Phrenic nerve and diaphragm function following open heart surgery: a prospective study with and without topical hypothermia. In a prospective study, 100 patients undergoing open heart surgery were randomly allocated to receive ice/slush topical hypothermia for myocardial protection (Group I, n = 56) or not (Group II, n = 44). Chest radiographs, diaphragm screening, lung function and phrenic nerve conduction time were assessed pre-operatively and at 1 week and 1 month post-operatively in all patients and subsequently at 3 months, 6 months, 1 year and 2 years in all patients with radiological evidence of diaphragm paralysis. The two groups were similar in terms of age, sex, diabetes and smoking habits. Cardiopulmonary bypass and aortic cross-clamp times were similar in the two groups. Radiological evidence of partial left lower lobe collapse was more frequent in Group I (79 per cent vs. 36 per cent, p < 0.01). Twenty (36 per cent) Group I patients developed unilateral diaphragm paralysis (19 left-sided) compared with none in Group II. Diaphragm paralysis was still present in 19 patients (34 per cent) at 1 month, in five patients (9 per cent) at 1 year and in one patient (2 per cent) at 2 years post-operatively. Phrenic nerve conduction time was recorded in 98 per cent of patients pre-operatively, but was unrecordable on the appropriate side in all 20 patients with diaphragm paralysis 1 week post-operatively. Prolonged phrenic nerve conduction time on the left side was found in a further seven Group I patients 1 week post-operatively. There were no significant differences between the two groups in terms of post-operative arrhythmias, myocardial infarction or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)


Renal replacement for diabetic patients: experience at King's College Hospital 1980-1989. Renal failure is an important cause of morbidity and mortality in diabetic patients, who account for up to 25 per cent of new patients entering renal replacement therapy. Between 1980 and 1989, 651 patients with renal failure were treated at King's College Hospital, of whom 177 (27 per cent) had diabetes. Of these 177 patients 148 had diabetic nephropathy (65 non-insulin-dependent), while the rest had other renal diseases. Of the non-insulin-dependent diabetics, 45 per cent (29 of 65) were Asian or Afro-Caribbean compared to only 12 per cent (10/83) of the insulin-dependent diabetics. Ninety-two patients (62 per cent) have received a renal transplant with actuarial patient survival of 82 per cent at 1 year and 61 per cent at 4 years. Both patient and graft survival have been improved by the introduction of cyclosporin A. Continuous ambulatory peritoneal dialysis is the main form of dialysis and has allowed increasing numbers of patients to be dialysed, especially older individuals with non-insulin-dependent diabetes. Rehabilitation is best in those with functioning transplants: 21 patients (19 with functioning grafts) have survived for longer than 5 years. Diabetic complications before and after renal replacement therapy are described. Cardiovascular disease is especially common and may limit the success of renal replacement therapy.


Bronchiectasis in HIV disease.

Bronchiectasis in HIV disease. An increased frequency of bacterial pneumonia occurs in HIV-infected individuals: however the development of bronchiectasis is not well recognized. We describe seven patients with HIV infection who developed chronic symptomatic lung disease, six with troublesome recurrent infective exacerbations. Bronchiectasis was demonstrated by computed tomography in five patients, and bronchial wall thickening was shown in a further two patients. The characteristics of the patients are described, and possible aetiological factors are discussed. As measures become available which prolong the later stages of HIV disease, bronchiectasis may become an increasing problem in this patient population. Early recognition and appropriate management may significantly alter morbidity in advanced HIV disease.


Use of prednisolone in the treatment of HIV-positive tuberculosis patients. Corticosteroids are beneficial in the treatment of some forms of tuberculosis, but their role in TB affecting HIV-positive patients is not clear. During a cohort study of tuberculosis patients in Lusaka, Zambia, prednisolone was prescribed for specific indications. Six of 47 (13 per cent) of patients who received prednisolone early in treatment developed herpes zoster, compared with 2 of 118 (2 per cent) of those who did not. Three patients who received prednisolone developed Kaposi's sarcoma, compared with none who did not. At 2 months patients who had received prednisolone showed a greater improvement in generalized lymphadenopathy and cough. Controlled studies of the risks and benefits of administration of corticosteroids to HIV-positive TB patients are urgently needed.


Coronary heart disease risk factors in relation to the menopause. The incidence of coronary heart disease increases after the menopause, but the mechanism is unclear. We assessed the relationship of age to fasting plasma insulin, total triglycerides, total cholesterol, total high density lipoprotein (HDL) cholesterol, including HDL2 and HDL3 subfractions, total/HDL cholesterol ratio, body mass index and waist-hip circumference ratio in 394 women and 824 men aged 40-69 years who participated in an epidemiological survey in East Bristol. Women over the age of 50 years were assumed to be post-menopausal, this being the median age of the menopause in Britain. Compared to younger women, post-menopausal women had higher plasma triglycerides by 0.31 mmol/l (95 per cent confidence interval 0.10-0.43), higher cholesterol by 1.0 mmol/l (0.77-1.24), higher total/HDL cholesterol ratio by 0.42 (0.15-0.69), higher insulin by 2.0 mU/l (0.02-0.11), higher body mass index by 0.9 kg/m2 (0.02-1.68), and higher waist-hip ratio by 0.02 (0.01-0.03). Age-related changes in men were absent or less marked. On multiple regression analysis the increases in plasma total triglycerides, total cholesterol, high density lipoprotein cholesterol, HDL3 cholesterol and total/HDL cholesterol ratio in postmenopausal women were independent of body mass index, waist-hip ratio, cigarette habits, alcohol consumption and antihypertensive therapy. On analysis of covariance sex had a significant effect on all variables which was independent of age. We conclude that there is an increase in coronary heart disease risk factors in women as they pass through the menopause, and insulin may play a central role.


Listeria monocytogenes meningitis in previously healthy adults: long-term follow-up. A few cases of Listeria meningitis in healthy individuals have been recorded in the world literature. The lack of a prolonged follow-up in most of these cases makes it difficult to exclude the existence of an underlying disease. The clinical and CSF data of four previously healthy patients with meningitis due to Listeria monocytogenes are presented. These patients were followed prospectively over 2-6 years; during this time none developed any disease associated with immunosuppression, including HIV infection, and none died. Listeria meningitis in an otherwise healthy person is, therefore, not always a sign of underlying immunosuppressive disease, and does not necessarily have a poor prognosis.


Percutaneous transluminal renal angioplasty in patients with renal failure. Renovascular disease is a common cause of end-stage renal failure in the elderly population. We assessed the role of percutaneous transluminal renal angioplasty in the treatment of patients with renal failure due to renovascular disease by analysing our results in 60 patients treated between 1982 and 1991. All the patients had a baseline serum creatinine level greater than 150 mumol/l; improvement in renal function was defined as a 20 per cent reduction in this level. Seventy-five angioplasty procedures were attempted on 70 arteries in 60 patients. There was an improvement in renal function in 24 patients (40 per cent), whilst six (10 per cent) showed deterioration. The most dramatic improvement was seen in a small group of patients who had suffered an acute deterioration in renal function prior to angioplasty. There was a low incidence of serious complications. Renovascular disease is an important reversible cause of chronic renal failure and should be investigated aggressively so that percutaneous transluminal renal angioplasty can be undertaken in selected patients.


No effect of blood transfusion on muscle metabolism. 31Phosphorus magnetic resonance spectroscopy allows examination of skeletal muscle bioenergetics in vivo. The forearm muscle of four male patients receiving regular blood transfusions for myelodysplastic anaemia showed increased acidification and phosphocreatine depletion during exercise (compared to six age-matched male controls). Transfusion produced no significant improvement in these measurements or in the estimated maximum oxidative capacity of the muscle. We conclude that transfusion of patients with chronic anaemia (haemoglobin of 8-9 g/dl) does not improve skeletal muscle oxidative metabolism.


The potential impact of patient self-referral on mortality in acute myocardial infarction. Audit is now an important component of the provision of acute cardiology services. In particular, the desire to administer thrombolytic treatment early in acute myocardial infarction has led to a reappraisal of admission procedures. Using records collected prospectively onto a computerized coronary care database for 36 months to December 1991, median delay before arrival at the emergency department and delay between admission and thrombolytic treatment was calculated. Of 1993 consecutive admissions to the coronary care unit, 816 patients had an initial diagnosis of myocardial infarction (later confirmed in 89.6 per cent), and 608 (74.5 per cent) of these received thrombolytic treatment. Overall median delay before arrival at hospital was 147 min. Randomization during the ISIS-3 trial significantly prolonged delays after arrival at hospital (64 vs. 50 min; p < 0.007). General practitioner referral delayed arrival at the emergency department (175 vs. 100 min self-referred; p < 0.0001) and was associated with similar hospital delay (54 vs. 55 min self-referred). Older patients ( > 65 years) presented later in the self-referred group (120 vs. 99 min for age < 65 years; p < 0.04), but there was no difference in the GP-referred group. Previous ischaemic heart disease did not predict type of referral. If delays before thrombolytic treatment are to be reduced significantly patients should be encouraged to seek early medical assistance by telephoning for an ambulance. Delays for patients arriving at the hospital following referral by a GP should be reduced by facilities for direct admission to the cardiologist.(ABSTRACT TRUNCATED AT 250 WORDS)


Attentional modulation of size contrast. A test circle surrounded by smaller context circles appears larger if presented in isolation, whereas a test circle surrounded by large context circles is seen as smaller than in isolation. Two experiments are reported indicating that this phenomenon, the Ebbinghaus illusion, depends on whether subjects are attending to the context circles. Subjects first saw a reference circle and then a briefly presented (150 msec) test circle. Their task was to determine whether the test circle was larger or smaller than the reference. The test circle was surrounded by smaller context circles of one colour arrayed along a horizontal axis centred on the test, and larger context circles of a different colour arrayed along a vertical axis centred on the test. Subjects judged both the size of the test and the colours of either the small or large context circles. Perceived test size changed systematically, depending on which context circles were task-relevant.


Automatic activation of word phonology from print in deep dyslexia. The performance of deep dyslexics in oral reading and other tasks suggests that they are poor at activating the phonology of words and non-words from printed stimuli. As the tasks ordinarily used to test deep dyslexics require controlled processing, it is possible that the phonology of printed words can be better activated on an automatic basis. This study investigated this possibility by testing a deep dyslexic patient on a lexical decision task with pairs of stimuli presented simultaneously. In Experiment 1, which used content words as stimuli, the deep dyslexic, like normal subjects, showed faster reaction times on trials with rhyming, similarly spelled stimuli (e.g. bribe-tribe) than on control trials (consisting of non-rhyming, dissimilarly spelled words), but slower reaction times on trials with non-rhyming, similarly spelled stimuli (e.g. couch-touch). When the experiment was repeated using function words as stimuli, the patient no longer showed a phonological effect. Therefore, the phonological activation of printed content words by deep dyslexics may be better than would be expected on the basis of their oral reading performance.


Relative effectiveness of central, peripheral, and abrupt-onset cues in visual attention. The relative effectiveness of central arrow, peripheral arrow, and abrupt-onset cues was assessed in a character recognition task. On each trial, either a central or a peripheral arrow cue was presented 0, 100, or 200 msec before the appearance of a three-digit display. Two of the digits were "uncamouflaged" from previous figure-eight masks, whereas the third digit appeared abruptly in a previously empty space. Four different groups of subjects were run in factorial combinations of high or low expected validities for arrow and onset cues. In Experiment 1, arrow cues were located centrally, near the fixation point. Abrupt onsets showed larger cost-plus benefits than central arrows, except when subjects expected the central cues to have higher validity than the onsets. In Experiment 2, arrow cues were located peripherally, near the display digits, and abrupt onsets were again more effective in capturing attention except when peripheral cues had higher validity and led the onsets by 100 msec or more. In both experiments, the relative effectiveness of abrupt onsets decreased with arrow SOA. The results were consistent with a model in which automatic and voluntary processes interact in their control of attentional resources.


Scrutinization, spatial attention, and the spatial programming of saccadic eye movements. Results are presented from an experiment in which subjects' eye movements were recorded while they carried out two visual tasks with similar material. One task was chosen to require close visual scrutiny; the second was less visually demanding. The oculomotor behaviour in the two tasks differed in three ways. (1) When scrutinizing, there was a reduction in the area of visual space over which stimulation influences saccadic eye movements. (2) When moving their eyes to targets requiring scrutiny, subjects were more likely to make a corrective saccade. (3) The duration of fixations on targets requiring scrutiny was increased. The results are discussed in relation to current theories of visual attention and the control of saccadic eye movements.


Cognitive strategies and short-term memory for movement distance and location. A number of researchers (e.g. Kerr, 1978; Walsh, Russell, Imanaka, & James, 1979) have previously demonstrated interference between location and distance information in motor short-term memory. This interference manifests itself in a characteristic pattern of undershooting and overshooting, with reproduction movement location being drawn in the direction of criterion movement distance and, conversely, the distance of reproduction movements being influenced by the terminal location of the criterion movement. We investigated the effects of different cognitive strategies upon the appearance of this location-distance interference during the reproduction of movement location (Experiment 1) and distance (Experiments 2 and 3) in a linear arm positioning task. Experiment 1 compared performance in location reproduction between two strategy groups differing in the availability of explicit information about the change in starting position. The characteristic undershooting-overshooting interference pattern was observed for the group without the explicit information about the change in starting position but disappeared for the group in which explicit information about the change in starting position was provided. Experiment 2 examined the systematic undershooting-overshooting pattern in distance reproduction for a location strategy (involving some extrapolation of the start and end locations), a counting strategy, and a distance sense strategy (involving the use of visual imagery). The systematic response bias pattern disappeared when the subjects used a location strategy but was clearly observed for the subjects using the other two strategies. This finding was generally confirmed by Experiment 3, which showed a typical undershooting-overshooting pattern in distance reproduction for a counting/distance sense strategy but not for two location strategies (a general location and an explicit location strategy). The location strategies differed in the availability of explicit information about starting and end locations for both the criterion and reproduction movements. The results from these three experiments indicate that explicit information about the start and/or end locations prevents the usual interference between location and distance information from arising in movement reproduction. The notions of automatic and controlled processing and cerebral hemispheric specialization are discussed as potential explanations of these results and of the interference typically observed in motor short-term memory between distance and location information.


[Dermatophagoides: its role in infantile asthma]. The role and allergenic importance of dermatophagoides pteronyssinus in house and other environments is reviewed. This mite provokes asthma in children at an earlier age than pollens.


[Prevention of atopic diseases: recent findings and personal data]. Prevention of IgE-mediated diseases relies on the skill necessary to overcome the natural forces unceasingly working to sensitize humans to produce IgE antibodies. The phenotypic expression of allergic disease ensues from an elaborate inter-relationship between the atopy-prone genetic constitution of a child and the experienced environment surrounding it. Prevention of atopy could potentially by met by selectively interfering with the genetic and environmental factors that appear to be responsible in concert for the final phenotypic expression of atopy. As no ideal cow's milk substitute exists, and all the suggested formulas could cause allergy, the currently available foods for children are soy milk, hydrolyzed protein, and home-made meat-based formulas. From a nutritional point of view, soy milk formulas are adequate, however in IgE mediated forms and atopic dermatitis reactions to hydrolyzed protein are more common. Although no long-term studies on the nutritional value of hydrolyzed protein are available, some formulae have shown a satisfactory growth rate in short term clinical trials. Meat-based formulas, such as the home-made lamb formula are well accepted and economical.


[Conservative treatment of splenic trauma]. Authors present a series of 19 patients accepted for a splenic trauma. Four cases underwent TNO and 15 splenectomy, associated in 9 of them to autotransplant in omental pouch. Authors stress the importance of the conservative management of spleen injuries, to preserve its hematologic and immunologic functions.


[Perforated diverticulitis of the sigmoid. Our experience]. The authors report their experience on sigma acute perforated diverticulitis. They affirm that best results are obtained with a surgical treatment "case for case" depending to anatomopathologic pattern, patient age and his general conditions.


[Laser applications in ambulatory care. Review of the literature]. The authors present different kinds of laser used in the treatment of several surgical affections in out patients. A review of the international literature and main uses of this technique are shown.


[Congenital ptosis or blepharoptosis of the superior palpebrae: surgical correction by transplant of the fascia lata]. Description of a modified surgical technique for blepharoptosis correction. The homogeneous opening of eye is obtained by a fascia lata transplant with an upside-down "y" shape that joins the tarsus with the levator palpebrae superioris muscle.


[Variations of plasma renin in hemodialysis]. We evaluated the variations of serum renin concentrations during hemodialysis in 17 patients (5 hypertensive and 12 normotensive). In addition we have studied the relationships between serum renin levels, right heart atrium diameters, arterial pressure, and body weight. At the end of the hemodialytic process we observed in both groups of patients an increase in the serum renin concentrations, as well as changes in the above parameters.


[Hemospermia: cause, clinical significance and our experience]. The hemospermia is first of inflammatory origin, in the young, where it is due to urethro-prostatitis or orchio-epididymitis, in the old, to benign or malignant prostatic tumours. In 30-70% of the cases it is idiopathic. It can be connected with a prolonged sexual abstinence or with intense sexual activity. Predisposing diseases are prostatitis, epididymitis, urinary stones, gonorrhea, syphilis, tuberculosis, cirrhosis of the liver, blood hypertension, haematologic diseases. Our casistics, 60 patients in 4 years (1987-1990), has showed the hemospermia as isolated episode in 20% of the cases, in 35% associated with urologic symptoms. Juvenile forms, connected with urethro-prostatitis, are often associated with the echographic presence of periurethral calcifications or to a swelling of the seminal vesicles. In 8 patients, the hemospermia was recurrent, and due to a prostatic tumour. In 2 patients, with recurrent hemospermia, a urogenital tuberculosis has been detected.


[The importance of tumor markers in adenocarcinoma of the prostate]. The discovery of the new markers for the diagnosis and therapy of the carcinoma of the prostate, the prostatic acid phosphatase (PAP) and the prostatic specific antigen (PSA), and their correlation has opened new horizons in the field of the neoplastic prostatic pathology. The PAP fails have a rule in the diagnosis of a prostatic tumour in the initial phase, and therefore as a test of screening. It increases considerably only in the bone metastases. The PSA is highly specific, and together with the PAP is very useful in the check of the patients in treatment and in the surveillance of the appearance of metastases. We have considered over a period of 10 months, 70 patients with prostatic pathology. 22 were affected with carcinoma of the prostate. 48 were affected with benign prostatic hyperplasia. In both groups the simultaneous dosage of the PAP and PSA has been carried out with the RIA method. In the patients with BPH the simultaneous dosage of the 2 markers was elevated only in two cases. On the contrary, in the patients with carcinoma of the prostate we have noticed univocal data of increasing of both the markers. In the patients with metastases, the 2 markers behave in a very similar way, and progressively increase with the progressively increase with the evolution of the clinical stage of the tumour. The control after 3 months of treatment with analogues of the LH-RH and flutamide has showed a reduction of the serum levels of the 2 markers varying between 65 and 85% and over.


[Continued progress in the legal aspects of integrating handicapped patients--recommendations of the Federal Council on Rehabilitation to SGB IX]. In January 1991, the Government coalition parties agreed that the existing rehabilitation and severely disabled persons legislation should be rearranged in a distinct manner and integrated in the German Social Code as Book IX--Integration of disabled persons. This forthcoming codification moreover is intended as an opportunity for introducing appropriate adjustments and amendments, as well as for considering the possibilities for limited material reform. The Federal Rehabilitation Council has submitted a number of proposals to the Federal government aimed at settling various intersectoral aspects of rehabilitation legislation in the forthcoming Book IX.


[Immunohistochemical profile of the nasal mucosa during the acute phase of cluster headache]. We studied 20 patients with cluster headache (11 males, 9 females) and 10 subjects free from this disorder. Nasal cavities were endoscopically studied to evaluate the mucociliary transport, pH, IgG, IgA and IgM levels in nasal secretion and in serum, and Na, K and Cl serum levels. We observed in all patients in the study group in comparison with the control group an increase of pH, and of serum IgA and IgM levels (but not of IgG). Na, K, and Cl serum levels in the patients with cluster headache were lower than those in the control subjects.


[Early neurologic rehabilitation--an urgent requirement]. The majority of patients with severe craniocerebral damage can be enabled to return to a relatively independent life if early rehabilitation measures are provided. The number of beds currently available for early rehabilitation, however, covers little more than 10 percent of the demand at hand. Expanding the number of beds available hence is a pressing need. The present article contains pertinent information in view of qualitative and quantitative implementation of related efforts.


[Left ventricular thrombosis in acute myocardial infarction: incidence, complications, and clinical effects of calcium heparin]. It is known that the myocardial infarction may be associated with left intraventricular thrombosis (LIT) as the anatomopathologic studies and the heart surgery operations confirmed. The authors verified in this study the incidence and the complications of de LIT in the patients with acute myocardial infarction treated with low-dose heparin.


[Anesthesiologic experience with propofol in tumor pathology]. The author reports her experiences about the Propophol use in the tumor's pathology. This drug is used instead of traditional anesthetics in comparison with immunodepression in such pathologies and because of his lower toxicity.


[Decompressive craniotomy and its effect on recovery and rehabilitation of the patient]. The rehabilitation of patients who have to be operated on because of severe craniocerebral trauma and in whom the roof of the cranium must be removed because of severe post-traumatic cerebral oedema, is extremely difficult. The slow rehabilitation and recovery of these patients, who also show psychological changes in most cases, must be attributed to the pathological intracranial conditions which have arisen in consequence of large defects in cranial bones. A causal correlation between severe pathological intracranial conditions, which have arisen not only from trauma but also from bone flap decompressions, and protracted postoperative recovery and difficult rehabilitation has only recently been established. Our experience has shown that rapid rehabilitation of the injured person can only be expected after skullcap reconstruction and normalization of intracranial conditions.


[Traumatic paraplegia with injury of the upper extremity--effects on the success of rehabilitation]. The evaluation of a greater number of patients with traumatic paraplegia and tetraplegia showed more than 20% of associated injuries of the upper limbs. In view of the fact that arms and shoulders of the paraplegic person take over a decisive weight-bearing function, we were interested in the effects of these special injuries on rehabilitation outcome. Injuries of the distal arm were found to have more serious repercussions for achievement of the rehabilitation aim than the relatively more impressing injuries of the shoulder girdle and the upper arm. Serious limitations were found in the range of motion of the affected joints. Compensation was due only to the skill of the paraplegics in dealing with these deficits in motion and in using the uninjured extremity. This is the main reason why the functional deficits in independence were relatively minor.


[Occupational stress and decreased performance of psychiatric patients]. After a short summary of the state of research on problems of work performance and job strains of psychiatric patients, a pilot study in job and task analysis is presented which examines job strains and impairment of work performance of psychiatric patients in various vocational rehabilitation facilities, based on the interactive theory of subjective job analysis. Together with semi-structured interviews and self-developed rating scales for measuring impairment of work performance, standardized questionnaires in job analysis (SAA, Martin et al. 1980; ABB, Neuberger & Allerbeck 1978) are used. On comparison of the patients in the various rehabilitation facilities, differences in work performance and appraisal of job strains and work conditions were found. By discriminant analysis two types of facilities could be differentiated especially by features like work performance and prehospital vocational integration. The results of multiple regression analysis show that the impairment of work performance is influenced in particular by previous vocational integration and by the patients' appraisal of future vocational perspective. The results are discussed in comparison with other research studies in psychiatric rehabilitation. Further studies are suggested, inter alia, to record the present psychiatric state in a systematic manner and to include long-term criteria for success in vocational rehabilitation.


[PASS: a community, system-related program for occupational rehabilitation of chronic psychiatric patients in competitive employment]. Notwithstanding considerable success, the concepts currently applied by vocational rehabilitation workshops for persons with chronic mental illness are deemed open to criticism in some respects. Presented is the PASS programme, developed on the basis of more than two decades of experience with the clinic's own rehabilitation workshop. The greater part of the five-phase programme no longer occurs within the workshop but is spent at training workplaces with regional firms. A mobile rehabilitation team does not only support the patients at their training facilities but also their colleagues and immediate superiors, who have been prepared for their forthcoming tasks by psychoeducational information meetings. These community-based, ecological system-related aspects of the programme are complemented by repetitive social skills training and group work with relatives. Assessments carried out in each phase provide important decision-making data for programme development and render its scientific evaluation possible. Our experience so far demonstrates the possibility of recruiting enterprises to provide training places.


[Surgery of epithelioma in the outer canthus]. We review the tumors localized in the orbito-palpebral region. Their prevalence varies between 2.5 and 16.8%. Skin epitheliomas are more frequently seen. We discuss the surgical techniques for the repair and reconstruction of the orbital region.


[Effect of combination treatment by concentration and relaxation training after subarachnoid hemorrhage (single case analysis)]. Using an ABAB single case design, the effects of a combination therapy (phase A) of computer-assisted attention retraining and Progressive Relaxation (PR) are examined in comparison to those of condition B in which short breaks are used instead of PR. The patient was a 57 year-old man with specific attention deficits following spontaneous subarachnoid haemorrhage (without operation). In both conditions, A and B, the patient ran through three therapy sessions of 45 minutes duration in the course of three days, with 6 minutes of attention retraining alternating with 6 minutes of PR or break, respectively. The results revealed that a) in comparison to the baseline (attention retraining without PR or break), both conditions, A and B, enabled the patient to cope effectively with the 45 minute training sessions without significant increase of complaints (muscular tension, excitement); b) attentional performance (complete test d2) raised up to the average over the whole ABAB experiment; c) attentional performance (tested before and after each phase with a third part of test d2) decreased under the break condition during the individual sessions, while it was unchanged under PR; d) attentional performance at the computer retraining programme ("Bild" by Rigling) partially increased under PR and slightly decreased under break condition; e) there was less excitement and less muscular tension under PR in comparison to the break condition; and f) pain in the joints and exhaustion (both measured with the GBB) were reduced significantly under PR, as opposed to a marked increased in the break condition.


[The pathology of thyroid nodules. Our experience]. The authors report their experience on 149 surgical operations for thyroid nodules between 1979 and 1991 period. They underline the diagnostic preoperative difficulties related to solitary nodules existent before the fine needle-aspiration. Finally they observe that cytologic diagnosis allow to select malignant and benign lesions and planning surgical treatment.


Platelet-activating factor does not induce bronchial hyperreactivity in nonasthmatic subjects. Platelet-activating factor (PAF) is a phospholipid which plays a role as a mediator in inflammation. Recently, it has been implicated in the induction of bronchial hyperresponsiveness in man. In order to establish the effect of PAF on bronchial reactivity, 6 normal subjects without bronchial hyperresponsiveness inhaled 400 micrograms of PAF in 10 divided cumulative doses. All subjects felt a hot flush and a slight tracheal irritation after the inhalation of PAF. Forced expiratory flows (FEF) were measured between each inhalation of PAF and did not change significantly. Bronchial reactivity to methacholine (MCH up to a dose of 2 mg) was determined 1, 7, 14 and 21 days after inhalation of PAF. Forced expiratory volume in 1 s (FEV1), forced expiratory flow between 25 and 75%, and at 75% of vital capacity (FEF25-75% and FEF75%) measured after the inhalation of 2 mg of MCH did not differ significantly from baseline values determined before PAF challenge. In conclusion, the administration of PAF by inhalation in tolerable doses does not induce bronchial hyperresponsiveness as determined by a reduction of 20% of FEV1 nor by more sensitive indicators of ventilatory obstruction, such as FEF25-75% and FEF75%.


Effects of a constant dose rate of terbutaline on circadian peak expiratory flow, heart rate and systolic arterial pressure in patients with asthma exacerbation. The purpose of this study was to investigate the effect of a constant infusion rate of terbutaline on circadian bronchial peak expiratory flow rate (PEFR), heart rate and arterial pressure in patients with asthma exacerbation. Fifteen hospitalized asthmatic patients (6 females and 9 males, mean age 43.3 years, mean weight 67.0 kg) were included in this study. In order to reach the desired plasma concentrations of terbutaline immediately, a pharmacokinetic simulation was done. Based on the predicted values thus obtained, an initial 5-min bolus dose of 2.94 micrograms/kg was given to all patients at 7 a.m., i.e. at the beginning of the study. Over the following 24 h (7 a.m. to 7 a.m.), 33 micrograms/kg of terbutaline was infused intravenously at a constant rate with an electric pump. Since severe acute asthma requires corticosteroids, a 40-mg injection of methylprednisolone was given to all patients at 7 a.m. PEFR, heart rate, systolic arterial pressure, side effects and plasma terbutaline levels were recorded at 7 and 10 a.m., 1, 4, 7 and 11 p.m., and 3 and 7 a.m. the following morning. Terbutaline had a significant favorable effect on asthma exacerbation but no circadian rhythm was found in PEFR. Although terbutaline was infused at a constant rate, plasma levels depended on circadian variations.


Electron-microscopic evidence for cytochrome P-450 in Clara cells and type I pneumocytes of the rat lung. Using immunoelectron microscopy, we examined the distribution of cytochrome P-450 in rat lungs and determined the cell types in which P-450 was localized. To demonstrate P-450, a rabbit polyclonal antibody against P-450b (P-450 IIB1), the major constitutive isozyme of rat pulmonary P-450, was used. Strong reactivity for anti-P-450b antibody was observed in nonciliated bronchial and bronchiolar epithelial cells (Clara cells) and type I pneumocytes. Type II pneumocytes and Kultschitzky cells showed no reactivity. Most ciliated cells were negative, although a small number in peripheral bronchioles showed a weakly positive reaction. Endothelial cells and other mesenchymal cells were P-450b negative. Many studies have suggested that the Clara cell was metabolically very active and had P-450 containing mixed function oxidase systems. Our study shows that both Clara cells and type I pneumocytes have P-450 and may play an important role in the metabolism of xenobiotics. The metabolic significance of type I pneumocytes was not recognized, but it is reasonable to postulate that type I pneumocytes may have a xenobiotic metabolic function because they comprise most of the surface area of the lungs and are thus extensively exposed to the environment.


Increased prevalence of IgG-induced sensitization and hypersensitivity pneumonitis (humidifier lung) in nonsmokers exposed to aerosols of a contaminated air conditioner. Specific IgG antibodies against antigens of a contaminated air conditioner were estimated in serum of 134 workers of a printing company. Altogether 64% of the workers investigated revealed significantly elevated levels (> 3 U/ml) of IgG antibodies specific to these antigens as compared to a nonexposed control group. The occurrence of IgG antibodies for microbial extracts were 25% for Fusarium, 23% for Penicillium notatum, 13% for Alternaria tenuis, 12% for Aureobasidium pullulans, 9% for Sphaeropsidales species, 3% for Micropolyspora faeni, 2% for Aspergillus fumigatus and 2% for Thermoactionomyces vulgaris. Out of the 86 workers with elevated IgG antibodies for air conditioner antigens, 59 were nonsmokers. Considering a cut-off level of 10 U/ml IgG for high values, the proportion of smokers to nonsmokers becomes even more pronounced (6 to 36 respectively, binominal test p < 0.001). This is despite the fact that the distribution of smokers and nonsmokers among the 134 workers is approximately equal (60 to 74). All 3 workers with clinical diagnosis of humidifier lung or humidifier fever belonged to the nonsmoker group. Our findings indicate that crude water extracts of contaminated air conditioners are the best choice as antigen source for the diagnosis of humidifier lung in exposed workers. Nonsmokers are shown to have a high risk for immunological sensitization.


Iatrogenic pneumothorax: etiology and morbidity. Results of a Department of Veterans Affairs Cooperative Study. The purpose of this study was to delineate the etiological factors for iatrogenic pneumothorax in the era of increased use of invasive procedures and to determine its impact on morbidity. Between 1983 and 1987 the Department of Veterans Affairs conducted a cooperative study at 13 medical centers to assess the utility of the intrapleural instillation of tetracycline for the prevention of recurrent pneumothorax. Since all patients with any type of pneumothorax were screened at each medical center, it was decided to collect data on all the iatrogenic pneumothoraces during that period. During the study period, the number of reported iatrogenic pneumothoraces were 538. Because of incomplete data, 3 iatrogenic pneumothoraces reported from one center were excluded. The leading causes of iatrogenic pneumothorax were transthoracic needle aspiration (128), subclavicular needle stick (119), thoracentesis (106), transbronchial biopsy (54), pleural biopsy (45) and positive pressure ventilation (38). Most patients required treatment for 4-7 days; however, hospitalization was prolonged due to this treatment in only 8% of patients, presumably because of their underlying disease which required long hospitalization. Patients with underlying chronic obstructive pulmonary disease required significantly longer duration of treatment than those without. We conclude that in our patient population, the three leading causes of iatrogenic pneumothorax are transthoracic needle aspiration, subclavicular needle stick and thoracentesis. Hospitalization is prolonged in only a small percentage of the patients who required treatment for the iatrogenic pneumothorax.


Value of computer tomography in the detection of bullae and blebs in patients with primary spontaneous pneumothorax. In this prospective study, the value of computed tomography (CT) in detecting bullae and bleb formation of the lung in 35 patients with primary spontaneous pneumothorax (PSP) has been determined. The ability of CT in the detection of bullae and bleb formation and fibrotic changes is compared with the chest film in PSP. CT showed pathological lung changes in 31/35 patients. In most cases, few (n < 5) and small blebs (i.e., < 2 cm in diameter) were found. In 16/35 cases, blebs (< 2 cm) and bullae (> 2 cm in diameter) occurred in the extra-apical region. Contralateral pathological changes were found in 23/35. Bullae (> 2 cm) could be detected only in 6/35. In the chest film, bullae and blebs could be detected in 11/35 cases on the ipsilateral (in 2/35 cases not confirmed by CT), in 3/35 on the bilateral and in 4/35 only on the contralateral side. Thus, CT was proved to be of high value in the assessment of bullae and bleb formation in PSP compared with chest film. Negative pressure drainage was instituted as primary therapy. In a follow-up of 9.6 (+/- 5.7 SD) months, only early recurrences were noticed (n = 35). The rate of recurrences was 6/35 patients. The longer follow-up period (mean 31.7 +/- 6.1 months) could be performed for 32 patients; 3 were lost. Additionally, 2 recurrences occurred. No correlation between recurrences and anatomical status (number, size and distribution of blebs/bullae) as assessed by CT was found. Differential treatment protocols on the basis of the initial findings do not appear to be warranted.


Anterotracheal temperature during and after exercise in the guinea pig. We measured the temperature in the anterotracheal region of the guinea pig during and after various intensities of exercise (from 20 to 100 m/3 min). The temperature decreased during exercise, and the maximal drop of the temperature increased with increasing intensity of exercise up to a speed of 80 m/3 min. When the exercise was discontinued, the temperature initially fell rapidly, then rose progressively to equal or exceed the preexercise value. The changes in temperature were similar among 5 animals. These findings suggest that the tracheal wall temperature changes during and after exercise relative to the intensity of exercise. Using this method in guinea pigs may provide more information about the pathophysiology of exercise-induced asthma.


Phrenic nerve function in type 1 diabetic patients with diaphragm weakness and peripheral neuropathy. Phrenic nerve latency was studied in 14 male type 1 diabetic patients with impaired diaphragm function and in 14 healthy control subjects. The diabetics showed significantly decreased values regarding inspiratory vital capacity and forced volume in 1 s compared with the control subjects. All other lung function parameters were similar in both groups. Although motor and sensory nerve conduction studies provided evidence for peripheral neuropathy in all patients, phrenic nerve latencies turned out to be normal. These results rule out a neuropathic disorder of the phrenic nerve. Thus, impaired diaphragm function in type 1 diabetic patients is not caused by phrenic neuropathy.


Open lung biopsy: a safe, reliable and accurate method for diagnosis in diffuse lung disease. The ideal method for obtaining lung tissue for diagnosis should provide high diagnostic yield with low morbidity and mortality. We reviewed all 432 patients (mean age 55 years) who underwent an open lung biopsy at this hospital over a 10-year period. Twenty-four patients (5.5%) were immunocompromised. One hundred and twenty-five patients were on steroid therapy at the time of operation. Open lung biopsy provided a firm diagnosis in 410 cases overall (94.9%) and in 20 out of 24 patients in the immunocompromised group (83.3%). The commonest diagnosis was cryptogenic fibrosing alveolitis (173 patients). Twenty-two patients (5.1%) suffered complications following the procedure: wound infection 11 patients, pneumothorax 9 patients and haemothorax 1 patient. Thirteen patients (3.0%) died following open lung biopsy, but in only 1 patient was the death attributable to the procedure itself. We conclude that open lung biopsy is an accurate and safe method for establishing a diagnosis in diffuse lung disease with a high yield and minimal risk.


A case of pulmonary tuberculosis with bilateral hilar lymphadenopathy diagnosed by sputum culture subsequent to open thoracic biopsy. We report a case of pulmonary tuberculosis with bilateral hilar lymphadenopathy. Open thoracic lymph nodes and lung biopsy revealed findings consistent with sarcoidosis. Culture and special staining of the biopsied specimen for mycobacteria were negative. Culture of the postoperative sputum grew Mycobacterium tuberculosis and antituberculous therapy resulted in a decrease in sizes of the lymphadenopathy. A review of the literature, with emphasis on the differential diagnosis between tuberculosis and sarcoidosis, is discussed.


Treatment of pulmonary alveolar microlithiasis with a diphosphonate--preliminary results of a case. A diphosphonate, disodium etidronate, a compound known to inhibit microcrystal growth of hydroxyapatite was given to a 3.5-year-old girl with pulmonary alveolar microlithiasis (PAM) that was symptomatic. The drug was used for approximately 36 months in a single daily dose of 15 mg/kg. No significant side effects were encountered with somewhat clearing of lung bases in chest radiograms and subjective improvement in general condition. These findings suggest a role of diphosphonates in the treatment of PAM.


Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. The clinicopathologic findings of light and electron microscopic examination of a 78-year-old woman who underwent successful bilateral pars plana vitrectomy for bilateral stage III macular holes are reported. Examination disclosed anatomical repair of the full-thickness macular holes by glial cell proliferation in the left eye. The hole apparently collapsed with no glial cell proliferation in the right eye. The photoreceptors adjacent to the healed macular holes appeared normal. Defects in the internal limiting membrane in the foveal area were noted in both eyes.


Treatment of dislocated crystalline lens and retinal detachment with perfluorocarbon liquids. Removal of a crystalline lens dislocated into the vitreous cavity can be hazardous, particularly in the presence of a retinal detachment. Hard pieces of nuclear material may be difficult to extract and may repeatedly fall onto the retina when emulsification is attempted in the vitreous cavity. Cases involving four eyes with dislocated crystalline lens and rhegmatogenous retinal detachment, into which liquid perfluorocarbon was injected after vitrectomy to float the dislocated lens material off the retina and reattach the retina, are reported. The dislocated lens was removed while floating on the perfluorocarbon liquid, which also provided a cushion that prevented dropped fragments of lens from traumatizing the retina. In all four cases, surgery was not associated with complications and resulted in improvement in visual acuity and retinal reattachment.


Visual loss associated with pseudoxanthoma elasticum. An 18-year-old woman with pseudoxanthoma elasticum had sudden profound bilateral visual loss, presumably as a result of optic nerve infarction caused by anemia and hypotension from massive gastrointestinal bleeding. Her central visual acuity largely recovered in her right eye, but her left eye had only hand motions acuity. During the subsequent 24 years, she underwent three separate surgical procedures for gastrointestinal bleeding. Abdominal arterial angiography showed numerous aneurysms of the gastric arteries. A subtotal gastrectomy was done, and histopathologic examination found advanced degenerative changes of the elastic lamina of the gastric arteries. At age 42 years, the patient lost residual vision in her right eye. This was caused by an extrafoveal subretinal choroidal neovascular membrane, which was obliterated with laser photocoagulation. Degeneration of elastic tissue, the primary defect in this syndrome, may cause cardiovascular complications and formation of breaks in the Bruch membrane, which are visible as angioid streaks. Ingrowth of fibrovascular tissue through angioid streaks may cause disturbances of macular function. The optic nerve ischemia and infarction associated with the profound visual loss in this patient reminds the ophthalmologist of the systemic nature of this disorder and the possibility that systemic vascular complications with massive blood loss may occur.


Misconceptions and techniques in the management of retinoblastoma. The 1992 Paul Henkind Memorial Lecture. For many years, enucleation has been the most common treatment of retinoblastoma. It generally has been done on the affected eye of children with unilateral disease and on the more severely affected eye in children with bilateral disease. In recent years, there has been a trend toward earlier diagnosis of retinoblastoma, and there have been refinements in conservative therapeutic methods, such as radiotherapy, photocoagulation, and cryotherapy. Consequently, it often is possible to salvage the affected eye and retain useful vision in many patients who would have undergone enucleation in the past. This article provides an update on the diagnosis and treatment of retinoblastoma, with emphasis on certain misconceptions related to the management of this tumor. New genetic aspects and their relationship to counseling are discussed briefly.


Pneumocystis carinii and Mycobacterium avium-intracellulare infection of the choroid. It has been hypothesized that coinfection with mycobacteria occurs in patients with Pneumocystis carinii choroiditis, but cases demonstrating ocular infection by both organisms have not been reported. This study reports the case of a patient with P. carinii choroiditis who was treated with intravenous trimethoprim and sulfamethoxazole, followed by intravenous trimethoprim and dapsone. The choroidal lesions failed to resolve despite 6 weeks of treatment, and the patient died from massive pulmonary infection caused by P. carinii, Mycobacterium avium-intracellulare, and cytomegalovirus infections. Ocular histologic and electron microscopic examinations revealed choroidal infection by both P. carinii and M. avium-intracellulare. Serum levels of sulfamethoxazole were below the recommended therapeutic range for treating P. carinii infection during the first week of therapy, but adequate drug levels were subsequently obtained. Failure of choroidal lesions of P. carinii to resolve in some cases may suggest insufficient antimicrobial levels in the blood or raise the possibility of coexistent M. avium-intracellulare or other opportunistic infection.


Intravitreal corticosteroids as an adjunct in the treatment of bacterial and fungal endophthalmitis. A review. The use of intravitreal corticosteroids in the management of endophthalmitis remains controversial. Several clinical and experimental reports are reviewed that suggest that intravitreal corticosteroid therapy, when used in conjunction with antibiotics with and without vitrectomy, reduces the intraocular inflammatory process and secondary complications associated with microbial endophthalmitis.


Endogenous Aspergillus-induced endophthalmitis. Successful treatment without systemic antifungal medication. A 32-year-old man had unilateral visual loss, a gravitational layering of preretinal inflammatory cells in the macula (pseudohypopyon), subretinal infiltrates, and hemorrhagic vasculitis. The patient initially denied intravenous drug abuse. Apsergillus terreus was cultured from undiluted vitreous obtained from a diagnostic and therapeutic vitrectomy specimen. Intravitreal and subconjunctival injections of amphotericin B alone were successful treatment. To the author's knowledge, antemortem diagnosis and treatment of A. terreus-induced endophthalmitis has not been reported previously. This article describes the second case of aspergillar endophthalmitis successfully treated without adjunctive systemic antifungal therapy.


Hemorrhagic detachment of the internal limiting membrane after penetrating ocular injury. During surgery to remove an intraocular gunshot pellet, a loculated "preretinal" hemorrhage was identified. This provided an opportunity to evaluate the structural identity of the inner wall, presumably representing detached posterior vitreous. The preretinal membrane was excised and evaluated using lectin histochemical analysis. All lectins tested bound to the excised tissue, supporting the conclusion that the membrane was a hemorrhagic internal limiting membrane detachment resulting from direct penetrating ocular injury. During intraoperative biomicroscopic examination, this detachment was indistinguishable from a subhyaloid hemorrhage. Because there are no natural history studies on internal limiting membrane loss and damage to retinal visual function, caution is urged in the surgical management of these lesions.


Variation of perfluoropropane disappearance after vitrectomy. In complex cases of retinal detachment, perfluoropropane (C3F8) is frequently used after vitrectomy for tamponade of retinal breaks. Results of previous studies of C3F8 disappearance using 10% C3F8 after vitrectomy in human eyes have differed significantly. A wide variation in the decay rate and half life of C3F8 after vitrectomy was observed in eyes that had similar clinical settings and received the same C3F8 concentration (15%, 20%, or 25%). This occurred even in those eyes where there was no change in the geometric contour of the eye after a repeat vitrectomy.


Longevity of expanding gases in vitrectomized eyes. The effect of lensectomy and vitrectomy on the disappearance of intraocular gas was studied in a rabbit model. Ten rabbits underwent lensectomy and vitrectomy in one eye, and ten others underwent vitrectomy alone in one eye. The second eye of each rabbit served as a control. Equal amounts of perfluorocarbon gas, either perfluoromethane (CF4) or perfluoromethane (C2F6), was injected into both eyes of the 20 animals. After an interval corresponding to one or more half-lives of the gases had elapsed, the residual volumes of gas in the paired eyes were measured directly by an invasive method and compared. The volume of gas in the aphakic vitrectomized eye was 1.3 times greater, on average, than in the paired control eye. There was no significant difference between eyes that had undergone only vitrectomy and the control eyes. It is postulated that vascular congestion and decreased aqueous secretion caused by surgical trauma were responsible for the delay in the disappearance of gas in the eyes that underwent both lensectomy and vitrectomy.


Distribution of the posterior ciliary arteries revealed after vascular occlusions. A case report. Recognized posterior ciliary artery occlusion combined with central retinal artery occlusion is relatively uncommon. Clinical and experimental evidence of combined occlusions appear to support a nasal and temporal distribution for the posterior ciliary arteries in most cases. A case involving a patient in whom the posterior ciliary arteries divided superiorly and inferiorly to supply the region of the macula is reported. Some of the more common variations in the distribution of the posterior ciliary arteries are discussed. Clinicians should be aware that the territorial divisions of the choroidal perfusion in the macula may be horizontally based.


Evaluation of the blood-aqueous barrier after vitreous replacement with perfluoropropane gas and liquid silicone. Fluorophotometric measurements of blood-aqueous barrier permeability after intravitreal injection of perfluoropropane gas in rabbit eyes revealed fluorescein leakage immediately after injection; 3 days later, recovery of barrier integrity had begun to occur and 7 days and 14 days after gas injection, when the gas bubble was still in the eye, anterior chamber fluorescein concentrations were normal. Similarly, in eyes undergoing vitrectomy and injection of silicone liquid or vitrectomy only, anterior chamber fluorescein levels were elevated 3 days and 1 week after surgery. Nevertheless, normal barrier integrity was reestablished in both the silicone-filled eyes and the vitrectomized eyes after 1 week. Since there was no difference between the group injected with silicone and the group that underwent vitrectomy only with respect to anterior chamber fluorescein concentration at any of the times studied, it is concluded that the temporary disruption of the blood-aqueous barrier is associated with the surgical procedure rather than the presence of silicone liquid in the vitreous cavity.


[Treatment of chronic refractory idiopathic thrombocytopenia purpura. 10 years experience at the Salvador Zubiran National Institute of Nutrition]. A total of 126 patients with chronic idiopathic thrombocytopenic purpura were diagnosed from January 1980 to January 1990 in our institute. In this group of patients, 21 were refractory to prednisone therapy, splenectomy or both, or had had a relapse after a good response with these treatments. They were given other therapies. There was enough information for evaluation in 16 of the 21 patients. The treatment responses were classified according to the post-therapy platelet counts: complete response (CR) = > 150 x 10(9)/L for more than three months; partial response (PR) = 50-150 x 10(9)/L for more than three months; any response (AR) = CR + PR; no response (NR) = < 50 x 10(9)/L. There were 15 women and one male. The median age was 41 years (range 11 to 65). 6-mercaptopurine was given in all patients with CR = 31.2%, PR = 18.8%, AR = 50% and NR = 50%. Seven patients received cyclophosphamide with CR = 28.6%, PR = 14.3%, AR = 42.9% and NR = 57%. Vincristine was given in four patients with only one PR. Interferon alpha 2B was given in four patients with two transitory PR. One patient received colchicine and vitamin C without response. It is concluded that 6-mercaptopurine and cyclophosphamide are useful drugs in refractory thrombocytopenic purpura.


[Association of plasma ammonia and GABA levels and the degree of hepatic encephalopathy]. Several toxic factors have been implicated in the pathogenesis of hepatic encephalopathy (PSE) among which ammonia plays a dominant role. More recently, the gamma-aminobutyric acid (GABA) hypothesis in which an increase in the GABA-ergic tone and the presence of one or more GABA/benzodiazepine receptor ligands which interact with that receptor, has been proposed. We investigated the levels of GABA and ammonia in plasma of patients with acute PSE to test the hypothesis that elevated plasma GABA levels would be found in acute encephalopathy and that GABA levels would correlate with the degree of hepatic encephalopathy. We measured plasma levels of GABA and ammonia during an acute episode of PSE, spontaneous or precipitated by gastrointestinal bleeding or sepsis, and performed assessments of PSE by the PSE index. Patients were evaluated before and two days after standard treatment with lactulose. We also measured plasma GABA levels in the hepatic vein of a selected group of patients undergoing hemodynamic studies. Plasma GABA levels were significantly higher in patients with acute PSE (458 +/- 108 pmol/mL) when compared with normal subjects (110 +/- 23 pmol/mL) (p < 0.01) although no correlation was found between plasma GABA concentration and the degree of PSE. Changes in plasma ammonia, however, correlated with improvements in the PSE index (r = 0.56; p < 0.02) and with abnormalities in the EEG (r = 0.65; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)


[Pancreatic phlegmon: a potentially fatal form of acute pancreatitis]. To report the clinical characteristics of a group of patients with pancreatic phlegmon (PF) seen at the Instituto Nacional de la Nutricion Salvador Zubiran, Mexico City. We reviewed all the cases of acute pancreatitis hospitalized from January 1981 to December 1989. The diagnosis of pancreatic phlegmon was established when the CT scan showed a solid mass in the pancreas and peripancreatic region with more than 20 Hounsfield units without liquid collections or a fibrous capsule. We analyzed clinical, biochemical, and radiological data. Acute pancreatitis was diagnosed in 132 patients. In 14 a pancreatic phlegmon was observed (10.6%). Twelve were men; the mean age was 44.7 years. In six cases acute pancreatitis was secondary to alcohol abuse and in four to gallstones. Abdominal pain was present in all patients. Ten had leucocitosis and seven fever and/or jaundice. An abdominal mass was detected in three cases. The severity of pancreatitis was graded according to our institutional criteria as mild (0-2 signs) or severe (3-5 signs). In 10 patients AP was graded as mild: no mortality was observed in this group but three presented complications (two liquid collections and one an abscess). The four patients with severe pancreatitis presented complications and three died (one abscess, two multiorgan failure). Five patients were operated on. In three an abscess was drained. Pancreatic phlegmon is a potentially severe form of AP. All patients who died presented, in addition to PF, clinical criteria of severe pancreatitis.


The BCAA/AAA ratio of plasma amino acids in three different groups of cirrhotics. We studied the plasma amino acid profiles in the postabsorptive period in three groups of cirrhotic patients: stable, unstable, and with acute portal systemic encephalopathy (PSE), and compared them with a healthy control group in order to investigate the differences among the different groups and reevaluate the use of the branched-chain amino acid/aromatic amino acid (BCAA/AAA) ratio. Although plasma amino acid levels were similar to the control group, stable cirrhotics had a significantly decreased BCAA/AAA ratio (2.9 +/- 0.2) compared to the control group (3.9 +/- 0.3) (p < 0.05). Unstable cirrhotics had differences in plasma amino acid levels and the BCAA/AAA ratio was even lower (1.7 +/- 0.3) compared with stable cirrhotics and controls, respectively (p < 0.05 and p < 0.01). Patients with PSE had extreme elevations of most amino acids and showed the lowest BCAA/AAA ratio of all four groups (0.8 +/- 0.07) (p < 0.001 compared with controls). We conclude that it is possible to detect differences in plasma amino acid concentrations in different groups of cirrhotics, and that the BCAA/AAA ratio is a good index for the assessment of liver impairment. The latter could be used in the follow-up of a selected group of patients such as those undergoing major surgery or liver transplantation in whom the BCAA/AAA ratio could be used to help determine the best time for the transplant.


[Effects of the addition of conditioned media on the response of Fanconi anemia lymphocytes to mitomycin C]. It has been shown that the addition of normal plasma to Fanconi anemia (FA) lymphocyte cultures significantly decreases the frequency of mitomycin C (MMC) induced chromosome aberrations, suggesting that normal plasma contains a diffusible correction factor (CF) which is able to partially complement FA lymphocytes. On the other hand, there is evidence suggesting that FA cells are defective in the DNA postreplicative repair. CF could then be involved in DNA repair processes and in possible inducible mechanisms. In the present study MMC-treated FA lymphocytes were grown during the last 24 hours of culture, in conditioned media obtained from untreated and MMC-treated normal cells. The purpose was to investigate if MMC-stressed normal cells were induced to produce CF in vitro. The results failed to show a constant decrease of FA cells chromosome aberrations when plasma-free conditioned media from MMC-stressed normal cells were added (experiments 2 and 3). However, when the conditioned media were supplemented with normal plasma (experiments 1 and 4) a partial repair of MMC-induced damage of the FA cells was observed. The results suggest the presence of CF in normal plasma and two possible mechanisms of action are suggested: CF is involved in DNA repair of MMC-damaged FA cells or it induces cellular division selecting the less damaged cell population through mitosis.


[The perception of family function and psychosexual development in obese adolescents]. The interaction of psychological and social factors with family functioning and psychosexual development was studied in obese adolescents. Family functioning was evaluated using the triaxial classification of Tseng and McDermott. A total of 246 adolescents 8 to 18 years old (124 males and 122 females) were grouped in two: obese (n = 109) and non obese (n = 137). With the use of multivariate analysis it was found that the group of obese youngsters had higher rates of triangular parents-child dysfunction (p < 0.001) and more disapproval for their feeding behavior (p = 0.002); on the other hand, they considered they were more accepted in the family (p = 0.029) and felt greater concern from their parents (p = 0.004). It was concluded that the feeding behavior is interrelated with several aspects of the family psychodynamics which has an effect on the adolescents homeostasis and on his own body image perception. Those factors should be taken into consideration when the obese youngster is studied in clinical practice.


[Heterotopic pregnancy. Case report and review of the literature]. Heterotopic pregnancies (simultaneous ectopic and intrauterine pregnancies) can occur spontaneously or associated with assisted reproductive technology. It is infrequent in Mexico. We present a case of heterotopic pregnancy in a 32 year old woman submitted to surgery due to rupture of the ectopic pregnancy located in the right fallopian tube. The evolution was satisfactory for the woman, but the newborn died shortly after delivery because of meconium aspiration. We review the literature on this disease.


[Possible use of serum calcitonin in septic patients at risk of acute respiratory distress syndrome]. The acute respiratory distress syndrome (ARDS) is a late complication in critically ill patients and its diagnosis is usually made when the syndrome is fully established. There is an increased interest in developing early markers that may help to identify ARDS in its initial stages. Calcitonin was recently reported as a useful serum marker to identify burned patients at risk for respiratory failure. We report a case with abdominal sepsis and ARDS, whose serum calcitonin level was 1000 pg/mL without other known clinical causes of hypercalcitoninemia and who died in multiorganic failure. The possible mechanisms of hypercalcitoninemia and its possible utility as marker of ARDS in critically ill patients is discussed.


Estimating HIV prevalence and projecting AIDS incidence in the United States: a model that accounts for therapy and changes in the surveillance definition of AIDS. The AIDS incubation distribution is changing in calendar time because of treatment and changes in the surveillance definition of AIDS. To obtain reliable estimates of HIV prevalence and projections of AIDS incidence in the 1990s using the method of backcalculation, we constructed an appropriate incubation distribution for each calendar date of infection. We parameterized the impact of treatment on the incubation distribution by specifying the relative hazard for AIDS in treated versus untreated people as a function of duration of HIV infection. To account for trends in the incubation distribution, we modelled the prevalence of treatment, the distribution of treatment onset times, and the impact of the revision of the AIDS surveillance definition in 1987. We selected and evaluated backcalculation models based on consistency with external information. We defined a 'plausible range' of estimates that took into account uncertainty about the natural incubation distribution and treatment efficacy, as well as bootstrap assessment of stochastic error. Using these methods, we projected that national United States AIDS incidence will plateau during 1991-1994 at over 50,000 cases per year. Projections exhibited substantial systematic uncertainty, and we calculated a plausible range for AIDS incidence in 1994 of 42,300 to 70,700 cases. An estimated 628,000 to 988,000 cumulative HIV infections occurred as of 1 January 1991. After accounting for AIDS mortality, we estimated that 484,000 to 844,000 people were living with HIV infection on 1 January 1991. Favourable trends in HIV incidence appeared in gay men and intravenous drug users. Plausible ranges for our estimates overlapped with those from a 'stage model' approach to incorporating treatment effects in backcalculations. Our approach, however, tended to yield smaller estimates of epidemic size, mainly because the parameters used with the stage model implied that more treatment was in use and that treatment was more effective than in our model.


The epidemic dynamics of HIV-1 in Italy: modelling the interaction between intravenous drug users and heterosexual population. Data gathered through the Latium HIV Surveillance System were used in conjunction with a compartmental mathematical model to describe the transmission dynamics of HIV-1 in Italy. In the Latium region, as in the rest of Italy, fewer than 1 in 5 cumulative cases of AIDS are attributable to male homosexual transmission, while 55-60 per cent of the cases have been observed among intravenous drug users (IVDUs). Moreover, the number of non-drug-using heterosexual cases is increasing (14 per cent of cumulative cases). Anonymous notification of positive HIV-1 tests, mandatory in Latium since 1985, were used to produce a time series of new HIV-1 diagnoses; just over 400 new cases of infection per quarter were diagnosed from mid 1989 to mid 1990, with no evidence of increasing incidence. A minimum of 6009 and a maximum of 10,000 individuals with HIV-1 as of the end of 1989 were estimated, 80 per cent of adult cases occurring among IVDUs. The model included two main subgroups: IVDUs and non-drug-using heterosexuals, both with behavioural heterogeneities. Sharing of needles among IVDUs and heterosexual contact were considered as possible ways of transmitting HIV-1. A mathematical framework was developed to reproduce different mixing patterns within and between subgroups. A scenario analysis of the model showed incident cases of HIV-1 among IVDUs peaking early, then declining dramatically and stabilising at low values, with a stable-state prevalence higher than 0.75. Heterosexual interaction with IVDUs resulted in a significant, but non-self-sustaining, virus spread in the general population, affecting females more than males. The extent of this spread is associated with the assortativeness of the sexual mixing pattern adopted. The qualitative features of the Italian epidemic are well represented by the model, which highlights the role of IVDUs as an infection reservoir. However, the need emerges for more accurate information on the key parameters influencing the transmission dynamics of HIV-1.


Repeated measures in clinical trials: analysis using mean summary statistics and its implications for design. This paper explores the use of simple summary statistics for analysing repeated measurements in randomized clinical trials with two treatments. Quite often the data for each patient may be effectively summarized by a pre-treatment mean and a post-treatment mean. Analysis of covariance is the method of choice and its superiority over analysis of post-treatment means or analysis of mean changes is quantified, as regards both reduced variance and avoidance of bias, using a simple model for the covariance structure between time points. Quantitative consideration is also given to practical issues in the design of repeated measures studies: the merits of having more than one pre-treatment measurement are demonstrated, and methods for determining sample sizes in repeated measures designs are provided. Several examples from clinical trials are presented, and broad practical recommendations are made. The examples support the value of the compound symmetry assumption as a realistic simplification in quantitative planning of repeated measures trials. The analysis using summary statistics makes no such assumption. However, allowance in design for alternative non-equal correlation structures can and should be made when necessary.


Analysis of a clinical trial involving a combined mortality and adherence dependent interval censored endpoint. Clinical trials often involve a variety of clinical and laboratory measures that are used as endpoints and sometimes two of these measures are combined in one endpoint. When the individual components of such a combined endpoint are 'time to event' measurements, the analysis is straightforward if each of the components is measured frequently and regularly over time. However, the analysis of the combined endpoint is more difficult when one component of the endpoint is right censored and the other is interval censored. This paper describes a statistic, based on a rank ordering of events for such a combined measure. The power of the test statistic is explored.


Impact of measurement error and temporal variability on the estimation of event probabilities for risk factor intervention trials. The impact of measurement error and temporal variability of risk factors on estimates of disease probabilities based on the logistic function is discussed. Monte Carlo results and empirical findings from the Multiple Risk Factor Intervention Trial indicate that the degree of attenuation of logistic parameter estimates is well approximated by the reliability coefficient when the errors are assumed to be normal random variates and event probabilities are small. In the design of intervention studies, measurement error and temporal variability of risk factors do not usually influence estimates of the probability of developing the disease in the control group, but can result in mis-estimation of the probability of developing the disease in the experimental group, substantially reducing the statistical power of the clinical trial.


Prediction of short-term survival with an application in primary biliary cirrhosis. Many long-term follow-up studies for survival accumulate repeated measurements of prognostic factors. Survival models which include only covariate values at baseline do not use all available information, and do not relate to survival predictions for times other than at that baseline. Time-dependent covariate models (which update covariate values as measurements occur through time) might be used, though limitations of software for estimating the underlying hazard functions and difficulty in relating hazard function changes to survival prediction present serious drawbacks. By dividing each patient's follow-up into successive intervals of equal length (using a length of interest for prediction) and with measurements available at the start of each, we describe how an analysis taking person-intervals as the observation units can be undertaken using readily available software to produce short-term survival models. We show that this approach is related to both the baseline and time-dependent covariate models. The method is illustrated using data from a long-term study of patients with primary biliary cirrhosis, where interest is in short-term survival predictions to aid the decision when to undertake liver transplantation.


The concept of residual confounding in regression models and some applications. In this paper the concept of residual confounding is generalized to various types of regression models such as logistic regression or Cox regression. Residual confounding and a newly suggested parameter, the relative residual confounding, are defined on the regression parameters of the models. The estimator gives the proportion of confounding which has been removed by incomplete adjustment. The concept quantifies the effects of categorizing continuous covariables and of model misspecification. These are investigated by a simulation study and with data from an epidemiological investigation. A case-control study of laryngeal cancer is used to illustrate the residual confounding effect of arbitrary transformation of a continuous confounder, smoking, on the effect of alcohol consumption on laryngeal cancer risk. The data also showed that categorization into two levels can yield high residual confounding. The parameters described in this paper are of some use in quantifying the effect of inadequate adjustment for confounding variables.


Control sample size when cases are given in constant ratio stratum-matched case-control studies. Strata-matched case-control studies based on a given number of cases and k times as many controls are common. We obtain a necessary and sufficient condition for there to exist a numerical solution for k with a desired level of a power. We derive the maximum power of the Cochran test, which may be less than one, when the number of cases is fixed. We provide an approximate formula for the minimum number of cases required for a specified power. There exists a numerical solution (that is, convergence of an iterative method) for k if the number of cases given is greater than this minimum number and no such a solution otherwise. We also show that the incremental gain in relative efficiency of the test with respect to k is diminished as k gets large.


Comparison of the proportions of affected relatives of cases and controls: analysis and minimum sample size formula. The problem of familial aggregation has frequently been approached by comparing the proportion of affected relatives of index cases with the proportion of affected relatives of index controls. This type of study has an analogy with the case-control design and is frequently analysed as if it was one. It is however an essentially different design which may involve dependent observations. We show that conventional tests for comparing proportions of affected subjects are still valid with this design; we give a formula for computing the minimum sample size required to detect a given degree of aggregation measured by the intracluster correlation coefficient, which can be estimated very simply by the difference in proportions of affected relatives in the two groups.


Bioequivalence revisited.

Bioequivalence revisited. The FDA permits marketing of a generic formulation of a drug G for the same indications as a standard preparation S if one can show that G is bioequivalent to S. Present implementation requires convincing evidence that the population mean difference in bioavailability (drug exposure) between the two preparations lies within specified bounds. The basis for this standard does not appear to involve a comprehensive model for the dose-response relationship, or consideration of clinical issues, notably (i) whether a patient is to commence on the drug or to switch from an established regimen to a new one; or (ii) that the risk of inequivalence relates to uncertainty of outcome. In this paper, I propose a comprehensive model for dose response and a tentative model for risk that addresses these issues. Specifically, I propose two new measures of bioequivalence which are based on these models, which differ in the two clinical circumstances above, and which respond to both bias and variance of outcome. I present two examples, and some simulations of the application of the new measures.


[Descriptive epidemiology of gynecologic and breast cancers]. The epidemiology of gynecological and breast cancers are better known in France as a result of the mortality data provided by INSERM and the mortality data obtained from the French Tumor Register. Breast cancers are the most common form of cancer in women, accounting for about 30 p. cent of tumors (excluding skin cancers) followed by cancers of the uterine cervix, uterine body and the ovary. The change in incidence shows a definite reduction in the number of uterine cancers over the past 10 years, whereas the incidence of breast cancers is rising by 1 to 2 p. cent per year. Mortality due to breast cancer has risen steadily in France since 1950, particularly in higher age groups. At birth, the risk of developing a breast cancers is 7 p. cent, i.e. one woman in 14 will develop a breast cancer. The figures for cancers of the uterus and ovary are much lower. Survival curves for various types of cancer confirm the steady decline in survival for breast cancers, whereas for cancers of the cervix, uterine body and ovary, mortality rates stabilize after 5 years. The risk of a secondary cancer remains very high for breast tumors, and half the cases of a secondary tumor involve a contralateral breast tumor. In general, there is an increased risk of a secondary cancer after a primary gynecological tumor.


[Treatment of severe rhesus isoimmunization by repeated transfusions in utero]. Repeated transfusions in utero by umbilical cord puncture enable the treatment of severe forms of rhesus incompatibility. The two cases reported, including one involving seven transfusions between twenty and thirty seven weeks since the LMP, form the basis of a review of the literature defining the advantages and results of this technique.


Review on copper in male reproduction and contraception. The effect of copper on spermatozoa was studied as early as 1956 by Quatrefages, and has given rise to numerous studies and the assay findings have recurred in all the tissues of the male reproductive system, with considerable individual differences, the cause of which is not understood. Its role in the sperm is unclear, but it appears to be involved in spermatozoan mobility and it may also act at the pituitary receptors which control the release of LH. In the seminal fluid, the level of copper appears to fall in cases of azoospermia and to increase in oligo- and asthenozoospermia, but the findings of different authors are somewhat contradictory and some authors do not report any correlation between the seminal level of copper and the number of mobility of the gametes. It is true that the concentrations in the ejaculate vary considerably from one day to the next and that they also vary in different fractions from a single ejaculate. The toxic effects of copper on spermatozoa, which was demonstrated in 1850 by Quatrefages, has often been confirmed. Copper reduces the oxidative processes and glucose consumption, which reduces or abolishes mobility: this property is exploited in intrauterine devices. The use of copper for male contraception has given rise to experimental implantations at various sites within the male system: lumen of the deferens, epididymis, seminal vesicle scrotum and the mobility of the spermatozoa was abolished in all cases. Tissue toxicity makes it impossible to use this method in human practice.(ABSTRACT TRUNCATED AT 250 WORDS)


[Efficacy and tolerance of a dietary iron supplement (Bio-fer) in pregnancy anemia]. Fifty pregnant women with a hemoglobin between > 10 and < or = 12 g/100 ml during the second three months of pregnancy participated in a non-comparative clinical trial intended to evaluate, during a one month treatment period, the acceptability and effectiveness of an iron supplement (Bio-fer), combined with a high iron diet. Gastric discomfort regressed (present in 11 and 3 women before and after treatment) (p < 0.05), the same applying to constipation (p < 0.05) (present in 17 and 8 women before and after treatment). Reasons for abandoning treatment were nausea (n = 2) and vertigo (n = 1). Anemia or deficiency, evaluated on the basis of hemoglobin and iron-binding capacity levels, improved or stabilised in 34 patients out of 47 (72.3%). Hemoglobin increased (p < 0.0001) on average from 11.4 +/- 0.6 to 11.7 +/- 0.8 g/100 ml.


[Epidemiology of genetic hemoglobin diseases in metropolitan France]. The number of subjects with heterozygous beta-thalassaemia and sickle-cell anaemia in metropolitan France can be evaluated by the distribution of populations originating from countries with a high prevalence of genetic haemoglobinopathies. Taking into account the movements of these populations observed since the 1982 census, the current prevalences of beta-thalassaemic and drepanocytic traits are higher than the figures of 180,000 and 130,000 respectively found at that date. On the other hand, it appears from episodic screenings performed during the last few years that the percentage of subjects with heterozygous beta-thalassaemia is 3.09% in Corsica, 0.77% in school-age population in the Marseille area, and 0.72% in the general population of Marseille, Toulon and Nice. In 1992, the number of patients with heterozygous beta-thalassaemia and with major sickle-cell syndrome is estimated at 250-350 and 1000-3000 respectively. Patients with sickle-cell anemia predominate in the Paris area, whereas those with heterozygous beta-thalassemia predominate in the provinces, notably in the Provence-Côte d'Azur and Corsica regions.


[Health policies and sickle cell disease]. Issues of public health raised by sickle cell disease and available solutions vary greatly between countries. Two main variables lead the choices: the affordable health resources, and the distribution of the abnormal genes in the population. Three examples have been chosen to illustrate these challenges. 1. In continental France, the level of health resources is good but the distribution of sickle traits is very heterogeneous among the population. Health policies against sickle cell disease aim at organizing screening and care to reach populations at risk, and concentrate the efforts upon them. This task is made difficult by two usual characteristics of these minorities: their rather poor social condition, and their cultural isolation. 2. In Guadeloupe (French West Indies) available health resources are similar to those of France but the sickle trait is common and has a homogeneous distribution in the population (14% carriers). Sickle cell disease is a health priority. Such conditions have recently favoured the organization of an efficient program for prevention and care of the disease. 3. In Benin (West Africa) a very high prevalence of sickle trait (more than 30% individuals are carriers, and about 4% have the disease) comes along with quite precarious resources that have to be shared with several other health priorities. An efficient and sustained policy against sickle cell disease has not yet been developed, which impedes a rational use of the few available resources, and creates much distress for diseased individuals.


[Genetic aspects of sickle cell anemia]. The genetics of sickle cell anemia may be considered as a model. Its mendelian transmission was hypothesized even before the molecular era. Once the mutation identified, it could be studied at the protein and DNA level; a consistent pathophysiological mechanism was proposed; the various genetic forms of the disease could be identified; the way by which a balanced polymorphism with Plasmodium falciparum malaria is obtained was analyzed. More recently, investigations were run in order to understand how modulating, or epistatic factors could modify the pathophysiological mechanism and contribute to the high clinical diversity of the disease. Several factors have been identified, among which a concomitant alpha-thalassemia, an overproduction of fetal hemoglobin, due either to an activation of the gamma genes or to an increase of the F-cell number, and finally a quantitative control of the beta s chains themselves. Such a high number of genetic active factors questions the concept itself of a monogenic disease.


[Natural history of sickle cell anemia]. Sickle-cell anaemia is characterized by three categories of clinical signs: anaemia, vaso-occlusive phenomena and infective complications, which are described here according to age. The natural history of the disease can be divided into four periods: the neonatal period which is asymptomatic but important to organize an effective protection; the first 5 years of life are characterized by a high risk of mortality, a high level of morbidity due to severe infections, episodes of acute anaemia and painful crises typical of that age-group; the life of older children and adolescents is dotted with painful crises; it is in this period that degenerative tissue pathology begins; in adulthood, the acute episodes are less frequent, but multiple complications develop. Some of them (cerebral vascular accidents or lung diseases) may be fatal, while others are the source of chronic and disabling lesions, notably ocular, orthopaedic and renal lesions, which affect the functional prognosis. Pregnancy remains a high risk. There is, therefore, a striking contrast between the basic physiopathological mechanism (polymerization of haemoglobin S) and the various clinical manifestations which depend on the type of haemoglobin, on the social and sanitary conditions in each country and on other reasons which remain to be elucidated.


[Neonatal diagnosis of hemoglobinopathies]. The technical problem of neonatal diagnosis of haemoglobinopathies has definitely been solved. There is no longer a methodological obstacle to a formal distinction between heterozygous and homozygous subjects with sickle cell disease, despite the presence at birth of strong haemoglobin F and F-acetylated concentrations. In France as in the USA and Great Britain mass screening for sickle cell disease in the newborn is necessary because this disease is frequent- as a monogenic hereditary disease it ranks second to cystic fibrosis on average and first in the Paris region-detection is useful for an early diagnosis and the new method is inexpensive.


[Genetic counseling and sickle cell anemia]. In sickle cell anaemia genetic counselling benefits from the easy diagnosis and, as early as the foetal stage, from the heterozygosity (AS) and the major syndromes. Its main objective is to inform as many as possible of the subjects concerned and in particular couples with genetic risk. Counselling gives them all the elements they require to decide freely about their offsprings. It is part of the management of sickle cell anaemia patients and is often associated with the neonatal diagnosis. The ever increasing number of justified requests for a prenatal diagnosis and the early time of these requests during pregnancy show that the information has really been transmitted. Actions remain to be developed in certain medical groups and in the populations at risk. A sickle cell anaemia centre is necessary for a better rationalization of genetic counselling.


[Management of drepanocytic patients].

[Management of drepanocytic patients]. Comprehensive supportive care includes outpatient follow up (periodic evaluation of baseline status, psychosocial support, prevention of sepsis through oral prophylactic penicillin in young children and vaccinations, early treatment of acute episodes (painful crises, other vaso-occlusive events, infection, acute anemia...); In adulthood residual organ dysfunction becomes one of the foremost problems. Further, more specific high risk situations (pregnancy, anesthesia) require adequate responses. Early diagnosis, improved strategy of care best achieved in Sickle Cell Centers can reduce mortality and morbidity in the aim of providing a better quality of life.


[Intratumoral biological markers in breast cancers]. Tumoral biological markers of breast cancer expand the predictive value of conventional prognostic factors, such as tumor size, axillary lymph node status, and histoprognostic grade. They include tumor estrogen and progesterone receptor levels, flow cytometric DNA analysis, to convey a prognostic value. Expression of the product of the gene pS2, which reflects the functional integrity of the estradiol receptor, indicates a good prognosis. In contrast, presence of growth factor receptors, such as the EGF receptor, or amplification of the HER2/neu or INT2 oncogene indicate a poor prognosis. Study of protein gp 170 and GST-pi predicts the response of tumors to chemotherapy, while the study of the potential doubling time (Tpot) provides an indication of the renewal capacity of the tumor. Markers of tumor invasiveness and metastatic potential include proteases (activators and inhibitors) produced either by tumor cells or by the cells of the stroma, gene nm 23, and membrane fatty acids. The place of the last markers in patients' treatment is not known yet. The knowledge of the tumor biological parameters along with clinical features should provide an accurate prediction of the aggressiveness of the tumor, allowing the best adjustment of treatment with the expected behavior of the disease.


[Classification of angiomas: hemangiomas and superficial vascular malformations]. The present classification of angiomas is not only of nosological interest. If it has effectively replaced the previous multiple classifications, it is because it provides a perfect correlation between the clinical features of each type and its angio-architectural and haemodynamic features. In practice, this results in a well-established attitude since determining the clinical type makes it possible to select first the additional examinations required, then the therapeutic indications particular to each type. Angiomas are divided into two main groups: haemangiomas or pseudo-vascular tumours which are specific to infants and spontaneously resolve after the first months of life; superficial vascular malformations proper, with their elementary types each of them developed on a sector of the vascular blood system: capillary, venous or capillaro-venous, and arteriovenous malformations. These three types may be diversely associated in any given patient; they may also be associated with abnormalities of the lymphatic system, producing systematized and/or disseminated complex angiodysplasias.


[Diagnostic orientation in the presence of superficial vascular malformation]. Diagnosis relies first on clinical evaluation of the patients. Subsequently, modern diagnostic imaging techniques, such as CT scan, MRI and Echo-Doppler, confirm the clinical approach and define the type of vascular anomaly. Angiographic analysis is not performed for all cases: indications are carefully thought out.


[Immature hemangiomas in children].

[Immature hemangiomas in children]. Immature haemangiomas affect only infants and children and follow a peculiar course: first an expansion phase, then an involution phase which ends in complete cure in the majority of cases. Because of this favorable outcome, all inopportune treatments must be avoided, and abstention is the best attitude. However, early corticosteroid therapy must be prescribed when the lesion is located in a dangerous area, such as the eyelids or the lips. Specific treatments must be instituted only in very special cases, such as visceral or giant cutaneous haemangiomas or Kasabach-Merritt syndrome.


[Port wine hemangioma].

[Port wine hemangioma]. Port wine stains are mainly due to an increase in the number or size of dermal capillary vessels. They are a natural disgrace which, in their most common form (i.e. isolated and non-systematized), requires a cosmetic treatment. It is for this purpose that various therapies were formerly prescribed with inconstant results. Since the development of lasers, notably the argon laser and, most recently, the pulsed dye laser, these treatments have become obsolete. Before they fall into oblivion, it must be remembered that until the seventies radiotherapy was part of the old methods and that all cases of port wine stain now seen in adults must be followed up with particular attention if they have received radiotherapy in their childhood.


[Superficial venous malformations].

[Superficial venous malformations]. Mature vascular malformations of the venous compartment are haemodynamically inactive and persist throughout the patient's life. They have no systemic repercussions, except in patients with disorders of coagulation (e.g. disseminated intravascular coagulation), but they have local, cosmetic and functional repercussions. Percutaneous embolization, notably with Ethibloc, has modified their prognosis favourably. This simple and effective procedure is mainly used for superficial venous malformations of the face.


[Temporo-masseter vascular malformations]. Temporo-masseterine vascular malformations are mature capillarovenous malformations. Being congenital lesions, they are present at birth and progress throughout life, particularly before adolescence. The clinical diagnosis rests on the finding that the malformation swells when the patient is in supine position. Its extent is determined by MRI. Treatment is radiosurgical and always begins with one or several embolizations using Ethibloc. Surgical resection, which is exceptionally complete, may be performed to make the face symmetrical.


[Arteriovenous malformations].

[Arteriovenous malformations]. Arteriovenous malformations (AVM) are the most dangerous of vascular malformations, being haemodynamically active. These malformations proceed in two phases: a phase of quiescence which may last throughout life, and an unpredictable phase of activity sometimes triggered by a trauma or by hormonal variations (puberty, pregnancy, oral contraceptives). Treatment must be careful usually limited, and considered in the phase of activity. A multidisciplinary consensus is necessary.


[Lymphangioma].

[Lymphangioma]. The term lymphangioma applies to two types of vascular malformations with very different prognoses: cystic lymphangioma, a benign and easy to treat condition, and tissue lymphangioma, a deeply infiltrating lesion the course of which is sprinkled with complications which may be severe in some locations. Therapeutic sclerosis of cystic pouches with ethibloc gives excellent results and must be performed prior to any surgical treatment, but it is ineffective in tissue lymphangioma which requires a difficult and often maiming treatment. Both types of lymphangioma may coexist, each one following a different course.