Time management in radiation oncology: evaluation of time, attendance of medical staff, and resources during radiotherapy for prostate cancer: the DEGRO-QUIRO trial.

PURPOSE: In order to evaluate resource requirements, the German Society of Radiation Oncology (DEGRO) recorded the times needed for core procedures in the radio-oncological treatment of various cancer types within the scope of its QUIRO trial. The present study investigated the personnel and infrastructural resources required in radiotherapy of prostate cancer. METHODS: The investigation was carried out in the setting of definitive radiotherapy of prostate cancer patients between July and October 2008 at two radiotherapy centers, both with well-trained staff and modern technical facilities at their disposal. Personnel attendance times and room occupancy times required for core procedures (modules) were each measured prospectively by two independently trained observers using time measurements differentiated on the basis of professional group (physician, physicist, and technician), 3D conformal (3D-cRT), and intensity-modulated radiotherapy (IMRT). RESULTS: Total time requirements of 983 min for 3D-cRT and 1485 min for step-and-shoot IMRT were measured for the technician (in terms of professional group) in all modules recorded and over the entire course of radiotherapy for prostate cancer (72-76 Gy). Times needed for the medical specialist/physician were 255 min (3D-cRT) and 271 min (IMRT), times of the physicist were 181 min (3D-cRT) and 213 min (IMRT). The difference in time was significant, although variations in time spans occurred primarily as a result of various problems during patient treatment. CONCLUSION: This investigation has permitted, for the first time, a realistic estimation of average personnel and infrastructural requirements for core procedures in quality-assured definitive radiotherapy of prostate cancer. The increased time needed for IMRT applies to the step-and-shoot procedure with verification measurements for each irradiation planning.

[Biotechnological therapies for the treatment of back pain: alternatives to corticosteroids]. / Biotechnologische Konzepte zur Behandlung von Rückenschmerzen : Erste Erfahrungen mit Alternativen zu Glukokortikoiden.

In recent years, it is increasingly clear that back pain is not only caused by biomechanical problems. Currently, biologically-based local therapy concepts for the treatment of affected spinal regions as an alternative to the standard treatment with steroids are in development or in early stages of clinical application. The common features of these new therapies are to intervene in the regulation of homeostasis at various key points at the affected region and specifically to suppress or block catabolic influences as well as to provide with anti-inflammatory substances and growth factors. These include on one hand the genetically produced Biologicals such as TNF-α inhibitors and cytokine antagonists and on the other hand therapies with autologous blood preparations (Autologous Conditioned Serum [ACS], and Platelet Rich Plasma formulations [PRP]). This article presents the individual methods, gives an overview of developments and results of various studies and discusses current recommendations.

Time management in radiation oncology: development and evaluation of a modular system based on the example of rectal cancer treatment. The DEGRO-QUIRO trial.

PURPOSE: The goal was to develop and evaluate a modular system for measurement of the work times required by the various professional groups involved in radiation oncology before, during, and after serial radiation treatment (long-term irradiation with 25-28 fractions of 1.8 Gy) based on the example of rectal cancer treatment. MATERIALS AND METHODS: A panel of experts divided the work associated with providing radiation oncology treatment into modules (from the preparation of radiotherapy, RT planning and administration to the final examination and follow-up). The time required for completion of each module was measured by independent observers at four centers (Rostock, Bamberg, Düsseldorf, and Offenbach, Germany). RESULTS: A total of 1,769 data sets were collected from 63 patients with 10-489 data sets per module. Some modules (informed consent procedure, routine treatments, CT planning) exhibited little deviation between centers, whereas others (especially medical and physical irradiation planning) exhibited a wide range of variation (e.g., 1 h 49 min to 6 h 56 min for physical irradiation planning). The mean work time per patient was 12 h 11 min for technicians, 2 h 59 min for physicists, and 7 h 6 min for physicians. CONCLUSION: The modular system of time measurement proved to be reliable and produced comparable data at the different centers. Therefore, the German Society of Radiation Oncology (DEGRO) decided that it can be extended to other types of cancer (head and neck, prostate, and breast cancer) with appropriate modifications.

In vitro potency tests: challenges encountered during method development.

Vaccines play a key role in the control of viral diseases both in humans and in animals. In order to ensure the quality and consistency of vaccines they are extensively tested, including potency control of individual batches. In the case of vaccines against rabies the most widely used test for batch potency control is the National Institutes of Health (NIH) test. The NIH test is performed in mice leading to the consumption of thousands of animals every year. Protection against rabies after vaccination is associated with neutralizing antibodies directed against the viral glycoprotein (G). Therefore the amount of G-protein in vaccine preparations is an important parameter with regard to potency. Additionally the structural integrity of virus particles in vaccine preparations may be crucial for their immunogenicity. The objective of our work is the development of in vitro methods to determine the potency of vaccines against rabies. The result of this ongoing project shall be an assay panel including measurement of the antigenic content as well as parameters of antigen quality in a vaccine preparation allowing a precise prediction of the potency of rabies vaccines without using animal experiments.

Identification of a structural glycoprotein of an RNA virus as a ribonuclease.

One of the three structural glycoproteins of classical swine fever virus (CSFV) is E0, a disulfide-bonded homodimer that induces virus-neutralizing antibodies and occurs in a virion-bound as well as a secreted form. E0 was shown to be similar to a family of fungal and plant ribonucleases. Purified E0 from CSFV-infected cells was a potent ribonuclease specific for uridine and inhibitable by zinc ions.

Factors influencing the antibody response to vaccination against rabies.

Preventive vaccination against rabies virus is a highly effective method for preventing rabies in humans and animals. For travel purposes, vaccination of domestic carnivores is obligatory. In addition, some countries require testing for neutralizing antibodies against rabies. The minimal threshold level accepted by WHO/OIE is 0.5 IU/ml. Despite proper vaccination some animals do not reach the threshold. The objective of this study was to identify specific risk factors in dogs and cats for post-vaccination rabies antibody titres below 0.5 IU/ml by FAVN test. Rabies vaccination protocols and recommendations were reviewed with regard to travel regulations. Comprehensive data was collected on animals tested for rabies antibodies via a questionnaire sent to veterinarians who submitted sera for rabies titration. The questionnaire included data on species, age, sex, breed, vaccine used, date of last vaccination and blood sampling, vaccination history and further medical treatments at time of vaccination. Data on around 1,200 animals was analysed. Most animals older than one year had already received more than one rabies vaccination. The influence of breed and sex on antibody titre seems to be insignificant. Young dogs have a high risk of results below 0.5 IU/ml after their first vaccination. This risk can be minimised by the application of a second vaccination and blood sampling according to the manufacturer's recommendations. An important factor for the test outcome might be the virus strain used in the vaccine.

[Tick-borne encephalitis (TBE) with special emphasis on infection in horses]. / Die tick-borne Enzephalitis (TBE) unter besonderer Berücksichtigung der Infektion beim Pferd.

The tick-borne encephalitis (TBE), also known as early summer meningo-encephalitis, is a geographically limited virus infection transmitted mainly by ticks. The importance of TBE is largely underestimated. The causative agent TBE-Virus (TBEV) is grouped into the genus Flavivirus of the virus family Flaviviridae. Clinical disease including fatal outcomes has been described for men and dogs. With regard to horses only a limited number of case reports is available. In a study performed at the Institute of Virology, Justus-Liebig-University Giessen serum samples from the German endemic region of Marburg-Biedenkopf were tested for antibodies against TBEV. From 240 sera tested 7 (2.9%) were regarded as positive in a serum neutralization test (SNT). In an ELISA, performed in parallel to confirm the SNT results, 5 out of 7 positive sera from the SNT were also positive. The remaining two samples with low SNT-titres and all sera from horses negative in the SNT were also negative in the ELISA. This article is focussed on TBE of horses. In this context different aspects of TBE are included such as properties of the causative agent, interactions between causative agent, host animals and environment, spread of TBEV, pathogenesis, clinical symptoms, diagnosis and control.

Feline Coronaviruses: Pathogenesis of Feline Infectious Peritonitis.

Feline infectious peritonitis (FIP) belongs to the few animal virus diseases in which, in the course of a generally harmless persistent infection, a virus acquires a small number of mutations that fundamentally change its pathogenicity, invariably resulting in a fatal outcome. The causative agent of this deadly disease, feline infectious peritonitis virus (FIPV), arises from feline enteric coronavirus (FECV). The review summarizes our current knowledge of the genome and proteome of feline coronaviruses (FCoVs), focusing on the viral surface (spike) protein S and the five accessory proteins. We also review the current classification of FCoVs into distinct serotypes and biotypes, cellular receptors of FCoVs and their presumed role in viral virulence, and discuss other aspects of FIPV-induced pathogenesis. Our current knowledge of genetic differences between FECVs and FIPVs has been mainly based on comparative sequence analyses that revealed "discriminatory" mutations that are present in FIPVs but not in FECVs. Most of these mutations result in amino acid substitutions in the S protein and these may have a critical role in the switch from FECV to FIPV. In most cases, the precise roles of these mutations in the molecular pathogenesis of FIP have not been tested experimentally in the natural host, mainly due to the lack of suitable experimental tools including genetically engineered virus mutants. We discuss the recent progress in the development of FCoV reverse genetics systems suitable to generate recombinant field viruses containing appropriate mutations for in vivo studies.

Simultaneous radiochemotherapy versus radiotherapy alone in advanced head and neck cancer: a randomized multicenter study.

PURPOSE: A prospective randomized multicenter trial was performed to evaluate the contribution of simultaneously administered chemotherapy (CT) and radiotherapy (RT) in previously untreated patients with unresectable stage III/IV head and neck cancer. PATIENTS AND METHODS: Patients with locoregionally advanced head and neck cancer were treated either with RT alone (arm A) or simultaneous RT plus CT (RCT; arm B). RT was identical in both arms and administered in three courses with 13 fractions of 1.8 Gy each twice daily. During one course, from day 3 to 11, 23.4 Gy was delivered. In arm B, cisplatin (CDDP) 60 mg/m2, fluorouracil (5-FU) 350 mg/m2 by intravenous (i.v.) bolus, and leucovorin (LV) 50 mg/m2 by i.v. bolus were given on day 2, and 5-FU 350 mg/m2/24 hour by continuous infusion and LV 100 mg/m2/24 hours by continuous infusion were given from day 2 to 5. Treatment was repeated on days 22 and 44; a total RT dose of 70.2 Gy was administered. Treatment breaks were scheduled from days 12 to 21 and days 34 to 43. RESULTS: From 1989 to 1993, 298 patients were enrolled and 270 patients were assessable. Acute mucositis grade 3 or 4 was more frequent in arm B (38%) than in arm A (16%) (P < .001). Total treatment time was significantly longer in arm B than in arm A (P < .001) due to prolonged breaks. According to hematologic toxicity, scheduled drug doses were given in 74% of patients for the second course and 46% for the third course. The 3-year overall survival rate was 24% in arm A and 48% in arm B (P < .0003). The 3-year locoregional control rate was 17% in arm A and 36% in arm B (P < .004). Both arms showed similar distant failure patterns (arm A, 13 of 140; arm B, 12 of 130). Serious late side effects were not significantly different between treatment arms (arm A, 6.4%; arm B, 10%; not significant). CONCLUSION: Concomitant CT offered improved disease control and survival in advanced head and neck cancer patients. Due to increased acute toxicity, more supportive care is demanded when CT is given simultaneously. Increased total treatment time does not exert a negative impact on outcome in this combined modality regimen.

Color vision tests for early detection of antiepileptic drug toxicity.

A previous suggestion that antiepileptic drugs may induce color vision deficiencies prompted us to examine whether color vision deficiencies may occur at lower drug serum concentrations than those associated with symptoms of neurotoxicity. Eighty patients presenting with epilepsy received monotherapies of valproic acid, phenytoin, or carbamazepine; 18 patients did not receive antiepileptic drug therapy. Color vision was tested by the Farnsworth-Munsell 100-hue test, spectral sensitivity, and the newly developed tritan screening plates. Patients treated with phenytoin or carbamazepine developed blue-yellow color vision deficiencies. In contrast, patients exposed to valproic acid or receiving no drug treatment showed normal color vision. There was a significant correlation (p < 0.0001) between signs of neurotoxicity induced by phenytoin or carbamazepine and blue-yellow color vision deficiencies. In contrast, we found no correlation between these signs of neurotoxicity and the drug serum concentrations (p = 0.0637). Color vision testing in epileptic patients treated with phenytoin or carbamazepine appears to be a sensitive method for early detection and monitoring of clinical neurotoxicity.

Preliminary results of treatment of invasive bladder carcinoma with radiotherapy and cisplatin.

From October 1985 to February 1988, 41 patients with invasive bladder cancers were treated with transurethral resection (TUR) and radiotherapy with simultaneous cisplatin chemotherapy at the University Hospital in Erlangen. Radiotherapy was performed as primary treatment in case of macroscopic residual tumor after TUR (n = 22) or as adjuvant treatment in patients with macroscopically complete transurethral resection (n = 19). Age ranged from 44 to 77 years. Radiotherapy was given in daily fractions of 1.8 Gy. The pelvis was treated with a box up to 41.4 Gy and the bladder was boosted up to 50.4 Gy by a rotation technique. Cisplatin was administered in the first and fifth treatment week on five consecutive days with 25 mg cisplatin/m2 per day as short infusion. Pathohistologic response was examined by control cystoscopy with biopsies from the deep layers 6 weeks after completing radiochemotherapy. Maximum follow-up is 24 months after control cystoscopy. After TUR plus radiochemotherapy, histologically confirmed complete remission rates according to T-stage were: 7/8 T1-, 26/31 T2-3-, and 2/2 T4-tumors. In patients with macroscopic tumor prior to radiochemotherapy, histological and cytological complete remission was achieved in 2/3 T1-, 14/18 T2-3-, and 1/1 T4-cancers with an overall complete response rate of 77%. In complete responders, 3 isolated local recurrences (2 T1- and one T3-recurrence) and two local recurrences with distant metastases have occurred until now. Six patients had only partial response. Mild to moderate side effects occurred frequently, but overall treatment tolerance was good even in older patients. Complications did not occur. So far, 7 cystectomies have been performed, 6 were a result of persistent or recurrent tumor and one a result of a contracted bladder after multiple TURs. Thirty-four of forty-one patients (83%!) maintained their bladder and normal bladder function. In conclusion, moderate dose radiation therapy (50 Gy) in combination with simultaneous cisplatin chemotherapy is a well-tolerated treatment and highly effective for controlling local disease and preservation of bladder function in invasive bladder cancers.

Radiotherapy in stage IIA and IIB testicular seminoma with reduced portals: a prospective multicenter study.

PURPOSE: A prospective multicenter study was carried out to estimate the treatment outcome of radiotherapy in Stage II seminoma after the application of modern staging and radiotherapy techniques. The lower margin of the iliac field was positioned on the upper rim of the acetabulum to reduce the amount of scattered irradiation to the remaining testicle. METHODS AND MATERIALS: The study was carried out in 25 centers in Germany. Patients with pure seminoma, negative AFP-values, and retroperitoneal lymph node metastases of less than 5 cm in diameter were entered into the study. All patients received a ventrodorsal opposed field irradiation of the para-aortic and the ipsilateral iliac lymph nodes. The fields extended from the top of the 11th thoracic vertebra to the top of the acetabulum. Patients in Stage IIA (lymph nodes <2 cm ) received 30 Gy, and patients with Stage IIB (lymph nodes between 2 and 5 cm) 36 Gy total dose. RESULTS: 39 patients in Stage IIA and 19 patients in Stage IIB were evaluated. After a median observation time of 37 months all patients are alive and disease free. Recurrence free survival in stage IIA was 100%. Two patients in Stage IIB experienced a recurrence 10 and 17 months after the end of radiotherapy. The actuarial recurrence free survival estimate in Stage IIB was 94.1% for 1 year and 87.4% for 2 years. One recurrence in Stage IIB occurred in the mediastinum, one in the mediastinum, and one the lung. Both patients could be salvaged by chemotherapy. There were no pelvic recurrences. The treatment was well tolerated, with nausea being the most common side effect (56.9% Grade 1, 15.5% Grade 2, and 8.6% Grade 3). Diarrhea occurred in 15.5% (Grade 1), 15.5% (Grade 2), and 5.2% (Grade 3) of the patients. CONCLUSIONS: The outcome of para-aortic and ipsilateral iliac irradiation in Stage IIA/B testicular seminoma is excellent with the currently available staging methods and treatment facilities. The treatment is well tolerated. The lower margin of the iliacal field can be placed at the acetabulum.

In vivo study of leukocyte-endothelium interaction in endotoxin-induced uveitis.

PURPOSE: To analyze leukocyte-endothelium interaction in iris venules of living rats and to quantify changes of leukocyte dynamics in endotoxin-induced uveitis (EIU). METHODS: Lewis rats received an intraperitoneal injection of 100 micrograms of lipopolysaccharide (LPS; Salmonella typhimurium). Using intravital fluorescence microscopy, the iris vessels were examined, 2, 4, 6, 10, 14, 24, and 72 hours after LPS injection. A setup for intravital fluorescence microscopy of iris venules in the rat is described. Images are recorded with a video camera and stored on S-VHS videotape for off-line analysis. For contrast enhancement, erythrocytes and plasma were stained with fluorescein isothiocyanate (FITC) and FITC-hydroxyethylstarch, respectively. Rhodamine 6G was used for intravital staining of leukocytes. Resolution and magnification (x850) of the system facilitates observation of individual cells in the bloodstream in real time. Leukocytes were either flowing in the center stream, rolling along the endothelium, or firmly adherent. Image analysis provided data on microvascular leukocyte flux and leukocyte velocity. RESULTS: The percentage of leukocytes rolling on postcapillary venular endothelium increased significantly (P < 0.05) 4 hours after endotoxin administration, as did the number of firmly adherent cells. Leukocyte-endothelium interaction reached its maximum 6 to 10 hours before an increase of inflammatory cells in the aqueous humor. The response to endotoxin was reversible, subsiding to near-normal values after 72 hours. CONCLUSIONS: Intravital fluorescence microscopy provides data on microvascular parameters, including the number of rolling and sticking leukocytes on vascular endothelium. Inflammation of the anterior uvea was characterized with regard to leukocyte recruitment from blood to the vessel wall.

Relevance of host-derived and bacterial factors in Pseudomonas aeruginosa corneal infections.

Two pathogenic mechanisms of Pseudomonas aeruginosa corneal infections are discussed, one involving bacterial exoenzymes, the other involving polymorphonuclear leukocyte (PMN)-derived lysosomal enzymes. The objective of the present study was (1) to show the relative importance of the two mechanisms and (2) to evaluate the effect of active immunization against P. aeruginosa exoenzymes on ocular damage. Rabbits were immunized against P. aeruginosa alkaline protease (AP) or elastase (Ela) and challenged with the respective enzymes. Corneal damage was studied by light photography (LP). In another group, rabbits were immunized against AP, Ela and exotoxin A (ExoA) and challenged with P. aeruginosa strains PA01 or PA103. Corneal damage was studied with LP, light microscopy, and electron microscopy. Immunized animals were totally protected against intracorneal inoculation of P. aeruginosa proteases. Twelve hr and 24 hr after challenge with whole bacteria, immunized rabbits revealed less corneal damage than non-immunized animals. However, after 48 hr corneal damage (ie severe corneal ulceration) was comparable in both groups. The study suggests that corneal damage involving lysosomal enzymes from stimulated PMN is more important after bacterial infection than direct damage by P. aeruginosa exoenzymes.

Effect of topically applied anti-CD4 monoclonal antibodies on orthotopic corneal allografts in a rat model.

PURPOSE: Monoclonal antibodies (mAb) have generated interest as therapeutic agents. Limited data are available on the treatment of corneal graft rejection. The purpose of this study was to assess the use of topically applied mAb on experimental corneal grafts. METHODS: W 3/25, an IgG 1 mouse antirat mAb that recognizes a CD4+ cell subset, was used to treat Lewis recipient rats that received orthotopic corneal grafts of Wistar-Furth donors. Recipients were randomly assigned to receive topically applied drops of liposome-incorporated anti-CD4 mAb (LIP-anti-CD4 mAb), an equivalent amount of free anti-CD4 mAb, an isotype-matched control mAb encapsulated in liposomes (LIP-control mAb), or empty liposomes (emp-LIP) 5 times daily for 10 days. To investigate the immunologic effect of mAb treatment, flow cytometry of the targeted cells and cytotoxic activity of lymphocytes were analyzed. RESULTS: Application of LIP-anti-CD4 mAb was effective in reducing the rejection rate (P < .05) and in prolonging the mean survival time of corneal grafts that underwent rejection (P < .05). In contrast, no significant effect on graft outcome was observed after the application of control agents. Flow cytometry analysis did not reveal systemic depletion of the targeted lymphocyte subset in any anti-CD4 mAb treated animals. Rejected grafts elicited a cellular cytotoxic immune response in a cell-mediated lymphocytotoxic assay independent of the treatment given. CONCLUSION: The results suggest that treatment with topically applied LIP-anti-CD4 mAb prolongs graft survival in orthotopic corneal grafts in a rat model. The beneficial effect of LIP-anti-CD4 mAb, probably due to enhanced intraocular delivery, was achieved by using relatively low doses of mAb.

Ocular involvement in epidermolysis bullosa acquisita.

A 23-year-old man had epidermolysis bullosa acquisita that was diagnosed at the age of 20 years. The eye examination showed bilateral, small subepithelial vesicles in the cornea. The direct immunofluorescence microscopic examination of the conjunctiva revealed homogeneous, linear IgG and fibrinogen deposits in the basement membrane area. The same pattern appeared in the skin biopsy specimen. No systemic disease common to epidermolysis bullosa acquisita was found in the patient.

Molecular characterization of hog cholera virus.

An efficient tissue culture system was established which allowed to obtain substantial quantities of hog cholera virus (HCV) from the cell free tissue culture supernatant. After preparation of viral RNA and cDNA synthesis, the complete HCV genome was cloned and sequenced. Comparison with published BVDV sequences revealed a surprisingly high homology between HCV and BVDV at both the nucleotide and the amino acid level. In addition host cellular sequences were identified in BVDV genomes. The genomic localization of HCV glycoproteins was determined by the use of sequence specific antisera directed against bacterial fusion proteins. The order on the HCV genome was determined as follows: N-gp44/48-gp33-gp55-C. HCV gp33 and HCV gp55 were shown to be intracellularly linked by disulfide bridges. A cDNA fragment covering the genomic region that encodes the structural proteins of HCV was inserted into a vaccinia recombination vector. Expression studies with vaccinia/HCV recombinants led to identification of HCV specific glycoproteins which migrated on sodium dodecyl sulfate-gels identically to glycoproteins precipitated from HCV-infected cells. The vaccinia virus/HCV recombinant that expressed all four structural proteins induced virus-neutralizing antibodies in mice and swine. After immunization of pigs with this recombinant virus, full protection against a lethal challenge with HCV was achieved. A construct that lacked most of the HCV gp55 gene failed to induce neutralizing antibodies but induced protective immunity.

Molecular characterization of positive-strand RNA viruses: pestiviruses and the porcine reproductive and respiratory syndrome virus (PRRSV).

Molecular characterization has become an important tool for the analysis of viruses including their classification. The manuscript focuses on the molecular analysis of two members of the genus pestivirus (hog cholera virus, HCV and bovine viral diarrhea virus, BVDV) and of the recently discovered porcine reproductive and respiratory syndrome virus (PRRSV). The first protein encoded within the single large pestivirus ORF is a nonstructural protein with autoproteolytic activity. The cleavage site between the protease and the capsid protein p14 has been predicted previously, but recent experimental data indicate that processing occurs at a different site. The capsid protein is followed by a putative internal signal sequence and three glycoproteins which are part of the virion envelope. According to a new proposal for the nomenclature of the structural proteins of pestiviruses they are termed C, E0, E1 and E2. The genomes of BVDV pairs isolated from animals which came down with mucosal disease were analyzed. The genomes from cytopathogenic (cp) BVD viruses may contain insertions highly homologous to cellular sequences. In addition, cp BVDV may differ from its non cytopathogenic (noncp) counterpart by mere rearrangement of viral sequences. The disease PRRS, which emerged a few years ago, is caused by a single strand RNA virus; the viral genome is of positive polarity and has a size of 15 kb. Data concerning morphology, morphogenesis and virion composition suggested already that PRRSV belongs to a group of so-called arteriviruses which comprises equine arteritis virus (EAV), lactate dehydrogenase elevating virus (LDV) and simian hemorrhagic fever virus (SHFV). This conclusion has now been confirmed by analysis of genome organization, gene expression strategy and by comparison of deduced protein sequences.

Insertion of cellular sequences in the genome of bovine viral diarrhea virus.

The genomic sequences of four pestiviruses, two BVDV strains (Osloss and NADL, both of which are cytopathogenic) and two HCV strains, were analyzed. Comparative studies revealed the presence of small insertions of cellular sequences in the genomes of both BVDV strains; the insertions are located in a region coding for a nonstructural protein. Such insertions are not present in the HCV sequences. The insertion identified in BVDV Osloss encodes a complete ubiquitin-like element. The sequence inserted in the BVDV NADL genome shows no homology to a ubiquitin gene but is almost identical with another bovine mRNA sequence. Molecular characterization of a BVDV "pair", isolated from an animal with mucosal disease, led to the detection of a ubiquitin-like sequence in the genome of the cytopathogenic strain, but not of the noncytopathogenic strain. It is proposed that recombination between viral and cellular RNA leads to formation of cpBVDV genomes. This hypothesis has direct implications for the pathogenesis of mucosal disease.

Cataract surgery at the end of the 19th century at Tübingen.

Cataract extraction with a Graefe knife incision was the most important development in cataract surgery during the 19th century. To determine the indications, visual outcome, complications, and problems of cataract surgery performed a century ago, we reviewed patient records from the year 1895. With use of Graefe's technique of cataract extraction, the early postoperative visual acuity was 20/200 or better in 63% and 20/40 or better in 5%. A secondary cataract developed in about 30% of eyes. A flat anterior chamber persisted for more than two days in about 20% of eyes. Astigmatism was not regularly measured, but was markedly increased after surgery. Surgery for secondary cataract was performed in only 20 eyes. There was a complication rate of nearly 50% in secondary cataracts. These results demonstrate some of the major problems of cataract surgery 100 years ago: secondary cataract, insufficient wound closure, high astigmatism, and aphakia as a refractive problem.