Haemolytic anaemia in alcohol abuse. A review of 14 cases.

Clinical and haematological data on 14 patients (8 women and 6 men) with alcohol-induced haemolytic anaemia and mild to moderate liver injury are presented. Nine of the patients were obvious drinkers, while 5 were socially well adjusted individuals in whom alcohol dependence was not suspected on admission to hospital. Four patients presented with a typical Zieve's syndrome. Two further patients had a moderate transient stomatocytosis, as assessed by microscopy of dried blood smears and by scanning electron microscopy. The majority of the patients, however, did not fit into any of the syndromes proposed in the literature. Indeed, the validity of both Zieve's syndrome and the "transient stomatocytosis with hemolysis" syndrome is questioned.


Association of pancreas affection and yersiniosis. A case report.

A case history of a 25-year-old female is reported. She had no diseases predisposing for pancreatic disease. A few days after a familial outbreak of yersinia enteritis, she again became ill and was referred to hospital. Clinical and laboratory examination made it likely that she underwent an acute pancreatic affection, and the serological test proved that she had been through an acute yersiniosis. The coincidental occurrence may of course be by change, but considering the immunological aspects of secondary yersiniosis, there might also be an etiological link.


A prognostic model for head injury.

A prognostic model for head injured patients was developed. Patients fall into one of four prognostic categories at the end of the first hospital day: I. Discharge alive on or before the seventh hospital day. II. Discharge alive 8--42 days after admission. III. Discharge alive after 42 days, or dead after five years. IV. Discharge dead before five years. The outcome of 63% of the patients was predicted correctly. The model correctly placed, or missed by only one category, 97% of the patients observed. Errors tended to the optimistic side of observed outcomes. Age and pattern of consciousness were critical prognostic factors.


Computerized tomography (CT), electroencephalography (EEG), and clinical symptoms in severe cranio-cerebral injuries: A comparative study.

In the first six months of 1977 156 patients with craniocerebral injuries underwent computerized tomography. Twelve had severe deficits which led to neurosurgical interventions. Only five had space-occupying haematomas. CT was useful in detecting neurosurgical complications, whereas EEG was useful in staging the severity of the trauma. The two methods, the functional one of EEG and the morphological one of CT, are complementary, especially with regard to the posttraumatic course. The clinical symptoms are reflected by EEG better than by CT.


CT scanning after drainage of subdural haematoma: An unusual case.

A unique patient with bilateral subdural haematomas with localized subdural membranes on one side is reported. Serial CT scans suggested that the membranes resolved spontaneously after drainage of the haematoma. The pathophysiology of subdural haematoma and the value of CT scanning in postoperative follow-up are discussed, especially in regard to learning more about the optimal treatment in this still somewhat enigmatic problem.


Repair of cerebrospinal fluid rhinorrhoea with pedicled dural flap.

Four cases of persistent cerebrospinal fluid rhinorrhoea through the ethmoid sinus are presented. Using the operative microscope, the margin of the dural defect was easily identified, and a pedicled dural flap supplied by branches of a meningeal artery was successfully sutured to the dural margin in a watertight fashion without increasing pre-existing neurological deficits. To prevent intracranial infection, the watertight closure with a predicled dural flap is presumably more complete and reasonable than are various grafts without vascular circulation.


An unusual case of multiple intracranial aneurysms.

A 49-year-old female patient with six intracranial aneurysms, all of which were treated successfully by direct surgery, is reported. She had a major subarachnoid haemorrhage 10 years ago. Because of difficulty in identifying the offending aneurysm she was not surgically treated at that time. The natural progression of intracranial aneurysms, the problem of identifying the lesion in a patient with multiple aneurysms, and an example of excellent recovery of visual function following surgical treatment are discussed.


Pseudo-tumoural aneurysm in the third ventricle: Report of three cases.

3 cases of giant sacciform aneurysm developed in the third ventricle are reported. They were observed in patients over 50 years. Clinical symptomatology evoked a tumor rather than a vascular malformation. Diagnosis can be difficult even with angiography and CT scan performed conjointly when the giant aneurysm is completely thrombosed. The size of the lesion is not a matter of age since 10% at least of these giant aneurysms are observed in children. They are mainly seen along the large arteries at the neck or at the base of the brain; the high focal pressure of the blood flow at these levels can perhaps play a role in the usual site of these lesions. Surgical treatment remains a challenge when the aneurysm is burrowed deep into the third ventricle and when being thrombosed, it is mainly symptomatic by its mass.


Removal of intraventricular craniopharyngiomas through the lamina terminalis.

Radical, but subtotal, removal of four craniopharyngiomas, three of which were primarily within the third ventricle, has been carried out by an approach beneath the frontal lobe and through the lamina terminalis. A good result was obtained in two cases, and in two other cases the patients were left with considerable disability from hypothalamic damage. The technique, and the indications for radical surgery on these lesions are discussed.


Pre- and postoperative evaluation of hypothalamo- pituitary function in children with craniopharyngiomas.

Pre- and postoperative evaluation of hypothalamic-pituitary function was performed in six children, aged 5.5 to 13.3 years with craniopharyngiomas. Before surgery growth hormone deficiency (GHD) was documented in four, hypothalamic hypothyroidism in three, and secondary ACTH-deficiency and hyperprolactinaemia in one patient. Diabetes insipidus was absent in all patients. After neurosurgical treatment GHD was present in all, hypothyroidism in five, ACTH-deficiency in three, hyperprolactinaemia in three, and diabetes insipidus in four children. The study shows that all endocrine functions tested may be defective even before surgery, although diabetes insipidus seems to be a rare preoperative complaint. Surgical intervention, however, often leads to additional endocrine disorders. From the data presented here one may suggest that TRH stimulation tests, evaluation of serum prolactin, and lysin-vasopressin stimulation tests are the most useful investigations to distinguish between hypothalamic and primary pituitary disorders.


Epidural pressure monitoring with the so-called Rotterdam transducer. Further in vivo results.

Results of measurements in vivo of intracranial pressure obtained with a new telemetric epidural pressure transducer are described. The relations of epidural pressure to ventricular fluid pressure are studied in acute experiments and found to be linear, but variable. The functioning of 18 transducers was studied over many months of implantation.


Supracondylar fractures of the humerus in children.

Supracondylar fractures most commonly result in posterior and medial displacement of the distal fragment. The periosteum on the medial and posterior aspects of the humeral shaft is often intact. Closed reduction with immobilization by casting is preferred. Flexion of the elbow must be maintained in the cast. Internal fixation with percutaneous pins may be required, but only after satisfactory reduction. Olecranon skeletal traction is useful if ischemia develops. Neuropathies, ischemia and technical failures with angular deformities are not rare.


Child molestation.

Sexually molested children are thought to be more common than battered children but, like rape, cases of child molestation are greatly underreported. Physical trauma occurs frequently, including vaginoperineal tears and head injuries. The child's father is frequently the offender. In nearly one-half of the cases, the abuse occurs repeatedly. Physicians must be aware of the potential physical and emotional damage and must be prepared to offer gentle care, effective support and appropriate counseling.


Amyotrophic lateral sclerosis: comprehensive management.

The cause of amyotrophic lateral sclerosis remains unknown, and no curative treatment is available. From a rehabilitation perspective, however, comprehensive management and symptomatic treatment can minimize complications, increase function and improve the patient's quality of life. Quinine, diazepam (Valium) and phenytoin (Dilantin) may relieve muscle cramps, and orthoses may permit greater participation in daily activities. Problems with respiration and swallowing may require surgical procedures and the use of feeding tubes. Decisions regarding surgical intervention must be made in the context of the patient's overall status.


Prevention of thromboembolism.

Thromboembolism is the leading preventable cause of death in the hospitalized patient. It is not well managed by the application of current diagnostic and treatment techniques. Prevention should be the major clinical emphasis. Low-dose heparin is a safe and effective method of prophylaxis for postoperative venous thromboembolism. Its administration is simple and requires minimal monitoring. The low-dose heparin protocol is recommended for widespread use with major operations in high-risk patients.


Practical management of chronic renal failure.

Initial evaluation of patients with chronic renal failure demands a careful search to exclude reversible causes such as dehydration, obstruction and nephrotoxins. Subsequently, strict management of sodium and fluid intake is necessary to avoid either dehydration or congestive heart failure. As renal failure advances, restriction of dietary protein and potassium and binding of phosphate are indicated. Referral to an end-stage renal disease center should be accomplished early, before and appearance of uremic symptoms, to facilitate a smooth transfer to the next phase of rehabilitative therapy.


Family behavior modification.

Behavior modification has been effective in dealing with problems in individual patients. The adaptation of behavior modification techniques to the family unit can help to lessen some harmful consequences of adverse human behavior. After identification of the problem and analysis of the stimuli, the behavior and its consequences, stimulus control and contingency management are discussed. A formal written contract, involving all family members and the physician, is useful.


Echocardiographic diagnosis of pericardial disease.

Echocardiograms were performed in 11 patients with constrictive pericarditis or effusive-constrictive pericarditis confirmed by cardiac catheterization and pericardiectomy. Three echocardiographic patterns of pericardial disease were noted and were related to three types of pericardial pathology. Parallel moving echoes separated by a clear space were reflected from chronically fibrosed and thickened pericardium without associated pericardial exudate. Effusive-constrictive pericarditis or subacute wet pericarditis was characterized on the echocardiogram by a posterior echo-free space representing the liquid pericardial effusion and multiple ultrasonic lines from the thickened visceral pericardium. Subacute dry pericarditis was associated with numerous ultrasonic signals filling the space between the visceral pericardium and the relatively flat parietal pericardium. These ultrasonic signals were reflected from coagulated pericardial exudate which was adherent both to the parietal pericardium and the visceral pericardium. Parallel moving echoes or dense bands of echoes were reflected from either or both thickened visceral and parietal pericardium.


Noninvasive assessment of myocardial function in young patients with mitral valve prolapse.

To evaluate myocardial function in patients with documented mitral valve prolapse (MVP) 14 patients (six men and eight women with a mean age of 28 +/- 6.3 years) were examined noninvasively. Systolic time intervals were recorded at rest (in the supine and upright position) and after bicycle ergometry (upright position) and were compared with 10 healthy control subjects of similar age. Tracings were coded with random numbers and were evaluated by two blinded investigators. Contractility indices such as pre-ejection period index (PEPc) and ratio pre-ejection period/left ventricular ejection time (PEP/LVET) revealed no significant differences between patients and controls both at rest and after exercise. We conclude that young patients with MVP have no evidence for impaired myocardial function, provided there is no significant mitral incompetence or associated heart disease.


Evidence in favor of the vasospastic cause of coronary artery thrombosis.

Evidence is presented which suggests that it is likely that vasospasm initiates coronary artery thrombosis. Spasm causes a violet constriction of the vessel and also produces stasis, and both factors are implicated in the thrombotic process. Spasm can occur in sclerotic segments, and intimal tears and plaque ruptures in arteriosclerotic plaques are attributed to spasm. The thrombus forms over the intimal disruption, abetted by the stasis of spasm. In arteries with mild or no intimal injury, continuing stasis over a period of time is considered as the major factor in thrombus formation. This ongoing stasis is attributed to an injury-spasm reaction to necrotic muscle, and probably is equivalent to the "no-reflow" phenomenon of infarction.


Predictive value of electrocardiographic patterns in localizing left ventricular asynergy in coronary artery disease.

Transmural myocardial infarction by ECG (ECG-MI) was correlated with left ventricular asynergy by biplane left cineventriculography in 200 patients with coronary artery disease. The ability of individual ECG-MI patterns to predict and correctly localize asynergy was: anterior--98 per cent (43 of 44), inferior--82 per cent (36 of 44), true posterior--73 per cent (11 of 15). Of various combinations of criteria for true posterior ECG-MI, the pattern of an R wave and upright T wave in Lead V1 was most predictive of posterior asynergy--80 per cent (8 of 10). The LAO projection demonstrated a wall motion abnormality not appreciated in the RAO in 8 per cent (10 of 122) of cases of inferoposterior asynergy and enhanced assessment of asynergy in 30 per cent (36 of 122) of cases. It is concluded that: (1) ECG-MI has a high predictive accuracy for left ventricular asynergy, (2) an R-wave and upright T wave in Lead V1 is the best ECG predictor of posterior asynergy, and (3) the LAO projection makes an important contribution to the assessment of regional asynergy in coronary artery dieseas.


Effect of exercise on left ventricular ejection fraction in men with coronary artery disease.

Left ventricular ejection fraction (LVEF) was measured at rest and during supine bicycle exercise in 31 men with arteriographically defined coronary disease and in 15 normal men. LVEF was calculated from a left ventricular time vs activity curve (collimated scintillation probe, 99m Technetium) as the fracitonal fall in count-rate divided by the background-corrected left ventricular end-diastolic count-rate. In normal men LVEF at rest averaged .59 +/- .06 (+/-SD) and during exercise was .72 +/- .08. LVEF did not increase with exercise in men with coronary disease (.55 +/- .03 to .57 +/- .03; N = 31; AVE +/-SEM; NS). In 17 men with coronary disease who had ST segment depression with exercise, LVEF either decreased or was unaltered in all (55 +/- .04 to .49 +/- .03; P less than 0.05); whereas in 14 without ST depression, LVEF increased in 10 (71 per cent) and was unaltered in 4 (29 per cent) (.54 +/- .04 to .66 +/- .04; P less than 0.01). Results suggest that LVEF during exercise normally increases, but in men with coronary disease LVEF either fails to increase or actually decreases. In addition there appears to be a relationship between ST segment changes during exercise and ejection fraction.


Determination of pre- and postoperative flow obstruction in patients undergoing closed mitral commissurotomy from non-invasive ultrasound Doppler data and cardiac output.

A non-invasive ultrasound Doppler system and indwelling thermodilution catheter system were used to determine the pre- and postoperative mitral flow obstruction in eight adults undergoing closed mitral commissurotomy. The effective valve area (Ae) was used as a measure of the obstruction. In the eight patients Ae was 1.08 +/- 0.34(SD) cm. 2 preoperatively and increased to 1.71 +/- 0.43(SD) cm. 2 postoperatively. The technique used in the investigation appears useful for the evaluation of surgical procedures designed to reduce the mitral flow obstruction.


Reproducibility of exercise-induced ventricular arrhythmia after myocardial infarction.

To evaluate the reproducibility of exercise-induced ventricular arrhythmia, 155 men with a mean age of 53 +/- 8 years underwent serial exercise testing 3 to 52 weeks after myocardial infarction. The reproducibility of categorical test responses, that is, the presence or absence of ventricular arrhythmia, was evaluated with the kappa coefficient, which considers negative as well as possible test responses and expresses reproducibility above the chance level. Reproducibility was highest at an intertest interval of 1 to 5 days and was not enhanced by further categorizing premature ventricular complexes as simple or complex based on their frequency or configuration. Continuous response measures such as frequency of premature ventricular complexes yielded higher reproducibility than categorical responses. Continuous response measures appear preferable to categorical responses for evaluating the clinical significance and response to antiarrhythmic therapy of ventricular arrhythmias.


Comparison of two-dimensional and M-mode echocardiography in the evaluation of patients with infective endocarditis.

M-mode and two-dimensional echocardiographic evaluation of infectious endocarditis and its complications was reviewed. In 21 consecutive patients with clinical endocarditis, 22 valves were involved (12 aortic, 5 mitral and 5 tricuspid). M-mode echocardiography detected vegetations in 10 patients (four aortic, two mitral and four tricuspid) and detected complications of endocarditis in 2 patients (one aortic root abscess and one flail aortic cusp). Two-dimensional echocardiography detected vegetations in 9 patients (four aortic, one mitral and four tricuspid) and detected complications in ten patients (five flail aortic cusps, one aortic root abscess, one sinus on Valsalva aneurysm, two flail mitral leaflets and one flail tricuspid valve). Thus, although M-mode and two-dimensional echocardiography had a similar ability to detect actual vegetations, two-dimensional echocardiography was superior to M-mode echocardiography in diagnosing complications of the destructive process.


Platelet function studies in coronary artery disease. V. Evidence for enhanced platelet microthrombus formation activity in acute myocardial infarction.

Circulating platelet microthrombi were evaluated during the acute and convalescent phases of illness in 44 patients admitted to the hospital for chest pain. Similar studies were performed in 10 healthy volunteers and 6 patients with infection. Circulating platelet microthrombi were significantly increased during the acute phase in 22 patients with transmural myocardial infarction compared with values in the other 22 patients without myocardial infarction, the healthy volunteers and the patients with infection alone. This increase in circulating platelet microthrombi declined to normal levels by the 7th hospital day in all but two patients who had evidence of extension of myocardial infarction and died. In contrast, circulating platelet microthrombi were similar in acute and convalescent phases of patients with chest pain but without myocardial infarction and were comparable with values in healthy volunteers. This study suggests that increased circulating platelet microthrombi may be related to tissue necrosis associated with transmural myocardial infarction.


A biologic model of parasystole.

The electrotonic interactions of a parasystolic pacemaker with ventricular responses to the normal pacemaker across an area of depressed excitability were simulated in a model consisting of strands of canine Purkinje fibers mounted in a sucrose gap preparation. Experiments were conducted to study the patterns of ectopic activity that result from entrainment of the "ectopic" pacemaker (EP) on one side of the sucrose gap by evoked responses (sn) on the other side of the gap. When one-way conduction ("entrance block") was established, manipulations of the SN frequency and of the impedance between the two outer chambers resulted in periods of silence, concealed or manifest bigeminy, trigeminy and quadrigeminy, and periods of more complex patterns of group beating as the entrainment ratios changed. The results confirm the predictions of the previously described mathematical model that these patterns depend on the magnitude of the electrotonic influence of SN on the EP cycle length and also on the ratio of the intrinsic frequencies. These studies should help to distinguish between reentrant and parasystolic mechanisms in clinical arrhythmias.


Mechanism of reduction of mitral regurgitation with vasodilator therapy.

Acute mitral regurgitation was produced in six open chest dogs by excising a portion of the anterior valve leaflet. Electromagnetic flow probes were placed in the left atrium around the mitral anulus and in the ascending aorta to determine phasic left ventricular filling volume, regurgitant volume and stroke volume. The systolic pressure gradient was calculated from simultaneously measured high fidelity left atrial and left ventricular pressures. The effective mitral regurgitant orifice area was calculated from Gorlin's hydraulic equation. Infusion of nitroprusside resulted in a significant reduction in mitral regurgitation. No significant change occurred in the systolic pressure gradient between the left ventricle and the left atrium because both peak left ventricular pressure and left atrial pressure were reduced. The reduction of mitral regurgitation was largely due to reduction in the size of the mitral regurgitant orifice. Reduction of ventricular volume rather than the traditional concept of reduction of impedance of left ventricular ejection may explain the effects of vasodilators in reducing mitral regurgitation.


Photokymography: a noninvasive method of detecting ischemic segmental myocardial wall motion abnormalities.

The photokymograph is a new and simple noninvasive device for assessing epicardial segmental myocardial wall motion utilizing cardiac fluoroscopy and image intensification. The validity of this technique in detecting wall motion changes occurring with ischemia was assessed in seven closed chest dogs undergoing acute balloon occlusion of the left circumflex coronary artery. Acute occlusion resulted in a prompt change in the analog signal of the photokymogram, characterized first by a decreased systolic inward motion and late systolic outward movement that later became akinetic and dyskinetic. Systolic amplitude decreased 18 +/- 7 percent (mean +/- standard error of the mean) within 5 seconds of occlusion and progressed to systolic outward motion (- 106 +/- 24 percent) at 2 minutes. The time course and type of morphologic changes observed after occlusion were similar to those previously described using invasive methods. Furthermore, such changes preceded electrocardiographic S-T segment elevation. These data suggest that photokymography is a sensitive technique for noninvasive detection of acute ischemic segmental wall motion abnormalities and holds promise as a simple method of detecting ischemic heart disease in man.


Paradox of improved exercise but not resting hemodynamics with short-term prazosin in chronic heart failure.

In patients with chronic heart failure exercise allows the simultaneous observation of the cardiovascular pathophysiology and the symptoms of these patients. We administered short-term, oral prazosin to 10 patients with severe chronic heart failure. Prazosin increased cardiac output and stroke volume significantly during exercise (both P less than 0.05) but not at rest (both P greater than 0.10). Prazosin decreased the arteriovenous oxygen difference and left ventricular filling pressure significantly during exercise (both  P less than 0.05) but not at rest (both P greater than 0.10). There was no significant correlation between prazosin-induced changes at rest and during exercise in cardiac output (r = 0.12), stroke volume (r = 0.02), arteriovenous oxygen difference (r = 0.33) or left ventricular filling  pressure (r = 0.43). Prazosin predominantly affects hemodynamics during exercise because its pharmacologic activity as an alpha-adrenergic blocking agent is most prominent during exercise. The full evaluation of prazosin-induced changes in the hemodynamics of patients of patients with chronic heart failure requires evaluation during exercise.


Single and two dimensional echocardiographic features of the interatrial septum in normal subjects and patients with an atrial septal defect.

The interatrial septum is one of the least studied structures in M mode echocardiography. Two dimensional echocardiography has made it possible to record simultaneous M mode and two dimensional echocardiograms. Such studies were performed in 10 normal subjects and in 9 patients with a secundum atrial septal defect. In the short axis view of the base of the heart, the interatrial septum was visualized in the two dimensional studies as a linear echo running from the posterior aortic wall to the posterior atrial wall and in the M mode records as a series of dense echoes posterior to the aorta. The great variability in echo dropout of the interatrial septum made it impossible to distinguish the normal subjects from the patients with atrial septal defect. The dense echoes of the interial septum in the M mode records gave the false impression that they were filling the left atrium. These data indicate that (1) a secundum atrial septal defect cannot be reliably differentiated from a normal septum using these echocardiographic methods, and (2) the medial location of the interatrial septum should be appreciated so that it will not be confused with a left atrial mass.


Right atrial ultrastructure in congenital heart disease. II. Atrial septal defect: effects of volume overload.

Portions of operatively resected right atrium from 15 patients with atrial septal defect were studied ultrastructurally to determine whether the cell hypertrophy in the right atrium of patients with increased right atrial blood flow and increased right atrial pressure is caused by the increased blood flow. In 12 patients with normal right atrial mean pressure but increased right atrial blood flow the atrium was dilated but no atrial arrhythmias were noted clinically. Ultrastructurally, the atrial myocardial cells in these patients were normal, measuring 6 to 10 mu in diameter, and there was no evidence of cell hypertrophy or degeneration. The remaining three patients had elevated right atrial mean pressure and increased right atrial blood flow. Ultrastructurally, the atrial myocardial cells in all three patients were hypertrophied, and two patients had evidence of focal cell degeneration; the atrium was markedly dilated, but atrial arrhythmias were not noted. The lack of cell hypertrophy in the right atrium of the 12 patients with increased blood flow but normal mean pressure suggests that in congenital heart disease volume overload alone does not lead to cell hypertrophy of the right atrial myocardium.


Role of the renin-angiotensin-aldosterone system in hypertensive children with coarctation of the aorta.

To investigate the role of the renin-angiotensin-aldosterone system as a cause of hypertension, 20 hypertensive patients with coarctation of the aorta were studied during normal and low sodium intake and after diuresis with flurosemide. Eight patients with essential hypertension and 13 control subjects were similarly studied. Plasma renin activity values in patients with coarctation were similar to those in patients with essential hypertension and in control patients during normal and low sodium diets. However, after the administration of furosemide, plasma renin activity values were significantly higher in the patients with coarctation than in the other two groups (P less than 0.005 and less than 0.01, respectively).  The values for urinary aldosterone, plasma volume and extracell fluid volume (bromide space) were increased in patients with coarctation during both normal and low sodium intake. These renin and aldosterone responses and body fluid spaces in patients with coarctation suggest that their hypertension resembles a one-kidney Goldblatt model. The data help to better define the role of the renin-angiotensin-aldosterone system in the hypertension of coarctation and thus may help guide the clinician in therapeutic interventions.


Toxoplasmic infection in cardiac disease.

In 18 patients who presented in less than 2 years with heart disease characterized by arrhythmias (including atrial fibrillation, ventricular arrhythmias and heart block), atypical chest pain, pericarditis and cardiac failure, extensive investigation revealed no cause for the disease except for evidence of toxoplasmic infection. One patient had acute toxoplasmosis; the other 17 patients had chronically increased titers, higher than the expected level in the community and also higher than in a control series of patients with well defined heart disease. Toxoplasmosis is probably a fairly common cause of heart disease in this community. The source of infection appeared to be cats, uncooked meat and congenital infection. Patients received chemotherapy with either pyrimethamine and sulfadiazine or tetracycline. Serious relapse occurrred in three patients and embolic complications in two. Experimental myocarditis occurs when toxoplasmic cysts rupture within the heart; therefore clinical symptoms may occur sporadically during a chronic infection.


Echocardiographic manifestations of persistence of the right sinus venosus valve.

The echocardiographic features of a neonate born with a persistent right sinus venosus valve are presented. Because surgical correction of this serious anomaly may be possible, the diagnosis should be made soon after birth. An echocardiogram suggesting a right atrial myxoma, an unlikely finding in a neonate, should be an important clue to the diagnosis of this anomaly.


Propranolol in human plasma and breast milk.

To assess the problem of continuing propranolol therapy in a breast-feeding mother, studies were performed to determine simultaneously plasma and breast milk concentrations of propranolol after single dose (40 mg) and continuous dose (40 mg 4 times daily) treatment with this drug. Breast milk and plasma concentrations of propranolol peaked between 2 and 3 hours after dosing. Propranolol concentrations in breast milk were less than 40 and 64 percent, respectively, of peak plasma propranolol concentrations after single dose and continuous dose administration. It was estimated that the maximal cumulative propranolol load to this breast-feeding infant, consuming 500 ml of whole milk, when the mother received 40 mg of propranolol 4 times daily would be 21 microgram/24 hours. This dose is considerably less than the usual therapeutic dose of propranolol for infants.


Candidal infection of gastric ulcers. Histology, incidence, and clinical significance.

Fungal organisms morphologically resembling Candida were found in one third of 72 consecutive surgically resected gastric ulcers. In over half of these cases the organisms were present in the mycelial form. Large numbers of fungi forming clusters were found in 13 cases (18%) and were associated with a surprisingly high postoperative mortality, (38.5%). These organisms are most likely one manifestation of debility in otherwise poor-risk patients rather than a cause of the high morbidity and mortality in these patients. Although organisms of the Candida group are probably not directly etiologic in the development of gastric ulcers, it is possible that their presence aggravates and perpetuates gastric ulceration.


Histologic comparison of mammary carcinomas among a population of Southwestern American Indian, Spanish American, and Anglo women.

Primary carcinomas of the breast were studied in age-matched populations of Southwestern American Indian, Spanish American, and Anglo women from an area served by the New Mexico Tumor Registry. Histologic tumor type, nuclear grade, and stromal inflammatory response were compared among these three groups. Indian women presented with less favorable tumor stage at diagnosis. Histologic tumor types were similar with the the exception that lobular carcinoma was less frequent among Indian and Spanish American than among Anglo women. Carcinomas from Indian patients showed less differentiated nuclei than those from the other groups.


The surface ultrastructure of Gaucher cells.

The Gaucher cells of seven patients with Gaucher's disease were examined by both transmission and scanning electron microscopy. The ultrastructure of the cells, as seen by transmission electron microscopy, did not differ from that reported in the literature. The surface structure varied not only in the different patients but also in the same individual. The cells were oval or round, most of them with a rough surface due to presence of microvilli, ruffles, ridges, and blebs of various numbers and shapes. In two patients the Gaucher cells showed phagocytosis. The appearance of the surface ultrastructure of the Gaucher cells supports the accepted view that they are related to the cells of the reticuloendothelial system.


The effect of smudge cells on leukocyte counting--are chamber counts necessary?

Leukocyte counts obtained in the Coulter Model S and Model F were compared with counts from hemocytometers and estimates from peripheral blood smears from 38 patients with increased numbers of smudge cells associated with chronic lymphocytic leukemia, with leukemias other than chronic lymphocytic leukemia, and without leukemia. The results indicate no method-dependent pattern of count loss. Cell counts were not related to the number of smudge cells present; the number of smudge cells were unrelated to the nature of the patient's disease state. We conclude that in the presence of smudge cells, leukocyte counts can be made as reliably by automated methods as by pipette and chamber technics. This conclusion is at variance with what has been previously reported. Although the basis for this discrepancy is not clear, it may be related in part to differences in the formulation of the lysing agents used.


A computer program for analysis of clotting factor assays and other parallel-line bioassays.

A computer program for the analysis of coagulation factor assays is presented. It can be run on small computers utilizing FORTRAN. It allows considerable flexibility in assay design, accommodates any sample dilution scheme, different numbers of standard and test doses, and missing data points. The report lists the input data for each assay, the analysis of variance for the regression lines, and the potency ratio, as well as statistics that allow estimates of the precision of the potency ratio. It is suggested that interpretation of clotting factor assay results would be facilitated if reports regularly included such information about the reliability of the potency ratio measurements.


Recovery of soil Amebas from the nasal passages of children during the dusty harmattan period in Zaria.

Following a fatal case of primary amebic meningoencephalitis during the dusty harmattan period in an 8-month-old child in whose case Naegleria fowleri was recovered both from the cerebrospinal fluid and from material from the nose in absence of a history of swimming, it was hypothesized that dust during the harmattan might harbor amebic cysts, which may be inhaled by human beings and cause infection. A preliminary survey was thus carried out to examine the nasal passages of children for the presence of soil amebas during the harmattan. In all, 50 children were evaluated for the presence of soil amebas. Positive cultures for the soil amebas were obtained from 12 children (24%). Four species of amebas were isolated singly or in combination with other species. Pathogenic Naegleria fowleri, proved pathogenic for mice, were cultured from specimens from two children.


Spurious hypocalcemia in hemodialysis patients after heparinization. In-vitro formation of calcium soaps.

Patients on long-term hemodialysis via arteriovenous fistula received heparin when the fistula needle was inserted, before a sample of blood was obtained for chemical analysis. The resultant release of lipoprotein lipase activity in vivo and continued lipolytic activity in vitro sometimes produced sufficient free fatty acid to precipitate calcium soaps. The consequent spurious hypocalcemia was most frequently observed when the patients had chylomicronemia. This cause of apparent hypocalcemia was eliminated either by immediate  analyses of the blood samples or by obtaining samples before systemic heparinization.


Postmortem vitreous humor chemistry in sudden infant death syndrome and in other causes of death in childhood.

Postmortem vitreous humor concentrations reflect antemortem serum chemical values. The authors measured the postmortem vitreous humor concentrations of Na+, K+, Cl-, Ca+2, Mg+2, urea nitrogen, creatinine, and total protein of 127 children who died from sudden infant death syndrome (SIDS) and other causes. Forty-seven children, 1 hour to 13 years old, had died of medical or surgical causes; 21 children, 7 weeks to 11 years old, had died following acute trauma; 59 children, 8 days to 1 year old, had died of SIDS. There was no significant difference between mean postmortem vitreous humor concentrations of those who died of medical and surgical causes and those who died after acute trauma (non-SIDS). in both groups, the mean postmortem vitreous humor concentrations of Mg+2 and Ca+2 were significantly higher in premature infants. There was direct correlation of postmortem vitreous humor concentration and postmortem interval for K+, but the variation, +/- 26 hours, was too large to be of practical importance in estimating time of death in individual cases. The three patient groups were compared and the mean postmortem vitreous humor concentrations of all eight constituents in the SIDS and non-SIDS groups were in the same ranges. In SIDS, the mean postmortem vitreous humor concentrations of Mg+2, Cl-, and urea nitrogen were significantly different from values of the non-SIDS cases, but not enough to indicate SIDS or to be informative about the etiology of SIDS. Measurement of the concentrations of postmortem vitreous humor constituents may not aid in the diagnosis of SIDS, but may aid in discovering unsuspected antemortem serum chemical abnormalities.


Verruciform xanthoma of the vulva. Report of two cases.

Two cases of verruciform xanthoma of the vulva are described. This rare lesion, previously reported to occur only in the oral cavity, is characterized by a verrucous epithelial proliferation accompanied by xanthoma cells distributed exclusively in the papillary dermis. The histologic features of the lesion are diagnostic and include (1) regular acanthosis in which the rete pegs extend to a uniform level into the dermis; (2) hyperkeratosis with parakeratosis often extending deep into the rete pegs and manifesting a massive neutrophilic infiltrate; (3) hyalinization of the collagen and infiltrates of xanthoma cells that are restricted to the papillary dermis between the rete pegs. Additionally, a lichenoid inflammatory infiltrate is seen at the periphery of the verrucous lesions, and in one case this has the pattern of classic lichen sclerosus. Verruciform xanthoma must be differentiated from verruca vulgaris, condyloma acuminatum, granular cell tumor with pseudoepitheliomatous hyperplasia, and verrucous carcinoma.


Primary Kaposi's sarcoma in lymph nodes concurrent with chronic lymphatic leukemia.

Both Kaposi's sarcoma and chronic lymphatic leukemia affect the lymph nodes, and not infrequently, the same patient. The authors describe the occurrence of both diseases in the same lymph node. The rarity of this finding suggests different histopathogenic origins of the two diseases.


Primary suppurative myositis in children.

Primary suppurative myositis is rare in the United States when compared with the incidence of disease in the tropics. Clinically, it may mimic many of the more common diseases, such as hematoma, osteomyelitis, arthritis, or appendiceal abscess. It usually has a benign course, with complete recovery after appropriate treatment. Prolonged morbidity and an increased mortality may result from unfamiliarity with this entity. Six children had primary suppurative myositis; one died as a result of perforation of a psoas abscess into the dural sac causing staphylococcal meningitis.


Infant rumination syndrome: report of a case and review of the literature.

The infant rumination syndrome is an uncommon disorder difficult to differentiate from commoner conditions causing vomiting and weight loss. Its validity has recently been questioned. Its importance is heightened by the availability of newer diagnostic and operative procedures that might be misapplied. An 8-month-old male infant had been regurgitating for two months with increasing inanition. Results of diagnostic tests suggested pylorospasm or gastric pseudo-obstruction syndrome. Medical management failed. A therapeutic trial of special nursing eight hours a day resulted in rapid rehydration, weight gain, and avoidance of surgery. This case exemplifies each of the ten characteristics of the infant rumination syndrome.


Fanconi's anemia with growth hormone deficiency.

The association of Fanconi's anemia (FA) and growth hormone (-gh) deficiency is not commonly reported. These children may have the typical features of the FA syndrome, or may exhibit much variability in clinical and hematological findings. In a single family, members may have FA with or without GH deficiency. The genetic basis for this heterogeneity is unknown. We describe here two siblings with FA, one of whom had dwarfism due to GH deficiency. Combined treatment with GH and androgen (oxymetholone) resulted in strikingly greater acceleration of growth than did the use of GH alone. Pancytopenia was not influenced by hormone therapy.


Salmonellosis in children with cancer: review of 42 cases.

Forty-two episodes of culture-proved salmonellosis were found retrospectively among 2,262 patients treated for malignant diseases at St Jude Children's Research Hospital, Memphis. These cases were reviewed in an effort to determine whether Salmonella infections in childhood cancer patients are associated with an increased frequency of septicemia and death, as has been reported for adults with cancer. Septicemia occurred in only 10% of the patients studied, consistent with the frequency established in general populations. There were no deaths attributable to Salmonella infection. Most of the patients (57%) with salmonellosis had gastroenteritis, and the clinical course of this syndrome was no more severe or prolonged than that seen in otherwise normal children. We recommend that management of Salmonella infections in children with cancer follow presently accepted guidelines for normal hosts.


Psychosocial support for adults with cystic fibrosis: a group approach.

This article describes the first time-limited psychosocial support group for adults with cystic fibrosis (CF). The chronology of the group is traced, focusing on issues of importance for health professionals who work with patients with CF. Some of the issues raised by patient members include doubts about the competence of nonpediatricians to adequately treat CF; resentment towards "normals" (those without CF), including health professionals; and the desire to control as many areas of their lives as possible. Covert (ie, unrecognized) issues, the role of staff, risks, and outcome are detailed as a guide for others who may wish to conduct such groups. The literature on groups for medical patients and a rationale for the beneficial effects on the group are given.


Cholelithiasis in children with sickle cell disease.

A group of 47 children with homozygous sickle cell disease ranging in age from 2 to 18 years was studied for the prevalence of gallstones. All of these patients had oral cholecystogram and cholecystosonogram. Eight of the 47 patients (17%) had gallstones both on oral cholecystography and on cholecystosonography. These eight patients had a history of recurrent abdominal pain usually localized to the right upper quadrant. All were admitted on several occasions for sickle cell abdominal crises and four of these were admitted for acute hepatic crisis. These patients have undergone elective cholecystectomy and gallstones were found in every patient. The patients have been followed up from seven to 17 months after cholecystectomy and none have had abdominal symptoms or required hospitalization for abdominal crises.


A case-control study of relationships of diet and other traits to colorectal cancer in American blacks.

Ninety-nine black colorectal cancer patients and 280 matched controls from hospitals and multiphasic health checkup clinics were interviewed about past dietary habits and other traits. The colon cancer cases tended to report less frequent use of foods with at least 0.5% fiber content than did their controls. This relationship, though small, showed a consistent dose-response gradient, appeared in both case-hospital control and case-multiphasic health checkup control comparisons, and could not be accounted for by the effects of other variables. Colon and rectosigmoid junction cancer patients tended to have eaten foods with at least 5% saturated fat somewhat more often than controls. When consumption of these two groups of foods was considered in combination, significantly more colon cancer patients than controls reported a high saturated fat foods-low fibrous foods eating pattern, as opposed to a low saturated fat foods-high fibrous foods diet. Statistically significant excesses of the following traits were also reported by the colorectal cancer patients: prolonged cigar smoking in men, nulliparity in women, and history of colorectal polyps.


Fatal and nonfatal coronary attacks in relation to smoking in some Dutch communities.

The association between acute coronary events (ACE) and cigarette or cigar smoking was evaluated in a case-referent study. The association was apparent for cigarette smokers of one and two packs daily. An association could be shown for cigar smoking also, with no appreciable difference between inhalers and non-inhalers. Cigarette smoking was related more strongly to rapidly fatal than to nonfatal ACE, especially in the younger age categories.


Carcinoma of the gallbladder and extrahepatic biliary ducts in Rochester, Minnesota, 1935--1971.

Because the causes of carcinoma of the gallbladder and extrahepatic biliary ducts are largely unknown, a descriptive epidemiologic study has been developed. The extensive record system at the Mayo Clinic for the population of Rochester, Minnesota, provided the basis for this study of the incidence, secular trend, pathologic features, relationship with gallstones, and survivorship of patients with carcinoma of the gallbladder and extrahepatic biliary ducts in the period 1935 through 1971. The mean annual incidence rate of carcinoma of the gallbladder and extrahepatic biliary ducts was 4.4 (3.1 for men and 5.4 for women) per 100,000 population. The rates increased rapidly with age in both males and females. For the 51 known deaths, the death certificates listed carcinoma of the gallbladder or extrahepatic biliary ducts, or both, as the underlying cause of death in 39 cases and as a contributory cause in three. The frequencies of gallstones in females (75%) and males (62%) were significantly higher than the expected numbers.


An objective measure of physical activity for epidemiologic research.

The development of a device is reported called the Large-scale integrated Motor Activity Monitor to examine physical activity during individuals' normal daily lives. The unit which is slightly larger than a wrist watch records body movement when worn at various body locations. Two population studies were conducted to evaluate the units. Experiment 1 examined 20 male graduate students for a two-day period. The data indicated that the units were sensitive to individual differences in physical activity and did not interfere with normal activities. Experiment 2 compared 10 Physical Education majors with 10 non-Physical Education majors by having individuals log activities and record movement counts for a two-day period. The movement data revealed that the monitors significantly discriminated between the two populations. The energy expenditure derived from the specific loggings was highly related (r = +.69) to the trunk movements, indicating that the movement counts are an accurate estimate of physical activity. The high relationship to energy analysis, the sensitivity of the units and the ease of implementation indicate that the units may be useful in relating normal activity to acute heart disease and to risk factors such as obesity and lipoproteins.


Osteoarthritis of the hand: age-specific joint-digit prevalence rates.

The left hand of each of 903 white males, most of them well-educated professionals, was evaluated for osteoarthritis, in the ongoing Baltimore Longitudinal Study of the Gerontology Research Center. The results of the joint-digit prevalence study indicated that: 1) the prevalence of osteoarthritis varies from one digit to the other; 2) osteoarthritis is considerably more prevalent in the distal than the proximal interphalangeal joints, regardless of digit or age group; 3) this disease is not only more prevalent in the distal interphalangeal joints, but it usually appears in a more severe form in the distal than in the proximal interphalangeal or the metacarpophalangeal joints. 4) Assuming that the presence of osteoarthritis in one joint is independent of the presence of the disease in the other joint of the same digit, there is an excess of digits with osteoarthritis in both the distal and proximal interphalangeal joints. This is suggestive of either a common etiology or that the presence of the disease in one joint enhances the development of osteoarthritis in the other joint of the same digit.


Variations in the reporting of menstrual histories.

This investigation examined the accuracy of recall of females to questions concerning ages at memarche, natural and surgical menopause, first use of oral contraceptives and mean menstrual cycle length and variance. A sample of 160 women who had recorded their menstrual and reproductive events as they occurred were administered a questionnaire concerning these events, with responses compared to the original data. For the variables age at menarche, age at natural memopause, age at surgical menopause and age at first use of oral contraceptives, the percentage of women who correctly recalled within a year ranged from 75% to 90%. Recollection of menstrual cycle length and variability by interview was considered unreliable. These findings are encouraging regarding the ability to recall the age when certain menstrual and reproductive events occur, but not for menstrual cycle intervals or patterns. Because these women were well-educated and had once recorded study variables, these results might be considered optimal.


Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents.

The relationship between social and community ties and mortality was assessed using the 1965 Human Population Laboratory survey of a random sample of 6928 adults in Alameda County, California and a subsequent nine-year mortality follow-up. The findings show that people who lacked social and community ties were more likely to die in the follow-up period than those with more extensive contacts. The age-adjusted relative risks for those most isolated when compared to those with the most social contacts were 2.3 for men and 2.8 for women. The association between social ties and mortality was found to be independent of self-reported physical health status at the time of the 1965 survey, year of death, socioeconomic status, and health practices such as smoking, alcoholic beverage consumption, obesity, physical activity, and utilization of preventive health services as well as a cumulative index of health practices.


Extrapulmonary tuberculosis in the United States.

In recent years, the decrease in reported tuberculosis in the United States has been due almost entirely to a drop in the number of cases of pulmonary disease. There has been little change in the average number of extrapulmonary cases reported. A retrospective survey of extrapulmonary tuberculosis has shown that it differs from pulmonary tuberculosis with regard to sex and race distribution, diagnosing physician's speciality and proportion of cases bacteriologically confirmed. There is variation within extrapulmonary cases according to specific anatomic site with regard to the above characteristics as well as age distribution. These epidemiologic differences in tuberculosis of different sites are unexplained.


Changing risk of scrub typhus in relation to socioeconomic development in the Pescadores islands of Taiwan.

Long term changes in risk of Rickettsia tsutsugamushi infection among civilian residents of the Pescadores Islands of Taiwan were associated with changing social conditions. Age specific incidence rates of scrub typhus in the Pescadores before 1940 were highest among children under 5 years of age. Rickettsiae can be demonstrated in vectors, wild animals continue to be infected and scrub typhus occurs in military personnel. A serologic survey for antibody to R. tsutsugamushi was conducted during 1975 and 1977 and failed to show evidence of previous infection among children. Two events appear to be associated with the decreased incidence of rickettsial infection in the young: increased urbanization and increased enrollment in schools. Both changes accompanied socioeconomic development which took place in the islands during the past 50 years. Prevalence of antibody to R. tsutsugamushi continues to be equal in the sexes and is undoubtedly due to similar occupational exposure of both sexes in fields and farms where vectors are numerous. The absence of apparent morbidity due to scrub typhus among the civilian populace was attributed to the mild nature of the disease caused by Pescadores strains, misdiagnosis and a lack of obligatory reporting.


Small airways in progressive systemic sclerosis (PSS).

Obstructive disease involving peripheral airways has been noted in diffuse interstitial pulmonary disease, including sarcoidosis and cryptogenic fibrosing alveolitis. The possibility of obstruction of small airways in progressive systemic sclerosis (PSS) has been suggested by widespread bronchiolectasis and peribronchial fibrosis noted at necropsy. We performed pulmonary function studies in 39 subjects (22 nonsmokers and 17 smokers) with PSS, most of whom had functional evidence of interstitial pulmonary involvement (increased static recoil pressure and reduced diffusing capacity). The 1 second forced expiratory volume to forced vital capacity ratio (FEV1:FVC) was normal in all subjects. Although the severity of the restrictive process was greater in nonsmokers compared with that in smokers, the maximal mid-expiratory flow rate, closing volume, closing capacity, volume of isoflow, change in maximal expiratory flow at 50 per cent of vital capacity during 80 per cent helium--20 per cent oxygen breathing compared with air breathing (delta Vmax50), ratio of dynamic to static lung compliance at different breathing frequencies and upstream airway conductance at static recoil pressures of 5 and 10 cm H2O were nearly always normal in the nonsmokers but were frequently abnormal in the smokers with PSS. These findings suggest that diffuse interstitial pulmonary disease due to PSS generally does not lead to functional evidence of obstruction in peripheral airways and that when the latter is found it can likely be attributed to the effects of concomitant cigarette smoking.


The relationship between plasma dobutamine concentrations and cardiovascular responses in cardiac failure.

Plasma dobutamine concentrations and hemodynamic and noninvasive cardiac measurements were made during dobutamine infusions in eight patients with congestive cardiomyopathy and low output heart failure. Plasma concentrations correlated well with infusion rates (2.5, 5.0, 7.5 and 10 microgram/kg/min). Cardiac output and stroke volume increased linearly, whereas pulmonary capillary wedge pressure, and total pulmonary and systemic resistances decreased linearly with increasing dobutamine concentrations. No constant relationship existed between plasma dobutamine levels and changes in heart rate or mean arterial pressure. The noninvasive left ventricular function data (echocardiographic and systolic time intervals) correlated linearly with plasma concentrations and suggest that these noninvasive technics be employed in guiding the administration of this new inotropic agent.


Plasma erythropoietin in polycythemia.

Erythropoietin titers of plasma cannot be used to differentiate polycythemia vera from secondary polycythemia since the limit of sensitivity of our current bioassay technics is 50 mU, considerably higher than levels found in normal subjects and in patients with polycythemia. However, erythropoietin is relatively heat stable, and since abundant plasma is available from therapeutic phlebotomies it is possible to prepare and assay highly concentrated, erythropoietin-containing extracts. In 35 normal subjects, erythropoietin levels ranged from less than 5 mU/ml (the limit of sensitivity) to 18 mU/ml with a mean of 7.8 mU/ml. In 21 patients with proved polycythemia vera, the levels were less than 5 mU/ml in all. In 41 patients with suspected secondary polycythemia or polycythemia of unknown origin, the levels ranged from less than 5 to 3,000 mU/ml. Three of the 11 patients with levels less than 5mU/ml were subsequently shown to have polycythemia vera. These results suggest that this refinement of the routine bioassay for erythropoietin may be of clinical importance in the differential diagnosis of polycythemia.


Right-sided infective endocarditis: an echocardiographic study.

Echocardiographic observations are described in 10 patients with right-sided bacterial endocarditis. Six of the nine patients with tricuspid regurgitation had shaggy echoes on the tricuspid valve, which were confirmed to be vegetations on autopsy in two patients. In six patients, right ventricular dilatation was present, and paradoxic septal motion was seen in four. In one of the patients with pulmonic valve endocarditis, the pulmonic valve and right ventricular outflow tract revealed the shaggy echoes in diastole, along with systolic fluttering of the pulmonic valve, right ventricular dilatation and paradoxic septal motion. When the findings are supplemented to the clinical picture, echocardiography is found to be a useful noninvasive adjunct in the diagnosis of acute vegetative bacterial endocarditis involving the right side of the heart, especially if other clinical features, e.g., fever, leukocytosis and positive blood cultures are absent.


Cardiovascular and metabolic manifestations of heat stroke and severe heat exhaustion.

We prospectively studied the clinical, biochemical (including creatine phosphokinase (CPK) isoenzymes) and electrocardiographic features of exertional heat stroke in 13 patients (group 1) and severe heat exhaustion in 14 patients (group 2). Despite initial presentations with severe hyperthermia, tachycardia and hypotension, only one patient with heat stroke had myocardial ischemia. The CPK isoenzymes were not indicative of myocardial damage in any patient. The patients with heat stroke were somewhat more dehydrated than those with heat exhaustion as measured by differences in serum creatinine, sodium and osmolality, and the former (group 1) had a significantly lower initial glucose level (P less than 0.05). Although significant differences in potassium were not observed in the pretreatment samples, at 12 hours the serum potassium was significantly lower in group 1 (P less than 0.05). This suggests that this group may have been more potassium-depleted at the time of heat stroke. Prompt recognition and vigorous therapy were successful in rapidly lowering high temperatures and in preventing serious complications.


Malabsorption syndrome occurring in the course of disseminated histoplasmosis: case report and review of gastrointestinal histoplasmosis.

Histoplasmosis is caused by the dimorphic fungus, Histoplasma capsulatum. The disease spectrum varies from a mild respiratory infection to a lethal, disseminated form. Involvement of any part of the gastrointestinal tract may occur with the disseminated form, and symptoms reflect that portion involved. A case of malabsorption syndrome occurring during the course of disseminated histoplasmosis is reported, and the literature of gastrointestinal histoplasmosis is reviewed.


Pulmonary alveolar proteinosis: successful treatment with aerosolized trypsin.

A 37 year old man with pulmonary alveolar proteinosis and severe pulmonary physiologic impairment was treated empirically for 12 months with continuous oxygen, intermittent positive pressure breathing and aerosolized saline solution, heparin and acetylcysteine. Because of progression of disease, he was treated with aerosolized trypsin in a dose of 100,000 U twice daily for six months. This treatment was associated with dramatic symptomatic, chest roentgenographic and pulmonary physiologic improvement that has lasted for two and a half years without remission. The absence of adverse effects of trypsin aerosol allowed its administration in the patient's home. It is suggested that the preferred initial therapy for symptomatic alveolar proteinosis is aerosolized trypsin.


Association of teichoic acid antibody with metastatic sequelae of catheter-associated Staphylococcus aureus bacteremia: a failure of the two-week antibiotic treatment.

A patient with Staphylococcus aureus bacteremia associated with an infected intravenous catheter was treated with oxacillin for two weeks. During that period all blood cultures were sterile, he rapidly became afebrile, and there were no signs of endocarditis or metastatic abscesses. However, serum antibodies against staphylococcal teichoic acid, initially undetectable by the agar gel immunodiffusion technic, became positive during the second week of treatment. Three weeks after discharge, the patient was readmitted to the hospital because of back pain and weakness in the lower extremities. Vertebral osteomyelitis and a spinal epidural abscess caused by Staph. aureus of the same phage type as the bacteremic isolate were demonstrated. This case illustrates the importance of careful follow-up of patients with Staph. aureus bacteremia and the potential value of serial measurement of teichoic acid antibodies in detecting clinically inapparent complications of infection.


Reversible hypertension due to carcinoma of the ureter.

A patient who presented with hypertension of recent onset was found to have unilateral hydronephrosis. Increased activity of the renin-angiotensin system was documented with renal-vein-renin concentrations. The hydronephrosis was due to a primary transitional cell carcinoma of the ureter. Following nephroureterectomy, blood pressure returned to normal and has remained so for two years.


Metabolic mimicry of Bartter's syndrome by covert vomiting: utility of urinary chloride determinations.

Bartter's syndrome characteristically exhibits the constellation of hypokalemic alkalosis with moderate kaliuresis, normotensive hyperreninemia, hyperaldosteronism, urinary hyperexcretion of prostaglandin E (PGE) and vascular hyporesponsivity to pressor agents. We describe precise biochemical mimicry of these metabolic abnormalities in a patient with surreptitious repetitive vomiting, in whom simple urinary chloride excretion data subsequently excluded the diagnosis of Bartter's syndrome.


A study of serum protein fractionation.

Serum protein fractionation was studied using the techniques of ammonium sulfate precipitation, molecular seiving chromatography, and ion-exchange chromatography. Whole human serum was fractionated by precipitation with ammonium sulfate at 40, 50, 60, and 70 percent saturation. Molecular seiving chromatography was performed on whole human serum and on four ammonium sulfate precipitated fractions. The eluted peaks from molecular seiving chromatography were further separated by ion-exchange chromatography to obtain isolated fractions of IgG, transferrin, and albumin. Qualitative analysis of the various fractions and assessment of the purity of isolated IgG, transferrin, and albumin was done by polyacrylamide gel electrophoresis and by immunoelectrophoresis.


Colorimetric microdetermination of plasma lactate.

A simple ten-minute colorimetric procedure for plasma lactate is described. Good agreement with an ultraviolet procedure indicates acceptable accuracy. Precision, recovery, and interference studies further substantiate this procedure's validity.


Continuing education: factors which affect cognitive benefits.

A 16-week continuing education course in clinical chemistry provided for a group of laboratory professionals was evaluated in terms of those factors in the participants' backgrounds which influenced their performance on precourse and postcourse examinations. Work setting, facility size, educational background, and sex influenced precourse scores. Educational background and occupational function influenced postcourse test scores.


A comparative study of student MLT traits and articulation interests.

Allied health community college students have not been characterized according to their intentions to pursue a health careers ladder. This paper describes an analysis of the demographic-biographic, cognitive, psychomotor, and affective profiles of 326 female second-year MLT students contrasted with their articulation interests. The articulation categories included AAS termination, delayed MT transfer, immediate MT transfer, and non-MT continuation. Chi-square analysis and analysis of variance revealed few statistical differences between such articulation interests and test outcomes. Results are interpreted and directions for future study are presented.


Controlling laboratory costs is as easy as ABC.

A long-used inventory technique can help lower laboratory supply costs by pinpointing items which justify creative administrative attention.


The use of pooled patient plasma as an abnormal prothrombin time control.

Five abnormal prothrombin time pooled patient plasma samples and seven commercially prepared abnormal prothrombin time control plasmas were compared. A fibrometer was used to run prothrombin time tests from 8 to 51 days on individual aliquots of the pooled patient plasmas and individual vials of the commercial products. Pooled patient plasmas exhibited greater reproducibility with generally lower coefficients of variation than did the commercial products, with the added advantage that they reflected the patient population more directly. Almost all samples displayed a significant rise in mean clotting times during the testing period. However, the reasons for this rise are not entirely clear.


Forecasting: which type is for you?

Planning--one of the most important functions of laboratory management--cannot be done efficiently without forecasts of external and internal conditions that affect the laboratory. The successful Delphi Method for external forecasting of technological events is discussed. The internal forecasting methods covered in this report include judge and jury methods, time series analysis, and regression models. A brief description of each of these methods is presented along with information on accuracy, typical applications, costs, and references that provide the details of how to perform the forecasts.


Medicolegal aspects of paternity testing.

Blood group testing has achieved wide acceptance by the courts as a major scientific determinant in paternity proceedings. Other tests, including H-LA types and hemoglobin determinations, are also being used with increasing frequency; however, there are legal safeguards which must be met to satisfy the court's need to ensure the validity of the tests and their interpretation. In order for the results of paternity testing to be admitted into testimony (evidence) the following should be established: 1) proof that proper persons provided the blood samples; 2) consent to the tests and permission for release of information regarding test results; 3) proof that the speciment was correctly labeled and transported; 4) documented accuracy of the testing procedures; 5) fact testimony regarding the test results; and 6) expert testimony explaining the exclusion principle. In the future, laboratory personnel can expect wider application of these and other laboratory results to legal proceedings. For determinations derived from any laboratory testing to be admissable as evidence, the courts will apply the above safeguards.


The use of "clear" enzyme control materials.

Low turbidity, "clear" enzyme controls commercially produced in three concentrations and conventional human lyophilized control sera, which are more turbid, were evaluated to determine which was superior for quality control purposes. Criteria used to evaluate the controls were: 1) turbidity measurement, 2) daily assays for 30 days to estimate day-to-day precision, and 3) stability of the enzyme assay value for these controls when they were reconstituted and frozen for 0 to 30 days and 0 to 10 days with three aliquots separately prepared and frozen for 0 to 10 days for a total of 30 days. The controls were analyzed for lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, creatine kinase, and alkaline phosphatase activities with the Perkin-Elmer KA 150 enzyme analyzer.


Determining continuing education interests of medical technologists: an initial step.

Continuing education is an ever-increasing need for medical technologists who want to maintain and upgrade their professional knowledge and skills. Professional groups strive to develop programs to meet a diversity of needs. Planning groups often encounter difficulty during the program development process as they identify topics and select effective educational strategies for presentation. In order to help identify topics of interest and desirable educational methods for the continuing education of laboratory personnel, a continuing medical technology education interest assessment tool was developed and used by a medical technology continuing education committee. Development and use of this assessment tool and resulting statistical survey results formed the basis for two continuing education courses, both considered highly successful.


The development and operation of an efficient laboratory preventive maintenance program.

The development and implementation of a preventive maintenance program are described. The details of the program are discussed to demonstrate its initial planning and the subsequent stages as a process that would be applicable to any medical laboratory.


The liver histology and frequency of clearance of the hepatitis B surface antigen (HBsAg) in chronic carriers.

Two hundred four volunteer blood donors with hepatitis B surface antigen found in their blood were followed for 3 to 44 months. The annual clearance rate of this antigen was 1.7%. Liver enzyme levels (aminotransferase) were elevated in 45 (22.1%) on at least one occasion, in 26 (12.7%) for one month or more, and in 13 for more than six months. Liver biopsies were performed on 17 chronic carriers with normal enzymes and nonspecific histologic abnormalities were found in 14 and mild diffuse hepatitis in three. Seventeen carriers with abnormal enzymes were biopsied, and specimens revealed chronic active hepatitis (CAH) in seven, including two with bridging necrosis and three with cirrhosis. CAH was found in 7 of 26 (26.9%) carriers with abnormal liver enzymes persisting for at least one month and 4 of 13 (30.8%) with abnormal liver enzymes for more than six months.


Pancreatic venography and plasma ketone measurements in the diagnosis of hyperinsulinism.

Preoperative localization of an insulinoma was possible using a technique of transhepatic pancreatic venography, with measurement of insulin levels in six pancreatic veins. Surgical exploration confirmed the presence of an insulinoma at the site predicted by venography. Peripheral plasma insulin levels were only minimally elevated at the time of hypoglycemia. However, complete suppression of ketogenesis during a 74-hour fast was observed, and felt to be a biological marker for hyperinsulinism. These observations suggest that transhepatic pancreatic venography and the measurement of plasma ketones in addition to glucose and insulin during fasting, may be useful supplementary studies in the evaluation of patients with fasting hypoglycemia.


Central retinal vein occlusion associated with hemodialysis.

Central retinal vein occlusion (CRVO) occurred in 3 of 15 maintenance hemodialysis patients over a two-week period. There have been no previous reports of this ophthalmologic catastrophe observed in the dialysis setting. Lupus nephritis, Henoch-Schönlein purpura and nephrosclerosis constituted the patients' major underlying diseases. Moderate hypertension was also present. Impaired vision of the left eye noted 24 to 36 hours following dialysis was the presenting symptom in all cases. Findings included decreased visual acuity, retinal vein engorgement, hemorrhage, and disc edema. All three patients subsequently lost the vision in their left eye (two received anticoagulation therapy). With the exception of hypertension, there were no known underlying predisposing conditions present. Although we are unable to offer a definite explanation for these unusual cases of CRVO, we feel a hypercoagulable state may have been responsible. Because our three cases occurred during a two-week period, some transient unidentified procoagulant factor associated with hemodialysis could have been present.


Hospital admissions due to adverse drug reactions.

One hundred three (4.1%) of 2,499 patients hospitalized in a general medical ward were admitted because of an adverse drug reaction (ADR). Of 60 drugs involved, the most common were cardiac, antibiotic, and antineoplastic agents. The main reactions included skin rashes, bone marrow depression, arrhythmia, bleeding, and heart failure. Five (4.9%) of the patients died and 11 (10.7%) had life-threatening reactions. Risk factors predisposing to admissions due to ADR were: female sex, decreased renal function, polypragmasia, and the underlying disease. Twenty-seven percent of the admissions could have been avoided by a more careful choice and dosage of drug.


Acinetobacter calcoaceticus variety anitratus: an increasing nosocomial problem.

Acinetobacter calcoaceticus var anitratus is an increasing nosocomial problem in some institutions. Duirng a recent 16-month period, we observed 15 patients with blood isolates of this organism. Thirteen of these patients acquired the organism from the hospital environment. Eleven of these represented real disease and concurrent growth of the organism from another site was predictive of infection (P less than 0.03). A review of laboratory records showed that there was a three-fold increase in nonblood isolates of this organism from hospitalized patients in 1975 and 1976, as compared to 1972 (P less than 0.0001), and a marked seasonal effect was noted, with increased isolations during the summer. Aminoglycoside resistance had increased considerably with 25% of nonblood isolates being resistant to gentamicin and 16% resistant to tobramycin despite its restriction; blood isolates were uniformly susceptible to gentamicin and tobramycin. Reporting of A anitratus as a nosocomial pathogen and serotyping of isolates may be useful to further define its role in nosocomial infections.


Language factors in vocational evaluation of mentally retarded workers.

Vocational teachers described maladaptive social behavior of retarded workers in vocational training classrooms and sheltered workshops. A rating scale was developed from 28 items measuring unacceptable language behavior. Twenty-seven teachers rated (a) 196 retarded workers with respect to the frequency of maladaptive behavior and (b) the 28 items with respect to the probability that a given behavior would result in termination of employment. Patterns of language behavior of retarded workers were factor analyzed, yielding two primary dimensions: verbal manners and communication skills. Irritating verbal manners were rated as more likely to result in termination of a worker than were poor communication skills. Both factors correlated significantly with the AAMD Adaptive Behavior Scale, and communication skills correlated significantly with the San Francisco Vocational Competency Scale. Results suggested the need to remediate maladaptive verbal behavior in sheltered or educational settings and to assign workers to jobs in accordance with their communication skills.


Environmental change and psycholinguistic ability of mentally retarded adults.

Effects on linguistic ability of transferring retarded adults from a large institution to small "family" bungalows were examined. Effects of environmental change on linguistic ability were assessed using the Illinois Test of Psycholinguistic Abilities (ITPA) and by video-tape recordings of subjects engaging in speech. Results indicated that the bungalows had more resident-oriented as opposed to institution-oriented practices and more staff-resident interaction than did the large institution. The residents to be transferred were matched with control subjects who remained in the large institution. The ITPA was administered and resident interviews were video taped for both groups immediately before the transfer date and 9 months later. Psycholinguistic ability improved significantly more for transferred residents than for control subjects. Transferred residents increased the number of words used in affirmative and negative replies to simple questions during the videotaped interview, but there were no indications of any progression from one language stage to the next. The findings are comparable to previous studies concerning environmental change and increase in language ability of retarded children.


Predictive value of in vitro colony and cluster formation in acute nonlymphocytic leukemia.

Granulocytic-monocytic colony-forming activity of marrow cells was evaluated at presentation in 20 patients with acute nonlymphocytic leukemia (ANLL). A double-layer agar culture was employed to determine colony- and cluster-forming activity. All patients underwent induction chemotherapy with cytosine arabinoside and daunorubicin. Five patients died during induction. Eight of the 11 patients entering complete remission had absent or decreased colony and cluster growth of marrow cells. Four patients who failed to obtain a complete remission produced increased or only cluster growth in culture. Our data support the conclusions of others that decreased colony and cluster formation in vitro is associated with a more favorable response to induction chemotherapy for ANLL.


Generalizability of behavioral observations: a clarification of interobserver agreement and interobserver reliability.

Sixteen indices of interobserver agreement and six methods for estimating coefficients of interobserver reliability were critiqued. The agreement statistics were found to be imprecise, limited psychometrically, and relatively inflexible in terms of the diverse categorical and quantitative data sets typically encountered in mental retardation research. Five of the reliability statistics produced precise estimates of agreement, yet possessed similar limitations. Only the intraclass correlation--generalizability theory approach seemed to offer the precision, comprehensiveness, and flexibility required to deal with the complexity of reliability assessment. A basic generalizability model was described and illustrated with group and single-subject research data.


Case report: Association of giant cell arteritis and pituitary tumor. Report of two cases.

Two patients with giant cell arteritis and visual deficits were found to have pituitary tumors, which accounted for the optic findings. The various ophthalmologic abnormalities in these two conditions, which were apparently coincidentally associated in these two patients, are compared. These cases illustrate the importance of careful neuro-ophthalmologic examination and roentgenograms of the head in patients with giant cell arteritis who have visual field loss.


Errorless discrimination and picture fading as techniques for teaching sight words to TMR students.

The effectiveness of two approaches for teaching beginning sight words to 30 TMR students was compared. In Dorry and Zeaman's picture-fading technique, words are taught through association with pictures that are faded out over a series of trials, while in the Edmark program errorless-discrimination technique, words are taught through shaped sequences of visual and auditory--visual matching-to-sample, with the target word first appearing alone and eventually appearing with orthographically similar words. Students were instructed on two lists of 10 words each, one list in the picture-fading and one in the discrimination method, in a double counter-balanced, repeated-measures design. Covariance analysis on three measures (word identification, word recognition, and picture--word matching) showed highly significant differences between the two methods. Students' performance was better after instruction with the errorless-discrimination method than after instruction with the picture-fading method. The findings on picture fading were interpreted as indicating a possible failure of the shifting of control from picture to printed word that earlier researchers have hypothesized as occurring.


Case report: Antemortem diagnosis of central nervous system strongyloidiasis.

Strongyloidiasis is usually a benign illness confined to the gastrointestinal tract. However, dissemination (hyperinfection syndrome) may occur, particularly in patients with impaired cell-mediated immunity. The diagnosis of hyperinfection syndrome is often made postmortem, and mortality is high, even when the disease is recognized during life. Central nervous system involvement with Strongyloides stercoralis has previously been recognized in only a few cases at postmortem examination, and in one case antemortem. We describe a patient with disseminated strongyloidiasis in whom central nervous system involvement was diagnosed antemortem. This patient developed multiple bacterial and fungal systemic and central nervous system infections as a complication of disseminated strongyloidiasis. The natural history of the disease in man, factors predisposing to dissemination, immunologic aspects of helminthic infection, and treatment modalities are discussed.


Modifying echolalic speech in preschool children: training and generalization.

An operant-conditioning technique was used to teach three handicapped children exhibiting echolalia to respond appropriately to a series of questions. The technique included punishment of echolalic responses and reinforcement of appropriate responses that were cued by a tape recording of the appropriate response. Frequencies of correct responses to the questions increased for each child following a within-subject multiple baseline design. Echolalic responding eliminated in response to trained questions. Generalization of training to several functional responses was found in addition to increased spontaneous use of a functional phrase. Generalization of trained responses across settings and stimuli was also suggested. A 12-month follow-up of two of the subjects revealed no increase in echolalic responding and moderate maintenance of the trained responses. The subjects also showed notable response generalization to untrained questions at the time of the follow-up probe.


Effects of sensorimotor training on intellectual and adaptive skills of profoundly retarded adults.

Effects of sensorimotor training on intelligence and adaptive skills of profoundly retarded young adult residents of a state institution were investigated during a 6-month intensive training program. Comparison of pre- and posttraining test scores showed that the training group made significant gains in awareness (p less than .01) and gross-motor skills (p less than .001) as well as in intellectual (p less than .02) and adaptive skills (p less than .01). No significant gains in fine-motor and imitation skills were found nor were significant changes observed in the attention (control) group. Results were interpreted in terms of sensorimotor-training integration patterns, and they substantiated previous findings that gross-motor functioning and adaptive skills improve with sensorimotor training done in the living unit.


Comparison of tangibly reinforced speech-reception and pure-tone thresholds of mentally retarded children.

Sixteen mentally retarded children who had normal hearing were examined with two tests of auditory sensitivity. One procedure employed a tangibly reinforced operant-conditioning paradigm for pure tones, and the other test was based on a modification of operant conditioning for obtaining speech-reception thresholds. The speech procedure, utilizing an attractive mechanical device in the form of a clown, proved to be effective and efficient for use with retarded children.


Adaptive Behavior Scale: development as a diagnostic tool via discriminant analysis.

The multidimensional nature of behavior often causes a dilemma for the diagnostician who must interpret inconsistent behavior. Three classifications of 6- through 12-year-old children were evaluated on the public school version of the Adaptive Behavior Scale by their teachers. Of the 388 nonretarded, 115 EMR, and 85 TMR children, 86 percent were correctly identified via 12-variable classification functions. The results indicate that further development of an adaptive behavior instrument would be desirable as a cost-efficient and powerful diagnostic tool.


Teaching number-word equivalences: a study of transfer.

The study was designed to determine whether retarded adolescents and nonretarded preschool children would generalize to other tasks involving printed number names if they were taught the number names in an auditory-receptive task. Four nonretarded preschool children and three retarded children participated. All children could count and use spoken and printed numerals. None of the children could adequately perform any task involving printed number words. After receiving training on an auditory-receptive task involving printed number words, all children improved their performance on tasks involving matching printed number words and numerals and printed number words and sets and improved in their ability to name printed number words.


Fetal breathing movements and the abnormal contraction stress test.

The presence or absence of fetal breathing movements (FBMs) in a 30 minute observation period was determined in 29 patients with abnormal contraction stress tests (CSTs). The study population included 14 patients with positive CSTs, 11 patients with equivocal CSTs, and four patients with unclassified CSTs. In patients with either an equivocal or a positive CST, the presence of FBMs was associated with a high incidence of false predictive tests. Conversely, the absence of FBMs in a patient with a positive CST was uniformly associated with intrapartum fetal distress. The presence or absence of FBMs was not helpful in assessing the patients with unclassified CSTs. These data suggest FBMs may be a useful means of evaluating the patient with a positive or equivocal CST.


Calcium accumulation by human uterine microsomal preparations: Effects of progesterone and oxytocin.

A microsomal fraction was prepared from human pregnant uteri at term and at 6 to 19 weeks' gestation, and from nonpregnant uteri by differential centrifugation and purified on a discontinuous sucrose density gradient. This fraction bound calcium in the presence of adenosine triphosphate (ATP). ATP-dependent calcium binding in microsomal preparations was found to increase with advancing pregnancy. Addition of progesterone increased the ATP-dependent calcium binding, while addition of oxytocin decreased the ATP-dependent calcium binding. In combination, oxytocin and progesterone counteracted each other. The progesterone effect was specific for progesterone; three biologically inactive analogues had no effects on calcium binding. The actions of progesterone and of oxytocin on ATP-dependent calcium binding were found to be consistent with their respective in vivo uterine relaxing and contracting actions.


Treatment of obstetric and gynecologic infections with cefamandole.

Cefamandole nafate is a derivative of 7-aminocephalosporanic acid which has been shown to have good in vitro activity against aerobes traditionally susceptible to cephalosporins as well as many anaerobes, including B. fragilis. One hundred women with obstetric or gynecologic infections completed treatment with cefamandole: 53 had post-cesarean section infections: 24, acute pelvic inflammatory disease: 16, posthysterectomy cuff cellulitis/abscess; and seven, vulvar or abdominal wound abscess. Almost 90% of these women had either polymicrobial aerobic/anaerobic bacterial infections or an anaerobic infection alone. Ninety women responded to cefamandole alone; in 10 cases chloramphenicol was added, but in addition five of these women required surgical therapy for eradication of infection. Mild to severe phlebitis at the infusion site that responded to conservative therapy was demonstrated in 14 women. Of 312 bacterial isolates from these women, 89% were sensitive to cefamandole at 32 microgram/ml, an easily achievable serum level; 93% of anaerobic streptococci, the most common isolates, were sensitive at 32 microgram/ml. Also, 90% of all Bacteroides species were susceptible at 32 microgram/ml; 82% of B. fragilis were susceptible at this concentration. These data indicate that cefamandole is safe and effective for treatment of women with polymicrobial pelvic infections but that approximately 5% of these women will require surgical exploration in addition to antimicrobial administration.


Thyroxine uptake and metabolism by fetal sheep after intra-amniotic thyroxine injection.

Thyroxine (T4) uptake from amniotic fluid was investigated in fetal sheep. Samples of fetal and maternal blood and of amniotic fluid were obtained from indwelling catheters at specific intervals after intra-amniotic injection of T4. T4 and reverse T3 (rT3) were measured by radioimmunoassay. Basal levels of T4 were 7.3 +/- 0.92, less than 2, and 6.28 +/- 0.49 microgram/dl in the fetus, amniotic fluid, and ewe, respectively. Basal levels of rT3 were 3,858 +/- 214, 189 +/- 62, and 385 +/- 20 pg/ml in the fetus, amniotic fluid, and ewe, respectively. T4 and rT3 rose progressively in the fetus with maximum concentrations of 25 to 30 microgram/dl T4 by 10 hours and 11,000 to 14,000 pg/ml rT3 by 20 hours after intra-amniotic injection of 500 microgram of T4. These concentrations returned toward baseline by 50 and 70 hours for T4 and rT3, respectively. The increase of fetal T4 was proportional to the amount of T4 injected in a range of 250 and 2,500 microgram. Esophageal ligation abolished the changes in fetal T4 but not rT3. Amniotic fluid rT3 increased with time after intra-amniotic injection of T4 and returned to baseline long after amniotic fluid T4 had reached basal levels. This pattern persisted despite esophageal ligation. T4 was converted to rT3 during incubation in amniotic fluid in vitro. It is concluded that (1) substantial amounts of T4 are taken up by fetal fetal sheep from the amniotic fluid by deglutition, (2) increases in fetal concentrations of T4 and rT3 are related to the amount of T4 added to the amniotic fluid, (3) amniotic fluid and fetal rT3 concentrations increase following intra-amniotic injection of T4 in the absence of significant uptake of T4 by the fetus, and (4) significant amounts of T4 may be converted to rT3 in vitro during incubation of T4 in amniotic fluid.


Whole-blood fibrinolytic activity in normal and hypertensive pregnancies and its relation to the placental concentration of urokinase inhibitor.

Whole-blood fibrinolytic activity was measured in 68 pregnant and 29 nonpregnant women with a sensitive, solid-state assay in which 125I-labeled fibrin was bound to polystyrene tubes. Antepartum fibrinolytic activity in 36 normotensive gravid women [234.5 +/- 29.2 (mean +/- standard error of the mean) ng fibrin lysed/30 min] was significantly (p less than 0.001) greater than that found in 28 nonpregnant normotensive women not taking oral contraceptives (63.61 +/- 7.66 ng fibrin lysed/30 min) and not different from the activity observed during the active phase of labor (198.50 +/- 16.5 ng fibrin lysed/30 min.) Normotensive pregnant patients had a significant (p less than 0.001) increase in whole-blood fibrinolytic activity (341.04 +/- 25.7 ng fibrin lysed/30 min) within the first 24 hours after delivery which persisted in measurements taken the second postpartum day. Fibrinolytic activity values before labor, in the active phase of labor, and in the first and second postpartum days in 17 patients with mild to moderate pregnancy-induced or pregd or pregnancy-aggravated hypertension were not different from those found in the normotensive group. However, patients with severe pregnancy-induced or pregnancy-aggravated hypertension had significantly (p less than 0.01) lower levels of fibrinolytic activity than normotensive patients before labor, during the active phase of labor, and on the first and second postpartum days. The placental 800 X g and 110,000 X g fractions of patients with severe hypertension had a significantly (p less than 0.001) greater capacity to inhibit "in vitro" urokinase-induced fibrinolysis than similar fractions obtained from placentas of normotensive women, and there was a significant inverse correlation (r = 0.61; p less than 0.01) between whole-blood fibrinolytic activity and urokinase inhibition by placental fractions. Our findings indicate that contrary to widely held views, fibrinolysis is extremely active in term pregnancies and during labor and that a derangement of this activity is present in cases of severe pregnancy-induced or pregnancy-aggravated hypertension.


Effect of dopamine on hypotension induced by spinal anesthesia.

Chronically instrumented, near-term pregnant sheep were subjected to autonomic blockade with spinal anesthesia. Systemic arterial pressure, heart rate, and uterine blood flow decreased and uterine vascular resistance increased during the spinal blockade. Infusion of dopamine during the spinal hypotension corrected the disturbed circulatory parameters. These data provide evidence that: (1) the peripheral circulation of the near-term pregnant sheep is as sensitive as that of pregnant women to autonomic blockade, (2) the sensitivity is probably related to factors other than the changes in venous pressure in areas below the pelvis, and (3) dopamine represents a useful agent in the management of spinal hypotension.


Premature menopause. I. Etiology.

The premature menopause syndrome has been regarded as one of the organ-specific autoimmune disorders because circulating antibodies to ovarian tissue have been demonstrated. Fifteen women with spontaneous cessation of menses after initial menarche before they were 35 years old were seen between 1975 and 1977. Increased serum levels of gonadotropin and failure of estrogen secretion were documented. Serum from each woman was examined for antibodies to normal ovary. Proteins from ovaries of normal premenopausal women were extracted and iodinated with 125I. The labeled proteins were incubated with sera for 48 hours, after which goat antihuman gamma-globulin was added and allowed to incubate for 72 hours. The precipitate was washed and evaluated for radioactive label. The binding of antibodies increased in the sera of patients with the premature menopause syndrome, compared with the control sera. This suggests that the etiology of premature menopause may be mediated by circulating antibodies to ovarian tissue.


In vitro perfusion studies of the human placenta. VI. Evidence against active glucose transport.

Previous studies in our laboratory using "in vitro" perfusion have established that glucose transport across the human placenta is a carrier-mediated process. It is not known whether these carriers require the expenditure of metabolic energy to function. In the experiments presented here we demonstrate in the perfused placenta that there is not reduction in the rate of glucose transport or its analogue 3-O-methyl-alpha-D-glucopyranoside (3MG) in the presence of 10(-4) M dinitrophenol (DNP), an uncoupler of oxidative phosphorylation. The presence of DNP, however, does cause an increase in the glucose utilization rate as well as increased lactic acid production. In order to test whether glucose transport depends on the functioning of a sodium pump system, the sodium in the perfusion system was replaced with choline chloride. The final sodium content was 30 mEq/L. In the presence of a low sodium concentration there was no decrease in the rate of 3MG transport compared to the control experiments run at normal sodium levels. Also "counter transport" of glucose was observed, a further indication that the glucose carrier mechanism does not require a sodium gradient in order to function. Since the transport rate of glucose or its analogue 3MG across the placenta is not reduced in the presence of 10(-4)M DNP and is not reduced in the absence of a sodium gradient, it is unlikely that the mechanism of glucose transport is an active process requiring the expenditure of metabolic energy.