Termination of pregnancy: attitudes and behavior of women in a traditional society.

OBJECTIVES: The Bedouin Arabs, a Muslim traditional ethnic minority in Israel, are faced with difficult choices when offered prenatal diagnosis as part of the universally provided prenatal care in Israel. This paper is to examine attitudes towards and practice of pregnancy termination, following an unfavorable prenatal diagnosis. METHODS: Semistructured interviews with 83 women were conducted to study attitudes. Data from the Soroka Medical Center, where all births in the area take place, were used to assess the rate of terminations of pregnancies following a diagnosis of a chromosomal anomaly. RESULTS: While divided on the question of termination, many women believed that a second medical opinion is needed, preferably from an Arab physician. The reasons for termination are both child- and mother-related. Opposing termination is based on both the suspicion that the diagnosis might be wrong and on religious reasons. Between 1995 and 1999, 686 Bedouin women had undergone amniocentesis (2.4% of all pregnancies). Six of 11 pregnancies with the diagnosis of a trisomy were terminated (54.5%). All cases in which a trisomy was terminated were trisomy 21. CONCLUSIONS: Culturally acceptable prenatal diagnostic services for Muslim populations should be based on early testing, and should involve Muslim physicians and religious authorities.

Mathematical models of cognitive recovery.

Longitudinal psychological test results are used as dependent variables to explore the complex relationship between length of coma, time of testing on the recovery curve, and corresponding cognitive status after traumatic brain injury (TBI). A database containing 319 TBI patients with a broad spectrum of coma duration was used. Statistical analysis of mixed effects modelling was applied to longitudinal WAIS-R (Wechsler Adult Intelligence Scale-Revised) scores to construct two mathematical models (verbal IQ and performance IQ). The models predict the course of recovery (initial cognitive level post-coma, eventual recovery level, and level of cognitive functioning at any point on the recovery curve) when the duration of coma is known. Performance IQ was found to recover at a rate that is almost four times slower than verbal IQ. The results have important clinical rehabilitation implications. This statistical modelling technique also enables the medical researcher to investigate disease progression or recovery using structured assessments, which would normally be part of the routine medical monitoring.

Topical transfection using plasmid DNA in a water-in-oil nanoemulsion.

Expression plasmids encoding chloramphenicol acetyltransferase (CAT) or human interferon-alpha2 cDNA were formulated in water-in-oil nanoemulsions and applied to murine skin. The histological location of transfected cells was assessed by in situ DNA PCR and showed that the deposition of plasmid DNA was primarily in follicular keratinocytes. Transgene expression in the skin was monitored for 24-72 h, following topical application of either single or multiple daily doses by quantitative RT-PCR and ELISA. It was found that transgene expression was optimal at 24 h following topical application of a single dose of water-in-oil nanoemulsion containing plasmid DNA. Dose-response studies using a total dose of 3, 10 or 30 microg of plasmid DNA suggested that topical transfection using nanoemulsions is subject to both threshold and saturation effects. None of the cationic liposome formulations tested as controls mediated transgenic protein expression at levels higher than background values of the ELISAs used to assay transgenic protein. Single and multiple dose experiments using human interferon-alpha2 as a transgene indicated that the efficiency of nanoemulsion mediated transfection was most effective in the context of normal versus atrophic hair follicles. In addition, the total amount of human interferon-alpha2 present in skin appeared to accumulate as a consequence of multiple dosing. Histologic evaluation of treated skin showed no overt signs of toxicity or irritation associated with the short-term application of the nanoemulsions. The results suggest that water-in-oil nanoemulsions can be used to facilitate transfection of follicular keratinocytes in vivo.

Topical transport of hydrophilic compounds using water-in-oil nanoemulsions.

A variety of water-in-oil nanoemulsions were prepared using sorbitan monooleate (Span80), polyoxyethylene 20 sorbitan monooleate (Tween80), olive oil and water. The nanoemulsions were tested for their ability to facilitate transport of a model hydrophilic solute, inulin, across hairless and hairy mouse skin and hairy rat skin following topical in vitro application. The transport of inulin incorporated in water-in-oil nanoemulsions was found to be significantly higher (5- to 15-fold) than that obtained with micellar dispersions or aqueous controls. The rate and extent of inulin transport across hairy mouse skin was found to be highly dependent on the hydrophile-lipophile balance (HLB) of the surfactant mixture in the nanoemulsion. Nanoemuslions prepared using mixtures with lower HLB exhibited significantly higher rate and extent of transport. It was also found that nanoemulsion-mediated transport was independent of molecular size of the hydrophilic solute and the nature of the aqueous phase. More importantly, transport of inulin from nanoemulsions was independent of animal skin characteristics such as stratum corneum thickness and follicle-type. The combined results suggest that water-in-oil nanoemulsions that are compatible with the lipophilic sebum environment of the hair follicle facilitate efficient transport of incorporated hydrophilic solutes and imply that such transport is predominantly transfollicular in nature.

Amplification of the MLL region in acute myeloid leukemia.

We report amplification of the MLL gene region (11q23-->11qter) in a 72-year-old woman with myelodysplastic syndrome progressing to acute myelomonocytic leukemia and in a 51-year-old man with a history of hairy cell leukemia and secondary myelodysplasia progressing to acute myelogenous leukemia. The amplicons containing MLL were shown by molecular cytogenetics to extend from chromosomal region 11q23 to the distal long arm of chromosome 11 and to be present in the first patient in five copies on a large ring chromosome and present in the second patient also in five copies on two derived chromosomes. Other karyotypic findings in the first patient included del(5q), +8, and der(21)t(17;21), resulting in the loss of a copy of 17p, whereas deletion 7q was observed in the second patient. Southern-blot analysis for the second patient was consistent with MLL amplification but did not demonstrate rearrangement of the germ-line MLL band. Amplification of MLL and the 11q23 region has been documented in only a few cases and appears to be yet another mechanism by which MLL contributes to the leukemia phenotype.

Neutrino mass anarchy

What is the form of the neutrino mass matrix which governs the oscillations of the atmospheric and solar neutrinos? Features of the data have led to a dominant viewpoint where the mass matrix has an ordered, regulated pattern, perhaps dictated by a flavor symmetry. We challenge this viewpoint and demonstrate that the data are well accounted for by a neutrino mass matrix which appears to have random entries.

Application of membrane-based dendrimer/DNA complexes for solid phase transfection in vitro and in vivo.

In this study a general description of the use of solid support membranes as the device for DNA delivery mediated by PAMAM dendrimers is presented. In contrast to the other DNA carriers, dendrimer/DNA complexes retain the ability to transfect after drying, which enabled coating or incorporation of complexes into poly(DL-lactide-co-glycolide) or collagen-based bioerodable membranes. These studies provide support for the use of this technology for in vitro and in vivo transfection of skin cells. Expression of luciferase or green fluorescent protein from pCF1-Luc and pEGFP1 plasmids indicated that dendrimer/DNA complexes can mediate transfection after dissociation from the solid support and/or when retained on the surface of the membranes. Modification of the membranes by incorporation of an anionic lipid, phosphatidyl glycerol (PG) at 1-5% concentrations, resulted in more efficient in situ transfection, particularly with dendrimer/DNA complexes formed at the low charge ratios (1-5). We also report data supporting the feasibility of membrane-based dendrimer/DNA complexes, particularly formed at lower than neutralizing conditions, for topical in vivo delivery of DNA to hairless mouse skin.

A syngeneic mouse glioma model for study of glioblastoma therapy.

Animal models of human tumors serve a vital role in the development and testing of new anticancer therapies. Since the immune system is likely to play an essential role in tumor eradication, there is a particular need for modeling human disease in immunocompetent hosts. Few models of glioma have been developed in immunocompetent mice that are commercially available and none of these tumors have histological and antigenic characteristics of human gliomas. We have used a cell line, 4C8, derived from a spontaneous glioma-like tumor that arose in a transgenic mouse to develop a new glioma model. The intracranial injection of 4C8 cells into immunocompetent syngeneic B6D2F1 mice resulted in tumors that were densely cellular, developed a pseudopallisading pattern of necrosis, and expressed GFAP; all important features of human malignant gliomas. The average neurological endpoint was 51 days after intracranial injection. The 4C8 cells also grew rapidly in the flank, retaining histologic features seen in intracranial tumors. Flank tumors reached an average volume of 100 mm3, a volume ideal for therapy testing, by 34 days postinjection. These results suggest that the 4C8 mouse glioma model is an excellent system in which to test new antiglioma therapies for use in humans.

Quantification of axonal damage in traumatic brain injury: affinity purification and characterization of cerebrospinal fluid tau proteins.

Diffuse axonal injury is a primary feature of head trauma and is one of the most frequent causes of mortality and morbidity. Diffuse axonal injury is microscopic in nature and difficult or impossible to detect with imaging techniques. The objective of the present study was to determine whether axonal injury in head trauma patients could be quantified by measuring levels of CSF tau proteins. Tau proteins are structural microtubule binding proteins primarily localized in the axonal compartment of neurons. Monoclonal antibodies recognizing the form of tau found in the CSF of head trauma patients were developed by differential CSF hybridoma screening using CSF from head trauma and control patients. Clones positive for head trauma CSF tau proteins were used to characterize this form of tau and for ELISA development. Using the developed ELISA, CSF tau levels were elevated >1,000-fold in head trauma patients (mean, 1,519 ng/ml of CSF) when compared with patients with multiple sclerosis (mean, 0.014 ng/ml of CSF; p < 0.001), normal pressure hydrocephalus (nondetectable CSF tau), neurologic controls (mean, 0.031 ng/ml of CSF; p < 0.001), or nonneurologic controls (nondetectable CSF tau; p < 0.001). In head trauma, a relationship between clinical improvement and decreased CSF tau levels was observed. These data suggest that CSF tau levels may prove a clinically useful assay for quantifying the axonal injury associated with head trauma and monitoring efficacy of neuroprotective agents. Affinity purification of CSF tau from head trauma patients indicated a uniform cleavage of approximately 18 kDa from all six tau isoforms, reducing their apparent molecular sizes to 30-50 kDa. These cleaved forms of CSF tau consisted of the interior portion of the tau sequence, including the microtubule binding domain, as judged by cyanogen bromide digestion. Consistent with these data, CSF cleaved tau bound taxol-polymerized microtubules, indicating a functionally intact microtubule binding domain. Furthermore, epitope mapping studies suggested that CSF cleaved tau proteins consist of the interior portion of the tau sequence with cleavage at both N and C terminals.

Perifollicular transgenic expression of human interleukin-1 receptor antagonist protein following topical application of novel liposome-plasmid DNA formulations in vivo.

Expression plasmid DNA for the human interleukin-1 receptor antagonist (IL-1ra) protein was formulated with nonionic:cationic (NC) liposomes or phosphatidylcholine:cationic (PC) liposomes and applied to the auricular skin of hamsters in single- and multiple-dose protocols. Confocal microscopy identified delivery of plasmid DNA proximal to perifollicular cells, and successful transfection of perifollicular cells was identified by immunohistochemistry and ELISA. Skin treated for 3 days with the NC liposomes had statistically significant levels of transgenic IL-1ra present for 5 days post-treatment. Expression of transgenic IL-1ra was specific to areas of skin treated with NC liposomes but not PC liposomes. The results indicate that the NC liposomes can deliver expression plasmid DNA to perifollicular cells and mediate transient transfection in vivo.

Dissolution media for in vitro testing of water-insoluble drugs: effect of surfactant purity and electrolyte on in vitro dissolution of carbamazepine in aqueous solutions of sodium lauryl sulfate.

The intrinsic dissolution rate and solubility of carbamazepine was measured in aqueous solutions of sodium lauryl sulfate (SLS) prepared with two different grades of purity, 95 and 99%, and 95% SLS in 0.15 M NaCl to determine the effect of surface-active impurities and electrolytes. Four significant observations resulted from this work: (1) the equilibrium coefficients calculated from the solubility experiments in the 99% SLS, 95% SLS, and 95% with 0.15 M NaCl SLS solutions were 295, 265, and 233 L/mol, respectively; (2) the dissolution rate enhancement in the 99% SLS was 10% greater than that in the 95% SLS and 95% with 0.15 M NaCl solutions, which were not significantly different; (3) the diffusion coefficients of the drug-loaded micelles estimated from the dissolution experiments were 8.4 x 10(-7) cm2/s for the 99% SLS, 9.5 x 10(-7) cm2/s for the 95% SLS, and 1.2 x 10(-6) cm2/s for the 95% with 0.15 M NaCl; and (4) the critical micelle concentrations for the 99% SLS, 95% SLS, and 95% SLS with 0.15M NaCl were 6.8, 4.2, and 0.35 mM, respectively. The results of this study clearly illustrate the sensitivity of the micelle to impurities and electrolytes with regard to size and loading capacity and the effect these changes have on the solubility and dissolution rate. Therefore, when using surfactants in dissolution media for in vitro testing of dosage forms, consideration must be given to the level of impurities present so that the results are consistent and reliable. Intrinsic dissolution rate, surface tension, or solubility measurements may be useful, convenient methods for identifying changes in the surfactant due to either degradation or lot-to-lot variability.

Evaluation of the hairless rat as a model for in vivo percutaneous absorption.

Percutaneous absorption of topically applied mannitol and progesterone was compared in vivo with the hairless and hairy rat. Urinary excretion and skin concentration profiles after topical application of mannitol demonstrated that hairless rat skin was a "leakier" barrier to percutaneous absorption of polar compounds than was hairy rat skin, independent of formulation. Liposomal, but not aqueous mannitol was retained in hairy rat skin (> 0.5% after 12 h), whereas only negligible amounts were retained in hairless rat skin, regardless of formulation. Progesterone absorption from hydroalcohol and liposomal formulations into hairless rat skin was about five times greater than that in hairy rat skin. Skin delipidization by acetone resulted in a dramatic reduction in the cutaneous barrier to systemic mannitol absorption, which was much more pronounced in hairy than in hairless rat skin. Histological findings of patulous cysts and enlarged, highly vascularized sebaceous glands in the hairless rat suggested that these structures may enhance polar pathways and provide a lipophilic reservoir relative to the fully developed hair follicles of the hairy rat. Collectively, the results document percutaneous absorption differences as a function of animal model, and also suggest that follicular structures make a major contribution to passive percutaneous absorption.

Effect of neonatal thyroid hormone alterations in CNS ethanol sensitivity in adult LS and SS mice.

LS and SS mice develop their differential sensitivity to the motor-incoordinating and hypothermic effects of ethanol at 10-16 days after birth, when thyroid hormones (T4) show a transient peak. This rise in the thyroid hormones is an important element in the normal development of monoaminergic systems and thyroid hormones reach a significantly higher level in the less ethanol-sensitive SS mice than in the more ethanol-sensitive LS mice. Previous investigation have suggested the differential ethanol response of brain monoaminergic neuronal systems in adult LS and SS mice may be related to this development difference in thyroid status. To test the hypothesis that neonatal thyroid status can influence adult CNS ethanol sensitivity. LS and SS mice were treated neonatally with the thyrotropin-releasing hormone (TRH) and propylthiouracil (PTU) to enhance or diminish, respectively, thyroid status at this critical developmental period. The subsequent effect on adult CNS ethanol sensitivity was then determined. Contrary to expectations, both PTU and TRH administration attenuated the transient rise in plasma T4 levels at postnatal days 10-16 in LS mice and in both instances this was associated with decreased CNS ethanol sensitivity (sleep time and hypothermia) in adults. In SS mice, PTU treatment attenuated the postnatal rise in T4 levels as expected, whereas TRH treatment had no significant effect. However, neither neonatal treatment altered CNS ethanol sensitivity in adult SS mice. The decrease in ethanol-induced sleep times and hypothermia of neonatally treated LS mice was associated with an attenuation of ethanol-induced decreases in in vivo tyrosine and tryptophan hydroxylase activity that was not seen in the SS mice. These findings are consistent with the notion that the response of monoaminergic neuronal systems to ethanol is an important determinant of behavioral intoxication. However, the observation that neonatal administration of both TRH and PTU blunted the postnatal rise in thyroid levels in LS mice, yet both treatments resulted in a decrease in adult ethanol sensitivity in LS mice, indicates that the relationship between postnatal thyroid development and CNS ethanol sensitivity is more complex than originally hypothesized.

Topical delivery of erythromycin from various formulations: an in vivo hairless mouse study.

Topical products containing erythromycin, a macrolide antibiotic with poor aqueous solubility, are usually formulated as high alcohol content solutions or gels. In this study, we evaluated the deposition of erythromycin base into various strata of hairless mouse skin following topical in vivo application from various low- and nonalcoholic formulations. The formulations tested included nonionic liposomal formulation composed of glyceryl dilaurate, cholesterol, and polyoxyethylene-10-stearyl either at a weight ratio of 57:15:28, two nonionic oil-in-water (o/w) liposomal emulsions containing isopropyl myristate or light mineral oil as the oil phase, a conventional o/w emulsion, a 40% hydroalcoholic solution, and two commercially available topical products. Eight hours after topical administration of these formulations, the efficiency of uptake of erythromycin into the living skin strata was in the order: liposomal isopropyl myristate emulsion > > liposomal mineral oil emulsion > > nonionic liposomes approximately Emgel approximately Theramycin-Z > > conventional emulsion > > hydroalcoholic solution. Alcohol-free liposomal systems are shown to be as efficient as high alcohol content products in facilitating permeation of erythromycin through the stratum corneum into living skin tissue.

Percutaneous absorption of biologically-active interferon-gamma in a human skin graft-nude mouse model.

PURPOSE: Topical delivery has been suggested to reduce systemic side effects while targeting cytokines for the treatment of certain skin conditions. Liposomes have been proposed as an enhancing agent for such a delivery. We have tested the potential of liposomes to augment the uptake of biologically active recombinant human interferon-gamma (rhIFN-gamma) into human skin lacking adnexa in an in vivo model. METHODS: Stable grafts of human skin on nude mice were used to test aqueous formulations of rhIFN-gamma containing or lacking liposomes composed of phosphatidylcholine and cholesterol. Transport of rhIFN-gamma was assessed by monitoring the stimulated expression of intercellular adhesion molecule-1 (ICAM-1) by keratinocytes by light-level immunomicroscopy and ELISA. RESULTS: A single application of liposomal rhIFN-gamma increased ICAM-1 levels in the epidermal basal and suprabasal cell layers of grafts. Continued application maintained this response. An aqueous formulation of rhIFN-gamma or liposomes alone applied to grafts failed to induce an ICAM-1 response. Preliminary studies suggested that at least some of the lipids applied in the liposomal formulation also entered the epidermis. CONCLUSIONS: Using a nude mouse-human skin graft model lacking adnexa, we have demonstrated that a liposomal formulation can augment the uptake of a biologically-active human cytokine, rhIFN-gamma, into the epidermis of viable human skin. The therapeutic application of topical IFN-gamma delivery remains to be evaluated.

Interactions of dopaminergic and GABAergic neurotransmission: impact of 6-hydroxydopamine lesions into the substantia nigra of rats.

We have evaluated (a) the effects of dopamine (DA) denervation on gamma-aminobutyric acid (GABA) turnover in terms of in vivo rate of GABA synthesis; (b) effects of DA D1 and D2 receptor agonists and antagonists on the in vivo GABA synthesis rate; and (c) the effects of GABAA and GABAB receptor agonists and antagonists on the intracellular accumulation of cAMP in the ipsi- and contralateral striatum and substantia nigra of rats after unilateral 6-hydroxydopamine-induced lesions of the nigrostriatal DA system (DA depletion > 90%). We observed that the in vivo rate of GABA synthesis remained unaffected when the DA levels were depleted by 95% and 50% in the ipsilateral striatum and substantia nigra, respectively, compared with the contralateral intact side. Basal cAMP levels were increased significantly (92%) in the ipsilateral striatum only, compared with the contralateral intact side. The DA D2 agonist quinpirole (1.0 mg/kg) significantly decreased the rate of GABA formation in the ipsi- and contralateral striatum and substantia nigra. In contrast, the D2 antagonist (+/-)-sulpiride (25.0 mg/kg) augmented the rate of GABA formation in the DA-denervated and intact striatum and substantia nigra. On the other hand, D1 agonist SKF 38393 (10.0 mg/kg) did not affect the GABA synthesis rate. The in vivo rate of GABA synthesis also remained unaffected after administration of D1 antagonist SCH 23390 (1.0 mg/kg) except in the ipsilateral striatum.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of neurochemical and behavioral sensitivity to ethanol in long-sleep and short-sleep mice.

The postnatal development of certain neurochemical correlates of CNS ethanol sensitivity was examined in the long-sleep (LS) and short-sleep (SS) mice. The differences in sensitivity to the motor-incoordinating and hypothermic effects of ethanol emerged during the second and third weeks of life. Prior studies have shown the sleep time differences between LS and SS mice became significant at 8-10 days of age whereas the present results established that the differences in ethanol-induced hypothermia became prominent at 12-16 days of age. Previous results from our laboratory suggested that the greater CNS ethanol behavioral sensitivity (sleep time and hypothermia) of LS mice is related to the greater ethanol-induced depression of brain monoamine synthesis in the LS line. The timing of the developmental changes in neurochemical ethanol sensitivity in LS and SS mice was found to parallel that found in the development of behavioral ethanol sensitivity as follows. Ethanol-induced decreases in in vivo tyrosine hydroxylase activity in the cerebellum, hypothalamus, and brain stem did not differ between LS and SS mice at postnatal day 8, but became substantially greater in LS mice between postnatal days 8 and 12, coincident with the appearance of the greater sleep times of LS mice. Likewise, ethanol-induced decreases in in vivo tryptophan hydroxylase activity in the dorsal raphe and hypothalamus, which were similar in LS and SS mice at postnatal days 8 and 12, became significantly greater in LS mice by postnatal day 16, the age at which their increased sensitivity to ethanol-induced hypothermia appeared.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of nonionic liposomal composition on topical delivery of peptide drugs into pilosebaceous units: an in vivo study using the hamster ear model.

PURPOSE: The purpose of this study was to test the hypothesis that nonionic liposomes facilitate the topical delivery of peptide drugs into pilosebaceous units. METHODS: The hamster ear was used as a model for human pilosebaceous units. The deposition of a hydrophilic protein, alpha-interferon (alpha-IFN), into pilosebaceous units and other strata of the hamster ear 12 hours after topical in vivo application of three nonionic liposomal formulations, one composed of glyceryl dilaurate/cholesterol/polyoxyethylene-10-stearyl ether (Non-1), the second composed of glyceryl distearate/cholesterol/polyoxyethylene-10-stearyl ether (Non-2) and the third composed of polyoxyethylene-10-stearyl ether/cholesterol (Non-3), a phospholipid-based liposomal formulation (PC) and an aqueous control solution (AQ) was determined. We also determined the deposition of a hydrophobic peptide, cyclosporin-A (CsA), into pilosebaceous units and other strata of the hamster ear after topical in vivo application of these liposomal formulations and a hydroalcoholic control solution (HA). RESULTS: The deposition of alpha-IFN into the pilosebaceous units was in the order: Non-1 >> PC > Non-2 > Non-3 = AQ. The deposition of CsA into the pilosebaceous units was in the order: Non-1 >> HA > PC > Non-2 = Non-3. CONCLUSIONS: Despite differences in the hydrophobicities and size of the drug molecules, deposition into the various ear strata was significantly enhanced by the Non-1 liposomal system.

Age-related changes in tetrahydrobiopterin and GTP-cyclohydrolase activity in the brain and adrenal gland of rats.

In the present study, we observed that tetrahydrobiopterin (BH4) levels were decreased significantly in the striatum, substantia nigra, frontal cortex, hypothalamus, and cerebellum of 25-month-old and in the cerebellum only in case of 18-month-old rats as compared to 4-month-old rats. In contrast, BH4 levels in adrenal glands of 25-month-old rats were increased significantly. Kinetic analysis of GTP-cyclohydrolase revealed a decrease in the apparent Km along with an increase in Vmax value in the adrenal of 25-month-old rats compared to 4-month-old rats. Whereas, in cerebellum we observed that the apparent Km of the high affinity form of the enzyme was increased and a decrease in the Vmax value of the low affinity form only in case of 25-month-old rats compared to the young animals. These alterations in the BH4 levels and its synthesizing enzyme kinetics in specific brain areas and adrenal glands of aged rats are consistent with the reported changes in the catecholamine function in central and peripheral nervous system with aging.

Anti-Jkb delayed hemolytic transfusion reaction after coronary bypass surgery.

Delayed hemolytic transfusion reaction occurred in a 74-year-old woman after coronary bypass. Antibodies were not detected during preoperative screening but did appear late after exposure to Jkb-positive red blood cells, probably as an anamnestic response to previous exposure during childbirth or remote transfusion. The incidence, pathophysiology, clinical presentation, diagnosis, and management of this syndrome are discussed.