Evaluation of the new Viewmax laryngoscope in a simulated difficult airway

BACKGROUND

In this study, we evaluated the learning curve and performance of the Viewmax laryngoscope during simulated difficult laryngoscopy in an intubation manikin (Laerdal Airway Management Trainer).

METHODS

To determine the learning curve, 25 anaesthesiologists without previous experience with the Viewmax laryngoscope performed 10 successive intubations in an intubation manikin with a normal airway. Time to intubation and failed intubation attempts were recorded. Another manikin was modified to enable comparison of the Viewmax laryngoscope with Macintosh and McCoy laryngoscopes. The time to intubation, number of failed intubation attempts, modified Cormack and Lehane (MCL) laryngeal view grading, percentage of glottic opening (POGO score), use of gum elastic bougie and subjective rating of degree of difficulty were recorded.

RESULTS

The learning curve for the Viewmax laryngoscope showed a progressive decrease in time to successful intubation and reached a plateau at the sixth attempt. In simulated difficult laryngoscopy, the Viewmax laryngoscope demonstrated significantly better laryngeal view than the Macintosh and McCoy laryngoscopes in terms of MCL grading (Macintosh, P = 0.01; McCoy, P < 0.01) and POGO score (Macintosh, P < 0.01; McCoy, P < 0.01). The time required for intubation in simulated difficult laryngoscopy for the Viewmax laryngoscope was significantly longer than that for the Macintosh (P = 0.02) and McCoy (P < 0.01) laryngoscopes. There was no significant difference in the degree of difficulty, number of failed intubations and use of gum elastic bougie.

CONCLUSION

When compared with the Macintosh and McCoy laryngoscopes in a manikin, the Viewmax laryngoscope appears to improve the view of the larynx but requires a longer time for tracheal intubation.

Growth mechanism of tubular ZnO formed in aqueous solution

Tubular ZnO microstructural arrays were fabricated by a hydrothermal decomposition method. The dependence of the morphologies on the growth time and temperature was investigated in detail. An experiment was carried out to determine the mechanism of tubular ZnO formation. Our results showed that ZnO microtubes originated from an ageing process from ZnO microrods at a lower temperature (compared to the temperature when hydrothermal deposition of ZnO microrods was dominant) due to the preferential chemical dissolution of the metastable Zn-rich (0001) polar surfaces. A growth model was proposed based on the coexistence of hydrothermal deposition and dissolution of ZnO in the fabrication process.

An Octree Approach to Rough Machining

This paper presents an octree subdivision based algorithm of automatic cutter path generation for machining on a numerical control machining centre. Both the stock and the part are represented by solid models. The machining strategy is based on a layer by layer approach taking care of the cutter strength and the variation of the part geometry. This approach allows the problem to be reduced from a three-dimensional to a two-dimensional cutter path generation problem which is solved by a quadtree representation of the plane. The method can be easily extended to include the jigs and fixtures and any other obstacles which would be represented by solid models. Algorithms are described in Pascal-like structure.

Pulsed dye laser therapy for rosacea

Rosacea is a chronic and progressive inflammatory skin disorder affecting the facial convexities for which no curative measure is currently available. Forty consecutive patients with rosacea were treated with the Cynosure PhotoGenica V pulsed dye laser. The improvement following laser therapy was assessed according to a sliding scale: 1 (worse after treatment), 2 (no improvement), 3 (slight improvement), 4 (moderate improvement), 5 (marked improvement). Following an average of 2.4 (range 1-10) laser treatments, a mean score of 4.4 and 4.3 for overall improvement was achieved as judged by the patients and independently assessed by a family member or a close friend of the patients, respectively. The response of erythema and telangiectasia to laser therapy, evaluated by an independent panel of 10 members, showed a mean score of 3.7. Three patients experienced an exacerbation of rosacea during the treatment period requiring antibiotic therapy. During the follow-up period of 6.0-55.5 (mean, 23.3) months after completion of laser therapy, no patient (including 13 patients in whom papulation and pustulation which were amongst the presenting symptoms) required medical treatment. Six patients developed post-inflammatory hyper-pigmentation necessitating skin bleach but no other complication such as scarring was observed. Three patients reported that the residual erythema had progressed after an initial improvement during follow-up periods of 52.4, 15.8 and 6.0 months. All patients felt that laser therapy was worthwhile. We conclude that pulsed dye laser therapy is a useful treatment for rosacea.

Acute-on-chronic subdural haematoma: a rare complication after spinal anaesthesia

An 88-year-old woman with an undiagnosed chronic subdural haematoma underwent emergency repair of a femoral hernia under spinal anaesthesia. The patient complained of headache postoperatively, and a subsequent computed tomography brain scan showed an acute-on-chronic subdural haematoma, with midline shift and impending coning. The patient recovered completely after surgical decompression. The difficulty in diagnosing chronic subdural haematoma in the elderly patient with no history of trauma is discussed, along with the differential diagnosis of headache following spinal anaesthetic in this age-group.

Effects of five commonly used glucocorticoids on haemangioma in vitro

1. High-dose systemic or intralesional steroids are the first-line pharmacological treatments for haemangioma. However, the mechanism of action of steroids is unknown. Using the in vitro model developed by us, the present study examined some of the effects of five commonly used glucocorticoids on haemangioma biopsies taken from two patients. 2. At 12 micro mol/L, triamcinolone and dexamethasone consistently exhibited capillary growth inhibition, whereas methylprednisolone displayed an inhibitory effect during the first 7 days of culture. At this concentration, inhibition of capillary growth was observed in betamethasone-treated cultures derived from one patient but not in those derived from the other. However, hydrocortisone had a negligible effect on capillary growth. 3. Transcription of various factors considered important for haemangioma development were studied by reverse transcription-polymerase chain reaction. Neither vascular endothelial growth factor nor fibroblast growth factor-2 played a vital role in steroid-induced inhibition of capillary growth. All glucocorticoids induced a marked decrease of interleukin (IL)-6 transcripts. 4. Capillary growth inhibition in cultures treated with all glucocorticoids, except triamcinolone, was associated with an increased transcription of clusterin/apolipoprotein J (clust/apoJ), an apoptotic gene. There was increased transcription of mitochondrial cytochrome (cyt) b in the inhibited cultures resulting from triamcinolone, dexamethasone or methylprednisolone treatment that was associated with capillary growth inhibition, suggesting an important role of mitochondria in glucocorticoid-induced regression of haemangioma. 5. Our results indicate that glucocorticoids may modulate haemangiogenesis via an upregulation of cyt b, clust/apoJ and/or IL-6. The variable effects of different glucocorticoids on one or more of these factors may explain the interindividual variation in the in vivo response of haemangioma to the steroids.

Altered mitochondrial cytochrome b gene expression during the regression of hemangioma

Hemangioma is a primary tumor of microvasculature. Its development typically exhibits a proliferative phase followed by an involuting phase that continues into the involuted phase. Although apoptosis has been reported, the mechanisms regulating the spontaneous regression of hemangioma are largely unknown. The authors recently demonstrated up-regulation of the mitochondrial cytochrome b gene in hemangioma associated with steroid-induced regression. The present study investigated whether a similar change occurred during spontaneous regression. Biopsy material was obtained from 11 patients with hemangiomas at different phases of development. In one of these patients, a biopsy was taken from the proliferative, involuting, and involuted areas of the hemangioma. In another patient, a biopsy was taken before and 5 weeks after the intralesional administration of steroids. From each tissue specimen, RNA was isolated and subjected to reverse transcriptase-polymerase chain reaction analysis by use of specific primers for the human mitochondrial cytochrome b gene. Semiquantitative reverse transcriptase-polymerase chain reaction analysis revealed that the strongest expression of the mitochondrial cytochrome b transcripts was in specimens taken from hemangiomas in the involuting phase compared with those from the proliferative and involuted phases. The authors concluded that mitochondrial cytochrome b is associated with both the spontaneous and the steroid-induced regression of hemangioma, probably by regulating apoptosis.

Cellular and extracellular markers of hemangioma

Several cellular and extracellular markers that distinguish the phases of the hemangioma life cycle have been described previously. However, details of the phenotypic changes of; the various cellular elements during hemangioma development have not been fully reported, and the extracellular matrix composition, especially in the vicinity of the proliferating endothelial cells, is poorly described. This study examined the expression of cellular and extracellular molecules and cytokines in the proliferative, involuting, and involuted phases of hemangioma. Paraffin-embedded hemangioma specimens, four from each phase, were examined histochemically and immunohistochemically. Throughout the three phases, vascular endothelial cells stained positive for CD31 and von Willebrand factor, although in the involuted phase, not all vessels in the tissue expressed these endothelial markers. Proliferating cell nuclear antigen was expressed by the majority of endothelial cells and pericytes in the proliferative and early involuting phases, but its expression was negligible in the involuted phase. In addition to finding that the total number of mast cells was highest in the involuting phase, the authors observed that the proportion of chymase-positive mast cells decreased with the progression of hemangioma and that virtually all mast cells expressed the biogenic amine phenotype throughout the hemangioma life cycle. The localization of vascular endothelial growth factor predominantly to the pericytes and endothelial cells during the proliferative phase and of basic fibroblast growth factor to the endothelial cells in both the proliferative and early involuting phases is consistent with previous reports, although the latter growth factorwas also observed in mast cells. Type IV collagen and the beta chain of laminin and perlecan were detected in the basement membranes in all phases. Interestingly, collagen types I, III, and V were present in basal membranes throughout the phases and with increasing density in the stromal areas with involution, although type I collagen was less prominent during the proliferative phase. Short-chain collagen type VIII was localized extracellularly throughout the development of hemangioma but, during the early proliferative phase, it was also detected within mast cells. The expression of specific cytokines and cellular and extracellular markers may help distinguish the different clinical phases of the hemangioima life cycle. These results provide further insight into the biology of hemangioma.

Paralysis of the marginal mandibular branch of the facial nerve: treatment options

Isolated paralysis of the marginal mandibular branch of the facial nerve results in an asymmetrical smile with elevation of the lower lip on the affected side. We discuss the surgical options for its correction and present a series of 26 patients who underwent either botulinum toxin injection, anterior belly of digastric transfer or free extensor digitorum brevis transfer as treatment. Botulinum toxin injection provided satisfactory results although these were temporary. Anterior belly of digastric transfer was the surgical procedure of choice. It yielded superior cosmetic results, less donor-site morbidity and required a shorter operating time. In more complex congenital facial hypoplastic syndromes, or following extensive surgery in the digastric triangle, the anterior belly of the digastric muscle may be absent or damaged. Extensor digitorum brevis transfer is the preferred option in these cases.

Clusterin/apoJ expression during the development of hemangioma

Hemangioma is the most common tumor of infancy. This vascular tumor is characterized by an initial rapid proliferation followed by an inevitable regression. The life cycle of hemangioma is divided into proliferative, involuting, and involuted phases. The cellular and molecular mechanisms responsible for controlling the biological behavior of hemangioma are largely unknown. Differential display analysis using mRNA isolated from biopsy specimens representative of the 3 different phases showed increased expression of clusterin/apoJ (clust/apoJ) in the involuting samples. Clust/apoJ is a multifunctional glycoprotein that has been associated with apoptosis. Reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry showed that both the transcription and protein expression of clust/apoJ were increased in hemangioma as the tumor progressed from the proliferative to the involuting and involuted phases. This suggests that clust/apoJ is involved in regulating apoptosis during the spontaneous regression of hemangioma. It has been suggested that mast cells (MC) play a role in the regression of hemangioma. The increase in the number and proportion of clust/ apoJ-positive MC with progression of hemangioma, along with the localization of clust/apoJ to MC granules, supports this hypothesis. We suggest that MC may be synthesizing/releasing this apoptotic modulator, leading to the regression of the tumor. Better understanding of the pathogenesis of hemangioma by identification of the relevant factors involved in its regression such as clust/apoJ will result in the development of novel therapies for this condition and tumors that do not undergo spontaneous regression.

Steroid therapy of a proliferating hemangioma: histochemical and molecular changes

OBJECTIVES

Hemangioma is a primary tumor of the microvasculature in which angiogenesis is initially excessive, followed by regression of the newly formed vessels. Intervention is necessary in up to 20% of cases, high-dose systemic or intralesional steroids being the first-line treatment. As the mechanism of action of steroids is unknown, we undertook an investigation of the cellular and molecular effects of their action.

STUDY DESIGN

A unique opportunity to study the effect of steroid treatment was presented when biopsy material was obtained from an infant with an ulcerated proliferating hemangioma before and after intralesional triamcinolone injection, which resulted in an accelerated regression of the lesion. Histochemical quantitation of mast cells, molecular analysis by reverse transcriptase-polymerase chain reaction (RT-PCR) for 7 growth factor transcripts and differential display RT-PCR (DD RT-PCR) were conducted.

RESULTS

After steroid therapy, the mast cell number increased (untreated = 2.22 +/-.27 [standard error of the mean ¿SEM¿]; treated = 8.7 +/-.71 [SEM] mast cells per field, respectively; P <.0001; n = 40 fields for each group), and the transcriptional expression of cytokines: platelet-derived growth factor-A and -B; interleukin-6; transforming growth factor-beta1 and -beta3 decreased, while that of basic fibroblast growth factor (bFGF) and vascular endothelial cell growth factor remained unaltered. Elevated urinary bFGF levels noted in cases of proliferating hemangioma, persisted even after steroid treatment. Using DD RT-PCR an amplicon that shared 100% sequence homology with the human mitochondrial cytochrome b gene was detected in the hemangioma biopsy after steroid treatment.

CONCLUSIONS

The regression of this hemangioma subsequent to steroid therapy was accompanied by a significant increase in mast cell density, reduced transcription of several cytokines, and an enhanced expression of the mitochondrial cytochrome b gene.

A novel in vitro human model of hemangioma

Hemangioma, the most common tumor of infancy, is characterized by a proliferation of capillary endothelial cells with multilamination of the basement membrane and accumulation of cellular elements, including mast cells. The initial rapid growth is followed by an inevitable but slow involution. The currently available therapies are empirical and unsatisfactory because what is known of the cellular and molecular basis of hemangioma development is rudimentary. Advances in the understanding of its programmed biologic behavior has been hampered by the lack of a valid human model. We report here a novel in vitro culture system that is a useful human model of hemangioma. A small fragment of hemangioma biopsy is embedded in fibrin gel in a well of culture plates and incubated in a serum-free, buffered-salt, minimal medium. A complex network of microvessels grows out from the tissue fragments. Biopsies taken from all three phases of hemangioma development were cultured successfully; proliferative phase samples developed microvessels in 1 to 4 days, involuting phase in 5 to 7 days, and involuted phase in 7 to 12 days. The relative growth rates of the microvessels in the culture of biopsies taken from different stages of hemangioma development reflect the growth patterns seen clinically. This model has been validated using histochemistry, immunohistochemistry, and reverse transcriptase-polymerase chain reaction. Comparison of the number, localization, and phenotype of endothelial and mast cells and the distribution of basement membrane constituents (type IV collagen, perlecan, and laminins) and growth factors (basic fibroblast growth factor, vascular endothelial growth factor, transforming growth factor-betas) in the biopsy and the tissue after culture shows that many of the characteristics of the original tissues were retained in culture. This in vitro human model of hemangioma overcomes some of the deficiencies associated with earlier models. It offers an opportunity for studying the precise cellular, biochemical, and molecular basis of hemangioma It may also help to elucidate the mechanisms of action of existing therapies and may lead to the identification of novel treatments for hemangioma.

Pulsed dye laser therapy for viral warts

Twenty-eight patients with 103 recalcitrant and 20 simple viral warts were treated with the Cynosure PhotoGenica V pulsed dye laser at 585 nm, and fluencies of 6.0-9.0 J/cm(2). An eradication rate of 92% for recalcitrant warts after an average of 2.1 (range 1-7) treatments and 75% for simple warts after an average of 1.6 (range 1-2) treatments was achieved with a mean follow-up period of 7.2 (range 3-15) months. Mild hypopigmentation was noted in one patient and superficial infection in another. Unlike ablative treatment modalities, with pulsed dye laser therapy, no wound was created thus avoiding prolonged postoperative pain, disability and scarring. Treatment was well tolerated by patients, most of whom returned to work or normal activities immediately postoperatively. Pulsed dye laser is an effective treatment for both recalcitrant and simple warts. It is the treatment of choice for these lesions in cosmetically sensitive areas.

Anomalous extensor muscles of the hand: a review

Anomalous extensor muscles of the hand are not uncommon. Well-recognized anomalies anomalous extensor indicis proprius, extensor digitorum brevis manus, extensor medii proprius, and extensor indicis et medii communis are reviewed and discussed in detail. Anomalous extensor indicis proprius and extensor digitorum brevis manus may occasionally give rise to dorsal wrist pain and the diagnosis is often confused especially in the presence of other pathologic findings such as a ganglion. An analysis of the embryologic development of the extensor muscle mass with phylogenetic comparisons between species of the animal kingdom is presented to underscore the clinical relevance of these anomalous extensors.

Modified Antia-Buch repair for full-thickness upper pole auricular defects

Various reconstructive techniques have been described for repair of full-thickness upper pole auricular defects. The wedge excision commonly used for treatment of upper pole tumors allows excision and reconstruction in a single stage. However, this technique suffers from major deficiencies. We apply the concept of crescentic scaphal excision and the Antia-Buch advancement-rotation flap principle to repair various full-thickness upper pole auricular defects resulting from excision of skin lesions in eight consecutive patients. The technique achieves a natural auricular shape in three dimensions with minimal disruption of the anatomic landmarks and avoids conspicuous scars. It has several advantages over the original Antia-Buch repair and other techniques used for reconstruction of full-thickness upper pole auricular defects.

Hormone responses to stress in patients with major burns

The responses of the plasma stress hormones corticotrophin (ACTH), vasopressin (AVP), cortisol and corticotrophin releasing hormone (CRH) have been studied in seven consecutive patients aged between 15 and 65 years who suffered from burns of 15-95% total body surface area. There was a distinct peak in AVP (up to 100 pmol/l) and ACTH levels well above the upper limit of normal in all except one patient within 24 h of burn injury. Following the initial rise, AVP and ACTH tended to fall. Plasma CRH with one exception remained within the normal range. Concurrent measurement of plasma renin activity (PRA), haemoglobin (Hb), haematocrit (Hct) and plasma sodium (Na), to assess hydration, showed that PRA was increased in all except one patient during the first 4 days of hospital admission. The correlation between ACTH and cortisol was highly significant (P < 0.001), as was the correlation between ACTH and AVP, AVP and Na, PRA and Hb, and Hct and Na. Other significant correlations were ACTH and Hct (P = 0.023), ACTH and Na (P = 0.017), AVP and Hct (P = 0.029), CRH (P = 0.018), CRH and Hb (P = 0.001). No significant correlation could be demonstrated between CRH and ACTH or AVP. Our findings suggest that AVP plays a role in the hypercortisolaemia which accompanies major burns. The possible detrimental effect of very high levels of AVP leading to progression of burn depth and reduction of skin graft take by its potent vasoconstrictive action and water retention effect (resulting in oedema) deserves further study. As AVP has the potential to reduce tissue perfusion, the possible use of antagonists in major burns merits further consideration. Persistently raised PRA levels, despite normal biochemical and haematological parameters, may indicate that volume expansion therapy may not be adequate, and that both hypovolaemia and stress may contribute to the AVP response. Stress hormone monitoring may lead to better treatment and a reduction in burn stress.

Molding therapy for infants with deformational auricular anomalies

Congenital auricular anomalies can be categorized as either malformed or deformational. Auricular deformations most commonly affect the helix and antehelix. Surgical correction involves sutural modeling, wedge excision, reshaping and reversing cartilage segments, and morselization. Since neonatal auricular cartilage is extremely pliable, we used early splinting to correct deformational ear anomalies. Splints were constructed of leadfree, soft soldering wire threaded into polyethylene tubing and held in place with Steri-Strips. From August 1995 through February 1996 we treated 19 infants with 32 deformed auricles: 10 infants were male and 9 were female, ranging in age from 1 day to 10 weeks. Thirteen infants had both ears affected. There were 8 prominent ears, 23 lop ears, 2 Stahl's ears, and 1 infant with an inverted concha. For prominent ears, the helical-mastoid distance decreased from an average of 16.8 to 12.2 mm, after an average of 13 weeks of splinting. Fourteen corrected lop ears had a normal appearance, and 9 were improved with minor residual deformity. There was only one complication: skin irritation requiring adjustment of the prosthesis. Five children had molding started after 3 months of age and all had no significant improvement. In addition, the parents of 5 children refused therapy and 12 children had either poor compliance to therapy or were lost to follow-up. Our experience with auricular molding confirmed that it is easy, effective, and inexpensive. If molded sufficiently early, most auricular deformations should not need surgical correction in childhood.

Hypertelorism: nosologic analysis of 90 patients

The word hypertelorism is used to describe increased interorbital distance, a condition that is causally and pathogenically heterogeneous. Because not all wide-set eyes are the same, accurate terminology and nosology are critical to understanding and management. Orbital hypertelorism signifies an increased distance between both medial sides and lateral sides of the orbits. Interorbital hypertelorism denotes increased distance only between the inner orbital walls. In this retrospective analysis of 90 patients with hypertelorism, the most common cause was frontonasal malformation (n = 30), a heterogeneous category of nonfamilial disorders including a newly described subgroup, rugose frontonasal malformation. The second most common cause was craniofrontonasal dysplasia (n = 18), a genetic syndrome comprising coronal synostosis, frontonasal anomalies, "frizzy" hair, narrow/sloping shoulder girdle deformity, and longitudinal ridging of nails in association with various truncal and extremity anomalies. Paramedian craniofacial cleft(s) (n = 10) and (sincipital) encephalocele (n = 6) were infrequent causes of hypertelorism. The fifth, miscellaneous category comprised well-defined, mostly chromosomal and syndromic disorders (n = 26). Patients in the various diagnostic categories were designated as having either orbital or interorbital hypertelorism. Hypertelorism also was graded as either first, second, or third degree based on deviation from age- and gender-matched normative data. The etiology and type of hypertelorism influence the selection of operative procedure, whereas the grade of severity indicates the need for surgical correction.

Vertical orbital dystopia

Many pathologic processes may lead to vertical orbital dystopia. We reviewed 47 consecutive cases seen over a 13-year period. Twenty-nine patients underwent eye leveling procedures to improve cosmesis, 2 of these by camouflage procedures and 27 by orbital translocation. Ten patients had 16 secondary operations. There was one death, serious complications occurred in 3 patients, and nuisance complications occurred in 20 others. Seven patients developed diplopia postoperatively, and in 6 patients it was troublesome. In these, it resolved fully in 2 patients, improved to be of no consequence in 2, and in the remaining 2 troublesome symptoms persisted requiring inferior oblique muscle recession in 1. Binocular vision was never restored when not present preoperatively, and in 3 patients temporary loss occurred. There was an overall modest but significant improvement in appearance after surgery. It is concluded that vertical orbital translocation is rewarding and worthwhile.

Isolation and characterization of a novel Deinococcus radiodurans mutant abnormally susceptible to mutation induction by UV, gamma-ray, and mitomycin C

We isolated and characterized a novel, radiation 'hypermutable' mutant of Deinococcus radiodurans. Compared with the wild-type strain D. radiodurans IR, this mutator strain, designated S101, exhibited sensitivity to UV light, gamma-ray, mitomycin C, and N-methyl-N'-nitro-N-nitrosoguanidine. Spontaneous revertants of S101 that restored wild-type phenotype (non-mutability and resistance to these DNA-damaging agents) were also isolated. Furthermore, the increased susceptibility to DNA-damaging agents and mutability observed in S101 could be mimicked by treating D. radiodurans IR with Mn(II) ions. Our results suggest a putative new pathway of DNA repair in the extremely radioresistant bacterium D. radiodurans.

Hemifacial hypoplasia and hypomelanosis of Ito

We present three cases of hemifacial hypoplasia associated with hypomelanosis of Ito. The facial deformity is often severe with marked soft tissue shortage and underlying skeletal hypoplasia posing difficulty in reconstruction. The external ear is relatively uninvolved, although a degree of hypoplasia is usually present. The hallmark of hypomelanosis of Ito is linear depigmentation of skin often associated with asymmetric abnormalities. It is a heterogenous disorder due to chromosomal mosaicism, but cytogenetic confirmation of the diagnosis may be difficult. The relationship between mosaicism and anatomical asymmetry is discussed.

A splint for correction of congenital ear deformities

Fourteen non-hypoplastic congenitally deformed ears were treated with a simple splint with satisfactory results in all but one. These deformities can be treated non-surgically in the early neonatal period, effectively, without anaesthetic, and with minimal cost. We confirm other reports that better results are obtained and a shorter duration of splintage is needed if treatment is started early in the neonatal period. Our neonatal paediatric colleagues and midwives should be encouraged to manage these deformities in this way, and the need for surgical correction may be largely avoided in the future.

When do ears become prominent?

Non-hypoplastic congenital ear deformities are amenable to non-surgical treatment with splinting in the neonatal period. It is therefore important to determine when the deformity occurs. 100 postal questionnaires were sent to parents to study, retrospectively, the evolution of the prominent ear deformity in their children. 79 questionnaires were returned. As remembered by parents, the deformity was first noted at birth in 48 (61%) children, in 68 (86%) by 6 months and in all cases by 5 years. Therefore a large number of patients with prominent ears could be treated effectively, non surgically, early in life, without anaesthetic and with minimal cost.

A comparison of Zenoderm with DuoDERM E in the treatment of split skin graft donor sites

A prospective, randomised, controlled study compared Zenoderm (ZM) with DuoDERM E (DE) in the treatment of split skin graft donor areas in 64 patients. The donor site comfort was similar in the two groups. DE usage resulted in significantly faster healing but also a higher leakage rate than ZM. Two patients in the ZM group developed infection in their donor sites. The cost is significantly less with ZM than DE.