Vitrectomy to remove a posteriorly dislocated endocapsular tension ring.

We treated a patient who had a posteriorly dislocated endocapsular ring associated with decreased vision and intravitreal cortical remnants. The ring was removed by uneventful pars plana vitrectomy. By the last examination, best corrected visual acuity had improved to 6/12 and intraocular pressure had stabilized to within normal limits. A posteriorly dislocated endocapsular ring is a rare complication of cataract surgery. Its removal by pars plana vitrectomy under direct observation is effective and safe.

Objective and subjective measures of the pharmacodynamic effects of Adderall in the treatment of children with ADHD in a controlled laboratory classroom setting.

In a randomized double-blind crossover study of children with attention deficit hyperactivity disorder (ADHD), the time course effects of four doses of Adderall (5, 10, 15, and 20 mg) and an inactive (placebo) control, and an active (Ritalin) control were evaluated. A laboratory classroom setting was established in which subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measurements were taken every 1.5 hours across the day. In addition to significant time and dose effects of Adderall, significant time-of-day effects were documented in the placebo condition for the subjective measure of deportment and objective measures of performance. Regression analyses were used to estimate the magnitude of these baseline effects. Correlations across time were used to evaluate the test-retest reliability of each measure in the face of these time-dependent placebo effects. After placebo/time adjustments, within-subject correlations between pairs of measures were used to evaluate the validity of the math test as a measure of response to stimulant medication.

Analog classroom assessment of Adderall in children with ADHD.

OBJECTIVE: This was a randomized, double-blind, crossover study of 30 children with attention-deficit/hyperactivity disorder (ADHD) that evaluated the time course effects of four doses of Adderall (5, 10, 15, and 20 mg), an inactive control (placebo), and a positive control (clinical dose of methylphenidate). METHOD: For each treatment condition, a capsule was administered in the morning and assessments were performed in an analog classroom setting every 1.5 hours across the day. Subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measures were obtained for each classroom session, and these measures were used to evaluate time-response and dose response effects of Adderall. RESULTS: For doses of Adderall greater than 5 mg, significant time course effects were observed. Rapid improvements on teacher ratings and math performance were observed by 1.5 hours after administration, and these effects dissipated by the end of the day. The specific pattern of time course effects depended on dose: the time of peak effects and the duration of action increased with dose of Adderall. CONCLUSIONS: This documentation of efficacy in a controlled study supports the addition of Adderall to the armamentarium of psychotropic medications for the treatment of ADHD. The differences in time-response patterns of Adderall and methylphenidate may help tailor treatment to meet specific clinical needs of different children with ADHD.

Association of the dopamine receptor D4 (DRD4) gene with a refined phenotype of attention deficit hyperactivity disorder (ADHD): a family-based approach.

Previously in this journal, we reported an association of the dopamine D4 receptor gene (DRD4) and attention deficit hyperactivity disorder (ADHD). In a population-association (case-control) study of 39 children with a refined phenotype of ADHD and 39 ethnically matched controls, we observed an increased percentage of the 7 repeat allele (29% vs 12%) and the 7+ genotype (49% vs 21%) in the ADHD group compared to the control group. In a replication and an extension of our initial study, we recruited another sample of ADHD subjects and found percentages of the 7 repeat allele (28%) and the 7+ genotype (48%) consistent with our previous findings. We used a family-based approach to evaluate a predicted association of DRD4 and ADHD based on a test of allele transmission focused on the 7 repeat allele. We identified 52 families based on the diagnosis of the refined phenotype of ADHD in the proband and the availability of DNA from both biological parents as well as the proband. Haplotype relative risk (HRR) analysis was performed to test our a priori hypothesis and produced significant results (chi-square = 4.65, P < 0.035). This provides additional evidence that the DRD4 gene is associated with a refined phenotype of ADHD.

Evaluation of individual subjects in the analog classroom setting: I. Examples of graphical and statistical procedures for within-subject ranking of responses to different delivery patterns of methylphenidate.

In this article, we describe graphical and statistical methods developed to evaluate the response patterns of individual children with attention deficit hyperactivity disorder (ADHD) to different conditions of treatment with stimulant medication. We used data from an investigation of drug delivery patterns to demonstrate these methods. Thirty-one children with ADHD participated in a double-blind crossover study of four conditions (three patterns of delivery of methylphenidate and a placebo control). In each condition, the children were evaluated across an 11-hour (7:00 a.m. to 6:00 p.m.) laboratory school day, and ratings of classroom behavior were obtained at regular intervals across the day. Graphical procedures were developed to display, for each individual, time courses of multiple measures of behavior taken across each double-blind test day. Expert clinicians judged these graphs and used this information to rank-order the test days from best to worst. A within-subject variant of Kendall's W was used to evaluate, for each subject, whether the rankings of these multidimensional graphs were reliable (concordant) across judges. A generalized kappa statistic was used to evaluate, for each condition, the reliability of the judges' rankings across subjects. Friedman's analysis of variance of ranks was used to evaluate, for the study, whether the conditions differed in terms of the average (consensus) rank assigned by the judges.

Evaluation of individual subjects in the analog classroom setting: II. Effects of dose of amphetamine (Adderall).

Multiple dependent variables were graphed for 29 subjects who participated in a double-blind evaluation of 4 doses of Adderall, plus positive (methylphenidate) and placebo control conditions. Five judges ranked the conditions for each subject, and analyses of individual subjects indicated that these rankings were concordant (reliable) across judges. Consensus rankings were assigned to each subject, and an analysis of these ranks showed that the conditions differed significantly. The choice of best conditions were judged to be across 3 doses of Adderall (10, 15, and 20 mg). This confirms the clinical impression of individual differences in optimal dose of stimulant medication. The methodological, graphical, and statistical methods presented in this article provide a systematic, reliable procedure for evaluating relative response of individuals to different doses of stimulant medication.

Mushroom-shaped choroidal hemangioma.

PURPOSE: We examined the clinicopathologic features of a mushroom-shaped choroidal tumor that originated in the right eye of a 13-year-old girl. METHODS: The clinical, ultrasonographic, and histopathologic features of the enucleated eye were studied. RESULTS: On clinical examination, the choroidal tumor appeared mushroom-shaped with ultrasonic characteristics of high internal reflectivity and choroidal excavation. The enucleation specimen contained a cavernous hemangioma that extended through Bruch's membrane. CONCLUSION: Choroidal hemangioma may extend through Bruch's membrane and be mushroom shaped.

Insulin autoimmune syndrome as a cause of spontaneous hypoglycemia in alcoholic cirrhosis.

Hypoglycemia in fulminant hepatic failure and hyperinsulinemia in cirrhosis are well-described phenomena. A patient with alcoholic cirrhosis who developed fasting hypoglycemia with an extremely high immunoreactive insulin level and a mildly elevated C-peptide level is reported. An insulinoma was excluded by detailed radiological imaging of the pancreas and by endoscopic ultrasonography. Detection of very high levels of insulin autoantibodies with no prior exposure to exogenous insulin confirmed the diagnosis of insulin autoimmune syndrome. During his hospital course, the patient developed another rare syndrome, acquired inhibitors to factor V, which led to the fatal coagulopathy that resulted in his death. Insulin autoimmune syndrome is the third leading cause of spontaneous hypoglycemia in Japan, where it has been associated with a variety of diseases and drugs. Outside of Japan, only approximately 20 cases have been reported and usually have been found in the context of an underlying autoimmune disorder or prior exposure to sulfhydryl drugs. It is believed that this is the first case reported outside Japan occurring in association with alcoholic liver disease, and the first in the world with coexisting acquired inhibitors to factor V.

Estrogen and androgen dynamics in liver disease.

Constant infusions of 3H-androgen/14C-estrogen were given to 18 men with increased serum bilirubin concentrations and biopsy proven hepatic cirrhosis. From data obtained from the infusions and the radioimmunoassay of circulating endogenous steroid levels metabolic clearance rates (MCR), blood production rates (PB), aromatization rates (fraction of androgen infused into and measured as estrogen in blood; [p]And, Est BB) and conversion ratios (ratio of concentration of radioactivity of infused precursor to product steroid in blood; CRPREC,PROD were calculated. These data were compared to normal data obtained from similar studies in a group of normal men similar in age and weight. The mean concentrations of testosterone (T), and dihydrotestosterone (DHT), were decreased but those of estrone (E1) and estradiol (E2) were increased, and the concentration of androstenedione, (A), was similar compared to the normal values. Compared to the values in normal men the mean MCR of T was decreased those of A and E2 were normal, and that of E1 was slightly increased. However, the PB's of both estrogens were increased while that of A was normal T was decreased. The increase in the PB's of the estrogens could be explained on the basis of a marked increase in [p]And, Est BB probably due to a shift in blood flow from the liver to peripheral tissue. These findings were noted in men with alcoholic cirrhosis as well as cardiac cirrhosis and in 1 subject with infectious hepatitis. Abnormalities in steroid metabolism occur in men with several types of liver disease and are not limited to those with alcoholic liver disease.

Extremely rapid growth of a primary choroidal melanoma.

A small, minimally elevated, nonpigmented choroidal tumor increased in volume 12-fold and grew from the edge of the fovea to the optic disk within 60 days. Histopathology of the enucleated globe demonstrated a mixed spindle and epithelioid cell malignant melanoma with numerous mitotic figures. The calculated doubling time of this tumor was 17 days.

Congenital retinal arterial loops with spontaneous vitreous hemorrhage.

A young adult demonstrated a spontaneous vitreous hemorrhage in an eye which harbored two retinal arterial loops, with bleeding originating in the area of the larger loop. These congenital vascular anomalies characteristically originate on the optic disk and terminate by anastomosing with or forming a retinal vessel. Although uncommon, congenital retinal arterial loops can no longer be thought innocuous and must be considered when decreased visual acuity occurs.

Effect of iontophoretic and topical application of antiviral agents in treatment of experimental HSV-1 keratitis in rabbits.

Cathodal (-) iontophoresis of 9-beta-D-arabinofuranosyl-adenine 5'-monophosphate (vidarabine monophosphate; Ara-AMP) was performed once daily for 3 days for the treatment of experimental herpes simplex virus type 1 (HSV-1) keratitis in rabbit eyes, and the therapeutic efficacy was compared with that of topical treatment of Ara-AMP and idoxuridine (IDU) administered five times daily for 4 days. With the treatment initiated 24 hr after viral inoculation, Ara-AMP cathodal iontophoresis resulted in significant suppression of epithelial and anterior segment disease processes. Topical IDU (0.5%) or Ara-AMP (10%) also significantly improved the disease process when compared to the placebo-treated group; however, iontophoresis of Ara-AMP resulted in a more marked improvement. Slit-lamp examination indicated that iontophoresis did not cause any observable pathologic changes in corneal epithelium, stroma, conjunctiva, or iris of rabbit eyes. This experiment suggests that iontophoresis of Ara-AMP is a safe and effective approach for preventing the development of herpes simplex keratitis in rabbits.

A stable base for an operating microscope.

We developed a 1/4-inch mild steel plate underbase with reinforced steel angles and three-inch diameter casters for our nonmotorized operating microscope floorstand. When fully weighted with an automatic focus zoom microscope head, a stereoscopic assistant scope, and a television camera, the unit proved stable and safe. It can be moved more easily than the existing floorstand.

Starvation-induced alterations of circulating thyroid hormone concentrations in man.

Serum concentrations of triiodothyronine (T3), thyroxine (T4), and TSH were examined in seven men and seven women of normal weight during a 60-hr fast. Similar studies were conducted in two women who received daily for 1 mo before and during a similar fast, 0.4 mg and 0.5 mg of 1-thyroxine. The serum concentrations of T3 decreased in each of the untreated normal subjects (sign test of significance, P less than 0.001). The mean control concentration of T3 in women was 152 +/- 9 ng/100 ml (X +/- SEM); after 24 hr of fasting, 131 +/- 31 ng/100 ml; and at the termination of the fast, 90 +/- 15 ng/100 ml. The latter value differed from the control value with a p value of less than 0.01. Similar changes of T3 concentration occurred in men (mean basal T = 160 +/- 11 ng/100 ml; mean at termination of fast = 87 +/- 16 ng/100 ml). The range of decrease for T3 in all subjects varied from 24% to 55%. The mean T4 concentration at the beginning of the fast was 6.9 +/- 0.9, and at the termination of the fast, 7.5 +/- 0.6 (p = NS). TSH concentrations remained unchanged (Control, 3.8 +/- 0.45 muU/ml; at 60 hr, 4.0 +/- 0.26 muU/ml, p = NS). Studies in two women who received, before and during a fast, T4, indicate that a decreased peripheral conversion of T4 to T3 is the most likely mechanism responsible for this change.

Proliferation and metaplasia of intravitreal retinal pigment epithelium cell autotransplants.

Pigment epithelium cells autotransplanted into the vitreous cavity of owl monkey eyes, proliferated and metaplased. The metaplastic cells looked like pigmented macrophages, membrane forming fibrocyte-like cells, and frank epithelium cells. This in vivo experiment demonstrated that the vitreous cavity is an adequate culture medium for cells deriving from the pigment epithelium and that pigment epithelium cells could be the source of intraocular proliferation seen in massive periretinal proliferation.

Sulfur hexafluoride in owl monkey vitreous cavity.

Sulfur hexafluoride (SF6) gas, tested in the vitreous chamber of owl monkey eyes, remained in the vitreous cavity about twice as long as air (ten to 11 days vs. five to six days). Its volume expanded from the diffusion of other gases into the created gas pocket. Lens opacities developed when the lens was in continuous contact with SF6 or air. Sulfur hexafluoride appeared to be no more toxic to the retina than air, using electroretinographic, histologic, and electron microscopic criteria.