Determinants for persistence of Pseudomonas aeruginosa in hospitals: interplay between resistance, virulence and biofilm formation.

Pseudomonas aeruginosa (Pa) is one of the major bacterial pathogens causing nosocomial infections. During the past few decades, multidrug-resistant (MDR) and extensively drug-resistant (XDR) lineages of Pa have emerged in hospital settings with increasing numbers. However, it remains unclear which determinants of Pa facilitated this spread. A total of 211 clinical XDR and 38 susceptible clinical Pa isolates (nonXDR), as well as 47 environmental isolates (EI), were collected at the Heidelberg University Hospital. We used RAPD PCR to identify genetic clusters. Carriage of carbapenamases (CPM) and virulence genes were analyzed by PCR, biofilm formation capacity was assessed, in vitro fitness was evaluated using competitive growth assays, and interaction with the host's immune system was analyzed using serum killing and neutrophil killing assays. XDR isolates showed significantly elevated biofilm formation (p < 0.05) and higher competitive fitness compared to nonXDR and EI isolates. Thirty percent (62/205) of the XDR isolates carried a CPM. Similarities in distribution of virulence factors, as well as biofilm formation properties, between CPM+ Pa isolates and EI and between CPM- and nonXDR isolates were detected. Molecular typing revealed two distinct genetic clusters within the XDR population, which were characterized by even higher biofilm formation. In contrast, XDR isolates were more susceptible to the immune response than nonXDR isolates. Our study provides evidence that the ability to form biofilms is an outstanding determinant for persistence and endemic spread of Pa in the hospital setting.

Comparative testing of disinfectant efficacy on planktonic bacteria and bacterial biofilms using a new assay based on kinetic analysis of metabolic activity.

AIMS: The aim of our study was to develop a new reproducible method for disinfectant efficacy testing on bacterial biofilms and to evaluate the efficacy of different disinfectants against biofilms. Clinical multidrug-resistant strains were chosen as test isolates to ensure practical relevance. METHODS AND RESULTS: We compared the standard qualitative suspension assay for disinfectant testing, which does not take into account biofilm formation, to the new biofilm viability assay that uses kinetic analysis of metabolic activity in biofilms after disinfectant exposure to evaluate disinfectant efficacy. In addition, the efficacy of four standard disinfectants to clinical isolates was tested using both methods. All tested disinfectants were effective against test isolates when in planktonic state using the standard qualitative suspension assay, while disinfectants were only weakly effective against bacteria in biofilms. CONCLUSIONS: Disinfectant efficacy testing on planktonic organisms ignores biofilms and overestimates disinfectant susceptibility of bacteria. However, biofilm forming, e.g. on medical devices or hospital surfaces, is the natural state of bacterial living and needs to be considered in disinfectant testing. SIGNIFICANCE AND IMPACT OF THE STUDY: Although bacterial biofilms are the predominant manner of bacterial colonization, most standard procedures for antimicrobial susceptibility testing and efficacy testing of disinfectants are adapted for application to planktonic bacteria. To our knowledge, this is the first study to use a newly developed microplate-based biofilm test system that uses kinetic analysis of the metabolic activity in biofilms, after disinfectant exposure, to evaluate disinfectant efficacy. Our study shows that findings obtained from disinfectant efficacy testing on planktonic bacteria cannot be extrapolated to predict disinfectant efficacy on bacterial biofilms of clinically relevant multidrug-resistant organisms.

The effect of thymosin treatment of venous ulcers.

Venous ulcers are responsible for about 70% of the chronic ulcers of the lower limbs. Standard of care includes compression, dressings, debridement of devitalized tissue, and infection control. Thymosin beta 4 (Tbeta4), a synthetic copy of the naturally occurring 43 amino-acid peptide, has been found to have wound healing and anti-inflammatory properties, and is thought to exert its therapeutic effect through promotion of keratinocyte and endothelial cell migration, increased collagen deposition, and stimulation of angiogenesis. To assess the safety, tolerability, and efficacy of topically administered Tbeta4 in patients with venous stasis ulcers, a double-blind, placebo-controlled, dose-escalation study was conducted in eight European sites (five in Italy and three in Poland) that enrolled and randomized 73 patients. The safety profile of all doses of administered Tbeta4 was deemed acceptable and comparable to placebo. Efficacy findings from this Phase 2 study suggest that a Tbeta4 dose of 0.03% may have the potential to accelerate wound healing and that complete wound healing can be achieved within 3 months in about 25% of the patients, especially among those whose wounds are small to moderate in size or mild to moderate in severity.

Isolation and characterization of a gene encoding carbonic anhydrase from Ostertagia ostertagi and quantitative measurement of expression during in vivo exsheathment.

The first event in the establishment of Ostertagia ostertagi infection in cattle is exsheathment. Exsheathment is the process whereby the L(2) cuticle retained from the previous molt is cast from the L3. For those trichostrongyle nematode species with a predilection site in the abomasum, such as O. ostertagi, exsheathment is initiated as the larvae pass through the rumen. Although the stimulus for exsheathment is not known, previously reported biochemical studies suggest a major role for the enzyme carbonic anhydrase (CA). Partial support for this hypothesis comes from the reported failure of the Haemonchus contortus L3 to exsheath following pretreatment with ethoxzolamide, a known inhibitor of CAs. Although convincing, a CA has not been previously reported from a trichostrongylid nematode. Therefore, our objective was to isolate a CA gene from O. ostertagi L3 and begin initial characterization studies. This work resulted in the successful isolation, cloning and sequencing of the first CA isolated from a gastrointestinal nematode. The gene, designated OoCA, shows 90.5% sequence identity with the CA eukaryotic consensus sequence, 78% similarity to the Caenorhabiditis elegans cah-6 and 55% similarity to the human CAIII. Sequence analysis of the genomic DNA encoding OoCA shows 8 exons and 7 introns covering 4.5kb. The first 1758 bases of the promoter region suggest OoCA may be regulated in part by transcription factors associated with hypoxic signaling and development. The mRNA profile of OoCA in exsheathing O. ostertagi L3 suggests this particular CA may play a role in immediate early developmental events following exsheathment initiation.

Dose determination of the persistent activity of moxidectin long-acting injectable formulations against various nematode species in cattle.

The effectiveness, safety and production-enhancing benefit (improved weight gains) of moxidectin long-acting injection given subcutaneously in the ear at the rates of 0.75, 1.0 and 1.5mg/kg bw were evaluated in three studies under common protocol. The only adverse reaction to treatment was a mild (<2 tablespoons in volume), and for the most part transient (<28 days for the treatment rate of 1.0mg/kg bw) injection site swelling as noted in a minority of the animals (12.2% of the animals treated at the rate of 1.0mg/kg bw). Regardless of study site, post-treatment interval or dose rate, average daily gains were improved over control cattle by approximately 33%. Reductions in strongyle EPG counts relative to controls were > or = 90% for all dose rates of moxidectin for a post-treatment period of 42 days (Wisconsin), 84 days (Arkansas) and 140 days (Louisiana). In Arkansas and Louisiana, the majority (>80%) of post-treatment strongyle eggs, as determined by coproculture, were Cooperia spp. As determined by sequential necropsies, periods of continuous, post-treatment protection (> or = 90% efficacy in at least two out of three studies) for moxidectin long-acting injection given at the rate of 1.0 mg/kg bw were 90 days (adult Haemonchus spp.), 120 days (Dictyocaulus viviparus and adult Ostertagia and Oesophagostomum) and 150 days (Ostertagia spp. EL4).

Exsheathment of Ostertagia ostertagi infective larvae following exposure to bovine rumen contents derived from low and high roughage diets.

The objective of this study was to characterize the exsheathment kinetics of Ostertagia ostertagi infective larvae (L3) following in vivo exposure to bovine rumen contents derived from low and high roughage diets. O. ostertagi L3 were placed in disposable dialysis bags and incubated for various time points between 0 and 360 min in the rumen of a fistulated steer maintained on a 71% grain diet or a 100% grass diet. The maximum percentage of exsheathed L3 was observed 120 min post-exposure to grass-derived rumen contents, while maximum exsheathment for L3 exposed to grain-derived rumen contents did not occur until 360 min. This work provides the first report of the in vivo exsheathment kinetics for O. ostertagi in its bovine host. Results of this study also support earlier reports that rumen pH may affect the exsheathment efficiency of abomasal trichostrongylids.

Effect of horn fly and internal parasite control on growth of beef heifers.

The effects of horn fly and gastrointestinal nematode control on body weight gain of yearling Angus-Brangus cross heifers were evaluated in three separate studies during the years 1999, 2000 and 2002. In each year, the studies started in late May and lasted for 150, 148 and 123 days, respectively. In all three studies, the tag treatment (10% lambdacyhalothrin+13% piperonyl butoxide impregnated ear tags) provided excellent horn fly control. In the three studies, the average weekly horn fly counts for tagged heifers were 1, 3, and 0 flies per side while the average on untreated heifers was 52, 163 and 90 flies per side. In studies 1 and 2, there was no difference (P>0.1) in weight gain between tagged and untreated heifers, but in study 3, tagged heifers gained 50% more weight (P<0.001) than the untreated heifers. For gastrointestinal nematode control, ivermectin (IVM) was administered on Day 0 in studies 1 and 3 using a sustained release bolus and on Day 0 and subsequent 56-day intervals in study 2 using either the injectable or pour-on formulation. Heifers treated with IVM in studies 1 and 3 had significantly lower (P<0.05) GI nematode fecal egg counts compared to control heifers. In study 2, IVM treated heifers also had significantly lower GI nematode fecal egg counts compared to control heifers, except for Day 90 when no differences in fecal egg counts were observed between IVM pour-on treated and control heifers. Weight gain of heifers that received IVM was significantly greater (P<0.005) than untreated heifers in each of the three studies. IVM treated heifers gained 45, 61 and 184% more weight than the untreated heifers during the three studies. There was no interaction (P>0.1) between the main treatment effects of fly control and gastrointestinal nematode control.

Dose confirmation of moxidectin 0.5% pour-on against adults and fourth-stage larvae of various Cooperia spp. and Trichostrongylus colubriformis in Louisiana.

Thirty-five castrate or intact Holstein male calves, ranging in weight from 122 to 210kg, were used in the study. On study Days -15 and -14, all study calves were treated with fenbendazole 10% paste at 10mg/kg to remove existing nematode infections. All cattle had zero egg counts on Day -1. Experimental infections of a mixed species inoculum were administered to all calves on Day 0. The inoculum consisted of Cooperia spp. (primarily C. punctata, but also C. pectinata, C. spatulata, C. oncophora and C. surnabada-total 40,961); Ostertagia ostertagi-1550; Trichostrongylus colubriformis-4996; and Oesophagostomum radiatum-38. Necropsy results from two of three monitor calves slaughtered on Day 6 after infection indicated that Day 6 was an appropriate time to evaluate efficacy of moxidectin against fourth larval stages (L(4)). The remaining 32 calves were randomly allotted to four groups of eight based on body weights. Eight calves (Group 1) were treated with moxidectin 0.5% pour-on at 0.5mg/kg on Day 6 to evaluate efficacy against nematode larval stages; eight control calves (Group 2) were matched with these principals. Eight calves (Group 3) were also treated with moxidectin pour-on at the same dosage on Day 23 in order to determine efficacy against adult nematodes; eight control calves (Group 4) were matched with these principals. In both cases, principals and controls of the Days 6 and 23 treatments were necropsied at 14-15 days after treatment. C. punctata was the only species found in a sufficient number of controls to evaluate moxidectin efficacy against the L(4). Moxidectin pour-on was not effective (P<0.05) against C. punctata L(4) by arithmetic means, but was highly effective based on geometric means. Regardless of whether arithmetic or geometric means were used for percent efficacy calculations, moxidectin pour-on was demonstrated to be highly effective (>99%) against the adult stages of C. oncophora, C. punctata, C. spatulata, C. surnabada, Cooperia spp. adult females and T. colubriformis adults.

Effect of gastrointestinal nematode and liver fluke infections on weight gain and reproductive performance of beef heifers.

Spring born, crossbred beef heifers (n=372) were utilized over four years to measure reductions in body weights, reproductive performance and calf weights caused by gastrointestinal nematodes (primarily Ostertagia ostertagi) and the bovine liver fluke (Fasciola hepatica) and to differentiate losses attributable to each type of parasitism. Each year, weaned heifers were allotted to one of the four treatment regimens: Group 1, untreated controls; Group 2, treated for nematodes; Group 3, treated for liver fluke; and Group 4, treated for both nematodes and liver fluke. Nematodes were controlled with subcutaneous injections of either ivermectin (Ivomec, Merial) or doramectin (Dectomax, Pfizer), both at the recommended dose of 200 ug/kg bodyweight. Clorsulon (Curatrem, Merial) drench was given at the recommended rate of 7 mg/kg bodyweight to control flukes. Treatments and fecal collections were initiated at allotment each year and were repeated at 28-84-day intervals until palpation for pregnancy diagnosis. Open heifers were removed from the study at this time. Treatment dates were based on expected length of treatment efficacy, the stage of growth of the heifers and the seasonal risk of infection by the parasites. Pregnant females were pooled and received their assigned treatments prior to their calving and breeding seasons and remained together until their calves were weaned. Heifers treated for nematode infections were heavier and had higher condition scores (P<0.01) than untreated control heifers at initiation of breeding, and maintained that difference through pregnancy diagnosis. Liver fluke infection did not affect heifer gains or condition scores prior to palpation (P<0.01). At palpation, heifers treated for both forms of parasitism had the highest condition scores and weight gains (P<0.01), and also higher pregnancy rates than control heifers and heifers treated for nematodes only (P<0.01). Pregnancy rates for heifers treated for flukes only were not significantly different from those treated for both nematodes and flukes. Heifers treated for nematodes weaned heavier calves than those not treated for nematodes (P<0.05).

Effects of parenteral administration of doramectin or a combination of ivermectin and clorsulon on control of gastrointestinal nematode and liver fluke infections and on growth performance in cattle.

OBJECTIVE: To compare effects of an injectable doramectin preparation with those of an injectable ivermectin-clorsulon preparation on control of gastrointestinal nematodes and liver flukes and on growth performance in cattle. DESIGN: Randomized complete block design. ANIMALS: 60 crossbred calves. PROCEDURES: Calves (20/treatment group) were treated with doramectin or ivermectin-clorsulon or were not treated. Fecal samples were collected for nematode and Fasciola hepatica egg counts on day 0 and for up to 140 days after treatment. Cattle were weighed before treatment and at 28-day intervals until day 140. RESULTS: From day 7 through day 49, nematode egg counts for calves treated with doramectin or with ivermectin-clorsulon were significantly lower than those for untreated control calves. As the study progressed beyond day 56, the percentages of cattle with fluke eggs in their feces increased, but differences in regard to these percentages were not detected among the 3 groups. Average daily gain for the doramectin-treated cattle (0.79 kg/d [1.74 lb/d]) was significantly greater than that for the cattle treated with ivermectin-clorsuIon (0.71 kg/d [1.56 lb/d]); values for both groups were significantly greater than that for the control cattle (0.62 kg/d [1.37 lb/d]). CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that doramectin had a greater impact on subclinical gastrointestinal tract parasitism in calves, as demonstrated by growth performance, than did ivermectin-clorsulon. In the Gulf Coast region of the United States, spring-born nursing beef calves may have minimal grazing exposure to F hepatica during the peak fluke transmission period; therefore, mature fluke burdens may be negligible at the beginning of the fall season.

A comparison of persistent anthelmintic efficacy of topical formulations of doramectin, ivermectin, eprinomectin and moxidectin against naturally acquired nematode infections of beef calves.

Persistent anthelmintic efficacy of topical formulations (all at a dosage of 500 microg/kg) of doramectin (DOR), ivermectin (IVM), eprinomectin (EPR) and moxidectin (MOX), in comparison with untreated control cattle (CONT), was observed in stocker beef calves during a 112-day winter-spring grazing trial. Five groups of 15 calves per group were grazed on 15 separate 2 ha pastures following random assignment of animals to specific pastures and then to treatment groups. All of the 5 treatments were represented in each of the 15 pastures. All cattle were weighed on study Days 1, 0, 28, 56, 84, 111 and 112. Fecal samples for nematode egg counts were collected on Days 7, 0, at 7 day intervals through Day 56 and at 14 day intervals to Day 1 12. Pooled group fecal cultures for determining generic composition of nematode infections were prepared at 14 day intervals throughout the study. As based on fecal egg counts, anthelmintic activity of EPR and MOX was greater (p < 0.05) than values for IVM or CONT through Day 28. Activity of DOR was greater (p < 0.05) than that of IVM on Days 7 and 14 only. Although significance levels varied little among treated groups from Day 42 to the end of the study, egg counts and percent reduction values of EPR and MOX remained consistently lower numerically than egg counts and higher than reduction values respectively, of DOR and IVM through Day 70. From Day 70 on, IVM counts were numerically, but not significantly higher than values of CONT. Based on larval culture, Cooperia predominated from Day 0 through 28 and again from Days 70 to 98; Ostertagia was second in prevalence with highest percentages, which exceeded those of Cooperia, between Days 42 and 70. Bodyweights of all treated groups, with exception of IVM, were always significantly greater (p < 0.05) than weights of CONT. Weights of IVM were numerically greater, but not significantly greater than CONT only on Days 84 and 112. From Day 56 on, there were no significant differences between weights of DOR, EPR and MOX, however, numerical values for MOX were consistently higher than values for the other two. Final average total bodyweight gains were: 153.7 kg for MOX, 148.5 kg for EPR, 146.9 kg for DOR, 139.7 kg for IVM and 127.7 kg for CONT.

A comparison of the efficacy of two treatments of doramectin injectable, ivermectin injectable and ivermectin pour-on against naturally acquired gastrointestinal nematode infections of cattle during a winter-spring grazing season.

Four groups of 18 crossbred beef steer calves (three replicates of six per group) were used to compare persistent efficacy of doramectin injectable, ivermectin injectable and ivermectin pour-on against naturally acquired infections of gastrointestinal nematodes during winter-spring grazing in Louisiana. The experiment was initiated on January 11. Treatments administered on Day 0 and again on April 5 (Day 84, 12-week interval) were: Group 1, untreated controls (CONT); Group 2, doramectin (DOR) at 200 micrograms/kg, s.c. injection; Group 3, ivermectin (IVM-INJ) at 200 micrograms/kg, s.c. injection; Group 4, ivermectin pour-on (IVM-PO) at 500 micrograms/kg, back midline. The cattle were weighed and fecal samples (for egg counts and for culture-larval identification) were collected at regular intervals throughout the 161 day experiment. In the interval between Day 0 and 84, arithmetic mean egg counts of the CONT group averaged about 890 eggs per gram, but then decreased markedly between Days 119 and 126, and remained at a lower plane for the remainder of the experiment. From Day 28 to 56, egg counts of the DOR group were consistently lower (P < 0.05) than those of controls and both IVM-treated groups. Egg counts of the DOR group were always lowest after the second treatment, but differed (P < 0.05) only from IVM-PO counts between Days 119 and 140 (35 and 56 days after the second treatment). Ostertagia was the predominant genus, followed by Cooperia in all four groups. Oesophagostomum, Trichostrongylus, Haemonchus, and Bunostomum were other genera identified. Bodyweights of the DOR group remained significantly greater (P < 0.05) than those of all other groups from Day 112 through the end of the experiment. Total gains for the CONT, DOR, IVM-INJ, and IVM-PO groups were 96, 159, 147, and 150 kg, respectively; treated groups were significantly (P < 0.05) greater than CONT, but differences among treated groups was not significant (P > 0.05).

Comparative efficacy of ivermectin pour-on, albendazole, oxfendazole and fenbendazole against Ostertagia ostertagi inhibited larvae, other gastrointestinal nematodes and lungworm of cattle.

An experiment was conducted to evaluate the current efficacy of albendazole (ABZ), oxfendazole (OXF) and fenbendazole (FBZ) compared with ivermectin pour-on (IVM-PO) against inhibited early fourth-stage larvae (IEL4) of Ostertagia ostertagi, other gastrointestinal nematodes and lungworm of cattle during spring in Louisiana. Twenty-five crossbred beef heifer calves of 235 kg average weight and 10-12 months of age were acquired in late winter and grazed for 9 weeks on pasture contaminated with O. ostertagi and other nematodes until May 15. The cattle were weighed and randomly allotted into 5 groups of 5 calves on May 16 (day 0) and treatments were as follows: group 1, nontreated controls (CONT); group 2, IVM-PO on mid-backline at 500 micrograms/kg; group 3, ABZ suspension (oral) at 10 mg/kg; group 4, OXF suspension (oral) at 4.5 mg/kg; group 5, FBZ suspension (oral) at 5 mg/kg. After treatment and confinement in separate pens for each group, approximately equal numbers of cattle from each group were necropsied daily between days 29-31. Mean numbers of O. ostertagi developmental stages present in CONT were: adult, 5234; developing (DL4), 3130; IEL4, 44,077. The mean percentage of IEL4 was 84.1. Cooperia spp. were the second most prevalent in CONT (20,307) and smaller numbers of abomasal and intestinal species and Dictyocaulus viviparus were present in nearly all CONT. Percent reductions for the four compounds against O. ostertagi adult, DL4 and IEL4, respectively, were IVM-PO: 99.7, 98.3, 98.1; ABZ: 74.1, 76.5, 75.3; OXF: 78.5, 42.1, 32.0; FBZ: 63.6, 17.7, 39.7. Efficacy of IVM-PO was greater (P < 0.05) against all O. ostertagi stages than the benzimidazole (BZ) drugs, except for ABZ (DL4). There were no significant differences in group means (except for C. punctata adult males, P < 0.05 lower for IVM-PO) or wide variation in reduction percentages for other abomasal and intestinal species and D. viviparus between IVM-PO and BZ drugs. The low efficacy of all three BZ drugs for O. ostertagi, but especially for OXF and FBZ, under conditions of this experiment, were suggestive of drug tolerance to dosages employed or resistance. However, problems of drug availability/concentration in the abomasum, and the factor of IEL4 and DL4 replacing adult worms after treatment cannot be excluded. Efficacy of the BZ drugs against all other species were essentially similar to that of IVM-PO.

Efficacy of a spring strategic fenbendazole treatment program to reduce numbers of Ostertagia ostertagi inhibited larvae in beef stocker cattle.

Efficacy of a spring strategic treatment program with fenbendazole (FBZ) to reduce the accumulation of Ostertagia ostertagi inhibited early fourth-stage larvae (EL4) was investigated in two groups of crossbred beef heifers which were 7-9 months of age and ranged in weight from 155 to 223 kg. The cattle were allocated to groups and treated on 27 April (Day 0). Group 1 calves served as nontreated controls. Group 2 calves were treated with FBZ 10% drench suspension at 5 mg kg-1 on Day 0 and with 6-day courses of FBZ free-choice mineral (to provide 5 mg kg-1 per animal) on Days 28 and 56. Each group grazed on a separate 4.9 ha pasture for 105 days to 10 August. On 10 August the cattle were taken off pasture and each original group was re-allocated to subgroups of three cattle which were treated orally with FBZ (5 mg kg-1), oxfenbendazole (OXF, 4.5 mg kg-1) or left nontreated (CONT). The cattle were necropsied on Days 120 and 121. Mean actual and cumulative fecal egg counts indicated near total suppression of egg output in the strategically treated group (high of 5.2 eggs g-1 feces (EPG) on Day 28). Egg counts of the nontreated group remained above 100 or 200 EPG to Day 63 and then decreased to less than 100. Ostertagia was the predominant genus, followed by Cooperia on most sampling dates. The largest O. ostertagi worm burdens were recovered from the CONT-CONT subgroup; numbers of EL4 ranged from 18,922 to 51,137. Reduction in numbers of EL4 in original controls, treated with FBZ or OXF in August, were low, being 60.2% and 74.3%, respectively. The numbers of O. ostertagi recovered from subgroups originally treated strategically with FBZ were generally lower than in original controls. The largest reduction in O. ostertagi numbers was in the FBZ-CONT subgroup, which was not treated in August. Percent reduction values for O. ostertagi adults, developing L4 (DL4) and EL4 were 84.6%, 96.7%, and 99.0%, respectively. Percent reduction values for adults, DL4 and EL4 in the FBZ-FBZ and FBZ-OXF subgroups were 90.7%, 61.3%, 85.6% and 92.4%, 45.5%, and 73.0%, respectively. Variability in numbers of EL4 acquired during grazing by original controls and strategically treated cattle and variability in efficacy of August treatments was evident as observed in high outlier numbers of worms in all subgroups except the FBZ-CONT subgroup. Liveweights and gains were nearly identical in the two groups on 10 August.

Hemorrhagic retinopathy as the presenting manifestation of sarcoidosis.

BACKGROUND: The diagnosis of ocular sarcoidosis is particularly challenging in patients who present with atypical clinical findings and no evidence of systemic disease. We describe a patient whose initial clinical manifestation of sarcoidosis was a unilateral hemorrhagic retinopathy. METHOD: Clinicopathologic case study. RESULTS: The diagnosis of sarcoidosis in this patient was delayed for over a year principally because of the atypical retinal findings and because repeated chest X-rays and serum angiotensin covering enzyme (ACE) levels were normal. Surgical enucleation of the eye once it was blind revealed a large noncaseating granuloma of the ciliary body. Inflammation and thrombosis of several large caliber retinal veins and a single branch of the retrolaminar hemicentral retinal vein were found. CONCLUSIONS: Major retinal branch vein occlusion and hemi-central retinal branch occlusion are rare complications of ocular sarcoidosis. Normal serum ACE levels do not exclude the diagnosis of ocular sarcoidosis even in patients with considerable amounts of intraocular granulomatous inflammation.

The adult who is an only child: achieving separation or individuation.

60 women and 60 men between the ages of 18 and 45 years (M = 30.5, SD = 9.6) were categorized by sex, age, and birth order (only child, firstborn, lastborn) to assess the differences among the adult only-child, the youngest child, and the oldest child in autonomous characteristics and cohesiveness in family interaction. Analysis of the responses on a biographical data sheet, the California Psychological Inventory, and the Family Adaptability Cohesion Scales III showed that main effects for birth order and sex are significant in the process of separation-individuation and that the only child is less autonomous than the oldest child.

Bereavement support groups for school-age children: theory, intervention, and case example.

Children's bereavement support groups can provide useful surrogate support for families when a parent dies, and may contribute new social meaning for this traumatic event. Theories and techniques for intervention in such groups are presented and their application illustrated via a clinical case history. Results indicate that categorization of children's bereavement should be abandoned in favor of conceptualization in terms of prior adaptation processes.

Self-concepts of adolescent siblings of children with mental retardation.

Self-concepts of 70 adolescent siblings of children with profound levels of mental retardation were investigated. Their mean self-concept was compared with a matched group of 70 adolescent siblings of children without profound levels of retardation. Using the Tennessee Self-concept Scale, two variables (maternal self-concept and siblings' self-concept) were assessed for differences between siblings and mothers (the target group) of mentally retarded children and siblings and mothers (the comparison group) of children without mental retardation. No significant mean difference between the two groups suggests no special difficulties in psychosocial adjustment for siblings of the mentally retarded.

Effects of familiar proctor on fifth and sixth grade students' test anxiety.

The effect of the proctor's familiarity on four groups of students in Grades 5 and 6 was investigated. The 137 children took a reading examination, half of which was administered by a familiar proctor, the other half by an unfamiliar one. Order of conditions was controlled. Analysis showed that students had significantly lower reading scores with the unfamiliar proctor. Students with midrange IQs had significantly lower reading scores than those in the low or high ranges. A significant relationship between test anxiety and effects of the unfamiliar proctor on test performance was shown. Test anxiety contributed significantly to the relationship between self-esteem and performance.