Risk factors for death and emergency transfer in acute and subacute inpatient rehabilitation

OBJECTIVES

To compare the risk of death or emergency transfer (ET) to an acute care hospital for acute and subacute rehabilitation inpatients, to identify risk factors, and to determine whether the risk factors vary by level of care.

DESIGN

Proportional hazards regression analysis of retrospective cohort data. Explanatory variables included level of care, age, sex, medical stability at admission, and diagnosis.

SETTING

An acute inpatient rehabilitation hospital and a skilled nursing facility-based subacute rehabilitation program.

PATIENTS

Patients were selected from a database of all acute and subacute inpatients discharged between January 1992 and August 1994 (N = 4,755). Readmissions and pediatric patients were excluded (n = 896). Patients who had complete data (n = 3,185) were included in the survival analysis; a separate univariable analysis was performed for patients who lacked complete data (n = 674).

OUTCOME MEASURE

Rate of death or emergency transfer during rehabilitation.

RESULTS

The overall risk was greater for subacute patients than for acute inpatients, 20.6% vs 11.6%, odds ratio = 2.0, CI = 1.6 to 2.5. The survival analysis indicated that age, level of care, sex, and stability were associated with the risk of death or emergency transfer (2.1 < or = zeta < or = 4.7; p < .05 for each). However, the difference in risk between subacute and acute care was greatest among younger patients.

CONCLUSIONS

Careful consideration of risk factors is critical for proper assignment of patients to rehabilitation levels of care. However, research is needed to test these findings in other settings and to improve identification of high-risk patients.

Social marketing and diffusion-based strategies for communicating with unique populations: HIV prevention in San Francisco

We conducted a 2-year investigation of the extent to which strategies based on social marketing and diffusion of innovations concepts are used in preventive health communication with unique (highly ostracized) populations. Of the 49 organizations in San Francisco that operate HIV prevention programs (N = 100), programs that most highly targeted unique populations were surveyed. Personal interviews were then conducted with 38 staff leaders who operated the most and least effective programs. Audiotapes and transcripts were content analyzed to identify the strategies used by program staff. Strategies based on social marketing concepts were more prevalent than strategies based on the diffusion of innovations: More effective programs were characterized by emphasis on homophily, audience segmentation, compatibility-based strategies, and interorganizational collaboration.

The effect of food on the relative bioavailability of deflazacort

The effect of high- and low-fat meals on the relative bioavailability of deflazacort tablets was investigated in 12 healthy, adult males who were administered 36 mg deflazacort under fasted and fed conditions in a crossover fashion. Serial plasma samples were drawn up to 24 h post-dose and quantified for the active metabolite 21-desacetyl deflazacort (DFZ 21-OH) by a rapid and sensitive HPLC method. Following deflazacort administration with high-fat and low-fat meals and under fasted conditions, DFZ 21-OH area under the curve to infinity averaged 508.39 +/- 131.70, 510.05 +/- 148.30 and 511.90 +/- 188.16 ng.h/ml. DFZ 21-OH Cmax averaged 156.31 +/- 33.31, 156.85 +/- 40.17 and 188.05 +/- 53.35 ng/ml for high-fat, low-fat and fasted treatments, respectively. Differences in Cmax between the fed versus fasted treatments were statistically significant (P < 0.05). The decrease in Cmax under fed conditions was accompanied by an increase in mean Tmax of approximately 17-85% compared to fasted conditions. As expected, terminal half-life was not affected. These data indicate that co-administration of deflazacort tablets with high-fat and low-fat meals leads to a small decrease in rate but does not affect its extent of absorption.

A blood group-related polymorphism of CD44 abolishes a hyaluronan-binding consensus sequence without preventing hyaluronan binding

CD44 is a widely expressed integral membrane protein that acts as a receptor for hyaluronan (HA) and is proposed to be important to cell-extracellular matrix interaction. The Indian (In) blood group antigens reside on CD44, and most individuals express the Inb antigen. Homozygosity for the Ina allele occurs as a rare event and is associated with production of alloantibody to the common Inb antigen after transfusion or pregnancy. The present study demonstrates that a single point mutation (G252 --> C) causes an Arg46 --> Pro substitution, which is responsible for the Inb/Ina polymorphism. Additional mutations were found in In(a+b-) cDNA but were not necessary to the antigenic phenotype as determined in site-directed mutagenesis studies. In studies using CD44 chimeric constructs, Arg46 has previously been shown to be crucial for maintenance of HA-binding ability to a CD44 peptide. However, the present study demonstrates that the Arg46 --> Pro substitution does not reduce HA binding to the intact CD44 protein, which contains two proposed extracellular HA-binding motifs. Down-regulation of HA binding to In(a+b-) CD44 by anti-CD44 monoclonal antibody (mAb) ligands, however, was weakened, although all mAbs tested bound In(a+b-) and In(a-b+) CD44 equally well. Competitive inhibition studies using human anti-Inb also showed that some mAbs that inhibit HA binding to CD44 may do so by interacting with a domain separate from, but affecting the structure of, the Inb epitope.

Squamous cell carcinoma of the conjunctiva in a patient with the acquired immunodeficiency syndrome

PURPOSE

To alert ophthalmologists to the possibility of human immunodeficiency virus (HIV) infection in individuals with conjunctival squamous cell carcinoma.

METHODS

We treated a 24-year-old patient with the acquired immunodeficiency syndrome who developed a limbal mass. The mass was excised and examined by routine histologic and immunohistochemical methods.

RESULTS

The histopathologic examination disclosed infiltrating squamous cell carcinoma with features of spindle cell carcinoma. Frequent abnormal mitotic figures were present in this neoplasia.

CONCLUSIONS

Squamous cell carcinoma with histologic features of aggressive behavior in a young individual should alert physicians to the possibility of HIV infection. Such patients may require frequent follow-up examination, even after complete excision of the tumor.

Emergency department do-not-attempt-resuscitation orders: next-of-kin response to the emergency physician

OBJECTIVE

To evaluate the response by families of incompetent, chronically debilitated, and/or terminally ill patients who were contacted for do-not-attempt-resuscitation (DNAR) status by an emergency physician (EP).

METHODS

A prospective observational study was performed to assess next-of-kin willingness to support DNAR status for incompetent, chronically debilitated, and/or terminally ill patients. The families also were contacted by telephone follow-up 48-72 hours after the ED visit. Upon follow-up evaluation, the families were surveyed regarding prior DNAR instructions and their perceptions of the establishment of DNAR status in the ED. The study was conducted in an urban teaching hospital with an emergency medicine residency training program.

RESULTS

Of the 71 patient families contacted, 60 (85%) of the patients had DNAR orders written in the ED. The families of these 60 patients had no negative response regarding contact by ED personnel. Of the 11 (15%) patients whose families wished no DNAR order, only two families had negative responses to being contacted by the EP. In both cases the families had previously given detailed instructions to the chronic care facility.

CONCLUSION

The EP can play an important role in assisting the decision making process of families of incompetent, chronically debilitated, and/or terminally ill patients regarding institution of DNAR orders in the ED. Improved communication regarding existing DNAR orders with chronic care facilities might minimize the rare complaints received from families with preestablished DNAR orders.

JMH variants: serologic, clinical, and biochemical analyses in two cases

BACKGROUND

JMH is a high-frequency red cell blood group antigen that resides on a 76- to 80-kDa glycosylphosphatidylinositol-linked protein also known as CDw108. Antibodies with JMH specificity are often autoimmune and are usually, if not always, clinically benign. Some individuals with JMH-variant antigen produce alloantibodies to JMH, but little evidence concerning their clinical significance is available. This article reports on two patients who express a JMH-variant antigen and produced alloanti-JMH.

STUDY DESIGN AND METHODS

Murine monoclonal antibodies and human antibodies to JMH were used in hemagglutination, radioimmunoassay, and Western blot testing of red cells from two JMH-variant patients; antiserum from one of these patients was also used in biochemical studies. In addition, in vivo survival of JMH-positive red cells was studied in the same patient.

RESULTS

Biochemically, both examples of red cells with the JMH-variant phenotype expressed a JMH protein with a molecular weight similar to that of the normal JMH protein. For both patients, family studies suggested an autosomal recessive pattern of inheritance. Survival study demonstrated reduced in vivo red cell survival in one patient.

CONCLUSION

JMH-variant phenotypes express a protein of normal molecular weight and are inherited in an autosomal recessive pattern. Furthermore, individuals with this phenotype can produce clinically significant antibodies.

Changing indications for penetrating keratoplasty, 1989-1993

The purpose of this study was to identify new trends in the changing indications for penetrating keratoplasty. We retrospectively reviewed the clinical and pathologic diagnoses of 1,104 corneal buttons that had been submitted to the Estelle Doheny Eye Pathology Laboratory, Los Angeles, during the 5-year period 1989-1993. The leading indications, in order of decreasing frequency, were pseudophakic corneal edema (24.8%), regrafts (21.3%), scarring with or without chronic inflammation (11.1%), keratoconus (7.1%), aphakic corneal edema (6.4%), and ulcerative conditions (5.8%). The incidence of pseudophakic corneal edema remained stable over the study period and was actually surpassed by regraft in the last year of the study. Although pseudophakic corneal edema remains the predominant indication for penetrating keratoplasty, our findings suggest that its occurrence rate has begun to level off.

Limbal and choroidal Cryptococcus infection in the acquired immunodeficiency syndrome

PURPOSE

A 30-year-old patient with the acquired immunodeficiency syndrome (AIDS) had limbal nodules and multifocal choroidal lesions.

METHODS

A biopsy of the limbal nodules was performed.

RESULTS

The biopsy showed Cryptococcus neoformans surrounded by thick mucinous capsules without inflammatory cell infiltration.

CONCLUSION

In the differential diagnosis of limbal mass in patients with AIDS, cryptococcal infection should be considered.

Physical and genetic mapping of the CMT4A locus and exclusion of PMP-2 as the defect in CMT4A

We have previously localized one form of the autosomal recessive Charcot-Marie-Tooth disease type 4 (CMT4A) to a 5-cM region of chromosome 8q13-q21. We now report the formation of a 7-Mb YAC contig spanning the region. This contig was used to map nine additional microsatellites and six STSs to this region, and subsequent haplotype analysis has narrowed the CMT4A flanking interval to less than 1 cM. In addition, using SSCP and our physical map, we have demonstrated that the myelin protein PMP-2, mapped by FISH to this region, is not the defect in CMT4A.

Evidence that CDw108 membrane protein bears the JMH blood group antigen

BACKGROUND

CDw108 is a cluster-of-differentiation antigen that resides on a glycosylphosphatidylinositol (GPI)-linked protein; it has not previously been shown to be expressed on red cells. JMH is a high-frequency red cell blood group antigen that resides on a GPI-linked protein of molecular weight similar to that bearing CDw108. The purpose of this study was to investigate whether CDw108 is expressed on red cells and whether it resides on the same membrane protein as does JMH.

STUDY DESIGN AND METHODS

Murine monoclonal antibodies to CDw108, MEM-121 and MEM-150, as well as a murine monoclonal antibody and human antibodies to JMH were used in radioimmunoassay, inhibition assay, Western blotting, and monoclonal antibody-specific immobilization of erythrocyte antigen assay.

RESULTS

MEM-121 and MEM-150 were found to bind to red cells, and MEM-150 blocked binding of human anti-JMH to red cells. Anti-CDw108 and anti-JMH identified red cell membrane proteins that were of similar size and that were absent from JMH-negative red cells on Western blotting. MEM-150 and MEM-121 also immobilized the same protein that reacted with human anti-JMH.

CONCLUSION

CDw108 is expressed on red cells and resides on the same GPI-linked membrane protein as does the JMH blood group antigen.

Investigations using a novel monoclonal antibody to the glycosylphosphatidylinositol-anchored protein that carries Gregory, Holley, and Dombrock blood group antigens

BACKGROUND

The high-frequency Hy and Gya antigens have been shown to reside on the same protein. Gy(a-) Hy-negative red cells are also Do(a-b-). A mouse monoclonal antibody, 5B10, was produced with specificity related to the human Gregory, Holley, and Dombrock blood group antigens.

STUDY DESIGN AND METHODS

The antibody reacted in direct hemagglutination assays, and its specificity was investigated by radioimmunoassay, inhibition assay, and Western blotting.

RESULTS

The 5B10 antibody failed to bind to abnormal paroxysmal nocturnal hemoglobinuria red cells and human erythroleukemia cell line K562, but it was weakly reactive with HEL cells. Red cells, but not other circulating hematopoietic cells, express the 5B10 antigen. The 5B10 antibody had a specificity similar but not identical to that of Gya. Gy(a-) Hy-negative red cells reacted extremely weakly with 5B10 antibody, but Gy(a-) Hy-negative red cells treated with a variety of proteases bound 5B10 antibody strongly. This suggests that these cells express a variant form of the protein recognized by 5B10.

CONCLUSION

Identification of a monoclonal antibody to this glycosylphosphatidylinositol-linked protein opens a new avenue for investigation of the biochemistry, genetics, and function of the glycosylphosphatidylinositol-linked protein that bears the Gya, Hy, and Do antigens.

Identification of the Tcb allele of the Cromer blood group gene by PCR and RFLP analysis

The Cromer blood group antigens reside on the complement regulatory protein, decay-accelerating factor (DAF). The Cromer system comprises 10 antigens, 3 of which are of low incidence. When an individual is homozygous for the allele encoding one of these low-incidence antigens, they are liable to produce an antibody to the antithetical high-frequency antigen if challenged by pregnancy or transfusion. These antibodies are often difficult to identify, because of the lack of readily available antigen-negative cells and typing sera. In blacks, about 5 percent of individuals carry the rare Tcb Cromer allele. We have shown that the presence of the low-incidence Tcb allele can be detected by polymerase chain reaction (PCR) amplification of a fragment of the gene encoding DAF, followed by allele-specific restriction enzyme digestion.

Identification of the urokinase receptor as an adhesion receptor for vitronectin

Urokinase receptors, expressed on surfaces of many cell types, focus to the pericellular space plasminogen-dependent proteolysis important in matrix remodeling and cell movement. We now report that the urokinase receptor (uPAR) is also a high affinity (Kd < 30 nM) receptor for vitronectin. Recombinant uPAR binds vitronectin in the absence of urokinase, but vitronectin binding is promoted by concurrent receptor binding of either urokinase or fragments thereof containing its uPAR binding domain. Stable epithelial cell transfectants expressing membrane-anchored uPAR, but not cells expressing soluble uPAR, become strongly adhesive with altered morphology in the absence of urokinase. These observations identify a new class of vitronectin receptor and imply a duality in function for the receptor that intrinsically links matrix adhesion to regulation of protease activity. Increases in urokinase receptor expression known to be associated with cellular activation and malignant transformation could modulate cellular trafficking and function by promoting attachment to vitronectin.

Schistosoma mansoni: fractionation and characterization of the glycocalyx and glycogen-like material from cercariae

The glycocalyx (GCX) that covers schistosomal cercariae is a complex molecule that has immunomodulating properties. Here, we purified milligram amounts of GCX using Anguilla lectin which binds to the GCX covering the cercarial body and tail. Typically, 10 million cercariae were extracted with phenol, dialyzed, and chromatographed on a Sepharose 2B-CL column. An average of 39 mg of total carbohydrate eluted near the void volume from which 31 mg of glycogen-like material was further separated by lectin affinity chromatography. Its identity was established by compositional analysis, sensitivity to amylase digestion, and its nuclear magnetic resonance spectrum. The lectin-bound GCX was eluted with 0.1 M fucose with a final yield of 5.3 mg carbohydrate. Fucose composed 40% of the total GCX carbohydrate with lesser but approximately equal amounts of galactose, glucosamine, and galactosamine present. NMR data indicated that the amino sugars were N-acetylated. Glucose was also present but in varying amounts in different preparations of GCX. Oligosaccharides were released from GCX by hydrazinolysis and separated by electrophoresis after reductive amination to 8-aminonaphthalene-1,3,6-trisulfonic acid (ANTS). Bands comigrating with standards containing 11, 12, 16, and 17 sugar residues were detected. Thus, the GCX is a complex structure composed of oligosaccharides, probably linked to a peptide.

Molecular mapping of the Cromer blood group Cra and Tca epitopes of decay accelerating factor: toward the use of recombinant antigens in immunohematology

Cromer blood group antigens reside on the complement regulatory protein decay accelerating factor (DAF, CD55). This glycosyl-phosphatidylinositol-anchored glycoprotein is widely distributed, especially among cell types in contact with plasma. Numerous Cromer blood group antigens have been defined using alloantibodies induced by transfusion or pregnancy. However, few pairs of antithetical antigens have been described in this system, presumably because of the rarity of the low-frequency alleles. Analysis of polymerase chain reaction-amplified genomic DNA showed that the Cr(a-) phenotype has a Ala193-->Pro substitution in short consensus repeat 4 (SCR4) of DAF, and the Tc(a-b+) phenotype has a Arg18-->Leu substitution in SCR1 of DAF. The locations of Cra and Tca epitopes were confirmed by analysis of Chinese hamster ovary cell transfectants expressing a Cr(a-) allele-specific transfectant and a chimeric protein containing only SCR1 of DAF, respectively. Overall, these studies further show the usefulness of an approach based on recombinant proteins in mapping blood group antigen epitopes and identifying blood group antibodies.

Presenting characteristics of trisomy 8 as the primary cytogenetic abnormality associated with childhood acute lymphoblastic leukemia. A Pediatric Oncology Group (POG) Study (8600/8493)

Although trisomy 8 is the single most common numerical abnormality in acute myeloid leukemia (AML), relatively few cases with acute lymphoblastic leukemia (ALL) and trisomy 8 have been reported. We report the clinical and laboratory features of seven children with ALL and trisomy 8 as the sole cytogenetic abnormality and review nine similar cases from the literature. Among the children studied by the Pediatric Oncology Group (POG) with newly diagnosed ALL, only 0.3% had trisomy 8 as the sole abnormality. Four of our patients had T-cell ALL and three had early pre-B ALL. Presenting clinical features were typical for the respective immunophenotypes. Six of the seven children achieved complete remission. Our study suggest that trisomy 8 is an infrequent, recurring abnormality among children with ALL, which appears to be associated with a T-cell immunophenotype.

Recent advances in immunohematology

Knowledge of the biochemistry and genetics of erythrocyte blood group antigens has been growing rapidly over the past several years. Last year, the molecular basis for the major Rh blood group antigens was delineated. In addition, the genetic and biochemical bases of several other blood group antigens were identified. One of the most interesting matches of blood group antigens to a functional membrane protein was that of the Diego antigens to the erythrocyte anion channel (band 3) protein. In addition, knowledge of the molecular basis of blood group antigens is now leading rapidly to the usefulness of molecular techniques in identifying blood group genotypes and even blood group antibody specificities. This knowledge has also broadened our understanding of the pathogenesis of erythrocyte disorders associated with null blood group phenotypes. The diagnosis and treatment of autoimmune hemolytic anemia has seen slow but steady progress. New techniques appear promising as methods for distinguishing clinically important from benign autoantibodies. The molecular targets for erythrocyte autoantibodies were also largely identified. Treatment of autoimmune hemolytic anemia is also slowly being improved with the use of agents such as intravenous gammaglobulin, danazol, and immunosuppressive agents, all of which have also been important in the treatment of autoimmune thrombocytopenic purpura.

Conjugated deferoxamine reduces blood-brain barrier disruption in experimental optic neuritis

The purpose of this paper was to investigate the role of deferoxamine (DFO) scavenging of hydroxyl radical (.OH) on disruption of the blood-brain barrier (BBB) and demyelination in experimental optic neuritis. Eighteen strain-13 guinea pigs were sensitized for experimental allergic encephalomyelitis. Nine animals received 100 mg/kg of hydroxyethyl starch-conjugated (HES) DFO by daily intraperitoneal injection commencing the day of antigenic sensitization. Nine paired litter mates received daily IP injections of HES. Serial fat-suppressed magnetic resonance imaging of the optic nerves was obtained with a T2 weighting (T2w) to evaluate demyelination and after intravascular administration of Gd-DTPA to evaluate BBB disruption. The intensity of Gd-DTPA enhancement and T2w signal of the optic nerves was quantitated 3, 7, 10 and 14 days after antigenic sensitization. Animals were then sacrificed and the optic nerves processed for light and transmission electron microscopy with ultracytochemical localization of endogenous hydrogen peroxide (H2O2) and immunogold colocalization of extravasated serum albumin. The area of the optic nerve head, intensity of toluidine blue staining, and the cellular infiltrate were digitized and quantitated. Administration of HES-DFO significantly reduced the intensity of Gd-DTPA enhancement in the optic nerves of HES-DFO-treated animals compared to paired control HES animals (p = 0.0236), with the mean difference between control and treated animals of 19.39. The difference in T2w signal was not significant (p = 0.39), with a mean difference between control and treated animals of -5.51. The intensity of toluidine blue staining of optic nerve specimens was slightly less with HES-DFO compared to untreated animals (mean pair difference 2.48), and the inflammatory infiltrate was reduced with HES-DFO compared to untreated animals (mean pair difference = 61.57); these differences were not statistically significant. In the optic nerve specimens of both groups cerium perhydroxide-derived H2O2 reaction product was evident in a predominantly perivascular and perineural distribution. Immunogold-labeled serum albumin showed extravasation at foci of perivascular inflammation in both the presence and absence of H2O2-derived reaction product. Conjugated DFO reduces disruption of the BBB, as measured by Gd-DTPA enhancement, suggesting the .OH radical generated from perivascular H2O2 may play a role in alterations of vascular permeability in experimental optic neuritis.

Two novel pathogenic mitochondrial DNA mutations affecting organelle number and protein synthesis. Is the tRNA(Leu(UUR)) gene an etiologic hot spot?

We identified two patients with pathogenic single nucleotide changes in two different mitochondrial tRNA genes: the first mutation in the tRNA(Asn) gene, and the ninth known mutation in the tRNA(Leu(UUR)) gene. The mutation in tRNA(Asn) was associated with isolated ophthalmoplegia, whereas the mutation in tRNA(Leu(UUR)) caused a neurological syndrome resembling MERRF (myoclonus epilepsy and ragged-red fibers) plus optic neuropathy, retinopathy, and diabetes. Both mutations were heteroplasmic, with higher percentages of mutant mtDNA in affected tissues, and undetectable levels in maternal relatives. Analysis of single muscle fibers indicated that morphological and biochemical alterations appeared only when the proportions of mutant mtDNA exceeded 90% of the total cellular mtDNA pool. The high incidence of mutations in the tRNA(Leu(UUR)) gene suggests that this region is an "etiologic hot spot" in mitochondrial disease.

Differential S100 beta expression in choroidal and skin melanomas: quantitation by the polymerase chain reaction

PURPOSE

S100 beta, a member of a calcium-binding protein family (S100s), is an important clinical marker for skin melanoma. In contrast, uveal melanomas appeared to express S100 beta protein less frequently and to a lesser degree. This study was performed to verify and extend this finding to the mRNA level.

METHODS

A quantitative polymerase chain reaction (PCR)-based method was used. A ratio, comparing the S100 beta PCR fragment to that of beta-actin (an internal reference gene), was generated to compare S100 beta mRNA expression among samples.

RESULTS

The ratios for skin melanomas (1.2 to 3.9; three tissues and two cell lines) were significantly higher than that for choroidal melanomas (0.1 to 0.63; seven of eight primary tumors and four of four cell lines). Only one choroidal melanoma biopsy had a ratio greater than 1. The PCR products from choroidal melanoma were identical in size and sequence to the S100 beta, as determined by gel electrophoresis and RNA conformational polymorphism. Because the ratios were also low in choroidal melanoma cell lines, the S100 beta phenotype appears to be genetically stable.

CONCLUSION

S100 beta is differentially expressed at the RNA and protein levels by skin and choroidal melanomas, which are derived from distinct populations of melanocytes. However, choroidal melanomas expressing little or no S100 beta were significantly stained by antiserum specific for the S100 protein family. Taken together, these data suggest that choroidal melanocytes express another, perhaps even novel, S100 protein(s).

Trabeculectomy and Molteno implantation for glaucomas associated with uveitis

PURPOSE

This study compares the outcomes of trabeculectomy and Molteno implantation in the treatment of glaucomas associated with uveitis.

METHODS

Forty-five patients with uveitis, who had undergone filtering surgery for glaucomas associated with uveitis, were reviewed retrospectively. Successful outcome was defined as final intraocular pressure (IOP) of 6 to 21 mmHg, with a minimum follow-up of 6 months without visually devastating complications or loss of light perception.

RESULTS

One- and two-year life-table success rates, respectively, were 81% and 73% with trabeculectomy (16 patients); 53% and 31% with combined trabeculectomy and first-stage (reserve) Molteno implantation (19 patients); and 79% and 79% with one-stage Molteno implantation (10 patients). In 11 patients who underwent second-stage Molteno implantation after trabeculectomy failure, 1- and 2-year life-table success rates were 79% and 79%, respectively. Complications included surgically treated choroidal effusions (1/45; 2%), choroidal hemorrhages (3/45; 7%), and chronic hypotony (3/45; 7%). Follow-up in all groups ranged from 5 to 70 months (mean +/- standard deviation, 28 +/- 17 months).

CONCLUSIONS

Trabeculectomy provides surprisingly good results in glaucomas associated with uveitis (modulation of wound healing with antimetabolites probably would afford an even higher success rate). However, when significant, immediate postoperative and/or moderate chronic postoperative inflammation is likely, aqueous drainage devices appear more likely to control IOP.

Developing a Chinese version of the psychoeducational profile (CPEP) to assess autistic children in Hong Kong

The Psychoeducational Profile (PEP) has been used to assess the developmental functioning and behavior of autistic children in the West. To examine its suitability for assessing autistic children in Hong Kong, the PEP was translated into Chinese and certain items were adapted for local conditions. The Chinese version of the PEP (CPEP) was administered to 23 autistic children and 40 children with normal development, ranging in age from 3 to 7 years. Some of the children were also given the Merrill-Palmer Scale of Mental Tests. Results indicated that CPEP scores correlated significantly with Merrill Palmer scores, demonstrating criterion-related validity. Significant positive correlations were also found between age and CPEP scores for children with normal development, verifying that the CPEP has properties of a developmental scale. There was also a significant difference between children with normal development and children with autism on the Pathology scale, suggesting that the scale has discriminant validity.

Structure and biological activities of a heparin-derived hexasaccharide with high affinity for basic fibroblast growth factor

We demonstrated previously that heparin-derived hexasaccharides are the smallest fragments of the polysaccharide with comparable basic fibroblast growth factor (bFGF)-modulating activity in vitro (Ishihara, M., Tyrrell, D.J., Stauber, G.B., Brown, S., Cousens, L., and Stack, R.J. (1993) J. Biol. Chem. 268, 4675-4683. In this report, a specific hexasaccharide having high affinity for recombinant human bFGF was isolated and its structure deduced by analysis of its reduced disaccharide products after treatment with nitrous acid at pH 1.5, and by 1H NMR spectroscopy. The hexasaccharide has the structure [IdoA(2-OSO3)alpha 1-4GlcNSO3(6-OSO3)alpha 1-4]2IdoA(2-OSO3)alpha 1-4 AManR(6-OSO3). The hexasaccharide effectively inhibits the binding of syndecan-transfected RO-12 UC cells to bFGF-coated wells (Ishihara, M., Tyrrell, D.J., Kiefer, M.C., Barr, P.J., and Swiedler, S.J. (1992) Anal. Biochem. 202, 310-315), prevents the binding of 125I-bFGF to confluent monolayers of adrenocortical endothelial (ACE) cells, and inhibits the bFGF-dependent proliferation of ACE cells. Unlike the heparin from which it was derived, however, the hexasaccharide cannot promote the binding of 125I-bFGF to a recombinant high affinity bFGF receptor (flg) or restore the bFGF-dependent proliferative response to ACE cells grown in the presence of 5 mM sodium chlorate. Collectively, these data indicate that a hexasaccharide can be as effective as heparin as an antagonist of bFGF-mediated cell mitogenesis.

Human erythrocyte acetylcholinesterase bears the Yta blood group antigen and is reduced or absent in the Yt(a-b-) phenotype

The Cartwright (Yt) blood group antigens have previously been shown likely to reside on a phosphatidylinositol-linked erythrocyte membrane protein. In this study, an unusual individual whose red blood cells (RBCs) were of the previously unreported Yt(a-b-) phenotype were used, along with normal Yt(a+) cells, to investigate serologically and biochemically the relationship of the Yta antigen to known phosphatidylinositol-linked erythrocyte proteins. Yt(a-b-) RBCs expressed normal amounts of various phosphatidyl-inositol-linked proteins except acetylcholinesterase. Further, human anti-Yta reacted with acetylcholinesterase in immunoprecipitation and immunoblotting studies. Thus, acetylcholinesterase is now identified as the protein bearing the Yt blood group antigens.

Sex-differences in the disposition of substituted benzamides: pharmacokinetics of a gastroprokinetic agent (4-amino-5-chloro-2-[2- (methylsulfinyl) ethoxy]-N-[2-(diethylamino)ethyl] benzamide hydrochloride) (ML-1035) in male and female New Zealand white rabbits

The disposition of 4-amino-5-chloro-2-[2-(methylsulfinyl)ethoxy]-N- [2-(diethylamino)ethyl] benzamide hydrochloride (ML-1035) following intravenous (10 mg kg-1) and oral (200 mg kg-1) dosing was investigated in male and female New Zealand white rabbits. After intravenous dosing ML-1035 was eliminated with a half-life of 1.45 +/- 0.49 h in males and 0.79 +/- 0.08 h in females. Volume of distribution at steady-state was 2.08 +/- 0.98 l kg-1 in males and 9.11 +/- 5.86 l kg-1 in females. Clearance averaged 2.99 +/- 1.11 l h-1 kg-1 in males and 16.73 +/- 7.29 l h-1 kg-1 in females. All pharmacokinetic parameters were significantly different between males and females (p < 0.05). Absolute bioavailability after oral administration was 7.35 per cent for males and 12.31 per cent for females, suggesting that ML-1035 undergoes significant first-pass elimination. Plasma area under the curve for the metabolites of ML-1035 after both oral and intravenous administration were also different between the two sexes. These data suggest that the disposition of ML-1035 shows significant differences between male and female rabbits.

Predicting return to work in traumatic brain injury using assessment scales

This study compared two frequently used brain injury assessment scales with a comprehensive functional scale in their capability to predict return to work in a traumatic brain injured population. Fifty-seven consecutive admissions to an inpatient brain injury program were rated at admission and discharge using the following scales: Patient Evaluation and Conference System (PECS), Disability Rating Scale, and Levels of Cognitive Functioning Scale. Their relative accuracy in predicting return to work or school up to 26 months after the injury was assessed using hierarchical logistic regression analysis. In each analysis, return to work/school was the dependent variable. The independent variables were initial status and discharge status on each rating scale. Overall these scales predicted return to work with 73.5% to 84.4% accuracy. Total PECS and PECS Cognition scores were the most accurate predictors. Analysis of incorrect predictions revealed the importance of additionally tracking the social factors of substance abuse, family/community support and financial need to return to work.

Molecular cytogenetic analysis of a familial 8p23.1 deletion associated with minimal dysmorphic features, seizures, and mild mental retardation

We report a family in which three members presented with minimal phenotypic abnormalities, normal intelligence to mild mental retardation, and a cytogenetically terminal chromosome deletion at band 8p23.1 Whole chromosomal painting with a chromosome 8-specific DNA library confirmed this familial chromosome abnormality as a deletion, while fluorescence in situ hybridization with telomeric probes demonstrated the presence of telomeres at the deletion site. Coagulation studies were additionally performed to evaluate the purported location of the coagulation factor VII regulator gene at 8p23.1. A review of the clinical findings of seven cases of del(8)(p23.1) is presented.

The teacher's role in facilitating memory and study strategy development in the elementary school classroom

The efforts of 69 elementary school teachers to instruct children in cognitive processing activities were observed. Although the teaching of such activities was relatively infrequent, it varied by grade (occurring more often in grades 2-3 than in higher or lower grades) and by the content of instruction. Teachers of grade 4 and above more often provided rationales for the use of cognitive strategies than did teachers of younger children. In a second study, children of three achievement levels were selected from classrooms in which teachers varied in their use of suggestions regarding cognitive processes. Subsequent to training in the use of a memory strategy, children's performance on a maintenance trial was evaluated: Among average and low achievers, those whose teachers were relatively high in strategy suggestions showed better maintenance and more deliberate use of the trained strategy than did children whose teachers rarely made strategy suggestions. The role of school experience in the development of children's memory skills is discussed.

Propionibacterium acnes-enhanced lens-induced granulomatous uveitis in the rat

Propionibacterium acnes (Corynebacterium parvum) is being implicated more frequently as a cause of intraocular inflammation following cataract surgery. In addition to its role as an infectious agent, P. acnes also may possess adjuvant-like or adjuvant-enhancing properties. The presence of this organism in an eye with residual lens material after extracapsular cataract surgery could augment inflammation resulting from a phacoantigenic (phacoanaphylactic) response. We have modified an established rat model of lens-induced granulomatous uveitis (LIGU) to examine the adjuvant properties of P. acnes. Our results suggest that P. acnes effectively potentiates LIGU.

45,X/46,X,+r(X) can have a distinct phenotype different from Ullrich-Turner syndrome

We present a patient with 45,X/46,X,+r(X) mosaicism and lack of inactivation of either the normal or the ring X in the 46,X,+r(X) cells. The patient has mental retardation, syndactyly, minor facial anomalies, and a congenital heart defect. Although most patients with 45,X/46,X,+r(X) have the Ullrich-Turner syndrome, 2 previously described patients with this karyotype also had a distinct phenotype consisting of severe mental retardation, syndactyly, and abnormal face. The unusually severe phenotype in these patients was thought to be due to lack of X-inactivation of the ring X chromosome. The findings in our patient support this hypothesis.

Structural requirements for the carbohydrate ligand of E-selectin

The acute inflammatory response requires that circulating leukocytes adhere to, and then migrate through, the vascular wall at the site of injury or infection. Several receptors have been implicated in this adhesion and migration process, including the selectins, a family of carbohydrate-binding proteins. The ligand for one of these proteins, E-selectin (LECAM-2, ELAM-1) has been described by several groups to contain a polylactosamine structure bearing a terminal sialic acid residue and at least one fucose residue. We report here a more detailed investigation into the minimum structural requirements for carbohydrate recognition by E-selectin. Using both direct binding and inhibition studies we demonstrate that the sialyl Lewisx tetrasaccharides Sia(alpha 2-3)Gal(beta 1-4)[Fuc(alpha 1-3)]GlcNAc, and Sia(alpha 2-3)Gal(beta 1-4)[Fuc(alpha 1-3)]Glc are the smallest oligosaccharides recognized by the lectin. In addition, an oligosaccharide containing the sialyl Lewisa epitope is also recognized, but less avidly. We propose a structural model of functional groups necessary for recognition by E-selectin, based on these data and additional experiments on modifications of sialic acid and the reducing terminal saccharide.

De novo inv(2)(p21q31) associated with isolated bilateral microphthalmia and cataracts

We report on a patient with bilateral microphthalmia and unusual cataracts with a de novo pericentric inversion of chromosome (2)(p21q31). A literature review of previous associations of eye abnormalities and anomalies of chromosome 2 suggests probable gene locations for eye development.

Triple trisomy in a 17-week-old fetus

Autosomal trisomies account for the majority of chromosome abnormalities associated with spontaneous miscarriages. Occasionally, double autosomal trisomies are found to be present in abortuses. This report describes the second occurrence of triple trisomy associated with fetal demise.

Identification of human erythrocyte blood group antigens on the C3b/C4b receptor

The Knops/McCoy (Kn/McC) human erythrocyte blood group system belongs to the category of blood group Ag that generate so-called "high titer low avidity" antibodies in immunized transfusion recipients. Screening of red cells lacking certain high titer low avidity Ag demonstrated markedly diminished CR1 expression on McC(d-) and Kn/McC "null" (Kn(a-)McC(a-b-c-d-e-f-] erythrocytes. Additional testing by other methods confirmed these data, and biochemical assays demonstrated no detectable immunoreactive CR1 protein in membranes from Kn/McC null red cells. Human antisera to various Kn/McC Ag were then used to demonstrate that many of these antisera could be used to isolate a protein of identical m.w. to that isolated from the same cells using murine mAb CR1 antisera. Finally, protein isolated by using murine mAb anti-CR1 reacted specifically with anti-Kn/McC antibodies, demonstrating the identity of the Kn/McC and CR1 proteins. Thus, CR1 protein bears the human erythrocyte Kn/McC blood group Ag.

Identification of human erythrocyte blood group antigens on the C3b/C4b receptor

The Knops/McCoy (Kn/McC) human erythrocyte blood group system belongs to the category of blood group Ag that generate so-called "high titer low avidity" antibodies in immunized transfusion recipients. Screening of red cells lacking certain high titer low avidity Ag demonstrated markedly diminished CR1 expression on McC(d-) and Kn/McC "null" (Kn(a-)McC(a-b-c-d-e-f-] erythrocytes. Additional testing by other methods confirmed these data, and biochemical assays demonstrated no detectable immunoreactive CR1 protein in membranes from Kn/McC null red cells. Human antisera to various Kn/McC Ag were then used to demonstrate that many of these antisera could be used to isolate a protein of identical m.w. to that isolated from the same cells using murine mAb CR1 antisera. Finally, protein isolated by using murine mAb anti-CR1 reacted specifically with anti-Kn/McC antibodies, demonstrating the identity of the Kn/McC and CR1 proteins. Thus, CR1 protein bears the human erythrocyte Kn/McC blood group Ag.

Rehabilitation of three patients after treatment for herpes encephalitis

Patients with Herpes simplex encephalitis often are considered to be poor rehabilitation candidates because of their multiple deficits and grave prognosis. This report presents case reports on three patients with biopsy-proven Herpes simplex encephalitis, all of whom were treated with acyclovir in acute care and then admitted to an inpatient rehabilitation program. All had multiple brain lesions with minimal motor findings but cognitive and communication deficits. One patient, two weeks after admission, slipped into a coma and was transferred to an acute care hospital where he subsequently expired. The other two made useful functional gains and were discharged home in two weeks and 10 weeks, suggesting that a trial of rehabilitation may be warranted after Herpes simplex encephalitis.

45,X/47,XYY mosaicism: clinical discrepancy between prenatally and postnatally diagnosed cases

45,X/47,XYY mosaicism is a rare chromosomal disorder with clinical information limited to 11 postnatal cases in the literature and with uncertainty regarding prenatal prediction of phenotype and prognosis. We report on 7 new cases of 45,X/47,XYY mosaicism, three detected prenatally and 4 diagnosed postnatally. A clinical comparison of the cases of 45,X/47,XYY mosaicism is presented together with a literature review.