Radiographic appearance of the chest in emphysema.

Accuracy of the radiologic diagnosis of emphysema was assessed in 696 patients from whose lungs paper-mounted whole-lung sections had been made. Emphysema was diagnosed radiographically primarily on the basis of arterial deficiency. In addition, lung length, lung width, size of the retrosternal space, heart size, and diaphragm position were recorded from the chest films. Recognition of emphysema was poor when radiographs of inadequate quality were included (anteroposterior films or films from patients with acute or chronic lung disease). When these films were excluded, only occasional radiographs from patients without emphysema or with mild emphysema were thought to have emphysema radiologically. Of the patients with moderately severe and severe emphysema, 41% were diagnosed as having emphysema, as were two-thirds of those with the most severe grade of emphysema. For a given grade of emphysema, the radiologic diagnosis of emphysema was made more frequently when patients had severe chronic airflow obstruction. Emphysema was usually most severe in the zones of the lung in which emphysema was radiologically apparent. Centrilobular emphysema was usually present when emphysema was diagnosed radiologically in the upper zones of the lung, and panacinar emphysema was usually present when emphysema was diagnosed in the lower zones. Lung length and the size of the retrosternal space increased, the level of the diaphragm lowered, heart size decreased, and lung width was unchanged as emphysema became more severe. Lung length and diaphragm level were the most discriminating measurements, followed by size of the retrosternal space. No combination of radiologic variables was found that recognized emphysema better than the subjective diagnosis of emphysema based on arterial deficiency. Radiologic lung dimensions are related to stature; for given stature these measurements are larger in men and women.


"Saber-sheath" trachea: relation to chronic obstructive pulmonary disease.

Sixty male patients with marked coronal narrowing of the intrathoracic trachea (saber-sheath configuration) were compared with 60 controls. Scores were assigned to patients according to separate clinical and radiographic indexes of chronic obstructive pulmonary disease (COPD). Of the 60 patients with the saber-sheath configuration, 57 (95%) had clinical evidence of COPD compared to only 18% in the control group. Of these 57, 26 (45%) lacked conventional radiographic evidence of COPD. This study establishes a strong correlation between saber-sheath trachea and clinical COPD. The value of this radiographic sign is twofold: (1) as an aid in diagnosing COPD when other convincing radiographic evidence is lacking; and (2) to avoid an erroneous assumption that coronal narrowing is due to a mediastinal mass.


Giant mediastinal lymph node hyperplasia (Castleman's disease): angiographic and clinical features.

The angiographic and clinical features of two cases of mediastinal angiofollicular lymph node hyperplasia (Castleman's disease) are presented. The masses were angiographically and microscopically extremely hypervascular. Both patients had profuse bleeding at initial surgery. In one patient, angiographic embolization after an initial attempt at resection made complete excision possible. These lesions behave in a benign fashion, and complete surgical excision is curative.


Angiocardiographic differentiation of constrictive pericarditis and restrictive cardiomyopathy due to amyloidosis.

The cineangiocardiograms and coronary angiograms of two cases of amyloidosis of the heart were compared to six cases of constrictive pericarditis. Three angiographic differentiating points were seen: (1) right ventricular free wall motion showed diastolic restriction in both disorders, whereas the crista supraventricularis, which moved normally in constrictive pericarditis, demonstrated restriction in amyloidosis; (2) ventricles in cases of constrictive pericarditis showed subtle further expansion during atrial systole after initial rapid filling (atrial kick), while in both cases of amyloidosis there was no motion during atrial systole; (3) pericardial thickening in constrictive pericarditis was demonstrated by failure of the distal coronary arteries to reach the surface of the cardiac image. In amyloidosis, the distal coronary arteries normally reached the periphery of the image. All three signs may be useful in differentiation, but the first is the easiest to evaluate. The right anterior oblique or posteroanterior view is the recommended projection.


Complications of angiographic examinations.

A prospective study of angiographic complications in 1,217 consecutive adult patients seen during a 1 year period was undertaken. Neuroangiographic and angiocardiographic examinations were excluded. All forms of complications were reported, including those occurring within 3 days after the examination, and the degree of seriousness was evaluated. Complications at puncture which required surgery occurred in 0.14%. Potentially serious complications from catheter manipulation for selective position in abdominal arteries occurred in 0.5%. At catheterization of the internal iliac artery there was a high frequency of lesions (14.3%), one an indirect cause of lethal outcome. Nine patients had thromboembolic complications, and the value of heparinized catheters is discussed. The frequency of serious complications due to contrast agent was remarkably low.


Irregularity of Silastic breast implants mimicking a soft tissue mass.

Seven patients were identified who developed a palpable breast mass following augmentation mammoplasty. Xeromammography showed the "mass" to be a puckering or bulge in the Silastic implant.


Transverse folds in the proximal ureter: a normal variant in infants.

Infants frequently have a "corkscrew" appearance of the upper segment of the ureter at excretory urography. In most instances, this tortuous appearance is due to thin transverse folds. These folds are full-thickness inward projections of the ureteral wall. They are believed to represent a persistence of normal fetal tortuosities of the ureter.


Streptococcal skeletal infections: observations in four infants.

The radiographic findings and clinical presentations of four patients with group B beta hemolytic streptococcal osteomyelitis and pyoarthritis are described. Radiographic features, though not specific, are similar in these patients and others reported in the literature. The combination of radiographic patterns and clinical presentations in children of this age group should alert clinicians and radiologists to the possibility of infection with this organism.


Medial herniation of the parietal pleura: a useful sign of pneumothorax in supine neonates.

In a series of 235 consecutive infants with respiratory distress syndrome, pneumothorax was demonstrated radiographically in 20. On anteroposterior supine chest radiographs of such infants, the intrapleural gas tends to seek an anteromedial position within the involved hemithorax. When the pneumothorax is large, the gas may cause the ipsilateral mediastinal pleura to bulge and herniate across the anterior mediastinum into the contralateral hemithorax. This was seen in 12 or the 14 right pneumothoraces, but only in two of the 10 left ones. The gas-containing sac appeared radiologically as a crescent-shaped lucency medial to the upper thoracic spine which was sharply delineated laterally by the mediastinal pleural layers and the somewhat atelectatic contralateral lung. In some patients treated with a chest tube, the gas disappeared more slowly from the herniated portion of the pleural sac than from elsewhere in the pleural space. Therefore, in addition to being a useful confirmatory sign of pneumothorax, this finding is also important in assessing the completeness of pleural drainage.


Chronic mucocutaneous candidiasis: radiologic abnormalities in the esophagus.

Chronic mucocutaneous candidiasis is a disorder characterized by chronic recurrent infection with Candida. The esophagus may be involved, resulting in chronic candidal esophagitis, which is clinically and radiographically distinct from acute candidal esophagitis. The clinical and radiographic features of four new and four previously reported cases are presented. Esopahgeal narrowing was found in all patients; it was focal in six and diffuse in two. Motor abnormalities were common, but mucosal changes seen characteristically in acute candidal esophagitis were unusual. Esophageal intramural pseudodiverticulosis was documented in one patient, substantiating the belief that Candida may be the etiologic agent in some patients with this condition.


Preliminary abdominal films in oral cholecystography: are they necessary?

A survey of 45 radiologists with a special interest in gastrointestinal radiology showed that only 8% used a preliminary abdominal film for oral cholecystography. Review of 467 cases of oral cholecystography with preliminary films over a 1 year period disclosed 88 confirmed cases of cholelithiasis. Of these 88 cases, 27% had opaque gallstones visible on the preliminary film. In one-third of the cases, the opaque gallstones had a classic diagnostic appearance, while the remainder required oral cholecystography for confirmation. Opaque calculi were obscured by oral contrast material in 2% of cases. Other significant pathology on the preliminary films was found in 5.5% of the 467 cases.


Selective intubation of the afferent loop.

A selective intubation method for examination of the afferent loop is described and brief review of complications involving the afferent loop is outlined. The value of the intubation method in patient management is illustrated by three case reports. We find this a helpful method for studying selected patients with clinical problems related to the afferent loop.


Fractures of the thoracolumbar spine in ankylosing spondylitis.

Fractures through the disc or juxta-end plate region of the vertebra as well as the posterior elements have been observed in the thoracic and lumbar spine in ankylosing spondylitis. These are usually associated with increasing pain, usually do not produce neurologic deficit, and may require orthopedic fixation to heal. Irregularity and sclerosis at the margins secondary to pseudarthrosis may develop and should not be confused with a pyogenic or granulomatous infection. Biomechanically these fractures resemble the "seat belt type" or Chance fracture probably because of shifting of the axis of flexion and extension in the ankylosed spine away from its normal location in the center of the nucleus pulposus.


Radiologic soft tissue shadows in the pelvis: another look.

In patients with adequate amounts of intramuscular fat, the normal contours of the muscles of the pelvic floor and side-walls may be visualized on plain radiographs. Knowledge of the relationships of these muscles to surrounding structures has been facilitated by computed tomography. Obliteration of the medial margin of the psoas muscle with an attendant soft tissue mass implies pathology in the region of the medial chain of external iliac lymph nodes; similarly, obliteration of the obturator internus shadow suggests internal iliac adenopathy. Nonnodal masses in these regions can cause similar radiographic abnormalities. The normal shadow of the piriformis muscle may simulate external iliac adenopathy. Pitfalls which may lead to overinterpretation are discussed.


Sequelae of metrizamide myelography in 200 examinations.

Twenty pediatric and 180 adult patients underwent myelography using metrizamide (Amipaque). All patients were examined and interviewed before and after the studies. New or exacerbated symptoms attributed to metrizamide myelography were graded according to severity. After the procedure, 51 of 200 patients were unchanged from baseline. Headache was the most common complaint, with an overall incidence of 62%. Nausea and/or vomiting occurred in 38%. Back or leg pain, neck stiffness, temperature elevation, and a variety of less common manifestations were also observed. The incidence of sequelae was higher than in comparable Scandinavian studies with this contrast medium.


Computed tomography of the trapped fourth ventricle.

A dilated fourth ventricle due to outlet obstruction is a clinical-radiologic entity with symptoms similar to those of a posterior fossa space-occupying lesion. Computed tomography reveals cystic dilatation of the fourth ventricle and hydrocephalus supratentorially. Frequently the symptoms resolve completely and the fourth ventricle returns to normal following lateral ventricular shunting. If there is actual obliteration of the aqueduct, the fourth ventricle must be shunted directly. While the exact mechanism by which the fourth ventricle becomes trapped is not fully known, outlet obstruction must be present. It is most frequently related to previous episodes of meningitis or subarachnoid hemorrhage. In a review of 48 cases of an abnormally enlarged fourth ventricle demonstrated on CT, six were found to have a trapped fourth ventricle. Careful attention to densities and configurations on CT allows its differentiation from other lesions such as cystic tumors and cysts.


Subdural hematomas due to ruptured cerebral aneurysms: angiographic diagnosis and potential pitfall for CT.

Two patients with subdural hematoma secondary to rupture of intracranial aneurysms are described. Computed tomography and plain skull films are generally the examination of choice for the patient with significant head trauma. In selected patients, however, cerebral angiography in place of, or along with, computed tomography may be necessary to demonstrate an underlying cause for the subdural hematoma.


Computed tomography in leptomeningeal infections.

In a review of CT scans of 6,078 patients, 47 patients with well documented leptomeningeal infections were identified; 45 were infants or children. Most of the infections were bacterial; 53% were due to Haemophilus influenzae. The 47 patients were divided into two groups according to whether the initial scan was obtained during the acute illness (group A) or after initial treatment had been completed (group B). The 30 patients in the acute group A had 24 complications: 18 with areas of diminished attenuation in the brain parenchyma and six with dilated ventricles. Eleven patients had initially normal scans, but three of these subsequently developed complications. In group B, the 17 patients had 28 complications: nine with enlarged ventricles; eight with subdural effusion; seven with areas of diminished attenuation; and four with abscess formation. An unusually high percentage (40%) of the patients with areas of diminished attenuation had involvement of the anterior poles of the frontal lobes. Of the patients who showed this predilection for the frontal lobes, 72% had Haemophilus influenzae meningitis. CT was found to be useful in early detection of complications of leptomeningeal infections, as well as in evaluation of the extent of the lesions.


Quantitative thyroid fluorescent scanning: technique and clinical experience.

A method for quantifying thyroid gland iodine content using a modified fluorescence scanning system is described. The technique does not require a computer. Two single channel analyzers and digital scalers are used to determine net counts from iodine k-alpha x-rays and system response in counts per milligram is calibrated from studies of known quantities of iodine placed in thyroid phantoms. Fluorescence quantification of thyroid gland iodine content was performed in 250 patients with a wide variety of thyroid disorders. Thirty euthyroid patients judged to have no evidence of thyroid disease averaged 10.1 +/- 3.9 mg glandular iodine. Results for several major diagnostic categories were: untreated Graves' disease, 28 patients, 24.4 +/- 9.9 mg; diffuse euthyroid goiter, 14 patients, 16.1 +/- 7.4 mg; primary hypothyroidism, seven patients, 0.5 mg; and nontoxic multinodular goiter, 28 patients, 7.3 +/- 4.1 mg. Follow-up studies on patients treated for Graves' disease both medically and with 131I generally revealed elevated iodine contents in persistently hyperthyroid patients, lower than normal average amounts in euthyroid patients, and only trace amounts in hypothyroid patients. Although the clinical role of fluorescence iodine quantification remains to be fully established, the technique provides information not otherwise available on an important parameter of thyroid status.


New technique for localization of therapeutic emboli using radionuclide labeling.

A sensitive method for localizing the resting place of catheter-injected therapeutic gelatin emboli is described. Surgical gelatin (Gelfoam) is labeled with 99mTc and each embolus observed on the persistence scope of a gamma camera after injection. This technique reduces the chance of obstructing blood vessels other than those intended. Two cases of embolization, one arterial and one venous, are illustrated.


Double inferior vena cava or iliac vein occlusion? A diagnostic problem in radionuclide venograms.

Radionuclide venography in two patients with suspected deep venous disease revealed double channel drainage with cross-pelvic collateral circulation. Contrast inferior venacavograms revealed that one patient had persistent right and left supracardinal veins (double inferior vena cava) and the other had iliac vein occlusion with ascending lumbar collateral circulation. The similarity of radionuclide venographic findings in these two patients emphasizes the importance of contrast venacavography in patients with this appearance on radionuclide venography.


The inferior vena cava: mass effects.

Gray scale ultrasound evaluation of the inferior vena cava is essential for adequate workup of abdominal tumors. Demonstration of perivascular nodal masses and/or invasion of the inferior vena cava is of prognostic significance and of value in planning the surgical approach. In addition, accurate delineation of the extent of such tumor invasion by ultrasonography may preclude additional study by more invasive diagnostic procedures, such as angiography. Results of ultrasonic examination of six patients are reported; all were shown to have significant mass effects on the inferior vena cava.


Fetal movement patterns: a possible means of defining neurologic developmental milestones in utero.

Phased-array ultrasonography provides a means for continuous observation of moving structures. This method can be used for assessing fetal movements from the middle of the first trimester. Eleven separate spontaneous movement patterns were defined in 40 examinations of clinically normal women (6 weeks to term). A trend of increasingly complex movement with advancing gestational age was noted with indication that discrete developmental events such as isolated body extension, thumb sucking, or repetitive chest wall excursions can be recognized. Fetal movement responses to a simple pressure stimulus were noted.


Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies.

Intravascular embolization of polyethylene catheter fragments continues to occur, the majority from intravenous indwelling catheters. Sixty-nine nonsurgical retrievals of embolized fragments have been reported. The various recorded retrieval techniques are reviewed as well as their respective successes and limitations. Complications of snare techniques, unsuccessful retrieval attempts, and factors influencing the choice of local surgical removal versus snare techniques are discussed. The fate of patients from whom embolized catheter fragments were not removed is reviewed in depth. Our figures indicate a 71% incidence of death or serious complication, which is significantly higher than previously reported.


Neurofibromatosis in children.

Neurofibromatosis occurs once in every 3,000 live births. Café au lait spots are the most common presenting lesion. Five spots with a diameter of at least 0.5 cm. should be considered diagnostic in children. Spinal deformity is the most common bony lesion. Scoliosis varies from mild nonprogressive forms to hairpin curvatures. Four types of pseudarthrosis of the tibia can be distinguished, with progressively more serious prognoses. The incidence of neoplasia greatly exceeds that of the general population.


The biological effects of magnetic fields on man.

The biological effects of the interaction of stationary magnetic fields (SMF) with man and other animals have been reviewed. The lowest detectable limit of interaction between higher animals and a SMF is 80 to 100 G. The recommended limit on an extended-period basis for whole-body or head exposure is 200 G. Higher limits of magnetic-field exposure for limited periods of time are contained within this report.


Hypophysial portal vascular infusion of TRH in the rat: an ultrasturctural and radioimmunoassay study.

The hypophysial portal vessels and anterior pituitary gland of adult male Wistar rats were exposed surgically. A hypophysial portal vessel was cannulated and infused for one minute with saline or thyrotrophin (TRH). Anterior pituitary glands were collected at 1,5,15,30 or 60 minutes after cessation of infusion, for light and electron microscopic examination. Before and immediately after cannulation of a portal vessel, a 1-ml sample of blood was collected at 1,5,15,30, or 60 minutes, from the femoral vein for radioimmunoassay (RIA) of growth hormone. Thyrotrophs from anterior pituitary glands of rats infused with TRH displayed emiocytic activity at all time-periods studied. Rough endoplasmic reticular (RER) cisternae were dilated at 15 minutes following infusion and remained dilated at 30 and 60 minutes. TRH was observed to stimulate emiocytic activity in most pituitary cell-types. Extensive dilations of RER cisternae were also observed in mammotrophs and gonadotrophs, but were not observed in somatotrophs or adrenocorticotrophs. The demonstration that thyrotrophs, mammotrophs, somatotrophs, and gonadotrophs respond to TRH suggests that some common features may be shared by these cells. Preliminary analysis of the RIA data show that TRH was potent in elevating radioimmunoassayable growth hormone levels. Significant increases (p less than 0.02) in plasma GH levels were present at the earlier time periods studied (1,5, and 15 minutes) following the infusion of TRH, but no at 30 or 60 minutes. These findings provide additional support for the non-specific action of TRH upon hte various adenohypophysial cell types, and demonstrate that TRH stimulates these cells by a direct action on the adenohypophysis.


Protein deprivation in primates. X. Test performance of juveniles born of deprived mothers.

Forty juvenile rhesus monkeys whose mothers were fed semisynthetic diets containing 13.4, 6.7, or 3.35% protein during pregnancy were tested as juveniles on four tests of perceptual-discrimination learning. All juveniles were well fed since birth. No significant differences in proficiency due to diet could be detected. It is concluded that thanks to the mother's proficient adaptation to the diet the fetus is well protected, and not deprived.


Protein deprivation in primates. XI. Determinants of weight change during and after pregnancy.

Individual differences in weight gain of rhesus monkeys during pregnancy far exceed the variation in infant weight. Weight gain thus reflects maternal adjustment to her physiological state in relation to her environment rather than growth of the infant. Diets high in protein lead to great weight gain. Skeletal length is positively correlated and conception weight negatively correlated with weight gain. Season of pregnancy, length of gestation and sex of the infant are unrelated to weight gain. None of the monkeys exhibited edema during gestation. Postpartum changes in body weight were small during the first 6 weeks.


Thyroid iodide clearance and radioiodide uptake in protein-calorie malnutrition.

The thyroid function was evaluated in two comparable groups of 12 protein-calorie malnourished children respectively by oral and intravenous test using radioiodine 131I. Maximal radioiodide uptake (RAIUmax) peaked within 24 hr in the intravenously investigated children, but only after 48 hr in the orally investigated children. In both protein-calorie malnutrition groups, the mean RAIUmax was significantly decreased by comparison with the mean normal RAIUmax (P less than 0.01). In protein-calorie malnutrition children, the RAIU curve reached intermediate values ranging from subnormal to about nearly half the normal. Thyroid clearance was early depressed and in some cases, dropped to values as low as one tenth of the normal mean (P less than 0.001), reflecting a severe thyroid involution. There is a high correlation between the RAIUmax and thyroid clearance values (r = 0.95); the regression line is defined by the equation Y = 1.12X + 17.08. Both functional parameters of thyroid activity appear to be mainly lowered in relation to the duration of protein deficiency.


Assessment of protein-calorie malnutrition in surgical patients from plasma proteins and anthropometric measurements.

Six plasma proteins, two anthropometric measurements, hemoglobin and total lymphocytes were determined in 54 surgical patients and 19 normal individuals. Preoperative patients had a low mean values for prealbumin, retinol binding protein, and arm muscle circumference. In postoperative patients, plasma transferrin, albumin, hemoglobin, total lymphocytes and body weight were also low and complement C3 was higher than normal. A correlation matrix for 10 variables showed interrelationships between the biochemical and anthropometric data. Prealbumin and transferrin were highly correlated with most of the variables. The effects of protein-calorie malnutrition were analyzed from the data ranked and grouped according to the plasma prealbumin or transferrin concentration. Those groups with low mean values for these proteins also had low values for most of the other variables. Protein calorie malnutrition in surgical patients may be conveniently assessed from plasma prealbumin, transferrin, arm muscle circumference, percentage weight loss, and hemoglobin.


Intravenous feeding of the rat with short chain fatty acid esters. II. Monoacetoacetin.

Acetoacetic acid is oxidized independent of carnitine transport into the cell mitochondria and its monoglyceride is a water soluble compound. The latter was examined as an intravenous nutrient. The monoglyceride of acetoacetic acid was prepared from the acid anhydride, diketene, and glycerol and was found to be totally miscible with water. The nutritional properties of monoacetoacetin were investigated by continuous intravenous infusion of 25 or 50 g/kg body weight per day into ad libitum fed rats. The response of these animals was compared to normal and food restricted rats. All experimental animals survived the 7 day study period in good health and were free of detectable physiological and behavioral abnormalities. The test rats demonstrated weight gain dependent on the infusion rate while on an inadequate spontaneous oral food intake diet. Ketonuria, hyperketonemia and monoglyceride excretion in the urine accompanied the infusion of monoacetoacetin and were dependent on the infusion load. At 50 g/kg per day total plasma ketones were found to be comparable with the infusion load. At 50 g/kg per day total plasma ketones were found to be comparable with the maximum level obtained in fasted rats, but the acetoacetate concentration was relatively higher than in fasting. This was consistant with ketosis derived from the hydrolysis of the monoglyceride. It was concluded from these results that monoacetoacetin might be an asset for intravenous nutrition.


Are proteinase inhibitors a factor for the derangement of homoeostasis in protein-energy malnutrition?

In protein-energy malnutrition essential amino acids for the synthesis of proteins are derived from the mobilization of endogenous proteins in order to maintain homoeostasis. Data are presented to support the hypothesis that proteinase inhibitors, which increase rapidly at the onset of infection, interrupt this catabolic effect which is the normal adaptive response to protein-energy malnutrition.


Effects of antineoplastic drugs on Lactobacillus casei and radioisotopic assays for serum folate.

Microbiologic assay, usually employing Lactobacillus casei, remains the standard assay for serum folate to date. Among its disadvantages have been falsely low results in patients receiving bacteriostatic agents such as antibiotics. This study examined whether commonly used antineoplastic drugs had similar effect. Methotrexate and 5-fluorouracil depressed microbiologic serum folate levels. No effect was found for adriamycin, bleomycin, BCNU, cyclophosphamide, cytosine arabinoside, vincristine, vinblastine, mechlorethamine, mithramycin, hydroxyurea, and hydrocortisone. None of the drugs affected radioassay except methotrexate, which produced falsely high folate results. Thus, it appears that L. casei assay for folate becomes unreliable in patients receiving 5-fluorouracil and radioisotopic assay becomes unreliable in those receiving methotrexate.


Cost effectiveness of the autopsy in maintaining and improving the standard of patient care.

A research model has been designed to attempt to obtain data that would help make the autopsy more effective in bringing about better patient care. To maintain and improve patient care, we must demonstrate that which is good about the present state of the practice of medicine and maintain it, and those areas in which improvement is possible, and then strive to change them. The autopsy can play an important role in this process. A better understanding of the mechanism by which the autopsy achieves this key role will enhance its contributions.


Crisis intervention and the prevention of institutionalization: an interrupted time series analysis.

In the context of the community mental health movement in Illinois, the evolution and development of a crisis intervention program aimed at avoiding state hospitalization and bringing more appropriate and efficacious resources to bear on the difficulties of the individual and/or family is described. This intervention program is characterized by a more active-seeking style of delivering mental health services. With the novel application of interrupted time series analysis to both the targeted and matched nonequivalent control communities the efficacy of this more active intervention in reducing the number of state hospital administrations diagnosed as "mentally ill" is highlighted. The cost/benefit to the taxpayer is also discussed.


HB-Ag in sweat.

Thirty patients were studied at the Hacettepe University Medical Center. Ten patients had hepatic cirrhosis, 20 patients had viral hepatitis. HB-Ag in the serum was positive in all patients by the counterimmunoelectrophoresis method. One and a half milliliters of sweat was collected from each patient, dried and dissolved in 0.2 ml. of buffer solution. HB-Ag was positive in all patients by radioimmunoassay method. This study indicates that direct contact is one of the most important factors in the epidemiology of the disease and this may even be more important in asymptomatic carriers.


Health care cost-containment regulation: prospects and an alternative.

Regulation of the health care system to achieve appropriate containment of overall costs is characterized by Professor Havighurst as requiring public officials to engage, directly or indirectly, in the rationing of medical services. This rationing function is seen by the author as peculiarly difficult for political institutions to perform, given the public's expectations and the symbolic importance of health care. An effort on the part of regulators to shift the rationing burden to providers is detected, as is a trend toward increasingly arbitrary regulation, designed to minimize regulators' confrontations with sensitive issues. Irrationality and ignorance are found to plague regulatory decision making on health-related issues, even though it is the consumer who is usually thought to suffer most from these disabilities. The author argues that consumer choice under some cost constraints is a preferable mechanism for allocating resources because it better reflects individuals' subjective preferences, has a greater capacity for facing trade-offs realistically, and can better contend with professional dominance of the resource allocation process. In view of the unlikelihood of regulation that is both sensitive and effective in containing costs, the author proposes that we rely primarily on consumer incentives to reform the system. A simple change in the tax treatment of health insurance or other health plan premiums, to strengthen consumers' interest in cost containment while also subsidizing needy consumers, is advocated. Steps to improve opportunities for innovation in cost containment by health insurers, HMOs, and other actors are outlined briefly.


Control of fraud and abuse in Medicare and Medicaid.

This Comment explores issues concerning the control of fraud and abuse in health programs financed with public funds, specifically the Medicare and Medicaid programs. It summarizes the nature, scope, and possible causes of what some regard as a fraud and abuse "crisis," and points out the difficulties and obstacles facing those who attempt to develop legislative and executive action aimed at controlling fraud and abuse. Recent federal initiatives in fraud and abuse control are examined, and a brief summary of key provisions of H.R. 3 (the Medicare-Medicaid Anti-fraud and Abuse Amendments, which may prove to be a landmark piece of legislation in this area) is provided. The author emphasizes that more effective control of fraud and abuse is necessary if further expansion of government financing of health programs, including national health insurance, is to occur in the near future. At the same time, caution must be taken not to neglect the appropriate use of other mechanisms necessary for reducing the costs of medical care and improving its quality. In addition, it is likely that efforts to stem fraud and abuse will raise important medicolegal and public policy issues that will require careful interdisciplinary consideration.


Formulation of a trace element solution for long-term parenteral nutrition.

The reproduction of phage T7 in the presence of hydroxylamine (HA) (mutagenesis in vivo) results in the phenotypic suppression of some amber mutants. The presence of O-methylhydroxylamine (OMHA) results in a similar effect, including a simlilar mechanism for the action of the two compounds. Since the rate of reaction of mutagen with nucleoside residues under these conditions is negligibly low, one of the most plausible explanations of this effect is the enzymic formation of modified precursors and their incorporation into bacterial tRNAs or phage-induced RNA.


Cost-benefit and cost-effectiveness: methodologies for evaluating innovative pharmaceutical services.

Cost-benefit and cost-effectiveness analysis techniques which can be of assistance in the evaluation of innovative pharmaceutical services are reviewed. Process and outcome measures are considered, and suggested steps in a cost-benefit study are presented. Samples of pharmacy studies using these techniques are appraised. Possible measures for benefits and costs along with literature references for evaluations of innovative pharmaceutical services are presented. Areas of pharmaceutical service discussed are ambulatory patient consultation, unit dose drug distribution, drug information services, monitoring drug therapy in acute care and long-term care, parenteral admixture services, patient and therapy responsibilities, patient discharge interviews, patient drug histories and profiles, and personnel substitutions. Although there have been several encouraging reports on the cost-benefit of pharmaceutical services, more evaluative research is needed to develop programs which maximize the benefit-to-cost ratio to society.


Self-instructional program on pediatric parenteral nutrition.

A self-instructional package on pediatric parenteral nutrition was designed and its effectiveness in educating health-care practitioners was studied. Participants included eight medical students, 10 pediatricians, 10 pharmacists and 10 pharmacy students at a teaching hospital. Each participant reviewed the program and completed 25-point pre- and posttests. Participants consistently scored higher on the posttest than on the pretest. Further, participants felt that they better understood parenteral nutrition therapy and that they better understood how to write or check orders as a result of their participation in the program. It is suggested that a self-instructional package is an effective method of educating practitioners and students in total parenteral nutrition.


Hyperbilirubinemia and cholestasis.

Although the morphologist continues to describe cholestasis on the basis of precipitated bile seen on light microscopic sections of the liver or dilated canaliculi with loss of microvilli seen by electron microscopy, the physiologist can distinguish clearly between hyperbilirubinemia and cholestasis. Both bilirubin and bile acids are specifically removed from sinusoidal plasma by the normal hepatocyte and appear in bile in high concentration. Bilirubin conjugation and excretion appear to be governed by hepatocellular mechanisms that are, for the most part, separate from the conjugation and excretion of bile acids. Disturbances in bilirubin transport are recognized by hyperbilirubinemia which represents a number of clinical syndromes that can be classified by the nature of the block in the transport system. Serum bile acids appear to remain normal in hyperbilirubinemic syndromes. By contrast, cholestatic syndromes are characterized by marked bile acidemia with normal to slightly elevated bilirubin levels. Severe cholestasis, because of the marked reduction in bile flow, can however, engender jaundice. Further exploration of these excretory pathways will provide interesting new insights on the numerous cholestatic and hyperbilirubinemic syndromes that occur in nature.


Visual evoked responses in strabismic and anisometropic amblyopia: effects of check size and retinal locus.

Sinusoidally modulated checker board patterns were used to investigate the effects of check size and retinal location on the "steady-state" visual evoked response (VER) of strabismic and anisometropic amblyopes. Fourier analysis of the averaged VER suggests that the waveforms produced by these techniques are complex, and that they consist of a fundamental component plus 1 or more harmonics. In all of the subjects, the VERs elicited from the amblyopic eyes by small checks in a 3.5-deg disc were significantly smaller in amplitude than those from the nonamblyopic eyes, whereas the responses to larger checks were far more similar. Large annular targets were quite effective in eliciting VERs from the peripheries of both amblyopic and nonamblyopic eyes, and these responses were at times as large as, or larger than, those produced by the central targets. Statistically no significant differences were found between the responses of the amblyopic and the nonamblyopic eyes to the annular targets.


Morphologic effects of dietary plant and animal lipids rich in docosenoic acids on heart and skeletal muscle of cynomolgus monkeys.

Cynomolgi (Macaca fascicularis) were fed diets containing 25% rapeseed oil (RSO), partially hydrogenated herring oil (PHHO), or a 3:1 mixture of lard and corn oil as control for 4 months. The RSO contained approximately 25% of the fatty acids as erucic acid; the PHHO contained a similar concentration of mainly cetoleic acid. The control diet did not include such fatty acids. At the time of necropsy, the RSO- and PHHO-fed monkeys showed myocardial and skeletal muscle lipidosis. Foci of mononuclear cell infiltration, although infrequent, occurred in all three groups and were thought to be nonspecific. The only significant intergroup difference in serum biochemical or hematologic parameters was an increase in serum glutamic-oxaloacetic transaminase activity in both RSO and PHHO groups. Ultrastructural studies confirmed the presence of lipidosis in cardiac and skeletal muscle and revealed mild mitochondrial degeneration, causing a depression of the P/O ratio of the RSO group and a State III respiratory rate depression of the PHHO group. The difference in the exposure/life span ratio represented by this experiment may account for the absence of clear intergroup differences such as are reported in rats used in similar studies, but a true species difference in regard to dietary oils containing docosenoic acids has to be considered as well.


Origin of tubular complexes developing during induction of pancreatic adenocarcinoma by 7,12-dimethylbenz(a)anthracene.

Implantation of 7,12-dimethylbenz(a)anthracene (DMBA) into the pancreas of rats has been shown to induce adenocarcinoma. Complexes of tubules, which have the appearance of proliferated intralobular ducts, frequently appear during tumor development. These complexes were studied by light and electron microscopy to determine their method of formation. In addition, a tubular complex was reconstructed from serial sections to determine its three-dimensional configuration. Although tubular complexes have been thought by others to result from ductal proliferation, the following observation indicate that they originate from zymogen-granule-containing cells: a) there is a continuum of transitional stages between acini and tubules, b) most tubules decrease in size and are replaced by connective tissue (evidence of regression rather than proliferation), c) few mitotic figures are seen in tubular complexes, d) the tubules comprise many cells which have an abundance of rough endoplasmic reticulum, an organelle which is sparce in ducts, and e) the three-dimensional arrangement of tubules appears identical to the branching, anastomosing arrangement of zymogen-granule-containing cells of the normal rat pancreas. Control animals in which only sutures were placed in the pancreas showed minimal reaction. It is concluded that "acini" become recognized as tubules when loss of zymogen granules accompanies tumor induction by DMBA. Transformation of these cells could be erroneously interpreted as transformation from proliferating ducts.


The pathology of feline GM2 gangliosidosis.

An 11-week-old and a 6-month-old kitten with feline GM2 gangliosidosis and deficiency in both A and B isoenzymes of beta-D-N-acetyl hexosaminidase were studied by light transmission (TEM), and scanning electron microscopy (SEM). Neurons throughout the nervous system contained cytoplasmic, membrane-bound inclusions which were PAS-positive at the fine structure level these inclusions were composed of membranous arrays in whorls, vesicles, or multilaminated stacks. Fusion of the bounding membranes of adjacent inclusions resulted in large inclusion-containing vacuoles. Hepatocytes and Kupffer cells contained inclusions slightly different from those in the central nervous system. SEM of cryofractured liver demonstrated their coalescence to form larger composite vacuoles. Vacuoles with inclusions were also seen in pancreatic acinar cells, endothelial cells, vascular smooth muscle, fibroblasts, myocardial cells, renal interstitial cells, corneal stromal cells, and R-E cells of bone marrow and spleen. The specific granules of eosinophils were swollen and took on bizarre forms. Pathologic manifestations of feline GM2 gangliosidosis differ from those seen in feline GM1 gangliosidosis but closely resemble those of Sandhoff disease in humans.


Effect of magnesium on sodium transport in toad urinary bladder.

Voltage-clamp techniques were employed to examine the effect of magnesium (Mg) on sodium transport in the isolated urinary bladder of the Dominican toad. Substitution of 1 mM Mg had no effect, but 3-mM Mg substitution resulted in a reversible increase in short-circuit current (27%) and potential difference (19%) and decrease in transepithelial resistance (14%); no greater effect was seen with 5- or 10-mM Mg substitution. The effect was produced by mucosal or mucosal and serosal Mg substitution; serosal Mg substitution was without effect. Analysis of electrical parameters disclosed that magnesium increased net sodium transport via an effect on the sodium pump.


Effects of nitroglycerin on cardiac function and regional blood flow distribution in conscious dogs.

The effects of intravenous infusion of nitroglycerin (NTG), 8 and 32 microgram/kg.min for 7 min, and of sublingual NTG, 1.2 mg, were examined on direct and continuous measurements of systemic, coronary, and regional hemodynamics, left ventricular (LV) dimensions, pressures, and myocardial contractility in conscious dogs. NTG induced sustained reductions in LV dimensions and transient increases in heart rate and dP/dt, and decreases in mean arterial pressure. Initially NTG increased cardiac output and flows to the coronary, mesenteric, renal, and iliac beds, while systemic and regional vascular resistances fell. Later, cardiac output, cardiac work, and mesenteric and iliac flows fell significantly below control, and significant vasoconstriction in the systemic as well as mesenteric, iliac, and coronary beds was observed at a time when LV end-diastolic dimensions were still significantly reduced. Peripheral vasoconstriction was not observed with systemic NTG in deafferented dogs or when NTG, 1 microgram/kg.min, was infused intra-arterially into the iliac bed. Thus, systemic NTG induces a biphasic response consisting of initial arteriolar vasodilation followed by vasoconstriction in the mesenteric, iliac, coronary and systemic beds, which is presumably due to longer lasting effects on preload and to secondary reflex responses to the drug.


Cardiovascular-respiratory reflex interactions between carotid bodies and upper-airways receptors in the monkey.

The carotid bodies were stimulated in the anesthetized pig-tailed macaque monkey (Macaca nemestrina) using i) brief injections of cyanide or CO2-equilibrated bicarbonate solution into a common carotid artery, and ii) longer perfusion with hypoxic hypercapnic blood in vascularly isolated chemoreceptor preparations. In spontaneously breathing animals, brief stimulations of the chemoreceptors consistently caused an increase in pulmonary ventilation, bradycardia, and an increase in femoral vascular resistance. When the same chemoreceptor stimulus was superimposed during the apneic period, reflexly evoked by stimulating either the central ends of the superior laryngeal nerves or the nasopharynx, the respiratory stimulation was absent or minimal, but the bradycardia and vasconstriction were greatly enhanced and exceeded the summed responses of separate stimulation of the chemoreceptors and one or the other of the upper-airways inputs. With sustained stimulation of the carotid bodies, hyperventilation, tachycardia, and femoral vasodilatation occurred due to overriding respiratory mechanisms. When superior laryngeal nerve stimulation was superimposed on this response, apnea occurred and tachycardia was reversed to bradycardia, and femoral vascular resistance increased above resting level. The interaction of autonomic responses resulting from chemoreceptor stimulation and from increases in the upper-airways inputs are qualitatively similar in the monkey and in subprimate species. Those involving specifically cardioinhibitory vagal responses are, in part at least, dependent on mechanisms related to the concomitant changes in respiration.


Comparison of synchronization of primate circadian rhythms by light and food.

Several circadian rhythms in squirrel monkeys (Saimiri sciureus) entrained by two different agents were studied to compare their mode of coupling with the environmental zeitgebers. Synchronization was accomplished either by light-dark cycles consisting of 12 h of 600 lx followed by 12 h of less than 1 lx (LD 12:12), or by eat-fast cycles in which the animals could eat for 3 h and then had to fast for the remaining 21 h each day (EF 3:21). The rhythms of drinking, colonic temperature, and urinary potassium and water excretion were measured in chair-acclimatized monkeys. The drinking and urinary rhythms were more reproducible (smaller mean variance) and more stable (smaller standard deviation of the timing of a phase reference point) in EF than in LD cycles, whereas the temperature rhythm was more tightly controlled by LD cycles than by EF cycles. In constant light an 8-h phase delay in the EF cycle caused the drinking and urinary rhythms to resynchronize to the EF cycle within one day, while the temperature rhythm required about 6 days to resynchronize. In contrast, previously published data for a similar phase delay in the LD cycle with food available ad libitum show that the drinking and temperature rhythms resynchronized more rapidly than the urinary rhythms. These results indicate that separate mechanisms are involved in transducing temporal cues from LD and EF cycles in the circadian timekeeping system of these nonhuman primates.


Comparative educational approaches to screening for colorectal cancer.

The purpose of the study was to evaluate the public's willingness to perform the do-it-yourself Hemoccult Test for colon-rectum cancer and to assess the relative effectiveness of alternative means of persuading people to do the test. American Cancer Society volunteers in four different part of the country contacted a total of 11,115 members of the American Association of Retired Persons, using five methods that differed in the extent of personal and impersonal contact involved. Other variables such as inclusion of postage and dietary restrictions were studied and cost efficiencies were estimated. The Group Meeting Method was the most effective personal distribution method. The Selective Mail-Out Method was the most effective impersonal method. The return rate was higher when postage was provided. Dietary restrictions did not markedly reduce participation. Including digital examinations did not affect the return rate. The findings suggest that the Hemoccult Test has the potential of reaching a significant proportion of the nation's older population.


Serological evidence for a high incidence of transmission of Rickettsia tsutsugamushi in two Orang Asli settlements in Peninsular Malaysia.

Two communities of Orang Asli (aborigines) in Peninsular Malaysia were observed for evidence of Rickettsia tsutsugamushi infection over periods of 1-8 mo. Sequential sera were examined for antibody by the indirect immunofluorescence test. The incidence of infection in the two self-selected populations in the two communities was calculated to be 3.9% per month and 3.2% per month.


Recovery from heart norepinephrine depletion in experimental Chagas' disease.

Norepinephrine (NE) was assayed fluorimetrically in the hearts of rats killed at different periods after inoculation with the Y strain of Trypanosoma cruzi. The levels of cardiac NE which, as reported previously, were not measurable 18, 22, and 32 days after inoculation became detectable at day 48. At day 70 these levels were around 50% of the control values and at day 97 normal values were attained in most animals. These results strongly suggest that sympathetic nerve fibers are destroyed in the acute phase of T. cruzi infection and regenerated during the chronic phase.


North Borneo (Malaysia): a new locality for Schistosoma japonicum.

Eleven pairs of schistosomes, indistinguishable from the classical Schistosoma japonicum, were found in a monkey (Macaca fascicularis) taken near Ranau in North Borneo. The new locality is within the recorded range of the species which extends from Japan, China, Taiwan, and Philippines through Southeast Asia to the Celebes.


Selection of increased quinine resistance in Plasmodium falciparum in Aotus monkeys.

Although partial resistance (RI) of Plasmodium falciparum to quinine is common in some areas of the world, failure to obtain an initial response (RII or RIII) is unusual. Furthermore, emergence of quinine resistance during therapy of malaria infections in humans and animals is uncommon. In the current study, exposure of the Panama II strain of P. falciparum in Aotus monkeys to subcurative quinine therapy during six serial passages over 6 months resulted in a shift in the quinine responsiveness of the strain from mild insensitivity to quinine to uniform resistance of a marked degree. Treatment with quinine for 14 days of infections in 12 monkeys with the original isolate resulted in cure in 8 monkeys and RI resistance in 4. Infections with the resistant isolate (selected under quinine pressure) were uniformly resistant to cure by 14 days of quinine; resistance to quinine was RIII in 4 of 12 monkeys and was RII in 5. These results suggest that extensive usage of quinine or related drugs (e.g., mefloquine) in the field may result in decreasing sensitivity of falciparum malaria to quinine.


Metabolic responses to enteral and parenteral nutrition.

Seven pairs of rats were simultaneously infused with a chemically formulated nutritionally complete amino acid-glucose diet which was delivered, at the same rate, into a central vein or into a feeding gastrostomy. The intragastrically infused rats showed greater weight gain than did the intravenously infused rats. This could not be explained by fluid retention since intake and output were similar in the two groups of animals. There was a greater increase in serum immunoreactive insulin (IRI) at day 8 in the intragastrically infused animals, but a smaller increment in serum immunoreactive pancreatic glucagon (IRG) at that point. Levels of enteroglucagon or glucagon-like immunoreactivity (GLI) were maintained in the intragastrically infused rats but declined markedly in the intravenously infused rats. It is possible that the greater release of IRI seen with the intragastric amino acid-glucose feeding contributes to better disposal of nutrients and greater weight gain. The presence of nutrients in the intestinal lumen may have stimulated the release of GLI, which in turn is insulinotropic.


Immunogenetic studies of rhesus monkeys. 8. A new reagent of the G blood group system and an example of the founder principle.

A new reagent called G-3' has been discovered which detects the product of the G3 allele, regardless of the other G allele in the genotype. With this new reagent we can delineate nine of 10 genotypes of the G blood group system. The explicit detection of G3 revealed an example of the founder principle in that the frequency of this allele between the feral and laboratory-reared monkeys was significantly different.


Gold salt in the treatment of bronchial asthma--a double-blind study.

The efficacy of gold salt on bronchial asthma was investigated by double-blind design in 79 patients. The rate of improvement was significantly higher in the gold-treated group (20/28) than in the controls (16/36). This was reflected by greater reduction of requirement for symptomatic medications. Only mild side effects were observed in 14 patients out of 38 gold-treated patients.


East Coast fever: cultivation in vitro of cell-free schizonts and merozoites of Theileria parva and their immunogenicity in cattle.

Cell-free schizonts and merozoites of Theileria parva and Theileria lawrencei, derived from parasitized lymphoid cell lines, were propagated in vitro using enriched medium. Use of radioisotopic markers showed that the bovine cell-independent parasites passed through a limited but marked replication by day 4. If normal bovine RBC were inoculated in vitro with the cell-free merozoites, development of piroplasms in the RBC occurred. Electron microscopic studies of the merozoites and piroplasms revealed their structure to be similar to previous descriptions. Cattle inoculated with T parva merozoites and schizonts and later challenge exposed with homologous stabilate developed leukopenia, showed low macroschizont index, and survived longer than unvaccinated controls.


Serologic response of vaccinated cattle to strains of Moraxella bovis isolated during epizootics of keratoconjunctivitis.

In studies to determine whether there were antigenic differences between strains (isolates) of Moraxella bovis, the sera from vaccinated calves were tested with isolates of M bovis while the calves were experiencing epizootics of infectious bovine keratoconjunctivitis (IBK). Before the epizootics of IBK, the calves were intramuscularly vaccinated with a formalin-killed autogenous M bovis bacterin. During the epizootics, the eyes were examined by cultural technique, and isolates which were obtained were categorized by catalase activity, source (diseased or nondiseased eyes), and reactivity with the various sera. The serum reactivity of the isolates was compared with that of the vaccinal strain. The vaccinal strain and 8 of the 1 5 selected isolates obtained during the 1974 epizootic were catalase negative. Seven of the 15 isolates from the 1974 epizootic and all of the selected isolates from the 1975 epizootic were catalase positive. A significantly higher (P less than 0.01) percentage of calf sera were serologically reactive with the vaccinal strain and other catalase-negative isolates (45.0%) than with catalase-positive isolates (34.8%). The results, although not definitive, suggest that there may be antigenic differences among strains of M bovis. These differences should be considered when cattle are vaccinated against IBK under natural conditions of exposure.


Kinetics of in vitro bovine lymphocyte immunostimulation with a Brucella abortus antigen.

A Brucella abortus-soluble antigen was investigated, using in vitro assay of lymphocyte immunostimulation, to determine which concentration of this antigen and which period of incubation of the lymphocyte cultures would induce maximum specific lymphocyte immunostimulation as an additional method for further study of B abortus infection in cattle. Soluble antigen was prepared from autoclaved cells of B abortus strain 1119-3. Peripheral blood lymphocytes were obtained from cattle infected with B abortus and from healthy control cattle not infected with B abortus. The lymphocytes were prepared by the Ficoll-Hypaque density gradient technique, suspended in RPMI 1640 medium (1.5 X 10(6)/ml), cultured with several dilutions of soluble antigen, and incubated. Prior to termination of incubation, cultures were labeled with 1 muCi of [3H]thymidine and, after harvesting, assayed for [3H]thymidine incorporation in DNA by a liquid scintillation spectrometer. Maximum specific immunostimulation of lymphocytes from B abortus-infected cattle was induced in this assay system with 6 days' incubation and 22 microgram of protein/ml/1.5 X 10(6) lymphocytes, using protein content to express concentration of soluble antigen in this system.


Effect of staphylococcal enterotoxin B on cardiorenal functions in rhesus macaques.

Selected cardiovascular and renal functions were measured for 5 hours in conscious, chair-restrained, female rhesus macaques (Macaca mulatta) after IV (0.05 and 1.0 mg/kg) or oral (1.0 mg/kg) administration of staphylococcal enterotoxin B (SEB). Cardiovascular functions, renal hemodynamics, and renal metabolism were also studied between 6 and 11 hours after IV SEB inoculation. Oral SEB produced few changes in cardiorenal functions. In contrast, IV SEB produced hypotension, tachycardia, increased total peripheral and renal vascular resistance, and decreased cardiac and renal functions. The early significant (P less than 0.05) renal depression was not associated with hypotension (mean arterial blood pressure greater than 100 mm of Hg). However, all measured renal functions except extraction ratio of PAH were positively correlated with decreased blood pressure (r = 0.52 - 0.71) in the later phase of SEB toxemia. It is concluded that the kidney is one of the organs affected by IV SEB. Renal impairment may partially contribute to death during SEB enterotoxemia in macaques.


Caliciviruses infecting monkeys and possibly man.

Caliciviruses have, for the 1st time, been shown experimentally to infect a primate. Twenty-four hours after being inoculated with San Miguel sea lion virus (SMSV), an African green monkey developed a febrile response and vesicular lesions at injection sites. Virus was recovered from lesion material 96 hours later and from the stool at 48 hours. Possible human infection with SMSV was indicated by serologic evidence. Three persons working with 4 distinct serotypes of SMSV developed neutralizing antibody titers to 2 SMSV types. The positive serum-neutralization test results were confirmed, using immunoelectron microscopy to demonstrate complexes of viruses and antibodies.


The isolation by immunoabsorbent affinity chromatography and physicochemical characterization of Mycobacterium tuberculosis antigen 5.

Mycobacterium tuberculosis antigen 5 was purified from unheated culture filtrates by absorption onto an immunoabsorbent prepared with globulin from a monospecific goat antiserum and elution with 4.0 M urea at pH 9.0. The product was a homogeneous protein giving a single stainable band in acrylamide gel electrophoresis and a single precipitin arc in immunoelectrophoresis. It was found to have a molecular weight of 28,500 to 35,000 daltons and a sedimentation constant of 2.0. Amino acid analysis demonstrated it to be rich in aspartic acid, suggesting a cytoplasmic origin.


[Limulus test in diagnosis of acute meningitis (author's transl)].

We tried to evaluate the utility of the Limulus Test in the diagnosis of acute meningitis. The study was made in 60 patients divided in three groups: Group A, formed by 37 children affected by purulent meningitis of known etiology; Group B, formed by 10 children affected by purulent meningitis of unknown etiology; Group C, formed by 13 children with viral meningitis. The results were compared with a control group (Group D), of 10 healthy children. The results correlated with the etiology, the cuantitative count of germs/ml. in C.S.F. and the clinical evolution. The results indicated that the Test is a rapid, simple and useful tool for the detection of endotoxin in the C.S.F. of purulent meningitis caused by Gram negative germs.


[Fasting insulinemie levels and after overload with oral glucose in malnourrised children (author's transl)].

Fasting insulinemie levels and after overload with oral glucose are studied in 43 malnourished children aged between 3 months and 12 years. The results are: Increasing of insuline secretion according to the age. This correlation is positive in both, fasting levels and after overload. We found a tendency to low levels of insuline without statistical significative differences on comparing the healthy child of the same age, excluding the infants.


[Incidence, clinical, forms and complications of meningococcal infections (author's transl)].

Eighty four cases of meningococcal infections are reviewed. Fifty seven cases presented themselfs as meningococcal meningitis, twelve cases as sepsis with moderate hypotension and 15 cases were sepsis with septic shock. A brief course of the disease, shock, echymosis, absence of meningeal signs, leucopenia and intravascular coagulation were findings more frequent in the group of patients with hiperacute sepsis, whereas other signs as fever, headaches, vomiting and petechiae were present with equal frequency in the three groups. N. meningitis was isolated in 73% of the cases. Shock (18.85%) and intravascular coagulation (12%) were the complications more frequently found, followed by convulsions (4.81%), arthritis (4.81%), skin necrosis (4.81%), subdural efusion (3.57%), cerebral palsy (3.40%), thrombophlebitis (1.20%), recurrence (1.20%), inapropiate antidiuretic hormone secretion (1.20%) and subaracnoideal hemorrage (1.20%). The overall mortality was 10.70% and 60% of the patients which initially presented with shock and intravascular coagulation died. Autopsy findings included wide spred hemorragic lesions and intravascular thrombi in skin, mucous membranes and viscera. Adrenal hemorrhage was present in five of the six cases studied.


Respiratory syncytial virus infection in adults: clinical, virologic, and serial pulmonary function studies.

We prospectively studied 10 previously healthy adults who developed an acute respiratory illness while working in an infants' ward during a community outbreak of respiratory syncytial virus infection. In addition to clinical and viral evaluation, total respiratory resistance before and after carbachol aerosol inhalation was measured. All 10 subjects had respiratory syncytial virus infection documented by viral isolation, and all developed pronounced cough, nasal congestion, and fever. Eight subjects missed work for an average of 6 days. In all 10 patients, the total respiratory resistance was significantly elevated through 8 weeks. Altered airway reactivity, characterized by exaggerated responses of pulmonary resistance to carbachol challenge, was also observed through the first 8 weeks of evaluation. In this group, respiratory syncytial virus produced a protracted illness associated with appreciable morbidity. The pathophysiologic mechanism of this illness in part appeared to arise from altered airway reactivity.


Diabetic ketoacidosis with retinal tear.

A 59-year-old women with no previous history of diabetes mellitus was admitted in diabetic ketoacidosis. Ultrasonic biometry was used to measure axial vitreous length during therapy. Vitreous length increased from 14.09 mm shortly after admission to 14.26 mm (p less than 0.05) when the episode of diabetic ketoacidosis cleared. An interesting finding was the presence of a horseshoe-shaped retinal tear after the patient was discharged. Severe dehydration with resultant shrinkage of the vitreous compartment may provide sufficient vitreoretinal traction to cause a retinal tear. In addition, an estimate of volume change showed a comparable decrease in vitreous volume seen with therapy using osmotic agents measured in rabbits.


15alpha-Hydroxyoestriol and other polar oestrogens in pregnancy monitoring.

Although oestriol measurements are well established for the assessment of 'at risk' pregnancies, there are a number of other oestrogens, excreted during pregnancy, which contain additional hydroxyl groups and might be more sensitive indicators of the condition of mother or fetus. Some of these result from the action of hydroxylases possibly present only in the fetus and others from maternal hydroxylations. We review the evidence for the biosynthesis of these polar oestrogens, summarise methods of measurement, and compare values obtained in normal and pathological pregnancies. There is as yet insufficient evidence to enable their potential value to be confirmed.


[Biological properties of an asparaginase-glutaminase preparation from Pseudomonas fluorescens in cell cultures].

Specific L-asparaginase activity and non-specific cytotoxicity of asparaginase-glutaminase preparation from Pseudomonas fluorescens were studied. Two cell lines, i.e. the asparaginase-dependent (Berkitt lymphoma cells) and the asparaginase-independent (the ovary cancer cells) were used as the test-system. Incorporation of 3H-timidine into DNA was used as the criterion of the drug effect on the cells. Krasnitin was used as the reference preparation. The preparation of asparaginase-glutaminase was inferior to krasnitine by its specific antitumour asparaginase activity and superior to it by the general cytotoxicity in the cells of CaOv. With the help of the above test-system it is possible to study the specific asparaginase activity of the drugs containing L-asparaginase. For studying the specific glutaminase properties it is necessary to develop another cell test-system.


[Combined action of antiblastoma preparations on lysozyme activity in animal organs].

The lysozyme activity in the spleen, kidneys and lungs of the mice treated with neocid, sarcolysine or Tio-Fef in therapeutic doses increased or remained at the control level by the 5th or 10th day after the drug administration. The use of sarcolysine per se or in combination with neocid increased the activity of lysozyme in the spleen, kidneys and lungs during the whole period of the experiment as compared to the control. The values of the lysozyme activity in the spleen and lungs of the animals treated with neocid in combination with sarcolysine were higher for 5 days, and in all organs examined were higher by the 10the day as compared to the animals treated with neocid alone. Increased lysozyme activity in the spleen, kidneys and lungs was observed under the effect of neocid in combination with sarcolysine as compared to the lysozyme activity in mice treated with sarcolysine per se (assay on the 10th day). Decreased lysozyme activity was determined in the spleen, kidneys and lungs by the 5th day and in the kidneys by the 10th day in the mice treated with sarcolysine in combination with Tio-Tel and in the spleen and lungs by the 5th and 10th days in the animals treated with neocid in combination with sarcolysine or Tio-Tef as compared to the animals treated with sarcolysine. The lysozyme activity in the kidneys under the effect of sarcolysine combination with Tio-Tef was lower by the 5th days and higher by the 10th day as compared to that under the effect of Tio-Tef.


[Testing the sterility of injection preparations of penicillin series antibiotics].

The efficiency of 3 variants of the method for determination of microbial flora was compared on the injection preparation of potassium benzylpenicillin artificially infected with Staph. aureus 209P and the spores of Bac. subtilis ATCC 6633 in different doses and with different amounts of the preparation in the vials. The procedure of the preparation dissolution in the vial with the thioglycol medium containing penicillinase proved to be most effective. The microbe detection amounted to 100 per cent. The procedure was less labour- and time-consuming since addition of penicillinase to each vial with the thioglycol medium was excluded. The risk of the medium occasional infection with microbial flora during the assay was decreased.


Sensitive bioassay for vancomycin.

An accurate and sensitive assay for vancomycin in serum and body fluids has not been available. This paper reports an assay for vancomycin that can detect serum and fluid levels as low as 0.8 mug/ml. A disk diffusion technique was designed employing buffered glucose minimal salts agar and Bacillus subtilis as an indicator strain. A linear relationship was obtained between zone diameter and concentration for vancomycin standards from 0.8 to 50 mug/ml prepared in pooled human serum. Results were accurate (<10% error) and reproducible (within-sample standard deviation, 0.25 mug/ml) for concentrations of from 0.8 to 25 mug of vancomycin per ml. Zone diameters were at least 6 mm larger on minimal salts agar than on standard assay media. The increased sensitivity and accuracy of the assay make it possible to accurately measure levels in cerebrospinal fluid and dialyzate fluid as well as in serum.


Secondary cutaneous mucinosis with systemic lupus erythematosus. A case presentation and review of the literature.

A patient had papular and nodular cutaneous deposits of mucin and cutaneous and systemic manifestations of lupus erythematosus (LE). Since many of the mucinous deposits occurred at sites that were clinically free of skin lesions of LE, we considered initially that the patient had both LE and papular mucinosis. However, after a review of the English literature and further study of the patient, it seemed more likely that the papular and nodular deposits of mucin were secondary to LE and not a previously unreported simultaneous occurrence of the two diseases in the same patient. To our knowledge, this is the third case report of a patient with papular and nodular cutaneous mucinosis secondary to LE. In addition to the case report, this article is concerned with a discussion of cutaneous mucinosis in LE and other "collagen vascular" diseases.


Treatment of Bartter's syndrome in early childhood with prostaglandin synthetase inhibitors.

The diagnosis of Bartter's syndrome was made in a 9-month-old boy investigated for poor weight and height gain. Initial treatment with oral potassium supplements and later spironolactone had little or no effect on his growth, although plasma potassium rose to normal after spironolactone. At 33 months indomethacin therapy was started with dramatic results. His symptoms went and his height and weight accelerated into the normal range. In view of the toxicity of indomethacin it was replaced after 12 months by another prostaglandin synthetase inhibitor, ketoprofen, with a satisfactory result. During the change-over period from indomethacin to ketoprofen the expected deterioration in clinical well-being was observed, accompanied by a rise in urinary prostaglandins and plasma renin activity. Prostaglandin synthetase inhibitors provide the best available treatment for Bartter's syndrome.


Examination of complement C3 metabolism in rheumatoid arthritis using 2-dimensional immunoelectrophoresis.

A previous report that C3 activation products are demonstrable in the plasma of subjects with rheumatoid arthritis was reinvestigated using 2-dimensional immunoelectrophoresis. Initially it seemed that results were in agreement, but the occurrence of similar patterns in normal sera and poor reproducibility of results suggested the findings were artefacts. When calcium and magnesium ions were removed with EDTA, C3 activation products were no longer demonstrable in plasma from normal subjects or from patients with rheumatoid arthritis. The results obtained without EDTA in the buffer showed a greater degree of complement activation in patients with rheumatoid arthritis, suggesting that in this condition the serum may have a greater potential ability to bring about complement activation.


Identification of nitric oxide (NO) in human blood.

The amount of nitric oxide (NO) in the blood of residents of urban and suburban areas was measured under steady-state conditions by isotopic dilution with N15O, followed by field-ionization mass spectrometry. Approximately 20 nmoles of NO per ml of blood was characteristic of both smokers and nonsmokers, except for one of the eight subjects who had a significantly lower level. Monkeys (Macaca speciosa) had values comparable to those of seven human subjects, and rats had values like that of the unique human subject. Whether the origin of the NO was endogenous or exogenous was not determined.


Gentamicin-resistant bacillary infection. Clinical features and amikacin therapy.

Infections caused by gentamicin sulfate-resistant Pseudomonas aeruginosa and Serratia marcescens have occurred in multiple areas of our hospitals and have caused serious clinical illness and death. Isolates of Pseudomonas organisms were sensitive to some alternative drugs including collstin sulfate, but isolates of Serratia organisms were often resistant to all commercially available parenteral antimicrobiais. All isolates were inhibited by amikacin sulfate, and 95% were killed by concentrations achievable in serum with recommended doses. Twenty patients with hospital-acquired infections, including ten with septicemia, were treated with amikacin. Eighteen of the 20 patients had a good clinical and bacteriologic response. Ototoxicity and nephrotoxicity each occurred in one patient.


[Bacterial pollution in the hospital and bacteriological control of the hospitalier staff (author's transl)].

The Authors report the results of the researches made in their Hospital, about the bacteriological control of some  departments and services, and of the staff that works there. After pointing out the scanty presence of pathogeneus germs in their hospitalier place, they augur a constant and repeated prophylactic sanitary control, whether of the structures, or the hospitalier staff, to avoid the possibility of diffusion of these germs in persons, already predisposed, since suffering from the most various diseases.


[Coronary artery spasms].

In a series of 2000 coronary arteriographies, spasm of the coronary artery was found in 52 cases, which were divided into three groups: 41 cases of "iatrogenic" spasm caused by stimulating the ostium of the coronary artery (usually the right) with the tip of the catheter; 8 cases of spasm on top of an organic fixed lesion; 4 cases of coronary spasm on a coronary artery which was reported as "radiologically normal". The study includes a review of the circumstances which favour or impede discovery of coronary spasm, as well as a provocation test using methyl ergometrine. This test seems to be specific in that it only produced coronary spasm in patients with Prinzmetal's syndrome, and excluded the cases of angina with normal coronary arteriography. The patients with spasm on top of a fixed organic lesion underwent a successful aorto-coronary bypass graft together with resection of the pre- and sub-aortic nerve plexus. Patients with a spasm in an artery which was "arteriographically normal" were treated medically by nitrate compounds and vaso-dilators. Three of these patients had an excellent result with medical treatment. Treatment failed in the fourth patient, who then obtained benefit from straight-forward resection of the pre- and sub-aortic nerve plexus with an excellent result which has been maintained for over six months.


[Long-term results of aortocoronary bypass. 1. Clinical aspects].

Eighty patients undergoing one or several aorto-coronary bypass graft procedures had longterm clinical and arteriographic follow-up (mean follow-up period of two years, extremes 1 and 6 years). The indication fort operation in these patients was unstable angina in 39 (49%), threatened infarction in 16 (20%), Prinzmetal's angina in 8 (10%), and stable but incapacitating angina in 17 (21%). Significant lesions involved the three coronary trunks in 49 cases, two trunks in 25 cases, and one trunk in 6 cases. The longterm clinical results were excellent in 65% of cases, and fair in 26%; the procedure failed in 9% of cases. Angina pectoris either disappeared or improved in 96% of cases. After operation, myocardial infarctions occurred in 11 cases (14%), 7 of which were early and 4 late with a delay of 1 to 4 years. The pre-operative cardiac failure disappeared or decreased in 13 cases out of 16. Finally the quality of the clinical results does not seem to be influenced by the various indications for operation with the exception of Prinzmetal's angina, where the results have been excellent in all cases (8 cases out of 8).


[Long-term results of aortocoronary bypass. 2 Angiographic aspects].

Follow-up arteriograms carried out between one and six years (mean follow-up period two years) in 80 cases of aorto-coronary bypass graft procedures showed a good correlation between the quality of the clinical results obtained -- as detailed in the first part of this article -- and a larger proportion of patent grafts: 82% of 130 grafts had remained patent, and 94% of patients have all or some of their grafts patent. Late occlusion of the grafts is rare, and does not appear to be influenced by abnormalities of the graft found at early follow-up, these abnormalities being fairly stable. These follow-up have especially shown the good correlation between the quality of the clinical results and the functional status of the coronary network in the long term, a function not only of the permeability of the grafts which have been carried out, but also of the complete or incomplete correction of the lesions of the three coronary trunks. Such a complete procedure which was carried out or could have been carried out in only 30% of the total patients, was then successful in 94% undergoing it. The clinical results should therefore lead us to carry out operations which remove the lesions as completely as possible.


[Non-invasive study of the patency of aortocoronary bypass with pulsed Doppler technic. Preliminary studies].

The pulsed Doppler effect is a non-invasive investigation technique based on the fact that the blood cells moving in a vessel on which ultrasound is incident cause a rebound of different frequency, according to their rate. This technique allows us to measure flow in a "measuring volume", whose size and depth are regulable. It is also possible to collect the signal from one or several aorto-coronary grafts, and to distinguish these from the sorrounding vasculature by their diastolic perfusion. This preliminary study (11 cases) is an attempt to formulate strict procedural criteria by comparison with follow-up arteriography of the grafts. The ease of performance of this investigation should, eventually, make it unnecessary to have to carry out repeated arteriography.


[Cause of death in recent myocardial infarct. Correlation between extent of necrosis and clinical, electrocardiographic and anatomical findings].

A retrospective study of 100 case notes of patients who died from a recent myocardial infarction (less than one month before death) has established the causes of death: cardiac failure (52), rupture of the heart (40), major pulmonary emboli (3), primary irreversible ventricular fibrillation (2), unexplained death (3). Study of the extent of the necrosis by the technique of segmentation of the ventricular mass has allowed us to clarify the correlation between the "index of extent" ("i"), an the clinico-pathological findings. It has been noted in particular that those infarctions complicated by cardiogenic shock and/or by bilateral bundle branch block were those with the highest value of index of extent (i = 8.91, i = 9.40); also that cardiac failure and ventricular tachycardia were found in the extensive infarctions (i = 7,33, i = 9.52); also that rupture of the outer wall and pulmonary thromboses complicated infarctions of very small extent (i = 4,80, i = 5,67). It would not seem possible to reduce the hospital mortality of infarctions significantly, since it is essentially linked with circulatory failure caused by extensive necrosis, and with ruptures of the heart which are unpredictable and untreatable.


["In vitro" activity of gentamicin, sisomicin and tobramycin against "pseudomonas aeruginosa" strains from hospital sources (author's transl)].

The in vitro activity of two amynoglicosidic antibiotics, tobramycin and sisomicin, against 215 strains of Pseudomonas aeruginosa isolated from clinical specimens during the years 1972-1975, was evaluated in comparison with that of gentamicin. Tobramycin showed a greater activity than sisomicin and gentamicin. At the concentration of 5 mu/ml tobramycin resulted inhibitory on 94% of strains and sisomicin and gentamicin on 78.6% and 49.8% of strains respectively. The susceptibility of Pseudomonas aeruginosa strains to gentamicin decreased from 1972 to 1975, with an increasing of resistant strains of 23%. In an evaluation of possible cross-resistance of 14 strains of Pseudomonas aeruginosa highly resistant (MIC greater than or equal to 25 gamma/ml) to gentamicin, 13 showed a high degree of resistance also to sisomicin; on the other hand 7 strains highly resistant to gentamicin was sensitive to tobramycin at concentration less than or equal to 10 gamma/ml.


[Fatal cardiac insufficiency in the course of an initial acute myocardial infarct. Anatomical-clinical data].

In a series of 51 clinico-pathological examinations on patients who died during the first 15 days after the onset of clinical symptoms of their first and only transmural myocardial infarction (anterior: 29 cases; posterior: 22 cases) the causes of death were divided into: heart failure -- 26 cases (53 p. 100); rupture of the heart -- 22 cases (43 p. 100); disorders of ventricular rhythm -- 2 cases (4 p. 100). The anatomical basis of fatal cardiac failure is twofold: either a very extensive area of necrosed muscle, of poor quality of the mass of muscle not involved in the infarction. In the anterior infarctions (16 cases, representing 55 p. 100 of deaths in this group) the first factor was foremost, the mean extent of necrosed muscle constituting 42 p. 100 of the total left and septal ventricular mass; stenotic coronary lesions, which were commonly found on the anterior descending artery, were confined to this artery alone in 10 cases 62 (p. 100). In posterior infarctions (11 cases, representing 50 p. 100 of deaths in this group), the mass of muscle destroyed was less (mean 36 p. 100), but the stenotic coronary lesions were diffuse, involving the three main trunks in 9 cases, which also explains the poor quality of the muscle not involved by necrosis. Thus there is a clear difference between anterior and posterior infarctions followed by deaths from cardiac failure: in the first group, the remaining muscular mass is quantitatively insufficient to maintain the haemodynamics, while in the second it is qualitatively insufficient, because of poor blood supply, to maintain an adequate cardiac output.


[Coronary arterial thrombosis and transmural myocardial infarct. Cause or consequence?].

Macroscopical examination at postmortem of 64 patients who died of their first transmural myocardial infarction (32 with anterior infarctions, 28 with posterior and 4 with lateral), during the first 30 days after the onset of symptoms, has shown that in 59 cases (92.2 p. 100) there was a totally occlusive thrombosis in the coronary artery. In all cases these thromboses were sited on the major coronary arterial trunk to zone of muscle which was destroyed, and on top of an ulcerated atheromatous plaque. The age of the thrombosis and the infarction were identical. There was no relationship between the presence (59 cases) or the absence (5 cases) of coronary arterial thrombosis with the age, sex, survival time or extent of the infarction. These postmortem findings are strongly suggestive of a fairly constant cause and effect relationship between coronary arterial thrombosis and acute transmural myocardial infarction.


[Mathematical simulation model of cardiac contraction].

The authors describe a mathematical model simulating cardiac contraction based onMaxwell's well known analogue model. The general equations of the model are presented and discussed in relation to published findings. The functioning and compute application of the model are briefly described. The investigations were carried out in normal subjects and in some cases with simulated pathology. The first results obtained with the model and their relation to some biological phenomena (hemodynamics, ATP phasic activity, cardiac contractility) are discussed. The hypotheses on which the model is based are also discussed.


[Paradoxical atrioventricular block within the bundle of His].

We have been able to record an atrio-ventricular block dependent upon bradycardia, but also no tachycardia, in a patient of 76 who presented with syncopal attacks. The basal electrocardiogram showed no significant delay in atrio-ventricular or intraventricular conduction. Intracavitary electrophysiological investigation allowed us to localise the site of this block in the main trunk of the bundle of His; we also established, under basal conduction conditions, a first degree block with an exactly similar relationship to the duration of the preceding diastole.


[Echocardiographic diagnosis of d-transposition of the great vessels by deductive analysis].

The process of diagnosis by echocardiography of transposition of the great vessels is based fundamentally on the recognition of the position and relative orientation of the two ventricles and of the two vessels of the base of the heart. Traditional two-dimensional echocardiography allows us to establish the position of the left ventricle because of the atrio-ventricular (mitral) valve and its direct continuity with a sigmoid valve. If this continuity is absent, the mitral valve may be recognised because it closes after the tricuspid valve. It the tricuspid valve is on the right of and/or in front of the mitral valve, the aorta will in principle be found on the right of the pulmonary artery ("loop rule"). The orientation of the great vessels may then be determined. Two-dimensional systems are particularly useful in diagnosis of vascular disorders. If these are not available, traditional echocardiography may lead us to suspect this abnormality: 1. Provided that the orientation of the transducer is known at all times during the recording; 2. Provided the recording demonstrates simultaneously the two great vessels with their respective valves. Two other criteria are important if Van Praagh's rule or the "loop rule" is unhelpful: the diameter of the two vascular trunks, and identification of the valve by a study of the ejection times.


[Electrocardiagraphic changes of Prinzmetal's angina type in the acute phase of myocardial infarct].

The authors have studied the frequency and severity of anginal attacks of the Prinzmetal type coming on during the acute phase of a myocardial infarction in 13 patients. They have occurred in 5.50% of cases (anginal attacks of all types occurring in 18.34% of cases). The severity of these attacks is shown by their clinical features: the multiplicity of the attacks, the high incidence of arrhythmias, the difficulties encountered with medical treatment. This also confirmed by the enzyme studies: when the curve of myocardial creatinine kinase release is drawn, there is seen to be an extension of the lesion in 2/3 cases, whereas the electrocardiograph does not show this up.


[Coronary stenosis in angina pectoris with normal resting electrocardiogram].

The arteriographic abnormalities found in 104 patients with typical angina pectoris and an electrocardiogram at rest which was normal at the time of arteriography were compared with those of 238 cases with typical angina pectoris, but with an abnormal electrocardiogram (127 having ST/T changes, 111 having transmural necrosis). There was no major difference between the two groups as far as the degree of coronary stenosis was concerned, nor in its extent and distribution. However, by comparison with the group with an abnormal electrocardiogram, very tight stenoses of the three trunks or of one trunk alone were slightly less common in the patients with a normal electrocardiogram; also, for each of the three trunks, the index of the lesion was slightly less raised, and the circumflex and right coronary arteries were slightly less commonly, affected, although the difference was not usually great enough to achieve significance. The action of the left ventricle and/or the value of left ventricular end-diastolic pressure were, however, manifestly better conserved in those with a normal electrocardiogram (p less than 0.001). An aorta-coronary bypass graft is more likely to be indicated in this group of patients.


[Pacemakers in children].

This is a study of pacemakers in 32 children with permanent pacemakers, 7 of them for congenital block, and 25 for post-operative block, representing a total of 69 pacemaker implantations. After a brief survey of the results, there is a discussion of the problems of the indications, relative for the congenital blocks, and absolute for the surgical blocks after a short period of observation. The choice of type of pacemaker rests upon three essential features: minimum inconvenience, a good length of active life, and the facility of an increased rate. Recent technical progress has allowed these features to be combined. The pacemakers currently available are shown on a table. The results are to a large extent determined by extreme care being taken over the implantation; meticulous asepsis, a low threshold on the electrode test, a pacemaker which is "comfortable" in its site, all these are essential if the serious complications are to be avoided, namely infection and pacemaker failure. The best route for the child, as for the adult, is by way of an epigastric approach with an abdominal pocket. In the very small infant, it seems better to implant by left thoracotomy, and to site the pacemaker intrapleurally.


[Value of hemodynamic surveillance by radiocardiography in human heart transplants].

Eighteen cases of cardiac transplantation have been carried out for 16 recipients since October 1973, there being 8 survivors at present. The importance of screening in such a treatment is vital. It is a simple method, easy to control, can be carried out at the bedside, is reproducible, reliable, and completely harmless, and by allowing the haemodynamic function of the graft to be seen at all times, helps in the marching of the donor and the recipient, in following the function of the graft in the immediate post-operative period, and in discovering rejection crises, and evaluating the long-term fate of the transplant.


[Simultaneous measurement of cardiac output by indium 113 m detected externally and by dye dilution of indocyanine green].

The cardiac output of 11 patients was measured by a method of dilution of a short-life radio-isotope, and compared with measurements obtained simultaneously by a dye dilution technique. After sudden intravenous injection of siderophilin (transferrin) labelled by Indium 113 m, the precoridal radioactivity was measured by a single panel detector probe. In 9 patients these measurements were carried out twice with a 15 minute interval. The correlation coefficient between the two methods was 0.884 for 20 measurements, and 0.939 for the first 11 measurements. The reproducibility of these measurements was comparable for the two techniques. The radio-isotope method of measuring cardiac output, which can be carried out at the bedside, is a simple, reliable and reproducible technique.


[Abnormalities of insulin secretion in coronary patients. Apropos of 67 cases].

The curve of blood insulin levels recorded during the oral provoked hypoglycaemia test (OPHG) was studied in 67 proven coronary patients. None of the curves obtained was normal. The abnormalities found in this way are of two types: either a hypoinsulinaemic response, with a high non-retarded peak (type 1) or a high retarded peak (type 2), or else a hypoinsulinaemic response, with a flat curve (type 3) or a very small late peak (type 4). The possible role of these abnormalities of insulin secretion in the pathogenesis of atheroma is discussed. The correlations between age, sex, obesity, hypertriglyceridaemia, and the OPHG curve are investigated. The preliminary results of a test in which insulin levels are monitored after intravenous provoked hypoglycaemia, followed by tolbutamide, are reported.


[Action of chloro-acetyl-ajmaline on the electrical properties of the human heart].

The electrophysiological changes caused by the intra-atrial injection of 1.5 mg/kg of chloro-acetyl-ajmaline were studied in 23 patients by recording the His potential and by the stimulustest method. The length of the basal cycle being kept constant by atrial stimulation, measurements were made before and after the injection, on the one hand of the -VA node conduction time (A-H interval) and the infra-His conduction time (H-V interval) and on the other of the refractory periods of the right auricle, A-V node, and the His-Purkinje system. The effective refarctory period of the right ventricle was determined under pace-making of the ventricle. Finally, the variability of the sinus rate was measured. The results were as follows: 1. The sinus cycle was significantly shortened after administration of the drug (p 0.001); 2. The conduction time and refractory periods of the A-V node were not influenced by this substance; 3. The H-V interval was increased in 20 patients by an average of 11 ms (p less than 0.001). The relative refractory period of the His-Purkinje system was reduced in 4 cases out of 7 by 21 ms (p less than 0.05); the effective refractory period in one case showed a reduction of more than 45 ms. These findings will serve as a base line for assessing the anti-arrhythmic action of chloro-acetyl-ajmaline.


[Effect of a depressant drug on the recovery time of the sinus. Attempt of application to the diagnosis of sinus dysfunctions].

The authors have studied the effect of a depressant drug, 71247 or piprofurol, on the recovery time of the sinoatrial node after rapid electrical stimulation of the atrium (CSRT). 72 patients, divided into three groups, underwent the test: 14 patients with documentary evidence of sinus dysfunction; 48 patients in whom a sinus disorder was suspected, and 10 controls. As a general rule, the sinus recovery time was found to be significantly prolonged in the patients as compared with the controls. The authors have applied this test to the diagnosis of latent sinus dysfunction, categorising three different degress of RESA values: normal (less than or equal to 550 ms), average (between 550 and 1,000 ms), and prolonged (greater than 1,000 ms). In 6 patients from group one and seven from group two, the post-stimulatory pause was normal or average before the test, and prolonged after the injection of 71247; on the other hand the test did not give evidence of any prolongation of the pause in the controls. In this way a dynamic pharmacological test of depression brings and interesting slant on the diagnosis of disorders of the sinus.


[Contribution of echocardiography to the diagnosis of infradiaphragmatic total anomalous pulmonary venous return].

The authors report the case of a neonate with an abnormal pulmonary venous return which was totally infradiaphragmatic. Multiscan and monoscan echocardiography made the diagnosis, demonstrating an echo-free zone behind the left atrium extended backwards behind the mitral ring and the left ventricle. The child underwent successful surgery, and a follow-up echocardiogram showed that this abnormal space was lessened, responding with the collecting trunk.


[Obstinate diarrhea in infants. A review of 84 cases].

Eighty-four cases of obstinate severe diarrhoea in infants are reported. Criteria for clinical and biological severity are precised. Histological examination of the small bowel was performed in 57 cases; a total atrophy of intestinal villi was found in only 33% of the cases during the first 3 months. Exclusive parenteral feeding, from the beginning or after failure of enteral feeding was given to 71 infants. Later on, enteral renutrition at constant flow, was administered, after simple preparation, in most cases. Seventeen died out of 84 infants, 7 of them within 2 weeks. For the others, the average time for recovery was 4 months. The conditions of prevention of obstinate severe diarrhoea in infancy are emphasized.