Evaluation of IgG RAST FEIA for the assay of venom-specific IgG antibodies during venom immunotherapy

BACKGROUND

Successful venom immunotherapy (VIT) in Hymenoptera allergy is usually associated with a strong increase in venom-specific serum IgG antibodies (sIgG).

METHODS

We evaluated a new commercial test for the assay of sIgG (Pharmacia CAP Systemtrade mark IgG RAST(R) FEIA; FEIA), in comparison with a conventional ELISA technique. Sera from 40 bee- and 40 Vespula-allergic patients were analyzed by FEIA and ELISA before and 3 months after starting VIT.

RESULTS

The correlation between sIgG obtained with the two methods was significant: r = 0.862, p<0.0001 for bee venom (BV), r = 0.861, p<0.0001 for Vespula venom (VV). The geometric mean values obtained with FEIA were higher for both venoms (BV p = 0.03; VV p<0. 01). A highly significant increase (p<0.0001) was observed during VIT with both methods. This increase was concordant in 93% of VV- and 90% of BV-treated patients. Intra- and interassay relative coefficients of variation were below 10% for FEIA.

CONCLUSION

IgG RAST FEIA is a reproducible and sensitive method for the assay of venom-specific sIgG.

[Posterior pars plana high frequency capsulotomy]

In special forms of complicated secondary cataract, especially after a cataract operation in eyes with proliferative disease and after a cataract operation associated with pars plana vitrectomy and silicone oil instillation, surgical capsulotomy must be performed.

METHODS

We developed a new surgical technique for posterior capsulorhexis via pars plana by using the high-frequency capsulotomy method developed by Klöti. We analyzed 14 consecutive patients undergoing late pars plana capsulotomy using a specially designed instrument for radiofrequency capsulorhexis. The indication for surgical capsulotomy was extreme secondary cataract; in 6 eyes fibrosis was associated with vascularizations.

RESULTS

The high-frequency technique for posterior capsulotomy allowed reliable and precise tissue cutting. The cutting required minimal application of pressure to the capsule, and therefore damage to zonula fibers is minimized. Furthermore, use of the radiofrequency technique permitted hemostatic incision in vascularized membranes by inducing a fine coagulation margin.

CONCLUSIONS

Posterior capsulorhexis using radiofrequency offers precise and effective tissue cutting if surgical capsulotomy is necessary.

Changes in sample size and length of follow-up to maintain power in the coronary artery bypass graft (CABG) patch trial

The CABG Patch Trial is testing the hypothesis that prophylactic use of implantable cardiac defibrillators (ICDs) will improve survival in high-risk coronary heart disease patients undergoing CABG surgery. The original design called for 800 patients to be randomized to ICD prophylaxis or to no therapy and followed for 2 to 6.5 years (average, 40 months) to a common termination date. Since the ICD pulse generators used in this trial lasted about 42 months, the original design required ICD replacement in many patients. At its first two meetings in 1993, the Data and Safety Monitoring Board (DSMB) formalized a plan to adjust sample size in October 1994 if the control group mortality rate was lower than expected. In June 1994, an unanticipated and unique event--a subpoena from the Office of the Inspector General (OIG)--made it impossible to replace about half of the ICD generators and threatened to shorten follow-up substantially. If follow-up had been stopped on the date originally planned, but without replacing ICDs, the average follow-up would have fallen from 40 months to about 33 months. Also, in October 1994, the control group mortality rate was found to be somewhat lower than expected. Together, the abbreviated follow-up and lower control group mortality threatened to reduce power substantially. The DSMB reviewed several options for restoring power. Because mortality rates in the first month after CABG surgery were about seven times as high as thereafter and because ICD therapy did not reduce surgical mortality (death during the first 30 days), extending the follow-up benefits power more than does increasing the sample size. However, the limit on extending follow-up was 42 months (the expected battery life of the ICD). Data from the ICD-treated group was not reviewed or considered in making the decision. After reviewing many options for restoring power, the DSMB recommended that the sample size be increased from 800 to 900 patients and that almost all patients be followed for 42 months. This recommendation extended follow-up for 2 years beyond the original termination date planned for the trial and dictated that patients close out after 42 months rather than on a common termination date.

[Autologous thrombocyte administration in treatment of idiopathic macular foramen]

BACKGROUND

Recent studies have shown the usefulness of pars plana vitrectomy with the use of growth factors in the treatment of macular holes. Autologous platelet concentrates contain many growth factors to stimulate glial wound healing.

PATIENTS

Nineteen patients with idiopathic macular hole underwent vitrectomy, membrane peeling, air injection and installation of autologous platelet concentrate (0.1 ml). The platelet concentrate contained a mean of 1.8 x 10(9) platelets/ml.

RESULTS

The anatomic success rate in stage 2 macular hole was 100%, in stage 3, 82% and in stage 4, 50%. Visual acuity improved in all patients with stage 2 (two lines) and in 73% of stage 3 at least (one line).

CONCLUSION

Platelets are effective in the treatment of macular holes due to the high amount of different growth factors (PDGF, EGF, bFGF, IGF-1) which have a high affinity binding to Müller cells helping to seal the hole by photoreceptor adaption.

[Paracelsus and sectarian movements in medicine]

During his entire life Paracelsus used to criticize sectarianism in medicine. All trends, even the scientific ones, incur the danger to develop into sects, namely when they consider solely one cause for diseases and one treatment. Paracelsus often filled traditional prescriptions and used traditional methods, however, he worked as well in part with early homeopathy, magnetopathy and with magic and spiritual healing. Even wonders were not excluded. This all corresponds to an open, realistic medicine. Sectarian behaviour begins, however, when any of these trends is considered the only effective one. Most important in the medical philosophy of Paracelsus is the admission of the limitations of medicine and of all its trends. Through this scientific humility the physician knows that palliation in seemingly or really hopeless situations is one of his noblest tasks.

Vitrectomy for traction macular detachment in diabetic retinopathy

BACKGROUND

A small number of eyes with proliferative diabetic retinopathy develop massive central fibrovascular membranes characterized by vitreoretinal tractions along the arcades and optic disk and retinal traction lines extending through the macula. The aim of our study was first to present the results of vitrectomy for removal of these central membranes and second to determine the correlation between preoperative parameters and postoperative visual outcome.

SUBJECTS AND METHODS

We treated 28 eyes with severe central fibrovascular diabetic membranes by a modified bi-manual en bloc excision technique during vitrectomy. Preoperative examination included general status, visual acuity, slit-lamp investigation, binocular funduscopy, ultrasound investigation and visual evoked potentials (VEP). Further, we analyzed intraoperative complications and postoperative anatomic and functional outcomes.

RESULTS

The retinas of 27 eyes with central traction retinal detachments were reattached by surgery. With a minimum of 6 months' follow-up, the macula remained attached in 24 eyes, while the retinas were completely attached in 22 eyes. Preoperative visual acuity was defective light perception to 0.1; an increase in visual acuity to maximal 0.1 was seen in 50% of the patients postoperatively. Preoperative visual acuity of light perception was associated with no functional improvement. Preoperative ultrasound investigation gave information about the real anatomic situation of the retina, especially if funduscopy was not possible. The other preoperative parameters could not predict correctly the functional outcome of vitrectomy in diabetics with severe central fibrovascular membranes because of the damage of the optic nerve and the retina.

CONCLUSIONS

The high rate of anatomical reattachment after vitrectomy in diabetic eyes with severe central fibrovascular membranes is associated with a slight improvement of function; only preoperative visual acuity of hand motions or better was associated with an improvement of function.

[Primary vitrectomy in endophthalmitis]

From January 1994 to January 1996, 18 patients underwent vitrectomy as a result of endophthalmitis. All patients received intraocular and systemic antibiotics in accordance with the first group of patients in the Endophthalmitis Vitrectomy Study. The aim of this retrospective study was to analyze the visual outcome of surgical treatment.

METHODS

Data from 18 consecutive patients, 11 women and 7 men, with the diagnosis of endophthalmitis as indication for vitrectomy were evaluated. The patients' ages ranged from 14 to 93 years (mean 66.6 +/- 21.3). Postoperative follow-up ranged from 6 weeks to 10 months.

RESULTS

Endophthalmitis resulted from cataract surgery with implantation of an intraocular lens in 14 patients and from ocular trauma in 2 patients. Endophthalmitis followed the resection of posterior capsule fibrosis in 1 patient. Another patient suffered from endogenous endophthalmitis. Positive cultures were obtained in 12 patients. The most frequent causative organisms were coagulase-negative Staphylococcus (n = 7) and Streptococcus species (n = 4). Visual outcome: 13 of 18 patients (72%) gained a visual acuity of 20/400 or better at the final examination after vitrectomy. Four patients (22%) reached a visual acuity of 20/50 or better. Two eyes were enucleated. Good functional outcome was achieved in 2 patients with streptococcal infection (20/200; 30/50).

CONCLUSION

Vitrectomy in combination with intraocular antibiotics is a suitable method for the treatment of endophthalmitis and results in preservation of ambulatory vision in 72% of patients. Vitrectomy in endophthalmitis can result in good functional outcome even in the case of infections with streptococcal species.

A serine/arginine-rich nuclear matrix cyclophilin interacts with the C-terminal domain of RNA polymerase II

The largest subunit of RNA polymerase II shows a striking difference in the degree of phosphorylation, depending on its functional state: initiating and elongating polymerases are unphosphorylated and highly phosphorylated respectively. Phosphorylation mostly occurs at the C-terminal domain (CTD), which consists of a repetitive heptapeptide structure. Using the yeast two-hybrid system, we have selected for mammalian proteins that interact with the phosphorylated CTD of mammalian RNA polymerase II. A prominent isolate, designated SRcyp/CASP10, specifically interacts with the CTD not only in vivo but also in vitro . It contains a serine/arginine-rich (SR) domain, similar to that found in the SR protein family of pre-mRNA splicing factors, which is required for interaction with the CTD. Most remarkably, the N-terminal region of SRcyp includes a peptidyl-prolyl cis - trans isomerase domain characteristic of immunophilins/cyclophilins (Cyp), a protein family implicated in protein folding, assembly and transport. SRcyp is a nuclear protein with a characteristic distribution in large irregularly shaped nuclear speckles and co-localizes perfectly with the SR domain-containing splicing factor SC35. Recent independent investigations have provided complementary data, such as an association of the phosphorylated form of RNA polymerase II with the nuclear speckles, impaired splicing in a CTD deletion background and inhibition of in vitro splicing by CTD peptides. Taken together, these data indicate that factors directly or indirectly involved in splicing are associated with the elongating RNA polymerases, from where they might translocate to the nascent transcripts to ensure efficient splicing, concomitant with transcription.

[Endophthalmitis--clinical picture, therapy and prevention]

BACKGROUND

Infectious endophthalmitis is a dreaded situation in ophthalmology, since it often induces a substantial reduction of visual acuity, and in some cases the loss of the eye despite modern medication and surgical treatment methods.

OBJECTIVE OF THE STUDY

Compilation of the most important characteristics of postoperative endophthalmitis with acute, delayed and chronic course, posttraumatic endophthalmitis and endogenous endophthalmitis. Comprising the results of the endophthalmitis vitrectomy study, a review of the pharmacotherapy and surgery required is presented.

THERAPY

Acute postoperative endophthalmitis is treated by a combination of broad-spectrum antibiotics (vancomycin and ceftazidime or amikacin), which are administered intravitreally, subconjunctivally and topically, if appropriate in combination by systemic antibiotics (vancomycin and ceftazidime or amikacin). If vision diminshes to mere light perception, performance of pars plana vitrectomy is indicated. Treatment of acute postoperative endphthalmitis with delayed occurrence requires that the underlying complications (e.g. suture dehiscences) are eliminated, and is carried out in accordance with the therapeutic principles for acute postoperative endophthalmitis. In chronic postoperative endophthalmitis, which is caused by bacteria, antibiotics (aminoglycosides or vancomycin) are administered topically and intravitreally. If antibiotic treatment is unsuccessful, a pars plana vitrectomy must be performed including posterior capsulotomy, appropriate with total removal of the capsular sac including the posterior chamber lens. In postoperative mycotic endophthalmitis, antimycotics (amphotericin B) are administered intravitreally. If findings are severe, a pars plana vitrectomy must also be carried out with excision of capsule, if necessary with removal of the posterior chamber lens. Antimycotics are applied topically to support treatment. Acute posttraumatic endophthalmitis is treated by intravitreal antibiotic administration (vancomycin and ceftazidime or amikacin) in combination with pars plana vitrectomy and removal of foreign body. Treatment is supplemented by systemic, subconjunctival and topical antibiotic administration. To reduce ocular destruction due to inflammation, systemic and intravitreal administration of steroids is recommended in all postoperative and posttraumatic endophthalmitis conditions. Treatment of endogenous endophthalmitis requires collaboration with an internist. Systemic therapy with antibiotics or mycotics is obligatory. In addition, broad-spectrum antibiotics (vancomycin or aminiglycosides) or antimycotics (amphotericin B) are administered topically and intravitreally in these conditions. In severe ocular infections, pars plana vitrectomy is indicated.

PREVENTION

To reduce the risk of infection, patients with infectious eye diseases should be excluded from elective operations. Special attention must be paid to risk patients with defects of the immune system. Observation of hygienic regulations is obligatory. Prophylactic perioperative administration of antibiotics has proved to be effective. Patients suffered from penetrating or perforating injuries get systemic antibiotics prophylactically. Qualified follow-up care of the patient is necessary.

CONCLUSIONS

The therapeutic principles for treatment of acute postoperative endophthalmitis are determined by the endophthalmitis-vitrectomy-study. Further investigations are required with respect to corticosteroid use.

[Hymenoptera venom allergy]

In the light of two case reports we summarize the clinical presentation, classification, diagnosis and therapy of hymenoptera sting allergy. Clinically, large local reactions are distinguished from systemic allergic reactions. The latter are divided into four degrees of severity as defined by H.L. Mueller. Diagnosis is based primarily on the history. Detection of venom specific IgE-antibodies and/or positive venom skin tests confirm the diagnosis and are helpful for identification of the responsible insect. All patients should be equipped with an emergency kit (antihistamine, corticosteroid). In the presence of a history of systemic allergic reactions, adrenaline must be added. For highly exposed patients and those with a history of threatening reactions, specific immunotherapy is recommended. Most patients are fully protected by this treatment.

The rewards outweigh the efforts: breastfeeding outcomes for mothers of preterm infants

This study describes the rewards and efforts of breastfeeding for mothers of preterm infants. Using a semi-structured interview guide, 20 mothers of preterm infants were interviewed in their homes approximately 1 month after infant discharge from a Level III NICU. Mothers described the following rewards of breastfeeding: knowing they were providing the healthiest nutrition for the infant, enhancing closeness between the mother and infant, perceiving infant contentment and tranquility during breastfeeding, providing convenience for the mother, and giving the mother a tangible claim on the infant. Most mothers identified some "efforts" associated with breastfeeding their preterm infants, but indicated that overall, breastfeeding was a rewarding experience. These data provide scientific support for the promotion and facilitation of breastfeeding for mothers of preterm infants, in that mothers perceive specific emotional advantages that they relate to the breastfeeding experience.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median) and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

[Sudan staining of impression cytology retinal specimen]

BACKGROUND

Long-term silicone oil tamponade may cause increased numbers of vacuoles in the retina. Conventional methods of histological preparation dissolve silicone oil and optically empty spaces are seen.

METHOD

We examined the retinas of 20 human eyes after silicone oil injection. We obtained the material by peripheral retinectomies during vitrectomy for recurrent retinal detachment. The material was prepared by impression cytology. The time between silicone oil injection and vitrectomy was 3-18 months. The non-fixed cell sheets were stained with Sudan III, followed by a counterstaining with hematoxyline.

RESULTS

Sudan III stained silicone oil 1000 mPa orange-yellow. Sudan-III-stained vacuoles in the retina were found in eight eyes with intraocular silicone oil instillation; in five of these eyes an emulsification of silicone oil was observed. The staining of retinal vacuoles seemed to be caused by the presence of silicone oil in the vacuoles.

CONCLUSIONS

Using impression cytology and the Sudan staining procedure, it was possible to stain vacuoles in non-fixed retinal preparations. A long-term silicone oil tamponade induces these vacuoles in the retina, especially if the silicone oil is emulsified. In order to prevent this complication, removal of emulsified silicone oil should be performed as early as possible.

[Vitreous and fundus changes in Terson syndrome. 3 case reports]

BACKGROUND

Terson syndrome is defined as the presence of intraocular hemorrhages in association with a sudden increase in intracranial pressure. The hemorrhages can occur in the subretinal space, within the sensory retina, between the retina and the hyaloid membrane and in the vitreous cavity.

PATIENTS

We report about three eyes from two patients with Terson syndrome, in which vitreous hemorrhages were noted. In one eye we observed a preretinal macular hemorrhage. Pars plana vitrectomy was performed in two eyes.

RESULTS

The hyaloid was surgically peeled away, which showed a membrane covering the macula. When this membrane was stripped away a retinal fold 360 degrees surrounding the macula was noted, in one eye a light fibrotic line was visible. The premacular hemorrhage and the intrahyaloidal hemorrhages in this eye were resorbed spontaneously after 5 months. In all eyes visual acuity increased to 1,0.

CONCLUSION

In most eyes with Terson syndrome it is possible to wait for the spontaneous resorption of the blood. It is hypothesized that blood from a ruptured vein or capillary hydrodissects the internal limiting membrane from the underlying neurosensory retina. If a pars plana vitrectomy is performed the possibility of a hydraulical dissected internal limiting membrane has to be considered. Postoperatively perimacular retinal folds or fibrotic lines may occur, they didn't have any clinical evidence.

The Pittsburgh randomized trial of tacrolimus compared to cyclosporine for hepatic transplantation

BACKGROUND

Tacrolimus (formerly FK506) was first used clinically in 1989 to successfully replace cyclosporine in hepatic transplant recipients who were experiencing intractable rejection or as the baseline drug from the time of operation. After extensive pilot experience, an institutional review board-mandated clinical trial comparing cyclosporine with tacrolimus was performed.

STUDY DESIGN

From February 16, 1990 to December 26, 1991, 154 patients were recruited. The competing drugs were combined with equal induction doses of prednisone in both arms of the study for the first 81 patients and with subsequently higher doses of prednisone in the remaining 35 patients who received cyclosporine and were entered into the trial. Drug crossover was permitted for lack of efficacy or adverse events. End points were rejection confirmed by biopsy and treatment failure leading to retransplantation or death.

RESULTS

Seventy-nine patients were randomized to the tacrolimus arm and 75 to the cyclosporine arm during 1990 and 1991. All patients were available for follow-up throughout the trial, which terminated on May 30, 1995. The mean duration of follow-up was four years. Patients randomized to the tacrolimus arm were less likely to experience acute rejection than were those receiving cyclosporine, with 36.2 percent of the patients receiving tacrolimus and 16.8 percent of the patients receiving cyclosporine showing freedom from rejection at one year (p = 0.003, likelihood ratio test). Survival of patients over the course of the study was virtually the same in the two groups.

Endoscopic management of biliary tract strictures in primary sclerosing cholangitis

BACKGROUND AND STUDY AIMS

In a subgroup of patients, primary sclerosing cholangitis (PSC) is complicated by high-grade focal strictures of the bile ducts, and this can have an unfavorable influence on the natural course of the disease. The aim of this study was to evaluate the efficacy and safety of endoscopic treatment in this selected patient group.

PATIENTS AND METHODS

Twelve symptomatic patients with primary sclerosing cholangitis and major ductal strictures were included in a prospective study of endoscopic treatment. All patients were managed by repeated angioplasty-type balloon dilation and nasobiliary catheter perfusion. A minimum of two treatment sessions was used, and therapy was continued until satisfactory reopening of the strictures was obtained. Routine endoscopic follow-up was performed after three, six, 12, 18, and 24 months, and then at yearly intervals. The efficacy of therapy was assessed by evaluating clinical symptoms, laboratory data, and cholangiograms.

RESULTS

The long-term follow-up averaged 23 months (range: 12-50 months). Two to nine (mean: three) treatment sessions were required to obtain satisfactory reopening of major biliary strictures. Eight patients showed considerable and sustained improvement. The mean serum bilirubin, alkaline phosphatase, gamma-glutamyl-transpeptidase, and alanine aminotransferase levels felt significantly by 73% (P = 0.0164), 46% (P = 0.0022), 55% (P = 0.0022), and 58% (P = 0.0022), respectively. The average radiographic stricture score before treatment was 3.2 +/- 0.8 (P = 0.0033). Three patients required liver transplantation seven, 12, and 40 months after the initiation of endoscopic treatment, due to a deterioration in hepatic function or an inability to exclude complex biliary malignancy. No major procedure-related side effects were observed.

CONCLUSIONS

Our results suggest that the endoscopic treatment of PSC patients with dominant bile duct strictures is effective, safe, and well-tolerated. However, it is important not to overlook the potential development of cholangiocarcinoma.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median), and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

The Pittsburgh randomized trial of tacrolimus compared to cyclosporine for hepatic transplantation

BACKGROUND

Tacrolimus (formerly FK506) was first used clinically in 1989 to successfully replace cyclosporine in hepatic transplant recipients who were experiencing intractable rejection or as the baseline drug from the time of operation. After extensive pilot experience, an institutional review board-mandated clinical trial comparing cyclosporine with tacrolimus was performed.

STUDY DESIGN

From February 16, 1990 to December 26, 1991, 154 patients were recruited. The competing drugs were combined with equal induction doses of prednisone in both arms of the study for the first 81 patients and with subsequently higher doses of prednisone in the remaining 35 patients who received cyclosporine and were entered into the trial. Drug crossover was permitted for lack of efficacy or adverse events. End points were rejection confirmed by biopsy and treatment failure leading to retransplantation or death.

RESULTS

Seventy-nine patients were randomized to the tacrolimus arm and 75 to the cyclosporine arm during 1990 and 1991. All patients were available for follow-up throughout the trial, which terminated on May 30, 1995. The mean duration of follow-up was four years. Patients randomized to the tacrolimus arm were less likely to experience acute rejection than were those receiving cyclosporine, with 36.2 percent of the patients receiving tacrolimus and 16.8 percent of the patients receiving cyclosporine showing freedom from rejection at one year (p = 0.003, likelihood ratio test). Survival of patients over the course of the study was virtually the same in the two groups.

Transcription factor AP-2 essential for cranial closure and craniofacial development

During closure of the neural tube in the mouse, transcription factor AP-2 is expressed in ectoderm and in neural-crest cells migrating from the cranial neural folds. Cranial neural crest cells provide patterning information for craniofacial morphogenesis, generate most of the skull bones, and together with placodal ectoderm, form the cranial ganglia. To study the role of AP-2 during embryogenesis, we undertook a targeted mutagenesis of the AP-2 gene in the mouse. Here we report that AP-2(-/-) mice died perinatally with cranio-abdominoschisis and severe dismorphogenesis of the face, skull, sensory organs and cranial ganglia. Failure of cranial closure between 9 and 9.5 days postcoitum coincided with increased apoptosis in the midbrain, anterior hindbrain and proximal mesenchyme of the first branchial arch, but did not involve loss of expression of twist or Pax-3, two other regulatory genes known to be required for cranial closure.

Resolution of intracranial calcifications in infants with treated congenital toxoplasmosis

PURPOSE

To determine the natural history of intracranial calcifications in infants with treated congenital toxoplasmosis.

MATERIALS AND METHODS

Between January 1982 and March 1994, cranial computed tomography was performed in 56 infants with treated congenital toxoplasmosis when they were newborns and approximately 1 year old. Locations and sizes of intracranial calcifications were noted.

RESULTS

Forty newborns had intracranial calcifications. By 1 year of age, calcifications diminished or resolved in 30 (75%) and remained stable in 10 (25%) of these treated infants. Ten (33%) of the 30 infants whose calcifications diminished versus seven (70%) of the 10 infants with stable calcifications received less intensive antimicrobial treatment than the other treated infants. In contrast, a small number of infants who were untreated or treated 1 month or less had intracranial calcifications that increased or remained stable during their 1st year of life.

CONCLUSION

Diminution or resolution of intracranial calcifications was an unexpected and remarkable finding in infants with treated, congenital toxoplasmosis, consonant with their improved neurologic functioning.