Gentamicin-induced chronotoxicity: use of body temperature as a circadian marker rhythm

Aminoglycoside antibiotics produce varying degrees of ototoxicity, dependent on dosage time, in animals synchronized for rhythm study. Herein, we illustrate the use of an economical and reliable system to telemeter body temperature of laboratory animals as an endogenous marker rhythm for gentamicin-induced ototoxicity. Two groups of 3 male Sprague-Dawley rats (250-400 gm) were housed in separate cages in a temperature-controlled room programmed with a 12:12 LD schedule and monitored for hearing thresholds at the frequencies of 8kHz, 16 kHz, 24 kHz and 32 kHz at 2-week intervals. Each rat was dosed with 100 mg/kg/day gentamicin subcutaneously for a duration of 28 days. The animals from one group were dosed at their daily temperature maximum, while the animals of the other group were dosed at their daily temperature minimum. Both after 14 and 28 days of gentamicin treatment there was no important changes in auditory thresholds from baseline values when treatment was timed daily to the circadian peak of body temperature. Animals dosed daily at the trough of the circadian temperature rhythm evidenced an auditory threshold shift of between 5 and 25 dB after 14 days of treatment and a total hearing loss (80-90 dB) after 28 days of such treatment. These results document a dramatically greater level of hearing loss induced in those animals dosed with gentamicin at the body temperature trough (diurnal rest span) as compared to those dosed at the acrophase (nocturnal activity span). The findings indicate that the peak and trough of the circadian pattern of body temperature serve as meaningful markers of the resistance and susceptibility, respectively, of gentamicin-induced ototoxicity in rodent models.

Shared and specific allergenic and antigenic components in the two sexes of American cockroach--Periplaneta americana

The whole body extracts (WBEs) of female and male cockroaches (Periplaneta americana; Pa) were prepared separately to study the specific and/or shared allergenic and antigenic components in the two sexes. These two extracts were skin-tested on 170 respiratory allergy patients and 52 (30.6%) of them elicited a markedly positive cutaneous reaction (2+ to 4+) to any one or both the WBEs. Of these 52 patients, 32 (61.5%) produced a 2+ to 4+ response to only one, and the remaining 20 (38.5%) to both the extracts. In female and male RASTs to Pa both the extracts produced dose-related inhibition. Using rabbit anti-Pa female serum: (1) immuno-diffusion experiments resulted in lines of identity with the two extracts, and (2) the two-dimensional immunoelectrophoresis of Pa female and Pa male WBEs elicited 12 and nine precipitin peaks, respectively. In partial purification studies, only fraction Pa(F)III (approximately 50 kD) of Pa female WBE and Pa(M)I (greater than or equal to 600 kD) and Pa(M)III (approximately 50 kD) fractions of Pa male WBE revealed significant allergen activity both on skin testing and also in RAST inhibition studies. These results provide evidence for the presence of shared as well as specific allergenic and antigenic components in the two sexes of American cockroach.

Venobronchial fistula: a complication associated with central venous catheterization for chemotherapy

We report a case in which a venobronchial fistula developed 4 months after insertion of a silicone rubber chronic central venous catheter for chemotherapy administration. In retrospect, the tip of the catheter was in the azygous vein rather than in the superior vena cava. The suboptimal position of the catheter tip, in combination with the infusion of sclerosing chemotherapeutic agents and hyperalimentation solution, may have predisposed the patient to this complication. Accurate localization of the tip of central venous catheters at the time of placement should minimize catheter-related complications, including the rare complication of venobronchial fistula. After placement of chronic central venous catheters, biplanar chest X-rays should be obtained to determine catheter tip location prior to the instillation of chemotherapeutic agents. Any residual questions concerning the catheter tip location after biplanar X-rays should be addressed by prompt venography through the catheter.

Pediatric surgery--whither goest thou?

What I have attempted to do in this analysis is to give you my views of pediatric surgery as it stands today in terms of its original goals. I have also attempted to look ahead and to analyze the straws in the wind, hopefully offering some potential solutions for the issues we are currently facing. If we remember who we really are and what our purpose is, great opportunity lies ahead. To those of us who are not satisfied with the present outlook there is much to be investigated and much to be contributed.

Extracellular DNA in blood and urine as a potential marker for cytotoxicity and nephrotoxicity in the mouse

Cell death releases products of chromatin catabolism, particularly DNA, which can be measured by a DNA assay (using the nick translation reaction) as a marker of toxicity. Conditions for blood and urine collection have been established for quantitation of extracellular DNA in mice. Toxic doses of lipopolysaccharide (5 mg/kg) and HgCl2 (3.2 mg/kg) release DNA to plasma and urine. Increase in urinary DNA is observed 24 hours after a single injection (5 mg/kg) of gentamicin. Quantitation of extracellular DNA can be used to investigate the occurrence of cell death in vivo and applied to toxicological studies, in animals and man.

Sudden, unexpected, natural death in childhood

One thousand nine hundred and fifty four autopsies performed at British Columbia's Children's Hospital during a 7-year period were reviewed to determine the causes of sudden unexpected natural death in the age group from birth to 17 years. Of the 126 cases found, the largest group, 86 cases, was sudden infant death syndrome (SIDS). Nine deaths were the result of infection: 4 cases of H. influenza meningitis, 2 cases of meningococcemia, 2 cases of acute epiglottitis, and 1 case of necrotizing tracheobronchitis. Epilepsy, ruptured AV malformations, and brain tumors combined to make up an equally large group of 9 cases. Cardiac lesions were the third largest group, 6 cases. The three groups that posed the most difficulty in assigning a cause of death were (a) the group that were like SIDS yet had other confounding features, (b) the group in which metabolic death was suspected but not proven, and (c) death in epilepsy.

Current role of gallium scanning in the management of lymphoma

Gallium 67 scanning in the malignant lymphomas has been done, with variable success, for over 20 years. After initial enthusiasm, the technique fell into disrepute and it was not until the early 1980s that it enjoyed a revival. There have been many major contributions to the literature, both favourable and unfavourable. The reasons for the latter include: poor instrumentation (only single-pulse height analysis), low gallium 67 doses, impatient and careless scanning techniques, timing of the study after treatment (chemotherapy, radiation) and insensitive methods of confirmation of the presence or absence of disease ("truth"). Anatomical diagnostic techniques (computed tomography, plain X-radiography, magnetic resonance imaging and others) are incapable of distinguishing viable tumour in normal-size lymph nodes or necrotic/fibrotic residual masses. With improvements in instrumentation (triple-pulse height analysis, gamma camera resolution and tomographic techniques) gallium 67 can detect active tumour in residual masses and in normal-size nodes. This is due to gallium 67's unique ability to localize in viable tumour cells. It has greater than 90% sensitivity, specificity, accuracy and positive predictive value in patients with lymphoma. Its major contributions are in: staging (changing management of mediastinal disease, obviating the need for a laparotomy and clearly identifying stage IV disease); detecting relapse or residual, progressive disease (it establishes true complete remission and is often the first and only evidence of relapse before clinical evidence); predicting response to therapy (failure to convert to a negative scan post-treatment signals a poor prognosis and alternative therapy is required); and predicting outcome--prognosis (it is the only diagnostic modality to predict outcome accurately).

Endoscopy in inflammatory bowel disease: indications and differential diagnosis

Colonoscopy with multiple biopsies adds a considerable amount of information to the overall clinical approach to the patient with inflammatory bowel disease. Because colonoscopy is an invasive procedure requiring a vigorous bowel clean-out, it is not a first-line investigative procedure for patients with inflammatory bowel disease. However, in certain indicated circumstances, colonoscopy can assist greatly in the management and diagnosis of patients with inflammatory bowel disease.

But what if a patient gets hooked? Fallacies about long-term use of benzodiazepines

Is a person who needs a certain drug to function normally and has a relapse of symptoms when it is withdrawn addicted? Dr Talley says no. Patients with a chronic anxiety disorder depend on benzodiazepines to enable them to live among the stresses of the real world, much like ulcer patients need ongoing drug therapy to subdue their problem. The fact that symptoms recur on withdrawal of the drug proves the continuing efficacy of the drug in controlling symptoms. Dr Talley gives advice on prescribing benzodiazepines for the long term that will help physicians and patients to avoid trouble.

Surgery for melanoma metastatic to the gastrointestinal tract

Melanoma frequently disseminates to the gastrointestinal tract, being found post-mortem in 60 per cent of patients with disseminated disease, while during life it is diagnosed in only 4 per cent. During the period 1981-87, 835 melanoma patients were referred and 30 developed complaints caused by gastrointestinal metastatic melanoma. Twenty-three patients were treated surgically. The interval between treatment of the primary melanoma and detection of intestinal involvement was a median of 34 months (range 2-87 months). In four patients recurrence in the gut was the first evidence of dissemination. Major complaints were nausea and vomiting, abdominal pain, signs of anaemia, and blood in the stools. Complications were bleeding (ten cases), ileus due to intussusception (five cases), bowel perforation (four cases) and cholecystitis (one case). The metastases, mainly localized in the small bowel, were removed by relatively simple procedures. Symptoms were reduced in 19 patients. Two patients died after operation: one from sepsis due to suture leakage, the other from pneumonia and a cerebrovascular accident. Of the remaining patients, 16 survived a median of 7.5 (range 0.7-32.0) months. Five patients are still alive 72, 72, 70, 7 and 2 months after the metastasectomy, three of whom are tumour-free. The actuarial 5-year survival of all patients is 19 per cent. These results support surgical intervention for patients with complaints and/or complications attributable to gastrointestinal metastatic melanoma.

Neuroblastoma and other childhood neural tumors: a review

Neuroblastoma is the most common nonhematopoietic solid tumor of childhood and has been intensively studied for at least 4 decades. Despite this, few predictive histopathologic clues to its behavior exist. Age, anatomic sites of occurrence, and clinical stage have traditionally been the only reliable prognostic factors in this disease. A number of laboratory studies that focus on biologic features such as neurotransmitter synthesis (adrenergic and noradrenergic catecholamines), neurotransmitter enzyme expression (dopamine beta hydroxylase, choline acetyl transferase), cytogenetics (homogeneously staining regions, double minute chromosomes, chromosome 1p deletions), molecular genetics (N-myc oncogene amplification and expression), and immunophenotype (surface epitopes such as HLA antigens and GD2 ganglioside and intracytoplasmic determinants such as neurofilament protein, synaptophysin, chromogranin, and neuron specific enolase) now enable the pathologist to predict clinical course in many cases and to distinguish bona fide neuroblastomas, regardless of age, site, or histologic appearance, from a host of related but distinctly separate neuroectodermal tumor entities with apparent different histogenesis, treatment sensitivity, and prognosis.

Early diagnosis of enteroviral meningitis by a solid-phase reverse immunosorbent test and virus isolation

45 cases of aseptic meningitis/meningoencephalitis were studied with regard to enteroviral etiology by virus isolation and solid-phase reverse immunosorbent test (SPRIST), a cross-reacting test for enterovirus IgM. An etiological diagnosis was reached in 37/45 (82%) patients. Etiological diagnoses other than enteroviruses were found in 8 patients: Borrelia burgdorferi in 4, varicella-zoster virus in 2, herpes simplex virus in 1 and mumps virus in 1 patient. Enteroviruses (echovirus 6, 21 and 30) were isolated from cerebrospinal fluid (CSF) in 26/37 (70%) and from stool samples of 20/21 (95%) of patients with no other etiology. Altogether enteroviruses were isolated from CSF and/or faecal samples in 29 patients. Echovirus 30 dominated as etiologic agent. In 34/40 (85%) of the samples with an enterovirus, a cytopathogenic effect was observed in cell culture within 4 days. In patients with an enterovirus isolate a SPRIST IgM response to echovirus 3, 5, 7 and/or coxsackievirus B3 was detected in 6/13 (46%) sera sampled 3-4 days after the onset of meningeal symptoms and in altogether 17/25 patients (68%). In 4 out of these virus isolation positive and SPRIST negative patients a single serum for SPRIST was available less than 4 days after onset of meningeal symptoms. Antigen from echovirus 5 gave the highest diagnostic yield. The SPRIST IgM test was positive in 2 cases where virus isolation, complement fixation and neutralization tests were negative. Epidemiological data however supported an enteroviral diagnosis in both of them. In conclusion, both SPRIST and virus isolation seem to be valuable for the early diagnosis of enteroviral meningitis.

Immunohistochemical staining of bone marrow biopsies for detection of occult metastasis in breast cancer

Immunohistochemical (IHC) techniques should allow for a greater detection of bone marrow micrometastasis in patients with breast carcinoma. We studied a series of bone marrow (BM) biopsies negative by conventional histologic techniques from 93 patients with breast carcinoma. Prior to this study, twelve BM biopsies, positive by conventional histology, were stained with a panel of monoclonal antibodies (MoAb), directed either against cytokeratin (KL1, AE1-AE3, CAM5-2) or epithelial membrane antigen (EMA, HMFG2). KL1 appeared to be the most sensitive of the markers used in the detection of metastases and is available commercially. It therefore was the only MoAb used with the series of 93 BM biopsies negative by conventional examination. Within this series, among 45 patients clinically suspected of having bone marrow metastasis but with BM biopsies negative by conventional staining, one case showing myelofibrosis stained positive with KL1 demonstrating isolated tumor cells. For the 48 patients without suspicion of bone marrow metastasis at initial diagnosis for breast carcinoma, KL1 revealed no marrow metastasis. Single bone marrow biopsy techniques whether stained by conventional or IHC methods do not appear to be useful tests to detect occult bone marrow metastasis, especially at initial diagnosis of clinically Mo breast carcinoma patients.

Depressive symptoms in Parkinson's disease: a comparison with disabled control subjects

A high incidence of depressive symptoms has been observed in patients with Parkinson's disease (PD). PD involves a loss of central monoamines, and a decrease of monoamines has been implicated in depression; therefore, it is possible that depressive symptoms in PD result from the loss of endogenous neurotransmitters. However, it is equally possible that depressive symptoms represent a reaction to the chronic disabling course of PD. By comparing depressive symptoms in PD patients to those in matched patients with other chronic disabling diseases not involving a loss of central monoamines, it may be possible to decide between these alternatives. Thus, depressive symptoms were assessed in 45 patients with PD and 24 disabled controls that did not differ from the PD subjects on a measure of functional disability. Results showed that PD subjects obtained significantly higher total scores on the Beck Depression Inventory (BDI) than controls. PD subjects scored significantly higher than controls on BDI items grouped to reflect cognitive-affective and somatic depressive symptoms. The BDI scores of PD subjects were not reliably related to age, sex, duration of PD, or clinical ratings of PD symptom severity or functional disability. Self-rated disability and the number of recent medical problems were the greatest predictors of depressive symptoms. These findings supported the hypothesis that depressive symptoms in PD may not represent solely a reaction to disability.

Boerhaave's syndrome complicating acute myocardial infarction. Case report

A case of spontaneous rupture of the oesophagus (Boerhaave's syndrome) following acute myocardial infarction is presented. Conservative management with chest drainage and parenteral, later jejunostomy, feeding was successful. Progress was monitored with methylene blue swallow. A review of the literature revealed only two previous cases of this type.

Treatment of testicular hydrocele with tetracycline sclerotherapy

Fifteen patients with primary hydrocele of the testis were treated by aspiration and injection of tetracycline. Only 5 patients (33.3%) were cured by a single injection of tetracycline. Furthermore, 46.6% of our patients experienced severe scrotal pain, three of whom required open surgery. We do not recommend single injection tetracycline therapy, and further injections were not performed due to severe side effects.

Effects of cyclosporin on C57BL/6 splenocytes before and after culture with high-dose recombinant interleukin-2: implications for immunosuppression with cyclosporin

Lymphokine-activated killer cells appear to arise from precursor cells bearing natural killer (NK) cell antigens. Cyclosporin (CsA) is a well-known immunosuppressive agent that can down-regulate NK cell cytotoxicity. Studies were initiated to evaluate the effects of CsA on splenocytes before and after exposure to recombinant interleukin-2 (rIL-2). Normal C57BL/6 mice receiving CsA at a dose of 100 mg/kg demonstrated a decrease in NK cell lysis against the YAC-1 lymphoma target in a 4-h chromium-release assay. When splenocytes obtained from CsA-treated mice were cultured for 3 days in complete medium containing 1000 U rIL-2/ml, they demonstrated a return of NK cell lysis to normal (mean cytotoxicity = 65 LU versus 60 LU for control and CsA-exposed splenocytes respectively; P, NS, five consecutive experiments) but revealed a decrease in the lysis of a NK-resistant target: the MCA-102 sarcoma (mean cytotoxicity = 20 LU vs 12 LU for control and CsA-exposed splenocytes respectively; P less than 0.02, five consecutive experiments). Fresh splenocytes cultured in media containing rIL-2 and CsA demonstrated a decrease in proliferation, cell-cycle S-phase fraction and cell yields compared to splenocytes cultured in media containing rIL-2 alone. In addition, a decrease in tumor cell lysis for NK-cell sensitive (mean percentage lysis = 98% vs 60%, rIL-2 vs rIL-2 + CsA; effector-to-target ratio 100: 1) and resistant targets (mean percentage lysis = 68% vs 28%, rIL-2 vs rIL-2 + CsA; effector-to-target ratio 100: 1) was also seen. CsA had no effects on the phenotypic antigenic expression of splenocytes cultured with high-dose rIL-2 although activated T cell antigens were down-regulated when fresh splenocytes were evaluated after in vivo exposure to CsA. These studies support the down-regulating effects of CsA on NK cell lysis and suggest that the rIL-2-activated cell population is heterogeneous as demonstrated by the differential down-regulation and recovery of NK-resistant cell lysis versus NK-sensitive cell lysis.

Effect of concurrent sucralfate administration on the absorption of erythromycin

To determine the influence of sucralfate on the absorption of erythromycin, prior to evaluating its efficacy in decreasing erythromycin-associated gastrointestinal (GI) intolerance, we assessed pharmacokinetic parameters in six healthy adult volunteers. Erythromycin ethylsuccinate administered alone or with sucralfate as a single dose was compared. Sucralfate did not significantly alter the elimination rate constant, half-life, or area under the curve for erythromycin ethylsuccinate. It is therefore unlikely that efficacy of erythromycin ethylsuccinate will be altered when sucralfate is coadministered.

A new technique to define and clarify esophageal motor disorders

Ambulatory 24-hour esophageal manometry was applied to analyze motility in 12 normal subjects and 9 patients with chest pain and dysphagia caused by diffuse esophageal spasm (DES). Pain episodes characterized by nonperistaltic activity occurred in 7 of 9 patients. A score based on 10 variables of the motility pattern differentiated patients from normal subjects and quantitated the severity of the disorder. Ambulatory motility monitoring was prospectively performed in 8 normal subjects and 37 patients: 8 with DES, 13 with hypertensive contractions, and 16 with a nonspecific disorder on standard manometry. The score was positive in 6 of 8 patients with DES and negative in all normal subjects (accuracy 87 percent). Nine of the 13 patients with hypertensive contractions (70 percent) and 6 of 16 with nonspecific disorders (38 percent) had a pathologic score reflecting a dysmotility as severe as DES. Ambulatory esophageal manometry is a more physiologic way to identify a motor disorder than standard manometry and has the potential to improve selection of patients for a surgical myotomy.

Acute coronary events following cisplatin-based chemotherapy

Six patients with no previous signs or symptoms suggestive of coronary artery disease developed acute coronary ischemia/infarction shortly after cis-diamine-dichloroplatinum II (cisplatin) -based chemotherapy. In two patients this was the sole chemotherapeutic agent used. One patient underwent coronary angiography which disclosed no pathology, but following which, while on a calcium channel blocking agent regimen, he had an uneventful course of chemotherapy with cisplatin. Documentation of cisplatin-related vascular events is important in view of the growing number of patients who undergo cisplatin-based chemotherapy.

Well-differentiated liposarcoma of the paratesticular area: report of a case with fine-needle aspiration preoperative diagnosis and review of the literature

This article presents a rare case of well-differentiated liposarcoma of the paratesticular area (spermatic cord) with a preoperative cytological diagnosis. A 0.6-mm fine-needle aspiration biopsy (FNAB) of a paratesticular lump showed many spindle and polygonal atypical cells with numerous cytoplasmic vacuoles. On the basis of a diagnosis of "malignant mesenchymal neoplasia consistent with liposarcoma," the patient underwent radical orchiectomy. A 8 x 7 x 8.5 cm, whitish mass was found, which was histologically classified as a "well-differentiated liposarcoma" (with lipoma-like, sclerosing, and myxoid areas), according to the classification of Enzinger and Weiss. A review of the literature is presented.

Determinants of active self-care behaviour of insulin treated patients with diabetes: implications for diabetes education

The most important aim of diabetes education is to alter the self-care behaviour of patients with diabetes. In order to change their behaviour its determinants must be known. The pretest of a multicentre evaluation study with 558 participating insulin treated patients with diabetes was analysed to test the usefulness of the attitude-behaviour theory of Fishbein & Ajzen in explaining and possibly changing diabetes related active self-care behaviour. The theory of Fishbein & Ajzen is based on the assumption that human behaviour is reasoned behaviour. The theory views a person's intention as the immediate determinant of action. Determinants of intention are attitude and social norm. The results showed that the attitude was the most important determinant of active self-care, while a sufficient level of knowledge and a low orientation on the powerful others health locus of control scale were prerequisites for a positive attitude. The influence of the social environment was detrimental; although people tried to motivate patients to active self-care, they could not provide any real help in performing this desired behaviour. According to the results of this study, diabetes education should first aim at improving the level of knowledge and the health locus of control of the patients and second, at a positive attitude to active self-care. It is necessary to educate the social environment to create a more supportive atmosphere for the patient with diabetes.

Bilateral congenital pseudarthrosis of the clavicle

A case of bilateral congenital pseudarthrosis of the clavicle in a baby boy is described. The patient is fully asymptomatic, and no functional impairment is present. This is probably only the seventh case described of this rare congenital anomaly.

Treatment of chronic pancreatitis complicated by obstruction of the common bile duct or duodenum

In patients with chronic pancreatitis, common bile duct obstruction is reported in 3.2-45.6% of patients; however, only 5-10% of all patients with chronic pancreatitis require operative decompression of the bile duct. The cause of the intrapancreatic stricture of the common bile duct may be either a fibrotic inflammatory restriction, or compression by a pseudocyst. Obstruction of the duodenum is much less common than common bile duct obstruction in chronic pancreatitis occurring in less than 1-2% of patients with chronic pancreatitis. Colonic obstruction secondary to pancreatitis is very infrequent. The intrapancreatic strictures of chronic pancreatitis are characteristically smooth and tapering on endoscopic retrograde cholangiopancreatography (ERCP), but in some patients, they may have a sharp cut-off and closely resemble the appearance of carcinoma of the pancreas invading the bile duct. The natural history of these intrapancreatic strictures is variable. They may progress and be associated with cholangitis, biliary cirrhosis, common duct stones, or may remain stable for years or regress. Prior pancreaticojejunostomy is not protective against the development of intrapancreatic biliary strictures which may follow in 5-30% of patients, with most authors reporting an incidence of less than 10%. Evaluation of alkaline phosphatase, bilirubin, the presence of jaundice, or the appearance of an intrapancreatic stricture on ERCP is not predictive of whether cholangitis or biliary cirrhosis may or may not develop. The incidence of cholangitis and biliary cirrhosis in patients with intrapancreatic stricture is 9.4% and 7.3%, respectively. Laennec's cirrhosis occurs in a similar number of patients. Operation is indicated in patients with intrapancreatic strictures of the common bile duct in association with chronic pancreatitis in patients developing cholangitis, biliary cirrhosis, common duct stones, progression of the stricture, persistent high elevations of alkaline phosphatase and/or bilirubin for over a month or inability to rule out cancer of the pancreas or periampullary region. The operation of choice is choledochoduodenostomy or Roux-en-Y choledochojejunostomy to bypass the obstructed intrapancreatic portion of the common bile duct. Persistent duodenal obstruction for over 3 or 4 weeks is an indication for gastrojejunostomy. Pain is not a feature of common bile duct obstruction in the absence of cholangitis. In the presence of pain associated with chronic pancreatitis, longitudinal pancreaticojejunostomy is the operation of choice combined with Roux-en-Y choledochojejunostomy. Some of the newer operations, e.g., the Beger and Frey procedures, may make the necessity of a separate operation for biliary decompression superfluous.

Comparison of the classical immunofluorescent antibody tests for Epstein-Barr virus with commercially available test kits

Twenty reference sera with previously reported titers plus 10 normal seropositive and 10 seronegative sera were used to determine which assay for the detection of antibodies to Epstein-Barr virus should be utilized in our laboratory. By three commercially available test systems and by slides prepared in our laboratory, all techniques detected the same number of samples positive for IgG antibodies to viral capsid antigen (VCA) and Epstein-Barr virus-determined nuclear antigen (EBNA), but the geometric mean titers (GMTs) varied. Major discrepancies arose in the sensitivity of detection of early antigen-diffuse (EA-D) and -diffuse and restricted (EA-DR). Slides prepared in our laboratory gave the best results, detecting 12 of 12 (100%). Slides prepared according to Gull and Hillcrest detected 11 of 12 (92%), and those prepared according to Zeus detected 9 of 12 (75%). From these data, we conclude that all of these methods for detection of VCA and EBNA are adequate. However, in determining antibody levels to EA-D and EA-DR, great care should be taken as to the source of the slide and specificity and sensitivity.

[Acute necrotizing hemorrhagic pancreatitis]

There is no etiologic treatment for acute necrotizing pancreatitis. Advances in intensive care resulted in a reduction in early death rate by a better control of systemic complications. Delayed death rate from infection is high (20-60%). Diagnostic problems are an important cause, in spite of the aid of computed tomography and echography. The prognosis will further be improved by earlier diagnosis, a better definition of surgical treatment when complications arise, and constant medicosurgical collaboration.

Mother-and-child cases of sporotrichosis infection

We report the appearance of lymphocutaneous sporotrichosis on the left arm of a 28-year-old farmer's wife, followed two months later by the same type of lesion on the right upper eyelid of this patient's three-year-old child. According to the mother, the child was accustomed to sleeping with the right side of her face applied to the lesion on the mother's arm, and so it was presumed that the infection had been transmitted by direct contact from mother to child. Cases of person-to-person contagion of this disorder are thought to be extremely rare, but where there has been close contact on a daily basis, such contagion is likely to occur.

Nodular mesangial glomerulosclerosis in patients without manifest diabetes mellitus

Nodular mesangial glomerulosclerosis is considered to be the specific renal lesion of diabetes mellitus, and typical histological lesions in non-diabetic patients have been reported only occasionally. A similar lesion has recently been described in patients suffering from light chain disease. We report on two patients without manifest diabetes and without light chain disease, showing progressive impairment of renal function and typical nodular mesangial glomerulosclerosis.

Diagnostic paracentesis. A potent clinical tool

Diagnostic paracentesis is a potent diagnostic tool capable of rapidly detecting portal hypertension and peritonitis. Gram's stain and chemical analysis of ascitic fluid add additional information by determining the predisposition to SBP, the presence of organisms, and the severity of peritonitis. In patients with a narrow A-GRAD, the chemical analysis, cell count and differential, and cytology will add direction for the work-up if the etiology is not apparent and confirmation if it is. This information should be available within a few hours of admission if the paracentesis and blood are obtained immediately. The results should optimize patient care and minimize costs.

Reacquisition of dressing skills after stroke

A group of stroke patients were assessed over four occasions using the Nottingham stroke dressing assessment. A similar pattern of difficulty in dressing was found for both males and females. The consistency of ordering of problems was highly significantly correlated in each of the four assessments.

New directions in the optimization of ocular drug delivery

The main effort in ocular drug delivery during the past two decades has been on the design of systems to prolong the residence time of topically applied drugs in the conjunctival sac. Four recent developments promise to chart a new course in ocular drug delivery research: collagen shield as a topical ocular drug delivery system, in-situ activated gel-forming systems, noncorneal route of ocular drug penetration, and need for minimizing the systemic absorption of topically applied drugs.

The response of cerebral metastases in small cell lung cancer to systemic chemotherapy

Although small cell lung cancer (SCLC) is very chemosensitive, cerebral metastases are treated with radiotherapy in the belief that they are protected from chemotherapy by the blood-brain barrier (BBB). The validity of this assumption has not been tested in clinical practice. In a randomised trial of treatment in 610 patients with SCLC, 19 patients who had symptomatic cerebral metastases at presentation were treated initially with chemotherapy, and cranial irradiation withheld. Chemotherapy was cyclophosphamide 1 g m-2 i.v. day 1, vincristine 2 mg i.v. day 1 and etoposide 100 mg tds p.o. days 1-3, repeated every 21 days, with response assessed objectively by computerised tomography (CT) or radionuclide brain scan, and by clinical examination. A post-chemotherapy scan was obtained in 14 patients, eight of whom achieved a partial remission and one a complete remission of the cerebral metastases. The radiologically proven responses were sustained and accompanied by rapid neurological improvement. Of the remaining five patients who were assessed by clinical examination alone, one had improved neurological function after chemotherapy. The response rate for SCLC cerebral metastases treated with chemotherapy was therefore 10/19 (53%). Chemotherapy has the advantage over cranial irradiation of simultaneously treating both cerebral metastases and extracranial disease. The place of chemotherapy in the management of cerebral metastases in this and other chemosensitive tumours should be reconsidered since these findings indicate that the BBB does not prevent response to chemotherapy.

Environmental control of asthma self-management

We describe a model of asthma self-management based on environmental control of behavior. The model emphasizes aspects of the environment that either prompt or strengthen asthma self-management behavior. In prompting behavior, environmental events function as behavioral cues; in strengthening behavior, they represent reinforcers. We describe concepts related to cueing and reinforcement, and how these operations might be incorporated in individualized self-management programs. Finally, we discuss evidence supporting asthma self-management programs based on environmental control behavior.

Disseminated intravascular coagulation in Fusobacterium necrophorum septicemia

A previously healthy 42-year-old man developed, after a neglected tonsillitis, a severe Fusobacterium necrophorum septicemia with disseminated intravascular coagulation. Peripheral, painful, cyanotic and gangrenous lesions appeared on toes, external ears and nose tip. The patient survived. Consumption coagulopathy associated with tonsillitis should suggest F. necrophorum infection. Growth of these bacteria in blood cultures is slow and confirmation of the infection may thus be delayed.

Post-mortem serum concentration of cantharidin in a fatal case of cantharides poisoning

A patient admitted to hospital died shortly after admission without a proper diagnosis having been made. Symptoms as well as the presence of a brown powder found in the possession of the deceased indicated the possibility of cantharidin intoxication. Cantharidin was positively identified by means of a GC/MS analysis, utilizing the selected ion monitoring technique (SIM), for m/z = 197.0813, (M + H+) for cantharidin, under positive chemical ionization conditions at a resolution of 7000 and a mass window of 30 ppm. Quantitation was done by means of a GC/MS SIM analysis of a toluene extract of acidified post-mortem serum under El+ conditions at a resolution of 3000, using clofibrate as internal standard and monitoring m/z = 128.0473 and 128.0029 for cantharidin and clofibrate respectively. The post-mortem serum was found to contain cantharidin at a concentration of 72.3 ng/ml whilst the cantharides powder contained 0.87% cantharidin.

Splenic Rupture in Chronic Lymphoid Disorders: Possible Role of Opportunistic Infections

Two patients with lymphoproliferative disorders, one with chronic lymphocytic leukemia and the other hairy cell leukemia, developed spontaneous rupture of the spleen during the course of their disease. In both cases, this rare complication occurred during systemic atypical infections with Salmonella Dublin and Candida tropicalis respectively. We suggest that severe infection may sometimes play a decisive role in the development of the splenic rupture in some patients who have splenomegaly due to these disorders.

Keloids: a review of the literature

A review of the literature on keloids, a complex and poorly understood subject, is presented. Keloid is a disease principally of the human dermis, and occasionally the cornea, appearing as thick scar tissue invading normal skin or cornea and produced by the deposition of excessive amounts of collagen over prolonged periods. The African negro is particularly susceptible. Available methods of treatment include surgical excision, external superficial radiotherapy, interstitial irradiation, intralesional steroid injections, cryotherapy, ultrasound, systemic chemotherapy, zinc tape strapping, pressure and silicone gel. Any of these could be used alone or in combination with other forms of treatment. The lesions are notoriously recurrent and their management frustrating. The risk of late tumour induction following radiotherapy and systemic complications of depot steroids are underlined. There is still the need for a better understanding of the behaviour of keloids. This should form the biological basis on which to plan more effective prevention and treatment, with minimal complications.

Double-blind randomized crossover trial of luteal phase estrogens (Premarin) in the premenstrual syndrome (PMS)

Eleven patients with moderate to severe premenstrual syndrome were given Premarin during the latter half of the menstrual cycle for at least two cycles, and a placebo for at least two cycles. Mental and physical symptoms were monitored daily with a self-rating scale. Premarin was significantly less effective than placebo in relieving the severity of both mental (p less than 0.02) and physical (p less than 0.02) symptoms of PMS (combined data p less than 0.01). It is concluded that luteal phase Premarin is ineffective as a treatment for PMS, and may actually aggravate the symptoms.

Failure of CAVH to remove digoxin-Fab complex in piglets

Digoxin toxicity may be associated with renal failure and an inability to excrete the digoxin-Fab (antibody fragment) complex used in detoxification. We are unaware of any previous reports regarding the removal of digoxin-Fab fragment complex by continuous arteriovenous hemofiltration. Continuous arteriovenous hemofiltration allows ultrafiltration of molecules less than 50,000 daltons. Because the digoxin-Fab fragment complex has a molecular weight of 45 - 50,000 daltons, we evaluated the efficiency of continuous arteriovenous hemofiltration in removing the digoxin-Fab fragment complex. Three piglets were given 100 mcg/kg digoxin IM, in divided doses. Animals were anesthetized and continuous arteriovenous hemofiltration was begun using a Diafilter 10 cartridge. A mean ultrafiltration rate of 3.6 +/- 0.4 ml/min was obtained. The system equilibrated for 30 minutes and initial serum and ultrafiltrate digoxin levels were obtained. Mean serum values were total 6.20 +/- 1.74 ng/ml and free 3.72 +/- 0.88 ng/ml. Digibind 40 mg IV was given and then samples of serum and ultrafiltrate were obtained at 30, 60 and 90 minutes for digoxin levels. Mean values were as follows: 30 min serum total 54.23 +/- 26.13 ng/ml and free 0.08 +/- 0.08 ng/ml; 60 min serum total 61.24 +/- 27.31 ng/ml and free 0.07 +/- 0.04 ng/ml; and 90 min serum total 67.63 +/- 26.78 ng/ml and free 0.10 +/- 0.10 ng/ml. Ultrafiltrate levels throughout the experiment were negligible (less than or equal to 0.04 ng/ml). Continuous arteriovenous hemofiltration appears to be ineffective in removing the digoxin-Fab fragment complex.

Teaching models in an ambulatory training program

Ambulatory care training is increasingly important in internal medicine. Such training centers on the practice where residents and faculty see their patients; thus, features of the practice model influence what residents learn. A resident-faculty group practice affiliated with a division of general internal medicine has many advantages. In such a practice, learning centers on resident-patient interactions, around which a comprehensive teaching program must be built. Major features of such a program include the mentoring of residents by faculty who work with them longitudinally and the presence of a well-balanced structured curriculum addressing clinical and nonclinical topics related to patient care. Teaching residents to interact and communicate with patients is crucial; approaches include role-modeling by faculty, use of videotaping, and role-playing and other innovative methods. Feedback is integral to learning and helps shape the attitudes and values that permeate residents' practices.