Pneumonia in low and middle income countries: progress and challenges.

Pneumonia remains the leading cause of childhood mortality and the most common reason for adult hospitalisation in low and middle income countries, despite advances in preventative and management strategies. In the last decade, pneumonia mortality in children has fallen to approximately 1.3 million cases in 2011, with most deaths occurring in low income countries. Important recent advances include more widespread implementation of protein-polysaccharide conjugate vaccines against Haemophilus influenzae type B and Streptococcus pneumoniae, implementation of case-management algorithms and better prevention and treatment of HIV. Determining the aetiology of pneumonia is challenging in the absence of reliable diagnostic tests. High uptake of new bacterial conjugate vaccines may impact on pneumonia burden, aetiology and empiric therapy but implementation in immunisation programmes in many low and middle income countries remains an obstacle. Widespread implementation of currently effective preventative and management strategies for pneumonia remains challenging in many low and middle income countries.

Balloon-assisted endoscopic brow lift: preliminary experience.

Balloon dissectors are inexpensive, disposable devices originally designed to provide rapid, atraumatic development of the work space needed for endoscopic hernia repair. We sought to evaluate the utility of these devices for endoscopic brow lift. Cadaver testing (n = 5) was followed by clinical use with assessment of flap loss, dissection time, completeness of dissection, and, more subjectively, amount of bleeding and tissue trauma. Dissection time over the forehead was less than 3 minutes in all cases; the remainder of the procedure was completed in times ranging from 20 to 35 minutes. No partial or total flap loss was experienced (n = 12). Bleeding after dissection was minimal. Dissection was possible in either the subperiosteal (n = 7) or subgaleal plane (n = 5), creating a smooth optical cavity. Dissection advanced to nearly the orbital rims, leaving only nerve identification, muscle removal, and flap elevation/fixation to complete the brow lift. Balloon dissection devices allow rapid mobilization of tissue planes with a minimum of effort. The feasibility of using balloon devices to speed and simplify endoscopic brow lift dissection has been demonstrated. Their full utility must await the results of outcome studies in a larger clinical series and must be balanced against their cost.

Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies.

Presented is a prospective study comparing limited SMAS (lateral SMASectomy), conventional SMAS, extended SMAS, and composite rhytidectomies. Randomized patients received either a limited SMAS or conventional SMAS face lift on one side and an extended SMAS or composite rhytidectomy on the other. All procedures were performed at Manhattan Eye, Ear and Throat Hospital in accordance with their well-defined surgical descriptions. Postoperative courses were followed clinically for at least 1 year. Photographs were taken preoperatively and at 6 and 12 months postoperatively. Photographs were reviewed by three independent experienced face lift surgeons. The study comprises 21 patients, 20 women and 1 man, with a mean age of 59 years (range 47 to 70 years). Nineteen patients underwent primary rhytidectomies; two underwent secondary face lifts. For the first 12 patients, each had an extended SMAS procedure performed on one side; on the other, 7 had a conventional SMAS and 5 had a limited SMAS (lateral SMASectomy) face lift. In the last 9 patients, a conventional SMAS was carried out on one side in 8, a limited SMAS in 1, and on the opposite side, a composite rhytidectomy was performed. Complications were few. Temporary weakness of the buccal branch of the facial nerve occurred in 2 patients on the side of the more extensive surgery. On the operating table at completion of the surgery, there was more improvement in reversal of midfacial ptosis and flattening of the nasolabial folds with both extended SMAS and composite rhytidectomies. The composite flap had the most dramatic effect on the nasolabial folds and oral commissure. After 24 hours, once swelling developed and facial motion became reactivated, the noticeable differences in the midface and nasolabial folds were lost. No discernible differences in facial halves were noted again. Differences between facial sides on the 6- and 12-month postoperative photographs were not detectable. We conclude that for routine facial plasty, comparable clinical outcomes are obtained at 6 months and 1 year with limited (lateral SMASectomy) and conventional SMAS face lifts compared with extended SMAS and composite rhytidectomies. All procedures are lacking in their improvement of midface ptosis and the nasolabial folds. The increased surgical risks, morbidity, and convalescence associated with those more extensive procedures do not seem to be warranted in the average patient.

Influence of steroids on postoperative swelling after facialplasty: a prospective, randomized study.

Steroids are widely used in facial aesthetic surgery to reduce postoperative edema. We performed a randomized, double-blind study to try to document the effectiveness of this practice. Fifty consecutive facialplasty patients of one surgeon were randomized to steroid and no steroid groups. Steroid group patients received betamethasone 6 mg IM preoperatively. Postoperative scoring of swelling was performed at approximately days 5 and 9 by a single observer. There were no significant differences between the two groups at either postoperative interval or in the rate of improvement. Subgroups of patients who underwent additional procedures also showed no significant differences. We were not able to demonstrate any statistically significant difference in swelling after facialplasty with this steroid regimen.

Neurosensory preservation in endoscopic forehead plasty.

The recent introduction of endoscopic techniques and instrumentation in aesthetic surgery was caused in part by the desire to minimize surgical scars as well as to decrease the possibility of sensory changes secondary to extended incisions, such as the execution of a coronal incision in performing a forehead plasty. Although endoscopic surgical techniques provide field magnification together with excellent illumination, localization and preservation of the forehead neurovascular bundles via the endoscope can be time consuming and tedious. A new method is introduced where percutaneous localization of the supraorbital and supratrochlear nerves enables the surgeon to perform an endoscopic forehead plasty in an expeditious manner with preservation of sensation of the forehead and scalp.

Malar augmentation with silicone implants.

This study is a retrospective review of all consecutive surgeries involving insertion of silicone malar implants performed at the Manhattan Eye, Ear and Throat Hospital from January 1, 1985 to April 30, 1993. Sixty-four patients underwent placement of 126 silicone malar implants. Three different sizes were utilized: 23 size 1, 85 size 2, and 18 size 3. Eleven patients underwent unilateral implant placement, all for reconstructive purposes. The average and median ages of the patients were 43 and 44 years, respectively, with a range of 18 to 83 years. Malar implants were inserted for the following reasons: hypoplasia, post-traumatic deformity, post-tumor resection deformity, and correction of hemifacial microsomia. In 79 percent of the patients, malar augmentation was performed in conjunction with other surgical procedures. All implants were placed in a subperiosteal pocket by either the intraoral, subciliary, or preauricular approach. Forty-one percent were fixed in place by percutaneous sutures. Malar augmentation with silicone implants for both aesthetic and reconstructive purposes is an increasingly common surgical procedure. Good results are obtained with few complications. Infection is rare even with transoral placement. Silicone malar implants should be placed in a subperiosteal pocket and can be inserted safely through various routes. Malpositioning of implants is infrequent, and fixation sutures are not required. The most common problem is improper size selection. Patient satisfaction is high, in that no patient underwent permanent removal of a malar silicone implant once inserted.

The graying of America: optometric considerations. Introduction.

Normal and abnormal effects of aging impact greatly on individuals and their families. Health care providers must therefore be knowledgeable about how to care for elderly persons. In order to interact among elderly persons and within the aging network, optometrists need to have a broad understanding of gerontology.

Geriatric educational programs.

Information on the geriatric patient is needed in the curricula of all health professional programs. During the 1988 Academy Meeting a Symposium on the Graying of America: Optometric Considerations, was held. The following paper will: (1) summarize a recent survey of geriatric education in the United States schools and colleges of optometry, (2) describe two continuing education projects on gerontology conducted for practicing optometrists, and (3) discuss two recently completed projects involving the training of optometric faculty.

Symposium on the delivery of optometric care in nontraditional settings. Summary and conclusions.

During the 1987 Academy Meeting, a joint Optometric Education/Public Health and Occupational Optometry Symposium was held on The Delivery of Optometric Care in Nontraditional Settings. Papers were presented on prison systems, long-term care facilities, schools for the mental/physically handicapped, home eye care services, migrant work program, and juvenile detention facilities. This paper is an overview of care delivered in nontraditional settings, including important health care and demographic considerations, brief summation of the nontraditional populations presented, the impact on optometric education, and implications for optometric manpower needs.

Skin-muscle flap lower lid blepharoplasty.

Lateral to medial dissection in the "potential space" between the orbicularis oculi muscle and the septum orbitale simplifies the skin-muscle flap lower lid blepharoplasty. The procedure is safe, rapid, and atraumatic.

Tongue-flap reconstruction of the lip vermilion in hemifacial atrophy.

The lips are key features to be considered in facial balance. Correction of lip atrophy in Romberg's disease, therefore, contributes significantly to restoration of facial symmetry. Along with other ancillary surgical procedures used for facial reconstruction in hemifacial atrophy, tongue flaps provide an excellent means of correction of the lip deformity with minimal morbidity and good results.

Platysma-SMAS cervicofacial rhytidoplasty.

Platysma/SMAS procedures are still in the evaluation stage. Two significant advantages of the platysma/SMAS procedures are that (1) an operation can be designed for the individual patient's anatomic deformity, and (2) some problems that were little corrected by conventional facelifting techniques are improved dramatically with the extended procedures.

Propranolol-epinephrine interaction: a potential disaster.

Presented here are six examples of potentially life-threatening propranolol-epinephrine interactions. The only report found that warns of a deleterious clinical interaction between propranolol and epinephrine appeared in 1980. With widespread use of propranolol for approved and unapproved conditions, the population at risk is significant. All physicians and dentists using local anesthetic with epinephrine should be aware of this interaction.

Personnel for the office surgical facility.

Ambulatory surgery in a private plastic surgery office is a practical and desirable reality. This can be achieved only in a properly staffed facility. A small number of employees are needed but each must be carefully selected for proper qualifications and attributes, appropriate training and skills necessary to execute the assigned duties, the correct attitude toward patient care, and a sense of responsibility to the surgeon. The facility must be appropriately built and job descriptions organized so as to achieve efficient and good patient care and high employee satisfaction. This common sense approach has proved effective in our experience and should serve the prospective office-based plastic surgeon well.

A comparison of capsule formation following breast augmentation by saline-filled or gel-filled implants.

A retrospective analysis of data on 307 patients was made. The incidence of firmness in breasts augmented by saline-filled prostheses was compared to the incidence in breasts augmented by gel-filled prostheses. A statistically significant lower rate of constricting capsule formation was found in the saline-inflated group.

Skin-muscle flap lower lid blepharoplasty: an easier dissection.

Most descriptions of the skin-muscle flap lower lid blepharoplasty, the so-called McIndoe technique, indicate dissection of the flap in a cephalad-to-caudad direction from near the ciliary margin toward the bony orbital rim. However, this report describes a technical variation in which counter-traction and lateral-to-medial blunt dissection "opens up" the potential anatomical space between the orbicularis oculi muscle and the tarsus and septum orbitale. This technique is easier and faster than the McIndoe procedure.