Evaluation of mean transit time in children as an indicator of airways obstruction.

Mean transit time was evaluated as a test of pulmonary function in normal and asthmatic children. It was found to be independent of body size and negatively correlated with PEFR, FEV1 and FVC in normal children. Mean transit time was less sensitive in detecting the effects of bronchodilator therapy in asthmatic children than other simpler tests of lung function. The range of normal was so wide that there was no clear demarcation between normal and abnormal. The degree of overlap makes isolated tests of mean transit time of little diagnostic value. It is therefore concluded that mean transit time though it theoretically offers the attractive advantage of being a sensitive indicator of both large and small airways obstruction, is unlikely to play a major part in the routine evaluation of lung function in asthmatic children.


Relationship between inspiratory mouth pressure and respiratory muscle activity in normal subjects.

The relationship between inspiratory mouth pressure and respiratory muscle activation was investigated in 20 normal non-smoking subjects (13 males). Surface electromyography (EMG) was recorded from the seventh intercostal space bilaterally during different levels of inspiratory effort monitored by a respiratory mouth pressure gauge. The mouth pressure and EMG relationship was non-linear between 20 and 100% of inspiratory effort. Quadratic regression analysis was performed between percent inspiration and percent EMG on each side of the chest. The regression equation and coefficient of determination (r2) for the right side were y = 9.73 (e0.024x-1), r2 = 0.91, and for left side were y = 10.79 (e0.023x-1), r2 = 0.88. An independent t-test did not reveal significant difference (P > 0.05) between the slopes of the regression lines from the two sides of the chest. Therefore, results of the two sides were pooled and the predictive regression equation for the combined results was y = 10.05 (e0.0236x-1). Reasons for such a non-linear relationship may include the loading mechanism of respiratory muscles, inefficiency of intercostal muscles at high levels of inspiration, their recruitment pattern and the histochemical characteristics of respiratory muscles. Since absolute EMG values cannot be used to assess changes in activation on different days, further work is required to establish the between-day repeatability of the technique described which is potentially useful for assessing respiratory muscle function pre- and post-operatively in chest surgery patients.


A long-term prospective assessment of home nebulizer treatment.

Forty-nine patients (15 asthma, mean FEV1/FVC 1.3/2.1; 34 COPD, mean FEV1/FVC 0.7/1.8) were referred for consideration of home nebulizer treatment. All were monitored for 2 weeks while using their usual inhaled treatment followed by 2 weeks using a 'Nebuhaler' spacer to deliver 1 mg of terbutaline and 80 micrograms of ipratoropium bromide (IB) four times daily. They then borrowed a System 22 nebulizer to self-administer salbutamol nebulizer solution (5 mg), IB unit dose vials (0.5 mg) or a mixture of these drugs four times daily for 1 month each. Both asthmatic and bronchitic patients had a significant rise in their mean daily peak flow rate (PFR) during home nebulizer treatment (P < 0.03) and the COPD patients also had a significant PFR rise during Nebuhaler treatment (P = 0.0004). The mean daily peak flow rates (PFR 1 min-1 were: baseline 179, Nebuhaler 195, salbutamol nebulizer 200, IB nebulizer 198, mixed nebulizer 216). Four patients failed to respond subjectively or objectively to either Nebuhaler or nebulizer treatment. Five patients responded well to Nebuhaler treatment and did not proceed to a home nebulizer trial. Eight further patients preferred Nebuhaler to nebulizer treatment or could not tolerate nebulizer treatment (two cases). Thirty-two patients requested home nebulizer treatment for long-term use (nine salbutamol, five IB, 18 mixture). Twenty-seven of these patients had an increased mean daily PFR (compared to their usual therapy) while using their chosen nebulized treatment. The mean increase in PFR for all 32 patients was 191 min-1 (11%).(ABSTRACT TRUNCATED AT 250 WORDS)


Relation of hypocapnic symptoms to rate of fall of end-tidal PCO2 in normal subjects.

Hyperventilation is of little clinical relevance unless it causes symptoms. These are often non-specific. Their threshold for onset and relation to steady level of arterial (or its equivalent, end-tidal PCO2; PETCO2) are uncertain, and it has been suggested that they may relate better to the rate of fall of PCO2 than to the absolute level. We investigated this in nine normal subjects, who breathed to and fro through a pneumotachograph into an open circuit in which the concentration of CO2 could be varied. Tidal volume, respiratory frequency and ventilation was measured on-line by a Compaq computer, and PETCO2 at the mouth was measured by capnograph. Subjects overbreathed at a fixed rate and depth until symptoms consisting of dizziness, paraesthesiae and light headedness occurred. Then, without their knowledge and while they continued to overbreathe, inspired CO2 was increased to restore PETCO2 to normal and abolish symptoms, and was then withdrawn again over either approximately 0.1, 2.5 or 5 min until symptoms were again reported. The PETCO2 at this point was noted. The three protocols were performed in each subject in a random order and the same symptoms were reported each time. When averaged across all subjects, symptoms occurred at mean PETCO2 values of 20.3, 19.2 and 18.6 mmHg (2.71, 2.56 and 2.48 kPa), respectively. These were not significantly different, and it can be concluded that there was no influence of rate of fall of PCO2 on threshold for symptoms. Chest pain only occurred in one subject and may have a different mechanism.


The impact of reimbursement issues on rehabilitation nursing practice and patient care.

Rehabilitation nursing practice and patient care are affected profoundly by reimbursement trends. This article provides a basic understanding of current and proposed reimbursement issues in Medicare, Medicaid, and private insurance--information that should help the rehabilitation nurse make the changes necessary to provide patient care within the constraints of the reimbursement systems. Furthermore, an understanding of these economic issues should assist nurses in working collaboratively and positively with administration while reducing their level of frustration. Nurses can play an important role in managing length of stay, using ancillary services, and moving the patient along the continuum of care, all of which are critical financial factors in a facility's successful management of its payer mix.


Pressure ulcer prevalence and incidence in a rehabilitation hospital.

Pressure ulcers remain a serious health problem, especially in terms of personal suffering and economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time) and the incidence (number of persons developing pressure ulcers over a given time) of pressure ulcers. Skin assessments and risk assessments of the subjects were completed using the Braden Scale for Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.


Metronidazole use in malodorous skin lesions.

Malodorous skin lesions (primarily fungating tumors and decubitus ulcers) can be extremely resistant to efforts to control their odors. The offending bacteria appear to be anaerobes, specifically the Bacteroides species. Topical metronidazole has shown promise for odor control without the cost or side effects of a systemic drug. In various anecdotal reports, lesions in patients treated with topical metronidazole were virtually free of odor within 24 hours, and in some cases, slight improvements in wound appearance and pain also were noted. The encouraging results of these initial experiences with topical metronidazole warrant further study for its efficacy in reducing skin lesion odor.


Traditional Chinese medicine in rehabilitation nursing practice.

Traditional Chinese medicine (TCM) employs methods of treatment such as acupuncture, acupressure, and Qi Gong (treatment based on meditation). The nurse using TCM can affect rehabilitation patient outcomes positively. With TCM training, nurses have an opportunity to learn the nuances of the Oriental environment and integrate them into their skills to nurse the spirit, mind, and body of patients in a holistic manner.


The foot at risk: identification and prevention of skin breakdown.

This article presents the major predisposing factors and measures associated with preventing nosocomial foot lesions. The combination of nursing interventions and the appropriate use of protective devices can markedly reduce the incidence of foot lesions acquired in the hospital. Patient and family education is another important aspect in preventing skin breakdown of the foot at risk.


Human responses to traumatic brain injury.

A traumatic brain injury can have devastating effects on the patient and the family. The patient with TBI faces deficits that influence life after hospitalization. With the use of specific nursing therapies, human responses to TBI can be treated and a patient can return to a satisfactory lifestyle.


Nursing diagnoses used most frequently in rehabilitation nursing practice.

This article describes a study of 346 rehabilitation nurses in which the nurses identified the nursing diagnoses most frequently used in rehabilitation. The study identified patterns of diagnosis used by nurses in inpatient and community settings, found no pattern of use by educational background, and delineated etiologies used with diagnoses characteristic of rehabilitation nursing.


Construction of a broad host range shuttle vector for gene cloning and expression in Actinobacillus pleuropneumoniae and other Pasteurellaceae.

We have constructed a pair of broad host range expression vectors, pJFF224-NX and pJFF224-XN, based on plasmid RSF1010, which enable cloning and efficient expression of genes in Actinobacillus pleuropneumoniae and Pasteurella haemolytica and in Escherichia coli. The vectors consist of the minimal autonomous replicon of the broad host range plasmid RSF1010 and a type II chloramphenicol acetyl transferase gene for chloramphenicol resistance selection. In addition, they contain a gene expression cassette based on the E. coli bacteriophage T4 gene 32 promoter region and a transcription stop signal, which are separated by a segment of multiple cloning sites in both orientations. Electroporation and subsequent selection for chloramphenicol resistance was used for the introduction of the vectors in A. pleuropneumoniae and P. haemolytica. A promoterless xy/E gene from the Pseudomonas putida TOL plasmid was cloned onto pJFF224-NX. This plasmid enabled efficient expression of active catechol2,3oxygenase in A. pleuropneumoniae and P. haemolytica. It was stably maintained in A. pleuropneumoniae without antibiotic selection, showing less than 0.1% loss after 100 generations, while native RSF1010 and other RSF1010-based vectors were unstable in this host.


Use of specific oligonucleotides for direct enumeration of Listeria monocytogenes in food samples by colony hybridization and rapid detection by PCR.

Two 18-mer oligonucleotides derived from the sequence of hly, the gene coding for listeriolysin O, were shown to be specific for Listeria monocytogenes in the genus Listeria in colony hybridization tests. The oligonucleotides did not hybridize with any of the bacterial species found in food and co-isolated with Listeria on selective media. They were used in colony hybridization tests for enumeration of L. monocytogenes present in food samples after direct plating on selective media plates. In addition, two 24-mer oligonucleotides, each including the sequence of one of the 18-mers, were successfully used for the PCR-based detection of L. monocytogenes bacilli present in food samples after 48-h enrichment period. Using this technique, as little as 10(2) bacteria per ml of enrichment broth can be detected.


The bacterial phosphotransferase system as a potential vehicle for the entry of novel antibiotics.

During the past twenty-nine years, not a single class of antimicrobial agents has been discovered that has led to new approved human drugs. Despite a dramatic increase in the potency of existing classes, the need for new effective antimicrobial agents continues. The bacterial phosphotransferase system (PTS) offers the possibility of providing new opportunities for the discovery of important agents. This system offers a vehicle for entry into infecting bacteria and pathways for the initiation of metabolism of such agents. Antimicrobial agents which would use the PTS may be found which are active on both growing and sessile bacterial forms, and due to the lack of a eukaryotic PTS counterpart, such analogues may be expected to be non-toxic to the animal host.


Corynebacterium group D2 ("Corynebacterium urealyticum") constitutes a new genomic species.

Twenty-one Corynebacterium group D2 ("C. urealyticum") strains were found to constitute a tight DNA hybridization group distinct from named Corynebacterium species. The strains of Corynebacterium group D2 had cell wall component type IV, short chain mycolic acids and G+C content of DNA of 65-66 mol %. Corynebacterium group D2 constitutes a genomic species which can be identified by phenotypic tests.


Expression of M6 protein gene of Streptococcus pyogenes in Streptococcus gordonii after chromosomal integration and transcriptional fusion.

The M6 protein of Streptococcus pyogenes was expressed on the cell surface and secreted in Streptococcus gordonii Challis (formerly Streptococcus sanguis) after chromosomal integration of a promoterless M6 protein gene (emm-6.1). The ermC gene, conferring resistance to erythromycin, was cloned downstream of emm-6.1, within the same ClaI fragment. The initiation codon of emm-6.1 was 19 bp downstream of a ClaI site, so that ClaI cleavage would leave the gene promoterless. The ClaI fragment containing the promoterless emm-6.1 and ermC was ligated in vitro with a ClaI digest of S. gordonii chromosomal DNA. Random chromosomal integration of the heterologous DNA was obtained by using the ligation mixture to transform the naturally competent S. gordonii Challis. Twenty-eight percent of transformants selected for erythromycin resistance also expressed M6. Among the best M6 producers, 10 clones were selected for the stability of their phenotype. Nine of the 10 clones were shown to harbour one intact copy of the emm-6.1/ermC ClaI fragment integrated into the chromosome. These strains both expressed M6 protein on the surface and secreted different amounts of the molecule, since in each case the protein was produced after a transcriptional fusion of emm-6.1 with a different chromosomal promoter. A S. gordonii strain expressing large amounts of surface M6 protein, as judged by immunofluorescence and Western blot, was compared to the M- parental strain in a standard opsonophagocytosis assay. Of the isogenic pair, M6+ S. gordonii survived better in human blood and was phagocytosed at a slower rate.


Cloning and characterization of a Neisseria gene homologous to hisJ and argT of Escherichia coli and Salmonella typhimurium.

We have isolated from a genomic library of the pathogenic Neisseriae gonorrhoeae T2 strain, a gene encoding a putative protein of 268 amino acids which exhibited significant similarity to the hisJ and argT gene products of Salmonella typhimurium and Escherichia coli, periplasmic proteins deputed to amino acid transport within the cell. The gene is transcribed as a monocistronic mRNA species of about 960 nucleotides flanked by regulatory elements for initiation and termination of transcription that are efficiently recognized in an E. coli host.


Conserved structural and regulatory regions in the Salmonella typhimurium btuB gene for the outer membrane vitamin B12 transport protein.

The Salmonella typhimurium btuB gene encodes an outer membrane protein that is necessary for the transport of vitamin B12 and the uptake of the E colicins and bacteriophage BF23. The sequence of this gene showed 87% identity of the deduced polypeptide to its Escherichia coli homolog, and its product was found to function in transport as effectively in cells of E. coli as did the native protein. The extensive sequence conservation within the first 300 transcribed nucleotides, which include the leader and early part of the coding sequence, supports the proposed role of this region in the regulation of btuB gene expression.


Two unrelated alkaliphilic Bacillus species possess identical deviations in sequence from those of other prokaryotes in regions of F0 proposed to be involved in proton translocation through the ATP synthase.

The a and c subunits of two unrelated alkaliphilic Bacillus species contain unusual motifs in regions previously implicated by others in H(+)-coupled oxidative phosphorylation. The facultative alkaliphile B. firmus OF4 apparently does not contain genes encoding an alternative F0, supporting other evidence that a single species of proton-translocating F1F0-ATPase catalyses oxidative phosphorylation both at low and high pH. The unusual F0 sequence motifs may be part of the adaptation of the extreme alkaliphiles to growth at very high pH.


Degradation of non-phenolic beta-o-4 lignin substructure model compounds by Acinetobacter sp.

Acinetobacter sp. utilized non-phenolic beta-o-4-model compounds, 2-methoxy-4-formylphenoxyacetic acid and veratrylglycerol-beta-guaiacyl ether (VGE) as sole carbon source. Vanillin, vanillic acid, protocatechuic acid and catechol were detected in the 2-methoxy-4-formylphenoxyacetic acid amended culture. Veratryl alcohol, veratraldehyde, veratric acid, vanillic acid, protocatechuic acid, catechol and guaiacol were identified from veratrylglycerol-beta-guaiacyl ether culture. Acinetobacter sp. produced catechol 1,2-dioxygenase and protocatechuate 3,4-dioxygenase that cleaved catechol and protocatechuic acid, respectively.


Typing of Listeria strains by random amplification of polymorphic DNA.

The polymerase chain reaction (PCR) was used to obtain randomly amplified polymorphic DNA (RAPD) profiles for typing of Listeria strains. In this procedure, whole cells were incubated in the reaction mixture. The discriminating ability of a randomly designed 10-mer primer, HLWL74, was assessed. A total of 60 collection strains of Listeria, encompassing all 7 Listeria species and all known serovars was submitted to PCR with the primer HLWL74. Upon agarose gel electrophoresis, 29 different banding profiles were reproducibly obtained. No common profiles were recorded for strains from different Listeria species. For various groups of strains sharing the same serotype (e.g. 4b, 1/2a, 1/2b), RAPD analysis could generate further subdivision. On the other hand, some strains from different serotypes produced identical RAPD profiles with the primer HLWL74. The RAPD typing method from whole cells is proposed as an attractive alternative for other Listeria typing systems, and the 10-mer HLWL74 as a primer to include in a forthcoming set of standard primers for RAPD typing of Listeria isolates.


Immunoaffinity purification, stabilization and comparative characterization of listeriolysin O from Listeria monocytogenes serotypes 1/2a and 4b.

We developed a simple and highly effective procedure for stabilizing the haemolytic activity of listeriolysin O (LLO) from Listeria monocytogenes after immunoaffinity purification. The haemolytic activity of LLO was stabilized by eluting it directly into tubes containing an alkaline buffer (5 mM lysine, 140 mM KCl, 50% ethylene glycol, pH 11.5). The purified LLO retained 100% of its haemolytic activity after 6 weeks of storage at -20 degrees C. LLO purified from a strain of L. monocytogenes serotype 1/2a (ATCC 43249) and LLO purified from a strain of L. monocytogenes serotype 4b (F 2365) isolated from a Mexican-style cheese, showed no significant differences in pH and temperature stability. When incubated in buffers at pH values from 4 to 12 at 4 degrees C and 25 degrees C, LLO from serotypes 1/2a and 4b retained maximal haemolytic activity at pH 8 after 4 h of incubation. LLO from both serotypes lost their haemolytic activity after incubation at 50 degrees C for 25 min.


Detection of enterotoxigenic Escherichia coli in faecal specimens by acetylaminofluorene-labelled DNA probes.

The present study describes acetylaminofluorene(AAF)-modified DNA probes for the identification of heat-labile (LT) and heat-stable (porcine STp and human STh) toxins from enterotoxigenic Escherichia coli (ETEC). AAF probes were compared with established biotinylated probes and bioassays. Ultracentrifugation was not necessary in the preparation of AAF-labelled probes, and the procedures, i.e. chemical modification of probes, hybridization and immunodetection steps, were optimized to detect ETEC by colony hybridization or direct dot blot techniques. The method combines chemical labelling (covalent attachment of AAF group to guanosine is achieved by treatment of DNA with N-acetoxy-2-acetylaminofluorene) and detection of the hybridized target DNA by means of anti-AAF monoclonal antibodies and alkaline phosphatase-labelled second antibodies.


Putative nickel-binding sites of microbial proteins.

Nickel is biologically important because of its catalytic role in the mechanisms of action of metalloenzymes, and also because of its toxic cellular effects. There exist at least 3 groups of nickel-binding proteins in microorganisms: nickel-specific transporters, accessory proteins involved in nickel incorporation and nickel-containing enzymes. The differences in their physiological functions determine the nature of the ligands and the structures of the nickel-binding sites. The homology among the accessory proteins HypB, ORF4 and UreG suggests that the mechanism of nickel incorporation into hydrogenases in Escherichia coli is the same as or similar to that into hydrogenases of Rhodobacter capsulatus and into urease of Klebsiella aerogenes.


A comparative study of randomly amplified polymorphic DNA analysis and conventional phage typing for epidemiological studies of Listeria monocytogenes isolates.

The analysis of RAPD profiles generated by PCR with a single 10-mer, HLWL74, was compared to bacteriophage susceptibility data for epidemiological typing of Listeria monocytogenes strains. A total of 104 L. monocytogenes strains was screened, all from serogroup 1 or serotype 4b. Of these, 53 had been isolated during 6 different listeriosis outbreaks. The remaining 51 strains were chosen randomly from our collection. A total of 38 RAPD types were observed, although each epidemic group of strains isolated during one of these outbreaks displayed a specific RAPD profile. For 98% of the strains isolated during outbreaks, the correlation between RAPD typing and phage typing was complete. Only one strain, typed as epidemic by phage typing, was clearly distinguishable from the others by RAPD analysis. Among the 51 strains not related to an outbreak, 12 were linked to epidemic groups by RAPD analysis. Two of these rearrangements were supported by phage typing. The remaining 10 strains could be excluded by phage typing from any of the epidemic groups studies. Considering all 104 isolates, the decision to relate a strain to a particular epidemic group or to exclude a strain from any epidemic group was the same for 92 isolates, using either phage typing or RAPD analysis. The RAPD analysis, which is quick, simple and suited for automation, is proposed as an attractive alternative for phage typing in epidemiological studies of listeriosis.


A rapid and sensitive method for the identification of Brucella species with a monoclonal antibody.

A coagglutination test using monoclonal antibody BmE10-5 with specificity for the M antigen of Brucella melitensis 16M has been developed for the rapid identification of the smooth Brucella species. All reference strains of several biovars of B. melitensis, B. abortus, B. suis and B. neotomae tested were positive in this assay. No significant differences in reaction intensity were observed in relation to the different distribution of the A and M antigens among the Brucella serovars analysed. Conversely, rough Brucella species, with the exception of B. abortus 45/20, were negative in the assay. Among the different organisms tested not belonging to the genus Brucella, serovar O9 of Yersinia enterocolitica was the only one that gave a weak positive reaction of coagglutination. Thus, in view of its rapidity, simplicity, specificity and low costs, this technique could be highly useful for rapid identification of smooth Brucella strains in diagnostic laboratories.


Thin-layer chromatography systems for the identification of Mycobacterium tuberculosis, M. bovis BCG, M. kansasii, M. gastri and M. marinum.

Knowledge of mycobacterial glycolipid antigens and the study of their specificity have resulted in their utilization as species markers. We describe a thin-layer chromatography method which could serve as a useful adjunct for the identification of Mycobacterium tuberculosis, M. bovis BCG, M. kansasii, M. gastri and M. marinum.


Enzyme electrophoretic polymorphism differentiates invasive from non-invasive Chlamydia psittaci ruminant isolates.

A group of 24 Chlamydia psittaci strains isolated from ruminants, belonging to serotype 1 and previously classified as invasive in a mouse model of virulence, was compared to a group of 10 non-invasive strains belonging to serotype 2 by using determination of glucose-6-phosphate and L-malate dehydrogenase zymotypes resulting of the infection of cells by these strains. The serotype 1 or invasive isolates represent a homogeneous group by sharing a unique zymotype which was not observed in the non-invasive strains. On the contrary, the serotype 2 or non-invasive isolates constitute a heterogeneous group in generating 2 different zymotypes. Zymotyping clearly distinguishes the ruminant strains from an avian C. psittaci and two C. trachomatis isolates studied for comparison. Our results suggest the usefulness of the studied molecular approach for chlamydiae typing. Furthermore, it can be used as marker of virulence within the C. psittaci strains isolated from ruminants.


DOT-ELISA for detection of phenolic glycolipid PGL-Tb1 and diacyl-trehalose antigens of Mycobacterium tuberculosis.

A DOT-ELISA method for detection of 2,3-diacyl-trehalose (DAT, previously referred to as SL-IV antigen) and triglycosyl phenol phthiocerol di-mycocerosate (PGL-Tb1) antigens from Mycobacterium tuberculosis is described. The method enabled the detection of both antigens in 14 clinical isolates of M. tuberculosis from different geographic origins; the presence of the glycolipids was confirmed by chemical analysis. It was therefore concluded that the synthesis of both of these compounds is characteristic of the species.


[Pathology of myxoid mitral valve degeneration: literature review and personal results].

Mitral prolapse is a parachute-like protrusion of the value into the left atrium. Almost always a myxoid degeneration of the valve is the base of such a prolapse. Myxoid degeneration is understood as dissolution of the collagenous fibrous layer and its replacement by acid glucosaminoglycans. An alteration of collagen is suspected as primary defect in this sometimes also inherited disorder. The electron microscope reveals fragmentation of collagen fibrils and elastic fibers and, within the myxoid material, free lysosomes, so called "matrix-vesicles". An isolated disturbance of collagen types I and III could not be detected by immunohistochemistry. Studies could also to date not demonstrate mutations in the genes coding for collagens.


[Rickets due to vitamin D deficiency--a reminder].

Vitamin D deficiency, because of prophylactic supplementation, has become a rare disorder in Switzerland and therefore is usually not considered in the clinical routine. In the few cases we could diagnose, the affected children either have been of East-Mediterranean origin with insufficient nutrition and vitamin supplementation, or were raised in families who, for philosophical or other reasons, refuse any "non-biological" measure including vitamin supplementation. For the orthopedic surgeon the challenging task is to screen out of the many children presented with physiologic gait "disturbance", bow-legs or flat feet the few children with true disorders. An important point is the history of vitamin D prophylaxis; in selected cases X-ray and laboratory findings are indicated. Finally the response to the treatment with vitamin D will confirm the diagnosis of rickets due to vitamin D deficiency.


[Advantages of 24-hour ambulatory blood pressure monitoring for the assessment of dose-effect relations and dose-equivalency].

Because of the high variability of blood-pressure, clinical studies using casual measurements require rather large numbers of patients for assessment of pharmacologic efficacy. By the use of blood-pressure monitoring over 24 hours this number can be dramatically reduced. Additional benefits are the precise determination of dose-effect relationships and the more accurate estimate of the response-rate. Comparing two retarded galenic forms of Verapamil we show that even dose-equivalence can be studied with this type of blood-pressure recording.


[Clinical-pharmacological case report: drug-induced inappropriate ADH secretion].

The syndrome of inadequate secretion of antidiuretic hormone (SIADH) following treatment with a tricyclic antidepressant is demonstrated using the example of a 70 year-old man admitted for weakness and cognitive disturbances. Because of incontinence he had been periodically treated since 1989 with imipramine (Tofranil) by his family doctor. On admission he was seriously hyponatriemic and had low plasmatic osmolality, significantly lower than urinary osmolality. Creatinine, urea and uric acid in serum were also below normal values. Like other drugs tricyclic antidepressants can rarely induce an increased release of ADH by direct hypothalamic stimuli. In this patient imipramine was terminated and within a few days of reduced fluid intake and substitution of sodium a sustained clinical improvement and normalisation of laboratory parameters was noted. The patient was discharged to his home after three weeks.


[Diagnosis of neurological symptoms of psychogenic origin].

The principles of neurological examination of patients in which psychogenic disturbances are suspected are first described. After mentioning the frequency of this type of disturbances in the medical literature, some of the most characteristic and most frequent psychogenic disturbances in neurology are described: cranial nerve symptoms, sensory disturbances as well as psychogenic paralysis including paraplegia and psychogenic disturbances of gait. A chapter is dedicated to psychogenic disturbances of consciousness and to psychogenic attacks mimicking epilepsy. Finally a description is given of those organic neurological diseases in which in our experience the erroneous diagnosis of psychogenic disturbances is most frequently made. Some recommendations, how to behave in the presence of a patient with psychogenic neurological symptoms is added.


["Psychogenic" bulbar paralysis].

This 58-year-old female presented with a history of difficulties in swallowing for 30 years. No diagnosis was made in spite of repeated investigations including barium-contrast radiography. A probative strumectomy and psychotherapy were unsuccessful. After an episode of major depression the swallowing disturbances increased. In addition the patient complained of mastication difficulties and was dysarthric. Finally, neurological examination and neurophysiological studies established the diagnosis of progressive bulbar palsy.


[Autoimmune paraneoplastic neurological syndromes].

Paraneoplastic neurological syndromes are well established causes of neurological dysfunction in cancer patients. Recently an auto-immune origin has been found for the Lambert-Eaton myasthenic syndrome, the subacute sensory neuronopathy of Denny-Brown, the paraneoplastic cerebellar degeneration, the paraneoplastic opsoclonus-myoclonus as well as a few other minor syndromes. Indeed patients suffering from these diseases have been found to produce antibodies directed against the central nervous system. These antibodies can be detected as much as a year before the cancer is found and they are therefore interesting for neurological and oncologic diagnosis.


[Current developments in the long-term therapy of Parkinson syndrome].

In the course of long-term treatment of Parkinson's disease many problems, which cannot yet be satisfactorily solved, arise with time in a large number of patients. This overview describes some strategies which are used nowadays to tackle these problems. Special attention is drawn to the treatment of painful dystonias and off-periods with apomorphine.


[Bell's palsy--a field of controversies. I. Etiology and pathogenesis--diagnostic delimitation--prognosis].

Facial paresis as a sign or symptom is caused by a number of different conditions. Although being the most common type of facial paresis, Bell's palsy represents a diagnosis of exclusion characterized by an acute, unilateral peripheral facial palsy of unknown etiology. Clinical features and laboratory findings are considered with regard to their diagnostic as well as prognostic significance.


The phenotypic expression of different mutations in transmissible human spongiform encephalopathy.

Clinical, pathological, and experimental transmission characteristics are reviewed for each of the known mutations in the amyloid precursor gene (PRNP) associated with familial spongiform encephalopathies. All mutation groups show an earlier age at onset and longer duration of illness than sporadic disease, and more or less distinctive patterns of illness can be recognized for each mutation, although much variability may occur even among affected members of the same family. Experimental transmission of disease has been accomplished for most of the mutations, with shortened incubation periods in the inoculated animals that parallel the earlier age at onset of human illness in these cases, implying a shortened pre-clinical phase of disease rather than an earlier 'infecting event'. Mutations thus not only predispose to spongiform encephalopathy, but also accelerate its pathogenetic tempo and influence its phenotypic expression.


[Creutzfeldt-Jakob disease in 4 children treated with growth hormone].

Creutzfeldt-Jakob disease was diagnosed in four growth hormone recipients at the age of 10, 11, 18 and 19 years. To our knowledge, the two first cases are the first instances of Creutzfeldt-Jakob disease recorded in children. Three of them were still being treated with synthetic hormone at the onset of the disease. Neurological disorders: ataxia and diplopia, appeared first, dementia and myoclonus appeared later. Eighteen cases of Creutzfeldt-Jakob disease in growth hormone recipients are now recorded, and the present risk of Creutzfeldt-Jakob disease in pituitary growth recipients is estimated to be 1/300. Because of the long incubation period, new cases are to be feared. Other causes of iatrogenic Creutzfeldt-Jakob disease are reviewed. These facts incite to consider carefully using products of human origin in human therapy. The interactions between growth hormone, prion and host's genomic make-up are still not clear.


[Gerstmann-Sträussler-Scheinker disease. Pathologal and genetic study].

Gerstmann-Sträussler-Scheinker's disease is a familial spongiform encephalopathy whose pathological hallmark is the existence--especially in the cerebellum--of numerous amyloid plaques. We report here the third clinicopathological case in a French family. Brain tissue from one of its members--initially described as familial Creutzfeldt-Jakob's disease--has been reported as successfully inoculated to monkeys. We present the currently accumulating data favouring the hypothesis of a common etiology for familial Creutzfeldt-Jakob's disease and Gerstmann-Sträussler-Scheinker's disease. The familial characteristics, resulting in different durations of incubation and evolution, could lead to different clinical and histological expressions.


[Ambulatory autonomy and visual motion perception in a case of almost total cortical blindness].

A 37-year-old man experienced cortical blindness following a bilateral stroke in the territory of the posterior cerebral arteries. Four years later, the measurement of visual field defects (Goldmann perimeter) showed persistence of bilateral blindness with a 2-degree preservation of macular vision and a perifoveal sparing between 10 to 30 degrees of eccentricity in the left inferior quadrant. Despite this visual impairment, the subject was able to perform visually-guided locomotion. Moreover he consciously perceived visual motion in the blind parts of his visual field. CT and MRI showed a lesion involving most of the striated cortex. The visual cortex located in the internal occipito-parital regions was relatively spared. The contribution of this structure to extra-striated vision of motion is discussed.


[Stiff-Man syndrome with late onset].

We report a case of Stiff-Man syndrome according to Gordon, Januszko and Kaufman's criteria. Onset at age 76, association with insomnia and a rapid course leading to death within 2 years were the characteristic features. CSF data, electromyographic and immunological findings suggest abnormalities of catecholaminergic and GABA ergic systems, with release of segmental or suprasegmental inhibitory influence. The presence of antibodies against glutamic acid decarboxylase, considered a useful marker of this syndrome, raises the possibility of an autoimmune pathogenesis.


[Post-poliomyelitis syndrome: 29 cases].

The post-polio syndrome refers to new neuromuscular symptoms developed by some patients many years after recovery from acute poliomyelitis. Several groups were separated: musculo-skeletal symptoms (different from a new spinal cord disease), infraclinical signs (EMG), post-polio muscular atrophy (new lower motor neuron objective signs) with several subgroups: cramps and fasciculations, benign focal weakness and atrophy (in previously affected muscles or in unaffected muscles), progressive spinal muscular atrophy. The following examination were performed in some cases, but not all, in this retrospective study: muscle CT scan, conventional electromyography (EMG), quantifying-EMG, macro-EMG and single-fiber EMG. The serum titers of neutralising antibodies to polio virus type 1, type 2 and type 3 were negative. No oligoclonal bands were found in the CSF from 6 patients screened by electrophoresis immunoelectrophoresis. Serum creatine kinase or aldolase was high in 6 patients. The same unusual features in this syndrome were observed on muscle biopsies: muscular hypertrophy and interstitial eosinophils; two patients had rimmed vacuoles in the muscle fibers.


[Suprascapular nerve entrapment at the spinoglenoid notch].

The suprascapular nerve passes through the spinoglenoid notch with a risk of entrapment. This results in distal nerve lesion characterized by isolated paralysis of the infraspinatus muscle and, most often, by shoulder pain. We report 7 clinical and electromyographical cases of pure infraspinatus muscle paralysis. The value of the electrodiagnosis, which demonstrated prolonged suprascapular distal nerve latencies (over 5 milliseconds) in the infraspinatus muscle affected while latencies were normal in the supraspinatus muscle, is emphasized. Mechanical factors were associated with paralysis in 5 cases. Compressive synovial cysts were found in 2 patients operated upon. Surgical enlargement of the spinoglenoid notch regularly and rapidly relieves pain and sometimes helps in recovery of the infraspinatus muscle.


[Paralytic pontine exotropia disclosing endocarditis].

A case of bacterial endocarditis complicated by paralytic pontine exotropia is reported. Magnetic resonance imaging clearly showed a rostral lesion of the paramedial pontine reticular formation and the medial longitudinal fasciculus. The occurrence of paralytic pontine exotropia is suggestive of ischaemia, and patients with this so-called "one-and-a-half syndrome" associated with signs of infection should be investigated for endocarditis.


[Hashimoto's encephalopathy: toxic or autoimmune mechanism?].

A 36-year-old woman presented with partial complex status epilepticus. Magnetic resonance imaging with T2-weighted sequences showed a high-intensity signal in the left posterior frontal area. Hashimoto's thyroiditis was then discovered. The disappearance of the high-intensity signal after corticosteroid therapy was suggestive of an autoimmune mechanism. However, improvement could be obtained only with a hormonal treatment, which supports the hypothesis of a pathogenetic role of the Tyrosine-Releasing Hormone (TRH).


[A progressive case of ataxia in a family of Huntington's chorea].

One case of ataxic, pyramidal and demential syndrome associated with retinitis pigmentosa occurred in a family with Huntington's disease (36 patients among 7 generations). The disease started at 15 years of age. Ataxia was transiently attenuated by isoniazid. The patient died of the disease at 26 years of age.


[Dementia disclosing primary Gougerot-Sjögren syndrome].

Two cases of primary Sjögren's syndrome revealed by dementia are reported. The patients had progressive or subacute memory dysfunction and psychiatric disorders with depression and delirium. The diagnosis of Sjögren's syndrome was established by biopsy of the minor salivary glands. Both patients were treated with corticosteroids. The neuropsychiatric symptoms improved dramatically in one case and remained unchanged in the other case. Dementia in Sjögren's syndrome seems to be without aphasia, apraxia or agnosia, and associated with psychiatric features, particularly depressive symptoms, thus including some characteristics of subcortical dementia. Diagnosis may be difficult because, as shown in our cases, symptoms of ocular and buccal dryness can be absent. Salivary gland biopsy can be useful in the evaluation of patients with dementia of undetermined etiology.


[Chorea disclosing polycythemia and renal adenocarcinoma].

A 79-year-old woman had chorea complicating polycythaemia. The polycythaemia and the chorea disappeared after surgical removal of a renal carcinoma. The literature on polycythaemic chorea is reviewed and its pathophysiology discussed.


[Magnetic resonance imaging in lupic chorea].

A case of disseminated lupus erythematosus with chorea is reported. CT was normal. Magnetic resonance imaging showed multiple focal lesions on T2-weighted sequences, predominating in the periventricular white matter. This MRI pattern did not change in a second MRI investigation, 7 months later. The contribution of MRI to our understanding of the neurolupus pathophysiology is discussed.


Cell kinetics of glial tumors.

The development of monoclonal antibodies against bromodeoxyuridine (BUdR) has made it possible to study the cell kinetics of individual brain tumors more extensively and more rapidly than previously possible. Over the past several years, we have performed in situ labeling studies of 502 neuroectodermal tumors with BUdR. The results have shown that the BUdR labeling index (LI), or percentage of cells in DNA synthesis, is generally higher in malignant gliomas; that histologically similar tumors may have different proliferative potentials, demonstrated by differences in the BUdR LIs; and that a higher LI indicates a higher proliferative potential as well as a shorter time to recurrence and duration of survival. Double-labeling studies with BUdR and iododeoxyuridine, performed to analyze the cell cycle progression in 29 gliomas, revealed that S-phase duration (Ts) was fairly uniform (mean +/- SD: 8.9 +/- 2.0 hours) regardless of the differences in the LIs. Nevertheless, the potential doubling time (the time for a tumor cell population to double in the absence of cell loss) varied from 2 days to over a month, being very short for tumors with a high LI, and correlated with the BUdR LIs (Tp = 17.8/LI0.77; r = 0.95). The cell cycle time calculated for gliomas with LIs of 1-20% was 1-2 days. These parameters are useful in determining the dose, duration, and interval of chemotherapy and in evaluating the effectiveness of treatment. Thus, cell kinetics studies not only elucidate the growth characteristics of individual gliomas but may also benefit to patients by providing a more precise prognosis and may be considered in the selection of treatment modalities.


Oncogenes and glial tumors.

Results of numerous studies indicate that both activation of dominant oncogenes and inactivation of tumor suppressor genes play important roles in the genesis and progression of human gliomas. Activation of the epidermal growth factor receptor (erbB1 oncogene) as the result of gene amplification or rearrangement is the best established example of a dominant oncogene involved in glioma development. There is also suggestive evidence for activation of the ros oncogene in gliomas, and activation of a variety of other dominant oncogenes may be operative in individual tumors. Deletion studies suggest that inactivation of tumor suppressor genes on chromosomes 17p (probably the p53 gene), 10, 9p and 22 also play roles in genesis and progression of human gliomas. Additional work remains to be done to identify other dominant oncogenes and tumor suppressor genes involved in gliomas, and to determine how these various factors interact to cause disease.


[Chromosome abnormalities and adenine metabolism in human glial tumors].

Most chromosome aberrations in gliomas are numerical, resulting in either gains or deficiencies of whole chromosomes. In tumors of low malignancy, the karyotype is frequently normal or exhibits a loss of sex chromosome and a gain of chromosome 7. These two anomalies may not be directly related to malignancy. In the highly malignant cases, the two most frequent aberrations are the gain of chromosome 7 and the loss of chromosome 10, other anomalies such as losses or deletions of chromosomes, 9, 22, 6, 13 and 14 being detected at various frequencies. Several of these chromosomes carry important genes of adenine metabolism: AK1 and AK3 (adenylate kinase) and MTAP (methylthioadenosine phosphorylase) for chromosome 9; ADK (adenosine kinase) and mitochondrial ATPase for chromosome 10; ADSL (adenylosuccinate lyase) for chromosome 22, NP (nucleoside phosphorylase) for chromosome 14. We performed the corresponding assays of enzyme activity on both fresh tumors and tumors grafted on nude mice, which showed that these enzymes had a relatively low activity although the tumors were proliferating. However, chromosome losses do not seem to directly cause the metabolic alterations by gene dosage effect. Interestingly, chromosome 10, frequently deficient, also carries genes of importance for glycolysis (hexokinase) and glutamate metabolism (glutamate dehydrogenase and glutamate oxaloacetate transaminase). The deficiency for these genes could be taken into account for a better type of chemotherapy by antimetabolics.


[Contribution of nucleolar organizers staining to the prognostic evaluation of meningioma].

Meningioma is often regarded as a benign tumour. It is easy to diagnose, but its prognosis is difficult to determine. Recurrences are numerous and occur at different periods of time. Various predictability factors have been studied, including Nucleolar Organizers Regions (NORs) staining. This technique is easy to perform and enables retrospective studies to be carried out. Comparisons of staining indices with the histoprognostic grades established by Zülch, and correlations between these indices, as well as with the time elapsed before a recurrence occurred, showed that NORs staining can be useful to determine the prognosis. In this retrospective study 69 cases were reviewed. The meningiomas had been removed surgically between January 1979 and December 1991. The clinical follow-up, which lasted from 11 months (for the most recent cases) to 132 months (for the earlier cases), shows that the staining index reaches a critical value beyond which an early recurrence might be expected.


Chemotherapy of malignant gliomas: studies of the BTCG.

Phase III Trial 8,301 tested the efficacy and safety of intraarterial (IA) BCNU for the treatment of newly resected malignant glioma, comparing IA BCNU vs intravenous (IV) BCNU (200 mg/m2 q 8 wks), each regimen without or with IV 5-FU (1 g/m2/d x 3 two wks after BCNU). All patients also received radiation therapy. 505 patients entered the study; 448 were in the Valid Study Group (VSG). Excluding 190 patients who for medical reasons were not eligible for IA BCNU, 315 patients were randomized between IA (167) and IV (148) BCNU. Actuarial analysis (log-rank) demonstrated worse survival for the IA group (p = 0.002). Serious toxicity was observed in the IA group; 16 patients (9.5%) developed irreversible encephalopathy with CT evidence of cerebral edema, and 26 patients developed visual loss ipsilateral to the infused carotid artery. 5-FU did not influence survival. Survival between the IV and the IA BCNU patients with glioblastoma multiforme did not differ, but was worse for IA BCNU patients with anaplastic astrocytoma than for IV BCNU (p = 0.002). Neuropathologically, IA BCNU produced white matter necrosis. IA BCNU is neither safe nor effective. Phase II Trial 8420, compared IA cisplatin, 60 mg/m2 every 4 wks, vs IV PCNU, 100 mg/m2 q 8 wks; 311 patients were randomized. Preliminary results have been presented. Severe encephalopathy occurred in only 1.5% of patients receiving IA cisplatin. The median survival of the IV PCNU patients was 11.8 months; that of the IA cisplatin patients was 9.4 months, not statistically different.(ABSTRACT TRUNCATED AT 250 WORDS)


[Chemotherapy of malignant glioma. Results of studies of the EORTC group of brain tumors].

The EORTC Brain Tumor Group has conducted 5 randomized and prospective phase-III trials in adults with supratentorial malignant gliomas testing the following adjuvant treatments: 1) CCNU 130 mg/m2, q.6 weeks (trial 26741); 2) VM-26 100 mg/m2 on day 1, plus CCNU 130 mg/m2 on day 2, q.6 weeks, given either during radiation therapy (trial 26751) or during 12 weeks prior to irradiation (trial 26841); 3) Misonidazole 12 mg/m2 total dose in 9 fractions (trial 26801); 4) Cisplatin 60 mg/m2 on days 1, 8, 15 and 21 of radiation therapy (trial 26851). None of these treatments did prolong significantly the survival nor the time to recurrence. The most powerful prognostic factors found in every trial were tumor pathology, patients' age and neurological status. Objective remission lasting 6 to 9 months, defined as a clinical improvement persisting after discontinuation of corticosteroids, was observed with CCNU, VM26 plus CCNU or HeCNU in approximately 20% of the patients, while 30% stabilized on HeCNU. The activity of procarbazine, AZQ or DDMP used as single agents was much lower.


[Treatment of supratentorial glioma in adults by intra-arterial HECNU. Experience of the Pitié-Salpétrière group].

Between 1984 and 1988, patients suffering from malignant gliomas received intraarterial chemotherapy with HECNU (IAC). Three groups were identified. Group 1 consisted of 56 patients previously treated with surgery and radiation therapy (RT), who received IAC at recurrence. Group 2 consisted of 46 patients with unresectable tumors, and group 3 of 40 patients who had their tumor surgically removed. In groups 2 and 3, three courses of IAC were administered prior to conventional RT (50-54 Gy). Immediate tolerance was good but delayed ocular and cerebral toxicity occurred in 14% and 11% of cases, respectively. A better therapeutic response was observed with anaplastic gliomas than with glioblastomas (GBM). For anaplastic gliomas, median survivals (MS) were 18 months (group 1), 24 months (group 2) and 30 months (group 3). For GBM, MS were 4.5, 7.5 and 10.5 months in groups 1, 2 and 3, respectively. IAC does not seem to improve the prognosis of GBM.


Interstitial irradiation of malignant gliomas.

Beginning in 1986, using software to optimize radiation dosimetry, we have stereotactically placed removable catheters containing high activity I-125 sources into malignant gliomas in 56 patients. There were 32 men and 24 women, age 7 to 73. Forty-four had glioblastoma multiforme, and 12 anaplastic astrocytoma. Mean Karnofsky performance score was 75, range 50-100. Twenty patients (all with glioblastoma) were implanted after resection before further therapy, and 36 were implanted at recurrence following resection, external irradiation and chemotherapy. Six thousand cGy was delivered to the enhancing tumor contour on CT scan. Mean dose rate was 37 cGy/hr. Mean tumor volume was 41 cc, range 5-187 cc. Mean volume of brain that received 60 cGy was 67 cc, range 11-184 cc. Of 20 patients treated after resection alone, 8 are alive, 3-43 months after implantation; median survival is 22 months. Of 36 patients treated at recurrence, 14 are alive, 0-19 months after implantation; median survival is 10 months. The most common side effect of the procedure, which occurred in five patients, was catheter misplacement. Twenty-four patients (43%) required 27 reoperations, 1-25 months after implantation. In 25 pathologic specimens available for review, microscopic tumor foci with substantial radiation necrosis were found in 18, radiation necrosis only was noted in 5, and glioma alone was seen in 2.


The cellular immunotherapy of primary brain tumors.

The use of adjuvant immunotherapy for the treatment of primary malignant brain tumors dates to studies performed in the 1960's and 1970's using non-specific immune stimulators. Although the theoretical designs have remained similar, recent advances in molecular biotechnology have produced a new group of recombinant cytokines, spawning a new generation of immunotherapy-based clinical trials. In contrast to other published Phase I/II studies, we have had highly encouraging preliminary results using lymphokine-activated killer (LAK) cells and recombinant human Interleukin-2 (rIL-2; Cetus, Emeryville, CA), when the patients' use of corticosteroids could be restricted while on study. Patients with recurrent grade 3/3 glioma received multiple cycles of autologous LAK cells and rIL-2, post-operatively, via an Ommaya reservoir implanted into the tumor cavity following re-operation. The overall median survival for 13 patients with grade 3/3 glioma has not yet been reached at 55 weeks following second surgery, [mean +/- SEM, 64.7 +/- 10.5 weeks], with 5 patients still alive. Three patients have had partial responses (PR) demonstrated by CT scanning. In addition, one patient with grade 2/3 glioma has had a complete response (CR), with the disappearance of all residual CT-documented enhancement and mass effect.


Childhood medulloblastoma.

The progress that has been made in the treatment of the patient with medulloblastoma is gratifying. Survival for those who fall into the lower risk category probably exceeds 75%. For this degree of success, however, patients and their families have had to pay a price in terms of suffering the deleterious late effects of treatment. With sophisticated neuroimaging techniques diagnoses are now being made in a timely fashion and surgical mortality has been reduced to almost zero in most major medical centers. Radiation therapy and chemotherapy regimens have been increasingly successful, and further refinements of treatment are to be expected with the completion of randomized cooperative group trials. It is time to focus on means of achieving similar, or even better results, with reduced doses of neuraxis radiation, whenever possible, especially in the younger patient.


Management of brain metastases.

Brain metastases are common and often occur in patients whose systemic cancer is quiescent. When brain metastases occur, they considerably decrease the quality of life in patients who otherwise might be functional. An early diagnosis and vigorous treatment of the brain metastasis, while only rarely curative, may lead to a useful remission of the brain symptoms and may both enhance the quality of the patient's life and prolong survival. Patients with known cancer and neurological symptoms should all undergo appropriate diagnostic tests which include either CT scan or magnetic resonance imaging and, if a lesion is found and a definitive diagnosis can not be established, biopsy. Single or solitary brain metastases in patients with good systemic performance status should be strongly considered for surgical extirpation which will both make the diagnosis and deliver definitive treatment to the lesion. Patients with poor systemic performance status and/or multiple brain metastases are candidates for whole brain radiation therapy. Whole brain radiation therapy is also indicated in patients after successful surgical extirpation of a single metastasis. The role of focal radiation therapy and chemotherapy in the treatment of brain metastases is still being evaluated. Preliminary evidence suggests that focal radiation therapy is probably useful for the treatment of relapsed metastases and that chemotherapy may be useful in the primary treatment of small or asymptomatic brain metastases. Appropriate use of therapeutic modalities directed at brain tumors will ameliorate symptoms in most patients and usually increase survival and enhance the quality of the patient's life.


[Inoperable brain metastases from bronchogenic cancers. Value of combined chemotherapy with cisplatin and 5 fluorouracil].

We report the results of a combined of chemotherapy with CDDP and 5 FU repeated every 3 weeks in sixteen men (age range 31-73 years) with brain metastases. CT was performed after 2, 4 and 6 cycles to assess efficiency. Response was considered complete when no lesion was found on the CT scan and partial when the lesion shrunk to least half its the total volume. After two cycles, the response rate was 8/16 (50%). Treatment toxicity was mild with only one case of severe but reversible myelotoxicity (grade III). CDDP and 5 FU combined chemotherapy can be a useful treatment for brain metastasis of lung carcinoma.


Clinical and pathological advances on central nervous system paraneoplastic syndromes.

In the last decade, several features have improved our knowledge of CNS paraneoplastic syndromes. Patients with paraneoplastic cerebellar degeneration (PCD) and breast or ovarian cancer, but not with other tumors, harbor an antibody against Purkinje cells (called anti-Yo). Clinical features of anti-Yo positive and negative PCD are similar but the latter may have a less progressive clinical course with occasional remissions. In addition to the association of opsoclonus with neuroblastoma, this syndrome has been identified in patients with breast or small-cell lung cancer (SCLC). Patients with opsoclonus and breast cancer have an antineuronal antibody (called anti-Ri) not present if opsoclonus is associated with SCLC or neuroblastoma. Paraneoplastic encephalomyelitis (PEM) is almost always associated with SCLC. Most patients present with sensory neuronopathy, limbic or brainstem encephalitis but involvement of multiple levels is usual. An antibody (called anti-Hu) against neuronal nuclear antigens is present in patients with PEM and SCLC. Autopsy studies demonstrate deposits of anti-Hu specific IgG in the neurons and a predominance of T cells in the inflammatory infiltrates. Treatment of the tumor and immunosuppressors are effective in opsoclonus whereas patients with PCD or PEM with circulating antibodies do not improve.


[Lambert-Eaton syndrome: clinical and electrophysiological study of 18 cases associated with lung cancer].

The clinical and electrophysiological data of 18 consecutive adult patients with paraneoplastic Lambert-Eaton myasthenic syndrome (LMES) have been reviewed. The cancer associated with LEMS was small-cell lung carcinoma (SCLC) in 15 cases and epidermoid lung carcinoma in 3 cases. The main clinical neurological features were proximal lower limb weakness (100%), depressed tendon reflexes (94%) and dryness of the mouth (66%). The results of repetitive nerve stimulation (RNS) were not statistically different in the paraneoplastic LEMS group and in a group of 6 LMS patients in whom no carcinoma had been detected. Low-amplitude compound muscle action potential (CMAP) was present in all cases; decremental response at low stimulation rates was present in 13/15 cases. An abnormal incremental response at high stimulation rates was observed in all cases. A close correlation between CMAP amplitude and clinical condition was found in 4 cases during the long-term follow-up. In one patient the RNS electrical pattern could be misinterpreted as myasthenia gravis in only one muscle tested. We underline the usefulness of a 50 Hz stimulation during 4 seconds to establish the diagnosis unequivocally, and that of post-exercise facilitation in routine detection among an SCLC population. Our results suggest that CAMP amplitude and RNS test could be used to evaluate the short-term improvement of LMS under treatment and, in some cases, for the long-term follow-up. The infraclinical axonal neuropathy detected in 8 patients probably was another associated autoimmune paraneoplastic complication.


NARES: a model of inflammation caused by activated eosinophils?

Twenty patients were selected on the basis of perennial rhinitis, the absence of allergy and with an eosinophil count higher than 20% of total leucocytes in nasal secretions (NARES). Nasal endoscopy with biopsies from the middle turbinate and sinus CT were performed. Biopsies were processed for histological examination and for immunofluorescence. The clinical progress during treatment was scrutinized. An acute congestive aspect of the nasal mucosa was noted in 4 cases, and micropolyposis in 9 cases. Sinus CT showed opacity of the ethmoidal cells in 87% of cases (maxillary sinuses: 75%; frontal sinus: 46%; sphenoidal sinus: 31%). An eosinophilic infiltrate of the nasal mucosa was constituted in 9 cases: In 6 cases, the cells expressed the Fc epsilon RII receptor, recognized by the monoclonal antibody Bb10. Anti-H1 drugs usually failed to result in a clinical improvement and local eosinophilia was not changed. Local corticoids were more effective but not sufficient in some cases, so that oral corticotherapy was needed. Ethmoidectomy was performed in three cases. NARES seems to evolve in three stages: (1) migration of eosinophils from the vessels to the secretions; (2) retention of eosinophils in the mucosa which might be linked to activation of unknown origin; (3) nasal polyposis. Numerous interactions between irritation of the epithelium, release of substance P, and eosinophils, lead to the hypothesis of a neurogenic origin of NARES.


Eosinophilia in nasal secretions compared to skin prick test and nasal challenge test in the diagnosis of nasal allergy.

This study was aimed to assess the usefulness of eosinophilia measurements in nasal smears (ENS) in the diagnosis of nasal allergy. Nasal smears were taken from 84 patients with histories suggestive of allergic rhinitis. The smears were stained by the Giemsa method and examined by light microscopy. Positive results were demonstrated in 69.2% of the samples. All the 84 patients also had a skin prick test (SPT); the perceniitage of correct correlation between ENS and SPT was 71.4%. Forty-two patients underwent nasal challenge test (NCT) and the percentage of correct correlation between ENS and NCT was 69%. Nine patients had negative SPT, but positive ENS. All were nasally challenged with 4 proving positive. This leaves 5 individuals (5.9% of the 84 studied) in the non-allergic rhinitis with eosinophilia category. Based on these findings, it is suggested that the assessment of eosinophils in nasal smears should be given more relevance and be more commonly used in the diagnosis of nasal allergy.


Rhinomanometric detection rate of rhinoscopically-assessed septal deviations.

Normal values for the flow at a transnasal pressure of 150 Pa were established with active anterior rhinomanometry (with decongestion) in a group of 33 normal subjects. These values were used to detect abnormalities in a group of 193 patients whose septum anatomy had been evaluated with rhinoscopy. About 25% of the rhinoscopically normal patients were found to have significantly low ("abnormal") flow values on one side. The same was true for patients with a small septal deviation restricted to one anatomical area. An abnormal flow was measured in about 35% of the patients with a moderate (restricted) septal deviation. In the patients whose septal deviation was not restricted to one anatomical area, about 45% had an abnormal flow. The highest detection rate was about 80% in patients with major deviations in the region of the vestibule and the valve. Such deviations were found only in a minority of the patients with complaints of nasal obstruction, which limits the importance of rhinomanometric evaluation in clinical practice.


Antroconchopexy for surgical treatment of perennial rhinitis.

We report on a rhinomanometric assessment of eleven patients undergoing antroconchopexy for relief of a "stuffy" nose. This little-known procedure involves the lateralization of the inferior turbinate through a large intranasal antrostomy. Our results demonstrate a significant improvement in postoperative inspiratory and expiratory nasal resistance. There was also a significant improvement in patient's scoring for nasal obstruction. Finer points of the surgical technique, and indications for the procedure are discussed.


The nasal provocation test in the diagnosis of allergic rhinitis. Behaviour and dynamics of nasal flow during the test.

We analyzed the value of the (n) coefficient of nasal flow in the formula of nasal resistances in order to: (1) calculate nasal flow during the course of the nasal provocation test, and (2) try to find out whether nasal flow maintains the same characteristics during the test. Our results show that values vary between 1.6589 and 1.8801, with a weighted mean of 1.7645--suggesting that the flow is of a mixed character--without significant differences during the course of the test. At the same time we carried out an analysis of the dynamics of nasal flow during nasal provocation.


Respiratory tubes with nasal packings following septorhinoplasty.

The use of packings following septorhinoplasty is a matter of controversy. The recommendations go from gluing with fibrin glue only, if anything at all, over quilting stitches, perhaps in combination with silastic or teflon sheats or plates or these sheats alone, to the employment of various more substantial materials and in from 1 to even 14 days postoperatively. If long-term nasal packing is chosen following consideration of primary healing, patients will experience discomfort of mouth-breathing, but pressure in the ears, too. Therefore, our department has used respiratory tubes simultaneously with packings since 1971. In this study, 47 patients who underwent septo- and/or rhinoplasty were treated by nasal packings 6 days postoperatively. All patients were treated by silicone respiratory tubes, one group in all 6 days, one in 4 days only. Self-assessment as far as some typical complaints is concerned was carried out as well as tympanometry. There were statistically significant less complaints of pressure in the ears when tubes were used, and the period with tubes was significantly preferred to the period without. A low pressure in the middle ears was seen in many patients. The normalization was occurring significantly sooner with tubes. At the same time they seem to secure that the normalization will take place as fast as it has been demonstrated in an earlier study employing only 3 days of nasal packing. No synechias or perforations were seen at an early follow-up, 1-3 months postoperatively. When long-term packing is preferred, respiratory tubes then can be recommended as effective.


Diagnostic value of plain radiographs in chronic maxillary sinusitis: a comparison between radiological and endoscopic findings in 75 patients.

Preoperative radiologic and intraoperative endoscopic findings of maxillary and ethmoid sinuses were compared in 75 adult patients, in whom 135 chronically inflamed maxillary sinuses were operated using functional endoscopic sinus surgery (FESS). At sinoscopy, secretion was found in 91% (41/45) of the radiologically opacified antra and in 47% (31/65) of the antra with moderate or marked mucosal swelling in plain radiographs. Antral fluid level in radiographs was a relatively rare (23%) finding and showed secretion as reliably as opacification. Radiographic detection of secretion in maxillary sinuses with mucosal thickening is difficult. There was a fair correlation in both antral and ethmoidal mucosal changes with the mucosal findings in antroscopy and endoscopic ethmoid surgery.


[Acute intermittent porphyria in pregnancy: glucose or hematin therapy?].

The symptoms and management of acute intermittent porphyria (AIP) during pregnancy and delivery are presented on the basis of three case reports. Two patients became asymptomatic after infusion of a concentrated glucose solution (600 ml 50% glucose = 300 g glucose per day), while the third patient needed treatment with hematin (1 mg/kg body weight, 6 infusions at intervals of 12 hours) because of deterioration of psychic state in spite of glucose infusion. Whenever an attack of AIP occurs, concentrated glucose solution should be administrated as a first measure accompanied by an analgesic and possibly a neuroleptic agent after elimination of precipitating factors. However, if symptoms persist for 48-96 hours or the psychic and/or neurological state of the patient further deteriorates, administration of 1-3 mg hematin per kg body weight can be recommended.


[Long-term follow-up after thyroidectomy: incidence of recurrent goiter and functional results].

We analyzed the postoperative longterm results after strumectomy for sporadic goiter in 26 patients. The follow-up time was 25.1 +/- 14.7 (7-58) years (x +/- SD, extremes). Actual goiter recurrence without need for surgery was observed and sonographically confirmed in 3 patients, and 1 patient without actual recurrence had had a second strumectomy for goiter recurrence in the past. Hence the overall frequency of goiter recurrence in this study is 15% (4/26 patients). The patients with a present recurrence (n = 3) were significantly younger at the time of operation (29 +/- 11, 14-41 years) than those without recurrence (n = 23; 45 +/- 11, 28-60 years; p < 0.001). No patient had clinical endocrine dysfunction. Only four patients had been treated with thyroxine and they all suppressed TSH in the presence of euthyroid FT4 and T3 levels without present recurrence of goiter. 22 patients had no thyroid hormone prophylaxis and in only four of them (18%) was observed a recurrence in the longterm follow-up without endemic iodine deficiency. Prophylaxis with thyroid hormones often is not required in low risk patients operated upon and carefully controlled after strumectomy from non-iodine-deficient regions. Patients at risk for recurrence (second strumectomy, family history, elevated TSH, clinical or sonographic evidence for thyroid growth) should be considered for thyroxine therapy with regular follow-up.


[Health status of methadone recipients before entering a methadone program].

Data were analyzed from 905 opiate addicts who participated for the first time in a methadone maintenance program in the Canton of Bern, Switzerland, between 1979 and 1989. Data of their physical and psychological state at the time of application for the methadone maintenance program were related to data of the addiction history and program progress. Only one fifth of the participants in the methadone maintenance program report to be in good health. Poorer health corresponds to reported psychological disorders. No correlation between demographical data and health status could be found, except that less qualified patients were in poorer health. Poorer health status is associated with the consumption of a higher amount of heroin per kg body weight and often with consumption of benzodiazepines before entrance into the methadone maintenance program. Methadone maintenance patients with a lower health status are given higher methadone doses. Compared to patients in better shape, more do not work before and during the methadone program. The physicians express less optimism with regard to the success of the program in patients in poorer health, and these are more often expelled from the program by their physicians or the health department. The results indicate that patients generally profit from the methadone maintenance treatment. However, better integrated patients and persons in better health may derive greater benefit from the methadone maintenance treatment.


[Immunology and diagnostic test results in Lyme borreliosis].

Borrelia burgdorferi (B. burgdorferi), the etiologic agent of Lyme borreliosis, shows both a variety of outer surface proteins with molecular weights between 16 and 100 kiloDalton (kD) and a 41 kD flagellar protein, which induce the immunologic response. Lipopolysaccharides, another constituent of the bacterial capsule, are responsible for the inflammatory reaction, constitutional symptoms and for the Jarisch-Herxheimer reaction. First a vigorous T-cell immune response develops, followed later by a more slowly evolving humoral B-cell immune response. The delayed onset of the humoral immune response may explain why antibodies against B. burgdorferi could not be detected early in the course of the disease. But the antibody titers increase with duration of the illness. The humoral response shows the usual pattern of IgM appearing first, followed by IgG and IgA. The IgM titer normalizes after recovery while the IgG titer could persist over years or decades. It is hardly possible to detect B. burgdorferi microscopically or by cultivation from blood, joint or cerebrospinal fluid. For routine diagnosis the fluorescent antibody staining and the ELISA methods are available which detect IgM or IgG antibodies against B. burgdorferi. But the sensitivity and specificity of these tests are still unsatisfactory. Other methods such as the ELISA-capture method, complement binding reaction, passive hemagglutination or the polymerase chain reaction are not yet established for routine purposes. Western blot analysis did not yield an essential diagnostic advantage but may be helpful in long term observation or in special cases. The measurement of the cellular immune response by T-cell proliferation tests remains controversial. First of all Lyme borreliosis has to be diagnosed by clinical findings and by elimination through differential diagnosis. An elevated antibody titer or a positive T-cell proliferation test may confirm the diagnosis but cannot prove it. Without consistent clinical findings they are of no practical significance. Some general guidelines for interpretation of laboratory results are given.


[Abdominal aortic aneurysm. Risks and early postoperative course].

A review of the literature shows a very variable mortality, especially after emergency operations for abdominal aortic aneurysm (AAA) (14-70%). We therefore analyzed the mortality of our patients in different subgroups. The hospital data of 82 patients operated on for abdominal aortic aneurysm were analyzed retrospectively. 42 patients underwent emergency operations and 40 patients elective surgery. The mean age was 67.5 +/- 9.4 and 70.7 +/- 7.3 years respectively. The overall 30-day mortality in elective cases was 5% (2/40); elective patients under the age of 75 years had a mortality of 0%. 33% of the emergency cases died within 30 days. The mortality in various subgroups was as follows: "asymptomatic AAA" 5.4% (2/37), "symptomatic AAA" 10% (1/10), "retroperitoneal rupture" 34% (11/32) and "intraperitoneal rupture" 66.6% (2/3). Preoperatively 21/42 patients who underwent emergency surgery were in hypovolemic shock (systolic blood pressure < or = 90 mm Hg). The mortality of these patients was 52% (11/21) compared to 9.5% (2/21), (p < 0.01), in emergency patients without preoperative shock. The causes of death after emergency procedures were hypovolemic shock in 6, heart failure in 4, and multi-organ failure, respiratory insufficiency, unknown and pulmonary embolism in 1 each. 5/14 patients died in theatre. Two patients died after elective procedures: one 9 days postoperatively from myocardial infarction and the second 23 days after the operation from an unknown cause. Reoperation rate after elective and emergency procedures was 7.5% and 16.6% respectively. Mortality after reoperation was 40%.(ABSTRACT TRUNCATED AT 250 WORDS)


[Fever of unknown origin in a cohort of HIV-positive patients].

The purpose of this study was to determine the prevalence of fever of unknown origin (FUO) in a cohort of HIV positive patients and to describe their evolution and the final diagnosis. The clinical records of 412 patients followed from January 1987 to December 1990 at our HIV outpatient clinic were reviewed: in 151 patients 255 episodes of fever had been observed of which 22 (in 21 patients) met the criteria for FUO. 19 patients (90%) presented with a CDC/WHO stage IV HIV infection and the mean CD4+ lymphocyte count was 0.160 G/l. The etiology was ultimately determined in 13/22 episodes (3 Pneumocystis carinii pneumonia, 3 invasive infections due to atypical mycobacteria, 2 bacterial pneumonia, 1 Cytomegalovirus colitis, 1 Isospora belli enteritis, 1 visceral leishmania, 1 candida septicemia and 1 lymphoma). In 6/22 episodes, the fever subsided after zidovudine was started and was therefore attributed to HIV itself. In 3/22 episodes no etiology was found. In conclusion, this series shows that FUO is usually seen in advanced HIV infection and that it often represents an early sign of opportunistic infection. This observation underlines the importance of follow-up, since it finally served to detect the etiology of FUO in 86% of cases. Trial treatment with zidovudine can be useful where no pathology has been discovered despite 3 weeks' follow-up and appropriate investigations.


[Glomerulonephritis with transient C3 hypoclompimentemia and endotheliomesangial glomerulonephritis in childhood. A long-term experience].

62 children (20 girls and 42 boys, ranging in age between 3 and 15 years), presenting with acute hypocomplementemic glomerulonephritis or morphologically confirmed endotheliomesangial glomerulonephritis, were admitted to the University Children's Hospital, Berne from 1970 to 1991. The annual incidence of cases of acute hypocomplementemic glomerulonephritis was stable during the study period. The site of the antecedent infection was the throat in 26 patients, upper respiratory tract in 15, the skin in 9, and unknown in 10. The latent period ranged from 0.5 to 3.5 weeks. 41 patients developed hypertension and 17 renal failure. Hypertensive complications were observed in 6 patients and remitted completely in 5 cases. A nephrotic syndrome (edema, proteinuria of 40 mg/[m2.h], albuminemia < 25 g/l) was observed in 11 patients. Microscopic hematuria persisted in many patients for one year or more. Proteinuria remitted in all but one patient, who was found to have Alport syndrome. This study shows the stable frequency of hypocomplementemic glomerulonephritis since 1970, its good prognosis, and the importance of the measurement of C3-complementemia in children presenting with acute glomerulonephritis.


[Acute poisoning due to oral intake of an organic solvent].

We report a case of paint thinner intoxication by oral intake, with loss of consciousness, upper gastrointestinal injuries, renal failure, rhabdomyolysis and cervical plexus injury. The clinical picture was similar to other cases reported in the literature.


Management of the do-not-resuscitate patient undergoing anesthesia and surgery.

Some unique questions and concerns arise when a patient with do-not-resuscitate orders is taken to surgery. This issue is discussed in the context of current data on cardiopulmonary resuscitation and ethical decision-making strategies.


Date and acquaintance rape among a sample of college students.

This article reports on a date and acquaintance rape needs-assessment survey of 106 male and 113 female students in undergraduate English courses at the University of Hawaii-Manoa. The sample was ethnically mixed, with Japanese being the largest ethnic group represented. Unduplicated counts showed that 28 percent (n = 32) of the women acknowledged that they were victims of rape or attempted rape, and the majority reported multiple victimizations. One-sixth (n = 18) of the men admitted to committing acts that meet the legal definition of sexual assault in Hawaii, and about one-third (29.2 percent, n = 31) admitted that they continue to make sexual advances even after a woman says no. Implications for date and acquaintance rape prevention programs are discussed.


Elderly black farm women: a population at risk.

Elderly black farm women are a neglected segment of the elderly population. Their self-reliance, mutual support, and rurality have helped keep them isolated and underserved. This article describes the productive life-styles that 10 such women in southeastern North Carolina recalled in oral-history interviews and the problems these women face because of their advancing age, poor health, caregiving responsibilities, and isolation and the deterioration of traditional resources.


Psychosocial implications of women and retirement.

This article explores the unique effects of retirement on women, many of whom are economically insecure when they retire. Because of the prevailing "myth" among women that they will be cared for in old age and women's fear of growing old, women often do not aggressively plan for their retirement. The women's movement should begin to advocate for women's preparation for the realities of old age.


Nosocomial colonisation and infection in a paediatric respiratory intensive care unit.

A study of the prevalence of nosocomial colonisation and nosocomial infection (NI) was conducted in the paediatric respiratory intensive care unit of a large teaching hospital serving a developing community. Surveillance specimens were collected regularly from 63 consecutive patients admitted over 4 months, and also from professional staff, boarder mothers, cleaners and the unit environment. The incidence among patients of colonisation (40%) and of NI (43%) was high. The risk of dying in children with NI was appreciably increased (relative risk 2,241, confidence interval 0,591-8,503). This did not reach statistical significance, probably because so few children escaped acquiring hospital organisms. The significant risk factor for acquiring colonisation (P = 0.008) and NI (P < 0.0001) was a ward stay of more than 10 days. In addition, for acquiring NI an age of under 6 months was also predictive (P = 0.0298). The nature of the primary illness dictated the time spent in the ward; an important proportion of patients had preventable diseases, such as measles, pneumonia and tetanus, which required prolonged treatment. All children with endotracheal intubation had hospital-acquired organisms in tracheal aspirates. Eighty-two per cent of children developed positive gastric aspirates, 17% a positive urine culture and 11% a positive blood culture. Colonisation occurred rapidly; organisms initially appeared in gastric aspirates (mean 2 days), then in tracheal aspirates (mean 5 days) and urine cultures (mean 10 days). The acquired organisms, many of which were antibiotic-resistant, were almost exclusively enteric Gram-negative bacilli (GNB) and Staphylococcus aureus.(ABSTRACT TRUNCATED AT 250 WORDS)


Antibiotic susceptibility of anaerobic bacteria isolated in Johannesburg.

In vitro susceptibilities of 198 anaerobic bacteria to seven antibiotics were evaluated by the agar dilution method. In addition to testing amoxycillin/clavulanic acid in a 2:1 ratio against the bacteria, the combination was also tested against 63 isolates using fixed concentrations of clavulanic acid and serial dilutions of amoxycillin. Penicillin and cefoxitin were not effective against beta-lactamase-producing Bacteroides isolates and only 50% of isolates were susceptible to the 2:1 amoxycillin/clavulanic acid combination. However, when varying concentrations of amoxycillin were used together with constant concentrations of clavulanic acid (4 micrograms/ml) only 9 of 55 amoxycillin-resistant Bacteroides were resistant to the combination. Two clostridia were found to produce beta-lactamases and as expected were resistant to penicillin. Of the non-beta-lactamase-producing clostridia 11% were resistant to penicillin and 5% resistant to cefoxitin. Imipenem was effective against the majority of anaerobes tested and only 5 Bacteroides isolates were resistant. All anaerobic strains were susceptible to chloramphenicol and only 6% of strains resistant to clindamycin. Eighty-five per cent and 51% of Bacteroides strains had minimum inhibitory concentrations within two dilutions of the breakpoints of chloramphenicol (16 micrograms/ml) and clindamycin (4 micrograms/ml) respectively. Three strains of Peptostreptococcus spp. were resistant to metronidazole.


Safety and efficacy of interferon alpha-2b following prednisone withdrawal in the treatment of chronic viral hepatitis B. A case-controlled, randomised study.

The therapeutic effects of interferon alpha-2b (Intron A; Scherag) in patients with chronic active hepatitis caused by hepatitis B virus (HBV) were assessed in a randomised, case-controlled clinical trial conducted between January 1988 and June 1990. Treatment involved a short course of prednisone followed by interferon alpha-2b, initially 10 million U by subcutaneous injection, 3 times a week for 16 weeks. All patients were symptomatic, were known to have had hepatitis B surface antigen and hepatitis B e antigen (HBeAg) in their blood for at least 6 months, and had elevated serum aminotransferase activities with histological evidence of chronic active hepatitis. Patients with carcinoma, renal or haematological abnormalities or decompensated cirrhosis were excluded. In 6 of 10 patients randomised to receive interferon and 1 of 10 controls, HBeAg and HBV DNA were cleared from the blood during the 12-month study period (P < 0.05). An indeterminate response with clearance of HBV DNA but persistence of HBeAg was noted in 1 patient receiving interferon. Serum aminotransferase levels decreased only in those patients who had responded to treatment, but this did not reach statistical significance for the group as a whole. Histological studies, where available, showed decreased hepatic periportal necrosis in patients who underwent treatment. Two patients relapsed to HBeAg-positive status 2 months after their initial seroconversion; 1 became clear again during a repeat course of interferon. Side-effects of treatment were common and included fever, malaise, myalgias and myelosuppression. One patient developed hypothyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)


A survey of the use of blood and blood components among South African anaesthetists working in teaching hospitals.

A survey of the peri-operative policies for blood and blood component therapy was carried out among anaesthetists in the nine South African teaching hospitals. All anaesthetists completed the questionnaire, without recourse to books or discussion. The survey revealed a possible over-utilisation of blood and blood components in the peri-operative period. There were significant deficiencies in the pre-operative assessment of blood and platelet requirements and the specific indications for platelet, fresh frozen plasma and blood transfusions. A significant number of respondents exhibited poor knowledge of the potential dangers and expense that the use of blood and blood components entails. Educational effort was perceived to be the main method of rationalising the anaesthetist's usage of blood and blood components.


The role of private hospitals in South Africa. Part I. Current trends.

This paper is the first of two that examine the present and the future role of private hospitals in South Africa. Part I describes the current structure and size of the private hospital sector, and analyses recent trends in the number and distribution of beds and hospitals, expenditure patterns, and utilisation of care. These observations are used as the basis for an analysis of the present role of the private hospital sector. It is argued that this sector is an important potential national resource for health care. However, the present contribution of private hospitals to national health care is limited by several factors. Access to a large proportion of these hospitals is restricted to those who can afford to pay, while the economic inefficiency and geographical maldistribution of fee-for-service and charity hospitals compound the negative effect private hospitals have on the public health sector. The gap between the potential contribution of private hospitals and current reality provides a strong argument for the development of a national policy that will improve the situation.


Psychiatric manifestations of neurosyphilis.

To investigate referral patterns, initial diagnoses and clinical features of patients with neurosyphilis who present with psychiatric manifestations, records were kept of 21 such patients admitted to an acute psychiatric ward. In none of the 12 cases referred from primary care workers was the possibility of neurosyphilis considered. In only 3 cases was this diagnosis considered on admission to the psychiatric ward before serum serological test results were known. Commonest presenting symptoms were personality change (16 patients) and memory impairment (13 patients). Neurological signs or symptoms were also common, particularly absent pupillary reaction to light (5 patients) and buccolingual masticatory movements (5 patients). A positive serological test remains the single most important factor in identifying patients with neurosyphilis.


Indications for computed tomographic brain scanning in psychiatric inpatients.

This study examined the rate of use of computed tomographic (CT) scanning as well as clinical parameters pertaining to that used in psychiatric patients. These patients were compared with a randomly selected control group of psychiatric patients who were not scanned. In addition, scan abnormalities were examined and correlated with clinical and electro-encephalographic (EEG) data. CT scanning was used on 13.5% of admissions. On axis 1 of the DSM III-R, the CT scan group had a significantly higher incidence of delirium and dementia (P < 0.05) and a much higher rate of medical illness (P < 0.01) on axis 3. The rate of CT abnormality was fairly high at 45.2%. An abnormal CT scan was associated with the diagnosis of dementia, the presence of organic mental status abnormality and of abnormality on neurological examination. Focally abnormal CT scans were associated with focally abnormal EEGs in a significant number of patients (P < 0.05).


The clinicoradiological profile of cerebral venous thrombosis.

The clinical presentation, diagnostic and radiological aspects and the probable aetiology in 20 consecutively studied patients with cerebral venous thrombosis (CVT) are described. In this retrospective analysis patients were evaluated extensively according to a stroke investigative protocol. Computed tomography signs for CVT may be identified in the majority of cases and frequently obviate the need for angiography. In those patients in whom no satisfactory precipitating factor was recognised further haematological tests revealed abnormalities that are known causes of thrombosis in 7 patients. Eighty-five per cent of the patients made an excellent recovery. It is concluded that CVT can often be diagnosed non-invasively, the presumptive cause can be found in the majority of patients and the prognosis is excellent.


Elective cholecystectomy via a 5 cm subcostal incision.

This report describes a technique whereby elective cholecystectomy is performed through a 5 cm abdominal incision. Initial results in 18 patients compared with 112 historical control patients undergoing conventional cholecystectomy suggest an encouraging reduction in postoperative hospitalisation time, analgesic requirements and period of recuperation. The procedure takes no longer to perform than conventional cholecystectomy and obesity is not a limiting factor, as originally thought. This technique deserves a place alongside laparoscopic and conventional cholecystectomy in future studies seeking the optimal method of managing symptomatic cholelithiasis.


The natural history of carcinoma of the cervix in young women.

Invasive carcinoma of the cervix was treated in 1,522 patients over a 10-year period at Groote Schuur Hospital. Data for each patient included place of residence, pathological characteristics of the tumour, nodal spread, histological evidence of human papillomavirus (HPV) infection, disease stage, treatment type, treatment complications, site of recurrence and survival time. Patients aged under 35 years comprised 11.6% of the total patient group. A retrospective cohort study compared women aged under 35 years of age at the time of entry into the study and women aged 35 years or more. In all, 82 eligible young patients were compared with random sample of 82 eligible older patients. Contingency tables, life tables and proportional hazards analysis were used where appropriate. There was no significant difference across the two age groups in the incidence of non-squamous tumours, or in the grades of squamous tumours. Similarly there was no evidence of differences in lymph node involvement or HPV infection. Young patients appeared to enter the study at significantly earlier stages of the disease, and a greater proportion of them underwent surgical treatment (diff = 36.4% +/- 13.5%). In both groups treatment complications were less frequently observed after surgery than after radiotherapy. Sites of tumour recurrence were similar in both groups, and there was no apparent difference in survival times.


[Failed postpartum sterilisation--a comparison of 5 methods].

A comparison of the standard Vienna method of postpartum sterilisation (3,580 patients with 18 failures and a sterilisation failure rate of 5.03/1,000) with 4 other methods at Paarl Hospital is presented: the Pomeroy method (892 patients with 19 failures and a sterilisation failure rate of 21.31/1,000); the total fimbriectomy method (1,578 patients with 23 failures and a sterilisation failure rate of 14.58/1,000); the Filshie clip method (808 patients with 18 failures and a sterilisation failure rate of 22.28/1,000); and the Irving method performed at caesarean section (456 patients and 1 failure). As no totally permanent technique exists to prevent pregnancy, a plea is lodged for legalised abortion after failed sterilisation.


Teenagers seeking condoms at family planning services. Part I. A user's perspective.

The promotion of condom use is an essential part of any AIDS prevention programme. By distributing condoms and promoting their use, clinics that provide family planning services can play an important role in preventing the spread of AIDS. This study assesses the accessibility of condoms to teenagers at selected family planning services in Durban. Twelve randomly selected clinics in Durban were visited by each of 4 teenage fieldworkers. During these visits, the fieldworkers' experiences were recorded in detailed notes which were subsequently analysed for content. The fieldworkers experienced difficulty in locating a few of the clinics and some were embarrassed by security staff. The two female fieldworkers, in particular, were intimidated by their reception at the clinics and found resistance to their requests for condoms. On two occasions, supplies of condoms had run out. When condoms were available, they were distributed in a setting that lacked privacy. Information on how to use condoms, if offered at all, was supplied by way of pamphlets and information on AIDS was rarely offered. Overall, the experiences of the fieldworkers indicated that it was difficult for teenagers to obtain condoms from clinics providing family planning services in Durban. It is recommended that there be signs indicating the location of the clinics, and that privacy be ensured and adequate stocks of condoms maintained. Most importantly, clinic staff need to use every opportunity to discuss AIDS prevention with teenagers attending the clinic.


Teenagers seeking condoms at family planning services. Part II. A provider's perspective.

This study assessed the ability and preparedness of staff at family planning clinics in Durban to assist in AIDS prevention by promoting condom use among teenagers. Staff at 12 randomly selected clinics were interviewed to assess their attitudes towards teenagers seeking condoms, the information imparted on AIDS and condom use, constraints faced in delivering services, and their perceived role in controlling the spread of AIDS. Despite their awareness of AIDS, those interviewed perceived their role to be that of promoting contraception. Condoms were perceived as a poor choice of contraceptive and their use was discouraged. The pamphlets dispensed along with condoms were thought to provide adequate information about condom use. Information on AIDS was given only if the clinic attender initiated discussion on the subject. Most of the clinic staff were keen to discuss other issues during their consultations, but felt constrained by the large numbers of people they had to attend to and the lack of adequate facilities. If family planning services are to play a role in controlling the spread of AIDS, the first step must be to make this function part of the overall policy. For there to be effective counselling on AIDS prevention, in-service training of current staff is required, as well as more staff and improvements in facilities to ensure greater privacy.