Faculty Bibliography

Angiotensin-converting enzyme (ACE) inhibitors have been extensively used for the treatment of patients with cardiovascular disease, but several concerns have been raised about their efficacy in African American (AA) patients with heart failure, hypertension, and left ventricular hypertrophy. In this study the authors assessed the effect of ACE inhibitors on total and cardiovascular mortality in high-risk AA patients with angiographically proven coronary artery disease (CAD). This was a retrospective analysis of 810 AA men who underwent diagnostic coronary angiography between 1995 and 2003. All patients had demonstrable CAD and had undergone a complete ischemic workup. Follow-up was from 3 to 10 years. ACE inhibitors were administered to 237 patients, while the remaining 537 patients were not taking ACE inhibitors. Patients taking ACE inhibitors had significantly more comorbidities (hypertension, diabetes, left ventricular hypertrophy, heart failure, severe CAD) at baseline, compared with patients not taking ACE inhibitors (P<.05 for all comorbidities). Despite the unfavorable baseline profile, patients taking ACE inhibitors had significantly lower mortality from CAD during follow-up than patients who were not taking ACE inhibitors (P=.006). Stroke mortality rates were similar in both groups. Cox regression analysis showed an 80% higher relative risk in patients not receiving ACE inhibitors. These data indicate a substantial benefit from ACE inhibitor therapy in high-risk AA patients with CAD.

BACKGROUND: Response assessment in advanced pancreatic cancer (APC) is difficult and predictive markers are needed. There are insufficient data on the value of carbohydrate antigen 19-9 (CA 19-9) and cytostatic-targeted therapies. Axitinib, a selective vascular endothelial growth factor (VEGF) receptors 1, 2, 3 inhibitor, may increase overall survival (OS) in APC. METHODS: We assessed serum CA 19-9, clinical outcomes and diastolic blood pressure (dBP) in APC patients receiving gemcitabine plus axitinib (Gem+A) or gemcitabine alone. RESULTS: In the total population (N=95), median OS was significantly longer in patients with baseline CA 19-9 values at or below the median than in those with values above it (12.2 months [95% confidence interval (CI), 8.6-16.6%] vs 5.0 months [95% CI, 3.9-5.7%]; P<0.0001). This also reached significance in the Gem+A arm (median OS, 12.5 months [95% CI, 8.6-16.6%] vs 4.9 months [95% CI, 3.6-5.6%]; P<0.0001). Patients with any dBP>90 mmHg had significantly longer OS than those who did not. However, there was no predictive significance of CA 19-9. CONCLUSION: Baseline CA 19-9 levels had prognostic value for OS, but caution is advised in interpreting CA 19-9 as a predictive biomarker for novel cytostatic agents such as VEGF-targeted therapies in phase II studies.

BACKGROUND: In lower root avulsion plexopathies, free muscle transfers for hand reanimation provide the only hope for the paralyzed hand, as the outcomes of hand functional restoration after primary brachial plexus reconstruction are uniformly poor. The purpose of this study was to analyze the outcomes of free gracilis muscle transfers for hand reanimation in severe brachial plexus injuries in relation to the respective motor donors. METHODS: Since 1981, 71 free gracilis muscles have been transplanted for hand reanimation. Thirty-eight were for finger flexion and 33 were for finger extension. Neurotizations included motor donors such as intercostal nerves (n = 29), contralateral C7 root (n = 28), spinal accessory nerve (n = 7), or upper roots of the ipsilateral plexus (n = 5). RESULTS: Preoperative and postoperative muscle grading and range of motion were found to be significantly different. The strongest motor donor for finger extension was the distal spinal accessory. The medial antebrachial cutaneous nerve as a conduit nerve carrying motor axons yielded worse results than other motor donors. Intercostals were useful for finger flexion and the contralateral C7 root was useful for finger extension. Scar formation in the volar wrist area was frequently a problem. CONCLUSIONS: After securing the stability and function of the proximal joints of the upper limb, attention should be shifted to the hand, and in compliant patients with supple finger joints, hand reanimation should be attempted. It is only through these efforts that the future of the paralytic limb can be upgraded to a useful assist extremity

BACKGROUND: The 'babysitter' procedure combines cross-facial nerve grafting with segmental transfer of the hypoglossal to the affected facial nerve. Introduced by Terzis in 1984, the technique can produce satisfactory to excellent results. In long-lasting paralysis, nonetheless, the babysitter procedure may need to be combined with a muscle(s) flap(s) for outcome upgrading, which was the focus of the present study. METHODS: Thirty-eight patients had the babysitter procedure over a 20-year period (1984 to 2003). Twenty patients had only the babysitter procedure, whereas 18 needed an additional muscle flap(s) (up to three) to enhance function and cosmesis. These muscles included nine free (gracilis, pectoralis minor) and 20 regional (frontalis, minitemporalis, platysma, digastric) muscles for distinct target needs: eye closure, smile restoration, and lower lip depression. The need for a muscle flap was determined at the initial consultation. All free muscles were transferred at the second-stage of the babysitter procedure, whereas regional muscles were also transposed later. Three independent observers graded the results at two time intervals, preoperatively and 2 years after all operations were completed. RESULTS: The average postoperative grading scores were significantly higher compared with preoperative scores for eye closure, smile, lower lip depression, and overall aesthetic outcome (p < 0.0001, Wilcoxon signed ranks test). All patients had upgrading of overall aesthetics and smile, whereas four maintained similar scoring for eye closure and one maintained similar scoring for lip depression. All but two had secondary procedures to further enhance facial symmetry. CONCLUSION: The babysitter procedure in conjunction with muscle transfers in selected patients with late presentation can provide highly satisfactory results when seeking uncompromising outcome

OBJECTIVE:Using the sequential inflation of 2 sphygmomanometers, Lewis et al. (Heart 16:1-32, 1931) concluded that compressive neuropathy was secondary to ischemia of the compressed nerve segment. Despite subsequent animal studies demonstrating that compressive lesions are more likely the result of mechanical nerve deformation, disagreement remains as to the etiology of rapidly reversible compressive neuropathy. Our hypothesis is that, during the classic sphygmomanometer experiments, the areas of nerve compression at the cuff margins overlapped, so that a region of transient nerve deformation persisted during the second cuff inflation. If true, the original results by Lewis et al. would be consistent with a mechanical pathogenesis. METHODS:In our study, 6 patients underwent sequential upper extremity dual-sphygmomanometer inflation with serial assessment by grip-dynamometer and 2-point discrimination. The order of cuff inflation, as well as the distance between cuffs, was varied. Mean grip force and 2-point discrimination values were statistically compared between conditions. RESULTS:Patients with overlapping cuffs maintained their neurological deficits, whereas those with separated cuffs experienced an improvement in both grip force (P = 0.02) and 2-point discrimination (P < 0.001) when cuff inflation was switched. CONCLUSION/CONCLUSIONS:Rapidly reversible compressive neuropathy seems to be secondary to mechanical nerve deformation at the margins of the compressive force rather than the result of ischemia of the compressed nerve segment. Overlap of the mechanically deformed nerve segments likely explains why neurological deficits persisted despite sequential cuff inflation in the classic experiments by Lewis et al.

OBJECTIVE: To determine whether a 3-day course of postoperative antibiotics is as effective as a 7-day course in reducing pain and reducing time to resumption of a normal diet and level of activity following pediatric tonsillectomy. DESIGN: A prospective, randomized, placebo-controlled trial. SETTING: Academic medical center. PATIENTS: Forty-nine patients were enrolled in the study. Preoperative demographic information was obtained. INTERVENTIONS: Tonsillectomy with or without adenoidectomy was performed by the senior author (J.J.) using electrocautery. Patients were randomized to receive either a 3- or 7-day course of amoxicillin. MAIN OUTCOME MEASURES: Parents were asked to record the following information: analgesic use for the first 7 postoperative days, postoperative days the child initiated his or her usual diet and level of activity, and medical treatment for oral hemorrhage or dehydration. RESULTS: Of the 49 patients, 26 were randomized to receive 7 days of postoperative antibiotics (group A) and 23 to receive 3 days of antibiotics, followed by 4 days of placebo (group B). Results were obtained for 47 of the enrolled patients (96%). No statistically significant difference was noted between the 2 groups with regard to postoperative pain or time to resumption of a normal diet and level of activity. CONCLUSION: A 3-day course of antibiotics following pediatric tonsillectomy is as effective as a 7-day course with regard to postoperative analgesic use and resumption of normal diet and level of activity. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00662987

When the editor asked me to write something related to the chin, I (B.M.Z.) told him I would like to concentrate on the soft tissue of the perioral and chin region, something previously not presented before in this Journal specifically or anywhere. Dr. Flores and I have chosen certain soft tissue cases of the lower face, each of which presents certain dilemmas. The reconstructive methods in each case are unique, previously not shown, and represent salvage from prior failures. Case 1 shows how an interior Abbe flap can be used for ipsilateral lip reconstruction. Case 2 shows how a large upper lateral lip elemental loss can be regained from cheek and not the lower lip. Cases 3 and 4 show how to regain proper white roll bulge and symmetry by overcorrection, then exact adjustment in a second stage. Case 5 shows how a failed chin/lip reconstruction can be salvaged to regain sulcus height and aesthetic unit reconstruction. Each case depicts unique reconstructive designs to produce an aesthetic final result

Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with bilateral cleft. The nasolaveolar molding (NAM) technique a new approach to presurgical infant orthopedics developed by Grayson reduces the severity of the initial cleft alveolar and nasal deformity. This enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This paper will discuss the appliance design, clinical management and biomechanical principles of nasolaveolar molding therapy. Long term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, 60 % reduction in the need for secondary alveolar bone grafting. No effect on growth of midface in sagittal and vertical plane has been recorded up to the age of 18 yrs. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair