and the data converted to bitmap images for analysis using box-counting method of fractal software.Results The log-log plots of the number of boxes containing the sutural pattern, Nr, and the size of the boxes, r, were all linear, indicating that human sagittal sutures possess scale-invariant features and thus are fractals. The linear portion of these log-log plots has limits because of the finite resolution used for data acquisition. The mean box dimension, Db, was 1.29289 ± 0.078457 with a 95% confidence interval of 1.27634 to 1.30944.Conclusions Human sagittal sutures are self-similar and have a fractal dimension of 1.29 by the box-counting method. The significance of these findings includes: sutural morphogenesis can be described as a repeated iteration function, and mathematical models can be constructed to produce self-similar curves with such Db. This elucidates the mechanism of actual pattern formation. Whatever the mechanisms at the cellular and molecular levels, human sagittal suture follows the equation log Nr= 1.29 log 1/r, where Nris the number of square boxes with sides r that are needed to contain the sutural pattern and r equals the length of the sides of the boxes.

Background Tbx2 is a member of the T-box family of transcriptional regulatory genes with an extensive but not yet fully understood role in embryonic development. This study explores the potential role of Tbx2 in calvarial morphogenesis.Objectives To explore the hypothesis that Tbx2 has a negative regulatory effect on the expression of connexin 43 (Cx43), a protein necessary for cell-to-cell communication; document the presence of Tbx2 protein in the developing cranial sutures; and determine the spatial pattern of expression of this developmentally regulated transcription factor in calvariae.Design The osteoblast-like cell line ROS 17/2.8 was stably transfected with sense or antisense Tbx2. Immunohistochemistry and Western blotting was used to study Tbx2 and Cx43 expression in these cells and sections of embedded developing coronal sutures.Results The ROS 17/2.8 cells transfected with antisense Tbx2 showed a decrease in expression of Tbx2 protein and an increase in expression of endogenous Cx43. The reverse is seen with sense-transfected cells. Both of these proteins are expressed in rat developing coronal sutures. The pattern of Tbx2 expression in the developing was also reciprocal to the pattern of Cx43 expression. Tbx2 protein is concentrated in the center of the sutural blastema, an area devoid of Cx43 protein localization. Conversely, Tbx2 protein expression is low in the periphery of the sutures, in which there is high Cx43 protein expression.Conclusions Taken together, these studies suggest that Tbx2 protein is a negative regulator of Cx43 expression at the transcriptional level in cranial sutures in vivo.

There are numerous studies cataloging the temporal profiles of the various growth factors during the morphogenesis of cranial sutures. There are also many clearly documented mutations of the receptors of some of these growth factors such as fibroblast growth factor (FGF)R-2 and FGFR-3 in clinical craniosynostosis. It is obvious, and often concluded, that growth factors play a roleor are involvedin craniofacial development. However, precisely what that role is, what causes the changes in the growth factor levels, and why these changes occur in the particular temporal and spatial patterns observed remains elusive. Using simple physics, we applied a plasma membrane disruption model and the principles of complex adaptive systems to arrive at a conjecture of calvarial morphogenesis. The purpose of this article is to introduce the concept of complex adaptive systems, to propose our conjecture, and to provide experimental proof of some key steps in this conjecture tension induces rapid and demonstrable physiological responses in somecells within the immature cranial sutures. These responses include increases of intracellular Ca , plasma membrane permeability, and the release of growth factors, e.g., FGF-2. Paired coronal sutures from 1-week-old Sprague-Dawley rat pups were subjected to either 0.59 N of tensile force or no force for 5 minutes in a protein-free medium. FGF-2 levels in the media were measured by slot blot analysis. Western blot analysis was used to determine FGF-2 levels in the sutures. To determine cell membrane permeability changes, fluorescein-conjugated dextran, with a molecular weight of 10 kd, was added to the media during the 5 minutes with or without tensile force. Laser confocal microscopy was used to compare the amount of entry of this impermeant tracer and the pattern of permeability change at the tissue level. To determine the intracellular pCa , the sutures were first loaded with a calcium indictor, FURA-2 AM, and then subjected isotonically to 0.059 N of tension. The intracellular pCa was expressed as ratio of Ca -bound FURA-2 to Ca -free FURA-2. The experimental findings were as follows 1) Sutures, in response to tension, release FGF-2. 2) Sutures contain higher levels of FGF-2 when strained. 3) There is an increase in the sutural cell membrane permeability as a result of tensile strain. 4) The cells along the leading edges of the ossification fronts (at the insertion sites of Sharpey's fibers) demonstrated the maximum permeability increase. 5) There was an immediate (within seconds) increase in intracellular Ca . and 6) This increase in intracellular Ca caused by tension was reversible and independent of the extracellular Ca ion availability. In summary, these data support, in part, the conjecture that growth of the brain places strain on the cells within the immature sutures, which causes the iteration of a set of cellular subroutines. These subroutines integrate to generate the emergent property of directed cranial expansion with dissipation of the initiating strains.

Many techniques are available for surgical correction of gynecomastia. In this article, we describe a technique based on geometrical principles that is simple to execute, effective, highly reproducible, and relies less on intuition of the surgeon.

Diplopia occurring after orbital trauma is a complex and difficult clinical problem. Numerous potential mechanisms exist by which it may occur. Restrictive ocular dysmotility caused by intraorbital scarring is a major component in diplopia's pathogenesis. The current large animal study was conducted to develop an experimental model of restrictive ocular dysmotility that would quantitatively characterize the biomechanical properties of the globe rotations. Using this model, a novel method of restoring the low-friction milieu within the orbit by interposing a buccal fat graft was tested. In the initial stage, the baseline force duction was measured in 20 pig eyes using a highly sensitive, digital tensiometer. Traumatic violation of Tenon's fascia with electrocautery into the extraconal fat and the periorbita was followed by direct suturing of the extraocular muscle to the nearest orbital periosteum. After 6 weeks, the measurements (again in the field of the traumatized muscle) were repeated, and the eyes were divided into two treatment groups (n= 10 eyes per group). The left eye received the standard lysis of adhesion, whereas the right eye received lysis and buccal fat interposition grafting. The third and final force measurements were performed 6 weeks after treatment. The results showed a baseline linear load-displacement curve of 0 to 8 mm, with the globe rotating 400 μm for every 1000 mg of tensile load. Surgical trauma increased the slope as defined by load/displacement but, surprisingly, the relationship remained linear in the entire range from 2 to 8 mm. This linear relationship was seen in all stages: baseline, after trauma to Tenon's fascia, after surgical lysis alone, and after lysis with buccal fat interposition. The difference was in the slope, or stiffness. Lysis alone partially reduced the slope, but it was still higher than baseline. Lysis and buccal fat grafting returned the slope to near baseline. This, however, did not reach the level of statistical significance. It seems that a focal intervention along the course of an extraocular muscle altered the composite behavior of orbital resistance to globe rotation. Although buccal fat grafting did not significantly improve motility, it did not worsen it.

The migration or passive intracranial translocation of microplates and screws in the pediatric craniofacial patient has been reported. A retrospective review was undertaken to clarify the incidence of microplate translocation and identify potential clinical implications. Computed tomographic imaging demonstrated internalization of microfixation in 14 of 27 pediatric patients. Statistically significant factors for microplate translocation include longer plates (p< 0.05) and those placed in the temporal region (p< 0.001). Younger patients and those with syndromic craniofacial dysostosis also had a higher incidence of translocation. Specific complications relating to the translocation of microplates were not found in any patient. The direct effects of translocated microplates and screws on the underlying brain and dura remain unclear.

Reported here are the results of a retrospective study of the speech outcome for 63 cleft subjects who had Furlow repairs compared with 20 subjects who had other procedures. The two groups of children were similar in cleft type, sex, and race. The same two surgeons repaired the palates in both groups, and the same two speech pathologists with high reliability examined the children at least 5 years postoperatively using the Pittsburgh Weighted Values for Speech Symptoms Associated with VPI (velopharyngeal incompetence). Subjects who had had Furlow repairs were superior on measures of hypernasality, articulation, and total speech scores; and fewer pharyngeal flaps were required by Furlow subjects. These findings suggest the need for randomized, double-blind investigations comparing outcome of the Furlow procedure with the intravelar veloplasty, the V-Y pushback, and other specified procedures.

This retrospective review of infectious complications was undertaken at two craniofacial centers (Dallas and Philadelphia). Fourteen infections were identified over a 6.5-year period in 567 intracranial procedures primarily for craniosynostosis. There were no infections in infants under 13 months of age and no cases of meningitis. The overall infection rate was 2.5 percent, and 85 percent of infections occurred in secondary reoperative cases. Tracheostomies were not identified as a risk factor for infection. No difference was found in infection rates between patients with shaved and unshaved scalps. Candidaand Pseudomonaswere the two most common organisms identified, and 28 percent of our infections involved yeast. The average time to diagnose infection was 11.5 days (excluding three patients who averaged 5 months). Thirteen of the fourteen infections were treated surgically with placement of a subgaleal irrigation/drainage system. Initial bony debridement was kept to a minimum. Based on our findings, recommendations are made to further lower infection rates, particularly those caused by opportunistic organisms.

Prostasin, denoted as PRSS8, is a newly identified human serine proteinase that shares high sequence identity with acrosin, plasma kallikrein, and hepsin (Yuet al.,1994, 1995). In the present study, a full-length PRSS8 gene has been isolated and characterized. A 7-kb PRSS8 gene fragment has been sequenced, including a 1.4-kb 5′-flanking region, the 4.4-kb PRSS8 gene, and a 1.2-kb 3′-flanking region. The gene consists of six exons and five introns based on comparison with its cDNA sequence. The sizes of these exons are 417, 18, 163, 272, 167, and 899 bp, while those of the introns are 243, 1763, 271, 85, and 92 bp. A number of potential regulatory elements have been revealed in the 5′-flanking region, including an AP2 site, two erythroid-specific promoter elements, and a sterol regulatory element. In addition, there are a variant GC box and a variant AP1 site in the promoter region. The transcription initiation site of the PRSS8 gene has been defined at the G residue and its adjacent A residue in a sequence CTCATGACT, which is similar to an initiator element CTCANTCT. Between the transcription initiation site and these putative regulatory elements, there is an AC-rich repetitive sequence that spans over 300 bp. Human PRSS8 is a single-copy gene and has been localized on chromosome 16p11.2 byin situhybridization.

We have purified a novel human serine proteinase, designated as prostasin, from seminal fluid (Yu et al., 1994). In the present study, we have cloned and characterized the full-length cDNA encoding prostasin and identified its tissue-specific expression and cellular localization. A cDNA fragment was obtained by polymerase chain reaction using degenerate oligonucleotide primers derived from the NH2-terminal and internal amino acid sequences. A full-length cDNA sequence encoding prostasin was obtained by amplification of the 5′- and 3′-ends of the cDNA. It contains a 1,032-base coding region, a 572-base 3′-noncoding region and a 138-base 5′-noncoding sequence. Prostasin cDNA encodes a protein of 343 amino acids, which consists of a 32-amino acid signal peptide and a 311-amino acid proprostasin. Proprostasin is then cleaved between Arg12and Ile13to generate a 12-amino acid light chain and a 299-amino acid heavy chain, which are associated through a disulfide bond. The deduced amino acid sequence of the heavy chain has 34-42% identity to human acrosin, plasma kallikrein, and hepsin. A potential N-glycosylation site at Asn127and the catalytic triad of His53, Asp102, and Ser206have been identified. The deduced prostasin has a unique 19-amino acid hydrophobic portion at the COOH terminus, which makes it suitable to anchor in the cell membrane. Carboxyl-terminal sequencing of purified prostasin indicates that the hydrophobic portion is removed and that there is a cleavage between Arg290and Pro291during secretion. Southern blot analysis, following a reverse transcription polymerase chain reaction, indicates that prostasin mRNA is expressed in prostate, liver, salivary gland, kidney, lung, pancreas, colon, bronchus, renal proximal tubular cells, and prostate carcinoma LNCaP cells. Cellular localization of prostasin mRNA was identified within epithelial cells of the human prostate gland by in situhybridization histochemistry.

Since the first report of autotransfusion and blood loss in major anesthetic procedures by Noone et al. in 1972, much has changed. The single most significant event is the development of the AIDS epidemic. With today's stringent and precisely defined transfusion criteria, the current practice of routinely using autologous units for reduction mammaplasties has caused considerable controversy. This study reviews the mean estimated blood loss during reduction mammaplasty and the use of autologous transfusion during a 46-month period at the Hospital of the University of Pennsylvania ending in November of 1991. The need for red blood cell transfusion is retrospectively analyzed. One-hundred female patients were entered into the study. The results demonstrate a decrease in blood loss from an average of 865 ml in the 1970s to 385 ml in the 1990s and suggest that routine employment of autologous transfusion is no longer necessary.

Dura plays an important role in calvarial morphogenesis. However, precisely what that role is remains unclear. We present here in vivo evidence that dura without other central nervous system components induces both chondrogenesis and osteogenesis. The mechanism is, at least in part, by proximate tissue interaction. The objectives of this experiment were to answer the following 1 Can dura actually induce osteogenesis without the influence of the underlying brain 2 What are the requirements of this durainduced heterotopic osteogenesis 3 What are the differences between dura underlying sutures and dura underlying the squamous portions of the cranial bones

Costimulatory molecules play an important role in activation of T cell responses, and T cells contribute to HSV-1-induced eye disease in the host. Similar to HSV-1 ICP22, the cellular costimulatory molecules CD28, CTLA4, and PD-L1 also bind to CD80.

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system. Although viruses have been suggested to be a contributing environmental factor, conventional experimental MS mouse models do not account for this aspect. Here, we describe a mouse model to induce and evaluate demyelinating disease with both a viral and an immune component via ocular infection with a recombinant herpes simplex virus expressing murine interleukin-2.

Epistaxis is a frequent finding in patients with facial trauma. Herein, we report an unusual presentation of pediatric naso-orbital-ethmoid (NOE) fracture with epistaxis as the only initial symptom. The course of the patient's condition was later complicated by meningitis, related in part to the delay in diagnosis. A 3-year-old girl with preexisting upper respiratory symptoms was involved in a traffic accident, sustaining blunt trauma to the right side of her face. During the initial examination, only right-sided epistaxis was noted. Five days later, she developed febrile convulsion and was admitted to the intensive care unit with other signs of meningitis such as mental status change and neck stiffness. Her craniofacial computed tomographic scan showed a right-sided NOE fracture with minimal displacement and without dura tear. The cerebrospinal fluid culture grew Streptococcus pneumoniae, which may be due to ascending infection as a result of cribriform plate fracture. Intravenous antibiotic therapy was initiated with good response, and she was discharged from the hospital after 2 weeks. The presence of epistaxis and periorbital bruise, together with other symptoms and signs, helps in the identification of NOE and cribriform plate fracture. A high index of suspicion with repetitive computed tomographic scans is necessary to achieve correct early diagnosis. Parental antibiotic therapy is indicated if ascending cerebrospinal fluid infection develops.

Introduction:In addition to hand washing and wearing masks, social distancing and reducing exposure time to <15 minutes are the most effective measures against the spread of COVID-19. Unfortunately, three of these guidelines are very difficult, if not impossible, for nursing babies: they cannot wear masks, stay six feet away from the lactating breasts, nor consistently finish within 15 minutes while nursing. We report a case of a nursing mother with SARS-CoV-2 infection, documenting changes of immune cells and cytokines in breast milk with and without the infection.Case Description:With Institutional Review Board (IRB) approval, we obtained expressed breast milk samples from a lactating mother before and during SARS-CoV-2 infection as documented by reverse transcription-PCR. Using flow cytometry analysis, we measured the immune cell profiles and expression of cytokines such as interferon alpha (IFNα) in milk leukocytes before and during infection.Results:There was an eightfold increase in IFNα+ milk leukocytes, from 1% before SARS-CoV-2 infection to 8% when actively infected. The milk macrophages showed the highest increase in IFNα expression. Both T and B lymphocytes showed mild increase. Innate lymphoid cells, neutrophils, and natural killer cells showed no increase in IFNα expression and the dendritic cells actually showed a reduction.Conclusion:We document the presence and high expression of IFNα in the breast milk macrophages of a lactating mother with confirmed COVID-19, compared with her milk before the infection.