Risk factors associated with the Motoric Cognitive Risk syndrome: A meta-analysis of data from a cross-national study.

BACKGROUND: Identifying risk factors associated with the Motoric Cognitive Risk (MCR) syndrome (a pre-dementia syndrome) can assist in developing risk reduction strategies and interventions to delay progression to dementia. Tailored interventions require comparisons of high- and middle-income countries to determine if the same or different risk factors should be targeted. We examined risk factors associated with MCR in seven Health and Retirement Studies with harmonized measures. METHODS: Data from adults aged ≥65 years (n = 20,036, mean age 71.2(SD 6.2)-80.1(SD 4.1)) from the U.S. Health and Retirement Study, English Longitudinal Study of Aging, Survey of Health, Aging and Retirement in Europe, China Health and Retirement Longitudinal Study, Harmonized Diagnostic Assessment of Dementia for Longitudinal Aging Study in India, Mexican Health and Aging Study, and Brazilian Longitudinal Study of Aging was included. MCR was defined as the presence of cognitive complaints and slow gait (no mobility disability and dementia). Associations of demographic [education], medical [hypertension, diabetes, heart disease, obesity, stroke, Parkinson's, falls], psychological [depressive symptoms, psychiatric problems], sensorimotor [grip strength, hearing], and behavioral factors [smoking, sedentariness, sleep], with prevalent MCR were examined using age- and sex-adjusted logistic regression models. A meta-analysis was performed to compare risk factors for MCR in high- versus middle-income countries. RESULTS: Except for depressive symptoms and weak grip strength, different risk factor clusters were associated with individual studies. Poor sleep, hearing, weak grip, and multiple falls emerged as novel associations with MCR. When grouped by income, some risk factors (i.e., education) were associated with MCR in high- and middle-income countries. Others (i.e., obesity) were specific to high-income countries. CONCLUSIONS: This cross-sectional, cross-national study identified new, shared, and specific risk factors associated with MCR in high- and middle-income countries, providing insights to develop public health approaches and interventions to forestall the onset of dementia in those with MCR.

Loneliness Predicts Progression of Frailty in Married and Widowed, but Not Unmarried Community Dwelling Older Adults.

BACKGROUND: Loneliness is highly prevalent among older adults and is associated with frailty. Most studies consider loneliness in isolation without consideration for structural and functional measures of social relationships - and longitudinal studies are scarce. OBJECTIVES: This study examined longitudinal associations between loneliness and frailty and analyzed how structural and functional social measures influence these associations. DESIGN: Linear mixed effects models examined longitudinal associations between loneliness and frailty assessed with the frailty index (scale 0-100). Models were adjusted for baseline age, gender, education, depressive symptoms, global cognition, and structural (e.g., social network, marital status), and functional social measures (e.g., social, cognitive, and physical activity, and social support). PARTICIPANTS: Loneliness and frailty data from 1,931 older adults without dementia at baseline from the Rush Memory and Aging Project were examined (mean age 79.6 ± 7.7 years, 74.9% female). MEASUREMENTS: Baseline loneliness assessed by the de Jong Gierveld Loneliness Scale was the predictor of interest. RESULTS: Frailty increased significantly over a mean follow-up period of 4.6 years. Effects of loneliness on frailty were modified by marital status. Loneliness predicted an additional accumulation of 0.37 and 0.34 deficits on the frailty index per year in married and widowed individuals respectively, compared to those who were not lonely (married: p=0.009, CI 0.09, 0.64; widowed: p=0.005, CI 0.1, 0.58). Loneliness did not predict frailty progression in unmarried individuals. CONCLUSIONS: Loneliness predicts frailty progression, highlighting the importance of social determinants on physical health in aging.

Centrally Acting ACE Inhibitor Use and Physical Performance in Older Adults.

BACKGROUND: There is conflicting evidence regarding the role of angiotensin-converting enzyme inhibitors and physical function. While some studies show improvements in muscle strength and physical function, others show no significant difference or decreased performance. This ambiguity could be due to differential effects of angiotensin-converting enzyme inhibitor subtypes which can be categorized as centrally or peripherally-acting based upon their ability to cross the blood-brain barrier. OBJECTIVE: The objective of this study is to compare physical performance measures among angiotensin-converting enzyme inhibitor subtype users. METHODS: Design: Cross-sectional Setting: Ambulatory Participants: Performed in 364 participants in the Health and Retirement Study cohort who were ≥ 65 years (median age (IQR) 74.00 (69-80) years. MEASUREMENTS: Average difference in hand grip (kg), gait speed(m/s) and peak expiratory flow (L/min). RESULTS: Compared to participants on a peripherally-acting angiotensin-converting enzyme inhibitor (113 (31%)), those on a centrally-acting agent (251(69%)) had stronger grip strength 28.9 ±1.0 vs 26.3±1.0, p=.011 and higher peak expiratory flow rates 316.8±130.4 vs. 280.0±118.5, p= .011 in unadjusted analysis. After multiple adjustments the difference in PEF remained statistically significant (Estimate(CI) 26.5, 95% CI 2.24, 50.5, p = 0.032). CONCLUSION: Our results suggest that in older adults the use of centrally-acting angiotensin-converting enzyme inhibitors compared to a peripherally acting angiotensin-converting enzyme inhibitors was associated with better lung function in older individuals.

Cognitive Motor Dual Task Costs in Older Adults with Motoric Cognitive Risk Syndrome.

The purpose of this study was to characterize Cognitive Motor Dual Task (CMDT) costs for a community-based sample of older adults with Motoric Cognitive Risk Syndrome (MCR), as well as investigate associations between CMDT costs and cognitive performance. Twenty-five community-dwelling older adults (ages 60-89 years) with MCR performed single and dual task complex walking scenarios, as well as a computerized cognitive testing battery. Participants with lower CMDT costs had higher scores on composite measures of Working Memory, Processing Speed, and Shifting, as well as an overall cognitive composite measure. In addition, participants with faster single task gait velocity had higher scores on composite measures of Working Memory, Processing Speed, and overall cognition. Taken together, these results suggest that CMDT paradigms can help to elucidate the interplay between cognitive and motor abilities for older adults with MCR.

Non-memory subjective cognitive concerns predict incident motoric cognitive risk syndrome.

BACKGROUND AND PURPOSE: Motoric cognitive risk syndrome (MCR) is a predementia condition that combines slow gait and subjective cognitive concerns. As the earliest markers of MCR are relatively unknown, the role of subjective cognitive concerns was investigated to predict incident MCR in a well-characterized prospective cohort of non-demented older adults. METHODS: Non-demented MCR-free older adults (n = 476) from the Central Control of Mobility in Aging cohort completed gait, subjective cognition and neuropsychological assessment at baseline and follow-up. Subjective concerns were analyzed via responses to 12 items from three validated measures, the Late-Life Function and Disability Instrument - Disability Component, the Activities of Daily Living Prevention Instrument and the Geriatric Depression Scale, and were independent of items utilized to diagnose MCR. Cox proportional hazard models examined the association between cognitive concerns and incident MCR. RESULTS: After 2.36 ± 1.4 years, 28 participants developed MCR. Executive functioning (adjusted hazard ratio 2.458, 95% confidence interval 1.094-5.524, P = 0.029) and mental clarity concerns (adjusted hazard ratio 3.917, 95% confidence interval 1.690-9.077, P = 0.001) were associated with incident MCR, controlling for age, sex, education and gait speed. CONCLUSIONS: Subjective cognitive concerns in non-memory cognitive domains predict incident MCR. Although most MCR studies assess cognitive concerns about memory, our findings suggest the need to broaden the scope of subjective cognitive assessment to enhance the accuracy of diagnosis and prediction of future cognitive decline.

NUTRITIONAL RISK STATUS, DIETARY INTAKE AND COGNITIVE PERFORMANCE IN OLDER ADULTS WITH MOTORIC COGNITIVE RISK SYNDROME.

Background: Modifiable lifestyle factors such as diet are associated with cognitive decline and dementia. Greater understanding of the nutritional intake of older adults who are at increased risk for cognitive decline may allow for the development of more effective dietary interventions to prevent or delay the onset of dementia. Objectives: The purpose of this study was to characterize the nutritional status, diet quality and individual nutritional components of older adults with motoric cognitive risk syndrome (MCR). MCR is a pre-dementia syndrome classified by slow gait speed and subjective memory impairments. Design: Cross-sectional analysis. Setting: A community-based senior center located in an urban setting. Participants: Twenty-five community-dwelling older adults with MCR aged 60-89 yrs. Measurements: Nutritional risk status was determined using the Nestle Mini Nutritional Assessment (MNA). A food frequency questionnaire was used to quantify: overall dietary quality using the Healthy Eating Index (HEI); adherence to the Mediterranean-DASH for Neurodegenerative Delay (MIND) dietary pattern; and intake of individual nutritional components shown to be protective or harmful for cognitive function in older adults. Participants completed a computerized cognitive testing battery to assess cognitive abilities. Results: More than one third (36%) of participants were at increased risk for malnutrition. Participants at lower risk for malnutrition had better working memory (r = 0.40, p = 0.04), executive functioning (r = 0.44, p = 0.03), and overall cognition (r = 0.44, p = 0.03). While participants generally consumed a reasonable quality diet (HEI = 65.15), 48% of participants had poor adherence to a neuroprotective MIND dietary pattern. Higher intake of B-complex vitamins was associated with better task switching (r = 0.40, p ≤ 0.05) and faster processing speeds (r = 0.39, p ≤ 0.05). Higher vitamin C intake was associated with better executive functioning (r = 0.40, p ≤ 0.05). Conclusions: Our findings suggest that a significant proportion of older adults with MCR may be at increased risk for malnutrition. While the diet quality of older adults with MCR appeared to need improvement, future studies should investigate the effects of more specific nutritional interventions, including the MIND diet, on cognition in at-risk older adults.

Cognitive Performance Does not Limit Physical Activity Participation in the Lifestyle Interventions and Independence for Elders Pilot Study (LIFE-P).

OBJECTIVES: We examined whether multiple domains of baseline cognitive performance were associated with prospective physical activity (PA) adherence in the Lifestyle Interventions and Independence for Elders Pilot study (LIFE-P). DESIGN, SETTING, PARTICIPANTS: The LIFE-P study was a single-blind, multicenter, randomized controlled trial of a PA intervention compared to a successful aging educational intervention in sedentary, mobility-limited older adults. INTERVENTION: A 12-month structured, moderate-intensity, multi-modal PA program that included walking, resistance training, and flexibility exercises. For the first 2 months (adoption), 3 center-based exercise sessions (40-60 min) / week were conducted. During the next 4 months (transition), center-based sessions were conducted 2 times / week. The subsequent maintenance phase consisted of optional once-to-twice-per-week center-based sessions and home-based PA. MEASUREMENTS: Tests of executive and global cognitive functioning, working memory and psychomotor speed were administered at baseline. Median test scores were used to dichotomize participants into low or high cognitive performance groups. RESULTS: 52 mobility-limited older adults (age: 76.9 ±5 yrs) were randomized to the PA arm of LIFE-P. Compared to participants with high cognitive performance, participants with low performance had similar PA adherence rates (all P ≥ 0.34). Furthermore, weak and non-significant univariate relationships were elicited between all measures of cognition and overall PA adherence levels (r values ranged: -0.20 to 0.12, P ≥ 0.12). CONCLUSION: These data suggest that cognitive performance does not limit long-term PA adherence in mobility-limited older adults. Additional studies in larger cohorts are warranted to verify these findings.

Assessment of Iron Deposition in the Brain in Frontotemporal Dementia and Its Correlation with Behavioral Traits.

BACKGROUND AND PURPOSE: Brain iron deposition has been implicated as a major culprit in the pathophysiology of neurodegeneration. However, the quantitative assessment of iron in behavioral variant frontotemporal dementia and primary progressive aphasia brains has not been performed, to our knowledge. The aim of our study was to investigate the characteristic iron levels in the frontotemporal dementia subtypes using susceptibility-weighted imaging and report its association with behavioral profiles. MATERIALS AND METHODS: This prospective study included 46 patients with frontotemporal dementia (34 with behavioral variant frontotemporal dementia and 12 with primary progressive aphasia) and 34 age-matched healthy controls. We performed behavioral and neuropsychological assessment in all the subjects. The quantitative iron load was determined on SWI in the superior frontal gyrus and temporal pole, precentral gyrus, basal ganglia, anterior cingulate, frontal white matter, head and body of the hippocampus, red nucleus, substantia nigra, insula, and dentate nucleus. A linear regression analysis was performed to correlate iron content and behavioral scores in patients. RESULTS: The iron content of the bilateral superior frontal and temporal gyri, anterior cingulate, putamen, right hemispheric precentral gyrus, insula, hippocampus, and red nucleus was higher in patients with behavioral variant frontotemporal dementia than in controls. Patients with primary progressive aphasia had increased iron levels in the left superior temporal gyrus. In addition, right superior frontal gyrus iron deposition discriminated behavioral variant frontotemporal dementia from primary progressive aphasia. A strong positive association was found between apathy and iron content in the superior frontal gyrus and disinhibition and iron content in the putamen. CONCLUSIONS: Quantitative assessment of iron deposition with SWI may serve as a new biomarker in the diagnostic work-up of frontotemporal dementia and help distinguish frontotemporal dementia subtypes.

Gait phenotype from mild cognitive impairment to moderate dementia: results from the GOOD initiative.

BACKGROUND AND PURPOSE: The differences in gait abnormalities from the earliest to the later stages of dementia and in the different subtypes of dementia have not been fully examined. This study aims to compare spatiotemporal gait parameters in cognitively healthy individuals, patients with amnestic mild cognitive impairment (MCI) and non-amnestic MCI, and patients with mild and moderate stages of Alzheimer's disease (AD) and non-Alzheimer's disease (non-AD). METHODS: Based on a cross-sectional design, 1719 participants (77.4 ± 7.3 years, 53.9% female) were recruited from cohorts from seven countries participating in the Gait, Cognition and Decline (GOOD) initiative. Mean values and coefficients of variation of spatiotemporal gait parameters were measured during normal pace walking with the GAITRite system at all sites. RESULTS: Performance of spatiotemporal gait parameters declined in parallel with the stage of cognitive decline from MCI status to moderate dementia. Gait parameters of patients with non-amnestic MCI were more disturbed compared to patients with amnestic MCI, and MCI subgroups performed better than demented patients. Patients with non-AD dementia had worse gait performance than those with AD dementia. This degradation of gait parameters was similar between mean values and coefficients of variation of spatiotemporal gait parameters in the earliest stages of cognitive decline, but different in the most advanced stages, especially in the non-AD subtypes. CONCLUSIONS: Spatiotemporal gait parameters were more disturbed in the advanced stages of dementia, and more affected in the non-AD dementias than in AD. These findings suggest that quantitative gait parameters could be used as a surrogate marker for improving the diagnosis of dementia.

Biology of gait control: vitamin D involvement.

BACKGROUND: Adverse neuromuscular events have been described in case of low serum 25-hydroxyvitamin D (25OHD) concentrations, suggesting that vitamin D may be involved in gait stability. The objective of this cross-sectional study was to examine the association between stride-to-stride variability of stride time (STV) and serum 25OHD concentration in adults aged 65 years and older. METHODS: STV and 25OHD concentration were assessed in 411 community-dwelling older adults (mean age 70.4 ± 1.8 years, 57.9% women). The following established 25OHD thresholds were used: severe 25OHD insufficiency <10 ng/mL, moderate 10-30 ng/mL, and normal >30 ng/mL. Age, number of drugs used per day, use of psychoactive drugs, depressive symptoms, cognitive decline, history of falls, distance visual acuity, lower limb proprioception, center of mass (CoM) motion, and walking speed were considered as potential confounders. RESULTS: A total of 16.6% (n = 68) of subjects had severe 25OHD insufficiency, 70.3% (n = 289) moderate insufficiency, and 13.1% (n = 54) normal concentrations. In the full adjusted and the stepwise backward linear regression models, high STV (worse performance) was associated with severe 25OHD insufficiency (p = 0.028 and p = 0.044, respectively), high CoM motion (p = 0.031 and p = 0.014, respectively), and low lower limb proprioception score (p = 0.017 and p = 0.008, respectively). The stepwise backward regression model also showed that high STV was associated with female gender (p = 0.041). CONCLUSIONS: Low serum 25OHD concentrations were associated with high STV reflecting a disturbed gait control. This association could be explained by a possible action of vitamin D on different components involved in gait control.

Differential effects of COMT on gait and executive control in aging.

Walking speed is associated with attention and executive control processes subserved by the prefrontal cortex. Because polymorphisms in catechol-O-methyltransferase (COMT) influence these cognitive processes we hypothesized that the same polymorphisms may influence gait velocity. We examined the associations between the Val(158)Met polymorphism in COMT and gait velocity as well as attention and executive function. Participants were 278 non-demented older adults. The results revealed that methionine (Met)/valine (Val) was associated with faster gait velocity. This association can be explained by the putative role of the Val allele in regulating tonic dopamine release in the striatum. In contrast, Met/Met was associated with better attention and executive function. Stratification by gender revealed that the association between COMT genotype and gait was significant only in men. Conversely, the association between COMT genotype and attention and executive function was significant only in women. These findings suggest a differential effect in relating the Val(158)Met polymorphism to gait and to cognitive function while supporting the previously described sexual dimorphism in the phenotypic expressions of COMT.

Cognitive activities delay onset of memory decline in persons who develop dementia.

BACKGROUND: Persons destined to develop dementia experience an accelerated rate of decline in cognitive ability, particularly in memory. Early life education and participation in cognitively stimulating leisure activities later in life are 2 factors thought to reflect cognitive reserve, which may delay the onset of the memory decline in the preclinical stages of dementia. METHODS: We followed 488 initially cognitively intact community residing individuals with epidemiologic, clinical, and cognitive assessments every 12 to 18 months in the Bronx Aging Study. We assessed the influence of self-reported participation in cognitively stimulating leisure activities on the onset of accelerated memory decline as measured by the Buschke Selective Reminding Test in 101 individuals who developed incident dementia using a change point model. RESULTS: Each additional self-reported day of cognitive activity at baseline delayed the onset of accelerated memory decline by 0.18 years. Higher baseline levels of cognitive activity were associated with more rapid memory decline after that onset. Inclusion of education did not significantly add to the fit of the model beyond the effect of cognitive activities. CONCLUSIONS: Our findings show that late life cognitive activities influence cognitive reserve independently of education. The effect of early life education on cognitive reserve may be mediated by cognitive activity later in life. Alternatively, early life education may be a determinant of cognitive reserve, and individuals with more education may choose to participate in cognitive activities without influencing reserve. Future studies should examine the efficacy of increasing participation in cognitive activities to prevent or delay dementia.

Placenta accreta.

Total placenta accreta is a rare condition. Its management is a dilemma. Attempted separation of the placenta in placenta accreta can cause torrential blood loss. Therefore an antenatal diagnosis of placenta accreta permits advance planning of delivery. Two alternatives are caesarean section through the fundus with subsequent immediate hysterectomy, which has traditionally been the treatment of choice or if the patient wishes more children, leaving the placenta in place and managing conservatively. We present a 38 year old lady who was diagnosed to have placenta accreta while performing a caesarean section for a breech presentation. We had to proceed with a total hysterectomy.

Hippocampal neurochemistry, neuromorphometry, and verbal memory in nondemented older adults.

BACKGROUND: Characterization of the behavioral correlates of neuromorphometry and neurochemistry in older adults has important implications for an improved understanding of the aging process. The objective of this study was to test the hypothesis that a measure of hippocampal neuronal metabolism was associated with verbal memory in nondemented older adults after controlling for hippocampal volume. METHODS: 4-T MRI, proton magnetic resonance spectroscopy ((1)H MRS), and neuropsychological assessment were conducted in 48 older adults (23 women; mean age 81 years). Average hippocampal N-acetyl aspartate/creatine ratios (NAA/Cr) and hippocampal volumes were obtained. Neuropsychological evaluation included tests of verbal memory (Buschke and Grober Free and Cued Selective Reminding Test-Immediate Recall [FCSRT-IR], Wechsler Memory Scale-Revised Logical Memory subtest) and attention and executive function (Trail Making Test Parts A and B). RESULTS: Linear regression analysis indicated that after adjusting for age, hippocampal NAA/Cr was a significant predictor of FCSRT-IR performance (beta = 0.38, p = 0.01, R (2) = 0.21). Hippocampal volume was also a significant predictor of FCSRT-IR performance after adjusting for age and midsagittal area (beta = 0.47, p = 0.01, R (2) = 0.24). In a combined model, hippocampal NAA/Cr (beta = 0.33, p = 0.03) and volume (beta = 0.35, p = 0.03) were independent predictors of FCSRT-IR performance, accounting for 30% of the variance in memory. CONCLUSIONS: These findings indicate that nondemented older adults with smaller hippocampal volumes and lower levels of hippocampal N-acetyl aspartate/creatine ratio metabolites perform more poorly on a test of verbal memory. The integrity of both the structure and metabolism of the hippocampus may underlie verbal memory function in nondemented elderly.

Education delays accelerated decline on a memory test in persons who develop dementia.

OBJECTIVE: To test the cognitive reserve hypothesis by examining the effect of education on memory decline during the preclinical course of dementia. BACKGROUND: Low education is a well known risk factor for Alzheimer disease (AD). Persons destined to develop AD experience an accelerated rate of decline in cognitive ability, particularly in memory. The cognitive reserve hypothesis predicts that persons with greater education begin to experience acceleration in cognitive decline closer to the time of diagnosis than persons with lower reserve, but that their rate of decline is more rapid after the time of acceleration due to increased disease burden. METHODS: We studied the influence of education on rates of memory decline as measured by the Buschke Selective Reminding Test in 117 participants with incident dementia in the Bronx Aging Study. Subjects had detailed cognitive assessments at entry and at annual follow-up visits. We estimated the time at which the rate of decline begins to accelerate (the change point), and the pre- and post-acceleration rates of decline, from the longitudinal data using a change point model. RESULTS: Each additional year of formal education delayed the time of accelerated decline on the Buschke Selective Reminding Test by 0.21 years. Post-acceleration, the rate of memory decline was increased by 0.10 points per year for each year of additional formal education. CONCLUSIONS: As predicted by the cognitive reserve hypothesis, higher education delays the onset of accelerated cognitive decline; once it begins it is more rapid in persons with more education.

High risk neurological gait syndrome and vascular dementia.

We defined a 'high-risk neurological gait' (HRNG) syndrome based on presence of any one of hemiparetic, frontal, and unsteady gaits, and examined its validity to predict vascular dementia (VD) over 3 and 5 years in 399 nondemented older adults, age 75 and over. Cox analysis was used to estimate hazard ratios (HR) for VD adjusted for potential confounders. At baseline, 54 subjects had HRNG. 14 subjects developed VD over 3 years and 25 by 5 years. HRNG predicted risk of VD within the first three (HR 3.3, 95% CI 1.8-5.9) and five years (HR 2.7, 95% CI 1.7-4.2). Including executive dysfunction (Digit symbol scores <16) improved validity; subjects with HRNG and executive dysfunction (HR 12.5, 95% CI 5.5-28.4) or either (HR 5.9, 95% CI 3.6-9.7) had higher risk of VD over five years. Diagnosing HRNG is a clinically relevant approach to identifying older adults at high risk of VD over short intervals.

Leisure activities and the risk of amnestic mild cognitive impairment in the elderly.

OBJECTIVE: To study the influence of leisure activity participation on risk of development of amnestic mild cognitive impairment (aMCI). METHODS: The authors examined the relationship between baseline level of participation in leisure activities and risk of aMCI in a prospective cohort of 437 community-residing subjects older than 75 years, initially free of dementia or aMCI, using Cox analysis adjusted for age, sex, education, and chronic illnesses. The authors derived Cognitive and Physical Activity Scales based on frequency of participation in individual activities. RESULTS: Over a median follow-up of 5.6 years, 58 subjects had development of aMCI. A one-point increase on the Cognitive (hazard ratio [HR] 0.95, 95% CI 0.91 to 0.99) but not Physical Activities Scale (HR 0.97, 95% CI 0.93 to 1.01) was associated with lower risk of aMCI. Subjects with Cognitive Activity scores in the highest (HR 0.46, 95% CI 0.24 to 0.91) and middle thirds (HR 0.52, 95% CI 0.29 to 0.96) had a lower risk of aMCI compared with subjects in the lowest third. The association persisted even after excluding subjects who converted to dementia within 2 years of meeting criteria for aMCI. CONCLUSIONS: Cognitive activity participation is associated with lower risk of development of amnestic mild cognitive impairment, even after excluding individuals at early stages of dementia.

Severe haematoma of the vulva--a report of two cases and a clinical review.

Haematoma of the vulva may occur following blunt trauma due to its highly vascular structure. We present two cases of haematoma of the vulva caused by domestic violence, following a kick on the perineum and falling astride on the perineum. Evacuation of the haematoma and repair of lacerated tissues were successfully performed.