Neuroendocrine response in patients with uveitis

Brain imaging techniques illustrate the plastic potential even of the adult human brain in healthy subjects as in patients with peripheral or central lesions. Recovery of lost function through a persistent structural lesion in the central nervous system is accompanied by a complex and individually variable pattern of reorganisation of the brain. Changes depend on the site of the lesion and are found in both hemispheres, the damaged and the sound one within a pre-existing, widespread and bilateral organised and parallel processing network without the formation of new centres. This implies changes at rest with increased or decreased activity and altered activation patterns during performance of the restituted function. Within the primary motor system an activation at the rim of the infarct, extension into neighbouring representations, which outflow is not disturbed, altered recruitment pattern of motor cortex neurons, and recruitment of ipsilateral direct descending corticospinal tract pathways originating in the sound hemisphere are found. Disruption of the primary system leads to re-weighting of activity between the various representational levels with increased activity in secondary of higher order areas. Early sensory reorganisation indicates the potential for recovery of lost motor function. Behavioural language training in aphasics results in improvement of altered comprehension function, which is related to right hemisphere activation. Thus, reorganisation can be beneficial and training or rehabilitation influence the pattern of reorganisation.     

Candidal meningitis in HIV-infected patients: analysis of 14 cases

Five cases of candidal meningitis in human immunodeficiency virus (HIV)-infected patients have been diagnosed in our hospital. This article describes these cases and reviews another nine previously reported in the literature. Most patients (71%) had at least one well-known predisposing factor for candidiasis. Median CD4 cell count was 135/mm3. Headache and fever, in the absence of focal neurologic signs, were the predominant clinical features. The CSF analysis revealed mild pleocytosis and hypoglycorrachia, indistinguishable from those seen in tuberculous or cryptococcal meningitis. Twelve patients (92%) received amphotericin B for a median of 51 days, in combination with flucytosine in five cases. The overall mortality among treated patients was 31%. Although the risk of relapse of candidal meningitis is unknown, maintenance antifungal therapy was given to seven patients (63%), usually with fluconazole. Candida species must be kept in mind as a cause of chronic meningitis in HIV-infected patients who have a known predisposing factor.     

Neurological form of cryptococcosis. Apropos of 2 atypical cases in non HIV-infected patients

Cryptococcal infection is the most common fungal infection of the central nervous system. More than 50% of the cases of cryptococcal infection are superimposed on an immunosuppressive or other general debilitating condition. Cerebral cryptococcosis usually presents as meningitis or meningoencephalitis, although cerebral granuloma has also been reported. Hydrocephalus is the most common neurosurgical complication of cerebral cryptococcosis. The majority of patients require only medical treatment with antifungal drugs. However, when complications ensue, surgical intervention is mandatory. We suggest that chronic meningitis be ruled out in all patients prior to the placement of shunts. In the two cases reported here treatment of cryptococcal meningitis was a combination of amphotericin B and flucytosine for six weeks. Fluconazole is a new alternative and at least as effective as amphotericin B.     

Pneumocystis carinii pneumonia in rheumatoid arthritis patients treated with methotrexate. A report of two cases

OBJECTIVE: The induction and repair of DNA single-strand breaks (SSBs) were measured in primary cultured infant rat lens epithelial cells (RLECs) following hydrogen peroxide (HP) exposure, and the influential factors were detected. METHODS: Utilizing nick translation methodology which utilizes incorporation of labeled nucleotides at the sites of DNA SSBs to sensitively quantitate the damage, we studied the effects of temperature, doses of HP and trace amount of selenium on cell survival. RESULTS: The number of DNA SSBs at 37 degrees was higher than that at 4C (P < 0.01). Significant numbers of SSBs were detected after being insulted by as low as 36.4 mumol/L hydrogen peroxide for 12 minutes 4 degrees (P < 0.05). Repair rapidly initiated and almost completed in 60 minutes after mild damage, and it was unable to repair when the DNA damage was induced by HP at toxic concentration. Trace selenium was added to the culture and incubated for 24 hours, then the number of SSBs was significantly decreased (P < 0.01). CONCLUSIONS: At 37 degrees HP may induce DNA SSBs in RLECs. HP induces the SSBs in a dose dependent manner. The DNA SSBs can not be repaired after severe damage. Trace selenium can decrease the degree of susceptibility to oxidative damage in infant RLECs.     

Anterior lumbar fusion. A comparison of noncompensation patients with compensation patients

One hundred fifty-one patients had an anterior interbody lumbar spinal fusion for intractable back pain. A solid bony fusion was obtained in 76% of the patients. Of patients unemployed before surgery, 50% had returned to work at review. Sixty-eight percent of patients rated themselves as significantly improved by the procedure. Posterior distraction instrumentation neither increased the rate of union nor improved the final results. Compensation status and psychological disturbance at presentation were significant prognostic factors. Psychological disturbance at review had a profound effect on the outcome and patient satisfaction ratings. It is recommended that in future studies compensation status and psychological disturbances are explicitly included in the outcome statistics.     

Posterior capsule opacification after cataract surgery in patients with uveitis

PURPOSE: To compare the incidence rate of posterior capsule opacification (PCO) after phacoemulsification and standard extracapsular cataract extraction (P/ECCE) in eyes with antecedent uveitis with the incidence rate in eyes without any history of intraocular inflammation. DESIGN: Review of records of 108 eyes of 78 patients with uveitis and 122 eyes of 106 patients with no uveitis who underwent P/ECCE. Rates of PCO were compared by the log-rank test of differences in the Kaplan-Meier survival curves. Proportional hazards regression models provided estimates of the relative risks of PCO among uveitic compared to nonuveitic eyes. MAIN OUTCOME MEASURES: Performance of neodymium: YAG laser posterior capsulotomy was used as a proxy measure for the main outcome of visually significant PCO. RESULTS: Study patients ranged in age from 6 to 81 years (median, 44.5 years) among those with uveitis and 27 to 96 years (median, 68.5 years) among those without uveitis (P = 0.0001). Crude incidence rates for visually significant PCO were 54% over a mean follow-up of 4.3 years in uveitic cases and 40% over a mean follow-up of 3.9 years among nonuveitic cases (P = 0.02). Estimates of PCO incidence (95% confidence interval) in uveitic eyes derived from the Kaplan-Meier models were 38.5% (range, 28.9%-48.2%) at 1 year and 56% (range, 45.8%-66.3%) at 3 years, and estimates among nonuveitic eyes were 11.5% (range, 6.2%-16.8%) at 1 year and 38.4% (range, 29%-47.8%) at 3 years. These rates of PCO among patients with uveitis and those patients without uveitis differed significantly by the log-rank test (P = 0.004). However, after adjusting for the younger age of patients with uveitis, the rates of PCO were no longer statistically different. CONCLUSIONS: The apparent higher rate of PCO in patients with uveitis is primarily due to their younger age at the time of surgery. A moderately increased independent risk of PCO from uveitis cannot, however, be ruled out by this study.     

Candidal meningitis in HIV-infected patients: treatment with fluconazole

Although mucocutaneous candidiasis is a common occurrence in HIV-infected patients, candidal meningitis is uncommon. We report 3 cases of candidal meningitis in HIV-positive patients, all intravenous drug abusers, and we discuss the clinical course and outcome, the treatment with fluconazole and possible prophylaxis.     

Detecting vascular problems in patients with diabetes treated with an intra-aortic balloon pump

Individuals with diabetes are at increased risk for both peripheral vascular disease and coronary artery disease. In patients with severe coronary artery disease, a cardiac assist device called an intra-aortic balloon pump (IABP) often is used to aid the failing heart and prevent further cardiac ischemia. Because this device is inserted via the femoral artery, patients are at risk of limb ischemia distal to the insertion site. Patients with diabetes are particularly prone to this complication. Detecting the early signs and symptoms of ischemia is crucial to preventing serious sequelae. Standard vascular examination techniques, in addition to being subjective and not easily reproducible, may be misleading in patients with diabetes. This article provides a review of the signs and symptoms of lower limb ischemia and noninvasive vascular tests that clinicians can use to evaluate lower extremity circulation. Also included are protocols for patient care during and after hospitalization, and two case studies of cardiac patients with diabetes who were treated with an IABP.     

Cytomegalovirus preemptive therapy with ganciclovir in renal transplant patients treated with OKT3

In an attempt to decrease the prevalence and severity of cytomegalovirus (CMV) disease, preemptive therapy with ganciclovir was administered to all renal transplant patients treated with OKT3 between February 1993 and December 1994 (26 patients). The results were compared with those of a historical group treated with OKT3 but not with ganciclovir (29 patients). Both groups were similar in age, sex, number of previous transplants, number of rejections, serological status of donor and recipient and OKT3 dose. Ganciclovir was administered during the period of treatment with OKT3. Only 2 (7.7%) treated patients developed CMV disease versus 11 (37.9%) of the control group (p = 0.01). In the control group the intensity of the disease was severe in 7 (63.6%) cases, whereas in the treated patients it was always of slight intensity (p = 0.01). In conclusion, preemptive therapy with ganciclovir during treatment with OKT3 decreases the prevalence and severity of CMV disease.     

Anorectal disease in HIV-infected patients

Alpha-1-antiproteinase E, the fourth isoform of rabbit alpha-1-antiproteinase (alpha-1-antitrypsin) having a glutamic acid at the reactive center, has been purified from the plasma by sequential chromatography on hydroxyapatite and anion-exchange columns. The E form of alpha-1-antiproteinase formed a complex with trypsin, chymotrypsin, elastase, plasmin and pancreatic kallikrein as judged by SDS-PAGE. The E form inhibited elastase in a stoichiometric manner and chymotrypsin moderately, but the inhibition of trypsin was gradual. The F form inhibited trypsin most effectively followed by chymotrypsin and elastase. N-chlorosuccinimide reduced the elastase inhibitory activity of the E form, while the F form was more effectively inactivated by the oxidant.     

Fungal infections in HIV-infected patients

Opportunistic fungal infections are commonly encountered in the acquired immunodeficiency syndrome (AIDS) patient population. Fungal infections in the patient infected with the human immunodeficiency virus (HIV) are a major cause of morbidity and mortality. The yeasts Candida and Cryptococcus neoformans, the dimorphic fungi Histoplasma capsulatum and Sporothrix schenckii, and the dermatophyte fungi are the most common pathogenic fungi in patients infected with HIV. The characteristics of these and other relevant mycotic pathogens, and their clinical presentation are discussed. Mycoses in the patient infected with HIV are often atypical, and can be masked by other infections. Cutaneous manifestations may provide valuable diagnostic clues. The clinician must maintain a high index of suspicion to establish an early diagnosis and rapidly institute therapy. Treatment may suppress rather than cure the mycosis, because host immunity in conjunction with antifungal agents is necessary to eliminate infection.     

Indications for photocoagulation with an argon laser. I. Anterior eye segment

1. Renal lithium clearance in healthy men was elevated while the subject was reclining, decreased upon standing and increased upon lying down during 45-60 min tests. 2. Parallel changes in renal clearance of creatinine, sodium and potassium, and urine flow rate occurred in response to the changes in posture. 3. The findings demonstrate for the first time that posture is a factor that can influence lithium excretion. Control of posture during lithium excretion tests is recommended.     

Ectopic parathyroid adenoma. Two cases treated with video-assisted thoracoscopic surgery

In recurrent or persistent hyperparathyroidism, accurate location of the abnormal gland is essential before further surgery, but the variety of available imaging techniques suggests that no one procedure is universally reliable. We report two cases in which clear preoperative visualization of adenoma with double-phase 99mTc-MIBI scintigraphy and exact high-resolution CT location permitted successful minimally invasive surgery.