A dense ring of the trans-Neptunian object Quaoar outside its Roche limit.

Planetary rings are observed not only around giant planets1, but also around small bodies such as the Centaur Chariklo2 and the dwarf planet Haumea3. Up to now, all known dense rings were located close enough to their parent bodies, being inside the Roche limit, where tidal forces prevent material with reasonable densities from aggregating into a satellite. Here we report observations of an inhomogeneous ring around the trans-Neptunian body (50000) Quaoar. This trans-Neptunian object has an estimated radius4 of 555 km and possesses a roughly 80-km satellite5 (Weywot) that orbits at 24 Quaoar radii6,7. The detected ring orbits at 7.4 radii from the central body, which is well outside Quaoar's classical Roche limit, thus indicating that this limit does not always determine where ring material can survive. Our local collisional simulations show that elastic collisions, based on laboratory experiments8, can maintain a ring far away from the body. Moreover, Quaoar's ring orbits close to the 1/3 spin-orbit resonance9 with Quaoar, a property shared by Chariklo's2,10,11 and Haumea's3 rings, suggesting that this resonance plays a key role in ring confinement for small bodies.

Cryptotia correction--the post-auricular transposition flap.

BACKGROUND: Cryptotia is a congenital ear deformity in which the upper pole appears buried beneath mastoid skin. Here we describe our method of cryptotia correction which we have used to good effect with minimal complications. PATIENTS AND METHODS: 20 patients and 24 ears were operated on. All surgery was performed by the senior authors WS and DG. Patient age range was 4-19 years and mean follow up was 2.1 years. We use a superiorly based V-shaped flap raised from the post-auricular skin. Following ear release, the flap is rotated into the defect and donor site closed directly. Our technique ensures all scars are hidden behind the ear, there are no skin grafts required. RESULTS: All patients had a satisfactory release of cryptotia, there were no cases of partial or total flap failure, none of wound dehiscence and no patients required revisional surgery. CONCLUSIONS: The post-auricular flap is a simple technique, retaining the depth of the auriculotemporal sulcus, providing a good skin colour match without the need for skin grafting and without distorting the hair line. Our results are comparable or superior to those seen with other techniques previously described.

Therapeutic education in persons with spinal cord injury: a review of the literature.

INTRODUCTION: Therapeutic education is an integrant part of the physical medicine and rehabilitation care of persons with spinal cord injury. It is often conducted in an empirical manner. The objective of this literature review was to evaluate the state of the art regarding the evaluations and therapeutic education programs for persons with spinal cord injury. MATERIAL AND METHOD: Systematic review of the literature with Medline and Cochrane Library databases from 1966 to 2009. RESULTS: The main areas of interest, for the evaluations found in the literature, focused on clinical variables, patients' knowledge, health behaviors, functional independence and quality of life but also psychological dimensions such as health locus of control, representations, abilities to resolve problems and self-perceived efficacy. Ten clinical studies were retained for analysis. These clinical studies were built around various health and educational models. An impact was highlighted on clinical variables (pressure ulcer, urinary tract infection), knowledge, quality of life and psychological criteria (depression, self-perceived efficacy, coping and problem solving strategies). DISCUSSION AND CONCLUSION: The global level of evidence on the effects of therapeutic education in persons with spinal cord injury is low because of the number of studies and their low statistical power and requires additional studies. However, the analysis of the literature allows for discussing the organization of therapeutic education in clinical practice.

Chronic neuropathic pain of spinal cord injury: what is the effectiveness of psychocomportemental management?

OBJECTIVES: To determine the efficacy of treating neuropathic pain in spinal cord injury (SCI) patients by psychological, cognitive or behavioral therapies and suggest recommendations for clinical practices. MATERIAL AND METHOD: The methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts. RESULTS: Due to the dearth of literature on the subject only one study is found, evaluating the efficacy of these therapies on neuropathic pain but not on the chronic neuropathic pain of SCI patients. The results show a greater efficacy on the associated symptoms: anxiety and depression level, sleep disorders, rather than the pain itself. CONCLUSION: There is no scientific evidence for validating this type of pain management care. However, the high level of evidence of the articles studying the efficacy of these therapies in patients with chronic pain suggest that it could be applied to SCI patients. These techniques must be developed in France and further studies should be conducted on SCI patients affected by neuropathic pain.

Metastatic paraplegia: care management characteristics within a rehabilitation center.

STUDY DESIGN: Retrospective study. OBJECTIVES: To determine the potential impact of rehabilitation care on associated symptoms and functional improvements of paraplegic patients with metastatic spinal cord compression. SETTING: CMN Propara, Montpellier (France). MEASURES: Demographics, Functional Independence Measure (FIM), Frankel Modified Score and Visual Analog Scale (VAS) for pain, intercurrent adverse medical events and neurological outcome, duration of stay, survival time, rehospitalization in a non-Spinal Cord Injury unit, number of contracts defining the patients rehabilitation goals, number of contracts defining the patients duration of stay within the rehabilitation center. RESULTS: We reviewed the charts of 26 patients. The initial neurological profile was paraplegia or paraparesis for 24 patients and quadriparesis for 2 patients. Regarding functional improvements: four patients demonstrated a poor functional evolution, five patients showed no functional improvements or very slight improvements and all the other patients showed an increase in their overall functional aptitudes. At the end of the stay, 14 patients were urinary independent. Our study reports 52 rehospitalizations in an another unit and 101 outpatient visits during their rehabilitation stay in a physical medicine and rehabilitation (PM&R) center. For the 14 patients who were deceased at the time of data collection, the median survival rate post-paraplegia was 12.7 months. A total of 12 of the 14 patients spent more than a third of their remaining survival time in a rehabilitation center. DISCUSSION: Compared to the patients' life expectancy, their stay in a rehabilitation center is too long and prevents them from spending time with family and loved ones. The occurrence rate of the associated symptoms is high because of both cancer-related disorders and neurological disorders caused by the spinal cord lesion. PM&R professionals are faced with patients affected by chronic pain and fatigue as well as frequent rehospitalizations, short stays and outpatient stays, in the primary oncology unit. This study focuses on the need to privilege the patients' comfort over their functional rehabilitation.

Operating in an eczematous surgical field: don't be rash, delay surgery to avoid infective complications.

Prominent ear correction is a common operation. Complication as a result of infection has been quoted at between 3% and 5% [Calder JC, Nasaan A. Morbidity of otoplasty: a review of 562 consecutive cases. Br J Plast Surg 1994;47:170-4 and Jeffery SLA. Complications following correction of prominent ears: an audit review of 122 cases. Br J Plast Surg 1999;52:588-90.]. We present two cases referred for ear reconstruction following catastrophic post-operative infection at the time of pinnaplasty, leaving each patient with significant helical rim deformities. Both patients displayed evidence of active post-auricular eczema at the time of their primary surgery. Dermatological research has highlighted the increased colonisation of Staphylococcus aureus in particular within areas of atopic eczema in comparison to normal skin. We advise delaying ear surgery in the presence of a rash in view of the potentially devastating complications that may result. This approach may be extended to all cutaneous surgery where treatment of the rash is advocated prior to embarking on an elective surgical procedure.

How we do it: BAHA positioning in patients with microtia requiring auricular reconstruction.

Keypoints * Bilateral microtia is a challenging problem as these patients require both reconstruction of the auricle and rehabilitation of hearing. * Our aim was to find the optimal position for bone-anchored hearing aids (BAHA) in patients requiring reconstruction of the auricle on the same side. * From an analysis of five such operated patients, it was found that siting a BAHA 6.5-7.0 cm from the position of the external auditory meatus is probably the correct distance to facilitate optimal auricular reconstruction. * Using these criteria, a group of another five patients with BAHA awaiting auricular reconstruction were reviewed. Of these only three (60%) have been satisfactorily sited.

Recurrent mycobacterial breast abscesses complicating reconstruction.

We present a patient with mycobacterial infection of the breast and subsequent mastectomy. After initial reconstruction, she developed multiple recurrent abscesses around the flap. This necessitated further debridement and a second reconstruction. This case demonstrates the need to beware mycobacterial infection in patients undergoing breast reconstruction, especially after recurrent "sterile" abscesses.

Mastectomy and reconstruction--an unusual solution to intractable breast pain.

Breast pain is a common complaint which usually subsides with simple reassurance or sometimes medication. This paper describes the case of a 41-year-old woman suffering from severe non-cyclical breast pain that had proved resistant to a battery of medical treatments. The pain was so disabling that it drove the patient to contemplate suicide. At the patient's request, a bilateral subcutaneous mastectomy with immediate implant reconstruction was performed, resulting in a complete resolution of the pain. Non-cyclical breast pain is less common than cyclical breast pain and tends to be more difficult to treat. This case suggests that mastectomy may be an appropriate option of last resort in the treatment of severe intractable breast pain.

The tuberous male breast.

Whilst tuberous female breasts are well described, the tuberous male breast is a very unusual variant of gynaecomastia. Two cases are presented, the development of the condition is considered and the surgical management is discussed.

Is hemifacial microsomia linked to multiple maternities?

Hemifacial microsomia describes a congenital orofacial malformation in which there is insufficient or disrupted development of the mandible affecting one side of the face. The aetiology of this condition remains unclear, but it has been postulated that twins (predominantly monozygotic) are more liable to be affected than singletons. This study investigates the incidence of multiple births amongst a large number of affected individuals and their families. Data were collected on 145 individuals with hemifacial microsomia and microtia, using postal questionnaires and interviews in a hospital setting. These data were compared with the mean age-standardised twin maternity prevalence for England and Wales between 1975 and 1995 of 1.06% and the triplet maternity prevalence for England and Wales for 1995 of 0.034% (a multiple maternity being where more than one baby is born, either alive or stillborn). The prevalence of twin maternities amongst the affected individuals was 3.96% (P>0.05) and amongst their siblings it was 4.02% (P<0.02). There was also an excess of twins in the rest of the family groups, predominantly due to a stronger history of twinning on the maternal side. As there were more twins amongst the affected individuals than in the general population, it seems likely that whatever the aetiology of hemifacial microsomia and microtia, the presence of a co-twin (or co-triplets) may make the causal event, or series of causal events, more likely to occur. This study supports the hypothesis that hemifacial microsomia and microtia are in some way linked to multiple births. Analysis of this link may provide new directions for research into the aetiology of a variety of congenital defects.

Piercing the upper ear: a simple infection, a difficult reconstruction.

Piercing the upper ear to retain jewellery is now commonplace. When infection ensues, devastating chondritis leads to collapse of the ear. To our knowledge, the surgical reconstruction of post-piercing deformities has not been documented in the literature. We present five such cases referred for autogenous-tissue ear reconstruction. In four of these, the destroyed segments of ear cartilage were replaced with a carved costal-cartilage framework. One patient declined surgery. The importance of preventing infection is stressed.

The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty.

Anterior riberation methods of otoplasty have been criticized because of the risk of anterior hematoma that can cause anterior skin necrosis, scarring, and even cartilage destruction caused by infection. As a result, cartilage-sparing otoplasty such as the Mustardé and Furnas types has been increasingly popular. However, postauricular suture extrusion may result, and recurrence rates of up to 25 percent have been recorded. In this study, cartilage-sparing otoplasty is refined by the addition of a postauricular fascial flap to reduce suture extrusion and recurrence rates. Fifty-one patients underwent otoplasty (45 bilateral, six unilateral). This technique involves the elevation of a fascial flap from the postauricular region. A new antihelical fold is then created by Mustardé sutures, and the conchal bowl is rotated by Furnas-type concha-mastoid sutures. The fascial flap is then advanced to cover the sutures with a supplementary vascularized layer to prevent suture extrusion. In addition, the advancement of the flap acts as a postauricular support to prevent recurrence. A natural-looking antihelical fold and helical rim is created by this technique. There were no hematomas. There was recurrence in eight ears (8 percent) in six patients. Two patients requested further surgery. No patients developed suture extrusion or granuloma. This is a simple and intrinsically safe procedure and does not cause irreparable complications such as anterior scarring or skin necrosis. The postauricular fascial flap seems to prevent suture extrusion. It may also help to reduce recurrence rates to acceptable levels.

Rib graft reconstruction versus osseointegrated prosthesis for microtia: a significant change in patient preference.

Until recently the options for reconstruction of the microtic ear were unsatisfactory and the ear was often left alone. With recent advances, both autologous rib reconstruction and osseointegration produce good quality results. It is our practice to offer all patients a choice of no surgery, autologous rib cartilage reconstruction or an osseointegrated prosthetic ear. This study reports on parental choice between the reconstructive options as assessed by questionnaire. Earlier patients who have had their surgery were compared with more recent patients who have chosen an option but are awaiting surgery. In the patients who have had surgery, seven (30%) chose a prosthetic ear and 16 (69.5%) chose rib cartilage reconstruction, compared to those patients that are awaiting surgery, four (11%) chose a prosthetic ear and 31 (88.6%) chose rib cartilage reconstruction. The results show a significant increase in the choice for rib cartilage reconstruction in those patients awaiting surgery. Although high quality autologous reconstruction is not widely available we feel it is important that parents are at least informed that it is an alternative to osseointegration and no surgery.

Does low penetration of human skin by the normal mode ruby laser account for poor permanent depilatory success rates?

Studies reported to date have shown a good depilatory response from patients treated with the normal mode ruby laser (NMRL) over 12 weeks, but a low response over a time period greater than this. Previous publications have suggested that this could be accounted for by the apparently poor skin penetration of laser light and so this study attempted to assess whether this was indeed the case. Skin samples of varying thicknesses were taken from six Caucasian patients and their depths measured. Each was laid individually on an energy meter before having pulses from an NMRL compatible with clinical doses (4.75 J/cm2, 9.24 J/cm2 and 13.41 J/cm2) fired on the epidermis. Several samples had the laser fired repetitively on the surface to assess whether this caused any change in laser/skin fluence depth profiles. Repetitive firing of the NMRL on the epidermis of skin samples did not alter the energy recorded by the meter beneath. The fluence/depth profiles were constructed showing the majority of energy was lost within the first 1 mm of the skin surface (50%) which then further reduced over distance but at a much slower rate. The maximum depth of penetration was 14.8 mm (SD +/- 0.478) which appeared to be a function of wavelength and not fluence. The results suggest that laser penetration of skin should be adequate for generating enough heat at the hair bulge and bulb, potentially causing permanent damage. The implications of this study are that it is probably the presence of the correct chromophore in large enough amounts which is required for successful permanent depilation to occur.

Zimmer splintage: a simple effective treatment for keloids following ear-piercing.

An auricular keloid occurring following ear-piercing remains a difficult condition to treat. Various treatments have been described, with different reported degrees of success. Pressure therapy has been shown to be an effective treatment for auricular keloids, although the devices used have not all been universally accepted. We assessed 30 patients, between 1989 and 1999, who had been fitted with pressure devices made from Zimmer splints. There was a 50% or greater reduction in the size of each keloid when assessed at 1 year. Zimmer splints are cheap, readily available, easily moulded to fit the patient and can be decorated so that they can be worn as earrings.