The role of scanning laser polarimetry using the GDx variable corneal compensator in the management of glaucoma suspects

AIM

To determine the role of scanning laser polarimetry using the GDx variable corneal compensator (VCC) in the management of glaucoma suspects.

METHODS

Over a 12-month period, 43 of 447 (9.6%) patients referred to a glaucoma screening clinic were classified as "glaucoma suspects" when it was not possible to categorise the optic disc appearance and visual fields as definitely glaucomatous or definitely normal. Of these patients, 39 underwent a full ophthalmic review, including assessment of the visual fields and analysis of the retinal nerve fibre layer with the GDx VCC.

RESULTS

After the review, 17 of 39 (43.6%) patients were discharged because of normal GDx VCC results. The remaining 22 of 39 (56.4%) were considered to be at risk of developing progressive glaucoma, and further follow-up in the hospital eye service was recommended. 3 (7.7%) patients received treatment. Of the 22 patients, 12 were considered to have pre-perimetric normal tension glaucoma, 7 normal tension glaucoma and 1 primary open-angle glaucoma (POAG). In 19 of these patients, abnormal GDx VCC results were found, particularly inter-eye asymmetry in the nerve fibre layer thickness. However, in 2 of 39 (5.1%) patients the GDx VCC was normal, despite the presence of a neuroretinal rim defect in the optic disc with corresponding visual field loss, and in 1 patient with POAG.

CONCLUSIONS

Scanning laser polarimetry using the GDx VCC is an important tool in defining the management strategies of glaucoma suspects. In screening for glaucoma, however, GDx VCC results should not be used in isolation, but in conjunction with conventional methods of optic disc and visual field assessment.

Iatrogenic eccentric full thickness macular holes following vitrectomy with ILM peeling for idiopathic macular holes

PURPOSE

To document a previously unreported complication after vitrectomy with peeling of the internal limiting membrane (ILM) for idiopathic macular holes.

METHOD

Retrospective review of notes of 232 consecutive patients who underwent vitrectomy with peeling of the ILM for idiopathic macular holes from 1996 to 2001. Four patients were found to have eccentric iatrogenic macular holes postoperatively. Optical coherence tomography was used to evaluate these holes.

RESULTS

The idiopathic macular holes were graded from stages II to IV preoperatively with visual acuities from 6/18 to 6/60. All patients had surgery within 6 months of presentation. They underwent vitrectomy with complete separation of the posterior cortical vitreous, peeling of the ILM, injection of platelets (0.1 ml), and gas tamponade with SF6 20%. Postoperatively the patients postured strictly face down for 10 days. Follow-up ranged from 8 months to 6 years. Iatrogenic eccentric macular holes were noted postoperatively. The holes were located between 3 and 6 o'clock in three patients and at 9 o'clock in the fourth patient, relative to the macula. Optical coherence tomography showed them to be full thickness and completely flat. No further intervention was necessary. No complications have arisen during follow-up.

COMMENT

To our knowledge iatrogenic eccentric full thickness macular holes after macular hole surgery have never been reported. We believe that the location of the holes represents the initial site of ILM elevation. These holes are asymptomatic, have not required any treatment and have not caused any complications in up to 6 years of follow-up.

Fatal fat embolism after vertebroplasty: identification of the high-risk patient

We report a rare complication of autopsy-proven fat and bone marrow embolization following percutaneous vertebroplasty in a patient who had no evidence of cement leakage. Cement injection was done during one patient encounter, covering 3 vertebral levels by using a unipedicular approach. Patients may have complications even without polymethylmethacrylate leakage.

Prevalence and distribution of soil-transmitted helminthiases among Orang Asli children living in peripheral Selangor, Malaysia

Soil-transmitted helminthiases are a public health problem in rural communities. A cross-sectional study of the prevalence and distribution of Ascaris lumbricoides, Trichuris trichiura and hookworm was conducted in 281 Orang Asli children (aborigines) aged between 2 and 15 years, from 8 Orang Asli villages in Selangor, Malaysia. All the children were infected with soil-transmitted helminthes, with 26.3% of the children infected either with A. lumbricoides, T. trichiura or hookworm and 72.6% having mixed infection. The overall prevalences of A. lumbricoides, T. trichiura and hookworm were 61.9, 98.2 and 37.0%, respectively. Approximately 19.0, 26.0 and 3.0% of the children had severe infection of ascariasis, trichuriasis and hookworm infection, respectively. The prevalences and mean egg per gram (epg) counts for A. lumbricoides and T. trichiura were not significantly dependent on age, therefore age-dependent convexity was not seen in this study. However, the results of this study reveal an age-dependent prevalence and mean epg count in children with hookworm infection. We conclude that ascariasis, trichuriasis and hookworm infection are still prevalent and therefore a public health concern in Orang Asli communities. Severe ascariasis and trichuriasis may lead to other health and medical problems.

Incidence of xeroderma pigmentosum in Larkana, Pakistan: a 7-year study

Xeroderma pigmentosum (XP) is a rare autosomal recessive inherited disorder caused by a defect in the normal repair of DNA of various cutaneous cell types damaged by exposure to ultraviolet radiation. We present our 7-year experience with 36 XP patients who either visited the Department of Dermatology or were seen in the medical camps arranged in remote areas for patients' welfare, from 1995 to 2001. For ease of discussion we classified all cases into the following subgroups on clinical grounds only: mild, those with light brown freckles on the face alone; moderate, those with dark brown freckles with burning on the face, neck, ears, chest, hands and photophobia but without other associated obvious cutaneous and ocular changes; severe, those with extensive dark brown freckles with burning on the exposed parts as well as on the unexposed parts of the body, i.e. the chest, back, abdomen and arms including other associated cutaneous and ocular changes such as ulcers and malignancy. Of 36 patients, three (8.3%) were classified as mild, nine (25%) moderate and 24 (66.7%) severe; there were 18 males and 18 females, age range 2-30 years (mean 8.9 years). Seventeen patients had cutaneous changes: actinic keratosis, keratoacanthoma, fissures and ulcerative nodules on the exposed parts of the body. Four patients had wide ulcers, along with mass formation and severe pigmentation on the face, neck and head. Twenty-nine patients developed ocular symptoms: photophobia, conjunctivitis, corneal keratitis and lid ulcer. One patient had complete loss of vision. Histopathological findings revealed that six patients had squamous cell carcinoma (SCC) on the face, head, ear or lip. More than one sibling (two to four) was affected in four families. The majority of cases (20/36, 55.6%) were from the Brohi tribe (skin type III), while the remaining cases (16/36, 44.4%) were from the Sindhi population (skin type IV). The large number of XP patients seen in those with skin type III (Brohi tribe) compared with skin type IV (Sindhi population) indicates that the skin type and the race has a considerable value in the pathogenesis of XP. Furthermore, 24 of 36 patients were in the severe group and six of these had SCC. Moreover, no neurological abnormalities were observed in our patients. All patients were treated according to disease severity by prescribing oral antibiotics, local steroids, sunscreens and/or chemotherapy followed by irradiation in malignant cases. Two patients died because of extensive SCC.

Primary Non-Hodgkin's Lymphoma of the Bone: A Single Institution Experience

Primary non-Hodgkin's lymphoma of the bone is an unusual entity. Twenty-five patients with diffuse large cell lymphoma of the bone were registered at the Tata Memorial Hospital (TMH) from August, 1991, to May, 2002. Pain at the local site and soft tissue swelling were the commonest symptoms. Involvement of the bones in the lower half of the body was more frequent than the bones in the upper half. Osteolytic lesions and an associated soft tissue mass were the common radiological findings. Nineteen patients received CHOP chemotherapy and five received COP chemotherapy. Twenty-three patients received involved field radiotherapy. The overall response to therapy was 96%. On follow-up, two patients had a nodal relapse. One patient died of progressive disease, and one patient died of cryptococcal meningitis. There were no deaths due to treatment-related toxicity. The mean progression free survival was 9.39 yr and the overall survival was 11.66 yr. The median overall survival has not been reached. At last follow-up, 21 patients were being following up at TMH and are free of disease.

CONCLUSION

Primary bone lymphoma is a malignancy that is highly curable with a combination of chemotherapy and radiotherapy.

The effects of introducing or lowering legal per se blood alcohol limits for driving: an international review

In this review evidence on the impact of introducing or lowering legal blood alcohol limits on traffic safety measures is examined. There is substantial variability in the types and rigour of methods used to evaluate these legislative measures, and thus not surprisingly there is variability in the results observed. In most but not all cases where an evaluation of an introduced or lowered legal limit has been conducted, some beneficial effect on traffic safety measures has been reported. These effects are in some cases relatively small, and in other cases may be temporary. In some jurisdictions, lasting reductions in collision rates have been reported. Available evidence suggests that where beneficial effects are observed they are due to general deterrence, and not restricted only to drivers at blood alcohol concentrations (BAC) specifically affected by the legal change.

Dexamethasone, paclitaxel, etoposide, cyclophosphamide (d-TEC) and G-CSF for stem cell mobilisation in multiple myeloma

Forty-one patients with multiple myeloma were treated with a novel stem cell mobilisation regimen. The primary end points were adequate stem cell mobilising ability (>1% circulating CD34-positive cells) and collection (> or = 4 x 10(6) CD34-positive cells/kg), and safety. The secondary end point was activity against myeloma. The regimen (d-TEC) consisted of dexamethasone, paclitaxel 200 mg/m(2) i.v., etoposide 60 mg/kg i.v., cyclophosphamide 3 g/m(2) i.v., and G-CSF 5-10 microg/kg/day i.v. A total of 84 cycles were administered to these 41 individuals. Patient characteristics included a median age of 53 years, a median of five prior chemotherapy cycles, and a median interval of 10 months from diagnosis of myeloma to first cycle of d-TEC. Seventy-five percent of the patients had stage II or III disease, 50% had received carmustine and/or melphalan previously, and 25% had received prior radiation therapy. Eighty-eight percent of patients mobilised adequately after the first cycle of d-TEC and 91% mobilized adequately after the second cycle. An adequate number of stem cells were collected in 32 patients. Of the remaining nine patients, three mobilised, but stem cells were not collected, two mobilised but stem cell collection was < 4 x 10(6) CD34-positive cells/kg, three did not mobilise, and one died of disease progression. Major toxicities included pancytopenia, alopecia, fever and stomatitis. One patient died from multi-organ failure and progressive disease. Fifty percent of evaluable patients demonstrated a partial response and 28.6% of patients had a minor response. This novel dose-intense regimen was safe, capable of stem cell mobilisation and collection, even in heavily pre-treated patients, and active against the underlying myeloma.

Effects of Ba2+ and Cs+ on apical membrane K+ conductance in toad retinal pigment epithelium

Intracellular microelectrode techniques were employed to characterize the blocker sensitivity of the K+ conductance (gK) at the apical membrane of the toad retinal pigment epithelium (RPE). Increasing the K+ concentration in the apical bath ([K+]o) from 2 to 5 mM produced a rapid depolarization of the apical membrane potential (VA). The addition of 0.5 mM Ba2+ or 5 mM Cs+ to the apical bath rapidly depolarized VA and increased the transepithelial resistance and ratio of apical-to-basolateral membrane resistance. In the presence of apical Ba2+ or Cs+, the response of VA to delta [K+]o was markedly reduced, indicating that these ions are effective blockers of apical gK. The Ba(2+)- and Cs(+)-induced decreases in the apparent apical-to-basolateral membrane conductance ratio were concentration dependent, with apparent dissociation constants of 17 microM and 0.5 mM, respectively. The apparent blocker sensitivity of apical gK is similar to that previously demonstrated for the inwardly rectifying K+ conductance in isolated toad RPE cells, suggesting that the inwardly rectifying K+ conductance comprises much of apical gK.

The fimA locus of Streptococcus parasanguis encodes an ATP-binding membrane transport system

The gene encoding fimA, a 36 kDa fimbrial adhesion of Streptococcus parasanguis FW213, is highly conserved in all four genetic groups of sanguis streptococci. FimA-like peptides were produced by all strains tested. The nucleotide sequence directly upstream of fimA contains two open reading frames, ORF5 and ORF1, whose deduced protein products are homologous to members of a superfamily of ATP-binding cassette membrane transport proteins, including both prokaryotic and eukaryotic uptake and export systems. The amino acid sequence of FimA contains the consensus prolipoprotein cleavage site (LxxC) common to the 'periplasmic' binding proteins of Gram-positive transport systems. The deduced product of ORF5 is a 28.6 kDa membrane-associated protein that has the consensus binding site for ATP (GxxGxGKS). It shares significant homology with AmiE of Streptococcus pneumoniae as well as with Escherichia coli proteins involved in iron(III) uptake. Allelic-replacement mutagenesis of ORF5 resulted in greatly increased resistance to aminopterin. These data demonstrate functionality with the amiE locus as well. The deduced product of ORF1 is an extremely hydrophobic integral membrane protein of 30.8 kDa with a pattern of six potential membrane-spanning regions, typical of a component of these types of transport system. The nucleotide sequence downstream of fimA, ORF3, encodes a 20 kDa protein having 78% identity with the 20 kDa protein encoded downstream of ssaB, a fimA homologue in S. sanguis 12. It also exhibits significant homology with bacterioferritin co-migratory protein (Bcp) of E. coli K-12. Allelic-replacement mutagenesis in the fimA locus of FW213 showed that (i) expression of fimA was initiated at a site far upstream of the fimA start codon, and (ii) expression of fimA was not linked to expression of ORF3. Northern blots probed with internal fragments of ORF5, ORF1, fimA or ORF3 hybridized to the same transcript of 3.3 kb, which suggested that these loci were transcribed as a polycistronic message. The ORF3 probe also hybridized to a 540 bp transcript consistent with the size of ORF3 alone and supportive of the mutagenesis data of non-linkage. Strains mutated in fimA continued to produce fimbriae, indicating that FimA was not the fimbrial structural subunit. Immunoelectron microscopy revealed FimA was localized at the tips of the fimbriae of FW213. This is the first study that demonstrates that an adhesin which binds a bacterial cell to a substrate is associated with an ATP-binding cassette.

Management of congenital dacryocele

Congenital dacryocele is a distension of the naso-lacrimal sac usually present at birth or in the first three months of life. It occurs commonly in females and may present with dacryocystitis. Treatment includes probing and antibiotics if infection is present.

Characterization of allelic replacement in Streptococcus parasanguis: transformation and homologous recombination in a 'nontransformable' streptococcus

We have obtained transformants of Streptococcus parasanguis FW213 containing allelic replacements in several chromosomal loci. Transformation occurred following electroporation with nonreplicating plasmids carrying two antibiotic-resistance-encoding genes, one of which is inserted into DNA homologous to the chromosomal target. In contrast with other streptococci, S. parasanguis FW213 is not transformed by linear DNA. Mutations in nonreplicating plasmid DNA preferentially replaced their homologues in the S. parasanguis FW213 chromosome by a double-crossover homologous recombination event, as shown by the fact that over 90% of transformants were sensitive to the vector-coded antibiotic marker. Southern blot analysis of these transformants showed that three of the five target loci had been mutated, and that the wild-type sequence had been replaced by the mutated sequence carried on the transforming plasmid. This bias toward homologous replacement rather than integration of the entire transforming plasmid DNA simplifies site-specific mutagenesis and genetic analysis of the streptococcal chromosome.

Suppression of human IgE antibody forming cell responses by IL-6

To study the effects of cytokines on human IgE antibody forming cells (AFCs), log phase U266 myeloma cells (3 x 10(3)/ml), which secrete immunoglobulin E (IgE), were cultured for 0-24 h with and without cytokine or with or without antibodies against various cytokines. The numbers of IgE AFCs were determined in ELISPOT assay. We found that interleukin-6 (IL-6) suppressed (to 95%) whereas anti-IL-6 increased (to 148%) the numbers of IgE AFCs and that both worked in a dose-dependent fashion. IL-4 and interferon-gamma (IFN-gamma) also suppressed IgE AFC responses in a dose-dependent fashion. However, antibodies to these cytokines had no effect. In contrast, IFN-alpha increased (to fourfold) the numbers of IgE AFCs in a dose-dependent fashion. The data are the first to show a suppressive effect of IL-6 on human IgE responses and may also suggest a role for IL-6 in the treatment of atopic disease.

Balloon coarctation angioplasty in adolescents and adults: early and intermediate results

Twenty-three adolescent and adult patients with native coarctation of the aorta underwent balloon dilatation. Dissection of the aorta developed in one patient. Data were collected on the remaining 22 patients. They ranged in age from 15 to 55 years (mean 23 +/- 9.2 years). Invasive measurement of the peak systolic gradient (PSG) and biplane angiography were performed before and immediately after angioplasty and at follow-up 4 to 48 months (mean 15 months) later. PSG before dilatation was 37 to 100 mm Hg (mean 66.9 +/- 19.9 mm Hg) and decreased to 0 to 30 mm Hg (mean 9.1 +/- 11 mm Hg) immediately after dilatation (p less than 0.001). Restenosis occurred in two patients 6 months after dilatation, and one patient had an incomplete dilatation. These three patients underwent successful redilatation and remained improved 12 to 19 months later. There was no significant change in gradient at repeat catheterization in the remaining 20 patients. PSG was 0 to 20 mm Hg (mean 5.8 +/- 7.2 mm Hg). Angiography showed that a small aneurysm developed in one patient immediately after dilatation and in another 6 months later. Eleven patients were restudied more than once, and no change in gradient or size of the aneurysm was noted at mean follow-up 25 months after dilatation. This study demonstrated that balloon angioplasty is an effective method of treating adolescent and adult patient with native coarctation of the aorta. However, because of the uncertain natural history of aneurysm after dilatation, this procedure should be considered investigational until much longer follow-up times are available.

Percutaneous mitral valvotomy with the Inoue balloon catheter in children and adults: immediate results and early follow-up

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 60 consecutive patients with severe symptomatic mitral stenosis. There were 10 children (mean age 13 years) and 50 adults (mean age 31 years). Forty patients were females and 20 were males; 53 were in sinus rhythm. The procedure was technically successfully performed in 57 (95%) patients. There were no deaths or thromboembolic complications. Balloon valvotomy was done using a 22 to 30 mm diameter catheter with the echo/Doppler guided stepwise mitral dilatation technique. After PMV the mean left atrial pressure decreased from 23.0 +/- 5.0 to 14.0 +/- 4.0 mm Hg (p less than 0.001). The mean mitral valve gradient (MVG) decreased from 15.0 +/- 4.0 to 6.0 +/- 2.0 mm Hg (p less than 0.001). The mitral valve area (Gorlin formula) increased from 0.7 +/- 0.2 to 1.6 +/- 0.4 cm2 (p less than 0.001). The mitral valve area as determined by echocardiography increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (p less than 0.001). Mild mitral regurgitation (MR) developed in six patients (11%) and increased by one grade in another five patients (9%). No patient developed severe mitral regurgitation. Mitral valve area at mean follow-up of 4.8 months remained unchanged at 1.9 +/- 0.3 cm2. We conclude that PMV, using the Inoue balloon catheter, is safe and effective in the treatment of severe mitral stenosis in children and adults, without inducing significant mitral regurgitation.

Mitral balloon valvotomy using the Inoue balloon technique for selected patients with severe pliable rheumatic mitral valve stenosis: immediate and short-term results

We selected 40 patients with severe symptomatic rheumatic mitral stenosis for balloon valvotomy using the Inoue balloon technique. The patients' mean age was 31 +/- 14 years and there were 24 females and 16 males. The patients were selected according to the following echo/Doppler criteria; 1. Severe mitral stenosis, i. e. mitral valve area (MVA) less than 1.1 cm2; 2. pliable anterior mitral valve leaflet; 3. absence of calcification of the mitral commissures and 4. absence of significant subvalvular mitral valve disease (Block echo score less than 8). We failed to cross the mitral valve in three cases and repeat attempts in two patients with higher transeptal puncture was successful. Thirty-nine procedures were technically successful (98%). There were no complications. We used an Inoue balloon size 24-30 mm using echo/Doppler guided stepwise mitral dilatation. After mitral balloon valvotomy, the MVA increased from 0.8 +/- 0.2 to 1.7 +/- 0.5 cm2 (p less than 0.001). Five patients developed mild mitral regurgitation and in one patient the degree of mitral regurgitation increased from mild to moderate. The mean mitral valve area 48 hours after the procedure measured 1.9 +/- 0.4 cm2 (echo/Doppler); one patient (2.5%) had residual mitral stenosis (MVA less than 1.5 cm2). At six weeks follow-up study the mean mitral valve area was 1.9 +/- 0.5 cm2 (Echo/Doppler), with no restenosis. We conclude that in selected cases of severe pliable mitral stenosis, the Inoue balloon technique achieves a greater than 100% increase of the MVA, without inducing significant iatrogenic mitral regurgitation or residual stenosis.

Decrease in pulmonary artery pressure with slow release nifedipine in Saudi patients with primary pulmonary hypertension

We studied the acute and short-term hemodynamic effects of vasodilators in three Saudi patients with primary pulmonary hypertension. The study protocol included the measurement of pulmonary artery pressure, resistance and cardiac output at baseline and at 15, 30, 45 and 60 minutes after 10 mg sublingual nifedipine. These hemodynamic studies repeated at 3 and 6 months follow-up. A 24 hour profile of pulmonary artery and aortic pressures were recorded to evaluate the effect of 20 mg of slow release nifedipine, after 25 mg of captopril and 5 mg of sublingual isordil. After nifedipine there was a marked reduction in systolic pulmonary artery pressure from 85 +/- 18 to 55 +/- 8 mmHg and the pulmonary resistance decreased from 1422 +/- 367 to 954 +/- 69 dynes-sec/cm-5. The cardiac output increased from 2.9 +/- 0.2 to 0.2 to 4.0 +/- 0.4 l/min after nifedipine. The patients were discharged on nifedipine 10 mg qid, except for patient #3 who was a non-responder. At follow-up there was a symptomatic improvement and a favourable hemodynamic response was maintained, though patient #2 required a higher dose of nifedipine. The pulmonary artery 24 hour pressure profile revealed that 20 mg slow release adalat reduced pulmonary artery pressure for a 6 hour period. Whereas, regular nifedipine decreased pulmonary artery pressure for a period of less than 90 minutes. There was no favourable hemodynamic response to either captopril 25 mg oral of isordil 5 mg administered sublingually. We conclude that slow release nifedipine decreases the pulmonary artery pressure for longer periods compared to regular nifedipine in patients with primary pulmonary hypertension.

Regression of infundibular pulmonary stenosis after successful balloon pulmonary valvuloplasty in adults

Between July 1985 and March 1988, 22 adult patients with congenital pulmonary stenosis underwent balloon pulmonary valvuloplasty. There were 10 males and 12 females aged 16-45 (average 25 +/- 9.9) years. All patients had additional mild to severe infundibular stenosis; 16 were restudied 6-36 (mean 12.6) months later by repeat catheterization. Student's t-test was used for comparison of data. Right ventricular (RV) systolic pressure before dilatation was 84-196 (mean 129 +/- 32.3) mm Hg, and the peak pulmonary gradient (PPG) was 60-176 (mean 111 +/- 33.2) mm Hg immediately after dilatation. The RV systolic pressure dropped to 32-140 (mean 59.2 +/- 27) (P less than 0.001); and PPG dropped to 10-113 (mean 37.8 +/- 26.4) (P less than 0.001), and the infundibular gradient ranged from 8 to 113 (mean 35.1 +/- 25.8) mm Hg. The infundibular diameter, before dilatation, ranged from 2 to 15 (mean 9.5 +/- 4) mm Hg. At repeat catheterization, the RV systolic pressure dropped further to 33-66 (mean 42.8 +/- 9.7) mm Hg and the PPG was reduced to 0-48 (mean 18.4 +/- 10.9) mm Hg (P less than 0.001). The infundibular gradient regressed to 0-34 (mean 15 +/- 8.8) mm Hg (P less than 0.001). The infundibular diameter increased to 8-25 (mean 15.8 +/- 5.4) (P less than 0.001). It is concluded that moderate to severe infundibular stenosis, in adults, can regress after successful pulmonary valvuloplasty.

Benign migratory stomatitis: a literature review and case report

Although benign migratory stomatitis (BMS) was first reported in the literature as early as 1955 (Cooke), fewer than 40 cases have been recorded. This article reviews the literature and describes a case of BMS involving the ventral surface of the tongue of a 74-year-old male. This is the first South African case to be reported.

The ideal tissue adhesive in facial plastic and reconstructive surgery

In this paper we have reviewed cutaneous wound closure in facial plastic and reconstructive surgery using two different tissue adhesives: (1) Fibrin glue (Tisseel), and (2) N-butyl-2-Cyanoacrylate (Histoacryl Blue). Fibrin glue was used on 23 patients: eight lower blepharoplasties, eight hemi-facelifts, five mid browlifts and seven facial reconstructive procedures. Histoacryl glue was used in 108 blepharoplasty incisions, 30 facelift incisions, 21 submental incisions for liposuction, and 19 local flaps for facial reconstructive procedures. Comparison was made of the adequacy of bonding, cosmetic result of the incision, ease of use and cost. The results of our experience with tissue adhesives indicate the use of fibrin glue mainly on the undersurface of flaps. We think histoacryl glue is the ideal tissue adhesive for surface cutaneous wound closure in regards to safety, reliability, tensile strength and cost effectiveness.

Increased mitral valve insufficiency during precordial "whoop"

A patient with rheumatic mitral valve stenosis and regurgitation presented with shortness of breath and a "noise" in her chest. Cardiac auscultation revealed an intermittent late systolic "whoop." An increase in severity of mitral valve insufficiency during the periods of "whoop" was observed by pulsed Doppler, hemodynamic tracings and left ventriculography.

Cross-cultural comparison: psychiatric admission of Asian and indigenous patients in Leicestershire

Sixty-nine Asian patients were admitted to the psychiatric hospitals of Leicestershire in 1978. A case-note comparison was made with sixty-nine matched indigenous control patients. Four aspects were studied in particular, which showed: There was no significant difference in the number of compulsory admissions between Asian and indigenous patients. The two groups did not differ in their length of stay in hospital. The diagnoses given to the Asian patients were significantly different from those of the control group. Major treatment received by the two groups differed according to the diagnostic labels but there was slightly increased use of Electro-convulsive Therapy in the Asian patients with a diagnosis of Schizophrenia.

Coxsackie-B-virus-specific IgM responses in children with insulin-dependent (juvenile-onset; type I) diabetes mellitus

Coxsackie B1-6 virus IgM responses were detected by an enzyme-linked immunosorbent assay (ELISA) in 11 of 28 (39%) children aged 3-14 years in whom insulin-dependent (juvenile onset; type I) diabetes mellitus (IDDM) developed in 1982. 5 patients had a homotypic response to Coxsackie B4 and 1 had a homotypic response to B5. A serum sample had been obtained from each patient 2 to 16 weeks after onset of IDDM symptoms. Islet-cell cytoplasmic antibodies (IgG) and complement fixing islet cell antibodies were detected in 15 of 18 sera tested, but only 6 of these sera were positive for Coxsackie-B-virus-specific IgM which suggests that Coxsackie-B-virus and islet-cell antibodies are not cross-reactive. Coxsackie-B-virus-specific IgM responses were present in only 16 of 290 (5.5%) age-matched non-diabetic London children whose sera were also collected during 1982. Sera from children with virologically confirmed Coxsackie-B-virus infections showed that development of homotypic or heterotypic Coxsackie B1-6 responses was age-related. 29 of 36 (81%) children aged 6 months to 4 years had a homotypic response, whereas 44 of 57 (77%) persons aged 15 years had heterotypic responses. Mothers of 2 children with Coxsackie-B-virus-induced neonatal myocarditis had Coxsackie-B-virus-specific IgM responses directed against serotypes 3 and 4, whereas their infants had a response to Coxsackie B2 virus alone.