The use of prostaglandin E1 and Blalock-Taussig shunts in neonates with cyanotic congenital heart disease.

Six unselected neonates with cyanotic congenital heart disease and life-threatening degrees of arterial oxygen desaturation have been managed by a protocol that includes administration of prostaglandin E1 (PGE1) and early Blalock-Taussig shunting. In 5 patients (seven paired observations) partial pressure of arterial oxygen (PaO2) rose from 19 mm Hg to a mean of 32.9 mm Hg within 20 minutes of initiation of PGE1 (0.1 to 0.2 microgram/kg/hr), infused intravenously or through an aortic catheter placed at ductal level or with both methods. The nonresponsive patient was older than the patients showing a positive response (1 month versus 24 to 96 hours). Following catheterization, immediate palliative operation including a Blalock-Taussig shunt was carried out. Although all had a satisfactory PaO2 (mean, 49 mm Hg) postoperatively, the PGE1-nonresponsive patient experienced serious intraoperative bradycardia, hypotension, and acidosis in contrast to the PGE1-responsive group. In this study, the use of PGE1 was not associated with any apparent serious side effects.


Right stellate ganglion block for treatment of hypertension after cardiopulmonary bypass.

Right stellate ganglion block was performed on 24 patients in whom hypertension developed after cardiopulmonary bypass. Changes in blood pressure, central venous pressure, cardiac output, and heart rate were evaluated. Most patients evidenced a decrease in systolic blood pressure (average, 40 mm Hg) and diastolic blood pressure (average, 19 mm Hg). Systemic vascular resistance was measured in 8 patients, and 7 demonstrated a decrease (average reduction, 6.7 resistance units). Changes in cardiac output were variable. Although stellate ganglion block can be safely performed and, in most patients, markedly reduces systolic blood pressure, the results suggest that other hypotensive agents may be more advantageous in the treatment of hypertension subsequent to coronary artery operation.


Nitroprusside and epinephrine for treatment of low output in children after open-heart surgery.

We evaluated the acute hemodynamic effects of treatment of the low output state with sodium nitroprusside and epinephrine in 13 children after intracardiac operation. The 13 patients were selected from a consecutive series of 106 children undergoing cardiopulmonary bypass. They had a cardiac index less than 2.0 L/min/m2, even after an increase in left ventricular filling pressure and during infusion of nitroprusside. Although the nitroprusside brought about a significant increase in cardiac output and decrease in systemic vascular resistance, the cardiac index remained critically low (less than 2 L/min/m2). Epinephrine resulted in a further significant increase in the cardiac index, without a significant change in systemic resistance. This study suggests that in selected patients the simultaneous use of both a vasodilator drug (sodium nitroprusside) and a positive inotropic agent (epinephrine) is advantageous in the short-term treatment of the low cardiac output state after intracardiac operation.


Echocardiography and valve replacement in the critically ill patient with acute rheumatic carditis.

In 4 critically ill patients with acute rheumatic carditis, valve incompetence, and severe life-threatening cardiac failure, medical treatment consisting of bedrest, oxygen, digitalis, diuretics, and steroids produced little or no clinical improvement. Echocardiography showed that in each patient myocardial function was relatively well preserved despite active rheumatic carditis and the critical clinical state. Emergency valve replacement was performed, and a good clinical result was achieved in all 4 patients.


The cause of the hemodynamic disturbances in Ebstein's anomaly based on observations at operation.

Ten adult patients with Ebstein's anomaly had open-heart operation for interruption of a Kent bundle. The 4 patients in Group 1 had arrhythmias. One patient had a patent foramen ovale, which was closed. In 3 patients the Kent pathway was identified and interrupted, but in the other only the pathway's anterograde function was interrupted, leaving the patient subject to supraventricular tachycardia (SVT). The 3 patients in Group 2 had mild to moderate cyanosis and dyspnea during SVT as well as mild impairment during strenuous physical activity. Only interruption of their Kent bundles and closure of the patent foramen ovale were done. The 3 patients in Group 3 had dyspnea and cyanosis on exertion, and 1 had overt right heart failure. In each patient, obstruction between the atrialized right ventricle (RV) and functioning RV by the displaced tricuspid valve (TV) was relieved by valve excision and replacement. Interruption of the Kent bundle was successful in 2 of the 3 patients. Operation for Ebstein's anomaly is indicated when any of the following conditions are present: arrhythmias due to Kent bundles that are refractory to medical management; a defect in the atrial septum that must be closed because of a history of cyanosis or paradoxical emboli, or an arrhythmia that must be corrected by right atriotomy; and obstruction between the atrialized and functioning RV or a small functioning RV, both of which can be corrected by TV replacement.


Myocardial rupture: III. Chamber pressure, rate of distention, and ventricular disruption in isolated hearts.

We have developed an in vitro technique for producing myocardial rupture in lamb hearts, which relates tensile strength to a variety of conditions which can prevail in normal and infarcted human hearts. Retrograde perfusion of saline solution and inflation of the left ventricle was used to apply progressive stress to the left ventricular wall. Three separate sites of myocardial rupture were observed and occurred with the frequency of 54% at the papillary muscle, 30% at the interventricular septum, and 16% at the free wall of the left ventricle. The distribution and configuration of the experimental ruptures were similar to those usually noted as complications of human myocardial infarction. The mean rupturing pressure was 526 mm Hg in normal lamb hearts. Application of these techniques should ultimately provide data relevant to the diagnosis, prevention, and treatment of myocardial rupture.


"Collis-Belsey" fundoplication for uncomplicated hiatal hernia and gastroesophageal reflux.

The combined Collis gastroplasty-Belsey Mark IV fundoplication was used in 86 patients with uncomplicated hiatal hernia followed for up to 8 years. Marked relief of symptoms was obtained, with no initial morbidity and mortality. Recurrence of hernia occurred in 1 patient. Minimal gastroesophageal reflux was observed in a few patients. Manometric and pH studies performed after operation showed a competent valve without notable esophageal reflux. The Collis gastroplasty creates a lesser curvature gastric tube that lengthens the so-called functional esophagus and eliminates tension at the suture line of the Belsey Mark IV fundoplication.


Surgical management of an aneurysm of the left main coronary artery.

A 28-year-old woman underwent cardiac catheterization three months after sustaining an acute anterolateral myocardial infarct. An aneurysm of the left main coronary artery was found at angiography and also was visualized by two-dimensional echocardiography. The patient had no evidence of atherosclerotic vascular disease. At operation, vein grafts were placed to bypass the aneurysm and the orifice of the left coronary artery was oversewn to exclude the aneurysm from the coronary circulation.


Clinical experience with the isotopic cardiac pacemaker.

Clinical experience with isotopic pacemakers in 59 patients is compared with that in 77 control patients having conventional chemical battery-powered pulse generators. The review covers a 51/2-year period. Statistical analysis of the two series is impossible because of the numerous variables such as age, type of disease, number of controls, types of test and control pulse generators, dates of insertion, and protocol regulations. However, there were pulse generator failures in the control group, but not in the test group. Though not proven in this study, the isotopic cardiac pacer is likely to last longer than conventional chemical battery-powered units, and could provide lifetime pacing for many patients. The risk of carcinogenesis is minimal and seems negligible in older patients. The isotopic cardiac pacer, in spite of restrictions of the Nuclear Regulatory Commission, should be considered for any patient with a life expectancy of 10 or more years. Paradoxically, it might be indicated in older rather than younger patients.


Does preservation of the posterior chordae tendineae enhance survival during mitral valve replacement?

During a 30-month period, 51 patients underwent mitral valve replacement. There were 3 hospital deaths (5.9%), 2 of which were due to ventricular rupture. The 3 patients who died were among 13 patients in whom mitral valve replacement was combined with tricuspid or aortic valve operation or both. Postmortem findings in the 2 patients who died of ventricular rupture showed that the ventricular tears were located between the atrioventricular groove and the unresected papillary muscle stumps, in an area of ventricle formerly tethered by the posterior chordae tendineae. In the last 14 patients in the series, the posterior leaflet of the mitral valve and its chordae tendineae were left intact, and there was no mortality or prosthetic valve dysfunction. In patients with myxomatous or ischemic disease, the posterior leaflet was left completely intact. For patients with fibrocalcific rheumatic disease, we have developed a technique of partial excision and debridement of the posterior leaflet, preserving the intermediate and basal chordae tendineae attachments. With the techniques described, preservation of all or part of the posterior leaflet and its chordae tendineae does not appear to interfere with prosthetic valve function and, by reducing the risk of ventricular rupture, should enhance survival after mitral valve replacement.


Calcific stenosis of the porcine heterograft.

We have encountered two cases of late calcification of the porcine heterograft. A patient in chronic renal failure died of sepsis and endocarditis fifteen months after replacement of the mitral and tricuspid valves. At postmortem examination, both heterograft valves exhibited severe calcification and thrombosis. A second patient with rheumatic heart disease and sickle cell disease underwent mitral valve replacement for severe regurgitation. Thirty months later, cardiac catheterization revealed prosthetic valve stenosis. The valve was replaced successfully, and the excised heterograft exhibited severe calcification with restriction of leaflet motion. Although calcification of the porcine heterograft is known to occur in patients with infection or disorders of calcium metabolism, dysfunction of the heterograft is rare in our experience.


Surgical management of lung bud anomalies: lobar emphysema, bronchogenic cyst, cystic adenomatoid malformation, and intralobar pulmonary sequestration.

Recently we saw 9 infants with life-threatening respiratory distress. Four patients had bronchogenic cyst, 2 had cystic adenomatoid malformation, and 9 had congenital lobar emphysema. Another group of 14 older children had recurrent infection and hemodynamic abnormalities, which responded to operative intervention. Each child required an appropriate resection following definitive diagnosis. These lesions represent a spectrum of closely related anomalies that arise during an early stage of embryonic lung bud maturation. Bronchoscopy is rarely useful, but special roentgenographic studies, including perfusion scans and arteriography, are usually diagnostic. Our operative experience is used to emphasize the urgency of precise diagnosis and surgical management of this poorly recognized clinical syndrome.


Bilateral pulmonary resection for bronchiectasis: a 40-year experience.

Ninety-nine patients underwent bilateral pulmonary resection for severe multisegmental bilateral bronchiectasis at the Overholt Thoracic Clinic during the period 1937 to 1977. A total of 216 operations were performed, and 20 patients underwent three or more procedures. The operative mortality was 1.4% and the incidence of severe complications, 7%. Follow-up ranged from 1 to 30 years (average 10.2 years). Only 1 patient was lost to follow-up. Improvement in pulmonary symptoms was achieved in 83 patients; there was no improvement in 9 patients; and 4 patients were worse following resection. The results suggest that bilateral bronchiectasis need not be a contraindication to operation. In properly selected patients, lasting symptomatic improvement can be provided by resection.


Avoidance of esophageal stricture following severe caustic burns by the use of an intraluminal stent.

The high incidence of stricture following conventional therapy for caustic esophageal injuries prompted us to incorporate the esophageal stenting technique of Reyes and colleagues [3, 5, 6] into our protocol for management of such patients. Four adult patients were treated following severe esophageal burns caused by the ingestion of caustic drain cleaner. The severity of the burn was established by early esophagoscopy. Laparotomy and gastrotomy revealed severe but nontransmural gastric burns. The stent was left in place for 21 days. Antibiotics and corticosteroids were also employed. There have been no late strictures. One patient required laryngeal dilation for adhesions and another, tracheal dilation for subglottic stenosis. Contrast roentgenographic studies and esophageal manometry have revealed nearly normal esophageal function up to 20 months following the injury.


Tracheobronchial ruptures due to cuffed Carlens tubes.

At our institution in the past 22 years, more than 3,000 patients have undergone chest procedures, and 2,700 of them were intubated with a cuffed Carlens endotracheal tube. In this paper we report on 5 patients with tracheobronchial ruptures caused by intubation with these tubes. We believe this hazard should be brought to the attention of physicians.


Use of activated coagulation time to monitor heparin during cardiac surgery.

Activated coagulation time (ACT) for protamine reversal was monitored in 28 consecutive patients (Group 1) and a standard heparin-protamine protocol was used for an earlier series of 28 patients (Group 2). Although Group 1 received a significantly higher total heparin dose than Group 2 (p less than 0.01), the protamine dose for reversal was significantly less for the ACT group than for the controls (p less than 0.0005). The mean ratio of protamine to total heparin was 1 : 1 (range, 0.33 to 1.44) for the ACT group and 2 : 1 (range, 1.42 to 2.59) for the controls. There were no significant differences between the two groups in operative and postoperative blood loss, transfusion requirements, hematocrit, and partial thromboplastin time. This study shows that the ACT test did not reduce postoperative bleeding significantly when compared with our standard protocol. It also indicates that there is wide individual sensitivity to heparin and that significantly less protamine is required for reversal.


Impasse at the crossroads: evolution or regulation.

Today, the free enterprise system of health care delivery is being challenged in the United States, where availability and consumption of health services and their cost are epochal. Review of the health care delivery systems of other nations reveals failure of the system when the national medical community has been divided, when government has monopolized the system, and when fee for service has been abandoned. Government intervention in American health care has been increasingly regulatory and promises to extend regulation in the immediate future. The American medical community can respond by unifying, by reducing its contribution to health care costs, and by changing physician behavior. Consumers have the responsibility to eliminate unnecessary utilization and to become more informed buyers of health care and insurance. The fiscal intermediary has the responsibility to provide tailored insurance options that are cost-effective. As informed and unified medical community can be a formidable force in shaping the future of health care in the United States.


Supraclavicular thoracotomy for diagnosis of apical lung and superior mediastinal lesions.

Despite the use of mediastinoscopy, anterior mediastinotomy, transcarinal biopsy, needle biopsy, and transbronchial fluoroscopic brushing, thoracotomy is necessary to obtain tissue for diagnosis in patients suspected of having carcinoma of the lung. A technique we have employed is exploratory thoracotomy, as described for the approach to cervical and upper dorsal sympathetic ganglion, with entrance into the pleural space through a supraclavicular incision. Five patients, 3 with marginal pulmonary function and 2 with brachial plexus and upper mediastinal or vertebral involvement, had tissue diagnosis of lung carcinoma by this method without postoperative complication. Supraclavicular thoracotomy offers a safe, easy, and definitive method of tissue diagnosis of apical lung and superior mediastinal lesions.


Polymyalgia rheumatica begins at 40.

Three cases of polymyalgia rheumatica with onset under age 50 are described. Most large series of patients with this entity contain a few examples of onset below age 50. This diagnosis should be made with confidence in younger patients with typical symptoms and laboratory findings, and showing complete suppressions of disease activity with relatively small daily doses (20 mg or less) of corticosteroids.


Lung cancer in young women.

A comparison was made between cigarette smoking histories of 31 women below age 50 years who had a diagnosis of lung cancer on hospital discharge and smoking histories of 124 women below age 50 years who had been hospitalized for other conditions. Of the women with lung cancer, 28 (90%) were current or former cigarette smokers; 72 (58%) of the comparison women were smokers. The relative risk estimate for lung cancer among smokers as compared with nonsmokers is 6.7, with 90% confidence limits of 4.0 and 11. Risk of lung cancer increased with the amount that the women smoked. The smokers with lung cancer had been smoking for longer periods than the smokers with other conditions. Assuming that the association is causal, cigarette smoking was responsible for about 77% of the lung cancer of young women in this survey.


The beneficial effects of verapamil in chronic atrial fibrillation.

Digitalis preparations frequently fail to control heart rate in many patients who have chronic atrial fibrillation, particularly during physical exertion. The effects of orally administered verapamil, 160 to 240 mg/day, on the heart rate at rest and during mild exercise were studied in 23 digitalized patients with chronic atrial fibrillation of various causes. Verapamil substantially reduced the excessive heart rate response to exercise in well-digitalized patients who had chronic atrial fibrillation.


Heroin-induced thrombocytopenia.

Six cases of acute thrombocytopenic purpura occurred secondary to heroin abuse. Five of the six affected patients were seen over a six-month period between November 1977 and March 1978, and the last patient was seen in November 1978. The clinical manifestations were characteristic of drug-induced immune thrombocytopenia. We suspect this syndrome is related to a new adulterant added to local street heroin.


Levels of serum thyroid-stimulating hormone in hyperthyroidism.

A modified thyroid-stimulating hormone (TSH) radioimmunoassay with particular sensitivity at the bottom end of the normal range was developed using dog serum in standard tubes and reduced quantities of TSH labeled with radioactive iodine (125I) and antiserum. The standard deviation of B0 points was 1%, implying an assay sensitivity of less than 0.1 microU/mL. This procedure was used to measure serum TSH levels in 32 normal subjects, 18 patients with hyperthyroidism, and seven patients with elevation of serum triiodothyronine (T3) levels. The range of values obtained from normal subjects was less than 0.1 to 4.1 microU/mL, with 97% of the subjects' values greater than 0.2 microU/mL. All of the hyperthyroid patients had values less than or equal to 0.2 microU/mL. Hence, the modified TSH assay was thought to be of use in distinguishing hyperthyroid from normal subjects. The TSH levels in subjects with elevated T3 levels ranged from less than 0.1 to 1.8 microU/mL. These results were thought to indicate heterogeneity within this group and suggest that only certain of these individuals merit the diagnosis of "T3 toxicosis."


Probability of a positive transbronchial lung biopsy result in sarcoidosis.

Forty-one consecutive patients with suspected sarcoidosis underwent pulmonary function testing and transbronchial lung biopsy at three community teaching hospitals. Transbronchial biopsy disclosed noncaseating granulomas in 22 of 23 patients (96%) in whom parenchymal disease was roentgenographically apparent and in eight of 18 patients (44%) in whom it was not. The stage of the disease as determined by the chest roentgenogram was the most reliable determinant for a positive biopsy result. Not the presence of cough, dyspnea, or constitutional symptoms or pulmonary function as measured by forced vital capacity and carbon monoxide diffusing capacity served to predict a positive transbronchial biopsy finding any more accurately than did the roentgenographic staging of the disease itself. This study suggests that while transbronchial lung biopsy may be an acceptable initial diagnostic procedure in suspected sarcoid patients without parenchymal lung disease, clinical symptoms and pulmonary function abnormalities are not helpful in predicting the liklihood of a positive biopsy result.


Splenectomy for hemocytopenia in systemic lupus erythematosus. A controlled appraisal.

We compared 15 patients with systemic lupus erythematosus (SLE) treated with splenectomy for thrombocytopenic purpura and/or hemolytic anemia to 15 similar SLE patients treated only medically. There was no significant difference between the splenectomized and the nonsplenectomized patients when their entire course, as well as the presplenectomy and postsplenectomy or their equivalent control periods, were compared by means of an overall severity index. Splenectomized patients, however, had a significantly higher frequency of cutaneous vasculitis after splenectomy than in their own presplenectomy period and a significantly higher frequency of cutaneous vasculitis than the nonsplenectomized patients. Serious infections were more frequent in the postsplenectomy period than in an equivalent period in the nonsplenectomized patients. Splenectomy produced only short-term benefit in the management of hemocytopenic episodes in SLE and seems only warranted as an emergency procedure in patients unresponsive to medical treatment.


Periodic peritonitis. Present management and future prospects.

Thirty-three patients with periodic peritonitis were treated with colchicine for 863 patient-months of observation (average, 27 months). There is a personal optimum dose, and the daily requirement varies at 1 or 1.5 mg. All patients responded to treatment. Episodes were precipitated in all patients who stopped their medications. No side effects were noticed. Four normal full-term infants were born to patients taking colchicine during the study.


Intravenous miconazole therapy of mycotic infections.

The efficacy and safety of intravenously administered miconazole nitrate was examined in eight patients with the following infections: cutaneous North American blastomycosis (one), extensive dermatophytosis(one), and chronic mucocutaneous candidiasis (six). Mycologic assessment included direct examination for fungal elements, fungal culture, and histopathology. Laboratory evaluations were performed before and at regular intervals during the study. The total miconazole nitrate dosage, which was administered over a seven- to 32-day period, ranged from 4.0 to 46.8 g. Follow-up examinations extended from two to 15 months. Excellent results were obtained in five patients and fair results in three. No renal, cardiac, hepatic, or hematopoietic toxicity was observed. Other side effects, however, necessitated premature cessation of therapy in four patients. Overall, intravenously administered miconazole is an effective antifungal agent for these cutaneous infections.


Hypouricemia by defect in the tubular reabsorption.

Two patients with hypouricemia with high levels of uric acid in their urine were given pyrazinamide and probenecid. The uric acid clearance decreased to low or normal values after pyrazinamide administration. In both cases, probenecid produced a slight increment in the uric acid excretion. This type of response suggests a defect in the reabsorption component. It is tempting to speculate on a postsecretory reabsorption defect based on the results of pyrazinamide and probenecid tests.


Acute pseudogout in chronic renal failure.

Acute pseudogout (calcium pyrophosphate dihydrate deposition disease [CPPD disease]) developed in two patients with chronic renal failure. The disease had atypical features. The calcification of the involved joints was more diffuse than the usual linear stippled calcification. The first patient, age 39, was young to have pseudogout. The second patient had pseudogout and chondrocalcinosis limited to the elbow. Review of wrist roentgenograms of 82 patients (mean age, 49.0 years), undergoing hemodialysis for chronic renal failure revealed three patients (a 3.7% incidence) with chondrocalcinosis. The incidence increased to three of 19 (15.8%) in the patients over the age of 60. Although considered uncommon, pseudogout may cause acute arthritis in chronic renal failure more often than previously suspected. Joint aspiration and identification of CPPD cystals with compensated polarized light microscopy will establish the diagnosis of pseudogout.


The effect of infusion of mannitol-sodium bicarbonate on the clinical course of myoglobinuria.

Twenty patients who had evidence of myoglobinuria were treated with intravenous infusions of mannitol and sodium bicarbonate. Nine patients (group 1) responded with higher urine output, and continued infusion improved renal function; none required dialysis and all survived. Eleven patients (group 2) did not respond to the infusion, and required an average of 5.3 (range, 0 to 11) dialyses; one patient died. There was no significant difference in initial BUN level, creatinine level, BUN/creatinine ratio, or fractional sodium excretion level between the two groups. However, group 2 patients had a significantly higher creatine phosphokinase (CPK) level, serum phosphate level, and hematocrit reading initially than did group 1, indicative of more severe muscle injury and hemoconcentration. These results demonstrate that some patients with myoglobinuria will respond to infusion of mannitol and sodium bicarbonate. This treatment may be effective in altering the clinical course of myoglobinuric acute renal failure.


Pseudodysrhythmias in ambulatory ECG monitoring.

Artifacts mimicking a variety of dysrhythmias occur relatively frequently in ambulatory ECG (Holter) monitoring records. Proper interpretation is imperative if serious therapeutic errors are to be avoided. Two-channel recording systems may facilitate recognition of some, but not all, of these artifacts. Pseudodysrhythmias may mimic paroxysmal supraventricular tachycardia and atrial fibrillation, atrial dissociation, extrasystoles, and sinus pauses. There are several causes of pseudodysrhythmias. Failure to recognize these patterns may result in serious errors in patient management.


The MB fraction of creatine phosphokinase. An indicator of myocardial involvement in acute pericarditis.

An elevated level of the MB fraction of creatine phosphokinase (CPK) with normal serum myoglobin and normal CPK values was found in a case of acute idiopathic pericarditis. The elevated serum CPK-MB isozyme is suggested to be an indicator of myocardial involvement accompanying acute pericarditis. The normal CPK and serum myoglobin values and the pattern of rapid decrease of CPK-MB level ruled out the possibility of acute myocardial infarction.


Candida fungus balls in the common bile duct. Unusual manifestation of disseminated candidiasis.

Disseminated candidiasis appearing as Candida fungus balls in the common bile duct developed in a patient with acute myelogenous leukemia. The patient had received broad-spectrum antimicrobial therapy for fever of unclear origin and subsequently manifested signs of liver cell dysfunction. A percutaneous transhepatic cholangiogram demonstrated three radiolucent defects in the distal part of the common bile duct, which proved to be fungus balls at operation. The liver was studded with microabscesses that disclosed C albicans on biopsy. The biliary tract fungus balls were removed surgically, and the patient was treated with 2,001 mg of intravenously administered amphotericin B over a 2 1/2-month period. No evidence of Candida infection is evident eight months after completion of therapy.


Long-term selenium exposure.

Metabolic pathways and toxic effects of long-term selenium exposure in animal models and humans have both similarities and significant differences. In animal models the target organ is the liver, in which chronic cirrhosis develops. In man the target organ appears to be the lung, which manifests acute "rose cold," or, as in our patient, a chronic granulomatous hypersensitivity. Our data indicate not only a different target organ than would have been predicted from animal models, but also a difference in the distribution of selenium in human tissues. Long-term use of selenium favors production of dimethylselenide, which is excreted by the lungs and should be considered a pulmonary toxin. The ramifications of these findings may require a change in the monitoring techniques of long-term industrial exposure and mandate a close follow-up of selenium as a health fad.


Leukopenia due to penicillin and cephalosporin homologues.

Leukopenia is an infrequently recognized complication of penicillin-related antibiotic and cephalosporin therapy. We describe our experience with nine individuals and reviewed reports of 11 cases from the literature. Seventy-six percent of cases occurred in individuals receiving 150 mg/kg/day or more of the various penicillin and cephalosporin homologues; 67% received these high doses for two or more weeks before the onset of leukopenia. Leukopenia was unusual within the first week of antibiotic treatment. Standard medical texts often recommend blind administration with 12 to 23 g/day of these antibiotics regardless of weight. It is suggested that these antibiotics be administered according to a maximum milligram per kilogram per day dosage as is done in children. Beyond the first week of administration, careful monitoring of the blood cell count should be conducted for those receiving high doses of these antibiotics.


[Electron microscopic studies in enzootic muscular dystrophy in cattle].

Electron microscopy was used to examine the sekeletal muscles of young cattle, aged between 13 and 24 months, with spontaneous enzootic myodystrophy (nutritional myodegeneration due to selenium deficiency, white muscle disease). The animals had been received from Sumava District, Southern Bohemia, an area known for shortage of selenium. Outbreaks of clinical illness were recorded from them between four and 18 days from the beginning of grazing. Most of the ultrastructural changes included decomposition of myofibrils and hyalinisation of fibres as well as defective fibril synthesis (Z-striation abnormality), some of the latter phenomena recordable even from regenerating fibre. However, minor disorders only were established from the mitochondria, sarcoplasmic reticulum, components of sarcoplasm, and vessels. There were far-reaching ultrastructural similarities to nutritional myodegeneration of sheep. The changes recorded are likely to suggest a specific role played by selenium in the formation and preservation of myofibril proteins.


[Pharmacological and toxicological study of turimycin].

Turimycin is characterised by low acute toxicity. Mean lethal doses for mouse and rat are 750 mg/kg body weight for intraperitoneal application of something in excess of 3,000 mg/kg for oral administration. The blood pressure of anaesthetised cats may be reduced by amounts depending on intravenous Turimycin doses (between 10 and 50 mg/kg). The hypotensive effect of Turimycin is attributable to its negative inotropic effect on the heart and its spasmolytic action on the unstriated muscles. Reversible reduction of urine and ion excretion of rat following intraperitoneal application of 50 mg/kg body weight of Turimycin is interpreted as a consequence of such action upon blood pressure. A preliminary study was conducted into dogs which had orally received daily Turimycin doses of 50 or 125 mg/kg body weight over twelve months. No substance-depending functional or morphological damage was recorded.


[Requirements for the toxicological testing of new pesticides and agents for controlling biological processes].

Growing amounts of pesticides and plant growth regulators are being used in our time and call for action to ensure safety for man and farm animals. Toxicological rules and requirements are discussed with reference to the legal provisions in the USSR, USA, and FRG. Specifications for toxicological assessment of new preparations have been prepared in the GDR and Poland and are described. Particular emphasis is laid on studies into acute, subacute or subchronic, and chronic toxicity and delayed consequences. Conclusions are suggested and steps discussed to decide tolerances for food and feedstuffs.


[Electron microscopic findings in the skeletal musculature of broilers with nutritional encephalomalacia].

Sings of myopathy were recorded by means of electron microscopy from the skeletal muscles of 20 broiler chickens, aged five and six weeks and suffering from spontaneous nutritional encephalomalacia. Focal deposits of osmiophilic, granular or amorphous matter, intermixed also with membrane fragments and condensed to homogenous osmiophilic bodies, were found quite often in the sarcoplasm. Those deposits were interpreted as lipoproteid complexes (pigmentation due to vitamin E deficit). Also observed were degenerative disorders of compensatory reactions of membraneous fibre organelles (sarcoplasmic reticulum, mitochondria) as well as decomposition of myofibrils and fibre hyalinization. Fibre regeneration and vascular damage occurred less often. Pathogenetically, the changes are interpreted particularly with regard to a membrane-stabilising anti-oxidant action of vitamin E and compared to the selenium-dependent myopathies of ruminants from which primary myofibrillar damage was recordable but no pigment accumulation.


[Heme binding by the serum proteins of fish].

Starch gel and disc electrophoretical results about heme binding of serum proteins of fishes (Pike, perch, bream) are reported on. Metheme albumin binding and a hemopexin polymorphism could be detected in all species of the fishes. The problems of differentiation between heme and hemoglobin binding are discussed.


[Electron microscopic and histochemical studies of the transverse striated musculature of birds after long-term hypokinesia].

Electromicroscopical and histochemical studies of the gastrocnemius muscle has been carried out in 4 months old cockerels of the laying hybrid after hypokinesis lasting 15 and 30 days. It was found that restricted movement resulted in dystrophic changes of myofibrils, enlargement of the sarcoplasmic reticulum and oedem of interfibrillar spaces. Histochemical studies revealed focuses of increased activity of non-specific esterase decreased activity of dehydrogenase of lactic acid and a positive reaction of acid phosphatase.


[Course of spermiogenesis in the ram].

Reference is made to transformation of spermatids into sperms. The various phases in the development of ram sperm and transformation of spermatids into sperms are demonstrated by microphotographs. Reference is also made to abnormal forms and types of sperms due to defective development.


[Quantifiable morphokinesis of parts of the hypothalamo-adenohypophyseal-gonadal axis of hormonally desexed boars. 4. Studies on boars that have undergone combined treatment with the steroid test substance 547 and norgestrel].

Steroid test substance 547 and Norgestrel were used in a combination treatment of parts of the hypothalamo-adenohypophyseo-gonadal axis of boars. The quantifiable parameters of the morphokinetic effect thus produced (cell nucleus volumes of Nucleus praeopticus medialis hypothalami and its neurons as well as those of Leydig's cells testicle weight, length and diameter of tube, percentage of Leydig's cells, testicle weight, length and diameter of tube, percentage of Leydig's cells) did not differ significantly from the findings obtained from boars treated with Norgestrel only (cf. Dorst and co-workder, 1978). The same combination treatment, however, differed from exclusive Norgestrel treatment by causing the occurrence of socalled castration cells, which led to the assumption of an anti-androgenic effect of such combination treatment.


Monoamine oxidase inhibitors. A review of antidepressant effectiveness.

Data from double-blind, placebo-controlled trials of the monoamine oxidase (MAO) inhibitors show that phenelzine is clearly effective in neurotic or atypical depressives, but the findings concerning its effect in endogenous depressives are inconclusive. Although few controlled studies have been done with tranylcypromine, similar conclusions are warranted. Studies have contrasted MAO inhibitors and tricyclic antidepressants (TCAs) to gain further information about the type of patients likely to respond to MAO inhibitors. We believe that simply contrasting the relative efficacy of TCAs and MAO inhibitors is outdated. Neurotic or atypical depression is probably a heterogeneous syndrome, and delineation of subtypes responsive to specific antidepressants is needed. The implications of fast acetylation, selective MAO inhibitors, types MAOA and MAOB, and measures of platelet MAO inhibition are discussed in this article.


Follow-up evaluation of treatment of drug abuse during 1969 to 1972.

A sample of 3,131 persons from approximately 25,000 admitted to drug abuse treatment programs in the Drug Abuse Reporting Program during 1969-1972 were followed up in 1975-1976. Treatment groups included methadone hydrochloride maintenance, therapeutic community, outpatient drug free, outpatient detoxification, and a comparison group that completed intake but did not enter treatment. Outcome criterion measures (drug use, employment, criminality, and treatment readmissions) based on the first year after treatment were more favorable in the methadone maintenance, therapeutic community, and outpatient drug-free groups than in the outpatient detoxification and intake-only groups. Evaluation of differential outcomes and their relationships with pretreatment and during-treatment measures within each group indicated that pretreatment criminal history, during-treatment performance, and length of time in treatment were significantly related to posttreatment outcomes.


Interpersonal effects of marijuana. A model for the study of interpersonal psychopharmacology.

The effect of marijuana on affective changes and interpersonal skills, including empathy, acceptance, warmth, and genuineness, was studied in 20 dyadic relationships in which the experimental subject smoking marijuana containing 6 mg of delta-9-tetrahydrocannabinol and a placebo in separate trials. Marijuana caused a relative decrease in the ratings of the interpersonal skills of the experimental subjects and decreased affective resonance between the experimental subjects and their partners.


Obesity and food choices in public places.

More than 5,000 food choices were observed at nine eating sites--four where meals were served and five where snacks were served. Caloric content of food choice was strongly affected by eating site and there was great variability in the amount chosen at each site. Men chose somewhat more food than women. Body weight had no overall effect on food choice, although obese people chose somewhat more food than nonobese people at one site--that serving food with the highest caloric content. These findings are consistent with the six earlier studies of food choice, which concluded that the major influence on how much people choose to eat is where they eat, and that there is great variability in the amount they choose at any one site. The presence of obesity is not a major determinant of food choice in public places.


Behavior modification in the treatment of obesity. The problem of maintaining weight loss.

The introduction of behavior modification in the treatment of obesity a decade ago resulted in a substantial increase in weight loss of persons treated for mild to moderate obesity. It has been hoped that this increased effectiveness of treatment would extend also to maintenance of weight loss, and the first controlled clinical trial suggested that it did. This article reports the results of (1) a five-year follow-up of this first trial and (2) all follow-up studies of behavior modification for obesity yet conducted, six published and four previously unpublished. A new method of data analysis shows that weight losses are only modestly maintained, although the question of how their maintenance compares with that of other treatments cannot be answered because comparable data on other treatments are not available. In contrast to the vast amount of work on the initiation and generalization of behavior change, study of its maintenance has been a neglected area of behavior modification. We suggest that this area constitutes a new frontier for research in behavior modification.


The outcome of behavior therapy for agoraphobia in relation to marital adjustment.

After intensively treating 18 agoraphobic patients with 13 1/2 hours of exposure in vivo, we examined the effects on both patients and their spouses over a period of six months, using questionnaire measures of symptoms and marital adjustment. Those patients whose marriages were rated as unsatisfactory before treatment improved less during treatment, and were significantly more likely to relapse during follow-up, than those patients with satisfactory marriages. The marriages of nine patients appeared to be adversely influenced by their symptomatic improvement, and two distinct types of marital interaction were observed in relation to this. In one pattern, the patients' symptoms appeared to strengthen aspects of largely affectionless "compulsory" marriages; in the other, the patients' symptoms appeared to protect their spouses from recognizing or examining aspects of their own personal and interpersonal problems.


Behavioral response to vasectomy.

This article reviews the literature concerning the behavioral and psychological response of men and their wives to the vasectomy operation when used as a contraceptive technique. The data suggest that two primary changes may frequently be observed postoperatively. Individuals who have experienced anxiety in conjunction with intercourse because of a fear of contraceptive failure or pregnancy tend to report a decline in anxiety and a disinhibition of sexual arousal postoperatively. Also, test results suggest that behavoir patterns within the marital dyad are altered in some cases when the men adopt stereotyped masculine behavior, presumably to deny any suggestion that they are less masculine because of the operation. Ramifications of these findings as well as numerous other speculations, are considered, along with the suggestion that prescreening and postvasectomy counseling may help reduce negative response to the operation.


Observations on vaginismus in Irish women.

This article describes a group of 23 Irish women with vaginismus. This figure represents 42% of the total female referrals to the author, and is quite high when compared with other reports. The type of treatment before referral, and the characteristics of the patients, tend to confirm the author's diagnosis, which was made only after vaginal examination. Social and cultural factors unique to Ireland are believed to be of importance in the clinical presentation of this form of sexual dysfunction. A number of differences are seen when women with vaginismus are compared with those who complain of orgasmic dysfunction. These differences relate to childhood experiences, their perception of their marriage, and their sexual dysfunction. The success rate, number of sessions required for treatment, and recovery rate at follow-up are described for vaginismus. All women with this condition who persisted with treatment recovered, whereas those described as failures stopped within three visits. The author believes that the therapeutic claims of sex therapists in recent years must be viewed critically, as self-selection seems to be an important influence on prognosis.


Muscular hypertonia: quantitative analysis.

By a statistical method of analysis, the force applied to move a limb passively can be translated into physiologically relevant parameters relating to the muscle. The parameters identified and measured are the dynamic and static activity of the muscle and their interactions with the varying length of the muscle during stretch. This method of analysis has been shown to be of assistance in evaluating the reflex status of persons with central nervous system disorders in preparation for treatment and in measuring the effects of treatment.


Reliability of quantitative strength measurements in children.

In normal children, sex, age, height and weight account for approximately 50% to 70% of variance in the strength scores obtained by quantitative measurements. Although quantitative techniques accurately measure the forces generated by muscle contraction, technical and psychological variables may cause some inconsistency of scores and contribute to the variance observed. To explore the role of these factors, reliability of quantitative strength measurements was examined in children withe normal intelligence and with mild mental retardation using the isokinetic method. Results showed mean score deviations of 5.3% to 5.8% for different muscle groups within the same test. When testing was repeated by the same examiners 7 to 10 days apart, mean score deviations were 7.9% to 9.8% in various muscle groups. Repeated measurements by different examiners 7 to 10 days later yielded 8.7% to 10% mean score deviations for various muscles. Statistical analyses showed that these differences were not significant. Technical and behavioral aspects of test performance are not an important source of inaccuracy and, therefore, cannot contribute significantly to the variance of scores.


Training appropriate eating behavior in a pediatric rehabilitation setting: case study.

The study demonstrates an effective operant conditioning treatment technique to train appropriate eating behavior in a child with brain damage. The child, a 7-year-old boy, received the training during brief hospitalization in a pediatric rehabilitation unit. The principal treatment modality consisted of verbal commands, praise, and manual guidance. During 2 baseline meals the child ate appropriately on the average of 21% of the time. Rapid improvement in correct eating responses occurred during the first week of treatment, reaching a level of 100% in 2 of the last 4 training meals. Following withdrawal of treatment, correct responses decreased to an average of 69%. When treatment was resumed the child reached a correct eating response level of more than 90% on the fifth meal. This level of performance was maintained when hospital staff and the child's mother were introduced into the program. The child's teacher was trained in the technique prior to his discharge from the hospital. School follow-up of more than 15 weeks indicated proper performance had been maintained at more than 90%. High levels of appropriate eating behavior can be learned in the hospital and generalized to the home and school if parents and teachers are actively engaged in rehabilitation efforts.


Teaching the concepts of rehabilitation in a primary care setting.

To teach the concepts of rehabilitation to undergraduates in a clinical, primary-care setting, it is essential to first mobilize student awareness regarding patient dysfunction. After some sensitivity has developed, faculty can focus on rehabilitation theories and processes. This method of teaching is generally accepted positively by students. A daily chart review has proved useful for identifying rehabilitation issues for students and is suggested for other health care agencies as a practical way to promote rehabilitation among primary-care providers.


Environmental and typewriter control systems for high-level quadriplegic patients: evaluation and prescription.

A formal 44-month clinical evaluation was conducted to determine the suitability of selected electronic equipment for use in high-level quadriplegia. A total of 52 traumatic high-level quadriplegic patients (C-2 to C-5,6) participated in the testing of 13 commercial electronic assistive devices including 8 environmental control units, 1 self-contained telephone, and 4 typewriter systems. Most devices were pneumatically ("breath") controlled. Devices were tested in an occupational therapy laboratory, bedside, and homes. Testing yielded data on device reliability, suitability, and acceptance by patients.


Spinal cord injury: a comparison of preinjury and postinjury marriages.

A study of the preinjury and postinjury marriages of 55 spinal cord injured persons and their partners revealed several differences between the relationships. Although all patients had comparable levels of spinal cord injury, the disabled persons in preinjury marriages were judged to have less motivation for independence; a larger proportion of them received daily personal care assistance from their spouses. Furthermore, those in postinjury marriages were more likely to be employed and were judged to be better adjusted psychologically. Psychologists' assessment of marriages based on interviews with the spinal cord injured subjects and their spouses revealed that the postinjury marriages were happier than the preinjury marriages. Possible explanations for these findings are discussed, which include age and state of health, the impact of disability on the marital relationship and the personal assets of disabled persons who attract new partners.


Pulmonary function in quadriplegia: effects of a corset.

Fifteen quadriplegic patients underwent multiple pulmonary function studies performed in 2 positions, sitting and supine, and in both positions under 2 circumstances, wearing and not wearing a corset. Analysis of variance showed that 3 volumes were significantly improved (p less than 0.05) supine, especially without the corset: vital capacity (C), inspiratory capacity (IC) and tidal volume (Vt). Although most pulmonary function tests were improved when the patients were supine the trends when sitting were for improvement when wearing a corset. Most of these patients were studied at least 1 year postinjury and results are not substantially different from those 6 months postinjury. Corsets do not have an untoward effect on pulmonary function tests.


Detrusor muscle and sphincteric response to anorectal stimulation in spinal cord injury.

Twelve patients with spinal cord injuries were studied to determine whether the anal sphincter could be used as an index of urethral sphincter activity and to determine the bladder and striated sphincter response to anal and rectal stimulation. Electromyogram (emg) needle electrodes were placed in the external urethral sphincter, external anal sphincter and levator ani. The output of a cystometer was simultaneously recorded on the printout so that the relationship of the striated muscle response to distension of the bladder could be observed. The response to inserting a finger into the external anal canal, external anal sphincter stretch and rectal balloon distension was also observed. The external urethral and anal sphincter activity was closely linked during bladder contraction and anorectal stimulation. The levator ani showed divergent activity. Stretch of the external anal sphincter caused an initial period of increased striated muscle activity, then in 10 of 12 patients abrupt and often marked inhibition of both sphincters and levator ani developed with continued stretch. Ongoing bladder contractions were inhibited and a decrease in bladder tone developed in 7 of 12. Stretch of the rectum produced results similar to those with anal stretch except that bladder facilitation was seen in 4 of 12 patients.


Doppler ultrasonography for detection of deep vein thrombosis in lower extremities.

Doppler ultrasonography, a rapid, noninvasive and portable technique, has been available to clinicians for more than 10 years, but its accuracy in detecting deep vein thrombosis (DVT) has been questioned. A consistent and detailed method for testing venous circulation in the lower extremities is described. This method was used in a prospective study in which results of 50 phlebograms were compared with those of the Doppler test. A specificity of 92% and sensitivity of 100% were demonstrated, indicating that Doppler ultrasonography is a useful and accurate screening test for DVT.


Intact heel decubitus: an innovative treatment with a special cleansing sponge.

An innovative treatment of intact blue-black heel decubitus with a nonmedicated cleansing sponge was investigated. Forty-five patients over an 18-month period were identified with this type of decubitus and were treated tid for 21 days with a soak and massage of the heel. Analysis of variance was based on changes in size, color, and pliability of decubitus.


Mechanical ventilation of patients with late stage Duchenne muscular dystrophy: management in the home.

Death in the late stage of Duchenne muscular dystrophy is most frequently a consequence of respiratory failure. Since muscles of ventilation become weakened the bellows mechanism fails insidiously. Patients exhibit symptoms of ventilatory insufficiency, the first to be noticed are those associated with CO2 retention: dyspnea, nightmares, increased heart rate, and increased blood pressure. Ten patients with late stage Duchenne muscular dystrophy have been supplied with mechanical aid for ventilatory assistance. The age of onset of respiratory distress needing mechanical assistance varied from 10 to 20 years. Meaningful survival after allegedly reaching the end stage has been from 2 to 7.5 years with an average of 3.4 years. With a caring family, these patients can have a meaningful life, even though they require continuous mechanical ventilatory aid.


Energy costs of below-knee prostheses using two types of suspension.

The choice of suspension in below-knee prosthetics poses a problem for the clinician because cuff suspension weighs less than side-joint-thigh corset suspension but the latter offers more stability. The energy costs of one compared with the other is of prime consideration when dealing with the older person after an amputation. To determine the energy costs of cuff and side-joint-thigh corset suspension, 17 patients were selected for study. A sepcial prosthetic bucket was fabricated for each patient and designed so that the suspensions could be quickly and easily interchanged. Trials with each method of suspension were carried out before and after a training period, and the cardiorespiratory parameters were measured. After the training period all patients demonstrated less oxygen consumption, but the type of suspension did not affect energy costs.


Oxygen concumtpion and biochemistry of Australian women physiotherapists.

Oxygen consumption and related spirometric, biochemical, and anthropometric variables were measured in 28 practicing Australian women physiotherapists at 3 teaching hospitals. Heart rate while on ward duty was also measured in 2 randomly selected physiotherapists. The majority of measurements were found to be within normal limits for Australian women and consistent with women of similar age in occupational groups in other countries, except for body fat, which was lower, and maximum oxygen consumption, which was higher. The later exceptions are believed to be the result of the physical work required of Australian women physiotherapists.


Hydrotherapy burn treatment: use of chloramine-T against resistant microorganisms.

The presence of highly resistant gram-negative microogranisms is an area of major concern in the treatment of burned patients. Criteria for the germicide used for hydrotherapy must include effectiveness against the organism, absence of gross side effects, and conservation of human effort and materials. In the program described, these criteria seem to be successfully met. Microbial samplings from numerous patients and repeated examinations of residue taken from equipment demonstrate the elimination of pseudomonas and other gram-negative organisms.


Conduction velocity in the proximal sural nerve.

Sensory conduction velocity in the proximal portion of the sural nerve differs significantly from that in the distal portion and is less variable. Its determination should improved the value and accuracy of the electroneurographic examination of this nerve. Antidromic conduction velocities in 3 contiguous nerve segments of 10cm each, were determined in 102 sural nerves in normal subjects. The mean velocity in the most distal segment was 33.9 +/- 3.25m/sec. The mean velocities for the middle and most proximal segments were 51.0 +/- 3.8m/sec and 51.6 +/- 3.8m/sec respectively and were not significantly different. There was a positive correlation between conduction velocities and skin temperatures below 84F (28.9C), and no correlation for temperatures above 84F. A sural communicating branch from the common peroneal nerve was demonstrated by electrical stimulation in 9 of 107 cases. The results showed that proximal conduction velocity determination in the sural nerve is a practical procedure.


Shear vs pressure as causative factors in skin blood flow occlusion.

An instrument was developed to measure the external pressure, shear, and pulsatile arteriolar blood flow existent at a given portion of the anatomy. Application of this device to the thenar eminence of 4 healthy subjects showed that externally applied pressure was approximately twice as effective as shear in reducing pulsatile arteriolar blood flow. The combination of pressure plus shear was found particularly effective in promoting blood flow occlusion. At a sufficiently high level of shear (roughly 100 g/cm2) the pressure necessary to produce occlusion was half that required when little shear was present.


Breast pain: a symptom of cervical radiculopathy.

Eighteen women, all of whom had extensive but noninformative breast evaluations, including 10 mammograms and 4 biopies, were successfully treated by cervical traction for chronic breast pain. Each patient had distinct clinical or electromyographic evidence of cervical root compromise. Fifteen had roentgenographic evidence of cervical spondylosis, primarily at levels C6 and C7. Cervical angina, as a symptom constellation produced by cervical radiculopathy and mimicking coronary ischemic disease, is a well-defined entity. Less well recognized is persistent breast pain as a primary presenting symptom of cervical root compromise. In both instances, the early identification of the cervical radicular origin of the pain, with its quite different prognosis and associated therapeutic implications, can promptly help to allay the patient's physical and psychologic discomfort. The pathologic mechanism of pain production and the anatomic pattern of referral are described.


Semimembranosus insertion syndrome: a treatable and frequent cause of persistent knee pain.

The semimembranosus insertion syndrome causes pain at the medial aspect of the knee. This pain is aggravated by exercise, walking downstairs and sharp bending of the knee. The patient experiences tender, moderately puffy swelling at the lowest part of the medial hamstrings muscles and painful passive rotation of the knee, while finger pressure over the insertion of the semimembranosus tendon elicits sharp pain. One hundred patients with semimembranosus insertion syndrome were treated with local injection of lidocaine hydrochloride and triamcinolone. All experienced temporary relief of pain immediately. Long-lasting relief of signs and symptoms was achieved in 58 patients, 30 of whom required repeat injections in 3 to 5 months. Pain decreased and disability was less severe in 9 other patients. There were 18 treatment failure, and 15 patients were lost to follow-up.


Electromyographic changes reviewed in chronic spinal arachnoiditis.

A retrospective study was done to determine if specific electromyographic findings are present in spinal arachnoiditis. The electromyographic (emg) findings in 32 surgically and 35 myelographically diagnosed cases were examined. The cases were categorized into 3 groups. The 1st groups consisted of 37 cases with surgical or myelographic evidence believed to be highly diagnostic of multilevel chronic spinal arachnoiditis. The 2nd group was composed of 23 cases with surgical or myelographic evidence consistent with a localized problem. The 3rd group was a control group with normal or minimal changes on myelography or at surgery. Electromyographic findings were divided into 3 groups of changes: localized, nonlocalized or normal. Localized emg changes were considered to be present over 2 or less root levels in either or both anterior or posterior primary ramus distribution. Nonlocalized changes occurred over more than 2 such levels. A comparative analysis of the myelographic and surgical findings with the emg changes indicated that there was not diagnostic emg picture indicative of chronic spinal arachnoiditis.


Transverse myelopathy in systemic lupus erythematosus.

There have been 28 reported cases of transverse myelopathy associated with systemic lupus erythematosus. In a 6-month period, the authors saw 2 new cases. Both of these patients were young women (29 and 31 years old) who had received a diagnosis of systemic lupus erythematosus prior to the onset of the transverse myelopathy. The case histories of the 2 patients are reported in detail and the findings are compared with those of previously reported cases. The rehabilitation program and outcome are described. Systemic lupus erythematosus should be considered in the differential diagnosis of transverse myelopathy because there may be many unsuspected cases.


Femoral nerve palsy: compression by lymph glands in the inguinal region.

Femoral neuropathy caused by compression of the femoral nerve is not a common syndrome when compared with other compression neuropathies. In most cases reported, the compression was intraabdominal, either in the retroperitoneal region or in the course of the nerve through the psoas major muscle. In this case, the lesion was located extraabdominally. Enlarged and inflamed nodes in the inguinal region caused compression of the nerve resulting in femoral neuropathy. Electromyography (emg) and nerve conduction studies revealed that the lesion was neurapraxia. As expected, the condition was reversible; the patient responded to treatment of the inflamed glands and to physical therapy. The use of emg was helpful for confirming the diagnosis and making the prognosis.


Speech and respiration.

This investigation deals with the temporal aspects of air volume changes during speech. Speech respiration differs fundamentally from resting respiration. In resting respiration the duration and velocity of inspiration (air flow or lung volume change) are in a range similar to that of expiration. In speech respiration the duration of inspiration decreases and its velocity increases; conversely, the duration of expiration increases and the volume of air flow decreases dramatically. The following questions arise: are these two respiration types different entities, or do they represent the end points of a continuum from resting to speech respiration? How does articulation without the generation of speech sound affect breathing? Does (verbalized?) thinking without articulation or speech modify the breathing pattern? The main test battery included four tasks (spontaneous speech, reading, serial speech, arithmetic) performed under three conditions (speaking aloud, articulating subvocally, quiet performance by tryping to exclusively 'think' the tasks). Respiratory movements were measured with a chest pneumograph and evaluated in comparison with a phonogram and the identified spoken text. For quiet performance the resulting respiratory time ratio (relation of duration of inspiration versus expiration) showed a gradual shift in the direction of speech respiration--the least for reading, the most for arithmetic. This change was even more apparent for the subvocal tasks. It is concluded that (a) there is a gradual automatic change from resting to speech respiration and (b) the degree of internal verbalization (activation of motor speech areas) defines the degree of activation of the speech respiratory pattern.


[Studies on the psychopathology of adults with 4-5 c/s EEG rhythm (author's transl)].

Nineteen subjects (10 males and 9 females, aged between 18 and 61 years) with an occipital 4-5 c/s EEG rhythm were tested using a multidimensional psychological test program. The program consisted of the IST of Amthauer, the Raven Test, the German version of the MMPI ("MMPI Saarbrücken"), the Cattell 16-PF-questionnaire, Brickenkamp's d2-Test, and a test battery for psychomotor impairment. A group of normal persons with a regular alpha EEG, matched according to sex and age, was used to provide test norms for the 4-5 c/s EEG group. No difference in intelligence was found, but statistically significant differences were found in some personality traits in the MMPI and the 16-PF-questionnaire. Taking into consideration that the 4-5 c/s EEG group of the study is a subjective sample not randomly selected, this study showed that the male subjects with a 4-5 c/s rhythm as more sensitive, more tender and gentle, more anxious, and less tolerant of stress when compared with the control group; in terms of sex-specific personality traits, they tend to show more female features. Furthermore, the clinical observations of the psychological test date are discussed, i.e., that the subjects with 4-5 c/s rhythms suffer more frequently from functional somatic complaints (observed in 13 cases: 9 with neurovegetative disturbances, 4 with psychosomatic diseases) and/or show psychopathological features (observed in 12 cases: 8 with abnormal personality traits, 4 with neurotic personality development).


[Water intoxication and brain edema in psychogenic polydipsia (author's transl)].

A case of psychogenic polydipsia is presented that showed psychic decompensation and compulsive drinking under the acute stress of an imminent operation for ovarian cyst. Without any indication of an underlying organic disease process the patient developed acute water intoxication due to the uncontrolled intake of water from the tap, this caused hyponatremia, brain edema, coma and status epilepticus. The physiology of water intoxication is reviewed in relation to this case, which is also remarkable for the acute onset and the shortness of the polydipsic state.


[Cauda equina syndrome with total myelographic block (author's transl)].

Twenty-seven cases of complete subarachnoid block discovered through myelography are analysed with regard to the causes of obstruction, the neurologic symptoms, and the cerebrospinal fluid. The neurologic signs in cases of cauda equina compression, most often caused by massive disc protrusions (20 patients), vary considerably and rarely correspond to the gross myelographic findings. Bilateral neurologic symptoms of any degree with or without sphincter disturbance were observed in 21 among 27 cases and are signs of cauda compression. In contrast to cases of sciatica with unilateral root compression and radicular symptoms neurological symptoms are not reliable in revealing the site of the lesion in cases of massive central disc protrusions. Therefore radiculography (myelography of the cauda equina) is necessary for diagnosis. In addition to the well-known elevation of the spinal fluid protein and pleocytosis, the presence of neutrophile granulocytes is frequently found (11 of 20 cases) in cytological analysis.


[The frequency of adult anticonvulsant osteomalacia in relation to duration of therapy and dosage of anticonvulsants (author's transl)].

Of 837 epileptics over 16 years of age treated with mono- or combined hydantoin therapy 20.3% showed radiographic signs of anticonvulsant osteomalacia. With the exception of the patients with severe disturbances of the skeletal system no positive correlation was found with duration of therapy. The percentage of moderate bone changes was the highest in the patients treated for 1 to 2 years; the percentage of severe bone changes in the group treated over 10 years. The rate of osteomalacia correlated with the total dose of hydantoin, phenobarbital, or primidone; the correlation with the dose per year was even more evident. The risk of osteomalacia rose distinctly with doses over 3000 equivalent units/year. The patients with combined hydantoin-barbiturate treatment showed a higher risk than those treated with phenytoin alone. The rate of osteomalacia was the highest in the patients aged under 20 years and over 50 years. Males showed a relatively higher rate of osteomalacia than females, they were treated however with a higher dose per year. The chemical parameters blood alkaline phosphatase and 25-hydroxycholecalciferol corresponded to the radiographic signs, whereas calcium and anorganic phosphate showed no correlation. Early routine radiologic and chemical control especially of the epileptic patients with high risk of osteomalacia should be routinely performed in future.


Hereditary cerebellar atrophy (Holmes type) with optic atrophy: a clinico-pathological study of four generations in a family.

A family with a dominantly inherited progressive cerebellar ataxia is described; four members of successive generations were affected. Neuropathological examination of one family member classified this disorder as hereditary cerebellar atrophy of Holmes type. An associated optic atrophy has not been previously reported in this disease.


[Electrolytes in the CSF of hydrocephalic patients (author's transl)].

The concentrations of Na+, K+, Cl-, Ca++, and Mg++ were measured in the CSF and serum of controls and in those of patients with hydrocephalus. Hydrocephalus was proved with pneumoencephalography. The amounts of Na+, K+, Ca++, and Mg++ were significantly higher in the CSF of patients with hydrocephalus than in the CSF of controls. The changes in the electrolyte concentration gradients seem to indicate that it is not the blood-brain barrier but the brain-CSF barrier which is disturbed in hydrocephalus.


[Control mechanisms of aphasic patients in verbal and phonemic paraphasias (author's transl)].

In the current literature on aphasia, two explanations of paraphasic errors are suggested: one is based on the idea of conscious verbal substitutions, and the other on that of uncontrolled faults in production. The purpose of this study was to relate both explanations to a) the usual classification of verbal and phonemic paraphasias, b) the different types of aphasia, and c) the severity of the aphasic disturbance. In free reproductions of 19 fluent aphasics A(F) and 21 nonfluent aphasics A(NF), the immediate verbal context of paraphasias was examined in relation to a) the nature and severity of the paraphasic errors and b) the severity of the aphasia. The A(NF) group made significantly more hesitations before both verbal and phenemic paraphasias. There was no significant difference between the two groups in control after phonemic paraphasias, but the A(NF) showed a significantly higher rate of control incidents after verbal paraphasias. Thus the two explanations of paraphasia may correspond to different kinds of paraphasic behavior, which are symptomatic of two varieties of aphasia, fluent and nonfluent.


In vitro haemolysis from adrenochrome in the blood of schizophrenic patients, revised.

The recently reported abnormal in vitro haemolysis from catecholamine metabolites in schizophrenia was tested. We did not find the postulated increase in haemolysis, though the exchange of plasma for Ringer solution renders some patients' erythrocytes more susceptible to the effects of adrenochrome. The possibility of a subgroup of schizophrenia with a defect in membrane stability is discussed.


[The 'schizophrenic reaction'--a follow-up study after 20 years (author's transl)].

The concept of schizophrenic reaction was introduced in 1920 by Popper for single schizophrenic manifestations of short duration and full recovery, occurring after a traumatic experience. Of the 29 probands with a primary diagnosis of schizophrenic reaction when recruited for study by Rohr (report published 1961), 28 were reevaluated 20 years later. Nineteen subjects now had a clear-cut schizophrenic symptomatology (ICD 295); 16 with, and three without, remaining symptoms and/or relapse. The other nine were now diagnosed under nosologic categories other than ICD 295. Of these subjects, four were symptom free and had suffered no relapse. The study did not reveal criteria suggesting a distinguishable nosologic category 'schizophrenic reaction' with reference to a schizophrenic syndrome of acute or subacute onset after a brief traumatic event (without remaining symptoms and/or relapse). Such probands did not differ from the schizophrenic group in any of the following criteria: psychopathology, heredity data (diagnosis of relatives was undertaken without reference to the respective index cases), time of onset, duration of psychopathologic manifestation, length of hospitalization, period without remaining symptoms or relapse, and frequency and type of traumatic experiences. The two groups with schizophrenic symptomatology (ICD 295) are genetically characterized by the fact that their first-degree relatives had an incidence of schizophrenia of 8.3 +/- 2.6%. On the other hand, no certain cases of schizophrenia were found among such relatives of subjects in other diagnostic groups. The results do not support the concept of schizophrenic reaction.


The expanded polytetrafluoroethylene graft. Three years' experience with 362 grafts.

A total of 362 polytetrafluoroethylene (PTFE) grafts were implanted in patients as vascular substitutes in a variety of vascular reconstructive procedures. A total of 184 were used in femoropopliteal bypass operations. Cumulative patency rates showed 74% patency at the end of the first year of observation and 58% after two and three years. Seventeen grafts were used for femorotibial bypasses, with a cumulative patency rate of 40.4% after one year. Ninety-eight grafts were implanted in the upper or lower extremity to serve as vascular access for hemodialysis. For this group, the cumulative one-year patency rate was 83%. Sixty-three additional grafts were implanted in various other anatomic locations. Based on this experience, the PTFE graft seems to be a promising and versatile vascular prosthesis, although it should be used cautiously.


Use of umbilical vein graft as an arterial substitute.

Seventy reconstructions, 14 to the popliteal artery above the knee, 40 to the popliteal artery below the knee, and 16 to the tibioperoneal arteries were performed with the Dardik umbilical vein graft tanned in glutaraldehyde. Indications for use included absence of or inadequate saphenous veins, or for expediency during emergency or complex procedures. The cumulative patency rate (calculated by the life table method) for the total group was 77% at 18 months. The failures are further analyzed according to the type of procedure, the grade of disease, and the distal runoff vessel. Early failures were attributed primarily to poor runoff and not to intrinsic properties of the graft. Our overall experience with the umbilical vein graft has been good. Further long-term follow-up is necessary.


In vivo comparison of replamineform, Silastic, and bioelectric polyurethane arterial grafts.

The replamineform process allows fabrication of microporous prostheses with control of both pore diameter and structural geometry by means of a variety for biomaterials. Tubular prostheses 3 cm long, 6 mm inside diameter, and 1 mm wall thickness were made of Silastic or Bioelectric Polyurethane (BEP) with use of a template of the echinoderm Heterocentrotus mammillatus. Pore diameter of the prosthesis wall was 18 to 25 mu. Light and scanning-electron microscopy of grafts removed between 1 and 32 weeks demonstrated that organization and endothelialization of neointima were similar for both polymers, being complete by 4 to 8 weeks. However, the character of prosthesis wall ingrowth was strikingly different: the microporous lattice of BEP was completely ingrown early, but was apparently fragmented by continued granulomatous inflammation by 32 weeks, while Silastic generated minimal inflammatory response and slower fibrous tissue and capillary ingrowth. Thus, with Silastic and BEP, similarities in neointima organization appeared independent of distinct differences in wall ingrowth. The replamineform process is a unique means of studying surface healing and wall ingrowth of different biomaterials as microporous vascular prostheses in a controlled fashion.


Predictability of present outcome and future recurrence in acute pancreatitis.

Although acute pancreatitis is relatively common, factors useful in predicting immediate outcome or likelihood of recurrence have seldom been studied in greater detail. A ten-year experience with 389 patients hospitalized for 821 separate episodes of acute pancreatitis was reviewed. The overall mortality was 6.7%, being highest on the first admission and considerably greater for white males. Respiratory complications accounting for 27% of the fatalities were the most common causes of death. The incidence of considerable morbidity was 19.5%. Clinical diagnoses of "shock" and "respiratory distress" were associated with mortalities of 88% and 71%, respectively. The overall recurrence rate was 50.1%, with little variation regardless as to the number of previous bouts. Recurrence was more likely if the patient was black, male, older than 30 years of age, and had experienced a second episode of acute pancreatitis. Admission data aid considerably in identifying high-risk patients in whom major complications develop, who die during the present episode, or who have a future recurrent bout of acute pancreatitis.


Carotid endarterectomy shunting. Effectiveness determined by operative ocular pneumoplethysmography.

The theoretical advantages and practical disadvantages of carotid endarterectomy shunting are well known. To assess shunt physiology, we performed operative ocular pneumoplethysmography on six patients before carotid clamping, during carotid clamping, during carotid shunting, and on completion of carotid repair. In each case the shunt functioned, at best, as a vessel with at least a 75% or greater cross-sectional area stenosis. However, in all cases it appreciably elevated the ipsilateral ophthalmic systolic pressure over that noted during carotid clamping. There is no question that carotid shunting provides a margin of safety during prolonged carotid clamping.


Jejunoaortic fistula from ingested seamstress needle.

A 27-year-old man was evaluated for sudden onset of massive hematemesis and hematochezia. A bleeding site was not seen on esophagogastroduodenoscopy. There was little blood in the stomach, which suggested that the bleeding site was below the ligament of Treitz. Angiography demonstrated the presence of an intra-aortic metallic foreign body that resembled a sewing needle. At operation, a chronic jejunoaortic fistula that contained the sewing needle was found and repaired. The patient had no recollection of having swallowed the needle, and it is presumed that he ingested it in infancy. He had an uneventful recovery.


Spontaneous rupture of the liver. A complication of oral anticoagulant therapy.

Therapeutic doses of oral anticoagulants have been associated with spontaneous hemorrhage and rupture of apparently normal abdominal viscera. To our knowledge, this is the second reported case of such rupture involving the liver. The patient had sudden severe epigastric pain and signs of acute abdomen and shock. Discrete microscopic changes in the liver may precede massive hemorrhage.


Porcelain appendix. A calcified mucocele fractures to produce an acute abdomen.

Mucocele of the appendix is rare and occasionally is accompanied by calcification. In a recent case, an eggshell-thin calcified mucocele fractured to produce an acute abdomen. This situation was not found in a review of the literature. A brief summary of the properties of mucocele is presented.


Rhizopus surgical wound infection with elasticized adhesive tape dressings.

We report a case of cutaneous Rhizopus infection associated with the use of an elasticized adhesive tape (Elastoplast) bandage over a surgical wound. At the present time, it is recommended that such dressings not be used on open wounds.


Studies of peripheral glucose uptake during sepsis.

Glucose intolerance occurs in patients with sepsis, and resistance to insulin has been thought to be part of this process. To study this phenomenon, peritonitis was produced in rats by cecal ligation and puncture. One group was killed ten hours later (early sepsis). A second group of rats was killed 16 to 24 hours after ligation, just prior to their expected death (late sepsis). Insulin stimulated glucose uptake to the same extent in muscles from rats in early sepsis, late sepsis, and from control rats. Even at an insulin concentration that produced submaximal stimulation of glucose uptake, no difference in glucose uptake between the three groups of muscles was observed. Thus, there was no resistance to the stimulatory action of insulin on glucose uptake by skeletal muscle during early and late sepsis. However, basal glucose uptake by isolated soleus muscle from animals in late sepsis was significantly increased compared with controls when these muscles were incubated in an aerobic environment. Under anaerobic conditions, glucose uptake in these two groups of muscles increased to the same level. This indicates that there is some stimulus that increases glucose uptake in late peritonitis and may explain the hypoglycemia of late experimental or untreated sepsis. This stimulus could be hypoxia or some other factor resulting from decreased blood flow and increased anaerobic metabolism.


Experience with the Hunter-Sessions inferior vena cava balloon occluder.

During a two-year period, 12 patients with indication for inferior vena cava interruption underwent vena cava occlusion with the transvenous Hunter-Sessions balloon. The device permitted simultaneous anticoagulation (when not contraindicated), was tolerated by sick patients, did not cause mortality or significant morbidity, and prevented pulmonary emboli.


Biliary clonorchiasis.

Parasitic infection of the biliary tree may be seen more frequently because of changing patterns in travel, and may come to the attention of the surgeon when obstruction or secondary bacterial infection occurs. In this case, intraoperative cholangiography indicated common duct abnormalities, and choledochotomy led to the diagnosis of Clonorchis sinensis. A recommendation is made to follow up patients with bilary parasite infections to determine the long-term sequelae.


A safe and secure technique of cystic duct catheterization.

An easily fabricated, small-caliber, flare-tipped polyethylene catheter was used for transcystic duct cholangiography in 385 patients. A modified cystic duct clamp and a Potts-Smith scissors have expedited the intubation. The catheter has proved to be a versatile tool during biliary surgery, being used in different technical maneuvers. Its value as a transcystic duct drain has been demonstrated in a selected group of patients.


Avoiding renal vein entry when implanting the Mobin-Uddin vena cava umbrella filter.

Transvenous placement of a Mobin-Uddin vena cava umbrella filter is a safe and effective method of vena cava interruption in high-risk patients who cannot undergo laparotomy. When the renal veins enter the vena cava acutely, there may be preferential passage of the filter insertion device into the aberrant renal veins. If the usual maneuvers of changing the patient's position do not correct this aberrant passage, then a venous thrombectomy catheter may be used to temporarily occlude the vein orifice. This technique avoids the problems of incorrect placement and abandonment of the transvenous approach to vena cava interruption.


Microbiologic environment of the conventional operating room.

Areas of potential contamination of the surgical wound in the conventional operating rooms include the back table, the unsterile suction receptacle, and the lack of a positive pressure relationship between the operating room and adjacent areas. Use of an impermeable hood with a large mask diminished contamination of the instrument table and the the wound from fallout of bacteria from the surgical team. The level of airborne bacterial comtamination in the operating room can be reduced by limiting the traffic and controlling the activity and the number of operating room personnel. Higher rates of postoperatively wound sepsis were noted in older operating rooms, particularly with difficult procedures and those performed later in the day. Conventional operating rooms should be categorized by the level of room air exchange per hour and the level of airborne bacterial contamination.


Environmental bacteriology in the unidirectional (horizontal) operating room.

The continuing attempts to reduce bacterial contamination through clean air systems have been of special interest to surgeons dealing in joint replacement surgery. Although the definitive relationship between airborne contamination and surgical infections is not universally agreed on, there is little question that clean air systems reduce bacterial contamination of the surgical wound at the time of operation. This report reviews the history of surgical infections, presents statistical data that show the reduction of bacterial contamination by a clear air system, and suggests a pragmatic attitude regarding airborne bacterial contamination of surgical wounds.


Environmental bacteriology in the unidirectional (vertical) operating room.

An integrated body exhaust/clean air operating room system was evaluated in terms of the microbiologic and particulate contamination control it afforded. The clean air unit was of a vertical unidirectional airflow design and employed high-efficiency particulate air filters to provide air low in both microbes and particulates. The body exhaust portion of the system was composed of an exhaust tube the surgeon's mask, a transparent plastic faceplate, and a microbe-retentive surgical gown and hood. Measurements were made of airborne and surface contamination at the wound site and of microbial burden levels associated with the surgical team. Sampling techniques were designed to parallel those used in a previous study of a horizontal flow/body exhaust system so as to provide comparative data on the effect of airflow configuration on wound site contamination. The data showed the vertical flow room to exhibit significantly lower (P less than .05) contamination levels than the horizontal flow enclosure. Surgical lights, draping techniques, and personnel and material positoning unobstructive to the airstream were judged to the prime factors in reducing wound site contamination.


Bacteriology of the operating room with the use of helmet aspiration systems.

The bacteriology of the operating room with the use of the helmet-aspirator system has been discussed. The surgical team predictably contaminates the operating room. Current cotton gowns worn loosely about the neck do not serve as effective barriers to bacterial penetration. Barrier draping of the surgical team is possible with impervious materials, but requires the use of a helmet-aspirator system to dissipate the heat and particulate debris. These are commercially available and their use has been shown to decrease colony-forming particles, decrease wound contamination, and decrease wound infection. Barrier draping of the surgical team through the helmet-aspirator system is effective and is to be recommended for infection-prone cases.


Clean air bench. Use for sterile maintenance of unwrapped surgical instruments.

Microbiologic sterility of unwrapped surgical instruments has been maintained for long periods by the use of an operating room instrument cabinet that continuously circulates high-flow, "particle-free" air. Use of this clean air bench has had excellent acceptance by operating room nurses and by surgeons because fewer instrument storage procedures are needed and setup time, takedown time, and case turnover time in the operating room are diminished. It has been found to be effective in operating rooms having busy schedules for both elective and emergency procedures.


Reduction of deep sepsis after total hip arthroplasty.

The role of the operating room environment in the development of deep sepsis after total hip arthroplasty was studied at four centers. The incidence of deep sepsis after 5,865 total hip arthroplasties performed in the four centers varied from 0.5% to 2.3%. Procedures performed in a conventional operating room were associated with the highest incidence of deep sepsis (1.3%). The use of a vertical, unidrectional airflow system with a helmet aspirator suite was associated with the lowest incidence of deep sepsis (0.6%). Although patients with previous hip surgery had an increased incidence of deep sepsis regardless of the operating room environment, those procedures performed in a vertical, unidrectional facility had a lower incidence of deep sepsis. Newer techniques designed for the reduction of airborne contamination of the operative wound seem to reduce the incidence of deep-wound sepsis after total hip arthroplasty, especially in patients with previous hip surgery.


Use of antimicrobials in the management of open fractures.

The role of antibiotic therapy in open fractures is secondary to adequate debridement, irrigation, and definitive wound care. Experimental and clinical studies indicate that parenteral administration of appropriate antibiotics within three hours after injury helps to prevent wound sepsis. Intial wound cultures of 158 open fracture wounds revealed bacterial growth in 70.3%. Eighty-six were Gram-positive, 57 were Gram-negative, and 32 yielded mixed bacterial growth. Sensitivity studies of these organisms suggest that cephalothin sodium is the most effective antibiotic for prophylaxis. In a prospective study from 1969 to 1975, treatment of 520 patients was as follows: debridement, copious irrigation, and primary closure for types 1 and 2 fractures and secondary closure for type 3 fractures. No primary internal fixation was done except in vascular injuries. Cultures were taken of all wounds and antibiotics were given before surgery and for three days postoperatively. In type 3 open fractures, severe soft tissue injury, and segmental or traumatic amputation, the infection rate was 9%, compared to a 44% infection rate in the retrospective study from 1955 to 1968.


Wound infections in patients undergoing total hip arthroplasty. Ultraviolet light for the control of airborne bacteria.

Ultraviolet (UV) irradiation (1,537 A) during total hip arthroplasty will effectively reduce risk of airborne bacterial contamination of the operative field. An air sampling study at the operative site compared 28 total hip arthroplasties with UV lights on and 19 operations with UV lights off. The use of UV irradiation significantly reduced the average number of airborne bacteria over the operative site, although the results indicate that the number of airborne bacteria collected at the operative site in each conventional operating room without UV irradiation was quite low. Data confirmed the fact that airborne bacteria are a reflection of operating room personnel and their activities. With UV light, the rate of infection from possible airborne sources was 0.15% for 1,322 total hip patients. Thus, emphasis is now placed on those causes of infection that are not airborne.


Airflow effects in surgery.

Accumulated evidence of the last decade has emphasized the multifaceted nature of wound infection control. Clean air is definitely one of the facets in the complex, but its place in the hierachy of precautions against wound infection has not been established, nor has the method of achieving acceptably clean air been universally agreed on. The surgical team and the patient are the prime sources of contamination during an operation, as evidenced by the good matches between bacteria of infected wounds and those of the team or the patient and by the poor matches between bacteria of infected wounds and airborne bacteria. Therefore, special air-handling systems, despite their ability to lower ambient bioparticulate counts, cannot be credited with being a highly relevant factor in the reduction of wound infection rates.


Diagnostic errors with peritoneal lavage in patients with pelvic fractures.

Diagnostic peritoneal lavage, considered to be a highly accurate, technique for detecting intraperitoneal blood in the trauma patient, may be less reliable in the presence of a pelvic fracture. In a retrospective review of 222 patients with pelvic fractures, 61 patients were found who had had a diagnostic peritoneal lavage performed as part of the initial evaluation of their condition. Twenty-six of these patients had had a negative lavage result negative lavage result. There had been no false-negative results in this group, although six patients required operations for extraperitoneal injuries. Of the 35 patients with a positive lavage results, 10 (29%) were found to have false-positive lavage results with no intraperitoneal source of bleeding. The only deaths in this series occurred in the group requiring operations, eight of 41 (20%). Four of the eight detahs were due to uncontrollable bleeding that resulted from exploration of the retroperitoneal hematoma. These data suggest that a negative lavage result is highly reliable in the patient with a pelvic fracture and should allow management with confidence that there is no severe intraperitoneal injury. Positive lavage results, however, must be interpreted with caution.


Cardiopulmonary bypass in anesthetic management of resection. Its use for severe tracheal stenosis.

On initial evaluation, two patients were found to be in severe respiratory distress from tracheal obstruction. One patient had late obstruction after a crushing injury to the chest, whereas the other had subtotal tracheal obstruction from a carcinoid adenoma. In each case, the state of the patient seemed to preclude safe anesthetic induction with an endotracheal tube as the sole means of oxygenating the patient. Partial cardiopulmonary bypass provided an adjunct to ensure adequate oxygenation for tracheal resection. Consideration for the use of this technique is recommended in similar circumstances.


Abdominal aortic aneurysm and horseshoe kidney. A different perspective.

We report a case of abdominal aortic aneurysm with horseshoe kidney. The anatomic distribution of the renal vessels, the position of the thin portion of the isthmus of the kidney, and concern for the preservation of the sexual potency of the patient made standard aneurysm repair untenable. We describe a method of repair by exclusion of the aneurysm.


Nonoperative internal drainage of obstructive common bile ducts.

A new nonoperative method for internal drainage of common bile duct obstructions by endoscopic retrograde cannulation of the papilla of Vater is described. After introduction of a tube in the common bile duct, a substantial decrease in serum activity of bilirubin, alkaline phosphatase, and gamma-glutamyl transferase was found. In addition, a rapid improvement of the clinical condition could be observed. No serious complications occurred. It is concluded that internal drainage of common bile duct obstructions might be of great value in the preoperative treatment of patients with common bile duct obstructions.


Studies on the toxicology of hexachlorobenzene. IV. Sulphur-containing metabolites.

After administration of hexachlorobenzene rats excrete sulphur-containing conjugates from which pentachlorothiophenol can be split off. In the present study we describe the identification of pentachlorothiophenol and pentachlorothioanisol in the livers of animals treated with hexachlorobenzene. In order to clarify the further fate of these two substances, we administered them to rats, and isolated the conversion products excreted in the urine and feces. The metabolites of pentachlorothiophenol and pentachlorothioanisol are excreted in both conjugated and free form. From extracts of the excreta, we isolated tetra- and trichlorobenzene with two or three sulphur-containing substituents on the ring, analogous compounds in which thiol groups were converted into sulphoxide and sulphone groups, as well as analogous compounds with a phenolic oxygen in addition to sulphur, and sulphur-containing compounds in which clorine was replaced by hydrogen. Following administration of the sulphoxide and of the sulphone of pentachlorothioanisol under analogous conditions, pentachlorothiophenol and pentachlorothioanisol and their metabolites were detected in the excreta of the animals. No evidence was obtained that the parent compounds are excreted in the unchanged form.


Distribution of Fe59 in benzene and iomex treated rats.

The distribution of Fe59 in plasma and blood at various time intervals has been studied in control, benzene and iomex administered, and anemic rats. A significant difference between control and benzene, and iomex treated animals was observed in the rate of reappearance of Fe59 in blood circulation. The accumulation of Fe59 in various organs was noted at the end of 48 h. A significant increase in the radio-iron content was observed in bone marrow, spleen and liver of benzene and iomex treated rats as compared to those of control rats.