[Long-term treatment of Lambert-Eaton syndrome by 3, 4 diaminopyridine].

A patient with a 5 year history of slow-progressive Lambert-Eaton Myasthenic Syndrome (LEMS) was treated for a period of 12 months with 3,4-diaminopyridine (3,4-DAP). The therapy led to an objective increase in muscle power. During the treatment period, there was no increase in muscle weakness, but attempts at withdrawal of the drug confirmed a progression. The mouth dryness disappeared and autonomic regulation disturbances were improved. All of the laboratory parameters remained unchanged. A neoplasia was excluded by extensive endoscopic and radiological investigations. Side-effects included initial perioral paresthesia and, later, paresthesia down the skin and along the ulnar edge of the forearm. 3,4-DAP seems to be an effective and acceptable long-term symptomatic therapy in LEMS.


[Cerebral ischemic accidents and tuberculous meningitis].

Two cases of tuberculous meningoencephalitis mimicking regressive or transient ischaemic attacks or migraine with aura are reported. The value of MRI with gadolinium in demonstrating inflammation of the leptomeninges, of transcranial Doppler sonography in detecting segmentary accelerations in the basal cerebral arteries suggestive of arteritis and of CSF examination with polymerase chain reaction (PCR) are emphasized.


[Thrombosis of the upper longitudinal sinus and syphilitic cranial osteitis].

A 33-year old man developed progressive intracranial hypertension with papilloedema due to thrombosis of the superior sagittal sinus (SSS) by extension of a skull osteitis. Serological tests for syphilis were positive in blood, CSF and synovial fluid. Under treatment with penicillin and corticosteroids signs of intracranial hypertension and CT scan abnormalities disappeared. SSS thrombosis persisted at angiographic control.


[Hemichorea-hemiballismus and toxoplasmosis in AIDS].

The authors report two cases of hemichorea-hemiballism revealing a toxoplasmic abscess in the subthalamic nucleus during AIDS. Despite the great frequency of this opportunistic infection such cases are exceptional. This rarity seems to be explained by the frequent association of other lesions of the basal ganglia which may prevent the movement disorders. Nevertheless an hemichorea-hemiballism in young people must suggest a cerebral toxoplasmosis. Finally a symptomatic treatment is often necessary; in these cases the use of sodium valproate must be considered, this drug being able to induce a clinical improvement.


[Intracranial dural arteriovenous fistula with spinal venous drainage].

Two cases of intracranial dural arteriovenous fistulae draining into the medullary veins are reported. One patient was a 68-year old man who experienced brief and repeated episodes of paraplegia, followed by a permanent spinal cord syndrome. The other patient was a 74-year-old woman who rapidly developed a syndrome of the medulla and spinal cord. In both cases spinal cord angiography failed to show vascular malformations, but myelography revealed venous imprints and magnetic resonance imaging of the cervical spinal cord disclosed a pre-medullary signal. Cerebral angiography showed an intracranial arteriovenous fistula fed by the external carotid artery and draining into the veins of the posterior fossa and the spinal venous network. Complete occlusion of the fistula was achieved by embolization with microparticles. Intracranial dural arteriovenous fistulae draining into the medullary veins are rare: to our knowledge, only 4 cases have been reported. Such lesions must be considered whenever a spinal cord syndrome has no detectable cause.


[Surgery for cancer with mediastinal lymph node invasiveness (N2)].

Resection is indicated in about 20% of N2 cases. When it is complete a 5-year survival rate may be expected. It represents for these patients a chance of cure and therefore must be considered in all cases of N2, either immediately or after an adjuvant treatment. Its results can be improved by strict selection of the patients and by an efficient chemotherapy.


[Surgery of cancers extending to the carina].

When small and inextensive these tumours are rare and often surgical; when extensive they are usually unresectable. Owing to the late development of dyspnoea and to the frequent normality of thoracic radiography the endoscopic diagnosis is seldom made at an early stage, which explains why these tumours are often regarded as non surgical. In limited forms the best treatment is resection of the carina with or without reconstruction of the tracheal bifurcation, but this surgical procedure is frequently difficult. However, this type of surgery has benefited from modern imaging for the preoperative evaluation, of advances in anaesthesia and ventilation techniques for the operation itself, and from changes in techniques and strategies by medico-surgical teams specialized in pneumology. The results of this surgery are difficult to evaluate due to the absence of published homogeneous series.


[Conservative treatment of bronchogenic cancers: lobectomy with excision-anastomosis and limited excision].

Lung cancer resection surgery often reduces the respiratory function to the point that it can preclude pneumonectomy or even standard lobectomy. When these usual operations are impossible for functional reasons more restricted procedures can be performed, local conditions permitting. Thus, lobectomy with resection anastomosis may be a suitable alternative to pneumonectomy, and segmental resection may be considered when standard lobectomy is rejected. However, this conservative surgery can be envisaged only when it does not risk to affect the quality of the long-term results. While lobectomy enlarged to the bronchial tree has proved to be justified for the treatment of cancers without lymph node invasion, limited resections give uncertain results and must be regarded as an alternative to surgical abstention.


[Surgery of bronchogenic cancer in aged patients].

The lung cancer mortality rate increases with age, but the progressivity and radioclinical features of this cancer in the elderly are not very different from those observed in younger subjects. As in these subjects, the pretherapeutic evaluation must be complete whenever surgery seems to be possible, but special attention must be paid to the cardiovascular system. Several recent studies have reported postoperative mortality and morbidity rates paradoxically similar, or even lower, in both old and relatively young patients, probably because of a better selection. Moreover, the survival rate at 5 years of the elderly compares favourably with that of younger subjects. Thus, age is not an absolute contra-indication to surgery, but it requires a more rigorous selection and a closer postoperative supervision.


[Complications and mortality of surgery for bronchogenic cancers].

Resection surgery for lung cancer is beset with specific or non-specific complications which often darken the prognosis for life. The specific complications, related to surgical dissections, are mainly per- and postoperative haemorrhages of various origins and, less frequently, disturbances in respiration, nerve wound or chylothorax. Soon after pneumonectomy a bronchial fistula encouraged by different factors may appear (3.3% of the cases) and empyema, usually caused by staphylococci, may develop (3%). Non-specific complications may disturb the post-resection period, involving the lungs (atelectasia, parenchymal infections, acute respiratory failure) or the cardiovascular system (pulmonary embolism, dysarrhythmia). The overall perioperative mortality rate has decreased with time owing to advances in anaesthesia and intensive care: in the hands of certain medico-surgical teams it does not exceed 3%. It is significantly lower in lobar (mean: 4.5%) than in pulmonary (mean: 8.4%) resections. Enlarged resections and lymph node dissections are aggravating factors. Patients aged 70 or more do not tolerate these operations so well: their mean overall mortality rate is twice that observed in younger patients (8% on average and up to 20%). Resection surgery for lung cancer remains a necessarily hazardous procedure but is the only treatment that can cure the patient. Its success is directly conditioned by a good preoperative risk evaluation.


The effect of ATP on Ca(2+)-dependent K+ channels of human red cells.

The action of ATP on Ca(2+)-dependent K+ channels was studied in fresh human erythrocytes using patch-clamp techniques. Single-channel current was recorded at pH 6.5 from inside-out patches in the presence of symmetrical K+ gluconate solutions, containing both 1 microM free Ca2+ in the bath and 0.5 mM LaCl3 on the pipette side. With no ATP, the electrical activity revealed low-conductance K+ channels (25 pS), which showed inward rectification and an opening kinetics dependent on membrane potential. When ATP (1 mM) and Mg2+ (2 mM) were added together and a depolarizing potential was simultaneously applied, only a high-conductance channel (about 75 pS) was observed. This channel showed no rectifying properties and it was not found if ATP was added in the absence of Mg2+. Channel activity was enhanced by adding fluoride (10 mM) or trifluoperazine (50 microM) whilst it was reduced after incubating with dibutyryl cAMP (50 microM) or alkaline phosphatase (250 U/ml). On the other hand, when fragmented membranes from inside-out vesicles were incubated with gamma-32 P-ATP and 1 microM free Ca2+ under above conditions, only two high-molecular weight polypeptides (235 and 320 kDa) were labelled with 32P. The results suggest that ATP-mediated phosphorylation of Ca(2+)-dependent K+ channels leads to a high-conductance state.


Effects of simultaneous denervation and tenotomy on the ultrastructure of a rat slow twitch muscle.

Simultaneous denervation and tenotomy causes atrophy of rat slow twitch soleus muscle. Apparently, the alterations are similar to those seen in denervated or tenotomized slow muscle. However, the extent of disorganization of myofibrils appears lower than that expected after a moderate period of time in only denervated or tenotomized muscle. This study indicates that after an initial proliferation of lysosomes, alterations of sarcotubular system and mitochondria proceed. Nevertheless, 45 days after denervation and tenotomy many mitochondria have a normal aspect.


[Value (and limitations) of the RAST fx5 in pediatric allergological practice].

RAST f x 5 (CAP-system, Pharmacia), an in vitro assay testing a mixture of 6 food antigens, was systematically applied to 400 children and adolescents with respiratory pathologies possibly of allergic origin. The clinical aspects of the 293 test-negative patients were compared with those of the 107 positive cases. Furthermore, 84 positive sera were also evaluated against each of the 6 antigens regrouped in the f x 5. In this population with allergic respiratory diseases, the most frequently positive tests reacted with antigens of plant origins: wheat, peanut and soybean. From an economic point of view, first-line use of f x 5 markedly reduced the cost of a systematic study of food allergens, whose clinical justification remains to be demonstrated.


[Objective evaluation of sclerodermic skin using the slip-test. Results and validation with 30 patients and 60 controls].

The slip test is a non-invasive way to objectively evaluate the extent of scleroderma by measuring the "slipping" of the skin over an underlying bone. The results obtained in 30 scleroderma patients and 60 controls (178 tests due to multiple measurements) were analyzed to determine which test sites show a significant difference between patients and controls (Student's t-test) and which sites are the most discriminating for the diagnosis of the disease (multivariate analysis). Patient values were clearly distinct from those of controls. The best sites (defined by p < 0.05) were: the mandible, the second and first phalanges of the middle finger, the hands, the forearms, the epicondyles, the sternum, the iliac crests, the patellae, the tibias (the upper and lower fourths) and the feet; in all, 23 sites to which can be added the opening of the mouth (measurement of the maximal interlabial distance), which proved to be a reliable parameter. Multiple regression analysis yielded an equation that identified patients with scleroderma based on 4 variables (right forearm, right iliac crest, sternum and right rib). The slip test is thus the first reproducible quantitative test able to confirm and quantify clinical impressions in scleroderma. It is entirely able to objectively monitor the evolution of the disease under treatment. Nevertheless, complementary studies are needed to verify whether the slip test, which can be performed in 20 minutes during an office visit, can be used advantageously in the routine clinical evaluation of scleroderma.


[Recurrence of Guillain-Barré syndrome].

Fifteen of the 238 patients (6.3%) who recovered from an initial episode of Guillain-Barré syndrome had one or several acute relapses. Usually, there was only one relapse. The durations of the plateau and recovery phases of the relapses were longer than those of the initial episodes. The protein level in the cerebrospinal fluid was higher during relapses (1.37 +/- 1.30 milligrams) than during the initial episode (0.87 +/- 0.44 milligrams). The intensity of the symptoms during relapses was comparable to that of the initial episodes, but the occurrence of these relapses aggravated functional sequelae. Comparison of relapsing patients with those who experienced monophasic Guillain-Barré syndromes and were treated in the same unit revealed no element predictive of relapses.


[Long-term survival and prognostic factors in stage II-III multiple myeloma treated with conventional chemotherapy].

In this retrospective study, survival and prognostic factors were analysed in 65 patients with stage II-III multiple myeloma with osteolytic lesions. Multiple myeloma was diagnosed from 1976 to 1984, and patients were treated with conventional chemotherapy. The response rate to initial chemotherapy was 46%. The median survival time was 31 months. The 10-year survival rate was 10%. Four variables were individually prognostic: response to initial chemotherapy, bone marrow plasma cell percentage, the Durie and Salmon staging system, a biological staging system derived from Durie and Salmon's biological criteria regardless of bone lesions. In the multivariate analysis, only two prognostic variables were retained, namely the response to chemotherapy and the biological staging system. No prognostic value was observed for the extent of osteolytic lesions. This study suggests that, in conventionally treated multiple myeloma, long-term survival has improved compared with the previous decade. It also indicates that the extent of osteolytic lesions has little value for the definition of high-risk myeloma.


[Pneumopathy induced by amiodarone. Radiological data].

Amiodarone is a drug used to treat refractory tachyarrhythmias. Unfortunately, amiodarone causes numerous side effects, among them the most serious is a pulmonary toxicity. Conventional radiographic findings are non specific and may be observed in various diseases, however. Early recognition of pulmonary toxicity is important, since prompt discontinuation of the drug, and institution of corticosteroids should result in resolution of toxicity.


[Wegener's disease: value of thoracic computed tomography. Apropos of a case and review of the literature].

The authors demonstrate the value of thoracic HR-CT in a case of Wegener's granulomatosis with a typical presentation. This uncommon disease, often has a pseudo-infectious or pseudo-neoplastic appearance and the diagnosis can be difficult as indicated by a review of the literature.


[Primary mediastinal myxoid liposarcoma. Apropos of a case].

Liposarcoma is an uncommon mediastinal tumor provides limited CT histologic date. The prognosis depends on the histological grade and surgical possibilities. The authors report a case of mediastinal liposarcoma and discuss the correlation between imaging findings, outcome and histological status.


[Neurinomas of the trigeminal nerve in neurofibromatosis. Apropos of two cases and review of the literature].

We report two cases of trigeminal neuroma in patients with Von Recklinghausen neurofibromatosis (NF1). Despite the high frequency of intracranial neuroma in neurofibromatosis, the localization on the fifth cranial nerve is an uncommon findings. In our two cases, neuromas were asymptomatic clinically and electrophysiologically, but computed tomography showed a small nodular lesion in the cerebellopontine cistern, independent of the seventh and eight nerve and which can only correspond to the fifth nerve. MR imaging very clearly demonstrates intracranial neuromas of all cranial nerves.


[Blind ureter associated with a dysplastic kidney and ureterocele. Apropos of a case and review of the literature].

The association of a blind ureter with dysplastic kidney and ureterocele is known in children but are in adults. This paper presents one case, and provides simple diagnostic clues which help to recognize the malformation.


[Aneurysm of the superior mesenteric vein].

Aneurysms originating in the superior mesenteric vein are extremely rare: 4 cases have been reported in the international literature. The authors describe a case of a female patient admitted to hospital for vague abdominal pain. The CT findings revealed a cyst-like neoformation. By means of angiography it was then identified as a dilatation of the superior mesenteric vein. The causes of such dilatations are not altogether clear. Current interpretations refer to possible congenital and acquired factors, as well as trauma. The accompanying symptoms are abdominal pain, icterus, gastrointestinal haemorrhage or portal hypertension, but occasionally patients may present no symptoms whatsoever.


[Ectatic tumoral thrombosis of the superior vena cava revealing thyroid cancer].

Microscopic angio-invasion by carcinoma of the thyroid is known. Extension into the great veins is much more uncommon. Most of the cases which have been previously described were discovered on post-mortem examination. We report the case of a 55 year-old woman who was found to have an asymptomatic small cervical goiter 6 years ago; during the last 12 months she developed superior vena cave (SVC) syndrome radiological investigation (angiography, CT scan) and surgical exploration showed a carcinoma of the thyroid with intraluminal extension of the tumor leading to thrombosis and ectasia of the SVC. Surgery was performed with resection of the whole thyroid, the SVC and the innominate veins. A double prosthetic venous by pass was then inserted between the innominate veins and right atrium. Five years after resection, the patient has no recurrence or metastasis and no clinical symptom of SVC syndrome. To our knowledge, this is only the third reported case successfully treated by surgery.


[Secondary bronchogenic pulmonary hydatidosis].

Secondary bronchogenic hydatid disease is a rare and little known complication of primary hydatid cyst of the lung, which is even refuted by some authors. We report 7 cases of secondary bronchogenic hydatid after surgical cure of a hydatid cyst which had ruptured into the bronchi, while the last case concerned a young girl who was treated by corticosteroids for rheumatoid arthritis and who developed secondary bronchogenic hydatid from a cyst rupturing into the bronchi in the absence of surgery. Hydatid dissemination was ipsilateral to the primary cyst in 5 cases, contralateral in one case and bilateral in one case. Five patients underwent radical surgery. The patient with bilateral dissemination was operated on one side and a large number of residual cysts were eliminated by vomica, as for the last patient; these two patients are still under surveillance. The operation and general anaesthesia played a predisposing role in the pathogenesis of this complication and inhibition of immune mechanisms could also play a role. Prevention is necessary when treating a hydatid cyst of the lung which has ruptured into the bronchi. Treatment is surgical, bearing in mind that a large number of secondary cysts can be eliminated by vomica or may involute spontaneously.


[Primary intrahepatic lithiasis].

Isolated intrahepatic lithiasis is a very rare condition in western countries; the reported case has to be added to the 29 cases described to date in the literature. The pathogenesis of this disease is unknown; physical and chemical bile alterations favouring lithogenesis is the most reliable hypothesis. In this case the Roux-en-Y hepaticojejunostomy with cutaneous stoma allowed us to perform periodic cleaning of intrahepatic bile ducts until complete elimination of all stones.


[Ileovaginal fistula after ileo-anal anastomosis. Recovery by transposition of the gracilis muscle. Good anatomical and functional result].

One women developed a pouch-vaginal fistula after reconstructive proctocolectomy for ulcerative colitis. This study describes the risk factors which predispose to the development of this rare complication, as well as the various treatment options available. A diverting ileostomy was maintained and gracilis muscle interposition flap was used to treat the patient. An excellent result was achieved. This procedure can be useful in this rare but distressing complication.


A randomized trial of intrahepatic infusion of fluorodeoxyuridine with dexamethasone versus fluorodeoxyuridine alone in the treatment of metastatic colorectal cancer.

To decrease the toxicity of hepatic arterial fluorodeoxyuridine (FUDR) administered through an Infusaid pump (Shiley Infusaid, Inc., Norwood, MA), 50 patients with liver metastases from colorectal cancer were selected randomly to receive FUDR, 0.3 mg/kg/d, for 14 of 28 days, with or without a total dose of 20 mg of hepatic arterial dexamethasone for 14 of 28 days. Patients were stratified according to the percentage of liver involvement by tumor and the perfusion pattern on macroaggrated albumin perfusion scan (MAA) scan. There was a trend toward decreased frequency of bilirubin levels in the group receiving dexamethasone plus FUDR versus the group receiving FUDR alone (9% and 30%, respectively, had a 200% or greater increase from baseline; P = 0.07). Patients in the group treated with dexamethasone and FUDR received higher doses of FUDR in the second, third, fifth, and sixth months than those receiving FUDR alone; however, this was statistically significant only in the fifth month (percentages of planned dose received: 42% and 19%, respectively; P = 0.05), and there was no overall difference for the total 6-month period. The complete and partial response rates were increased in patients receiving dexamethasone and FUDR versus FUDR alone (8% and 63% versus 4% and 36%, respectively; P = 0.03), and there was a trend toward increased survival with the addition of dexamethasone (median, 23 months and 15 months, respectively; P = 0.06). In conclusion, the use of hepatic arterial dexamethasone is associated with an increased response rate and a trend toward increased survival and decreased bilirubin levels. Therefore, the authors recommend additional investigation of the use of dexamethasone with chemotherapy to treat hepatic metastases.


Second-look laparotomy and salvage therapy: a research modality only?

Two hundred twelve patients who underwent second-look laparotomy as part of their treatment for epithelial ovarian cancer were evaluated. Factors associated with positive second looks were initial stage, tumor grade, age, and residual disease (P less than 0.05). One factor not of significance was whether adjuvant therapy was platinum based. Initial stage only was associated with recurrence after a negative second look (P less than 0.001). When controlled for volume of disease no difference in survival between various salvage therapies could be demonstrated. Survival between patients with recurrence after negative second look and patients with microscopic residual disease was similar even though the former group was not treated until recurrence (P = 0.75). Second-look laparotomy does not improve survival with currently existing salvage modalities and should primarily be confined to those patients willing to participate in research protocols evaluating new second-line therapy.


Dermatopathia pigmentosa reticularis: a report of a family demonstrating autosomal dominant inheritance.

Dermatopathia pigmentosa reticularis is a rare heritable disorder consisting of a triad of cutaneous findings including reticulate hyperpigmentation, noncicatricial alopecia, and onychodystrophy. In addition to this triad, other variable features of dermatopathia pigmentosa reticularis have been described, including adermatoglyphia, hypohidrosis or hyperhidrosis, and palmoplantar hyperkeratosis. Only 10 cases have been described in the world literature to date, and no clear inheritance pattern has been demonstrated. We present a patient with the classic features of the dermatopathia pigmentosa reticularis triad, along with adermatoglyphia, hypohidrosis, and punctate hyperkeratosis of the palms and soles. A family pedigree demonstrates the autosomal dominant inheritance of dermatopathia pigmentosa reticularis.


Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine.

An American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference was held in Northbrook in August 1991 with the goal of agreeing on a set of definitions that could be applied to patients with sepsis and its sequelae. New definitions were offered for some terms, while others were discarded. Broad definitions of sepsis and the systemic inflammatory response syndrome were proposed, along with detailed physiologic parameters by which a patient may be categorized. Definitions for severe sepsis, septic shock, hypotension, and multiple organ dysfunction syndrome were also offered. The use of severity scoring methods when dealing with septic patients was recommended as an adjunctive tool to assess mortality. Appropriate methods and applications for the use and testing of new therapies were recommended. The use of these terms and techniques should assist clinicians and researchers who deal with sepsis and its sequelae.


Evaluation of tissue oximetry in perioperative monitoring of colorectal surgery.

Twenty patients undergoing elective colorectal surgery were studied during and after operation by means of tissue oximetry measuring the subcutaneous partial pressure of oxygen (PscO2) and by gastric intramural pH measurement. Mean(s.d.) PscO2 recorded 24 h after surgery was significantly lower than the peroperative value: 14(10) versus 24(14) mmHg, P less than 0.02. The postoperative PscO2 was also significantly lower than that measured in a control group of ten healthy volunteers: 14(10) versus 34(18) mmHg, P less than 0.001. The peroperative PscO2 of the patients who developed a postoperative complication was significantly lower than that of those who had an uneventful postoperative clinical outcome: 16(9) versus 32(14) mmHg, P less than 0.02. The peroperative PscO2 of the patient group with complications was also significantly lower than that of the control group: 16(9) versus 34(18) mmHg, P less than 0.02. The peroperative PscO2 of the group of patients without complications was almost identical to that of the control group. During operation only one patient developed gastric intramural acidosis. Perioperative oxygen debt and the response of subcutaneous tissue oxygen tension to oxygen breathing seemed to correlate better with clinical outcome than gastric wall pH values and the conventional parameters of tissue perfusion.


Output factors for blocked fields.

This study investigates the output from blocked treatment fields with 6 MV and 18 MV photons. Square fields, defined by collimators, were blocked down to smaller symmetrical square, rectangular and asymmetrical rectangular fields using blocks on a tray beneath the collimators. Up to 7.5% difference was found between the output measured for the blocked field and the output calculated using a collimator output factor for the surface field size. A method is described by which output factors for the blocked fields can be measured and used in practice. Three methods of approximating these output factors are also presented.


Birth prevalence study of the Apert syndrome.

Estimates of the Apert syndrome birth prevalence and the mutation rate are reported for Washington State, Nebraska, Denmark, Italy, Spain, Atlanta, and Northern California. Data were pooled to increase the number of Apert births (n = 57) and produce a more stable birth prevalence estimate. Birth prevalence of the Apert syndrome was calculated to be approximately 15.5/1,000,000 births, which is twice the rate determined in earlier studies. The major reason appears to be incomplete ascertainment in the earlier studies. The similarity of the point estimates and the narrow bounds of the confidence limits in the present study suggest that the birth prevalence of the Apert syndrome over different populations is fairly uniform. The mutation rate was calculated to be 7.8 x 10(-6) per gene per generation. Apert syndrome accounts for about 4.5% of all cases of craniosynostosis. The mortality rate appears to be increased compared to that experienced in the general population; however, further study of the problem is necessary.


Ketorolac trometamol for postoperative analgesia after orthopaedic surgery.

We have compared the postoperative morphine requirements and analgesic efficacy of four doses of i.m. ketorolac 30 mg administered 6-hourly with placebo in a double-blind study of patients undergoing major or minor orthopaedic surgery. During the 24-h postoperative study period which began at the end of surgery, patients were prescribed i.m. morphine 10 mg as required 2-hourly and assessments were made of pain at 4 and 24 h. After major surgery, the median morphine consumption over 24 h was 10 mg in patients who received ketorolac, compared with 30 mg in those who received placebo (P = 0.008). Visual analogue pain scores and verbal pain assessments were better than placebo at 4 h (P = 0.028 and P = 0.008, respectively), but were not statistically different between the groups at 24 h. Overall assessment of pain was similar in both groups who had undergone major surgery. In the minor surgery groups, median morphine consumption was 0 mg in patients who received ketorolac, compared with 10 mg in those given placebo (ns). Visual analogue pain scores at 24 h after surgery were significantly less in patients who had received ketorolac compared with placebo (P = 0.046) and the overall assessment of pain relief was better in the ketorolac group (P = 0.0007). Mandatory administration of ketorolac appeared to be of benefit in both major and minor orthopaedic surgery, although the principal effects were reduction in requirement for supplementary morphine for major surgery and better overall analgesia for minor surgery.


Human immunodeficiency virus type 1-infected monocytic cells can destroy human neural cells after cell-to-cell adhesion.

Primary cultures of human embryonic neurons and astrocytes have been used to test the interactions between neural cells and either human immunodeficiency virus type 1 (HIV-1) or HIV-1-infected monocytes. After direct infection with HIV-1, neither morphological alteration of neurons and astrocytes nor signs of viral replication were observed. Similarly, cultured human neurons and astrocytes were resistant to incubation with the supernatant of HIV-1-infected U937 cells, a human monoblastoid cell line. In contrast, HIV-1-infected U937 monocytic cells adhered to neural cells and induced large plaques of necrosis surrounding them. This cytopathic effect began at the time of viral replication (day 16 after infection). Its intensity depended on that of viral replication, and its range was identical to the region of diffusion of viral antigens, as judged by immunocytochemistry. The cytopathic effect was not dependent on the release of free radicals. It could not be induced by cytokines or cytokine-stimulated U937 cells. It is likely that this cytopathic effect depends on the release of viral antigens either within the site of adherence itself or within close range of the astrocyte membrane.


The response of 99Tcm-methylene diphosphonate and 99Tcm-hexametazime-labelled neutrophils to intra-articular steroid injection in rheumatoid arthritis.

The synovial and bone uptake of tracer in the knees of patients with rheumatoid arthritis (RA) was quantified using 99Tcm-hexamethyl propylene amine oxime-labelled leucocytes and 99Tcm-methylene diphosphonate (MDP), respectively. Significant neutrophil migration and MDP uptake occurred in the knees of patients with RA irrespective of the disease duration. In all but one patient neutrophil migration was reduced after intra-articular steroid injection. The change in MDP uptake after steroid injection was variable. There was a significant correlation between the percentage reduction in neutrophil migration and pain score, while the latter correlated poorly with the change in MDP uptake. The quantification of the neutrophil component of the inflammatory process is a sensitive index for monitoring RA activity and response to pharmacological interventions, while quantitative bone scintigraphy should not be employed to monitor changes in joint inflammation in patients with RA.


Pharmacokinetics of ethylene in man; body burden with ethylene oxide and hydroxyethylation of hemoglobin due to endogenous and environmental ethylene.

The inhalation pharmacokinetics and the endogenous production of ethylene has been determined in healthy volunteers with respect to the formation of the carcinogen ethylene oxide. Ethylene showed a low degree of accumulation in the body determined in six subjects, the thermodynamic partition coefficient "body/air" being 0.53 +/- 0.23 (mean +/- SD) and the accumulation factor "body/air" at steady-state being 0.33 +/- 0.13 (mean +/- SD). The rate of metabolism was directly proportional to the exposure concentration. Only 2% of ethylene inhaled was metabolized to ethylene oxide, whereas 98% of ethylene was exhaled unchanged. The rate of the endogenous production of ethylene was 32 +/- 12 nmol/h (mean +/- SD), as calculated from exhalation data from 14 subjects. The resulting body burden was 0.44 +/- 0.19 nmol/kg (mean +/- SD). By analyzing published data on ethylene oxide in man its half-life was estimated to be 42 min. Using the pharmacokinetic parameters of ethylene and ethylene oxide, the body burden of ethylene oxide due to the sum of the exposure to environmental ethylene of about 15 ppb and to endogenous ethylene exposure of 0.44 nmol/kg was predicted to be 0.25 nmol/kg. In the blood of five non-smokers and one smoker the hemoglobin adduct resulting from the reaction of ethylene oxide with the N-terminal valine, N-(2-hydroxyethyl)valine, was quantified by gas chromatography/mass spectrometry. The value of 20 +/- 5 pmol/g Hb (mean +/- SD) found in the non-smokers corroborated the steady-state level of 18 +/- 3 pmol/g Hb (mean +/- SD) calculated from the pharmacokinetic approach.


Internal medicine and the training of international medical graduates: a time for open discussion and new approaches.

The number of foreign national medical graduates entering internal medicine residency training programs in the United States has doubled since 1986. A rigorous, standardized preresidency evaluation of the basic clinical skills and language abilities of international medical graduates should be implemented. Those found to have significant deficits should undertake a preparatory curriculum designed to meet special educational needs before entry into the formal training program. A relevant curriculum might include formal lectures, reading assignments, physical diagnosis sessions, language classes, patient encounter sessions, and a tutorial on U.S medical culture that includes medical ethics and the basics of the our health care system. All or only some of these may be required for any given individual. The Educational Commission for Foreign Medical Graduates (ECFMG) could provide many of the methods needed for an evaluation program and work collaboratively with program directors. This new approach to training of international medical graduates will require an evaluation system to to measure its effectiveness. Important questions about the funding of graduate medical education for international medical graduates must also be addressed.


Recurrent parotitis.

Recurrent parotitis in children is a well described but rare condition of unknown cause. The clinical features of 11 children with recurrent parotitis are described.


A randomized trial of psychosocial support during high-risk pregnancies. The Latin American Network for Perinatal and Reproductive Research.

It is often suggested that psychological and social support and health education for women at high risk for delivering a low-birth-weight infant can improve the outcomes of pregnancy, but the evidence is inconclusive. We undertook this prospective trial to evaluate a program of home visits designed to provide psychosocial support during pregnancy. At four centers in Latin America, 2235 women at higher-than-average risk for delivering a low-birth-weight infant were recruited before the 20th week of pregnancy. The women were randomly assigned either to an intervention group (n = 1115) that received four to six home visits from a nurse or social worker in addition to routine prenatal care or to a control group (n = 1120) that received only routine prenatal care (with a mean of eight prenatal visits). The principal measures of outcome were low birth weight (< 2500 g), preterm delivery (< 37 weeks of gestation), and specified categories of maternal and neonatal morbidity. The women who received the home visits as well as routine prenatal care had outcomes that differed little from those of the women who received only routine care. The risks of low birth weight (odds ratio for the intervention group as compared with the control group, 0.93; 95 percent confidence interval, 0.68 to 1.28), preterm delivery (odds ratio, 0.88; 95 percent confidence interval, 0.67 to 1.16), and intrauterine growth retardation (odds ratio, 1.08; 95 percent confidence interval, 0.83 to 1.40) were similar in the two groups. There was no evidence that the intervention had any significant effect on the type of delivery, the length of hospital stay, perinatal mortality, or neonatal morbidity in the first 40 days. There was no protective effect of the psychosocial-support program even among the mothers at highest risk. Interventions designed to provide psychosocial support and health education during high-risk pregnancies are unlikely to improve maternal health or to reduce the incidence of low birth weight among infants.


Blood lead level in children living close to a smelter area: 10 years later.

A survey conducted at the end of the summer of 1989 in Rouyn-Noranda showed that children living near the smelter had blood lead levels between 2.3 and 26.9 mg/dl. A comparison with a similar survey done in the same area in 1979 shows that there are fewer children today with a blood lead level higher than 20 mg/dl, that is 7 versus 18, ten years ago. The soil lead level of the area where these children live was elevated but comparable to that of 10 years ago, even if the smelter atmospheric lead emissions show an important decrease, as is the case for atmospheric lead contamination by leaded gas. Shall we reconsider our criteria for remedial action on the soil?


Low anion gap resulting from unexplained exposure to bromide in a patient with renal amyloidosis.

A patient with nephrotic syndrome secondary to renal amyloidosis was consistently observed to have serum anion gap levels as low as -1 mEq/L and averaging approximately 2 mEq/L. Neither multiple myeloma nor extreme hypertriglyceridemia was present, and the patient's serum albumin concentrations were not low enough to depress the anion gap to this degree. An increased serum bromide level (below the range expected to produce clinical toxicity) was the apparent cause of the low anion gap. The patient's parents, who live in the same apartment, also manifested low anion gaps and inexplicably elevated serum bromide levels. Despite detailed investigation, no environmental or pharmacologic source of bromide was uncovered. Although the source of the bromide in the present instance remains elusive, this report illustrates the necessity to measure serum bromide when a low anion gap cannot be explained by other factors, even when there is no history to suggest bromide exposure.


Diet and breast cancer.

Studies show no correlation between dietary fat and breast cancer. It is time to move on.


Intestinal parasite control in an institution for developmentally handicapped adults.

An intestinal parasite eradication program consisting of antiparasitic drug treatment and hygiene measures was conducted at an Ontario residential facility for developmentally handicapped adults from October, 1989 to August, 1990. The prevalence of intestinal parasites in general was initially over 90% while that of pathogenic species was 59%. Six months later, overall prevalence and that of pathogenic species were reduced to 32.9% and 11%. In one subgroup, the reduction in the prevalence of pathogenic parasites was sustained for at least one year. However, the prevalence of non-pathogenic species was similar to the baseline level. Simultaneous treatment and application of hygiene measures appeared to be effective in reducing pathogenic intestinal parasites.


Screening for neuroblastoma in the north of England.

To determine the feasibility of establishing a system of screening for neuroblastoma. Prospective study of mass screening in four clearly defined geographical areas. Four health districts of the Northern region of England. 20,829 babies aged 6 months, 92% of target population. Collection of urine on filter paper for analysis of content of homovanillic and vanillylmandelic acid in relation to urinary creatinine concentrations. Derivation of reference range. Identification of babies with homovanillic or vanillylmandelic acid > 3 SD above the mean (positive cases). Investigation of positive cases for evidence of neuroblastoma. The upper limit of normal (3 SD above the mean) for vanillylmandelic acid was 15 mumol/mmol creatinine and for homovanillic acid 24 mumol/mmol creatinine. Of the 20,829 babies screened, 2537 (12.2%) required a second sample to be taken because the first sample was inadequate. Of these, 527 (2.5%) provided a liquid urine specimen and 10 (0.04%) had positive results for neuroblastoma. Two of them had neuroblastoma (true positives) and eight did not (false positives). A further three children from the cohort were subsequently found to have neuroblastoma; they had raised homovanillic acid or vanillylmandelic acid values, or both, but screened negative at 6 months. Screening for neuroblastoma is possible in the health care system of the United Kingdom. Evaluation of the efficacy of screening in reducing the mortality from neuroblastoma requires a controlled trial.


Detection of undiagnosed coeliac disease with atypical features using antireticulin and antigliadin antibodies.

Eighteen patients with a variety of non-gastrointestinal symptoms were incidentally found to have circulating antireticulin antibody and on subsequent testing were also positive for antigliadin antibody. They prospectively underwent jejunal biopsy to determine whether or not they had coeliac disease. Their age range was 21-79 years (mean 42 years). Enteropathy was present in 13 (72 per cent) and was always associated with circulating IgA antigliadin antibody. Enteropathy was not present in the five cases who had only IgG antibody. Clinical improvement occurred in eight of 11 patients who complied with a gluten-free diet and was paralleled by an improvement in the mucosal histology in seven of eight who were re-biopsied. The most remarkable cases were two patients who presented with severe debility and no apparent haematological or biochemical abnormalities, and who subsequently made a dramatic recovery on a gluten-free diet. It is concluded that antireticulin antibody detected by routine autoantibody screening and confirmed to have IgA antigliadin antibody specificity is a useful indicator of an otherwise undiagnosed enteropathy. This serves to emphasize that the condition can sometimes be associated with atypical features and significant morbidity.


Selection of optimal lipid sources in enteral and parenteral nutrition.

The manipulation of dietary fat intake can affect the response to disease, injury, and infection. These effects include enhancement or inhibition of immune function, altered susceptibility to cardiovascular disease, promotion or maintenance of gut integrity, and prevention of total parenteral nutrition-induced hepatic dysfunction. These effects may occur as a result of changes in the fatty acid composition of biomembranes or changes in concentrations of lipid moieties such as prostaglandins or leukotrienes. Those fats that have been shown to affect physiologic function include long-chain, medium-chain, and short-chain fatty acids and omega-3 and omega-6 fatty acids. Currently available enteral and parenteral products used for nutrition support contain widely varied amounts of these different fatty acids. Therefore, the selection of the most appropriate product or nutrition support regimen for an individual patient requires an understanding of the metabolism of these different fat substrates, their therapeutic indications, and the contraindications and controversies that surround their use. This article reviews these issues and also focuses on several alternate lipid sources such as short-chain fatty acids, medium-chain fatty acids, omega-3 fatty acids, and blended and structured lipids.


[Effect of anisodamine on cochlear blood flow in living guinea pigs].

Anisodamine is commonly used in clinic as vasodilator. In the present study, the effects of anisodamine on cochlear blood flow were investigated in living guinea pigs using intravital microscopic techniques. The results showed that intravenous infusion of anisodamine (10mg/kg, 5mg/kg, 2 mg/kg) produced a dose dependent reduction in blood pressure. Large dose (10mg/kg) caused significant decrease in blood flow rate to 68.7 +/- 7.4% of the control value with no significant change in vessel diameter. On the other hand, medium and small doses (5mg/kg, 2mg/kg), which produced relatively smaller reduction in blood pressure caused no significant alternation in blood flow rate and vessel diameter. Also, when intramuscular, infusion of anisodamine (2mg/kg) was used no significant difference in blood flow rate, vessel diameter as well as blood pressure were found. The results indicated that increase in cochlear blood supply can not be induced by anisodamine in normal guinea pigs.


[Effect of impulse noise exposure on the endocochlear potentials].

Effects of impulse noise exposure (25 impulses, peak level 165 dB SPL) on endocochlear potentials (EP) and CAP threshold were investigated in guinea pigs. Eight hours after exposure, EP recorded from the second turn of the cochlea was very low (19.0 +/- 1.7 mV) and the negative EP resulted from prolonged anoxia was markedly diminished (-EPmax = -6.4 +/- 1.3 mV). The return rate of EP after reventilation was also reduced. The positive EP returned to normal values 7 days after exposure but the negative EP and the CAP threshold did not. The results suggest that the stria vascularis was also damaged together with the organ of Corti, the degree of damage seemed to be heavier in the latter if only complete recovery of positive EP is taken into consideration. The stria vascularis was also not completely restored when examining the return rate of EP after reventilation. Mechanisms underlying the changes in EP and hearing sensitivity after noise exposure are discussed.


[Compensation of the inner ear exposed to stabile noises of different intensities].

The dynamic changes of AP to click stimuli. the values of the static EP and the cochlear ultrastructures of the albino guinea pigs after exposure to stabile noise of three intensities (115dBA, 125dBA, 130dBA) for 4 hours were observed. At 115dBA, EP did not change; the threshold of AP was 46 +/- 6dBHL, which returned to normal 3 days after exposure. At 125dBA, EP increased to 91.6 +/- 6.9mv, and took 3 days to recover; AP was 64 +/- 3dBHL, and recovered completely in 14 days. At 130dBA, EP decreased to 68.7 +/- 19.3 mv, spending 7 days to resume; AP was 68.5 +/- 4.7dBHL, not returned to control level during 14 days. The cochlear impairment aggravated with intensified noise level, and did not improve as EP and AP recovered. At 130dBA, there were several minor holes and fractures in the reticular lamina. These results indicate that the different intensities of noises cause different conditions of noise-induced inner ear injury. The inner ear has a peculiar compensation mechanism to resume stability.


[Distorsion-products otoacoustic emissions in acoustic neuroma].

Eight cases with surgically confirmed 1.5-3.5 cm acoustic neuromas were tested through measuring distorsion-products otoacoustic emissions (DPO), which objectively reflects the cochlear status. Only one frequency (Ft) corresponding to behavior threshold highest dB HL is selected as a frequency site of DPO. The DPO is collected at a level of 75 dB SPL with equilevel of stimuli f1 and f2 and proper frequency separation (f2/f1 = 1.2). The frequencies of stimuli f1 and f2 can be calculated through the formula Ft=2f1-f2. Six cases with less than 3.0 cm neuromas had normal amplitude of DPO. Decreased amplitude of DPO is found in two cases suffered from 3.0-3.5 cm neuromas. The discrepancy between behavior threshold and amplitude of DPO can be an important indication for distinguishing early retrocochlear lesions, for instance, acoustic neuroma.


[Transtemporal supralabyrinthine approach].

Transtemporal supralabyrinthine approach is a modified middle cranial fossa approach. It offers all the advantages of a middle cranial fossa procedure and avoids its disadvantages, mainly the extensive temporal lobe retraction and frightening complications. The principle of the approach is to gain sufficient access toward the internal auditory canal by removing bone from the roof of the petrous pyramid rather than by elevating the middle fossa dura away from it. Fifteen patients underwent this approach for decompression of paralysed facial nerve resulted from temporal bone fracture, Bell's palsy and herpes zoster oticus; for removal of facial neuromas and primary cholesteatomas in temporal bone and for sectioning of great superficial petrous nerve. Preliminary study showed good results.


[Detection of G-T mutations at codon 12 of c-Ha-ras oncogenes in squamous cell carcinomas of the sinus maxillaris].

DNA extracted from paraffin-embedded minor carcinoma tissues of the sinus maxillaris, G-T mutations at codon 12 of c-Ha-ras oncogenes were detected with polymerase chain reaction and mutation-specific oligonucleotide probe hybridization, the mutations were identified in 5 out of 20 squamous cell carcinomas of the sinus maxillaris. This result indicated that c-Ha-ras oncogene is one of the genes associated with the development and progression of the squamous cell carcinomas of the sinus maxillaris, and G-T mutation may lead to activation of the c-Ha-ras oncogene.


[Functional endoscopic sinus surgery].

Eighty-two cases of functional endoscopic sinus surgery were analyzed. It include 62 males and 20 females; the oldest was 72 years of age and the youngest eight years of age. A hard endoscope with a diameter of 4mm and the CCD micro-videorecorder produced by Circon and Olympus Company were used. Operations were done under general anesthesia in all cases. Twenty-three cases (28.1%) recovered in one stage and recovery was delayed in 28 cases (34.2%); late inflammation occurred in 23 cases (28.1%); 8 cases failed (9.8%). The cure rate was 62.2%. Two cases (2.4%) had operative complications namely injury to the lamina papyracea and anterior ethmoidal artery, all recovered uneventfully.


[Chromosomal analysis of human squamous cell carcinoma of the larynx].

Twenty cases of human squamous cell carcinomas of larynx were processed with an improved direct chromosome preparations. Metaphases were obtained from 5 cases and detailed G-banding analyses were completed in 3 cases. In addition, a cell line of squamous cell carcinomas of larynx (HEP-2) was analyzed with high resolution banding technique. Three generations were cytogenetically analyzed (365, 375, 395). DM, which indicate gene amplification was found in case 4 and the cell line. 6q- and i (8q) appeared in both primary tumors and the cell line, and thus could be considered as characteristic changes in human squamous cell carcinomas of larynx.


[Effect of the father-daughter relationship on the morphological development of the mammary glands].

The puberal development of the mammary glands is the result of a final increase of serum estradiol. Having observed that the relationship with the father can affect the concentration of estradiol in the serum, the authors studied the relationship between the intensity of that interaction and the morphological development of the breasts, a standing witness in a woman's body of the concentration of estradiol in the serum during the pubertal stage. The study had two parts: 1) The review of the clinical histories of 145 nulliparous women between 18 and 25 years of age. 57.3% lived with their fathers, while 42.6% had no father, either because of death or separation. The difference between both groups in breast size as well as in the width of the areola was significant. There was also a significant difference depending on whether the separation occurred before or after the girl was 9 years old. 2) The administration of a questionnaire to 90 nulliparous women between the ages of 18 and 25, to establish the intensity of the father/daughter relationship. The results showed significant differences between the intensity of the father/daughter relationship, breast size and width of the areola. There was no significant correlation between the intensity of the relationship and the pigmentation of the areola in either of the two phases.


[CD10(CALLA)-negative acute lymphoblastic leukemia. A group with a bad prognosis].

The results of 188 patients with acute lymphoblastic leukemia, studied between 1985 and 1990, showed that 8 cases were CD10 negative, Dr, and CD19 positive. These findings indicate cell dedifferentiation and poor prognosis. The patients age ranged from 2 to 30 years, with a mean of 11 years. The male/female ratio was 5/3. Lymph node enlargement and splenomegaly were found in the 8 patients. With the exception of one patient in whom leucopenia was present, the white cell counts were always higher than 30,000/dl. The karyotype was studied in four cases, and all of them were hyperdiploid. This is the first report in Venezuela of cases with acute lymphoblastic leukemia - CD 10 negative.


[Renal osteodystrophy in Maracaibo].

In the present work we report the bone histologies obtained from the iliac crest of 49 patients on chronic hemodialysis in Maracaibo. All of them were dialyzed thrice weekly with untreated tap water containing high aluminum (Al) levels. Their mean blood Al levels were found to be higher than 100 micrograms/L. Histomorphometry was used for the diagnosis of the underlying renal osteodystrophic type. Al-staining techniques (Aluminum) were applied for detection of bone Al deposits. Additionally, bone Al content was determined quantitatively by means of graphite furnace atomic absorption spectroscopy. A mixed type of osteodystrophy (type III according to Delling's classification) consisting in the simultaneous presence of hyperparathyroid bone lesions (osteitis fibrosa, OF) and a hyperosteoidosis (osteomalacia, OM) was found in 63.3% of the studied patients. The other patients (37.7%) exhibited a pure osteomalacia (OM). Bone Al deposits at the mineralization front were observed in 70% of cases and were frequently associated with bone pain, spontaneous fractures and skeletal deformities. We conclude that bone biopsy should be performed in all patients presenting bone pain and high blood Al levels.


Anti-diabetogenic effect of fusidic acid in diabetes prone BB rats.

Fusidic acid and its sodium salt (fusidin) are anti-staphylococcal drugs. In vitro studies have shown that they prevent the lymphocyte co-stimulatory activities of the cytokines IL-1 and IL-6 in a manner similar to that of cyclosporin A, and prevent the inhibitory effect of IL-1 on glucose-induced insulin production. As IL-1 and IL-6 are thought to play a role in the pathogenesis of Type 1 diabetes, the aim of this study was to investigate whether fusidin could influence the disease incidence of the spontaneously diabetic BB rat model. Accordingly, a group of 50 BB rats receiving fusidin dissolved in their drinking water were compared to a control group of 55 rats over a period of 200 days. The incidence of diabetes was found to be 52% in the experimental group and 71% in the control group (P < 0.05). The degree of insulitis and the number of islets at histological examination were similar among the non-diabetic animals whereas the diabetic fusidin-treated animals showed a higher degree of islet preservation than the diabetic control rats. The results are highly indicative of an anti-diabetogenic effect of fusidin.


A new player in the antiphospholipid syndrome: the beta 2 glycoprotein I cofactor.

The study of antiphospholipid (aPL) antibodies has been greatly developed in recent years and conclusive evidence now exists concerning the correlation between aPL and clinical signs such as thrombosis, thrombocytopenia, abortion, and fetal loss. Several hypotheses have been put forward concerning the pathogenic mechanism of aPL, but none has received final confirmation from experimental data. Many studies have been devoted to characterizing the antigens recognized by the different aPL autoantibodies and to a cofactor involved in the binding of autoantibodies and phospholipids; this cofactor has been identified as an apolipoprotein, the beta 2 glycoprotein I (beta 2GPI) or APO-H. Direct evidence now exists which suggests that both the beta 2GPI and the phospholipid comprise the epitope to which aPL are directed. On the other hand anti-beta 2GPI antibodies have been identified in sera of patients suffering from SLE and primary Antiphospholipid Syndrome. beta 2GPI is normally present in human plasma/serum and possesses numerous inhibitory functions in multiple coagulation pathways. The amino acid sequence of beta 2GPI has been identified and found to consist of five repeating units that belong to the complement control protein (CCP) superfamily. This development of knowledge related to aPL has followed three steps respectively: 1. the standardization of the techniques of detection: 2. identification of the clinical signs related to the autoantibodies: and finally 3. the discovery of a new player, the beta 2GPI cofactor.


Prevention of miscarriage in antiphospholipid syndrome.

Recurrent adverse pregnancy outcome may be the final result of different causes, including autoimmune diseases, as the Antiphospholipid Syndrome. Antiphospholipid antibodies (lupus anticoagulant and/or anticardiolipin antibodies) were found in 16% of 197 patients with prior unexplained recurrent miscarriages. During our study 22 out of 32 antiphospholipid antibodies positive women became pregnant again. To prevent abortion relapses, 16 of them were treated with acetylsalicylic acid (50 mg x 2/day) and/or fluocortolone (20 mg/day for 5 days/week). Such therapy started as soon as pregnancy was diagnosed in 14 patients. Two patients began the therapeutic regimen during the third month of gestation. Six patients, who didn't accept this therapeutic approach, represent our control group. All the 14 early treated patients ended pregnancy with success. The 2 women that began the therapy later presented abortion relapses. Among the 6 not treated patients, 5 presented spontaneous abortion and only one gave birth to a baby. No side effect was observed neither in treated mothers nor in their babies. In conclusion, even if further studies would be necessary to standardise a therapeutic protocol, our results encourage the clinical care of patients with antiphospholipid antibodies and adverse pregnancy outcomes.


Failure of blood mononuclear cells from human donors with autoimmune haemolytic anaemia to reconstitute severe combined immunodeficient mice.

The use of severe combined immunodeficient (SCID) mice to study humoral responses by peripheral blood mononuclear cells (PBMC) from patients with autoimmune haemolytic anaemia (AIHA) was assessed. Upon transfer to SCID mice, PBMC from normal donors and patients with autoimmune thyroid disease (AITD) produced substantial levels of immunoglobulin (Ig), detectable in the plasma of recipient SCID mice. In contrast, the majority of PBMC from AIHA donors did not produce Ig in recipient mice. The capacity of PBMC to reconstitute SCID mice was not related to the donor's age. In one case, remission of AIHA allowed the donor's PBMC to successfully reconstitute SCID mice, despite the fact that the donor had developed immune thrombocytopenic purpura (ITP). AIHA PBMC were viable by dye exclusion and contained cells in various states of activation, as judged by their IgG secretion profiles when cultured in vitro. The proportions of leukocytes in AIHA PBMC (T to B cell ratios, CD4+ to CD8+ cell ratios and monocytes) were highly variable compared to non-AIHA PBMC. To determine the effect of abnormal lymphocyte proportions on SCID reconstitution, depletion experiments were carried out on normal and AITD PBMC. This work demonstrated a requirement for high T cell numbers, especially CD4+ cells, and minimal B cell numbers for successful reconstitution. CD8+ depletion of PBMC led to increased levels of Ig production in some instances. It is considered that PBMC from AIHA patients have a defect different from that of other autoimmune disorders, which renders them incapable of reconstituting SCID mice.


Suppression of experimental autoimmune uveoretinitis by intraorchidic administration of S-antigen.

Experimental autoimmune uveoretinitis (EAU) induced by immunization of albino Lewis rats with a retinal soluble antigen (S-antigen) has been studied extensively by many workers. An intraorchidic injection of S-antigen 4 days prior to immunization of the animal with the antigen emulsified in adjuvant was found to prevent the onset of the disease. Orchiectomy in 24 hr after the intraorchidic injection did not abolish the effect of treatment. The systemic suppression induced by the orchidic treatment persisted at least for 3 weeks after treatment. In rats that received orchidic treatment, delayed-type hypersensitivity was markedly inhibited but anti-S-antigen antibody levels in the serum were as high as those in immunized rats without orchidic pretreatment. These results indicate that antigen challenge to the testis is a novel method to systemic activation of the immunosuppressive mechanism.


Protection against hyperglycemia in female nonobese diabetic mice treated with 15-deoxyspergualin.

The effects of 15-deoxyspergualin (15-DS), a newly described immunosuppressive agent, have been studied on the development of diabetes in female NOD mice. 15-DS treatment was started two weeks after weaning i.e. at five weeks of age. The mice received either one daily intraperitoneal injection of 15-DS (2.5 mg/kg body weight) or saline for two weeks. The mice were then injected every third day up to eight months of age for evaluation of the diabetes incidence. In another set of experiments the mice were treated up to three months of age, whereafter islet insulin release, islet insulin content and DNA content was measured together with an evaluation of spleen cell proliferation rates. Different spleen cell subsets were studied directly after the two weeks of daily injections. In the saline group 8 out of 9 mice developed diabetes, whereas only 4 out of 11 of the 15-DS treated mice became diabetic (p < 0.05). There was no difference between the groups in islet insulin release in response to glucose, however, the islet insulin release increased after one week in culture. The 15-DS treatment did not affect the insulin or DNA content of the isolated islets or the insulin concentration in the pancreas. No detectable changes in the relative number of CD4+ and CD8+ T-cell subsets in the spleen were seen and there were no obvious differences in splenocyte proliferation rates. The histological examinations of the pancreatic glands showed gradual increasing signs of islet inflammation with age and 15-DS could apparently not prevent this.(ABSTRACT TRUNCATED AT 250 WORDS)


Autoantibodies to the Ro/SSA autoantigen are conformation dependent. II: Antibodies to the denatured form of 52 kD Ro/SSA are a cross reacting subset of antibodies to the native 60 kD Ro/SSA molecule.

The immune response to the Ro/SSA particles is conformation dependent. In sera with only anti-Ro/SSA precipitins, the autoantibodies to the 60 kD Ro/SSA are largely to the native 60 kD Ro/SSA while autoantibodies to the 52 kD Ro/SSA particle when present are exclusively to the denatured 52 kD Ro/SSA particle. Antibodies eluted from a recombinant 52 kD Ro/SSA fusion protein reacted in a sandwich ELISA which only measures antibody to native 60 kD Ro/SSA antigens and this reaction is largely inhibited by native homogeneous 60 kD Ro/SSA. In addition, antibody binding to the 52 kD Ro/SSA antigen in Western blot is also strongly inhibited by native 60 kD Ro/SSA. These experiment strongly suggest that reactivity of denatured 52 kD Ro/SSA antigen represents a cross reaction with autoantibodies directed to the native 60 kD Ro/SSA antigen. As a corollary of these experiments, data are presented that suggest the hY-RNAs are not associated with the 52 kD Ro/SSA protein but only with the 60 kD Ro/SSA protein. These data are consistent with the hypothesis that the autoanti-Ro/SSA response is driven by native 60 kD Ro/SSA and the immune response to denatured 52 kD Ro/SSA is largely a cross-reactive subset of the immune response to native 60 kD Ro/SSA.


The role of capsular antigens in Staphylococcus aureus immunity.

Most clinical blood isolates of Staphylococcus aureus have been shown to be encapsulated. Techniques are now available for the preparation of type-specific capsular antisera and to provide reliable serologic methods for the identification of clinical isolates of Staphylococcus aureus. Epidemiologic studies in the U.S.A. and Europe indicated the prevalence of capsular types 5 and 8 among clinical isolates from human, bovine, and poultry. Encapsulated types 5 and 8 resisted in vitro phagocytosis and specific anti-capsular serum facilitated type-specific opsonization of S. aureus by polymorphonuclear leukocytes (PMN). The structure of the prevalent types 5 and 8 capsular polysaccharides (CP) have been elucidated. Vaccines of CP conjugated to exotoxin A of Pseudomonas aeruginosa have been prepared and have been injected into animals and human volunteers. Antibodies elicated by these conjugates facilitated opsonization of specific S. aureus types by human PMN.


Composition of lipid A in the S and R forms of Shigella dysenteriae serovar 1.

A chemical analysis was performed of lipid A, isolated by acid hydrolysis of the lipopolysaccharide from the S and R forms of Shigella dysenteriae serovar 1. Differences in the moiety of both lipids and sugars were compared. The lipid portion consisted of a homologous series of fatty acids ranging from C12:0 to C18:0 (predominant homologues, C12:0, C14:0 and C16:0) and the homologous series of 3-hydroxy acids ranging from C12:0 to C16:0 (predominant homologue, 3-OH-C14:0). The major sugar portion consisted of D-glucosamine. The toxicity of lipid A in mice (LD50) ranged between 300-400 micrograms/mouse, and values from the Limulus amebocyte lysate assay were recorded as titres of 10(-5) to 10(-6) mg/ml.


Purification of Chlamydia psittaci antigen by affinity chromatography on polymyxin B agarose for use in the enzyme-linked immunosorbent assay (ELISA).

The purification of cell wall antigens of Chlamydia psittaci by affinity chromatography on polymyxin B agarose is described. Chlamydial cell wall antigens were prepared using different methods: heat treatment, ultrasonication and sodium deoxycholate treatment. The antigens were subsequently purified by gel chromatography. The highest amount of cell wall antigens was obtained by heat treatment of the chlamydiae at 90 degrees C and pH 8.5. The purified antigens showed molecular weights of 450 kDa to 700 kDa. Treatment of heat-extracted antigens with trypsin, pronase E or proteinase K did not destroy antigenic activity or alter the molecular weight. On the other hand, potassium metaperiodate treatment led to a significant decrease of both. Chlamydial cell wall antigens extracted by heat treatment and purified by affinity chromatography were used as ELISA-antigen. Using this ELISA and the complement fixation test (CFT), a total of 576 bovine sera was tested. 92 of these sera reacted positively in the ELISA and only 13 in the CFT. In addition, the prepared ELISA was compared with a commercial ELISA. 12 out of 15 sera tested were positive when using the ELISA described and 10 were positive when using the commercial ELISA.


Evaluation of the polymerase chain reaction (PCR) for detection of Chlamydia psittaci in abortion material from ewes.

The polymerase chain reaction (PCR) was evaluated as a diagnostic tool for detection of Chlamydia (C.) psittaci in abortion material from 40 ewes. For this purpose, PCR results of 87 samples were compared with direct microscopic identification after chemical staining, cell culture isolation and a commercially available enzyme-linked immunosorbent assay (ELISA). The value for sensitivity as compared to cell culture was 97.7% whereas the specificity-value was calculated to be 84.1%.


Computer-assisted identification of mycobacteria using code lists--results of a multi-centric study. German Working Group on Mycobacteria.

The frequency of isolation of environmental mycobacteria from clinical specimens has increased significantly in the course of the last years. Assessment of the medical importance of such isolates always depends on a correct identification of any of these strains. In a multicentric study, the efficacy of a standardized, computer-aided system for identification has been evaluated. 13 Laboratories received 24 strains of mycobacteria each and were asked to test all these strains for 16 different features. The results were coded in a standardized way. For the evaluation of these tests, the laboratories were supplied with a list containing all possible codes, which might be indicative of one or another identification. The results proved the logic of the approach. However, the application of the system lead to a correct identification in only 74% of all attempts. It is concluded that such a standardized approach is not useful for mycobacteria, because it requires too much working time and material. It will be more practical to concentrate on a smaller number of tests in the peripheral laboratories, which might allow the identification of M. tuberculosis and a few other species and to leave the definitive identification to reference laboratories. The development of faster, simpler and more reliable methods remains highly desirable.


Spectrum of drugs against atypical mycobacteria: how valid is the current practice of drug susceptibility testing and the choice of drugs?

The in vitro activity of 13 drugs against 552 clinical isolates of atypical mycobacteria representing 12 species was performed in 7H11 agar medium at the National Reference Laboratory for Mycobacteria, using the 1% proportion method. All the species tested were resistant to isoniazid and pyrazinamide. In general, clofazimine and D-cycloserine showed the widest spectrum of activity except in the case of Mycobactrium fortuitum and M. chelonei which were resistant to both drugs, and the M. szulgai and M. terrae complex which was resistant to D-cycloserine. The next broad-spectrum drug was ethionamide, followed by ansamycin, rifampin, capreomycin, kanamycin, streptomycin and ethambutol. Among the fluoroquinolones, both ciprofloxacin and ofloxacin were active against M. xenopi, M. gordonae and M. fortuitum whereas M. kansasii and M. gastri were sensitive to ofloxacin only. When the species were listed in respect of the number of drugs to which they were susceptible (less than 10% of resistant strains), they were classified as follows; 7/13 drugs for M. kansasii, M. gastri and M. xenopi; 6/13 for M. gordonae; 5/13 for M. marinum; 3/13 for M. szulgai; 2/13 for M. fortuitum; 1/13 for the M. avium, M. scrofulaceum, M. simiae, and M. terrae complex, and none of the 13 in the case of M. chelonei. These results are discussed in relation to the multiple drug resistance of atypical mycobacteria. We conclude that the critical concentrations of drugs established for M. tuberculosis are not appropriate for atypical mycobacteria.


Antibacterial in vitro-activity of meropenem against 200 clinical isolates in comparison to 11 selected antibiotics.

The antimicrobial activity of meropenem, a new parenteral carbapenem, was tested in vitro by an agar dilution method against 200 clinical isolates (gram-negative/positive aerobes and anaerobes). Meropenem was compared with imipenem, ceftazidime, cefotaxime, piperacillin, ciprofloxacin, gentamicin; and metronidazole, cefoxitin, chloramphenicol, clindamycin, vancomycin when appropriate. Meropenem and imipenem exhibited an extended spectrum of activity with low minimal inhibitory concentrations (MICs). Only one strain each of Enterococcus faecium and Pseudomonas (Xanthomonas) maltophilia were resistant. Of the carbapenems, imipenem was slightly more active against Enterococcus faecalis, Streptococcus agalactiae, and staphylococci, but meropenem was obviously more active against enterobacteriaceae and Clostridium perfringens. Both, meropenem and imipenem had similar activities towards Pseudomonas aeruginosa, Acinetobacter calcoaceticus, Streptococcus pyogenes and Bacteroides sp. All other antibiotics tested were less potent than the carbapenems with the exception of ciprofloxacin which generally exhibited similar antibacterial activities, except for anaerob microorganisms.


Extracellular deoxyribonucleases of streptococci: a comparison of their occurrence and levels of production among beta-hemolytic strains of various serological groups.

Production of extracellular deoxyribonuclease by 394 strains of beta hemolytic streptococci was examined employing a deoxyribonucleic acid-methyl green assay. Enzymatic activities were measured in supernatants of bacterial cultures. Of the strains tested, 316 (80%) produced the enzyme. Nuclease production was demonstrated in 100% of group A strains and in 85, 74 and 58% of groups B, C and G, respectively. Levels of nuclease activity were then evaluated statistically. The analysis of variance showed that group A strains produced more enzyme than did streptococci of groups B, C or G. Group B strains produced less nuclease than did isolates of groups C or G. There was no significant difference in the levels of nuclease produced by groups C and G or by the various serological types of group B streptococci. Human group C strains produced more enzyme than animal strains.


Prevalence of antibodies to Borrelia burgdorferi in serum and cerebrospinal fluid samples from patients with neurological disorders in Berlin.

Paired serum and cerebrospinal fluid (CSF) samples from 800 patients of a neurological department were tested for antibodies to Borrelia burgdorferi. A flagellum enzyme-linked immunosorbent assay was used for antibody screening. All serum/CSF pairs with any elevated antibody response were also tested by Western blotting a method for confirmation. 65 patients (8.1%) had serum IgG antibodies in ELISA and 22 of these patients (2.8%) were confirmed by Western blot. 20 patients (2.5%) had elevated antibody titres in CSF by ELISA and 12 (1.5%) reacted in the Western blot. Clinical features of Bannwarth's syndrome were present in 12 patients (1.5%) and 4 patients (0.5%) showed other manifestations of Lyme borreliosis. All patients with Bannwarth's syndrome were seropositive by both methods and 10 had elevated antibody activity in the CSF proved by the two methods. The combination of a sensitive ELISA for screening and a sensitive and specific Western blot for confirmation reduced the number of false positive results but kept its standard in detecting antibodies in patients with active disease.


Inflammatory signs, antibody response and antigen detection in cerebrospinal fluid over the course of neuroborreliosis.

CSF and serum specimens were consecutively obtained from three patients with neuroborreliosis (stage I, II and III), CSF protein content, cell counts and differential, IgG index, oligoclonal bands and anti-B. burgdorferi antibodies were measured. Cerebrospinal fluid (CSF) was tested for Borrelia-DNA being present prior to and after antibiotic treatment. While DNA could be identified before ceftriaxone was administered, there were no more amplification products afterwards. The goal of this study was to compare the usefulness of serodiagnostic methods and the detection of Borrelia burgdorferi-DNA in patients with clinically confirmed neuroborreliosis to test the efficiency of antibiotic therapy.


Binding of Lactobacillus reuteri to fibronectin immobilized on glass beads.

Human fibronectin was immobilized on glass beads. The beads were used to evaluate binding of Lactobacillus reuteri to fibronectin. Organisms bound to the glass beads were detected using fluorescence microscopy after treatment with acridine orange. This binding was confirmed and quantified with the use of [3H]-labelled organisms. Three strains of Lactobacillus reuteri, three strains of Lactobacillus acidophilus and one strain of Lactobacillus fermentum were tested for binding capacity. L. reuteri strain 1063 exhibited a strong binding to the immobilized fibronectin, and L. acidophilus 1754 showed a slight binding. The binding of L. reuteri to the fibronectin was mediated by a protein as judged by the absence of binding after treatment of the bacteria with proteolytic enzymes. Treatment of the bacteria with urea, SDS and heat (80 degrees C) also reduced binding. Treatment of the bacterial cells prior to the assay with fibronectin interfered with binding. Albumin did not show this interaction.


Adjuvant properties of Propionibacterium avidum KP-40 in vaccination against endemic viral and bacterial infections. II. Swine immunized with inactivated Haemophilus pleuropneumoniae vaccine and experimentally infected with different virulent serotypes of H. pleuropneumoniae.

Forty 3-month old swine were treated with immunomodulating Propionibacterium avidum KP-40 (PA) and/or vaccinated with a formalin-inactivated mixture of serotypes 1, 3, 5 and 9 of Haemophilus pleuropneumoniae (Pleurovac). Three weeks after revaccination all animals were inoculated with viable single serotypes of Haemophilus pleuropneumoniae. The IgG antibodies induced by vaccination agglutinated all serotypes of Haemophilus pleuropneumoniae, except for serotype 5. Antibody titers were not influenced by the application of PA together with the vaccine. Infection of vaccinated piglets resulted in the development of pleuropneumonia in 8 out of 10 animals, while vaccination together with application of PA lowered the morbidity rate to 1 out of 10 (p < 0.05). The usefulness of a PA prophylaxis was also demonstrated in non-vaccinated piglets infected with Haemophilus pleuropneumoniae. Because of the considerable variability of strains and serotypes of Haemophilus pleuropneumoniae and the generally low prophylactic potency of pleuropneumonia vaccines it is concluded that long-lasting enhancement of non-specific antiinfective resistance caused by PA may lower the risk of endemic infections in vaccinated piglets.


Adjuvant properties of Propionibacterium avidum KP-40 in vaccination against endemic viral and bacterial infections. III. Swine immunized with live attenuated Erysipelothrix rhusiopathiae vaccine and experimentally infected with virulent strains R203 and R270B of E. rhusiopathiae.

Fifty 4-month old piglets were treated with immunomodulating Propionibacterium avidum KP-40 (PA) and/or immunized with live attenuated Erysipelothrix rhusiopathiae vaccine (Orvac). Four weeks after vaccination all animals were inoculated with viable Erysipelothrix rhusipathiae. The vaccine induced the appearance of high titers of specific IgG antibodies with peak values (1:115-1:200) three weeks after immunization. Administration of PA together with the vaccine did not influence antibody titers. Analysis of the course of experimental erysipelas infection in vaccinated and/or PA-treated swine revealed the prophylactic and beneficial effects of PA. PA-treated animals showed a significantly lower lethality rate than untreated controls and the course of the disease was considerably milder, with a shorter period of fever and a faster recovery. Vaccination provided good protection of swine against the development of erysipelas and therefore, the only significant difference in animals treated with PA applied together with the vaccine was a higher gain of body mass after infection.


Detection of tick-borne encephalitis (TBE) virus in Liechtenstein.

In this study, we present the first detection of a focus of tick-borne encephalitis (TBE) virus-infected ticks in Liechtenstein. The focus is located on a much-used forest path near Vaduz, the capital of the principality. The virus isolated is a representative of the Western subtype of the TBE virus. It is thus closely related to or identical with the other strains isolated in western Europe.


Isolation of Mycobacterium simiae from the environment.

An examination of 18 sphagnum samples collected in two different biotopes of the coastal region of southeastern Madagascar revealed an unexpectedly high positivity for mycobacteria (83.3%). The concentration of alcohol acid-fast bacilli reached a high level of 10(5) and 10(6)/g, respectively, compared with the sphagnum biotopes in moderate climates. Besides the habitat-specific mycobacterial species in sphagnum vegetation, like M. sphagni, M. gordonae and M. madagascariense, potentially pathogenic species, like M. avium, M. scrofulaceum and M. xenopi and M. marinum, were found. Furthermore, pathogenic M. simiae was found in sphagnum vegetation of Madagascar, first time isolated in the environment until now. It should be considered as a potential source of infection for human and animals.


[Perimetry equivalents of glaucoma progression].

Loss of sensitivity in chronic open-angle glaucoma is generalized, but heterogeneous. Particular parts of the visual field deteriorate proportionally, which also applies to the spatial behaviour. The proportionality factor and the slope of decay are most pronounced at the nasal and superior border of the field. In single cases, the topography of the field is variable, but it follows the retinal nerve fiber lines. For follow-up, topography seems to be unimportant. A number of standard threshold programs are adequate for this task. For follow-up the same type of instrument and the same program should always be used. The optimal value for analysis in perimetric follow-up is so far unknown. Although progression is often not linear, linear regression seems to be the most suitable statistical procedure. Some new methods of visualization help to process the information like the double representation, GATT, time diagram or the gray-scale bar.


[3-dimensional topographic analysis of the papilla as a component of glaucoma diagnosis].

Three-dimensional topography of the optic nerve head can be objectively described by means of quantitative parameter values. Owing to interindividual variability in the disc configuration, new structural variables, such as the relative height of the peripapillary retinal nerve fiber layer in stereo-videography and height variations in the contour line along the disc border in laser scanning tomography, have been shown to differentiate normal optic discs and optic nerve heads with pathological alterations better than standard volumetric data. Using laser scanning tomography, the effect of age on the parameter values of disc area, rim area and the ratio of the cup-to-disc area was evaluated in 61 healthy subjects (age 14 to 77) who had normal visual fields on computerized static perimetry. The rim area decreased with age (rs = -0.26, P < 0.05); the ratio of the cup area to disc area increased (rs = 0.25; P < 0.05). No relationship was found between patient age and disc area (Spearman correlation). Although the coefficients of correlation are rather small, they may reflect the physiological age-related decline in axonal count. The high resolution of strictly confocal laser scanning microscopy allows for visualization of nerve fiber bundle defects underneath a surface of regular reflectivity. The existence of such hidden nerve fiber bundle defects has been postulated before on the basis of experimental studies and may be an early morphological sign of glaucomatous damage.


[Glaucoma parameters of the papilla. Comparison of clinical and stereophotography methods with laser scanning tomography].

The observations recorded by laser tomographic scanner (LTS) and with clinical and stereophotographic evaluation of 40 optic discs in the same glaucomatous patients were compared. Quantitative parameters (vertical and horizontal cup-to-disc ratio) and qualitative parameters (nasal excavation, notch, pseudo-pit, overpass, bayonetting) were evaluated. The correlation coefficients for the quantitative parameter ranged from 0.59 to 0.73. The definition of excavation used meant that the values found with the LTS were consistently higher. The qualitative parameter did not differ significantly with the method. Therefore, the LTS can be considered equivalent to the standard methods.


[Contact cyclophotocoagulation with the continuous wave Nd:YAG laser with quartz fiber. Optimizing coagulation parameters].

Transscleral cyclo-photocoagulation with a cw-Nd:YAG-laser was studied in enucleated porcine eyes with application times of between 10 ms and 1.5 s. Contact coagulation via a quartz fiber (core 600 microns) required about 32% less power to create visible ciliary body coagulation compared to non-contact coagulation via a focusing handpiece. Application of focusing fiber tips led to a further reduction in the coagulation threshold by a factor of 0.6. The energy per laser application required for ciliary body coagulation increased with application time. During contact coagulation using plane fiber tips a pronounced temperature rise was sometimes observed at the fiber tip due to deposits of carbonized tissue with the subsequent risk of scleral damage. In a pilot study five eyes with secondary glaucoma were treated under coagulation conditions found to be optimal (8 W at 0.2 s).


[Echographic follow-up of the chamber angle in suspected simple glaucoma].

We have recently seen a number of patients with angle-closure glaucoma who had been treated for glaucoma simplex (primary open-angle glaucoma). The main cause of this misdiagnosis was gonioscopy, as its findings are subject to the impression of the examiners. For objective examination of the chamber angle and the iris configuration, B-scan ultrasonography was performed using a contact eye cup filled with saline. Two groups of patients were noted in particular. The first group contained relatively young patients, more men than women, with plateau iris and a central normal, deep anterior chamber. The second group consisted of patients with presumed glaucoma simplex. The findings were quite different between eyes. In the eye with a higher IOP, pronounced optic nerve damage and visual field defect, the chamber angle was distinctly more narrow and closed. Most of the patients were treated with beta-blocker drops, which they felt were agreeable.


[New aspects of surgical treatment of glaucoma. Comparison of viscoelastic substances in chamber angle surgery].

The development of new viscoelastic substances opens up new perspectives for chamber angle surgery under direct view. The success of "Cyclodialysis ab interno" treating children with glaucoma is often reduced by scar formation of the cleft. Therefore four different viscoelastic substances were instilled during an animal experimental study into the cleft and compared in their effect. We used hyaluronic acid with different molecular weight (Healon and Healon GV) and cross-linked forms of hyaluronan as a fluid and a gel (Hylan fluid and Hylan gel). A cyclodialysis ab interno was performed on 14 eyes of cynomolgus monkeys. The functional results (tonometry, outflow facility, autoradiography) and the morphological findings will be presented and their consequences for an extended indication of the cyclodialysis ab interno will be discussed.


[Tarsoconjunctival transposition. Causes, prevention and possibilities for correction of postoperative complications].

The Hughes' tarsoconjunctival flap technique has proved to be a reliable operative procedure for the treatment of large lower-lid defects for more than 55 years. The Hughes' procedure has maintained its importance despite the development of numerous other operations, two reasons for this being that there have now been several modifications to this technique and that the lids do not have to be closed as long. To help the surgeon avoid and eliminate problems and errors in the operative technique we provide details and some useful tricks we have learned over the years while treating over 50 patients. The causes, prophylaxis, and correction of postoperative complications are described for the following: lowering the lid margin; thinning of the lid in the area of the tarsal transposition; lymph edema of the transplant; lid margin defects, and dehiscence of the wound; corneal epithelial defects; trichiasis caused by lanugo hair; keratinization of the lid margin; ectropion of the conjunctiva; retraction of the upper lid, and entropion of the upper lid. If these details are taken into consideration, the Hughes' procedure is a simple operative technique that is free of serious complications and gives good results in the reconstruction of the lower lid.


[Diagnosis and therapy of chronic canaliculitis].

The chronic lacrimal canaliculitis is often overlooked and unsatisfactory treated. The purpose of this long-term study (1978-1991) is to call attention to special bacteriological signs and to give recommendations for proper treatment. 54 patients (39 females and 15 males) in age from 29 to 85 years (average age of 60 years) with a chronic lacrimal canaliculitis were evaluated. "Sulfur granules" were obtained from 32 patients and 54 specimens were collected from 44 patients and processed immediately for aerobic and anaerobic cultivation as well as microscopic investigation. Altogether 100 bacteria could be isolated: 56 anaerobes, 38 aerobes as well as 6 microaerophilic and capnophilic strains, respectively. Members of the genus Actinomyces were the most often isolated anaerobes. They could be detected in specimens of 15 patients by culture and in materials of 4 patients only by microscopic study. 42 from 50 patients were permanently cured by immediate treatment according to our operative procedure despite the splitted canaliculus. The most common cause of chronic lacrimal canaliculitis is a mixed infection. Despite the characteristic clinical symptoms the laboratory evaluation should be done to provide the diagnosis. The surgical procedure leads to a permanent functional healing in a high degree.


[N2 cryotherapy and excision. Indications and limits in eyelid basalioma].

Some ophthalmic surgeons have preferred N2-cryosurgery for many years. Others feel that only excisional surgery should be used. In this article both possibilities are discussed in an effort to facilitate a well-balanced choice. A total of 262 basalioma patients treated by cryosurgery from 1979 to 1988 were evaluated to assess the indications for cryosurgery. The histological findings were taken into consideration, as were the results of other authors. The comparison with histopathologically controlled excisions was based on discussions with users of the Mohs technique, literature, and personal experience. No other technique permits as much healthy tissue to be saved as N2-cryosurgery; this is especially important in the areas of the lid margin and lacrimal pathways. Complete involvement of the tumor edges can be achieved by generous extension of the treatment area and biopsies taken beyond the expected tumor margins and tumor base (subsequent to tunneling and cryosurgery from the basal side). In excisional surgery, the Mohs technique is required. Its advantage is that biopsies can be taken all around the tumor for histology and its disadvantage is prolonged operation time (in ad hoc frozen sections) or delayed wound closure (second or third surgical procedure several days later). This can be avoided in tumors that are suitable for cryosurgery. The Mohs technique, however, is mandatory in deeply infiltrating tumors in which cryosurgery is not indicated. The two methods complement one another. This is supported by the long-term results.


[Gold implantation in lagophthalmos].

In 20 patients with irreversible facial palsy, dynamic voluntary lid closure was achieved by implantation of 0.8-1.6 g gold weights in the upper lid. Because of the high rate of efficiency, low complication rate and technical simplicity, this method is recommended more often than comparable procedures (magnet or wire-spring implantation).


[Documentation of digital dacryocystography using video technique].

Digital dacryocystography is considered the optimal radiodiagnostic method in obstructions of the lacrimal pathways. The examination is carried out by a computer-controlled X-ray unit with a C-arc attached to an image-intensifying TV system. In this way the advantages of this technique and of modern video recording are linked. The bilateral filling process of the contrast medium is recorded and the findings simultaneously recorded on videotape. Consequently, pictures of the dynamic flow are retrievable at any time. This provides good diagnostic documentation and an outstanding basis for any scientific analysis.


[Ewald Hering's opponent colors. History of an idea].

Ewald Hering (1834-1918) was one of the founders of modern visual science. Among his contributions, his color concept gave rise to mostly fruitless controversies, because it appeared to be incompatible with the trivariance of vision theory put forward by Young and Helmholtz. It is now clear that the two color concepts can be reconciled with one another. Hering's theory is based upon an analysis of visual perception. Experience indicates that a conscious subject needs four unique colors in order to characterize perception: blue, yellow, red and green. Usually, two of these hues, but never more, constitute a color sensation, e.g., orange contains red and yellow while blue and green are the components of turquoise. The central idea in Hering's concept was that red and green are opposite hues because they are never elicited simultaneously by a color stimulus; the same is true for blue and yellow. Hering also postulated that the perception of opponent colors is mediated by opponent processes in certain elements of the nervous system, i.e., that there are neurons that respond in a qualitatively different way to spectral stimuli of different frequencies. Today we know that, in fact, the majority of neurons in the retina and the visual pathway is capable of opponent-type responses as anticipated by Hering. It was, however, a long way until his concept was understood and finally accepted by the science community. Among those who helped to acknowledge it were the German physiologist von Kries, the Austrian physicist Schrödinger, the Finnish neurophysiologist Svaetichin, and the American psychophysicists Hurvich and Jameson. In 1906, the German Ophthalmological Society honored Ewald Hering by awarding him the Albrecht von Graefe Medal.


Nursing diagnosis: implications for health, with particular concerns for community nursing.

As nursing terminology develops to include positive health/wellness related concepts, the appropriateness of nursing diagnoses is questioned. Nursing diagnoses have the potential to lead community nurses towards a reductionist and simplistic view of the complexities associated with community issues. Concerns and questions are raised in relation to the acceptance of nursing diagnoses in Australian community nursing practice.


Reform in higher education for nurses: comparative comments from Canada.

This article compares the move of basic nursing education in Australia into the university sector with the status of higher education for nursing in Canada. The influence of nursing unions and nursing associations in nursing education, and the role of human resource planning and development in nursing are addressed. Four major issues confronting university-based education are explored: essential qualities of nursing education, content versus process curricula, transition of faculty into academia, and relationships with other disciplines, especially medicine.


Maternal-infant health beliefs and infant feeding practices: the perception and experience of immigrant Vietnamese women in Sydney.

The purpose of this study was to describe and compare the health beliefs and infant feeding behaviour of Vietnamese women before and after immigration to Sydney. Findings from 20 in-depth face to face interviews conducted in the women's homes revealed that infant feeding behaviour was shaped by the women's beliefs about maternal, infant and family health. Through a process of adaptation these health beliefs had been modified under the influence of the social, cultural, and economic environment of the host country. The findings offer a greater understanding of Vietnamese culture and infant feeding behaviour on which to base nursing intervention programs to promote breast feeding.