A gas chromatographic method for determination of acetate levels in body fluids.

A simple, sensitive and accurate gas chromatographic method for the determination of acetate in plasma and urine is described. Following precipitation of proteins by perchloric acid and removal of potassium perchlorate by precipitation with KOH, acetic acid is quantitated by injection of the acidified sample on a highly polar column. A flame ionization detector is used. Propionic acid is added to the sample initially as internal standard. The sample volume required for the analysis is 0.5 ml. The standard curve is linear in the range from 0.01 to 10 mmol/l. Recovery of added acetate is complete, and the coefficient of variation is less than 4% even at low concentrations. The concentration of free acetate in plasma from 10, and urine from 4, healthy humans ranged from 0.04 to 0.07 and 0.09 to 0.24 mmol/l, respectively.


Quantitation of hemoglobin A1c: a rapid, automated precision-chromatography technique.

Hemoglobin A1c is increased in patients with diabetes mellitus and its level reflects the status of blood glucose equilibrium over a period of several weeks. The practical use of its estimation was hampered by technical difficulties in investigating large series of samples. In order to apply this examination for routine purposes we describe in this paper acceleration and full automatization of the original chromatographic method allowing quantitation of hemoglobin A1c in 45 min.


Partial characterization of cytosol and membrane-bound protein kinases in hereditary spherocytosis erythrocytes.

The protein kinase activity located in the cytosol of hereditary spherocytosis erythrocytes is due to multiple forms which can be resolved by Sepharose 6B filtration at high ionic strength into two fractions phosphorylating the whole casein on different sites. The membrane-bound protein kinases, solubilized by 0.7 M NaCl, display an elution volume from Sepharose column and a phosphorylation behaviour towards casein quite similar to those of the more retarded fraction of hemolysate. When compared with the multiple protein kinase forms from normal human erythrocytes, no significant difference has been found.


Creatine kinase forms in human skeletal and cardiac muscle.

The creatine kinase (CK) activity in human skeletal and cardiac muscle submitted to QAE-Sephadex chromatography was found to distribute into three peaks (m and h I, II, III fractions). Characterization according to electrophoretic behaviour, approximate molecular weight, thermal stability and immunological properties unambiguously demonstrated the coincidence of fractions I and III with reference MM-CK and MB-CK isoenzymes, while both cardiac and muscular forms II proved to escape any assignment within the dimeric (M, B) model. A higher molecular weight than for reference CK and the absence of interaction with BB-antiserum resulted for both forms II, which on the contrary were found to diverge as for reactivity to MM-antiserum and stability characteristics. Quantitation of the CK forms, attempted on a limited number of samples, confirmed the expected relative levels of MM-CK and BB-CK and gave evidence for the presence of hII- or mII-CK amounting up to 30% of the total activity in cardiac and skeletal muscle, respectively. The results of the study both confirm a complexity greater than supposed for the CK system and point to the inadequacy of several of the commonly used analytical approaches to derive correct information.


The assay of sphingolipid hydrolases in white blood cells with labelled natural substrates.

Methods were elaborated for the assay on leukocytes of sphingolipid hydrolases with native and artificial substrates. The optimal conditions for the isolation of leukocytes and the preparation of labelled sphingolipids were investigated. The KM and Vmax values for all substrates are given as the specific activities of the sphingolipidhydrolases in normal males and females. It is concluded that leukocytes are the enzyme source of choice for the enzymic diagnosis of neurolipidoses.


Studies of cerebrospinal fluid and plasma amino acids in patients with steady-state chronic renal failure.

The concentration of free amino acids in the plasma and lumbar CSF of 11 patients with steady-state chronic renal failure has been measured and the CSF: plasma concentration ratios calculated. The results have been compared with the corresponding data from 37 control subjects. In renal failure, elevation of the mean plasma concentration of total amino acids and a reduction in the ratio of essential to total amino acids have been found. Whereas some individual plasma amino acid concentrations in renal failure were higher than normal, others were lower. Striking abnormalities of the CSF amino acid concentration have been observed. Some amino acids have shown similar patterns of abnormality in both CSF and plasma, whereas in the case of others, the changes have been restricted to either CSF or plasma. Significant variations from normal of the CSF: plasma concentration ratios were observed for four amino acids.


The effect of haemodialysis on cerebrospinal fluid and plasma amino acids.

The concentration of free amino acids in CSF and plasma has been measured in 19 patients with renal disease undergoing haemodialysis therapy. The values obtained have been compared with those measured in non-haemodialysed patients. At the end of a 10-h dialysis period, the total CSF amino acid concentration had fallen by only 23.3% compared with a 57.7% fall in plasma. Examination of the results for individual amino acid concentrations showed 3 different patterns of inter-relationship between plasma and CSF.


A column chromatographic method for the determination of 5-hydroxytryptamine (serotonin) and 5-hydroxyindole acetic acid in cerebrospinal fluid.

A method is described for measurement of 5-hydroxytryptamine (5-HT) and 5-hydroxyindole acetic acid (5-HIAA) in cerebrospinal fluid. 5-HT and 5-HIAA are isolated from columns of Biorex BR-70 and Sephadex G-10 with recoveries of 85 and 89% respectively. The indoles are quantitated by fluorometric measurement of the ortho-phthaldialdehyde derivatives in acidic solution. Correction for interfering 5-methoxytryptamine and 5-methoxyindole acetic acid is accomplished by a second measurement at alkaline pH. Thin-layer chromatographic analysis of column eluates has revealed no other interfering indoles in the 5-HT and 5-HIAA fractions. Preliminary results in normal cerebrospinal fluid samples have been in the ranges 10--60 ng/ml 5-HIAA and 0--13 ng/ml 5-HT.


Unconjugated bilirubin kinetics in Dubin-Johnson syndrome.

Plasma unconjugated bilirubin kinetics were studied by a two-compartment analysis in 10 patients with Dubin-Johnson syndrome (DJS) and 7 normal controls. The clearance of unconjugated bilirubin from plasma was significantly reduced in the patients with DJS as compared to the controls (p less than 0.01). Kinetic analysis of plasma disappearance data showed an increase in reflux and decrease in conjugation. These results indicate that defects in both conjugated and unconjugated bilirubin metabolism exist in DJS.


Action of purine nucleosides on the release of intracellular enzymes from rat lymphocytes.

Rat lymphocytes incubated under hypoxic conditions in vitro show a time-dependent release of intracellular enzymes. As reported previously, enzyme release (lactate dehydrogenase) is decreased by metabolite, notably ATP and glucose, that contribute towards lymphocyte energy metabolism. The action of purine nucleosides in relation to enzyme release was investigated. Inosine was shown to decrease significantly lactate dehydrogenase release, whereas adenosine exerted a supportive action only at concentrations less than 0.5 mmol/l. Inosine decreased enzyme efflux maximally at concentrations of at least 2--3 mmol/l. The mechanism of inosine action was deduced to be primarily ribose 5-phosphate formation and its subsequent metabolism by energy-yielding pathways. Inosine was presumed also to enter the purine 'salvage pathway' and thereby maintain intracellular adenine nucleotide pools.


Radiation dewlap.

A dewlap is a hanging fold of skin under the throat of oxen and dogs. A similar swelling sometimes occurs in man after radiation therapy. The incidence and natural history of this 'radiation dewlap' has been assessed in patients receiving radiotherapy to malignant growths in the head and neck region. The appearance of this complication has been correlated with the age of the patient, the site and stage of the tumour and the type of radiation employed. The aetiology and significance of the complication are discussed with reference to the anatomy and physiology of the affected tissues and the physical characteristics of the radiotherapy administered. Possible methods of prevention are suggested.


Lymphoepitheliomas of the larynx (undifferentiated carcinomas of nasopharyngeal type).

Three cases of lymphoepitheliomas of the larynx are reported. This type of carcinoma--which occurs almost exclusively in nasopharynx--is very unfrequent in the larynx (0.2%). In the 3 cases, the tumors arose in a ventricular diverticulum which presented the same lymphoepithelial structure as the tonsils. Under such conditions, these lymphoepitheliomas, which have to be called 'undifferentiated carcinomas of nasopharyngeal type' are believed to develop from the lymphoepithelial tissue of the laryngocele.


Temporary threshold shift, loudness, and auditory evoked potentials.

TTS2 of 20dB was produced in a group of subjects using a 1000 Hz pure tone. All TTS and related measurements were made at 1500 Hz. The recovery of TTS, and of TLS or 'temporary loudness shift' (measured against a reference tone at 20db, 40dB and 60dB SL in the opposite ear), as well as N1-P2 amplitude of the Vertex potential, were plotted. There was an orderly recovery of both TLS and TTS although the rate of recovery of the latter was noticeably more rapid. Recovery of N1-P2 amplitude was much less orderly, although it did recover in much the same way. When the amplitudes were measured at 40dB SL the recovery was more orderly and followed the course of TTS more closely. It was concluded that any relation between N1-P2 amplitude and growth of loudness was indirect.


Amniotic fluid cell culture II. Evaluation of a red blood cell lysis procedure for culture of cells from blood-contaminated amniotic fluid.

Second trimester amniotic fluid samples obtained transabdominally for genetic analysis not infrequently are contaminated with blood. There has been disagreement as to whether blood contamination interferes with the efficiency of culture of amniotic fluid cells for genetic diagnosis. A procedure using ammonium chloride to lyse contaminating red blood cells has been recommended to increase culture success. In this report we document that cultures derived from blood-contaminated amniotic fluids form fewer cell colonies than cultures from clear amniotic fluids. We also show that a recommended procedure using ammonium chloride to lyse red blood cells is ineffectual in improving the efficiency of cell culture, and may be detrimental to successful culturing of cells from bloody amniotic fluids. A hypothesis concerning the mechanism of interference with culture of amniotic fluid cells by contaminating blood is presented and a means of preventing this complication is suggested.


Epidermolysis bullosa simplex and mottled pigmentation: a new dominant syndrome. I. Clinical and histological features.

A family is reported in which 11 members presented epidermolysis bullosa simplex with some unusual features, and 10 of whom had congenital mottled hyper- and hypopigmentation of the skin. Both anomalies are inherited together in an autosomal dominant fashion, although dominant X-linkage cannot be excluded. The epidermolysis without dyspigmentation in the 11th individual suggests that the syndrome in the other 10 members is due to genetic linkage of two independent genes and not to pleiotropism of a single mutant gene. The mottled pigmentation seems distinct from previously known dyspigmentations and is also suggestive of autosomal inactivation in man. (See addendum).


Familial occurrence of syngnathia congenita syndrome.

A case of familial occurrence of syngnathia congenita in mother and child is described; this syndrome has been seen only sporadically until now. Due to the distinct appearance of the intraoral chords--they were situated on both sides between the ridges of the jaw and also between the left half of the bifid uvula and the retrolingual region--a relationship to the autosomal-dominantly transmitted Cleft Palate Lateral Synechiae Syndrome (CPLS-Syndrome) is suspected. Complete penetrance with different expressivity may explain the different clinical manifestations of the cases seen up to now and the absence of bifid uvula in the mother of our patient. The probable pathogenesis during embryological development is discussed.


Craniometaphyseal dysplasia--variability of expression within a large family.

Fifteen individuals in five generations of a kindred with branches in South Africa and England had the autosomal dominant form of craniometaphyseal dysplasia. The majority of affected adults had mild to moderate mandibular distortion, while paranasal bossing was a transient manifestation in childhood. Facial palsy with onset in childhood was present either unilaterally or bilaterally in about 30% of the patients, while 50% had auditory dysfunction which varied from mild impairment of hearing to total deafness. Stature and intellect were normal, and bone fragility, osteomyelitis and dyshaemopoesis were not features of the condition. Five other potentially affected family members had deafness or facial palsy of uncertain aetiology in the absence of other stigmata of CMD. It is uncertain whether these complications represent minor degrees of phenotypic expression of the abnormal gene.


Turner's syndrome with a duplication-deficiency X chromosome derived from a maternal pericentric inversion X chromosome.

A 31-year-old woman of short stature with severe oligomenorrhea was found to carry a duplication-deficiency X chromosome, 46,X,rec(X)dup q,inv(X)(p22q11), inherited from her mother who carried a pericentric inversion X chromosome, 46,X,inv(X)(p22q11). By a combination of autoradiography and BUdR incorporation, the duplication-deficiency X chromosome was always found to be the inactive and late replicating one. In the cultured fibroblasts with the recombinant X chromosome, some of the cells were seen to have bipartite X chromatin bodies. In the mother with inv(X), the normal and the inverted X chromosome were inactivated at random.


Prenatal diagnosis of trisomy 20 mosaicism.

Three cases of trisomy 20 mosaicism in amniotic fluid cell cultures are described. Two of the pregnancies resulted in normal full-term infants. The third pregnancy was terminated and revealed a phenotypically normal fetus. A review of five previously reported cases is presented. Explanations of these findings include in vitro nondisjunction, culture of extraembryonic tissue, and true fetal mosaicism. The diagnostic dilemma this presents is discussed.


The effects of intraperitoneal injection of 6-hydroxydopamine on the turnover and the levels of the brain catecholamines and the levels of plasma corticosterone in rats.

1. The effects of intraperitoneal injection of 6-hydroxydopamine (6-OHDA) on the levels and the turnover of brain catecholamines and the levels of plasma corticosterone were studied in rats. 2. Two weeks after intraperitoneal injection of 6-OHDA (150 mg/kg) a virtually complete disappearance of cardiac noradrenaline was observed. 3. An increment and an accelerated turnover of noradrenaline in the hypothalamus was observed 2 weeks after peripheral administration of 6-OHDA (150 mg/kg). 4. There was no change in the levels and the turnover of noradrenaline in the cortex of the rats so treated. 5. There was not change in the levels and the turnover of dopamine in either the hypothalamus or the cortex of the 6-OHDA-treated rats. 6. An increment and an accelerated turnover of hypothalamic noradrenaline were not associated with any change in plasma corticosterone.


Effect of dithiothreitol on histamine receptors in rabbit colon and guinea-pig ileum.

1. Dithiothreitol, an agent which reduces disulphide linkages to sulphydryl groups, potentiated the contractile responses of the rabbit colon and guinea-pig ileum to histamine, but had no effect on the resting tone or on the responses of these preparations to acetylcholine. 2. The potentiation was greater than that produced by antagonism of histamine's weak inhibitory action by metiamide, and still occurred after blockade of H2-receptors with metiamide; it is concluded that DTT potentiates responses to stimulation of H1-receptors in both preparations. 3. In this respect, these H1-receptors resemble those in vascular smooth muscle in the rabbit but not in the guinea-pig; it is concluded that there is a tissue variation rather than a species variation in the response of H1-receptors in the rabbit and guinea-pig to DTT.


Blood clearance rates of angiotensin II and its metabolites in sheep: presence of immunoreactive fragments in arterial blood.

1. The blood clearance rates of exogenous (des-1-Asp)-angiotensin II and (des-1-Asp-2-Arg)-angiotensin II calculated from the arterial blood level during steady state infusion in conscious sodium-replete sheep were found to be 125 litre/h (s.d. = 27, n = 18) and 188 litre/h (s.d. = 23, n = 18), respectively. These blood clearance rates were in the same order as values for angiotensin II previously reported. 2. Using descending paper chromatography, immunoreactive fragments of angiotensin II in arterial blood extracts were adequately separated from angiotensin II. Quantitative determination of angiotensin II by direct immunoassay on whole blood extract using recovery tracer to correct for losses during extraction were on the average 31% (n = 9) higher than those obtained after the same blood extract had been subjected to chromatographic separation. 3. The blood clearance rates of exogenous 1-Asp-5-Ile-angiotensin II calculated from infusion rate/blood angiotensin II concentration before and after chromatographic separation were significantly different, being 103 litre/h (s.d. = 16, n = 18) and 134 litre/h (s.d. = 25, n = 9), respectively (P less than 0.001;t-test, 16 d.f.). 4. Our data demonstrate the presence of immunoreactive fragments of angiotensin II in arterial blood of sheep during steady-state infusion and indicate that direct immunoassay on arterial blood extracts without adequate separation may result in artificially higher values of angiotensin II in blood and consequently false value for its clearance rate.


99mTc-methylene diphosphonate imaging in neural crest tumors.

Thirteen patients with neural crest tumors were each studied with a radionuclide skeletal survey, a radiographic skeletal survey, and an iliac crest bone marrow aspiration. The RN skeletal survey proved to be more accurate that the radiographic skeletal survey in: 1) detecting the primary tumor; 2) demonstrating bony metastatic disease; and 3) evaluating response to therapy. The overall accuracy of the RN skeletal survey in detecting metastatic disease correlated with the results of bone marrow aspiration both in the initial detection of metastatic disease and the evaluation of response during therapy.


Scintiscans and computer assisted tomographic findings of herpesencephalitis.

The radionuclide, CAT and angiographic features of a case of herpes simplex encephalitis are present. A dramatic change in the abnormal perfusion and static concentration of tracer activity resulted following chemotherapy with Adenine arabinoside. The improvement seen on the dynamic and static scintiscans correlates closely with the patient's clinical course and CAT findings. The radionuclide perfusion study is of particular importance in documenting the diminished activity of the inflammatory process following therapy.


Increased localization of 201 Tl-chloride in subacute thyroiditis.

We present two cases of subacute thyroiditis in which increased radionuclide activity in the affected areas was observed on 201 Tl thyroid scintigrams. These were taken to evaluate cold areas on the 99m Tc-pertechnetate thyroid scintigrams. This finding suggests that 201 Tl may be a potentially useful radionuclide in visualizing inflammatory lesions.


Brain scan abnormalities in intracerebral sarcoidosis.

We present a case in which dramatic anterior midline uptake of 99mTc-pertechnetate simulated a suprasellar tumor in a patient with sarcoid. The brain scan abnormalities proved to represent extensive hypothalamic and basal ganglia involvement by sarcoidosis.


Lateral-view ventilation images with 133Xe.

For better delineation of regional ventilation abnormalities, a lateral-view imaging has been employed when one or more areas of abnormal retention were visible in posterior views of 133Xe washout images. It is technically simple to obtain lateral views during the 133Xe washout phase. The resulting images were found to be very useful in detecting regions of ventilation-perfusion mismatch and in evaluating regional obstructive lung disease.


The multiscan appearance of eosinophilic granuloma.

A case of multifocal eosinophilic granuloma is presented in which a 99mTc-methylene diphosphonate bone scan revealed areas of increased, normal, and decreased uptake of the radionuclide. A radiographic bone survey demonstrated some but not all of the lesions seen on the bone scan; additionally, certain lesions were demonstrated only by the radiographs. A radionuclide bone scan is therefore unreliable as the sole diagnostic procedure for evaluating the distribution of eosinophilic granuloma and should always be complemented with a radiographic bone survey.


False-positive studies in early 67Ga-citrate scintigraphy.

Two cases of false-positive early 67Ga-citrate scintigraphs are presented. In both cases, the initial accumulation of the radiotracer in the region of the right iliac fossa could not be substantiated on the delayed study. It is suggested that the results of an early gallium scan be interpretated cautiously, especially when any apparent abnormality is within the region of the normal colonic anatomy. A delayed study should be performed whenever possible.


A visual index of thyroid function.

A visual index of thyroid uptake (VITU) is introduced as a qualitative measure of thyroid trapping. This index is determined from the 20-minute 99mTc-pertechnetate scan by visually comparing the relative tracer uptake between the thyroid and salivary glands. Three categories are defined: low, normal and elevated. The VITU correctly identified the functional status of the thyroid in 94% of 123 patients studied and agreed with the 24-hour radioiodine uptake (RAIU) in 89%. The VITU is a very simple but highly accurate, reliable and reproducible test. It was primarily designed to complement other tests of thyroid function by contributing qualitative information about the thyroidal trapping mechanism, but it can also be useful in confirming blood tests of thyroid function in cases in which one would prefer to avoid 131I administration for RAIU studies.


32P-sodium phosphate treatment of metastatic malignant disease.

Thirty-four patients with cancer of the breast and 12 with cancer of the prostate were treated with testosterone and 32P-sodium phosphate for relief of pain from bony metastases. Thirty were treated with chemotherapy as well, and 34 were treated with external radiation to single ports for localized pain. Of the 46 patients treated, good results were achieved in 34, fair results in six, and no improvement in six. Subsequent marrow depression necessitated transfusion in 10 patients; no other side effect was observed.


Value of routine abdominal nuclide angiography as part of liver scan.

Routine performance of a dynamic study as part of the liver scan results in a significant rate of discovery (19%) of intraabdominal abnormalities such as aortic aneurysms, cystic masses, ischemic intestinal diseases and collateral circulation. The procedure aids in the demonstration of space-occupying hepatic lesions and is often decisive in the diagnosis of chronic liver disease. Alterations in the perfusion of the liver as reflected in the dynamic scan may have a predictive value in the course of alcoholic hepatic disease as to the ultimate development of cirrhosis. Therefore, the dynamic study assumes an important role in the management of the alcoholic patient.


Single fraction half body radiation therapy.

High-dose radiation therapy given as a single fraction to upper and lower halves of the body provides extremely effective palliation of widespread malignant disease. The side effects are tolerable to patients and the problem of numerous hospital attendances for palliative therapy is avoided. In view of its good tolerance and the theoretical tumour cell kill that may be achieved by this treatment its use in radical treatment should be considered.


Factors influencing plasma concentrations of ethosuximide.

The relation between steady-state plasma ethosuximide level and drug dose was studied in 46 patients. In this population, plasma drug levels were proportional to drug dose, expressed on a body weight basis. Age did not alter this relationship, but plasma levels increased more rapidly, relative to dose, in females than in males. Intake of methylphenobarbitone, but not intake of certain other anticonvulsants (phenytoin, phenobarbitone, primidone and carbamazepine) altered the relationship between plasma ethosuximide level and ethosuximide dose. In individual patients, successive dose increments of equal size produced progressively greater increases in steady-state plasma ethosuximide levels. This phenomenon has obvious therapeutic implications.


The value of bone scanning in the staging of breast cancer.

Bone scans using technetium phosphate complexes were performed on 874 patients with breast cancer referred to the South Wales Radiotherapy Centre between January 1973 and December 1976. Most of the patients also had radiological skeletal surveys performed within one month of the scan. Scans proved to be more reliable and sensitive than X-rays for detection of bone metastases. 20% of all patients with clinically localised disease had positive scans, bone metastases were confirmed within two years in four-fifths of the patients with positive scans and negative X-rays. It is suggested that a patient with an abnormal scan should not receive radical local treatment.


Embolisation of the external carotid artery in the treatment of carotid cavernous sinus fistulae.

A review of treatment methods used to control carotid cavernous sinus fistulae is presented. Three cases are described in which embolisation of the external carotid artery was done along with intracranial vascular procedures in the management of carotid cavernous fistulae.


Diffuse cord enlargement in radiation myelopathy.

Radiation myelopathy is a well-documented complication of the irradiation of neoplasms adjacent to the spinal cord. Myelography has been used to distinguish intraspinal metastases with the diagnosis of radiation myelopathy being made if the study is normal. Four cases of radiation myelopathy are here described which were associated with swelling of the spinal cord and, in three cases, this was demonstrated at myelography. The fusiform expansion of the cord, which is indistinguishable from an intrinsic tumour or hydromyelia, is maximal in the irradiated zone, but may extend beyond it. The demonstration of swelling was associated with an abrupt clinical deterioration and, in two patients, followed a recent normal examination. The severe degree of damage underlying the cord enlargement was reflected in the poor prognosis.


Malabsorption of hydrochlorothiazide following intestinal shunt surgery.

Hydrochlorothiazide 775mg was administered orally to 5 patients who had undergone intestinal shunt operations for obesity 1.5 to 6 years previously. Postoperative weight loss averaged 53.4kg. The concentrations of hydrochlorothiazide in plasma and urine were determined with gas/liquid chromatography. The mean area under the plasma concentration time curve during 9h in 4 of the patients was 889ng/ml.h. Mean total urinary recovery of hydrochlorothiazide amounted to 23.0mg in the 5 patients, which corresponds to approximately half that seen in healthy volunteers. The gastrointestinal hydrochlorothiazide appears to be substantially reduced after intestinal shunt surgery.


Antiepileptic drugs: metabolism in pregnancy.

In an open prospective clinical study, plasma clearance of phenytoin, phenobarbitone and carbamazepine was assessed in 14 epileptic patients during and after pregnancy. Plasma clearance showed a marked increase during pregnancy, reached a maximum just before or after delivery, and then decreased to early pregnancy values. The relative plasma concentration of carbamazepine-10,11-epoxide to that of carbamazepine increased similarly during pregnancy. The protein binding of carbamazepine and the epoxide was not influenced by pregnancy. A higher rate of hepatic drug metabolism, due to alteration of the physiological state in pregnancy is suggested as the most reasonable explanation. No change in seizure frequency was seen, probably because of frequent dose adjustments in order to keep plasma levels within the optimum range.


Bowel wall thickness as a differentiating feature between ulcerative colitis and Crohn's disease of the colon.

The colonic wall thickness was assessed from the plain abdominal radiograph and double contrast barium enema in 33 patients with ulcerative colitis, 28 with Crohn's colitis and 20 with neoplasia. The maximum wall thickness in the control group with neoplasia measured in non-diseased colon, was 2 mm. Accurate measurement was possible from only 34% of the plain films, owing to inadequate gas in the lumen. Measurement was possible in 84% of barium enemas, mainly in the descending colon. The maximum wall thickness associated with ulcerative colitis was 5 mm. In 50% of Crohn's colitis the wall thickness was above 5 mm. Estimation of the wall thickness was a slightly less sensitive index of the presence of colitis than the mucosal changes on double contrast enema. Distinction between the types of colitis was usually possible from the mucosal lesions. Where these could be similar, such as with confluent shallow ulceration, the tendency of Crohn's disease to be associated with a wall thickness in excess of 5 mm was valuable diagnostically.


Radiological evaluation of anal fistulae: a prospective study of fistulograms.

A review of 33 fistulograms in a four-year study is presented. Four types of communicating tracts have emerged: single (58%), branched (18%), fistulous abscess (15%) and compound (9%). This classification has formed the basis of selection of operative treatment in all the cases. Diminished lumbo-sacral angle was also found in most of the anal fistula cases and this establishes a possible association between the pathology of anal fistula and the low back syndrome.


Strictures and other late complications of neonatal necrotising enterocolitis.

Eighty infants have been treated for neonatal necrotising enterocolitis within a period of five years. Twenty-five per cent developed strictures of the small or large intestine. Four cases of atresia including two with multiple cyst formation were seen. Four patients developed severe malabsorption requiring hyperalimentation with slow recovery of small bowel function in two survivors. The radiological features of these complications is illustrated and the role of radiology in the management of these patients is discussed.


Right-angled narrowing of the distal oesophagus secondary to carcinoma of the tail of the pancreas.

Dysphagia due to secondary involvement of the oesophagus by pancreatic carcinoma is relatively rare. Occasionally, the oesophagus may be involved by direct extension of a carcinoma of the body and/or tail of the pancreas or metastatic lymphadenopathy in the posterior mediastinum. Although the literature contains a few case reports in which barium studies revealed displacement or obstruction of the distal oesophagus, a benign-appearing, smooth, tapered narrowing of the distal oesophagus with a fixed, right-angled configuration is a radiological finding which has not been previously emphasised. In the author's experience, this abnormality may be a helpful radiological clue to the diagnosis of carcinoma of the tail of the pancreas. The clinical, radiological and pathological findings in four patients with dysphagia and a right-angled narrowing of the distal oesophagus secondary to carcinoma of the tail of the pancreas are described and illustrated; the radiological differential diagnosis is briefly discussed.


Diverticulum formation in Crohn's disease of the colon.

Three patients are described with ulceration of the colon in whom the disease was complicated by the formation of diverticula. In one patient this took the form of pseudo-diverticulum formation, which is well recognised, but in the others diverticula were wide-necked, and in one patient followed deep ulceration, a finding which does not appear to have been described before. In the latter it is suggested the diverticula are projections of mucosa through the fibrous scar of the healed ulcers.


Glucagon as a hypotonic agent in cholangiography.

The effects of Glucagon on 35 cholangiographic studies was examined. Relief of spasm at the choledochoduodenal sphincter resulted in consistently improved demonstration of this area. Diminished spasm-induced pain was also recorded. The use of intravenous Glucagon is recommended for cholangiographic studies where there is total biliary obstruction, or where there is unsatisfactory demonstration of the choledocho-duodenal area.


Renal papillary adenocarcinoma.

Papillary adenocarcinoma of the kidney is an uncommon variant of renal tubular carcinoma, which on radiographic and ultrasonographic evaluation presents characteristically as a predominantly solid hypovascular or avascular mass. Surgery is required to distinguish this lesion from other solid renal lesions, which differs from the more common form of renal tubular carcinoma in several important respects.


Urographic and angiographic changes in acute unilateral pyelonephritis.

The pyelographic and angiographic changes in acute unilateral bacterial pyelonephritis are illustrated in our series of 12 patients. The radiographic abnormalities were completely reversible within a few weeks after clinical recovery. Complications (abscess) occurred in only one patient. Unilateral renal enlargement, diffuse or focal, impaired or absent excretory function, and attenuated calyces were the predominant findings; non-obstructive pelvicalyceal and/or ureteral dilatation were infrequent. Angiographic studies (fivepatients), performed to rule out vascular occlusion, tumour or carbuncle, showed attenuated and somewhat stretched intrarenal vessels associated with the diffuse or focal cortical swelling. Occasionally, a characteristic striated nephrogram is seen.


Prediction of vesico-ureteral reflux in children from intravenous urography films.

Intravenous urography and voiding urethrocystography were performed on 255 children with urinary tract infection. Eighty-six (34%) of these children had some kind of abnormality of the urinary tract. Vesico-ureteral reflux was observed to 96 ureters (19%) in 69 children (27%). The prediction of vesico-ureteral reflux by two radiologists from urography films only gave 46 (48%) and 51 (53%) false negative results respectively. In cases of clinically important reflux (III--V degrees), however, the rate of false negative predictions was 0/18 and 1/18 (6%) respectively. The rate for false positive predictions were 45/413 (11%) for both radiologists. In view of the number of pathological findings in this series i.v. urography is recommended as a routine in children undergoing urological work-up after their first urinary tract infection. As the clinically important vesico-ureteral reflux seems to be predictable from urography films alone, voiding urethrocystography seems not to be justified in children with negative i.v. urography, and can be postponed and carried out later if the urinary tract infection recurs.


The urinary tract image obtained during 99mTc bone scanning.

During the course of a technetium (99mTc) bone scan, it is usual to obtain an image of both kidneys and the bladder. A review of 96 bone scans performed over a two-year period was undertaken in an attempt to assess the accuracy of this image. Ten examinations showed abnormalities of the urinary image suitable for inclusion in the paper, and were subsequently further investigated. Three cases showed that relatively small lesions may be detected within a kidney if localised caliectasis produced a 'hot-spot'. However, greater diffuse concentration of the imaging agent within one renal image does not necessarily represent an abnormality. Space-occupying lesions can be detected as areas of diminished activity within the renal image, if the tumour is extensive. 'Defects' in the bladder image reflect extrinsic impression rather than intrinsic lesions. A further six cases are included to demonstrate how unusual accumulation of the imaging agent within the abdomen may mimic renal tract pathology.


The radiographic manifestations of hypochondroplasia.

Hypochrondroplasia is an inherited skeletal dysplasia that resembles achondroplasia in mild degree. Radiographic manifestations encountered in 12 affected individuals in South Africa include slight shortening of all segments of the tubular bones, moderate caudal diminution of the lumbar interpedicular distances, increased lumbar lordosis with sacral tilt and distal prolongation of the fibula. Hypochondroplasia can be distinguished from other osteochondrodystrophies such as achondroplasia, pseudoachondroplasia and metaphyseal chondroplasia by the recognition of its clinical and radiographic manifestations.20


Hyperostosis generalisata with striations of the bones, a further report in two related families.

Hyperostosis generalisata with striations of the bones falls within the large group of sclerotic bone dysplasias and is characterised by a marked widening of cortical bone, sclerosis of the base of the skull, and dense striations in the cancellous bone. All the bones of the skeleton, with the possible exception of the vault of the skull, may be involved to some extent. A milder form exists in which thickening of cotrical bone occurs, mainly in the long bones of the limbs and striations are absent. The disorder has never been described in the female. Apart from a slight elevation of the serum alkaline phosphatase in some patients, no significant biochemical changes and no impairment of intelligence, growth, or life expectancy have been found. The diagnosis is made entirely on its radiological features. Its occurrence in four members, covering two generations, and three members, covering three generations, of two related families is described. A possible relationship to progressive diaphyseal dysplasia (Camurati--Englemann disease) is discussed.


The radiological evaluation of atrial situs.

Visceral situs, as evidenced by the position of the stomach and liver on the plain film, does not predict atrial situs as accurately as does bronchial situs. In particular situs ambiguus of the atria is not reliably indicated by visceral situs, and its subdivision into either right and left isomerism, where both atria show either right or left morphology respectively, cannot be made. As a result serious abnormalities of venous connections, which are common in the isomerisms, can be missed. Bronchial situs indicates atrial situs much more reliably and can be determined from penetrated chest radiographs or tomograms since the right and left main bronchi normally show different lengths. A ratio of lengths of 2 : 1 or more diagnoses bronchial situs solitus if the longer bronchus is on the left or situs inversus if the longer bronchus is on the right. A ratio of 1.5 : 1 or less indicates an isomerism. Data are presented from which the type of isomerism can be deduced and ratios between 2 and 1.5 : 1 clarified as isomerism or no isomerism.


CT and acute head trauma.

The value of CT in the management of 500 patients with head trauma is described. In these cases CT defined the effect of edema, contusion, subdural or epidural hematoma, or hydrocephalus.


Computed tomography of isodense subdural hematomas.

Eight cases of isodense subdural hematomas were evaluated by computed tomography (CT). CT demonstrated varying degrees of compression of a lateral ventricle, shift of the midline structures and, in some cases, obliteration of the subarachnoid sulci on the side of the lesion. Contrast enhancement was helpful in one case and demonstrated medial displacement of enhanced cortical margins away from the inner table of the skull. Two of the eight patients had no clear history of trauma.


Pitfall in the CT diagnosis of abdominal abscess--the full stomach.

A case is presented to illustrate that the CT appearance of the unenhanced full stomach may be misinterpreted as an abdominal abscess in the appropriate clinical setting. The need for administering oral contrast material prior to the study is emphasized.


Imaging of the pancreas with computed tomography.

In this paper we present our experience with computerized tomographic imaging of the pancreas, both in normal and abnormal conditions. Eighty patients were studied for evaluation of pancreatic disease. A further 50 patients, all with a normal pancreas, were studied for abnormalities of other abdominal organs and served as the control group. Helpful signs in establishing the diagnosis of carcinoma of the pancreas were mass effect within the pancreas, alteration of organ contour and obliteration of retroperitoneal fat planes. We found that differentiation from pancreatitis or retroperitoneal lymphadenopathy may at times be difficult. Our results showed that in 22 out of 23 patients with proven normal pancreas, the pancreas size on the CT display was within the adopted normal range. In 30 patients with proven carcinoma of the pancreas, a pancreatic mass was seen in 24 (83%). Computerized tomography is clearly a valuable method for viewing both normal pancreatic anatomy and anatomical variations and pathologies.


Computer tomography, radionuclide imaging and ultrasonography in hepatic mass lesions.

The livers of 86 patients comprising this report were examined by both transmission computerized tomography (CT) and radionuclide scans (LS). Fifty-nine of them were also examined by gray-scale ultrasound (US). In a comparative study, the strengths and weaknesses of each modality were evaluated. CT demonstrated 85%. US 82%, and LS 73% of masses involving the liver. Because of better resolution and sectioning capabilities, together with stop-motion imaging, CT and US detected smaller and deeper mass lesions than did LS. However, LS was more informative in hepatocellular disorders than was US or CT. Our experience indicated that information obtained on the liver and surrounding structures by each imaging modality used here tends to be somewhat unique, and thus these procedures complement one another rather than being competitive.


Application of the ACTA-scanner to visualization of the spine.

The development of a new computer program called VISUAL, designed to be applied to a series of cross-sectional ACTA scans of the body, makes possible the three-dimensional visulaization of spinal structure without the necessity of surgical exploration. With VISUAL, a molded three-dimensional image of the spine can be displayed on a CT scanner monitor from any of several angles, or from several angles successively, with the direction of illumination determined by the operator.


Computer assisted tomography in rapidly growing brain tumor.

A case of undifferentiated astrocytoma with rapid increase in size of the tumor as documented by sequential computer assisted tomography (CAT) of the head is reported. The case also demonstrates the sensitivity of computer assisted tomography in the detection of intracranial pathology, in the presence of fals localizing neurological findings.


Predictive evaluation in animals of the contact allergenic potential of medically important substances. II. Comparison of different methods of cutaneous sensitization with "weak" allergens.

Results of the optimization method and of other methods used to assess contact allergy in laboratory animals were compared with known epidemiological data on the occurrence of hypersensitivity reactions in man. Tests were performed with preservatives (formalin, ethylenediamine and sorbic acid), drugs (penicillin G, Benzocaine and sulphathiazole) and other contactants belonging to widely different chemical classes (p-phenylenediamine, triclosan, pyrazole derivatives, nickel and chrome salts, eugenol, isoeugenol and mercaptobenzothiazole). The degree of sensitization achieved in guinea pigs by the optimized procedure (intradermal test with adjuvant combination) and the maximization procedure was invariably superior to that produced by the epidermal method using prior irritation of the site of application. Both the optimized procedure and the maximization test seem to be capable of identifying contact allergens that cause hypersensitivity reactions in as few as 1 in 10,000 of the human population as a whole. The optimization test merits consideration as a standardized and efficiently predictive procedure.


Nickel sensitivity in the general population.

The incidence of nickel sensitivity in a population above the age of 10 was examined through epicutaneous tests with 5% nickel sulphate performed on certain school and occupational test subjects and on subjects at a home for elderly people. Nickel sensitivity was observed in 4.5% (in 44 cases of 980 tested subjects), in 8% of the females and in 0.8% of the males. In 42 of the 44 nickel-sensitive subjects there was a history of dermatitis from metal contact. At the time of testing, 16 (34%) of the nickel-sensitive subjects revealed eczema. A manifest nickel sensitivity was thus found in 1.6% of all tested subjects, in 2.8% of females and in 0.4% of males. Nickel sensitivity and a simultaneous hand eczema was noted in 0.9% of the tested population, in 1.6% of females and in 0.2% of males. Hand eczemas were rarer (20.5%) in the nickel-sensitive subjects in the population study than in the nickel-sensitive patients tested at the same time in the clinic (56.6%). No case of nickel sensitivity was occupationally related.


Nickel in food: the role of stainless-steel utensils.

Nickel may be found in prepared foods (tinned foods) at markedly higher concentrations than the safe threshold laid down for hypersensitive patients. Some foodstuffs cooked in stainless-steel utensils attack the metal and thus contain much more nickel than when enamel or aluminum saucepans are used. Among the natural organic acids which may be responsible for dissolving stainless-steel, oxalic acid is the most active at equivalent concentrations.


Successful treatment of reactive perforating collagenosis with tretinoin.

The clinical and histologic features of lifelong reactive perforating collagenosis in a twenty-five year old woman are presented. Experimentally induced lesions showed the expected evolution and regression, although total time for the experimental lesion to develop and regress was shorter than the time necessary for those occurring spontaneously. Therapeutic trials with a wide variety of topical and systemic medications were without benefit, with the exception of tretinoin cream (0.1 percent), which was regularly effective in reducing the total number of lesions present.


A familial epidemic of cutaneous sporotrichosis occurring in north Texas.

A small familial epidemic of cutaneous sporotrichosis occurring in North Texas is reported. The disease occurred in four out of six children in two separate families of paternal cousins. The presumed source of infection was old prairie hay used for mulching. Trauma at the time of exposure seemed minimal or absent. Response to oral potassium iodide therapy was prompt and satisfactory.


The challenge of biophysics to dynamic dermatology.

Dermatologic biophysics has much to offer both clinical and investigative dermatology. For the clinician, the radiation biophysicist can provide accurate measurements of ionizing and nonionizing outputs, including those for PUVA, and critical evaluation of radiation safety measures. In optics, there is a need for accurate measurements of skin color and examination of the skin at moderate magnification. The biophysicist, with the biomedical engineer, can improve all the physical modality instrumentation used in practice. In investigative dermatology, there is the cellular biophysics of radiation. Doppler techniques for skin circulation, spectroscopy of living cells, and many other applications are suggested for current and future studies.


Topical tretinoin, hydroquinone, and betamethasone valerate in the therapy of melasma.

Twenty adult female patients with melasma were followed over a ten week clinical trial in which a combination of depigmenting agents was used daily. Past clinical experience and objective assessment point to enhanced efficacy of this simple depigmenting combination. Certainly, most of depigmenting agents at our command to date have been relatively ineffective. Even this new combination is not the final answer. The purpose of this study is to provide the clinician with a simple yet effective and readily accessible combination of commercially-formulated and available depigmentary agents. A stable combination in a single vehicle with greater efficacy remains to be perfected.


Epithelioma cuniculatum: verrucous carcinoma of the foot.

A patient with epithelioma cuniculatum, an unusual, highly keratinizing squamous cell neoplasm of the foot with locally aggressive behavior, is presented herein.  Review of the literature reveals several similar cases that are reported under the names of epithelioma cuniculatum, papillomatosis cutis carcinoides, and verrucous carcinoma of the skin. The relationship of this neoplasm to other forms of verrucous carcinoma is noted. Lack of metastatic involvement indicates that a conservative surgical approach should be used, when possible, in the therapeutic management of this lesion.


Acquired digital fibrokeratoma.

Three patients with acquired digital fibrokeratoma are presented herein. This tumor may be confused clinically with other lesions including supernumerary digits, fibromas, neuromas, and neurofibromas. As a result, the histologic picture is most helpful in making a correct diagnosis. Since this lesion has been noted to occur in areas other than the digits, a more appropriate designation may be "acquired fibrokeratoma".


Multiple tumors arising in nevus sebaceus.

A forty-three year old woman with nevus sebaceus of Jadassohn involving the scalp is described. The unusual features of this case include the presence of adenoidal basal cell epithelioma, pigmented basal cell epithelioma, syringocystadenoma papilliferum, and nevocytic nevus. This case suggests the importance of prophylactic removal and close follow-up of nevus sebaceus.


Apocrine cystadenoma of the skin of the chest.

A black patient with an enlarging apocrine cystadenoma on the chest is presented herein. This location is very infrequent for this benign lesion. This is the second report of an apocrine cystadenoma in a black person.


Basal cell carcinoma in a hair transplant recipient site.

A basal cell carcinoma developed in the central scalp of a forty-one year old man at the recipient site of a hair transplant plug that was placed five years previously. The patient was never noted to have premalignant or other malignant skin lesions. Although the relationship is probably coincidental, medico-legal factors dictate consideration of a cause and effect relationship.


The diagonal earlobe crease: a cutaneous manifestation of coronary artery disease.

Skin signs of systemic disease are of great interest to dermatologists. Reports based on coronary angiographic studies and postmortem examinations have shown that there is a higher prevalence of earlobe creases in patients with coronary heart disease. In this report seven patients with documented coronary heart disease are presented. Five of the seven patients had bilateral diagonal ear creases. The evidence to date indicates that this ear crease may be a cutaneous sign of coronary heart disease, and can therefore be used to identify patients at an increased risk for coronary heart disease.


Halo congenital nevus.

A case of halo congenital nevus is reported in a fifteen year old Mexican-American girl with pre-existing vitiligo.


Injectable sodium chloride as a local anesthetic for skin surgery.

Sodium chloride injected intracutaneously has proved to be an effective local anesthetic for superficial skin surgery. Among the advantages of sodium chloride over the "caines" are: absence of burning or stinging on injection, lack of sensitization, and lower cost. Lesions can be removed by the parallel scalpel technique, razor technique, or curettage. Saline also provides adequate anesthesia for punch biopsies and electrocautery techniques. Lesions removed to date have been numerous--nevi, papillomas, and verrucas. Biopsies of benign and malignant lesions have also been performed with this technique.


Dystrophia unguis mediana canaliformis.

Three cases of dystrophia unguis mediana canaliformis are presented herein. The presence of verruca vulgaris at the base of the dystrophic canal could be the cause of such dystrophy. The course of dystrophia unguis mediana canaliformis varied. The effect of treatment in such dystrophy remains questionable.


Squamous cell carcinoma. Case report of an unusually aggressive skin cancer.

A squamous cell carcinoma developed on the chin of a seventy-five year old woman of Irish extraction. This tumor had recurred following standard means of therapy and resisted treatment by chemosurgery. The patient had used a cream containing 5-fluorouracil for several years prior to the appearance of this tumor. The increased incidence of skin cancer and its possible cause is briefly discussed and the role of immunobiologic factors in the development of squamous cell carcinomas is mentioned.


Perifollicular fibroma.

Perifollicular fibroma is a very unusual lesion and infrequently seen. The present report describes a thirty-two year old white man with unusual manifestations of this condition which usually presents as a small number of lesions on the head and neck, most often in adults. It has a characteristic pathologic picture of perifollicular fibrosis. The origin of this lesion is uncertain, but most probably represents a tumor of the connective tissue sheath of the follicle.


Recurring digital fibrous tumor of childhood.

Two cases of recurring digital fibrous tumor of childhood are reported. Both patients were infants who had lesions on the toes or fingers. In one case the lesions recurred after surgical excision and in the other the lesions started to resolve without therapy. The histologic sections of tissue showed the intracytoplasmic inclusion bodies typical of this condition.


Soaps in the management of xerosis.

Fifty men and women, aged twenty to sixty-one, with dry skin of the legs, were treated over a four week period, comparing the effects of "hard-milled" versus "dry-skin" (triethanolamine) soaps on the condition of the stratum corneum commonly known as dry skin. Subjective preferences of the subjects heavily favored the dry skin soap. Objective grading of skin changes showed a trend in favor of the dry skin soap.


Effects of breathing warm humidified air on bronchoconstriction induced by body cooling and by inhalation of methacholine.

The effect of breathing warm humidified air upon bronchoconstriction induced with body cooling or inhalation of methacholine was studied in two groups of eight asthmatic subjects. One group had the body cooled using one-minute exposures, first to a cold shower at 15 degrees C and then to a current of wind. The other group received methacholine by inhalation until a decrease of 20 percent or more occurred in the forced expiratory volume in one second. Both groups of asthmatic subjects were tested when breathing room air and warm humidified air. Pulmonary functions were assessed before and after cooling of the body and during inhalation of methacholine. Breathing warm humidified air substantially reduced bronchoconstriction induced by body cooling, but not that induced by inhalation of methacholine. Thus, bronchoconstriction induced by cooling of the body appears to be related to cooling of the airways, which may be compensated by breathing warm humidified air.


Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis.

The effects of a 30-minute period of chest percussion and postural drainage were compared to a sham treatment (infrared lamp) in 35 patients with stable chronic bronchitis and to a period of directed coughing in 11 of these same patients. There were no differences in subjective responses or arterial blood gas levels following therapy. Spirometric studies showed small improvements over baseline values following either treatment but no difference between active and sham treatments. The volume of sputum expectorated during percussion and drainage was significantly greater than during the infrared warming (5.5 vs 1.4 ml) or during the directed coughing (9.0 vs 3.5 ml). Although chest percussion and postural drainage are effective in augmenting the volume of expectorated sputum, no significant alternations in air flow or gas exchange after two hours were demonstrated.


The relationship between acute mountain sickness and pulmonary ventilation at 2,835 meters (9,300 ft).

We have demonstrated a small but statistically significant decrease in forced vital capacity and in pulmonary flow rates among 126 persons studied daily for the first three days after arrival at an altitude of 2,835 meters (9,300 ft). Nearly half of these individuals had symptoms attributable to altitude sickness, and those with the most dyspnea and worst headache also showed the greatest changes in pulmonary function studied. We suggest that there is a relationship between the symptoms of altitude sickness and pulmonary function consistent with the appearance of early interstitial or alveolar edema.


Effects of aortic balloon pumping during cardiopulmonary bypass on myocardial perfusion, metabolism, and contractility.

This study was undertaken to determine if the production of pulsatile flow by the intra-aortic balloon pump during cardiopulmonary bypass has any beneficial effect on coronary flow, regional myocardial flow, myocardial metabolism, and left ventricular function. Thirty-six conditioned dogs were subjected to one hour of total normothermic cardiopulmonary bypass. They were divided into the following five groups: (1) controls, beating heart and femoral inflow; (2) balloon, beating heart, and femoral inflow; (3) balloon, beating heart, and aortic inflow; (4) control, fibrillating heart and femoral inflow; and (5) balloon, fibrillating heart, and femoral inflow. Total coronary flow, left ventricular flow, coronary sinus flow, and the endocardial-to-epicardial flow ratio increased in group 3. This increase in flow may have been in part due to increased resistance to flow in the descending aorta by the balloon. No differences in flow were noted in the other groups, all of which were perfused via the femoral artery. No significant differences in myocardial metabolism or left ventricular contractility could be demonstrated between balloon-treated and control groups in these normal hearts.


Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia.

A thoracoscopic examination was performed in 41 patients under local anesthesia in the lateral decubitus position. Prior thoracocentesis (38 patients) and blind biopsy with an Abrams' needle (32 patients) had been nondiagnostic. The initial nine patients were examined with the flexible fiberoptic bronchoscope, yielding a diagnostic accuracy of 56 percent (five cases). This technique was discontinued when two patients had normal findings on biopsies, despite the visual observation of later diagnosed carcinoma. Subsequent thoracoscopic procedures were performed with a rigid 11-mm single-puncture thoracoscope (Storz), which was diagnostic in 28 (88 percent) of the remaining 32 patients. A hemothorax (400 ml) was the only potentially serious complication. Twelve patients were prospectively monitored during the thoracoscopic procedure for changes in cardiac rhythm and oxygen saturation. Sinus tachycardia was the only arrhythmia observed. The mean fall in oxygen saturation was 1.4 percent. We conclude that thoracoscopic examination with the rigid thoracoscope is diagnostically superior to the fiberoptic bronchoscope and is a safe procedure which can be performed under local anesthesia.


Management of pleural effusions in breast cancer.

Ninety-seven patients with breast cancer developed pleural effusions between January, 1971 and December, 1976. A retrospective analysis of 170 treatment procedures showed that 75 involved thoracocentesis alone, 23 involved thoracocentesis plus therapy with an alkylating agent, 22 involved drainage via a chest tube plus instillation of an alkylating agent, and 50 involved drainage via a chest tube plus instillation of tetracycline. The results are presented as censored survival curves. When management by chest tube plus instillation of an alkylating agent or tetracycline was compared with management by thoracocentesis plus therapy with an alkylating agent, analysis at six months after treatment showed that 42 percent (30/72) of the procedures left patients free of effusion using the former method, compared with 22 percent (5/23) of the procedures using the latter method. This is not quite significant at the 5 percent level using a summary chi2 procedure. The reasons for preferring tetracycline as a sclerosing agent are discussed.


Electrocardiographic axis deviation in Navajo and Apache indians.

It has been our clinical impression that the range of the mean frontal-plane electrocardiographic QRS axis was greater than might have been anticipated in healthy Navajo and Apache Indians. To determine whether this clinical impression was correct, electrocardiograms were obtained from 146 Navajo, 144 Apache, and 159 non-Navajo non-Apache schoolchildren with normal findings on cardiovascular examinations. A mean frontal-plane QRS axis between -1 degrees and -90 degrees was present in 19 percent of the Navajo, 12 percent of the Apache, and 2 percent of the control schoolchildren. A mean frontal-plane QRS axis between +91 degrees and +180 degrees was present in 18 percent of the Navajo, 19 percent of the Apache, and 5 percent of the control schoolchildren. There is a high incidence of electrocardiographic mean frontal-plane QRS axis deviation in healthy Navajo and Apache schoolchildren.


Prolonged respiratory paralysis in wound botulism.

Two patients had wound botulism with longer duration of respiratory paralysis than previously described. Each sustained extensive trauma to soft tissues and grossly contaminated wounds when thrown from a vehicle in a rural area. Progressive muscular weakness and respiratory distress occurred 8 and 13 days after injury, in the presence of infected wounds and clinical and laboratory findings characteristic of botulism. Spontaneous vital capacity and inspiratory effort served as bedside indicators of ventilatory function throughout 11 weeks of ventilatory support in each case and paralleled other clinical assessments of progress and recovery. Wound botulism may result in neuromuscular paralysis for a prolonged period. These cases illustrate the primary role of scrupulous nursing and respiratory care throughout such a period of ventilatory insufficiency.


Post-pneumonectomy syndrome. Surgical correction using Silastic implants.

A post-right pneumonectomy syndrome is described which manifests symptoms of exertional dyspnea and inspiratory stridor on rapid inspiration. These symptoms were associated with marked rightward and posterior deviation of the trachea, over-distention of the left lung with its herniation into the right side of the chest and kinking of the left lower lobe bronchus. At the time of surgery, the tracheal deviation, lung herniation and the kink in the left lower lobe bronchus were immediately corrected by releasing the adhesions between the malpositioned structures and the right chest wall. To maintain the corrected positions, Silastic implants totalling a volume of 990 ml were placed into the space created in the right chest. Following surgery, exertional dyspnea was present with only extraordinary activity, and inspiratory stridor was eliminated. The patient remains asymptomatic three years following surgical correction, and is able to carry on a normal and productive life. We conclude that a syndrome associated with marked exertional dyspnea and inspiratory stridor might develop in situations of marked tracheal shift and overdistention of the remaining lung following right pneumonectomy.


Nocturnal vs diurnal cardiac arrhythmias in patients with chronic obstructive pulmonary disease.

Continuous electrocardiograms were recorded from ten patients with chronic obstructive pulmonary disease. During 24 hours of recording, the patients breathed air; and for 24 hours, they breathed oxygen at 2 L/min by nasal cannula. Oxygenation, as monitored by ear oximetric studies and by periodic analysis of arterial blood, showed frequent nocturnal desaturation. Nine patients demonstrated arrhythmias during the monitoring period, and the frequency of premature ventricular contractions was significantly greater at night. Therapy with supplemental oxygen dramatically reduced the frequency of premature ventricular contractions in four patients, but the reduction in frequency of arrhythmias in the total group did not reach statistical significance. These results show that cardiac arrhythmias occur commonly at night during sleep in patients with chronic obstructive pulmonary disease. The data suggest that arterial desaturation may be responsible for some of these arrhythmias.


Sleep apnea syndrome. Practical diagnostic method.

We report a method of evaluating sleep apnea by equipment available and easily assembled in the majority of community hospitals. Two cases fully studied by this method are presented.


Yellow nail syndrome with reduced glucose level in pleural fluid.

The yellow nail syndrome, consisting of deformed yellow nails, lymphedema, and pleural effusions, is a rare disorder of unknown etiology. The underlying mechanism in this disease is believed to be hypoplasia of the lymphatic system. To date, only 47 cases of the yellow nail syndrome have been reported. We report an additional case, with a defect in cell-mediated immunity and development of an empyema. The patient also had a very low glucose level in the pleural fluid (10 mg/100 ml or less), which did not increase after loading with oral or intravenously administered glucose. The mechanisms for low levels of glucose in the pleural fluid are discussed.


Respiratory distress and hypoxemia in systemic mastocytosis.

A 25-year-old woman with documented mastocytosis developed hypoxemia with pruritus, diarrhea, headache, and hypotension on two separate occasions. The hypoxemia appeared to be related to a massive release of histamine. Resolution of the patient's symptoms was accompanied by the return of her arterial oxygen tension to normal levels.


MB isoenzyme of creatine phosphokinase. Indicator of ischemia in coronary arterial disease.

After undergoing a stress test that showed abnormal findings, a patient with severe coronary arterial disease had an elevated concentration of the MB isoenzyme of creatine phosphokinase, in the presence of normal levels of creatine phosphokinase and myoglobin in the serum.


Atrial myxoma mimicking a collagen disorder.

A 14-year-old boy had a protracted illness characterized by bilateral tenderness and weakness of the extremities; the illness was considered to be a connective tissue disease similar to polymyositis. Not until nine months later, when the patient had new cardiac murmurs, pulmonary edema, and then a cerebrovascular accident, was the true nature of his illness suspected. The diagnosis of left atrial myxoma with the triad of constitutional, obstructive, and embolic effects was confirmed by echocardiographic studies and cardiac catheterization. The tumor was successfully removed.


Unique massive pulmonary hamartoma. Case report with review of hamartomata treated at Brompton Hospital in 27 years.

A 30-cm tumor was removed from a 32-year-old man. It consisted of a collection of multiple small tumors, each histologically typical of a chondromatous hamartoma. Sixteen years earlier, identical histologic findings were noted in "cysts" in the right lower lobe. A review of other cases of cartilaginous hamartoma treated at Brompton Hospital since 1950 and a study of the literature suggest that this tumor is unique.


Endobronchial lipoma.

An endobronchial lipoma has been studied with light, scanning, and transmission electron microscopes, and the literature has been reviewed. Endobronchial lipoma is a type of hamartoma unique only in terms of its specific adult-type fat cell and its location. Of 49 endobronchial lipomas, eight have been reported in obese persons. The neoplasm appears to propagate at its peripheral zone through continuous incorporation and fusion of globules of fat in the spindle-shaped precursor cells. Although benign pulmonary tumors make up about 3 percent and endobronchial lipomas only about 0.1 percent of all pulmonary tumors, benign endobronchial tumors may cause unnecessary morbidity and mortality if not properly managed.


Pulmonary mycobacterial infections due to Mycobacterium intracellulare-avium complex. Clinical features and course in 100 consecutive cases.

One hundred consecutive cases of pulmonary infection due to Mycobacterium intracellulare-avium seen during a 3 1/2-year period qualified for review on the basis of a compatible chest x-ray film, repeated isolations from cultures of sputum, and follow-up of three to eight years. Infections with M intracellulare-avium represented 27 percent of all mycobacterial infections seen during this period, including those due to M tuberculosis. The cases of disease due to M intracellulare-avium were predominantly in men with preexisting pulmonary disease, with a peak incidence in the sixth decade, but nearly one-third of the cases were in younger persons free of coexisting disease. The disease was chronic and indolent in most cases, and only a few showed a progressive course. A stable course was frequently observed despite prolonged persistently positive cultures of sputum. A favorable prognosis was most often found in those with previously treated tuberculosis. Poor prognosis was often due to a serious associated disease, such as cancer, rather than to advancing mycobacterial infection itself. Age, sex, or race was unrelated to prognosis. Conversion to negative status on culture was attained in one-half of the cases. Those with extensive radiographic involvement or cavitation were more likely to have treatment fail bacteriologically. No combination of chemotherapy appeared to be particularly effective, including the use of five or more drugs in eight cases demonstrating progressive disease. Surgery, too, was ultimately disappointing in that recurrence appeared in six of 18 carefully selected cases.


A demographic study of disease due to Mycobacterium kansasii or M intracellulare-avium in Texas.

The number of patients reported th have disease due to Mycobacterium kansasii or M intracellulare-avium has increased in Texas from January 1967 to December 1976, in contrast to a decrease in tuberculosis. Presented is an analysis of 1,409 patients infected with M kansasii and 706 patients infected with M intracellulare-avium. The former group clustered in urban areas with more than twice the incidence compared to nonurban areas (P less than 0.001). The latter group was more diffusely distributed with approximately twice the incidence in nonurban areas compared to urban areas (P less than 0.001). The average age of the group infected with M kansasii was 50 years and of the group infected with M intracellulare-avium 58 years. In patients infected with M kansasii only, the average age was significantly higher for men than women. There was a male predominance in both groups, ie, 3:1 in M kansasii and 2:1 in M intracellulare-avium. Persons with Spanish surnames had a low incidence of disease due to M kansasii. No other racial or ethnic association was noted. The various factors involved in determining the atypical mycobacterial diseases are discussed.


The advantages of open mitral commissurotomy for mitral stenosis.

Mitral commissurotomy is the treatment of choice for mitral stenosis. If this is not feasible, replacement of the valve becomes necessary. Open commissurotomy has been performed at Loyola University Medical Center, Maywood, Ill, in 105 patients since 1970. The mean age was 45 years. The indication for surgery was heart failure in 92 of the cases. Sixty of the patients were in class 3 of the New York Heart Association (NYHA) classification. Eighty-five underwent open mitral commissurotomy alone. This was not feasible in 42 patients scheduled for it who required valvular replacement. Twenty-five patients had a left atrial thrombus. Two patients died, one from aortic dissection and the other from acute infarction in the perioperative period. Ninety-eight patients are NYHA class 1 or 2 at present. Two patients required valvular replacement following the commissurotomy. The low mobidity and mortality with excellent long-term results support our contention that open mitral commissurotomy is the treatment of choice for mitral stenosis.


Effects of smoking and inhalation of carbon monoxide on systolic time intervals and blood pressure. Differences between two types of cigarettes and a cigar.

The effects of smoking and inhalation of carbon monoxide on the systolic time intervals and blood pressure were examined in ten healthy smokers with a mean age of 24.3 years. Each subject smoked a low-nicotine cigarette with a ventilated filter (0.1 mg nicotine, 1.1 vol percent CO), and a high-nicotine plain cigarette (2.6 mg nicotine, 4.5 vol percent CO), as well as a cigar in random sequence and in a standardized way. Cigar smoke was not inhaled. The product heart rate x blood pressure was increased and the left ventricular ejection time index (LVETc) prolonged following smoking the high-nicotine cigarette, whereas changes after smoking the low-nicotine cigarette and the cigar were not as pronounced. These changes are presumably caused by nicotine-induced catecholamine release. Inhalation of CO did not affect cardiac performance acutely as shown by unchanged systolic time intervals. When a high-nicotine cigarette was smoked after the subject received a beta blocker, a significant prolongation of the pre-ejection period index (PEPc) occurred as a result of the increased afterload. Thus, the effects of catecholamines on parameters of myocardial contractility (PEPc, PEP/LVET) were presumably offset by the increased afterload. We conclude that the acute hemodynamic changes of smoking in healthy subjects depend upon the amount of nicotine absorbed.


Biopsy and brushing of peripheral lung cancer with fluoroscopic guidance.

Forty-eight patients underwent flexible fiberoptic bronchoscopic examination under fluoroscopic guidance, with biopsy and brushing of an endoscopically invisible primary cancer of the lung. A diagnostic (abnormal) specimen was obtained by biopsy of brushing (or both) in 29 patients (60 percent), by biopsy alone in 22 (46 percent), and by brushing alone in 19 (40 percent). Success in obtaining diagnostic tissue was related to cellular type, location by bronchopulmonary segment, size of the tumor, and distance of the tumor from the hilum.


Improvement in pulmonary function with diuretic therapy in the hypervolemic and polycythemic patient with chronic obstructive pulmonary disease.

Central hemodynamics and gas exchange were studied in six patients with chronic obstructive pulmonary disease (mean age, 60 years). Patients were selected for the study if the volume of blood was 1 L larger than the predicted normal value, if there was no history of infection, and if no drug assumed to influence pulmonary circulation had been given during the last four weeks. Measurements were first performed in the hypervolemic state. This was followed by a venesection of 0.5 L, and the measurements were repeated 15 minutes later (immediate effects of dehydration). After two weeks to two months of intensive diuretic therapy, new measurements were performed (long-term effects of dehydration). With hypervolemia, there was pulmonary hypertension, increased pulmonary vascular resistance, and normal cardiac output. The arterial oxygen tension (PaO2) was markedly reduced. The arterial carbon dioxide tension (PaCO2) was increased in two patients, and dead-space ventilation (VD/VT) increased in all. The sole immediate effect of venesection was a small increase in heart rate and a reduction in PaCO2. The long-term effects were a maintained low blood volume (on the average, 0.7 L less than before bloodletting) and lowered hematocrit reading (8 percent less than before bloodletting), a reduced and in some patients normalized pulmonary arterial pressure, a reduced pulmonary vascular resistance, and an unchanged cardiac output. The PaO2 improved, while PaCO2 did not change; neither did VD/VT. The changes correlated partly with the diminution in blood volume and partly with the reduction in hematocrit reading.


Electrocardiographic voltage in pericardial effusion.

The usefulness of the electrocardiographic sign of "low voltage" in the diagnosis of pericardial effusion was investigated in 122 patients comprising three study groups. Sixty-four patients (group 1) had a pericardial effusion detected and measured by echocardiographic studies. The volume of the effusion showed no correlation with electrocardiographic voltage. A second group of 36 patients was identified as having low voltage on routine electrocardiograms. Only 13 (36 percent) had echocardiographically demonstrable pericardial effusion. Group 3 consisted of 22 patients who required pericardiocentesis. The ECGs obtained immediately after pericardiocentesis showed an increase in average voltage of 0.48 mm in the limb leads and 0.83 mm in the precordial leads for each 100 ml of fluid removed. This study demonstrates that a single ECG with "low voltage" is not useful in the diagnosis of pericardial effusion but that a reduction in the voltage of serial ECGs may suggest the development of pericardial effusion.


Bronchogenic carcinoma in chronic lymphocytic leukemia.

Fourteen cases of bronchogenic carcinoma were found in 191 patients with chronic lymphocytic leukemia seen at the Rosewell Park Memorial Institute, Buffalo, NY, from 1951 to 1976. Four of these were not diagnosed until the time of autopsy. There was an average lag of nine months between the onset of symptoms and signs suggestive of bronchogenic carcinoma and its diagnosis. In patients with chronic lymphocytic leukemia, a high index of suspicion for bronchogenic carcinoma is necessary fo its early detection.


Delayed appearance of left-to-right shunt following aortic valvular replacement. Report of two cases.

Two cases are presented in which a left-to-right shunt occurred late following aortic valvular replacement. In one patient a fistula was found between the aortic root and the right atrium and ventricle. In the second patient a defect developed in the membranous septum, allowing shunting from the left ventricle to both the right atrium and right ventricle.


Cardiac dysfunction in a patient with familial hypokalemic periodic paralysis.

A 19-year-old white man with familial hypokalemic periodic paralysis developed evidence of cardiac dysfunction during a episode of flaccid paralysis. This consisted of elevated total creatine phosphokinase (CPK), an increased myocardial fraction of CPK (myocardial band), alteration in the lactic dehydrogenase isoenzyme pattern, severe bradycardia, and evidence of left ventricular dysfunction. These findings, in conjunction with selected cases from the literature, suggest the possibility that cardiomyopathy may be a heretofore unrecognized complication of this disorder.


Reexpansion pulmonary edema.

A case of pulmonary edema following reexpansion of a collapsed lung due to pneumothorax is described and illustrated. The importance of recognizing this relatively uncommon phenomenon is stressed. The development of such edema can be prevented by avoiding application of sudden and excessive negative pleural pressures during the evacuation of a pneumothorax or a pleural effusion. The edema generally occurs in a lung that has been collapsed for more than three days. The importance of the duration of pulmonary collapse in the causation of edema is demonstrated in this patient.


Isoniazid-induced fever.

A 56-year-old man was started on therapy with isoniazid after exhibiting a positive reaction to an intradermal injection of intermediate-strength purified protein derivative of tuberculin. After the first dose and each of the following three doses, nausea, vomiting, chills, and an elevated body temperature ranging from 38 degrees C (100.4 degrees F) to 40 degrees C (104. degrees F) occurred. There was no evidence of a hypersensitivity reaction to isoniazid, such as cutaneous rash, eosinophilia, elevated concentration of IgE, and abnormal results on tests of hepatic function. Following discontinuance of therapy with isoniazid, the temperature returned to normal. This experience illustrates the potential of isoniazid to cause febrile reactions, a situation that could be misdiagnosed as an infectious process.


Alternating Wenckebach periods with acute myocardial infarction. Report of two cases.

This report describes two patients with the spontaneous occurrence of alternating Wenckebach periods during the course of acute myocardial infarction. Both patients demonstrated alternating Wenckebach periods which terminated in a sequence of two blocked P waves. In one patient, His bundle electrocardiographic study documented the site of block to be proximal to the His bundle. Alternating Wenckebach periods with the block proximal to the His bundle may be compatible with a benign prognosis.


Acute intoxication with verapamil.

A healthy 18-year-old man was admitted to our unit two hours after a suicidal ingestion of 2 gm of verapamil. There was mild hypotension, depression of the sinus node, atrioventricular dissociation, changes of repolarization, and first-degree intranodal atrioventricular block (the His bundle electrogram revealed an atrio-His [A-H] interval of 155 msec). Twenty-four hours after ingestion, the patient was well, and the electrocardiogram was completely normal. This case gave us a good opporturnity to study the electrocardiologic effects of a huge oral dose of verapamil on a healthy young heart.


Silicosis and tuberculosis.

Two subjects had silicosis complicated by tuberculosis. In both patients, there was a relapse of the tuberculosis after chemotherapy was discontinued, in one case after 13 years of therapy with isoniazid and p-aminosalicylic acid. It would appear that the risk of tuberculosis in subjects with silicosis persists for life, and the suggestion is made that chemotherapy should be continued indefinitely.


Percutaneous use of fiberoptic bronchoscope to investigate bronchopleurocutaneous fistula.

The fiberoptic bronchoscope was used percutaneously to visualize the track of a bronchopleurocutaneous fistula and to obtain tissue and microbiologic specimens for examination. The bronchoscopy turned out to be a very simple procedure and patient discomfort was minimal. The findings aided in the successful management of this patient.


Traumatic injuries of the diaphragm.

Traumatic injury of the diaphragm is not an infrequent occurrence. With the rise in violence and increasing use of automobiles, more diaphragmetic injuries may be seen, especially in inner-city hospitals. Sixty-six cases from our institution within the last five years were reviewed. Of these there were 41 penetrating injuries and 23 secondary to blunt trauma. Two cases were surgically induced following a difficult decortication for pleuropulmonary tuberculosis. There were ten deaths (15 percent mortality). All deaths were related to the severity of associated injuries. In addition, we analyzed 307 patients with multiple injuries who were dead on arrival and were autopsied by the county medical examiners in a 24-month period. Of the 307 autopsied cases, 16 (5.2 percent) had ruptured diaphragms. Interestingly, all but one of these cases were associated with thoracic aortic injuries. Diagnoses of penetrating diaphragmatic injuries were made during exploration of other injuries. In blunt diaphragmatic rupture, a high index of suspicion in most important in the diagnosis. In 10 of 23 blunt injuries, visceral herniation was noted on initial x-ray films. In four, follow-up films several hours to a day later showed loops of bowel in the chest. In nine cases, there were no apparent visceral herniations on initial films, and in these, the diagnosis was made during surgery for other indications. The surgical approach to diaphragmatic injuries is individualized. Acute left-sided injuries are best approached through the abdomen. Acute right-sided injuries and all chronic injuries should be approached through the chest.


Surgery for mitral valve endocarditis.

The records of 20 patients who underwent mitral valve replacement for complications of bacterial endocarditis were reviewed. Although the indications for surgery were the same as those for patients with aortic endocarditis, major emboli (cerebral, coronary or retinal) prompted surgery in 8 of 20 patients, a much higher incidence than reported for surgery in aortic valve endocarditis. Eighteen of the patients had mitral regurgitation; 14 of these had severe congestive heart failure, but the development of congestive failure tended to be more insidious than in patients with aortic endocarditis. Continued septicemia despite appropriate antibiotics was the least common indication for surgery. Sixteen of the 20 patients were salvaged by surgery, although some had major residual deficits, related mainly to preoperative emboli. These results are a marked improvement in the expected 90-100 percent mortality rate for patients with these complications of endocarditis. The main reason for a poor result following surgery was temporization leading to continued deterioration of vital functions preoperatively. Reinfection of the prosthesis did not occur, and we do not consider duration of preoperative antibiotic therapy an important factor in the decision to perform surgery.


Mediastinal granuloma and fibrosing mediastinitis.

Thirty-one patients with mediastinal granuloma and fibrosing mediastinitis were seen at the Mayo Clinic from 1975 through 1977. Review of this series reveals that surgery is necessary to establish a diagnosis if the lesions are noncalcified and indeterminate. Fibrosing mediastinitis most likely develops after rupture of the fibrocaseous material from mediastinal lymph nodes into the mediastinum. Thoracotomy, with evacuation of the granulomas, is recommended, especially when the lesions are large, in order to prevent subsequent fibrosing mediastinitis with involvement of the contiguous structures, such as the superior vena cava, azygos vein, trachea, esophagus, and left atrium. In most patients, obstruction of the superior vena cava develops slowly, and efficient collateral venous circulation occurs, allowing long-term survival and minimal disability.


M-mode ultrasonic localization and identification of fluid-containing pulmonary cysts.

Successful ultrasonic localization of pleural fluid has been well documented in recent reports. The ability of ultrasound to detect and identify fluid within a parenchymal lesion has not been defined. We examined nine patients with cystic lesions and air-fluid levels noted on the chest roentgenogram. In all nine patients, an echo-free space that corresponded anatomically to the level of fluid noted on the x-ray film could be recorded in the M-mode presentation. The combined thickness of the wall of the chest and the overlying lung as judged by ultrasound ranged from 2 to 8 cm, with a mean of 4 cm. The following two characteristics appeared to distinguish parenchymal from pleural fluid: (1) similar characteristics of motion of the proximal and distal interfaces of the sonolucent space; or (2) the ultrasonographic pattern of overlying lung proximal to the loculation of fluid. Ultrasonograms in eight (89 percent) of nine patients demonstrated one or both of these characteristics. These findings indicate that ultrasound can detect fluid within a parenchymal structure and may be used to differentiate intraparenchymal loculations from those in the pleural space.


Incidence of ruptured chordae tendineae in the mitral valvular prolapse syndrome: an echocardiographic study.

Echocardiographic studies were performed in 190 consecutive patients with mitral valvular prolapse. All patients had either midsystolic posterior motion of the mitral valve or holosystolic hammock-like movement of the valve in systole. Thirteen patients (7 percent) were noted to have ruptured chordae tendineae. In four patients, a combination of abnormalities was observed. Five patients had clinical and bacteriologic evidence of infective endocarditis, two of whom had severe intractable pulmonary edema consequent to acute mitral regurgitation which required mitral valvular replacement. At surgery, one of these patients had ruptured chordae tendineae to both leaflets, and the other had chordal rupture of the posterior leaflet. The other patients probably had spontaneous rupture of the chordae tendineae. A spectrum of clinical findings was noted. Six patients had marked mitral regurgitation, while two had isolated systolic clicks. Thus, chordal rupture does not always result in severe hemodynamic deterioration. Serial echocardiographic studies will be of value in studying the natural history and progression of disease in patients with chordal rupture.


Aggressive therapy in acute respiratory failure from leukemic pulmonary infiltrates.

Three young adults with respiratory failure as a first or early manifestation of acute leukemia were hospitalized. Aggressive support with mechanical ventilation, high fractions of inspired oxygen, and positive end-expiratory pressure provided time for appropriate chemotherapy to be used. One patient was alive, with the disease controlled, 18 months after these events. The other two patients responded to therapy but died subsequently from other aspects of their disease. With the advent of effective specific chemotherapy, the onset of acute respiratory failure in the presence of certain malignancies in young adults should not be considered a terminal event when no other organ is involved.


Echocardiographic abnormalities in patients with cystic fibrosis.

An echographic study was undertaken to evaluate left (LV) and right ventricular (RV) function in 30 patients with cystic fibrosis. Echographic recording of the pulmonary and aortic valve echogram permitted measurement of the phases of right and left ventricular systole. The ratio of the LV preejection period/LV ejection time (LPEP/LVET) and shortening of the LV internal dimension %SID was employed to reflect LV function, while RV preejection period/RV ejection time (RPEP/RVET) has excellent correlation with pulmonary artery diastolic pressure. RPEP/RVET and two other echographic measurements, right ventricular wall (RVW) and internal dimension (RVD) were compared with pulmonary function tests and clinical scores. RPEP/RVET correlated well with percent vital capacity(%VC), r = -0.73, percent residual volume (%RVol) r = +0.72, and clinical score, r = -0.77. Multilinear regression of RPEP/RVET, RVD, and RVW improved correlation for %VC (r = -0.80), %RVol, r = +0.82, and clinical score, r = -0.84. Patients in overt right heart failure exhibited elevated RPEP/RVET (mean = 0.48) when compared to patients not in right heart failure (mean = .33). Marked diminution of LV function was present in two patients. A variety of cardiovascular abnormalities were demonstrated echographically and were valuable in assessing the degree of cardiac involvement in patients with cystic fibrosis.


Clinical importance of the interaction of phenytoin and isoniazid: a report from the Boston Collaborative Drug Surveillance Program.

Six (27 percent) of 22 hospitalized medical patients who received phenytoin and isoniazid concurrently for at least five days experienced toxic effects on the central nervous system (CNS). In contrast, only 30 (3 percent) of 1,093 patients who received phenytoin without isoniazid had toxic effects on the CNS. Thus, the risk of toxic effects from therapy with phenytoin is greatly increased among patients concurrently receiving isoniazid, probably because of isoniazid-induced impairment of the clearance of phenytoin. Schedules of dosage for phenytoin whould be appropriately adjusted to compensate for this clinically important interaction of drugs.


Systolic time intervals before and after cardioversion of atrial fibrillation.

The effect of cardioversion of atrial fibrillation to normal sinus rhythm on systolic time intervals was evaluated in 18 patients. Variable results in the left ventricular ejection time index, the external isovolumic contraction time (EICT), and the ratio of the left ventricular ejection time over the EICT (LVET/EICT) and shortening of the preejection period (PEP) (P less than 0.01), the PEP index (PEPI) (P less than 0.005), and the ratio of PEP/LVET (P less than 0.001) occurred at five hours after cardioversion. Six (33 percent) of the 18 patients developed recurrent atrial fibrillation within one month after cardioversion, and the hearts of 12 (67 percent) of the 18 patients remained in sinus rhythm for one to ten months after cardioversion. Four of five patients in whom the EICT became worse at five hours after cardioversion and two of two patients in whom the PEPI became worse at five hours after cardioversion developed recurrent atrial fibrillation. The EICT and PEPI at five hours after cardioversion may be helpful in predicting subsequent recurrence of atrial fibrillation.


Hemodynamic alterations of heat stroke in the elderly.

Serial hemodynamic alterations were investigated in seven elderly patients with heat stroke. Their mean age was 72 +/- 6 years. The circulatory response to heat stroke was either hyperdynamic of hypodynamic. Two patients had increased cardiac index (4.3 and 4.4 L/min/m2), increased right atrial pressure (10 and 12 mm Hg), normal pulmonary capillary wedge pressure (10 and 12 mm Hg), and decreased systemic vascular resistance (542 and 738 dyne.sec.cm-5). Five patients had decreased cardiac index (mean 2.3 +/- 0.2 L/min/m2), decreased right atrial pressure (mean 2 +/- 1 mm Hg), normal pulmonary capillary wedge pressure (mean 6 +/- 3 mm Hg), and increased systemic vascular resistance (mean 2020 +/- 204 dyne.sec.cm-5). Circulatory failure appears to be secondary to peripheral pooling of blood or hypovolemia. The inability to compensate hemodynamically when stressed by heat may predispose certain elderly individuals to develop heat stroke.


Improved oxygenation of ischemic myocardium by hemodilution with stroma-free hemoglobin solution.

Experiments were conducted in anesthetized open-chest dogs subjected to occlusion of the left anterior descending coronary artery for three hours. The oxygenation of myocardial tissue was monitored by a polarographic technique capable of recording simultaneously the oxygen tension (Po2) of myocardial tissue and electrograms. Ischemic injury was monitored by means of ST-segment elevations on myocardial and epicardial electrograms. The volume of the myocardial infarct was measured at the end of each experiment by incubation of transverse slices of left ventricle in a solution of nitroblue tetrazolium and by separation of the unstained (ischemic) from the stained (normal) portions. In one group of dogs, hemodilution was performed after 15 minutes of ischemia by exchanging blood with a stroma-free hemoglobin solution (from a hematocrit reading of 45 +/- 3 percent to 23 +/- 2 percent). Changes occurring in this group were compared with those occurring in dogs that did not undergo hemodilution, underwent hemodilution with dextran 75, or were transfused with whole blood. Hemodilution with hemoglobin reduced aortic and left ventricular filling pressures while increasing coronary blood flow, increased myocardial Po2 from 2 +/- 2 mm Hg to 8 +/- 2 mm Hg (P less than 0.005), lowered the ST-segment elevation of both myocardial and epicardial electrograms, and reduced the volume of the myocardial infarct. These effects were unmatched by hemodilution with dextran or infusion of whole blood.


Mediastinal herniation of the pleural sac: occurrence in massive pleural effusion.

In a review of 50 patients with massive pleural effusion, mediastinal herniation of the pleural sac occurred in 16 patients (32 percent). Right-to-left herniation (ten patients) was more common than left-to-right (six patients). Herniation occurred only in the posteroinferior mediastinum (D5-D11). Fourteen patients had displacement of the mediastinum away from the side of pleural effusion. Disappearance of herniated sac in every patient following thoracocentesis confirmed the diagnosis.


Congenital ankylosis of the temporomandibular joint: resultant upper airway obstruction and cor pulmonale.

Cor pulmonale and severe congestive heart failure secondary to chronic upper airway obstruction developed in a three-year-old girl with congenital ankylosis of the temporomandibular joint complicated by frequent respiratory infections. Nearly absent mouth opening, micrognathia, and mandibular retroposition with resultant glossoptosia obstructed the airway. Medical treatment followed by a tracheostomy and bilateral condylectomy relieved the obstruction allowing normal function of the temporomandibular joint. The clinical, electrocardiographic, radiologic, and hemodynamic findings returned to normal. Congenital ankylosis of the temporomandibular joint has not been previously reported as a cause of cor pulmonale secondary to upper airway obstruction.