[Influence exercised by physicians on the vaccination rate]. / Der Arzteinfluss auf die Durchimpfungsrate.

This paper deals with the question whether physicians promote vaccinations among their patients. Besides this, we analyse which determinants influence the acceptance of vaccination among physicians. The investigations are based on data of a project granted by the DFG (Deutsche Forschungsgemeinschaft; "Munich Vaccination Study 2001"). Within this study physicians as well as parents have been interviewed. The vaccination rate of the physicians' patients are influenced by attitudes of the physician and the attitudes he/she believes his/her patients have, but not so much by aspects of his/her behaviour. How many pamphlets and posters about vaccination are available in the doctors' practice or how long consultations about vaccination last on average has only marginal effects on the rate of vaccination among the doctors' patients. If it is a political aim to enlarge vaccination rates steps should concentrate on changing relevant attitudes.

Vertical rectus muscle transposition and botulinum toxin for complete sixth nerve palsy.

BACKGROUND: Effective surgical treatment of complete unrecovered sixth nerve palsy must include the transfer of abducting power to the temporal aspect of the globe with release of medial rectus contracture nasally. We describe our experience in the treatment of five such patients who underwent full vertical rectus transposition combined with botulinum toxin chemodenervation of the ipsilateral medial rectus muscle. METHODS: The five patients all had primarily unilateral complete unrecovered sixth nerve palsy. They all underwent a complete preoperative and postoperative eye examination and an orthoptic assessment. Excursion into abduction was graded from -8 (globe immobilized in extreme adduction) to -4 (abduction as far as primary position) to 0 (full abduction). Abduction saccades and a forced muscle generation test confirmed the presence of complete unrecovered sixth nerve palsy, and forced duction testing measured the degree of medial rectus contracture. All patients received ipsilateral medial rectus injection of botulinum toxin in the preoperative (8 to 2 months before surgery) and perioperative periods, and underwent complete superior rectus-inferior rectus transposition temporally. RESULTS: The average length of follow-up was 21 (range 6 to 48) months. The average preoperative distance alignment was 52 (range 25 to 80) prism dioptres (PD). Vertical rectus transposition combined with botulinum toxin injection resulted in an average distance alignment change of 66 PD (range 50 PD to 82 PD) of exoshift. The average final deviation was 1 PD of esotropia (range 4 PD of esotropia to 6 PD of exotropia). Average abduction improved from -6 (range -3 to -8) preoperatively to -1.7 (range -1 to -2) postoperatively. Saccades averaged -4 preoperatively and improved to -2 postoperatively. Normal vertical eye movements were preserved in all patients. A total field of single binocular vision was created in all patients, which averaged 55 degrees (range 30 degrees to 75 degrees) in the horizontal meridian. The field of single binocular vision from primary position into abduction averaged 23 degrees (range 18 degrees to 28 degrees). INTERPRETATION: Temporal transposition of the vertical rectus muscles combined with perioperative botulinum toxin injection of the ipsilateral medial rectus muscle is a reliable and effective way of restoring functional binocular vision in patients with complete unrecovered sixth nerve palsy.

Anterior dislocation of a posterior chamber intraocular lens after blunt trauma.

An 85-year-old man developed an anterior dislocation of a posterior chamber intraocular lens (IOL) after blunt trauma. The dislocated IOL was exchanged for an anterior chamber IOL. Visual acuity was 20/40 at the 6 month follow-up. This case presents an unusual sequela of trauma to a pseudophakic eye and discusses management issues that should be considered.

The prognosis of amaurosis fugax and hemispheric transient ischemic attacks.

BACKGROUND: The natural history of amaurosis fugax and of hemispheric transient ischemic attacks (TIAs) may be different. We analysed the ischemic risk factors, carotid status and prognosis with respect to future ischemic events in a cohort of patients who presented with either of these transient ischemic episodes. METHODS: The charts of patients who presented to our institution between February 1983 and April 1995 with amaurosis fugax or hemispheric TIAs were reviewed. Patients under the age of 45 years with a history of migraine or previous carotid surgery were excluded. Follow-up by a clinical visit or telephone interview was performed. Information was obtained regarding demographic features, presenting symptoms, ischemic risk factors, carotid status (as measured by duplex ultrasonography), type of medical treatment prescribed and occurrence of subsequent ischemic events. Outcome ischemic events were graded as major (myocardial infarction, cerebrovascular accident or death due to either of these) or minor (recurrent amaurosis fugax or hemispheric TIA). RESULTS: A total of 141 patients were followed for a mean of 47 months. Risk factors were more prevalent in patients with hemispheric TIAs than in those with amaurosis fugax. Most patients had a low degree of carotid stenosis. There was no statistically significant difference in the occurrence of major outcome events between the two groups. Kaplan-Meier survival curves were similar for the two groups. INTERPRETATION: Amaurosis fugax and hemispheric TIA both carry a risk for future ischemic events. However, we did not find a statistically significant difference in prognosis between the two groups.

The perils of a sneeze.

A 51-year-old woman had a 3-day history of severe left supraorbital pain associated with blurred vision of the left eye. Examination revealed visual acuity of 20/20 OD and 20/100 OS. A left relative afferent pupillary defect was present. Neuroimaging revealed a large intra-, supra-, and parasellar mass that had eroded through the sphenoid sinus into the maxillary sinus. Secondary pneumocephalus was present. Pathologic examination of the tissue revealed a pituitary adenoma of the null cell type. To the best of our knowledge, there is only one other case in the literature in which a spontaneous pneumatocele represents the initial manifestation of a pituitary adenoma.

Discontinuation of antimalarial drugs in systemic lupus erythematosus.

OBJECTIVE: To assess the reasons for and timing of discontinuation of antimalarial drugs, principally hydroxychloroquine (HCQ), in systemic lupus erythematosus (SLE). METHODS: A lupus database was reviewed to identify antimalarial use from inception to April 1996. Reasons for drug discontinuation were assessed by medical record review. RESULTS: Of 224 patients with SLE, 156 (70%) had received antimalarials. The 156 users received 203 courses of antimalarials, of which 197 (97%) were for HCQ. The average duration of use was 6.9 years/patient. Antimalarials were discontinued at least once in 62 patients. When only the first course of use was considered, 67, 50, and 38% of patients continued to receive antimalarials at 5, 10, and 15 years, respectively (for all courses, the rates were 82, 66, and 52%, respectively). Reasons for discontinuation were disease remission in 26 (42%), side effects in 18 (29%), noncompliance in 9 (15%), lack of efficacy in 5 (8%), and miscellaneous causes such as pregnancy/surgery in 4 (6%). When all courses were considered, 20 subjects were withdrawn for side effects, including gastrointestinal in 11; headache and dizziness, and nonretinal eye problem in 2 each; and hearing loss and rash in one each. Two developed HCQ myopathy (1.9 cases/1000 patient-years of HCQ therapy; 95% CI 0.2, 7.0). One developed HCQ retinopathy after 6 years at a dose of 6.5 mg/kg/day (0.95 cases/1000 patient-years of HCQ; 95% CI 0.0, 5.5). Among patients who had received HCQ for at least 6 years, 1.3% developed retinopathy (95% CI 0.03, 7.0%). CONCLUSION: HCQ is well tolerated in SLE. However, ophthalmologic testing remains essential, as retinopathy does occur, albeit rarely.

Neuro-ophthalmic findings in progressive multifocal leukoencephalopathy.

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disorder of the central nervous system found in immunodeficient patients, most frequently now in those infected with HIV. It may represent the initial manifestation of HIV infection. Since the central visual pathways may be affected, a variety of neuro-ophthalmic signs and symptoms can manifest. We studied the clinical, radiographic and histopathological characteristics of patients with PML. METHODS: The charts of 13 patients in whom PML was diagnosed in the Neuro-AIDS clinic at the Montreal Neurological Institute between November 1987 and March 1995 were reviewed. The diagnosis of PML was established by characteristic clinical features together with typical computed tomographic or magnetic resonance imaging findings, such as nonenhancing low-density (on computed tomography) or hyperintense (on T2-weighted magnetic resonance imaging) white-matter lesions, without mass effect. Neuro-ophthalmic findings were based on clinical examination by an ophthalmologist, neuro-ophthalmologist or neurologist. Tissue for pathological examination was obtained by biopsy in one case and at postmortem study in a second case. RESULTS: The most common finding was homonymous hemianopia, in five patients (38%). Other features included nystagmus (in two patients), diplopia with cranial nerve palsy (in one) and cortical blindness (in one). One of the patients exhibited involvement of the brain stem, a site not usually affected by this demyelinating process. INTERPRETATION: The diagnosis of PML should be considered in immunocompromised patients with neuro-ophthalmic findings, particularly those with homonymous hemianopia.

Pedigree analysis of French Canadian families with T14484C Leber's hereditary optic neuropathy.

We analyzed the clinical phenotype and determined the recurrence risks to relatives of patients with T14484C Leber's hereditary optic neuropathy (LHON). LHON is a maternally inherited optic neuropathy that primarily affects adolescent males. It is usually associated with one of three mtDNA mutations: G3460A, G11778A, or T14484C. Definition of recurrence risks for the T14484C mutation previously has not been possible due to the relative scarcity of families with this mutation. We obtained blood samples from index patients and their consenting family members, all of whom were of French Canadian ancestry and screened for LHON mutations in mtDNA. Referring ophthalmologists furnished clinical summaries and patients provided pedigree data. T14484C was the most common mutation in the pedigrees analyzed and was always homoplasmic. In these pedigrees, the ratio of affected males to females was 8:1. Median age at onset for males was 19 years (95th percentile, 40.8 years; range, 6 to 48 years). Some improvement of vision was observed in 58% of patients. Recurrence risks to brothers were 28%, sisters 5%, nephews 30%, nieces 3%, male matrilineal first cousins 19%, and female matrilineal first cousins 4%. Recurrence risks to brothers and nephews were not different; however, recurrence risks to brothers and male cousins and to nephews and male cousins were significantly different. There were no differences in recurrence risks to sisters and nieces or to either group compared with their female cousins. Affected females did not have more affected children than unaffected females. The clinical characteristics of French Canadian patients with T14484C LHON were strikingly similar to those in previous reports, suggesting that recurrence risks are generalizable to other T14484C LHON populations for genetic counseling of T14484C LHON families.

Social status and aggression: a field study analyzed by survival analysis.

A field experiment was conducted in Germany to explore whether driver characteristics and the social status of cars are related to an aggressive response. Drivers waiting at a traffic light (N = 57) were blocked by an experimental car. The amount of time that elapsed until the drivers responded by honking their horns or beaming their headlights was recorded, and bivariate and multivariate methods of survival analysis were used to analyze the data. The status of the blocked cars was positively correlated with the tendency toward an aggressive response.

Flamenco, a gene controlling the gypsy retrovirus of Drosophila melanogaster.

Gypsy is an endogenous retrovirus of Drosophila melanogaster. It is stable and does not transpose with detectable frequencies in most Drosophila strains. However, we have characterized unstable strains, known as MG, in which it transposes at high frequency. These stocks contain more copies of gypsy than usual stocks. Transposition results in mutations in several genes such as ovo and cut. They are stable and are due to gypsy insertions. Integrations into the ovoD1 female sterile-dominant mutation result in a null allele of the gene and occurrence of fertile females. This phenomenon, known as the ovoD1 reversion assay, can be used to quantitate gypsy activity. We have shown that the properties of MG strains result from mutation of a host gene that we called flamenco (flam). It has a strict maternal effect on gypsy mobilization: transposition occurs at high frequency only in the germ line of the progeny of females homozygous for mutations of the gene. It is located at position 65.9 (20A1-3) on the X chromosome. The mutant allele present in MG strains is essentially recessive. Flamenco seems to control the infective properties of gypsy.

Amaurosis fugax: prognosis and the role of acetylsalicylic acid.

Amaurosis fugax has been grouped together with other forms of transient ischemic attacks (TIAs) in the neurologic literature in analyses of prognosis. Although episodes of transient visual loss (TVL) are presumed to be due to ischemia, the prognosis with respect to subsequent stroke and myocardial infarct (MI) appears to differ from cerebral TIAs. We reviewed the clinical course of 73 patients above the age of 45 years who presented to our clinics with a distinct history of TVL. With an average follow-up period of 38 months, the incidence rates of cerebrovascular accident, cerebral TIA and MI following presentation with TVL were 1%, 4% and 7% respectively. Although there was a trend toward fewer episodes of amaurosis with use of acetylsalicylic acid (ASA), the difference was not statistically significant. In addition, ASA did not appear to offer a benefit with respect to future ischemic events. Patients with monocular TVL appeared more likely to experience a TIA, whereas those with binocular TVL appeared more likely to experience an MI.

Developmental anomalies derived from exposure of zygotes and first-cleavage embryos to mutagens.

Results of continuing studies indicate that the mouse zygote and two-cell embryo stages are a window of susceptibility in the experimental induction of congenital anomalies with certain mutagenic agents. The mechanisms by which the mutagens initiate the pathogenesis of these developmental defects are not known. However, in certain cases there is evidence that a nonconventional, perhaps epigenetic, mechanism is involved. Detailed characterization of the spectrum of anomalies induced and comparison of responses at the various stages exposed allowed classification of the mutagens generally into two groups. One group is characterized by being effective only in the early stages of zygote development and capable of producing a relatively high incidence of fetal death and hydrops. The other group affects all of the zygote stages studied as well as the two cell-embryo, but does not increase the incidence of fetal death and hydrops. Except for hydrops, chemicals in the two groups do not differ in terms of the types of anomalies present among malformed live fetuses, which bear a resemblance to a subset of common, sporadic human developmental anomalies that are of unknown etiology. This similarity raises the possibility that certain human developmental defects may have their origins in events that happen in the zygote and early pre-implantation stages.

Visual function after optic neuritis: a preliminary study.

We assessed visual function after recovery from optic neuritis in 15 consecutive patients using five objective tests: colour vision testing with Ishihara colour plates and with D15 colour desaturated spots, Humphrey automated perimetry, contrast acuity testing with Regan letter charts and testing of visual evoked response (VER). Recovery of visual function was not found to be dependent on presenting Snellen visual acuity or treatment with oral steroids. The most sensitive measures of residual visual deficit were mean defect on automated perimetry, low-contrast acuity and VER.