Comparison of intrinsic versus paced ventricular function

There is increasing evidence supporting the benefits of providing optimum AV delay in cardiac pacing, though controversy exists regarding its value and the benefits of intrinsic versus paced ventricular activation. This study compared various AV delays at rest in patients whose native AV delays were > or = 200 msec. Only patients with DDD pacemakers who had intact AV conduction and normal ventricular activation were included in the study. Nine patients were studied.

METHODS

Ten studies were performed. Evaluation was done in AAI and DDD modes at paced heart rates of 60/min or as close as possible to the intrinsic heart rate if this was > 60/min. Stroke volume (SV) and cardiac output (CO) were measured.

RESULTS

When AV sequential pacing in the DDD mode with an optimum AV delay was compared to AAI pacing with a prolonged AV interval, the average optimum AV delay in the DDD mode was 157 msec and ranged from 125 to 175 msec. The average AV interval in the AAI mode was 245 msec and ranged from 212 to 300 msec. In the DDD mode, there was an overall significant improvement in CO of 11% and SV of 9%. Patients with intrinsic AV conduction times of > 220 msec showed an overall significant improvement in CO of 13% and SV of 11%. In patients with intrinsic AV conduction times of < 220 msec, an improvement in CO of 6% and SV of 4% was seen.

CONCLUSIONS

(1) An optimum AV delay is an important component of hemodynamic performance; and (2) AV sequential pacing at rest with an optimum AV delay may provide better hemodynamic performance than atrial pacing with intrinsic ventricular conduction when native AV conduction is prolonged > 220 msec.

Neurological deterioration after lumbar cerebrospinal fluid drainage

Large-bore lumbar spinal fluid drainage is used frequently as part of the preoperative and intraoperative management of patients undergoing cranial base tumor resection. Such drainage allows displacement of the brain with minimal force, thereby potentially decreasing retraction damage to it. We document 2 patients in whom serious complications resulted from lumbar drainage systems. These patients deteriorated into a coma state following cerebrospinal fluid (CSF) drainage. Reinfusion of synthetic CSF solutions caused a brisk return to normal neurological status. These plus other potential complications associated with lumbar drainage, such as persistent CSF leaks into the back and soft-tissue nerve root injury, warranted abandoning the lumbar cistern drainage route of CSF drainage in favor of drainage directly from the intracranial compartment. Depending on the particular operation performed, drainage of CSF near the cribriform plate, the suprachiasmatic cistern, or from the sylvian fissure may be effective sites for CSF drainage. Unlike lumbar drainage, intracranial CSF drainage does not have the added risk of promoting cerebral herniation.

Small-cell carcinoma of the head and neck. A novel treatment regimen

Four patients with small-cell carcinoma (SCC) of the head and neck were treated in a pilot Phase I-II study to evaluate the response rate and toxicity of weekly non-cross-resistant combination chemotherapy administered as primary therapy in small-cell carcinomas. All four patients had locoregional disease without evidence of distant metastasis. The treatment regimen consisted of dose-intensive chemotherapy administered for 16 weeks. One or two of six cytotoxic agents (cisplatin, vincristine, methotrexate, Adriamycin, cyclophosphamide, and etoposide) were used weekly in different combinations followed by radiotherapy and/or surgical resection. To date, three of the four patients have completed therapy and achieved a complete response. The fourth patient is currently receiving chemotherapy and has achieved a partial response. Our treatment regimen appears effective in producing high initial response rates in SCC of the head and neck.

Effective head and neck tumor markers. The continuing quest

To evaluate the clinical value of two serologic tumor markers, squamous cell carcinoma-associated antigen and plasma lipid-bound sialic acid, for identifying cancers of the head and neck, plasma specimens were obtained from patients receiving care for untreated newly diagnosed cancers of the head and neck, routine surveillance for recurrence, or treatment for chronic nonmalignant otolaryngologic conditions. Using identical methods at two institutions, levels of both markers were determined blind to diagnoses for patients with biopsy-proven cancers of the head and neck (n = 134) and for those defined as cancer free based on clinical evaluation for 6 months (n = 140). Disease status was determined blind to tumor marker level results. Cancer prevalence was 48.9%. Applying standard normal limits used alone, plasma lipid-bound sialic acid test sensitivity was 63.4% and specificity was 77.9%. For squamous cell carcinoma-associated antigen alone, test sensitivity was 27.6% and specificity was 85.0%. Neither test alone appears sensitive enough to effectively detect early cancers of the head and neck. When the results of both tests in series combination were positive, sensitivity was 18.7% and specificity was 95.0%. If either was positive in parallel combination, sensitivity was 72.4% and specificity was 68.0%. Further evaluation is required that applies different definitions of normal and determines longitudinal changes with disease status.

The influence of extent of neck treatment upon control of cervical lymphadenopathy in cancers of the oral tongue

This is a retrospective analysis of the management of the neck in 84 patients with squamous cell carcinoma of the oral tongue treated with curative intent between 1968 and 1985. Patients with a clinically negative neck were treated to the neck only if the patient was thought to have a reasonable probability of occult neck metastases. This policy resulted in a 3-year adjusted neck control rate for N0 patients treated with limited (no, bilateral-partial, or ipsilateral) neck therapy of 38% compared with 95% for patients treated with bilateral, whole neck irradiation (p less than .001). None of the relapses in the patients with limited irradiation were in the treatment portal. Attempted salvage with a neck dissection resulted in cure in only 30%. The 3-year adjusted neck control rate for the N1 and N2 patients treated with total neck irradiation and surgery was 75% and 63%, respectively. The location of recurrence in these patients was in the field of irradiation, but contralateral to the side of the neck dissection.

Dynamic CT of the neck

The authors describe a technique for dynamic incremental computed tomography (CT) of the neck with use of slow-power intravenous injection of contrast material. CT scans of the necks of 55 subjects were evaluated with this technique and were found to exhibit adequate opacification of the neck vessels. This method of contrast enhancement enables vessels to be confidently distinguished from enlarged lymph nodes or masses. It also provides information about the boundaries of masses, their vascularity, and their relationship to surrounding structures. In addition, the authors have optimized this technique by reducing contrast material volume while maintaining diagnostic quality.

Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology

The emergence of the multitude of modified techniques for neck dissection procedure has resulted in a nomenclature system that is nonuniform. To eliminate potential misinterpretation, overlap, and lack of standardization, the Academy's Committee for Head and Neck Surgery and Oncology, with input from the Education Committee of the American Society of Head and Neck Surgery, has developed a classification system for these procedures. This has now been adopted by the American Academy of Otolaryngology-Head and Neck Surgery. The classification is based on the following concepts: (1) radical neck dissection is the fundamental procedure with which all other neck dissections are compared, (2) modified radical neck dissection denotes preservation of one or more nonlymphatic structure(s), (3) selective neck dissection denotes preservation of one or more group(s) of lymph nodes, and (4) extended radical neck dissection denotes removal of one or more additional lymphatic and/or nonlymphatic structure(s). Adherence to the principles of this classification system to describe neck dissection techniques should provide an improved method of communication. Furthermore, the system provides a rational framework on which subsequent terminology can be added.

CA-125: a potential prognostic indicator in patients with cervical cancer?

We evaluated 104 patients with newly diagnosed carcinoma of the cervix. Pre- and post-therapy and follow-up CA-125 levels were measured in 64 patients. Fifty-five patients (86%) had squamous cell carcinoma and 9 (14%) had adenocarcinoma of the cervix. At initial presentation 19 (30%) had CA-125 levels greater than 35 U/ml, 12 (19%) had levels of 16-35 U/ml, and 33 (51%) had levels less than 16 U/ml. Of the 11 patients who had pre- and post-treatment levels greater than 35 U/ml, 10 are dead of the disease and 1 is alive with persistent or recurrent disease. Of the 20 patients with elevated CA-125 levels at presentation who reverted to normal after therapy, 19 are clinically without evidence of disease at 14-46 months (median 27 months). Of the 33 patients with normal pre- and post-therapy CA-125 levels, 31 are clinically without evidence of disease. Two of these thirty-three patients had increasing CA-125 levels during routine follow-up and both have disease recurrence confirmed. There was no apparent correlation between CA-125 level and tumor type, tumor grade, or stage of disease. Our data suggest that patients with initially elevated CA-125 levels that revert to normal after therapy have a favorable prognosis. Persistent elevation of CA-125 levels during and after therapy in patients with carcinoma of the cervix was associated with a poor prognosis.

Comparative evaluation of rate modulated dual chamber and VVIR pacing

While dual chamber pacing is considered superior to VVI pacing at rest, there is a continuing debate as to the relative benefit of AV synchrony versus rate increase with exercise. To evaluate this question and to correlate different methods of evaluation, 14 patients with DDDR pacemakers were studied using serial treadmill exercise test with a CAEP protocol. Patients were exercised in DDD, DDDR, and VVIR modes. Echo-Doppler cardiac outputs were determined and pulmonary gas exchange was measured during exercise. There was a significant improvement in cardiac output with exercise in the DDDR versus VVIR modes, and in DDDR versus DDD modes in patients with chronotropic incompetence. There were small increases in exercise duration in DDDR versus VVIR modes, and small but consistent increases in VO2 at all levels of exercise, though not statistically significant. In this group of patients, DDDR pacing was superior to VVIR pacing, and superior to DDD pacing when chronotropic incompetence was present.

Craniofacial trauma: an assessment of risk related to timing of surgery

Following the retrospective analysis of approximately 4000 head-injury patients, 49 were identified with a combination of displaced facial fractures and significant cerebral trauma. The purpose of this study was to define clinical and radiographic features in these patients that are associated with a poor prognosis, which in turn might influence the timing of facial fracture repair. The presence of an upper-level facial fracture, low Glasgow coma score, intracranial hemorrhage, displacement of normally midline cerebral structures, and multisystem trauma was associated with a statistically significant poorer prognosis. Additionally, in demographically similar groups of patients (age, sex, concomitant injury) preselected for intracranial pressures of less than 15 mmHg at the time of surgery, no significant difference in survival was appreciated in patients who underwent early (0 to 3 days), middle (4 to 7 days), or late (greater than 7 days) surgical repair. Early surgical repair of facial fractures in these circumstances does not appear to have a negative impact on recovery.

Gadolinium-enhanced MRI of tumors of the head and neck

High-resolution computed tomographic (CT) scanning and, more recently, magnetic resonance imaging (MRI) have provided more accurate evaluation of the extent of head and neck neoplasms. With increasing experience, better methodology is being developed to improve imaging accuracy. We present a series of patients with clinically proven neoplasms of the oropharynx and larynx, evaluated by MR using T1-weighted, T2-weighted, and post-gadolinium (Gd)-DTPA T1-weighted imaged. The concept behind the use of Gd-DTPA was that it might permit the use of only pre- and postcontrast T1-weighted sequences, reducing examination time and increasing the sensitivity of the examination. It was also anticipated that Gd-DTPA could increase tumor conspicuity and edge definition. Imaging planes were chosen to best define the tumor extent and axial images were performed to evaluate adenopathy. The imaging results were compared with the clinical evaluation and with non-Gd-enhanced MRI. We present examples of the significantly improved soft tissue contrast with Gd-DTPA T1-weighted images and discuss the improved tumor margin definition with Gd-DTPA. Those cases in which it does not provide improved information will also be presented.

Beta-tubulin epitope expression in normal and malignant epithelial cells

The expression of a unique beta-tubulin isoform (class III) was monitored in squamous cell carcinoma (SCC) and normal epithelial cells using a monoclonal tubulin antibody called TuJ1. Whole tissue homogenates of SCC, normal tissue, SCC grown in nude mice, and SCC cultured cells were examined using sodium dodecyl sulfate polyacrylamide gel electrophoresis and Western blot. TuJ1 antibody localization was performed using peroxidase immunostaining on paraffin sections of SCC, normal tissue, nude mouse SCC, and immunofluorescent microscopy of SCC cultured cells. The malignant tissues examined stained positive with TuJ1 and a general beta-tubulin antibody, whereas the normal tissues stained positively only for the general beta-tubulin antibody. TuJ1 epitope expression may be a useful marker for SCCs and may assist in understanding differences between normal and malignant squamous cells.

Virulence of papillary endometrial carcinoma

While uterine papillary serous carcinoma (UPSC) has been well described as a virulent subtype of endometrial adenocarcinoma (AC), with behavior similar to that of papillary serous ovarian carcinoma, the papillary endometrial (PE) variant has not been well characterized. We studied 117 patients with endometrial carcinoma identified by our tumor registry, pathology files, and practice records from March 1981 to February 1989: 76 with AC, 26 with PE, and 15 with UPSC. Age and demographic data were similar for all three groups. All of the AC patients, 84% of PE patients, and 87% of UPSC patients had early-stage disease by clinical exam; however, 10% of AC patients, 23% of PE patients, and 87% of UPSC patients had extrauterine disease at surgery (P less than 0.05). Deep myometrial invasion occurred in 29% of AC patients, 36% of PE patients, and 60% of UPSC patients (P less than 0.05). Comparative analysis of the PE and UPSC groups revealed more marked nuclear anaplasia (P less than 0.05) and more frequent vascular space involvement (nonsignificant) in the UPSC group. At 3 years, 75% of the AC group was alive without disease. In contrast, the median progression-free interval for the PE group was 33 months, and for the UPSC group, 9 months (P less than 0.05). These data suggest a transition of increasing virulence corresponding with increasing papillary features, from AC to PE to UPSC. The papillary feature may be a new, significant risk factor in endometrial carcinoma.

The versatile frontal sinus approach to the floor of the anterior cranial fossa. Technical note

A technique to expose the anterior cranial base is described with entry through the anterior and posterior walls of the frontal sinus. Burr holes are avoided in the visible portion of the forehead. Expansion of the operative field may be accomplished, if necessary, by supplemental superior frontal or supraorbital rim osteotomy. The technique is rapid, safe, and provides excellent operative exposure and superior cosmetic results.

NMR spectroscopy evaluation of plasma "oncolipids" in head and neck cancer

The use of water-suppressed proton nuclear magnetic resonance spectroscopy of plasma as a serologic test for the detection of malignancy was first described in 1986. That report prompted the present study, which was undertaken to evaluate the efficacy of this test in differentiating patients who have head and neck malignancy from normal controls. Forty-six patients who had a biopsy-proven malignancy of the head and neck and 32 healthy individuals provided plasma for which the nuclear magnetic resonance spectrum was plotted, blind to patient diagnosis or group. The average line-width of methyl and methylene resonance was calculated. Significant differences (p less than 0.05) were found between the group with disease and the group with no disease for the methyl line-widths, using analysis of variance. In spite of this statistical difference, plotting of the values for the methyl, methylene, and average line-widths clearly demonstrated that these three oncolipid measures have no clinical use because of the tremendous overlap between the disease and nondisease groups. The findings of this study do not support the use of water-suppressed proton nuclear magnetic resonance spectroscopy as a clinically useful test for the diagnosis of head and neck malignancy.

The craniofacial resection--eleven-year experience at the University of Virginia: problems and solutions

From September 1976 to December 1987, 25 patients underwent 27 craniofacial resections at the University of Virginia Health Sciences Center. Two of these patients, who had recurrent disease involving the cavernous sinus, underwent repeat, extended resections. Seventeen of the tumors were esthesioneuroblastomas. Only one patient had received no treatment before surgery. The complications of this surgical technique are reviewed. The most significant complications were neurologic problems and infection. Additional issues, such as the handling of the eye, lacrimal sac, and medial canthal ligament, are also reviewed.

Ineffectiveness of recombinant interferon-beta serine nasal drops for prophylaxis of natural colds

Two randomized, double-blind, placebo-controlled trials during early autumn of 1986 and 1987 evaluated the efficacy and tolerance of recombinant interferon-beta serine (rIFN-beta ser) nasal drops for prevention of natural rhinovirus colds. In 1986, 9 X 10(6) units of rIFN-beta ser (139 subjects) or placebo (157) were administered once daily except Sundays for 4 w. Rhinovirus colds occurred in 2.8% of rIFN-beta ser recipients and 6.0% of placebo recipients during the treatment period (52% reduction, P = .3). In 1987, 24 X 10(6) units of rIFN-beta ser (186) or placebo (197) were given daily for 25 consecutive days. Rhinovirus colds developed in 6.3% of rIFN-beta ser recipients and 5.3% of placebo recipients. In each study, illness frequency and number of days with subjective colds did not differ between the groups. Recipients of nasal drops of rIFN-beta ser at either dosage did not differ in tolerance from placebo recipients. The lack of both prophylactic efficacy and nasal toxicity are in contrast to prior observations with nasal sprays of rIFN-alpha 2b.

Squamous cell carcinoma masquerading as focal myositis of the tongue

The diagnosis of squamous cell carcinoma of the head and neck is not usually a problem for the otolaryngologist/head and neck surgeon. However, we describe a patient whose ultimate diagnosis of squamous cell carcinoma required 16 months and eluded several clinicians, despite an aggressive diagnostic regimen. The diagnostic difficulty was due to the fact that the small, centrally located tumor was surrounded by an intense inflammatory reaction that histologically mimicked a recently described rare entity of the head and neck, focal myositis. Our purpose is to make the otolaryngologist/head and neck surgeon aware of this previously unreported presentation of squamous cell carcinoma of the tongue; to review the pertinent findings associated with focal myositis; and to reinforce the need to maintain a constant vigil for the diagnosis of cancer, in spite of negative pathologic confirmation, when dictated by the clinical situation.

Computed tomographic features of esthesioneuroblastoma

Esthesioneuroblastomas are uncommon neoplasms of the superior nasal cavity originating from olfactory epithelium. High resolution CT features of this neoplasm have not been well studied. Nine cases of esthesioneuroblastoma were reviewed to evaluate findings on high resolution CT. Homogeneous soft tissue masses with relatively uniform enhancement centered in the superior nasal cavity are characteristic. Bony erosion is frequent and usually accompanied by molding of bone. Staging, determined by extension and critical for treatment decisions, is well evaluated by CT.

High-dose chemotherapy and autologous marrow transplantation for esthesioneuroblastoma and sinonasal undifferentiated carcinoma

Eight patients with recurrent esthesioneuroblastoma or sinonasal undifferentiated carcinoma of the nasal or sinus cavities were treated with high-dose chemotherapy and autologous bone marrow transplantation. All patients had stage C disease initially and had received extensive prior conventional treatment with surgery, radiotherapy, and chemotherapy. Two patients achieved prolonged relapse-free survival for 18+ and 60 months. The latter patient relapsed at 60 months, but died of progressive disease after a second transplant. Two additional patients remain alive without disease progression at 17+ and 31+ months posttransplant. No deaths occurred secondary to toxicity. Progression of tumor accounted for failure in five patients. High-dose chemotherapy and autologous bone marrow transplantation should be considered as a salvage regimen for selected patients who fail conventional therapy for these diseases.

Design dependent loss of telemetry: uplink telemetry hold

Bidirectional telemetry in cardiac pacing is the ability of the programmer to communicate with the pacemaker and vice versa. It is an essential capability if one is to interrogate the pacemaker as to its programmed parameters and to access the diagnostic capabilities incorporated in the present generation pacemakers. Pacemaker to programmer telemetry capability was lost in two Medtronic SymbiosR pacemakers due to a design eccentricity termed "uplink telemetry hold". It is initiated by a complex sequence of spontaneous sensed and internal timing events, once activated it cannot be reversed in the clinical setting. It is potentially dangerous in that the subsequent application of a magnet over the pacemaker can result in total output inhibition. The initiating sequence of events included activation of the "cancel magnet" command. If that command is not activated, "uplink telemetry hold" cannot occur. Once telemetry uplink hold does occur, the pulse generator should be replaced.