Antral follicle count recovery in women with menses after treatment with and without gonadotropin-releasing hormone agonist use during chemotherapy for breast cancer.

PURPOSE: After chemotherapy for breast cancer, most women will recover some ovarian function, but the timing and extent of this recovery are poorly understood. We studied post-chemotherapy ovarian recovery in women with and without a history of ovarian suppression during chemotherapy. METHODS: Reproductive age breast cancer patients who were seen prior to chemotherapy for fertility preservation consult were consented for follow-up ovarian function assessment (every 3-6 months after chemotherapy) with antral follicle count (AFC) in this prospective cohort study. We restricted our analysis to those with menses present after chemotherapy. Box plots were used to demonstrate the change in follow-up AFC versus time elapsed after chemotherapy. A mixed effects regression model was used to assess differences in AFC. RESULTS: Eighty-eight patients with a history of newly diagnosed breast cancer were included. Forty-five patients (51%) had ovarian suppression with GnRH agonist (GnRHa) during chemotherapy. AFC recovery appeared to plateau at 1 year after completing chemotherapy at a median of 40% of pre-chemotherapy AFC. After adjustment for age, initial AFC, cyclophosphamide exposure, combined hormonal contraceptive (CHC) use, and tamoxifen use, AFC recovered faster and to a greater degree for those women who underwent GnRHa therapy for ovarian protection during chemotherapy (P = 0.032). CONCLUSIONS: Women with menses after chemotherapy for breast cancer appear to recover their full potential AFC 1 year after their last chemotherapy dose. Treatment with GnRHa during chemotherapy is associated with a higher degree of AFC recovery. The findings of this study can aid in counseling patients prior to chemotherapy about expectations for ovarian recovery and planning post-treatment fertility preservation care to maximize reproductive potential when pre-treatment fertility preservation care is not possible or has limited oocyte yield.

Nonsurgical management of binocular diplopia induced by macular pathology.

OBJECTIVE: To treat binocular diplopia secondary to macular pathology. METHODS: Seven patients underwent evaluation and treatment. All had constant vertical diplopia caused by various maculopathies, including subretinal neovascularization, epiretinal membrane, and central serous retinopathy. Visual acuity ranged from 20/20 to 20/30 in the affected eye. All except 1 patient had a small-angle, comitant hyperdeviation with no muscle paresis. Sensory evaluation demonstrated peripheral fusion and reduced stereoacuity. Neither prism correction nor manipulation of the refractive errors corrected the diplopia. A partially occlusive foil (Bangerter) of density ranging from 0.4 to 1.0 was placed in front of the affected eye to restore stable, single vision. RESULTS: The Bangerter foil eliminated the diplopia in all patients. Two patients elected not to wear the foil; 1 patient was afraid of becoming dependent, and the other was bothered by the visual blur. Visual acuity in the affected eye was reduced on average by 3 lines. All patients maintained the same level of sensory fusion, with only 2 having reduced stereoacuity. Symptoms returned when the foil was removed or its density was reduced. CONCLUSION: Low-density Bangerter foils provide an effective, inexpensive, and aesthetically acceptable management for refractory binocular diplopia induced by macular pathology, allowing peripheral fusion to be maintained.

Retinal detachments in incontinentia pigmenti.

We report on retinal detachments in six eyes of four patients with incontinentia pigmenti. These nonrhegmatogenous traction retinal detachments are characterized by extensive preretinal and vitreous fibrous organization that pull the retina anteriorly behind the lens. The clinical course and fundus appearance of the retinal detachments, beginning with the avascular peripheral retina and leading to traction retinal detachment, are similar to those of cicatricial retinopathy of prematurity. Vitreous surgery was performed on three eyes (two patients), with partial reattachment of a total retinal detachment in one eye and complete reattachment of a partial retinal detachment in a second eye. These cases represent the first successful surgical interventions reported for retinal detachment in incontinentia pigmenti.

Neodymium:YLF picosecond laser segmentation for retinal traction associated with proliferative diabetic retinopathy.

PURPOSE: To determine the applicability of laser segmentation for severing fibrovascular tissue and hyaloid interfaces in the treatment of tractional complications of proliferative diabetic retinopathy. METHODS: A prototype neodymium:yttrium-lithium-fluoride (Nd:YLF) picosecond pulse photodisruptive laser was used in eight eyes (seven patients) with proliferative diabetic retinopathy as part of a Food and Drug Administration-approved phase 1 protocol. There were three indications for treatment: type I: distortion and shallow elevation of the macular caused by taut, adherent, posterior hyaloid interface (two eyes); type II: traction retinal detachment involving the fovea (two eyes); and type III: fovea-threatened, traction retinal detachment (four eyes). Traction release was accomplished by laser segmentation of the detached hyaloid interfaces and fibrotic, contracted proliferative tissue. The Nd:YLF uses low pulse energy (0.10 mJ, 1,000 pulses per second for 10 consecutive seconds) that allows tissue cutting near the retinal surface. RESULTS: Both type I eyes had relief of traction forces; visual acuity improved from 20/400 to 20/50 in one eye; the other remained stable. Of the two type II eyes, one had anatomic reattachment of the fovea with improvement in visual acuity (hand movements to 20/50); the second required vitrectomy. Of the four type III eyes, all had anatomic improvement; three maintained pretreatment acuity; the fourth eye developed vitreous hemorrhage at 6 months and underwent vitrectomy. Three treatments (two eyes) caused vitreous hemorrhage that resulted in a transient drop in acuity (1 to 2 lines). No patient developed a retinal break or choroidal hemorrhage. CONCLUSION: In a small pilot study, the Nd:YLF laser segmented proliferative tissue near the retinal surface and elevated hyaloid interfaces. In selected cases, this may enable flattening of traction retinal detachment or release of retinal distortion.

Posterior scleritis in children.

Posterior scleritis was diagnosed in four adolescent boys. These patients represented a distinct subgroup of patients with posterior scleritis that differed from the adult variant by gender, lack of systemic disease, and absence of the associated ocular findings often seen in the adult variant of the disorder. The four patients had diminished visual acuity, ocular pain, and exudative retinal detachments at initial examination. Fluorescein angiography demonstrated multiple pinpoint leaks at the level of the retinal pigment epithelium in three patients with late-phase patchy staining of a mass-like lesion in one patient. B-scan ultrasonography demonstrated choroidal and scleral thickening with increased acoustic density of the choroid in all patients. Systemic evaluation of these patients disclosed no underlying disease. Clinical signs and symptoms resolved in three of the patients after treatment with low-dose, orally administered corticosteroid or noncorticosteroid anti-inflammatory medication. High systemic doses of corticosteroid in combination with noncorticosteroid anti-inflammatory medication and local corticosteroid therapy was required to induce remission in one patient. All patients recovered good visual acuity.

Evidence that a Single Polypeptide Catalyses the Two Step Conversion of Orotate to UMP in Cells from a Tomato Suspension Culture.

A single polypeptide catalysing the two step conversion of orotate to UMP in cultured tomato cells was purified to near homogeneity as judged by analytical disc gel electrophoresis. After electrophoresis of the dodecyl sulphate denaturated enzyme one single protein band appeared from which both enzyme activities could be renaturated by addition of Triton X-100. As introduced by McClard et al. (Biochemistry 19, 4699-4706, 1980) for the mammalian system, this plant enzyme should be termed UMP synthase, consequently. The enzyme consists of a single polypeptide chain of a molecular weight of about 51,000. Molecular weight determination by gel filtration under non-denaturating conditions gave a value of about 100,000, suggesting dimer formation in vivo. The enzyme contains thiol groups essential for enzyme activity. Kinetic characteristics of the orotate phosphoribosyltransferase activity are: pH optimum 8.0, Km values for orotate and PRPP of 4.5 and 5.4µM, respectively. Orotidine-5'-phosphate decarboxylase activity is optimal between pH 7.2 and 8.5, the Km value for orotidine-5'-phosphate 2 µM.

Comprehensive care and the sanatoria: Cuba's response to HIV/AIDS.

The authors present an overview of Cuba's response to HIV/AIDS including: (a) the development of comprehensive health care in Cuba; (b) the epidemiology of AIDS in Cuba; (c) the sanatoria approach to treatment and recent changes; (d) the idea of comprehensive HIV/AIDS care as a basic human right; (e) the effects of the special period on the HIV/AIDS program and containment of the epidemic; and (f) a critique of Cuba's HIV/AIDS program.

The politics of school-based programs which address sexual orientation.

This study examined both the content of school district programs related to sexual orientation, and the social and political determinants of these school programs. Data were collected from districts within all 126 U.S. communities with legal protection against discrimination on the basis of sexual orientation, and from a random sample of 129 U.S. jurisdictions without such legislation. Results showed that most school districts are not offering recommended program elements related to sexual orientation issues. Districts within localities with gay rights protection are doing more than those without. Although compositional factors account for some of the differences in educational efforts, a politically engaged constituency also made a major difference in school district efforts. To the extent that gays and lesbians served in local public office and mobilized to influence school elections, they were able to affect school programs and policies.

Politics and the success of school-based health centers.

School-based health centers (SBHCs) provide access to health services by bringing providers to children (and sometimes parents) and furnishing low cost services in an atmosphere of trust. While the number of SBHCs has continued to grow and some clinics have continued to expand their services, others have barely survived and some have even closed. This study investigated factors, particularly political forces, that affected the success of SBHCs. Using a national survey of clinic directors, this study assessed clinic success in terms both of longevity and service delivery. Findings indicate the factors most consistently and significantly associated with success include not only measures of "need" (school size and percent African-American enrollment or population) but of "politics" (citizen political ideology and Southern conservatism). Thus, politics matters more than previous studies suggested.

Human immunodeficiency virus in Cuba: the public health response of a Third World country.

This article describes Cuba's effort to develop a comprehensive program for control of its human immunodeficiency virus (HIV) epidemic. The program consists of multiple interventions, including blood donor screening, a ban on imported blood and blood products, widespread semicompulsory screening of defined and general populations, research and clinical trials on treatment and diagnostic methods, and health education in the press, radio, television, workplace, and schools. The most controversial of the program's measures has been the treatment of HIV antibody-positive persons (both asymptomatic and clinically ill) through what Cubans term a "sanatorial regimen," consisting of admission into an institutional setting where both preventive and curative treatment is offered, and where residents have limited contact with their families, neighborhoods, friends, and the rest of society. The Cuban HIV control program merits studying because of the comprehensiveness of the measures in a poor country; the special experience of screening large, mostly healthy populations; its potential contribution to understanding the natural history of the disease due to the early identification and follow-up of HIV antibody-positive individuals; and the cultural, political, and socioeconomic conditions that give rise to a different epidemiologic profile of the disease and to an apparent societal consensus on the controversial issue of institutional semiconfinement.

PIP: Cuba has a single, unified health system, locally administered, with professional oversight at the national level. The health care system is based upon the following operational principles, unchanged since 1961: health is the responsibility of the state and the right of the people; care must be comprehensive, integrating curative and preventive services; care must be free and accessible to all; social services, health care, and the socioeconomic development of the population are to be coordinated; and popular participation in the health system is fundamental. With the stated objective of controlling the spread of HIV and AIDS in the country, policymakers and administrators of Cuba require that HIV-seropositive individuals be committed to state-operated sanatoria. As of 1990, approximately 0.47 per 10,000 inhabitants of Cuba were infected with HIV, while the average annual incidence over the period 1986-90 is 0.102 per 10,000 population. 362 of the 497 seropositive individuals in Cuba are male, of whom 59% classify themselves as heterosexual and 41% as either bisexual or homosexual. The proportion of HIV-seropositive persons who classify themselves as bisexual or homosexual has been steadily, although slightly, increasing every year. HIV infection rates in Cuba are quite low, with Cuba not experiencing the exponential increase seen in other areas of the world, either in asymptomatic HIV infections or in AIDS cases. The authors reviewed available literature and conducted extensive interviews in Cuba on HIV/AIDS control in the Cuban health system for varying durations over the period 1986-90, making extreme efforts to assure the accuracy of information reported. They found a program which continues to evolve and the existence and provision of factual and nonhysterical educational materials. The educational component of the Cuban HIV control program is, indeed, of high quality and imaginative, yet somewhat disconnected and uncoordinated. Almost everyone in the country has at least heard a talk or radio program or seen information on the television, and understand that HIV can infect anyone, not only gay men. Many people do, however, believe that they can enjoy risk-free sexual intercourse because of the policy to commit HIV-seropositive individuals to sanatoria. Cuban health officials, however, acknowledge that ultimately only education affecting behavior will prevent infection. The sanatoria will therefore soon be functioning as back-up ambulatory facilities for receiving care and support instead of as permanent residences. It remains to be seen whether the program in Cuba will successfully lower or stabilize the rate of HIV transmission in the country.

Primary care in Cuba: low- and high-technology developments pertinent to family medicine.

Cuba's accomplishments in primary care, while controversial, include several developments pertinent to family medicine. These accomplishments involve low-technology and organizational innovations such as neighborhood-based family medicine as the focus of primary care; regionalized systems of hospital services and professional training; innovative public health initiatives and epidemiologic surveillance; universal access to services without substantial barriers related to race, social class, gender, and age; and active programs in treatments such as "green medicine" and "thermalism." High-technology achievements include innovations in pharmacology and biotechnology, surgical procedures, and care of patients infected by the human immunodeficiency virus (HIV). Limited access to Cuban publications, impediments to presentations by Cuban health care professionals at professional meetings, and the prohibition on importing products of Cuban biotechnology to the United States inhibit a detached, scientific appraisal of Cuba's accomplishments. Cuba's isolation from the US clinical and research communities has prevented interchanges that would improve primary care services in both countries.

Modified technique of blunt cannula retrobulbar anesthesia for vitreoretinal surgery.

We prospectively evaluated a modified version of a previously reported technique of retrobulbar anesthesia for vitreoretinal surgery involving the use of a blunt 19-gauge cannula to directly infuse anesthetic into the retrobulbar space. Using this method, 60 consecutive patients undergoing scleral buckling surgery had effective anesthesia and akinesia, with no complications.

Choroidal effusions in two patients with glomerulonephritis.

Two patients with renal disease and choroidal effusions are presented. The renal disease was mediated by humoral immunologic mechanisms as demonstrated by immunofluorescent studies of renal biopsies. Experimental and clinical studies provided evidence of simultaneous immune-complex deposition in both the renal glomerulus and the uvea of the eye. Immune-mediated vascular damage may result in glomerulonephritis and choroidal effusions.

Adverse occurrences in intensive care units.

Analysis of 145 reports of adverse occurrences involving patients in a medical-surgical intensive care unite (ICU), during the yearts 1974 through 1978, disclosed 92 instances of human error and 53 cases of equipment malfunction. A peak occurrence of reported incidents was found between midnight and 1 AM. Harm occurred more frequently if the patient was unattended (72%) than attended (49%) during the incident. Mortality for patients with an incident report filed during their ICU admission (41%) was higher than for all ICU patients (21%). The importance of a well-structured incident-reporting program to minimize problems of human error and device malfunction is stressed.

Protracted posttraumatic optic disc swelling.

BACKGROUND: Optic disc swelling is a rare sequela of blunt ocular trauma. METHODS: The authors examined three young patients who had an unusual post-traumatic optic neuropathy in which protracted swelling of the optic nerve head was the salient clinical feature. RESULTS: Associated choroidal ruptures in two patients suggested a contrecoup mechanism of injury to the optic nerve at its junction with the globe. All patients had partial recovery of vision over months, concurrent with resolution of the nerve head swelling and development of optic disc pallor. CONCLUSION: Despite its protracted course, posttraumatic optic disc swelling appears to be associated with a favorable prognosis for visual recovery.

Hemodilution therapy in central retinal vein occlusion. One-year results of a prospective randomized study.

Systemic hemorheologic abnormalities may play a part in the pathogenesis of central retinal vein occlusions. A statistically significant elevation of plasma viscosity was found in patients with acute central retinal vein occlusion compared with control patients. Local retinal blood flow parameters including arteriovenous passage time and mean arterial dye bolus velocity were significantly altered in the central retinal vein occlusion patients compared with age-matched controls at baseline examination. We performed a randomized, prospective, single-blind clinical investigation to determine the effect of hemorheological manipulation on the clinical course and retinal blood flow of eyes with central vein occlusion. Hemodilution included plasma expansion with hydroxyethyl-starch, withdrawal of whole blood if the hematocrit was above 42%, and rheologic manipulation with parenteral pentoxifylline. We found a statistically significant improvement in visual acuity at 1 year post-treatment for the treated group compared with the control group (increase of visual acuity of 1.5 lines vs decrease of 1.5 lines). The retinal blood flow parameters were markedly improved soon after the institution of therapy, and this may have contributed to the improvement in visual acuity in the treated group. There was no statistically significant difference between the two groups in the progression to ischemic central vein occlusion.