Cerebral palsy--an increasing contributor to severe mental retardation?

It is estimated that the prevalence of nongenetic SMR associated with cerebral palsy has risen from 0.7 to about 0.9 per 1000 live births in the last decade. This is due to the predicted rise in total cerebral palsy prevalence to 2.5/1000 live births. This predicted prevalence of cerebral palsy is similar to that given for Western Australia in 1979-82, allowing for postnatal causes, but is higher than prevalence data from England and Sweden for that period. The estimated rise is due largely to improved survival and increased proportion of low birthweight babies since 1983 and also reflects the use of prevalence rates based on Mersey data. Improvements in prenatal diagnosis, and a parental choice of selective termination may lead to reductions in other causes of SMR, such as Down's syndrome and neural tube defects, so it seems that children both physically and mentally handicapped due to brain damage will contribute a greater proportion of the SMR population. The careload of these children is greater than that associated with many other causes of SMR and most survive into adult life. The implications for planning future services will need to be recognised.


Haemorrhagic shock encephalopathy syndrome in the British Isles.

The aetiopathogenesis of haemorrhagic shock encephalopathy syndrome (HSES) remains unclear and after concern that a novel environmental agent was the cause, the British Paediatric Association and the Public Health Laboratory Service Communicable Disease Surveillance Centre in 1983 initiated surveillance of this condition in the British Isles. After 1986 cases were ascertained via the British Paediatric Surveillance Unit 'active' reporting scheme; this report presents the findings for 1985-8. Sixty five patients were reported, of whom 52 satisfied the criteria for inclusion. Of those whose outcome was known, 24 (46%) died, 18 had severe neurological damage, and six survived apparently intact. Epidemiological features of note were: the median age of 15 weeks (range 3-140); statistically significant clustering of admission times suggesting a peak onset period at night; lack of geographic clusters, of secular trends and, except for a slight excess in winter months, of seasonality. Clinical and pathological features followed a highly consistent pattern, suggesting that HSES is an individual clinical entity distinguishable from conditions with similar presentations, such as septicaemia and Reye's syndrome. There was no microbiological or epidemiological evidence to support the emergence of a novel environmental agent. Many of the features of HSES were, however, the same as those described in heat stroke and we suggest that the two conditions are the same even though there is usually no history of overt overheating.


Optimum method for administration of biosynthetic human growth hormone: a randomised crossover trial of an Auto Injector and a pen injection system.

The use of optimum conventional growth hormone administration, using a growth hormone vial combined with an Auto Injector, was compared with a pen injection system using a cartridge of growth hormone. In both methods of administration the concentration of growth hormone was 16 IU/ml. Thirty patients (22 boys, eight girls) who had all previously been treated with growth hormone (4 IU/ml) administered using needles and syringes (without an Auto Injector) were randomised into receiving one of either treatment for three months and then crossed over for a further three months. Fourteen patients (10 boys, four girls) initially received KabiVial 16 IU/ml combined with an Auto Injector while 16 patients (12 boys, four girls) were treated with KabiPen 16 IU/ml. Mean age in both groups was 9.6 years. The majority of patients in both groups were treated with a regimen of either 15 or 20 units/m2/week as a daily subcutaneous injection. Of the 30 patients who started in this trial, two who commenced using an Auto Injector refused to change to a pen system and were excluded from further analysis. When scored on a scale of -5 to +5 general convenience when changing from an Auto Injector to the KabiPen decreased from +4.7 to +1.0. When assessed for pain, the Auto Injector group scored +4.7, which decreased to -0.2 (more painful) for the pen. At the end of the trial 23 patients (82%) chose to continue with the KabiVial/Auto Injector combination as they found this less painful and the child did not see the needle or need to insert the needle manually. Five patients (18%) continued with the KabiPen as they considered the device smaller and easier to use. The accuracy of dosing using KabiVial was 100% compared with the range of 88% to 111% using KabiPen as the latter was available only in 0.5 unit increments. No growth hormone was wasted using KabiVial, although a mean of 0.6 units was wasted with every 16 IU cartridge in the KabiPen system. It is concluded that patients should be able to contribute to the choice of growth hormone delivery systems and that newer methods need careful assessment.


Plasma and cerebrospinal fluid arginine vasopressin in patients with and without fever.

Hyponatraemia has been described in association with a number of acute infectious diseases, mainly bacterial and tuberculous meningitis and pneumonia, and has been attributed to inappropriate secretion of arginine vasopressin (AVP). The mechanism of inappropriate AVP production is uncertain, but there is experimental evidence to suggest that fever may stimulate secretion of AVP into plasma and cerebrospinal fluid. In this study, AVP concentrations in plasma and cerebrospinal fluid from 37 febrile children with infections have been compared with those from 27 afebrile control subjects. Ten of the febrile children had meningitis (eight bacterial, two viral) and the remainder a variety of other infectious diseases. Seventy four per cent of febrile infected children were hyponatraemic (serum sodium less than 135 mmol/l) compared with only 8% of the afebrile controls. Plasma AVP concentrations were significantly higher in the febrile patients (median 2.92 pmol/l, range 1.0-23.25, n = 28) than in controls (median 1.67 pmol/l, range 0.57-6.0, n = 14) but there was no significant difference in cerebrospinal fluid AVP concentrations. There was no difference in plasma AVP concentrations between patients with meningitis and those with infections not involving the central nervous system. Careful attention should be paid to fluid and electrolyte balance in all children with acute infections.


The great Chicago flood of 1992.

Despite many years of experience in a chosen field, a systematic response to a disaster situation can only be measured when experiencing such a situation. During the Great Chicago Flood of 1992, our dialysis unit appropriately responded to the various needs of our dialysis population. How each department responded, what steps were taken, and the immediate outcomes in the first critical hour of the disaster are the focus of this article.


Testimony: controversies in organ donation.

The National Kidney Foundation recently held four regional forums to discuss controversies in organ donation. All interested parties, both in the public and private sectors, were invited to submit written and oral testimony. The following is the written testimony submitted by ANNA and presented orally by Ms. McNatt at the regional forum in Chicago, April 9, 1992.


Family styles of coping in end stage renal disease.

The introduction of a serious life-threatening illness such as end stage renal disease (ESRD) is an added stress dimension to the already enormous demands placed on the contemporary family system. The purpose of the present study was to identify qualitatively and describe selected aspects of psychosocial adaptation among the families of ESRD patients experiencing four primary modes of dialytic therapy: incenter hemodialysis, home dialysis, continuous ambulatory peritoneal dialysis (CAPD), and continuous cyclic peritoneal dialysis (CCPD). Five family coping styles emerged from content analysis of the data collected from 50 family members at four time periods. These styles have been labelled: Remote Family Style, Enfolded Family Style, Altered Family Style, Distressed Family Style, and Receptive Family Style.


Renal physiology series: Part 3 of 8. Urinary concentration and dilution.

The maintenance of extracellular volume depends on the appropriate excretion of both salt and water. When extracellular volume is expanded, the excretion of a dilute urine facilitates the return of extracellular volume to normal. When extracellular volume is contracted, the retention of both salt and water and the excretion of a small amount of concentrated urine contributes to the reexpansion of extracellular volume. The formation of either a dilute or concentrated urine is dependent on the physical arrangement of the loops of Henle, collecting tubules, and vasa recta within the kidney medulla, the transport properties of each segment; and the appropriate presence or absence of antidiuretic hormone (ADH), a hormone synthesized in the hypothalamus and secreted from the posterior pituitary gland.


Images of nephrology nursing practice: report of a survey.

The results of a survey designed to identify existing images of nephrology nursing practice are reported. The sample included 374 attendees at meetings sponsored by the American Nephrology Nurses' Association (ANNA). Content analysis revealed that the typical nephrology patient is elderly, has a chronic illness and negative affect, is not compliant, and is dependent on others. The typical nephrology nurse-patient interaction emphasizes teaching and support. The most common nursing activities are assessment, teaching, dialysis treatment, and psychological support.


Varying heparin requirements in hemodialysis patients receiving erythropoietin.

A two-phase study was undertaken to investigate the incidence, extent, and management of increased heparin needs occurring during erythropoietin (EPO) therapy in the hemodialysis patient. Individual heparin doses and activated clotting time (ACT) test values were the parameters used to indicate changes in heparin requirements. It appears that increased heparin requirements are frequently associated with EPO therapy, and awareness of this finding, coupled with close ACT monitoring, may possibly prevent complications associated with undetected increases in heparin requirement.


Successful use of Orthoclone OKT 3 for steroid-resistant acute rejection in pediatric renal allograft recipients.

Use of Orthoclone OKT 3 for the treatment of steroid-resistant acute rejection in kidney transplant recipients is well described in the literature. Our experience with the use of OKT 3 in 16 pediatric kidney transplant recipients supports the use of this therapy in the pediatric population by reporting efficacy and lack of major complications. Monitoring of OKT 3 antibodies is recommended because of potential need to reuse OKT 3 in subsequent transplants. In addition, techniques of improving medical compliance, particularly in the adolescent population, is an area identified as needing further study. The combination of improving rejection therapies and specific nursing interventions in preparing children and their families in the use of OKT 3 as well as in enhancing compliance will improve the outlook of pediatric transplant recipients.


Case management of the anemic patient. Epoetin alfa: focus on quality of life.

Dialysis patients often experience a diminished quality of life. Epoetin alfa therapy, which increases hematocrit, can result in improvements in exercise capacity, cognitive function, and other factors. Nurses play a critical role in monitoring and educating dialysis patients and in helping them achieve an optimal quality of life.


Effects of electropermeabilization on the association of foreign DNA with pig sperm.

This study was conducted to evaluate the effects of an electric pulse (electroporation/electropermeabilization) on the binding of foreign DNA molecules to porcine spermatozoa. We previously examined various parameters involved in the association of foreign DNA with sperm after a simple incubation procedure and now report the effects of electroporation on this association. Using end-labeled and random primer labeled lambda HindIII DNA fragments (23-0.125 kb), it was demonstrated that the DNA fragments interacted with the sperm after electroporation. These samples were then centrifuged and washed extensively to establish if any of the labeled DNA was associated with the spermatozoa. It was determined that approximately 10(8) molecules of DNA were associated with 1.5 x 10(7) mL-1 motile spermatozoa after five medium washes. After each wash, samples were withdrawn for gel analysis and scintillation counting. Gel analysis followed by autoradiography revealed the distinctive band pattern of lambda HindIII DNA associating with sperm. In situ visualization studies with biotin-labeled DNA revealed that approximately 75% of motile sperm carried DNA bound to the post-acrosomal region. However, the intensity of the binding varied, with some sperm being more strongly stained than others. Using [3H]dCTP-labeled DNA followed by light microscope autoradiography, approximately 70% of the sperm were strongly stained in the post-acrosomal region. There was a 5-10% increase in the amount of DNA bound by sperm when the samples were electroporated.


Influence of male sexual rest and oocyte aging on parthenogenesis frequency in mice: cytogenetic analysis after in vitro fertilization.

This study was conducted to evaluate the influence of male sexual rest and oocyte aging on fertilization rate and parthenogenesis frequency after in vitro fertilization of mouse oocytes. We used a comparison between cleavage rates and fertilization rates according to chromosomal analysis of oocytes to estimate the parthenogenesis frequency. Fertilization rate was not impaired by male sexual rest. Parthenogenesis frequency was increased by male sexual rest. This effect was enhanced by a concomitant moderate oocyte aging. It is concluded that cleavage rate could not be considered as a reliable test of fertilization after attempted in vitro fertilization in such conditions.


Sex ratio of male sex preselected children born to couples with exclusively female offspring.

The present study was undertaken to determine if couples with exclusively female children had a decreased probability of a male child after using male sex preselection. Selection criteria for subjects necessitated that couples have had only female children previously and had produced a child at one of 14 centers after using protocol 3 (n = 70) and modified 3 (n = 28) male sex preselection. Prior to sex selection, protocol 3 couples produced a combined total of 135 female children for an average of 2.01 (range 1-4) females per couple; modified 3 couples produced a combined total of 62 female children for an average of 2.21 (range 1-4) females per couple. The normal approximation to the binomial distribution was used to determine significant differences between the sex ratios prior to and after male sex preselection. For couples using protocol 3 there were significant differences in the sex ratio prior to sex preselection (0%) and after sex preselection (73.0%) (p less than .00003). There were also significant differences between the sex ratio prior to modified 3 (0%) and after sex preselection (86%) (p less than .00003). Couples using male sex preselection do not have a decreased probability of a male child if they have had exclusively female children.


Seminal plasma transferrin in infertile men.

Seminal plasma transferrin levels were estimated in 51 men with various infertility problems and in 15 fertile subjects. The estimation of transferrin was carried out by using the radial immunodiffusion technique on LC-partigen transferrin plates. The mean value of transferrin decreased (p less than .05) in cases of azoospermia (91 +/- 51 micrograms/ejaculate). No significant difference was found in other sperm quality disorders (asthenoteratospermia = 227 +/- 141, mild OTA = 186 +/- 96, severe OTA = 247 +/- 137 micrograms/ejaculate). The mean value of transferrin decreased (p less than .05) in obstructive azoospermia cases (73 +/- 70 micrograms/ejaculate), whereas in the other causes of infertility no statistical differences were found. Transferrin was correlated with sperm count, sperm volume, and serum LH.


Pharmacy and Therapeutics committee. Cost-containment considerations.

The Pharmacy and Therapeutics committee is a frequently used mechanism for health care organizations to meet mandated standards. The control that the committee has over the formulary is often seen as a potential way of controlling the expenditures for drugs. As the Pharmacy and Therapeutics committee is the means for the clinical staff to have an effect as to what agents are available to practitioners, it is incumbent on the committee members to have a clear idea of what their role should be in cost containment. An important concept that impacts on cost is that optimal health benefit is not necessarily the result of maximum expenditure. The welfare of the patient is paramount to all in the health care field; however, it is the task of clinicians to determine what constitutes optimal health benefit and to act as agents of the patient. Clinicians must maintain patient care as their top priority. Although health care expenditures are an extremely important issue, quality of patient care cannot be subrogated to a secondary concern.


NADH-dependent oxidoreductase (diaphorase) activity and isozyme pattern of sperm in infertile men.

Diaphorase activities were measured in spermatozoa from 104 infertile men. The relationships between enzyme activity, sperm characteristics (density, motility, viability), and distribution of electrophoretic patterns were examined. There was a highly significant difference (p less than .001) between the sperm diaphorase activities in specimens with sperm concentration above 40 million per milliliter (0.685 +/- 0.5 mIU/10(6) sperm; n = 57) when compared with the diaphorase values of the oligospermic specimens with sperm density below 40 million per milliliter (1.53 +/- 1.5 mIU/10(6) sperm; n = 47). However, there was no evidence to support any relationship between sperm diaphorase activities, sperm motility, viability, and the distribution of three diaphorase electrophoretic patterns. This indicates that these parameters do not account for the differences between the diaphorase activity of spermatozoa of infertile men with sperm concentrations below and those above 40 million per milliliter.


Sperm motility should be assessed in fresh sperm and after a sperm washing procedure.

A prospective study was carried out on semen samples from 118 consecutive unselected men attending our infertility clinic to determine whether sperm motility may be affected by seminal plasma. The incidence of asthenozoospermia as defined by fewer than 50% of spermatozoa with forward progressive motility in the untreated semen was 37.4%. This value was significantly reduced to 23% after washing and removing seminal plasma. Men with asthenozoospermia in untreated semen but normal in the washed sample had a percentage of normal sperm morphology and a percentage of swollen tails in the HOS test similar to those of controls, and higher than those of asthenozoospermics in both the untreated and washed sample. Sperm velocity was also significantly improved after the washing procedure. Spermatozoa selected by swim-down procedure and applied to a seminal plasma medium reduced sperm motility affecting negatively the HOS test. Sperm motility should be assessed after a sperm washing procedure, since seminal plasma contains constituents that decrease sperm motility without affecting membrane integrity.


Significance of distal polyps detected with flexible sigmoidoscopy in asymptomatic patients.

Colorectal cancer is a frequent cause of death from cancer. To reduce the mortality associated with this disease, regular flexible sigmoidoscopy is recommended. However, the significance of diminutive polyps (adenomatous or hyperplastic) detected during flexible sigmoidoscopy remains controversial, as does the appropriate endoscope length (35 vs 60 cm) for colorectal cancer screening. One hundred one consecutive patients with no history of colonic disease, gastrointestinal tract symptoms, or positive results of fecal occult blood testing underwent flexible sigmoidoscopy as part of a colorectal cancer screening program. All patients with distal polyps detected during flexible sigmoidoscopy underwent colonoscopy. More than 25% of these asymptomatic, predominantly male subjects had colonic neoplasms or polyps detected. Fifty percent more lesions could be detected with a 60-cm sigmoidoscope than with a 35-cm sigmoidoscope, and detection of any distal polyp, whether adenomatous or hyperplastic, was associated with at least one proximal colon adenoma in 20% of patients. "Extended flexible sigmoidoscopy" for colorectal cancer screening was well tolerated by patients, as evidenced by insertion to the hepatic flexure in 25% of patients, and provided significantly more information than could be obtained with a 35-cm sigmoidoscope. Colorectal cancer screening should be performed with a 60-cm flexible sigmoidoscope, and distal colonic polyps or neoplasms will be detected in 25% of asymptomatic patients.


Expression of a gene encoding a specific human sperm protein in Chinese hamster ovarian cells.

The cDNA (RSD-2) encoding a human sperm protein (YWK-II) was isolated from a rat testis lambda gt11 expression library. Its nucleotide sequence was determined. The deduced polypeptide showed high identity with the transmembrane-cytoplasmic domains of A4 amyloid precursor protein of Alzheimer's disease. The RSD-2 was inserted into the EcoRI site of the pSV2-EP vector to construct the pSVRS-2 vector. Chinese hamster ovarian (CHO-dhfr) cells were cotransformed with pSV2-neo and pSVRS-2. mRNA and chromosomal DNA prepared from the transformed cells interacted with [32P]RSD-2 as probe by dot hybridization. The production of the YWK-II protein was determined by staining with the YWK-II mAb by an indirect immunofluorescence technique. There was marked staining of the cytoplasm. The RSD-2 cDNA encoding the YWK-II sperm was expressed in the transformed CHO cells. The pSV2-EP vector and the CHO cell expression system can be utilized to produce sperm proteins for antifertility studies.


Comparison of gemfibrozil and lovastatin in patients with high low-density lipoprotein and low high-density lipoprotein cholesterol levels.

The efficacy of gemfibrozil and lovastatin in the treatment of patients who have an elevated low-density lipoprotein cholesterol (LDL-C) level and a low high-density lipoprotein cholesterol (HDL-C) level was compared. After at least 6 weeks of a cholestgerol-lowering diet, 17 patients who had a mean baseline LDL-C level above 4.14 mmol/L (160 mg/dL) and an HDL-C level below 1.03 mmol/L (40 mg/dL) received gemfibrozil 600 mg twice daily and lovastatin 20 mg twice daily each for 6 weeks according to a randomized, crossover, double-blind research design. Lovastatin and gemfibrozil reduced LDL-C levels 34% and 9% and raised HDL-C levels 15% and 18%, respectively. Lovastatin is more effective in lowering LDL-C levels and is as effective as gemfibrozil in increasing HDL-C levels in these patients.


Use of theophylline to enhance sperm function.

Poor sperm motility is an important factor in male infertility. Preliminary results in our laboratory on a group of 19 men (10 suspected infertile men and 9 fertile donors) showed stimulation of sperm fertilizing ability after sperm washing with theophylline as demonstrated by zona free hamster egg penetration test. The egg penetration rate for the control spermatozoa samples from subfertile men was 16%. Incubation with theophylline (10 mM) increased the penetration rate to 46%, whereas semen incubation with theophylline (20 mM) increased the penetration rate to 51%. A similar twofold increase in egg penetration was observed in the semen of fertile men incubated with theophylline of similar concentrations. Subfertile patients with ejaculate volumes of less than or equal to 1 ml or total motile sperm count of less than or equal to 10 x 10(6)/mL or increased semen viscosity did not exhibit beneficial effects with theophylline washing as measured by hamster egg penetration test score. The increase in percentage of penetrated eggs with theophylline use in both fertile and subfertile men was significant at 10 mM concentration (p less than .001) and 20 mM (p less than .001) when compared to control (untreated) samples. No significant difference in penetration rate was seen between 10 and 20 mM theophylline concentrations. It appears that theophylline may be useful in improving the fertilizing capacity of selected human semen samples with poor motility and poor penetration ability under artificial insemination conditions.


Impact of human immunodeficiency virus on medical and surgical residents.

BACKGROUND--Previous surveys of resident physicians on human immunodeficiency virus (HIV) matters have tended to focus on urban programs serving a patient population with an expected high prevalence of HIV infection. The objective of this study was to survey a community hospital residency program in a nonurban area with a perceived low HIV patient seroprevalence. METHODS--A 32-question survey was completed on an anonymous basis by the entire 74 member multidisciplinary resident physician group at a two-campus university-affiliated hospital program in southeastern Pennsylvania in May 1991. RESULTS--Residents perceived their patient population's HIV seroprevalence rate to be low although they believed their personal risk of occupational exposure to blood-borne infection was moderate to high. House staff most often complied with universal precautions for fear of acquiring a blood-borne illness and most often did not comply because of time constraints. Not perceiving the exposure as a health risk was the primary reason for nonreporting of exposures. Occupational exposure rates were alarmingly high, with suturing using a curved needle being the most common exposure method. Most residents were unfamiliar with HIV legislation. A majority of the house staff wanted improved HIV patient management training and life and disability insurance against occupationally acquired HIV. Many other important issues were addressed in this survey. CONCLUSION--Residents even in low seroprevalence environments do fear occupationally acquired HIV. A great need exists for improved training in universal precautions, acquired immunodeficiency syndrome legislation, and HIV patient management as well as for insurance against occupationally acquired HIV.


Pneumococcal pneumonia in adult hospitalized patients infected with the human immunodeficiency virus.

To determine the attack rate; clinical, radiologic, and laboratory characteristics; and outcome of pneumococcal pneumonia in patients infected with the human immunodeficiency virus (HIV) and to compare these characteristics with those of pneumococcal pneumonia in the general population. This is a retrospective (13-month), prospective (14-month) study. All adult hospitalized patients with pulmonary infiltrates and isolation of Streptococcus pneumoniae in blood, pleural fluid, transtracheal aspirate, or respiratory secretions obtained by plugged telescoped catheter (counts greater than 10(3) colony-forming units per milliliter) are included. We identified 22 HIV-infected patients and 84 HIV-seronegative patients with pneumococcal pneumonia (76% and 56%, respectively, were bacteremic). The estimated attack rate was 5.9 per 1000 for HIV-infected patients and 0.31 per 1000 for HIV-seronegative patients. Pneumococcal pneumonia was the first manifestation of HIV infection in 48% of cases. Seventy-two percent of patients younger than 40 years of age with pneumococcal pneumonia were HIV infected. No predisposing factors for pneumococcal pneumonia were identified in 76% and 2% of HIV seropositive and seronegative patients, respectively. Clinical and radiologic presentation was similar in the two populations. Of all S pneumoniae isolates, 35% were resistant to penicillin and 10% to erythromycin, without differences in the two groups. Prognosis was good, with only one infection-related death in the HIV-infected group (10 patients died in the other group). No relapses were documented in HIV-infected patients. The HIV-infected patient is at increased risk for pneumococcal pneumonia and bacteremia. Patients younger than 40 years of age who present with pneumococcal pneumonia should be considered for HIV testing, since it may be the first manifestation of HIV infection. Specific antimicrobial therapy is curative in the majority of HIV-infected patients.


Teaching medical interviewing. A basic course on interviewing and the physician-patient relationship.

Recent advances in educational theory and methodology have made it possible to teach medical interviewing with as much rigor as other clinical skills. We describe a first-semester, first-year medical student course that effectively teaches basic interviewing skills. This course provides faculty development, small group learning, detailed faculty and student coursebooks, and an interview checklist that delineates specific interviewing skills and content areas, serving as a template for teaching, practice, and feedback. Students have many opportunities for practice in role play and with patients, followed by feedback by self, peers, and faculty. Use of audiotape and videotape reviews enhances the learning experience. This article describes our course, suggests educational principles and standards for the teaching of medical interviewing, and presents educational research demonstrating significant gains in students' skills associated with improvement in standardized patient satisfaction.


The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient.

Simulated patients are used with increased frequency for medical students and residents, but have not been used very often with practicing physicians. We hypothesized that educational materials could improve primary care physicians sexual practices history taking and counseling as assessed by a simulated patient in the physician's office. Simulated patient (SP) visits were made to 232 (75% of eligible) primary care physicians. The patient simulated was a sexually active young woman with vaginitis and sexually transmitted disease/human immunodeficiency virus risk behaviors. In advance of the visit, physicians were provided educational materials (monograph, pamphlet, and audiotape) developed for the study, including a risk assessment questionnaire that could be used with patients. Most physicians randomly allocated to the intervention participated. Twenty-one percent of physicians refused to schedule an SP visit. Physicians who received an SP rated the experience highly. Physicians who prepared for the visit with the educational materials performed significantly better than those who did not. About two thirds of physicians reviewed the materials, many for the second time, after the SP visit. Physicians who used the study risk assessment questionnaire performed better. Many physicians (24.9% to 39.8%) did not meet each of the four goals for the visit, as assessed subjectively by the SP. Physician performance was better for measures of general patient interaction than for measures of sexual practices history taking and counseling techniques. The SP visit was acceptable to most physicians practicing in a community and was evaluated by them as an appealing and an effective educational experience. The SP, however, has limited feasibility because of cost. The SP led to review of materials by nearly all physicians either before or after the visit. Physicians who prepared before the visit performed better on every dimension, eliciting more information, displaying better patient interaction skills, and meeting more of the educational goals. Even with educational preparation, however, many physicians were not perceived as being effective counselors.


Effectiveness and efficiency of selective vs universal screening for chlamydial infection in sexually active young women.

Since chlamydial cervicitis is not associated with specific complaints, screening asymptomatic women is an important initiative to prevent pelvic inflammatory disease and its sequelae. Compared with universal screening, selective screening is less costly but less effective so the cost savings vs the consequences of missing infected women need to be weighed carefully. In two family planning clinics, 1002 women were surveyed for chlamydial infection (prevalence, 7%) and its predictors to determine whether universal or selective screening is the most efficient strategy. Two rules for the selection of patients were determined by logistic regression modeling and their relative efficiencies were compared by incremental cost-effectiveness and sensitivity analysis. The validity of the screening rules was tested in 191 students attending a university health clinic. If those with cervical friability, suspicious discharge, urinary frequency, or intermenstrual bleeding had been tested, 55.3% of all women would have been screened and 83.3% of all cases would have been detected. If those reporting a new sex partner in the preceding year had also been tested, 75.4% would have been screened, identifying 93.3% of all cases. The predictive power and practicality of the selection rules were validated in the university health clinic sample. Sensitivity analyses showed selective screening using cervical enzyme immunoassay with blocking confirmation was efficient if the prevalence of chlamydial infection was 16% or less, 11% or less, or 5% or less depending on whether base analyses, overestimated costs, or worst performance scenarios, respectively, were used. Selective screening based on four or five predictors and confirmed cervical enzyme immunoassay is an effective and efficient strategy in low prevalence settings.


Half a loaf is better than waiting for the bread truck. A computerized mini-medical record for outpatient care.

We describe a locally developed system for partial computer storage of medical data, called the mini-medical record system. The system produces a typed face sheet prior to each patient visit. The face sheet, which also serves as a progress note, contains patient demographic data, medical problem lists, previous vital signs, allergies, medication profile, and health maintenance reminders. Between regularly scheduled visits, all computerized data are available by computer printout for unscheduled visits to walk-in clinics and the emergency department. Structured reports are generated by the system that describes each resident and faculty members' practice. Quality assurance reports are also available. Since the system draws from several already existing databases, new data entry requirements are modest and cost to the institution is low. Partially computerized systems can be developed inexpensively and are well received in multispecialty practices, where interphysician communication is vital.


Epidemiology of bacterial endocarditis in The Netherlands. I. Patient characteristics.

Studies of the epidemiology of bacterial endocarditis are usually based on a retrospective review of medical records from referral centers serving diverse patient populations. These studies are therefore likely to suffer from selection bias. We conducted a nationwide prospective epidemiologic study of endocarditis in the Netherlands. During a 2-year period, all cases of consecutively hospitalized patients with suspected endocarditis in the Netherlands were reported to us. While hospitalized, patients were visited for an in-person interview and a review of the medical record. Of 559 episodes, 438 met the criteria for endocarditis; these included 89 episodes of prosthetic valve endocarditis and 349 episodes of native valve endocarditis. Adjusted for age- and sex-specific population figures, the incidence was 19 per million person-years. The incidence increased significantly with age, and men were more often affected than women (266 and 172 cases, respectively). Rheumatic and congenital cardiac lesions formed most of the underlying heart diseases. Mitral valve prolapse was present in only 29 patients with native valve endocarditis (8.3%). A history of intravenous drug abuse was present in 32 patients (7.3%). Viridans streptococci, staphylococci, and enterococci together constituted 86% of the isolated bacterial strains. Only 1.1% of the patients had culture-negative endocarditis. Overall case fatality was 19.7% and varied widely according to causative microorganism. The distribution of causal microorganisms, the case fatality rate, and the incidence rate of endocarditis are age related. Therefore, a meaningful comparison of data is only possible between population-based cohorts of patients with endocarditis.


Epidemiology of bacterial endocarditis in The Netherlands. II. Antecedent procedures and use of prophylaxis.

The reported frequency with which endocarditis is ascribed to an antecedent dental or medical procedure varies from 3% to 62%. We performed a nationwide prospective study of the epidemiology of bacterial endocarditis in the Netherlands. During a 2-year period, all consecutively hospitalized patients suspected of having endocarditis were visited while still hospitalized for a review of the medical record and an in-person interview that focused on antecedent procedures and administered prophylaxis. All information was checked with pharmacists and dental and medical practitioners. Of 427 patients with late prosthetic or native valve endocarditis, 275 were eligible for antibiotic prophylaxis because of a previously known cardiac lesion (n = 197) or a prosthetic valve (n = 78). Of these 275 patients, 64 (23.3%) had undergone a procedure with an indication for prophylaxis within 180 days of onset; in 31 (11.3%) the procedures had been within 30 days of onset. Antibiotic prophylaxis had been administered to 17 (26.6%) of the 64 patients and to eight (25.8%) of the 31 patients. The results indicate that medical and dental procedures cause only a small fraction of endocarditis. The majority of patients develop the disease along other routes. For an incubation period of 180 days, full compliance with prophylaxis might have prevented endocarditis in 47 (17.1%) of 275 patients with late prosthetic or native valve endocarditis involving a previously known cardiac lesion who underwent a procedure with an indication for prophylaxis. For an incubation period of 30 days, prophylaxis might have prevented endocarditis in 23 (8.4%) of these 275 patients, or 5.3% of all patients with endocarditis (n = 427).


Treatment of nocturnal leg cramps. A crossover trial of quinine vs vitamin E.

This study compared the efficacy and safety of quinine sulfate, vitamin E, and placebo in the treatment of nocturnal leg cramps. A random-order, double-blind, placebo-controlled crossover trial was performed. The study was conducted at the Veterans Affairs Medical Center, White River Junction, Vt. Twenty-seven male veterans, aged 38 to 73 years, who experienced at least six leg cramps per month were recruited through the general medicine walk-in clinic or were referred from other clinics. Fifty-five subjects were contacted, 30 were enrolled consecutively, and 27 completed the study. Subjects received, in random order, quinine sulfate (200 mg at supper and 300 mg at bedtime), vitamin E (800 U at bedtime), or placebo for 4-week periods. These periods were separated by 4-week washout intervals. Patients reported cramp frequency, severity, and sleep disturbance caused by cramps. Compared with treatment with placebo, quinine reduced the frequency of cramps and sleep disturbance, but not the average cramp severity. Thirteen of 27 patients had at least a 50% reduction in the number of cramps while receiving quinine; the response was usually seen within 3 days. There was evidence of a mild increase in side effects while subjects received quinine. Vitamin E was not effective in reducing leg cramp frequency, severity, or sleep disturbance. Quinine sulfate, but not vitamin E, is superior to placebo in the treatment of nocturnal leg cramps.


Community-acquired invasive group A beta-hemolytic streptococcal infections in Zuni Indians.

Outbreaks of invasive group A beta-hemolytic streptococcal (GABS) infections have recently been reported. We observed a high incidence of invasive GABS disease among Native Americans at a small rural community hospital between 1982 and 1991. A retrospective chart review was performed, and all cases of invasive GABS disease were studied for their clinical features. Sixteen cases of invasive GABS infection were identified during the 10-year study period. The rate of invasive GABS infection was 13.3 cases per 100,000 population per year. Mortality was 25%. Nearly half of the patients presented with systemic signs of sepsis without any obvious source of infection. Our experience documents a high rate of invasive GABS infections in a defined Native American population. To determine whether this population has a unique susceptibility to GABS disease requires further study.


Surrogate decision-maker preferences for medical care of severely demented nursing home patients.

In the absence of advanced directives, physicians treating demented patients rely on surrogates to help make medical care decisions. We surveyed family members of severely demented nursing home residents to determine preferences for medical intervention in five hypothetical situations involving tube feeding, hospitalization, intensive care unit admission, mechanical ventilation, and cardiopulmonary resuscitation. Only 11.8% of surrogates rejected all interventions. Cardiopulmonary resuscitation and tube feeding were accepted least frequently (31.6% and 36.4%, respectively). Mechanical ventilation, hospitalization, and intensive care unit admission were accepted by 43.6%, 63.4%, and 75.2%, respectively. There was no correlation between previous surrogate experience with an intervention and its acceptance. Nearly 70% of surrogates indicated that decisions were independent of any previously expressed resident views. In this study, surrogates of even the most demented nursing home patients prefer hospital level services including intensive care unit care for the treatment of acute illness. Efforts to control access to services on ethical or economic grounds may meet with resistance.


Eosinophilia-myalgia syndrome. Natural history in a population-based cohort.

To determine the natural history of eosinophilia-myalgia syndrome, we followed up all patients with eosinophilia-myalgia syndrome reported to the Oregon Health Division, Portland, during the recent epidemic caused by contaminated tryptophan. Patients were interviewed by telephone from 1 to 5 months after illness onset and again at least 12 months after onset. Symptoms (type, onset, and duration), overall disability, treatment, and tryptophan lot and dose were assessed for each patient. Information was obtained for 55 (96%) of 57 case-patients: 53 patients completed interviews and two patients had died. For the 53 patients who were interviewed, symptoms with onset more commonly during the first 3 months of illness included severe myalgias, fatigue, generalized weakness, edema, and rash. Symptoms with later onset included paresthesias, muscle cramps, extremity weakness, and alopecia. At 12 months, 41 patients (77%) continued to report fatigue, 36 (68%) weakness, and 34 (64%) myalgias; 26 patients (49%) had difficulty climbing stairs, 23 (43%) had difficulty getting up from a chair, and 15 (28%) had difficulty holding a cup. Higher doses of tryptophan were correlated with more severe disability, both initially (rs = .33) and at follow-up (rs = .42). Although most patients reported improvement in symptoms at 12 months, only 14 (26%) patients reported that they were able to perform all normal daily activities. Most patients with eosinophilia-myalgia syndrome in this population-based cohort are still symptomatic 1 year after onset, primarily with the complaints reported early in the illness. The association between degree of disability and daily tryptophan dose suggests that ingestion of varying amounts of contaminant may be responsible, in part, for the severity of symptoms experienced by individual patients.


Twelve cases of pituitary apoplexy.

In 12 cases of pituitary apoplexy, a preexisting unsuspected adenoma was found. The initial manifestations were sudden onset of headache (12 patients), signs of meningeal irritation (10) with fever (four), altered consciousness (12), and ophthalmologic disturbances (eight). The diagnosis was retrospective in three cases. Radiologic investigations were always suggestive if carefully considered. The plain skull roentgenograms, in particular, showed an enlarged sella turcica in 11 cases. Three patients had prolactin adenomas, and nine had nonfunctional adenomas. Medical treatment was successful in only three patients; surgery was performed in 10 cases by means of a sublabial transseptal microsurgical approach. Postoperative neurologic complications were serious in two cases. Endocrine insufficiencies were common: eight cases of permanent panhypopituitarism, two cases of pluritropic anterior pituitary dysfunction, and three cases of persistent hyperprolactinemia.


Detection of deep vein thrombosis with impedance plethysmography and real-time compression ultrasonography in hospitalized patients.

Serial testing with impedance plethysmography or compression ultrasonography has been demonstrated to be feasible and accurate for the detection of deep vein thrombosis (DVT) in symptomatic outpatients, and these techniques are replacing contrast venography in this patient category. Limited data, however, are available on the clinical utility of these noninvasive tests in symptomatic hospitalized patients. The objectives of our study were to determine the feasibility of ascending contrast venography and to evaluate the accuracy of these two noninvasive methods for the detection of DVT in symptomatic hospitalized patients. A prospective, "blind" comparison of impedance plethysmography and compression ultrasonography with ascending contrast venography was performed in consecutive hospitalized patients with clinically suspected DVT of the leg. Of the 127 potentially eligible patients, 44 had to be excluded; 25 of these could not undergo venography (feasibility of venography, 80.3%). The sensitivity, specificity, and positive and negative predictive values of impedance plethysmography for proximal DVT were 96%, 83%, 82%, and 97%, respectively. For compression ultrasonography, these measures for proximal DVT were 97%, 86%, 87%, and 97%, respectively. The overall prevalence of DVT was 53%, of which 85% was located proximally. Contrast venography cannot be performed in about 20% of consecutive symptomatic patients. Both impedance plethysmography and compression ultrasonography are feasible and valid alternatives to contrast venography in the diagnostic treatment of these patients.


Reevaluation of eosinophilic pneumonia and its diagnostic criteria.

Eosinophilic pneumonia has been defined as pulmonary infiltration of the lung by eosinophils that may or may not be accompanied by an excess of these cells in the peripheral blood. However, the concept of this disease and its nomenclature have not yet been established. In the present study, the clinical course of 11 cases of eosinophilic pneumonia, which were clinico-pathohistologically diagnosed and found not to be associated with organic disorders producing peripheral blood eosinophilia, were investigated extensively and compared with various types of eosinophilic pneumonia, as previously reported. Of five cases of acute eosinophilic pneumonia with a history (less than 1 month) of symptoms before diagnosis, a short clinical course, and no recurrence, four cases showed peripheral blood eosinophilia, and four cases did not require treatment with steroids. Of six cases of chronic eosinophilic pneumonia with a history (greater than 2 months) of symptoms before diagnosis, a prolonged clinical course, and recurrence, all showed peripheral blood eosinophilia, four cases required treatment with steroids, and four cases were recurrent. In one case with simultaneous occurrence of asthma and another case with asthma that occurred 4 years after the appearance of eosinophilic pneumonia, abnormal shadows on chest roentgenograms had continued for several years. These results suggested that various types of previously reported eosinophilic pneumonia classified by sex, the presence or absence of peripheral blood eosinophilia, the degree of clinical symptoms or peripheral blood eosinophilia, and the degree of abnormalities on the chest roentgenograms should be extensively reevaluated.


[Studies on the mechanism of late asthmatic response by Candida antigen inhalation using bronchoalveolar lavage].

To elucidate the mechanism of late asthmatic response (LAR), which is related to intractable asthma attack, the cellular and humoral components of LAR were examined in bronchoalveolar lavage fluid (BALF) obtained after bronchial inhalation tests with Candida allergen on Candida-sensitive asthma patients. BAL examination was carried out 2 hours after remission of LAR, and differential cell counts and measurements of leukotrienes (LTs) by high performance liquid chromatography were investigated in BALF and peripheral blood. The number of neutrophils and basophils in circulating blood showed a peak before LAR, and then decreased markedly at LAR. And an increase in the percentage of eosinophils (p less than 0.01) and neutrophils was evident in BALF after LAR compared with the level in the non-attack state. The percentage of basophil-mast cells, however, did not change in the same manner. The serum level of LTC4 increased significantly at LAR in comparison with its level in the phase before LAR. And the level of LTC4 was also significantly higher in BALF after LAR (p less than 0.01). However, LTD4 and LTB4 were at almost undetectable levels in BALF in the non-attack state and after LAR. The results indicate that neutrophils as well as eosinophils may accumulate and release several kinds of leukotrienes at local sites in late asthmatic response provoked by the inhalation of Candida antigen; this gives clues as to the mechanism of severe and intractable asthma attacks.


[Studies on the T-cell subset in lung tissue and BALF from patients with interstitial pneumonia].

The cellular components in bronchoalveolar lavage fluids (BALF) have been analyzed to obtain information on cellular kinetics in lung tissues of patients with diffuse pulmonary diseases. While various cells, alveolar macrophages, lymphocytes, and granulocytes appear in BALF, an increase in the percentage of lymphocytes has been noted in a variety of interstitial pneumonia. The T-cell subset of lymphocytes in BALF and biopsied lung tissues was, therefore, examined in patients with hypersensitivity pneumonitis (HP), sarcoidosis (Sar), idiopathic interstitial pneumonia (IIP) and rheumatoid arthritis with interstitial pneumonia (RA+IP) to compare the ratios of CD4/CD8 in BALF and lung tissues. The T-cell subset in BALF was analyzed by flow cytometry and the T-cell subset in lung tissues was detected with fresh frozen and thin-sliced specimens using an avidine-biotin complex (ABC) kit (Vecta Co. Ltd). The mean CD4/CD8 ratio in BALF was 0.36 in HP, 3.1 in Sar, 1.07 in IIP and 2.59 in RA+IP, while the mean CD4/CD8 ratio in lung tissues was 0.52 in HP, 2.59 in Sar, 1.11 in IIP and 2.25 in RA+IP, respectively. The ratios of CD4/CD8 in BALF and lung tissues from patients with these various interstitial pneumonia showed a positive correlation indicating that the changes of cellular components in BALF would reflect the changes in the lung tissues. Furthermore, CD4/CD8 ratios of lymphocytes infiltrating the alveolar portion and granuloma in lung tissues of HP were analyzed separately, because the CD4/CD8 ratios varied considerably from part to part of the lung tissues.(ABSTRACT TRUNCATED AT 250 WORDS)


[Role of thromboxane A2 and prostaglandin I2 in the increase of airway responsiveness in dogs after ozone exposure].

To investigate the role of thromboxane (Tx) A2 and prostaglandin (PG) I2 in the development of airway responsiveness after ozone exposure, we measured the airway responsiveness to inhaled methacholine (Mch), TxB2 and 6-keto-PGF1 alpha levels in bronchoalveolar lavage fluid (BALF) in 18 dogs after ozone exposure. Airway responsiveness to Mch was determined by Astograph (7 Hz oscillation method), and ozone exposure was carried out for 2 hr at an ozone level of 3.01 +/- 0.05 ppm (mean +/- SEM). Airway responsiveness to Mch increased significantly after ozone exposure (p less than 0.001). TxB2 levels in BALF were not affected by ozone exposure, but the levels of 6-keto-PGF1 alpha decreased significantly after ozone exposure (p less than 0.001). The ratio of TxB2/6-keto-PGF1 alpha increased significantly after ozone exposure, and the change in this ratio correlated significantly with the change of airway responsiveness to Mch (p less than 0.01, r = 0.654). These results suggest that airway hyperresponsiveness after ozone exposure is induced by the relative increase of TxA2 due to the decrease of PGI2.


[Platelet activating factor (PAF)-induced late asthmatic response in sensitized but not in non-sensitized guinea pigs].

We have recently demonstrated that pretreatment with WEB 2086, a specific PAF antagonist or cyclosporine A (CsA), a potent helper T cell suppressant, resulted in preventing the development of late asthmatic response (LAR) and increase of airway hyperreactivity (AH) in guinea pig experimental models of asthma. We have now examined whether exogenously applied PAF causes LAR in these models in vivo. The respiratory resistance (Rrs) of guinea pigs was measured by an oscillation technique and histological studies of the bronchi were also made. Guinea pigs, actively sensitized by repeated antigen (ovalbumin; OA) inhalation, showed a leftward shift of the inhaled PAF dose response curve of Rrs compared with that in control animals, indicating that the sensitized animals were more sensitive to inhaled, PAF. PC200 PAF, which indicate provocative concentrations of PAF aerosols causing a 200% increase in the baseline Rrs, were 3800 +/- 604.9 micrograms/ml and 780 +/- 94.3 micrograms/ml, in the control and sensitized animals, respectively. The same magnitude of immediate bronchoconstriction after 780 and 3800 micrograms/ml of PAF exposure was observed in the actively sensitized and non-sensitized control animals, respectively. However, LAR developed 4 out of 6 animals only in the sensitized guinea pigs. We conclude that both exogenously applied PAF by inhalation and antigen exposure are capable of inducing LAR in sensitized guinea pigs, and thus the priming effect of immunization and PAF may contribute to the development of LAR observed in asthma.


[A study of opioid peptides in synovial fluid and synovial tissue in patients with rheumatoid arthritis].

Authors have often experienced that psychological stress influences rheumatoid arthritis (RA). In addition, recent reports show a modulatory role for neuropeptide such as substance P in arthritis. These findings prompted us to study endogenous opioid peptides in RA, which are found mainly in the brain and have an effect on the central nervous system. We examined methionine-enkephalin (Met-enk), leucine-enkephalin (Leu-enk) and beta-endorphin (beta-end) in opioid peptides. We measured these peptides in plasma and synovial fluid samples obtained from 28 knees of 24 RA patients and the quantity in the synovial tissue of 13 knees. We also measured plasma and synovial fluid samples from patients with osteoarthritis of the knee and plasma samples from healthy candidates. Leu-enk and beta-end levels in synovial fluid were significantly higher than plasma levels only in RA. Larger quantity of Leu-end and beta-end were contained apparently in the synovial tissue than Met-enk. The synovial tissue with proliferative change tends to contain larger quantity of opioid peptides. These results indicate that the synovial tissue produces or secretes Leu-enk and beta-end and that opioid peptides are related to the degree of inflammation in RA.


Increased serum levels of soluble interleukin 2 receptor in patients with drug-induced allergic hepatitis.

Soluble interleukin 2 receptor (sIL2R) level in the serum of 10 patients with drug-induced allergic hepatitis (DIAH) were quantified with a solid-phase enzyme immunoassay using two monoclonal antibodies against the receptor. The sIL2R levels in patients with DIAH were significantly higher than in 15 normal subjects (p less than 0.01). The high sIL2R levels observed during the florid stage of DIAH returned to normal during convalescence (p less than 0.05). SIL2R from the serum of DIAH patients was found to bind to a recombinant IL2 affinity column. It seems likely that sIL2R inhibits the hyper-immune reaction that occurs in drug allergies due to bind IL2. But, we have no data that sIL2R inhibits actually the biological activity of IL2.


HDL does not promote cholesterol efflux from macrophages of hypercholesterolemic rabbit: efflux differences between species.

The purpose of this study was to investigate the difference between species (mouse and rabbit) and the effect of hypercholesterolemia on the ability of their peritoneal macrophages to release unesterified cholesterol to an exogenous acceptor. The macrophages from mouse, normocholesterolemic rabbits and hypercholesterolemic rabbits (Mm, Mnr, Mhr) were loaded with cholesterol esters by incubation with oxidatively modified low density lipoprotein or plasma lipoprotein (beta-migrating very low density lipoproteins). When human HDL was used as cholesterol acceptor for 24 h of incubation, the Mm Cells, the Mnr cells and Mhr cells retained about 40%, 70%, and more than 90% of their cholesterol esters. The difference between species of lipoproteins were not effective for the ability to release cholesterol esters. ACAT (acylcoenzyme A: cholesterol acyltransferase) inhibitor 58-035 increased these capacities. These data suggest that the limited capacity of macrophages from hypercholesterolemic rabbits to release cholesterol may be related to the progression and resistance to regression of atherosclerosis, and that ACAT activity might influence this capacity.


Effect of a low calcium intake on the vascular sensitivity to angiotensin II in normotensive pregnant rats.

Vascular responsiveness to angiotensin II in pregnant rats with a normal or a low calcium diet were examined. From day 6 of pregnancy, Wistar rats were separated into two groups. One group was fed a normal diet containing 1.2% calcium (control group) and the other group was fed a low calcium diet containing 0.02% calcium (low Ca group). Using a tail cuff method, the systolic blood pressure in the low Ca group was found to be significantly higher than that in the control group on day 18 of pregnancy. On days 12 and 18 of pregnancy using the hindquarters perfusion technique, the vascular response to bolus angiotensin II (30, 100, 300, and 1000 ng/kg of rat body weight) in the low Ca group increased significantly more than that in the control group. However, the pressor response to norepinephrine and the depressor response to acetylcholine did not differ between the low Ca group and the control group. Urinary sodium excretion in the low Ca group was lower than that in the control group on days 12 and 18 of pregnancy, and decreased toward term, whereas urinary phosphorus excretion in the low Ca group was higher than that in the control group on days 12 and 18 of pregnancy. These data indicate that low calcium intake during pregnancy increases sensitivity to the pressor effects of angiotensin II and increases systolic blood pressure in normotensive pregnant rats.


Peptidergic nerve involvement in the control of endothelium-dependent vascular relaxation.

The ability of Acetylcholine (ACh) and A23187 to induce endothelium-dependent relaxation was compared in the isolated perfused mesenteric arterial bed of untreated adult rats, adult rats treated neonatally with capsaicin, and adult rats treated as adults with capsaicin. Following neonatal capsaicin treatment, the response to both agents was reduced. Following adult treatment, the response to both agents was reduced seven days following capsaicin treatment. The same results were obtained in the presence of L-arginine or indomethacin. Tissues from all rats responded equally to sodium nitroprusside. Following capsaicin treatment no change in the structural relationship of the arterial intima was detected but no perivascular nerve fibres immunoreactive to substance P (SP) or calcitonin gene-related peptide (CGRP) could be demonstrated. It is suggested that the reduced response to ACh and A23187 does not involve a change in endothelial muscarinic receptors or a structural change in the arterial intima, but is directly related to the absence of immunohistochemically demonstrable CGRP/SP-containing perivascular innervation.


Oral heparin prevents hypertension and elevated cytosolic calcium in salt-sensitive rats.

This study examined the effect of oral heparin on systolic blood pressure, platelet cytosolic free calcium, aortic calcium uptake and renal vascular changes in Dahl salt-sensitive (DS) rats on low (0.4% NaCl) and high (8% NaCl) salt diet. Twenty-four male DS rats, age 8 weeks, were divided into four groups of 6 animals each. Groups I and II were on low salt diet and groups III and IV on the high salt diet. Additionally, groups I and III were placed on 100% H2O and groups II and IV on sodium heparin 0.5 mg/ml in H2O as their drinking water for a period of 6 weeks. At 14 weeks, systolic blood pressure, platelet cytosolic free calcium and aortic calcium uptake were significantly higher in rats on high salt diet and water compared with rats from all other groups. Oral heparin treatment prevented the increase in systolic blood pressure, platelet cytosolic free calcium and aortic calcium uptake in rats on high salt diet. Heparin also prevented or attenuated the onset of adverse renal vascular changes observed in Dahl salt-sensitive rats on high salt diet. Oral heparin treatment did not cause abnormal hematological, biochemical or pathological changes in rats.


A large New England kindred with autosomal dominant neurogenic scapuloperoneal amyotrophy with unique features.

We describe a large New England kindred bearing an autosomal dominant syndrome of neurogenic amyotrophy with variable expression. Features include congenital absence of muscles, progressive scapuloperoneal atrophy, laryngeal palsy, and progressive distal weakness and atrophy. The pattern of expression and progression varies in different branches of the family. Males are more severely affected than females. Disease expression is more severe and progressive in succeeding (third and fourth) generations. This striking increase in severity and progressivity in succeeding generations may have genetic implications. The syndrome most resembles the Stark-Kaeser chronic scapuloperoneal amyotrophy, but is considered a distinct entity.


Severity of vascular dementia is related to volume of metabolically impaired tissue.

The relation between dementia severity and regional cerebral metabolic rate of glucose was studied in 28 patients with vascular dementia (VD) in comparison with 20 age-matched patients who were suffering from Alzheimer's disease (AD) and 24 normal subjects by using positron emission tomography with fludeoxyglucose F 18. Similar metabolic impairment was found in the temporoparietal and frontal association cortex in patients with VD and in those with AD. Metabolism of the basal ganglia, thalamus, and cerebellum was reduced significantly in patients with VD only. The total volume of regions with metabolism below the 95% confidence interval of control values was significantly related to the severity of dementia but did not differ between patients with VD and those with AD. A metabolic ratio of regional cerebral glucose metabolism of association areas divided by regional cerebral glucose metabolism of structures that were typically not affected by AD was significantly lower in patients with AD than in those with VD. This ratio was also related to dementia severity in both types of dementia.


Interrelations between migraine and tension-type headache in the general population.

In a cross-sectional epidemiological survey of a general population, headache disorders were diagnosed according to a structured interview and a neurological examination using the criteria of the International Headache Society. The prevalences and sex distribution of the primary headache disorders were assessed, and characteristics of and interrelationships between different types of headache were analyzed. Severity and frequency of migraine attacks were not correlated, indicating that the migraine attack is an all-or-none phenomenon triggered with an individually variable threshold. Tension-type headache, in contrast, showed increasing severity with increasing frequency, indicating that it is a graded phenomenon. In the previous year, 6% had migraine without aura (previously called "common migraine") and 4% had migraine with aura (previously called "classic migraine"); 63% had episodic tension-type headache and 3% chronic tension-type headache. In women, migraine without aura was twice as prevalent as migraine with aura; in men, an opposite trend emerged. In migraine without aura, pain was more severe than in migraine with aura. Tension-type headache in migraineurs was not significantly more prevalent than in nonmigraineurs and, except for greater frequency and severity, it did not deviate nosographically from pure tension-type headache. Our results support the contention that migraine and tension-type headache are distinct entities, contradict the so-called continuum-severity model, and indicate that the terms combination headache, mixed headache, and interval headache should be avoided.


Increased sympathetic and decreased parasympathetic cardiac innervation in patients with Alzheimer's disease.

To assess whether Alzheimer's disease affects the sympathetic and parasympathetic influences on the heart rate, we used power spectrum analysis of heart rate variability derived from simple body-surface electrocardiography. We calculated the energy ratio of low- to high-frequency bands. This ratio was significantly higher in patients with Alzheimer's disease than in normal controls (upright posture, 0.41 +/- 0.21 vs 0.23 +/- 0.08). The parasympathetically mediated baroreceptor activity reflected by the energy ratio of medium- to low- and high-frequency bands was significantly depressed in patients with Alzheimer's disease (upright posture, 0.12 +/- 0.02 vs 0.07 +/- 0.03; supine posture, 0.11 +/- 0.02 vs 0.085 +/- 0.025). Compared with normal volunteer controls, patients with Alzheimer's disease manifested a relatively hypersympathetic, hypoparasympathetic state.


Clinical diagnosis of Alzheimer's disease and other dementias in a population survey. Agreement and causes of disagreement in applying Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, Criteria.

In a population survey aimed to detect cases of Alzheimer's disease and other dementias, two preliminary diagnoses were made independently with the purpose of using the concordant diagnoses as final diagnoses. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, diagnostic criteria were followed. The 668 subjects examined were selected from the population of an area in Stockholm, Sweden, aged 75 years or more, with the Mini-Mental State Examination used as a screening test. The agreement on dementia diagnosis was moderate (kappa = .54) and could be clearly improved (kappa = .70) with modifications to the diagnostic criteria, such as adding a category of questionable dementia and giving more guidelines in the definition of impairment of a function. The agreement on the diagnosis of Alzheimer's disease vs vascular dementia vs secondary dementia was substantial (kappa = .67) when the cases with concordant dementia diagnoses were examined.


An antispasticity effect of threonine in multiple sclerosis.

To determine whether the naturally occurring amino acid threonine, a potential precursor for glycine biosynthesis in the spinal cord, has an effect on spasticity in multiple sclerosis, 26 ambulatory patients were entered into a randomized crossover trial. Threonine administered at a total daily dose of 7.5 g reduced signs of spasticity on clinical examination, although no symptomatic improvement could be detected by the examining physician or the patient. In contrast to the side effects of sedation and increased motor weakness associated with antispasticity drugs commonly used for the treatment of multiple sclerosis, no side effects or toxic effects of threonine were identified. Levels of threonine were elevated in serum and cerebrospinal fluid during treatment, but glycine levels did not change. Enhancement by threonine of glycinergic postsynaptic inhibition of the motor reflex arc in the spinal cord may represent a non-sedating, nontoxic approach to the management of spasticity in multiple sclerosis.


The role of dominant premotor cortex and grapheme to phoneme transformation in reading epilepsy. A neuroanatomic, neurophysiologic, and neuropsychological study.

We studied a 24-year-old man who had reading epilepsy after removal of a left frontal arteriovenous malformation. Lesion analysis by means of a neuroanatomic template placed a 2-cm region of encephalomalacia anterior to the left central sulcus in premotor cortex (Brodmann's area 6). Lexical and nonlexical reading activation tests demonstrated seizures during reading and increased discharge rates when the patient was reading aloud or silently articulating. Seizures (perceived or actual jaw clicking) were electrographically characterized by brief left frontocentral epileptiform transients. Grapheme to phoneme transformation, not linguistic complexity, appears to be the critical stimulus in some reading epilepsies. The case adds anatomic relevance to the phonologic component of reading and supports the putative role of dominant premotor cortex in activation of precise sequences of motor linguistic output in reading and writing. Reading epilepsy may be a reflex or action myoclonus syndrome localized to Brodmann's area 6 (Exner's area).


Absence of Lyme borreliosis among patients with presumed Bell's palsy.

In a prospective study, 69 patients with a presumed idiopathic (Bell's) peripheral facial palsy were clinically and serologically evaluated for the presence of Lyme borreliosis. In addition, their clinical spectrum was compared with clinical manifestations collected retrospectively in nine patients with symptomatic peripheral facial palsy due to Lyme borreliosis. The seroprevalence of Borrelia burgdorferi antibodies, determined by flagellum enzyme-linked immunosorbent assay, among 69 patients with idiopathic peripheral facial palsy (6%) and 153 healthy controls (4.5%) was not significantly different (odds ratio, 1.28; 95% confidence interval, 0.27 to 5.25). None of the patients with idiopathic peripheral facial palsy had or experienced the development of Lyme borreliosis. All patients with Lyme peripheral facial palsy had additional manifestations not present in patients with idiopathic peripheral facial palsy. These findings show that patients with a Lyme peripheral facial palsy can be differentiated from patients with idiopathic peripheral facial palsy by clinical examination. Therefore, screening of antibodies to B burgdorferi among patients with idiopathic peripheral facial palsy without additional manifestations is not recommended.


Evidence for early vulnerability of the medial and inferior aspects of the temporal lobe in an 82-year-old patient with preclinical signs of dementia. Regional and laminar distribution of neurofibrillary tangles and senile plaques.

Detailed neuropathologic studies of neurofibrillary tangle and senile plaque distribution have shown that key elements of certain neocortical and hippocampal circuits are either compromised or lost in Alzheimer's disease. It has been suggested that a global corticocortical disconnection underlies dementia and leads to the dramatic disruption of integrated functions exhibited by patients with Alzheimer's disease. To investigate the distribution of lesions associated with the earliest indications of incipient dementia, we performed a quantitative neuropathologic evaluation of a non-demented 82-year-old patient demonstrating globally intact intellectual function but initial signs of impairment of specific cognitive functions before death. We observed densities of senile plaques comparable to those found in Alzheimer's disease throughout the cerebral cortex, whereas extensive neurofibrillary tangle formation was restricted to selective areas of the temporal lobe. The results of this systematic quantitative and comparative analysis of medial and inferior temporal lobe structures suggest a functional relationship between the degree of cognitive decline evidenced in the earliest stages of Alzheimer's disease and the anatomic progression of Alzheimer's disease-related pathologic changes along specific elements of the cortical circuitry.


Oculomotor, auditory, and vestibular responses in myotonic dystrophy.

In 13 patients with myotonic dystrophy, oculomotor, auditory, and vestibular tests were performed. All 13 patients showed one or more abnormalities. There was a significant increase in the penetrance of the separate abnormalities with age. Saccadic slowing was found in 10 patients, in a severe form in three. Seven patients had a sensorineural high-tone hearing loss (30 to 85 dB at 8 kHz), which was in excess of that expected for their age, that could be attributed to myotonic dystrophy. Brain-stem auditory evoked potentials showed a significant interwave delay of the I-V interval (0.35 to 0.7 milliseconds). An abnormal vestibulo-ocular reflex was found in six patients; three had vestibular hyperreflexia with increased gain, and three had hyporeflexia with short time constants. This study confirms that in myotonic dystrophy, sensory system involvement can be found on both a peripheral and a central level.


Neurocysticercosis and human immunodeficiency virus infection. A possible association.

We present four patients with active neurocysticercosis and human immunodeficiency virus type 1 infection. In three patients, symptoms of neurocysticercosis brought the patient to medical attention and led to the diagnosis of human immunodeficiency virus infection. Neurocysticercosis should be considered in human immunodeficiency virus-infected persons who have been in areas where cysticercosis is endemic.


Progressive amusia and aprosody.

We report a case of slowly progressive amusia and aprosody in association with orofacial and eyelid apraxias. The patient was independent in daily living activities. Insight, judgment, and behavior were intact. Her language was normal, and she demonstrated no limb, dressing, or constructional apraxia. She had no prosopagnosia, no visuospatial disturbances, and no memory impairment. Imaging studies (computed tomography, magnetic resonance imaging, single photon emission computed tomography) indicated a selective disorder of the right frontal and temporal regions. Review of the literature shows an increasing number of reports of this degenerative syndrome affecting the left dominant hemisphere and language areas, whereas cases of the syndrome affecting the right hemisphere are rare. To our knowledge, this is the first case in which aprosody and amusia were associated with a focal cortical degeneration.


Dissociation of color from object in amnesia.

A patient with persistent amnesia after bilateral medial temporal and left inferotemporo-occipital infarction could not match colors to objects in verbal, visual, or visuoverbal tasks. A severe naming disorder for objects was present but the patient could name colors and point to colors whose name was given. The matching disorder appeared to be a deficit in the semantic classification of objects rather than a problem in identifying colors.


Inhibition of human subgingival plaque protease activity by chlorhexidine.

Subgingival plaque samples from three discrete sites in each of eight patients with adult chronic periodontitis were used to determine the ability of 0.001, 0.01, 0.1 and 1.0 mM chlorhexidine to inhibit bacterial proteolytic activity. This activity was measured by monitoring the increase in relative fluorescence (excitation and emission wavelengths of 495 and 525 nm, respectively) accompanying the degradation of fluorescein isothiocyanate (FITC)-labelled bovine serum albumin or FITC-labelled transferrin. Chlorhexidine at concentrations of as low as 0.01 mM inhibited the proteolytic degradation of both substrates by more than 50%. As the growth of dental plaque bacteria is dependent upon the liberation of nutrients (amino acids, peptides and carbohydrates) from host-derived macromolecules, similar effects in vivo might explain the ability of chlorhexidine to inhibit plaque formation at subminimal inhibitory concentrations.


Side asymmetry of the jaw jerk in human craniomandibular dysfunction.

The jaw jerk elicited by tapping the chin with a reflex hammer was electromyographically recorded in 14 patients with craniomandibular dysfunction, who were selected because of their strictly unilateral symptoms. Mandibular deviation, as measured by means of a kinesiograph, was on the same side as the pain. Neurological and neurophysiological investigations, including the recording of masseter motor potentials evoked by transcranial stimulation, showed normal function of the sensory and motor trigeminal nerve fibres. Latency and amplitude of the jaw jerk recorded in postural position and intercuspal occlusion were, respectively, longer and smaller on the affected side. In some cases the latency difference exceeded 1 ms, the limit usually considered significant for trigeminal neuropathy or brainstem lesions. Jaw-jerk asymmetry is probably due to facilitation on the side contralateral to mandibular deviation. In intercuspal occlusion, contralateral facilitation might be produced by a stronger input from muscle spindles and periodontal mechanoreceptors. In postural position, other factors probably intervene.


Development of the rabbit craniomandibular joint in association with tooth eruption.

The adult rabbit craniomandibular joints (CMJs) are stress-bearing joints. The two CMJs and the teeth form an articular triad. In early fetal life the developing triad consists of the CMJ primordia, the tooth germs for the entire set of deciduous teeth, as well as the posterior extensions of the dental lamina, which will give rise to the permanent teeth with no deciduous predecessors. During postnatal life, before occlusion is established, there is a remodelling stage in which the CMJ builds up its matrix components such as collagenous and elastic fibres, proteoglycans and type II collagen. Remodelling gradually diminishes into the maintenance stage once occlusion is fully established and after eruption of the first and second molars. Chondrocytes first appear in the CMJ articular disc during the second week of postnatal development. These cells localize in the band areas of the disc and establish an extensive cartilaginous matrix 3-4 weeks postnatally. This study supports the concept that the full development of a fibrocartilaginous articular disc, rich in proteoglycans, occurs as adult occlusion is established.


Purification and partial characterization of analogous 26-kDa rat submandibular and parotid gland integral membrane phosphoproteins that may have a role in exocytosis.

Rat submandibular and parotid gland exocytosis is primarily controlled by beta-adrenergic receptor stimulation. Although its precise role in the regulation of salivary gland exocytosis is not fully understood, protein phosphorylation, mediated by the activation of cAMP-dependent protein kinase, may be directly involved. Previous studies suggest that analogous 26-kDa integral membrane phosphoproteins may play a direct role in regulating exocytosis. Studies were here undertaken to purify and partially characterize both phosphoproteins. After endogenous phosphorylation with 32P, subcellular fraction and solubilization of the microsomal fraction in n-octyl beta-glucopyranoside, the 26-kDa integral membrane phosphoproteins were purified by high performance liquid chromatography (HPLC), followed by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and electroelution of the proteins. Amino acid analysis indicated a significant number of serine amino acids: N-terminal sequence data demonstrated a high level of homology; and trypsin digestion followed by reversed-phase HPLC indicated the possibility of multiple phosphorylation sites.


Na+ influx mechanisms in submandibular salivary cells of newborn rats.

Uptake of this isotopic tracer was essentially the same as in cells derived from salivary glands of adult animals, both in the absence and in the presence of 1 microM acetylcholine, 10 microM monensin or 10 microM A23187. Tracer accumulation in resting cells was inhibited in the immature cells by 1 mM amiloride but the inhibition was significantly smaller than in fully mature cells (16 and 33%, respectively). Bumetanide inhibited tracer uptake by 28% in mature cells not exposed to agonist, but had essentially no effect in those of newborn rats. The tracer content of adult cells exposed to acetylcholine in Ca(2+)-free incubation solutions was significantly reduced when compared to that of cells exposed to agonist in solutions containing 1.0 mM CaCl2. A similar but significantly smaller reduction in tracer content was observed in cells of newborn animals incubated in the Ca(2+)-free medium. The inhibition of 22Na uptake observed in the presence of amiloride was the same in both types of cells in the presence or absence of external Ca2+. The findings suggest that Na entry into immature salivary cells of newborn rats is quantitatively similar to that in mature cells, but that the contribution of the loop diuretic-sensitive co-transporter and of the amiloride-sensitive Na/H exchange to Na+ entry is less in the immature cells. Na entry in the immature cells is likely to occur, therefore, primarily by other mechanisms such as Ca(2+)-regulated channels.


Masseteric facilitation induced by electrical stimulation of rat orofacial tissues.

The effects of a conditioning electrical shock applied to the periodontium of the lower incisor or the glabrous area of the lower lip on the jaw-closing reflex in the anesthetized, non-paralysed rat were studied. The masseteric reflex was triggered by stimulation of the mesencephalic nucleus as a test shock and was recorded from the masseter muscle. There was facilitation of the jaw-jerk reflex, which culminated at an interval of 10-15 ms between the conditioning and the test shocks. This facilitation was not suppressed by digastric excision or by blocking a possible rebound closing reflex evoked by jaw opening. No inhibitory influence was observed. This facilitatory effects relies on an A alpha input and on cell bodies making up the mesencephalic nucleus. The direct excitatory electrical events observed in the masseter muscle after periodontal or labial stimulation proved to be due to the diffusion of the bioelectrical activity generated in the neighbouring jaw-opening muscles.


Trends in the ophthalmic literature, 1949-1989.

Trends in the ophthalmic literature were analyzed through five decades of the Archives. Original articles from 1949, 1959, 1969, 1979, and 1989 were reviewed. The mean number of authors per article increased steadily from 1.24 in 1949 to 3.50 in 1989. The mean number of institutions per article increased from 1.04 in 1949 to 1.30 in 1989. The mean number of authors with a doctor of philosophy degree increased from 0.03 per article in 1949 to 0.41 in 1989. Financial support increased from 13.5% of manuscripts in 1949 to 62.6% in 1989. These findings emphasize the growing trend in the ophthalmic literature toward multiple authors, multiple institutions, collaboration with basic scientists, and increased reliance on grant support.


Statistical techniques in ophthalmic journals.

Over the years, the use of statistics to evaluate experimental data in ophthalmology has increased. The present study sought to assess the frequency and types of statistical techniques used in ophthalmic journals. We reviewed 974 original articles from the Archives for 1970, 1980, and 1990; the American Journal of Ophthalmology for 1990; and Ophthalmology for 1990. Of the 592 articles reviewed for 1990, 391 (66.0%) contained statistics, with measures of central tendency most commonly used (385 articles [65.0%]), followed by dispersion (298 [50.3%]), t test (120 [20.3%]), and contingency tables (98 [16.6%]). A reader familiar with 10 statistical techniques would have "statistical accessibility" to 526 (88.9%) of 1990 articles. A statistically significant difference was found in the percentage of articles containing statistical methods among the journals (P = .0003; Archives, 75.3%; Ophthalmology, 66.8%; and American Journal of Ophthalmology, 55.2%).


Repeated excimer laser treatment after photorefractive keratectomy.

Scarring or undercorrection occurs in a small percentage of patients after myopic photorefractive keratectomy. Scarring occurred in 1.8% of 298 patients with a baseline myopia of 6.0 diopters or less, increasing to 8.8% in those with corrections of more than 6.0 D. Undercorrection of more than 1 D occurred in 2.7% of the eyes with a baseline myopia of up to -6.0 D. A much greater incidence of undercorrection (30% to 40%) was found after corrections of more than 6.0 D. Thirty eyes in 30 patients were reoperated because of scarring (11 eyes) and/or undercorrection (27 eyes) and were observed for 6 to 18 months (average, 7.8 months). Only one of the eyes has shown mild scar formation after this second laser treatment. Sixty-three percent of these patients had a manifest refraction between -1.0 D and +1.0 D six months after reoperation. Repeated phototablation seems to be a valuable technique for treatment of undercorrection and/or scarring after photorefractive keratectomy.


Ofloxacin vs tobramycin for the treatment of external ocular infection. Ofloxacin Study Group II.

A multicenter, double-masked, randomized clinical investigation was conducted comparing 0.3% ofloxacin and 0.3% tobramycin for topical treatment of external ocular infection. One drop (1.35 micrograms) of either test solution was instilled six times daily for 2 days and thereafter four times daily for the next 8 days. At the day 3 to 5 follow-up examination, the severity of signs and symptoms based on a clinical summary score of 10 key variables was reduced from baseline values significantly (P less than .05) more with ofloxacin (-6.4 +/- 4.37; mean +/- SD) than with tobramycin (-4.78 +/- 3.13); by day 11, the difference between the groups was no longer significant. At days 3 to 5 and day 11 examinations, clinical, microbiologic, and overall improvement rates were similar, with no significant differences seen between the groups. Ofloxacin was found as effective, safe, and comfortable as tobramycin in patients with external ocular infection and may provide earlier symptom relief.


Subconjunctival cysts as a complication of strabismus surgery.

Six patients were operated on for large subconjunctival cysts that developed up to 35 years after strabismus surgery. In four of these patients the cyst was found to arise between the anterior edge of the muscle and the site to which the muscle had been sutured during previous surgery. The muscle was attached to the posterior wall of the cyst and not to the sclera. A pseudotendon was found running between the point on the sclera to which the muscle had been sutured and the undersurface of the muscle far posteriorly. In the other two patients a sudoriferous cyst was found that the referring ophthalmologist had mistakenly thought to represent an abscess when excision was attempted.


Comparison of the double-plate Molteno drainage implant with the Schocket procedure.

A randomized, prospective study was undertaken to compare the results of the double-plate Molteno implant with those of the anterior chamber tube shunt to encircling band (ACTSEB) procedure, described by Schocket, for eyes with complicated glaucoma. One surgeon performed all the procedures. For statistical analysis there were 21 eyes in the ACTSEB group and 19 eyes in the Molteno group, with at least 6 months of follow-up (mean follow-up, 26 months; range, 6 to 49 months). Eyes with aphakia/pseudophakia, uveitis, previous penetrating keratoplasty, previous unsuccessful trabeculectomy, and neovascular glaucoma were evenly distributed between the two groups. Mean preoperative intraocular pressures in the ACTSEB and Molteno groups were 35.2 and 34.6 mm Hg, respectively. With the exclusion of one phthisical eye in each group final mean intraocular pressure in the ACTSEB group was 15.1 mm Hg, with a mean of 0.43 medications, and 14.4 mm Hg, with a mean of 0.95 medications, in the Molteno group. Seven (33%) of 21 eyes and 13 (68%) of 19 eyes in the ACTSEB and Molteno groups, respectively, were receiving additional antiglaucoma medication at the most recent visit (P = .027). Final visual acuity was stable (within one Snellen line of baseline visual acuity) or improved in 10 (48%) of 21 eyes in the ACTSEB group compared with 13 (68%) of 19 eyes in the Molteno group. Complications or inadequate pressure control requiring further surgical intervention were seen in nine (47%) of 19 eyes in the Molteno group and 12 (57%) of 21 eyes in the ACTSEB group.(ABSTRACT TRUNCATED AT 250 WORDS)


Diffuse unilateral subacute neuroretinitis in South America.

We describe two cases of diffuse unilateral subacute neuroretinitis in South America. These Brazilian patients presented with subretinal worms similar in size to those described in the southeastern United States. This is the first report, to our knowledge, of diffuse unilateral subacute neuroretinitis occurring outside the United States and Caribbean Islands.


Observations on patients with idiopathic macular holes and cysts.

We reexamined 96 patients with macular holes or cysts. The mean follow-up period was 4.7 years. Of 19 eyes with macular cysts, only two (10.5%) showed progression to a macular hole. In 15 (79%) of those 19 eyes, the cyst disappeared. Of 80 patients with a macular hole or cyst in one eye and a normal fellow eye, a hole developed in the fellow eye in only one patient (1.2%) and a cyst developed in the fellow eye in only two patients (2.5%). Of 66 eyes with a stage 3 full-thickness macular hole, three eyes (5%) showed resolution without any sign of a hole. Our results suggest a favorable prognosis for normal fellow eyes of patients with macular holes or cysts and for eyes with cysts. Eyes with full-thickness macular holes have a less favorable prognosis, although their natural history may not be as poor as previously thought.


A long-term follow-up of metallic intraocular foreign bodies, employing diagnostic x-ray spectrometry.

We describe 10 eyes harboring metallic intraocular foreign bodies (IOFBs) for 9 to 46 years that had undergone diagnostic x-ray spectrometry to measure metal dissolution 9 years before this study. Findings from the present clinical and laboratory examinations, including perimetry, electroretinography, electrooculography, and diagnostic x-ray spectrometry examinations are reported. Deterioration in visual acuity consequent to metal dissolution of the IOFB was found in only one eye. Visual fields and electrophysiologic performances deteriorated in two other eyes for reasons that were probably unrelated to IOFB dissolution. Visual functions remained stable during the follow-up period in seven eyes, although excess copper levels were demonstrated in one of them. Eight of 10 eyes retained visual acuity of 6/24 or better. Diagnostic x-ray spectrometry confirmed siderosis in one patient and ruled out metallosis in the two patients with deteriorated vision for reasons that were unrelated to metallosis. The favorable outcome of this series of patients may influence one to consider a more conservative approach in the decision to remove IOFBs. A careful, life-long follow-up might be considered with periodic electroretinographic and diagnostic x-ray spectrometry examinations; the IOFB should be promptly removed if and when metallosis with damage to visual functions is demonstrated.


'Black cornea' after long-term epinephrine use.

Fifteen years after a partial maxillectomy and radiation therapy for left antral carcinoma, a 53-year-old woman presented to the Eye Plastics and Orbit Service of the Massachusetts Eye and Ear Infirmary, Boston, with phthisis and a large, black corneal lesion in the left eye. She had been treated for unilateral glaucoma in the left eye for more than 10 years with topically administered epinephrine borate, timolol maleate, and pilocarpine hydrochloride. Clinically, the lesion was smooth, black, and homogeneous, and was thought to represent uveal prolapse covered by a thin layer of epithelium. An eyelid-sparing anterior exenteration was performed. Histopathologic examination revealed an acellular, homogeneous substance that stained positively with the Fontana Masson stain for melanin and bleached with potassium permanganate, findings consistent with corneal adrenochrome deposition. Since adrenochrome can be easily dissected free from the cornea, this case illustrates that misdiagnosing adrenochrome deposition may lead to unnecessary surgery.


Progressive enlargement of a circumscribed choroidal hemangioma. A clinicopathologic correlation.

A man with a circumscribed choroidal hemangioma was followed up for almost 10 years as the tumor showed gradual, progressive enlargement in both diameter and thickness. In spite of photocoagulation therapy, a total retinal detachment and blindness ensued. Enucleation was performed because the possibility of amelanotic choroidal melanoma could not be absolutely excluded. Although the tumor thickness measured by ultrasonography before enucleation was 4.5 mm, the lesion measured only 2.0 mm in thickness in the pathology laboratory. Circumscribed choroidal hemangioma rarely demonstrates clinical evidence of growth. It appears that the tumor enlargement noted in this case was due to venous congestion in the tumor and not to cell multiplication.


Assessment of visual acuity via a telephone interview.

We compared the visual acuity of 89 patients obtained via a telephone interview with visual acuity elicited from the same patients in an ophthalmologist's office. Agreement within one line of vision between the telephone interview, in which patients used a modified Rosenbaum near card with attached patch, and the clinic near vision test was observed in 91% of eyes, while agreement within one line of vision between the telephone interview and clinic distance vision test was found in 86% of eyes. We conclude that testing visual acuity via a telephone interview is a potentially useful approach to assessment of visual acuity and prevalence of visual impairment in the larger population.


Corneal wound healing in monkeys after repeated excimer laser photorefractive keratectomy.

Five rhesus monkey eyes underwent repeated argon fluoride (193 nm) excimer laser myopic photorefractive keratectomy 3 months following an initial ablation that had produced mild subepithelial haze. At 3 months all eyes had development of a dense subepithelial opacity and a thickened epithelium (12 cells, 80 microns) with vacuolization of basal cells, fragmented basement membrane, and a layer of subepithelial fibrosis containing activated fibroblasts. By 6 months the opacity was clearing; epithelium was thinner (50 microns); subepithelial fibrosis was more lamellar. By 15 months only mild haze persisted clinically; epithelium was 30 microns thick, with persistent basal vacuolization and focal basement membrane disruption; subepithelial fibrous tissue was more organized. Early repeated excimer laser ablation of the monkey cornea apparently induces vigorous stromal wound healing. Use of shallower ablations, corticosteroids, or a longer delay between ablations may be necessary for repeated laser surgery to be practical clinically.


Interleukin 6 facilitates corneal epithelial wound closure in vivo.

Rapid corneal epithelial wound healing is essential to the maintenance of clear visual acuity. The cytokine interleukin 6 is thought to participate in the wound-healing process. We investigated the effect of interleukin 6 eye drops on the rate of corneal epithelial wound closure in rabbits in vivo. Recombinant human interleukin 6 in phosphate-buffered saline at concentrations of 0.1, 0.3, or 1 mg/L was administered immediately after the epithelium was débrided with the n-heptyl alcohol treatment and 2, 4, 6, 8, 10, 18, 20, 22, 24, 26, and 28 hours after débridement. The eyes were stained with fluorescein and photographed at baseline and at 7, 10, 18, 21, 24, 27, 30, and 43 hours after débridement. The rate of wound healing was calculated with a linear regression analysis based on the areas of the epithelial defects, which were recorded from hour 10 to hour 30. The mean (+/- SD) healing rate in the control group, which received phosphate-buffered saline alone, was 1.03 +/- 0.15 mm2/h. The administration of interleukin 6 at concentrations of 0.1, 0.3, or 1.0 mg/L increased the healing rate significantly (P less than .001) to 1.27, 1.39, or 1.44 mm2/h, respectively. Our results indicate that the administration of interleukin 6 might have clinical applications in the treatment of persistent corneal epithelial defects.