Prospective assessment of aneurysmal rupture risk scores in patients with subarachnoid hemorrhage: a multicentric cohort

PURPOSE

The natural evolution of unruptured intracranial aneurysms (UIA) is indeed difficult to predict at the individual level.

OBJECTIVE

In a large prospective multicentric European cohort, we aimed to evaluate whether the PHASES, UCAS, and ELPASS scores in patients with aneurysmal subarachnoid hemorrhage would have predicted a high risk of aneurysmal rupture or growth.

METHODS

Academic centers treating patients with intracranial aneurysms were invited to prospectively collect de-identified data from all patients admitted at their institution for a subarachnoid hemorrhage-related to intracranial aneurysmal rupture between January 1 and March 31, 2021 through a trainee-led research collaborative network. Each responding center was provided with an electronic case record form (CRF) which collected all the elements of the PHASES, ELAPSS, and UCAS scores.

RESULTS

A total of 319 patients with aneurysmal subarachnoid hemorrhage were included at 17 centers during a 3-month period. One hundred eighty-three aneurysms (57%) were less than 7 mm. The majority of aneurysms were located on the anterior communicating artery (n = 131, 41%). One hundred eighty-four patients (57%), 103 patients (32%), and 58 (18%) were classified as having a low risk of rupture or growth, according to the PHASES, UCAS, and ELAPSS scores, respectively.

CONCLUSION

In a prospective study of European patients with aneurysmal subarachnoid hemorrhage, we showed that 3 common risk-assessment tools designed for patients with unruptured intracranial aneurysms would have not identified most patients to be at high or intermediate risk for rupture, questioning their use for decision-making in the setting of unruptured aneurysms.

Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

BACKGROUND AND PURPOSE

Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1.

MATERIALS AND METHODS

Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy.

RESULTS

Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment.

CONCLUSIONS

Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.

Coping mechanisms and resilience in psychiatric trainees during COVID-19 pandemic

Introduction

The Covid-19 pandemic has a profound impact on all domains of day to day life, forcing individuals to make substancial change in the way of living. Such change is known to cause an important psychological distress, and in some persons evidencing silent disorders among apparently functional individuals. Good coping mechanisms and resilience can be the key to overpass this difficult period.

Objectives

The aim of this study is to evaluate the coping mechanisms and resilience that Romanian psychiatric trainees used during Covid19 pandemic.

Methods

We developed an online questionnaire. We included questions about different socio-demographical variables and about coping mechanisms (using COPE scale), resilience (using Connor-Davidson Resilience Scale) and quality of life (using QoL Scale).

Results

The preliminary data show that staying busy, seeking social support and having a positive minset are emotion-focused coping strategies present in individuals who overpass easier this period.

Conclusions

The Covid-19 pandemic is creating significant distress and impairment in functioning, but individuals who have good psychological mechanisms and who are more adaptable are less vulnerable during Covid-19 pandemic. Future research should build upon these findings to better understand coping mechanisms during crises and also social policies should be developed to acknowledge the variable needs in adults.

Cervical myelopathy caused by ventrally located atlanto-axial synovial cysts: An open quest for the safest and most effective surgical management. Case series and systematic review of the literature

OF BACKGROUND DATA

Despite a good understanding of the natural history of spinal synovial cysts (SCs), a widespread agreement regarding their optimal management is still lacking. This is particularly true for SCs occurring at the C1-C2 level, which are rare, but oftentimes lead to a rapidly evolving cervical myelopathy.

METHODS

We report a series of 4 patients (M:F ratio=1:1; mean age 63.5 years) presenting with progressive cervical myelopathy secondary to ventrally located C1-C2 SCs. All patients underwent a postero-lateral facet-sparing intradural approach with total excision of the SCs. Functional status was assessed pre- and postoperatively with Nurick scale and the modified Japanese Orthopaedic association grading. Furthermore we conducted a systematic review, following PRISMA guidelines of pertinent literature to contextualize the options for surgical management of such lesions.

RESULTS

Complete excision of the SCs was confirmed radiologically and on histological analysis. All measures of functional status improved post-operatively, and no cyst recurrence or need for instrumented fusion were noted during follow up (range from 22 to 88 months).

CONCLUSION

Our experience suggests that the facet-sparing intradural approach provides excellent clinical outcomes without causing any C1-C2 instability. This is in keeping with the take home message emerging from our literature review, which confirms that treatment should aim at radical resection of SCs while minimizing the risk of postoperative instability.

Intraoperative imaging for remnant viability assessment in bilateral posterior retroperitoneoscopic partial adrenalectomy in an experimental model

BACKGROUND

A surgical approach preserving functional adrenal tissue allows biochemical cure while avoiding the need for lifelong steroid replacement. The aim of this experimental study was to evaluate the impact of intraoperative imaging during bilateral partial adrenalectomy on remnant perfusion and function.

METHODS

Five pigs underwent bilateral posterior retroperitoneoscopic central adrenal gland division (9 divided glands, 1 undivided). Intraoperative perfusion assessment included computer-assisted quantitative fluorescence imaging, contrast-enhanced CT, confocal laser endomicroscopy (CLE) and local lactate sampling. Specimen analysis after completion adrenalectomy (10 adrenal glands) comprised mitochondrial activity and electron microscopy.

RESULTS

Fluorescence signal intensity evolution over time was significantly lower in the cranial segment of each adrenal gland (mean(s.d.) 0·052(0·057) versus 0·133(0·057) change in intensity per s for cranial versus caudal parts respectively; P = 0·020). Concordantly, intraoperative CT in the portal phase demonstrated significantly lower contrast uptake in cranial segments (P = 0·031). In CLE, fluorescein contrast was observed in all caudal segments, but in only four of nine cranial segments (P = 0·035). Imaging findings favouring caudal perfusion were congruent, with significantly lower local capillary lactate levels caudally (mean(s.d.) 5·66(5·79) versus 11·58(6·53) mmol/l for caudal versus cranial parts respectively; P = 0·008). Electron microscopy showed more necrotic cells cranially (P = 0·031). There was no disparity in mitochondrial activity (respiratory rates, reactive oxygen species and hydrogen peroxide production) between the different segments.

CONCLUSION

In a model of bilateral partial adrenalectomy, three intraoperative imaging modalities consistently discriminated between regular and reduced adrenal remnant perfusion. By avoiding circumferential dissection, mitochondrial function was preserved in each segment of the adrenal glands. Surgical relevance Preservation of adrenal tissue to maintain postoperative function is essential in bilateral and hereditary adrenal pathologies. There is interindividual variation in residual adrenocortical stress capacity, and the minimal functional remnant size is unknown. New intraoperative imaging technologies allow improved remnant size and perfusion assessment. Fluorescence imaging and contrast-enhanced intraoperative CT showed congruent results in evaluation of perfusion. Intraoperative imaging can help to visualize the remnant vascular supply in partial adrenalectomy. Intraoperative assessment of perfusion may foster maximal functional tissue preservation in bilateral adrenal pathologies and procedures.

Stroke Thrombectomy in Patients with COVID-19: Initial Experience in 13 Cases

We performed a retrospective review in both comprehensive stroke units of a region affected early by the coronavirus disease 2019 (COVID-19) pandemic, between March 1 and April 26, 2020, including patients with COVID-19 who underwent mechanical thrombectomy for ischemic stroke. We identified 13 cases, representing 38.2% of 34 thrombectomies performed during this period. We observed increased mortality and a high incidence of thrombotic complications during hospitalization. Given the high rate of infected patients, systematic use of full personal protection measures seems justified.

A combined single-stage procedure to treat brain AVM

Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.

Impact of the COVID-19 outbreak on acute stroke pathways - insights from the Alsace region in France

Background and purpose

To date, no study has attempted to quantify the impact of the COVID‐19 outbreak on the incidence and treatment of acute stroke.

Methods

This was a retrospective review of acute stroke pathway parameters in all three stroke units in the Alsace region during the first month of the outbreak (1–31 March 2020), using the similar period from 2019 as a comparator. A secondary detailed analysis of all stroke alerts and stroke unit admissions was performed in the centre with the largest case volume.

Results

Compared to the same period in 2019, in March 2020 there were 39.6% fewer stroke alerts and 33.3% fewer acute revascularization treatments [40.9% less intravenous thrombolysis (IVT) and 27.6% less mechanical thrombectomy (MT)]. No marked variation was observed in the number of stroke unit admissions (−0.6%). The proportion of patients with acute revascularization treatments (IVT or MT) out of the total number of stroke unit admissions was significantly lower in March 2020 (21.3%) compared to 2019 (31.8%), P = 0.034. There were no significant differences in time delays or severity of clinical symptoms for patients treated by IVT or MT, nor in the distribution of final diagnosis amongst stroke alerts and stroke unit admissions.

Conclusion

These results suggest that the overall incidence of stroke remained the same, but fewer patients presented within the therapeutic time window. Increased public awareness and corrective measures are needed to mitigate the deleterious effects of the COVID‐19 outbreak on acute stroke care.

Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions

BACKGROUND AND PURPOSE

There are very few published data on the patency of carotid stents implanted during thrombectomies for tandem lesions in the anterior circulation. We aimed to communicate our experience of stenting in the acute setting with systematic follow-up of stent patency and discuss predictors and clinical repercussions of delayed stent thrombosis.

MATERIALS AND METHODS

We performed a retrospective study of stroke thrombectomies in a single center between January 2009 and April 2018. Patient files were reviewed to extract patient characteristics, procedural details, imaging studies, and clinical information. Predictors of delayed stent thrombosis and clinical outcome at discharge were analyzed using univariate and multivariate analyses.

RESULTS

We identified 81 patients treated for tandem lesions: 63 (77.7%) atheromas, 17 (20.9%) dissections, and 1 (1.2%) carotid web. TICI 2b-3 recanalization was achieved in 70 (86.4%) cases. Thirty-five patients (43.2%) were independent (mRS score ≤ 2) at discharge. Among 73 patients with intracranial recanalization and patent stents at the end of the procedure, delayed stent thrombosis was observed in 14 (19.1%). Among 59 patients with patent stents, 44 had further imaging controls (median, 105 days; range, 2-2407 days) and 1 (1.6%) had 50% in-stent stenosis with no retreatment. Stent occlusion rates were 11/39 (28.2%) for periprocedural aspirin treatment versus 3/34 (8.8%) for aspirin and clopidogrel (P = .04). Delayed stent thrombosis was independently associated with higher admission NIHSS scores (OR, 1.1; 95% CI, 1.01-1.28), diabetes (OR, 6.07; 95% CI, 1.2-30.6), and the presence of in-stent thrombus on the final angiographic run (OR, 6.2; 95% CI, 1.4-27.97). Delayed stent thrombosis (OR, 19.78; 95% CI, 2.78-296.83), higher admission NIHSS scores (OR, 1.27, 95% CI, 1.12-1.51), and symptomatic hemorrhagic transformation (OR, 23.65; 95% CI, 1.85-3478.94) were independent predictors of unfavorable clinical outcome at discharge.

CONCLUSIONS

We observed a non-negligible rate of delayed stent thrombosis with significant negative impact on clinical outcome. Future studies should systematically measure and report stent patency rates.

Low sensitivity of needle aspiration cultures in patients with cellulitis/erysipelas

Purpose

Cellulitis is normally treated without knowledge of the responsible pathogen. Blood cultures are positive in about 2–4 %, and superficial swabs are of no value. Needle aspiration has been proposed with identifying the likely pathogen in up to 29 %, but these studies are of older date and the technique is not widely used.

Methods

We prospectively evaluated the sensitivity of needle aspiration cultures in all patients with erysipelas/cellulitis. Diagnosis was made clinically by the treating physician. Needle aspiration was done with a 1 ml syringe and a 26G needle. The needle was removed and the syringe brought to the microbiological laboratory and analysed according to standard procedures.

Results

95 Patients were seen during a period of 22 month. 4 Patients were excluded, as diagnosis was not confirmed. Cellulitis was present in 10/91 and erysipelas in 81/91 patients. In the first 25 patients with needle aspiration from the margin, none was positive. In 8/66 (12 %) patients where needle aspiration was done at the site of maximum inflammation, the pathogen was identified. 4/8 Cultures were positive for S. aureus, 2/8 for streptococci and 2/8 for other bacteria. In 11/66 (16.6 %) patients, skin colonisation flora was detected. In the subgroup of patients without prior antibiotic treatment and needle aspiration from the site of maximum inflammation, sensitivity was slightly better 8/55 (14.5 %; 95 % CI 7.5–25.8 %).

Conclusions

Needle aspiration culture had a low sensitivity for detecting responsible pathogen in patients with cellulitis/erysipelas. No impact in antibiotic treatment could be observed.

DEVELOPMENT OF SYNTHETIC GROWTH CHARTS FOR ROMANIAN POPULATION

There are no new national growth references for the Romanian population and the current recommendations for short stature evaluation is the use of the Swiss growth charts developed based on a longitudinal study.The aim of the present paper is to present the new synthetic growth references for Romanian children.

Material and methods

We used local Romanian data from 9 studies with information on height and weight obtained between 1999 and 2016. Based on their plausibility and methodology six studies were selected for generating the National Synthetic Growth References for Romanian Children based on the specific methodology described previously. The selected studies included 8407 subjects measured in schools/kindergartens. Age is reported in years covering a range from 3-18 years. Height and weight were measured at a precision of 0.1 cm and 0.1 kg. All children were measured at normal temperature, in light clothes, without footwear.

Results

We present the charts and tables with the common centiles for height, weight and body mass index for boys and girls.

Conclusion

We suggest synthetic growth references based upon recent growth data from 6 different Romanian regions as new National Growth Charts for Romanian children.

A thousand points of light or just dim bulbs? Radiolabeled antibodies and colorectal cancer imaging

Radioimmunoscintigraphy (RIS) is coming into its own as an imaging modality in clinical oncology. Early experience with indium-111-labeled intact murine monoclonal antibodies (MoAbs) in colorectal cancer suggested that RIS images hepatic metastases poorly. Moreover, an antimurine immune response was frequently provoked, precluding multiple follow-up RIS studies in individual patients due to reticuloendothelial sequestration of the radioimmunoconjugate before tumor targeting could occur. Recent trials of technetium-99m-labeled antibody fragments and human MoAbs have demonstrated significant improvement in imaging efficacy, and repeated or serial imaging is possible because of the absence of associated immunogenicity. RIS is demonstrably more sensitive than conventional diagnostic modalities (CDM) such as computed tomography (CT) for detection of extrahepatic abdominal and pelvic colorectal carcinoma and is complementary to CDM in imaging liver metastases. In a surgical decision-making analysis comparing CT, RIS (IMMU-4 99mTc-Fab'; CEA-Scan), and CT plus RIS in patients with recurrent or metastatic colorectal cancer, CT plus RIS improved correct prediction of resectability by 40% and correct prediction of unresectability by 100% compared with CT alone. At the present time, RIS used in combination with CDM contributes an incremental improvement in diagnostic accuracy in colorectal cancer patients with known or suspected recurrent disease. Basic and clinical research currently in progress promises to yield agents and methods that provide rapid high-resolution imaging, high tumor-to-background ratios in all organs at risk for tumor recurrence or metastasis, negligible immunogenicity and toxicity, and a significant further improvement in the accuracy of clinical decision making in oncology patients.

[The neurogenic mechanisms of ocular inflammation and their modulation under local treatment with indomethacin]

Neurogenic modulation of the inflammation is an essential mechanism of initiate and conditionate an inflammatory reaction. SP, NKA and NKB--neurokinins are involved in the modulation of the local ocular inflammation initiated by the surgical perforating trauma of the anterior pole. They determine the increase of vascular permeability and the breakdown of the aqueous-humor-blood barrier by direct action on the endothelial vascular receptors and by indirect mechanism (releases prostaglandins). This effect is demonstrated by the increase of the blue Evans concentration in the aqueous-humor after local application of SP, NKA and NKB in a dose-dependent manner. Local treatment with non-steroidal-antiinflammatory drugs like Indomethacin stabilizes the aqueous-humor-blood barrier, by diminishing the local effect of neurokinins. By increasing the vascular permeability SP, NKA and NKB make an important linkage by which the nervous system mediators contribute to the modulation of eye inflammatory responses whose intimate mechanisms are not entirely known yet.

[The posterior chamber artificial crystalline lens implant in the diabetic patient]

The purpose of this study is to display the influence of diabetes on the course of the operation, postoperative complications and functional results in operated primary cataract.

MATERIAL AND METHODS

We performed a study on 72 eyes with cataract and diabetes operated in the University Eye Hospital from Cluj-Napoca during 1992-1997.

RESULTS

From the 72 cases, 58 had diabetes noninsuline dependent. Background diabetic retinopathy was present in only 18 cases. In 71 cases it was performed EEC + IOL-CP and 1 case with open angle glaucoma we made the triple procedure (EEC + CP-IOL + trabeculectomy). In 43 cases it was striate keratitis, in 30 eyes pigmentary migration and in 4 cases uveitis. As late postoperative complication we had 10 secondary cataract and i retinal detachment. Functional results were in majority cases between 0.1-0.3.

CONCLUSIONS

Diabetes do not influence the course of planned extracapsular extraction with PC-IOL, which is the best choice for the patients with cataract and diabetes. Functional results depends on the presence of diabetic retinopathy.

Dissolution and in vivo evidence of differences in reference products: impact on development of generic drugs

The WHO List of International Comparator Pharmaceutical Products (CPP) For Equivalence Assessment of Interchangeable Multi-Source (Generic) Products will address an important issue in developing new generic drugs because it will identify the 'correct' reference product. This list will reduce unnecessary clinical studies in jurisdictions requiring new generics to be compared with brand products sold locally. Eventually, by employing the CPP, there will be a world-wide standard for brand and generic drugs, assuring the same level of quality internationally. The strategy of a single global reference is meritorious, but there are several hurdles to overcome. Most important is that the same brand may differ in dissolution and/or bioavailability in various jurisdictions, including some drugs with a narrow therapeutic index like phenytoin. Several examples are provided in this manuscript. This issue of regional differences has relevance, not only to the WHO list, but also to the matter of how safety and efficacy was established for that product in the first place. Normally, phase III clinical studies are conducted on a product manufactured in a single site, set to one standard. If the product differs in bioavailability in different jurisdictions, one is left with the question: 'which product has remained true to the original formulation?' Alternatively, if safety and efficacy is maintained with all formulations, then one is faced with the question: 'are the criteria currently employed for bioequivalence unnecessarily restrictive?'

Unfiltered sulfur colloid and sentinel node biopsy for breast cancer: technical and kinetic considerations

BACKGROUND

There are few clinical data on technical limitations and radiocolloid kinetics related to sentinel lymph node (SLN) biopsy for breast cancer.

METHODS

In 70 clinical node-negative patients, unfiltered 99mTc sulfur-colloid was injected peritumorally and cutaneous hot spots were mapped with a gamma probe. SLN biopsy was performed followed by axillary lymph node dissection. Missed radioactive nodes (nodes not under hot spots) were removed from axillary lymph node dissection specimens and submitted separately.

RESULTS

At least one hot spot was mapped in 69 patients (98%) and SLNs were retrieved in 62 (89%). No radiolabeled nodes were found in five (7%) and only nodes not under hot spots were retrieved in three patients (4%). Residual nodes not under hot spots were retrieved in 17 patients (24%) in whom at least one SLN specimen had been found. Diffuse radioactivity around the radiocolloid injection site impeded identification of all radiolabeled nodes during SLN biopsy, and was responsible for one of two false negatives (20 node-positive patients; false-negative rate 10%). Hot spot radioactivity, number of radiolabeled nodes, and nodal radioactivity did not change with time interval from radiocolloid injection to surgery (0.75-6.25 hours).

CONCLUSIONS

Although SLN localization rate is high, intraparenchymal injection may predispose to failure of radiocolloid migration, failure to identify SLNs because of high radiation background, and false-negative outcomes. Alternative routes of radiocolloid administration should be explored.

[The functional results in primary surgical cataract associated with diabetes mellitus]

The purpose of this study is to display the influence of diabetes on the course of the operation, postoperative complications and functional results in operated primary cataract.

MATERIAL AND METHODS

We performed a study on 42 eyes with cataract and diabetes operated in the University Eye Hospital from Cluj-Napoca during 1992-1996.

RESULTS

From the 42 cases, 32 had diabetes non-insulin-dependent. Background diabetic retinopathy was present in only 16 cases (38%). In 33 cases it was performed EEC + PC - IOL. Postoperative, in 38 cases it was striate keratitis, in 21 eyes pigmentary migration and in 3 cases uveitis. As late postoperative complications we had 5 secondary cataract and 1 retinal detachment. Functional results were in majority cases between 0.1-0.3.

CONCLUSIONS

Diabetes do not influence the course of planned extracapsular extraction with PC-IOL, which is the best choice for the patients with cataract and diabetes. Functional results depends on the presence of diabetic retinopathy.

[The functional prognosis of traumatic cataracts operated on for an artificial lens implant]

The authors shows the modern possibilities of rehabilitation of the vision in traumatic cataract on a group of 57 cases hospitalised and operated in the Department of Ophthalmology of the University of Medicine from Cluj-Napoca. The study includes the repartition of cases on age, sex, profession, the type of traumatic cataract, different techniques of surgery and the functional results. In all cases it were used intraocular lenses (pupillary, anterior chamber and posterior chamber).

[Complications specific to posterior chamber lens implantation]

The purpose of the study is to evaluate posterior chamber intraocular lenses complication, causes and their prevention.

[Staphylococcal anatoxin, an alternative in the treatment of endogenous uveitis]

The paper presents one clinical study effected by fourty-four patients with endogenous uveitis which beneficiary of a general treatment with staphylococcal anatoxin. The conclusions of the study impose that one effective treatment is obtained at the young patients with anterior, acute uveitis with moderate inflammatory phenomenon and what present one effective answer of the lymphocyte T by interleukin 1. The application of the treatment suppose several exams reminiscent of the immunologic status especially of the cellular immunology.

[Herpetic keratitis. Clinical and therapeutic aspects]

The authors have made a retrospective study of 161 cases of herpetic keratitis. 121 cases of them have been superficial herpetic keratitis and 40 of them discoid forms. 72 cases of superficial keratitis have been the first manifestation and 49 have relapsed. 53 cases of superficial herpetic keratitis and 39 cases of relapsed herpetic keratitis have been treated with specific antiviral medication. This treatment decreased significantly the hospitalisation period of first superficial attack herpetic keratitis. In relapsed and discoid forms the number of the hospitalisation days have not been influenced by the antiviral treatment, needing the association of nonsteroid anti-inflammatory drugs and vitamins.

[Postoperative uveitis in cataract surgery]

Postoperative uveitis is a complication of cataract surgery; this complication may compromise the functional outcome and sometimes loss of the eye ball. Between 1995-1996 in Ophthalmological Clinic from Cluj five hundred patients underwent one surgical procedure for cataract; from these in fifteen cases occurred postoperative uveitis. At thirty cases from them was practised the implant by posterior chamber and by anterior chamber at two cases. The debut and the clinical aspect shows the exogenic character in two cases and the endogenic character in thirty cases. The postoperative uveitis frequency in the cataract surgery was 0.4 per cent. In two cases the outcome was the functional loss of the eyeball. The endogenous uveitis answered favorable at the treat with topic and general corticotherapy. In none of the cases was the implant explantation effected.

High variability in drug pharmacokinetics complicates determination of bioequivalence: experience with verapamil

PURPOSE

For the assessment of bioequivalence it is assumed that drug clearance in each subject on each of the study days is the same and any observed differences in AUC and/or Cmax between a brand and generic formulation are due to differences in bioavailability. We hypothesized that this assumption was invalid for highly variable drugs such as verapamil and tested it by comparing bioavailability for the brand vs itself.

METHODS

To avoid any contribution from potential formulation differences, we evaluated bioavailability for isoptin SR 240 mg tablets in 9 healthy volunteers on 2 occasions separated by 1 week as part of a larger study. A validated HPLC assay was used to measure serial blood samples over 36 hours.

RESULTS

The AUC0-1 varied 3.8 fold among subjects and 5/9 subjects had > 30% difference in AUC0-1 on the 2 days. After log transformation, the mean AUC0-1 +/- %cv (ng.h/mL) on Occasion 1 (878 +/- 38) was 23% greater (p = 0.031) than on Occasion 2 (713 +/- 41). The 90% confidence interval of Occasion 1/Occasion 2 was 106-143%. The Cmax varied > 9 fold (30-278 ng/mL) among subjects. The intrasubject difference between days ranged from -46% to +298%. The 90% confidence interval was 72-152% for Cmax. Since the same lot of Isoptin was used in the same subjects on 2 occasions, the observed differences must be due to biological variability in verapamil pharmacokinetics, not formulation differences.

CONCLUSIONS

The intra-subject biological variability complicates bio-equivalence assessment and can lead to an erroneous assumption of bioinequivalence.

[Anterior ischemic optic neuropathy. The experience of 71 cases]

The purpose of the study is to point out the characteristic clinical, therapeutical and evolutive features in the acute ischaemic suffering of the optic nerve's preliminary portion. A retrospective study has been performed, on the patients with anterior ischaemic optic neuropathy (AION), hospitalized in the Ophthalmologic Clinic from Cluj-Napoca, between 1986-1994: 71 cases. The main functional (visual field, visual acuity) and ophthalmoscopic aspects are analyzed, as their evolution after treatment. Results are significantly better if corticosteroids are systemically used (43.3% improvement of the visual field) than in their absence (17.07% improvement of the visual field). The high percentage of failures (70%) proves the absence of a therapeutical method to cure or bring a significant visual function's improvement in AOIN.

[A re-update of the indications for the Fadenoperation and the results obtained]

The paper presents the clinic's experience regarding the utilization of the Thread operation in strabismus surgery. This surgical technique was done on 27 patients with convergent strabismus for correcting the spastic component of the deviation angle. The post-operation results are promising; the control done one month after the intervention showed in all cases solving of the variable component of the strabismic deviation angle, orthophoria in 17 cases, remaining deviation angle under 5 grades in 8 cases, and above 5 grades in 2 cases.

[The surgical results in rhegmatogenous retinal detachment]

The paper present the functional and anatomic results obtained in 376 retinal detachment operations done in the Ophthalmological Clinic from Cluj-Napoca. The following types of operations were done: cerclage Arruga, scleral indentation, surface diathermy, laser photocoagulation. The retrospective study revealed percentages of 73.41% the anatomic reapplication and 50% in functional recovery. The negative influencing factors of the prognosis were: aphakia, large and old retinal detachments, macular region affectation.

[Penetrating orbital wounds with retention of the plant foreign bodies]

Here are presented the clinical observations of 5 patients with these diagnosis. We discussed the necessity of attentive exploration of the orbital injuries in the moment of urgency interventions because the foreign bodies can be multiplied. It is also important to suspect the retention of wood foreign bodies in the orbit in the presence of the patients: orbital fistula with an orbital injury in their antecedents.

[The early changes in the fundus oculi of premature infants]

The authors prospect the fundus at 69 prematures with birth weight under 1,500 g and at 49 prematures with birth weight over 1,600 g, whose neonatal pathology required intermittent administration of oxygen. The examination were done at the medium age of 5.5-6.9 weeks, when the retinal development is completed. The results show a greater proportion of the nervous systems lesions and of the retinopathy at the prematures with birth weight less than 1,500 g, in similar conditions of oxygen administration and prophylaxis with E-vitamin. It is indicated the opportunity of fundus investigation at all the prematures with very low birth weight and the necessity of prophylactic administration of E-vitamin starting from the first day of life.

[Echographic differential diagnosis in oculo-orbital tumors]

Within the period October 1987-September 1990, the authors submit 130 patients to clinical examination and ultrasonography the latter performed by adapting commercially available ultrasonograph type Bruel and Kjaer 3405 and Shimasonic. Among the investigated individuals, 25 exhibited oculo-orbital tumours of various types. The cases are assessed considering the following for establishing the diagnosis: clinical examination, ultrasonography, fluorescein angiography, radiotracer and morphopathological examinations. Besides the use an adapted device, the authors propose a simple and fast morphopathological method: the fixation in formaldehyde solution as long as 48 hours.

[Clinico-statistical observations on malignant ocular tumors surgically resolved at the Cluj-Napoca Ophthalmological Clinic between 1970 and 1990]

During the period mentioned above there ware hospitalized 54 patients having epibulbar tumours. The anatomopathological exam which was effectuated for 33 patients hes shown Bowen's disease for 14 cases, spinocellular carcinoma for 15 patients and basocellular for 3 patients. There were 4 cases for epibulbar precancerous. There was retinoblastoma for 19 cases; it had been practiced the enucleation of ocular globe for 17 patients and for two cases it had been practiced the exenteration of the eye socket. At the same period there were 91 uveal melanosis 6 of which having iridial localization, 10 cases of ciliary body [correction of cylar corpus], 75 cases of choroid. The hepatic scintigraphy was practiced for 56 patients and had shown for 8 cases hepatic metastasis. The histopathological exam of the melanomata of ciliary and choroidal corpus had shown type A fusiform cells for 22 cases, type B for 43 cases, epithelioid cells for 6 cases and mixed type cells for 13 cases. The hepatic metastasis were epithelioid cells for all the cases and, for 2 cases there were with mixed type cells, It is necessary an active discovering of intraocular and episcleral malign tumours, for increasing the chance of an earlier diagnosis during a stadium that would be able to be treated as conservator as possible be.

[The serology of toxoplasmosis in uveitis]

Determinations for decelerating the antitoxoplasma anticorps that have been effectuated for 696 uveas proved positivity at 123 aerums (17.6%). The repartition of the positive serology concerning the clinic form of the uvea has proved 48 iridocyclitis, 26 serous central corioretinals, 23 in panuveitis, 13 in posterior uveitis, 11 muscular chorioretinitis, 2 in hyalitis. Taking into consideration only the equal or less than 1:160 titrures, these have been at 7 iridocyclitis, 4 serous central chorioretinitis, 4 panuveitis, 3 posterior uveitis and 3 atrophic central chorioretinitis. It is shown that the diagnosis of ocular toxoplasma must be effectuated just corroborating the clinic data with the positive serology. The antiparasitic treatment doesn't influence upon the low titrures of serous anticorps, which generally maintain at the same value all the life.

[Spontaneous luxation of the crystalline lens into the anterior chamber (a clinical case report)]

A patient of 45 years old presents a sprained crystal in the anterior chamber, with secondary acute glaucoma at the left eye and surgically aphakia with ciliary staphyloma and optic atrophia for the right eye. VOR zero; VOL-PL; TOR-17,3 mm Hg; TOL-81, 9 mm Hg. After hypotension of the eye using a perfusion of mannitol and acetazolamide the ocular tension is normalized. It is practiced the extraction of the lens from the anterior chamber with a good post-surgically evolution. The disease may be joined to Marfan, Marchesani, syndrome homocystinuria or an early diagnosis of the zone without any manifest cause.

[Rare palpebral tumors in children]

The paper reports on two cases of rare palpebral tumours--pilomatrixomas--existent in two children under the age of two years.

[The possibilities for early diagnosis in primary open-angle glaucoma]

The study was carried out on a group of 127 patients, admitted into the Cluj-Napoca Clinic of Ophthalmology, suspected of primary glaucoma with open angle. The complex antiglaucomatous investigation confirmed the diagnosis in 57 cases.

Structural and catalytic properties of L-alanine dehydrogenase from Bacillus cereus

Alanine dehydrogenase from Bacillus cereus, a non-allosteric enzyme composed of six identical subunits, was purified to homogeneity by chromatography on blue-Sepharose and Sepharose 6B-CL. Like other pyridine-linked dehydrogenases, alanine dehydrogenase is inhibited by Cibacron blue, competitively with respect to NADH and noncompetitively with respect to pyruvate. The enzyme was inactivated by 0.1 M glycine/HCl (pH 2) and reactivated by 0.1 M phosphate (pH 8) supplemented with NAD+ or NADH. The reactivation was characterized by sigmoidal kinetics indicating a complex mechanism involving rate-limiting folding and association steps. Cibacron blue interfered with renaturation, presumably by competition with NADH. Chromatography on Sepharose 6B-CL of the partially renatured alanine dehydrogenase led to the separation of several intermediates, but only the hexamer was characterized by enzymatic activity. By immobilization on Sepharose 4B, alanine dehydrogenase from B. cereus retained 66% of the specific activity of the soluble enzyme. After denaturation of immobilized alanine dehydrogenase with 7 M urea, 37% of the initial protein was still bound to Sepharose, indicating that on the average the hexamer was attached to the matrix via, at most, two subunits. The ability of the denatured, immobilized subunits to pick up subunits from solution shows their capacity to fold back to the native conformation after urea treatment. The formation of "hybrids" between subunits of enzyme from B. cereus and Bacillus subtilis demonstrates the close resemblance of the tertiary and quaternary structures of alanine dehydrogenases from these species.