Reduction of pain episodes and prothrombotic activity in sickle cell disease by dietary n-3 fatty acids.

The effects of dietary n-3 fatty acids (n-3FAs) on the frequency of pain episodes and ex vivo blood tests of thrombosis have been evaluated in patients with sickle cell disease (SCD) utilizing a double-blind, olive oil-controlled clinical trial. Dietary n-3FA therapy (0.1 g/kg/d) was provided as menhaden fish oil (0.25 g/kg/d) containing 12% eicosapentaenoic acid (EPA), and 18% docosahexaenoic acid (DHA). Within 1 month dietary n-3FAs exchanged with n-6FAs in plasma and erythrocyte membrane phospholipids (p <0.01 in all cases). Treatment with dietary n-3FAs for 1 year reduced the frequency of pain episodes requiring presentation to the hospital from 7.8 events during the preceding year to 3.8 events/year (p <0.01; n = 5). By contrast, subjects receiving control dietary olive oil (n = 5) experienced 7.1 pain events/year, compared to 7.6 during the previous year (p >0.4). The reduction in episodes in n-3FA-treated subjects was also significant when compared to control subjects (p <0.01). Dietary n-3FA therapy was not associated with hemorrhagic, gastrointestinal or other adverse effects. Compared to 10 asymptomatic African-American controls, sickle cell subjects demonstrated significantly increased pretreatment: 1) flow cytometric expression of platelet membrane P-selectin (CD62p; p <0.01) and annexin V binding sites (p = 0.02); 2) plasma levels of platelet-specific secretory proteins platelet factor 4 (PF4) and beta-thromboglobulin (betaTG) (p <0.01 in both cases); 3) plasma products of thrombin generation, prothrombin fragment 1.2 (F1.2) and thrombin:antithrombin (TAT) complex (p <0.01 in both cases); and 4) plasma levels of thrombolytic products, D-dimer and plasmin:antiplasmin (PAP) complex (p <0.01 in both cases). Treatment with dietary n-3FAs concurrently decreased plasma levels of F1.2, D-dimer, and PAP (p <0.05, compared to olive oil controls), implying that the reduction in pain events was related to n-3FA-dependent inhibition of thrombosis. We conclude that dietary n-3FAs reduce the frequency of pain episodes perhaps by reducing prothrombotic activity in sickle cell disease.

Thrombogenesis in sickle cell disease.

Thirty-three subjects with sickle cell disease (SCD), 11 during episodes of pain and 22 during periods without pain, were evaluated for in vivo thrombogenic activities as compared with 10 normal black control subjects. Measurements were performed for (1) platelet surface activation, assessing flow cytometric expression of activated integrin alpha(IIb)beta(3) receptor (GPIIb/IIIa, CD41a) and P-selectin (CD62p); (2) platelet and erythrocyte surface procoagulant activities, measuring flow cytometric binding of activated factor (FVa) and annexin V; (3) plasma levels of platelet-specific secreted proteins platelet factor 4 (PF4) and beta-thromboglobulin (betaTG); (4) plasma markers of thrombin generation, prothrombin activation fragment (F(1.2)), and thrombin: antithrombin complex (TAT); and (5) plasma markers of fibrinolysis, D -dimer, and plasmin:antiplasmin complex (PAP). As compared with control subjects, asymptomatic subjects with SCD demonstrated significantly increased platelet activation (P <.01 for P-selectin and annexin V binding), elevated plasma levels of PF4 and betaTG (P <.01 and P <.03, respectively), and increased plasma concentrations of F(1.2), TAT, PAP, and D -dimer (P <.05 in all cases). During episodes of SCD pain, platelet activation was increased as compared with periods without pain (P <.01 for expression of activated integrin alpha(IIb)beta(3) receptor and P-selectin and binding of FVa and annexin V), erythrocytes expressed procoagulant activities (P <.01 for FVa and annexin V binding), and platelet microparticles appeared in the circulation (3% to 30%; P <.001). SCD pain episodes were associated with elevated plasma levels of F(1.2), TAT, PAP, and D -dimer (P <.05 as compared with asymptomatic intervals). The frequency of pain episodes correlated with enhanced platelet procoagulant activity (r = 0.61, P <.05) and elevated plasma fibrinolytic activity (r = 0.74, P <.01) measured during periods without pain. Plasma fibrinolytic activity was inversely correlated with time to the next pain episode (r = -0.50, P <.05). Thus, asymptomatic subjects with SCD exhibit ongoing platelet activation, thrombin generation, and fibrinolysis that increases during episodes of pain. These changes are predictive of frequency of pain and interval to next pain episode, thereby implicating thrombogenic activity in the development of SCD pain episodes.

Beta-cell function and visceral fat in lactating women with a history of gestational diabetes.

Lactation has been recommended as beneficial for the maternal metabolic abnormalities associated with glucose intolerance and diabetes risk, although associations between breastfeeding (BF), glucose tolerance, and adipose tissue distribution are unknown. Therefore, a population of women with recent gestational diabetes (GDM) was evaluated with comparison of results for lactating versus nonlactating women. A total of 26 women participated (14 BF and 12 nonbreastfeeding [nonBF]) with a singleton vaginal delivery after 36 weeks gestation. At 3 months postpartum, each woman completed a 75-g oral glucose tolerance test (OGTT), a frequently sampled intravenous glucose tolerance test (FSIGT), and computed tomography (CT) scanning for adipose distribution and mass. Insulin sensitivity was not significantly different between BF and nonBF groups (4.97 +/- 0.78 v 3.44 +/- 1.0 x 10(-4) min(-1)/(microU/mL) nor was glucose effectiveness (1.92 +/- 0.22 v 1.56 +/- 0.19 x 10(-2) min(-1)). However, the disposition index (DI) (insulin sensitivity [S(I)] x acute insulin response to glucose [AIRg]) was higher in the BF group (129.9 +/- 26.0 v 53.4 +/- 18.0 x 10(-4) min(-1); P =.03). Visceral fat (103 +/- 14 v 97 +/- 15 cm(2)) and subcutaneous fat (362 +/- 36 v 460 +/- 68 cm(2)) were similar between the groups. We conclude that 3 months of BF in a population with previous GDM was associated with improved pancreatic beta-cell function, but not with any difference in measures of adiposity.

The sensitivity of indicators of thrombosis initiation to a bileaflet prosthesis leakage stimulus.

BACKGROUND AND AIM OF THE STUDY: The recent clinical history and experimental studies of the Medtronic Parallel (MP) valve suggest that bileaflet valve leakage flow is a primary initiator of thrombosis. These studies investigated the effects of physiologic leakage flow through a MP valve on various markers of blood damage. METHODS: A centrifugal pump was used to drive whole, human blood anticoagulated with PPACK through a circuit containing a MP 27 mm valve in the closed position (experimental runs) or a MP 27 mm valve in the open position (control runs). Samples were taken at set time intervals after the start of the pump. These samples were analyzed by cell counting, flow cytometry, and ELISA. RESULTS: Cell counts remained relatively constant in both the experimental and control runs. Increases in plasma hemoglobin concentration and the percentage of glycophorin A-positive fragments in the cell population were not significant in either the experimental or the control runs. Plasma platelet factor 4 activity and the percentage of the CD41-positive population which was positive for annexin V increased significantly (p <0.05) in the experimental runs compared with the control runs. CONCLUSION: The results indicate that bileaflet valve leakage flow causes significant platelet disruption, that erythrocytes are more resistant to disruption by leakage flow than platelets and granulocytes, and that annexin V binding to platelets and plasma platelet factor 4 activity are more sensitive markers of leakage induced blood damage than plasma hemoglobin concentration.

Expressions of positive emotion in women's college yearbook pictures and their relationship to personality and life outcomes across adulthood.

To test hypotheses about positive emotion, the authors examined the relationship of positive emotional expression in women's college pictures to personality, observer ratings, and life outcomes. Consistent with the notion that positive emotions help build personal resources, positive emotional expression correlated with the self-reported personality traits of affiliation, competence, and low negative emotionality across adulthood and predicted changes in competence and negative emotionality. Observers rated women displaying more positive emotion more favorably on several personality dimensions and expected interactions with them to be more rewarding; thus, demonstrating the beneficial social consequences of positive emotions. Finally, positive emotional expression predicted favorable outcomes in marriage and personal well-being up to 30 years later. Controlling for physical attractiveness and social desirability had little impact on these findings.

Effects of megakaryocyte growth and development factor on platelet production, platelet life span, and platelet function in healthy human volunteers.

The effects of thrombopoietic stimulation on megakaryocytopoiesis, platelet production, and platelet viability and function were examined in normal volunteers randomized to receive single bolus subcutaneous injections of 3 microg/kg pegylated recombinant megakaryocyte growth and development factor (PEG-rHuMGDF) or placebo in a 3:1 ratio. PEG-rHuMGDF transiently doubled circulating platelet counts, from 237 +/- 41 x 10(3)/microL to 522 +/- 90 x 10(3)/microL (P <.0001), peaking on day 12. Baseline and day-12 samples showed no differences in responsiveness of platelets to adenosine diphosphate or thrombin receptor agonist peptide (P >.4 in all cases); expression of platelet ligand-induced binding sites or annexin V binding sites (P >.6 in both cases); or density of platelet TPO-receptors (P >.5). Platelet counts normalized by day 28. The life span of autologous (111)In-labeled platelets increased from 205 +/- 18 hours (baseline) to 226 +/- 22 hours (P <.01) on day 8. Platelet life span decreased from 226 +/- 22 hours (day 8) to 178 +/- 53 hours (P <.05) on day 18. The theoretical basis for senescent changes in mean platelet life span was illustrated by biomathematical modeling. Platelet turnover increased from 43.9 +/- 11.9 x 10(3) platelets/microL/d (baseline) to 101 +/- 27.6 x 10(3) platelets/microL/d (P =.0009), and marrow megakaryocyte mass expanded from 37.4 +/- 18.5 fL/kg to 62 +/- 17 x 10(10) fL/kg (P =. 015). Although PEG-rHuMGDF initially increased megakaryocyte volume and ploidy, subsequently ploidy showed a transient reciprocal decrease when the platelet counts exceeded placebo values. In healthy human volunteers PEG-rHuMGDF transiently increases megakaryocytopoiesis 2-fold. Additionally, peripheral platelets expand correspondingly and exhibit normal function and viability during the ensuing 10 days. The induced perturbation in steady state thrombopoiesis resolves by 4 weeks. (Blood. 2000;95:2514-2522)

Reduction in vascular lesion formation by hirudin secreted from retrovirus-transduced confluent endothelial cells on vascular grafts in baboons.

BACKGROUND: The hypothesis that thrombin mediates the formation of neointimal vascular lesions at sites of mechanical vascular injury has been tested in baboons by measurement of the effects of hirudin delivered by retrovirus-transduced hirudin-secreting vascular endothelial cells (ECs) lining surgically implanted arterial vascular grafts (AVGs). METHODS AND RESULTS: The antithrombotic efficacy of baboon ECs transduced with cDNA encoding hirudin was assessed in vitro and in vivo on thrombogenic segments in chronically exteriorized femoral arteriovenous (AV) shunts. Bilateral brachial AVGs lined with hirudin-transduced versus nonhirudin control ECs at confluent density were surgically implanted, and vascular lesion formations at distal graft-vessel anastomoses were compared after 30 days. Hirudin-transduced ECs secreted 20+/-6 ng x 10(6) cells(-1) x 24 h(-1) (range, 14 to 24 ng x 10(6) cells(-1) x 24 h(-1)) hirudin in supernatants of static cultures. Hirudin-secreting ECs on segments of collagen-coated graft interposed in chronic AV shunts decreased the accumulation of (111)In-labeled platelets to 0.52+/-0.34 x 10(9) platelets, compared with 0.82+/-0.49 x 10(9) platelets in controls (P = 0.03) and reduced platelet deposition in propagated thrombotic tails extending downstream from segments of vascular graft from 1.38+/-0.41 x 10(9) platelets in controls to 0.59+/-0.22 x 10(9) platelets (P = 0.04). ECs recovered from 30-day AVG implants generated 17+/-9 ng x 10(6) cells(-1) x 24 h(-1) (range, 9 to 25 ng x 10(6) cells(-1) x 24 h(-1)) hirudin. Hirudin-secreting ECs reduced neointimal lesion formation at distal graft-vessel anastomoses, ie, 1.02 mm(2) (range, 0.88 to 1.95 mm(2)) versus 1.82 mm(2) (range, 0.88 to 2.56 mm(2)) in contralateral AVGs bearing nonhirudin control ECs (P<0.01). CONCLUSIONS: Viral vector-directed secretion of hirudin from ECs lining implanted AVGs significantly reduces the formation of thrombus and neointimal vascular lesions.

Comparative safety and tolerability of clopidogrel and aspirin: results from CAPRIE. CAPRIE Steering Committee and Investigators. Clopidogrel versus aspirin in patients at risk of ischaemic events.

OBJECTIVE: The objective of this study was to provide a comprehensive comparison of the long term safety and tolerability of clopidogrel, a new adenosine diphosphate (ADP) receptor antagonist that inhibits platelet activation induced by ADP, and aspirin (acetylsalicylic acid). PATIENTS AND METHODS: The study population comprised 19,185 patients with symptomatic atherosclerosis manifested as recent ischaemic stroke, recent myocardial infarction or symptomatic peripheral arterial disease. Patients were randomised to receive clopidogrel 75 mg/day or aspirin 325 mg/day for a minimum of 1 year and a maximum of 3 years. RESULTS: Compared with aspirin, clopidogrel reduced the combined risk of ischaemic stroke, myocardial infarction or vascular death by 8.7% (p = 0.043). The incidence of early permanent discontinuations of the study drug due to adverse events was almost identical in both treatment groups (11.94% for clopidogrel vs 11.92% for aspirin). Reported neutropenia was similar in the clopidogrel and aspirin groups (0.10 vs 0.17%, respectively) with corresponding rates (0.05 vs 0.04%, respectively) for severe neutropenia. Thrombocytopenia was identical in the clopidogrel and aspirin groups (0.26%), with the rates of severe thrombocytopenia being 0.19 vs 0.10%, respectively. None of these observed differences was statistically significant. The overall incidence of haemorrhagic events did not differ statistically significantly between treatment groups (9.27% for clopidogrel vs 9.28% for aspirin; p = 0.98). There was a trend towards a lower incidence of intracranial haemorrhage in the clopidogrel group (0.31%) compared with the aspirin group (0.42%). Any reported gastrointestinal haemorrhage was significantly less frequent with clopidogrel (1.99%) than with aspirin (2.66%) [p < 0.002]. The corresponding data for severe gastrointestinal bleeding were 0.49 vs 0.71%; p < 0.05. Overall, there were significantly fewer gastrointestinal adverse events with clopidogrel than with aspirin (27.1 vs 29.8%; p < 0.001), with less abdominal pain, dyspepsia, constipation, or peptic, gastric, or duodenal ulceration with clopidogrel. Diarrhoea was significantly more common in the clopidogrel group (4.46 vs 3.36%; p < 0.001), although the incidence of severe diarrhoea (0.23 vs 0.11%) was low and was not significantly different between groups. There were significantly more patients with rash in the clopidogrel group (6.0%) compared with the aspirin group (4.6%) [p < 0.001]. However, these events were generally mild and transient in nature. CONCLUSION: Given the favourable benefit/risk ratio, clopidogrel represents a clinically important advance in the treatment of patients with manifest atherosclerotic disease.

The progression of thrombus in an ex-vivo shunt model evaluated by intravascular ultrasound radiofrequency analysis.

We tested the ability of ultrasound radiofrequency (RF) signal analysis to characterize thrombus accumulation in a Dacron graft incorporated into the exteriorized arteriovenous shunt in 3 baboons with constant blood flow for 60 min. Thrombus formation was quantified by sequential measurements of 111Indium-labeled platelet deposition. RF signals were acquired every 15 min at 2 sites in the graft, using a 2.9 Fr intravascular ultrasound catheter-based transducer (30 MHz) and digitized at 250 MHz in 8-bit resolution. Regions of interest were placed within a 0.5-mm perimeter adjacent to the graft wall. Integrated backscatter increased significantly (p < 0.001) with increasing platelet deposition. However, mean-to-standard deviation ratio of the RF envelope showed no significant change and the distribution pattern of the RF probability function remained constant and consistent with a Rayleigh scattering process. These results provide a basis for using RF analysis to monitor the time-course of thrombus formation.

Physiology and clinical applications of platelet growth factors.

Recombinant human thrombopoietin, or pegylated recombinant human megakaryocyte growth and development factor, produces log-linear increases in megakaryocytopiesis and platelet production. Recent clinical studies investigating the efficacy, safety, and cost benefit of administering platelet growth factors indicate that appropriate dosing of pegylated recombinant human megakaryocyte growth and development factor, or recombinant human thrombopoietin, during chemotherapeutic marrow suppression produces these increases in four ways. First, these factors improve ensuant thrombocytopenia without producing platelet-dependent thrombo-occlusive complications. Second, recombinant human thrombopoietin or pegylated recombinant human megakaryocyte growth and development factor mobilize hematopoietic progenitor cells into the peripheral blood. Third, chronic dosing of HIV-infected thrombocytopenic patients with pegylated recombinant human megakaryocyte growth and development factor normalizes peripheral platelet counts without antibody formation. Fourth, the administration of pegylated recombinant human megakaryocyte growth and development factor to normal human volunteer platelet donors increases platelet yields nearly fourfold, with corresponding increases in peripheral platelet counts when transfused into thrombocytopenic recipients. The clinical application of platelet growth factors is continuing to be defined.

Prophylactic angioplasty reduces thrombosis in virgin ePTFE arteriovenous dialysis grafts with greater than 50% stenosis: subset analysis of a prospectively randomized study.

PURPOSE: To determine if prophylactic percutaneous transluminal balloon angioplasty (PTA) can extend patency in functioning virgin ePTFE arteriovenous hemodialysis grafts. MATERIALS AND METHODS: The results of a prospectively randomized study of 64 patients with greater than 50% stenosis of functioning ePTFE arteriovenous hemodialysis grafts who were blindly assigned to be treated with PTA (treatment group) or observed without treatment (control group) were subjected to statistical subset analysis. Within this group were 21 patients (virgins) who had never undergone surgery, PTA, or thrombolysis. Eight patients had been assigned to the treatment group and 13 to the control group. The virgin groups were well matched as to age, sex, and risk factors. The virgin treatment group versus virgin control group had 1.63 versus 1.46 stenoses per patient and 61.3% versus 63.3% average percentage stenosis per lesion, respectively. Stenoses were treated with PTA 27 times (average, 3.4 per patient) in the virgin treatment group. Primary study patency began at the time of randomization and ended with graft thrombosis or nonfunction. RESULTS: Among the 32 patients randomized to treatment with PTA, study patency was significantly increased (P > .0001) and the incidence of graft thrombosis significantly decreased (P = .0151) in the eight-patient virgin subset when compared with the 24-patient nonvirgin subset of the treatment group. During the 81.3 patient-dialysis-year study period, patency in the virgin-treatment versus virgin-control groups, respectively, was terminated by thrombosis in two versus nine, by death in two versus two, and cadaveric renal transplant in one versus zero. There was a statistically significant prolongation of study patency (P = .0349) and a reduction of graft thromboses, 0.10 versus 0.44 thromboses per patient-dialysis year, in the virgin-treatment group compared to the virgin-control group. CONCLUSION: Patency after PTA of ePTFE hemodialysis grafts is significantly affected by previous interventions. Prophylactic PTA of stenoses greater than 50% in functioning virgin ePTFE arteriovenous hemodialysis grafts can significantly extend their patency. PTA should be included as an important treatment option in this patient population.

Implantation of the CLARION cochlear implant in an ossified cochlea.

This report describes the successful implantation of the CLARION Multi-Strategy Cochlear Implant electrode in the totally ossified cochlea of a 5-year-old child via a radical mastoidectomy approach. Postoperatively, the child demonstrated responses to auditory stimuli, even though the electrode array contacted only bone and muscle graft tissue with no visible evidence of nerve fibers or cochlear lumen. Responses to sound did not begin to emerge until 10 weeks following initial stimulation and improved slowly over time. Although the child's postoperative auditory performance is more limited than that of most implanted children, she derives substantially more benefit from her implant than she did from conventional hearing aids.

Multichannel cochlear implantation in children with large vestibular aqueduct syndrome.

This study examined the postoperative performance of multichannel cochlear implantation in children with severe-to-profound sensorineural hearing loss secondary to large vestibular aqueduct syndrome. Five children between ages 4 and 13 years who had large vestibular aqueducts confirmed by computed tomography scans underwent implantation of a CLARION Multi-Strategy Cochlear Implant between January 1995 and June 1996 at Boys Town National Research Hospital. In addition to preoperative evaluations, they were examined postoperatively with their implants on a battery of open-set speech recognition tests at 3, 6, 12, and 18 months following initial stimulation. Results indicated a noticeable improvement in open-set speech recognition within the first 3 months of implant use compared to preimplant performance with hearing aids. All 5 patients demonstrated substantial benefit from their implants, but there was variation among the children in the rate and amount of improvement in speech recognition skills.

Clopidogrel inhibition of stent, graft, and vascular thrombogenesis with antithrombotic enhancement by aspirin in nonhuman primates.

BACKGROUND: A recent study showed that clopidogrel reduces thrombo-occlusive complications in patients with symptomatic atherosclerosis more effectively than aspirin. METHODS AND RESULTS: The effects of clopidogrel and aspirin have been compared, singly and in combination, for measurements of 111In-labeled platelets and 125I-labeled fibrin deposition in baboon models of arterial thrombosis and related to platelet aggregation and expression of activation epitopes induced by ADP, collagen, and thrombin receptor agonist peptide (TRAP) and to template bleeding times (BTs). Low-dose oral clopidogrel (0.2 mg. kg-1. d-1) produced cumulative (1) intermediate decreases in 111In-platelet and 125I-fibrin deposition for segments of prosthetic vascular graft, deployed endovascular metallic stents, and endarterectomized aorta (P<0.009 in all cases); (2) elimination of ADP-induced platelet aggregation (P<0.001); (3) modest inhibition of collagen-induced platelet aggregation (P<0.01); (4) no reduction in TRAP-induced platelet aggregation; and (5) minimal prolongation of BTs (P=0.03). High-dose oral clopidogrel (>/=2 mg/kg) produced the same effects within 3 hours. The effects of clopidogrel dissipated over 5 to 6 days. Aspirin 10 mg. kg-1. d-1 alone did not decrease 111In-platelet and 125I-fibrin deposition on segments of vascular graft but detectably decreased 111In-platelet and 125I-fibrin accumulation on stents (P<0.01), minimally inhibited ADP- and collagen-induced platelet aggregation (P<0.05 in both cases), and minimally prolonged BTs (P=0.004). Within 3 hours of aspirin administration, the antithrombotic effects of acute high-dose or chronic low-dose clopidogrel were substantially enhanced, and BTs were modestly prolonged without inhibiting platelet aggregation induced by TRAP (P<0.001 in all cases compared with clopidogrel alone). CONCLUSIONS: Clopidogrel produces irreversible, dose-dependent, intermediate reduction in thrombosis that is substantially enhanced by the addition of aspirin. The effects of combining aspirin and clopidogrel need to be evaluated in patients at risk of vascular thrombosis.

Tone burst auditory brain stem response latency estimates of cochlear travel time in Meniere's disease, cochlear hearing loss, and normal ears.

OBJECTIVE: The current study sought to determine whether tone burst auditory brain stem response (ABR) latencies could be used to detect an increase in the cochlear traveling wave velocity in patients with Meniere's disease. BACKGROUND: It has been proposed that the derived band ABR technique can be used to show an increase in cochlear traveling wave velocity in patients with Meniere's disease. The current study sought to replicate these findings using tone burst ABR at frequencies of 0.5, 1, 2, 4, and 8 kHz and intensities from 40-100 dB hearing loss (HL) in 10-dB steps. METHODS: Wave V latency differences between adjacent frequencies were taken to represent the time it takes the traveling wave to travel between the "place" on the basilar membrane where these two frequencies are represented. Thirty-two subjects participated in the project consisting of 10 with normal hearing, 10 with cochlear HL (not caused by Meniere's disease), and 12 with Meniere's disease. RESULTS: There were no significant differences in absolute wave V latencies or in wave V latency differences (travel time estimates) between the groups (repeated measures analysis of variance, p > 0.05). CONCLUSION: These results suggest that wave V latencies and estimates of cochlear travel time cannot be used to distinguish Meniere's disease from other forms of cochlear HL or from normal-hearing ears. The results of this study differ from those using the derived band ABR technique. This difference may be because of the disease state of the authors' subjects or differences in stimulus paradigm.

Single gene influences on radiologically-detectable malformations of the inner ear.

Inner ear malformations associated with hearing loss or vestibular dysfunction are discussed from the viewpoint of the etiologies of the malformation. Symptoms of classification of inner ear malformations are discussed. The significance of malformations of the cochlea and vestibular aqueduct to auditory function are discussed. Genetics features and characteristics of Branchio-oto-renal, Waardenburg's, Pendred's, DiGeorge's, Wildervanck, Fountain, and Treacher Collins syndromes are discussed in relation to ear abnormalities and hearing. Similar attention is given to genetic studies of nonsyndromic hearing loss.

Therapeutic inhibition of platelet function in stroke.

Platelet-dependent thrombotic- and thromboembolic-occlusive events are the usual cause of ischemic strokes. Antiplatelet strategies target one of the three platelet recruitment pathways (thromboxane A2, adenosine diphosphate, or thrombin) or the common cohesion pathway involving integrin alphaIIbbeta3 fibrinogen receptors. Aspirin selectively and irreversibly interrupts TxA2 and decreases events by 20-25%. Clopidogrel selectively and irreversibly inactivates platelet-ADP receptors and reduces events by 30-35%. Additive effects are produced by combining aspirin and clopidogrel. Integrin alphaIIbbeta3 fibrinogen receptor antagonists, such as abciximab, produce dose-dependent inhibition of platelet recruitment and thrombo-occlusive events, regardless of the agonist(s) initiating platelet activation, but correspondingly impair platelet hemostatic function. Because chronic antiplatelet therapy has the potential for producing abnormal bleeding it is important for current clinical trials to evaluate the benefit risk relationship.