Ultrastructure of calcified cartilage in the endoskeletal tesserae of sharks.

The tesserate pattern of endoskeletal calcification has been investigated in jaws, gill arches, vertebral arches and fins of the sharks Carcharhinus menisorrah, Triaenodon obesus and Negaprion brevirostris by techniques of light and electron microscopy. Individual tesserae develop peripherally at the boundary between cartilage and perichondrium. An inner zone, the body, is composed of calcified cartilage containing viable chondroxytes separated by basophilic contour lines which have been called Liesegang waves or rings. The outer zone of tesserae, the cap, is composed of calcified tissue which appears to be produced by perichondrial fibroblasts more directly, i.e., without first differentiating as chondroblasts. Furthermore, the cap zone is penetrated by acidophilic Sharpey fibers of collagen. It is suggested that scleroblasts of the cap zone could be classified as osteoblasts. If so, the cap could be considered a thin veneer of bone atop the calcified cartilage of the body of a tessera. By scanning electron microscopy it was observed that outer and inner surfaces of tesserae differ in appearance. Calcospherites and hydroxyapatite crystals similar to those commonly seen on the surface of bone are present on the outer surface of the tessera adjacent to the perichondrium. On the inner surface adjoining hyaline cartilage, however, calcospherites of variable size are the predominant surface feature. Transmission electron microscopy shows calcification in close association with coarse collagen fibrils on the outer side of a tessera, but such fibrils are absent from the cartilaginous matrix along the under side of tesserae. Calcified cartilage as a tissue type in the endoskeleton of sharks is a primitive vertebrate characteristic. Calcification in the tesserate pattern occurring in modern Chondrichthyes may be derived from an ancestral pattern of a continuous bed of calcified cartilage underlying a layer of perichondral bone, as theorized by Orvig ('51); or the tesserate pattern in these fish may itself be primitive.


Organization of nucleus rotundus, a tectofugal thalamic nucleus in turtles. I. Nissl and Golgi analyses.

This study consists of a detailed cytoarchitectonic and Golgi analysis of a major tectofugal thalamic nucleus in the red-eared turtle, Pseudemys scripta elegans. Neurons in nucleus rotundus have a unimodal soma size distribution and a common dendritic branching pattern. They have long dendrites which undergo sparse, dichotomous branchings and contribute to dendritic fields that cover a third to half the dimensions of the nucleus. Spicules, 1-2 mu long, and complex appendages, 5-20 mu long, are found with low density on many dendrites in Golgi-Kopsch material. A few cells have beaded dendritic processes. Three cytoarchitectural regions can be differentiated in nucleus rotundus: a shell, a cell-poor region and a core. The shell is a monolayer of somata forming the peripheral boundary of most of the nucleus. The cell-poor region forms a thin zone concentric with and internal to the shell. Shell cells send some of their dendrites concentrically within this zone and others radially into the core region. Core neurons are dispersed within the neuropil of the nucleus and usually have spherical dendritic fields. However, peripheral core neurons have asymmetrical fields, so their dendrites do not extend beyond the shell. Caudomedial and central subregions of the core can be defined on the basis of neuronal density and cytology. Somata in the caudomedial area of the core are densely packed and have slightly darker staining cytoplasm than those in the central subregion. However, their dendrites are similar to those of the central core neurons. There is extensive dendritic overlap between the two subregions.


Ultrastructure of chloride cells in young adults of the anadromous sea lamprey, Petromyzon marinus L., in fresh water and during adaptation to sea water.

The chloride cells in the interlamellar areas of the gills of young adult, anadromous sea lampreys, Petromyzon marinus L., captured in fresh water undergo structural modification during the adaptation of these animals to sea water. In fresh water the chloride cells are partially overlapped by mucus-secreting superficial cells and contain an extensive reticulum of cytoplasmic tubules, which are confluent with both lateral and basal plasma membranes, numerous mitochondria, a Golgi complex of moderate size, and numerous apical vesicles. Adaptation to sea water results in a retraction of the superficial cells, exposing the entire apical surface of the chloride cells, and a proliferation of both cytoplasmic tubules and mitochondria. Extensive enlargement of the Golgi complex in the chloride cells of these animals suggests the involvement of this organelle in the proliferation of cytoplasmic tubules. The extracellular tracer, ruthenium red, enters the tubules from the lateral or basal intercellular spaces in both freshwater- and seawater-adapted animals but never enters either tubules or vesicles from the apical surfaces, indicating that these are not confluent. The presence of dividing basal cells and newly-forming chloride cells, combined with evidence of degeneration of chloride cells, suggests that there is a turnover of this cell type. Both superficial and basal cells are phagocytic and involved in heterophagy of degenerating chloride cells. This phenomenon occurs in both fresh water and sea water indicating that the chloride cells may be functional in both environments.


A model to explain the posterior limit of the bite point in reptiles.

A biomechanical model of the jaw mechanism in some reptiles is presented. Symmetrical muscle activity that produces equal forces on both sides of the head is assumed. The model predicts the position of the most posterior bit point and offers a functional explanation for this prediction. Turtles are used to illustrate the idea.


The effect of wear on the cheek teeth and associated dental tissues of the lizard Uromastix aegyptius (Agamidae).

Serial coronal sections of the teeth and their surrounding tissues in the agamid lizard, Uromastix aegyptius, were examined with the light microscope in order to determine how these structures change as the teeth wear. Because new teeth are added only at the posterior end of the tooth row and older teeth are not replaced, the series of sections included the youngest as well as the oldest teeth. Two types of changes occur as the teeth become older: bone under the teeth changes from cancellous to compact, and the pulp chamber of the tooth is obliterated. Although the labial surface of the dentary lacks a periosteal covering and some of the bone lacks any covering at all, it remains functional throughout the life of the animal.


The functional significance of primate mandibular form.

A stress analysis of the primate mandible suggests that vertically deep jaws in the molar region are usually an adaptation to counter increased sagittal bending stress about the balancing-side mandibular corpus during unilateral mastication. This increased bending stress about the balancing side is caused by an increase in the amount of balancing-side muscle force. Furthermore, this increased muscle force will also cause an increase in dorso-ventral shear stress along the mandibular symphysis. Since increased symphyseal stress can be countered by symphyseal fusion and as increased bending stress can be countered by a deeper jaw, deep jaws and symphyseal fusion are often part of the same functional pattern. In some primates (e.g., Cercocebus albigena), deep jaws are an adaptation to counter bending in the sagittal plane during powerful incisor biting, rather than during unilateral mastication. The stress analysis of the primate mandible also suggests that jaws which are transversely thick in the molar region are an adaptation to counter increased torsion about the long axis of the working-side mandibular corpus during unilateral mastication. Increased torsion of the mandibular corpus can be caused by an increase in masticatory muscle force, an increase in the transverse component of the postcanine bite force and/or an increase in premolar use during mastication. Patterns of masticatory muscle force were estimated for galagos and macaques, demonstrating that the ratio of working-side muscle force to balancing-side muscle force is approximately 1.5:1 in macaques and 3.5:1 in galagos during unilateral isometric molar biting. These data support the hypothesis that mandibular symphyseal fusion is an adaptative response to maximize unilateral molar bite force by utilizing a greater percentage of balancing-side muscle force.


Ultrastructural and histochemical features of the thymus glands of the adult lungless salamander, Plethodon glutinosus (Caudata: Plethodontidae).

The thymus glands of adult slimy salamanders (Plethodon glutinosus) were examined by light and electron microscopy with the objective of describing the populations of epithelial cells believed to be secretory. The results of various histochemical procedures designed to demonstrate nucleic acids, proteins, lipids, and mucosubstances were evaluated by light microscopy. Each thymus is incompletely subdivided into a variable number of interconnected lobules by trabeculae extending inward from a thin capsule composed of connective tissues. The thymic parenchyma lacks distinct cortical and medullary regions, although developing lymphocytes and plasma cells tend to accumulate in larger numbers in the outermost portions of the glands. Basophils are found regularly in the capsule and trabeculae, but only very rarely within the thymic parenchyma. The epithelial cells of the thymus can be classified into five categories: epithelial reticular cells; three varieties of granulated cells (types I, II, and III), and myoid cells. Epithelial reticular cells form a three-dimensional network which extends throughout all portions of the thymus. Type I and type II granulated cells can be distinguished from one another by various morphological criteria at the ultrastructural level, but only small differences in the composition of their inclusions can be demonstrated histochemically. Both types of granules are composed principally of a proteinaceous material containing an abundance of primary amino and guanidyl groups. In addition, most type I inclusions possess a lipid component that cannot be demonstrated in type II granules. Type III granulated cells possess very small cytoplasmic inclusions resembling those of gastroenteric endocrine cells. Myoid cells contain concentrically arranged myofibrils composed of sarcomeres. In favorably oriented material, small cysts can be identified whose walls are composed of mixtures of type I cells, type II cells, and epithelial reticular cells. Groups of degenerating epithelial cells form lamellated structures corresponding to Hassall's (thymic) corpuscles.


Evolutionary potential: a mathematical hypothesis of mouse hemoglobin beta chain evolution.

This paper examines the possibility that the linkage arrangements and regulatory properties of genes may be influenced by selection. A mathematical hypothesis is developed in order to show how selective properties of hemoglobin beta chains could have influenced the linkage and regulation of their structural genes. The hypothesis is applied to the case of mouse hemoglobin beta chains. In most mice, closely-linked pairs of loci (doublets) code for two structurally divergent beta chains in unequal amounts. Some mouse strains have singlet alleles, however, coding for another beta chain variant. With the mathematical hypothesis, one can show that selectively determined "evolutionary potentials" may have favored changes in proportions of major and minor chains produced by a doublet allele. In the extreme case, zero production of the minor chain may give a selective advantage, leading to a singlet; conversely, selection may favor linking another gene to the singlet locus to give a doublet. A specific prediction of the model is the stable maintenance under certain conditions of multiple alleles at regulatory loci. The concept of evolutionary potential thus suggests that selection could have influenced the evolution of genotypic fitnesses, in addition to causing changes in gene frequencies as in standard population genetics models


Hydrogen atom initiated chemistry.

H atoms have been created by the photolysis of H2S. These then initiated reactions in mixtures involving acetylene-ammonia-water and ethylene-ammonia-water. In the case of the acetylene system, the products consisted of two amino acids, ethylene and a group of primarily cyclic thio-compounds, but no free sulfur. In the case of the ethylene systems, seven amino acids, including an aromatic one, ethane, free sulfur, and a group of solely linear thio-compounds were produced. Total quantum yields for the production of amino acids were approximately 3 x 10(-5) and approximately 2 x 10(-4) with ethylene and acetylene respectively as carbon substrates. Consideration is given of the mechanism for the formation of some of the products and implications regarding planetary atmosphere chemistry, particularly that of Jupiter, are explored.


Are evolutionary rates really variable?

Langley and Fitch (1974, 1976) have shown that the pattern of nucleotide substitutions in proteins is inconsistent with a Poisson process with constant rate. From this they conclude that the rate is temporally heterogeneous. It is pointed out in this note that a process which is temporally homogeneous but not a Poisson process is compatible with the data if the coefficient of variation of the time between substitutions is around 1.63. Furthermore, theoretical analysis of samples from neutral phylogenies shows that these samples should not appear to be samples from a Poisson process, but should deviate from a Poisson process in the same direction, though perhaps not to the same extent, as do the data.


Beta-structures of polypeptides with L-and D-residues. Part I. Synthesis and conformational studies.

A series of five alternating poly(leucyl-lysyl) samples with varying amounts of L-and D-residues randomly distributed along the chain, but evenly shared out amongst leucyl and lysyl residues were synthesized by condensation of a mixture of the four diastereoisomeric dipeptide p-nitro-phenylesters. Their behavior in aqueous solution at various ionic strengths was studied by infrared spectroscopy which allowed measurement of the total amount of beta-structures, and by circular dichroism which gives the excess of L-residues over D-residues in the same structures. Comparison with the properties of the all L-poly(Lys-Leu-Lys-Leu) shows that incorporation of a few D-residues in a L-chain seems to reduce the width of the beta-sheets obtained in presence of salt. Higher proportions of D-isomers prevent the coil leads to beta transition from occurring when the ionic strength is increased except for segments containing at least 6 to 7 adjacent residues of the same configuration.


Beta-structures of polypeptides with L-and D-residues. Part II. Statistical analysis and enrichment in enantiomer.

The possible formation of beta-structures from polypeptide chains with L-and D-Residues randomly distributed was statistically analyzed within the frame of two hypotheses. Firstly, only those segments containing residues of identical chirality can associate to form antiparallel beta-structures, and secondly these segments must have a minimum length. The influence of different factors was examined: initial ratio of the L-and D-monomer, minimum length required for the segments to be incorporated into beta-sheets, average length of the peptide molecules, and stereoselectivity in the course of the polymerization process. The results show that in all cases nuclei of beta-sheets surrounded by random coil segments are formed, the optical activity of which very increases to purity when the initial ratio of monomers deviates from the racemic mixture. This suggests experiments to enrich the system in one enantiomer. Comparison is made with the corresponding behavior and properties of the alpha-helical structure.


Evolutionary changes in protein composition -- evidence for an optimal strategy.

The information contained in the composition of different proteins of the same family is analyzed. It is found that within each family the gain in information per amino acid replacement is constant. This finding is interpreted to imply that evolutionary changes in proteins follow an "optimal" path in the sense that they maximize the number of potentially functional sequences that can be generated by T accepted point mutations from a given protein, subject to restrictions due to biological function.


On the analysis of unrestricted mixed cultures in determining the fitness of microbial mutants.

Equations describing the growth of two microbial strains in unrestricted mixed culture are developed and their use described. With this treatment, mixed cultures maintained in growth by periodic dilution or by use of a turbidostat may be used to obtain a quantitative measure of the adaptive or maladaptive effects of specific mutant alleles.


Squalenes, phytanes and other isoprenoids as major neutral lipids of methanogenic and thermoacidophilic "archaebacteria".

The neutral lipids of nine species of methanogenic bacteria including five methanobacilli, two methanococci, a methanospirillum, one methanosarcina as well as two thermoacidophilic bacteria, Thermoplasma and Sulfolobus, were analyzed. The major components were C30, C25 and/or C20 acylic isoprenoid hydrocarbons with a continuous range of hydroisoprenoid homologues. The range of acyclic isoprenoids detected were from C14 to C30. Apart from Methanosarcina barkeri, squalene and/or hydrosqualene derivetives were the predominant components in all species studied. The components of Methanosarcina barkeri were a family of C25 homologues. The distribution of the neutral lipid components and their specific variations in relative intensities emphasized the differences between the test organisms while the generic nature of the isoprenoid hydrocarbons demonstrated similarities between the diverse bacteria. The neutral lipid compositions from these bacteria, many of which exist in environmental conditions like those described for the various evolutionary stages of the archean ecology, resemble the isoprenoid distribution isolated from ancient sediments and petroleum. Therefore, these finding may have major implications to biological and biogeochemical evolution.


Stressful life events and burn injuries.

About half of the 67 adults admitted to a burn treatment unit during the course of a year were found to have pre-existing physical and/or psychiatric conditions that increased their susceptibility to injury. In addition, the majority of victims were unmarried, unemployed, and came from low social class, circumstances that tended to increase their vulnerability. A significant increase in stressful life events was reported by these patients during the year preceding burn injury. This life change was negatively correlated with age, income, and number of friends, and positively correlated with social class and psychiatric illness. Two subgroups of persons vulnerable to burns were identified, the first, older women with physical illness, and the second, persons of low social class with psychiatric disorders. The findings have implications for burn prevention and rehabilitation of burn victims.


Gas myelography in spinal cord injury.

Using polytomographic techniques, gas myelography was performed in 162 patients with post-traumatic neurologic deficit. The type, extent, and location of lesions were easily demonstrated, allowing adequate preoperative surgical planning. In cases in which expected neurologic improvement did not follow surgery, postoperative myelography provided information so that remedial measures could be taken. No neurologic deterioration was noted in any of the patients and furthermore, arachnoiditis, which may accompany positive contrast myelography, has not been detected in any of the patients in the series reported.


Delayed definitive reconstruction of the burned hand: evolution of a program of care.

Experience gained in treating patients with hand burns admitted to an active Regional Burn Center has resulted in the development of a biphasic approach which separates early healing and later reconstructive surgical procedures. This schedule permits late definitive surgery on healed functioning hands and is accomplished in a single operation in most cases. This biphasic approach has led to better results at our institution in terms of hand function and appearance, and to a decrease in total numbers of surgical procedures. Reports of others using alternative methods and schedules, also with satisfactory results, are discussed.


The role of coronary artery injury and perfusion in the development of cardiac contusion secondary to nonpenetrating chest trauma.

Myocardial contusion secondary to nonpenetrating chest trauma can occur in the absence of any identifiable large vessel coronary artery occlusion or injury. It has also been reported in association with coronary artery atheromata, thrombosis, rupture, and fistula formation. After reviewing the clinical and experimental research literature, we conclude that myocardial contusion necrosis results from changes in perfusion of small vessels and the coronary microvasculature. Coronary arteriography and emergency coronary artery bypass surgery do not appear promising as therapeutic modalities to reduce myocardial necrosis in this condition. More appropriate therapeutic emphasis may result from research efforts to develop pharmacologic interventions to preserve contused myocardium similar to those currently being evaluated in the management of patients with ischemic myocardium secondary to coronary artery disease.


An emergency medical system approach to disaster planning.

The increasing prevalence of terrorist attacks and natural disasters has mandated that more emphasis be placed on emergency disaster planning. The report focuses on the 1976 Courthouse bombing in Boston, which generated 20 casualties. Ambulance response by Boston's Emergency Medical Service system was made in 2.5 minutes and all victims were transported from the scene within 20 minutes. Successful management of this incident employed several important principles of disaster planning. These include the initial medical response, staging at the scene, and hospital notification. Additionally, the concept of triage as an integral part of disaster planning is explained with examples of the on-site medical stabilization and treatment of casualties. The importance of these concepts in practice and the necessity of close coordination of ambulance response and the responses of other emergency agencies, i.e., Police and Fire, were clearly demonstrated in the disaster which resulted from the Courthouse bombing.


Computed tomography of post-traumatic extracerebral hematomas: comparison to pathophysiology and responses to therapy.

One hundred nine head-injured patients with epidural and acute and chronic subdural hematomas were evaluated by computed tomography (CT). Eighty-two patients had subsequent CT examinations in order to evaluate postoperative changes and responses to therapy. Results seen on CT studies were compared to patients' neurologic status at the time of scanning. The rapid return of the appearance of the brain and the patients' neurologic status to normal soon after evacuation of an uncomplicated epidural hematoma reflect the lack of parenchymal damage. In contrast, acute subdurals are usually produced by associated contusions or cortical lacerations. The mass effect of these parenchymal lesions is responsible for a degree of ventricular shift out of proportion to the usual small size of the acute subdural. Small acute subdurals managed medically and residual collections found after evacuation resolved spontaneously. No acute subdurals progressed to a chronic subdural. The latter are infrequently associated with cerebral parenchymal injury and their symptoms are due to the size of the collections. Deformity of the underlying brain by the chronic process and slow re-expansion of the brain account for the common finding of a slowly resorbing, residual fluid collection following surgical evacuation.


Energy transfer and regional blood flow changes following missile trauma.

The hemodynamic response to missile injury was studied in the hind legs of dogs. Spherical projectiles were used and velocity and mass were varied. The regional arterial blood flow to the injured thigh was recorded and the energy transfer to the tissues determined. In addition the presence within the aortic arch was recorded immediately after the impact of the missile. Missile penetration caused a marked peak of flow followed by a less pronounced elevation of the flow level for at least 30 minutes. The magnitude of the peak was related to the amount of energy transferred to the tissues. The origin of the circulatory changes is discussed. Shock waves of considerable magnitude were recorded within the aortic arch in connection with the bullet penetration.


Early fibular bypass procedures (tibiofibular synostosis) for massive bone loss in war injuries.

The techniques of fibular bypass grafting for massive tibial bone loss have been well described over the past 50 years. These techniques have generally been used as salvage procedures in post-traumatic civilian patients with chronic sepsis, or for congenital pseudoarthrosis. We present the experience of the Orthopaedic Department of the Hadassah University Hospital in successfully treating massive tibial bone loss by early fibular bypass grafting in four war injuries, where such definitive procedures would have been avoided in the past.


Fractures of the humerus, radius, and ulna in the same extremity.

Fracture of the humerus, radius, and ulna is a rare combined injury. In our review of 21 cases, it was found that this injury was usually a result of rather severe trauma. There are frequently associated injuries to other organ systems. The most common associated injury was residual nerve damage, which occurred in over 50% of cases. Of all the different treatment modalities no one was found to be better than the others.


Unreduced posterior dislocation of the elbow.

Six unreduced posterior dislocations of the elbow are reported and the clinical details, operative procedures, and results obtained are presented. The literature is reviewed and the necessity of triceps V-Y plasty at operation discussed.


Osteochondral fracture associated with dislocation of the patella: another mechanism of injury.

An apparently not previously reported type of osteochondral fracture of the lateral femoral condyle associated with dislocation of the patella is presented. The mechanism of the fracture is described as forced inward rotation of the femur against the tibia. Internal fixation is the surgical treatment of choice in this type of fracture.


Late false aneurysm of the carotid artery: repair with extra-intracranial arterial bypass.

A patient with a rapidly enlarging symptomatic false aneurysm of the internal carotid artery 30 years after nonoperative treatment of a penetrating neck injury is presented. Preoperative compression of the aneurysm precipitated transient cerebral ischemic attacks. Complete interruption of the right internal carotid artery inflow during aneurysmectomy was considered to be fraught with great danger. An extra-intracranial arterial bypass was therefore performed, and then aneurysmorrhaphy was easily performed and saphenous vein graft interposition accomplished. The importance of early definitive treatment of arterial injuries is emphasized. The bypass used allowed additional cerebral blood flow when complete occlusion of the carotid artery was contraindicated.


Injury to the suprascapular nerve associated with anterior dislocation of the shoulder: case report and review of the literature.

A young man with persistent pain beginning 2 days following reduction of an anterior subcoracoid dislocation was found to have a suprascapular nerve injury. The patient described was felt to have a neurapraxia of the suprascapular nerve. Possible causes of post-reduction subluxation are interposition of the shoulder joint capsule or biceps tendon, or rupture of the rotator cuff. EMG in 3 weeks, followup examinations, and active assisted motion 4 to 6 weeks postinjury are recommended.


An unusual fracture of the vertebral articular process in a skier.

An unusual vertical fracture through the superior articular process of L5 is described in a professional skier. This fracture, not associated with a pars interarticularis defect, is felt to be stress related. Standard oblique radiographs failed to demonstrate the defect but it was seen clearly on steep oblique views. The fracture was the casue of chronic backache to the patient. Followup radiographs after 14 months demonstrated a nonunion of the fracture.


The unchanged mortality of flail chest injuries.

Six hundred eighty-five patients with major blunt thoracic injuries from 1968 through 1977 were retrospectively studied. This series was compared to a similar series from 1959 through 1964. Between 1964 and 1968 a vastly improved hospital was built, laboratory support improved, pressure-controlled ventilators replaced by volume-controlled ventilators and the trauma service was reorganized. The treatment regimen for flail chest injuries during the last decade evolved from the previous early tracheostomy and prolonged ventilator support to an avoidance of tracheostomy and brief ventilator support. The overall mortality in the present series was 20% compared to 35% for the 1959--1964 series; however, improved mortality occurred only among patients with hemothorax who had one or more major concomitant extrathoracic injuries. The mortality for flail chest injuries did not improve (29.5 vs 35.0%). Mortality was unchanged for isolated flail chest injuries, isolated pneumothorax, isolated hemothorax, and for flail chest injuries, and pneumothorax in patients with concomitant major extrathoracic injuries. In both series deaths from isolated thoracic injuries were rare. It is evident that the continued high mortality for blunt thoracic trauma principally relates to concomitant extrathoracic injuries and that recent treatment innovations have not reduced the mortality of flail chest injuries.


Intracranial pressure monitoring in the acute neurologic assessment of multi-injured patients.

The trauma victim with a severe closed head injury, who requires general anesthesia for emergency repair of concomitant exigent major injuries, poses a clinical dilemma. During general anesthesia and during the immediate postoperative period, the status of the patient's central nervous system cannot be clinically monitored, and emergency cerebral arteriograms and/or CAT scans are not easily obtained. Under these circumstances, delays in the diagnosis of intracranial blood accumulations frequently occur, and occult cerebral edema often goes untreated. In an attempt to avoid these management problems, we have employed intraoperative intracranial pressure (ICP) monitoring in such patients, using a subarachnoid screw. Following placement of this screw, several clinical courses may occur: 1) The patient maintains a normal pressure; thus a significant mass lesion and/or cerebral edema requiring decompression is unlikely. 2) The patient's ICP is elevated but controlled by medical management. 3) The patient's ICP cannot be controlled below 20 to 25 mm Hg using medical management, and exploratory burr holes are made. 4) If intracranial blood is encountered during placement of the ICP monitor, immediate exploratory craniotomy is indicated.


Fresh-frozen plasma vs. plasma protein derivative as adjunctive therapy for patients with massive burns.

Twenty patients with burn injuries involving 45% or more total body surface area were randomly allocated to receive either fresh-frozen plasma (plasma), 200 ml/m2/d (11 patients), or an approximately equal amount of plasma protein derivative (Plasmanate) (nine patients) during the first 45 days postburn. To study the potential effects of these two adjunctive therapies on host resistance to infection, measurements were made twice weekly of the antibacterial funciton of neutrophils, the opsonic index (ability to opsonize alternative pathway dependent E. coli 075), C3(B), IgG, properdin, factor B, total protein, and albumin. The average size of burn in the plasma group was 61.5% total and 42% 3 degrees compared with 61% total and 46% 3 degrees in the Plasmanate group. Ten and 18 episodes of bacteremia occurred in the plasma and Plasmanate groups, respectively. Analysis of the results indicates only slightly better support of host resistance when plasma is administered, but this is counterbalanced by the increased risk of viral hepatitis.


Early mortality and temperature regulation in burned mice following administration of catecholamines and adrenergic receptor blocking drugs.

The effect of catecholamines and adrenergic receptor blocking drugs on mortality and body temperature was studied in mice subjected to burn, tourniquet, and endotoxin shock at an environmental temperature of 25 degrees C. Epinephrine and norepinephrine (0.5 mg/kg) injected intraperitoneally postburn increased shock mortality significantly (p less than 0.05); pretreatment with these catecholamines had no effect. Pretreatment of burn- and tourniquet-traumatized mice with propranolol (25 mg/kg) significantly decreased shock mortality, while pretreatment with dibenamine (25 mg/kg) significantly lowered early mortality after endotoxin. None of the catecholamines or their blocking drugs significantly prevented the characteristic immediate fall in core temperature after the three types of shock. At 6 days postburn, however, a combination of propranolol and dibenamine caused a marked fall in core temperature (p less than 0.05). These results indicate that beta-catecholamine agonists could play an important role in acute burn mortality and that both alpha- and beta-catecholamine agonists could significantly influence body temperature regulation and metabolic rate during the late postburn period.


Special problems of cardiac injuries in infants and children.

Cardiac injuries occur infrequently in children. Although the mechanisms of injury are not unique to the pediatric age group, the frequency of the various injuries is quite different. This unusual nature dictates an enhanced awareness for proper management. Twenty cases were recognized in a 16-year retrospective review. There were six children with perforations from cardiac catheterizations, ten children with penetrating injuries, and four children with blunt injuries. Two of the children with blunt injuries presented as myocardial contusion and one child survived blunt rupture of the right atrium. Only one death occurred in the series--a newborn baby who died from an unrecognized cardiac tamponade secondary to perforation of the right ventricle during catheterization. The diagnosis and special techniques for management of injuries due to catheter perforation and blunt injuries of the heart in infants and children are discussed.


Vascular trauma in infants and children.

A 20-year retrospective evaluation of vascular trauma in infants and children was undertaken. The study included 53 cases of blunt and penetrating vascular injuries in pediatric patients. There were 36 males and 17 females ranging in age from 24 days to 14 years (average, 10 years). The most frequently encountered sites of arterial trauma were the brachial or superficial femoral artery, and of venous trauma the inferior vena cava. Any patient presenting to the Emergency Center with an injury in proximity to a major vessel, hematoma formation, audible bruit, or palpable thrill underwent prompt arteriography or immediate operative exploration of the injury sit. All patients in the series were managed operatively. There were 41 major arterial and 32 major venous injuries. No patient required a major amputation. Most injuries were repaired by primary closure or segmental resection and end-to-end anastomosis; interposition vein grafts and substitute conduits were used in four patients with more extensive injuries. A 13% operative mortality was encountered: the most frequent cause of death was intraoperative exsanguinating hemorrhage. The triad for successful management of vascular trauma in pediatric patients is: 1) a high index of suspicion, 2) performance of aggressive diagnostic studies when indicated, and 3) prompt surgical intervention.


Management of supracondylar fracture with brachial artery thrombosis in a child: case report and literature review.

Brachial artery thrombosis following prompt reduction of a supracondylar fracture of the humerus in a 7-year old is described. Persisting absence of the distal pulses in a viable extremity may herald the insidious development of Volkmann's ischemia. Pulse volume recordings provide a safe, objective means of evaluation. Arteriography by direct open technique avoids the hazards of percutaneous puncture in children.


False aneurysm of axillary artery following resection of a traumatized humeral head: case report.

A case of false aneurysm and damage to the neurovascular bundle as a late complication to excision of a shattered humeral head is described. The authors advocate smoothing of the end of the remaining diaphyseal part of the humerus and, further, that if a swelling in the operative area occurs postoperatively, arteriography should be performed.


A follow-up study of paraplegics and tetraplegics discharged from hospital.

A study was conducted to investigate to what extent 76 paraplegics and tetraplegics were able to cope with their environment after discharge from hospital. The results showed that automobile accidents were responsible for most cases of paraplegia and tetraplegia; most patients died within one year of discharge from hospital; there was a significant differential in the survival rate between the upper and lower class patients in favour of the former; the younger the patient the longer was his chances of survival; the higher the lesion the greater were the chances of wife desertion among subjects and the lesser was the chance of survival; and finally none of the subjects except one was employed after discharge from hospital.


Case report of an ovarian hydatid cyst.

Hydatid cyst is a parasitic disease caused by Taenia echinococcus. The first and most important site for this parasite is the liver. Secondary involvement of the pelvic organs is seen. However, the primary involvement is very rare. Here we are reporting a case with primary involvement of the ovary which underwent laparotomy and was proven by microscopic studies.


Cardiac arrest after intravenous chloroquine injection.

In cases of severe malaria chloroquine phosphate is frequently given--diluted or undiluted--by the intravenous route. It is known that cardiac arrhythmias and hypotension may complicate such therapy, but cardiac arrest is not a well recognised hazard. In this report we describe such a tragic complication, and advocate that undiluted chloroquine should not be administered intravenously in severely ill patients since such patients usually have associated electrolyte disturbances which may render the heart vulnerable to toxic drugs. Chloroquine may be given diluted in normal saline infused over several hours with a close watch over the blood pressure.


Tuberculosis presenting with hemiplegia.

Five cases are reported of tuberculous patients who presented with hemiplegia as the initial symptom of their illness. In three patients the paralysis improved rapidly and completely with institution of antituberculous treatment. One case which came to necropsy revealed that the cause of the hemiplegia was a tuberculoma situated in the internal capsule.


Progressive systemic sclerosis: a case report from nigeria and review of african cases.

A Nigerian case of progressive systemic sclerosis is described. Special attention is drawn to the rarity of this condition in Africans.


Present and future developments in hearing aid design.

Although hearing aids have shown little outward change in the past decade, the development of new components has produced a steady reduction in size and improvement in performance. The near-perfect electret condenser microphone occupies a mere 50 cubic millimeters and its low vibrational sensitivity permits close packing of components without acoustic feedback problems. The integrated circuit packs a hundred components into each cubic millimeter and has allowed the miniaturization of complex aids while simultaneously boosting performance. Integrated circuits will permit future aids to compensate distorted loudness perception as a function of frequency, and extract speech signals buried in noise. These sophisticated, computerized, hearing aids will demand new evaluation and fitting methods and it  is the methodology rather than the technology that will pace their development.


The role of communication aids in the rehabilitation of hearing impairment.

The primary emphasis in rehabilitating the hearing impaired has involved fitting a hearing aid. There are patients however, who can be helped by communication aids in addition to, or in place of hearing aids. Communication aids include any device, other than a conventional hearing aid, which assists the hearing impaired in maintaining contact wiht the normally hearing. In Scandinavian countries a sophisticated system for rehabilitating the hearing impaired has evolved and communication aids are recommended extensively. Similar aids exist in North America, but clinicians have not yet developed a full awareness of how these devices can benefit their patients. This paper represents the results of a two year survey undertaken to identify and evaluate various devices available in Toronto. The contribution these aids can offer in rehabilitating patients is discussed.


Clinical experience with brain stem audiometry performed under general anesthesia.

Hearing tests were given to 22 difficult-to-test children using brain stem audiometry performed under general anesthesia. The effect of halothane and sodium thiopental on the brain stem response was assessed as well as the feasibility of using this technique with a difficult-to-test population. No effect on brain stem responses was observed to various levels of anesthesia. Successful hearing tests were carried out on all the children and results were helpful in their management. Brain stem audiometry perfromed under general anesthesia appears to be an effective and helpful technique for testing challenging diagnostic cases.


Brain stem audiometry: status and clinical applications of click evoked brain stem responses.

Over the past 10 years, numerous reports on click evoked brain stem responses have appeared in both the general otolaryngologic and the audiologic literature. Equipment is now commercially available, is relatively simple to operate, and permits the routine recording of these potentials. The technique is especially useful in the objective establishment of hearing thresholds in the newborn and in adult subjects and appears to be more reliable than the cortical evoked response (AEP). Other uses and applications of the technique, as in the detection of brain stem lesions and acoustic tumors, in coma and brain death, are discussed.


Seeding of parotid carcinoma along Vim-Silverman needle tract.

A case report of seeding of parotid carcinoma along a core biopsy needle tract is presented. Excision of the needle biopsy site at the time of definitive surgery is recommended. Aspiration needle biopsy with a fine needle is reliable, with tumor seeding less likely.


Some aspects of therapy in the non-healing granulomas of Wegener and Stewart.

The non-healing granulomas of Wegener and Stewart (Wegener's granuloma and lethal midline granuloma) have been recognized since 1897. A mainstay of therapy has been the empirical application of treatments based upon theoretical or pathological assumption, and we are only slightly closer to classifying these diseases. Between 1967 and 1975 eight patients with non-healing granuloma of Wegener's type, and one patient with non-healing granuloma of Stewart's type, presented to the Otolaryngology Service of the conjoined McGill University Hospitals. All received corticosteriods and all those with the Wegener type of granuloma received azathioprine (Immuran). Four patients are alive and well today from five months to eight years and 10 months after starting therapy. Some aspects of the changing historical, clinical, pathologic, and therapeutic indices of these diseases are presented, with our experiences in these areas.


Chronic middle ear disease with intracranial extension--a clinicopathologic case report.

A case is presented with chronic suppurative otitis media and subsequent tympanogenic labyrinthitis, extradural abscess, and otogenic meningitis. The clinical course is described and pathologic findings demonstrated using serial temporal bone sections. The difficulties of diagnosing and treating this clinical condition are illustrated.


The Nakasuk Project- the conservative treatment of chronic otitis media in Inuit elementary school children.

Modalities of local medical treatment of chronic otitis media in Inuit elementary school children were evaluated over a period of three and a half years in a project associated with the provision of amplification (hearing aids) for students who had significant conductive hearing deficits which interfered with their ability to communicate. The significant medical and educational benefits derived are reviewed.


Impedance audiometry in a young population. The effect of age, sex, and tympanogram abnormalities.

Static compliance, and acoustic reflex thresholds, were studied retrospectively in 883 subjects, aged one to 20 years. Age was a factor in both measurements. In 523 subjects with normal middle ear fuction, static compliance increased as a function of age. Acoustic reflex thresholds for pure tone signals improved with age, while acoustic reflex thresholds for broad band noise (BBN) tended to decrease. Minor tympanogram abnormalities exerted a distinct influence on static compliance and acoustic reflex thresholds. Static compliance was increased, and highly variable, in 93 subjects with A-deep tympanograms. In 212 subjects with either A-deep tympanograms, or slight negative pressure (i.e. -50 to -100 mm H2O), acoustic reflex thresholds were elevated for both pure tone, and BBN signals. In 132 sensorineural impaired subjects, the sensitivity loss differentially affected acoustic reflex thresholds for pure tone vs BBN signals. In view of the potential influence of age, and, especially, minor middle ear abnormalities, on static compliance and acoustic reflex measures, these factors should be seriously considered when interpreting impedance audiometry findings in children.


Audiologic evaluation of patients with localized intracranial lesions.

A battery of audiological tests for retrocochlear disorders was performed of 79 cases with localized intracranial lesions confirmed surgically or neurologically. The Type III trace of Békésy audiometry was found to originate from pathologies in the brainstem and the Type IV from abnormalities in the first neuron of the VIIIth nerve or in the brainstem. It was suggested that an unusually large amplitude peak in the Békésy tracing indicates a lesion in the temporal lobe. Large values of differential limen for short increment (DLSI) were found in patients with brainstem lesions. A good speech discrimination with a poor filtered speech discrimination apparently indicated supratentorial lesions. The binaural separation test using dichotically presented digit sounds was found to be helpful for differential diagnosis between the supratentorial and subtentorial lesions.


The bite in the temporomandibular joint pain dysfunction syndrome.

After reviewing the anatomy of the temporomandibular joint, the soft tissue classification of this syndrome is divided into three groups: macrotrauma, microtrauma, and stress situation. In each group, the etiology, physical findings, pathophysiology, and treatment are discussed. Bite assessment is reviewed so that the otolaryngologists will have a fuller understanding of the role that occlusal status plays in this syndrome. Before contemplating surgery, this status should be assessed by a competent dental colleague.


Granulomatous osteomyelitis of the maxillary sinus.

A case of granulomatous osteomyelitis of the maxilla, probably due to tuberculosis is reported, and the literature reviewed. Excision of the diseased tissue with antitubercular treatment forms the most effective line of treatment.


Zenker's diverticulum- carcinoma of the esophagus?

Malignant change may occur in a pharyngo-esophageal diverticulum and although it is rare, a small number of cases has been reported. A similar case is reported here to contribute to the awareness of the existence of such an entity.


Directional growth of renal calculi.

The forces involved in shaping urinary calculi reside in crystalline characteristics and especially in local influences. Box pleves may restrict passage and, by allowing mobility, help shape a round calculus. Fixation, occurring with a rapidly growing infection stone, facilitates initial growth on a matrix mold in a funnel pelvis, further aided by pelviocaliceal paralysis from bacterial endotoxins and later by stasis. Branched calculi are further shaped by contact with the pelvic and infundibular walls. Through pressure and mucous coating they grow only at the ends. Late caliceal obstruction frees the ends for clubbing. Consideration of these forces aids in prognosis and surgical removal, and may offer opportunities for prevention.


Biochemical profiles of stone-forming patients: a guide to treatment.

A formal protocol, controlled metabolic evaluation is essential to the most effective treatment of any patient with renal calculi, regardless of the crystalline composition of the stone. The design of the protocol and of the data sheets should be compatible with ease of diagnosis and selection of corrective therapeutic measures. These data also serve as a reference to monitor response to treatment. Treatment is highly individualized with the objective to reduce all potentially crystallizable ions to basal levels. If this is difficult to accomplish certain ratios of ions are brought to as near normal values as possible.


Adjunctive chemotherapy of infection-induced staghorn calculi.

Bacteria induce urinary crystallization of struvite and carbonate-apatite as a by-product of ureolysis by urease. Eradication of infection and/or inhibition of urease with acetohydroxamic acid for 5 to 30 months retarded stone growth and brought about partial or comple dissolution of stones in 9 patients. Long-term chemotherapy with antimicrobial agents that achieve steril urine or acetohydroxamic acid in those patients with recalcitrant infection lessens the risk of recurrent calculogenesis.


Staphylococcal protein A assay for detection of antibody directed at renal cancer cells.

Sera from 27 patients with renal cancer, 14 patients with transitional cell carcinoma of the bladder and 21 normal controls were tested against 2 renal cancer lines (CAKI-1 and CAKI-2) by the iodinated protein A assay. All sera tested against CAKI-2 were absorbed first with AB+ substance because CAKI-2 was found to have cell surface A antigen. Sera from 16 of 27 patients with renal cell carcinoma, 3 of 14 patients with transitional cell carcinoma of the bladder and 2 of 21 normal controls were reactive with CAKI-1. Sera from 11 of 27 patients with renal cell carcinoma, 2 of 14 patients with transitional cell carcinoma of the bladder and 3 of 21 normal controls were reactive with CAKI-2. There is a positive correlation between the number of counts obtained by the renal patients' sera tested against CAKI-1 and CAKI-2.


Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients.

Partial or total replacement of the ureter by small intestine was performed at the University of California/Los Angeles Hospital and affiliated hospitals 94 times in 92 patients from 1954 to 1978. Indications included recurrent calculi, ureteral stricture, fistula, congenital obstruction of the ureter and ureteral carcinoma with a solitary kidney. A special use has been for undiversion of an ileal conduit. Followup evaluation was possible in 95% of the patients and ranged from 6 months to 23 years. Thirty-six patients were followed for more than 5 years. The operation was judged successful in 81% of the cases. Serum creatinine was unchanged or decreased in 75.7% and the pyelogram was unchanged or showed decreased dilatation in 84.6% of the patients. Although reflux was seen in 40 of 55 patients who had cystograms 39 (97.5%) were considered to be treated successfully. Indications for and results of the operation are discussed. The procedure is recommended as optimal therapy for carefully selected situations when the normal urinary tract cannot be used.


Ureterosigmoidostomy and carcinoma of the colon.

The etiology for development of colon carcinoma associated with ureterosigmoidostomy seems to be related to the urine. The incidence of colon carcinoma associated with ureterosigmoidostomy is 500 times greater than in the normal population, indicating about a 5% life time risk. The development time of these lesions varies from 6 to 50 years postoperatively but it is significantly less in patients more than 40 years old. The possibility exists that colon carcinoma may develop in primary sigmoid urinary diversion conduits or sigmoid internal conduits to either bladder or bowel. No reported bowel carcinoma has developed in an ileal urinary diversion. Followup examination should include stools for blood every 3 months after 2 years, an excretory urogram yearly after 5 years, sigmoid or colonoscopy every 5 years and barium enema every 5 years. If the patient has hematochezia or the excretory urogram demonstrates ureteral obstruction sigmoid or colonoscopy and a barium enema should be done.


Posterior urethral stricture repair.

Experience with 54 operations for the membranous-prostatic urethral stricture is presented. There were 7 operations performed through pubectomy exposure, 6 Badenoch operations, 31 exteriorization 2-stage operations using a perineal-scrotal flap for the first stage and 10, 1-stage transperineal end-to-end anastomoses after scar tissue had been excised. The technique for the transperineal approach is presented. Presently, a 1-stage end-to-end anastomosis of the bu.ferred. Exteriorization urethroplasty using the perineal-scrotal flap is recommended when an end-to-end anastomosis is not feasible, either because of a long stricture or severe scar secondary to previous operative failures. The pubectomy approach is seldom needed but the Waterhouse pubectomy procedure is recommended as a possibility in patients who cannot be placed in the exaggerated lithotomy position.


Adenocarcinoma of the prostate: a comparison of the disease in blacks versus whites.

A retrospective analysis was done on 3,298 cases of adenocarcinoma of the prostate seen between 1948 and 1975. There were 2,324 black patients (70%) and 974 white (30%). Criteria for comparison included age and stage at original diagnosis and relative survival rates between the groups. Our study showed a difference in age and stage but a similar pattern in survival between groups.


The use of estramustine and prednimustine versus prednimustine alone in advanced metastatic prostatic cancer patients who have received prior irradiation.

Estramustine has been shown previously to be an effective drug in the treatment of metastatic prostatic cancer, demonstrating significant objective and subjective responses in long-term non-randomized trials and in other randomized trials. In this study prednimustine alone has shown a minimal over-all objective response rate of 12.9% of the cases, although with marked subjective improvement of pain relief and patient performance status. The combination of prednimustine with estramustine did not result in improvement of objective or subjective response parameters. The effects in terms of responses or in terms of toxicity for either agent were not additive when they were given in combination. Cross-over for those patients whose disease progressed on prednimustine therapy to estramustine had some benefit in over-all survival. Prednimustine alone or in combination with estramustine may be used safely and could improve markedly the quality of life for irradiated patients with advanced prostatic cancer who failed on hormonal treatment and have too poor a bone marrow reserve to be treated by other currently available myelosuppressive agents.


The benefits of evaluation of the patient with recurrent or multiple calcium stones.

Metabolic evaluation of patients with multiple or recurrent calcium stones has been fruitful. The great majority of cases has demonstrated abnormalities contributing to stone formation. Hypercalciuria on the basis of increased intestinal absorption of calcium was a common finding. The evaluation led to improved guide lines for therapy.


The bladder in boys with posterior urethral valves: a urodynamic assessment.

Urodynamic evaluation was performed on 8 of 62 boys (13 per cent) with persistent voiding difficulties after fulguration of posterior urethral valves. All had varying degrees of incontinence when evaluated. The striated muscle component of the external urethral sphincter was intact in each child. Five different types of bladder function were noted in the 8 children. Three boys had had a prior Y-V plasty of the bladder neck to improve upper and lower urinary tract emptying, which may have contributed to the subsequent incontinence. One additional boy had significant bladder neck obstruction requiring a unilateral bladder neck incision to improve voiding. Appropriate treatment plans were instituted based on the urodynamic findings of the bladder, bladder neck and external sphincter areas, and 6 of the 8 children are now completely continent.


Detrusor-sphincter dyssynergia.

We followed 62 patients with complete suprasacral spinal cord injuries and detrusor-sphincter dyssynergia for at least 2 years. The patients were evaluated urodynamically at regular intervals and 50 per cent were subjected to external sphincterotomy, after which they were compared for the presence of bacteriuria and upper urinary tract changes. Patients on prolonged intermittent catheterization did as well as those who achieved balanced bladder function as a result of sphincterotomy.


Urethral hypotonicity after suprasacral spinal cord injury.

Established suprasacral spinal cord injuries usually are associated with detrusor hyperreflexia and varying degrees of detrusor-sphincter dyssynergia. Occasionally, such injuries result in detrusor areflexia or urethral hypotonicity or both. The results of the urodynamic evaluation of 4 patients with suprasacral spinal cord injuries are described. Detrusor areflexia and urethral hypotonicity were demonstrated in 3 cases and urethral smooth muscular hypotonia but preserved reflex detrusor function in 1. It is shown that destruction of the thoracolumbar sympathetic outflow can cause the complete loss of urethral smooth muscular closing function and that resting urethral closure is totally independent of preganglionic cholinergic influences.


Intermittent catheterization in children less than 6 years old.

Neurogenic bladder dysfunction often requires treatment early in life. Intermittent catheterization is an accepted means of treatment in older children and adults but its use in young children and infants has been limited because of fear of urethral injury. The results of managing 42 patients less than 6 years old by intermittent catheterization are presented. Excellent results were achieved even in small infants.


Enuresis: principles of management and result of treatment.

We studied 115 consecutive cases of primary enuresis. Excretory urography, urodynamic testing and endoscopy are needed only in children with enuresis and concomitant urinary infection. A detailed urologic history was the most important factor in deciding upon a treatment program. Children with diurnal and nocturnal enuresis or nocturnal enuresis and daytime urgency and frequency of urination are started on anticholinergic medication. Girls with enuresis and urinary infection also are started on anticholinergic medication. Significant improvement occurs in up to 90% of the patients. Children with only nocturnal enuresis and no other symptoms are started on imipramine with a 70% improvement rate.


Familial pheochromocytoma: a report of 2 cases in a kindred.

A kindred with 2 current cases of pheochromocytoma is reported. The proband had classical features of adrenal medullary hyperfunction, in addition to Raynaud's phenomenon. After surgical removal of the right adrenal gland, containing a pheochromocytoma and a small paraganglioma, the patient was free of symptoms. The 12-year-old son of the proband was discovered to have relatively asymptomatic sustained hypertension on routine examination. Biochemical and radiological tests confirmed the diagnosis of a left adrenal pheochromocytoma, which was removed successfully.


Intrarenal pheochromocytoma: report of a case.

To our knowledge the first case of an intrarenal pheochromocytoma is reported. It is important to realize that an intrarenal or apparent intrarenal mass in a hypertensive patient might be a pheochromocytoma so that appropriate precautions can be taken.


Bilateral multilocular renal cysts with recurrence.

Multilocular renal cysts may occur bilaterally. A partial nephrectomy usually is curative but unroofing of the cyst may lead to recurrence. We suggest to delete the criterion of unilaterality and to base the diagnosis on histological features. The first case of bilateral multilocular renal cysts with unilateral recurrence is reported.


Dissolution of cystine ureteral calculus by irrigation with tromethamine.

An alternative to surgical intervention in cases of symptomatic cystine calculi is presented. A large obstructing ureteral calculus in a patient who had undergone 4 prior lithotomies was dissolved during a 5-day period by irrigation via a ureteral catheter with tromethamine-E, an alkaline organic amine intravenous solution.


Management of prolapsed ureterocele: past and present.

A prolapsed ureterocele occurs more frequently in female subjects than in male subjects. At least 64 cases in female patients have been reported and an additional case in a 2-year-old girl is reported herein. Only 3 cases have been reported in male subjects. A method for management of a non-reducible ureterocele in female patients is outlined and discussed briefly.


Vesicoureteral reflux and ureteropelvic junction obstruction: late occurrence of ureteropelvic obstruction after successful ureteroneocystostomy.

Ureteropelvic junction obstruction occurred in 2 patients after successful correction of vesicoureteral reflux. The correction of vesicoureteral reflux does not always allow complete resolution of pelvioureteral tortuosity, kinking and periureteritis. In cases with a severe degree of these changes the possibility of ureteropelvic junction obstruction occurring either early or late after ureteroneocystostomy should be considered when unsatisfactory renal function is noted during followup.


Emphysematous cystitis associated with Clostridium perfringens bacteremia.

Anaerobes are recognized rarely as the cause of urinary tract infection. A case is reported in which there were clinical signs of sepsis, positive blood culture for Clostridium perfringens and radiographic demonstration of emphysematous cystitis without any other recognized source of infection.


Redux testis: a potential pitfall in testicular imaging.

The use of radionuclide testicular imaging to assess testicular perfusion has been shown to be a valuable diagnostic procedure in the evaluation of the acute scrotum. However, if images are not evaluated in conjunction with physical findings falsely negative examinations can occur. A case of torsion of a retractile testicle (redux testis) is presented to demonstrate this potential limitation. To our knowledge this has not been reported previously.


Paratesticular rhabdomyosarcomas and leiomyosarcomas: a clinicopathological review.

One case of embryonal paratesticular sarcoma and 2 cases of leiomyosarcomas are reported. The 13-year-old boy with embryonal sarcoma is well after an orchiectomy and high ligation of the spermatic cord followed by radiotherapy and chemotherapy. A 66-year-old man has been doing well after orchiectomy and hemiscrotectomy for a paratesticular leiomyosarcoma. The third patient had a highly pleomorphic leiomyosarcoma and died 2 months postoperatively. The clinical and histological diagnosis of paratesticular rhabdomyosarcomas and leiomyosarcomas is reviewed and the various therapeutic approaches to these neoplasms are discussed. Retroperitoneal lymph node dissection, radiotherapy and chemotherapy are important adjuncts to orchiectomy in the management of rhabdomyosarcomas. On the contrary, retroperitoneal lymph node dissection and radiotherapy are not indicated in leiomyosarcomas, since these neoplasms tend to metastasize by the hematogenous route and are radioresistant. At the present time we are unable to evaluate chemotherapy in the management of paratesticular leiomyosarcomas.


Severe prostatic calcification after radiation therapy for cancer.

Severe symptomatic prostatic calcification was seen in 3 patients who had carcinoma of the prostate treated initially with transurethral resection, followed in 2 to 4 weeks by definitive radiation therapy. This complication is probably preventable if an interval of 6 weeks is allowed between transurethral resection of the prostate and radiation therapy.


Rectovesical fistula secondary to prostatic carcinoma.

Rectal invasion by carcinoma of the prostate occurs in a significant number of cases (approaching 10%). A case of a rectovesical fistula owing to direct extension of a prostatic carcinoma is reported. This complication of the disease has not been described previously.


Squamous cell carcinoma of the prostate: report of 2 cases and review of the literature.

Two cases of squamous cell carcinoma of the prostate are reported and criteria for diagnosis are suggested. Squamous cancer, which accounts for 0.5 to 1% of prostatic malignancies, differs from the common adenocarcinoma of the prostate in certain clinical features. It also appears to have a worse prognosis and to be unresponsive to the usual therapies for prostatic cancer, perhaps because of a different cell of origin.


Stone formation on polypropylene suture.

Polypropylene is a relatively new suture material with many advantages, which has been demonstrated in experimental studies to be a safe material for urologic operations. However, recently, 2 patients had polypropylene suture at the matrix of urinary calculi. Symptoms from the calculi developed in both patients in the late postoperative period and both had large amounts of fibrosis around the sutured urothelium.


Idiopathic retroperitoneal fibrosis in children.

A case of idiopathic retroperitoneal fibrosis in an 11-year-old boy is presented. A review of 7 previous case reports revealed that there was no characteristic presentation in this disease process and that the diagnosis usually is suspected on an excretory urogram. The treatment is primarily surgical but corticosteroids may be helpful in selective cases.


A review of 117 partial nephrectomies.

In this review of 117 consecutive partial nephrectomies calculi associated with infection was the most common indication for the operation. Other indications included congenital anomalies, trauma, arteriovenous malformations and tumor. Partial nephrectomy has been shown to be a relatively safe procedure, with a mortality rate of 1.7 per cent. However, considerable morbidity occurred when stone and/or infection persisted postoperatively. We herein emphasize that total intraoperative removal of calcareous debris, appropriate treatment of associated infection and avoidance of nephrostomy tubes are important to a successful postoperative result. Partial nephrectomy as a method to remove stones confined to or originating in a diseases calix appears unsurpassed.


Neurogenic bladder and the tethered spinal cord syndrome.

We report 2 cases of the tethered spinal cord syndrome. Early clinical detection of this syndrome in children with bladder dysfunction should be followed by diagnostic myelography and immediate surgical release of the spinal cord. The pathophysiology of the syndrome is discussed.


Non-papillary carcinoma in situ of the bladder: a clinicopathologic study of 2 cases treated with radical cystoprostatourethrectomy.

Two cases of carcinoma in situ of the bladder treated with radical cystoprostatourethrectomy were evaluted by histologic study of the totally embedded epithelium. Clinical symptomatology consisted of urinary frequency with diminished bladder capacity and pain on voiding. Urinary cytology and multiple biopsies were essential for diagnosis of this lesion. The resected specimens of both cases were fixed in formalin and totally embedded for step sections that were mapped after histopathologic study. In both cases atypical epithelium and carcinoma in situ with foci of microinvasion affected the bladder mucosa and extended continuously to the distal ureters as well as the prostatic urethra. Since the lesion subsequently may result in invasive bladder cancer and often involves the prostatic urethra and distal ureter as in our cases the radical cystoprostatourethrectomy is recommended.


Lesions of Cowper's glands in children.

Lesions of Cowper's glands in children are relatively uncommon. They may be totally asymptomatic or may cause mild irritative or obstructive voiding symptoms. We describe 4 cases to illustrate the varied manifestations of these lesions in children. A plan of treatment is suggested, which is based on the different anatomical presentations encountered.


Gracilis muscle flap for closure of rectourethral fistula.

A gracilis muscle flap can be used to close a rectourethral fistula caused by operative trauma and radiation. The flap is rotated easily into the perineum, brings vascularized muscle to irradiated and/or traumatized tissue and is a mechanical barrier between the urethra and the rectum.


Angiographic management of post-prostatectomy bleeding.

A case is reported of angiographic localization and management of a severe, life-threatening hemorrhage secondary to transurethral resection of the prostate in a 90-year-old man. The classical methods of controlling post-prostatectomy bleeding are discussed.


Urogenital aspects of actinomycosis.

Urogenital actinomycosis has always been a rare entity, limited to a few cases in any series. Treatment is highly successful but diagnosis remains elusive owing to low incidence, variable clinical picture, and biopsy and culture uncertainties. The general incidence of actinomycosis is believed to be decreasing in recent years but many infections may go undiagnosed while being suppressed or cured by conventional antibiotic therapy given for other resons. Our incidence of 4 cases of genitourinary and abdominal actinomycosis occurring in a 1-year period is highly unusual but the reasons remain speculative. Prior operation, abortion and induced infection via an intrauterine device were probably contributory. Whatever the case, if our experience is shared by others, genitourinary actinomycosis deserves more prominent diagnostic consideration in the future.


Sickle cell trait: forgotten cause of hematuria in white patients.

Extensive evaluations for intermittent gross hematuria, including selective renal arteriograms, failed to reveal the etiology of bleeding in 2 whtie patients. Sickle cell preparation and hemoglobin electrophoresis, obtained as long shot tests, revealed sickle cell trait in both patients. Both patients were treated successfully with low doses of epsilon aminocaproic acid. Sickle cell prepration and hemoglobin electrophoresis should be included in the evaluation of every patient, white or black, with unexplained hematuria.


Lower extremity complications of the lithotomy position: prevention and management.

We describe 2 unusual and serious complications of the lithotomy position, anterior compartment syndrome and peroneal nerve palsy. The methods of management and prevention are discussed.


Ultrasonic differentiation of renal pelvic filling defects.

We herein describe 9 patients with non-opaque calculi and 3 patients with soft tissue filling defects in the renal pelvis studied by ultrasound. The calculi varied in size from 1.5 cm. to staghorn calculi. All stones were imaged satisfactorily by ultrasound, allowing the diagnosis of stone to be made with confidence. Ultrasonic differentiation of renal pelvic filling defects proved to be a simple, reliable, non-invasive method to differentiate these clinically perplexing lesions.


Routine celiac angiography in patients with renal cell carcinoma.

Celiac and/or superior mesenteric angiography was done routinely in association with renal angiography on 115 patients with renal cell carcinoma. Metastases were demonstrated in 20 patients on extended angiography. In 10 of these patients no other signs of metastatic disease were noted at diagnosis. In the total clinical diagnostic stydy metastatic spread was present in 41 patients.


A new endoscopic urethral dilator.

A new endoscopic dilator that can be used either with a foroblique or end vision telescope is described. The design of the dilator and its use are demonstrated with diagrams and endoscopic photographs. The safety and the ease of operation are explained.


The association of histocompatibility antigens of the B7 cross-reacting group with Peyronie's disease.

A significant relationship between Peyronie's disease and histocompatibility antigens of the B7 cross-reacting group is described. The association of Peyronie's disease with a group of immunologically cross-reacting antigens, rather than with a single antigen, suggests that a yet undetermined agent of specific molecular configuration involves in some way its pathogenesis. This finding has diagnostic application and adds a new dimension to the etiologic investigation of Peyronie's disease.


Contact scrotal thermography: application to problems of infertility.

Traditionally, studies on the relationship between scrotal or testicular temperature and infertility have concerned patients with varicoceles. However, some varicoceles are difficult to palpate and, in fact, there now appears to be an entity called subclinical varicocele. These data have led to the development of a new diagnostic tool, a contact thermography camera, which is inexpensive in comparison to infrared thermography units, is portable and provides consistent permanent recordings of scrotal temperature. The initial use of this camera in 30 patients seen in an infertility clinic is reported.


Heterozygous cystinuria and calcium oxalate urolithiasis.

Many variables are known to be associated with the formation of calcium oxalate urolithiasis but none is essential for the initiation or growth of stones. It is likely that the predisposition to stone formation is related to multiple factors. We herein describe still another metabolic state that seems to predispose to calcium oxalate stone disease, namely heterozygosity for cystinuria. Cystine screening tests were done on 24-hour urine specimens obtained from 126 patients in whom recurrent calcium oxalate stones form and 84 controls and quantitative amino acid determinations were done on all positive specimens. Of those studied 17 of 126 stone patients and 1 of 84 controls were heterozygous cystinurics. A test of the differences between the relative frequencies of cystinuria heterozygotes in the 2 groups with Fisher's exact test revealed them to be highly significant (p less than 0.001). Our study indicates that carrier status for 1 of the cystinuria genes predisposes to calcium oxalate stone formation but, like other factors related to urolithiasis, it is not a necessary cause of stone disease.


Guanethidine sulfate in the prevention of autonomic hyperreflexia.

Autonomic hyperreflexia constitutes the only medical emergency seen in spinal cord injury patients. Uncontrolled hypertension and bradycardia can result in seizures and death. The acute treatment of the syndrome has ranged from medical ganglionic blockers to topical anesthetic agents to surgical procedures. The oral use of 10 mg. guanethidine sulfate 3 times daily successfully prevented the major symptoms of the syndrome in 200 spinal cord injury patients with lesions above T5. Toxicity has been mild and the drug is recommended until the patients are voiding and are capable of self-care.


An objective comparison of the effects of parenterally administered drugs in patients suffering from detrusor instability.

Cystometric changes produced by 3 parenterally administered drugs, flavoxate hydrochloride, emepronium bromide and imipramine hydrochloride, have been evaluated in 15 female patients with detrusor instability. Each patient was given 2 of the 3 drugs and cystometric recordings were done 10 and 30 minutes after the administration of each drug. Emepronium bromide was found to be the only drug to cause a significant improvement in bladder capacity and reduction in detrusor pressure.


Urodynamic assessment of incontinence after prostatectomy.

There were 15 men with incontinence after prostatectomy who were assessed with a urethral pressure profile and a multichannel filling and voiding study with sphincter electromyography. Of these 15 patients 7 had sphincter weakness alone, 7 had sphincter weakness and detrusor hyperreflexia, and 1 had detrusor hyperreflexia alone. Full urodynamic assessment is essential before treatment can be recommended for incontinence after prostatectomy.


Surgical management of massive neurogenic hydronephrosis.

Permanent urinary diversion has been the standard recommended treatment of massive dilatation of the upper tracts in the child with neurogenic vesical dysfunction. Reimplantation of relatively normal caliber ureters into neurogenic bladders has been shown to be effective. However, attempts to save urinary diversion in 39 neurogenic megaureters have been unrewarding, with the salvage rate of 15 per cent, and 64 per cent have been diverted permanently. Upper tract decompression by continuous or intermittent catheterization, nephrostomy or end cutaneous ureterostomy was used in this series. When ureteral caliber responded to decompression a reasonable success rate from non-tailored reimplantation may be anticipated. However, in those instances in which ureteral caliber failed to respond or when tailoring or ureteral caliber was done in conjunction with reconstruction the success rate was much lower.


Behavior of children undergoing hypospadias repair.

We performed a prospective study on 10 boys between 2 and 6 years old undergoing repair for hypospadias. Clinical observation in the hospital ward rooms and play environment demonstrated a distinctive postoperative course of withdrawal and aggressive behavior with resultant increased parental anxiety, which results in strained staff-family relations. We speculate that this distinctive behavior may be owing to an interaction among parental attitudes, the pain and immobilization from operation and the level of the child's sexual development. Intervention was designed to give the boys behavioral outlets and to involve their family in preoperative and postoperative education.


Usefulness of adrenal venography and iodocholesterol scan in adrenal surgery.

Adrenal scintiscanning and venography with sampling of adrenal venous blood are valuable methods to localize adrenal cortical lesions of Cushing's syndrome and primary aldosteronism. Adrenal scintiscanning with dexamethasone suppression is most useful in differentiating adenoma from hyperplasia of primary aldosteronism.


Paratesticular rhabdomyosarcoma in children.

The clinical characteristics, surgical treatment, clinical grouping, chemotherapy, radiotherapy, complications and survival of paratesticular rhabdomyosarcoma are discussed. When the combined approach of radical inguinal orchiectomy, retroperitoneal node dissection, chemotherapy and radiotherapy when indicated is used a survivorship in excess of 80 per cent can be anticipated for all stages of disease. A combined multidisciplinary approach to this lesion is stressed to achieve improved survivorship in this previously lethal lesion.


Adrenal cysts: pathogenesis and histological identification with a report of 6 cases.

Because of their rarity cysts of the adrenal gland are often misinterpreted and misdiagnosed. Six cases of surgically removed adrenal cysts are presented, including 3 endothelial cysts, 2 epithelial retention cysts and 1 pseudocyst. Evidence is presented that epithelial retention cysts could and do develop in the human adrenal cortex and are not theoretically impossible as propagated in the literature. We also emphasize the importance of evaluating the surrounding fibrous and adrenal tissue in the proper identification of these cysts, a point not sufficiently stressed previously.


The use of percutaneous nephrostomy in 42 patients.

Percutaneous nephrostomy has been used for the diagnosis and treatment of 42 patients with obstructive uropathy. Bilateral puncture was done in 6 cases and this was the sole means of establishing permanent urinary diversion in 8.


Fused pelvic kidney combined with absence of the vagina.

A case of a fused pelvic kidney combined with absence of the vagina in a girl referred for an inguinal hernia is presented.


Management of renal arterial injuries secondary to penetrating abdominal trauma.

Renal vascular injuries are found relatively frequently after non-penetrating abdominal trauma. Penetrating renal arterial lesions occur much less frequently, involving less than 5 per cent of all penetrating arterial injuries. The association of bowel and other organ injuries makes diagnosis and treatment somewhat complex. Four cases of penetrating renal arterial injuries were seen from January 1972 to June 1976. All patients had multiple bowel lacerations. All arrived in the emergency room in hypovolemic shock. Two patients were resuscitated and successfully treated. Three patients had complete transections and 1 had major branch transection. Two patients had an associated parenchymal lesion. One patient had a through-and-through ureteropelvic injury. Preoperative arteriography was not done because of vascular instability. Renal arterial injuries were suspected by loss of psoas shadow on abdominal x-rays and by retroperitoneal hematomas. Retroperitoneal hematomas were explored to eliminate the possibility of renal injury. Both of the patients operated upon attained good renal function after surgical repairs. Postoperative renal scans and arteriograms showed initially decreased function, which returned toward normal. Repair of renal arterial lesions is possible with good functional result. Preoperative arteriography, renographic scan or excretory urography is not justified routinely because of the seriousness of commonly associated injuries.


Case report: transitional cell carcinoma of the renal pelvis presenting with vascular obstruction.

A case of transitional cell carcinoma of the pelvis, which presented with vascular occlusion, is reported.


Neuroblastoma presenting with hematuria.

A 3-year-old boy with neuroblastoma presented with gross hematuria, an unusual initial complaint with this malignancy. Renal findings associated with neuroblastoma are discussed.


Transurethral ureteroscopy in men using juvenile cystoscopy equipment.

The inadequacies of current procedures to yield exact diagnostic information on the last portion of the ureter in men and the urologists' frequent frustration when manipulations are attempted in the lower ureter have prompted exploration of a direct endoscopic approach to diagnosis and treatment in the terminal ureter. In the last 3 years we have become accustomed to accomplishing ureteroscopy in women on a routine basis to discover and to treat with amazing ease ureteral tumors, calculi, obstructions and so forth. Ureteroscopy in men now has been practiced sufficiently to convince us that it also should join the urologists' armamentarium of diagnostic and therapeutic procedures. Herein is described the equipment and the technique to endoscope the lower ureter.


A 20-year experience with ileal conduits: the fate of the kidneys.

During the last 20 years 242 patients have undergone ileal conduit urinary diversion at our hospital. Although only 11 per cent of the renal units showed damage after the ileal conduit there was a progressive risk of renal deterioration with increasing time and obstruction was its major cause.


Urologic complications of pelvic exenteration for gynecologic malignancy.

We reviewed 43 cases of pelvic exenteration for gynecologic malignancies. Particular attention was paid to the postoperative urologic complications encountered in these patients. The major disease process was carcinoma of the cervix. Six patients had early postoperative complications and 2 of these patients died. Nine patients had late postoperative problems caused by urinary tract infections or stones. Nine other patients had problems related to the urinary diversion that necessitated a secondary operation in the majority of the cases and 2 of these patients died. Advantages of the ileal and colon conduits are discussed.


The incidence of bladder cancer after cyclophosphamide therapy.

The records of 19,082 patients with non-uroepithelial cancers were reviewed to determine the incidence of de novo bladder cancer in patients treated with cyclophosphamide versus patients not treated with this drug. A 9-fold increased incidence of bladder cancer was found in the cyclophosphamide-treated group.


Suprapubic endoscopic vesical neck suspension.

Experience with 20 endoscopic vesical neck suspensions (Stamey procedure) is compared to 20 matched anterior cystourethropexies (Marshall-Marchetti-Krantz procedure) performed by the same staff. The present procedure is a transvaginal vesical neck suspension, described in 1959 by Pereyra, modified in 1973 by Stamey and further modified in 1975 by Mason. The long-term success rate for relief of urinary stress incontinence was 90 per cent with either procedure. Advantages and disadvantages of the endoscopic vesical neck suspension are discussed.


Prostatosis, prostatitis or pelvic floor tension myalgia?

Patients with symptoms suggestive of prostatitis or prostatosis who do not have pathogenic bacteria in the prostatic secretions may, in fact, not have prostatic problems. The possibility of pelvic floor tension myalgia should be considered in these patients.


Pelvic lymphadenectomy for staging prostatic carcinoma: is it always necessary?

There were 100 patients with clinically localized prostatic carcinoma staged surgically for the evaluation of lymph node metastases. By correlating the incidence of lymph node metastasis with the level of serum acid phosphatase, and the stage and grade of the primary tumor, it was possible to identify 1 group of patients with less than 8 per cent incidence of lymph node metastases and another group with more than 92 per cent incidence of nodal involvement. It is in these 2 groups of patients that pelvic lymphadenectomy for the staging of prostatic carcinoma may not be necessary.


Reliability of bone marrow acid phosphatase as a parameter of metastatic prostatic cancer.

The reliability of bone marrow acid phosphatase determination by a spectrophotometric assay and 2 immunochemical methods was evaluated in 40 patients: 20 men with known prostatic carcinoma and 20 men of comparable age without clinical evidence of prostatic cancer. The large percentage of falsely positive results obtained by the colorimetric assay invalidates this method as the sole parameter of metastatic prostatic carcinoma.


Radical prostatectomy for carcinoma: 30-year experience and 15-year survivals.

Three strata of medical care are shown in this series of patients undergoing radical prostatectomy for carcinoma: (1) Medical School Hospital patients had an average age 4 years greater than patients in the other 2 groups and the lowest 15-year survival rate of 15 per cent. 2) The Veterans Hospital patients had an average age 4 years younger than patients in the Medical School Hospital group but there was little opportunity for preventive care by early diagnosis and they had a 15-year survival rate of 26 per cent. 3) The Emanuel series of private patients had good preventive private medical care, allowing for earlier diagnosis in a patient population without other serious medical problems, and a 15-year survival rate of 61 per cent. The 15-year survival figures for other modalities of therapy, including various types of radiation, chemotherapy and immunotherapy, are necessary for meaningful evaluation of efficacy.


Long-term survival after hormonal therapy for stage D prostatic cancer.

Hormonal therapy occasionally produces long-term survival of men with metastatic carcinoma of the prostate. To identify which patients will benefit for long intervals a retrospective analysis was done on 56 men with stage D carcinoma of the prostate treated between 1963 and 1968. Of this group 5 patients lived longer than 10 years. We were unable to identify clinical or pathologic characteristics that would have indicated which patients would have done well.


Urethral and bladder responses to anal electrical stimulation.

Urethral and bladder responses to anal electrical stimulation were evaluated by cystometry and urethral pressure profile measurements in 55 patients with different urethral-bladder dysfunctions. In 50 per cent of the patients examined the electrical stimulation caused normal reciprocal response, that is bladder inhibition with urethral contraction. In other patients the electrical stimulation caused almost all other possible bladder and urethral responses.


Urodynamic biofeedback: a new approach to treat vesical sphincter dyssynergia.

Some children with vesical sphincter dyssynergia are refractory to conventional pharmacologic therapy. Three such patients were treated using a method of sphincter retraining, biofeedback. They observed the urinary sphincter electromyogram while voiding to appreciate visually the abnormality. Two children learned to suppress voluntarily the inappropriate sphincter contraction during voiding. This normalized the subsequent electromyographic recordings and offered subjective improvement in the voiding symptoms. Retraining the urethral sphincter dysfunction may be approached using biofeedback techniques in selected patients.


Male peak urinary flow rate: relationships to volume voided and age.

We performed 126 studies of replicate voiding in 7 individuals and 552 observations in normal, abnormal or treated male populations with a disposable device that measures peak flow and volume voided. These observations have led us to suggest that a voided volume of 150 ml. be used as the minimum acceptable volume for studies of male subjects in which peak flow is used to define normal versus abnormal voiding. At volumes greater than 150 ml. a straight line describes the relationship between volume voided and peak flow as accurately as the previously suggested hyperbolic curve. Increasing age of men again reveals progressive decrease in peak flow rate no matter what volume is voided. Comparison of peak flow rate, volume voided and age by 3-dimensional graphing was attempted but was found unsuccessful for clinical use. However, 3 biaxial linear graphs may be used to chart effectively the 3 parameters (age, volume and peak flow) and thereby judge normality or abnormality of peak flow rate for any age and volume voided.


The value of the negative radionuclide scrotal scan in the management of the acutely inflamed scrotum in children.

Torsion of the testis remains a clinical diagnosis and confirmatory testing is not required when the classic signs and symptoms are present. Conflicting laboratory data or adjunctive diagnostic studies should not dissuade the surgeon from exploration when the clinical index of suspicion is high. In those patients having equivocal clinical findings when the diagnosis of torsion is not clear-cut radionuclide scrotal imaging may be useful. In this series a negative scrotal scan at the time of acute scrotal pain did predict reliably the diagnosis of non-torsion, suggesting that in the appropriate clinical setting scrotal imaging is useful in avoiding surgical exploration.


Post-biopsy intrarenal arteriovenous fistula.

We present 5 cases of intrarenal arteriovenous fistulas after renal biopsy. Of these cases 3 followed percutaneous needle biopsy and 2 occurred after open renal biopsy. A nephrectomy was necessary in 1 patient to control the severe hypertension secondary to a hydronephrotic kidney and 1 patient required a partial nephrectomy to control marked hematuria.


Treatment of traumatic renal arteriovenous fistulas by detachable silicone balloon embolization.

A new technique of detachable balloon arterial embolization allowed non-operative occlusion of 2 patients with post-traumatic arteriovenous fistulas in the kidney. This approach was successful in controlling hemorrhage with minimal loss of renal tissue.


Atherosclerotic renal artery occlusion extending into branches: successful revascularization in situ with a branched saphenous vein graft.

In some patients successful renal revascularization can be done after complete renal artery occlusion. We report on a patient with atherosclerotic occlusion of the renal artery and its branches in whom an aortorenal bypass with a branched saphenous vein graft was performed in situ, with cure of hypertension and reversal of azotemia. This is a useful and versatile technique for replacing the renal artery and its major branches.


Persistent fetal ureter.

Six patients have been seen with a peculiar ureteral lesion that has not been described previously. The lesion is characterized by either local segmentation or convolution and may represent either a persistent fetal ureter or a form of ureteral dysgenesis. Proximal dilatation, when present, has been less than the original radiographic appearance of high grade obstruction would lead one to expect. The ureteral lesions have disappeared progressively, suggesting that a period of conservative observation is warranted in similar situations.


Pelvic lipomatosis: diagnosis using computed tomography.

Pelvic lipomatosis is a rare, benign disease in which the characteristic roentgenographic findings may mimic those of pelvic malignancy. In the past more than two-thirds of reported cases have been explored surgically for diagnosis. We present 2 cases to demonstrate how the definitive diagnosis of pelvic lipomatosis can be made with the aid of computed tomography to avoid invasive techniques.


Transient neuropathic bladder following herpes simplex genitalis.

A case of transient bladder dysfunction and urinary retention concomitant with herpes genitalis is presented. The protean manifestations of the herpes simplex virus, the similar neurotropic behavior of simplex and zoster, and the neurologic sequelae of the cutaneous simplex eruption are discussed. The possibility of sacral radiculopathy after herpes genitalis must be considered when evaluating acute or episodic neurogenic bladders.


Salmonella virchow testicular abscess.

During the summer of 1977 an epidemic of salmonellosis traced to precooked, prepackaged roast beef occurred in the Northeastern United States. A case is reported of a testicular abscess, a rare manifestation of salmonellosis, in an adolescent boy who had a recent history of ingesting such roast beef. The type of Salmonella recovered from the patient was the same as a type in the epidemic.


Constrictive albuginitis: report of 3 cases.

Three sterile patients with constrictive albuginitis are described. The most common presenting symptom is a long duration of scrotal pain and the testicles are small and firm. Testicular biopsy is characterized by peritubular fibrosis. Spermatogenesis may be complete but the cells are degenerated. The condition is bilateral. At operation the tunica albuginea is thick, yellowish and rigid and, microscopically, it shows excessive fibrosis and hyalinosis. Sterility is related to the constrictive effect of the tunica albuginea. Treatment by decompression albugineotomy was successful in 2 patients. The benefits derived from the operation are discussed. A primary degenerative process of the tunica albuginea is suggested as causal.


Urologic manifestations of the iliacus hematoma syndrome.

Anticoagulated patients may have a characteristic syndrome of femoral neuropathy from an iliacus muscle hematoma. They may present with urologic signs and symptoms, including groin, flank and thigh pain, groin tenderness, an iliac fossa mass and hematuria. Urography may reveal an enlarged psoas shadow and hydronephrosis from ureteral obstruction. Prompt diagnosis is essential so that early operative decompression of the femoral nerve can be done. The urologist has an important role in the diagnosis and treatment of this syndrome.


Plasma biochemical values of clinically-normal Australian sea lions (Neophoca cinerea).

Seventeen biochemical constituents were assayed in the blood plasma of clinically-normal Australian sea lions (Neophoca cinerea). The sea lions formed part of a breeding colony which inhabits the southern coast of Kangaroo Island, South Australia. Little variation was found in any of the values obtained from animals of different age and sex. The results were compared with values published for California sea lions (Zalophus californianus), Northern fur seals (Callorhinus ursinus), Harbor seals (Phoca vitulina) and Northern elephant seals (Mirounga angustirostris).