[Short-latency somatosensory evoked potentials in patients with hypertensive intracerebral hemorrhage: clinical availability of N20 component].

Short-latency Somatosensory Evoked Potentials (SSEPs) were studied in 14 patients with putaminal hemorrhage and 17 patients with thalamic hemorrhage. After median nerve stimulation SSEPs were recorded from the electrodes placed on C3', C4' (2cm behind C3 or C4 of the internal 10-20 system respectively), and Cv7. (Reference was the linked ears.) Erb's potential was also recorded from the Erb's point using the contralateral one as the reference. The patients were classified into three groups according to central conduction time laterality index (CCT LI). CCT LI = (CCT on the affected side which is defined as the interpeak latency between N13 and N20)--(CCT on the non affected side). Group 1: CCT LI < or = 0.73 (it means within normal limit); Group 2: CCT LI > 0.73 (it means the significant latency delay of the N20 on the affected side); Group 3: CCT LI is not available (because the N20 was abolished on the affected side). We analyzed retrospectively the localization of the hematoma on CT scans, the degree of motor and sensory disturbance of the upper extremity in each group. Of the 14 patients with putaminal hemorrhage, 5 were in group 1; 3 were in group 2; 6 were in group 3. Patients in group 1 had a localized hematoma within the pallido-putamen complex. Patients in group 2 had a hematoma compressing the posterior limb of the internal capsule. Patients in group 3 had a hematoma involving the posterior limb of the internal capsule and had severer motor disturbance than those in group 1 or group 2.(ABSTRACT TRUNCATED AT 250 WORDS)


[Biochemical, rheological and clinical aspects of using the HELP system in the treatment of hypercholesterolemia and cerebrovascular disorders].

The HELP system is a new method of selective plasmapheresis, which decreases LDL concentration in plasma with the additional effect of lowering Lp (a) and fibrinogen, while HDL are increased during long-term treatment. The HELP system also significantly improves plasma viscosity, erythrocyte aggregation and red cells deformability. In patients with severe hypercholesterolaemia a good clinical effect of this therapy has been established. Preliminary results of the HELP system application in cerebrovascular disease indicated a clinical improvement in patients treated in this way in relation to the basic values as well as to the control group. No serious haemorrhagic or thrombotic effects have been observed during therapy, but in view of interference in coagulation and fibrinolysis this possibility should be considered.


[A rare case of choroid plexus papilloma in the third ventricle].

A rare case of choroid plexus papilloma in the third ventricle is presented. A 19 year old male patient was admitted to our hospital for further examination of a head injury. On admission, he was asymptomatic. CT and MRI showed a homogeneous mass extending from the third ventricle to the right lateral ventricle. The right lateral ventricle was slightly enlarged. Craniograms showed calcification above the sella turcica. Cerebral angiograms disclosed a tumor stain fed by the right medial posterior choroidal artery in the third ventricle. Anterior transcallosal approach was chosen for the extirpation of the tumor. Histological study revealed choroid plexus papilloma. The postoperative course was uneventful.


[Choroid plexus papilloma of the third ventricle in infancy: a case report].

The incidence of choroid plexus papilloma is about 0.5% of all intracranial tumors, but they are only infrequently found in the third ventricle. This is a case report of choroid plexus papilloma of the third ventricle in an infant. A make child in his 7th month of age was admitted because of large head circumference, on the 28th February, 1989. CT scan demonstrated hydrocephalus caused by a tumor in the third ventricle. Total removal of the tumor was performed on the 8th of March. Histologically the tumor was found to be choroid plexus papilloma. The patient suffered from postoperative subdural effusion and convulsions, so we performed ventriculoperitoneal shunt on the 14th April, and convulsions were controlled by zonisamid.


[Coexistence of intracranial and spinal cavernous angiomas: case report].

A case of a 43-year-old man with coexistence of intracranial and spinal cavernous angiomas is presented. The patient had a 2-year history of severe back pain incurred by neck flexion, and he became aware of weakness of the right lower extremity and paresthesia of the left lower extremity. Neurological examinations at the time of the first admission demonstrated incomplete Brown-Séquard syndrome. Myelograph, myelo-CT and contrast enhanced CT showed an intramedullary mass at the Th3-Th5 level. The patient received laminectomy with total removal of the lesion. Pathological diagnosis was cavernous angioma. Six years later, the patient complained of subacute weakness and numbness of the left upper extremity. Head CT demonstrated a high density lesion of about 2cm in diameter in the right frontal lobe. MRI showed a mixed signal intensity lesion with a marked low-intensity rim in the same area. Total extirpation of the lesion was performed. Pathological diagnosis of the intracerebral lesion was also cavernous angioma. Intramedullary cavernous angioma is very rare. Furthermore, bifocal cavernous angiomas involving both the spinal cord and the brain are extremely rare, and, only 5 cases have been reported in the literature. To our knowledge, this is the first case diagnosed by surgical specimens of coexisting intramedullary and intracerebral lesions.


[A case of granulomatous hypophysitis].

The patient was an unmarried, 25-year-old woman who presented herself with amenorrhea and lactation as her chief complaints. Radiography revealed a tumor in the sella turcica. Upon neurological examination at the time of admission, there were no abnormal findings affecting the field of vision or visual acuity, and no abnormalities were seen in the fundus oculi. In endocrinological tests, the basal plasma values of pituitary hormones were normal except for that of prolactin, which was 69.1 ng/ml. The preoperative diagnosis was nonfunctioning pituitary adenoma, and this neoplasm was resected by the transsphenoidal approach. Postoperative histological investigation showed vermiculous destruction of the anterior lobe of the pituitary gland, and also scattered lymph follicles accompanying infiltration by numerous lymphocytes and multinucleated foreign-body giant cells, and deposition of calcium. These findings, together with the epithelioid cells gathered around them, pointed to a diagnosis of granulomatous hypophysitis. The causes of granulomatous hypophysitis are known to include syphilis, tuberculosis, sarcoidosis, mycotic granuloma, and foreign-body granuloma due to the rupturing of a Rathke's cleft cyst, but no evidence of any of these was found in this patient. Another known source of inflammatory lesions in the hypophysis is lymphocytic hypophysitis, which resembles Hashimoto's autoimmune disease of the thyroid gland, and which is characterized both by the formation of lymph follicles and by extensive lymphocyte infiltration. In relation to the cause of granulomatous hypophysitis, thinking that it might possibly be an autoimmune disease, we conducted an immunological investigation, and also made a serological study of autoantibodies, but obtained no positive results.(ABSTRACT TRUNCATED AT 250 WORDS)


[A ruptured aneurysm of the distal posterior inferior cerebellar artery associated with basilar artery occlusion: a case report].

We presented a case of a distal posterior inferior cerebellar artery (PICA) aneurysm associated with basilar artery occlusion. A 66-year-old female was found unconscious at home and transferred to our hospital in a deep coma on February 9, 1991. Emergency CT scan revealed subarachnoid hemorrhage in the posterior fossa. She was treated conservatively because of her poor neurological status. The angiograms performed on February 13 showed occlusion of the basilar artery and a saccular aneurysm at the cortical branch of the PICA. The contrast material remained in the aneurysm for a long time throughout the venous phase. The left vertebral artery was markedly hypoplastic. The patient improved remarkably after admission and became almost alert late in February, although she still presented tetraparesis, dysfunction of lower cranial nerves and other neurological signs linked with the brain stem. The unusual angiographical findings in this case prompted us to perform the examination again, expecting some angiographical changes. The angiograms taken on March 15 revealed spontaneous disappearance of the aneurysm, although the basilar artery occlusion remained unchanged. The authors discussed some problems involved in this case, including the relation between the aneurysm and the arterial occlusion, and the mechanism of spontaneous disappearance of the aneurysm.


[Serial MRI findings in neuro-Behçet disease].

Behçet disease is a systemic disorder characterised by the triad of recurrent aphthous ulcers of the mouth, genital ulcers and uveitis. Neurological involvement is estimated at 10-25% in Behçet disease (neuro-Behçet). These include diplopia, pseudobulbar palsy, cranial nerve palsies, cerebeller ataxia, and cerebral and spinal sensory and motor disturbances. A case of neuro-Behçet disease is reported. A 51-year-old man was admitted with TIA attack. He had been suffering from recurrent oral and genital ulcers for several months before admission. Neurological examination on admission revealed poor mental activity, left facial nerve palsy and left hemiparesis. Lumbar puncture showed CSF pleocytosis. CT and MRI revealed multiple lesions in the cerebral hemisphere and the brain stem. CT showed spotty high density areas with perifocal low density areas in the frontal, temporal and parietal lobe which were enhanced with contrast materials. T1 weighted image of MRI revealed iso intensity areas with perifocal low intensity areas which were enhanced with Gd-DTPA in the frontal, temporal and parietal lobes. T2 weighted image revealed low intensity areas with perifocal high intensity areas in the same regions shown in the T1 weighted image. Moreover ring-like enhanced lesions with Gd-DTPA were revealed in the brain stem and corona radiata in the T1 weighted image. After high dose steroid treatment, he showed marked clinical improvement. CSF pleocytosis was normalized and the lesions were gradually reduced in size and were no longer enhanced with Gd-DTPA. MRI findings are well correlated with clinical features.(ABSTRACT TRUNCATED AT 250 WORDS)


[Interhemispheric choroidal epithelial cyst associated with partial agenesis of the corpus callosum: case report and review of the literature].

A case of interhemispheric choroidal epithelial cyst is reported. The patient is a 9-month-old female who was transadmitted to our hospital for further examination because of the enlargement of her head. She had no neurological deficits nor symptoms of increased intracranial pressure. CT scanning performed on admission showed multiple cystic lesions in the right frontoparietal interhemispheric space, whose circumference was partially enhanced with contrast medium. Metrizamide CT cisternography demonstrated no communication between the lesions and the ventricular system. The signal intensity of the cysts was higher than that of cerebrospinal fluid on both T1-weighted and T2-weighted MR images. Sagittal T1-weighted images showed partial agenesis of the corpus callosum. The surgical exploration was performed via interhemispheric approach. The cyst wall was found to be white, relatively rich in vascular components, and was removed as much as possible. The examination of the cyst fluid showed total protein levels of 1250 to 3440 mg/dl, and sugar contents of 43 to 99mg/dl. Callosal agenesis was confirmed at operation. The light microscopic examination revealed that the cyst wall was composed of a single layer of columnar or cuboidal epithelium with occasional papillary configuration and thick collagenous connective tissue. The epithelial cells contained PAS-positive granules in the cytoplasm. Electron microscopy showed numerous club-shaped microvilli with no coating materials, continuous basement membrane, tight junction, interdigitation, and multiple fenestrations of endothelium of stromal vessels. On the basis of these findings, the lesion was diagnosed as choroidal epithelial cyst. In the literature, interhemispheric choroidal epithelial cyst associated with partial callosal agenesis, confirmed ultrastructurally, has not, to out knowledge, been reported.


Deterioration of word meaning: implications for reading.

We investigated six patients with progressive focal dementia or progressive aphasia, who showed impairments in knowledge of word meaning ranging from moderate to very severe. In all cases, a test of oral word reading demonstrated preserved reading of words with regular spelling-to-sound correspondences (e.g. MINT), but impaired reading of words with atypical correspondences (e.g. PINT). The level of success on these "exception" words was significantly related to word frequency, and the most common error was the assignment of a more typical spelling-sound correspondence. Various explanations are considered for this common association between loss of word meaning and a surface alexic pattern of reading performance.


Lateralized mediation of arousal and habituation: differential bilateral electrodermal activity in unilateral temporal lobectomy patients.

The purpose of the present study was to increase our understanding of the differential hemispheric processing of arousal and habituation. Subjects were unilateral temporal lobectomy patients and controls. Each was exposed to an arousal/habituation task consisting of a series of tones and an auditory discrimination paradigm. Electrodermal activity was recorded from the left and right hands throughout. Results provide evidence for a state of hypoarousal in right temporal patients and some support for hyperarousability in lefts. This is consistent with data showing that right hemisphere damage is associated with inattention and denial and left hemisphere damage with hypervigilance and anxiety. The concept of laterally differentiated mediation of arousal and habituation was supported.


EEG and EMG responses to emotion-evoking stimuli processed without conscious awareness.

Dichotic stimulus pairs were constructed with one word that was emotionally neutral and another that evoked either negative or positive feelings. Temporal and spectral overlap between the members of each pair was so great that the two words fused into a single auditory percept. Subjects were consciously aware of hearing only one word from most pairs; sometimes the emotion-evoking word was heard consciously, other times the neutral word was heard consciously. Subjects were instructed to let their thoughts wander in response to the word they heard, during which time EEG alpha activity over left and right frontal regions, and muscle activity (EMG) in the corrugator ("frowning") and zygomatic ("smiling") regions were recorded. Both EEG and EMG provided evidence of emotion-specific responses to stimuli that were processed without conscious awareness. Moreover both suggested relatively greater right hemisphere activity with unconscious rather than conscious processing.


Loss of visual imagery and loss of visual knowledge--a case study.

As a sequel of a left posterior cerebral artery infarction a patient had severely defective mental imagery of shapes and colours of objects. Imagery of faces, letters, and topological relationships was preserved. The impairment of imagery of object colours was associated with colour agnosia and colour anomia. For colours, there was no difference between performance on tasks calling for imagery of object colours and tasks affording a distinction between correctly and incorrectly coloured objects. For shapes of objects, imagery appeared to be below the level of the patient's knowledge about the visual appearance of objects as manifested by the ability to identify objects and to distinguish correctly from incorrectly drawn pictures. The apparently selective image generation deficit for shapes of objects could be a sequel of loss of knowledge about visual attributes of objects, if superior performance on shape recognition tasks was afforded by perceptual entry level representation which enable a rapid identification of objects but are inaccessible to introspective consciousness.


A stimulus-response relationship in unilateral neglect: the power function.

We have previously suggested that patients with unilateral neglect may be limited in their ability to sequentially attend or act upon stimuli. To assess the nature of this capacity limitation, we examined the relationship between number of stimuli presented on cancellation arrays and how many targets a patient with neglect cancelled. This relationship was systematic and described by a power function: targets cancelled = K (targets presented)B, in which the constant and exponent were derived empirically. Density of targets and time taken to cancel targets did not account for the relationship. Improvement on subsequent testing was reflected in an increase in the constant. However, the exponent of the power function did not change, suggesting that some critical aspect of her dysfunction remained the same. These data also imply that she had implicit knowledge of quantity of stimuli presented, and that this knowledge systematically influenced her explicit behavior.


Influence of short-term ischemia on the ultrastructure of hippocampal gyrus in Mongolian gerbil. III. Synapses in late stage of the pathological process.

Electron microscope analysis of the CA1 Ammon's horn sector was performed in Mongolian gerbils three days after an incident of short-term ischemia of the forebrain. CA1 pyramidal neurons showed advanced disintegration. Some GABA-ergic interneurons revealed ultrastructural alteration of variable degree. The latter finding contradicts the generally helt view on the relative resistance of CA1 sector interneurons to the ischemic injury. Synapses localized in all cortical layers of the CA1 sector exhibited ultrastructural abnormalities involving both pre- and postsynaptic parts. They consisted in marked swelling and accumulation of unbound electron dense material, considered as calcium deposits. Presynaptic parts revealed additionally reduced number of synaptic vesicles and their abnormal distribution. Contrary to the early postischemic period, the most severe synaptic alterations appeared in stratum pyramidale, radiatum and oriens, involving both small dendritic branchings and their spines as well as large shafts of both basal and apical pyramidal dendrites. Synaptic alterations especially features of the postsynaptic damage correspond to those indicating excitotoxic neuronal lesions. Presynaptic alterations may indicate both cessation of neurotransmission function as well as direct ischemic damage. The presence of calcium deposition seems to favour the former possibility.


Blood-cerebrospinal fluid barrier integrity in cerebral infarction.

Using a sensitive isotachophoretic technique total cerebrospinal fluid protein, CSF-serum albumin and CSF-serum IgG ratios as indicators of blood-CSF barrier integrity were determined in 35 cases of ischemic cerebral infarction. Since it proved to be changed in about 57% of these patients, the CSF-serum albumin ratio was found to be the most sensitive parameter in evaluating the blood-CSF barrier disturbances. No clear-cut correlation was found between the age of patients, the clinical course of the disease, different periods after onset of the illness nor the size of the infarction and CSF-blood barrier permeability.


Expression of tumor necrosis factor-alpha cachectin in primary brain tumors of astrocytic lineage.

The tumor necrosis factor alpha (TNF-alpha) is a cytokine released within central nervous system from activated astrocytes and macrophages and involved in several pathologic processes including AIDS-myelopathy, multiple sclerosis and myelin dilatation in panencephalic type of Creutzfeldt-Jakob disease. We studied the expression of the TNF-alpha in brain tumors. Only tumors of astrocytic lineage like astrocytomas and glioblastomas, or tumors of mixed lineage as oligo-astrocytomas and multipotential primitive neuroectodermal tumors (PNET) expressed TNF-alpha-like immunoreactivity. We conclude that this lymphokine is expressed in neoplastic astrocytes. We postulate that TNF-alpha may participate in neoplastic transformation of astrocytes via cascade of interactions with receptor for TNF-alpha.


Effect of selected cytostatic drugs administration on the brain of young rabbits.

The aim of the study was to compare the effect of two selected cytostatic drugs (cyclophosphamide and vincristine) on the brain of young rabbits. The experimental models were similar to clinical administration of the examined drugs. Cyclophosphamide was given orally from the 5 to the 16th day of life and vincristine in a single intraperitoneal injection on the 8th day of life. Despite the assumed poor penetration of both drugs through the blood-brain barrier, both drugs induced changes in perivascular astrocytes. Other structural elements of the CNS exhibited lesions characteristic for the given drug: proliferation of endoplasmic membranes after cyclophosphamide administration and destruction of microtubules with proliferation of microfilaments after vincristine application.


Does damage of perivascular astrocytes in multiple sclerosis plaques participate in blood-brain barrier permeability?

In six young and two senile MS cases perivascular astrocytes within demyelination lesions were evaluated immunocytochemically. The peroxidase-antiperoxidase method of Sternberger et al. (1970) was used for visualization of glial fibrillary acidic protein (GFAP). In all cases very weak immunoreactivity of perivascular astrocytes was noted. Accumulation of perivascular glial fibers, and infrequently their fragmentation were observed both within active and old demyelination plaques. Clasmatodendrosis, Rosenthal's fibers and prominent regressive changes of astrocyte perikarya were found only in old plaques. A lack of immunoreactivity of perivascular astrocytes was noted within old demyelination lesions. The background of the latter was often immunonegative to GFAP. It is suggested that secondary damage of perivascular astrocytes influences vascular permeability within demyelination lesions including old plaques.


Chronic progressive axonal polyneuropathy simulating Guillain-Barré syndrome.

Six cases of chronic progressive and/or relapsing polyneuropathy are reported. All cases were idiopathic at the beginning of observation. Electrophysiological examination and biopsy of sural nerve in all cases as well as autopsy of spinal roots S1 in case 6 showed loss of fibers and axonal degeneration of myelinated fibers but neither active demyelination nor inflammatory cells were observed. Chronic progressive or relapsing idiopathic axonal polyneuropathy appear to be a distinct entity different from GBS. The term "axonal GBS" seems to be questionable.


Complications of laparoscopic cholecystectomy in a geriatric population group.

The purpose of this study was to assess the complications of laparoscopic cholecystectomy among geriatric patients in New York State who receive their medical care under the Federal Medicare Program. A 20% random sample survey (304 patients) of the 1,520 patients who underwent laparoscopic cholecystectomy between January 1, 1990, and June 30, 1991, was selected. Coded ICD-9 diagnoses and procedures were carefully reviewed for these patients. In some patients with complications, the medical charts were reviewed by a medical epidemiologist and a surgeon to more fully elucidate the reported complications. The patients in this study were randomly selected from public, proprietary, voluntary, and teaching hospitals. Seventy-two complications (23.68% of the 304 patients) were identified in 48 patients (15.78% of the 304 patients). Of these complications, 27 (8.88%) were surgical, and 43 (14.14%) were medical in character. There were two deaths (0.66% of the 304 patients). Individual chart review of 32 of the 48 cases with complications revealed physician-related surgical quality-of-care problems which directly contributed to complications in 10 patients (31.25%). The overall complication rate of 23.68% found in this study represents one of the highest so far reported among published studies of laparoscopic cholecystectomy. The results of this study indicate a significant level of morbidity when laparoscopic cholecystectomy is performed on a geriatric population group. Although age-associated risk factors contributed to this high complication rate, so too did errors of surgical judgment and technique.(ABSTRACT TRUNCATED AT 250 WORDS)


Economic interventions to discourage the illegal sale of cigarettes to minors in New York State.

In New York State it is illegal to sell tobacco products to persons under the age of 18 years. In most communities, compliance with this law is poor. This study provides estimates of teenage cigarette smoking and the illegal sale of cigarettes to minors in 1990 in each of New York's 57 counties and in New York City. Results show that in New York State, approximately 135,700 teens between the ages of 12 and 17 years are regular cigarette smokers. Data available on the cigarette consumption and purchasing habits of teenage smokers reveal that nearly 21.9 million packs of cigarettes were sold illegally to minors in 1991 in New York State. This finding underscores the fact that cigarette sales to underage youth in New York is big business, representing $39.5 million in sales annually. Government officials should consider levying an illegal drug profit tax on the cigarette industry to recover the millions in profits derived annually from the illegal sale of cigarettes to children.


Low level and bystander exposure to lead among factory workers.

A clinical field survey of 36 workers employed in the manufacturing of leaded products used in radiologic safety was conducted. Although the principal source of lead exposure was limited to an area where two individuals mixed lead oxide and vinyl liquid, increased lead absorption was found in other workers employed in adjacent areas. The mean lead concentration of the plant workers was 29.3 micrograms/dL (SD +/- 9.0), and four workers had blood lead levels of 40 micrograms/dL or higher. A statistically significant correlation was noted between blood lead and serum creatinine; linear regression analysis demonstrated that cigarette smoking was a significant factor in predicting the blood lead level. The exposure encountered in this plant may be typical of lead exposure in many similar industrial settings. It calls attention to the risk of excessive exposure among workers who are not working at the primary source of exposure, and should be considered in the design of medical surveillance programs for workers employed in small manufacturing plants.


The purchaser-provider split: implications for dental services.

In July 1991, the National Government announced proposals for a radical restructuring of the New Zealand public health system, a central feature of which is the separation of the purchasing and providing roles currently performed by area health boards. While the competitive market model suggests that the split should improve the efficiency of public health services by effectively creating a market system, this paper suggests that, in practice, there are likely to be a number of obstacles. Other potential sources of efficiency are improved accountability, improved management, and integration of primary and secondary care. For dental health services, the separation of purchaser and provider should introduce greater flexibility into State-funded dental services by opening up options for alternative providers and methods of provision. Factors such as the number and structure of provider units; the contractual arrangements between these units and the RHAs, especially in respect of payment mechanisms; and the regulatory regime which covers these contractual arrangements will all affect service delivery. If real choices between types of providers and methods of provision eventually emerge, a major challenge for RHAs will be to monitor and enforce at reasonable cost any quality measures built into contracts.


Some current factors restricting the potential of private general practice.

This background paper focuses on two or three aspects which, in the writer's opinion, are crucial to the healthy development of general dental practice, although the rapidly progressing health reforms have already altered the relevance of some comments made. The first aspect is equitable access, especially for the financially disadvantaged in this time of economic recession. The ability and inclination of providers to treat the financially disadvantaged has not currently been matched by the political will of funders, even though an effective system could simply be organised. Access problems also apply to the elderly. A smooth transitional system of oral health care should exist for every aging patient, whether economically, physically, and mentally healthy, or in a state of total dependence, and this should be an integral part of general dental practice management. Generally it is not. Secondly, the fragmentation of the New Zealand dental workforce, and the lack of a real team approach have hindered the logical development of oral health services and prevented many possible options from being offered. Dialogue to reduce the fragmentation must continue, hopefully to a successful conclusion. Perhaps the catalyst for meaningful change may be contained in the current health reforms. Certainly opportunities for change have been clearly signalled.


How the Maori community sees the dental-care system.

This report has addressed the question of how the Maori community sees the system of oral health care by indicating the complex factors influencing the Maori community's attitude toward health issues. These factors preclude the Maori community from many of the perceived benefits of the present oral health-care system. There is a need in this current climate of debate over health policies to re-focus on primary prevention policies that will be relevant to the Maori community of today. No one is seen in the Maori community to be articulating concern for oral health issues. The challenge for the Dental Council of New Zealand is how then to create a focus on oral health issues within the Maori community, and to actively promote oral health care and encourage usage of a system that is affordable, available, accessible, and appropriate. Practical and relevant recommendations arising from Rapuora: Health and Maori Women 1984 and the Hui Hauora Mokopuna, 1990(10) should be considered when planning future health-care systems. Health was one of the four key areas highlighted in the Ka Awatea report, and it will be an important feature of the work of the new Ministry of Maori Development. It is timely that the Dental Council of New Zealand and the Ministry of Maori Development should facilitate oral health-care systems for the future in partnership with the Maori community.


Inequities in oral health: implications for the delivery of care and health promotion.

This paper has summarised data showing that inequities in oral health and the receipt of oral health care exist in New Zealand. We submit that these inequities, and the consequences of oral ill-health, are of such seriousness that they cannot be ignored. Overcoming barriers to oral ill health and barriers to dental care will be a complex task. Although much can be done by the dental providers and their organisations, there is need for oral ill health to be viewed within the overall context of inequity and disadvantage within society.


The oral health and attitudes to dental treatment of a dentate elderly population in Mosgiel, Dunedin.

As part of the Mosgiel Community Study, a longitudinal investigation of the health of the elderly, a dental survey was used to determine the oral health status and treatment needs, both objective and subjective, of a group of dentate older adults. Sixteen percent of the 817 subjects were dentate. Of these, 95 were available for the dental survey, and they were questioned and examined at their homes. The mean age was 77 years, and 55 percent of subjects were male; disproportionately more older males than females had retained some of their natural teeth. Seventy-two percent regularly sought dental treatment, and 39 percent felt they were in need of treatment. Few real barriers to treatment were identified, although a major obstacle preventing many from seeking treatment was their lack of perceived need. However, even the realisation that they required treatment was not sufficient cause for many to seek treatment. All subjects required some form of dental treatment. Eighty-five of the 95 subjects required at least one restoration, and 16 percent advanced restorative treatment. The frequencies of coronal and root surface caries were similar. Oral mucosal pathology was also common. Sixty-five percent of denture wearers required prosthetic treatment. Most subjects needed simple periodontal treatment, but 11 percent required advanced therapy. The main oral health problems of this group related to the simple management of plaque-related disease, and the wearing of dentures. However, 24 percent of people required complex restorative and periodontal treatment, or both.


Back injuries: a review of liability reports in healthcare environments.

Physiotherapist, Margaret Hollis, has provided expert evidence in over 400 cases of back injury in health care environments. Reviewing her work over the last five years she believes that we still have a long way to go to ensure that practice matches teaching.


Managing migraine.

Absenteeism by migraine sufferers is treated with little sympathy by employers and fellow workers even though it is a condition that affects nearly eight per cent of the population. Helen Kogan looks at how an understanding of its debilitating effects can reduce the stigmatisation of employees.


Hypertension in pregnancy.

Pregnancies complicated by hypertension require a well-formulated management plan. Women with chronic hypertension should be evaluated prior to pregnancy. At onset of pregnancy, they should be classified into low-risk and high-risk groups. The majority of pregnant women identified as low-risk hypertensives will have good perinatal outcome without the use of antihypertensive drugs. In general, antihypertensive medications should be reserved for those considered as having high-risk hypertension. In either case, all these women should have close follow-up of maternal and fetal conditions throughout pregnancy. All women with diagnosed preeclampsia should be hospitalized at the time of diagnosis for evaluation of maternal and fetal well-being. Subsequent management will then depend on gestational age and the severity of the disease process. An individualized management plan and a referral to a tertiary care center will improve maternal and perinatal outcome in those women who are remote from term and in those with the HELLP syndrome.


Diabetes mellitus and pregnancy.

Diabetes mellitus represents the most common medical complication of pregnancy. Care programs emphasizing normalization of maternal glucose levels have resulted in perinatal outcome that is nearly equivalent to that observed in normal pregnancies. Reducing the rate of significant congenital anomalies in insulin-dependent women remains a goal for the future.


Endocrine disorders in pregnancy.

Disorders of the pituitary gland such as diabetes insipidus, pituitary adenomas, and hyperprolactinemia, disorders of the thyroid gland such as Graves' disease and hypothyroidism, and diseases of the adrenal gland such as adrenocortical insufficiency and Cushing's syndrome can complicate pregnancy. The goals of this article were to provide a basic scientific understanding of the normal function of these endocrine glands, their pregnancy-related changes, and suggestions for diagnosis and treatment of maternal and fetal endocrine disorders during pregnancy. Antenatal recognition and appropriate management of the disorders that especially affect the fetus (i.e., maternal Graves' disease, fetal hypothyroidism, and congenital adrenal hyperplasia) is essential in order to prevent fetal and neonatal morbidity and mortality.


Management of cardiovascular disease in pregnancy.

Pregnancy itself poses risks of morbidity and mortality to even the young, healthy woman. The nature of these risks may vary from country to country and, within the United States, from state to state. Hemorrhage, eclampsia, and infection, in general, are common obstetric risks. One of the most important nonobstetric causes of maternal death, and the focus of this article, is heart disease.


Pulmonary disorders complicating pregnancy.

The pulmonary physiologic changes associated with pregnancy increase oxygen transport to the developing fetus. Because of these changes, the fetus is allowed an extra measure of protection against insults that would decrease blood or oxygen flow to the uteroplacental unit. The goal of treating a patient with pulmonary disease in pregnancy should be to maximize pulmonary function throughout gestation. Experts in pulmonary disease should be readily available for patients with significant pulmonary disorders or worsening disease during pregnancy. Pregnancy affords all providers the opportunity to address the major respiratory health problem in the United States, which is smoking. This concerns not only the patient's personal health, but also that of her unborn offspring.


Autoimmune diseases in pregnancy.

Autoimmune diseases are a significant problem in women of reproductive age. This article reviews some of the more common autoimmune disorders and discusses their diagnosis and management during pregnancy. The effects of the autoimmune disorder on pregnancy and the effects of pregnancy on the course of the autoimmune disorder are also discussed with an emphasis on the implications for clinical management.


Gastrointestinal disorders in pregnancy.

Gastrointestinal disorders constitute one of the most frequent complaints of pregnancy. An understanding of the mode of presentation and the incidence of the various gastrointestinal disorders will optimize care in obstetric patients. Disorders of the esophagus, stomach, duodenum, ilium, jejunum, colon, rectum, and appendix are individually discussed with reference to physiologic changes in pregnancy, infectious diseases, autoimmune disease, and ulcer formation.


Pregnancies complicated by liver disease and liver dysfunction.

Although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and fetal compromise. An unrecognized case of acute fatty liver may result in both maternal and fetal death. Failure to screen for hepatitis B can result in a newborn who will be a hepatitis carrier for life. Because of such consequences, the obstetrician must remain vigilant for signs of liver dysfunction and must understand the pathophysiology of these disorders.


Neurologic diseases in pregnancy.

Although most neurologic problems require conservative management, such as headaches and nerve compression syndromes, other demand aggressive treatment, such as plasmapheresis in Guillain-Barré syndrome and prompt surgery in those patients with hemorrhagic strokes secondary to a ruptured aneurysm or arteriovenous malformation. Myasthenia gravis, discussed in the autoimmune disease section, and epilepsy are associated with congenital anomalies, whereas the progeny of patients with multiple sclerosis are at a much greater risk than the general population of contracting this disease. Therefore, knowledge of these risks is essential in providing quality preconceptional counseling. Pregnancy provides many physiologic changes that alter the course of preexisting neurologic conditions as well as increasing the risks and morbidity of other diseases. It is for this reason that a cooperative team effort, including the obstetrician, neurologist, and, if needed, the neurosurgeon, is essential for an optimal outcome.


Hematologic disorders in pregnancy.

Hematologic disorders in pregnancy are relatively common and encompass a wide spectrum of clinical conditions. The treatment and obstetric management of the majority of these diseases are well established, although controversy exists in areas such as sickle cell disease and ITP. Once the diagnosis of a specific disorder is confirmed, therapy is directed toward improved perinatal outcome. Recent advances in prenatal diagnostic techniques make in utero diagnosis feasible for most of the inherited disorders and aid in genetic counseling.


Management of genetic disorders during pregnancy.

Using several specific genetic diseases as examples, this article has illustrated basic genetic principles that can be applied to many clinical situations. Practicing obstetricians must be aware that advances are being made daily in the care of patients with inherited disorders and in prenatal diagnosis. A fundamental understanding of human genetics is essential in order to offer optimal care for patients during their reproductive years.


Cancer and pregnancy.

The diagnosis of cancer rarely complicates pregnancy. Despite the fact that advanced disease is often encountered, there is no scientific evidence that the pregnant state alters the neoplastic process. Only through careful attention to the patient can the clinician detect cancer at an early stage and offer the patient reasonable hope for a cure.


Compensatory epithelial hyperplasia in human corneal disease.

Compensatory hyperplasia of the corneal epithelium (CEH) has been observed histopathologically in animal and human eyes after excimer laser photoablative keratectomy, and has been implicated as a cause of variable refractive results and refractive regression after this procedure. Retrospective histopathologic analysis of routine keratoplasty specimens revealed CEH in 85 of 130 (65%) corneas with keratoconus, 18 of 36 (50%) corneas with chronic herpes simplex virus (HSV) keratitis, and 14 of 25 (56%) corneas coded as nonspecific scars. Mild CEH occurred apically and/or peripherally in keratoconus. Massive CEH (up to 200 microns thick) occurred in chronic HSV keratitis with irregular stromal loss. Our data indicate that CEH occurs frequently in several corneal diseases marked by stromal ectasia or loss. We postulate that stromal loss may contribute to CEH by providing relative protection against exfoliative shearing forces of superior eyelid closure. Our study complements previous reports that imply that CEH is a contributory factor in refractive regression after excimer laser photoablation.


A biomechanical evaluation of rabbit corneas in M-K and Dexsol.

We compared the average force required to separate normal corneas at a 50% stromal depth, with the force required to separate corneas stored for 2, 5, 7, 10, and 14 days in either McCarey-Kaufman or Dexsol corneal storage medium. The required interlamellar separation force was calculated by standardizing the width of the test strips. The average required force for 35 fresh rabbit corneas (no storage) was 9.1 +/- 1.5 g/mm. There was no significant change in the required separation force after storage in either medium for up to 14 days.


Pharmacologic alteration of corneal topography after radial keratotomy.

Contraction of corneal wounds as the incisions heal may account for changes in corneal topography after radial keratotomy; such contractility of avascular corneal wounds has been demonstrated in vitro. Using a cat model of radial keratotomy, we demonstrated in vivo contractility of radial keratotomy incisions. In eight eyes of adult female cats, four-incision radial keratotomies were performed, producing central corneal flattening. After 3 and 8 days, serotonin (1 mg/mL) was applied. On day 3, application of topical serotonin resulted in corneal steepening (P < .0001); serotonin produced no topographic changes when applied on day 8 and had no effect on normal unoperated corneas. Vehicle produced no change in corneal curvature before or at any time after radial keratotomy. Fluorescence microscopy revealed cells with myofibroblastic differentiation at the incisions. These data suggest that cells with contractile abilities play a role in determining corneal topography after radial keratotomy.


Comparison of two needle lengths in regional ophthalmic anesthesia with etidocaine and hyaluronidase.

The effect of needle length on the efficacy of regional ophthalmic anesthesia in conjunction with cataract surgery was studied in 97 patients using a two-site injection technique. The local anesthetic used was etidocaine 1.5% with hyaluronidase. In 48 patients, the anesthetic was administered inferolaterally with a 22-millimeter needle, and in the other 49 patients, with a 31-millimeter needle. Every patient had a medial injection with a 12-millimeter needle to achieve lid akinesia and to complete the globe akinesia. At 5 minutes, lid akinesia was considered better in the 22-millimeter needle group (P < .005). After one supplemental dose, when necessary, complete globe akinesia was achieved at 15 minutes significantly more often (94% vs 79%) in the 31-millimeter needle group (P < .05). Lid akinesia in the two groups was identical at that time. Eight patients in the short-needle group and three in the long-needle group experienced some pain during surgery. Throughout the study, the required intraorbital anesthetic volumes were smaller in the 31-millimeter needle group. We recommend the use of a 31-millimeter needle inferolaterally in combination with a 12-millimeter needle medially to achieve satisfactory regional anesthesia for cataract surgery.


A comparison of visual outcome in open-globe repair: succinylcholine with D-tubocurarine vs nondepolarizing agents.

We compared the visual outcome in patients with ocular perforations who received succinylcholine with d-tubocurarine during anesthesia induction, with the visual outcome of those who did not. No statistically significant differences in visual outcome were detected. No extrusion of intraocular contents occurred during induction in either group.


Optical principles related to optimizing sclerostomy procedures.

A simple probe, consisting of a 200-micrometer uncladded silica optical fiber, advanced from a protecting 22-gauge hypodermic needle, was used to create sclerostomy fistulas both ab interno and ab externo by means of a combined radiation/mechanical effect. Perforation was achieved by exerting gentle forward pressure on the fiber in synchrony with the delivery of radiation pulses. An irradiation protocol suitable for producing such canals in cadaver porcine eyes was delineated using Ho:YAG, Nd:YAG, and diode laser energy sources. Despite significant differences in the pulse energy required for perforation (0.25, 7, and 8 J for the Ho:YAG, diode, and Nd:YAG lasers, respectively), the extent of collateral damage was comparable for each type of laser. The physical mechanisms underlying these findings are discussed.


Histologic differences in the conjunctiva of black and white glaucoma patients.

We compared perioperative conjunctival biopsy specimens from 31 consecutive trabeculectomy patients to determine if there were any histologic differences between black and white glaucoma patients. We found a statistically significantly greater mean and distribution of mast cells and neutrophils in the white patients. No significant difference was found in the mean number of goblet cells, eosinophiles, macrophages, fibroblasts, plasma cells, or lymphocytes; or in thickness of the epithelium, vascular density, or collagen or mucopolysaccharide staining. We conclude that histological conjunctival factors that could be evaluated preoperatively probably are not related to the poor results in black patients of filtration surgery noted by some investigators.


Limiting applications of cryotherapy for severe retinopathy of prematurity.

In an effort to minimize surgical and visual morbidity of cryotherapy for retinopathy of prematurity (ROP), 18 eyes of 13 patients with 3 to 7 clock hours of stage 3 ROP with "plus" disease were treated by cryotherapy applications limited to the avascular retina adjacent to the areas of stage 3 disease. In 17 of 18 eyes, this limited use of cryotherapy was sufficient to cause regression of ROP without further treatments. After at least 3 months follow-up, ROP outcome showed a normal macular appearance in 16 eyes; two eyes developed macular dragging; no retinal detachments occurred.


Visual, astigmatic, and inflammatory results with the Staar AA-4203 single-piece foldable IOL: a randomized, prospective study.

One hundred twelve unilateral cataract extraction patients were randomly assigned to receive either a one-piece Staar Model AA-4203 silicone intraocular lens (IOL) implanted through a 3.2-millimeter incision, or a one-piece polymethylmethacrylate IOL implanted through a 6.0-millimeter incision. Follow up was 96% at 1 day postoperatively, 90% at 3 months, and 70% at 1 year. Fifty-three percent of the eyes that received a smaller incision could see 20/40 or better uncorrected at 1 day, as compared with 19% of the eyes that received a 6-millimeter incision (P < .01). At 3 months, significantly more smaller-incision eyes could still see 20/40 or better (P = .03). The smaller-incision eyes also had significantly less surgically-induced astigmatism at both 1 day (P < .01) and 3 months (P = .02), and had significantly less flare (P < .01) and cellular reaction (P = .04) at 1 day.


Surgical treatment and desensitization therapy of giant papillary allergic conjunctivitis.

We found that three cases of giant papillary conjunctivitis responded well to local specific desensitization therapy and transplantation of the conjunctiva with saphenous vein tissue.


Clinical experience with tissue plasminogen activator stored at -20 degrees C.

We developed a new dilution technique that allows tissue plasminogen activator (t-PA) to be stored at -20 degrees C, as opposed to the -70 degrees C recommended by the United States manufacturer (Genentech Inc). Following tests that showed neither loss in activity nor microbiological contamination, we clinically proved the efficacy of t-PA stored at -20 degrees C in 10 cases.


Hyperopia, anisometropia, and irregular astigmatism in a patient following revisional radial keratotomy.

We present a patient who underwent bilateral radial keratotomy (RK) followed by a bilateral revisional RK for undercorrection. After the second procedure, the patient had a severely flattened left cornea, with marked hyperopia and irregular astigmatism. The right eye, however, remained myopic, causing extreme anisometropia. We hypothesize that the different results in these two eyes may have been due to a critical number of damaged left corneal stromal fibers. Patients undergoing revisional RK or requiring additional incisions may be at increased risk for such a complication.


Adjunctive viscoelastic therapy for postoperative ciliary block.

Following Molteno device implantation, trabeculectomy, or needling revision of trabeculectomy, six eyes of six chronic glaucoma patients developed a flat anterior chamber without hypotony, ciliochoroidal detachment, pupillary block, or external wound leak. The ciliary block did not respond to vigorous medical and laser therapy. We performed an intracameral injection of sodium hyaluronate, which resulted in maintenance of a full anterior chamber and normal intraocular pressure in all of the six eyes. The use of intracameral viscoelastic appears to be a reasonable adjunct for management of ciliary block not responsive to vigorous medical therapy and intracameral air injection trial, before attempting more extensive surgery.


Reproducibility of data obtained by a newly developed anterior eye segment analysis system, EAS-1000.

The reproducibility of data obtained from the recently developed anterior eye segment analysis system (EAS-1000) was evaluated. 40 normal eyes and 62 cataractous eyes were examined at Kanazawa Medical University Hospital or Yayoi Hospital. The radius of the corneal curvature, the corneal thickness, anterior chamber depth, whole lens thickness, anterior chamber angle and the scattering light intensity were all observed on a slit section of the lens, and the intrapupillary area of the cataractous shadow was measured from a retroillumination image. The measurements were made twice at an interval of 14.2 days. There were no significant differences between the data of the 1st and 2nd examination in either place.


In vivo observation of the axial movement of intraocular lenses through an anterior eye segment analysis system.

The small axial movement of the anterior surface of implanted intraocular lenses (IOLs) were examined in pseudophakic eyes with one-piece and three-piece IOLs using an anterior eye segment analysis system. The movement was calculated as the distance between the posterior surface of the cornea and the anterior surface of an IOL under a normal pupil size, following the instillation of 1% pilocarpine and 1% cyclopentolate solutions, respectively. The axial movement including movement after instillation of pilocarpine and cyclopentolate was 0.17 +/- 0.06, 0.05 +/- 0.07 and 0.13 +/- 0.06 mm, in phakic eyes and eyes with one-piece and three-piece IOLs, respectively. Image analysis techniques using Scheimpflug images proved its usefulness in the research field of IOL implantation.


Quantitative evaluation of nuclear cataract using image analysis.

To quantitatively evaluate nuclear lens opacification, we applied image analysis techniques. Utilizing a newly developed anterior eye segment analysis system, Scheimpflug slit images were taken in 65 eyes with transparent lenses and 31 eyes with nuclear cataract. In transparent lenses, scattering light intensity of the anterior fetal nucleus (AFN) was equal to or less than that of the posterior fetal nucleus (PFN). In eyes with nuclear cataract, scattering light intensity of the AFN was higher than that of the PFN. Utilizing this phenomenon, nuclear opacification was evaluated by the difference of scattering light intensity between the AFN and PFN (delta i value). The methodology applied in this investigation provides precise grading of nuclear cataract and progression thereof.


Application of a new Scheimpflug camera (EAS-1000) to animal cataract models.

A newly developed anterior eye segment system, EAS-1000, was applied to animal experiments. Since the device was developed to be used with human eyes, several minor changes were made to facilitate the use with animals. These changes included an animal-holding place instead of a chin rest, an additional monitor screen for help in alignment, a foot pedal for flushing and image cancellation and variable illumination for adjusting the volume of the retroillumination image. The examined animals were mice, rats, rabbits, dogs and monkeys. The image quality of this camera was almost always satisfactory. One advantage of this device is that the quality of the images can be checked instantly, making it possible to store only images of superior quality. The mean of the repeatability test had a coefficient of variation of 6%.


A photodocumented study on lens thickness and densitometric value according to the type of cataract.

Photodocumented measurements of the lens thickness using an EAS-1000 Scheimpflug camera were performed in 261 cataract eyes (162 pure type) compared with 52 control eyes. The lens thickness in normal eyes usually increased with age by 0.015 mm annually. The cataractous lens, especially in the anterior subcapsular type combined with the superficial cortical and posterior subcapsular types of opacity, showed statistically significant lens thinning. The photodocumented values of lens thickness were higher in 7.9%, and those of the anterior chamber depth were lower in 5% compared with A scan ultrasonographic measurements.


Reproducibility of mydriasis.

A combination of a single drop of each of 0.5% tropicamide and of 10% phenylephrine hydrochloride instilled after routine applanation tonometry gave consistent pupil dilatation in a population with cataract studied over 5 years. The dilatation allows reproducible photographic documentation of cataracts in long-term studies.


Objectified measurements of eye lens transparency in a volunteer group of advanced age, carried out over a period of 3.5 years. Results of a Scheimpflug-photographic study.

The present study deals with a prospective investigation on the optical density of the eye lenses of 32 volunteers with initially normal eyes (mean age 65 years) over a period of 3.5 years. The negatives of the Scheimpflug photographs (Topcon SL-45) were evaluated by linear densitometry in 3 measure planes (Joyce Loebl 3CS). The evaluation of the coefficient of correlation, the representation of the regression straight line as well as the evaluation of the percent changes in lens density showed that during the observation period of 3.5 years a minimum increase in density took place mainly in the anterior cortex.


Scheimpflug photography in clinical ophthalmology. A review.

The development of a slitlamp camera system based on the Scheimpflug principle with image analysis has been a major improvement in lens and cataract research. Since its introduction into ophthalmology by Brown and Niesel in the sixties of this century and further technical amelioration by Hockwin, Dragomirescu and Sasaki it has been applied in various experimental and clinical investigations. The purpose of this paper is to summarize and review the application of Scheimpflug photography in clinical ophthalmology and to show possibilities and indications for the use of the Scheimpflug technique in clinical studies.


Comparison of the Nidek EAS 1000 system and the Topcon SL-45 in clinical application.

Some years ago, Nidek developed a new imaging system for the anterior eye segment, which offers the possibility of recording Scheimpflug and retroillumination images. The system consists of 2 different technical units, a camera unit for image recording and a computer unit for storage, system operation and image analysis. To evaluate the clinical use of the system and its reproducibility, a study with 31 volunteers/patients was performed that were photographed with the Nidek EAS 1000 at the meridians 0 degree, 45 degrees and 180 degrees. Two examinations with a 1-week interval were performed. In addition, a direct comparison of the EAS 1000 with the Topcon SL-45 was carried out with 32 volunteers that were photographed at 0 degree and 45 degrees; a retroillumination photo was additionally recorded. The video images were evaluated with the computer software, the SL-45 negatives were standardly measured with a Joyce-Loebl densitometer. The handling of the EAS 1000 in clinical use was found to be easy and comfortable for the patient, as the alignment is done with infrared light. Difficulties occur only with the retroillumination photography in that the infrared light for imaging may outshine the red fixation light during exposure. However, shadowing problems due to the eyelashes occur in oblique slit positions, especially in those patients with a pronounced front head. In studying the reproducibility, the mean values of the individual coefficients of variation for light scattering (density) were in a range between 3.6 and 5.06%, but more than 35% of the single values show a variation coefficient above 5% (maximum 20.3%).(ABSTRACT TRUNCATED AT 250 WORDS)


Nonlinear equations for calculating lens parameters based on Scheimpflug photographs: preliminary results.

Real lens diameter and real lens volume cannot be measured by Scheimpflug photography, but the apparent lens radii and the lens thickness (anterior and posterior) can. Some stereometric equations allow us to calculate lens volume and lens diameter. Equations for the adaptation of the data points to nonlinear curves are given. There are no linear but sigmoid relationships between the age-dependent parameters. These can be estimated with the aid of equations 2 and 3 presented in this paper. When carrying out further investigations a greater number of parameters should be included in the analysis. It is conceivable that the equations must be expanded in order to be able to take other important parameters into consideration. Preliminary results of the calculations with regard to age are reported.


Simultaneous thermal and optical breakdown mode dual laser action.

Tests on blood agar and human tissue prove that the combined simultaneous dual laser action of a thermal and an optical breakdown mode laser ablates tissue by a mechanism of mutual enhancement of each laser's effect. The force of pressure and the energy of heat combine to ablate tissue in sclerostomy and iridotomy procedures without inducing bleeding.


Drusen and 'choroidal filling defects': a cross-sectional survey.

The present study was designed as a cross-sectional survey to assess the association between soft drusen and 'choroidal filling defects'. Sixty-eight eyes presenting hard drusen and 58 eyes with soft drusen of 126 subjects with an age range of 45-83 years were examined in the present study. Choroidal filling defects were present in 13 out of 68 (19.1%) patients with hard drusen and 29 out of 58 (50%) with soft drusen (chi 2 square = 13.4; p < 0.0001 and an odds ratio = 4.2 with 95% CI 1.9-9.3). Age, ocular and systemic hypertension, and diabetes did not influence the results. The association between soft drusen and choroidal filling defects, found in our study, suggests that these abnormalities are possibly due to changes in the staining or permeability properties of Bruch's membrane rather than to a defect in the choroidal blood supply. Soft drusen and choroidal filling defects may both be caused by an accumulation of hydrophobic material within the Bruch's membrane, which is discrete in the case of drusen and diffuse in the case of choroidal filling defects. Choroidal filling defects and soft drusen may represent useful clinical sign of hydrophobicity of Bruch's membrane.


Hyperemic swollen optic disk in patients with primary open-angle glaucoma.

We report a hyperemic swollen optic disk as an initial manifestation of primary open-angle glaucoma. Two cases are presented; one bilateral, the other with unilateral involvement.


Pattern electroretinograms and visual evoked potentials in idiopathic intracranial hypertension.

A subclinical visual dysfunction can be detected by psychophysical methods in early-stage papilledema associated with idiopathic intracranial hypertension (IIH). We recorded steady-state pattern electroretinograms (PERGs) and visual evoked potentials (VEPs) to sinusoidal gratings of variable spatial frequency [0.6, 1.0, 1.4, 2.2 and 4.8 cycles/degree (cpd)] in 18 patients with IIH and early papilledema and in 21 age-matched controls. Spatial frequency selective reductions in the mean PERG (at 1-4.8 cpd) and VEP (at 4.8 cpd) amplitudes were found in patients in comparison with controls. The response functions of amplitude versus spatial frequency of patients' PERG and VEP displayed a low-pass shape, whereas in normal subjects PERG and VEP functions showed a band-pass and a high-pass shape, respectively. PERG and VEP abnormalities were found in 14 (77.7%) and 10 (55.5%) out of 18 patients, respectively. Most of these abnormalities involved only selected spatial frequencies (1.4-4.8 cpd). These results indicate spatial-frequency-dependent functional losses on both PERG and VEP in early papilledema, and suggest a potential value of these responses for detecting subtle visual abnormalities in IIH.


Difference of spatial summation property between b and d waves in focal electroretinogram of the cat.

A new system for focal electroretinogram (ERG) using a charge-coupled device camera was developed. With this device, focal ERGs to on-off luminance modulation of uniform fields with different area (circle diameter; 16, 12, 8, 6 and 3 degrees) centered on the area centralis were recorded in 12 eyes of 6 cats. With a decrease of the stimulus area, the reduction of the amplitude in both b and d waves was observed, however, the implicit times of these waves were almost same. The amplitude ratio (12 degrees stimulus/16 degrees stimulus, 8/16, 6/16, and 3/16) of b and d waves showed statistically significant differences between the b wave and d wave (8/16, 6/16 and 3/16; p < 0.01). The difference in spatial summation property was demonstrated between the b wave and the d wave.


Paul Stoewer, the forgotten inventor--a belated recognition.

Ninety years ago, Paul Stoewer introduced the vacuum method for cataract surgery. It is felt that it is about time to acknowledge his authorship which has been so far almost ignored in ophthalmic literature.


A six-generation family with autosomal dominant retinitis pigmentosa and a rhodopsin gene mutation (arginine-135-leucine).

This study documents the ophthalmological findings in a six-generation. Swedish family with autosomal dominant retinitis pigmentosa with a previously unknown rhodopsin, exon 2, mutation, Arg-135-Leu (CGG to CTG). Six affected patients from the family were available for analysis and were all found to be heterozygous for the mutation, whereas eight clinically normal family members and 29 unrelated normal individuals did not have it. The disease appears to be of a type with comparatively rapid progression to blindness.


Grating-acuity in children. Normal values of visual acuity in children up to 13 years as assessed by the acuity card procedure.

The acuity card procedure proved to be a useful method for assessing visual acuity in children. Normal values of visual acuity measured by this method had already been assessed in children up to four years. To enable application of the test in older children this study obtained values in a group of 396 normal children, aged three months to 13 years. The mean curve as well as the 10th centile was calculated in different age groups. A considerable variation of acuity values causing a 'dip' in the 10th centile was found in the ages 18 to 24 months. A smaller 'dip' was found in the ages 48 to 52 months. This has to be attributed to behavioural properties connected with age. The results obtained in the group of children under four years of age corresponded fairly well with other studies. In schoolchildren a fair agreement could also be found between the data obtained using the acuity card procedure and the data obtained with the Landolt-C rings. Obtaining normal values for the acuity card procedure in children covering a wide age range facilitates recognition of visual handicap in children who are difficult to assess.


Congenital glaucoma in a child with partial 1q duplication and 9p deletion.

A case of partial duplication of chromosome 1 (1q41-qter) and partial deletion of chromosome 9 (9p24-pter) with infantile congenital glaucoma is reported. The histopathology of the eyes is described. The clinical findings ascribed to trisomy 1q and partial monosomy 9p are summarized and compared to this case. As this is the second report of a patient with monosomy 9p24-pter and congenital glaucoma, it may indicate localization of a gene involved in congenital glaucoma in this region of the human genome.


Encephalocraniocutaneous lipomatosis and oculocerebrocutaneous syndrome. A differential diagnostic problem?

The authors describe a female patient with unilateral malformations of skin, cerebrum and eye. The symptoms consisted of local skin hypoplasia, skin appendages and lipomatous tissue; cysts, hypoplasia and lipomatosis of the brain; and ocular malformations. In the newborn period the symptoms led to the diagnosis of oculocerebrocutaneous (OCC) syndrome. In the first year of life the clinical course deteriorated and the psychomotor development was progressively retarded. Evaluation at the age of 15 months prompted the authors to change the diagnosis to encephalocraniocutaneous lipomatosis (ECCL). The differential diagnosis of ECCL and OCC syndromes is discussed and a possible common pathogenetic pathway of these two rare disorders is proposed.


Epidemiology of congenital eye malformations in 131,760 consecutive births.

The epidemiology of eye malformations was studied in the geographical area covered by the authors' registry of congenital malformations. For each of the 78 new cases studied during the period 1979 to 1988, more than 50 factors were compared in probands and in controls. The prevalence rate of congenital eye malformations was 7.5 per 10,000 with microphthalmia 1.8, anophthalmia 0.3, cataract 2.3 and coloboma 0.7 respectively. Sex ratio was 0.82. Prenatal diagnosis was performed in ten cases and three cases were induced abortions. The more common types of associated malformations in the 42 affected cases (53.8%) with at least one anomaly other than an eye malformation were clubfeet, microcephaly, hydrocephaly and facial dysmorphia. At birth infants with eye malformations and other malformations were smaller, weighed less and their head circumference was lower than in controls. Placental weight was also lower than in controls. Pregnancies with eye malformations were more often complicated by threatened abortion, oligoamnios and polyhydramnios. Mothers of children with congenital eye malformations took more often drugs during pregnancy than mothers of controls. Fathers of children with congenital eye malformations were more often exposed to occupational hazards than fathers of controls. There was a significant association between eye malformation and consanguinity of parents. First degree relatives of probands had more than three times the prevalence of non-eye malformations than controls. These results are of relevance to genetic counseling.


Electro-oculogram in vitamin A deficiency associated with cystic fibrosis. Short communication.

Electro-oculograms (EOGs) were recorded in a patient with cystic fibrosis and vitamin A deficiency before and during vitamin A supplementation (25,000 IU/day). Before vitamin A supplementation the EOG Arden light/dark ratio was 1.27. After seven months of vitamin A supplementation the Arden ratio increased to 3.0. These results reveal that vitamin A deficiency can cause an abnormal EOG.


Functional morphology of the human endolymphatic sac. A review.

Modern immunohistochemical methods allow a functional characterization of the human endolymphatic sac (ES) and its associated cell populations. The currently available immunohistochemical data on the extraosseous part of the human ES support the assumption that the epithelium is metabolically active and capable of both secretion and absorption. The reactivity of some epithelial cells with antibodies against neuroendocrine antigens implies a paracrine activity of the human ES. Further results provide evidence for a possible role of the human ES in inner ear immune defense and indicate a putative functional relationship of the human ES to the common mucosa-associated immune system.


Cytodifferentiation within the developing human endolymphatic sac.

The cytodifferentiation of the human endolymphatic sac was studied in the period between gestational weeks 8 and 20. This period is of particular interest since it covers the major part of the morphological and functional maturation of the human inner ear. The studied time, i.e. 8-20 weeks of gestation, may be divided into three periods. Before week 10, between weeks 11 and 15 and weeks 15-20. While the endolymphatic sac appears as a simple slit-like appendage in the first period, until week 10 with cells of uniform size and shape, a beginning cytodifferentiation occurs in the second period between weeks 10 and 15. Thus the cells attain a more mature shape with different stainability, i.e. light- and dark-staining cells, as well as open lateral intercellular spaces indicating some functional maturity. In the third period, after week 15, the endolymphatic sac more or less seems mature with a rugose appearance in its proximal portion and a more even, slit-like appearance in the distal portion. The cells are differentiated with morphological signs of functional maturation. It may be concluded that the development of the endolymphatic sac roughly follows that of the cochlea which is regarded to be functionally mature in the beginning of the second half of pregnancy.


Origin of sympathetic and sensory innervation of the endolymphatic sac. A retrograde axonal tracing study in the guinea pig.

Lectin-conjugated horseradish peroxidase (WGA-HRP) was used as a retrograde axonal tracer to determine endolymphatic sac (ES) innervation and the nature of such a nervous supply. WGA-HRP placed into the ES of the guinea pig resulted in labelling of neurons in the ipsilateral sympathetic superior cervical ganglion and the sensory trigeminal ganglion. The number of labelled neurons in the cervical superior ganglion varied according to the survival time with peak labelling occurring after 48 h. Sparse labelling of the sensory trigeminal ganglion was also present after 48 h. The results indicate that sympathetic neurons from the superior cervical ganglion and to a certain extent trigeminal somatosensory neurons innervate the ES or perisaccular tissue. If these findings reflect the existence of a sympathetic functional reflex unit remains to be elucidated.


Osmotically induced macrophage activity in the endolymphatic sac. On the possible interaction between periaqueductal bone marrow cells and the endolymphatic sac.

This study aimed to investigate the origin of the free cells in the lumen of the endolymphatic sac (ES). Activation of the cells was accomplished through osmotic induction using glycerol. The ES and the perisaccular tissue were analyzed with special reference to the activity of periaqueductal bone marrow cells after different time intervals following the injection of hyperosmotic agents. The results show that the perisaccular or periaqueductal bone marrow space may constitute a source of some of the free cells occurring in the ES. Osmotic challenging of the inner ear may cause activation of the periaqueductal bone marrow, initiating the locomotion and migration of cells (mostly monocytes, neutrophils and eosinophilic leukocytes) along bone marrow sinusoids that frequently anastomose with the ES vessels. The free cells show signs of transepithelial diapedesis and, in the lumen of the ES, cells may develop into phagocytes which initiate the ingestion and degradation of secreted macromolecular aggregates. It is thought that osmotic alterations in the inner ear may give rise to local changes in or around the ES, leading to the chemotactic attraction of bone marrow cells. The results verify the existence of a complex sugar/protein aggregate metabolism over the wall of the ES, which is linked to the turnover of free cells. The findings may indicate that ES macrophages are important in the regulation of inner ear fluid homeostasis.


Acidity in the endolymphatic sac fluid of guinea pigs.

The pH value and the DC potential in the endolymphatic sac (ES) were measured using H(+)-selective double-barreled electrodes and the intra- and extradural approach, the pH value in the ES fluid (6.65 +/- 0.12, n = 7) was markedly lower than that in the cerebrospinal fluid (7.39 +/- 0.07, n = 7). Acidity in the ES fluid, under normal (nontreated) conditions may be closely associated with metabolism in the epithelium of the ES.


Effects of glycerol on the endolymphatic sac. A time sequence study.

A time sequence study was performed on experimental animals to investigate long-term effects of intravenously administered glycerol on the epithelial cell activity in the endolymphatic sac (ES) and on the ES volume. Fifteen to 60 min after systemic glycerol administration, the ES volume decreased. During this time, the ES lumen was often obliterated. Subsequently, the lumen dilated. Meanwhile, many light epithelial cells showed granules with floccular and/or lamellar contents. Concomitant deposition of floccular material into the luminal space suggested secretion of macromolecular substances, presumably from these transformed light cells. The number of granule-containing cells was significantly increased 2 h (p < 0.01) and 4 h (p < 0.01) after glycerol administration. The ES was significantly dilated after 4 h (p < 0.01) and 6 h (p < 0.05). Thus systemic alterations in osmotic pressure led to a reversible change in ES volume, with initial collapse followed by dilation and normalization after 8 h. The secretory response of the ES preceded the volume increase. A great variability in ES volume indicated high compliance of this organ system. A secretion/degradation system or turnover of osmotically active macromolecular complexes in the epithelial lining and ES lumen seems to be linked to the ability of the ES to hold fluid volumes within a wide range. This may serve as a micromechanical pressure-volume-regulating device for monitoring endolymph fluid homeostasis.


Microorganism transport in the human endolymphatic duct.

There are indications that endolymphatic sac (ES) may be an immunologically active part of the inner ear. So far, no microorganisms or foreign substances have been localized in this area under 'normal' conditions. Only a limited number of human specimens, including the entire endolymphatic duct (ED) and ES, have been collected and analyzed from cadavers or surgical biopsy specimens. In this study, 6 human ED and ES collected from cadavers and at surgery were analyzed by light and electron microscopy. This was done in order to investigate if microorganisms may normally be drained at this route into the ES. Some microorganisms (Mycoplasma pneumoniae) were found in the lumen and subepithelial tissue of 1 human ED. These observations suggest that microorganisms may also be locally processed and disposed at the level of the ED. These results add further evidence as to the immunodefensive role of the human ES.


A technique to obtain and process surgical specimens of the human vestibular aqueduct for histopathological studies of the endolymphatic duct and sac.

The endolymphatic sac (ES) may play a crucial role in the pathophysiology of Ménière's disease. This paper presents a technique to obtain and process fresh human specimens of the endolymphatic duct (ED) and the presumably more active intraosseous portion of the ES obtained at surgery. The specimens are preserved with an intact bony shell around the ED and the intraosseous ES. This allows ultrastructural histopathological evaluation of the intraluminal contents, the epithelium and the subepithelial tissue as well as the mutual relationships of these structures. Various factors influencing ES ultrastructure are discussed. The results obtained from this method may increase our understanding of the possible role of the ES in the etiology of different inner ear disorders.


Cochlear structure and function in a recessive type of genetically induced inner ear degeneration.

An age-related consecutive morphological analysis of the cochlea has been performed in homozygote (je/je) and heterozygote (je/+) jerker mouse mutants. A difference in the time of onset of hair cell pathology was evident between the two, but, when taking place, it showed a similar morphological type of degeneration. The cuticular plate and the stereocilia are particularly vulnerable structures and are the primary sites of damage. The suprastructures on both outer and inner hair cells disintegrate at the same time, irrespective of the level along the basilar membrane. During aging, the je/+ animals showed a progressive age-related impairment of auditory brainstem response thresholds which was correlated semiquantitatively to hair cell pathology.


[Lyme borreliosis in childhood].

Ten years after detection of Borrelia burgdorferi as the etiologic agent of Lyme borreliosis and after introduction of serological methods an overview of the disease in children is given and compared with own observations. In view of the wide clinical spectrum and the difficulties in interpreting serological results the early diagnosis of Lyme borreliosis is still problematic at present. On the other hand, in case of late diagnosis therapeutic failure and/or partial recovery may result. Data of 138 children with clinically suspected recent Lyme borreliosis demonstrate that the early diagnosis particularly of neuroborreliosis can only be ameliorated when a careful synopsis of all specific and nonspecific laboratory parameters available is done. Additionally, the results of a prospective randomized study of the treatment of acute neuroborreliosis (penicillin G sodium versus ceftriaxone) and results of liquor patency and half-life of ceftriaxone are presented.


[Clinical medicine and homeopathy].

A growing number of physicians in everyday practice use homoeopathy not as an alternative but rather as a supplementation to conventional medicine. A whole number of trials concerning both basic and clinical research have given evidence of the efficacy of homoeopathy and of the way it works. Nevertheless, in order to draw definite conclusions, the methodological quality of the trials will have to be improved. The evidence accumulated so far justifies the planning of further studies in collaboration between homoeopathic practitioners and clinicians. In order to achieve relevant results further studies have to be designed according to the principles of homoeopathy, especially the individual prescription of remedies.


[Indications, problems and future perspectives of bone marrow transplantation in pediatrics].

Bone marrow transplantation (BMT) is an established therapy in pediatric oncology and is increasingly used as curative approach in the treatment of congenital, non-oncologic diseases of the lymphohematopoietic system. There is increasing evidence, however, that BMT can be followed by severe long term effects including neuroendocrine, ophthalmologic, dental and central nervous system abnormalities, particularly in children. Therefore the indication to BMT depends on the results obtained by conventional therapy. Due to the high cure rates of leukemia with conventional therapy BMT is only warranted following relapse except for certain forms with poor prognosis factors. For patients with chronic myelogeneous leukemia, however, BMT is the only chance of cure. In solid tumors the role of BMT is more difficult, because there is no clear evidence that BMT is superior to conventional therapy with regard to long term survival. In severe aplastic anemia, however, the long term results of BMT are clearly better than those obtained by conventional therapy. Other undisputed indications for BMT are severe combined immuno deficiencies and other congenital diseases for which BMT is currently the only curative therapy. Progress with matched unrelated donor transplantations by better histocompatibility testing and more specific immunosuppressive therapy to reduce graft-versus-host disease, still a major problem of allogeneic BMT, as well as the perspectives of gen therapy in the future will offer a chance of cure to many patients without a matched sibling donor.


The effect of meal frequency on postprandial thermogenesis in obese children.

The effect of meal frequency on the thermic effect of food (TEF) was studied in six obese boys and five obese girls (age: mean +/- SE, 12.7 +/- 0.6 yr). Post-absorptive and postprandial resting energy expenditure (REE) were monitored continuously by indirect calorimetry. The children consumed one large liquid meal (LM) or three consecutive small meals (SM) at 1.5 h intervals on subsequent days. The first mode of nutrient intake was determined random. The energy content of the LM and one SM was tailored to provide 30% and 10% of the 24 h postabsorptive REE, respectively. The postprandial changes in REE were monitored for 6 h. The postabsorptive REE (mean +/- SE) was 4.86 +/- 0.28 and 4.9 +/- 0.27 kJ/min before the LM and SM, respectively. REE, respiratory quotient, plasma glucose and insulin concentrations increased sooner, steeper and higher with the LM than with the SM. The magnitude of the TEF was greater (p < 0.02) after the LM (11.9 +/- 1.3%) than after the SM (8.5 +/- 0.7%). It is concluded that the frequency of food consumption influences the immediate thermogenic response as well as the changes in respiratory quotient, glycaemia and insulinaemia. However, the complex effect of different meal frequencies on the overall energy balance of obese patients cannot be answered on the basis of the present results.


[Schoenlein-Henoch syndrome with abdominal manifestations without skin involvement].

The etiology of Schoenlein-Henoch' Syndrome has not yet been fully clarified [10, 15]. An allergically toxic genesis is under discussion [8, 19]. The classical combination of symptoms consists of urticariel efflorescences, bleeding of skin and lining tissue and arthralgies [8, 19]. Involvement of kidneys and abdomen may occur [8, 19]. Our case report concerns exclusively an abdominal form with colics, vomiting and diarrhea [10, 18, 16]. Chemical tests reveal a reduction of factor XIII [1, 5, 21]. There is no involvement of kidneys, skin or joints. With reference to literature and this particular case, etiology, diagnosis and therapy are dealt with.


Plasma and cerebrospinal fluid beta-endorphin in chronic tension-type headache.

Previous studies have provided evidence of an increased sensitivity to pain, a decreased hypothalamic opioid tone, and decreased cerebrospinal fluid (CSF) beta-endorphin (beta-EP) concentration in patients with primary chronic headache. We applied separate specific radioimmunoassays for beta-EP in CSF and plasma on samples from age-matched controls and a group of 50 patients with chronic tension-type headache (CTH) fulfilling the diagnostic criteria set by the International Headache Society. Median CSF beta-EP concentrations (95% confidence limits) were 12.8 pmol/l (11.0-14.5) in CTH patients and 11.9 pmol/l (10.9-14.2) in the control group, which is not significantly different (P = 0.28). Plasma beta-EP concentrations did not differ either, being 3.1 pmol/l (2.4-3.7) and 3.3 pmol/l (1.8-4.0) in the patients with CTH and in controls, respectively (P = 0.88). Plasma and CSF beta-EP concentrations did not correlate. Reversed-phase high performance liquid chromatography (HPLC) of CSF pools from the headache patients and controls revealed similar profiles of beta-EP-immunoreactivity both when C-terminally and N-terminally directed antisera were used, suggesting a normal post-translational processing of the pro-opiomelanocortin gene in patients with CTH. beta-EP is not involved in the pathogenesis of CTH, or such a role is not reflected in CSF or plasma concentrations of the neuropeptide.


Cervicogenic headache, migraine, and tension-type headache. Pressure-pain threshold measurements.

Pressure-pain threshold (PPT) measurements were performed with a pressure algometer, at 22 specified points in the head in patients with cervicogenic headache (n = 32), migraine (with and without aura) (n = 26) and tension-type headache (n = 17). Comparisons were made with a group of healthy controls (n = 20). The average PPT differed significantly between the groups (ANOVA, F = 9.5, P < 0.0005), largely caused by the low threshold in cervicogenic headache patients. There were no significant differences between controls and the 2 other headache groups. In the cervicogenic headache group, the lowest PPT was found in the occipital part of the head on the side with pain predominance. The ratio between the dominant and non-dominant sides (all 11 points on each side) was 0.85 in cervicogenic headache, whereas it was 0.99 in migraine patients with side preponderance of the pain. The present results support the view that the pathogenesis of cervicogenic headache differs from that of migraine and tension-type headache. The results may further support the theory that fibres from the C2 level (innervating the occipital part of the head) may be included in the pathogenetic mechanism in cervicogenic headache.


Painful neuropathy: altered central processing maintained dynamically by peripheral input.

We performed sensory assessments before and during diagnostic tourniquet-cuff and local anesthetic blocks in 4 patients diagnosed with reflex sympathetic dystrophy (RSD). All patients complained of mechano-allodynia; lightly touching the skin evoked an intense pain sensation. At detection levels, electrical stimuli were perceived as painful, suggesting that the mechano-allodynia was mediated by A beta low-threshold mechanoreceptor afferents. A beta-mediated allodynia was further supported by reaction time latencies to painful electrical stimuli at threshold for A-fiber activation and, in 1 patient, by differential cuff blocks which abolished A beta function and allodynia while thermal sensation (warm and cold) were preserved. Local anesthetic block of painful foci associated with previous trauma abolished mechano-allodynia, cold allodynia, and spontaneous pain in all patients and relieved the motor symptoms in 1 patient with tonic contractures of the toes. Tactile and thermal perception in the previously allodynic area was preserved. When the local anesthetic block waned, spontaneous pain, allodynia, and motor symptoms returned. We propose a model of neuropathic pain in which ongoing nociceptive afferent input from a peripheral focus dynamically maintains altered central processing that accounts for allodynia, spontaneous pain, and other sensory and motor abnormalities. Blocking the peripheral input causes the central processing to revert to normal, abolishing the symptoms for the duration of the block. The model accounts for sympathetically maintained (SMP) and sympathetically independent (SIP) pain. The peripheral input can be independent of sympathetic activity or driven completely or in part by activity in sympathetic efferents or by circulating catecholamines. The shared final common pathway may explain the common features of SMP and SIP.


Formalin pain is expressed in decerebrate rats but not attenuated by morphine.

Subcutaneous injection of dilute formalin induces pain in humans and behaviors indicative of pain in animals. The formalin test, which is based on these observations, is now widely used as a model of pain produced by tissue injury, but the neural mechanisms of pain and analgesia in this test have not been identified. Rats with transections of the brain rostral or caudal to the pons show behavioral reactions to formalin similar to those of normal rats, although the temporary abatement of pain 10-15 min after formalin is absent in transected animals. Doses of morphine that suppress the behavioral response to formalin in normal rats are not antinociceptive in the formalin test in decerebrate rats although sedation, catalepsy and inhibition of the tail-flick reflex still occur. These results suggest that the response to formalin is organized in the brain stem but the antinociceptive effect of morphine in this test is mediated by the diencephalon or forebrain.


Dynamic and static components of mechanical hyperalgesia in human hairy skin.

The principle finding of the present study is that there are two types of mechanical hyperalgesia developing in human hairy skin following injurious stimuli. Mechanical hyperalgesia comprises a dynamic component (brush-evoked pain, allodynia) signalled by large myelinated afferents and a static component (hyperalgesia to pressure stimuli) signalled by unmyelinated afferents. While the static component is only found in the injured area, the dynamic component also extends into a halo of undamaged tissue surrounding the injury. The irritant chemicals, mustard oil or capsaicin, were applied transdermally in 20 subjects to a patch (2 x 2 cm) of hairy skin. Both substances evoked burning pain and hyperalgesia to mechanical stimuli. While stroking normal skin with a cotton bud was perceived only as touch prior to chemical stimulation, there was a distinctly unpleasant sensation afterwards. This component of mechanical hyperalgesia persisted for at least 30 min and was present in the skin exposed to the irritants (primary hyperalgesia) as well as in a zone of untreated skin surrounding the injury (secondary hyperalgesia) measuring 38 +/- 4 cm2 after capsaicin. Pressure pain thresholds dropped to 55 +/- 8% of baseline level after mustard oil and to 46 +/- 9% after capsaicin. However, this drop of thresholds was short-lived, lasting 5 min following mustard oil but persisting more than 30 min following capsaicin treatment. The reduction of pressure pain thresholds was only observed for treated skin areas, but not in the surrounding undamaged tissue from where brush-evoked pain could be evoked. When pressure pain thresholds were lowered, the pain had a burning quality which differed distinctly from the quality of brush-evoked pain. On-going burning pain and both types of mechanical hyperalgesia were critically temperature dependent. Mildly cooling the skin provided instant relief from on-going pain, abolished brush-evoked pain and normalized pressure pain thresholds. Rewarming resulted in a reappearance of on-going pain and hyperalgesia. The effect of a nerve compression block of the superficial radial nerve on these sensations was tested in 14 experiments. When the ability to perceive light touch had been abolished, there was also no touch-evoked pain, indicating that this component of mechanical hyperalgesia is mediated by large-diameter primary afferents. At a later stage of the block when the subjects' ability to perceive cold stimuli had also been lost, application of cool stimuli still eliminated on-going burning pain, suggesting that pain relief afforded by cooling the skin acts at the peripheral receptor level and not by central masking.(ABSTRACT TRUNCATED AT 400 WORDS)


Daily coping with pain from rheumatoid arthritis: patterns and correlates.

Seventy-five individuals with rheumatoid arthritis reported their pain coping, mood, and joint pain for 75 consecutive days. Pain coping strategies used most often were taking direct action to reduce the pain and using relaxation strategies; those used least often were expressing emotions about the pain and redefining the pain to make it more bearable. Several background characteristics, including gender, disability, neuroticism, and pain control perceptions predicted use of various coping strategies. Controlling for these characteristics, individuals who used relaxation more frequently as part of their daily coping repertoire had less daily pain during the course of the study, and those who reported more overall coping efforts were more likely to display declining levels of daily pain across time. Pain severity moderated the relations of seeking emotional support and use of distraction with daily mood. At low levels of pain, greater use of these strategies related to more positive mood but, at high levels of pain, related to less positive mood. Finally, individuals who reported a greater number of distinct forms of coping were more apt to enjoy improving daily mood over the course of the study. Findings are discussed in terms of the advantages of prospective daily research designs.


Behavior of patients with lung cancer: description and associations with oncologic and pain variables.

Although reflexes are recognized as protective responses to noxious stimuli, less is known about voluntary behavioral responses to cancer pain, which could provide clinicians with important diagnostic and therapeutic information. Forty-five patients with lung cancer were studied in their homes on 2 occasions to identify pain behaviors and to examine relationships between behaviors and selected variables. Patients completed the McGill Pain Questionnaire (MPQ) and Visual Analogue scale (VAS). Using a videotape observation method, patients sat, stood, walked, and reclined for 10 min. Videotapes were scored using 5 position-related and 31 pain-related behavior definitions. Within 3 days scored behaviors were described to patients who reported whether each scored behavior was performed: to express pain; because pain prevented usual behavior; to control pain; or as a habit. Patients reported that pain was controlled by 42 different behaviors; the number of different pain-reduction behaviors was correlated with pain intensity (r = 0.44) and pain quality (r = 0.64). Simultaneous multiple regression indicated that length of time pain was experienced, number of pain sites, pain quality, and pain intensity accounted for 41% of the variance in the number of pain control behaviors. None of the taped behaviors was reported as performed to express pain, and few of the patients reported that pain prevented behavior during the video session. Results clarify the pain-behavior construct, provide insight about the multidimensional nature of lung cancer pain, and suggest directions for behavioral interventions to augment pharmacological therapy for lung cancer pain.