Comparison of high flow nasal oxygen and conventional nasal cannula during gastrointestinal endoscopic sedation in the prone position: a randomized trial.

PURPOSE: Deep sedation for endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in elderly patients in the prone position. This study investigated the effect of a high flow nasal oxygen (HFNO) delivery system on oxygenation in this procedure compared with that of conventional nasal cannula oxygen administration. METHODS: A prospective randomized trial was conducted using HFNO and conventional nasal cannula in patients undergoing ERCP in the prone position. For each patient, the lowest oxygen saturation (SpO2), the incidence of hypoxemia defined as an SpO2 below 90%, and interruptions due to airway interventions were recorded during the procedure. RESULTS: The lowest mean (standard deviation) SpO2 recorded during the procedure was higher in the HFNO group than in the conventional control group [99.8 (0.6)% vs 95.1 (7.3)%; mean difference, 4.7%; 95% confidence interval, 2.3% to 7.1%; P Group x Time < 0.001]. While the lowest SpO2 during the procedure was lower than the baseline SpO2 in the control group, the lowest SpO2 during the procedure was higher than the baseline SpO2 in the HFNO group. Hypoxemia occurred only in the control group (n = 7; 19%; P = 0.01). Procedural interruptions, including discontinuation of sedation, patient stimulation, and jaw thrusting, occurred only in the control group (n = 9 [25%], n = 10 [28%], and n = 10 [28%] cases, respectively; P = 0.001 for each). CONCLUSION: In contrast to conventional nasal cannula, high flow nasal oxygen provided adequate oxygenation without causing procedural interruptions during ERCP, suggesting that HFNO may be used as a standard oxygen delivery method during these procedures. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03872674); registered 11 March 2019.

RéSUMé: OBJECTIF: La sédation profonde pour cholangiopancréatographie rétrograde endoscopique (CPRE) peut être difficile à réaliser chez des patients âgés en position ventrale. Cette étude a exploré l'effet d'un système d'oxygénothérapie nasale à haut débit (ONHD) sur l'oxygénation pendant cette intervention par rapport à l'administration conventionnelle d'oxygène via une lunette nasale. MéTHODE: Une étude randomisée prospective a été réalisée en utilisant une ONHD ou une lunette nasale conventionnelle chez des patients subissant une CPRE en position ventrale. Pour chaque patient, la saturation en oxygène (SpO2) la plus basse, l'incidence d'hypoxémie définie en tant qu'une SpO2 inférieure à 90 %, et les interruptions provoquées par des interventions au niveau des voies aériennes ont été enregistrées au cours de l'intervention. RéSULTATS: La SpO2 moyenne (écart type) la plus basse enregistrée pendant l'intervention était plus élevée dans le groupe ONHD que dans le groupe témoin conventionnel [99,8 (0,6) % vs 95,1 (7,3) %; différence moyenne, 4,7%; intervalle de confiance 95 %, 2,3 % à 7,1 %; P Groupe x Temps < 0,001]. Alors que la SpO2 la plus basse pendant l'intervention était plus basse que la SpO2 de base dans le groupe témoin, la SpO2 la plus basse pendant l'intervention était plus élevée que la SpO2 de base dans le groupe ONHD. L'hypoxémie n'est survenue que dans le groupe témoin (n = 7; 19 %; P = 0,01). Il n'y a eu d'interruptions de l'intervention, y compris la cessation de la sédation, la stimulation du patient et le déplacement de la mâchoire inférieure vers l'avant, que dans le groupe témoin (n = 9 [25 %], n = 10 [28 %], et n = 10 [28 %] cas, respectivement; P = 0,001 pour chaque intervention). CONCLUSION: Comparativement à une lunette nasale conventionnelle, l'oxygénothérapie nasale à haut débit a procuré une oxygénation adéquate sans provoquer d'interruptions de l'intervention pendant une CPRE, suggérant que cette modalité pourrait être utilisée comme méthode standard d'oxygénothérapie pendant de telles interventions. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03872674); enregistrée le 11 mars 2019.

MANAGEMENT OF REFRACTORY LARGE MACULAR HOLE WITH AUTOLOGOUS NEUROSENSORY RETINAL FREE FLAP TRANSPLANTATION.

PURPOSE: To investigate the morphological and functional outcome of refractory large macular hole (MH) with autologous neurosensory retinal free flap transplantation. METHODS: This case series enrolled 10 patients suffering from refractory large MH at Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. All eyes underwent pars plana vitrectomy, a neurosensory retinal free flap with a 1.5 to 2-MH diameter was harvested. We used an adhesive agent such as whole blood or Viscoat to assist the stabilization of the retinal free flap and then use tamponade silicone oil to tamponade the vitreous cavity. Silicone oil was removed 6 months postoperatively. Main outcome measures including closure of MH and change in best-corrected visual acuity change were recorded. RESULTS: The mean age was 64.9 ± 11.5 years. Before presentation, all cases had received at least two vitreoretinal procedures including vitrectomy, internal limiting membrane peeling, and fluid-gas exchange. At last visit, closure of the MH was achieved in 9 of 10 (90%) cases. The mean preoperative best-corrected visual acuity and that after 12 months of surgery improved from 1.65 ± 0.43 logarithm of minimum angle of resolution to 0.88 ± 0.49 logarithm of minimum angle of resolution (P < 0.001). CONCLUSION: For eyes with refractory or large MH, autologous neurosensory retinal free flap under silicone oil tamponade may provide a new option to improve the anatomical and function outcome, especially in cases where insufficient internal limiting membrane is left.

High body mass index is a strong predictor of intraoperative acquired pressure injury in spinal surgery patients when prophylactic film dressings are applied: A retrospective analysis prior to the BOSS Trial.

We reported the efficacy of soft silicone multilayered foam dressings in preventing intraoperatively acquired pressure injuries (IAPIs) in the prone position using a Relton-Hall frame (BOSS trial). The aim of this study was to clarify the incidence and extract the risk factors for IAPIs in cases in which polyurethane film dressing was used against IAPIs before the BOSS trial period. This study conducted as a retrospective dual-center cohort study between August 2014 and Jun 2015 using the medical records in the operating room. The incidence of IAPIs that developed within 24 hours after surgery was 7.1% (7/99). The multivariate logistic regression analysis revealed that body mass index (BMI) (P = .0016, odds ratio [OR]: 1.22, 95% confidence interval (CI) 1.08-1.4) and length of surgery (P < .0001, OR 2.47, 95% CI 1.86-3.51) were independently associated with the development of IAPIs. Since high BMI was not extracted in BOSS trial, we conclude that the application of soft silicone multilayer foam dressings is important for preventing the development of IAPIs in patients with high BMI values.

Prophylactic Chorioretinectomy in Open Ocular Trauma: A Series of 36 Eyes.

PURPOSE: The aim of this paper was to report the outcomes of prophylactic chorioretinectomy in open-globe injuries where a foreign body penetrated the choroid or perforated the globe. METHODS: We conducted a retrospective, consecutive, noncomparative, and descriptive study of patients registered in the ocular trauma database between January 2006 and December 2014, who underwent vitrectomy with chorioretinectomy. RESULTS: Thirty-six patients (33 male, 3 female) with a mean age of 40 years and a median of follow-up of 13 months were included. Twenty-one cases had penetrating globe injuries with an intraocular foreign body and 15 cases had perforating globe injuries. A concomitant chorioretinectomy was performed in all eyes, although it was only partial in 8 eyes. At the end of follow-up, proliferative vitreoretinopathy (PVR) rates were 6.5%, anatomical success was 80.6%, and the globe survival rate was 96.8%. CONCLUSION: Prophylactic chorioretinectomy is a surgical procedure that may decrease posttraumatic PVR, thus improving final visual acuity and increasing globe survival rates.

Preventing Facial Pressure Ulcers in Acute Respiratory Distress Syndrome (ARDS).

BACKGROUND: In patients with acute lung injury and/or severe acute respiratory distress syndrome (ARDS), prone positioning is a therapeutic intervention to improve oxygenation. Positioning a patient in a prone position increases the risk of medical device-related pressure ulcers in the facial area. CASE STUDIES: This article summarizes experience with 4 patients with ARDS. Two did not receive pressure ulcer preventive measures and subsequently developed multiple necrotic facial pressure ulcers related to prone positioning for treatment of ARDS. The other 2 patients were managed on a thin silicone foam dressing; neither of these patients developed facial pressure ulcers during pronation therapy. CONCLUSION: The use of thin soft silicone foam dressings may prevent the development of facial deep tissue injuries in patients receiving prolonged pronation therapy.

Infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling.

OBJECTIVE: To assess risks involved in using wearable blankets, swaddle wraps, and swaddling. STUDY DESIGN: This was a retrospective review of incidents reported to the Consumer Product Safety Commission between 2004 and 2012. RESULTS: A total of 36 incidents involving wearable blankets and swaddle wraps were reviewed, including 10 deaths, 2 injuries, and 12 incidents without injury. The median age at death was 3.5 months; 80% of the deaths were attributed to positional asphyxia related to prone sleeping, and 70% involved additional risk factors, usually soft bedding. Two injuries involved tooth extraction from the zipper. The 12 incidents without injury reported concern for strangulation/suffocation when the swaddle wrap became wrapped around the face/neck, and a potential choking hazard when the zipper detached. All 12 incidents involving swaddling in ordinary blankets resulted in death. The median age at death was 2 months; 58% of deaths were attributed to positional asphyxia related to prone sleeping, and 92% involved additional risk factors, most commonly soft bedding. CONCLUSION: Reports of sudden unexpected death in swaddled infants are rare. Risks can be reduced by placing infants supine and discontinuing swaddling as soon as an infant's earliest attempts to roll are observed. Risks can be further reduced by removing soft bedding and bumper pads from the sleep environment. When using commercial swaddle wraps, fasteners must be securely attached.

Methodology and recruitment for a randomised controlled trial to evaluate the safety of wahakura for infant bedsharing.

BACKGROUND: Sudden Unexpected Death in Infancy (SUDI) has persistent high rates in deprived indigenous communities and much of this mortality is attributable to unsafe sleep environments. Whilst health promotion worldwide has concentrated on avoidance of bedsharing, the indigenous Maori community in New Zealand has reproduced a traditional flax bassinet (wahakura) designed to be used in ways that include bedsharing. To date there has been no assessment of the safety of this traditional sleeping device. METHODS/DESIGN: This two arm randomised controlled trial is being conducted with 200 mother-baby dyads recruited from Maori communities in areas of high deprivation in the Hawkes Bay, New Zealand. They are randomised to wahakura or bassinet use and investigation includes questionnaires at baseline (pregnancy), when baby is 1, 3, and 6 months, and an overnight video sleep study at 1 month with monitoring of baby temperature and oxygen saturation, and measurement of baby urinary cotinine and maternal salivary oxytocin. Outcome measures are amount of time head covered, amount of time in thermal comfort zone, number of hypoxic events, amount of time in the assigned sleep device, amount of time breastfeeding, number of parental (non-feed related) touching infant events, amount of time in the prone sleep position, the number of behavioural arousals and the amount of time infant is awake overnight. Survey data will compare breastfeeding patterns at 1, 3, and 6 months as well as data on maternal mind-mindedness, maternal wellbeing, attachment to baby, and maternal sleep patterns. DISCUSSION: Indigenous communities require creative SUDI interventions that fit within their prevailing world view. This trial, and its assessment of the safety of a wahakura relative to a standard bassinet, is an important contribution to the range of SUDI prevention research being undertaken worldwide. TRIALS REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12610000993099 Registered 16th November 2010.

Self-positioning followed by induction of anaesthesia and insertion of a laryngeal mask airway versus endotracheal intubation and subsequent positioning for spinal surgery in the prone position: a randomised clinical trial.

BACKGROUND: Anaesthesia followed by positioning in the prone position takes time and may have complications. OBJECTIVE: The hypothesis was that self-positioning in the prone position followed by anaesthesia and introduction of a laryngeal mask airway (LM method) would be faster with fewer complications than positioning after tracheal intubation (ET method). DESIGN: Randomised, controlled trial. SETTING: University Hospital, March 2009 to March 2011. PATIENTS: One hundred forty patients scheduled for spinal surgery were allocated to the LM or the ET method. Exclusion criteria were surgery expected to last more than 2 h, American Society of Anesthesiologists status more than II, age more than 70 years, abnormal neck, throat, and mouth anatomy and function, Mallampati score III-IV, BMI more than 35 kg m, anticipated difficult airway/mask ventilation and decreased neck mobility. INTERVENTIONS: Patients in the LM group placed themselves in the prone position, anaesthesia was induced and a laryngeal mask was introduced. Patients in the ET group were anaesthetised, intubated and then placed in the prone position. MAIN OUTCOME MEASURES: Time taken from identification of the patient at the outset to readiness for radiographic examination following anaesthesia and positioning. Airway problems, sore throat, hoarseness and pain from muscles and joints were also noted. RESULTS: One hundred and forty patients were randomised to LM (n = 70) and ET (n = 70). Data from 64 and 67 patients were analysed. Values are expressed as median (interquartiles) [range]. The primary outcome time was 25 min (23 to 29) [16 to 44] in the LM group and 30 min (26 to 33) [17 to 47] in the ET group (P <0.001). In two patients in group LM, a complete seal could not be obtained; one was intubated, and the other had surgery cancelled due to arterial hypotension. There were fewer cases with sore throat, hoarseness and pain from muscles and joints in the LM group at 3 h, but not at 24 h postoperatively. CONCLUSION: Self-positioning and induction of anaesthesia in the prone position saves time. More patients should be studied to confirm safety and examine whether the method reduces the number of severe complications associated with the prone position. TRIAL REGISTRATION: www.clinicaltrials.gov identifier: NCT01041352.

The effect of body position on pulmonary function, chest wall motion, and discomfort in young healthy participants.

OBJECTIVE: The purpose of this study was to investigate the effect of different recumbent positions on pulmonary function, chest wall motion, and feelings of discomfort in young nonobese healthy volunteers. METHODS: Twenty healthy volunteers (age, 28.0±1.4 years; height, 167.5±10.1 cm; weight, 62.3±10.2 kg) were studied in the sitting position and in the following 6 recumbent positions: supine, left retroversion at a 45° tilt, left anteversion at a 45° tilt, right retroversion at a 45° tilt, right anteversion at a 45° tilt, and prone. After 5 minutes of a selected position, pulmonary functions, including vital capacity (VC), forced expiratory volume in 1 second, maximal inspiratory and expiratory mouth pressures (MIP and MEP, respectively), and breathing pattern components at the chest wall were assessed. Discomfort was assessed using a modified Borg scale. RESULTS: When participants changed position from sitting to each of the 6 recumbent positions, forced expiratory volume in 1 second values decreased significantly (P < .05). None of the participants showed changes in the MIP or MEP in any of the 6 recumbent positions. Rib cage motion was restricted in all recumbent positions except supine, left anteversion at a 45° tilt, and prone. In all 6 recumbent positions, discomfort was experienced during the pulmonary tests. However, in the left retroversion at a 45° tilt position, no discomfort was experienced during the MIP and MEP assessments. CONCLUSION: In young, nonobese, healthy volunteers, recumbent positions caused diminished pulmonary functions and induced feelings of discomfort.

Newer treatment modalities for pediatric obstructive sleep apnea.

The obstructive sleep apnea syndrome is common and its prevalence is expected to increase with the current obesity epidemic. If left untreated, it is associated with important morbidity such as growth failure, neurocognitive impairment, systemic and pulmonary hypertension, and endothelial dysfunction. Recent research has shown that many children, especially the obese or those with other underlying medical conditions, have residual obstructive sleep apnea after adenotonsillectomy (the primary treatment for childhood obstructive sleep apnea). These children could be effectively treated with continuous positive airway pressure but poor adherence is a significant limitation of this therapy. Therefore, new treatment modalities for the pediatric obstructive sleep apnea syndrome are needed. Current research has focused on newer therapies for pediatric obstructive sleep apnea, such as anti-inflammatories, dental treatments, high-flow nasal cannula, and weight loss. However, there are few randomized controlled trials assessing the effectiveness of these therapies. Further research is warranted.

Retinal thickness in eyes with idiopathic macular hole after vitrectomy with internal limiting membrane peeling.

PURPOSE: To compare the thickness of each retinal layer in the parafoveal and perifoveal regions of eyes after successful closure of a macular hole (MH) by pars plana vitrectomy with internal limiting membrane (ILM) peeling to the corresponding areas of the normal fellow eyes. METHODS: Twenty-two eyes of 22 patients with an idiopathic MH who underwent PPV with ILM peeling at the Matsumoto Dental University Hospital were studied. The retinal thickness was measured manually with the volume scan mode of the Spectralis HRA + OCT (Heidelberg Engineering, Germany). RESULTS: The average postoperative parafoveal thickness of the temporal sector was 314.8 µm, and that of the corresponding area of the fellow eyes was 325.0 µm (P = 0.01). The parafoveal thickness of the nasal sector was 360.7 µm, and that of the fellow eyes was 339.6 µm (P < 0.0001). Changes in the inner retinal layer thicknesses contributed to the decreased temporal and increased nasal sectors. The perifoveal retinal thickness was significantly increased in all sectors after PPV, probably due to an increase in the outer nuclear layer thickness. CONCLUSIONS: PPV with ILM peeling for MHs can cause microstructural changes in wide areas of the macula region, suggesting a loss of longitudinal support of the Müller cells.

Effects of body positions on respiratory muscle activation during maximal inspiratory maneuvers.

We evaluated the maximal mouth inspiratory pressure and the EMG patterns of major respiratory and accessory muscles used in the generation of voluntary inspiratory maneuvers during different body positions. Ten healthy subjects (F/M-4/6), the mean age 22.000B10.6 years, participated in the study. The maximal inspiratory mouth pressure (MIP) during Müller's maneuver was measured from residual volume in the standing, sitting, right-sided (RSL) and left-sided lying (LSL), supine, and head-down-tilt (HDT) (3000B0; relatively horizon) positions. EMG of the diaphragmatic (D), parasternal (PS), sternocleidomastoid (SM), and genioglossus (GG) muscles were assessed in each body position. The baseline MIP was 105.3 00B1; 12.0 in men and 59.9 00B110.1 cmH(2)O in women in the standing position and did not appreciable differ in the other positions, except the HDT where it was lower by 23 and 27% in men and women, respectively (P003C0.05). During Müllers maneuver, diaphragmatic EMG activity also was similar in all the body positions, but it was significantly enhanced in the HDT. In contrast, PS EMG showed the highest level of activation in the standing position, taken as the control, reference level, and was lower in the HDT. Activation of SM during the maneuver was near the control in the sitting position, lower in the supine (79%), RSL (85%), LSL (80%), and HDT (72%) positions (P 003C0.05). GG EMG was significantly greater during maximal inspiratory effort in the supine and HDT positions (125and 130%, respectively), while it was lower in the sitting, LRS, and LLS positions (76, 57, and 43%) compared with standing (P 003C; 0.05). We conclude that the inspiratory pressure generated during Muller maneuver is a reflection of complex interactions between several muscle groups during changes in body positions.

Alternative approaches to managing the cleft alveolus.

The cleft alveolus component of the oral cleft deformity is addressed with a separate surgical stage. Several host and operator related factors affect the surgical outcome. When factors that increase the likelihood of secondary alveolar bone graft failure are identified, alterative methods like dentoalveolar distraction (DAD) may be employed. In infants, molding of the alveolar segments is possible and when a synergistic surgical approach is used, the possibility of successful alveolar cleft repair is increased. The authors present two case reports wherein the use of nasoalveolar molding (NAM) and DAD helped to tackle the alveolar cleft deformity.

The effect of extubation in prone position on emergence and recovery in lumbar spinal surgery.

BACKGROUND: Extubation of patients in supine position after prone operations may lead to unwanted effects on hemodynamic and respiratory parameters during emergence and recovery period. We aimed to observe the effects of prone position on emergence and recovery periods after prone surgery. METHODS: This randomized controlled trial was studied with sixty patients extubated either in prone position (30 patients) or in supine position (30 patients) after lumbar spinal surgery in tertiary educational hospitals. Heart rate, non-invasive arterial blood pressure, peripheral oxygen saturation and Bispectral Index values were measured, and recorded in all patients during operation, at the time an anesthetic agent was discontinued, before and after extubation. The number of the mouth suctioning, Aldrete recovery score, and Ricker agitation score were recorded together with the severity of cough during emergence and recovery. Incidents such as nausea, vomiting, respiratory failure, uncontrolled airway, and decreased saturation were also recorded. RESULTS: Heart rate and mean arterial pressure values were significantly lower in the prone group during emergence and recovery period compared with the supine group (P<0.05). Aldrete Recovery Scores were higher in the prone group (P<0.001). The number of the mouth suctioning and the cough severity were lower in the prone group (P<0.001). CONCLUSIONS: Extubation in the prone position provides a more comfortable emergence and recovery periods by less altering the hemodynamic and respiratory status with better recovery profile.

Automated beam placement for breast radiotherapy using a support vector machine based algorithm.

PURPOSE: To develop an automated beam placement technique for whole breast radiotherapy using tangential beams. We seek to find optimal parameters for tangential beams to cover the whole ipsilateral breast (WB) and minimize the dose to the organs at risk (OARs). METHODS: A support vector machine (SVM) based method is proposed to determine the optimal posterior plane of the tangential beams. Relative significances of including/avoiding the volumes of interests are incorporated into the cost function of the SVM. After finding the optimal 3-D plane that separates the whole breast (WB) and the included clinical target volumes (CTVs) from the OARs, the gantry angle, collimator angle, and posterior jaw size of the tangential beams are derived from the separating plane equation. Dosimetric measures of the treatment plans determined by the automated method are compared with those obtained by applying manual beam placement by the physicians. The method can be further extended to use multileaf collimator (MLC) blocking by optimizing posterior MLC positions. RESULTS: The plans for 36 patients (23 prone- and 13 supine-treated) with left breast cancer were analyzed. Our algorithm reduced the volume of the heart that receives >500 cGy dose (V5) from 2.7 to 1.7 cm(3) (p = 0.058) on average and the volume of the ipsilateral lung that receives >1000 cGy dose (V10) from 55.2 to 40.7 cm(3) (p = 0.0013). The dose coverage as measured by volume receiving >95% of the prescription dose (V95%) of the WB without a 5 mm superficial layer decreases by only 0.74% (p = 0.0002) and the V95% for the tumor bed with 1.5 cm margin remains unchanged. CONCLUSIONS: This study has demonstrated the feasibility of using a SVM-based algorithm to determine optimal beam placement without a physician's intervention. The proposed method reduced the dose to OARs, especially for supine treated patients, without any relevant degradation of dose homogeneity and coverage in general.

[Case of laryngopharyngeal edema after a spinal tumor resection in prone position with extensive neck flexion].

A 63-year-old woman developed laryngopharyngeal edema after a cervical spinal tumor resection in prone position. The tracheal tube was removed after 11 hours of general anesthesia and nasal airway was inserted because stridor was audible. Blisters were found on the skin of the anterior neck of the patient. Examinations at 3 h after the extubation suggested upper airway stenosis including stridor, increased work of breathing, oxygenation impairment, and hypercapnia. The trachea of the patient was intubated and the examination of the upper airway by inserting a fiberoptic bronchoscope through the patient's mouth revealed laryngopharyngeal edema. It was considered that the disturbance of venous and/or lymphatic flow of anterior neck due to extensive neck anteflexion during the surgery in prone position had induced the laryngopharyngeal edema; however, we could not verify the cause of the edema. The edema persisted for weeks. We conclude that we should avoid extensive neck anteflexion during surgery in prone position and it is recommended to observe the upper airway for a few hours after extubation because there could be airway obstruction due to delayed and/ or progressive laryngopharyngeal edema.

Infant asphyxia, soft mattresses, and the "trough" effect.

Although unexpected infant death in a cot has traditionally been attributed to sudden infant death syndrome, careful evaluation of death scenes and sleeping environments has increasingly identified deaths due to accidental asphyxia from so-called sleeping accidents. The case of a 5-month-old infant boy who was found facedown and unresponsive in a wooden portable cot with a sagging canvas base is reported to illustrate another potentially lethal situation. Although the autopsy revealed no specific findings, examination of the cot showed a significant depression caused by the sagging canvas base that was exacerbated by a soft-foam mattress and layers of bedding. Once in the trough, the infant would not have been able to extricate himself. Death was therefore attributed to accidental suffocation due to the infant's position resulting in contact of the mouth and face with soft bedding. In addition to again demonstrating the potential dangers of using old second-hand cots, this case clearly shows the problems that may exist when soft and sagging bedding forms a central trough that may entrap an infant. Death scene investigators should specifically comment on the presence of such troughs and measure of depth of the trough and/or cot base to provide some quantification of the degree of concavity present.

Controversies in the diagnosis and management of the Robin sequence.

The Robin sequence, previously known as the Pierre Robin syndrome, is characterized by the sequence of clinical events that result from a small mandible. The tongue becomes posteriorly displaced (glossoptosis) and obstructs the airway. The obstructing tongue also makes oral feeding difficult and, in severe cases, impossible. Patients with Robin sequence may also present with a cleft palate, although this is not necessary to make the diagnosis. The small mandible either results from an inherent growth problem (genetic or syndromic) or is deformational where intrauterine growth of the mandible is restricted. Conditions of syndromic patients are generally more severe and difficult to treat. The phenomenon of "catch-up" growth is disputed, although it is likely to occur in deformational but not syndromic patients. Patients with Robin sequence are best managed by a multidisciplinary team familiar with the diagnoses and treatment of difficult pediatric airways. Approximately 70% of Robin infants are successfully managed by prone positioning alone. Tracheostomy is necessary in approximately 10% of these patients, especially for subglottic obstructions including laryngomalacia and tracheomalacia. Tracheostomy should be avoided if possible. Treatment of the remaining 20% remains highly contentious. Tongue-lip adhesion, nasopharyngeal airways, and distraction osteogenesis all have strong advocates. Ideally, treatment should be individualized. Patients who will have catch-up growth of the mandible will only need a tongue-lip or nasopharyngeal airway as a temporary measure. Patients who we know will not have catch-up growth will benefit from early distraction osteogenesis.

Dynamics of the macular hole-silicone oil tamponade interface with patient positioning as imaged by spectral domain-optical coherence tomography.

PURPOSE: The purposes of this study were to evaluate with spectral domain-optical coherence tomography the relationship between the retina and overlying silicone oil tamponade after macular hole surgery and to evaluate how this relationship changes with patient positioning. METHODS: We studied a retrospective consecutive case series of 10 eyes from 9 patients who underwent macular hole surgery with silicone oil tamponade and subsequent spectral domain-optical coherence tomography scans. Four of the included eyes were also imaged with patients in face-down posture to determine whether the silicone-retina apposition changes with prone positioning. Finally, a single patient was also scanned in the lateral and supine positions. RESULTS: The posterior surface of the silicone oil bubble was well visualized in all 10 eyes. In the majority of eyes (7 of 10), the oil tamponade bridged the macular hole, creating a prefoveal fluid space, but in 3 eyes the silicone oil filled the macular hole and was seen in touch with the underlying foveal depression or retinal pigment epithelium. In 75% of eyes (3 of 4), the silicone oil-retinal approximation did not vary with face-down position. Supine positioning clearly floated the silicone tamponade anteriorly and off the retinal surface. CONCLUSION: Silicone oil tamponade can either bridge macular holes or, in a novel finding, fill the underlying foveal depression or macular hole space. Generally, the oil position is stable between face-forward and prone spectral-domain optical coherence tomography images, suggesting that either of these patient positions allows waterproofing of the underlying macular hole. Finally, our images confirm that supine positioning should be avoided postoperatively because it leads to loss of oil-retinal tamponade.