The influence of previous exposure to environmental mycobacteria on the interferon-gamma response to bacille Calmette-Guérin vaccination in southern England and northern Malawi.

We report a large study of the effect of BCG vaccination on the in vitro 6-day whole blood interferon-gamma (IFN-gamma) response to antigens from eight species of mycobacteria among schoolchildren in south-eastern England, where bacille Calmette-Guérin (BCG) vaccination is highly protective against pulmonary tuberculosis, and among young adults in northern Malawi, where BCG vaccination is not protective. In the UK children, BCG induced an appreciable increase in IFN-gamma response to antigens from most species of mycobacteria. The degree of change was linked to the relatedness of the species to Mycobacterium bovis BCG, and provides further evidence of the cross-reactivity of mycobacterial species in priming of the immune system. IFN-gamma responses to purified protein derivatives (PPDs) from M. tuberculosis and environmental mycobacteria were more prevalent in the Malawian than the UK group prior to vaccination; BCG vaccination increased the prevalence of responses to these PPDs in the UK group to a level similar to that in Malawi. There was no evidence that the vaccine-induced change in IFN-gamma response was dependent upon the magnitude of the initial response of the individual to environmental mycobacteria in the United Kingdom or in Malawi. These observations should assist the development and interpretation of human clinical trials of new vaccines against M. tuberculosis in areas of both low and high exposure to environmental mycobacteria.

Variable tinted spectacle lenses: a comparison of aesthetics and visual preference.

PURPOSE: To determine the correlation between the aesthetics of lens tints preferred for cosmesis and lens tints preferred for viewing. METHODS: Thirty-five subjects (mean age: 25; 49% male, 51% female) with no significant ocular pathology participated in the study. Median visual acuity was 20/20. Color vision testing was performed on each subject using Ishihara plates, and those with abnormal scores were excluded from the study. Subjects were shown nine pre-selected tinted lenses (50% transmittance) of variable wavelengths. These lenses were mounted on two separate color backgrounds, one white and the other approximating their skin tone. Subjects were asked to choose from each background which tinted lens they would most prefer to wear and which lens they would least prefer to wear. The subjects were then shown a series of eight pictures (four nature photographs and four paintings) with different dominant wavelengths. Subjects were asked to grade the aesthetic effect of a clear lens and each of the nine tinted lenses on the appearance of the pictures. Chromaticity coordinates were calculated for each lens and picture. RESULTS: The blue lens was the most frequently chosen preferred lens to wear, followed by green, purple, and gray. The least preferred lenses were yellow, brown, and pink. For viewing the nature photographs, the clear lens was preferred over any of the tinted lenses. For viewing the paintings, the purple lens was most preferred. The yellow lens was least preferred for both photographs and paintings. CONCLUSIONS: Younger individuals with no significant ocular pathology preferred viewing both nature photographs and paintings through tinted lenses that did not, or only slightly, altered the chromaticity of the image. Whereas a clear lens was favored over the tinted lenses for viewing the photographs, some tinted lenses (purple and pink) were preferred for viewing paintings. There was no correlation between the most favored lens tint chosen based purely on cosmesis and the most favored lens tint based on viewing preference. However, the least preferred lens tint for cosmesis and viewing was yellow.

Clinical survey of lens care in contact lens patients.

PURPOSE: Overall, contact lenses provide a safe and effective modality for vision correction. However, problems do occasionally arise. Up to 80% of contact lens complications can be traced to poor patient compliance with recommended lens care guidelines. We conducted a survey to evaluate the level of patient compliance in specific areas of lens care and maintenance and to assess patient knowledge of basic contact lens information. METHODS: Patients were asked to complete an anonymous 15 question survey that focused on lens care--specifically the use of contact lens cleaners, methods of disinfection, enzyme treatments, use of rewetting drops, and the frequency of follow-up exams. In addition, the survey included six true/false questions relating to contact lens care and safety. RESULTS: There were a total of 103 participants in the study. Approximately 24% of patients stated they never cleaned their lenses prior to disinfection, and 5% used saline solutions as their primary mode of disinfection. A sizable portion of those surveyed (43% of soft lens wearers and 71% of rigid gas permeable lens wearers) either never used enzyme cleaners or used them less than once a month. Seventy percent of patients either never used rewetting drops or used them less than once a day. Twenty-nine percent of patients consulted their eye care professionals every 2 years and 6% less often than every two years. Six questions assessed patient knowledge of contact lens care safety. Of a possible six out of six correct answers, the mean number of correct responses was 3.74. CONCLUSIONS: A sizable proportion of contact lens wearers do not adequately adhere to recommended contact lens care, and many have an inadequate understanding of contact lens care guidelines. Therefore, it is important that practitioners place more emphasis on patient education at the time of initial contact lens fitting and reinforce such instruction during follow-up visits.

Immunohistochemical detection of CA-125 and carcinoembryonic antigen in ovarian tumors in relation to corresponding preoperative serum levels.

The immunohistochemically detectable expression of CA-125 and CEA in ovarian tumor tissue from 187 patients was related to corresponding preoperative serum levels. A strong positive association between tissue expression and the serum level of both the CA-125 and CEA antigens was found in cases of invasive epithelial ovarian carcinoma. However, this relationship was absent for CA-125 in borderline cases and patients with benign ovarian tumors, although the antigen frequently was detectable in them. The presence of ascites could be verified in 3 of 10 cases with benign CA-125 negative tumors, but elevated CA-125 levels in serum. 'False negative' CA-125 levels were found in 6 borderline and 7 true invasive carcinoma cases despite positive tissue staining. Eight of those patients had limited stage I disease. The data suggests that although the tissue expression of the CA-125 and CEA antigens in invasive ovarian carcinoma has an important influence in the corresponding serum level, compartment barriers and low cell turnover in benign, and to a lesser extent borderline, cases result in low serum levels. In addition, other factors influence serum levels of CA-125, such as secondary peritoneal response with or without ascites, which may cause 'falsely elevated' CA-125 results in benign disease.

Traumatic brain injury crisis intervention and family therapy--management and outcome. Brain Injury Treatment and Research Group.

This article presents a model for crisis intervention and family therapy after traumatic brain injury. Our program, firmly rooted in object-relations theory and transactional analysis, included patients and family members (significant others) living within 100 miles from the University Hospital of Umeå. The effects of the interventions were gauged at one and two years after the trauma are presented in terms of agreement/disagreement between the patient and the significant other concerning inter- and intrapersonal relationships as well as through a short case presentation. As a conclusion of our study a point is made to expand the scope of intervention to include also other segments of the social network of the patient.

Isolation and characterization of a new human microsporidian, Encephalitozoon hellem (n. sp.), from three AIDS patients with keratoconjunctivitis.

A new human microsporidian was isolated from cultures of Madin-Darby canine kidney cells incubated with conjunctival scrapings or corneal tissues from three AIDS patients with keratoconjunctivitis. The three isolates were morphologically similar to Encephalitozoon cuniculi. The spores averaged 1 x 1.5-2.0 microns, had six to eight polar filament coils, displayed monokaryotic nuclei, and possessed relatively thick endospores with irregularly shaped exospores. Organisms developed within a parasitophorous vacuole. By SDS-PAGE analysis, the three isolates appeared to be identical but were different from E. cuniculi. Identical banding patterns on Western blots of the three isolates were expressed by each patient's serum. By Western immunoblotting, murine antisera to E. cuniculi reacted to several antigens of the new AIDS-related microsporidian, whereas murine antisera bound weakly to Nosema corneum. The name Encephalitozoon hellem (n. sp.) is proposed to identify this new human microsporidian.

Microsporidial keratoconjunctivitis in acquired immunodeficiency syndrome.

We describe three patients with acquired immunodeficiency syndrome who presented with a bilateral coarse superficial epithelial keratitis due to infection with the protozoal parasite Microspora, Encephalitozoon cuniculi. Despite the extent of the corneal surface disease, conjunctival inflammation was minimal. Visual acuity ranged from 20/20 to 20/200. In one patient, the keratitis was complicated by the development of a surface defect with secondary Pseudomonas species infection. All patients had a history of exposure to household pets. Standard cultures were negative. Diagnosis was established in two of the three cases based on characteristic appearance of the protozoan in conjunctival scrapings. Electron microscopy of a conjunctival biopsy specimen in one patient confirmed the species. No recognized effective treatment is available for this infection.

Prognostic factors in invasive squamous cell carcinoma of the vulva treated with surgery and irradiation.

From 1958 through 1980, 113 women with invasive squamous cell carcinoma of the vulva were treated with vulvectomy. Post-operative irradiation was given with cobalt-60 beam or 10 MV photons from a linear accelerator from anterior fields including the vulva and groins, with the intention of delivering 40-52 Gy with 2-4 Gy/day at a depth of 0.5 cm or 2 cm. The overall corrected five-year survival rate was 68%. The prognosis was shown to worsen significantly with advancing stages (I/96%, II/75%, III/62% and IV/19%), increasing grades (GI/78%, G2/70% and G3/22%) and increasing size of the tumor (T1/90%, T2/71% and T3/37%), as it also did when there were signs of vascular invasion, multifocal tumors or positive nodes in the inguinal regions. Recurrences were diagnoses in 32% of the patients. With the less aggressive surgical approach used, combined with radiation therapy to eradicate subclinical disease, the morbidity rate was acceptable and the survival rate comparable to that reported after more aggressive surgery.

Prognosis of endometrial carcinoma stage I in two Swedish regions. A study with special regard to the effects of intracavitary irradiation with high dose-rate afterloading technique or with low dose-rate radium.

A high dose-rate afterloading technique (60Co) was compared with a low dose-rate packing method (226Ra) in the treatment of endometrial carcinoma stage I. In all, 1,021 patients treated during the period 1977-1986 at two Swedish gynecologic oncology centers were analyzed regarding treatment set-up, histopathologic outcome in the operative specimens, recurrence rates, survival rates and radiation side effects. Complete tumor eradication in the operative specimen was achieved in 80% after radium therapy and in 60% after irradiation by the high dose-rate technique. The overall recurrence rate was 15.7% in the radium packing series and 11.5% after cobalt afterloading treatment. The risk of pelvic recurrences increased by 2.1-2.6 if hysterectomy was replaced by dilatation and curettage. The two radiation techniques seemed to be comparable with regard to the risk of both pelvic recurrences and distant metastases. The 5-year crude survival rates were 85% in the afterloading series and 82% in the radium series. The corrected survival rates were similar (90%) for the two techniques. Age, tumor grade and uterine size were significant prognostic factors with regard to the probability of death due to cancer. Early radiation reactions had quite similar rates in the two series, whereas late radiation reactions were more frequent in the high dose-rate afterloading group in the 10-12 Gy dose fraction range, but not in the 5-8 Gy range. The radium packing method seemed to give a higher frequency of tumor-free operative specimens in this study, but with regard to recurrence rates and survival probabilities the techniques were comparable. Since the different proportion of surgery in the two series and the histopathologic evaluation might have influenced the rate of local tumor eradication in the operative specimens and the risk of pelvic recurrences the results must be assessed with great caution and only a crude comparison of the two treatment techniques could be made.

Preoperative intrauterine irradiation of endometrial carcinoma stage I. A clinical and radiographic evaluation of the bulb technique.

In a series of 146 cases of endometrial carcinoma stage I an afterloading technique using high dose-rate cobalt-60 sources has been evaluated for preoperative intracavitary irradiation. The uterine cavities were visualized by hysterograms and the target volumes were calculated. Absorbed doses were estimated at the surface of the target volume and within the uterine cavity. Surgery was performed six weeks after radiotherapy and the operative specimens were examined by a whole-organ sectioning technique. The frequency of residual carcinoma was assessed in relation to reference doses, minimum doses in the target and the position of the treatment catheter. The dose per fraction at the reference point, the minimum absorbed dose at the anterior surface of the target, the anterior-posterior diameter of the target volume and the position of the treatment catheter within the uterine cavity were found to be significant for tumor eradication. The irradiation technique and the histopathologic findings with reference to the operative specimen were significant for the rate of vaginal metastases but not for tumor recurrences at other sites. Radiation reactions involving the urogenital organs were few (4.8%). The most serious radiation reaction was obstruction of the small bowel (5.5%). The absorbed dose per fraction was the most important single risk factor for this complication.

Automatic analysis of Papanicolaou smears by digital image processing.

Papanicolaou smears from 378 patients were analyzed in a fully automated microscope system using an image analysis technique. The logic of the system subdivided the smears into "normal" (63%), "not possible to analyze in the machine" (17%) and "positive" (20%). The results have been compared with the conventional screening method available today taking into consideration the definition problems of a true diagnosis, cytopathological and histopathological consensus, reproducibility, sample-taking and interpretation mistakes, etc. As 37% (rejected and positive) of the smears in this particular study were analyzed visually after machine prescreening, it could be demonstrated that the false-negative rate among the remaining 63% of the specimens was significantly lower among the machine-screened smears when compared with visual screening if the results were correlated with histopathological consensus. The results clearly indicate that the technology required to build computerized microscope systems, which are able to automatically sort out at least two thirds of Papanicolaou smears is available today. The only limiting factor is the cost-benefit relationship.

Differences in DNA content and proliferation rate between adenocarcinomas of the uterine cervix and corpus.

The DNA content and the S-phase rate of 26 cervical adenocarcinomas and 100 endometrial adenocarcinomas, determined by flow cytometry, were compared. Statistically significant differences in DNA patterns were found, although only pure adenocarcinomas were studied in both groups. Peri-diploid values (1.8c-2.2c) were less common in cervical adenocarcinomas (38%) than in endometrial carcinomas (65%) (p less than 0.05). Six (23%) of the cervical carcinomas and 8 (8%) of the endometrial carcinomas had two detectable stem lines. The mean S-phase rate was significantly higher in adenocarcinomas of the uterine cervix than in endometrial carcinomas (p less than 0.02). The dominance of aneuploid values, the high proportion of polyclonal tumors and the high S-phase rates of the cervical adenocarcinomas have more similarities with the DNA patterns of cervical squamous cell carcinomas than with those of endometrial adenocarcinomas.

Laboratory studies in chronic conjunctivitis.

Conjunctival cultures and scrapings for cytological examination were done in 852 cases of chronic conjunctivitis. Bacteria were recovered in 464. Of these, Staphylococcus sp were isolated in 91%; their etiologic importance over normal flora is questionable. Important cytological findings included atypical epithelium (three cases), Halberstaedter-Prowazek inclusion bodies (two), and eosinophils (104). Epithelial degenerative changes were common (585 cases). Crystals (105) and microorganisms (283) were other frequent findings. Active infection seems to be an uncommon cause of chronic conjunctivitis. Cultures are important in avoiding unnecessary antibiotic therapy when no organism is present. Cytological examination can be a helpful diagnostic adjunct in selected cases and is to be recommended especially in chronic follicular conjunctivitis, possible drug toxicity or allergy, dry eye states, and other atypical clinical presentations.

Superior limbic keratoconjunctivitis associated with soft contact lens wear.

Four cosmetic soft contact lens wearers experienced lens intolerance and mild irritative symptoms. All four displayed changes suggestive of those seen in superior limbic keratoconjunctivitis with papillary hypertrophy and inflammation of the upper tarsus, superior tarsal and bulbar conjunctival fluorescein staining, superior limbal hypertrophy, and upper corneal punctate staining. Three of the four conditions resolved with discontinuance of lens wear alone; the fourth improved, but there was persistence of mild upper bulbar conjunctival and corneal staining for two years. No common causative contact lens-related factors were obvious in the four. Three of the patients were subsequently able to resume lens wear on a modified basis.

The results of cryosurgical treatment in young women with cervical intra-epithelial neoplasia.

A review is given of results from a 3-5-year follow-up of 105 young women treated with cryosurgery for a histopathologically verified dysplasia or carcinoma in situ of the uterine cervix. The recovery rate was 88%, with a slightly higher figure in the dysplasia group compared with that of carcinoma in situ. No invasive carcinoma was diagnosed and cases of treatment failure, all diagnosed within one year after cryosurgery, did not develop into a more severe form of neoplasia than previously. No recurrence has been noted so far and very few complications have been recorded. It is concluded that cryosurgery is an easy and effective method of treating cervical intra-epithelial neoplasia in young women. We stress, however, the importance of correct histopathological diagnosis prior to therapy and that after treatment the status of the patient must be checked with vaginal smears over a long period of time.

Focal giant papillary conjunctivitis from retained contact lenses.

Three cases of retained contact lenses leading to focal papillary conjunctivitis of the upper lids reminiscent of the more diffuse changes of lens or suture-induced giant papillary conjunctivitis are reported. One silicone and two cabufocon lenses were responsible. Corneal changes occurred in two of the three cases. Secondary infection with Staphylococcus aureus was found in one patient. In two, conjunctival cytology suggested a hypersensitivity mechanism. In all three patients the simple removal of the retained lens was sufficient to reverse pathology. The focal nature of the papillary changes observed in these patients as well as in those cases occurring post-operatively from exposed suture edges would point towards an important direct mechanical etiologic factor in addition to the proposed hypersensitivity basis for the similar diffuse upper lid papillary hypertrophy characteristic of giant papillary conjunctivitis.

Laboratory studies in acute conjunctivitis.

In 84% of 700 consecutive cases of untreated acute conjunctivitis subjected to conjunctival cultures and scrapings, a presumptive etiologic diagnosis could be made based on standard microbiologic and cytologic criteria. Of these 583 cases, 264 were bacterial, 245 were viral, 51 were allergic, and 17 were chlamydial. In 75% of the cases, clinical impressions were consistent with laboratory findings. On the basis of these results, laboratory workup is recommended in (1) follicular conjunctivitis to differentiate viral from chlamydial processes, (2) purulent conjunctivitis to identify pathogens and decide on appropriate antimicrobial therapy based on sensitivity data, and (3) those cases in which the clinical picture is not sufficiently distinctive to suggest an etiologic diagnosis.

Ocular findings in xeroderma pigmentosum: report of two cases.

Xeroderma pigmentosum is a hereditary precancerous dermatosis caused by a defect in DNA repair-replication after damage induced by exposure to ultraviolet light. The clinical course is characterized by progressive hyperpigmentation and atrophy of the skin with tumorigenesis, basal and squamous cell carcinomas being most common. Ocular involvement occurs in up to 80% of cases, with recurrent infection, neoplasia, and atrophy of the lids, conjunctiva, and cornea the most common findings. Two cases of xeroderma pigmentosum and their ophthalmic findings are described.