Dynamic analysis of maxillary perfusion during Le Fort I osteotomy using indocyanine green.

The aim of this study was to evaluate the dynamic perfusion of the maxilla during various stages of a Le Fort I osteotomy using indocyanine green (ICG) dye angiography. This was a retrospective evaluation of patients who underwent a Le Fort I osteotomy. ICG was used to assess perfusion at specific time points during the procedure. Twenty-four patients underwent a Le Fort I osteotomy with dynamic perfusion ICG angiography. Statistically significant differences in perfusion were noted at all three locations assessed between preoperative (T0), post down-fracture (T1), and postoperative (T2) time points. When controlling for mean arterial pressure, statistically significant differences were noted at all three locations assessed between T0 and T1, and between T0 and T2. There were no statistically significant differences in patient age, heart rate, preservation or sacrifice of the descending palatine arteries, or conventional vs. segmental Le Fort I osteotomies across T0, T1, and T2. In conclusion, there was a statistically significant decrease in perfusion, as assessed by intraoperative dynamic angiography, to the anterior maxilla following maxillary down-fracture. Patient age, conventional vs. segmental Le Fort I osteotomy, changes in mean arterial pressure and/or heart rate, and preservation of the descending palatine vessels had no statistically significant effect on perfusion.

Quantitative analysis of facial soft tissue perfusion during hypotensive anesthesia using laser-assisted indocyanine green fluorescence angiography.

The aim of this study was to quantitatively evaluate the efficacy of induced hypotensive anesthesia in decreasing facial soft tissue perfusion during orthognathic surgery using laser-assisted indocyanine green fluorescence angiography. This retrospective study involved the evaluation of 16 patients who underwent orthognathic surgery. Data collection included facial tissue perfusion of the bilateral cheeks and chin at normotension and with pharmacologically induced hypotensive anesthesia. There were statistically significant differences in the facial tissue perfusion at normal and depressed levels of blood pressure (P<0.001). This study used an objective measure to demonstrate the long-standing belief that hypotensive anesthesia is efficacious in reducing tissue perfusion in the surgical field. The data suggest that pharmacologically depressing the level of mean arterial pressure by 18% may result in a 41-52% decrease in facial soft tissue perfusion. This study reports a novel method of quantitative analysis.

Augmentation of the infraorbital rim in orthognathic surgery.

Mid-face augmentation via a Le Fort I osteotomy is a commonly performed operation. Advancement of the upper jaw and associated structures (nose, lower cheek areas) can certainly improve function as well as facial aesthetics and harmony. Often, in patients with severe mid-face deficiency, hypoplasia of the maxilla extends all the way up to the infraorbital rims. The receding infraorbital rim contributes to the negative vector of the globes. In patients with this level of mid-face hypoplasia, while advancing the maxilla at the Le Fort I level satisfies all of the requirements for orthognathic surgery, the deficient infraorbital rim remains unchanged and can actually accentuate the negative vector of the globes. This article explains our approach in augmentation of the deficient infraorbital rim using alloplastic silicone implants at the time of a Le Fort I osteotomy.

Primary delayed onset craniosynostosis in a child demonstrated by serial computed tomography imaging.

Primary delayed onset craniosynostosis is a rarely reported phenomenon. The unique case of a 2-year-old boy who had computed tomography (CT) scans performed 20 months apart demonstrating the post-gestational development of sagittal suture craniosynostosis is presented. The otherwise healthy male initially presented to the emergency department at age 7 months with soft tissue swelling over his left parietal region secondary to a fall. A CT scan revealed a possible left parietal skull fracture without intracranial pathology and patent cranial sutures with a normocephalic calvarial configuration. Twenty months later, his paediatrician referred the boy to the craniofacial service for evaluation of progressive dolichocephaly. A new CT scan showed complete fusion of the sagittal suture with resultant biparietal narrowing, frontal bossing, and occipital prominence. The patient subsequently underwent uncomplicated frontoparietal craniotomy with calvarial vault reconstruction. Prior reports in the literature of cases of non-syndromic primary delayed onset craniosynostosis all lack 'pre-synostosis' CT imaging that proves post-birth patency of the cranial sutures. This case report documents CT demonstrating true primary delayed onset craniosynostosis.

Sympathomimetic amines effectively control pain for interstitial cystitis that had not responded to other therapies.

PURPOSE: To further investigate the efficacy of treatment of interstitial cystitis that had been refractory to standard treatment with sympathomimetic amines. METHODS: Dextroamphetamine sulfate sustained release capsules up to 30 mg per day were prescribed in women with refractory painful bladder syndrome/interstitial cystitis in six new cases. The patients were carefully evaluated for relief of symptoms. RESULTS: All six women found marked relief in their painful bladder syndrome in a rather short length of time. The benefit persisted as long as the therapy was maintained. Temporary cessation resulted in prompt return of symptoms, but resumption of sympathomimetic amines again allowed good relief of bladder pain and related symptoms. CONCLUSIONS: Because of very few side-effects and no drug dependence in the dosage used, sympathomimetic amines should be considered for first-line therapy.

Do viral infections mimic bacterial sepsis? The role of microvascular permeability: A review of mechanisms and methods.

A dysregulated immune response and functional immunosuppression have been considered the major mechanisms of the bacterial sepsis syndrome. More recently, the loss of endothelial barrier function and resultant microvascular leak have been found to be a key determinant of the pathogenesis of bacterial sepsis. Whether a similar paradigm applies to systemic viral syndromes is not known. Answering this question has far-reaching implications for the development of future anti-viral therapeutic strategies. In this review, we provide an overview of the structure and function of the endothelium and how its barrier integrity is compromised in bacterial sepsis. The various in vitro and in vivo methodologies available to investigate vascular leak are reviewed. Emphasis is placed on the advantages and limitations of cell culture techniques, which represent the most commonly used methods. Within this context, we appraise recent studies of three viruses - hantavirus, human herpes virus 8 and dengue virus - that suggest microvascular leak may play a role in the pathogenesis of these viral infections. We conclude with a discussion of how endothelial barrier breakdown may occur in other viral infections such as H5N1 avian influenza virus.

Prevention of episodic migraine with topiramate: a prospective 24-week, open-label, flexible-dose clinical trial with optional 24 weeks follow-up in a community setting.

OBJECTIVE: To explore efficacy and safety outcomes of topiramate for episodic migraine prevention in community practice. RESEARCH DESIGN AND METHODS: Open-label, multicenter, flexible-dose clinical trial consisting of a 4-week baseline phase, 24-week core phase and an optional 24-week follow-up phase in patients (18-80 years) with episodic migraine treated in community practices outside tertiary care centers. MAIN OUTCOME MEASURES: The primary efficacy endpoint was the change in the number of migraine days/28 days (baseline vs. the last 4 weeks of core treatment) Secondary efficacy parameters included aspects of quality of life (QoL) and subjective patient ratings. RESULTS: A total of 360 patients entered the core phase (ITT population); 37.6% (97 patients) discontinued prematurely, mainly due to adverse events (AEs; 23.6%). Mean topiramate dosage was 90 mg/day. Migraine days decreased from 8.30/28 days to 5.65/28 days and QoL (HIT-6 and MIDAS) was improved. Efficacy, tolerability and satisfaction were rated as 'good' or better by 56, 61 and 63% of patients, respectively. A total of 321 of 364 patients (88.2%) reported at least one treatment emergent AE, and the most common during the core phase were paraesthesia (46.4% of 364 patients), fatigue (17.0%), nausea (15.4%), dizziness (12.9%), viral infection (12.9%), weight decrease (12.6%) and impaired concentration (10.2%). Of 227 patients completing the core phase, 199 (88%) participated in the follow-up phase. A total of 187 patients received topiramate and 38 (20.3%) of these stopped treatment prematurely due to insufficient efficacy (6.4%), AEs (4.8%) or other reasons (10.2%). Reduction in migraine days and improvements in QoL (HIT-6) were maintained or improved (MIDAS) during follow-up, and 84% rated their satisfaction with topiramate therapy as 'good to very good'. CONCLUSIONS: This community practice study showed that long-term treatment with topiramate in the prevention of episodic migraine was effective and well-tolerated, and it was associated with clinically relevant improvements in several aspects of QoL.

Comparative 3D quantitative analyses of trapeziometacarpal joint surface curvatures among living catarrhines and fossil hominins.

Comparisons of joint surface curvature at the base of the thumb have long been made to discern differences among living and fossil primates in functional capabilities of the hand. However, the complex shape of this joint makes it difficult to quantify differences among taxa. The purpose of this study is to determine whether significant differences in curvature exist among selected catarrhine genera and to compare these genera with hominin fossils in trapeziometacarpal curvature. Two 3D approaches are used to quantify curvatures of the trapezial and metacarpal joint surfaces: (1) stereophotogrammetry with nonuniform rational B-spline (NURBS) calculation of joint curvature to compare modern humans with captive chimpanzees and (2) laser scanning with a quadric-based calculation of curvature to compare modern humans and wild-caught Pan, Gorilla, Pongo, and Papio. Both approaches show that Homo has significantly lower curvature of the joint surfaces than does Pan. The second approach shows that Gorilla has significantly more curvature than modern humans, while Pongo overlaps with humans and African apes. The surfaces in Papio are more cylindrical and flatter than in Homo. Australopithecus afarensis resembles African apes more than modern humans in curvatures, whereas the Homo habilis trapezial metacarpal surface is flatter than in all genera except Papio. Neandertals fall at one end of the modern human range of variation, with smaller dorsovolar curvature. Modern human topography appears to be derived relative to great apes and Australopithecus and contributes to the distinctive human morphology that facilitates forceful precision and power gripping, fundamental to human manipulative activities.

Phagosomal acidification: measurement, manipulation and functional consequences.

Phagocytosis holds a central position in the development of a successful innate immune response and in the initiation of the corresponding adaptive response. The destruction of invading pathogens and the presentation of their antigens to lymphoid cells require acidification of the phagosomal lumen. The present review discusses the mechanism of phagosome acidification, with particular reference to the two components of the protonmotive force: the chemical (pH) gradient and the electrical potential across the phagosomal membrane. A method for the in situ measurement of the electrical potential across the phagosomal membrane is described. In addition, we discuss the finding that acidification is not only a consequence, but also a critical determinant of phagosome maturation. Luminal acidification appears to function as a timing device controlling the transition between early and late phagosomes.

[Effectiveness of an outpatient disease management programme for chronic heart insufficiency patients]. / Nutzen eines ambulanten Disease-Management-Programms für Patienten mit chronischer Herzinsuffizienz.

The effectivity of a disease management programme (DMP) for outpatients suffering from chronic heart insufficiency (CHI) in primary care is presented. The programme is predominantly based on a weekly telephone monitoring by a case manager using a standardised questionnaire that scores CHI-relevant information of the patient. If the score exceeds a predefined limit the patient's general practitioner is alarmed. An observational study including a total of 115 patients indicates a significant decline of the hospital admission rate (p < 0.0001), as the primary outcome measure, whereas the total length of hospitalization remained constant. The findings are compared with other studies' results and the aims of a randomised controlled trial on the efficacy of DMP on patients with chronic heart failure are discussed.

Narrow-band microcavity waveguides in photonic crystals.

A novel device, formed by a widely spaced periodic array of defects in a photonic bandgap crystal, is studied with the goal of designing a waveguide with a prescribed narrow bandwidth. Tunneling of radiation between the defect sites allows wave propagation along the line of the defects. An analytical study based on the weakly coupled cavity model is performed, and the dispersion relation omega(beta) of the new waveguide is derived. The frequency shift and the band structure of the periodic defect waveguide are linked by an analytic relationship to the distance between the defect sites and therefore can be tuned by varying the latter. Sections of such waveguides can be employed as ultra-narrow-band filters in optical routing devices. Numerical simulations demonstrate the performances of this new device and support the analytical predictions.

Interaction of human papillomavirus type 11 E7 protein with TAP-1 results in the reduction of ATP-dependent peptide transport.

Human papillomaviruses (HPVs) cause benign and malignant epithelial tumors of the respiratory and genital mucosa. We previously reported that recurrent respiratory papillomas caused by HPV 6/11 express low levels of antibody-detectable TAP-1, the protein that transports peptides into the endoplasmic reticulum for assembly and presentation by MHC Class I, and that the extent of TAP-1 immunostaining is inversely related to the frequency of disease recurrence. We have now determined a mechanism for the reduction in TAP-1 detection. Anti-TAP-1 antibody immunoprecipitated very low amounts of protein from papilloma cells. However, immunoprecipitation of calreticulin, another member of the MHC I assembly complex, coprecipitated TAP-1 at levels comparable to those of uninfected cells. Immunoprecipitation of an HPV-positive cell line with either anti-TAP-1 or anti-calreticulin coprecipitated HPV E7 protein. Finally, purified HPV 11 E7 protein inhibited ATP-dependent peptide transport in vitro. We propose that the interaction of E7 with TAP-1 prevents TAP-1 antibody detection and efficient peptide transport, resulting in poor presentation of viral antigen on HPV-infected cells and thus failure to mount an effective immune-mediated prevention of disease recurrence.

Sonographic discrimination between benign and malignant breast lesions with use of disparity processing.

RATIONALE AND OBJECTIVES: The authors performed this study to evaluate whether a digital processing technique called disparity processing (DP) can improve the differentiation between benign and malignant breast masses at ultrasound (US) and, thus, reduce the number of benign lesions being sampled for biopsy. MATERIALS AND METHODS: During an US examination, a sonographer slightly varies the pressure of the probe on the breast surface. DP can be used to evaluate pairs of B scans that represent the different parts of this compression cycle. The apparent displacement of the tissue is measured with DP, and a new image, called a correlation map, is constructed. This new image illustrates the similarity between the speckle patterns around each point. The authors evaluated 25 solid lesions with DP. Results were compared with those from (a) histologic examination of specimens obtained with core or surgical biopsy or (b) cytologic examination of specimens obtained with fine-needle aspiration. RESULTS: All 25 lesions were correctly diagnosed with DP. There were no false-positive or false-negative findings. All malignancies demonstrated a relatively low-brightness halo around the lesion perimeter with evidence of discontinuity. All benign lesions were associated with relatively high-brightness, continuous halos. CONCLUSION: The results suggest that DP can help differentiate benign from malignant masses.

Minimally invasive aortic valve replacement: echocardiographic and clinical results.

BACKGROUND: Port access has been described for mitral and bypass surgery. The purpose of this study was to review the clinical and echocardiographic outcomes of aortic valve replacement by use of port access. METHODS: Between 1996 and 1999, 153 port-access aortic valve replacements were performed at our institution. The mean age was 63 years (range 16-91 years); 58% were male. The New York Heart Association mean class was III; 18% were in class IV. Thirteen percent had diabetes, 42% hypertension, 7% prior transient ischemic episode or stroke, 7% lung disease, 3% renal failure, and 13% previous surgery. Echocardiograms were obtained after valve replacement in 125 patients (96 intraoperative transesophageal and 97 transthoracic echoes). RESULTS: Median length of stay was 8 days. There were no intraoperative deaths; 10 patients (6.5%) died in the postoperative period. Stroke occurred in 4 (2.6%), sepsis in 5 (3.3%), renal failure in 5 (3.3%), pneumonia in 3 (2%), and wound infection in 1 (0.7%). Tissue prosthesis was present in 83 and a mechanical prosthesis in 42. No or trace regurgitation was seen on 94 of 96 (98%) postbypass intraoperative echocardiograms and mild on 2. On follow-up echocardiograms, moderate regurgitation was seen in 4 of 97 (4.1%), mild-to-moderate in 2 (2.1%), mild in 18 (18.6%), and no or trace in 71 (73.2%). Of those who had aortic regurgitation on intraoperative or follow-up echocardiograms, it was paravalvular in 8. CONCLUSIONS: Minimally invasive aortic valve replacement with a port-access approach is feasible, even in high-risk patients. Small incisions, a low infection rate, and a short length of stay are attainable. However, the complications associated with traditional aortic valve replacement still occur. Echocardiography is valuable both for intraoperative monitoring and follow-up of this new procedure.

Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results.

BACKGROUND: This study compares intermediate-term outcomes of mitral valve reconstruction after either the standard sternotomy approach or the new minimally invasive approach. Although minimally invasive mitral valve operations appear to offer certain advantages, such as reduced postoperative discomfort and decreased postoperative recovery time, the intermediate-term functional and echocardiographic efficacy has not yet been documented. METHODS: From May 1996 to February 1999, 100 consecutive patients underwent primary mitral reconstruction through a minimally invasive right anterior thoracotomy and peripheral cardiopulmonary bypass and Port-Access technology (Heartport, Inc, Redwood City, Calif). Outcomes were compared with those for our previous 100 patients undergoing primary mitral repair who were operated on with the standard sternotomy approach. RESULTS: Although patients were similar in age, the patients undergoing the minimally invasive approach had a lower preoperative New York Heart Association classification (2.1 +/- 0.5 vs 2.6 +/- 0.6, P <.001). There was one (1.0%) hospital mortality with the sternotomy approach and no such case with the minimally invasive approach. Follow-up revealed that residual mitral insufficiency was similar between the minimally invasive and sternotomy approaches (0.79 +/- 0.06 vs 0.77 +/- 0.06, P =.89, 0- to 3-point scale); likewise, the cumulative freedom from reoperation was not significantly different (94.4% vs 96.8%, P =.38). Follow-up New York Heart Association functional class was significantly better in the patients undergoing the minimally invasive approach (1.5 +/- 0.05 vs 1.2 +/- 0.05, P <.01). CONCLUSIONS: These findings demonstrate comparable 1-year follow-up results after minimally invasive mitral valve reconstruction. Both echocardiographic results and New York Heart Association functional improvements were compatible with results achieved with the standard sternotomy approach. The minimally invasive approach for mitral valve reconstruction provides equally durable results with marked advantages for the patient and should be more widely adopted.

Cranial nerve clock. Part 1. A declarative memory paradigm.

RATIONALE AND OBJECTIVES: The authors performed this study to compare a declarative memory paradigm developed to help teach medical students about the cranial nerves with a traditional text-based approach. MATERIALS AND METHODS: The authors designed a clock-based paradigm to help medical students learn about the cranial nerves. To enhance memorization and related brain activation, the paradigm uses visual, spatial, and word associations in the context of an analog clock face. Twenty-one undergraduate students were randomly divided into two groups. Group T viewed traditional text slides, and group C viewed text slides followed by the corresponding cranial clock slides. Subjects were tested before and after these sessions. RESULTS: Group C performed significantly better than group T in learning the names of the cranial nerves and their correct order (P < .011). Recall of name, number, and function was better for 11 of 12 cranial nerves, with statistical significance reached for nerves III (P = .005), V (P = .04), and X (P = .03). CONCLUSION: Alternative teaching strategies may help improve declarative memory.

Cranial nerve clock. Part II: functional MR imaging of brain activation during a declarative memory task.

RATIONALE AND OBJECTIVES: The authors performed this study to assess brain activation during encoding and successful recall with a declarative memory paradigm that has previously been demonstrated to be effective for teaching students about the cranial nerves. MATERIALS AND METHODS: Twenty-four students underwent functional magnetic resonance (MR) imaging during encoding and recall of the name, number, and function of the 12 cranial nerves. The students viewed mnemonic graphic and text slides related to individual nerves, as well as their respective control slides. For the recall paradigm, students were prompted with the numbers 1-12 (test condition) intermixed with the number 14 (control condition). Subjects were tested about their knowledge of cranial nerves outside the MR unit before and after functional MR imaging. RESULTS: Students learned about the cranial nerves while undergoing functional MR imaging (mean post- vs preparadigm score, 8.1 +/- 3.4 [of a possible 12] vs 0.75 +/- 0.94, bilateral prefrontal cortex, left greater than right; P < 2.0 x 10(-12)) and maintained this knowledge at I week. The encoding and recall paradigms elicited distributed networks of brain activation. Encoding revealed statistically significant activation in the bilateral prefrontal cortex, left greater than right [corrected]; bilateral occipital and parietal associative cortices, parahippocampus region, fusiform gyri, and cerebellum. Successful recall activated the left much more than the right prefrontal, parietal associative, and anterior cingulate cortices; bilateral precuneus and cerebellum; and right more than the left posterior cingulate. CONCLUSION: A predictable pattern of brain activation at functional MR imaging accompanies the encoding and successful recall of the cranial nerves with this declarative memory paradigm.