4. Laryngoscope, 128:350-355, 2018.

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Using the glycogen depletion technique, we have examined utilization of specific fibre types during prolonged submaximal exercise to investigate the recruitment pattern employed by the central nervous system to sustain force generation in the face of a progressive glycogen depletion. Six male subjects (Vo2 max, 52.8 +/- 2.5 mL.kg-1.min-1, mean +/- SE) cycled at 59% of pretraining Vo2 max (the same absolute power output) for 99.5 +/- 6 min on two occasions, before training and after 10-12 days of intensive training, involving 2 h of cycling per day. Prior to the training, glycogen concentration during exercise in the type I and type IIA fibres of the vastus lateralis muscle as measured by microphotometric techniques was progressively reduced during exercise. The pattern of depletion in both of these fibre types was parallel and showed an early marked depletion amounting to 51 (p less than 0.05) and 35% (p less than 0.05) in the type I and type IIA fibres, respectively, during the first 15 min of exercise. At the end of exercise, glycogen levels in type I and type IIA fibres were reduced to 9 and 44% of initial levels, respectively. In contrast, glycogen concentration in type IIB fibres was not significantly (p less than 0.05) altered throughout the exercise. Following training, a pronounced glycogen sparing occurred that was conspicuous in only the type I and type IIA fibres, which was most pronounced during the first 15 min of the exercise. Similar to pretraining, glycogen concentrations in type IIB fibres were unaffected by either exercise or training.(ABSTRACT TRUNCATED AT 250 WORDS)

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T emporal bone injury overall is an infrequent presentation. In patients presenting with head trauma, only 5% have a temporal bone fracture. 1 Mechanisms of temporal bone trauma are divided into blunt and penetrating. Penetrating injuries of the temporal bone are less common than blunt injuries, but are likely to be more damaging. 2 Penetrating injuries are of two types: stab injuries and gunshot injuries. 3 Either injury may be limited to the temporal bone or involve other cranial structures. These injuries often require a team approach to management. CaseA 38-year-old man was transferred from a peripheral hospital to our trauma center after sustaining a gunshot wound to the head. The patient was awake, alert, and oriented with a Glasgow coma score (GCS) of 15, but a noncooperative historian. The patient was examined and was found to have an entrance wound posterior to the left auricle over the mastoid with scorching of the posterior pinna ( Fig. 1). A focused neurologic examination revealed a House-Brackmann grade 2 left facial weakness, with minimal weakness of the frontal branch of the left facial nerve. There was right beating nystagmus present only on rightward gaze (first-degree nystagmus). The left external auditory canal (EAC) was draining a mixture of blood and cerebrospinal fluid (CSF).A high-resolution computed tomography (HRCT) scan of the temporal bone revealed a mixed fracture of the left temporal bone with an adjacent subdural hematoma (SDH), temporal lobe contusion, and pneumocephalus (Fig. 2). A fracture line extended through the basal turn of the cochlea and the vestibule. The bullet had fractured into two main fragments; one was situated in the superficial lobe of the left parotid gland, the other was in the left mastoid adjacent to the sigmoid sinus extending anteriorly to the middle ear space and the posterior wall of the external auditory canal (Figs. 3 and 4).The patient was taken to the operating room where a left simple mastoidectomy was performed for removal of the mastoid bullet fragment (Fig. 5). This involved an exenteration of the central mastoid air cells with preservation of the posterior EAC wall and without modification to the EAC. A dural tear was situated in the region of the tegmen. Through this tear, the SDH was evacuated with subsequent suture closure of the dural tear, which was then reinforced with a temporalis muscle flap. Postoperatively, the patient developed CSF drainage from the bullet entry site that was resistant to treatment with a lumbar drain. This CSF leak was then subsequently closed using a middle cranial fossa approach to place a fascia lata graft. The patient was discharged from hospital shortly after this procedure without any evidence of a subsequent leak. An audiogram performed in follow-up revealed a profound hearing loss in the left ear. DISCUSSIONTemporal bone injury occurs in 20% to 50% of gunshot wounds to the head. 3,4 These injuries most commonly are not self-inflicted. Gunshots can be either of low velocity (90 -210 m/s) or high velocity (Ͼ610 m...

Cisplatin (25 to 120 mg. per m.2) was injected into the internal iliac arteries of 33 patients with locally advanced bladder cancer. Of the patients 9 were inevaluable for response to the cisplatin, since they began radiotherapy to the bladder before course 2 of cisplatin as part of a preplanned therapeutic approach. One patient received the treatment as postoperative adjuvant therapy, 1 did not return for followup and 1 with metastatic disease did not undergo repeat cystoscopy. Of 21 evaluable patients 3 (14 per cent) achieved complete remission, 12 (57 per cent) achieved partial remission, 2 (14 per cent) were stable and 4 (19 per cent) failed. The response rate was higher in patients receiving 100 to 120 mg. per m.2 per course than in patients receiving lower doses (all except 1 of whom received 60 or less mg. per m.2 per course) (86 versus 64 per cent) and it was higher in patients without prior radiotherapy or chemotherapy. The response rate in patients with previously untreated invasive transitional cell carcinoma was 88 per cent. Of the 33 patients 21 were alive at last followup, with a median duration of followup of 32 weeks. Toxicity was dose-related and local neurotoxicity was excessive at cisplatin doses of 100 to 120 mg. per m.2. Diabetic patients were particularly prone to have neurotoxicity. Other toxicity generally was not severe and consisted of ototoxicity, nephrotoxicity, myelosuppression, nausea, vomiting and diarrhea. Even elderly patients and patients with cardiac disease tolerated the treatment well. We plan to proceed with further intra-arterial cisplatin studies in which all patients except those more than 80 years old will be treated with an intra-arterial cisplatin dose of 90 mg. per m.2 per course combined with radiotherapy with or without cystectomy.

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