Small Bruises Research Articles

End-of-Life Skin Changes: Make Sure You Know What They Mean, a Case Study

Skin is the largest organ of the human body. Skin changes can result from natural ageing, as well as from acute or chronic diseases and failure of body systems. Various types of wounds are identified in Palliative Care, and terminal pressure ulcers are often incorrectly classified. This case study highlights the importance of recognizing skin ulcers in patients’ last hours and days of life as a diagnostic indicator for impending death. The first focus of nursing care was pain management and maintaining skin integrity. On the 20<sup>th</sup> of December 2023, a pressure ulcer was identified on a patient in the sacral region with unknown further characteristics. A skin modification was observed three days later in the neck area, with intense redness and no heat felt. Approximately ten minutes later, several minor purple-type discolorations, like small bruises, appeared on the chest area as a symmetrical mirror image. This change suggested a Trombley-Brennan Terminal Tissue Injury. The patient died 14 hours after the first skin change was observed on the neck. After examining this case study, it becomes clear that it is essential to expand knowledge and actively involve nurses in the accurate assessment and classification of skin changes, especially regarding Kennedy Terminal Ulcers or Trombley-Brennan Terminal Tissue Injuries, as they are indicators of death’s proximity.

Radial extracorporeal shock wave therapy for the management of spasticity in cerebral palsy: study protocol for a randomized controlled trial.

Spasticity is the most common motor disorder in cerebral palsy (CP), and its management is complex, posing a significant challenge for the rehabilitation team. Radial extracorporeal shock wave therapy (rESWT) has emerged in recent years as an effective, non-invasive, and low-risk alternative for the management of spasticity in CP patients, with only minor side effects such as small bruises or discomfort during application. There is great variability in rESWT administration protocols, ranging from a single session up to the 12 sessions. The most extensively studied protocol involves 3 rESWT sessions with a one-week interval between session. According to current literature, the effect of rESWT has not been investigated by extending the time interval between sessions beyond 1 week to determine if therapeutic effects on spasticity can be prolonged over time. Following a power calculation using the minimal clinical important difference of our primary outcome (R2 of Modified Tardieu Scale), 72 patients will be included in the study. Enrolment is based upon inclusion/exclusion criteria outlined in the Methods section. Participants will be randomized in 3 groups. Each patient will receive 2000 impulses in the Triceps Sural muscle (distributed by all the plantar flexor muscles: soleus and gastrocnemius), at a 2.2 Bars pressure and a frequency of 8 Hz. The Control Group will receive 3 rESWT sessions with a time interval of 1 week between each session. The Experimental Group A will receive 3 rESTW sessions with a time interval of 2 weeks between each session and the Experimental Group B will receive 3 rESTW sessions with a time interval of 4 weeks between each session. This study will provide further information regarding the effect of rESWT on spasticity in patients with CP. If an increase in the time interval between rESWT sessions allows for the prolongation of therapeutic benefits on spasticity, it will be clinically relevant fact. With the same treatment dosage, patients will be able to benefit from its effects for a longer period of time. ClinicalTrials.gov, identifier NCT05702606.

Safety Outcomes of Impact Microindentation: A Prospective Observational Study in the Netherlands.

Impact microindentation (IMI) is a technique to assess bone material properties of the cortical bone at the tibia in a transcutaneous, microinvasive, way. IMI is increasingly used in studies evaluating the contribution of tissue material properties to bone fragility in humans, and is approved for use in the clinic in Europe and the United States. Previous data show that IMI is well tolerated during and immediately after the procedure. The aim of this prospective observational study was to evaluate the longer-term safety and acceptability of an IMI measurement using the handheld OsteoProbe device®. Included were patients who were scheduled for a measurement at the Leiden University Medical Center from September 2019 to December 2020 and willing to participate. Patients were asked to review the procedure right after the measurement, and by telephone interviews 1 week and 1 month thereafter. The primary outcome was the 30-day complication rate after the measurement. Included were 106 patients (71 women) with a median age of 59 years (range, 20 to 86 years). Only three minor events were reported by 1-week follow-up, with an overall 30-day event rate of 2.8%. These were a very small hematoma in two patients, and a small bruise in one patient, all of which resolved without medical intervention. No other safety-related concerns were observed, and all 106 patients would undergo the measurement again if needed. The vast majority had no pain at baseline, 1-week and 1-month follow-up (80.2%, 88.4% and 94.3%, respectively). In this first and large longitudinal study we demonstrated that although minimally-invasive, IMI using the OsteoProbe® device at the tibia did not lead to any complications, and was well accepted by patients. Results strongly suggest that IMI can be safely used in studies as well as in the clinic in the hands of an experienced operator. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects.

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

Электронное развитие умных пластырей в Кыргызстане.

Idea of clever plasters is opened. It is shown that the flexible electric plaster providing stimulation of a human body in the right place with electric field was the first electronic plaster. The concept of a clever plaster which represents the smart wearable electronic innovative device directed to the most contactless measurement of various characteristics and parameters of an organism of the patient for the purpose of improvement of his initial health is given. Modern clever plasters not only are the physical barrier to small wounds and bruises having the antibacterial and warming-up properties but also are capable to carry out monitoring of a condition of an organism of the patient, often capable to define time of input of drugs and to provide their input.

Case Report: Idiopathic Subcutaneous Thrombotic Vasculopathy

Lower extremity ulcers have significant morbidity, with treatment determined by the underlying disorder. Reported is a 32-year-old female presenting with small skin nodules and bruises across her legs 4 weeks following her second COVID vaccination. These lesions progressed into large, necrotic ulcers over several months. Initial work-up showed widespread pannicular thrombotic vasculopathy with ischemic skin necrosis. The tissue was negative for calcification on Von Kossa histochemistry, and a working diagnosis of subcutaneous thrombotic vasculopathy was suggested. The ulcers progressed despite treatments with corticosteroids, therapeutic anticoagulation, intravenous immunoglobulin, plasmapheresis, sodium thiosulfate, wound care, and repeat debridement. Later debridement specimens demonstrated rare vascular and pannicular calcifications. This finding supports the hypothesis that subcutaneous thrombotic vasculopathy is a precursor to calciphylaxis, the patient’s current working diagnosis. However, based on the patient’s entire clinical picture, a definitive diagnosis has yet to be found. This report highlights the challenges of working with rare diseases and the importance of multidisciplinary cooperation.

Variable negative external pressure-an alternative to continuous positive airway pressure for the treatment of obstructive sleep apnea: a pilot study.

To assess variable negative external pressure (vNEP) therapy using a range of pressures and varying collar sizes and shapes to identify combinations that improve the efficacy and comfort of this emerging therapy for obstructive sleep apnea (OSA). This prospective, open-label pilot study included 28 eligible patients (71% men) having documented moderate OSA (apnea-hypopnea index [AHI] 15 events/h ≤ AHI ≤ 30 events/h) at 1 sleep clinic for an overnight, in-lab sleep trial. Each participant tested at least 2 of 6 available vNEP devices during sleep periods ≥ 2 hours. During the assessment of AHI by polysomnography, negative pressures of -20 cm H2O to -35 cm H2O were adjusted to improve each patient's response. Participants' therapeutic preferences were assessed by a questionnaire and interviews. Twenty (71%) of the participants responded to vNEP therapy: excellent response (AHI ≤ 5 events/h) was observed in 14 (50%); 6 (21%) achieved a partial response (AHI ≤ 50% baseline). For the 20 responders, the therapy reduced the fraction of total sleep time when peripheral oxygen saturation < 90% and improved minimum pulse oximetry oxygen saturation. Six patients experienced a minor, self-limited adverse event. Twenty-six participants (93%) stated that they would use vNEP nightly. In this pilot study, vNEP therapy markedly improved AHI and oxygenation in most patients with moderate OSA. The majority of participants found vNEP comfortable and preferable to prevailing OSA therapies. Further development and studies of vNEP are warranted. Registry: ClinicalTrials.gov; Name: Study of Variable Negative External Pressure (vNEP) in Reducing Respiratory Event in Individuals With OSA; URL: https://clinicaltrials.gov/ct2/show/NCT04718142; Identifier: NCT04718142. Kram JA, Pelayo R. Variable negative external pressure-An alternative to continuous positive airway pressure for the treatment of obstructive sleep apnea: A pilot study. J Clin Sleep Med. 2022;18(1):305-314.

Data of Real-Life Anticoagulant Treatment in Patients Diagnosed with Nonvalvular Atrial Fibrillation and Secondary Prevention of Venous Thromboembolic Disease with Edoxaban: Experience in Our Center

INTRODUCTIONAtrial fibrillation (AF) is one the most common disturbance of cardiac rhythm in adults and it is a major healthcare problem as it is associated with the risk of ischemic stroke. The prevalence of AF is estimated to affect at least 1% of the population in developed countries. In patients with AF, the risk of stroke is higher, according to the stroke risk stratification schemes CHADS2 and CHA2DS2-VASc. Oral anticoagulation therapy is a well-established treatment to prevent strokes in patients with AF who are at moderate to high risk of stroke, and the non-vitamin K antagonist oral anticoagulants have been recommended as alternatives to warfarin for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in various treatment guidelines.Edoxaban (Lixiana®, Daiichi-Sankyo) is an oral, reversible, direct factor Xa inhibitor with a linear and predictable pharmacokinetic. The edoxaban dose regimen consisted of 60 mg/24h, that was reduced to 30 mg/24h for estimated creatinine clearance of 15-50mL/min, body weight <60 kg or concomitant use of potent P-glycoprotein inhibitors. It was found not to be inferior to warfarin for prevention of stroke or systemic embolic events (SEE) in patients with AF and to reduce major bleeding, including a signicant reduction of intracranial haemorrhage and cardiovascular death.OBJECTIVEThe primary objective of the study is to evaluate the efficacy of Edoxaban in the prevention of stroke and Embolism Systemic. Besides, the secondary objective is to assess its safety, in function of the major bleeding defined according to the criteria of the International Society of Thrombosis and Hemostasis (ISTH).METHODSThis is a descriptive study. We have included a total of 102 patients with NVAF and venous thromboembolic disease (TED). The indication for anticoagulation was NVFA with 97 cases and 5 patients for secondary prevention of TED.The risk of stroke is assessed according to the scale CHA2DS2-VASc (average 3,83). Figure 1.We also evaluated the risk of bleeding according to the scale HAS-BLED (average 2.85). Figure 2.We have included 85 cases with doses of 60 mg/24h and 17 cases at a dose of 30 mg/24h. According to sex, it was about 56 women and 46 men, aged between 51 and 88 years old (average 72.2).All patients had received prior treatment with Anti-Vitamin K (AVK). The main reason of suspension of Anti-Vitamin K and its replacement with Edoxaban was because therapeutic time in range (TTR) was <65% (88 patients) and bleeding diathesis caused by anti-vitamin K (AVK) (14 patients). Of the patients included, 18 had presented previous stroke under treatment with AVK.We have evaluated complications in both bleeding and thrombosis during the treatment.The treatment time has been between 1 and 6 months (average of 4 months). Figure 3.RESULTSIt has not been reported any case of Stroke, Systemic Embolism, or Major Bleeding (criteria of ISTH) during the follow-up time of the patients treated.The only complications described were:- 1 case of small bruise on the thigh in a patient treated at a dose of 60 mg/24h. In the follow-up visit we performed a new evaluation of the Creatinine Clearance and we found that the figures were 44 ml/min, which was reduced at the dose of 30 mg/24h, as indicated in the Technical Data Sheet.- 1 patient attended the emergency department due to Delirium, which, after ruling out pathology-related (stroke, ischaemic or haemorrhagic, and TED by means of the relevant studies), or cause-effect relationship with the drug continued with the treatment with Edoxaban.- 1 patient presented self-limited Hemoptysis that did not require suspension of the treatment.During the study, a patient was diagnosed with lung cancer and the anticoagulant treatment was suspended. The patient died later by this oncology pathology.CONCLUSIONThe results obtained confirm the efficacy and safety of using Edoxaban in the prevention of stroke in the NVAF and in the few cases of TED.This is a small sample and with a short time of follow-up, due to the fact that the drug was approved in our country a few months ago.Our experience support the results of the trials. We believe that there is a good alternative to oral anticoagulation in patients with NVAF, being effective in the prevention of stroke and Systemic Embolism. It has a good safety profile with a clinical net benefit mainly at the expense of absence of bleeding.Subsequent studies will provide data confirmation. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Single Biaxillary Tunneling for Working Space Creation in Bilateral Axillo-Breast Approach (BABA) Thyroidectomy.

Endoscopic thyroidectomy using the bilateral axillo-breast approach (BABA) achieves excellent cosmetic results. However, concerns have been raised about the extensive dissection and violation of the breast during working space preparation. We developed a "single biaxillary tunneling" technique for working space creation in BABA thyroidectomy; this technique was applied in 30 cases. Skin bruise was hardly visible, and only minor and small bruises were observed. The whole process of working space creation typically finished within 20 to 30 minutes. Limited blunt dissection by a single stroke of biaxillary tunneling is a simple method, which significantly reduces ecchymosis formation and is time-efficient. This method can be used in routine practice and is feasible for beginner surgeons.

Prevalence of Occupational Health Consequences During Sugarcane Harvesting Among Harvesters of Morang District

Background: Sugarcane harvesting is widely practiced in Nepal. While harvesting most of the farmers are affected regularly with small bruises, cuts, wounds, lacerations and sometimes major cut injury or even an amputation of fingers. This study aims to find the prevalence of occupational health hazards among sugarcane harvesters during the sugarcane harvesting time.&#x0D; Methods: The descriptive cross-sectional study was conducted at Bhaudaha VDC which is now incorporated in Katahari rural municipality, Morang. Sample size was 96 during the two weeks of study from December 2014. Convenient sampling method was used. Ethical approval was cleared from the Institutional Review Committee.&#x0D; Results: Most of the sugarcane harvesters were male comprising 83.3 percent. Mean age among them was 31.71. Eighty six percent of harvester had nasal congestion, 67.7% had minor cuts whereas approximately 4.2% of them had major cuts. Shoulder joint, wrist joint, neck joint and low back pains were the mostly encountered musculoskeletal pain.&#x0D; Conclusions: Occupational hazards among sugarcane harvesters were mostly related to the musculoskeletal problems, respiratory problems, minor cuts, major cuts and eye related problems.

Digital metastasis in a patient with squamous cell anal cancer

This is a 69-year-old female with a history of squamous cell carcinoma of the anal canal who presented with a two week history of a mass at the base of the right fifth digit (pinky finger) with foul smelling discharge (Figure 1A). Five months prior, she noticed a small bruise in the area and related it to a recent trauma. She was initially diagnosed with localized anal cancer in 2012 and treated with concurrent chemoradiation. In 2015, she was found to have two lung metastases and had wedge resections for both diagnosis and treatment of metastatic disease. Unfortunately, she progressed in the lung and received several chemotherapy regimens and most recently immunotherapy with Nivolumab (anti-PD-L1). However, Nivolumab caused severe autoimmune hypothyroidism, significant facial and lower extremity swelling. To work up the pinky finger lesion, she had X-rays (Figure 1B and 1C) in February 2018 which showed a heterogeneously dense and lobulated mass with extension into the dorsal soft tissue and associated swelling with near complete destruction of the fifth distal phalanx. Differential diagnosis remained broad and included trauma, infection such as abscess, osteomyelitis, or paronychia, unreported autoimmune reaction to novel biologics such as Nivolumab, a subungal melanoma, or digital metastasis. Amputation of the fifth phalanx showed poorly differentiated carcinoma with basaloid squamous features morphologically consistent with her primary anal cancer. Both the anal biopsy and finger amputation specimens had strong diffuse immunohistochemical p16 expression, indicating human papillomavirus (HPV) positivity. The tumor cells also stained positive with P63 and CK5/6 and negative with CK7, CK20, synaptophysin, chromogranin and CD56, supporting metastatic squamous cell with basaloid features originating from the anus. She had an excellent cosmetic and functional result from the surgery (Figure 1D) and is alive now after seven months follow up.

An effective method to inspect and classify the bruising degree of apples based on the optical properties

Detection and classification of the bruising degree for fruit can provide useful information for appropriate postharvest handling and storage operations. However, the detection of early small bruises, which are hardly to detect directly by vision alone, remains a challenge. In this study, we investigated the optical properties of apple flesh with different bruising degree and combined principal component analysis and support vector machine to discriminate and classify the degree of bruising of apples. The apples were divided into three groups and dropped at heights of 0cm, 10cm and 20cm. The optical properties of each group were measured in 400–1050nm. The measurements of optical properties were performed using an integrating sphere setup and the results were assessed using the inverse adding-doubling method. Based on the measured optical properties, a discriminant model that combines PCA with SVM to classify and predict the bruise degree of apples was established. The accuracy of the model for bruise degree classification was as high as 92.5%. Overall, this study demonstrated it is feasible to detect the early small bruising degree of apples based on optical properties. It also laid a foundation for future studies about detecting early small bruising with non-destructive measurement of optical properties, which is a promising method for rapid and convenient classification of bruise degree of apples.

Untreated dentofacial deformity: in defence of Luis Suárez

uring the recent FIFA World Cup in Brazil, one of the most ontroversial episodes concerned the conduct of Uruguayan orward Luis Suarez. In the second half of Uruguay’s group xture with Italy on 24 June 2014, he was involved in a colliion with Italian defender Giorgio Chiellini, and both ended p on the turf. There was immediate world-wide condemnation of a erceived third biting offence by Suarez, and FIFA promptly cheduled a disciplinary hearing. In his defence Suarez enied the charges and stated: “I lost my balance... falling on op of my opponent... I hit my face against [Chiellini], leaving small bruise on my cheek and a strong pain in my teeth”.1 he disciplinary panel, however, was not persuaded by this rgument, and issued an unprecedented and severe sanction hat included a total ban from all footballing activities for 4 onths. The punitive nature of the ban was influenced by the layer’s apparent lack of insight and remorse. The authors wish to highlight Suarez’s evident dentofacial eformity, which could partly explain his version of events nd Chiellini’s tooth-related bruising to his left shoulder. uarez has an untreated severe skeletal class II division 1 alocclusion with associated vertical maxillary excess. The ass media reported that Suarez’s defence was dismissed out f hand as ridiculous, and this could be because his maloccluion is not recognised. However, it has been well documented hat people with a severe class II malocclusion have a coniderably higher incidence of dental trauma as a result of ripping or falling, and in this instance, the collision involved a ace-to-shoulder mechanism, which could potentially be conistent with the contact being inadvertent as Suarez claimed. recent Cochrane systematic review highlighted the fact

The necessity of repeated assessment of imaging studies contained in medical records in medico-legal opinions.

The paper presents two case reports of living victims, in which imaging studies of the chest conducted at a medical facility were an essential part of the medico-legal opinion. The first case was that of a young male hospitalized due to CT evidence of bilateral rib fractions, who claimed to have been assaulted by police officers. The other case was that of a six week old baby hospitalized due to chest X-ray evidence of right hand side rib fractions. The chest X-ray was performed due to one bruise found on the baby's forehead and two small bruises on the back, which gave rise to suspicions of child abuse. In both cases, expert witnesses in radiology definitively excluded the presence of any fractures. These cases indicate that a new assessment of imaging studies contained in medical records is needed. Expert opinions based solely on the description of imaging studies may result in grave consequences.

Cardiac Amyloidosis

Case presentation: A 55-year-old woman, who had previously been very physically active, noted a gradual decrease in exercise tolerance over a period of 3 to 4 months to the extent that she had to rest briefly after climbing a single flight of stairs. She had consulted a dermatologist 6 months earlier because of recurrent, small bruises of her eyelids, but no cause had been found. An ECG suggested an old myocardial infarction with an unusual axis (Figure 1), and a cardiology consultation described symmetrical left ventricular hypertrophy on the echocardiogram with normal left ventricular ejection fraction, normally functioning valves, and mild right ventricular hypertrophy. There was no family history of cardiovascular or neurological disease. Physical examination revealed mild elevation of the jugular venous pressure, normal heart sounds, no murmurs, and mild peripheral edema with clear lung fields and a mildly congested liver. Blood pressure was 110/65 mm Hg. There was 1+ proteinuria. Serum protein electrophoresis revealed no abnormal bands, but serum immunofixation revealed a monoclonal spike determined to be IgGλ. A bone marrow biopsy demonstrated 5% to 10% monotypical plasma cells staining for λ light chains. Serum-free light chains showed an elevation in free λ with an abnormal κ/λ ratio. Brain natriuretic peptide was 1019 pg/mL (normal <100), and troponin I was 0.07 ng/mL (normal <0.01). Endomyocardial biopsy (Figure 2) showed extracellular amorphous material that stained with Congo red and sulfated Alcian blue and that, on immunohistochemistry, reacted with antibodies to λ light chains but not to κ, AA, or transthyretin antibodies. A diagnosis of IgGλ light chain AL amyloidosis was made. Figure 1. ECG from the case described. There is borderline low limb-lead voltage with extreme right axis deviation. Atrial premature beats are present, and the chest leads, although typically showing preserved voltage, demonstrate very poor R-wave progression, …

A Method To Quantitatively Define and Assess the Risk of Cosmetic Glass Defects on Tubing Glass Vials

The pharmaceutical and biotechnology industries have long been challenged with setting appropriate cosmetic defect size acceptance criteria on glass vials. Limits are rarely data-driven and scarce information is available on defect survivability through shipping and handling downstream of final product visual inspection. This study was undertaken to quantitatively understand cosmetic defect dynamics on glass vials and their impact on patient safety. Scratch and bruise defects were artificially manufactured on product or placebo-filled, inspected, and glass defect-free tubing vials. The vials were processed and filled using commercial filling operations (i.e., vial washing, heat tunnel, conveyors, lyophilization, etc.). The defects were quantitatively characterized, subjected to automated packaging simulations, manually packaged in the approved commercial configurations, and subjected to ASTM Level I (highest intensity) shipping simulations in both pallet and small package configurations. The defects showed no statistically significant or applicable level of propagation, post-packaging and shipping simulation. Additionally, all test vials were subjected to dye leak testing, post-shipping simulation. All vials, except for one, met acceptance criteria for dye leak testing. Data-driven cosmetic defect dimensions for scratches and bruises were established based on this study. When delivering life saving medicines from the manufacturing plant to the patient, it is of great importance that the medicines arrive without damage that might harm the patient. In the case of medicines filled into glass vials, it is paramount that manufacturers understand whether minor cosmetic defects in the glass (such as small scratches and bruises) may weaken the vial enough to cause damage that might allow contamination of the contents. This study was performed to determine if scratches and bruises on the glass vials might propagate during operations that occur downstream of the manufacturer's final vial inspection. The study vials were filled with product or placebo on the commercial filling lines to fully simulate environmental factors in a typical run. Scratches and bruises were then artificially created on the vials. Each defect was measured microscopically and labeled. The study population was then manually packaged into the approved configurations and subjected to the highest level intensity shipping simulations (ASTM Level 1). Upon completion of the simulations, the vials were unpackaged and defects re-measured microscopically. The defects showed no statistically significant or applicable level of propagation. Additionally, all test vials were subjected to dye leak testing, post-shipping simulation. All vials, except for one, met acceptance criteria. Data-driven cosmetic defect dimensions for scratches and bruises were established based on this study.

Penetrated Arrow Shot Injury in Anterior Neck

Background: Although gunshot injuries are the most common penetrating anterior neck injuries in the developed world, this finding is not the case in the developing world, where knives, spears, arrows, and machetes are the preferred weapons, particularly in tribal societies. Aim: To present the case report of a patient with arrow shot injury to the anterior neck. Method: A 48 year old cattle rearer in a village in northern part of Nigeria presented with 3 hr history of an arrow shot in anterior part of the neck which he sustained the while trying to prevent some armed robbers from stealing his cow. There was scanty bleeding from the site with the arrow in-situ sealing the wound. Result: The entrance point of the arrow, about 1 cm in diameter, was just at the anterior border of the right sternocleidomastoid muscle; about 4 cm above the medial end of the right clavicle. There was a small skin bruise with slight swelling and tenderness around the opening but no active bleeding and no crepitus. Conclusion: Penetrating neck trauma from arrow shot may lead to potentially life-threatening injuries. A prompt diagnosis, a systematic treatment protocol, and an experienced trauma team are necessary to prevent a potential catastroph.

Restylane for facial dimpling following surgery

Sir, Hyaluronic acid fillers have had a well-documented use for restoring volume in facial aesthetic procedures [1–6]. There has also been an appreciable rate of dimpling documented following facial surgery when suspension sutures are placed close to the dermis. This can be seen with MACS face-lifting and in some cases of SMAS facelifting, and it will affect the appearance during a period of time [7–9]. In most cases, patients are happy to wait for the spontaneous resolution of the dimple as this phenomenon tends to be short-lived and resolves with time. However, there is a small group of patients who are severely emotionally distressed by the presence of dimpling [7]. We employ a previously undocumented technique which is indicated in this subgroup of patients and we found it to be a useful tool in the hands of the plastic surgeon. It is advantageous to use medium-density hyaluronic acid fillers (Restylane®) to temporarily fill the defect. Careful injection of this filler using the fanning and tunnelling technique is necessary to prevent any irregularities or a palpable mass. It is better. Inject without local anaesthetic as this can mask the defect, and we found that these injections can leave a small transient bruise. This filler has an expected longevity similar to that of the resolving dimple, so this will solve a practical problem as the filler will be slowly reabsorbed while the defect is subsiding. We advocate the use of medium-density hyaluronic acid fillers for this technique; otherwise, the highdensity hyaluronic acid is easily palpable and causes irregularities if placed too superficial. This has been a well-tolerated technique for those affected postoperative patients. Typically only 0.5 ml is needed, and repeat or incremental treatment is possible.

Self-assessment

A 7-year-old young boy presented to the hospital with 2-day history of painless bruise over his legs. There were no other significant symptoms or any past history of note and no family history of similar problems. System examination was unremarkable except for a moderate-sized bruise over both lower legs and a small bruise over the right knee. His weight and height were just over the 50th centile.

Methods of Measuring Bruise Volume of Pear (Pyrus Communis L.)

The grade of injures can be determined or measured by bruise volume using a sectioning and imaging analysis technique and different methods for calculating the size of pear bruises. The calculation methods were not consistent, with large calculation errors at small bruise sizes. The calculation of bruise volume was improved when the surface shape of the bruise was an ellipse instead of a circle. In this study, various methods are recommended for the calculation of the bruise volume depending on the range of the bruise sizes being investigated.