Vascular endothelial damage and repair in antineutrophil cytoplasmic antibody-associated vasculitis

OBJECTIVE

Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is characterized by necrotizing vessel wall inflammation, paralleled by the detachment of endothelial cells. The repair of such endothelial defects is crucial for the maintenance of regular structure and function of the injured vessels. Bone marrow-derived endothelial progenitor cells (EPCs) are thought to play a pivotal role in the regeneration of damaged endothelium. The aim of this study was to investigate whether EPCs are involved in vascular repair in AAV.

METHODS

We assessed disease activity, CD34+ hematopoietic progenitor cells (HPCs) using flow cytometry, EPCs using an in vitro assay, and circulating endothelial cells (CECs) by immunomagnetic isolation from the peripheral blood of 31 patients with active AAV at 1, 3, and 6 months after the initiation of immunosuppressive therapy.

RESULTS

In patients with untreated active disease, HPC and EPC numbers were comparable with those in healthy control subjects (n = 64). With the induction of remission, the number of HPCs and EPCs increased significantly, from a median of 1.5 cells/microl (range 0.0-7.0) to a median of 3.2 cells/microl (range 0.76-9.2) (P < 0.001) and from a median of 261 cells/high-power field (range 171-643) to a median of 470 cells/high-power field (range 168-996) (P < 0.021), respectively. In contrast, the initially elevated number of CECs decreased significantly (P < 0.001). We observed no correlation between the number of HPCs or EPCs and the leukocyte count, the thrombocyte count, or kidney function.

CONCLUSION

In patients with AAV, the numbers of circulating CD34+ HPCs and EPCs increased significantly after the institution of immunosuppressive therapy and disease remission. This finding points to a role of circulating CD34+ HPCs and EPCs in endothelial repair in vasculitis. Targeted stimulation of these cells might represent a new possibility of improving vascular healing in AAV.

Circulating endothelial cells in relapse and limited granulomatous disease due to ANCA associated vasculitis

OBJECTIVES

To evaluate numbers of circulating endothelial cells (CECs) in ANCA associated vasculitis and compare vasculitic relapse with limited granulomatous disease.

METHODS

Sixteen patients with vasculitic relapse of ANCA associated vasculitis and 12 patients with limited granulomatous disease due to Wegener's granulomatosis (WG) were studied. Six patients with newly diagnosed vasculitic disease and six patients with vasculitis with infectious complications were also studied. Twenty two patients in remission were studied, as were 20 healthy controls. Counting of CECs was performed with anti-CD146 driven immunomagnetic isolation and staining with Ulex Europaeus lectin 1(UEA-1).

RESULTS

Patients with vasculitic relapse had markedly increased numbers of circulating endothelial cells (12-800 cells/ml, median 88 cells/ml) as did patients with newly diagnosed systemic vasculitis (20-216 cells/ml, median 56 cells/ml). Patients with limited granulomatous disease due to WG had only slightly increased cell numbers (4-44 cells/ml, median 20 cells/ml), which were similar to those of patients in remission (4-36 cells/ml, median 16 cells/ml). Numbers of CECs in patients with granulomatous disease were significantly lower than in those patients with relapse or new onset vasculitis (p<0.001). Cell numbers in patients with relapse and new onset vasculitis declined with immunosuppressive treatment. Patients with infection had 4-36 cells/ml (median 10 cells/ml). A cut off value of 20 cells/ml for a positive result yielded 64% specificity and 95% sensitivity for active systemic vasculitis; the positive predictive value was 63% and the negative predictive value 95%.

CONCLUSION

Markedly increased numbers of CECs discriminate active vasculitis from limited granulomatous disease and remission. These findings add further proof to the concept of CECs as a marker of ANCA associated small vessel vasculitis.

An improved assay for enumeration of circulating endothelial cells

Circulating endothelial cells have been established as markers of vascular disease, such as small vessel vasculitis, acute vascular rejection in renal transplant recipients, and cyclosporine-induced endothelial damage. Enumeration of these cells by immunomagnetic isolation and acridine staining remains the gold standard but necessitates considerable experience and expenditure. A simpler test would therefore be of great utility. Hence, our aim was to develop an improved simple assay to enumerate endothelial cells in peripheral blood. We had already used various surface markers to corroborate the endothelial origin of cells. Here, we studied the enumeration of cell numbers with immunomagnetic isolation and a variety of subsequent stains, such as CD31, von Willebrand's factor (vWF) immunocytochemistry, and Ulex europaeus lectin-1 (UEA-1). Eventually, we devised a simple protocol for enumeration using immunomagnetic isolation and a subsequent UEA-1 lectin stain. We evaluated the use of this protocol in parallel to immunomagnetic isolation and acridine counting alone in 92 renal transplant recipients who underwent renal biopsy. Recovery of various concentrations of human umbilical vein endothelial cells from blood was also studied. Immunomagnetic isolation and subsequent UEA-1 staining permits easier enumeration of circulating endothelial cells in peripheral blood. The assay is simple and easy to use, thus allowing for a more widespread use of circulating endothelial cells as a marker of vascular damage.

Kyphectomy in children with myelomeningocele: a long-term outcome study

Twenty-four children with myelomeningocele and a kyphotic deformity treated by surgical correction between 1980 and 1994 were reviewed. Different techniques of instrumentation and spinal fusion were used. The mean age at surgery was 9.5 years. The mean kyphotic angle was 121 degrees preoperatively, 50 degrees postoperatively, and 57 degrees at final follow-up. The postoperative complication rate was high. Delayed wound healing and late skin breakdown with exposure of instrumentation were common problems. Further surgery to remove protruding hardware was necessary in 18 patients. Long posterior instrumentation with fixation to the pelvis had significantly better stability on follow-up than other methods. Despite the prolonged postoperative morbidity in the majority of the study group, the long-term clinical and radiologic outcome at a mean follow-up of 10 years was excellent.

Rural-urban differences in the distribution of parent-reported risk factors for substance use among young adolescents

PURPOSE

We examined rural-urban differences in cumulative risk for youth substance use. A recent report [National Center on Addiction and Substance Abuse (CASA) 2000] found that the rural-urban distribution of substance use and known risk factors for substance use differed; in many cases rural youth showed higher levels of use, as well as higher levels of risk factors. The current investigation, while not directly examining substance use, further examined rural-urban differences in the distribution of risk factors for youth substance use, based on information from parent reports.

METHOD

Study 1 data were collected from a random sample of Midwestern parents (n = 339) with a young adolescent between the ages of 11 and 13 years. Study 2 data were collected from a second sample of Midwestern parents (n = 593).

RESULTS

Analyses of rural-urban comparisons demonstrated higher levels of cumulative risk among rural youth. An evaluation of the sensitivity of the analysis to rural-urban classification schemes indicated that the findings were robust, but that there was some minor variation in rural-urban differences by classification scheme.

IMPLICATIONS

Results contribute to an explanation of findings from earlier reports of rural-urban differences in substance use, and suggest directions for future research on rural-urban distributions of youth risk factors.

Thalidomide produces transfusion independence in long-standing refractory anemias of patients with myelodysplastic syndromes

Thalidomide was administered to 83 patients with myelodysplastic syndrome (MDS), starting at 100 mg by mouth daily and increasing to 400 mg as tolerated. Thirty-two patients stopped therapy before 12 weeks (minimum period for response evaluation), and 51 completed 12 weeks of therapy. International Working Group response criteria for MDS were used to evaluate responses. Intent-to-treat (ITT) analysis classified all off-study patients as nonresponders. Off-study patients belonged to a higher risk category (P =.002) and had a higher percentage of blasts in their pretherapy bone marrow than patients who completed 12 weeks of therapy (P =.003). No cytogenetic or complete responses were seen, but 16 patients showed hematologic improvement, with 10 previously transfusion-dependent patients becoming transfusion independent. Responders had lower pretherapy blasts (P =.016), a lower duration of pretherapy platelet transfusions (P =.013), and higher pretherapy platelets (P =.003). Among responders, 9 had refractory anemia (RA); 5 had RA with ringed sideroblasts; and 2 had RA with excess blasts. By ITT analysis, 19% of patients (16 of 83) responded, and when only evaluable patients were analyzed, 31% (16 of 51) responded. It was concluded that thalidomide, as a single agent, is effective in improving cytopenias of some MDS patients, especially those who present without excess blasts. (Blood. 2001;98:958-965)

Healing madness and despair through meeting

An existential perspective on human suffering suggests that the psychoanalytic view of the unconscious poses a difficult dilemma in regard to self-examination: On the one hand, not to pursue introspection may leave one as a person driven by untoward instinctual urges; on the other hand, to vigorously self-reflect, may result in inexorable despair in regard to the limitations and finitude of mortal existence. The author contends that the reason for the dilemma is rooted in Western psychology--a perspective that regards the human being as an encapsulated consciousness, set separately and competitively apart from other objects in the cosmos. This orientation is shown to pose difficulties in treating madness and despair. By the use of clinical material, the author shows how Martin Buber's notion of authentic dialogue can be useful in efforts to bridge the separation between the sufferer and the healer.

Cognitive processes in panic disorder: an extension of current models

Beck and Clark's 1997 information processing model of panic was presented and evaluated. In general, studies using the Stroop task have shown panic patients have a cognitive bias toward negative and personally relevant information. Several studies have also shown that panic patients tend to have more catastrophic thoughts and are more likely to misinterpret bodily sensations. Further, cognitive-behavioral therapy is more effective than drug therapies. The limitations of the cognitive model and cognitive-behavioral therapy were discussed, and an extension of current models was proposed. The extension of current models combines cognitive-behavioral and psychodynamic concepts and techniques and suggests that exposure in vivo used for agoraphobic situations and interoceptive exposure used for panic should also be applied to the underlying themes of panic disorder.

Inducibility of intra-atrial reentrant tachycardia after the first two stages of the Fontan sequence

OBJECTIVES

We sought to examine the incidence and possible factors for inducible intra-atrial reentrant tachycardia (IART) in a group of patients after two stages of the Fontan sequence but before the operation.

BACKGROUND

Intra-atrial reentrant tachycardia occurs in 10% to 40% of patients after the Fontan operation. No data are available regarding the potential for IART after the first two stages of the Fontan sequence but before the operation.

METHODS

The IART induction protocol included programmed extrastimulation and rapid atrial pacing, with and without isoproterenol.

RESULTS

The median age of the study group (n = 44, 27 males) was 1.7 years (range 1.2 to 5.2). Forty patients were in sinus rhythm. Twelve patients (27%) had inducible, sustained (>1 min) IART. Three patients (8%) had inducible, nonsustained IART. Bivariate analysis revealed that patients with sustained IART were significantly older at their second operation (median 0.54 vs. 0.40 years, p = 0.05). Multivariate logistic modeling revealed that older age (> or =0.55 years) at the second palliative operation (p = 0.04), older age (> or =1.95 years) at evaluation before the Fontan sequence (p = 0.04) and female gender (p = 0.03) were independently associated with sustained IART. A trend toward a greater frequency of sustained IART was seen in those patients with moderate or severe atrioventricular valve regurgitation (p = 0.07) and in those with resection of the atrial septum (p = 0.06).

CONCLUSIONS

The rate of inducible, sustained IART in a group of patients before the Fontan operation is 27% and is associated with older age at the time of second-stage palliation, older age at pre-Fontan evaluation and female gender.

A humanistic psychology for the new millennium

In this article, it is contended that for the past century psychology has not lived up to its mandate as a trusted guide for the establishment of a well-functioning society. Ten responsibilities of an enlightened psychology for the new millennium that are based on humanistic values are discussed.

A psychoanalysis of love: the patient with deadly longing

Freud made some seriously mistaken assumptions about mature love based on his notion about the role unconscious guilt plays in human affairs. Clinical data are presented here about a young man, who implicated in the suicides of two of his colleagues, was more concerned with the failure of his love affair in college than with guilt for his involvement in the suicides. By tracing the functions of shame--a concept the author contends that Freud failed to understand properly--in the patient's relationship with his parents, the author formulates a proactive and optimistic theory of mature love to replace Freud's pessimistic and reductionistic explanation.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Temporal relationships between hormonal and hemodynamic changes in early human pregnancy

BACKGROUND

The systemic hemodynamic profile of human pregnancy is characterized by a decrease in mean arterial pressure, a rise in cardiac output and plasma volume in association with an increase in renal plasma flow and glomerular filtration rate. The factors and the time course responsible for the initial hemodynamic changes seen in human pregnancy have not been completely documented. We hypothesize that systemic and renal hemodynamic changes occur early, prior to the presence of the fetal-placental unit.

METHODS

Thirteen women were studied prior to and immediately following conception in identical fashion at gestational weeks 6, 8, 10, 12, 24 and 36. Individuals underwent mean arterial pressure, cardiac output, inulin and PAH clearance determinations.

RESULTS

Mean arterial pressure decreased by six weeks gestation (mid follicular 81.5 +/- 2.6 vs. six weeks 68.7 +/- 2.0 mm tig, P < 0.001) in association with a significant increase in cardiac output, a decrease in systemic vascular resistance and an increase in plasma volume. Renal plasma flow and glomerular filtration rate increased by six weeks gestation. Plasma renin activity and aldosterone concentration increased significantly by six weeks, whereas norepinephrine levels did not change throughout pregnancy. Atrial natriuretic peptide levels increased later, at 12 weeks gestation. Plasma cGMP levels decreased and cGMP clearance increased by six and eight weeks, respectively.

CONCLUSIONS

Peripheral vasodilation occurs early in pregnancy prior to full placentation in association with renal vasodilation and activation of the renin-angiotensin-aldosterone system. Plasma volume expansion occurs early, followed later by increases in ANP concentration, suggesting that ANP increases in response to changes in intravasular volume.

Cognitive-behavioral therapy for panic: effectiveness and limitations

The cognitive model of panic and cognitive-behavioral therapy were evaluated. It was argued that the cognitive model is not clear about the definition of threat, and that panic is evoked by the fear of the dissolution of the self. Furthermore, panic attacks will not lead to panic disorder unless the individual is experiencing general anxiety and is concerned with his/her physical or mental state. Controlled studies have demonstrated that cognitive-behavioral therapy is superior to other treatments for panic--85% of patients are panic-free at posttreatment and improvements are maintained at follow-up. However, 26% of waiting-list controls are also panic-free making the net percentage of panic-free treated patients 59%. There is room for improvement in at least 50% of patients, and a substantial number of patients continue to take medication and seek additional treatment. There is a need to determine the essential components of cognitive-behavioral therapy. It was predicted that exposure will prove to be the most crucial component. Exposure to phobic situations and interoceptive cues should be extended to the underlying causes of panic disorder, such as concerns with identity and dependency needs.

Patterns of mobilization of copper and iron following myocardial ischemia: possible predictive criteria for tissue injury

Direct evidence for substantial iron and copper mobilization into the coronary flow immediately following prolonged, but not short, cardiac ischemia is presented. When small volumes of coronary flow fractions (CFFs) were serially collected upon reperfusion, after 25-60 min of ischemia, the copper and iron levels in the first CFF were 50-fold and 12- to 15-fold higher, respectively, than corresponding pre-ischemic values. The copper and iron levels after shorter periods (15-21 min) of ischemia were only about five-fold higher than the pre-ischemic values. This demonstrates that the resumption of coronary flow is accompanied by a burst of both metal ions. The levels of Cu/Fe in the CFFs correlated well with the loss of cardiac function following global ischemia of varying duration. After 18 min of ischemia, the residual cardiac function was less than 50%, and the damage was essentially reversible. After 25 min of ischemia, it exceeded 50% and was only partially reversible, while after 35 min, the damage exceeded 80%, and was mostly irreversible. The results are in accord with the hypothesis that copper and iron play causative roles in myocardial injury through mediation of hydroxyl radical production. Thus, the pattern of Cu/Fe mobilization from the tissue into the CFF can be used for the prediction of the severity of myocardial damage following ischemia, and could be developed into useful modalities for intervention in tissue injury.

Contributing factors associated with agoraphobia

24 agoraphobics, 6 panic subjects, and 27 normal controls were compared on several factors assumed to be associated with agoraphobia. As compared to controls, agoraphobics scored higher on these factors, but, in general, there were no differences between agoraphobics and panic subjects without agoraphobia.

Functional biomechanical deficits in running athletes with plantar fasciitis

Plantar fasciitis is a relatively common injury that occurs in running athletes. The disease entity is a good example of an overloaded process of the plantar fascia at its calcaneal insertion. This study was designed to examine the strength and flexibility findings in the muscles that are put on tensile load during running, and which are responsible for controlling the forces on the foot during stance and pushoff, thus modifying the overload. Three groups of athletes underwent physical examination, including checking ankle range of motion in plantar flexion and dorsiflexion. Cybex peak torque measurements were taken at 60 and 180 deg/sec. The groups were a control group of 45 athletes with no symptoms, a group that included 43 affected feet with symptomatic plantar fasciitis, and a group that included the 43 unaffected contralateral feet. Analysis of data showed dynamic range of motion deficits in 38 of 43 affected feet, static range of motion deficits in 37 of 43 affected feet, deficits in peak torque at 60 deg/sec in 41 of 43 affected feet, and deficits in peak torque at 180 deg/sec in 37 of 43 affected feet. Statistical comparison of range of motion showed that the group with symptomatic plantar fasciitis was significantly restricted compared to both control and unaffected contralateral feet groups. Statistical comparison of peak torque showed that the symptomatic plantar fasciitis group was significantly lower than both other groups at both velocities. This study documents strength and flexibility deficits in the supporting musculature of the posterior calf and foot that are affected by plantar fasciitis.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective randomised controlled trial of antimicrobial prophylaxis in hydrocephalus shunt surgery

Despite attempts to reduce their incidence, shunt infections remain a major complication of the treatment of hydrocephalus. Various forms of antimicrobial prophylaxis are in use, but no controlled, statistically valid trial has been conducted to assess their efficacy. Such a trial was therefore carried out and its design is described here. After a 1-year retrospective and prospective study by members of the United Kingdom Hydrocephalus Group to establish feasibility and infection rates, a statistical study showed that at least 712 patients would be required. Six centres were enrolled to fulfil these requirements, and ethical committee approval was obtained at each. The chosen prophylactic regimen was 10 mg vancomycin administered into the ventricular system during surgery. Adults and children undergoing insertion or revision of ventriculoperitoneal shunts were included unless they were receiving therapeutic antimicrobials. Randomisation was by computer-generated numbers. Controls received the antimicrobial regimen, if any, currently used in that centre, the only difference between the two groups being intraventricular vancomycin in the test group. Diagnosis of shunt infection included accepted clinical and microbiological criteria reinforced by measurement of serum C-reactive protein levels. Follow-up was for at least six months. After 2.5 years only 158 patients had been enrolled in the trial, 80 controls and 78 tests. There were 5 preventable infections in the control group and 2 in the test group. In view of the small total the planned statistical analysis was not possible. Therefore, while no problems were encountered with toxicity, the trial failed to enroll enough patients to answer the question of efficacy of antimicrobial prophylaxis in shunt surgery and the reasons for this are discussed.

Handedness and scoliosis convexity: a reappraisal

The handedness of 254 girls with idiopathic scoliosis, minimum age eight years at diagnosis, attending Our Lady's Hospital was related to their scoliosis convexity. Curve patterns were assigned to right or left on the basis of the convexity of the low thoracic component only, regardless of primary curve. The curve pattern matched handedness in 82%. Of 228 right-handed children, 197 had a right convex curve pattern; of 26 left-handed children, 12 had a left convex pattern. The correlation between scoliosis configuration and handedness was statistically significant. This is in contrast to the findings of previous studies, which have considered convexity only, without reference to the configuration of the whole spine. The implication of this finding is that scoliosis is associated with cortical functions.

Equilibrial dysfunction in scoliosis--cause or effect?

To determine whether equilibrial dysfunction is the cause or effect of idiopathic scoliosis, patients with idiopathic scoliosis, congenital scoliosis, and comparable controls were tested, using clinical postural tests and electronystagmographic recording of spontaneous and positional nystagmus, smooth visual pursuit, and rotation-induced nystagmus. The scoliosis patients were stratified as progressive or nonprogressive. Dysfunctional responses occurred in the idiopathic progressive and congenital progressive groups, and in two idiopathic non-progressive patients whose curves subsequently deteriorated. These results suggest that equilibrial dysfunction is characteristic of patients with progressive curves, regardless of etiology, implying that it is secondary to the curve rather than a primary event. Seven patients with progressive curves undergoing surgical correction and stabilization were tested preoperatively and 6 months postoperatively. No change in the responses occurred, suggesting the dysfunction persists at least 6 months following arrest of progression.

Biological model of agoraphobia: a comment

The biological model proposed by Klein was evaluated. It was argued that agoraphobia is not invariably preceded by panic attacks, and Klein's observations may have been restricted to severe cases. Furthermore, there is a need to determine why some individuals who suffer from panic do not develop agoraphobia. The limitations of the basic premises concerning panic and anxiety, dependency needs, and separation anxiety are discussed. A comprehensive model of agoraphobia must consider the interaction between biological dysfunction and cognitive processes. In addition, several diagnostic groups should be compared to clarify which factors are specific to agoraphobia.

Electro-spinal stimulation in children with adolescent and juvenile scoliosis

A series of forty-one patients with adolescent or juvenile idiopathic scoliosis who were treated with electro-spinal stimulation is reported. Nineteen children were removed from the program because of curve progression or unacceptable deformity. Sixteen of these (39%) required surgery as a first alternative. Three were given a brace. Thirteen children have reached skeletal maturity without significant deterioration. Those who did well were in a lower risk category. The efficacy of this form of treatment has not been demonstrated in this series, and it is being discontinued.

Status of a group of spina bifida children not managed by early surgery

At Our Lady's Hospital for Sick Children, Crumlin, the policy towards neonates with Spina Bifida is one of individualised care. This means that those children who, experience has shown, will not be long term survivors are not subjected to procedures that are distressing and traumatic to the infant and parents. They are given full nursery care. A small number of children treated on this basis thrive. The question arises whether or not they have been further handicapped by this approach. Since this is a problem which causes concern to both parents and clinicians, this study reviews the present state of these survivors. In the five year period 1979-1983, there was a total of 192 infants admitted to Our Lady's Hospital with open myelomeningocoele. 66 were treated with early surgical intervention. 75 died without any surgical procedure at a mean of 46 days. 51 children underwent late intervention, despite which 29 died. A group of 22 are alive, aged 3-7 years. The mean first admission of these 22 patients was 77 days and was uneventful. However, all 22 are severely handicapped; all are paraplegic, doubly incontinent and have some degree of mental handicap. All have hydrocephalus graded moderate to gross and 17 have been shunted. Amongst these 22 surviving patients, we have been unable to identify, in the initial period, specific events or developments which have clearly caused additional damage to the infant's intellectual or physical well-being.

Should the tradition of right cerebral hemisphere shunting still prevail?

A review of the literature suggests that the right hemisphere compared with the left may be more sensitive to, and take longer to recover from, cerebral trauma. As there are also grounds for suggesting that shunting may be associated with limited cerebral insult, it is possible to conclude that, theoretically, left hemisphere shunting may be a preferable policy.

Agoraphobia: contributing factors, phobic situations, and exposure in vivo

Contributing factors such as fear of fear, stress, and dependency needs were discussed, and it was suggested that several diagnostic groups should be compared to determine which factors might be specific to agoraphobia. A two-factor theory and preparedness hypothesis were evaluated, and it was concluded that cognitive processes must be considered for a fuller understanding of the onset of agoraphobia. It was argued that the effectiveness of exposure in vivo is based on three essential components, viz., development of self-confidence, acceptance of anxiety, and acquisition of coping skills.

A review of the management policy for new-born spina bifida children at Our Lady's Hospital for Sick Children, Crumlin, 1973-1983

The management policy at Our Lady's Hospital for Sick Children, Crumlin, for newborn spina bifida infants consists of immediate operation for those considered likely to benefit and full nursery care for those who do not have early surgery. In the eleven years since this policy was first implemented, there have been 493 infants admitted with open myelomeningocele, of whom 260 (52.7%) were managed non-operatively. The mortality for all infants so managed was 78% at one year. 171 (66%) of this group died without further intervention. 89 (34%) survived long enough for some form of treatment to be instituted. 41 of these children are still alive and it is felt that their handicaps have not been increased by their early management. It is argued that an approach to management which considers the needs and interests of the individual infant is more acceptable than one that seeks to enforce total care, regardless of circumstances, or the impersonal assignment, by criteria, into "treatment" and "non-treatment" groups.

Diastematomyelia: a critical review of the natural history and treatment

Twenty-eight children whose diastematomyelia had been diagnosed at Our Lady's Hospital, Crumlin, were reviewed with respect to presenting symptoms, treatment, and outcome. Two children suffered significant neurologic damage during prophylactic removal of their bone spurs. Three children underwent spinal correction under traction with their bony spurs in situ without suffering any neurologic sequelae. The morbidity and mortality of surgical removal of bone spurs was considered and the traditional approach to this condition questioned.

A comparison of neurological function in growth-retarded and appropriate-sized full-term newborn infants in two ethnic groups

A comparative neurological study was undertaken of growth-retarded or small-for-dates (SFD) and appropriately grown (AFD) full-term infants in a Cape Coloured and a White (London, UK) population. There were no associated complications of pregnancy or labour. Consistent differences were found between SFD and AFD infants in both ethnic groups. In the SFD infants there was an increase in visual and auditory orientation, alertness, startle reflexes, tremors and tone, and some reduction in habituation. The difference between our results and those of earlier authors can probably be accounted for by factor such as use of drugs in labour, perinatal events and different causes of growth retardation, all of which may influence neurological behaviour.

Primary orbital schwannomas

Seven histologically proved cases of primary orbital schwannoma have been seen at the University of British Columbia Orbital Clinic between September 1976 and December 1980. We describe here their varied clinical presentations, preoperative investigations, operative findings, and appearances on light and electron microscopy. Although no single feature is pathognomonic, a multiplicity of clinical, radiographic, and surgical features point to this lesion. Of preoperative investigations the computed tomography scan was the most helpful, especially in localising the lesion. Of the 7, 4 were intraconal and 3 were extraconal. The surgical approach was dictated by tumour site and included anterior, lateral, and panoramic orbitotomies. At surgery the nerve of origin of 4 of the tumours was identified. All tumours were excised totally or subtotally. There has been no recurrence to date.

Interferences in the delta-aminolevulinic acid dehydratase (ALA-D) assay

A systematic study of the effect of procedural variables on the ALA-D assay has been carried out. Because of metal content in vacutainers, artifactual results are obtained on blood samples drawn by this method and the method of choice is the use of plastic syringes and tubes. The use of isopropyl alcohol as a skin sterilizing agent, although it gives measurable blood alcohol readings, does not affect the ALA-D assay. The handling of the whole blood has been investigated and the two methods of hemolysis compared. Trichloroacetic acid, a reagent used in the final assay of porphobilinogen, has been found to be a serious interference in the method, making it essential for this reagent to be kept in a securely sealed container. The deterioration of the trichloroacetic acid--mercuric chloride reagent is also a potential procedural problem that must be considered.

Assessment of gestation by ultrasound in various stages of pregnancy in infants differing in size and ethnic origin

A clinical assessment of gestational age after birth has been compared with the ultrasound measurement in utero at various stages of pregnancy in a population of mixed socio-economic status and racial origin. In infants who were small-for-dates or large-for-dates at birth, accurate prediction from ultrasound measurement could only be achieved if the crown rump length or the biparietal diameter was measured before 20 weeks gestation. At this time, the infants destined to be small-for-dates or large-for-dates at birth show no growth retardation or acceleration. There is also no influence of racial origin on the measurements.