Conversion from carbamazepine or oxcarbazepine to topiramate in adolescents and adults with epilepsy

OBJECTIVE

To explore effectiveness, tolerability and changes in quality of life in patients with epilepsy converting to topiramate (TPM) from carbamazepine (CBZ) or oxcarbazepine (OXC) due to insufficient effectiveness and/or tolerability.

METHODS

A multicenter, open-label, non-interventional trial was used to examine patients (> or = 12 years) with epilepsy, changing to TPM monotherapy from baseline mono- or combination therapy with CBZ or OXC. TPM was added to the existing antiepileptic drug (AED) treatment and started at a dose of 25 mg once daily. The dose was titrated up with 25 mg/day increments, once every 1-2 weeks, until a final dose between 50 and 200 mg/day was reached. On the basis of clinical judgment, the treating physician decided whether or not the existing AED treatment with CBZ or OXC could then be withdrawn. Type and number of seizures, preferred TPM dose, quality of life (QOLIE-10 questionnaire), subjective perception of improvement and adverse events (AE) were documented.

RESULTS

140 patients (53.5% women, mean age 47 years) decided to switch to TPM due to insufficient effectiveness (75% of patients) and/or poor tolerability (80%) of the CBZ/OXC treatment. Average duration of follow-up was 24 weeks with an overall discontinuation rate of 19.3%, mainly due to AEs (12.1%). At study endpoint, the intended shift to TPM monotherapy was achieved in 73% of patients at a median TPM dose of 100 mg/day. A seizure reduction of > or = 50% was achieved in 91% of patients in the last scheduled period (weeks 12-26); 62% of patients entering that period remained seizure free. Quality of life at endpoint improved significantly when compared with baseline for all domains of QOLIE-10 (P < 0.001). Most frequent AEs (reported by > or = 5% of patients) were paresthesia (9.3%), weight loss (7.9%), convulsions (5.7%) and memory disorders (5.0%).

CONCLUSION

In patients with epilepsy, previously not satisfactorily treated with CBZ or OXC, conversion to TPM may result in an improvement in seizure control as well as in quality of life.

Analysis of the VEGF family and their receptors in serum/plasma of patients with pre-invasive and invasive cervical cancer

5016

Background: The vascular endothelial growth factor (VEGF) family and their receptors are essential regulators of angiogenesis and lymphangiogenesis. This study examined the significance of circulating VEGF, VEGF-C, VEGF-D and their receptors VEGFR-1 and VEGFR-2 in patients with preinvasive and invasive cancer in relation to conventional prognostic parameters. Methods: Blood samples were obtained from 125 women before initial treatment (CIN I-III n = 50; FIGO stage I-IV n = 51; relapse n = 24). Plasma (p) and serum(s) levels of pVEGF, sVEGF-D, sVEGFR-1, sVEGFR-2 (R&D Systems, USA) and sVEGF-C (IBL, Japan) were determined by using a quantitative sandwich enzyme-linked immunosorbent assay (ELISA). Results: The highest level of pVEGF (p = 0.007) and sVEGFR-2 (p = 0.014) were detected in patients with recurrent disease, whereas the highest level of sVEGF-D (p = 0.046) were measured in patients with preinvasive lesions (CIN I-III). Furthermore, significantly elevated levels of sVEGF-C (p = 0.021) were detected in early stages (FIGO I-II) in comparison with advanced stages (FIGO III-IV) of cervical cancer. No significant difference in concentration was observed between the various grades of cervical intraepithelial neoplasia (CIN I-III). Correlations between conventional prognostic markers such as lymph node status (N0/N1), lymphangioinvasion (L0/L1), angioinvasion (V0/V1) and grading (G1/G2/G3) were investigated. Increased plasma levels of VEGF (p = 0.036) correlate with the dissemination of tumor cells to regional lymph nodes (N1),whereas serum VEGF-D levels were significantly decreased in women with lymph-node involvement (N1) (p = 0.045) and vascular invasion (L1) (p = 0.019). None of these members of the VEGF family were found to correlate significantly with histological subtype (squamous cell carcinoma, adenocarcinoma, adeno-squamous cell carcinoma) or grading of the tumor cells (G1/G2/G3). Conclusions: These results show that circulating concentrations of VEGF are associated with the stage of disease. In an early stage of cervical cancer a switch to a lymphangiogenic phenotype (VEGF-D, VEGF-C) might be possible.

No significant financial relationships to disclose.

Cost analysis of ELISA, solid-phase extraction, and solid-phase microextraction for the monitoring of pesticides in water

The implementation of a pesticide water monitoring program in South Africa is limited by a lack of financial and analytical resources. A cost analysis of three analytical methods, enzyme-linked immunosorbent assays (ELISA), solid-phase microextraction (SPME), and traditional solid-phase extraction methods (SPE), was conducted. The cost analysis assumed a hypothetical scenario in terms of the sampling area (a grape farming rural region in the Western Cape province of South Africa), sample collection (weekly grab samples collected from eight sites by an environmental health officer in a nearby town), transport of samples (via courier), and analysis (endosulfan and chlorpyrifos analysis conducted by a local higher educational institution laboratory in Cape Town). The cost per sample for the three analytical methods was determined by estimating the annual capital costs, including building and equipment, and recurrent costs, including transport, personnel, supplies, and building operating costs. At the optimal utility of resources, SPME had the lowest cost per sample (US $37), followed by SPE (US $48.50) and ELISA (US $60). Recurrent costs formed the bulk of the costs of all three methods (91-97%). The cost of supplies was particularly high for ELISA (US $34 per sample). The cost per sample estimated for all three methods is substantially lower than those quoted by other laboratories in South Africa. The low cost of SPME is particularly important because of the sensitivity and reliability of this method and the faster output compared to SPE, and SPME is recommended for the long-term monitoring of pesticide pollution.

[Vertical infraclavicular technique of brachial plexus block]

In comparison to preceding infraclavicular methods, vertical infraclavicular blockade of the brachial plexus (VIP), as described by Kilka et al. in 1995, has quickly established itself because of the high success rates and comparatively low risks. Users define the blockade success achieved at around 85 %. However, this figure includes a more or less large number of patients who require supplementary analgesia/sedation and/or sleep induction in addition to pre-medication. Such a combined procedure, VIP plus analgesia/sedation is sometimes problematic e. g. in geriatric patients with a number of additional diseases. This patient group in particular could possibly profit from VIP without additional medication. Based initially on purely clinical observations, the following study reports on a method to improve the success rate of VIP blockade (operability) without additional analgesia and/or sedation. Altogether 499 patients were included in a retrospective study. In 88 patients (Group 1), the method of Kilka et al. was strictly applied. In a second Group (99 patients) the determined puncture site was moved 1 cm laterally. In Group 3 (312 patients), elicitation of a response to stimulation of the fasciculi of the brachial plexus was examined. This was performed by multiple punction, as a rule lateral to the puncture site of Kilka et al. In this group, the total dose of anesthetic (identical in all groups) was divided into 2 - 3 single doses. The pre-operative data of the patients in all groups were comparable. In the course of the VIP (Group 1), the method was changed in 13 patients (14.8 %) with incomplete blockade and after initial modification (Group 2), this was necessary in 12 patients (12.1 %). By means of targeted stimulation of individual sections of the brachial plexus (Group 3), the rate of incomplete blockade could be reduced to 8.3 %. The clearly improved blockade success was achieved without an increase in complications. In contrast to other authors, we came to the conclusion that the success rate was considerably higher when the anaesthetist had several years of experience. In the case of the authors of this study (longest experience), only 3.7 % of the plexus blocks were incomplete. For the use of VIP in practice it can be concluded that the optimal puncture site is often somewhat lateral to that defined by Kilka et al. By means of multiple stimulation with the aim of locating the individual fasciculi of the brachial plexus, the success of blockade, in terms of operability with unchanged low complication rates, can be considerably improved without the need for additional analgesics and/or sedation.

[Angle closure glaucoma in association with relative anterior microphthalmus (RAM) after premature birth-retinopathy (ROP)]

BACKGROUND

The infantile angle-closure glaucoma is a common and well characterized complication of retinopathy of prematurity (ROP). Progressive shallowing of the anterior chamber by retrolental fibrous masses is mostly responsible for the pressure elevation during the first years of life. Apart of this pathogenesis, ROP-associated glaucoma is totally different in cases that do not manifest until adulthood. Only few cases are described in the literature.

CASE REPORT

A 36-year-old female patient presented with symptoms of acute intraocular pressure (IOP) elevation and fundus results of a cicatricial ROP stadium II. Control of IOP was not achieved by systemic and topical drug treatment. The biometry showed a relative anterior microphthalmus (RAM) in myopia. After peripheral iridectomy, the IOP normalized and remained stable over a long-time period.

CONCLUSION

Myopia induction after ROP and ROP treatment often lead to special anatomical conditions corresponding to the classical relative anterior microphthalmus. Shallowing of the anterior chamber and development of angle-closure glaucoma increase with age. Thus, a manifestation not before the third decade of life was a typical finding in the literature review. A detailed recording of history and consideration of the biometric data are of importance for diagnosis. Peripheral iridectomy was found to be the therapy with the highest success rate. The increase of a pupillary block mechanism can prevent further visual loss to the often pre-damaged eyes. Consideration of this entity is crucial in unilateral IOP elevation, because an increasing prevalence of these patients can be expected due to the increase of premature babies since 1970.

[Anesthesia for section caesarean with aortic dissection in Marfan Syndrome]

Marfan Syndrome (MFS) is associated with an increased anaesthesia risk because of the pathological manifestations in anaesthesia-relevant organ systems. If, in addition, a typical MFS complication - acute aortic dissection - presents and this in pregnant patients, a high-risk anaesthesia must be assumed. In the case reported, a 30 year old woman in the 35 th week of gestation presented with an acute aortic dissection, initially in the region of the descending aorta and later, in the course of the ascending aorta. An urgent Caesarean section was indicated in order to perform the equally urgent vascular surgery as quickly as possible. The most important goal of the anaesthesia management is to determine an anaesthesia procedure which addresses the combination of aorta dissection, gestation and MFS. On the one hand, the risk of an aorta rupture needs to be kept as low as possible and on the other hand, the vital functions of the baby have to be maintained. A general anaesthesia procedure under mild controlled hypotension was selected. Optimal monitoring and absolute freedom from pain were the prerequisites both for the anaesthesia management of the Caesarean section as well as for the immediate transport to a clinic for further treatment after completion of anaesthesia.

[Fantoni translaryngeal tracheotomy (TLT) with rigid endoscopic control]

RATIONALE

The incidence of translaryngeal tracheotomy (TLT)-associated peri- and postoperative complications should be assessed prospectively.

METHODS

TLT was carried out in operation-theatre under rigid endoscopic control. Peri- and postoperative complications, decanulement and late sequelae were assessed in ENT-patients. In patients of other wards only perioperative complications were evaluated.

RESULTS

41 patients (26 ENT-patients, 15 patients of other wards) were tracheotomised by TLT. Perioperatively, we observed 3 technical problems (accidental pulling through of the tracheostomy tube). In 2 of these cases TLT could be completed without problems, in 1 case TLT was converted to surgical tracheotomy. Postoperatively, we could find no complications in 26 ENT-patients. Decanulation took place after 7 days on average. We found no tracheocutaneous fistulas or tracheostenoses, scars were unobtrusive.

CONCLUSIONS

TLT with rigid endoscopy is a simple percutaneous tracheotomy-technique with a low complication rate.

A simple method for the identification and assay of extracellular plant beta-galactosidase

A simple, rapid and reproducible procedure for the identification of extracellular Californian poppy (Eschscholzia californica Cham.) beta-galactosidase is described using callus cultures of seedlings from the tested plant, roots of 4-days-old seedlings of Californian poppy germinating on agar plates and cell suspension cultures cultivated from callus cultures. 6-Bromo-2-naphthyl-beta-D-galactopyranoside and p-nitrophenyl-beta-D-galactopyranoside were used as substrates for the determination of the intracellular and extracellular activities of beta-galactosidase. The extracellular beta-galactosidase activity was identified by evaluating the dye-zones in an agar medium. The enzyme from Californian poppy callus cultures or from seedling roots cultivated on agar plates supplemented with 6-bromo-2-naphthyl-galactopyranoside hydrolyzed this substrate releasing 6-bromo-2-naphthol. By simultaneous coupling with hexazonium p-rosaniline the corresponding (reddish-brown) azo-dye was formed. The agar plate method described permits rapid, simple and specific detection of plant producers of extracellular beta-galactosidase.

Association between severity of atopic eczema and degree of sensitization to aeroallergens in schoolchildren

BACKGROUND

A subgroup of patients with atopic eczema exhibits aggravation through contact with aeroallergens. Little is known from population-based studies, however, about the association between the severity of eczematous skin disease and the degree of aeroallergen sensitization.

OBJECTIVE

We sought to investigate the relationship between IgE-mediated allergic sensitization to aeroallergens and severity of atopic eczema in schoolchildren.

METHODS

A nested case-control analysis on atopic eczema was performed on the basis of a cross-sectional study of 2201 East German schoolchildren aged 5 to 14 years. Atopic eczema and its severity was identified by dermatologic examination. Total and allergen-specific IgE antibodies to grass and birch pollen, Cladosporium herbarum, Dermatophagoides pteronyssinus, and cat epithelium in serum were determined, and additional information was obtained by means of standardized questionnaire.

RESULTS

The overall prevalence of actual atopic eczema was 2.5%. Thirty-seven percent of the children were sensitized to at least one allergen. Children with atopic eczema were significantly more often sensitized than those without skin disease (75.0% vs 36.3%; odds ratio, 5.27; 95% confidence interval, 2.54-11.15). This was observed for each single allergen. The prevalence of atopic eczema increased significantly with increasing RAST class (chi(2) trend test for each allergen, P <.0001). Also, the prevalence of sensitization increased with the severity of the disease (chi(2) trend test for each allergen, P <.0001). This association was pronounced for house dust mite and cat allergen. Multiple linear regression analyses showed significant associations between the severity score of atopic eczema and concentrations of allergen-specific IgE to dust mite (P =.032) and cat (P =.014) allergens after adjustment for sex, age, location, and parental predisposition.

CONCLUSIONS

The degree of sensitization is directly associated with the severity of atopic eczema. We speculate that early epicutaneous sensitization to aeroallergens may be enhanced by damage of the skin barrier function. The specific IgE response seems to contribute to the severity of the disease in a dose-dependent fashion.

Indoor risk factors for atopic eczema in school children from East Germany

This study aimed to investigate the relation between environmental influences such as arsenic, cadmium, lead, and mercury, as well as environmental tobacco smoke, pet keeping, and heating systems on the prevalence of atopic eczema. Therefore, a multicenter cross-sectional study of school children aged 5-14 years, including a standardized questionnaire, blood and urine analyses, and a dermatological examination, was undertaken. A cases-control approach was chosen in order to identify relevant risk factors. A total of 2200 school children (response 79.1%) of two areas (Bitterfeld, Hettstedt) polluted by industrial activities and an agricultural control region (Zerbst) of the former German Democratic Republic were examined. Atopic eczema as identified by dermatological examination and history was the outcome variable of interest. Body burden of arsenic and heavy metals and questionnaire data on environmental tobacco smoke exposure, pet keeping, and heating system were investigated as potential risk factors. The overall prevalence of atopic eczema was 2.6%, with higher prevalences in the industrial areas (2.5 and 2.9%) compared to the control area (1.6%, not significant). Bivariate analyses did not reveal statistically significant associations between atopic eczema and tobacco smoke exposure or the body burden of arsenic and heavy metals. According to multiple logistic regression analysis, atopic eczema was significantly more frequent in predisposed families and those who reported keeping guinea pigs (OR=4.37, CI 2.15-8.91), but not other pets, like dogs, cats, and hamsters. In comparison to a distant heating system, a decreased risk was observed in households with central heating system (OR=0.30, CI 0.10-0.90), whereas the presence of a gas heater with an exhaust pipe connection to the wall was associated with a significantly elevated risk for eczema (OR=8.22, CI 2.44-27.66). The heating system and exposure to certain animal allergens are related to the manifestation of atopic eczema. Further studies are needed to clarify how far a causal relationship is reflected by these findings.

[Anagrelide in control of myeloproliferative thrombocythemia: long-term experiences in 6 patients]

Symptomatic or asymptomatic chronic elevation of platelet count can be observed in all forms of myeloproliferative disorders (MPD). Benefits and limitations of the traditional platelet-reducing agents, such as radioactive phosphorus, alkylating agents, hydroxyurea and interferon alpha, are well known and have been largely described. Anagrelide (Agrelin) is an additional newer drug with a selective platelet-lowering effect. We describe our own long-term experience in 6 patients with MPD who were treated with anagrelide as part of a compassionate-use protocol between April 1991 and August 1997. The median duration of therapy was 54 months (range 17 to 75 months), with an overall response rate of 100% (complete and partial response for at least 4 weeks). The initial median platelet count of 1211 x 10(9)/l (range 847 to 2050 x 10(9)/l) was reduced rapidly and lastingly to 570 x 10(9)/l (range 216 to 667 x 10(9)/l) at the time of the last control. Under treatment with anagrelide 4 of the 6 patients showed a reduction of disease-associated symptoms or complications. Adverse reactions were generally mild and transitory, and no interruption or cessation of therapy was required. Development of drug resistance or late adverse events were not observed. Treatment with anagrelide is effective, safe and in our opinion easy to administer. It also appears to be suitable for long-term administration.

Nitric oxide and ocular blood flow in patients with IDDM

Endothelial dysfunction has been implicated in the pathogenesis of diabetic vascular disorders such as diabetic retinopathy. We hypothesized that either local endogenous nitric oxide (NO) synthesis or local reactivity to endogenous NO might be impaired in patients with IDDM and that this may contribute to the development of diabetic retinopathy. Ten otherwise healthy patients with long-standing IDDM and ten healthy control subjects were studied according to an open randomized two-way cross-over design. Subjects received intravenous infusions of either N(G)-monomethyl-L-arginine, an inhibitor of NO-synthase, or L-arginine, the precursor of NO synthesis, on two separate study days. Ocular hemodynamics were assessed by laser interferometric measurement of fundus pulsations and Doppler sonographic measurement of blood flow velocity in the ophthalmic artery. N(G)-monomethyl-L-arginine decreased fundus pulsations and blood flow velocity in the ophthalmic artery and increased blood pressure in healthy subjects. The responses to NO-synthase inhibition were significantly less in diabetic subjects. In contrast, L-arginine caused a comparable increase in fundus pulsations and decrease in blood pressure in both cohorts. These results indicate that systemic and ocular hemodynamic reactivity to NO-synthase inhibition is reduced in patients with long-standing IDDM, compared with healthy control subjects. Thus, this study indicates that either NO-synthase activity is increased or NO sensitivity is decreased in patients with IDDM and supports the concept of an involvement of the L-arginine-NO system in the pathophysiology of diabetic retinopathy.

[Current legislation in public health--an example for post-modern social ethics?]

Social ethics of affirmative postmodernists are discussed in relation to recent German health care legislation. It could be shown that: 1. the health care legislation 1989 and 1993 only partially fulfills the postmodern call for "cultivation of individual responsibility", 2. both laws largely fail to enforce the principle of subsidiarity, and 3. postmodernist thinking is weak on the question of global strategies but strong In the area of individualism and subjectivity. We conclude that postmodern social ethics are useful to compensate areas largely neglected by recent German health care legislation, rather than that the legislation is an example of postmodern social ethics.

Measles antibody in vaccinated human immunodeficiency virus type 1-infected children

OBJECTIVES

The goals of this study were to evaluate the proportion of previously vaccinated human immunodeficiency virus (HIV) type 1-infected children with detectable postvaccination measles antibody; to assess risk factors for vaccine failure; and to evaluate the response to reimmunization.

METHODS

A total of 81 perinatally HIV-infected children receiving medical care in the Bronx, New York who had previously received measles vaccine were enrolled. The Centers for Disease Control and Prevention (CDC) HIV class, lymphocyte subsets, and measles antibody were determined upon enrollment. Additional data abstracted from medical records included dates and number of prior measles vaccinations and CDC HIV class at the time of vaccination. Measles antibody was determined by microneutralization enzyme-linked immunosorbent assay (ELISA).

RESULTS

The median age at time of study was 42 months (range, 9 to 168 months). Overall, 58 (72%) subjects had detectable measles antibody (microneutralization ELISA titer > 1:5). Children studied within 1 year of vaccination were more likely to have detectable measles antibody than children evaluated more than 1 year after vaccination (83% vs 52%, P < .01). The proportion of children with detectable measles antibody was higher among children with no or moderate immunosuppression compared to those with severe immunosuppression when immune status was based on CD4%. Children vaccinated at 6 to 11 months of age appeared to have a higher proportion of detectable measles antibody than those who received a first measles vaccination after age 1. Only 1 (14%) of 7 previously vaccinated children who were seronegative or had very low titers experienced a four-fold rise in measles antibody when reimmunized.

CONCLUSION

These results support current recommendations to vaccinate HIV-infected children against measles. The proportion of children with detectable measles antibody among vaccinated HIV-infected children is considerably lower than in vaccinated healthy children. HIV-infected children may respond better to measles vaccine when it is administered before the first birthday. From our limited data it appears that reimmunization of previously vaccinated HIV-infected children with moderate to severe immunosuppression does not result in an antibody recall response.

Ontogenic expression of the erythroid-type glucose transporter (Glut 1) in the telencephalon of the mouse: correlation to the tightening of the blood-brain barrier

Since Glut 1 was shown to be highly abundant in brain microvessels, its distribution during early developmental stages seems of importance in respect to the timing of blood-brain barrier (bbb) formation in the developing CNS. Here we have followed the temporal expression of the erythroid-type glucose transporter Glut 1 in the telencephalon of the embryonic and newborn mouse, beginning at the 9th intrauterine day. Glut 1 immunofluorescence staining was done on cryosections using a rabbit polyclonal antiserum to purified human erythrocyte glucose transporter. Endothelial cells resp. capillaries were detected by staining with a rhodamin-coupled Bandeiraea simplicifolia lectin (BSL). In parallel, the developmental tightening of the embryonic bbb was assessed by perfusion of mouse embryos with Trypan blue and horse radish-peroxidase. At E9, prior to the onset of intraneural neovascularization, strong Glut 1 immunoreactivity was found in the whole neuroectoderm but only minor staining was seen in the perineural domain. Glut 1 expression remained uniformly distributed in the intraneural tissue at E10, the beginning of intraneural neovascularization in the mouse. From E11 onwards, Glut 1 immunoreactivity was invisible in neuroepithelial cells, but appeared tightly associated with intraneural capillaries. Perfusion of E12 embryos using trypan blue solution and HRP revealed that most parts of the CNS and spinal cord were impermeable to the tracer substances at that stage. Thus, we suggest that the bbb is established very early in CNS development, probably in the course of intraneural neovascularization. In addition, our data indicate that the restriction of Glut 1 expression to the intraneural capillaries reflects the onset of bbb function in the mouse embryo.

The recognition and management of melanoma and other skin lesions by general practitioners in New Zealand

AIM

To assess current levels of knowledge and management practices with respect to melanoma and other skin cancers, in a representative sample of New Zealand general practitioners.

METHODS

A self-administered questionnaire was sent to a random sample of 900 general practitioners. The questionnaire included 12 cases with coloured photographs of skin lesions and a brief presenting history. Responders were asked to assess probable diagnosis, need for biopsy and management of the lesion. Other attitudinal and relevant background information was also gathered. The questionnaire was sent to a comparison sample of 35 dermatologists.

RESULTS

The overall response rate was 66% among the general practitioners and 68% among the dermatologists. The sample responding was representative of the larger population of doctors practising in New Zealand. Correct decisions whether or not to biopsy lesions (mean score of 10.1 out of 12) were significantly higher than the number of correct diagnoses (mean 8.4). Correct identification and recognition of the need to biopsy melanomas was high. Diagnostic skills and recognition of the need for biopsy were somewhat lower among general practitioners aged 50 years and over than among younger doctors. Doctors who had experience of a patient with melanoma had higher diagnostic skills and made more correct biopsy decisions. The general practitioners' scores for correct biopsy decisions were similar to those of the dermatologists sampled, although their diagnostic skills were somewhat lower, particularly with respect to nonmelanoma skin cancers.

CONCLUSION

The findings indicate a high level of expertise in terms of diagnosis of skin lesions and identification of need to biopsy suspicious lesions among general practitioners in this country.

Application of silver acetate autometallography and gold-silver staining methods for in situ DNA hybridization

In situ hybridization using biotinylated DNA probes has become an important tool in histopathology. It is well known that the sensitivity of the methods used to demonstrate viral DNA in formalin-fixed and paraffin-embedded specimen depends strongly on the detection system used. In the present study, an optimized in situ DNA hybridization protocol was combined with four different approaches of gold-silver staining methods. For silver enhancement, the recently described method of silver acetate autometallography, a technique allowing highly efficient development without the necessity of dark room illumination has been used. The most efficient detection method found in our experiments was the use of gold-adsorbed anti-biotin antibodies with subsequent silver enhancement. This staining procedure can be completed in 5 hours including hybridization and is a highly sensitive alternative to peroxidase and alkaline phosphatase detection systems.