Nonoperative management of traumatic facial nerve palsy

Forty-five patients with facial nerve palsy resulting from head injury were treated nonoperatively between 1975 and 1981. Of 31 patients who had polytomography, temporal bone fractures were demonstrated in 29. In 44 of 45 injuries, satisfactory clinical improvement in motor function was noted, including 65% (overall) who showed complete recovery. Fracture direction on polytomography, results of electromyography (performed in ten cases), and time of onset of paralysis were not correlated with outcome. The present findings suggest a limited role for early surgery in closed traumatic facial nerve palsy.     

Superficial temporal-middle cerebral artery anastomosis associated with glioblastoma multiforme.

The authors report a case in which glioblastoma multiforme was intimately associated with a surgical anastomosis of the superficial temporal artery to a branch of the middle cerebral artery.     

Prevention of recurrence and prolonged survival in primary central nervous system lymphoma (PCNSL) patients treated with adjuvant high-dose methylprednisolone

Five patients at risk for primary central nervous system lymphoma (PCNSL) recurrence were treated with high-dose methylprednisolone (HDMP) to prevent 'trafficking' of malignant lymphocytes into the central nervous system (CNS). HDMP was chosen because of its ability to stabilize the 'blood brain barrier (BBB)'. Three men with newly diagnosed PCNSL, ages 62, 76 and 78y, whose survival was projected to be 6.6 months, began treatment after achieving complete response (CR) to initial radiation therapy alone and survived 27, 37 and 59 months after treatment. In none was death from recurrent disease in CNS but one patient did die of systemic non-Hodgkin's lymphoma (NHL) five years after PCNSL diagnosis. A 20 y old man was treated with HDMP after successful combined modality therapy and is alive 75+ months after initial diagnosis without evidence of disease recurrence. A 34 y old man relapsed after combined modality initial treatment and failed to respond to HDMP when treatment was begun after unsuccessful salvage therapy; he died of disease 12 months after initial diagnosis. There were no treatment complications. The promising results in this pilot study from the basis for a North Central Cancer Treatment Group (NCCTG) 96-73-51, a Phase 2 clinical trial of brain radiotherapy and HDMP for PCNSL patients 70y of age and older, a group of patients at high risk for toxicity from intensive combined modality therapy.     

Left Ventricular Apical Thrombus and Myocardial Viability: A Dobutamine Stress Echocardiographic Study

The objective of this article was to determine whether the presence of left ventricular apical thrombus is a marker of nonviable myocardium. Reduced coronary blood flow secondary to atherosclerosis may result in chronic reversible left ventricular wall-motion abnormalities. Severe regional abnormalities also predispose to formation of left ventricular thrombus. The relationship between left ventricular apical thrombus and myocardial viability has not been previously described. Eighty patients with coronary artery disease and chronic left ventricular dysfunction were studied by dobutamine stress echocardiography. Left ventricular apical thrombus was identified using echocardiographic criteria. Wall-motion analysis was performed using a standard 16-segment model and ejection fraction was calculated. As a result, 48 patients (60%) had definite or highly suspicious findings for left ventricular thrombus (group 1), and 32 patients (40%) had no thrombus (group 2). Group 1 had significantly higher composite (  54.0 ± 5.8 vs 43.3 ± 6.4  ) and apical (  6.0 ± 2.7 vs 12.4 ± 3.4  ) wall-motion scores compared to those in group 2 (  P = 0.01  ). Thirty-two patients (67%) in group 1 demonstrated no contractile reserve in the apical segments, consistent with lack of viability, versus eight patients (25%) in group 2 (  P = 0.0003  ). The number of viable apical segments per patient was significantly less in group 1 (  0.7 ± 1.2  ) versus group 2 (  1.8 ± 1.3  ) (  P = 0.01  ). Left ventricular apical thrombus is more likely to be present when there is absence of myocardial viability in the corresponding segments.     

Becoming an evidence-based practitioner through professional development

Occupational therapy practitioners need to incorporate evidence-based practice into their professional role to remain competent, relevant and clinically effective. However, therapists may feel uncomfortable with the emphasis on evidence, may not know how to use it in practice and may not know where to start to develop the necessary skills. This paper explores these issues and proposes six strategies for continuing professional development which individual therapists can consider using or promoting to become evidence-based practitioners. These strategies are: (i) changing individual practitioner behaviours; (ii) changing consumer behaviours and expectations; (iii) using evidence about how best to get evidence into practice; (iv) developing institutional requirements for evidence-based practice; (v) supporting professional association initiatives; and (vi) using or developing local clinical guidelines. Each of these strategies is described in detail.     

Temporal progression of cortical reorganization following nerve injury

Damage to peripheral nerves of adult mammals causes reorganization of somatosensory maps in the cerebral cortex. An understanding of the temporal progression of cortical changes is important for understanding the underlying mechanisms. The present experiments utilized neurophysiological recordings to analyze the time course of reorganization in the S-I cortical hindpaw area in adult rats. Following loss of sciatic inputs, the cortical area responding to low threshold inputs from the hindpaw saphenous nerve expands. A brief, early onset period of rapid expansion is followed by a prolonged period of slow increase. The temporal progression suggests that early onset changes condition the central nervous system for later changes.     

Deep venous thrombosis of the leg: US findings

In a prospective study, 121 consecutive patients with a clinical diagnosis of deep venous thrombosis of the leg were examined with real-time ultrasonography. The findings were correlated with the results of venography. The common femoral vein and the popliteal vein were evaluated for intraluminal echoes and compressibility, and the common femoral vein was also evaluated for an increase in diameter in response to the Valsalva maneuver. The superficial femoral vein and the calf veins were not evaluated. The results indicate that compressibility of the common femoral and popliteal veins is the best indication of deep venous thrombosis, with a sensitivity of 96% and a specificity of 97%. The accuracy of detection was not improved by including data from thrombus visualization or the response of the common femoral vein to the Valsalva maneuver.     

Cortical connections of the caudal subdivision of the dorsolateral area (V4) in monkeys.

Evidence suggests that all primates have rostral and caudal subdivisions in the region of visual cortex identified as the dorsolateral area (DL) or V4. However, the connections of DL/V4 have not been examined in terms of these subdivisions. To determine the cortical connections of the caudal subdivision of DL (DLC) in squirrel monkeys, injections of the neuroanatomical tracers wheat germ agglutinin conjugated to horseradish peroxidase, Diamidino Yellow, and Fluoro-Gold were made in cortex rostral to V II. To aid in delineating the borders of DLC, cortex was also evaluated architectonically. Based on similar patterns of connections, DLC extends from dorsolateral to ventrolateral cortex. DLC receives strong, feedforward input from V II and projects in a feedforward fashion to the rostral subdivision of DL (DLR) and caudal inferior temporal (IT) cortex, including a separate location in the inferior temporal sulcus. DLC has weaker connections with V I, the middle temporal area (MT), cortex rostral to MT in the location of the fundal superior temporal area (FST), cortex dorsal to DLC, ventral cortex rostral to V II, and cortex in the frontal lobe, lateral to the inferior arcuate sulcus. Only lateral DLC has connections with V I, and only dorsolateral DLC has connections with cortex dorsal to DLC. The topographic organization of DLC was inferred from its connections with V II. Thus, dorsolateral DLC represents the lower field, lateral DLC represents central vision, and ventrolateral DLC represents the upper field. Limited observations were made on DLR. Confirming earlier observations (Cusick and Kaas: Visual Neurosci. 1:211, 1988), DLR is paler than DLC myeloarchitectonically. DLR receives only sparse feedforward input from V II, but stronger input from DLC. DLR has strong connections with cortex just rostral to dorsal V II, ventral posterior parietal cortex in the sylvian fissure, MT, the medial superior temporal area, FST, and the inferior temporal sulcus. DLR also shares connections with IT cortex. Thus, while both DLC and DLR are involved in the pathway relaying visual information to IT cortex, an area specialized for object vision, DLR also projects densely to areas such as MT involved in the pathway relaying to posterior parietal cortex, a region specialized for spatial localization and motion perception.