Application of cine nuclear magnetic resonance imaging for sequential evaluation of response to angiotensin-converting enzyme inhibitor therapy in dilated cardiomyopathy.

Cine nuclear magnetic resonance (NMR) imaging was used to serially measure cardiovascular function in 17 patients with New York Heart Association class II or III heart failure and left ventricular ejection fraction less than or equal to 45% who were treated for 3 months with benazepril hydrochloride, a new angiotensin-converting enzyme inhibitor, while continuing treatment with diuretic agents and digoxin. Interobserver reproducibilities for ejection fraction (r = 0.94, SEE 3.3%), end-systolic volume (r = 0.98, SEE 10.6 ml), end-diastolic volume (r = 0.99, SEE 8.29 ml), end-systolic mass (r = 0.96, SEE 15.4 g), end-systolic wall stress (r = 0.91, SEE 10 dynes.s.cm-5) and end-systolic stress/volume ratio (r = 0.85, SEE 0.13) demonstrated applicability of cine NMR imaging for the serial assessment of cardiovascular function in response to pharmacologic interventions in patients with heart failure. During 12 weeks of treatment with benazepril, ejection fraction increased progressively from 29.7 +/- 2.2% (mean +/- SEM) to 36 +/- 2.2% (p less than 0.05), end-diastolic volume decreased from 166 +/- 14 to 158 +/- 12 ml (p = NS), end-systolic volume decreased from 118 +/- 12 to 106 +/- 11 ml (p less than 0.05), left ventricular mass decreased from 235 +/- 13 to 220 +/- 12 g (p less than 0.05), end-systolic wall stress decreased 29% from 90 +/- 5 to 64 +/- 5 dynes.s.cm-5 (p less than 0.05), end-systolic pressure decreased from 92.6 +/- 3.7 to 78.8 +/- 5.3 (p less than 0.05) and end-systolic stress/volume ratio, a load-independent index of contractility, decreased from 0.83 +/- 0.05 to 0.67 +/- 0.06 (p less than 0.05), demonstrating that improved ejection fraction is due to afterload reduction.

Auxin and physical constraint exerted by the perianth promote androgynophore bending in Passiflora mucronata L. (Passifloraceae).

The androgynophore column, a distinctive floral feature in passion flowers, is strongly crooked or bent in many Passiflora species pollinated by bats. This is a floral feature that facilitates the adaptation to bat pollination. Crooking or bending of plant organs are generally caused by environmental stimulus (e.g. mechanical barriers) and might involve the differential distribution of auxin. Our aim was to study the role of the perianth organs and the effect of auxin in bending of the androgynophore of the bat-pollinated species Passiflora mucronata. Morpho-anatomical characterisation of the androgynophore, including measurements of curvature angles and cell sizes both at the dorsal (convex) and ventral (concave) sides of the androgynophore, was performed on control flowers, flowers from which perianth organs were partially removed and flowers treated either with auxin (2,4-dichlorophenoxyacetic acid; 2,4-D) or with an inhibitor of auxin polar transport (naphthylphthalamic acid; NPA). Asymmetric growth of the androgynophore column, leading to bending, occurs at a late stage of flower development. Removing the physical constraint exerted by perianth organs or treatment with NPA significantly reduced androgynophore bending. Additionally, the androgynophores of plants treated with 2,4-D were more curved when compared to controls. There was a larger cellular expansion at the dorsal side of the androgynophores of plants treated with 2,4-D and in both sides of the androgynophores of plants treated with NPA. This study suggests that the physical constraint exerted by perianth and auxin redistribution promotes androgynophore bending in P. mucronata and might be related to the evolution of chiropterophily in the genus Passiflora.

Amiodarone neuropathy.

Amiodarone, a drug used to treat refractory cardiac arrhythmias, produced a peripheral neuropathy in 5 of 50 cases (10%). Although the neuropathy may be severe, it tends to improve with lowering of the dosage or discontinuation of the medication.

Increased left ventricular ejection fraction after a meal: potential source of error in performance of radionuclide angiography.

The effect of a standardized meal on left ventricular (LV) ejection fraction (EF) was determined by equilibrium radionuclide angiography in 16 patients with stable congestive heart failure but without pulmonary or valvular heart disease. LVEF was determined in the fasting state and 15, 30, and 45 minutes after a meal. Patients with moderately depressed fasting LVEF (30 to 50%), Group I, had a mean increase of 6.9 +/- 2.9% (p less than 0.005) in the LVEF at 45 minutes after the meal. Patients with severely depressed fasting LVEF (less than 30%), Group II, had no change after the meal. It is concluded that significant increases in LVEF may occur after meals in patients with moderate but not severe left ventricular dysfunction. Equilibrium radionuclide angiography studies that are not standardized for patients' mealtimes may introduce an important unmeasured variable that will affect the validity of data in serial studies of left ventricular function.

Amiodarone-digoxin interaction. Clinical and experimental observations.

Twenty-two patients were given amiodarone for refractory cardiac arrhythmias, and pre- and post-amiodarone serum digoxin levels were studied. The interval between pre- and post-amiodarone serum digoxin levels ranged from five days to nine months (mean interval, seven weeks). The mean (+/- SD) pre-amiodarone serum digoxin level was 1.0 +/- 0.4 ng/ml, and the post-amiodarone serum digoxin level was 1.9 +/- 0.8 ng/ml (p less than .001). To develop an animal model for study of the digoxin-amiodarone interaction, 18 pigs were given digoxin for a four-week period. Half of the animals were given amiodarone as well as digoxin for the last two weeks of the study. At the end of the initial two-week period, there was no difference in serum digoxin levels between the two groups. At the end of the second two-week period, the serum digoxin level in the group receiving digoxin alone was 0.6 +/- 0.2 ng/ml, and the serum digoxin level in the group receiving the digoxin and amiodarone was 1.2 +/- 0.6 ng/ml (p less than .01). These data confirm the presence of an amiodarone-digoxin interaction in man and show that the pig is an appropriate model for study of this clinical phenomenon in the animal laboratory.

Management of inadvertent injury to the carotid artery during head and neck surgery.

Rare, inadvertent injury to the carotid artery during head and neck surgery may result in disastrous neurologic sequelae or even death. Several cases are presented and used as the stimulus for an analytical discussion of the pathogenesis and management of cerebrovascular complications following head and neck surgery. The major pathogenetic mechanisms are identified as (1) microembolism from an ulcerated plaque; (2) intravascular thrombus with occlusion; (3) unintentional ligation, laceration, or transection; (4) ligation of a dominant external carotid; and (5) transient reduction in cerebrovascular perfusion pressure. Methods for identifying and evaluating the patient at risk for developing cerebrovascular complications are discussed and recommendations are made. The central question in the management of inadvertent arterial injury concerns whether to ligate the vessel or to restore blood flow. The controversies surrounding this issue are discussed in perspective through an analysis of current physiological concepts and of the collective clinical experiences of head and neck, vascular, and neurological surgeons handling extracranial cerebrovascular occlusive disease, penetrating injuries to the carotid artery, and tumor-related carotid catastrophes. Several factors are considered critical in determining appropriate management of any individual case; these include (1) whether recognition of the injury occurs intraoperatively or postoperatively; (2) the presence and severity of neurological deficits; (3) time from the injury to its recognition; (4) a quantitative assessment of collateral circulation; (5) a history of wound contamination or radiation therapy; (6) overall prognosis. These and other considerations are organized into a working framework through which the otolaryngologist and head and neck surgeon can better understand and manage the problem of inadvertent injury to the carotid artery.

Streptococcal endocarditis temporally related to transesophageal echocardiography.

A case of streptococcal sanguis endocarditis temporally related to a transesophageal echocardiogram is reported; and the literature on the incidence of bacteremia occurring during transesophageal echocardiography is reviewed. On the basis of this case and review of the literature, a reevaluation of the current guidelines for endocarditis prophylaxis during this procedure is recommended.

Early facial reanimation following radical parotid and temporal bone tumor resections.

A retrospective study of 35 patients who underwent early facial reanimation following extirpative parotid and temporal bone surgery requiring facial nerve sacrifice was performed. Regional facial reanimation performed immediately or within several days included 16 patients who underwent temporalis muscle transposition and 27 who underwent gold weight or eyespring lid reanimation with lower lid tightening. Simultaneous nerve grafts or nerve crossover procedures were performed in 22 patients. The authors' favored approaches to facial reanimation are discussed, with an emphasis on the value of early reanimation using properly selected techniques.

Objective comparison of physical dysfunction after neck dissection.

Thirty-five patients who underwent a total of 44 neck dissections of various types were prospectively studied to compare differences in postoperative shoulder function. Those who underwent a radical neck dissection suffered the greatest reduction in shoulder movement and had severely abnormal electromyograms. Those who underwent modified neck dissection with preservation of the spinal accessory nerve suffered less loss of shoulder function than the radical neck dissection group, but not to a significant degree at 16 weeks; however, the electromyograms of patients who underwent modified neck dissection were significantly better than those of the radical neck dissection group, which suggests that these patients may improve with time. Indeed, a reevaluation of several patients at 1 year showed improvement in both shoulder function and electromyograms in those who underwent modified neck dissection. Patients who underwent supraomohyoid neck dissection that involved minimal dissection of the spinal accessory nerve had minimal loss of shoulder function and usually, normal electromyograms at 16 weeks that documented less injury to the spinal accessory nerve. Again, these patients had improvement with time. A correlational analysis revealed that the physical parameters correlated well with the electromyographic findings, whereas each patient's perception of disability did not. These findings suggest that, in patients in whom it is oncologically sound, a neck dissection that spares the spinal accessory nerve offers significant benefit in terms of shoulder function.

Immediate facial rehabilitation in poor prognosis tumor patients.

Effective rehabilitation of facial paralysis in the poor prognosis tumor patient is best accomplished by the judicious and individualized use of that combination of static or static and dynamic procedures which will correct the major deformities present immediately and with minimal morbidity. This approach may be taken at the time of tumor ablation or later when the effects of paralysis become distressingly evident. In the rare patient whose disease is controlled, additonal dynamic rehabilitative efforts may be considered subsequently.

Hemilaryngectomy for verrucous carcinoma of the glottis.

Seven patients with verrucous carcinoma of the glottis treated by hemilaryngectomy are analyzed. The diagnostic criteria for this tumor are reviewed. Close cooperation between the clinician and pathologist is necessary for the correct diagnosis. The controversy regarding radiation therapy is discussed. Hemilaryngectomy is concluded to be a successful surgical modality for limited verrucous carcinoma of the larynx.

Palliative orbital decompression for metastatic melanoma to the orbit.

Although relatively rare, metastatic carcinomas to the orbit are the second most common orbital neoplasm in the adult. There are only ten cases reported in the literature of cutaneous melanoma metastatic to the orbit and, of these, only two had disease involving both orbits. This paper presents the third case of bilateral orbital melanoma; however, in this case, the primary site was the uveal tract in the first eye, with contralateral involvement being a metastasis of the orbital primary. The patient developed severe unilateral proptosis in his only seeing eye with progressive loss of vision. A palliative orbital decompression was performed which successfully restored visual acuity for an extended period of time. A brief discussion of the rationale for this procedure in this type of case is presented.

The location of the maxillary os and its importance to the endoscopic sinus surgeon.

As functional endoscopic sinus surgery continues to gain popularity and support, the necessity for a clear and accurate understanding of the anatomy of the ostiomeatal complex becomes essential. To clarify this anatomy, serial cadaver dissections were performed and the anatomy of the ostiomeatal complex was detailed in three dimensions, with an emphasis on precise localization of the internal os of the maxillary sinus as it relates to the orbit, natural antronasal canal, and ethmoid infundibulum. Measurements of the position of the internal os relative to the position of the anterior and posterior walls of the maxillary sinus and the position of the orbit were taken. The dimensions and configuration of the antronasal canal and its relationship to the infundibulum were also detailed. These measurements and relationships must be understood for an endoscopic sinus surgeon to locate the natural ostia without injuring the orbit.

Managing segmental facial nerve injuries by surgical repair.

This report describes our experiences and evolving philosophy with regard to managing segmental facial nerve injuries. We present the results of 13 facial nerve repairs of traumatic injury to a segment of the facial nerve. All peripheral facial nerve branches contribute essential elements to normal mimetic facial movement; therefore, we recommend early, appropriate repair of the nerve segment. This recommendation is based on principles established for managing disruptions of the main trunk of the facial nerve. It offers the patient the chance for complete recovery of facial function.

Laryngeal transposition flap for reconstruction of large oral cavity defects.

Resection of the entire tongue and floor of the mouth, with or without the anterior mandibular arch, may necessitate sacrifice of the larynx to prevent life-threatening aspiration and poses a significant reconstructive dilemma. Regional cutaneous or myocutaneous flaps can provide adequate healthy tissue for repair, but share the inherent disadvantage of resurfacing the oral cavity with skin (which may be hair bearing), rather than mucosa. Moreover, cutaneous flaps usually necessitate a planned orocutaneous fistula and secondary closure, and bulky myocutaneous flaps may interfere with oral competence. Larynx transposition has been used for some time at Memorial Sloan-Kettering Cancer Center to repair selected large oral cavity defects resulting from resection of the entire tongue and floor of the mouth. This report illustrates the laryngeal transposition flap which is developed from the skeletonized, laryngofissured larynx based on the superior laryngeal arteriovenous pedicle. The advantages and disadvantages of this technique, as compared with alternative methods of reconstruction, are discussed.

Malignant fibrous histiocytoma of the head and neck.

Eight cases, the largest series of malignant fibrous histiocytomas of the head and neck to date, are reported. In over one-half of the cases, the initial problems encountered in the case made the true diagnosis misleading. For correct diagnosis multiple biopsies may be required. The diagnosis is further confirmed by the clinical behavior of the tumor and its site, size, and depth of involvement. Four specific histopathologic variants are described. Wide surgical excision is the preferrred treatment. The potential role of adjunctive irradiation should be considered.

Vocal cord paralysis and recovery with thyroid lymphoma.

Vocal cord paralysis has been reported in 33 patients with thyroid lymphoma for an estimated overall incidence of 17%. There is little expectation of vocal cord function recovery, both because neoplastic invasion is believed irreversible and since surgery often necessitates sacrifice of the recurrent laryngeal nerve. Unlike in most well differentiated thyroid malignancies, external radiation therapy plays a vital role in the treatment of thyroid lymphoma. The patient presented here had complete recovery of vocal cord function following radiation therapy for a large thyroid lymphoma associated with vocal cord paralysis. This is the first reported case of such recovery following treatment for a thyroid neoplasm. The rather rapid and complete recovery of neural function suggests that, at least in some, paralysis is caused by reversible compression rather than by neural invasion or tumor-induced neurolysis.

Nutritional concepts in the management of the head and neck cancer patient. I. Basic concepts.

Proper nutritional management has assumed an increasingly important role in the care of cancer patients in recent years. Head and neck cancer creates disturbances in host nutritional balances. Profound nutritional depletion and cachexia are induced by local and distant effects of head and neck carcinoma. Radiation, chemotherapy and surgery tend to compromise the host further by compounding these nutritional deficits. This paper reviews the factors responsible for the malnutrition associated with head and neck malignancy, and discusses the current methods available for identifying and following the nutritionally depleted patient.

Nutritional concepts in the management of the head and neck cancer patient. II. Management concepts.

Essential to the management of the head and neck cancer patient is carefully monitored nutritional support. Traditionally, enteral alimentation, using the nasogastric feeding tube, has been the mainstay of treatment. Tube feedings should provide ample amounts of essential nutrients, minerals, vitamins, and adequate calories and protein. Knowledge of the tube feedings available and problems associated with their administration helps to avoid the pitfalls which limit their effectiveness. The inadequacies of enteral alimentation preclude its use in selected circumstances of severe nutritional depletion. Parenteral hyperalimentation, as a primary or adjuvant mode of therapy, may be capable of rapidly reversing deficits, improving postoperative morbidity and increasing tolerance to radiation and chemotherapy. Postoperative deglutition abnormalities may prolong the nutritional problems of head and neck cancer patients as well.

Panel discussion: glomus jugulare tumors of the temporal bone. Patterns of invasion in the temporal bone.

The purpose of this paper is to enumerate and define the exact patterns of glomus jugulare tumor invasion in the temporal bone. Special attention will be focused on those pathways which lead to central nervous system (CNS) invasion.