Guided bone regeneration of cranial defects, using biodegradable barriers: an experimental pilot study in the rabbit.

The aim of this study was to test if a biodegradable barrier could be used to achieve proper bone healing of full-thickness trephine skull defects, applying the biological principle of guided tissue regeneration (GTR). Two New Zealand white rabbits were used. In each animal, 2 circular through-and-through bone defects with a diameter of 8 mm were created in the midline of the frontal and parietal bones of the calvarium. One defect was covered with the mucoperiosteal flaps without placement of an intervening membrane barrier (control). One test defect (test 1) was covered by a biodegradable, non-porous polylactic acid membrane on the outer (supra-calvarial) side of the defect, and 2 test defects (tests 2 and 3) were covered by similar membranes on both the outer and the inner aspects of the defects, prior to flap closure. 6 weeks postsurgically, the animals were sacrificed and the defect areas including surrounding tissues were harvested for histological preparation. The control defect was essentially occupied by supra-calvarial soft tissue, located in direct contact with the dural tissue. In the test cavities, there was a continuous bridge of regenerated bone extending from one edge of the defect to the other, although in test 1 not attaining the same thickness as the bone bordering the defect. In the 2 other test defects, the regenerated bone had reached a thickness almost corresponding to that of the surrounding bone. The bone regeneration was achieved without recourse to adjunctive bone graft materials.(ABSTRACT TRUNCATED AT 250 WORDS)


The loadability of the 0.8-mm micro-system in thin midfacial regions--an animal experimental study.

The so-called 2-mm systems are well established in the osteosynthesis of the mid-face. Due to the relatively thin soft tissue covering of most of the mid-face, however, the plates and screws of these systems often appear large, and disturb the patient because they are palpable and/or bulge through the skin. To avoid this disadvantage, more delicate systems have been designed. The question arises here, however, whether the more delicate systems could also be applied in thin mid-face regions that experience high functional loads. This study compares the functional loadability of 0.8-mm Luhr and 2.0-mm AO screws in an animal experimental model. Histological evaluation of the implant beds of the loaded screws showed significant differences in postoperative bone remodelling which could be correlated to the systems. Extrapolation of the results to the clinical situation suggests that care should be exercised when using Micro-Systems in highly loaded regions of the mid-face.


Intramuscular onchocercoma. Case report.

Onchocerciasis is characterized by the presence of numerous microfilariae in the skin, formation of subcutaneous nodules and eye lesions that can lead to blindness. We present a case, rather uncommon in our environment, in which an incomplete life cycle of the parasite, led to a single intramuscular nodule. The clinical symptoms and histological features are described, together with the treatment, using Ivermectin.


Different patterns of mandibular fractures in children. An analysis of 220 fractures in 157 patients.

157 paediatric patients with a total of 220 mandibular fractures were evaluated retrospectively. All patients had been examined with the aid of orthopantomography. 72% of the children had fractures in the condylar region. The patients were divided into four age groups according to the development of the dentition (group A: 0-5 years, B: 6-9 years, C: 10-12 years, and D: 13-15 years). Bicycle accidents and falls were the two main causes of the fractures in all age groups. However, there were significant differences in the causes and location of the fractures between groups A+B and C+D. The proportion of condylar fractures decreased and the proportion of body and angle fractures increased with increasing age; fractures in the horizontal part of the mandible were mainly observed in groups C and D. Both aetiological factors and fracture patterns in the patients older than 10 years of age resembled those of adults. The differences observed should be taken into consideration in studies concerning mandibular fractures in paediatric patients. In this respect the age limit between the adult and child should probably be lowered significantly.


Disturbances of smell and taste after high central midface fractures.

Estimation of the senses of smell and taste in patients who had suffered a high central midface fracture between 1979 and 1989 was carried out. 180 of these patients were operated on for repositioning and fixation of their fractures. A written questionnaire was sent to 165 living patients, 109 individuals responded, a response rate of 66%. Of these patients, 38% claimed to suffer impaired ability to smell and 23% not to taste well. 64% mentioned unconsciousness after the trauma. With rising seriousness of the trauma, more disturbances of smell are found: from 25% of the nasal fractures, to 80% of the fronto-nasal-Le Fort fractures. In more than half of the cases of disturbance of smell, a simultaneous impairment of taste was reported. It can be concluded that disturbance of smell most often appears after fronto-maxillary and fronto-nasal fractures. However, the higher and more extensive the fracture is, the more frequently is unconsciousness reported. Consequently, impairment of smell can be attributed to the fracture itself, but also to a cerebral lesion located more proximally.


Hibernoma: unusual location in the submental space.

A 40-year-old woman with a hibernoma, of unusual location in the submental space is described. The patient presented with a submental space mass, without other associated symptoms. There was no recurrence after a 4 year follow-up.


Maxillofacial trauma: influence of HIV infection.

Between 1986 and 1990, 171 patients with mandibular and 129 with mid-face fractures were treated in our service. Both groups were separated into patients with HIV infection and patients without HIV infection. We carried out a retrospective review of these cases. The incidence of HIV+ve patients was higher in the mandibular fracture group (19.8%) than the group with mid-face fractures (7.75%). The most important aetiology of fractures was violence and the HIV infection was acquired through intravenous drug use (heroin). HIV infection was an independent associated factor where there was concomitant infection of mandibular fractures but not in mid-face fractures. In mandibular fractures, preoperative infections were significantly higher in HIV+ve patients (26.4%) than HIV-ve patients (6.5%) (p < 0.0001). Postoperative infections were higher in HIV+ve cases than HIV-ve cases, but this difference was not statistically significant (p > 0.05). Miniplates were a good osteosynthesis medium in HIV+ve patients and intermaxillary fixation seems to increase the infection rate in the HIV+ve group. The infections were treated with antibiotics with excellent results in preoperative infections and in the majority of postoperative cases, in both HIV+ve and HIV-ve patients.


Aneurysmal bone cyst of the maxilla--an association with tooth resorption.

The aneurysmal bone cyst is an uncommon lesion of the jaws. Cases involving the maxilla have been reported infrequently. Despite uncertainty as to the aetiology of the aneurysmal bone cyst, it is regarded as a benign lesion. Conservative surgical treatment with regular postoperative follow-up is recommended. The case described here presented with tooth mobility resulting from extensive root resorption. A review of the literature reveals that significant root resorption is not a commonly reported feature of aneurysmal bone cysts. For the present case we interpret the evidence as supporting a diagnosis of idiopathic root resorption complicated by the formation of a aneurysmal bone cyst.


Extrusion of a microplate: an unusual complication of osteosynthesis.

A case is presented of an unusual complication of internal fixation of a midfacial fracture; the spontaneous extrusion of a microplate.


Further development of titanium miniplate fixation for mandibular fractures. Experience gained and questions raised from a prospective clinical pilot study with 2.0 mm fixation plates.

Miniplate systems are often used instead of more rigid systems for the treatment of mandibular fractures. While the most stable fixation method for all mandibular fractures is the 2.7 mm plate, most fracture sites and types are eminently suitable for miniplate fixation via an intraoral approach. However, the relatively low stability of the miniplate systems compared with rigid plate systems limits the indications for their use in mandibular fracture treatment, especially when immediate postoperative function is desired. A more rigid miniplate which provides increased stability was studied. The results of a preliminary study and a clinical trial of a 2.0 mm titanium miniplate system are presented in this paper. The therapeutic consequences of the lesser stability afforded by small plate systems are discussed. Indications for miniplate fixation without additional immobilization are reviewed.


Epidermoid cyst in the temporomandibular joint after a dermal graft.

A very rare case of epidermoid cyst of the left temporomandibular join (TMJ) after a dermal graft inserted as the interposing material in the surgical correction of TMJ ankylosis is presented. Two years after the surgery, a cystic lesion the size of a walnut was observed in the TMJ region. The cyst contained an odorless, straw-coloured mucoid fluid and a wall lined by stratified squamous epithelium containing orthokeratin. It contained no hair follicles or sweat glands.


Anatomical study of the valves of the superficial veins of the forearm.

The valves of the cephalic, basilic and median cubital veins were investigated in the superficial veins of the left forearm in 9 cadavers, aged 25-95. The radial forearm flaps involving these veins are of special clinicoanatomical importance. The following results were obtained: (1) Valves were most frequently evident at Site G of the cephalic vein. No valves were present in Section A-B, (2) type B valves were located at confluences, junctions and branches and were more frequent (54.7%) than Type A (45.3%) located in the straight trunks of superficial forearm veins, (3) Type 2 valves accounted for most (82.3%), and these were followed by Type 1 and Type 4b (5.9%), Type 4a (4.4%) and Type 3 (1.5%).


A new condylar positioning technique in orthognathic surgery. Technical note.

In two-jaw surgery, special importance must be attached to the maintenance of the condylar position, particularly in combination with rigid fixation, not only to enhance the stability of the post-operative result but also to avoid iatrogenic temporomandibular joint complications. The new positioning method reported herein is based on a mini fragmentation plate, which can be easily adapted to the bone surface. Reinforcement of the plate by autopolymerizing acrylate, injected into a silicone tube which is pushed over the plate, prevents any unnoticed deformation of the positioning device during surgery. In clinical use, this positioning method has proved to be more versatile and technically less difficult to perform than previous techniques, without any decrease in reliability.


Surgical treatment of exophthalmos and exorbitism: a modified technique.

A modified surgical technique for the treatment of exophthalmos caused by Graves' disease or meningioma is presented. It is based on the orbital expansion as presented by Tessier (1969). It consisted of a lateral marginotomy with extension to the superior and inferior orbital rim and removal of the great wing of the sphenoid bone. The osteotomised orbital rim segment was advanced and stabilised by interposition of a calvarial bone graft. Concomitant lipectomy was carried out when indicated. Seven patients were operated on. No major complications occurred. The advantages of the method are discussed.


Dermatography, a treatment for sequelae after head and neck surgery: a case report.

Two patients with discolouration fo skin grafts after head and neck surgery, were treated with dermatography, a refined method of tattooing, and with intra-cicatricial keloidectomy, of which the results are described.


Reconstruction of full-thickness cheek defect affecting the oral commissure by galeal skin island flap: a case report.

This article describes the use of the galeal skin island flap in the reconstruction of a full-thickness cheek defect affecting the oral commissure, created after radical surgery in a 60-year-old patient suffering from carcinoma of the cheek. Advantages and drawbacks of the described technique are discussed.


Doubling time of ameloblastoma metastasizing to the lung: report of two cases.

Two cases of malignant ameloblastoma with metastases to the lungs are reported. One originated in the mandible and the other in the maxilla. The doubling time of the metastatic lesions to the lungs were calculated according to Collins' method, and ranged from 129 to 201 days.


Recurrent otitis media and parenting stress in mothers of two-year-old children.

This study examined the impact of recurrent otitis media on mothers' perceptions of themselves and of their 2-year-old children. Fifty-two mothers of children with and without histories of recurrent otitis media completed measures that rated the level of stress in the mother-child relationship at two points in time. The mothers of children who experienced six or more episodes of otitis media in the first 2 years of life rated their children as significantly more demanding at age two and at follow-up 6 months later than did the mothers of children who experienced no more than one episode of the illness. At the first point in time, these mothers also rated themselves as significantly more depressed and less competent than did control mothers, a pattern that was maintained at the follow-up. Findings of the study suggest that recurrent otitis media early in life may contribute to adverse perceptions of child and self that may persist for some time after the child has been relatively disease free and further suggest that parental perceptions may mediate relationships between early recurrent otitis media and later developmental outcomes.


Pattern of night waking and crying of Korean infants from 3 months to 2 years old and its relation with various factors.

Night waking and crying are very common in infancy and can cause problems for parents and families. This study surveyed 218 healthy Korean infants from 3 months to 2 years old to determine their night waking and crying patterns. On average, 83% awoke and 28% cried more than once per night. Ninety-eight percent of the babies slept with a member of the family. Infants with transitional objects or nighttime habits (e.g., finger sucking, touching and/or playing with mother's or own hair, touching a part of mother's or own body) cried more frequently. In terms of the maternal response toward the crying babies, most of the mothers used traditional methods, such as patting/holding, feeding, changing diapers. Only one mother ignored the crying baby, and none used medication, delayed response, or white noise. Sixteen percent of the mothers indicated that their babies' crying constituted a problem for them.


Cognitive patterns in school-age children with end-stage liver disease.

Although children with end-stage liver disease (ESLD) have been found to have cognitive delays, the relationship between patterns of cognitive function and diagnostic category, age of onset, duration and severity of disease has not been assessed before transplantation. Verbal and performance IQ (VIQ, PIQ) scores and scores on Bannatyne's cognitive factors for 43 children with ESLD were compared with those of 15 control children with cystic fibrosis (CF) and with existing normative data. Children with biliary atresia had deficits in PIQ, spatial and sequential scores. Children with alpha-1 antitrypsin deficiency did not differ significantly from CF controls but did show deficits compared with normative data. Children with onset of disease in the first year of life had deficits on all cognitive measures compared with both control groups. In contrast, children with later onset differed from the normative population only on VIQ and the acquired knowledge factor. In multiple regression analyses, duration of disease and indexes of liver dysfunction combine to predict cognitive scores. These preliminary findings suggest that children with early onset of liver disease are at high risk for cognitive impairment.


Casualties from a junior-senior high school during the Persian Gulf War: toxic poisoning or mass hysteria?

Mass hysteria is a bizarre and uncommon epidemic phenomenon. The usual victims are adolescent females and school settings are frequent. The epidemics are characterized by the rapid onset of a constellation of symptoms and signs which resolve quickly in the absence of abnormal laboratory results and physical findings that confirm a specific organic cause. It is common, however, for unexpected laboratory results to cause confusion and promote controversy about suspected etiologies. These outbreaks are often noted to be associated with periods of uncertainty and social stress. We describe an epidemic involving the explosive onset and rapid resolution of a constellation of symptoms that sent 17 seventh and eighth grade students and four teachers to the emergency department of a hospital after an apparent toxic gas exposure. Mildly elevated carboxyhemoglobin levels (for nonsmokers) in some patients raised concern that there had been exposure to excessive levels of carbon monoxide. Although no specific unusual stress could be identified at the school, the event took place 3 1/2 weeks after the beginning of the Persian Gulf War.


Psychosocial stressors and low birth weight: development of a questionnaire.

Low birth weight is a major public health problem because it is a major contributor to infant mortality as well as to various types of morbidity among young children. Of particular concern is that black women have an increased risk of low birth weight babies compared with white women. Many etiologic factors for low birth weight have been identified, but even within homogeneous strata of risk, black women have a greater risk of low birth weight babies than do white women. The reasons for this excess risk are not well understood. Available evidence suggests that exposure to psychosocial stressors is associated with adverse pregnancy outcomes. However, prior work in this area has been limited by the lack of a valid and reliable tool to assess exposure to stressors among pregnant women. We report on the development and testing of such a questionnaire, the Prenatal Social Environment Inventory. In this questionnaire, exposure to stressors is conceptualized and measured in the context of chronic stressful conditions. The questionnaire is self-administered and can be used in clinical settings with pregnant women. Findings of psychometric evaluations showed that the questionnaire has acceptable levels of 30-day temporal stability (reliability), internal consistency, and construct validity.


Early onset intractable seizures: nonverbal communication after hemispherectomy.

The nonverbal communication skills of 10 children (mean age = 44.2 months) who underwent hemispherectomy for early onset intractable seizures were tested before and after surgery. A within-group analysis suggests that the 10 seizure-free children used more nonverbal communication after a mean follow-up period of 11.2 months than before surgery. Young normal language age matches were available for the 4 older and higher functioning subjects in the sample. Before surgery, the surgical subjects used less requesting gestures than did the normal children. After surgery, these differences were no longer apparent. The patients also employed more gestures to focus an adult's attention on objects and events than language-age-matched normal children. The children who underwent left or right hemispherectomy used similar nonverbal communication behaviors. The study's findings suggest that children with early onset intractable seizures have impaired early social communication that improves to some extent after hemispherectomy.


Can learning disabilities in children who were extremely low birth weight be identified at school entry?

This prospective study was designed to test the hypothesis that a significant proportion of extremely low birth weight (ELBW) children identified as "at risk" for school problems at age 5 years by the Florida Kindergarten Screening Battery (FKSB) will present with specific learning disability (LD) when retested at age 8 years. A regional cohort of 81 of 84 ELBW survivors born between 1980 and 1982 were reassessed at age 8 years by Wechsler Intelligence Scale for Children-Revised (WISC-R), Wide Range Achievement Test-Revised (WRAT-R), and tests of motor function. The association of FKSB risk status and WRAT-R reading subtest for predicting general reading disability in the overall sample at age 8 years resulted in a sensitivity of 0.68, specificity of 0.48, and a likelihood ratio of 1.3. Of the 43 "normal" children at age 5 years with no neurosensory impairments and IQ > or = 84 (McCarthy GCI), 49% were considered to be at "mild" to "high" risk for future LD. The prevalence of specific LD (reading disorder) at age 8 years in children with normal IQ (WISC-R > or = 85) was 28%. The positive predictive value of the 5-year FKSB for identifying children with specific LD at age 8 years was 0.20 (sensitivity 0.33, specificity 0.48). We conclude the FKSB is not an efficient tool for predicting either general or specific LD in ELBW children.


The prevalence of joint noises as related to age and gender.

The interdependence of joint noises on age and gender was studied mixed-longitudinally in orthodontically treated subjects from 7 to 38 years of age. The prevalence of clicking signs and symptoms increased up to 25 years of age and leveled thereafter. Around age 19, a significant gender difference was present in clicking symptoms, with females reporting more clicks. The same pattern, although not significantly, was present for palpated clicks. Since male and female clicking prevalences are the same before and after adolescence, and since girls mature at an earlier age than boys, it is concluded that these noises reflect a maturity level rather than a multifactorial disorder. The prevalence of crepitation continued to increase slowly.


Predicting response to treatment for temporomandibular disorders.

This study examined whether pretreatment psychological characteristics of temporomandibular disorder (TMD) patients were related to the response to treatment in a TMD and facial pain clinic. The care provided to patients was either an evaluation only or an evaluation followed by a course of physical medicine/dental procedures (occlusal appliances, physical therapy, anti-inflammatory medications). Outcomes were assessed in terms of pain levels, jaw function difficulties, and satisfaction with care at 6 months posttreatment by phone and 16 months posttreatment by mail. There were no pretreatment differences between treated and evaluated patients except for higher pretreatment jaw function difficulty scores in the evaluated only patients. Factor analysis of pretreatment scores revealed distrust, pain, anxiety, and somatization. Somatization predicted follow-up pain levels at both follow-ups in the treated patients but only at the 16-month follow-up in the evaluated only patients. Pretreatment pain levels predicted posttreatment pain in both groups only at the 6-month follow-up. Posttreatment jaw function difficulties were related inconsistently to the pretreatment dimensions, while satisfaction was not predicted by pretreatment scores except for a possible connection between this outcome and distrust. It is concluded that an overconcern about bodily functioning appears to decrease the likelihood that patients obtain pain relief from physical medicine care.


Anatomical relationships and superior reinforcement of the TMJ mandibular fossa.

Only a few cases of condylar penetration into the middle cranial fossa have been documented in the literature. This study attempts to provide an anatomical explanation for this rare phenomenon. Mandibular (glenoid) fossa position in relation to important endocranial and exocranial structures located in close proximity to the TMJ, and relative condyle-fossa size, were evaluated on a dry skull sample. Additional osseous relationships were observed on cadaver material using dissection and x-ray. The anatomic relationships of the mandibular fossa and superior structures that appear to buttress it are described. It is concluded that the temporal squama that lies superior to the mandibular fossa provides a powerful buffer, which prevents condylar endocranial penetration in cases of an appropriate traumatologic mechanism.


Changes in mandibular masticatory movements after insertion of nonworking-side interference.

To investigate the influence of nonworking-side interferences on mandibular masticatory movements and signs and symptoms of dysfunction of the masticatory system, an experimental balancing-side interference was introduced in 12 healthy subjects for 1 week. The individual response to the interference varied substantially. However, some of the movement variables were significantly changed immediately after insertion, but an adaptation of the neuromuscular system to the interference was evident at the end of the experimental period.


Sleep movements in teethgrinders.

To investigate the nocturnal motor activity associated with teethgrinding, 12 patients and 12 controls were recorded during sleep with the masseter muscle electromyogram (EMG) and the static charge-sensitive bed movement sensor. The frequency of body movements per hour was 21.4 in the teethgrinders and 14.0 (P less than .05) in the control group. The movement time was 87.4 seconds per hour in the teethgrinders and 55.2 seconds per hour (P less than .01) in the controls. The differences were most obvious in the body movements with temporal association to EMG elevation during the first stage of sleep. The number of isolated EMG elevations showed great interindividual variation and did not differ between groups. The teethgrinders complained more frequently of delayed sleep onset and daytime tiredness. The data suggest that the motor disturbance of teethgrinding is not limited to masticatory muscles but is manifested also as increased general body movement activity.


The size and distribution of fiber types in jaw muscles: a review.

Histochemical enzyme reactions and physiological recordings of limb and jaw muscles have independently revealed three to five types of muscle fibers. Surprisingly, type II fibers are smaller than type I fibers in major human jaw muscles. This is the opposite of the situation in limb muscles. Human jaw muscles contain mixed fiber types. Type I fibers predominate in lateral pterygoid and type II fibers in digastric muscles. The masseters in carnivorans and rodents contain mainly type II fibers, whereas those of some herbivorans, including rabbits and bovids, contain mainly type I fibers. Attempts were made to describe the functional significance of some observations.


Observer variation in functional examination of the temporomandibular joint.

Agreement between observers classifying TMJ sounds from data given in records of nonpatient adolescents was almost perfect in this interobserver study. Intraobserver and interobserver agreement in classifying all specific TMJ sounds at palpation and auscultation was acceptable to moderate (kappa value = 0.49 to 0.74). The agreement was considerably more reliable when classifying only one specific TMJ sound. Measurements of linear jaw opening showed small interobserver differences (coefficient of variation = 2.4 to 3.8). The significant difference found in calculating the angular mandibular opening may be the result of difficulties in maintaining maximum passive opening.


Acute closed lock in a patient with lupus erythematosus: case review.

Collagen failure has been shown to result in synovitis, joint adhesions, and internal joint derangement. This case report illustrates the similarities between patients with systemic lupus erythematosus and an internally deranged temporomandibular joint and patients with internal derangement with no lupus erythematosus. If abnormalities in intra-articular collagen tissue lead to adhesion formation and restrict normal mobility during translatory movements, joint mechanics would be compromised. Arthritic changes, vasculitis, and synovitis of systemic lupus erythematosus appear to be contributory factors in this pathophysiologic process. Diagnostic and therapeutic arthroscopic surgery was performed. Acute and chronic signs of synovitis were observed during surgery, and tissue samples were obtained for histologic interpretation.


Symptom reporting in temporomandibular joint clicking: some theoretical considerations.

Analysis of research on psychological aspects of temporomandibular disorders suggests that self-reports of symptoms do not constitute reliable instruments for the measurement of physiological processes. In TMJ clicking, the actual physiological signal can be measured and compared with self-reports of the sounds. In this article a model is presented to describe perception, interpretation, and reporting of TMJ sounds. Three questionnaires are presented that measure aspects of these psychological processes. Recommendations are made for future research.


Validation of PTSD measures for older combat veterans.

This study evaluated three nosologically similar older groups (Older PTSD, POW, and Older Psychiatric) and a group of Younger PTSD veterans from Vietnam. Group membership was derived from index admission diagnoses and clinical validation of status. Groups were compared on the MMPI, PTSD measures, background variables, health measures and an outcome measure. Results showed that the Older PTSD group is closer to the Younger PTSD group than to the other groups on the MMPI and PTSD measures and also that members of this group remain in the hospital longer than do members of the other older groups. Parameters of effective test classification showed the PTSD measures to be helpful in correct identification of this disorder for the older groups.


Familiarity and anticipation of negative life events as moderator variables in predicting illness.

A 10-month longitudinal study with 79 university students examined the role of positive and negative life experiences on the subsequent development of health problems. The Life Experiences Survey (LES; Sarason, Johnson & Siegel, 1978) was modified to measure the potential role of five moderating variables on illness. Students gave monthly reports of life events experienced, as well as health status, on the Seriousness of Illness Rating Scale (Wyler, Masuda & Holmes, 1968). Results indicated that both positive and negative life events were predictors of subsequent health problems. Negative life events that were familiar to the students and were unanticipated proved to be significant moderator variables; both factors were significant predictors of the number of health problems subsequently experienced.


Psychological factors in the long-term prognosis of chronic low back pain patients.

This study appraised the significance of psychological factors in the long-term prognosis of patients with chronic low back pain (LBP). The MMPI ratings of 80 long-term sick-listed LBP patients were set in relation to their disability pension status 6 to 12 years later. The number of elevated scales, in combination with the level of certain scales (HS and HY), proved to be a better predictor than profile patterns, advocated in some studies. Moreover, in a review of prognostic studies, the HS and HY scales appeared most frequently as significant predictors. That result also was confirmed in this study of long-term prediction of overall functional level. The results are discussed in relation to the concepts of pain-fear and sick role.


A construct validation study of the Haan defense scales.

This study tested the validity of the Haan (1965) psychological defense scales, which have shown promise for clinical and research assessment. Three subject samples participated: ex-inpatients (n = 80) from a longitudinal high-risk project, their spouses (n = 104), and private college students (n = 124). Valid defense scales were predicted to show a specific pattern of correlations with MMPI ego-strength and standard scales across all three cohorts, with measures of symptoms among the ex-inpatients, and with overall severity of pathology for all groups in a pattern consistent with Vaillant's defense model. The regression scale showed excellent validity, and projection received equivocal support, but the other scales were not validated. Denial appeared to reflect psychological health.


The location of items of the Wiggins Content Scales on the MMPI-2.

The decision to exclude the Wiggins Content Scales from the MMPI-2 has hindered and, in many cases, may have prevented the ability to utilize the data collected over 25 years. There are questions with regard to the interpretation of some of the newer content scales of the MMPI-2, whereas most clinicians feel comfortably familiar, even if not entirely satisfied, with the Wiggins Content Scales of the MMPI. This report identifies the location and direction for scoring of items from the Wiggins Content Scales that appear on the MMPI-2. Preliminary data are presented and recommendations for utilizing these scales are offered.


Naivete and need for affection among pedophiles.

MMPI scores for items on the Harris and Lingoes (1955, 1968) subscales HY2 (need for affection) and PA2 (naivete) were compared among pedophiles (n = 50), non-sexually deviant psychiatric patients (n = 25), and a general control group (n = 50). Results indicated that pedophiles did not demonstrate a "naive need for affection," but, rather, a cynical need for affection. Scores on the Pedophelia (PE) Scale (Toobert, Bartelme, & Jones, 1959) also were compared, and no significant differences were found between the pedophiles and either control group, although a difference was found between the scores of the psychiatric control group and those of the general sample. Selected items from scale 4 (Psychopathic Deviate) and scale 9 (Hypomania) also produced no significant differences among groups.


Clinical construct validity of the Holden Psychological Screening Inventory (HPSI).

With a sample of 64 adult psychiatric patients, we examined the construct validity of the Holden Psychological Screening Inventory (HPSI) for a clinical population. Factor analysis supported the three-dimensional nature of the HPSI and the appropriateness of the instrument's scoring key. Reliability information confirmed the internal consistency of the inventory's scales. Clinical staff ratings were used as criteria, and analyses indicated that HPSI scales demonstrated convergent validity. Overall, findings extend previous nonclinical research on the HPSI and suggest that the instrument possesses construct validity for clinical applications.


Age differences in self-reported symptoms of psychological distress.

Some investigators have found higher levels of distress in late adulthood, but others have reported no differences between younger and older adults or even lower levels of distress in their older samples. In the present investigation, a sample of adults who had attended the same university and ranged in age from 22 to 86 were asked to complete the Brief Symptom Inventory. Subjects were divided into four age cohorts, and analyses were conducted to determine age-related differences in the reporting of symptomatology. Older adults were more likely than younger adults to report symptoms that reflected distress over physical ailments and memory problems, but young adults were more likely to report symptoms of a primarily psychological nature.


The clinical application of the Psychopathy Checklist-Revised (PCL-R) in a prison population.

Psychopathy ratings that employed the PCL-R (Hare, 1985, 1991) were compared in one clinical and three research samples (total N = 285). Differences among the samples were not related to whether ratings were completed under the expressed promise of confidentiality of a research context vs. a pre-parole psychological assessment. The problem of decision errors in prediction is highlighted to address the difficulty in integrating the PCL-R into correctional policy. General issues related to the clinical application of the PCL-R also are discussed.


Faking specific disorders: a study of the Structured Interview of Reported Symptoms (SIRS).

An untested assumption of malingering research is that persons who feign mental illness will not attempt to fake a particular disorder, but will be content to fabricate non-specific and possibly global psychiatric impairment. We tested the effectiveness of the Structured Interview of Reported Symptoms (SIRS) to detect feigning of three diagnostic groupings: schizophrenia, mood disorders, and PTSD on 45 psychologically knowledgeable correctional residents. We found that the SIRS maintained its powers of discrimination with respect to clinical samples. Similar research on faking specific disorders is needed on the MMPI-2 and other psychological measures.


Styles of psychological adjustment in diabetes: a focus on key psychometric issues and the ATT39.

While knowledge of the biomedical factors in diabetes has grown in a steady and systematic fashion over the past 60 years, attempts to define, measure, and understand the relevant psychological constructs have only begun recently. In particular, there is need for psychometrically sound tests to tap these dimensions. This study examined the psychometric characteristics of the ATT39, a promising measure of psychological adjustment to diabetes. The results, based on three patient samples and using the FACTOREP factor-matching procedure, suggested that the ATT39 has a large single factor only. This new subscale appears clinically to measure the integration of diabetes and its treatment into the lifestyle and personality of a patient with diabetes.


An evaluation of various WAIS-R factor structures in a psychiatric sample.

This report examines the factor structure of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) in a sample of 229 psychiatric patients from two community mental health centers (ages 16 to 85). One-, two-, and three-factor solutions were evaluated. The robustness of an overall intelligence dimension was supported. The two-factor solution proved more informative and showed both that the Verbal and Performance domains are highly correlated and the presence of a second-order factor that may represent a kind of intellectual orientation or style. The three-factor solution provided the least compelling results and was not seen as a viable representation of the WAIS-R factor structure.


Neuropsychological battery choice and theoretical orientation: a multivariate analysis.

In order to investigate the tests selected by neuropsychologists to make up clinical batteries, a large survey of neuropsychological test usage was cluster analyzed. This provided groupings of tests that are endorsed in common. Theoretical orientation within neuropsychology also was included in the analysis to determine which tests and clusters of tests are more and less associated with the reported orientation of the neuropsychologist. Fifteen clusters of tests were found. Strong and appropriate associations with the eclectic, hypothesis testing, process approach, Halstead-Reitan, Luria, and Benton orientations were seen.


Correlates of medical compliance among hemophilic boys.

Twenty-nine males with hemophilia completed the Medical Compliance Incomplete Stories Test (M-CIST), and their scores were correlated with health care professionals' ratings of four aspects of medical compliance, along with measures of possible moderating variables. The results indicated that significant associations were found between most of the M-CIST category scores, particularly the Compliance/coping subscale, and the health care specialists' ratings of how well the children exhibited compliant responses to bleeding episodes, and inverse associations with the incidence of monthly bleeding episodes. The findings suggested that the M-CIST continues to demonstrate promise as an instrument to be used in studies of compliance among pediatric chronic illness patients.


Efficacy of MMPI-2 validity scales and MCMI-II modifier scales for detecting spurious PTSD claims: F, F-K, Fake Bad Scale, ego strength, subtle-obvious subscales, DIS, and DEB.

This study compared 119 personal injury claimants' scores on MMPI-2 and MCMI-II malingering scales. Data from 55 pseudo-PTSD patients and 64 controls confirm the utility of the scales examined. The following cut-offs were most effective for identifying spurious PTSD: F greater than 62, F-K = greater than -4, Es = greater than 30, FBS = greater than 24 (men), FBS = greater than 26 (women), total obvious minus subtle = greater than 90, DIS = greater than 60, and DEB = greater than 60. Pseudo-PTSD patients were those who (1) claimed to be suffering a psychological injury (2) that was so severe that it was disabling (3) due to an experience that was entirely implausible as a candidate for PTSD criterion A in DSM-III-R and (4) scored T = 65 or higher on both PK and PS, the post-traumatic stress disorder subscales of the MMPI-2.


Visual improvement after transethmoid-sphenoid decompression in optic nerve injuries.

Transethmoid-sphenoid decompression has been performed on 11 patients with indirect optic nerve injury. Visual improvement occurred in 8 patients, including 4 patients with initial total blindness. Optic neuropathy improved even when there was a long interval, up to 92 days, between trauma and decompression. There is still controversy about the treatment of traumatic optic neuropathy. Our results suggest that surgery can be helpful in the management of this condition. Transethmoid-sphenoid optic nerve decompression is a minimally invasive procedure that gave, in this series, satisfactory results with low morbidity.


Sixth nerve palsy as the initial presenting sign of metastatic prostate cancer. A case report and review of the literature.

Cranial nerve palsies secondary to metastatic prostate cancer are uncommon occurrences. Usually appearing late in the course of the disease, they are associated with a poor prognosis. We report a case of a 71-year-old man who initially complained of diplopia and was found to have a right sixth nerve palsy and hyperdeviation caused by a mass in the clivus. Biopsy of the mass and extensive systemic workup revealed metastatic adenocarcinoma of the prostate gland.


Chronic idiopathic inflammation of the retropharyngeal space presenting with sequential abducens palsies.

We describe a patient who presented with sequential, bilateral abducens palsies associated with a mass of the nasopharynx. Biopsy of the mass showed chronic non-specific inflammation and fibrosis. The diagnosis of idiopathic inflammatory pseudotumor was arrived at by exclusion of other known causes of inflammation of the retropharyngeal space. Magnetic resonance imaging suggested that injury to the sixth cranial nerves probably occurred as they traversed the dura and subarachnoid space overlying the clivus.


Papilledema and intraspinal lumbar paraganglioma.

Optic nervehead swelling is most frequently caused by ocular or intracranial lesions. The case presented here demonstrates that the spinal subarachnoid space must also be considered as a potential site for a lesion causing optic nervehead swelling. A 56-year-old man is presented with an intraspinal lumbar paraganglioma associated with increased cerebrospinal fluid protein, papilledema, transient obscurations of vision, and back pain. This may be the first reported case of a paraganglioma associated with optic nervehead swelling. Magnetic resonance imaging of the lumbosacral region revealed the lesion noninvasively. The papilledema, transient obscurations of vision, and back pain resolved after resection of the tumor. The mechanisms are not defined for optic nervehead swelling in association with spinal tumors in general and paraganglioma in particular. The measured abnormal elevation of cerebrospinal fluid protein may have resulted in increased intracranial pressure and papilledema.


High myopia causing bilateral abduction deficiency.

We present two cases of degenerative myopia with abduction deficiency. Three mechanisms can explain the defect in the abduction: (a) the size of the long globe filling the space of the orbits, (b) the tightness of the medial recti due to long axis of the globe, and (c) longstanding esotropia becoming decompensated later in life. We believe that high myopia is not a well-known cause of abduction deficiency, and it should be considered in the differential diagnosis.


Interstitial keratitis and iridoschisis in congenital syphilis.

Bilateral interstitial keratitis and iridoschisis are reported in four cases with extraocular stigmata of congenital syphilis and positive syphilis serology. The iridoschisis was extensive in two cases giving the iris an unusual ragged appearance, while it was slight in one case. Iridoschisis may suggest the diagnosis of congenital syphilis, especially when interstitial keratitis is mild. Chronic open-angle glaucoma should be excluded in all patients with interstitial keratitis and iridoschisis.


Neuroretinitis due to seronegative syphilis associated with human immunodeficiency virus.

Syphilis serologic testing is felt to be extremely reliable. A case of syphilitic neuroretinitis is reported where serologic testing was negative due to human immunodeficiency virus infection. A prompt response to high-dose intravenous penicillin was achieved.


Prolonged course of bilateral acute idiopathic blind spot enlargement.

We report a patient with bilateral "acute idiopathic blind spot enlargement" (AIBSE) in whom visual symptoms and enlarged blind spots persisted for over 6 years and preceded the development of peripapillary hyperfluorescence on fluorescein angiography. These findings confirm the prolonged course that AIBSE can sometimes take and the suggestion that this rare disorder is due to peripapillary retinal dysfunction.


Aneurysmal oculomotor nerve palsy in an 11-year-old boy.

Cerebral aneurysms are rare in children. When they occur, they usually present with a history of subarachnoid hemorrhage. Gabianelli et al. (1) recently reported a 14-year-old girl with an isolated oculomotor nerve palsy due to aneurysm. In their discussion, they state that arteriography is, "Unnecessary in patients under 10 (years of age) if the symptoms and signs of subarachnoid hemorrhage are absent or high resolution computerized tomography scan or adequate magnetic resonance imaging scan is normal." To date, their patient is the youngest reported in the literature with an isolated oculomotor nerve palsy proved to be caused by cerebral aneurysm. We report herein an 11-year-old boy who presented with an oculomotor nerve palsy due to aneurysm with minimal preceding symptoms and no other signs of intracranial disease.


Absence of the relative afferent pupillary defect with monocular temporal visual field loss.

We report five patients with monocular temporal visual field abnormalities who did not have clinically detectable relative afferent pupillary defects. The causes for the field defects were posterior ischemic optic neuropathy, craniopharyngioma, pituitary adenoma, pseudotumor cerebri, and traumatic optic neuropathy. We discuss the possible explanations for our observations, considering the known anatomy of the pregeniculate visual pathways and the afferent pupillary pathways.


Suprasellar tumors of maldevelopmental origin in Klinefelter's syndrome. A report of two cases.

Patients with Klinefelter's syndrome may have a predisposition for the development of neoplasia, particularly extragonadal germ-cell tumors, but a suprasellar location is rarely reported. The clinical and neuroradiologic features in two patients with Klinefelter's syndrome and dysmorphic suprasellar masses of maldevelopmental origin (presumably lipomas or lipodermoids) are described. One patient had bilateral optic atrophy and decreased vision. To our knowledge, only one similar case (a suprasellar hamartoma) has been previously reported in association with Klinefelter's syndrome.


Permanent homonymous hemianopias following migraine.

Two patients with migraine and repetitive visual field defects of homonymous hemianopic type are reported. The visual field defects were confirmed by Goldmann perimetry and automated static perimetry. Neither computed tomography nor magnetic resonance imaging showed abnormal findings. Decreased cerebral blood flow at the left basal ganglion area was the only abnormal finding detected in one patient by 123I-IMP (iodoamphetamine)-SPECT (single photon emission computed tomography), which is applicable to right homonymous hemianopia. A visual field test that includes the current automated static perimetry is important to the diagnosis and the subsequent treatment of patients with migraine, particularly those who have experienced visual negative phenomena.


Transient oculomotor nerve synkinesis in non-Hodgkin's lymphoma.

A patient with large cell malignant lymphoma presented with transient left oculomotor nerve synkinesis, left trigeminal and abducens nerve palsies. Magnetic resonance imaging showed thickening of the oculomotor and trigeminal nerves characteristic of central nervous system lymphoma. To our knowledge, this is the first reported case of transient oculomoter nerve synkinesis in non-Hodgkin's lymphoma. The rapid onset and quick recovery of the synkinesis following 2 weeks of chemotherapy support the ephatic transmission theory.


Myxoma mix-up. A case report.

We present a 63-year-old lady who had atrial myxoma. The diagnostic difficulties distinguishing this from giant cell arteritis are highlighted. In particular, both conditions caused choroidal and retinal infarcts, anterior ischaemic optic neuropathy, with raised acute phase reactants. The authors stress the importance of continued ophthalmoscopy as the fundal changes become more apparent.


Myasthenia gravis-like syndrome induced by topical ophthalmic preparations. A case report.

This case study reports on a 64-year-old female who presented for cataract surgery. She relayed a history of allergic responses to local anesthetics such as xylocaine, but was otherwise in good health. Upon instilling ophthalmic preparations into her eyes during routine ocular examination, she developed general muscular weakness but not other allergic-like symptoms. Further investigation established her myasthenic-like syndrome to be precipitated by an ophthalmic mydriatic preparation. She was able to undergo uneventful cataract surgery and enjoy 20/20 vision postoperatively, with proper management.


A pragmatist's approach to pathology costing: the Welsh Datatree project.

The Datatree costing project in Wales has provided the Welsh pathology laboratories with a standard costing package that allows pathologists to understand how their own laboratory's test costs are compiled. The software provides answers to the question "what if? ..." and shows instantly the effect of salary or consumable cost alterations. Resource management at a laboratory level is enhanced by a greater knowledge of costs, particularly in relation to volumes of work. Perhaps this is one of the stepping-stones across the river to the "open market." In the United Kingdom NHS any information of this kind must be regarded as invaluable.


Expression of Ki-67 nuclear antigen in B and T cell lymphoproliferative disorders.

To determine whether the proliferation rates of tumour cells may relate to prognosis and reflect disease activity. Blood mononuclear cells from 155 patients with B cell (n = 120) or T cell (n = 35) chronic lymphoproliferative disorders were tested with the monoclonal antibody Ki-67 by indirect immunoperoxidase or immunoalkaline phosphatase techniques. B cell diseases included chronic lymphocytic leukaemia (CLL), CLL in prolymphocytic transformation (CLL/PL), prolymphocytic leukaemia (B-PLL) and non-Hodgkin's lymphoma (B-NHL) in leukaemic phase. The T cell diseases comprised large granular lymphocyte (LGL) leukaemia, T-PLL, and T-NHL. These showed significantly higher proportions of Ki-67 positive cells in T cell (11.2%) than in B cell (2.9%) disorders (p < 0.001). The highest values were found in NHL of both B and T cell types, particularly when low grade disease transformed to high grade. The lowest percentages of Ki-67 positive cells were found in CLL (1.4%) and LGL leukaemia (1.7%); intermediate values were seen in B PLL (3.3%) and T PLL (5.8%). There is a positive correlation between prognosis and proliferation rates in chronic B and T cell lymphoproliferative disorders. Estimation of Ki-67 in circulating leukaemic cells could be used to determine prognosis in low grade malignancies.


Human tonsil intraepithelial B cells: a marginal zone-related subpopulation.

To determine if intraepithelial B cells in reactive human palatine tonsils were similar to the marginal zone cells of the spleen and Peyer's patches. Reactive human palatine tonsils were studied using conventional methods of light microscopy, electron microscopy, and a panel of monoclonal antibodies for leucocyte common antigens. Clinically important numbers of marginal zone-related B cells around the mantle zone were absent in lymphoid follicles, but in the cryptal epithelium there were abundant lymphoid cells with centrocyte-like nuclei and clear cytoplasm, intermingled with macrophages and plasma cells. The immunophenotype of these intraepithelial B cells was distinctive and similar to that found in the splenic marginal zone cells (IgM+, IgD-, CD23-, CD10-, CD35+, CD21+, bc12+, KB61+). Intraepithelial B cells in human tonsil could represent the counterpart of the marginal zone described in Peyer's patches. Their presence within the epithelium could reflect the destination for the malignant B cells in the lymphoepithelial lesion of mucosa associated lymphoid tissue (MALT) lymphomas. Human palatine tonsil lymphoid tissue has morphological, immunophenotypic, and pathological features similar to those of MALT.


Non-isotopic in situ hybridisation and immunophenotyping of infected cells in the investigation of human fetal parvovirus infection.

To compare the use of biotinylated and digoxigenin labelled probes for diagnosis of human fetal parvovirus B19 infection in formalin fixed, paraffin wax embedded tissues; and to assess the cellular distribution of the virus in positive cases. Sections of lung tissue from 23 cases of anatomically normal non-immune fetal hydrops presenting between 1984 and 1989, and from 13 control cases of hydrops due to chromosomal abnormality were probed for B19 DNA by in situ hybridisation using both biotinylated and digoxigenin labelled probes. The distribution of the virus was then investigated in all cases of fetal B19 infection confirmed in this laboratory to date (n = 11) by combining in situ hybridisation for viral DNA (using the digoxigenin system) with immunohistological labelling for a range of cellular antigens. Five unequivocal cases of B19 infection were identified among the 23 fetuses with unexplained hydrops using both probe labels. When combined with data from previous studies of the period 1974-1983, the results indicate that B19 infection was responsible for 27% of cases of anatomically normal non-immune hydrops and 8% of all cases, of non-immune hydrops presenting to this hospital over 15 years. False positive signal was seen in an additional three cases, using biotinylated probes. Digoxigenin labelled probes gave greater specificity and permitted detailed investigation of tissues high in endogenous biotin. Though most cells containing B19 DNA colabelled as erythroid precursors, viral DNA was frequently detected within mononuclear-phagocytic cells. In three cases viral signal was also found within occasional myocardial cells labelled by antibody to desmin. A relatively high proportion of cases of anatomically normal, non-immune hydrops are caused by B19 infection. Digoxigenin is a more reliable probe label than biotin for in situ hybridisation in archival fetal tissues. Double labelling for cellular antigens and viral nucleic acid is a powerful technique for investigating virus-host cell interactions, and provides evidence that cell types other than those of erythroid lineage may have a role in human fetal parvovirus infection.


Glutathione S-transferases in neonatal liver disease.

To investigate the distribution of alpha and pi class glutathione S-transferases (GST) in normal fetal, neonatal, and adult liver; and to examine changes in GST expression in neonatal liver disease. alpha and pi class GST were immunolocalised in sections of formalin fixed liver tissue obtained from human fetuses (n = 21), neonates (n = 8), young children (n = 9) and adults (n = 10), and from neonates with extrahepatic biliary atresia (n = 15) and neonatal hepatitis (n = 12). Monospecific rabbit polyclonal antibodies were used with a peroxidase-antiperoxidase method. Expression of pi GST was localised predominantly within biliary epithelial cells of developing and mature bile ducts of all sizes from 16 weeks' gestation until term and in neonatal and adult liver. Coexpression of pi and alpha GST was seen in hepatocytes of developing fetal liver between 16 and 34 weeks' gestation. Although pi GST was seen in occasional hepatocytes up to six months of life, this isoenzyme was not expressed by hepatocytes in adult liver. By contrast, alpha GST continued to be expressed by hepatocytes in adult liver; this isoenzyme was also seen in some epithelial cells of large bile ducts in adult liver. No change was observed in the distribution of alpha GST in either neonatal hepatitis or extrahepatic biliary atresia. However, aberrant expression of pi GST was identified in hepatocytes of all but one case of extrahepatic biliary atresia but in only two cases of neonatal hepatitis. The phenotypic alterations noted in extrahepatic biliary atresia may result from the effect of cholate stasis. Evaluation of the pattern of pi and alpha GST distribution by immunohistochemical staining may provide valuable information in distinguishing between these two forms of neonatal liver disease.


Adenovirus infection of the large bowel in HIV positive patients.

To describe the microscopic appearance of adenovirus infection in the large bowel of human immunodeficiency virus (HIV) positive patients with diarrhoea. Large bowel biopsy specimens from 10 HIV positive patients, eight of whom were also infected with other gastrointestinal pathogens, with diarrhoea were examined, together with six small bowel biopsy specimens from the same group of patients. Eight of the patients had AIDS. The biopsy specimens were examined by light microscopy performed on haematoxylin and eosin stained and immunoperoxidase preparations, the latter using a commercially available antibody (Serotec MCA 489). Confirmation was obtained with electron microscopy. The morphological appearance of cells infected with adenovirus showed characteristic nuclear and cellular changes, although the inflammatory reaction was non-specific. Immunoperoxidase staining for adenovirus was sensitive and specific, and the presence of viral inclusions consistent with adenovirus was confirmed by electron microscopy. The light microscopic features of adenovirus infection are distinctive and immunocytochemistry with a commercially available antibody is a sensitive and specific means of confirming the diagnosis. Further studies of the role of adenovirus in causing diarrhoea in these patients are indicated.


Detection of hepatitis B pre-core mutant by allele specific polymerase chain reaction.

Development of a specific polymerase chain reaction (PCR) assay for detection of the pre-core, stop codon, mutant of hepatitis B virus (HBV). PCR primers, specific at the 3'-end for nucleotide 1896 of either the pre-core, stop codon, mutant or wild type HBV, were synthesised using published sequence data. Positive control templates for both types of virus were synthesised by the PCR, incorporating sequences specific for each virus type at the appropriate position. These templates were used to optimise the specificity of the procedure. Formalin fixed, paraffin wax embedded human tissue from acute or fulminant HBV hepatitis from Hong Kong or Oxford was then investigated for presence of mutant or wild type virus. The HBV DNA was amplified from this tissue using a two step procedure, with an initial amplification phase followed by a second diagnostic phase on optimally diluted target DNA. Specific detection of mutant or wild type HBV was achieved. An important factor in determining specificity was the temperature of annealing, 70 degrees C proving to be highly specific. To overcome the inherent variation of target copy number in clinical samples and to provide an intrinsic positive control, it was important to generate and standardise the amount of target HBV used for the specific PCR. Two cases of fulminant hepatitis and four cases of acute hepatitis from Hong Kong, and one case of fulminant hepatitis from Oxford, contained only wild type HBV, with no evidence of a mutant virus. This method can be applied to FFPE tissues. It is rapid, non-radioactive, and specific for the stop codon mutation at nucleotide 1896 of HBV. Preliminary investigation of a small number of cases of fulminant hepatitis from Oxford and Hong Kong showed only wild type virus. The result differs from results published from Japan and Israel.


Relative usefulness of electron microscopy and immunocytochemistry in tumour diagnosis: 10 years of retrospective analysis.

To determine retrospectively the relative usefulness of electron microscopy and immunocytochemistry for tumour diagnosis; to monitor the influence of new antibodies and antisera on the use of these techniques in one laboratory. During 1980 to 1989 inclusive, 726 tumours were examined by electron microscopy, 862 by immunocytochemistry, and 286 by both techniques. The choice of techniques and, for immunocytochemistry, the range of antibodies used were compared between each category of final diagnosis. During the study period there was a sharp fall in the use of electron microscopy and a corresponding rise in immunocytochemistry. These trends applied to all categories of final tumour diagnosis, but the use of electron microscopy was sustained longer for lesions suspected or eventually confirmed to be melanomas or amine precursor uptake decarboxylation cell carcinoma (APUDomas)--for example, carcinoid tumours. The immunocytochemistry:electron microscopy use ratios ranged from 2.07:1 to 0.44:1 for the categories in which lymphoma and APUDoma, respectively, were the final diagnoses. The abandonment of electron microscopy for suspected or confirmed lymphomas and carcinomas corresponded to the increasing availability of relevant antisera and antibodies. The wider application of immunocytochemistry for tumour diagnosis is endorsed, but electron microscopy should be retained for selected cases in which the results of immunocytochemistry might be predictably ambiguous or otherwise unhelpful.


Distinction between aleukaemic prodrome of childhood acute lymphoblastic leukaemia and aplastic anaemia.

To document the features of the so-called aplastic presentation of childhood acute lymphoblastic leukaemia (ALL) and to determine whether this prodrome can be distinguished from aplasia. The peripheral blood and bone marrow appearances of all cases of childhood ALL presenting in one health region of England in 13 years and eight months were reviewed. All cases presenting with cytopenia without circulating blasts and marrow aspirates with no infiltrate of blasts were studied in detail. Four of 305 (1.3%) children presented in this way. All four had reticulin fibrosis and increased cellularity in all or part of the marrow biopsy specimen. All were girls. Three had common and one surface membrane immunoglobulin positive ALL. Reassessment of this prodrome, by combining the features of four previously reported series of similar cases with the present one, highlighted the female preponderance (19 of 22 cases), bone marrow fibrosis (10 of 11 evaluable cases), prominent bone marrow lymphocytes (14 of 22 cases) and temporary recovery (all 12 evaluable cases). Six of 14 evaluable cases had bone marrow biopsy specimen appearances of apparently uniform hypocellularity, but only one of these did not have fibrosis. If, in addition to an aspirate, a bone marrow trephine biopsy is carried out the prodrome can be distinguished from aplasia in most cases. The similarity of this prodrome to aplastic anaemia is merely superficial. Clinicians and morphologists may fail to appreciate the implications of this mode of presentation if the term "aplastic" continues to be used to describe this aleukaemic prodrome of ALL.


The cause of turbidity in lyophilised plasmas and its effects on coagulation tests.

To investigate the cause of turbidity in reconstituted lyophilised plasmas and to determine its effect on coagulometers. The turbidities of 20 normal plasmas and 16 reconstituted lyophilised plasmas were determined by comparing a 1 in 4 dilution in distilled water with a standard suspension in an Aminco Fluorocolorimeter (American Instrument Co) in nephelometric mode. The turbidities of five other plasmas were determined before and after lyophilisation. The turbid components of fresh and reconstituted lyophilised plasmas were studied using electron microscopy. The effects of turbidity on five types of coagulometer were determined by adding varying concentrations of a turbidity enhancing material. Reconstituted lyophilised plasmas were more turbid than normal plasmas, because of agglomerated liposomes. Serum depleted of chylomicrons and very low density lipoproteins was not rendered more turbid by lyophilisation. Three out of five types of automated coagulometer tested gave activated partial thromboplastin times which were appreciably affected by plasma turbidity. One of the instruments was unable to detect a clot in a moderately turbid plasma. A second instrument gave results which were significantly affected by turbidity. Turbidity of the substrate plasma did not affect specific factor VIII assays in two types of coagulometer. Lyophilisation of plasma induces turbidity due to the agglomeration of lipids. Such turbidity can affect the results of coagulation tests. Suppliers of lyophilised plasmas should be aware of this problem.


Factors affecting the maintenance dose of warfarin.

To identify the possible factors determining the dose of warfarin prescribed in patients receiving anticoagulant treatment. The computerised records of 2305 patients maintained on the drug in seven hospitals were amalgamated and classified into one of seven diagnostic groups. The associations with the dose of warfarin prescribed were investigated by univariate and multiple regression analysis. Differences between hospitals were studied with regard to the coagulometric method and the thromboplastin preparation used. The geometric mean dose of warfarin was 4.57 mg and 5% of patients were prescribed 10 mg or greater. There was a noticeable decrease in dose with increasing age, which averaged about 6 mg for patients aged 30 but 3.5 mg for those aged 80. Men required slightly more warfarin than women. Patients with heart disease or atrial fibrillation required lower doses of warfarin, while higher doses were required by patients with deep vein thrombosis. Significant differences in mean warfarin dose among the seven hospitals were evident. These differences could not be explained entirely by the use of different coagulometric methods or thromboplastins. Clinicians should be aware that older patients need reduced doses of warfarin. The considerable differences in doses of warfarin among hospitals indicates that further efforts to improve uniformity are required.


Survey of oral anticoagulant treatment in children.

To find out which children are treated with oral anticoagulants and how their treatment is controlled in the United Kingdom. Two questionnaires were used. The first was sent to general haematologists and the other to paediatric cardiologists and cardiac surgeons. There were 273 (58%) replies to the first questionnaire. Most children were treated because of artificial cardiac valve replacement. The mean target International Normalised Ratio (INR) used was 2.73 to 4.0 for children with heart valves and 2.1 to 3.25 for children with venous thrombosis. The second questionnaire elicited replies from 11 of 22 cardiac centres. The mean target INR used for children with cardiac valves ranged from 2.59-3.77. Of 68 children covered in the survey, there have been two major bleeds and two thrombotic episodes: 78.8% of children were controlled with a venous prothrombin time and 21.2% with a capillary test. There was no consistency in the dose regimens used for the induction of oral anticoagulant treatment with warfarin. The levels of anticoagulation used for maintenance are similar to those recommended by the British Society for Haematology for adults (3.0 to 4.5). They seem to be safe for children too.


Mycobacterium tuberculosis: a continuing cause of sudden and unexpected death in west London.

To describe the pathological and background features of several cases of tuberculosis diagnosed at post mortem examinations and performed on behalf of HM Coroner over a three year period in west London. Postmortem examinations were carried out by two pathologists working at hospital and public mortuaries in west London. Cases of tuberculosis were provisionally diagnosed on gross examination and the diagnosis confirmed on haematoxylin and eosin and Ziehl-Neelsen staining of retained tissues. The background information was obtained by scrutinising hospital records and by direct enquiry to general practitioners by coroners' officers. Thirteen cases of pulmonary tuberculosis were diagnosed during the period. No other cause of death was found. The incidence of fatal pulmonary tuberculosis was 0.28% of coroners' necropsies in the study region. Cases had been referred to the coroner because death had occurred unexpectedly, or because no recent medical attention had been sought. Most cases arose among the elderly Asian immigrant population or the homeless or the alcoholic, or both. In 10 cases the macroscopic findings strongly indicated pulmonary tuberculosis and in the other three the diagnosis was considered to be a differential diagnosis. These findings have important health implications for those carrying out post mortem examinations from these groups as well as for those involved with the continuing care of immigrant or vagrant populations.


Diagnostic tests for Helicobacter pylori: comparison and influence of non-steroidal anti-inflammatory drugs.

To evaluate the efficacy of culture, histology, CLO-test, Helico-G and Pyloriset tests in diagnosing Helicobacter pylori in the presence or absence of non-steroidal anti-inflammatory drugs (NSAIDs). Of 134 patients studied, 75 had taken NSAIDs. At endoscopy, biopsy specimens were taken for culture, histology, and CLO-test. Blood was also taken for enzyme linked immunosorbent assay (ELISA) (Helico-G) and latex agglutination (Pyloriset) tests. The sensitivity, specificity, and predictive values of histology and CLO-test, compared with culture, ranged from 90% to 97%, regardless of NSAID intake. In the 59 patients not taking NSAIDs Helico-G had a sensitivity of 75% (p < 0.05) and a specificity of 61%; Pyloriset's sensitivity and specificity were, respectively, 63% (p < 0.05) and 67%. In the 75 patients taking NSAIDs the sensitivity of Helico-G was 81% and its specificity 45% (p < 0.05); Pyloriset had a sensitivity of 61% (p < 0.05) and a specificity of 50% (p < 0.05). These findings suggest that H pylori is more reliably diagnosed by culture, histology, and CLO-test than by the serological tests used in this study, especially in patients treated with NSAIDs.


Staphylococcal toxins and sudden infant death syndrome.

To investigate the hypothesis that commonly occurring bacterial toxins cause sudden infant death syndrome (SIDS) by (1), determining in which tissues bacterial toxins are concentrated after intravenous injection in rats; and (2), seeing if the same tissues contain detectable toxins in cases of SIDS. The tissue distribution of intravenously injected staphylococcal enterotoxin A (SEA), enterotoxin B (SEB), enterotoxin C (SEC), enterotoxin D (SED), toxic shock syndrome toxin (TSST-1), and alpha-haemolysin was studied in rats using immunohistology and polyacrylamide gel electrophoresis with immunoblotting. Immunostaining was also carried out on formalin fixed kidneys from cases of SIDS and a comparison series of necropsy cases using anti-SEA, anti-SEB, anti-SEC2 and anti-SED. Immunohistology showed that SEB, SEC, SED and TSST-1 were all concentrated in the proximal convoluted tubular cells of the kidney. The presence of these toxins was confirmed in kidney homogenates using electrophoresis and immunoblotting. There was positive granular staining in the proximal convoluted tubular cells of the kidney in 36% of SIDS cases and 12% of the comparison series with anti SEC2 (chi 2 = 6; p < 0.025). SEC, or a bacterial toxin with epitopes in common, could have a pathogenic role in SIDS.


Pulsed field gel electrophoresis on frozen tumour tissue sections.

The application of pulsed field gel electrophoresis (PFGE) to the molecular genetic analysis of solid tumours has been restricted by the requirement for whole single cells as a DNA source. A simple technique which allows for the direct analysis of histologically characterised solid tumour material by pulsed field gel electrophoresis was developed. Single frozen tissue sections obtained from colonic carcinoma specimens were embedded without further manipulation in molten, low melting temperature agarose. The tumour DNA contained within the agarose plug was subjected to restriction enzyme digestion and PFGE. Sufficient high molecular weight DNA is yielded by this method to obtain a hybridisation signal with a single copy probe. Histological examination of adjacent tissue sections may also be carried out, permitting correlation between molecular analysis and tumour histology.


Has there been an information explosion in histopathology?

The numbers of papers published between 1966 and 1990 which could be of relevance to a histopathologist were assessed. The search for papers was conducted under 18 medical subject headings using the CD-Plus Medline computerised database for the years 1966, 1978, 1982, 1986 and 1990. Between 1966 and 1990 16 categories showed an increase in the number of indexed papers and in 11 of these the increase was by over 200%. The two categories that showed a slight reduction were cytodiagnosis and polarisation microscopy. The total number of papers of probable relevance to histopathology in 1990 was 36,780, a 293% increase since 1966; this increase was greater than the increase in the total number of papers indexed (189%). The number of papers relevant to histopathology has increased dramatically in recent years and this increase has been proportionately greater than in some other areas of medicine.


Pseudohyperphosphataemia in patients with multiple myeloma.

The phosphate concentrations were measured in 41 patients who had multiple myeloma with paraproteinaemia using four different methods to compare the incidence of pseudohyperphosphataemia. The direct acid/molybdate method produced the highest number of anomalous results. The erroneously high phosphate concentration was attributable to the presence of turbidity in the reaction mixture. No association was found between paraprotein type and occurrence of turbidity. The direct acid/molybdate method was unreliable in patients with serum paraproteins and should therefore not be used for the measurement of phosphate concentration in such patients.


Expression of 120 kilodalton protein and cytotoxicity in Helicobacter pylori.

Antral biopsy culture supernatants from 14 subjects with chronic gastritis, known to have IgA antibodies to the 120 kilodalton protein, showed positive recognition of this antigen in western blots against a cytotoxin positive strain of Helicobacter pylori but gave negative reactions with two cytotoxin negative strains. Control immunoblots with culture supernatants from 13 non-responders to the protein were all negative. This indicates a direct association between expression of the 120 kilodalton protein in H pylori strains and cytotoxicity.


Selected cryopreservatives for long term storage of Helicobacter pylori at low temperatures.

To meet the need for information on cryopreservation, a study was done on 32 Helicobacter pylori strains, comparing different cryopreservative media. Sheep blood, horse blood, horse serum with and without glycerol, and mineral oil media were used for long term storage of H pylori at -70 degrees C or in liquid nitrogen. Procedures were developed which permitted recovery of 87.5% of the strains included in the study after they had been stored for 24 months. Of those strains stored for more than three years, 60% were recovered. It is concluded that most strains of H pylori can be stored for up to one year or longer, under refrigeration, at -70 degrees C or in liquid nitrogen.


Successful freeze storage and lyophilisation for preservation of Helicobacter pylori.

Long term storage techniques for the preservation of Helicobacter pylori were developed. The cells survived at -75 degrees C in the presence of glycerol and at +4 degrees C after freeze-drying. Both techniques are suitable for routine use.


A simple and direct method of turnround time audit in a microbiology laboratory.

A method of specimen turnround time audit, directly controlled by laboratory staff, was applied to a bacteriology service to assess service efficiency and identify delays and other deficiencies, so that resources could be optimised. The method provided a complete collection of turnround time data and was easy to use. Delays of both administrative and technical natures were identified, and with minimal reorganisation the mean turnround time was improved.


Evaluation of modified passive haemagglutination assay for Vi antibody estimation in Salmonella typhi infections.

A simple passive haemmagglutination assay (PHA) was developed to detect Vi antibodies, to improve the diagnosis of typhoid fever by small laboratories. The Vi capsular antigen of Salmonella typhi was extracted by alternate alcohol and acetone precipitation. Formalin fixed, sheep red blood cells treated with chromium chloride were sensitised with this Vi antigen and antibodies detected and measured by PHA. The test had a sensitivity of 83.3% among 30 cases of typhoid fever confirmed by culture. The specificity of the test was 94%, making it suitable for use in laboratories without facilities for IFAT or ELISA.


Alveolar rhabdomyosarcoma infiltrating bone marrow at presentation: the value to diagnosis of bone marrow trephine biopsy specimens.

To describe the histological appearances of bone marrow infiltrated with rhabdomyosarcoma at presentation and to determine their value in establishing the diagnosis. Patients presenting over seven years in the northern health region of England with rhabdomyosarcoma were studied. Bone marrow aspirates and trephine biopsy specimens taken at presentation were examined. Seven of 32 patients with rhabdomyosarcoma had bone marrow infiltration, resulting in marrow failure in all cases, at diagnosis. The diagnosis was established in these seven by the typical cytological appearances and immunophenotype of the infiltrating cells (all seven patients) and cytogenetic abnormalities (three patients). Histological examination of the bone marrow showed a pseudoalveolar pattern with fibrous septal bands, enlarged vascular channels, and lack of cohesion of the tumour cells within the subdivided aggregates in all seven. In four cases multinucleate giant cells, often with peripherally sited nuclei, were found. These histological features of infiltrated marrow are so characteristic that the diagnosis of alveolar rhabdomyosarcoma can be made, or at least suspected, in many cases even without recourse to technically difficult and expensive further investigations. Bone marrow biopsy should be a routine part of the investigation of patients with bone marrow failure and will be of particular value in the diagnosis of those with disseminated alveolar rhabdomyosarcoma.


Use of paraffin wax embedded bone marrow trephine biopsy specimens as a source of archival DNA.

To evaluate the use of DNA extracted from paraffin wax embedded trephine biopsy specimens as a source of archival nucleic acid for Southern hybridisation studies and polymerase chain reaction (PCR) amplification. DNA was extracted simultaneously from paraffin wax embedded bone marrow trephine and lymph node biopsy specimens after incubation of tissue sections for one to five days in lysis mix and proteinase K with periodic sampling. DNA from 10 trephine biopsy specimens was subjected to PCR amplification using HLA-DPB primers to determine whether the extracted nucleic acid was of sufficient quality to permit amplification. For most specimens the greatest yield of high molecular weight DNA was seen after five days' incubation. Unlike lymph node material the quality of extracted nucleic acid and the quantity obtained from trephines was insufficient for Southern blot analysis. PCR amplification using HLA-DPB primers yielded positive results in six out of 10 trephine biopsy specimens. DNA extracted from paraffin wax embedded trephine biopsy specimens is largely degraded and unsuitable for Southern analysis but serves as a useful source of archival nucleic acid for PCR amplification.


Increased interleukin 6 concentrations in the absence and presence of HIV-1 infection in haemophilia.

To measure IL-6 concentrations in asymptomatic HIV-1 antibody positive and negative haemophilic patients and to correlate these with IgG concentrations and CD4 positive cell numbers. IL-6 concentrations were measured by bioassay in stored serum from a prospective cohort of haemophilic patients in whom immunoglobulins and T cell subsets had been determined. Values of IL-6 and immunoglobulins were also correlated with severity of liver disease. IL-6 concentrations were raised in haemophilic patients independent of HIV-1 antibody status. In HIV-1 antibody positive patients there was no correlation between IL-6 concentrations and CD4 positive cell numbers, but there was a correlation with IgG (r = 0.4; p = 0.05). In HIV-1 antibody negative patients there were no significant correlations. Haemophilic patients have increased IL-6 concentrations; in HIV-1 positive patients this is independent of the decline in CD4 cell count. The raised concentrations do not correlate with the clinical severity of liver disease.


Improved PCR method for detecting monoclonal immunoglobulin heavy chain rearrangement in B cell neoplasms.

To develop a simple, optimised, polymerase chain reaction (PCR) based method for detecting the rearranged immunoglobulin heavy chain (IgH). Using as primers oligonucleotides (Fr2A, Fr2B) homologous to the conserved sequences to the framework II region and the joining (JH) region, 25 patients with B cell lymphoproliferative disorders, previously characterised by Southern blotting, and three patients with light chain myeloma were studied. The PCR product from a polyclonal B cell population showed a broad band when analysed on a 3% agarose gel; DNA from B cell lines and B lymphoproliferative disorders showed a discrete band. Specificity of the amplification was confirmed by cloning and sequencing the amplified product as well as by Southern blotting with an internal probe homologous to the framework 3 region. Primers Fr2A and Fr2B detected monoclonality in three patients with light chain myeloma, while primers directed against the FrIII region showed a polyclonal response. Deletions and extensive somatic mutations within the FrIII region may give false negative results with primers homologous to the region. A PCR using the method described, with a repertoire of primers homologous to the FrII and FrIII regions, will therefore increase the frequency of detection of monoclonality.


Alpha-1 antitrypsin gene exon use in stimulated lymphocytes.

To investigate the expression of mRNA transcripts containing exon A or B in lymphocyte cultures. An in situ hybridisation technique, using synthetic, biotinylated oligonucleotide probes was deployed to allow the demonstration of exon A, exon B, or the normal hepatocyte message containing exon C. Lymphocytes used the same alternative splicing technique as monocytes in the generation of their alpha-1 antitrypsin message. They also provided data on the frequency of exon A and B expression in cells from different subjects. Most circulating granulocytes failed to show the alpha-1 antitrypsin message, suggesting that this protein is synthesised in the marrow and represents a stored protein component in polymorph and circulating nuclear lymphocytes. In situ hybridisation is a sensitive technique for the detection of individual gene exon use in cell populations. Lymphocytes show the same promoter use as that described for monocytes.


Antibodies to choroid plexus in senile dementia of Alzheimer's type.

To investigate whether autoantibodies to choroid plexus are present in human senile dementia. Serum samples from 40 elderly people presenting with characteristic, diagnostic criteria of senile dementia of Alzheimer's type and 20 age matched healthy controls were tested by indirect immunofluorescence for the presence of autoantibodies to choroid plexuses, using frozen sections of rat or human fetal brain tissue. Significant labelling of choroid plexus basement membrane was observed in 17 of the 40 samples from patients with senile dementia; in the control series one sample of rat but not human plexus labelled positively (p < 0.01). The antibodies identified in this series of patients with Alzheimer's disease suggest that autoimmune mechanisms might be responsible for some of the changes in cerebrospinal fluid production described in this disorder.


Collagenous colitis: jejunal and colorectal pathology.

To determine: (1) whether there is an association between collagenous colitis and coeliac disease or lymphocytic colitis; (2) the distribution of lymphocyte subsets and macrophages in the lamina propria and surface epithelial layer in collagenous colitis; and (3) the colorectal distribution of the disease and whether a mucosal biopsy specimen, using a flexible sigmoidoscope, is sufficient to diagnose it. The clinical data and colorectal biopsy specimens from 38 patients with collagenous colitis were studied. In 10, small bowel biopsy specimens were also available for review. Immunostaining of the mucosal lymphoid infiltrate with a panel of relevant antibodies was carried out on formalin fixed tissue in seven cases; in three the phenotyping was performed on fresh biopsy specimens separately frozen or fixed in B5 solution. Coeliac disease was found in four out of the 10 patients with collagenous colitis who had had a small bowel biopsy, in contrast to the prevalence of the disease in Australia of 1 in 3000. Collagenous colitis did not respond to gluten withdrawal. Five of 29 (17%) of the patients had a mixed pattern of lymphocytic and collagenous colitis. Immunostaining of the lymphoid infiltrate showed that the striking increase in intraepithelial lymphocytes in collagenous colitis was due to an influx of CD8 positive cells. The occurrence and severity of collagenous colitis along the large bowel were independent of the anatomical site, and in more than 90% of cases biopsy specimens from the sigmoid colon or rectum were diagnostic. There is a very high incidence of coeliac disease among patients with collagenous colitis so that jejunal biopsy should be an essential part of their investigations, especially if symptoms persist. However, only a minority showed a mixed pattern of lymphocytic and collagenous colitis. The intraepithelial lymphocytes in collagenous colitis are CD8 positive cells. Collagenous colitis can be diagnosed from rectal or sigmoid colon biopsy specimens in more than 90% of cases.


Immunohistological study of intrahepatic expression of hepatitis B core and E antigens in chronic type B hepatitis.

To study the intrahepatic expression of hepatitis B virus (HBV) nucleocapsid antigen; and to determine the differential distribution of hepatitis B core and E antigens in chronic hepatitis B. Hepatocyte expression of HBV nucleocapsid antigen was studied using rabbit anti-HBc, directed against both HBcAg and HBeAg; differential distribution of HBcAg and HBeAg was studied using murine monoclonal anti-HBc and anti-HBe in 120 patients with chronic hepatitis B. HBV nucleocapsid antigen was detected in 14 of 16 (87.5%) HBeAg seropositive patients with chronic persistent hepatitis (CPH), and in 54 of 64 (84.4%) HBeAg seropositive patients with chronic active hepatitis (CAH). Nuclear expression of nucleocapsid antigen was more prevalent in patients with CPH than in those with CAH; this was reversed in terms of exclusive cytoplasmic expression of nucleocapsid antigen (p < 0.05). Of 45 patients with nucleocapsid antigen in the nucleus, samples from 44 (97.8%) and 17 (37.8%) stained positively with monoclonal anti-HBc and anti-HBe, respectively. Of 65 patients with cytoplasmic nucleocapsid antigen, samples from 61 (93.8%) and 57 (87.7%) stained positively with monoclonal anti-HBc and anti-HBe, respectively. HBV nucleocapsid antigen is more prevalent in HBeAg positive patients with CPH than in those with CAH. Cellular expression of HBcAg and HBeAg in the cytoplasm is more or less the same; in the nucleus HBcAg exceeds HBeAg expression.


Quantitative assessment of histological changes in chronic gastritis after eradication of Helicobacter pylori.

To evaluate the effect of 10 day triple treatment on H pylori eradication and associated gastritis. Fifty patients with H pylori positive non-ulcer dyspepsia were treated for 10 days with amoxicillin, tinidazole, and bismuth salts. Histological examination of the antral mucosa was performed before (T0), six weeks (T1), and six months (T2) after treatment. The new Sydney classification of gastritis was used, using a score from 0 to 3 to grade degree of inflammation, atrophy, activity (intraepithelial or lamina propria damage) and H pylori. At T0 all patients had chronic active gastritis. Lymphoid follicules were present in 12 cases. At T1 33 patients were H pylori negative: the score showed a decrease of activity (from 2.5 to 0.54). The result was confirmed at T2 (mean score 0.22). Inflammation decreased from 1.8 to 1.4 at T2. Only one case of follicular gastritis was observed. In H pylori positive patients the scores did not show significant modifications. Ten day triple treatment is effective in eradicating H pylori in 69% of cases, causing a decrease of the total score for gastritis. Activity, defined by polymorph infiltration, was promptly reduced when H pylori was eradicated. There was a trend to a reduction in inflammation, but atrophy was irreversible.


Lethal synergistic action of toxins of bacteria isolated from sudden infant death syndrome.

To test the hypothesis that lethal toxins of bacteria associated with sudden infant death syndrome (SIDS) can act synergistically. Bacteria occurring together in the nasopharynx of cases of cot death were studied. The lethal toxicity of crude toxin preparations was determined over a range of dilutions by injections into the chorioallantoic vein of the chick embryo. Toxin preparations of low lethality for the chick embryo SIDS model were then tested in combination. Staphylococcus aureus toxin preparations showed low lethality when tested alone, even at low dilution. At 1 in 100 dilution S aureus toxin was lethal to one out of 15 chick embryos. Escherichia coli toxin preparations showed high lethality except on high dilution (1 in 80) when lethality fell to two out of 15 of chick embryos. When the same toxin preparations were tested simultaneously in combination, lethality rose to 14 out of 15. Similar findings were observed over a range of toxin dilutions. This finding was highly significant (p = 0.0012). That synergy between toxins can enhance the lethality of toxins elaborated by bacteria associated with SIDS.


Possibility of separating toxins from bacteria associated with sudden infant death syndrome using anion exchange chromatography.

To develop techniques for the characterisation of toxins elaborated by a strain of Escherichia coli associated with sudden infant death syndrome (SIDS). E coli SIDS 04, isolated from the nasopharynx of a case of SIDS, was studied. Cell-free toxin preparations were standardised, their protein measured, and analytical separation of proteins achieved using sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE). Acetone precipitation of proteins was required prior to Coomassie blue staining of bands. Preparative separation was achieved on an anion exchange column using a programmed concentration gradient of NaCl in TRIS buffer. Fractions were tested individually or pooled for presence of lethal toxin including endotoxin. Lethal toxin was detected with the chick embryo test system. Endotoxin was measured using a chromogenic modification of the Limulus amoebocyte assay. Twenty one peaks were detected by chromatography. Ten individual, or pooled, fractions were assayed for endotoxin which ranged from 27-33 pg/ml. Much greater variation was found when the same fractions were assayed in chick embryos. E coli fractions varied considerably in lethal toxicity, from 0/10 to 10/10 chick embryos killed/tested. Certain E coli fractions tested individually (lethality four out of 10 to eight out of 10) proved more lethal (10 out of 10) if pooled prior to testing. In E coli infection associated with SIDS relatively low concentrations of extracellular protein are lethally toxigenic for the chick embryo model of SIDS. These proteins can be separated analytically by SDS-PAGE and preparatively by anion exchange chromatography. Toxicity of individual fractions is not correlated with endotoxin concentrations in samples tested.


Fungal infections of the small and large intestine.

To study the pathological features of fungal infections affecting the lower intestinal tract (duodenum, small and large bowels). Between mid-1981 and mid-1991, 14 cases of deep mycotic infections affecting the lower intestinal tract were found among 890 consecutive necropsies on patients with malignant disease treated in a regional cancer centre (incidence 1.6%). These 14 cases accounted for 54% of all gastrointestinal fungal infection detected. The relevant clinical, necropsy, histological and microbiological data were reviewed. Candida spp and Aspergillus spp accounted for all infections. The macroscopic appearances included ulcers of varying configuration, mucosal flecks, sloughed mucous membranes, polypoid masses and segmental lesions. Either organism could produce this range of lesions, but Candida tended to have a mucosal location and Aspergillus was associated with transmural invasion. Combined infections showed Candida in the surface mucosa and Aspergillus hyphae in submucosal vessels with spread into the bowel wall in a radiating pattern. During the final illness, gastrointestinal symptoms and signs were often slight and microbiological investigations were unhelpful. Variable gross appearances are relevant for endoscopists, particularly lesions which resemble pseudomembranous colitis. Endoscopic biopsy specimens may have a role in antemortem diagnosis. Failure to diagnose these infections during life emphasises the importance of necropsy in the clinicopathological audit of deaths in this group of patients.


New selective medium for isolating Clostridium difficile from faeces.

To compare CCFA (cycloserine, cefoxitin fructose agar) with a new selective medium CDMN (containing cysteine hydrochloride, norfloxacin, and moxalactam) for the isolation of Clostridium difficile after direct faecal culture. The minimum inhibitory concentration (MIC) of norfloxacin was determined for 64 strains of C difficile, 17 strains of other Clostridium sp, and 66 various isolates of faecal origin, together with MIC determinations of moxalactam against the 81 strains of Clostridium sp and 15 isolates of Bacteroides sp. Using C difficile agar base with 0.5 g/l of cysteine hydrochloride, norfloxacin and moxalactam were incorporated into the medium and compared with CCFA for the isolation of C difficile after direct faecal culture. Norfloxacin (12 mg/l) inhibited the growth of enterobacteriaceae and faecal streptococci; moxalactam (32 mg/l) inhibited the growth of most strains of Bacteroides sp tested, together with Clostridium sp other than C difficile. Using the antibiotics in combination (CDMN), the growth and colonial morphology of 64 strains of C difficile were unaffected. When CDMN medium was compared with CCFA for the isolation of C difficile from 832 faeces from inpatients with diarrhoea, the CDMN agar isolated 20% more strains and reduced the number of contaminating colonies by 30%. CDMN both improves the isolation rate of C difficile from faecal specimens and reduces the growth of other organisms compared with CCFA.