Changes in sample size and length of follow-up to maintain power in the coronary artery bypass graft (CABG) patch trial

The CABG Patch Trial is testing the hypothesis that prophylactic use of implantable cardiac defibrillators (ICDs) will improve survival in high-risk coronary heart disease patients undergoing CABG surgery. The original design called for 800 patients to be randomized to ICD prophylaxis or to no therapy and followed for 2 to 6.5 years (average, 40 months) to a common termination date. Since the ICD pulse generators used in this trial lasted about 42 months, the original design required ICD replacement in many patients. At its first two meetings in 1993, the Data and Safety Monitoring Board (DSMB) formalized a plan to adjust sample size in October 1994 if the control group mortality rate was lower than expected. In June 1994, an unanticipated and unique event--a subpoena from the Office of the Inspector General (OIG)--made it impossible to replace about half of the ICD generators and threatened to shorten follow-up substantially. If follow-up had been stopped on the date originally planned, but without replacing ICDs, the average follow-up would have fallen from 40 months to about 33 months. Also, in October 1994, the control group mortality rate was found to be somewhat lower than expected. Together, the abbreviated follow-up and lower control group mortality threatened to reduce power substantially. The DSMB reviewed several options for restoring power. Because mortality rates in the first month after CABG surgery were about seven times as high as thereafter and because ICD therapy did not reduce surgical mortality (death during the first 30 days), extending the follow-up benefits power more than does increasing the sample size. However, the limit on extending follow-up was 42 months (the expected battery life of the ICD). Data from the ICD-treated group was not reviewed or considered in making the decision. After reviewing many options for restoring power, the DSMB recommended that the sample size be increased from 800 to 900 patients and that almost all patients be followed for 42 months. This recommendation extended follow-up for 2 years beyond the original termination date planned for the trial and dictated that patients close out after 42 months rather than on a common termination date.

[Autologous thrombocyte administration in treatment of idiopathic macular foramen]

BACKGROUND

Recent studies have shown the usefulness of pars plana vitrectomy with the use of growth factors in the treatment of macular holes. Autologous platelet concentrates contain many growth factors to stimulate glial wound healing.

PATIENTS

Nineteen patients with idiopathic macular hole underwent vitrectomy, membrane peeling, air injection and installation of autologous platelet concentrate (0.1 ml). The platelet concentrate contained a mean of 1.8 x 10(9) platelets/ml.

RESULTS

The anatomic success rate in stage 2 macular hole was 100%, in stage 3, 82% and in stage 4, 50%. Visual acuity improved in all patients with stage 2 (two lines) and in 73% of stage 3 at least (one line).

CONCLUSION

Platelets are effective in the treatment of macular holes due to the high amount of different growth factors (PDGF, EGF, bFGF, IGF-1) which have a high affinity binding to Müller cells helping to seal the hole by photoreceptor adaption.

[Paracelsus and sectarian movements in medicine]

During his entire life Paracelsus used to criticize sectarianism in medicine. All trends, even the scientific ones, incur the danger to develop into sects, namely when they consider solely one cause for diseases and one treatment. Paracelsus often filled traditional prescriptions and used traditional methods, however, he worked as well in part with early homeopathy, magnetopathy and with magic and spiritual healing. Even wonders were not excluded. This all corresponds to an open, realistic medicine. Sectarian behaviour begins, however, when any of these trends is considered the only effective one. Most important in the medical philosophy of Paracelsus is the admission of the limitations of medicine and of all its trends. Through this scientific humility the physician knows that palliation in seemingly or really hopeless situations is one of his noblest tasks.

Vitrectomy for traction macular detachment in diabetic retinopathy

BACKGROUND

A small number of eyes with proliferative diabetic retinopathy develop massive central fibrovascular membranes characterized by vitreoretinal tractions along the arcades and optic disk and retinal traction lines extending through the macula. The aim of our study was first to present the results of vitrectomy for removal of these central membranes and second to determine the correlation between preoperative parameters and postoperative visual outcome.

SUBJECTS AND METHODS

We treated 28 eyes with severe central fibrovascular diabetic membranes by a modified bi-manual en bloc excision technique during vitrectomy. Preoperative examination included general status, visual acuity, slit-lamp investigation, binocular funduscopy, ultrasound investigation and visual evoked potentials (VEP). Further, we analyzed intraoperative complications and postoperative anatomic and functional outcomes.

RESULTS

The retinas of 27 eyes with central traction retinal detachments were reattached by surgery. With a minimum of 6 months' follow-up, the macula remained attached in 24 eyes, while the retinas were completely attached in 22 eyes. Preoperative visual acuity was defective light perception to 0.1; an increase in visual acuity to maximal 0.1 was seen in 50% of the patients postoperatively. Preoperative visual acuity of light perception was associated with no functional improvement. Preoperative ultrasound investigation gave information about the real anatomic situation of the retina, especially if funduscopy was not possible. The other preoperative parameters could not predict correctly the functional outcome of vitrectomy in diabetics with severe central fibrovascular membranes because of the damage of the optic nerve and the retina.

CONCLUSIONS

The high rate of anatomical reattachment after vitrectomy in diabetic eyes with severe central fibrovascular membranes is associated with a slight improvement of function; only preoperative visual acuity of hand motions or better was associated with an improvement of function.

[Primary vitrectomy in endophthalmitis]

From January 1994 to January 1996, 18 patients underwent vitrectomy as a result of endophthalmitis. All patients received intraocular and systemic antibiotics in accordance with the first group of patients in the Endophthalmitis Vitrectomy Study. The aim of this retrospective study was to analyze the visual outcome of surgical treatment.

METHODS

Data from 18 consecutive patients, 11 women and 7 men, with the diagnosis of endophthalmitis as indication for vitrectomy were evaluated. The patients' ages ranged from 14 to 93 years (mean 66.6 +/- 21.3). Postoperative follow-up ranged from 6 weeks to 10 months.

RESULTS

Endophthalmitis resulted from cataract surgery with implantation of an intraocular lens in 14 patients and from ocular trauma in 2 patients. Endophthalmitis followed the resection of posterior capsule fibrosis in 1 patient. Another patient suffered from endogenous endophthalmitis. Positive cultures were obtained in 12 patients. The most frequent causative organisms were coagulase-negative Staphylococcus (n = 7) and Streptococcus species (n = 4). Visual outcome: 13 of 18 patients (72%) gained a visual acuity of 20/400 or better at the final examination after vitrectomy. Four patients (22%) reached a visual acuity of 20/50 or better. Two eyes were enucleated. Good functional outcome was achieved in 2 patients with streptococcal infection (20/200; 30/50).

CONCLUSION

Vitrectomy in combination with intraocular antibiotics is a suitable method for the treatment of endophthalmitis and results in preservation of ambulatory vision in 72% of patients. Vitrectomy in endophthalmitis can result in good functional outcome even in the case of infections with streptococcal species.

A serine/arginine-rich nuclear matrix cyclophilin interacts with the C-terminal domain of RNA polymerase II

The largest subunit of RNA polymerase II shows a striking difference in the degree of phosphorylation, depending on its functional state: initiating and elongating polymerases are unphosphorylated and highly phosphorylated respectively. Phosphorylation mostly occurs at the C-terminal domain (CTD), which consists of a repetitive heptapeptide structure. Using the yeast two-hybrid system, we have selected for mammalian proteins that interact with the phosphorylated CTD of mammalian RNA polymerase II. A prominent isolate, designated SRcyp/CASP10, specifically interacts with the CTD not only in vivo but also in vitro . It contains a serine/arginine-rich (SR) domain, similar to that found in the SR protein family of pre-mRNA splicing factors, which is required for interaction with the CTD. Most remarkably, the N-terminal region of SRcyp includes a peptidyl-prolyl cis - trans isomerase domain characteristic of immunophilins/cyclophilins (Cyp), a protein family implicated in protein folding, assembly and transport. SRcyp is a nuclear protein with a characteristic distribution in large irregularly shaped nuclear speckles and co-localizes perfectly with the SR domain-containing splicing factor SC35. Recent independent investigations have provided complementary data, such as an association of the phosphorylated form of RNA polymerase II with the nuclear speckles, impaired splicing in a CTD deletion background and inhibition of in vitro splicing by CTD peptides. Taken together, these data indicate that factors directly or indirectly involved in splicing are associated with the elongating RNA polymerases, from where they might translocate to the nascent transcripts to ensure efficient splicing, concomitant with transcription.

[Endophthalmitis--clinical picture, therapy and prevention]

BACKGROUND

Infectious endophthalmitis is a dreaded situation in ophthalmology, since it often induces a substantial reduction of visual acuity, and in some cases the loss of the eye despite modern medication and surgical treatment methods.

OBJECTIVE OF THE STUDY

Compilation of the most important characteristics of postoperative endophthalmitis with acute, delayed and chronic course, posttraumatic endophthalmitis and endogenous endophthalmitis. Comprising the results of the endophthalmitis vitrectomy study, a review of the pharmacotherapy and surgery required is presented.

THERAPY

Acute postoperative endophthalmitis is treated by a combination of broad-spectrum antibiotics (vancomycin and ceftazidime or amikacin), which are administered intravitreally, subconjunctivally and topically, if appropriate in combination by systemic antibiotics (vancomycin and ceftazidime or amikacin). If vision diminshes to mere light perception, performance of pars plana vitrectomy is indicated. Treatment of acute postoperative endphthalmitis with delayed occurrence requires that the underlying complications (e.g. suture dehiscences) are eliminated, and is carried out in accordance with the therapeutic principles for acute postoperative endophthalmitis. In chronic postoperative endophthalmitis, which is caused by bacteria, antibiotics (aminoglycosides or vancomycin) are administered topically and intravitreally. If antibiotic treatment is unsuccessful, a pars plana vitrectomy must be performed including posterior capsulotomy, appropriate with total removal of the capsular sac including the posterior chamber lens. In postoperative mycotic endophthalmitis, antimycotics (amphotericin B) are administered intravitreally. If findings are severe, a pars plana vitrectomy must also be carried out with excision of capsule, if necessary with removal of the posterior chamber lens. Antimycotics are applied topically to support treatment. Acute posttraumatic endophthalmitis is treated by intravitreal antibiotic administration (vancomycin and ceftazidime or amikacin) in combination with pars plana vitrectomy and removal of foreign body. Treatment is supplemented by systemic, subconjunctival and topical antibiotic administration. To reduce ocular destruction due to inflammation, systemic and intravitreal administration of steroids is recommended in all postoperative and posttraumatic endophthalmitis conditions. Treatment of endogenous endophthalmitis requires collaboration with an internist. Systemic therapy with antibiotics or mycotics is obligatory. In addition, broad-spectrum antibiotics (vancomycin or aminiglycosides) or antimycotics (amphotericin B) are administered topically and intravitreally in these conditions. In severe ocular infections, pars plana vitrectomy is indicated.

PREVENTION

To reduce the risk of infection, patients with infectious eye diseases should be excluded from elective operations. Special attention must be paid to risk patients with defects of the immune system. Observation of hygienic regulations is obligatory. Prophylactic perioperative administration of antibiotics has proved to be effective. Patients suffered from penetrating or perforating injuries get systemic antibiotics prophylactically. Qualified follow-up care of the patient is necessary.

CONCLUSIONS

The therapeutic principles for treatment of acute postoperative endophthalmitis are determined by the endophthalmitis-vitrectomy-study. Further investigations are required with respect to corticosteroid use.

[Hymenoptera venom allergy]

In the light of two case reports we summarize the clinical presentation, classification, diagnosis and therapy of hymenoptera sting allergy. Clinically, large local reactions are distinguished from systemic allergic reactions. The latter are divided into four degrees of severity as defined by H.L. Mueller. Diagnosis is based primarily on the history. Detection of venom specific IgE-antibodies and/or positive venom skin tests confirm the diagnosis and are helpful for identification of the responsible insect. All patients should be equipped with an emergency kit (antihistamine, corticosteroid). In the presence of a history of systemic allergic reactions, adrenaline must be added. For highly exposed patients and those with a history of threatening reactions, specific immunotherapy is recommended. Most patients are fully protected by this treatment.

The rewards outweigh the efforts: breastfeeding outcomes for mothers of preterm infants

This study describes the rewards and efforts of breastfeeding for mothers of preterm infants. Using a semi-structured interview guide, 20 mothers of preterm infants were interviewed in their homes approximately 1 month after infant discharge from a Level III NICU. Mothers described the following rewards of breastfeeding: knowing they were providing the healthiest nutrition for the infant, enhancing closeness between the mother and infant, perceiving infant contentment and tranquility during breastfeeding, providing convenience for the mother, and giving the mother a tangible claim on the infant. Most mothers identified some "efforts" associated with breastfeeding their preterm infants, but indicated that overall, breastfeeding was a rewarding experience. These data provide scientific support for the promotion and facilitation of breastfeeding for mothers of preterm infants, in that mothers perceive specific emotional advantages that they relate to the breastfeeding experience.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median) and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

[Sudan staining of impression cytology retinal specimen]

BACKGROUND

Long-term silicone oil tamponade may cause increased numbers of vacuoles in the retina. Conventional methods of histological preparation dissolve silicone oil and optically empty spaces are seen.

METHOD

We examined the retinas of 20 human eyes after silicone oil injection. We obtained the material by peripheral retinectomies during vitrectomy for recurrent retinal detachment. The material was prepared by impression cytology. The time between silicone oil injection and vitrectomy was 3-18 months. The non-fixed cell sheets were stained with Sudan III, followed by a counterstaining with hematoxyline.

RESULTS

Sudan III stained silicone oil 1000 mPa orange-yellow. Sudan-III-stained vacuoles in the retina were found in eight eyes with intraocular silicone oil instillation; in five of these eyes an emulsification of silicone oil was observed. The staining of retinal vacuoles seemed to be caused by the presence of silicone oil in the vacuoles.

CONCLUSIONS

Using impression cytology and the Sudan staining procedure, it was possible to stain vacuoles in non-fixed retinal preparations. A long-term silicone oil tamponade induces these vacuoles in the retina, especially if the silicone oil is emulsified. In order to prevent this complication, removal of emulsified silicone oil should be performed as early as possible.

[Vitreous and fundus changes in Terson syndrome. 3 case reports]

BACKGROUND

Terson syndrome is defined as the presence of intraocular hemorrhages in association with a sudden increase in intracranial pressure. The hemorrhages can occur in the subretinal space, within the sensory retina, between the retina and the hyaloid membrane and in the vitreous cavity.

PATIENTS

We report about three eyes from two patients with Terson syndrome, in which vitreous hemorrhages were noted. In one eye we observed a preretinal macular hemorrhage. Pars plana vitrectomy was performed in two eyes.

RESULTS

The hyaloid was surgically peeled away, which showed a membrane covering the macula. When this membrane was stripped away a retinal fold 360 degrees surrounding the macula was noted, in one eye a light fibrotic line was visible. The premacular hemorrhage and the intrahyaloidal hemorrhages in this eye were resorbed spontaneously after 5 months. In all eyes visual acuity increased to 1,0.

CONCLUSION

In most eyes with Terson syndrome it is possible to wait for the spontaneous resorption of the blood. It is hypothesized that blood from a ruptured vein or capillary hydrodissects the internal limiting membrane from the underlying neurosensory retina. If a pars plana vitrectomy is performed the possibility of a hydraulical dissected internal limiting membrane has to be considered. Postoperatively perimacular retinal folds or fibrotic lines may occur, they didn't have any clinical evidence.

The Pittsburgh randomized trial of tacrolimus compared to cyclosporine for hepatic transplantation

BACKGROUND

Tacrolimus (formerly FK506) was first used clinically in 1989 to successfully replace cyclosporine in hepatic transplant recipients who were experiencing intractable rejection or as the baseline drug from the time of operation. After extensive pilot experience, an institutional review board-mandated clinical trial comparing cyclosporine with tacrolimus was performed.

STUDY DESIGN

From February 16, 1990 to December 26, 1991, 154 patients were recruited. The competing drugs were combined with equal induction doses of prednisone in both arms of the study for the first 81 patients and with subsequently higher doses of prednisone in the remaining 35 patients who received cyclosporine and were entered into the trial. Drug crossover was permitted for lack of efficacy or adverse events. End points were rejection confirmed by biopsy and treatment failure leading to retransplantation or death.

RESULTS

Seventy-nine patients were randomized to the tacrolimus arm and 75 to the cyclosporine arm during 1990 and 1991. All patients were available for follow-up throughout the trial, which terminated on May 30, 1995. The mean duration of follow-up was four years. Patients randomized to the tacrolimus arm were less likely to experience acute rejection than were those receiving cyclosporine, with 36.2 percent of the patients receiving tacrolimus and 16.8 percent of the patients receiving cyclosporine showing freedom from rejection at one year (p = 0.003, likelihood ratio test). Survival of patients over the course of the study was virtually the same in the two groups.

Endoscopic management of biliary tract strictures in primary sclerosing cholangitis

BACKGROUND AND STUDY AIMS

In a subgroup of patients, primary sclerosing cholangitis (PSC) is complicated by high-grade focal strictures of the bile ducts, and this can have an unfavorable influence on the natural course of the disease. The aim of this study was to evaluate the efficacy and safety of endoscopic treatment in this selected patient group.

PATIENTS AND METHODS

Twelve symptomatic patients with primary sclerosing cholangitis and major ductal strictures were included in a prospective study of endoscopic treatment. All patients were managed by repeated angioplasty-type balloon dilation and nasobiliary catheter perfusion. A minimum of two treatment sessions was used, and therapy was continued until satisfactory reopening of the strictures was obtained. Routine endoscopic follow-up was performed after three, six, 12, 18, and 24 months, and then at yearly intervals. The efficacy of therapy was assessed by evaluating clinical symptoms, laboratory data, and cholangiograms.

RESULTS

The long-term follow-up averaged 23 months (range: 12-50 months). Two to nine (mean: three) treatment sessions were required to obtain satisfactory reopening of major biliary strictures. Eight patients showed considerable and sustained improvement. The mean serum bilirubin, alkaline phosphatase, gamma-glutamyl-transpeptidase, and alanine aminotransferase levels felt significantly by 73% (P = 0.0164), 46% (P = 0.0022), 55% (P = 0.0022), and 58% (P = 0.0022), respectively. The average radiographic stricture score before treatment was 3.2 +/- 0.8 (P = 0.0033). Three patients required liver transplantation seven, 12, and 40 months after the initiation of endoscopic treatment, due to a deterioration in hepatic function or an inability to exclude complex biliary malignancy. No major procedure-related side effects were observed.

CONCLUSIONS

Our results suggest that the endoscopic treatment of PSC patients with dominant bile duct strictures is effective, safe, and well-tolerated. However, it is important not to overlook the potential development of cholangiocarcinoma.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median), and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

The Pittsburgh randomized trial of tacrolimus compared to cyclosporine for hepatic transplantation

BACKGROUND

Tacrolimus (formerly FK506) was first used clinically in 1989 to successfully replace cyclosporine in hepatic transplant recipients who were experiencing intractable rejection or as the baseline drug from the time of operation. After extensive pilot experience, an institutional review board-mandated clinical trial comparing cyclosporine with tacrolimus was performed.

STUDY DESIGN

From February 16, 1990 to December 26, 1991, 154 patients were recruited. The competing drugs were combined with equal induction doses of prednisone in both arms of the study for the first 81 patients and with subsequently higher doses of prednisone in the remaining 35 patients who received cyclosporine and were entered into the trial. Drug crossover was permitted for lack of efficacy or adverse events. End points were rejection confirmed by biopsy and treatment failure leading to retransplantation or death.

RESULTS

Seventy-nine patients were randomized to the tacrolimus arm and 75 to the cyclosporine arm during 1990 and 1991. All patients were available for follow-up throughout the trial, which terminated on May 30, 1995. The mean duration of follow-up was four years. Patients randomized to the tacrolimus arm were less likely to experience acute rejection than were those receiving cyclosporine, with 36.2 percent of the patients receiving tacrolimus and 16.8 percent of the patients receiving cyclosporine showing freedom from rejection at one year (p = 0.003, likelihood ratio test). Survival of patients over the course of the study was virtually the same in the two groups.

Transcription factor AP-2 essential for cranial closure and craniofacial development

During closure of the neural tube in the mouse, transcription factor AP-2 is expressed in ectoderm and in neural-crest cells migrating from the cranial neural folds. Cranial neural crest cells provide patterning information for craniofacial morphogenesis, generate most of the skull bones, and together with placodal ectoderm, form the cranial ganglia. To study the role of AP-2 during embryogenesis, we undertook a targeted mutagenesis of the AP-2 gene in the mouse. Here we report that AP-2(-/-) mice died perinatally with cranio-abdominoschisis and severe dismorphogenesis of the face, skull, sensory organs and cranial ganglia. Failure of cranial closure between 9 and 9.5 days postcoitum coincided with increased apoptosis in the midbrain, anterior hindbrain and proximal mesenchyme of the first branchial arch, but did not involve loss of expression of twist or Pax-3, two other regulatory genes known to be required for cranial closure.

Resolution of intracranial calcifications in infants with treated congenital toxoplasmosis

PURPOSE

To determine the natural history of intracranial calcifications in infants with treated congenital toxoplasmosis.

MATERIALS AND METHODS

Between January 1982 and March 1994, cranial computed tomography was performed in 56 infants with treated congenital toxoplasmosis when they were newborns and approximately 1 year old. Locations and sizes of intracranial calcifications were noted.

RESULTS

Forty newborns had intracranial calcifications. By 1 year of age, calcifications diminished or resolved in 30 (75%) and remained stable in 10 (25%) of these treated infants. Ten (33%) of the 30 infants whose calcifications diminished versus seven (70%) of the 10 infants with stable calcifications received less intensive antimicrobial treatment than the other treated infants. In contrast, a small number of infants who were untreated or treated 1 month or less had intracranial calcifications that increased or remained stable during their 1st year of life.

CONCLUSION

Diminution or resolution of intracranial calcifications was an unexpected and remarkable finding in infants with treated, congenital toxoplasmosis, consonant with their improved neurologic functioning.

The protective effect of immunologic boosting against zoster: an analysis in leukemic children who were vaccinated against chickenpox

Whether reexposure of varicella-immune persons to varicella-zoster virus would protect against or predispose to development of zoster was analyzed. The rate of zoster in 511 leukemic recipients of varicella vaccine who had 1 or > 1 dose of varicella vaccine and in those who did or did not have a household exposure to varicella was determined. A Kaplan-Meier life-table analysis revealed that the incidence of zoster was lower in those given > 1 dose of vaccine (P < .05). A Cox proportional hazards analysis showed that both household exposure to varicella and receipt of > 1 dose of vaccine were highly protective (P < .01) against zoster. Thus, the risk of zoster is decreased by reexposure to varicella-zoster virus, either by vaccination or by close exposure to varicella.

[Postoperative vomiting after pars plana vitrectomy]

In the present investigation we compared two different techniques of anaesthesia--total intravenous anaesthesia (TIVA) versus balanced anaesthesia--with and without antiemetic prophylaxis, with regard to postoperative nausea, strangling irritation and vomiting and their influence upon postoperative complications (intraocular bleedings) and postoperative intraocular pressure after pars plana vitrectomia. For this investigation four groups were formed. The anaesthesias were carried out as orotracheal intubational anaesthesia following two standard techniques, which only differ in the choice of the narcotics. Half the patients in each group were treated with an antiemetic prophylaxis of 2.5 mg DHBP. With regard to the occurrence of postoperative nausea and vomiting, the TIVA-groups proved to be better than those with balanced anaesthesia (16% to 43.5%; p < 0.05): DHBP in both methods led to a reduction of postoperative vomiting and nausea, but the differences showed not to be significant (p > 0.05). Best results were achieved with a combination of TIVA (propofol, alfentanil, atracurium, air/O2) and DHBP (4.7%). The total rate of postoperative complications in form of intraocular bleedings amounted to 8.6%. The appearance of complications increased when postoperative nausea and vomiting or increased intraocular pressure were observed (16.6% to 6.3%; 21.2% to 6.1%). Intraocular pressure, measured for four hours postoperatively, was significantly lower in the TIVA-groups than in the balanced anaesthesia-groups (15.5 +/- 7.7 mmHg to 18.3 +/- 8.2 mmHg). Therefore, we conclude that TIVA with propofol appears to be especially suitable for intraocular surgery.

Alternative mRNAs encode multiple isoforms of transcription factor AP-2 during murine embryogenesis

Transcription factor AP-2 has been implicated as an important regulator of gene expression during vertebrate embryogenesis. We report here the cDNA cloning and analysis of mouse embryonic mRNA splice variants encoding four AP-2 isoforms. Isoform 1 is the homolog of the previously known human (HeLa) AP-2. The three new AP-2 isoforms all share the same DNA binding/dimerization domain as isoform 1 but either lack the proline-rich transcriptional activation domain encoded by exon 2 (isoform 2) or have different amino-termini encoded by two previously unknown alternative first coding exons for AP-2 (isoforms 3 and 4). All four AP-2 mRNA variants are present at significant levels between Days 11.5 and 17.5 of mouse embryogenesis. Variants 1, 3, and 4 show qualitatively but not quantitatively similar restricted expression patterns in 8.5-12.5 dpc embryos examined by in situ hybridization. At mid-embryogenesis, variant 3 is the major AP-2 mRNA species in the nervous system and in total embryo RNA but is less prevalent than variants 1 and 4 in the epidermis. The four mRNAs are all induced, although unequally, during differentiation of P19 cells into neural cell types and by cAMP stimulation of primary astrocytes. Variants 1-3 are coexpressed in different ratios in HeLa cells and in three human glioblastoma cell lines. These findings reveal that transcriptional regulation by AP-2 is likely to be more complex than previously assumed given the potential for multiple AP-2 homo- and heterodimeric DNA binding forms.

Human cytomegalovirus (HCMV) immediate-early enhancer/promoter specificity during embryogenesis defines target tissues of congenital HCMV infection

Congenital human cytomegalovirus (HCMV) infection is a common cause of deafness and neurological disabilities. Many aspects of this prenatal infection, including which cell types are infected and how infection proceeds, are poorly understood. Transcription of HCMV immediate-early (IE) genes is required for expression of all other HCMV genes and is dependent on host cell transcription factors. Cell type-specific differences in levels of IE transcription are believed to underlie differences in infection permissivity. However, DNA transfection experiments have paradoxically suggested that the HCMV major IE enhancer/promoter is a broadly active transcriptional element with little cell type specificity. In contrast, we show here that expression of a lacZ gene driven by the HCMV major IE enhancer/promoter -524 to +13 segment is restricted in transgenic mouse embryos to sites that correlate with known sites of congenital HCMV infection in human fetuses. This finding suggests that the IE enhancer/promoter is a major determinant of HCMV infection sites in humans and that transcription factors responsible for its regulation are cell type-specifically conserved between humans and mice. The lacZ expression patterns of these transgenic embryos yield insight into congenital HCMV pathogenesis by providing a spatiotemporal map of the sets of vascular, neural, and epithelial cells that are likely targets of infection. These transgenic mice may constitute a useful model system for investigating IE enhancer/promoter regulation in vivo and for identifying factors that modulate active and latent HCMV infections in humans.

Getting enough: mothers' concerns about breastfeeding a preterm infant after discharge

OBJECTIVE

To describe maternal concerns about breastfeeding a preterm infant in the postdischarge period and to delineate the strategies mothers used in managing these concerns.

DESIGN

Naturalistic inquiry was used.

SETTING

A semistructured interview was conducted with the mother in the home 1 month after discharge of the infant.

PARTICIPANTS

Twenty mothers of preterm infants; the infants had been in a level 3 hospital nursery, and the mothers had received individualized breastfeeding support services in the hospital.

MAIN OUTCOME MEASURES

Three categories of maternal concerns emerged from the data: adequate milk consumption by infants; milk composition; and problems with the mechanics of breastfeeding a preterm infant. Mothers identified strategies for these concerns.

RESULTS

The mothers' main concern was whether infants consumed an adequate volume of milk by breastfeeding alone. Strategies for managing concerns about getting enough included using supplemental and complemental feeding, using ongoing cues to tell that the infant is getting enough, and persevering with breastfeeding.

CONCLUSIONS

Mothers of preterm infants have unique concerns about breastfeeding in the postdischarge period and need individualized interventions.

Neurologic and developmental outcome in treated congenital toxoplasmosis

BACKGROUND

Earlier studies have shown that infants with untreated congenital toxoplasmosis and generalized or neurologic abnormalities at presentation almost uniformly develop mental retardation, seizures, and spasticity. Children with untreated subclinical disease at birth have developed seizures, significant cognitive and motor deficits, and diminution in cognitive function over time.

OBJECTIVE

To determine neurologic, cognitive, and motor outcomes for children with congenital toxoplasmosis who were treated for approximately 1 year with pyrimethamine and sulfadiazine.

DESIGN AND METHODS

Systematic, prospective, and longitudinal neurologic, cognitive, and motor evaluations were performed for 36 individuals with congenital toxoplasmosis. These infants were born between December 1981 and January 1991 and were treated with pyrimethamine and sulfadiazine for approximately 1 year beginning in the first months of life. Compliance with medications was documented. These individuals were evaluated in a standardized manner in a single center in the first months of life and at approximately 1, 3.5, 5, 7.5, and 10 years of age. Their cognitive function was compared with the cognitive function of a nearest-age, same-sex sibling when such siblings older than 3.5 years were available for study.

RESULTS

Signs of active central nervous system infection (eg, cerebrospinal fluid [CSF] pleiocytosis, hypoglycorrhachia, elevated CSF protein, and, in some instances, seizures and motor abnormalities) resolved during therapy. Six of the 36 children had perinatal seizures. Four had their anticonvulsant therapy discontinued successfully within the first months of life, and two additional children developed new seizures at 3 and 5 years of age. Tone and motor abnormalities resolved by 1 year of age in 12 of 20 infants who exhibited abnormalities of tone and motor function at their initial neonatal evaluation. By February 1992, 29 of the 36 children had been evaluated when they were 1 year old, and 23 (79%) had a mean +/- standard deviation Mental Developmental Index (MDI) of 102 +/- 22 (range, 59 to 140). Six (21%) had a measure of their cognitive function that was less than 50. Results of sequential IQ tests, performed at 1.5 year intervals or greater, did not differ significantly over time (P > .05). Seven children with MDIs greater than 50 were compared with sibling controls; they had scores of 87 +/- 11 (range, 68 to 97) and their siblings had scores of 112 +/- 15 (range, 85 to 132) (P = .008). Seventeen of 18 children without hydrocephalus and six of eight children with obstructive hydrocephalus responsive to shunting had normal or near-normal neurologic and developmental outcomes. Children with hydrocephalus ex vacuo present at birth, with high CSF protein, and with lack of response to shunting have done less well.

CONCLUSIONS

Neurologic and developmental outcomes were significantly better for most of these treated children than outcomes reported for untreated children or those treated for only 1 month (P < .001). Although the level of cognitive function for treated children was less than for their uninfected siblings (P < .008), there was no significant deterioration in neurologic and cognitive function of the treated children tested sequentially. These favorable treatment outcomes justify systematic identification and treatment of pregnant women with acute gestational Toxoplasma infection and young infants with congenital toxoplasmosis.

Noncytopathic strains of bovine viral diarrhea virus prime bovine bone marrow-derived macrophages for enhanced generation of nitric oxide

Bovine bone marrow-derived macrophages (BBMM) were infected in vitro with a cytopathic (cp) and a noncytopathic (ncp) biotype of bovine viral diarrhea virus (BVDV). The virus strains used, TGAN (ncp) and TGAC (cp), originate from one animal and are antigenically closely related. Both TGAC and TGAN infected a subset of BBMM. Only cp BVDV induced a cytopathic effect. Infection of BBMM resulted in the modulation of certain macrophage functions. Only ncp strains of BVDV primed BBMM for enhanced reactive nitrogen production in response to Salmonella dublin. In contrast, infection with both biotypes did not influence bacteria-induced procoagulant activity and both biotypes equally reduced PMA-induced superoxide production. This suggests that the two biotypes differentially and selectively affect certain macrophage functions related to host defense. For the first time, a BVDV biotype-associated difference has been related to a biochemical parameter of the host cell.

[Mycotic retrobulbar neuritis]

BACKGROUND

Fungal disease is one of the most common complications of malignant haematologic disease. In the major part of the patients the lungs and the gastrointestinal tract are affected. Infections of the eyes and adnexa are very rare.

PATIENT AND METHODS

A 75-year-old woman presented with acute unilateral loss of vision. The history revealed an anaplastic anemia. Vision of the affected eye decreased to light perception. The ophthalmoscopic findings were normal. A retrobulbar tumor was diagnosed by ultrasonography and CT. It was regarded as a glioma or a meningioma. A Non-Hodgkin lymphoma of low malignancy was proven by biopsy of bone marrow; hence a retrobulbar lymphoma was included in the differential diagnosis. Radiation was started, but the general state of health worsened and the patient died. AUTOPSY FINDINGS: A severe mycotic infiltration of the left optic nerve sheath was found, which had broadened the spatium intervaginale. Cause of death was a pneumonia by generalized immunocytoma.

CONCLUSIONS

In cases with retrobulbar tumors and malignant haematologic diseases fungal infections should be included in the differential diagnosis. Serologic investigations are useful. The prognosis is poor and depends on the course of the basic disease.

Caloric loss from expressed mother's milk during continuous gavage infusion

Expressed mother's milk (EMM) provides innumerable immunologic and nutritional benefits. However, the nutritional value of EMM, especially the calorie-rich lipids, may be reduced during continuous gavage infusion (CGI). The purpose of the study was to compare the differences in lipid loss of EMM for two types of CGI tubing: standard bore and minibore. In an experimental design, 30 specimens of EMM were infused using a simulated CGI apparatus with a syringe pump; each of the 30 specimens was aliquotted to infuse through both types of CGI tubing. Preinfusion and postinfusion lipid concentrations were measured by the creamatocrit technique. The mean preinfusion creamatocrit value was 6.57 percent (SD = 2.09) with minimum and maximum values of 3.41 and 10.72 percent respectively (mean caloric content of 22.91 Kcal/oz). The mean postinfusion creamatocrit for standard bore tubing was 4.98 percent (SD = 1.59), with minimum and maximum values of 1.90 and 9.38 percent respectively (mean caloric content = 20.14 Kcal/oz). Mean percent of decrease in lipid concentration between preinfusion and postinfusion values for standard bore tubing was 1.59 percent (SD = 1.10) (mean caloric loss 2.77 Kcal/oz). The mean postinfusion creamatocrit value for the minibore tubing was 5.24 percent (SD = 1.77) with minimum and maximum values of 2.55 and 9.68 percent respectively. This equates to a mean caloric content of 20.59 Kcal/oz. Mean percent of decrease in lipid concentration between preinfusion and postinfusion values for minibore tubing was 1.34 percent (SD = 1.02) (mean caloric loss of 2.32 Kcal/oz).(ABSTRACT TRUNCATED AT 250 WORDS)

[Can medicine move mountains?]

For the author involvement with Paracelsus demands consideration of both, socio-cultural as well as historico-cultural aspects. Each generation has obtained a different picture of this famous physician from Einsiedeln. Around 1941 the progress initiated by Paracelsus has been emphasized, such as the assumed foundation of chemistry, chemotherapy, and the renewal of surgery, occupational medicine, balneology and many more. For the year 1941 (= 400th anniversary of Paracelsus death) a nationalistic perception of Paracelsus was typical. For National-Socialistic Germany, Paracelsus was the founder of a "German medicine" as a contrast to medicine oriented towards France and Jewish-Arabia. Paracelsus also was seen as a pioneer of the experiment and as opponent of medical dilettantism in a popular direction. The perception of Paracelsus of 1993 is completely different. Today Theophrastus from Hohenheim is seen in a post-modern perspective, not as the man of progress, but as one, who opposed to the medicine of his age a partial ancient natural medicine, including the arts of gypsies, witches and midwives. The magic and psychosomatic informations of Paracelsus are seen as precious compensation for losses that we had to accept in the progress of modern medicine. As a psychiatrist Paracelsus was involved with diseases that originated from a "misuse of credo". He reports about collective psychoses, for example those appearing in the group of anabaptists in St. Gallen. Misuse of credo derives from intended provocation of martyrium. To move mountains with one's faith is another pathologic imagination. A therapy should aim at the restitution of such a "mountain" moved by the ill patient. Paracelsus demands the greatest mercy in dealing with mentally ill patients. This disease is also a challenge for theology: "What gives harm to the body destroys the house of the eternal".(ABSTRACT TRUNCATED AT 250 WORDS)

Absence of sensorineural hearing loss in treated infants and children with congenital toxoplasmosis

Educationally significant hearing loss has been reported in 10% to 15% of children with congenital toxoplasmosis. As part of a pilot study to assess feasibility and safety of prolonged therapy for congenital toxoplasmosis, 30 congenitally infected infants and children were evaluated for auditory function. Serial testing, beginning within 2 months of birth, was performed. Availability of auditory brainstem response (ABR) testing made evaluation at an earlier age than previously possible. Six (20%) of the 30 infants had mild to moderate conductive type hearing loss associated with otitis media. No infant or child had sensorineural hearing loss. The better outcome we observed compared to previous reports of a 15% to 26% incidence of sensorineural hearing loss and 10% to 15% incidence of educationally significant, bilateral hearing impairment may be related to early initiation and/or prolonged institution of antimicrobial therapy. Continued followup to exclude progressive hearing impairment and study of larger numbers of children are needed to verify these preliminary findings.

Inhibition by cyclosporine A of the prooxidant-induced but not of the sodium-induced calcium release from rat kidney mitochondria

The use of the immunosuppressive drug cyclosporine A (CSA) is restricted by its nephrotoxicity. Perturbation of Ca2+ homeostasis has been implicated in chemical toxicity. Mitochondria, a key regulator of Ca2+ homeostasis, may be a target of the drug. Here we show that CSA inhibits at low concentrations the prooxidant-induced but not the sodium-induced Ca2+ release from rat kidney mitochondria. CSA does not affect Ca2+ uptake by mitochondria. Inhibition of Ca2+ release is due to inhibition of intramitochondrial enzymatic hydrolysis of NAD+ to ADP-ribose and nicotinamide. These findings suggest a very specific effect of CSA on mitochondrial Ca2+ release by which the drug interferes with cellular Ca2+ homeostasis. This is possibly the basis of CSA nephrotoxicity.

Determination of thiopental in human serum and plasma by high-performance capillary electrophoresis-micellar electrokinetic chromatography

The quantitation of thiopental in human serum and plasma was investigated using high-performance capillary electrophoresis (HPCE) in a micellar configuration and the results were compared with reversed-phase high-performance liquid chromatography (HPLC). Thiopental and an internal standard (carbamazepine for HPCE and thiamylal for HPLC) were extracted from serum or plasma using pentane and a phosphate buffer (pH 6.4). HPCE analysis took place in a phosphate-borate buffer with 50 mM sodium dodecyl sulphate using an automated instrument and HPLC was performed with a C8 column and a mobile phase of phosphate buffer-acetonitrile (65:35, v/v). HPCE and HPLC data from 66 patient samples compared well based on linear regression analysis. However, estimates obtained with the inclusion of the internal standard were lower than those based on the sample peak only. This example allows the elucidation of the advantages of using HPCE as an assay methodology for the therapeutic monitoring of thiopental and other drugs.

Analysis of barbiturates in human serum and urine by high-performance capillary electrophoresis-micellar electrokinetic capillary chromatography with on-column multi-wavelength detection

The analysis of barbiturates in human serum (or plasma) and urine by high-performance capillary electrophoresis-electrokinetic capillary chromatography with on-column fast-scanning multi-wavelength detection is discussed. The use of a buffer of ca. pH 8 and containing sodium dodecyl sulphate provides a medium suitable for fast and high-resolution separations of barbiturates. Seven barbiturates are characterized by their retention and absorption spectra between 195 and 320 nm. Comparison of these computer-stored data with those of unknown samples is shown to allow the identification of barbiturates in samples of patients undergoing pharmacotherapy and in toxicological urine and serum specimens. Three-dimensional electropherograms provide reliable information on the requirement and suitability of sample pretreatment procedures. With urine, extraction of barbiturates prior to analysis is necessary. With human serum several barbiturates, including phenobarbital, are shown to elute in an interference-free window in front of uric acid and the proteins, allowing these substances to be determined by direct sample injection. The need for multi-wavelength detection over a relatively wide wavelength range as a means of peak confirmation in electrokinetic capillary analyses is demonstrated and limitations of this technique for compounds with similar retention behaviour and absorption spectra are discussed.

Patterns of contact phase proteins indicating neuropathy in diabetic patients

In 42 outpatients of the diabetology division, coagulation and fibrinolysis variables were determined in order to detect typical patterns of results with which it was possible to discriminate between three groups with different diabetic complications (17: no complication, 7: angiopathy alone, 18: neuropathy with or without other complications). There was a statistically significant discriminatory function involving C1-inhibitor concentration, high molecular weight kininogen coagulant activity and fibrinogen as the most decisive variables. The neuropathy group was appropriately separated from the others with an 81% correct reclassification. Heparin cofactor II, histidine-rich glycoprotein, alpha 2-macroglobulin, pre-kallikrein and factor XII had no discriminative power.

Inhibition of pro-oxidant-induced mitochondrial pyridine nucleotide hydrolysis and calcium release by 4-hydroxynonenal

Intra- and extra-mitochondrial Ca2+ participates in vital cellular processes. This work investigates the influence of 4-hydroxynonenal (HNE) on pro-oxidant-induced Ca2+ release from rat liver mitochondria. Ca2+ movements across the mitochondrial inner membrane, the pyridine nucleotide redox state and pyridine (nicotinamide) nucleotide hydrolysis were analysed. HNE did not influence Ca2+ uptake by mitochondria, but inhibited in a concentration-dependent manner Ca2+ release induced by t-butylhydroperoxide (tbh). Total inhibition was achieved with about 50 microM-HNE. Ca2+ release induced by the pro-oxidant alloxan was also inhibited by HNE. Oxidation of pyridine nucleotides, induced by tbh through the concerted action of glutathione peroxidase, glutathione reductase and the energy-linked transhydrogenase, was not affected by up to 50 microM-HNE. In contrast, HNE inhibited pyridine nucleotide hydrolysis in a concentration-dependent manner. The data suggest that HNE toxicity may be in part attributed to an impaired intramitochondrial Ca2+ homeostasis.