Children with craniofacial abnormalities associated with retromicrognathia and glossoptosis often have compromised upper airway flow. In severe cases, emergency intubation is necessary immediately after birth, and tracheostomy is advocated to manage the airway in the neonatal period and to allow for feeding. Early intervention with bilateral mandibular osteogenesis avoids the need for tracheostomy, along with its complications, and it targets the primary etiologic factor of the problem—the anomalous anatomy of the mandible. We report two neonates with severe Pierre Robin sequence managed with bilateral mandibular distraction osteogenesis on day 9 and day 11 of life. The surgical techniques and distraction and consolidation periods were similar apart from the distraction devices used. The procedures were successful with early extubation (day 5 and day 7), oral feeding tolerance (day 11 and day 13) and hospital discharge (day 19 and day 18). Total mandibular distraction was 19 mm and 23.45 mm, respectively. No major complications were reported. Medium to long-term results were good. Bilateral mandibular distraction osteogenesis in the neonate is a safe and accurate procedure and is the primary option in cases of selected severe Pierre Robin sequence.
We read with great interest the recent article by Thomas C. Wiener [1]. About 12 years ago Maia introduced the intradermal double-layer closure technique with the suture knot contained within the incision. Since that time he has used it as his standard suture technique in more than 3000 cases that include different aesthetic surgery procedures. The technique consists of an intradermal double-layer closure with a deep and a superficial dermal running component that are in continuity (Figs. 1 and 2), with no intradermal orientation stitches (except in very large incisions, i.e., [40 cm). The final knot is placed deep within one end of the incision (Fig. 2). In our experience this technique is safe and fast and puts less artificial material inside the wound compared with conventional techniques that have internal knots and running suture. We reported very few cases of knot extrusion, which were probably caused by a superficial position of the knot, and there were no major consequences. Because of the results we have with our technique we do not see any significant advantage of the remote-knot technique, which has the disadvantage of a second scar, even if it is a small scar.
Reference
Aims: We describe the clinical characteristics, management and outcomes of patients hospitalised with acute heart failure (AHF) in a south western European Cardiology Department. We sought to identify the determinants of length of stay (LOS) and heart failure (HF) rehospitalisation or death during a 12-months follow-up period.
Methods and Results:This was a retrospective cohort study including all patients admitted during 2010 with either a primary or secondary diagnosis of AHF. Death and readmission were followed through 2011.Amongst the 924 patients admitted, 201 (21%) had AHF, 107 (53%) of which with new-onset AHF. The main precipitating factors were acute coronary syndrome (ACS) (63%) and arrhythmia (14%). The most frequent clinical presentations were heart failure (HF) after ACS (63%), chronic decompensate HF (47%) and acute pulmonary oedema (21%). On admission 73% had left ventricular ejection fraction (LVEF) < 0.50. Median LOS was 11 days and inhospital mortality was 5.5%. Rehospitalisation rate was 21% and 24% at six and 12 months respectively. All-cause mortality was 16% at 12 months. The independent predictors of rehospitalisation or death were HF hospitalisation during previous year (Hazard Ratio -HR -3.177), serum sodium < 135 mmol/L on admission (HR 1.995), atrial fibrillation (HR 1.791) and reduced LVEF (HR 0.518).
Conclusions:Our patients more often presented new-onset AHF, due to an ACS, causing reduced LVEF. Several predictive factors of death or rehospitalisation were identified that may help to select high risk patients to be followed in a HF management programme after discharge.3
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