External urinary catheter devices: A multisite project involving point prevalence

External urinary catheter devices used in hospitals can offer an alternative to indwelling urinary catheters. Prevalence and patient outcomes are not well understood. This multisite project involved point prevalence of device use in patients with labia on acute care units. All patients on included units with corresponding anatomy were observed for presence of device in addition to review of indication of use and chart audit. Device use was 28.8 %. Immobility was the leading indication, and most patients had severe dysfunction as to mobility. For most patients, level of mobility remained the same from admission to discharge. Many patients were either potentially physically able to mobilize out of bed to urinate or were likely continent. There was variation in suction setting and chart documentation. The project lacked a comparison group and collected limited patient information. Areas for future inquiry include prevalence and impact on mobility, continence, and skin integrity.

Advocating for the Vulnerable: The Clinical Nurse Specialist and Nursing Home Reform

INTRODUCTION

Nursing homes have been disproportionally affected by the COVID-19 pandemic, particularly because of resident vulnerability, inadequate staffing, and poor quality of care.

CURRENT STATE

Despite billions of dollars in funding, nursing homes often do not meet minimum federal staffing requirements and are frequently cited for infection prevention and control deficiencies. These factors significantly contributed to resident and staff deaths. For-profit nursing homes were associated with more COVID-19 infections and deaths. Nearly 70% of US nursing homes are for-profit ownership, where quality measures and staffing levels are often lower than their nonprofit counterparts. Nursing home reform is urgently needed to improve staffing and care quality in these facilities. Some states, such as Massachusetts, New Jersey, and New York, have made legislative progress in establishing standards for nursing home spending. The Biden Administration has also announced initiatives, through the Special Focus Facilities Program, to improve nursing home quality and the safety of residents and staff. Concurrently, the "National Imperative to Improve Nursing Home Quality" report from the National Academies of Science, Engineering, and Medicine made specific staffing recommendations, including an increase in direct care registered nurse coverage.

CONCLUSION

There is an urgent need to advocate for nursing home reform by partnering with congressional representatives or supporting nursing home legislation to improve care for this vulnerable patient population. Adult-gerontology clinical nurse specialists have an opportunity to leverage their advanced knowledge and unique skill set to lead and facilitate change to improve quality of care and patient outcomes.

Radiotherapy plus temozolomide in elderly patients with glioblastoma: a "real-life" report

Background

The optimization of the management for elderly glioblastoma patients is crucial given the demographics of aging in many countries. We report the outcomes for a “real-life” patient cohort (i.e. unselected) comprising consecutive glioblastoma patients aged 70 years or more, treated with different radiotherapy +/− temozolomide regimens.

Methods

From 2003 to 2016, 104 patients ≥ 70 years of age, consecutively treated by radiotherapy for glioblastoma, were included in this study. All patients were diagnosed with IDH-wild type glioblastoma according to pathological criteria.

Results

Our patient cohort comprised 51 female patients (49%) and 53 male. The median cohort age was 75 years (70–88), and the median Karnofsky performance status (KPS) was 70 (30–100). Five (5%) patients underwent macroscopic complete resection, 9 (9%) had partial resection, and 90 (86%), a stereotactic biopsy. The MGMT promoter was methylated in 33/73 cases (45%). Fifty-two (50%), 38 (36%), and 14 (14%) patients were categorized with RPA scores of III, IV, and I-II. Thirty-three (32%) patients received normofractionated radiotherapy (60 Gy, 30 sessions) with temozolomide (Stupp), 37 (35%) received hypofractionated radiotherapy (median dose 40 Gy, 15 sessions) with temozolomide (HFRT + TMZ), and 34 (33%) HFRT alone. Patients receiving only HFRT were significantly older, with lower KPSs. The median overall survival (OS; all patients) was 5.2 months. OS rates at 12, 18, and 24 months, were 19%, 12%, and 5%, respectively, with no statistical differences between patients receiving Stupp or HFRT + TMZ (P = 0.22). In contrast, patients receiving HFRT alone manifested a significantly shorter survival time (3.9 months vs. 5.9 months, P = 0.018). In multivariate analyses, the prognostic factors for OS were: i) the type of surgery (HR: 0.47 [0.26–0.86], P = 0.014), ii) RPA class (HR: 2.15 [1.17–3.95], P = 0.014), and iii) temozolomide use irrespective of radiotherapy schedule (HR: 0.54 [0.33–0.88], P < 0.02). MGMT promoter methylation was neither a prognostic nor a predictive factor.

Conclusions

These outcomes agree with the literature in terms of optimal surgery and the use of HFRT as a standard treatment for elderly GBM patients. Our study emphasizes the potential benefit of using temozolomide with radiotherapy in a real-life cohort of elderly GBM patients, irrespective of their MGMT status.

[Jugal rejuvenation and jowls treatment]

The aim of this study is to analyze the anatomical changes leading to the appearance of jugal aging with the appearance of jowls. It is also to describe the different techniques and to highlight those that are most effective with the permanent concern of obtaining a natural result with a well-defined jawline and a harmonious distribution of jugal volumes. For this purpose, the techniques of lifting with relocation of the displaced volumes and lipostructure are often associated with the strict respect of different directional vectors for the underlying tissues and for the skin redraping. More precisely, the dissection of the pre-masseteric space makes it possible to address the specific problems posed by the jowls and the heavy labio-mental grooves. In responding to the psycho-sociological demand of our time, two major types of indications emerge with the facelift of the young patient, which makes it possible to obtain a long lasting result and a fast return to social and professional life and a later indication surgery, which requires more invasive techniques resulting in heavier surgical procedures and follow-up.

Comparison of three methods of diagnosis of plasma unmeasured anions in critically ill patients

BACKGROUND

The measurement of plasma unmeasured anions (PUA) is paramount in assessing metabolic acid base disorders. The aim of this study was to compare the accuracy of three methods in diagnosing abnormal PUA values: standard base excess (SBE), the albumin corrected anion gap (AGc), and the Stewart-Figge approach, based on unidentified anions (XAc-).

METHODS

Acid-base variables were prospectively collected in ICU patients admitted January-September 2008. Whatever the method, PUA values measured two standard deviations above or below the mean of those in control subjects were considered as abnormal.

RESULTS

Of the 205 consecutives patients included, 179 had an abnormal PUA value. The accuracy of AGc and XAc- in diagnosing abnormal PUA values was comparable (AUC: 0.89±0.03 and 0.89±0.03, P=0.82) but greater than that of SBE (0.67±0.06, P<0.001 and P<0.001, respectively). Of the high PUA values (n=161), 96% were diagnosed by XAc-, 88% by AGc (P<0.01) and 48% by SBE (P<0.001). Hyperlactatemia (n=111) was diagnosed equally by AGc and XAc-, (81% and 86%, P=0.37) but less by SBE (50%, P<0.001 and P<0.001, respectively). High PUA not associated with hyperlactatemia (N.=61) was more frequently diagnosed by XAc- (97%) than by AGc (84%, P=0.03).

CONCLUSION

In ICU patients, AGc and the Stewart-Figge approach should be preferred over SBE for diagnosing abnormal PUA values and predicting hyperlactatemia. The Stewart-Figge approach based on unidentified anions, is the most efficient in diagnosing high PUA values not associated with hyperlactatemia.

Clinical and genetic findings in a series of Italian children with pure hereditary spastic paraplegia

BACKGROUND

hereditary spastic paraplegias (HSP) are a group of neurodegenerative disorders characterized by progressive lower extremity spastic weakness. SPG7, SPG4 and SPG3A are some of the autosomal genes recently found as mutated in recessive or dominant forms of HSP in childhood. SPG31 is more often associated with a pure spastic paraplegia phenotype, but genotype-phenotype correlation is still unclear. The aims of the current study was: (i) to verify the mutational frequency of SPG4, SPG3A, SPG31 and SPG7 genes in our very-well-selected childhood sample, and (ii) to improve our knowledge about the clinical and electrophysiological HSP phenotypes and their possible correlation with a specific mutation.

METHODS

a sample of 14 Italian children affected by pure HSP (mean age at diagnosis 5.9 years) was extensively investigated with electrophysiological, neuroradiological and genetic tests.

RESULTS

three SPG4 mutations were identified in three patients: two novel missense mutations, both sporadic, and one multiexonic deletion already reported. A novel large deletion in SPG31 gene involving exons 2-5 was also detected in one young patient. No mutations in the SPG7 and in the SPG3A genes were found.

CONCLUSIONS

our data confirm that HSP represent a heterogeneous group of genetic neurodegenerative disorders, also in sporadic or autosomal recessive early onset forms. Multiplex Ligation-dependent Probe Amplification-based mutation screening for SPG4 and SPG31 genes would be added to sequencing-based screening of SPG4, SPG31 and SPG3A genes in the routine diagnosis of HSP children.

Sensitivity and specificity of decreased CSF asialotransferrin for eIF2B-related disorder

OBJECTIVE

This is a study estimating diagnostic accuracy of CSF asialotransferrin to transferrin ratio measurement in eIF2B related disorders by using clinical evaluation and EIF2B mutation analysis as the reference standard. eIF2B-related disorder is a relatively common leukodystrophy with broad phenotypic variation that is caused by mutations in any of the five EIF2B genes. There is a need for a simple and clinically valid screening tool for physicians evaluating patients with an unclassified leukodystrophy.

METHODS

CSF two-dimensional gel (2DG) electrophoresis analyses to measure asialotransferrin to transferrin ratios were performed in 60 subjects including 6 patients with documented EIF2B gene mutations, patients with other types of leukodystrophy, and patients with no leukodystrophy.

RESULTS

All six patients with mutation proven eIF2B-related disease showed low to nearly undetectable amounts of asialotransferrin in their CSF when compared to 54 unaffected controls by CSF 2DG analyses in this study. eIF2B-like patients, with clinically similar presentations but no mutations in EIF2B1-5, were distinguished from patients with mutations in EIF2B1-5 by this biomarker. Patients with mutations in EIF2B1-5 had asialotransferrin/transferrin ratio levels significantly different from the group as a whole (p < 0.001). Using 8% asialotransferrin/transferrin ratio as a cutoff, this biomarker has a 100% sensitivity (95% CI = 52-100%) and 94% specificity (95% CI = 84-99%).

CONCLUSION

Decreased asialotransferrin/transferrin ratio in the CSF of patients with eIF2B-related disorder is highly sensitive and specific. This rapid (<48 hours) and inexpensive diagnostic tool for eIF2B-related disorders has the potential to identify patients with likely eIF2B-related disorder for mutation analysis.

Exon deletion in the non-catalytic domain of eIF2Bepsilon due to a splice site mutation leads to infantile forms of CACH/VWM with severe decrease of eIF2B GEF activity

The CACH/VWM syndrome is an autosomal recessive leukodystrophy characterized by a broad spectrum of clinical presentations and by diffuse cavitary degeneration of the white matter on MRI. Mutations responsible for this disorder are missense or frameshift mutations occurring in the five genes (EIF2B1-5) that encode the translation eukaryotic initiation factor eIF2B. We found that a patient with infantile CACH/VWM carries a mutation in the acceptor splice site of EIF2B5 exon 6. In lymphoblastoid cells of the patient, we detected an abnormal EIF2B5 transcript in which exon 6 was absent, however, the predicted protein product lacking part of the non-catalytic domain encoded by exon 6 was not detected. The eIF2B GEF activity was severely decreased. These data support the importance of the non-catalytic domain of the eIF2Bepsilon subunit in the eIF2B complex formation and activity.

[Monoclonal IgM interference with immunoturbidimetric determination of ferritin and transferrin]

When they are present in important blood concentration, the monoclonal immunoglobulins are known to interfere with many immuno-analyze assays. We report the case of a patient presenting a Waldenstrom macroglobulinemia, for which the determination of some parameters of the martial assessment was impossible because of the presence of IgM kappa. The analysis of analytical alarms of the automat as well as the installation of simple and fast pre-treatment protocol of the interference enabled us to quickly make a result useful for the management of this patient.

Le syndrome CACH/VWM et les leucodystrophies liées à des mutations EIF2B

A new leukoencephalopathy, the CACH syndrome (Childhood Ataxia with Central nervous system Hypomyelination) or VWM (Vanishing White Matter) was identified on clinical and MRI criteria. Classically, this disease is characterized by (1) an onset between 2 and 5 years of age, with a cerebello-spastic syndrome exacerbated by episodes of fever or head trauma leading to death after 5 to 10 years of disease evolution, (2) a diffuse involvement of the white matter on cerebral MRI with a CSF-like signal intensity (cavitation), (3) a recessive autosomal mode of inheritance, (4) neuropathologic findings consistent with a cavitating orthochromatic leukodystrophy with increased number of oligodendrocytes with sometimes "foamy" aspect. A total of 148 cases have been reported so far. This disease is linked to mutations in the five EIF2B genes encoding the five subunits of the eukaryotic initiation factor 2B (eIF2B), involved in the protein synthesis and its regulation under cellular stresses. Clinical symptoms are variable, from fatale infantile forms (Cree leukoencephalopathy) and congenital forms associated with extra-neurological affections, to juvenile and adult forms (ovarioleukodystrophy) characterized by cognitive and behaviour dysfunctions and by a slow progression of the disease, leading to the term of eIF2B-related leukoencephalopathies. Prevalence of these remains unknown. Diagnosis lays on the detection of EIF2B mutations, affecting predominantly the EIF2B5 gene. A decrease in the intrinsic activity of the eIF2B factor (the guanine exchange activity, GEF) in lymphoblasts from patients seems to have a diagnostic value. The patho-physiology of the disease would involve a deficiency in astrocytes maturation leading to an increased susceptibility of the white matter to cellular stress. No specific treatment exists except the "prevention" of cellular stress. Corticosteroids sometimes proved to be useful in acute phases. Prognosis seems to correlate with the age of onset, the earliest forms being more severe.

Molecular characterization of 6 unrelated Italian patients with 5alpha-reductase type 2 deficiency

Steroid 5alpha-reductase (5alphaR) deficiency (OMIM number #264600) is a rare 46,XY disorder of sex differentiation caused by mutations in the 5alphaR type 2 gene (SRD5A2) resulting in dihydrotestosterone deficiency during fetal development. We report on the analysis of the SRD5A2 gene in 6 unrelated 46,XY Italian patients with external genitalia morphology ranging from predominantly female to nearly completely male. Three subjects were seen and assessed at birth, 1 patient was referred to us before puberty, and 2 at postpubertal age. Six different causative mutations (5 missense and 1 nonsense) and a rare polymorphism were identified. Four patients presented homozygous single-base substitutions. These SRD5A2 mutations were located in exon 2 (variant Cys133Gly), exon 4 (Gly196Ser and Ala207Asp) and exon 5 (Tyr235Phe). A fifth subject was a compound heterozygote who carried a nonsense mutation in exon 1 (Trp53X) and a second SRD5A2 alteration in exon 5 (Tyr235Phe). The final patient presented a mutation in only 1 allele (Gly34Trp) together with the Ala49Thr variant. The molecular characterization of these patients made it possible to identify novel mutations and to confirm, before gender assignment or any surgical approach, the suspected 5alphaR deficiency in 2 newborns, 1 of whom had inconclusive hormonal data. 5alphaR deficiency in subjects without parental consanguinity and the presence of compound heterozygotic patients suggest that SRD5A2 mutations carrier frequency may be higher than previously thought.

The large spectrum of eIF2B-related diseases

eIF2B (eukaryotic initiation factor 2B) is a GEF (guanine nucleotide-exchange factor) that plays, with its substrate eIF2, a key regulatory role in the translation initiation phase of protein synthesis. The importance of correct control of eIF2 and eIF2B for normal physiology is underlined by the recent involvement of the five genes that encode the five eIF2B subunits in a severe autosomal recessive neurodegenerative disease, described in young children as CACH (childhood ataxia with central nervous system hypomyelination)/VWM (leukoencephalopathy with vanishing white matter) syndrome. The syndrome is characterized by episodes of rapid deterioration during febrile illnesses or following head trauma and symmetrical demyelination of the brain white matter with cavitation aspects, leading to a progressive vanishing of the white matter replaced by CSF (cerebrospinal fluid). However, a wide clinical spectrum has been observed in the 148 patients presently reported, from congenital forms with rapid death to adult-onset forms with slow mental decline and progressive motor dysfunction, sometimes associated with congenital eye abnormalities or ovariodysgenesis. So far, 77 different mutations in each of the five EIF2B genes (EIF2B1-5), encoding subunits eIF2Balpha-epsilon, have been found, with two-thirds affecting the eIF2Bepsilon subunit. The correlation found between the level of GEF activity of eIF2B in the mutated white blood cells and the age at disease onset suggests a direct role of the abnormal translation control in the pathophysiology of the disease.

The effect of genotype on the natural history of eIF2B-related leukodystrophies

BACKGROUND

Recessive mutations in the five eucaryotic initiation factor 2B (eIF2B) subunits have been found in leukodystrophies of variable age at onset and severity.

OBJECTIVES

To evaluate the clinical spectrum of eIF2B-related disorders and search for a phenotype-genotype correlation.

METHODS

Ninety-three individuals (78 families) with an undetermined leukodystrophy were selected on MRI-based criteria of childhood ataxia with central hypomyelination/vanishing white matter (CACH/VWM) for EIF2B genes analysis.

RESULTS

Eighty-nine percent of individuals with MRI criteria of CACH/VWM have a mutation in one of the eIF2B beta to epsilon subunits. For 83 individuals (68 families), 46 distinct mutations (90% missense) in four of the five eIF2B subunits (beta, gamma, delta, epsilon) were identified. Sixty-four percent were in the epsilon subunit, a R113H substitution was found in 71% of eIF2B epsilon-mutated families. A large clinical spectrum was observed from rapidly fatal infantile to asymptomatic adult forms. Disease severity was correlated with age at onset (p < 0.0001) but not with the type of the mutated subunit nor with the position of the mutation within the protein. Mutations R113H in the epsilon subunit and E213G in the beta subunit were significantly associated with milder forms.

CONCLUSIONS

The degree of eIF2B dysfunction, which is involved in the regulation of protein synthesis during cellular stress, may play a role in the clinical expression of eIF2B-related disorders.

Nonhomologous Robertsonian translocations(NHRTs) and uniparental disomy(UPD) risk: an Italian multicentric prenatal survey

OBJECTIVES

The risk of uniparental disomy (UPD) occurrence associated with the prenatal finding of balanced nonhomologous Robertsonian translocations (NHRTs) has been estimated only on limited empirical data. The aim of the study was to verify the estimate of the general risk, to get narrower confidence intervals by cumulating the data and to obtain risk estimates for specific translocation types.

METHODS

We tested for UPD 160 prenatal specimens referred to the participant centers after the cytogenetic finding of NHRT.

RESULTS

One case of upd(14)mat was found, associated with a 45,XX,der(14;22)mat fetal karyotype. The general empirical risk of UPD occurrence in NHRT carrier fetuses, corrected for the actual number of chromosomes analyzed, was 0.76% (95% CI 0.02-4.25%). Cumulative data with previous studies gives a general risk of UPD associated with NHRT of 0.80% (95% CI 0.17-2.34%). The UPD risk for the specific NHRT der(13;14) did not significantly differ from that of the other NHRTs taken together.

CONCLUSION

The present survey confirms the previously estimated risk of occurrence of UPD in offspring of NHRT carriers as a low, but not negligible risk, worth being investigated in prenatal diagnosis.

[Aesthetic surgery and public health]

The increasing number of requests for aesthetic surgery legitimately leads to the question of whether it can be covered by Public Health. If we look at the definition of the World Health Organization, the answer is without any doubt an affirmative one. However, economic considerations show that there is no social system in the world that covers aesthetic surgery, except for some definite interventions. Requests for aesthetic surgery occur in all social classes. It is a personal choice and a voluntary decision. It is no longer society who assists a sick or ill patient but it is the person that assumes the responsibility for himself.

A severe variant of childhood ataxia with central hypomyelination/vanishing white matter leukoencephalopathy related to EIF21B5 mutation

Childhood ataxia with central hypomyelination (CACH)/vanishing white matter (VWM) leukoencephalopathy is related to mutations in all five genes of the eukaryotic translation initiation factor (eIF2B). In a fatal infantile leukoencephalopathy, which the authors previously classified as a severe variant of CACH/VWM, a new homozygous missense mutation in the EIF2B5 gene was found. Abnormal decrease in blood uric acid and increase of erythrocyte guanosine 5'-diphosphate sugars found in two siblings may contribute to the explanation of this particularly severe condition.

Identification of Fas (APO-1/CD95) and p53 gene mutations in non-small cell lung cancer

Fas (APO-1/CD95) is a broadly expressed death receptor involved in a series of physiological and pathological apoptotic processes. One of the possible mechanisms for resistance to apoptosis signaling in the immune system as well as in the pathogenesis of non-lymphoid malignancies is the presence of Fas mutations within the entire gene. We investigated, in 79 non-small cell lung cancer (NSCLC) samples, the promoter and the entire coding region of the Fas gene by polymerase chain reaction, single strand conformation polymorphism and DNA sequencing in order to detect putative alterations. Sixteen of 79 tumor samples (20.2%) were found to have Fas alterations, either in promoter or exon region. Since the loss of Fas apoptotic function might be linked to p53 alterations, which are often involved in the development of NSCLC, we analyzed p53 status in 40 of the 79 NSCLC samples. p53 mutations were found to be more frequently present than Fas gene alterations (25 out of 40 cases, 62.5%). These data increase the knowledge regarding mutations of apoptosis-genes involved in the pathogenesis of NSCLC, and give benefits for the clinical management of this type of tumor.

Alterations of Fas (APO-1/CD 95) gene and its relationship with p53 in non small cell lung cancer

The Fas (APO-1/CD95) system regulates a number of physiological and pathological processes of cell death. The ligand for Fas induces apoptosis by interacting with a transmembrane cell surface Fas receptor. The key role of the Fas system has been studied mostly in the immune system, but Fas mutations, one of the possible mechanisms for resistance to apoptosis signaling, may be involved in the pathogenesis of non-lymphoid malignancies as well. To better understand the potential involvement of Fas system in non-small cell lung cancer (NSCLC) we evaluated Fas and Fas-ligand mRNA expression by polymerase chain reaction in 102 tumor samples and in 44 normal surrounding tissues. Although over 60% of the human NSCLC analysed expressed both genes, they seem to be unable to induce apoptosis in vivo by autocrine suicide. In this regard, we investigated in 79 cases, the promoter and the entire coding region of the Fas gene by polymerase chain reaction, single strand conformation polymorphism and DNA sequencing for detecting putative alterations. Sixteen tumors (20.25 %) were found to have Fas alterations, in promoter and/or exon region. In all cases samples carried heterozygous alterations and mostly showed simultaneous mutations of p53 gene. Moreover, the quantitative analysis of Fas mRNA expression showed high levels of Fas messenger associated with p53 wild-type status alone. Taken together, these findings point to an involvement of Fas/Fas-ligand system in the development of NSCLC, suggesting that the loss of its apoptotic function might be linked to p53 alterations which contribute to the self-maintenance of cancer cells.

Identification of two paralogous regions mapping to the short and long arms of human chromosome 2 comprising LIS1 pseudogenes

Reiner et al. (1995b) reported on the existence of a gene with a coding region virtually identical to LIS1, the gene responsible for Miller-Dieker lissencephaly. This gene, LIS2, was mapped to chromosome 2p11.2, and a related pseudogene, LIS2P, was mapped to 2q13-->q14. By sequencing genomic clones that were mapped by means of 2p and 2q-only hybrids, we now demonstrate the existence of two LIS1 processed pseudogenes mapping to 2p11.2 and 2q13 (PAFAH1P1 and PAFAH1P2, respectively). The two sequences appear to lie within larger paralogous regions and share a 98.6% degree of identity. Comparative mapping data by cytogenetic analysis on great apes indicate that the duplication of the genomic region comprising the LIS1 pseudogenes occurred in humans. We also demonstrate that the cDNA sequence shown as part of the LIS2 gene and marking its chromosome 2 specificity belongs to the 3' untranslated region of a different gene (C1orf6) that we mapped to 1q21 by FISH analysis.

Intracellular levels of the LIS1 protein correlate with clinical and neuroradiological findings in patients with classical lissencephaly

We report on the genotype-phenotype correlation in 7 patients with classical lissencephaly carrying a heterozygous subtle mutation in the LIS1 gene. Six patients, showed a mutation predicted to encode for a truncated protein, and one mutation altered a splicing site, resulting in skipping of exon 4. Western blot analysis performed on the lymphoblastoid cell line of 2 patients bearing truncating mutations indicated that the mutated allele did not produce a detectable amount of the LIS1 protein; whereas the analysis performed on the fibroblasts from the patient with a splice-site mutation was suggestive of partial protein synthesis from the mutated allele. Although clinical and magnetic resonance imaging findings of patients with truncating mutations did not differ from those observed in patients with a heterozygous deletion, the patient bearing the exon-skipping mutation had less severe clinical and brain involvement. Our data suggest that truncating mutations in the LIS1 gene are relatively common among patients with classical lissencephaly not bearing a heterozygous deletion at 17p13.3, and strengthen the relevance of correct intracellular dosage of the LIS1 protein in the neuronal migration process.

[Internal hemorrhage in abdominal dermolipectomy. 2 reported cases, one of which needing emergency surgical repair of aortic fissure]

The authors report two very exceptional and similar cases. In the first case, during abdominal lipectomy, the surgical team was confronted suddenly with an internal hemorrhage requiring prompt resuscitation by the anesthetist. Laparatomy revealed an aortic fissure, one centimeter above the iliac bifurcation. Bleeding was controlled by clamping the aorta, followed by suturing of the fissure. Surgery was then completed uneventfully. The second patient developed a retroperitoneal hematoma confirmed by postoperative CT scan during lipectomy and liposuction. No further treatment was required after control of the hemorrhage. No such cases have been reported in the literature and the etiology of these cases remains unclear.

[Reduction mammaplasty according to McKissock's technique. A review of 312 cases]

312 cases of reduction mammaplasty performed over a period of 12 years according to McKissock's technique are reviewed. This technique is characterised by a pre-established drawing, a vertical nipple-bearing bipedicle flap, and perfectly defined cutaneo-glandular resection according to three blocks. it is indicated in almost 70% of women between the ages of 20 and 50 years with an equal distribution by 10-year age-groups. The remaining 30% are equally divided between women under the age of 20 years and women over the age of 60 years. Reduction mammaplasty is performed after menopause in 30% of cases. Maintenance of the results at two years and projection of the ANC are perfectly satisfactory. On the basis of these cases, secondary ptosis does not appear to be more severe with this technique and secondary glandular resorption is also unlikely. No necrosis of the ANC was observed in this series. In conclusion, this technique achieves aesthetic symmetrical breasts with long scars under very good conditions of safety. Shortening of the scars could only be achieved to the detriment of the shape of the breasts.

[Orbicularis oculi muscle and crow's feet. Pathogenesis and surgical approach]

Crow's feet is one of the characteristic signs of the aging face. Minor techniques designed to obliterate these lesions rapidly demonstrate their limits. The orbital fibers of the orbicularis oculi muscle play a fundamental role in the pathogenesis of wrinkles. Their contracture will create wrinkles in a similar way to the spokes of a wheel perpendicularly to the orientation of the muscle fibers. The dynamic action of the zygomatic muscles contributes to exaggerate these wrinkles. Statically, ptosis of the lateral brow and the aging skin also contributes to these lesions. Surgical treatment can be accomplished by a temporal lift or via a blepharoplasty approach. The vertical fibers of the orbicularis oculi muscle must be corrected by muscle incision or resection, muscle incision and suspension, muscle redraping and fixation, covering of the orbicularis oculi muscle with the malar SMAS. In patients with ptosis of the tail of the eyebrow one must either do a forehead lift or a mask-lift that will redrape the skin. The surface of the skin may require peeling by dermabrasion. Of course, these surgical techniques require a detailed knowledge of the anatomy of this region and especially the distribution of the branches of the facial nerve. The author analyses and compares the results of the different techniques.