Plasma epinephrine and control of plasma renin activity: possible extrarenal mechanisms.

Previous work from our laboratory has shown that physiological increments of circulating epinephrine concentration increase plasma renin activity (PRA) by an extrarenal beta-receptor mechanism. In the present experiments, epinephrine was infused intravenously at 125 ng.kg-1.min-1 for 45 min in trained, conscious dogs. PRA rose 3 to 5-fold, as previously described, and was accompanied by a transient decline of mean arterial pressure, decreased plasma potassium concentration, and increased hematocrit. Prior splenectomy to maintain hematocrit constant did not attenuate the PRA response to epinephrine. The kidneys of 4 dogs were denervated and constrictor cuff was placed around the renal artery. Renal denervation did not alter the PRA response to intravenous epinephrine infusion. A transient decline in renal perfusion pressure produced by cuff constriction only transiently increase PRA. Neither maintenance of a constant plasma potassium concentration nor oral administration of indomethacin altered the PRA response to epinephrine. We conclude that intravenous epinephrine increases PRA by a mechanism independent of the renal nerves, changes in renal perfusion pressure, hematocrit, plasma potassium concentration, and plasma prostaglandins.


Autonomic control of right atrial contractile strength in the dog.

The combined effects of parasympathetic and sympathetic stimulation on right atrial contractile strength were assessed in open-chest, pentobarbital-anesthesized dogs. A factorial experimental design was employed to quantify the percent changes in atrial contractile strength in spontaneously beating and paced hearts as a function of the frequencies of vagal and stellate ganglion stimulation. In 7 of 10 dogs, there was a substantial interaction between the two autonomic divisions; the sympathetically mediated inotropic effect became less pronounced as the background level of vagal stimulation increased. The relationship between stimulation frequencies and atrial contractile strength was not significnatly altered by pacing the hearts.


Aversive conditioning of elevations in total peripheral resistance in dogs.

Operant conditioning experiments were performed with 12 chronically instrumented dogs to which aversive stimulation was presented whenever total peripheral resistance (mean pressure/cardiac output) decreased acutely below a criterion level. Initial experiments in which aversive stimulation occurred whenever total peripheral resistance decreased below mean base-line levels resulted in sustained decreases in total peripheral resistance, accompanied by elevations in heart rate, cardiac output, and arterial pressure. Subsequent experiments showed, however, that if aversive stimulation occurred only following large-magnitude decreases in resistance (30% below base-line levels), a progressive cardiovascular response pattern emerged during daily sessions of 5--16 h. This cardiovascular pattern included progressive elevations in resistance (10--50%), accompanied by progressive decreases or no change in heart rate and cardiac output and moderate increases in arterial (up to 20 mmHg) and pulse pressure. These within-session cardiovascular changes were accompanied by sustained inhibition of overt behavioral acitivity and progressive inhibition in respiratory activity. Implications of these observation for behavioral regulation of circulatory function are discussed.


Blood pressure fluctuations in human nailfold capillaries.

Dynamic blood pressure was measured in 33 human finger nailfold capillaries after direct cannulation with glass micropipettes by means of a resistance servo-nulling pressure measuring method. ECG, finger pulsations, and respiratory thorax excursions were monitored simultaneously. All recordings exhibited pulsatile oscillations related to the cardiac rhythm. These oscillations resembled the wave forms of arterial pulsations with steep upstroke and dicrotic notch when the pressure amplitudes were above 10 mmHg. There was no apparent dependence on respiration. In 12 instances, pressure fluctuations with frequencies ranging from 0.2 down to 0.07 Hz were observed in both the arteriolar and venular limb. Blood pressure in human skin capillaries is pulsatile and subject to remarkable fluctuations in the arteriolar as well as in the venular limb, systolic pressure values ranging from 14 to 71 mmHg and from 11 to 52 mmHg, respectively.


High-resolution determination of the R-R interval.

A preprocessor is described that determines the time interval between successive R waves of the electrocardiogram with an error of less than 0.2 ms. It accomplishes this by sepearting in hardware the function of determining the approximate location of the R wave from the function of localizing with great accuracy the peak of the wave form. With this device it is possible to detect abnormal heart rate patterns characterized by exceedingly small beat-to-beat variability. The approach may be useful for other bioelectric signals.


Comparison of plethysmographic methods with pulsed Döppler blood flowmetry.

Hand blood flow was measured at rest, with local warming, and with local cooling. Three methods were simultaneously used: water plethysmography (WP), mercury-in-rubber strain gauge plethysmography (SG), and pulsed Döppler flowmetry (D). Of these, water plethysmography is the most sensitive and accurate; strain gauge plethysmography is simpler but less accurate; and pulsed Döppler flowmetry precisely measures instantaneous arterial blood flow without venous occlusion.


Vascular reactivity of the isolated tibia of the dog.

Experiments were performed to assess the responsiveness of vessels subserving bone tissue to nerve stimulation and to exogenously administered catecholamines and acetylcholine. Tibias of mongrel dogs were isolated and dissected free; the periosteum was left intact. The main nutrient artery was prepared and cannulated. Ring electrodes were placed around the artery. The preparation was perfused at constant flow with aerated (95% O2 - 5% CO2) Krebs-Ringer solution (37 degrees C) by means of a roller pump. The perfusion pressure was continuously recorded. For each preparation, the flow rate was used at which the response to a standard dose of norepinephrine was the largest. Periarterial electrical stimulation caused frequency-dependent increases in perfusion pressure; because these responses were blocked by phentolamine, they must be due to activation of sympathetic nerves. Injections of norepinephrine caused dose-dependent increases in perfusion pressure that were abolished by phentolamine. Acetylcholine caused dose-dependent, atropine-sensitive decrease of the constrictions caused by norepinephrine infusions. These experiments demonstrate that the isolated perfused tibia of the dog is a satisfactory preparation to investigate the direct effects of sympathetic nerve stimulation and naturally occurring vasoactive amines on bone blood vessels.


"Folk" criteria for the diagnosis of mental illness in rural Laos: on being insane in sane places.

"Folk" criteria for identifying the mentally ill, as distinguished from folk theories about the causes of mental illness, have been comparatively neglected in cultural psychiatry. The authors describe the criteria by which villagers in Laos labeled 35 subjects as baa (insane). Unprovoked assaultive or destructive behavior, social isolation, self-endangerment due to neglect of personal needs, nonviolent but socially disruptive or inappropriate behavior, and inability to do productive work were found to be important folk criteria. The authors emphasize that folk criteria for mental illness are determined primarily by the persistence of socially dysfunctional behavior rather than by disturbances in thought and affect.


Gonadotropin, estradiol, and testosterone profiles in homosexual men.

The authors evaluated the gonadotropin-testosterone-estradiol profiles of four homosexual men and four heterosexual men by a multiple-sampling technique. Although there was extensive overlap between the two groups, the homosexual subjects had higher estradiol levels than the heterosexuals (70.3 +/- 19.8 versus 56.8 +/- 10.7 pg/ml) and lower FSH values (5.1 +/- 1.0 versus 13.2 +/- 3.4 mIU/ml). Testosterone and luteinizing hormone levels were comparable in the two groups. These observations suggest that there may be subtle differences in gonadotropin and estradiol secretion in homosexual subjects that can be detected only by repeated sampling.


Hysterical psychosis and hypnotizability.

The very existence of hysterical psychosis as a diagnostic entity has been questioned as part of the general difficulty in defining both hysteria and psychosis. However, several recent investigations have documented a syndrome that usually involves brief and intense periods of psychotic behavior, generally with graphic decompensation, severe environmental stress, and rapid recompensation, in individuals with other hysterical features. The authors assert that such a syndrome does exist as a clinical entity and that the differential diagnosis can be facilitated by using a standardized measure of hypnotic trance capacity. They hypothesize that patients with hysterical psychosis are highly hypnotizable, while those who are schizophrenic and psychotic have low hypnotizability. The authors review the literature and present two case examples.


Emergency room medical clearance: an educational problem.

The term "medically clear" has a greater capacity to mislead than to inform correctly. The overuse of this term, especially in emergency room settings, may indicate difficulties in medical education and in the consultation/referral process between psychiatry and other specialties; further, it results in poor patient care. Nonpsychiatric physicians may prematurely refer patients as medically clear because of their unfamiliarity or discomfort with clinical psychiatry. Psychiatrists often ask for medical clearance of patients to hide their discomfort with or antipathy toward clinical medicine. The use of emergency room settings for interspecialty collaboration and training helps minimize the underlying difficulties that lead to the use of this term by fostering psychiatric skills in nonpsychiatrists and a sense of medical identity in psychiatrists.


Incidence of a history of incest among 18 female psychiatric patients.

The author ascertained the frequency of reports of a history of incest among the 18 female psychiatric outpatients he first evaluated or treated in a one-year period. Six of these patients (33%) reported a history of incest. The author suggests that if this figure reflects actual prevalence, previous estimates of a history of incest among female psychiatric patients may have been mistakenly low. He discusses the implications and limitations of the statistics.


Cognitive and affective responses to lithium in patients with organic brain syndrome.

The authors describe a series of patients with organic brain syndrome who showed a dramatic clinical response to lithium carbonate therapy. None of the patients had been diagnosed as manic-depressive. Most had extensive psychiatric treatment experiences and had been given both affective and cognitive diagnoses. Six of the eight patients also qualified for the diagnosis of alcoholism. They had been treated with a wide variety of psychotherapeutic medications. Lithium was found to be rapidly and dramatically effective in patients with static lesions of the central nervous system who showed a combination of dementia and agitated depression.


Cardiac sinus node dysfunction during lithium treatment.

Lithium treatment has been associated with a wide range of cardiac complications. The authors report three additional cases of cardiac sinus node dysfunction due to lithium. Two of the three cases were documented to be lithium dependent by the use of Holter monitoring of cardiac rhythm. On the basis of this finding as well as other reports in the literature the authors recommend careful monitoring of the pulse of patients taking lithium as well as ECG monitoring of patients who are over the age of 50 or who have a history of cardiac disease.


Variable attenuation of amphetamine effects by lithium.

In an open study of 8 subjects, approximately half showed some attenuation of CNS stimulant effects of amphetamine after pretreatment with lithium. Two showed specific blockade of euphoria, with persistence of some CNS stimulant effects. In 3 subjects lithium did not appear to affect the response to amphetamine. Lithium caused significant attenuation of the amphetamine-induced increase in systolic blood pressure for the group as a whole.


Lithium plus reserpine in refractory manic patients.

The authors report on six refractory manic or schizo-affective manic male outpatients who failed to respond to lithium combined with a neuroleptic. A beneficial response was noted in most patients when reserpine was substituted for their currently prescribed standard neuroleptic; in some cases lithium dosage could then be reduced. No major side effects were encountered. The use of reserpine may offer an alternative mode of therapy for manic patients who cannot tolerate large doses of lithium or do not completely respond to lithium either alone or in combination with a standard neuroleptic.


DSM-III field trials: I. Initial interrater diagnostic reliability.

The interrater agreement for major diagnostic categories in studies using DSM-I and DSM-II was usually only fair or poor. In phase one of the DSM-III field trials the overall kappa coefficient of agreement for axis I diagnoses of 281 adult patients was .78 for joint interviews and .66 for diagnoses made after separate interviews; for axis II--personality disorders and specific developmental disorders--the coefficients of agreement were .61 and .54. The interrater reliability of DSM--III is, in general, higher than that previously achieved and may be due to changes in the classification itself, the separation of axis I from axis II conditions, the systematic description of the various disorders, and the inclusion of diagnostic criteria.


DSM-III field trials: II. Initial experience with the multiaxial system.

The multiaxial system of DSM-III includes nondiagnostic data that are valuable in understanding possible etiological factors and in treatment planning and prognosis. The authors describe the reliability of axis IV--severity of psychosocial stressors--and axis V--highest level of adaptive functioning in the past year--for 281 adult patients interviewed in phase one of the DSM-III field trials. The kappa coefficient of agreement for axis IV was .62 for joint interviews and .58 for separate interviews, which the authors consider at least fair. Reliability for axis V was quite good, .80 for joint interviews and .69 for separate interviews. Eighty-one percent of the participating clinicians judged the multiaxial system to be a useful addition to traditional diagnostic evaluation, although many indicated that they had difficulty quantifying severity of psychosocial stressors.


Massive benzodiazepine requirements during acute alcohol withdrawal.

Severe alcohol withdrawal developed in an abstinent chronic alcoholic man. Massive doses of benzodiazepines (2,335 mg of diazepam intravenously, 21,225 mg of oxazepam orally) achieved only marginal control of delirium and agitation. Analysis of multiple blood samples drawn during and after the withdrawal episode indicated, as expected, very high concentrations of diazepam and metabolites and of oxazepam. There was no evidence of an abnormal pharmacokinetic profile. Benzodiazepine resistance in withdrawing alcoholics probably reflects a receptor-site phenomenon rather than an abnormal drug disposition.


Relations between academic departments of psychiatry and pharmaceutical companies.

The financial pressures placed on academic departments of psychiatry make the offers of assistance from pharmaceutical companies very attractive. The authors provide a sequential three-step decision-making approach to help the academic physician and the psychiatry department address the ethical issues involved in any given interaction with a pharmaceutical company. They also provide examples of the application of these guidelines.


A clinical note on hysterical psychosis.

The authors review the concept of hysterical psychosis and its reported psychodynamics. They suggest a psychodynamic issue that apparently has not been previously reported, namely, emotions engendered by an overt sexual advance or rage and disappointment over a lack of a sexual advance. This finding can be most helpful in distinguishing a case of hysterical psychosis from an acute schizophrenic episode.


Organic personality disturbance: a case of apparent atypical cyclic affective disorder.

The authors present the case report of a 19-year-old woman that contains several important points in the diagnosis and management of organic personality disturbance associated with temporal lobe epilepsy. The behavioral changes may antedate the onset of the clinical seizure. The diagnosis of complex partial seizures is a clinical diagnosis in which surface EEGs may repeatedly not demonstrate focal activity. Carbamazepine can have important psychotropic effects, in addition to its well-established anticonvulsant effects, and it may be particularly indicated if a lithium-resistant bipolar affective disorder is a differential diagnostic possibility.


The effect of infant death on subsequent fertility in Korea and the role of family planning.

This paper studies the effect of infant death on subsequent fertility in a developing country, examining spacing of children and additional births following the survival or death of the preceding infant. The material is provided by the 1971 National Fertility Survey of Korea, 23,635 retrospective birth records of 6,285 women. The findings suggest that prior to the introduction of a national family planning program, the influence of infant death was limited to the biological effect resulting from a shortened lactational period. Since fertility regulation methods have been made available throughout the country, motivational effects to replace the lost child appeared to emerge. The proportion of excess births attributable to infant deaths has increased in recent years. However, because of the lowered infant mortality, the overall impact of infant death on the national fertility level appears to be small.


The growing demand for midtrimester amniocentesis: a systems approach to forecasting the need for facilities.

A predicted shift in composition of the child-bearing population of the United States to higher maternal ages by year 2000 indicates that the number of chromosomally abnormal offspring of women age 35 and over will increase by 64% while the total number of women increases only 21%. We formulated a conceptual model of a health care system that predicts demand for amniocentesis from prospective patients in any particular region, the number of defective offspring detected, and the future cost of custodial care using any given level of detection effort. It was found that as capacity of clinic facilities and use by women age 35 and over in the area increased, the expenditure for amniocentesis combined with the cost of custodial care for undetected offspring decreased, assuming termination of affected pregnancies. Use of this model will enable health care managers to anticipate need for facilities, and also guide the formulation of social policy in the provision of new health services by enabling them to take into account the predictable effects of these services upon other public services.


Prevalence of hepatitis B in 27 Michigan hemodialysis centers.

A large epidemiological survey of inhospital chronic hemodialysis patients was conducted in 27 (93%) of the 29 dialysis centers in Michigan. Serum was collected from 699 patients on chronic maintenance hemodialysis for periods from one month to eight years. Hepatitis B surface antigen (HBsAg) was determined in all patients by radioimmunoassay and positive samples were confirmed by specific neutralization. Antibody against HBsAg (anti-HBs) was determined by radioimmunoassay in 110 HBsAg negative patients from six dialysis units with a high prevalence of hepatitis B. HBsAg was detected in 80 (11.4%) patients distributed among 21 (78%) of 27 dialysis units and anti-HBs in 34 (31%) patients from the selected dialysis units. The prevalence of HBsAg was related to duration of dialysis, number of blood transfusions, and to a history of bilateral nephrectomy, but not to age, sex, race, nor the underlying renal disease. Twenty-one (26%) of the 80 HBsAg positive patients had not been previously identified by the clinical laboratories of their institutions. Since preventive measures were not taken in the care of these inapparent carriers of HBsAg, they represent an unrecognized risk.


Exercise prescription: a clinical trial.

To assess the effectiveness of physician prescribed exercise, health education, and patient self-monitoring, 124 firefighters were medically screened and randomly allocated to a control and two treatment groups. Physiologic and reporting methods were employed to assess adherence to regular exercise at three months and six months after the initial exercise prescription. Addition of a health education program significantly improved compliance over that achieved by a physician consultation. Self-monitoring did not produce a further increase in compliance. Improvement in the treatment groups was limited to three months after prescription; at six months, the treatment and control populations had similar exercise patterns.


A hospital-based screening, referral, and follow-up program for high blood pressure.

A hypertension program staffed largely by volunteer nurses in a hospital outpatient department is described. A three-year evaluation shows 19% of 4,282 clients screened as having high readings, 86% of those referred saw a physician for high blood pressure, 92% of those who saw a physician began treatment for high blood pressure and 50% of those under treatment were showing successful control or progress toward successful control.


Rabies in translocated raccoons.

Two raccoons imported from Florida by a North Carolina hunting club were diagnosed as having rabies by fluorescent antibody testing of brain tissue. Although dead on arrival in North Carolina, they could have infected other raccoons in the same shipment which had already been released into the wild. Raccoon rabies has become increasingly important in recent years, but this is the first documented report of rabies presence in hunter-purchased interstate shipments.


Determinants of genocide fear in a rural Texas community: a research note.

Data were collected via a questionnaire administered to females 15-44 years of age and their most significant male partner from a 7% stratified random sample in Waller County, Texas. Analysis revealed that five independent variables combined explained 19% of the variance in race genocide fear (R2 = .19; p less than .01). The most important predictors of genocide fear were sex (Beta = .33; p less than .001) and education (Beta = .14; p less than .01).


Nitrous oxide and the middle ear.

A case of hearing deficit following nitrous oxide anaesthesia is reported. The mechanism and time course of nitrous oxide-induced intratympanic pressure changes are described and contrasted with the effects of non-nitrous oxide anaesthesia. The rate of increase is about 10 mm H20/min. The possibility that nitrous oxide may cause displacement of tympanic membrane grafts both outwards and inwards, or disrupt the reconstructed middle ear conducting mechanism, is raised again.


Electrocution during anaesthesia.

Cardiac arrest due to electrocution occurred in a young obstetric patient undergoing laparotomy. The patient subsequently died despite initial resuscitation. The cause was traced to an inappropriate and faulty switch in the base of the operating table; the circuit was completed by the ECG monitor which was of the direct earth type.


Post-partum intracranial subdural haematoma. A possible complication of epidural analgesia.

A case is reported of bilateral chronic subdural haematomas in a 29-year-old woman 1 month after childbirth under attempted epidural analgesia. The possible link between leakage of cerebrospinal fluid through a hole in the lumbar theca and the later development of an intracranial chronic subdural haematoma is discussed, with a review of eleven previous reported cases.


Potential hazard of methylene blue.

The administration of methylene blue to assist the identification of insulin secreting pancreatic adenomata, during surgery in a patient with normal haemoglobin and red cells, was associated with an increase in the methaemoglobin concentration from 0.6% to 7.1%. In patients with unstable haemoglobins or abnormalities of the hexose monophosphate pathway the administration of large amounts of methylene blue is potentially dangerous.


Hereditary angioneurotic oedema.

Hereditary angioedema (HAE) is characterised by episodic swelling of the extremities, face, larynx and recurrent abdominal pain, which can mimic the acute abdomen. Trauma of the larynx may result in acute airway obstruction. The management of emergency anaesthesia for Caesarean section of a patient with documented HAE is described and the special problems presented discussed. The methods of prophylaxis available are considered and the use of fresh frozen plasma advocated.


Anaesthesia for the separation of conjoined twins.

Anaesthesia for separation of thoracopagus twins is described. One twin died 10 hr postoperatively and was found to have an undiagnosed coarctation of the aorta. The second twin required long term respiratory support and survived. The anaesthetic management and postoperative care are discussed.


Infusion rates from different containers. A study of the influence of different types of container on intravenous infusion.

Different types of containers were investigated under standardised conditions to determine whether their design affected the rate of flow of the intravenous solution they contained. Fully collapsible plastic containers were found to empty fastest, with bottles intermediate, while semi-rigid plastic containers were slowest, particularly over the last 20% of their contents. Low flow rates were found to coincide with a high sub-atmospheric pressure within the container, being greatest in the semi-rigid containers and least in the fully collapsible containers. It is suggested, therefore, that resuscitation fluids should be supplied in fully collapsible containers which have an inherent tendency to rapid infusion.


Treatment for lumbar sciatic pain in posterior articular lumbar joint syndrome.

One-hundred-and-fifty-four selected patients aged 19--80 years with lumbar sciatic pain of 2-week-30-year duration, treated with percutaneous rhizolysis, epidural block and acupuncture are reviewed. One-hundred-and-eighteen (76.6%) patients were significantly relieved of their pain. One-hundred-and-twenty-two patients (79.2%) underwent rhizolysis. All 154 patients had been previously treated by an orthopaedic surgeon.


Morphologic effects of pressure changes on canine carotid artery endothelium as observed by scanning electron microscopy.

By using scanning electron microscopy (SEM) we were able to follow the sequence of ultrastructural alterations of the luminal surface which occurred when specimens of canine carotid artery were subjected to controlled transmural pressures. Specimens of carotid artery were removed from dogs following fixation at experimental pressures ranging from 0 mm Hg to 100 mm Hg. The endothelium of specimens fixed at 0 mm Hg has parallel longitudinal ridges formed by the contraction of the underlying internal elastic lamina. With increasing transmural pressure, the luminal surface undergoes a gradual flattening of the endothelial ridges so that at 100 mm Hg, these ridges have completely disappeared. The observed morphologic changes of the arterial endothelium indicate that SEM can provide good ultrastructural information on blood vessels subjected to controlled transmural pressure and that the pressure-dependent alterations must be considered in studies on vascular structure and function.


The innervation of the mouse adrenal cortex.

The fine structure of the mouse adrenal cortex was examined with the electron microscope for the presence of neural elements. Several axon terminals containing mostly clear vesicles (60 nm) were noted in the vicinity (250 nm) of the capsular fibroblasts. In the subcapsular region, myelinated as well as unmyelinated fibers were commonly found. Preterminal and terminal axons were also found in close relationship to the parenchymal cells in the zona glomerulosa. Nerve bundles were the most common neural elements in the zona fasciculata. In the zona reticularis axon terminals containing both clear (60 nm) and dense core (120 nm) vesicles were seen in close proximity (30 nm) to parenchymal cells. Although this study did not delineate the type of fibers involved, the axon terminals resemble those of autonomic nerves. This study demonstrates innervation of the mouse adrenal cortex, thus corroborating similar reports by others in different species.


Fine structural differentiation of germ layers in the mouse at the time of mesoderm formation.

The morphology of early postimplantation mouse egg cylinders was studied using light and electron microscopy. Implantation sites at seven, seven and one-half and eight days of gestation were dissected from the myometrium and whole implants, including both decidua and egg cylinders were processed for electron microscopy. Pre-primitive streak egg cylinders were composed of two germ layers, a tall columnar ectoderm and an outer visceral endodermal layer. Ectodermal cells demonstrated large oval nuclei and an organelle sparse cytoplasm except for many free polyribosomes. The visceral endodermal layer was composed of two cell populations. One visceral endodermal cell type observed was tall columnar in shape and appeared absorptive as demonstrated by many microvilli, pinocytotic profiles and lysosomal granules. This population was confined to extraembryonic regions of the egg cylinder. The second visceral endodermal cell type, squamous in shape, evidenced only a few microvilli, pinocytotic profiles and lysosomal granules. This population was confined to the embryonic region of the egg cylinder. Concurrent with the formation of the primitive streak an increased number of cellular junctions and nuclear pores became evident in the ectoderm. Mesodermal cells were large and stellate-shaped exhibiting many filapodia which made contact with adjacent mesodermal elements. Later the cephalic region of the primitive streak proliferated resulting in the migration of wedge-shaped mass of cells, the head process. At the most ventral extremity of the post-primitive streak egg cylinder the cells of the head process became intimately associated with the ectoderm by areas of focal contact and gap junctions.


Morphology of the perforating cartilage canals in the proximal tibial growth plate of the chick.

Perforating canals arise exclusively from junctional canals just above the reserve zone and they do not branch after entering the proliferative zone. They are uniformly spaced and arranged in parallel array. The cartilage canals terminate near the beginning of the zone of hypertrophic cartilage cells. Vascular components within the perforating canals consist of a central arteriole surrounded by enlarged, interconnected capillaries which are individually in contact with the adjacent cartilage matrix. TEM shows that the capillary endothelium is extremely attenuated, possesses numerous fenestrations and lacks a continuous basement membrane. The central arteriole is enlarged through the midpart of the canal and then narrows to communicate with the capillaries near the bottom of the canal. The large capillaries ascend from their point of origin and recombine near the top of the growth plate to exit as a single venule. The vascular arrangement therefore describes a system in which the outgoing blood runs in close proximity, but counter to, the incoming blood. This vascular arrangement within the perforating cartilage canal would most likely allow the zone of maturing cartilage cells to receive the highest concentration of nutrients.


Transventricular blood vessels in the third ventricle of the armadillo brain.

Transventricular filaments were observed with scanning electron microscopy on the dorsolateral wall of the infundibular recess of the third ventricle of the armadillo brain. Two to seven transventricular filaments per animal were present in 6 of 18 animals. There were two types of transventricular filaments, ciliated and bare. Using transmission electron microscopy, we determined that these filaments consisted of a single, central capillary surrounded by ciliated ependymal cells and a small accumulation of axons in five animals. In one animal, a bare filament had a central capillary surrounded by a large accumulation of axons with no surrounding ependyma. The consistent location and structure of these filaments indicate a possible function for a small vascular network, as well as a possible commissural network connecting right and left hypothalami in the region of infundibular nuclei.


Survey of the morphology of the dog kidney.

Dogs are frequent subjects in experimental studies of renal physiology and pathology in spite of the paucity of information on their normal renal morphology. In this study, gross morphology, light microscopy, and scanning and transmission electron microscopy were used to describe dog renal anatomy. The dog has a multilobed kidney with the medulla fused into an elongate crest and a renal pelvis of elaborate shape. The outer zone of the medulla lacks a definitive outer stripe. The proximal tubule consists of four distinct anatomical segments. Dark cells are abundant in the collecting duct of the inner medulla. The majority of the nephron segments demonstrate remarkable similarities to those of the human kidney and less to those of the kidney of the laboratory rat.


The morphology of extrachoroidal ependyma overlying gray and white matter in the rabbit lateral ventricle.

A morphologic investigation of ependyma over gray matter (caudate nucleus) and over periventricular white matter (tapetum) of the rabbit lateral ventricle was undertaken prior to evaluation of morphological changes which occur with experimental hydrocephalus. Ependymal cells over the caudate nucleus are cuboidal and heavily ciliated. Numerous microvilli cover the cell surface. The lateral margins are straight and interdigitations between adjacent ependymal cells are absent. Ependymal cells over white matter are squamous. Nonciliated as well as ciliated cells contribute to the epithelial lining. Microvilli are present at the cell surface but tend to aggregate near the cellular borders. The lateral margins are convoluted and complex interdigitations are present between adjacent cells. Morphologic differences between ependymal cells over the caudate nucleus and those over periventricular white matter may help to explain the differential response to hydrocephalus observed in these two regions of the lateral ventricle.


[Amino acid composition of human semen from different clinical diagnoses].

The amino acid analysis of human semen shows for the different clinical diagnoses the predominant amino acids aspartic acid, serine, glycine, leucine and lysine. Analytical data indicate that there were differences in the amino acid composition between oligo- or azoospermia and terato- or asthenozoospermia by aspartic acid, glutamic acid, threonine, glycine, alanine and isoleucine.


[Average concentrations of FSH and LH in seminal plasma as determined by radioimmunoassay].

In 322 males, 25 to 50 years of age, levels of LH and FSH respectively were determined in seminal plasma by radioimmunoassay. Average values of 0,78 ng/ml and 3.95 ng/ml were found as for FSH and LH respectively. Sperm count and mortality were not related to FSH levels, but were to LH levels. A high count of spermatozoa corresponded to high concentration of LH, and normal motility was associated with higher levels of LH as compared to levels associated with asthenozoospermia. With respect to count of spermatozoa of a single or the average patient, it is suggested that the ratio of FSH/LH would be more meaningful than LH level alone.


Vitality and morphology of human spermatozoa. Studies on the resistance to storage and centrifugation and on the removal of dead spermatozoa.

The effect of storage of human spermatozoa at room temperature and in the refrigerator was studied. Loss of vitality was found to be linear and the same within the temperature range studied. Vitality was reduced by 0,9% per hour on average. The rate of this loss did not show much variation. The morphology of both all spermatozoa and the living sperm population studied separately was only slightly impaired by storage. The effect of centrifugation and resuspension of spermatozoa was studied separately. Vitality was found to be reduced by gravitation forces of 800 g for 20 minutes whereas no effect on morphology was noted by this treatment. Gravitation forces of 600 g and below did not significantly affect the spermatozoa. Two methods of separation of spermatozoa with better motility and morphology from the rest of the semen sample were studied, (1) filtration through a layer of glass beads, (2) "sperm rise" after centrifugation at low gravitation force. The clinical value of these procedures is probably limited to selected cases.


Sperm concentration in different parts of the epididymis of buffalo-bulls by micropuncture technique.

Spermatocrit values of the epididymal fluid were determined in 8 buffalo-bulls by micropuncture technique. The spermatocrit index in caput and cauda epididymidis was 42.63 +/- 0.79 and 56.13 +/- 0.94 per cent respectively. Based on this study it was calculated that 13.5 per cent of the fluid is resorbed between caput and cauda epididymidis.


In vitro studies on histochemical localization of testicular delta5-3beta-hydroxysteroid dehydrogenase activity from indomethacin pretreated rats--effect of prostaglandins and luteinizing hormone.

In vitro studies on the effect of LH and prostaglandins on delta5 3beta-hydroxysteroid dehydrogenase activity using indomethacin pre-treated testis as the experimental model, revealed a greater stimulation of the enzyme activity when the incubation medium contained LH and PGE2 both at a concentration of 1 microgram/ml in comparison to the effect produced by 1 microgram LH/ml alone, but the augmentory effect of PGE2 on testicular response to LH was not evidenced as the LH: PGE2 ratio became 1 : 10. Neither PGE2 nor PGF2A produced any stimulation of the enzyme activity at concentrations of 1, 10, or 20 microgram/ml in the incubating medium. PGF2A at concentrations of 1 or 10 microgram/ml did not appear to interfere with LH action on this steroidogenic enzyme. On the contrary, prostaglandins, both PGE2 and PGF2A, at concentrations of 20 microgram/ml, antagonized LH action over testicular delta5-3beta-hydroxysteroid dehydrogenase activity. On the basis of these findings, it appears that prostaglandin E2 in some way, is necessary for manifestation of the steroidogenic action of LH in testis.


Decline of serum phosphorus in acute myocardial infarction.

Levels of serum calcium, phosphorus, magnesium, SGOT, CPK, and LDH were measured in 61 patients admitted to a coronary care unit. In 34 the ECG and enzymes confirmed an acute myocardial infarction, whereas the remaining 27 did not have an acute myocardial infarction. The serum phosphorus declined significantly in those with the acute infarction compared to the control group. The fall was most marked in the third and fourth postinfarction day, and by the fifth day had returned to baseline values. The serum calcium and magnesium did not change significantly over the 5 days. Thus the fall in the serum phosphorus serves as a sensitive indicator of acute myocardial infarction.


Transcutaneous electrical nerve stimulation in the symptomatic management of thrombophlebitis.

Transcutaneous electrical nerve stimulation (TENS) afforded significant relief of the pain associated with acute and recurrent thrombophlebitis in 90% of 39 patients so treated. The method is simple to administer, noninvasive, and apparently free of side effects. It can be self-administered by the patient after appropriate instruction. TENS can be given in conjunction with analgesics, anticoagulant therapy, and other supportive measures to achieve greater relief and mobility in patients with thrombophlebitis whose occupations and other activities are severely limited by their pain. Further clinical trials involving larger numbers of patients, and clarification of the analgesic mechanisms involved, are warranted because of the magnitude of this problem. TENS therapy can be uniquely beneficial in certain clinical situations. They include the contraindication of conventional treatments for the pain of thrombophlebitis, pelvic vein phlebitis, and the presence of concomitant painful orthopedic and neurologic disorders.


Prognostic value of radionuclide angiography in cerebral vascular disease.

To ascertain the prognostic value of the radionuclide angiogram in ischemic cerebral vascular disease, we reviewed the results of this study in 2200 patients who underwent this procedure. The arterial phase showed decreased activity in 175 patients studied in detail during the acute phase of their neurologic illnesses. In the 120 patients who proved to have ischemic disease and persisting neurologic signs, two basic patterns appeared during the venous phase: (1) no increased (diminished or equal) perfusion, or (2) increased perfusion. Following the initial incident, the clinical course varied from no change to marked clinical improvement. In the first group with either diminished or equal venous perfusion, the chances against improvement are greater than 6:1. In the latter group the chances for improvement or deterioration are equal.


Cardiac function and hemodynamic parameters after pentaerythritol tetranitrate: assessment by a noninvasive radionuclide technique.

The availability of a relatively small computer with programming providing multiple-gated acquisition capability (MUGA) permits the measurement of ejection fraction and evaluation of ventricular wall motion without the need for invasive techniques. It is probable that the various nitrates available--nitroglycerin, PETN, and isosorbide dinitrate--have somewhat different hemodynamic effects, and that the radionuclide technique can assist in determining these differences and may help to predict which agents might be most appropriate in specific situations.


Bilateral congenital coronary artery--pulmonary artery fistulae: report of two unusual cases.

Congenital coronary arteriovenous fistulae involving both coronary arteries are rare. Those terminating in a right heart chamber or the pulmonary artery usually mimic a patent ductus arteriosus because of the presence of a continuous murmur. Since the vascular resistance is much lower in the pulmonary circuit than in myocardial capillaries, a large percentage of coronary blood flow may be directed through the fistula. Such a "steal" can cause myocardial ischemia distal to the origin of the fistula. Angina has been reported to occur. About 20% of coronary A-V fistulae are associated with other congenital cardiac anomalies.


Abdominal angina and mesenteric insufficiency.

Chronic bowel ischemia is not uncommon. If it is considered in the differential diagnosis of gastrointestinal disorders, it can be corrected surgically. In selected cases symptomatic relief can be achieved, and thus high mortality and morbidity can be prevented.


Echocardiographic findings of posterior wall false aneurysm: case report and review of the literature.

A case of angiographically proven posterolateral left ventricular false aneurysm is presented. The patient underwent successful surgery. The echocardiogram revealed large echo-free spaces behind the posterior wall of the left ventricle, delineated by pericardial echoes and lined internally by extra echoes. These echocardiographic findings are consistent with false aneurysm containing a clot. This report indicates that in patients with previous infarction and distorted cardiac silhouette, echo-cardiography may be helpful in the diagnosis of true or false ventricular aneurysm.


Anemia producing mitral valve flutter on the echocardiogram.

Thirty-four patients in sinus rhythm with anemia due to chronic renal failure and one subject with chronic uterine bleeding were studied by means of echocardiography. Six patients (18%) had major diastolic fluttering of the mitral valve, and in 4 others the fluttering was equivocal. No subject had auscultatory or other clinical evidence of aortic insufficiency. In the patient with uterine hemorrhage, diastolic mitral valve motion reverted to normal after blood transfusion. It is concluded that anemia may produce diastolic mitral valve fluttering, which is probably based on increased blood flow in this setting. Caution should be exercised in ascribing diastolic murmurs associated with uremia to aortic regurgitation when anemia is present.


Diastolic flutter of aortic valves in aortic regurgitation: a report of seven cases.

Seven patients with aortic regurgitation, manifesting diastolic flutter of the aortic valve cusps (DFAVC) in the echograms, are described. Five patients with infective endocarditis revealed coarse or fine, irregular DFAVC. Two patients with severe aortic regurgitation and a musical murmur manifested regular DFAVC with a frequency identical to that of a simultaneously recorded diastolic murmur. Of the 5 patients with infective endocarditis, 4 required urgent aortic valve replacement and 1 died. The 2 patients with musical murmurs are clinically stable without surgery. This report extends the clinical spectrum of patients with DFAVC and describes the character of the flutter in patients with muscial murmurs. Furthermore, it suggests that DFAVC is a sign of severe aortic regurgitation.


Calf blood flow and systolic blood pressure in patients with hyperviscosity of the blood.

The calf blood flow and the ankle blood pressure at rest and during post-ischemic reactive hyperemia were measured by an airfilled rubber segment plethysmograph in 5 patients with hyperviscosity of the blood. The patients had no signs of peripheral arterial disease. A normal flow and pressure pattern was obtained. It is concluded that hyperviscosity does not contribute significantly to the peripheral resistance during reactive hyperemia in the patients studied. The importance of hyperviscosity for peripheral resistance in patients with atherosclerosis obliterans is discussed.


Localization of acid and alkaline phosphatase activities in the blood vessels of normotensive and hypertensive rats.

Samples of aortae and caudal arteries from normotensive and hypertensive rats were studied for cytochemical and biochemical determinations of acid and alkaline phosphatase activities. Cytochemical examination revealed an increased amount of acid phosphatase reaction product in hypertensive samples, with extensive localization to the extracellular matrix. Alkaline phosphatase activity was localized to the plasma membrane of fibroblasts and vascular smooth muscle cells and to the extracellular matrix. Biochemical assays of enzyme activities supported the cytochemical findings, showing increased activity in aortae from hypertensive rats.


A simple technique for measuring arterial blood pressures in conscious human subjects.

A new technique for measuring blood pressure utilizes the subject's ability to sense the onset and cessation of the Korotkoff phenomenon within the artery itself. Of the readings made in this manner with a standard arm cuff 94% were found to agree within +/- 10 mm Hg with readings made with a stethoscope. And 91% of the blood pressures measured by this technique using an infant cuff on the thumb were found to agree within +/- 10 mm Hg with those measured by the same technique with a standard cuff at the brachial artery. Therefore a simple device was designed with which subjects can measure their own systolic and diastolic blood pressure by utilizing a combined syringe and cuff applied to the thumb. There was a mean systolic difference of 4.7 and a mean diastolic difference of 6.1 mm Hg between readings made on 40 subjects with the new instrument and those made with a mercury sphygmomanometer.


"Push-up palpitations": unusual presentation of ruptured chordae tendineae: a case report.

A 47-year-old man experienced palpitations and shortness of breath following push-up exercises. Because of paroxysmal atrial fibrillation and fatigue, the patient underwent investigation. Echocardiography and cardiac catheterization indicated the diagnoses of mitral valve prolapse and rupture of the chordae tendineae. This report represents the first description of such a sequence of events.


[Methods of estimation of urinary kallikrein activity (author's transl)].

Catalysing the liberation of kinins, vasodilator and sodium duiretic substances, renal and urinary kallikreins are identical. The urinary excretion of kallikrein may be evaluated by various methods, biological, radioisotopic or enzymatic, giving comparable results. Specific radioimmunoassay of urinary kallikrein in man and the rat have been recently published. Details are given of a rapid and convenient enzyme method.


[Monoaminergic theories in depressive illness (author's transl)].

The biochemical exploration in man is limited by ethical and technical factors. Results are contradictory and it is only by the mean of the antidepressants used as pharmacological tools that monoaminergic hypotheses have been made. The specificity of action of these drugs is very different from one substance to another and the post synaptic impact of the antidepressants is more important than it was thought before. Finally the monoaminergic hypothesis is too simple and cannot summarize the biochemical factors in depression.


Study of disturbed tryptophan metabolism in depressive illness.

The evidence for disturbances of tryptophan and 5-hydroxytryptamine in depression and for various mechanisms by which such disturbances could occur is discussed. Two recent relevant studies in the author's laboratory are described: a) non-esterified fatty acid and total and free tryptophan were determined in plasmas of psychiatric patients unselected with respect to psychiatric diagnosis before and after a stress situation. Retarded patients had significantly low total and free tryptophan values which correlated negatively with agitation. Total tryptophan fell significantly after stress in the non-retarded subjects. The only biochemical abnormality significantly associated with a diagnosis of primary depression was the rise of plasma non-esterified fatty acid after stress. Thus tryptophan abnormalities were associated more with psychiatric rating scores than with diagnoses. b) Determinations on plasma and lumbar and ventricular CSF from psychiatric patients undergoing psychosurgery indicate that low plasma free tryptophan concentrations are associated with decreased 5HT turnover in the central nervous system.


Blood platelets as models for central 5-hydroxytryptaminergic neurons.

Blood platelets resemble 5-hydroxytryptamine (5HT) neurons of the central nervous system (CNS) with regard to uptake kinetics of 5HT at the plasma membrane and potencies of 5HT uptake inhibitors at this membrane. Furthermore, by comparing 5HT uptake in normal and reserpinized platelets the site of action of uptake inhibitors (plasma membrane, intracellular amine storage organelles) may be determined. The specific 5HT receptors of platelets whose stimulation induces a reversible shape change of platelets seem to react to drugs in a similar way as 5HT receptors of some CNS-regions such as spinal cord, cortex and possibly reticular formation. In other CNS areas e.g. those with dense 5HT innervation and the hippocampus the 5HT receptors show a reaction to drugs which is partially different from that of the platelet receptors. In other respects e.g. the synthesis and turnover of 5HT platelets do not resemble 5HT neurons. It is concluded that platelets may be used with caution as models for 5HT-neurons with regard to some aspect of 5HT-dynamics.


[The platelet model applied to the study of depressive illness (author's transl)].

The blood platelets, which serious arguments permit one to consider as valid models of serotoninergic neurones, were studied in various types of depression and during treatment with antidepressor drugs. The modifications of several platelet parameters were analysed in particular. The level of hydroxyndoles (OH-5-tryptamine or 5-HT for example) is generally lowered. The uptake of 5-HT is also reduced with normalisation by antidepressor treatments; the fixation of mepacrine, sign of the passive uptake of bioamines, is modified in the same direction, especially, in our experience, in maniacs, with a rise during treatment with phenothiazines. Finally, among the platelet enzymes, monoamine oxidase has a reduced activity in bipolar depressed patients, certain maniac depressive psychosis, and endogenic melancholias. Other platelet parameters, (liberation or release, nucleotide levels, 5-HT bonds at membrane level, etc.) may provide in the future, interesting information. In spite of sometimes contradictory data, the platelet model may be of interest, especially from pharmacological point of view.


[Biological approach to depressive conditions: study of sleep (author's transl)].

Sleep disturbances are common in depressive states, and have been recently precised. Apart from insomnia, alterations of the organization of sleep and especially a shortening of paradoxical sleep latency, as well as modifications of slow wave sleep, have been reported. The main effect of classical antidepressant drugs is a marked decrease or a complete abolition of paradoxical sleep. However, some antidepressant drugs do not affect paradoxical sleep, and other drugs, devoid of antidepressant properties, depress markedly the production of paradoxical sleep. The investigation of the modifications of sleep in depressive states, as well as of the effect of antidepressant drugs, may contribute to a better understanding of the physiopathology of these diseases.


[Renal kallikrein: variations in relation to sodium intake and experimental renovascular hypertension (author's transl)].

When rats are submitted to diets with variable sodium, concentration, one may observe a significant increase in the excretion of urinary kallikrein and in the kallikrein activity of the renal tissue in animals in chronic sodium depletion. During experimental renovascular hypertension induced in the rat by stenosis of the renal artery, one may note a significant rise in the excretion of urinary kallikrein; no change in this excretion is observed when the stenosis is associated with nephrectomy on the opposite side. It is possible to consider interrelations between the renin-angiotensin-aldosterone system and the kallikrein-kinin system.


The clinical usefulness of a screening test to detect static pulmonary blood using a multiple-breath analysis of diffusing capacity.

We devised a screening test to detect static blood in the lungs (e.g., with pulmonary vascular obstruction or pulmonary hemorrhage). A back pressure to CO will develop in static blood as the concentration of carboxyhemoglobin increases with time, and diffusing capacity (DLCO) will decrease. Instead of obtaining a single value for DLCO, we calculated DLCO over small decrements of the exhaled vital capacity during 4 sequential breaths using a modification of a method developed in our laboratory. In each of 5 healthy subjects there was no difference in DLCO during the 4 sequential breaths in the sitting, supine, or lateral decubitus positions. However, in a patient with a proved pulmonary embolus, DLCO decreased with sequential breaths, expecially at low lung volumes. In a patient with angiographic evidence of kinking of the left pulmonary artery when he assumed the right lateral decubitus position, DLCO showed a sequential decrease in this position only. Three patients with pulmonary hemorrhage also showed decreases in DLCO during sequential breaths during episodes of active bleeding.


Prognosis in severe chronic obstructive pulmonary disease.

A long-term prognostic study of 129 patients with severe chronic obstructive pulmonary disease (initial value for forced expiratory volume in 1 sec [FEV1] smaller than or equal to 1,000 ml) is reported. Data from the patients (72 per patient) were obtained in a clinically stable phase during the first hospital admission and subsequent regular outpatient visits; the data were processed using multiple regression and discriminant analysis. Five- and 10-year cumulative survival rates were 69 and 40 per cent, respectively. Prediction of survival rate was determined mainly by the rate of decrease in initial FEV1 per year and the degree of increase of initial FEV1 after administration of thiazinamium, a bronchodilator. Initial FEV1 values per se contributed to prediction only when they were less than 450 ml. Study of the data from the individual patients showed the presence of different types of decrease in FEV1: linear, exponential, combined linear-exponential, and phasic. FEV1 sometimes remained unchanged for several years or even showed an increase. No sudden decreases were observed. The better survival rate in patients with greater reversibility of airway obstruction after administration of thiazinamium has important bearing on treatment policy. The hypothesis is put forward that the better survival rate in the present study might be the result of continuing medical care. Comprehensive treatment, provided it includes a component directed at preventing and treating reversible airway obstruction, may be of major importance in determining survival in patients with severe chronic obstructive pulmonary disease. The value of so-called dominant, survival-predicting factors is considered to be of secondary importance; their main function is to alert the physician to the fact that prognosis as concerns survival may be unfavorable and that preventive and therapeutic measures should be taken without delay.


Effect of elastase and ventilation on elastic recoil of excised dog lungs.

The effect of porcine pancreatic elastase and mechanical ventilation on tissue elastic recoil was examined in excised dog lung lobes. Lobes incubated for one hour with an elastase-buffer mixture showed a significant (P less than 0.001) left shift of the liquid-filled pressure-volume curve at all pressures measured (0 to 12 cm H2O) when compared to lobes treated with buffer only. These results suggest that the contribution of elastin to the elastic properties of lung tissue is greatest at mid-lung volumes, but that it also contributes to delimiting maximal lung volume. Elastase and buff-treated lobes were inflated cyclically with humidified air to a pressure of 20 cm H2O 6 times per min during a 16-hour period. This mechanical ventilation caused no further decrease of tissue elastic recoil. Ventilation did cause an unexpected increase in the elastic recoil of liquid-filled lobes that was significant at pressures of 4 cm H2O (P less than 0.025) or more (P less than 0.001). Elastase and buffer-treated lobes showed an almost identical rightward shift of the pressure-volume curve after ventilation when compared to the respective nonventilated control lobes. This increased recoil cannot be attributed to altered surface tension.


Effects of starvation and refeeding on lung mechanics and morphometry.

Rats receiving one fifth of their usual daily food consumption for 10 days showed a significant increase in static recoil pressure of the lung (Pst[L]) due to surface forces at low lung volumes during inflation; their tissue Pst (L) decreased significantly over the entire volume-pressure loop compared to that of control rats. After 1 week of refeeding, the surface Pst (L) returned almost completely to normal, but tissue Pst (L) remained abnormally low. In starved rats, air-space enlargement with minimal loss of interalveolar septa was associated with a significant increase in mean linear intercept and volume fraction of air spaces, and with a significant decrease in corrected internal surface area and surface fraction of air space. These alterations returned partially toward normal in the refed group. We conclude that starvation increases surface elastic forces, decreases tissue elasticity of lung, and leads to air-space enlargement; redeeding leads to restoration of surface forces without the return of tissue elasticity to normal and to less severe air-space enlargement.


Disaturated phosphatidylcholine in rat lungs with altered numbers of type II alveolar epithelial cells.

Rats exposed to 85 per cent oxygen for 9 days demonstrated an increase in lung deoxyribonucleic acid (DNA) specific acitvity for [3H]-thymidine and a significant increase in the volume of interstitial and alveolar epithelial cells. This included a 63 per cent increase in the number of Type II alveolar epithelial cells. Lamellar body volume per lung significantly increased in animals exposed to oxygen and was related to the increased number of Type II cells, because lamellar body volume expressed per Type II cell remained relatively constant and was comparable to control values. The concentration of whole lung disaturated phosphatidylcholine also increased significantly, but the concentration of unsaturated phosphatidylcholine did not increase. Concomitantly, there was a significant decrease in [32P]-orthophosphate and [14C]-palmitate disaturated phosphatidylcholine specific activity that was proportional to the increased number of alveolar epithelial Type II cells present.


Nonspecific bronchial hyperreactivity after exposure to Western Red Cedar.

A 55-year-old nonatopic man presented with a 2-year history of progressively severe conjunctivitis, rhinitis, and asthma related to exposure to freshly cut red cedar. Chest roentgenogram, lung volumes, diffusing capacity for carbon monoxide, and expiratory flow rates were normal. A histamine inhalation test demonstrated mild, nonspecific bronchial hyperreactivity. After a 35-min cumulative exposure to Western Red Cedar sawdust in the laboratory, the patient developed a late asthmatic response. Bronchial reactivity to inhaled histamine increased significantly after exposure to red cedar in the laboraotry and again after natural exposure to red cedar at work. However, on both occasions forced expiraotry volume in one sec was decreased when compared to control values. Exposure to red cedar sawdust for 15 min was repeated in the laboratory, and histamine inhalation tests were performed the day before, for 4 consecutive days after, and 11 days after exposure. Before each test, one-sec forced expiratory volume, lung volumes, specific conductance, maximal expiratory flow rates at 25 and 50 per cent of vital capacity, closing capacity, and the slope of phase III from the single-breath O2 test were measured. Six hours after exposure to cedar, all measurements documented significant airway obstruction that persisted until the second day. Bronchial responsiveness to inhaled histamine also increased on the first 2 days after exposure to cedar, but this increase persisted on the third and fourth day when all other pulmonary function tests had returned to control values. Eleven days later, the bronchial hyperreactivity to inhaled histamine had also returned to control values. In a sensitized subject, exposure to Western Red Cedar induced a transient increase in nonspecific bronchial reactivity that was present in the absence of airflow obstruction. Factors other than decreased airway caliber are probably important in this phenomenon.


Pulmonary injuries associated with acute sulfur dioxide inhalation.

This report describes an industrial accident in which 5 previously healthy persons were acutely exposed to very high concentrations of sulfur dioxide. Of these 5 subjects, the 2 with the highest exposure died immediately; histologic examination of the lungs revealed extensive sloughing of the mucosa of large and small airways along with hemorrhagic alveolar edema. The 3 survivors were evaluated with pulmonary function tests performed at regular intervals. One subject subsequently developed symptomatic severe airway obstruction unresponsive to bronchodilators; another subject developed asymptomatic mild obstructive and restrictive disease, and the third subject continued to be asymptomatic with normal pulmonary function tests. This report severe to document the histologic features of fatal exposure to sulfur dioxide and stresses the need to follow parameters of pulmonary function in the nonfatal cases.


Characterization of precipitin response to Micropolyspora faeni in farmer's lung disease by quantitative immunoelectrophoresis.

Sera from 12 patients with farmer's lung disease (FLD) drawn during an acute episode and displaying precipitins to Micropolyspora faeni were analyzed by crossed immunoelectrophoresis with an intermediate gel combined with a rabbit reference precipitate system. Forty-six precipitin arcs were identified in the reference system, and FLD sera reacted with 36 of these antigens. The FLD sera displayed significantly more precipitates and higher precipitin scores when compared with sera from 16 precipitin-positive subjectw who did not have FLD. However, there was overlap between the 2 groups, and neither measurement distinguished the 2 persons who became ill after challenge from one person who did not. Three disease specific antigens were identified that may have special relevance for pathogenesis of disease. Ten exposure-relevant antigens were also identified. We propose that these antigens be important components of a standardized M. faeni antigen preparation.


Human response to controlled levels of inert dust.

We studied nasal mucous flow, airway resistance, and subjective response in 16 young healthy subjects during 5-hour exposures to 2, 10, and 25 mg of inert dust per m3 in an environmental chamber. The dust was a fully polymerized plastic dust containing carbon black. The number of these particles in room air, expressed as a per cent of the total number of particles was 36, 41, 14, 7, and 2, respectively, for the aerodynamic size ranges less than or equal to 1.8, 1.9 to 5.3, 5.4 to 8.9, 9.0 to 12.4, and greater than or equal to 12.5 micron. No significant changes in nasal mucociliary clearance rate or nasal resistance were observed. At all dust concentrations there was a decrease in 1-sec forced expiratory volume, but not in the forced vital capacity or the forced expiratory flow during the middle half of the forced vital capacity. The nasal penetration fraction of particles was approximately 55 per cent for the smallest particles and 20 per cent for the largest particles. Discomfort was proportional to the concentration of dust, but lagged almost 2 hours behind the changes in dust concentration. The discomfort was never excessive; the main complaints were dryness in the nose and pharynx.


Histoplasmin-CYL, a yeast phase reagent in skin test studies with humans.

A yeast phase histoplasmin, designated CYL, was studied in 156 humans living in areas of the United States endemic for histoplasmosis, coccidioidomycosis, or both fungal entities. Comparisons were made with Food and Drug Administration reference mycelial histoplasmin. Among persons without concurrent spherulin sensitivity, reactor rates and sizes were the same with both reagents. Some persons with spherulin sensitivity reacted only to the mycelial reagent. Histoplasmin-CYL skin tests did not induce significant changes in complement-fixing antibody in histoplasmin-reactive subjects.


Increased pulmonary vascular permeability follows intracranial hypertension in sheep.

After reviewing the characteristics of neurogenic pulmonary edema, Theodore and Robin suggested that it was probably due to rupture of lung vessels by marked but transitory pulmonary hypertension. In this study, we have determined the effects of increased intracranial pressure in a sheep model in which we could measure the flow rate and protein content of lung lymph, and thus detect changes in pulmonary vascular permeability. We found that increasing intracranial pressure to amounts near systemic arterial pressure produced a 3-fold increase in the flow of protein-rich lymph, which indicates increased lung vascular permeability. The high permeability often developed, and always persisted, without extraordinary increases in pulmonary vascular pressure. We conclude that increased lung vascular permeability may follow intracranial hypertension and that extreme pulmonary hypertension is not a prerequisite. Our data do not permit us to exclude barotrauma to exchanging vessels as a cause of capillary damage, but do suggest that other factors, perhaps local release of permeability mediators, may be involved.


Farmer's lung in early childhood.

A 5-year-old child with classic farmer's lung disease is reported. The disease started after a flulike episode and progressed during 3 months to severe respiratory failure. The clinical features were fatigability, weight loss, recurrent fever, dry cough, pulmonary rales, and clubbing. Serologic studies for precipitins to Micropolyspora faeni were positive. The chest roentgenogram showed a ground-glass appearance with air bronchogram. The open lung biopsy material was typical for alveolitis, with minute interstitial granulomas and obliteration of lung parenchyma. The child's condition improved rapidly with prednisone therapy and avoidance of the allergen.


[X-linked familial hypophosphatemic rickets report of six cases (author's transl)].

X-linked familial hypophosphatemic rickets (X.L.F.H.R.) is one of the D resistant rickets. The inheritance pattern is related to the X chromosome. Most constant feature is hypophosphatemia. Pathogenesis is still a subject of controversy. There are three main theories: a) An abnormal vitamin D metabolism. b) Secondary hyperparathyroidism developping as a result of the diminished calcium absorption by gut. c) A primary deffect of phosphate transport al various levels. Authors study and comment six cases of X.L.F.H.R., three of which belong to the same family. Clinical, radiological and higtological findings correspond to those of severe rickets. It is a chronic disease which affects children during growth period, giving rise to deforming bones invalidism. Treatment consists on continuous administration of oral phosphate and vitamin D.


[Total anomalous pulmonary venous drainage below the diaphragm. Report of three cases and semiologic considerations (author's transl)].

Clinical, hemodynamic and pathologic findings of three patients with total anomalous pulmonary venous drainage to the portal vein system are presented. Some of the findings are emphasized because of its rarity in previous reports. These are: 1) Cyanosis was mild. 2) There was some obstruction of the foramen ovale, besides the obstruction at the portal system level. In two patients gastrointestinal bleeding and analitical evidence of renal failure, were found, both findings not previously reported to our knowledge.


[Hypervitaminosis D. Review of fifteen cases].

Fifteen cases of hypervitaminosis D in childhood are reviewed. In all of them, vitamin D was given following medical prescription. In four occasions, excessive dosage of vitamine D impaired the evolution of a previous nephropathy. The clinical, analytical, radiological and histological findings as well as the therapeutical aspects are commented. Hypercalcemia, hypercalciuria, polyuria with hypostenuria, renal failure, bone lesions and nephrocalcinosis are the most prominent features of the picture. Occasionally, arterial hypertension and glycosuria were found. Prednisone, thyrocalcitonine and phosphates were used as therapeutical means. In spite of nephrocalcinosis and renal failure generally present at diagnosis, the clinical course was rather good.


[Evaluation of mechanical ventilation in meconial aspiration syndrome].

Twenty seven newborn with serious meconial aspiration syndrome are studied. Two groups are stablish weather they require or not mechanical ventilation during evolution. When comparing various perinatal and clinical data, only the Silverman test showed statistically significant differences; pH and gases in blood during the first hours of life did not showed differences. Pneumothorax incidency in both groups was 33%. Twelve newborn required mechanical ventilation. The starting age was 24 hours of life range 3-54 hours. Most frequent indication was hipoxemia and apnea. Use of intermitent positive pressure improved PaCO2 with a light increase in PaO2 though it also increased alveolo-arterial oxygen gradient. Hipoxemia was the most relevant data in evolution of these patients. In seven cases continuous distending pressure was applied, with a light increase in PaO2 only in three patients. No patient suffered pneumothorax during mechanical ventilation. In patients with mechanical ventilation mortality was 25%. The possibility of an addition in certain cases of pulmonary hypertension with right-to-left shunting ductal and atrial is reported.


[Ventricular fibrilation in children: electrical treatment (author's transl)].

Experience on the treatment of 85 ventricular fibrillation in 20 children by transthoracic electric shock with continuous electrical current is studied. Initially an energy level of 2 W./sec./Kg., was used and obtained 95% of effectivity. 50% of patients were dead because they did not recover effective cardiac rhythm, in spite of the effectivity of desfibrillation. Authors evaluate the importance of correction of metabolic disturbances and hipoxemia as predisposing factors of ventricular fibrillation and success of treatment. They think that energy level of 2 W./sec./Kg., is efficient. Effectivity of therapy depends, mainly, on rapidity and training of the pediatric intensive care team.


[Energy metabolism of the brain in children (author's transl)].

Oxygen consumption of the human brain is of the order of 3,5 ml./minute. Since the brain of a 70 Kg. man has a weight of 1,400 g., its total oxygen consumption is close to 50 ml./minute. Thus, whereas the brain weight accounts only for about 2 percent of the body weight its oxygen consumption accounts for some 20 percent of the resting energy metabolism (BMR) of the body. Measurements in animals of different size indicates that the oxygen consumption of the mammalian brain, per unit of weight, is practically independent of body size. Accordingly, the above figure can be used to make an estimate of the fraction of BMR accounted for by the energy metabolism of the brain, in different species. The proportion of brain weight to total body weight changes during the period of growth. The brain of a new-born baby represents some 10 to 11 percent of the total body weight. Therefore, in spite of the fact that the BMR/Kg. is higher in the infant, the fraction of BMR accounted for by the metabolism of the brain, is expected to be higher in the infant and child than in the adult. The calculations presented in this paper show that the energy metabolism of the brain may account for about 50 percent of the BMR in the new-born. As indicated by our calculations the proportion of BMR accounted for by the energy metabolism of the brain decreases with age, but it still accounts for about 30 percent of the BMR at age 12 years. Our calculations also show that much of the decrease of BMR/Kg. that takes place during infancy and childhood, is due to the decrease in the proportion of brain weight to total body weight. Undernourished children tend to have higher brain weight, relative to total body weight, than eutrophic children. It has been proposed, that this fact could explain the high BMR observed in malnourished children during nutritional rehabilitation.


[Cytological and bacteriological study of the vagina in newborn in a hospital environment (author's transl)].

An attempt has been made to ascertain the percentage of bacteriological transmission in the vaginal cavity, in a series of 98 studied cases between mother and daughter. All these findings have been correlated with the hormone quantities shown in smear tests. As a result of the work carried out it has been proved that transmission does not necessary take place, from the bacteriological point of view, in spite of the fact that E. coli is the bacteria most frequently found in cultures of smears from the vagina of both mothers and their newborn daughters. Similarly it was confirmed that differences between indices and percentages of cells from the vaginal epithelium of mothers and daughters is significant and are influenced by the presence of germs, among other factors.


[Short rib-polydactyly (author's transl)].

A new case of short rib-polydoctyly, Saldino-Noonan type is described. The authors make a differential diagnosis between another forms of neonatal chondrodysplasias and point-out principal features of this entity.


Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock.

Although cardiogenic shock in acute myocardial infarction is usually associated with a critical loss of myocardium, this may not be the case in papillary muscle rupture. During the past 21 years, 13 patients came to autopsy (11 died in cardiogenic shock) with a papillary muscle rupture complicating myocardial infarction. Rupture occurred from 2 to 7 (mean, 4) days after the infarct, and survival after rupture was usually brief (median, 3 days). The infarct involved between 1% and 50% (mean, 19%) of the left ventricle, and in 10 it was less than 25%. In all instances myocardium around the mitral annulus was not infarcted. Because papillary muscle rupture occurred mostly with first infarcts (eight), involved relatively small areas of necrosis, and spared the myocardium surrounding the annulus, early mitral valve replacement should make this cause of fatal acute myocardial infarction one of the most treatable forms of cardiogenic shock.


Paroxysmal supraventricular tachycardia induction in patients with Wolff-Parkinson-White syndrome.

In 54 patients with pre-excitation, 30 (56%) had inducible A-V re-entrant paroxysmal tachycardia. Of these 30, 20 had spontaneous paroxysmal tachycardia (four also had atrial fibrillation), four had spontaneous paroxysmal atrial fibrillation, five had a history of palpitation without arrhythmia, and one was asymptomatic. In 24 patients (44%), paroxysmal tachycardia was not inducible. Of these 24, none had documented paroxysmal tachycardia, four had atrial fibrillation, none had palpitation without arrhythmia, and 11 were asymptomatic. The incidence of documented paroxysmal tachycardia was higher in the patients with inducible tachycardia (P less than 0.001). Tachycardia induction was noted in 20 of 20 patients with spontaneous paroxysmal tachycardia, eight of 12 patients with paroxysmal atrial fibrillation, five of 14 patients with palpitation and no arrhythmia, and one of 12 asymptomatic patients. The frequency of ability to induce paroxysmal tachycardia was significantly higher in both the patients with documented spontaneous paroxysmal tachycardia and the patients with paroxysmal atrial fibrillation than in the asymptomatic group (P less than 0.01).


Urinary saturation measurements in calcium nephrolithiasis.

Urinary saturation with respect to calcium oxalate monohydrate was measured in 111 consecutive patients with calcium nephrolithiasis. Each patient also was evaluated by a detailed conventional metabolic protocol. Patients with idiopathic hypercalciuria produced abnormally oversaturated urine more frequently than normal subjects and normocalciuric patients, but normocalciuric patients had unexpectedly high levels of urine saturation. Measuring levels of calcium concentration, oxalate concentration, or the chemical concentration product of calcium and oxalate in urine did not predict oversaturation. During thiazide treatment, saturation level tended to fall if it was initially elevated, whether the patient was hypercalciuric or not. Patients whose urine was not remarkably oversaturated showed no tendency to elaborate even less saturated urine during thiazide treatment; instead, the average calcium oxalate saturation level remained constant. Direct urine saturation measurements can detect a small but significant number of normocalciuric patients who have marked oversaturation with respect to calcium oxalate and appear to benefit from treatment.


Accurate measurement of liver, kidney, and spleen volume and mass by computerized axial tomography.

Computerized axial tomography permits accurate cross-sectional radiographic visualization of visceral organs. Thus, "radiographic area" of an organ slice can be calculated and converted to actual area from a standard grid printed on the roentgenogram. Because the width between slices is known, the volume of an organ slice can be calculated as area times width. Mass of the organ slice is then the product of slice volume and organ density, and entire mass of the organ is the sum of the masses of all the organ slices. The validity of this method was examined in four water-filled balloons, in 12 excised human cadaver organs (six kidneys, three livers, and three spleens), and in two human cadavers while the organs (four kidneys, one liver, and two spleens) remained in situ. Radiographic volume and mass agreed with actual volume and mass within +/- 3% to 5%, thus confirming the accuracy of this method.


Pulmonary toxicity associated with bischloroethylnitrosourea (BCNU).

Ten patients developed pulmonary fibrosis after bischloroethylnitrosourea (BCNU) therapy for malignancy. This was lethal in seven patients, four of whom had no evidence of tumor at autopsy. Presenting symptoms were either the insidious onset of cough and dyspnea or the sudden onset of respiratory failure. Physical findings were unremarkable. Chest roentgenogram usually showed interstitial infiltrates. Pulmonary function studies showed resting hypoxia with diffusion and restrictive defects. This complication of therapy does not appear to be dose related and may be made more likely by the concomitant administration of cyclophosphamide. Prednisone therapy did not benefit most patients. The literature and the implications of the use of BCNU alone or in combination are reviewed.


A case of maturity-onset diabetes mellitus resistant to insulin but responsive to tolbutamide.

A nonobese patient with maturity-onset diabetes mellitus was hospitalized for treatment of an ulcer on his right foot. During this episode, his diabetic control worsened, and he proved unresponsive to exogenous insulin. Unresponsiveness to insulin persisted after healing of the ulcer. Tolbutamide therapy was then begun and produced a marked reduction in blood sugar levels. Withdrawal of the drug was accompanied by a progressive rise in blood sugar level. Intravenous infusion of regular pork insulin at rates of 45 U/h and single-component pork insulin at rates of 120 U/h had minimal effect on the blood sugar level. High levels of antibody to beef insulin were measured, with lower levels of pork insulin antibodies. C-peptide values were in a normal range before tolbutamide treatment and increased after use of the drug.


Factitious fever and self-induced infection: a report of 32 cases and review of the literature.

We review in detail the syndromes of factitious fever and self-induced infection, with discussion of 32 cases studied at the National Institutes of Health and the extensive English language literature. In addition, we describe the nature of the underlying psychiatric illnesses and present guidelines for the diagnosis and management of these patients.


Use of laboratory tests in a teaching hospital: long-term trends: reductions in use and relative cost.

We have assessed long-term trends in the use of laboratory tests among patients hospitalized on the medical service of a large teaching hospital. A significant decline in numbers of chemistry tests and no growth in numbers of microbiology or hematology tests or roentgenograms were noted between 1970 and 1977. Per-patient increases in laboratory costs and charges were considerably less than increases in total hospitalization costs and charges. These findings contrast to an average increase of 13.8% per year in numbers of laboratory tests for hospital laboratories in this country between 1970 and 1975. Factors responsible for the observed stability in numbers of laboratory tests per patient per hospitalization included, but were not limited to, increased reliance on test batteries as opposed to individual tests; changing patterns of care leading to decreased use of nonautomated tests; and the impact of administrative and educational strategies directed toward optimum use of the laboratory.


Drug evaluation after marketing.

After marketing, drugs should be evaluated for safety and for efficacy. Present national systems are inadequate for both tasks. Safety can be evaluated by means of nonexperimental research, whereas evaluation of efficacy in a variety of settings representing normal medical practice generally requires experiments, randomized and blinded. Research into safety requires the maintenance of routine, yet flexible, multipurpose data systems, different for established and newly marketed drugs. Ad hoc studies on safety and on efficacy can be mounted more swiftly and economically through the maintenance of "standby" capabilities, in addition to maximal use of resources outside the actual national system.


Epidemic measles in young adults. Clinical, epidemiologic, and serologic studies.

An outbreak of measles at the University of California at Los Angeles provided the opportunity to study clinical, epidemiologic, and serologic characteristics of the disease in young adults in the present vaccine era. Of the 34 cases studied, 18 occurred in persons who thought they were immune. Fifteen of 19 seronegative students vaccinated during the epidemic responded with a secondary (IgG) antibody response. Antibody prevalence studies indicated that 91% of the student population had measles antibody at the onset of the outbreak, and history relating to measles correlated poorly with antibody prevalence. Of 212 adults vaccinated, 58% complained of one or more symptoms. Seventeen percent were confined to bed, and in three women vaccine-associated illness was notably severe. That measles will continue to be a problem in adults with our present national approach to immunization is predicted.


Atypical measles in adolescents and young adults.

Seven patients, aged 12 to 19 years, had atypical measles. Prodromal symptoms of fever, malaise, myalgia, headache, nausea, and vomiting were commonly followed by coryza, sore throat, conjunctivitis, photophobia, nonproductive cough, and pleuritic pain. The characteristic rash was erythematous, maculopapular, and progressed frequently to vesicular, petechial, or purpuric lesions. It initially involved palms and soles with subsequent spread to proximal extremities and the trunk, sparing the face. Six of six chest roentgenograms showed infiltrates. Findings not previously described in atypical measles included liver enzyme elevations, thrombocytopenia, disseminated intravascular coagulation, possible transmission among three siblings, and suspected cardiac involvement. Measles complement fixation titers compatible with recent infection were seen in all patients. All patients had previously received killed measles vaccine. A substantial number of persons who are older adolescents or young adults may be at risk of developing atypical measles.


Atypical measles in adolescents: evaluation of clinical and pulmonary function.

During a community outbreak of measles, 10 patients aged 11 through 19 were hospitalized with prominent pulmonary infiltrates and clinical manifestations of high fever and rash. Diagnoses of atypical measles were confirmed by hemagglutination-inhibition and complement-fixation antibody studies. Patients were followed with pulmonary function studies for 12 weeks. The most common admitting diagnoses were varicella, scarlet fever, meningococcemia, and Rocky Mountain spotted fever, due largely to the protean cutaneous manifestations. Roentgenographic studies showed diffuse, segmental, and nodular chest lesions. Hypoxemia (mean arterial Po2, 58 mm Hg) and markedly reduced lung volumes were noted. Gradual resolution of physiologic abnormalities was noted during 12 weeks, but two children had persistent nodular densities seen on chest roentgenograms. Atypical measles in the older child and young adult has a wide spectrum of pulmonary manifestations ranging from acute respiratory failure to isolated nodular lesions. Proper recognition of this syndrome will prevent unnecessary invasive diagnostic procedures.


Misleadingly low free thyroxine index and usefulness of reverse triiodothyronine measurement in nonthyroidal illnesses.

Nonthyroidal illness is frequently associated with subnormal serum thyroxine (T4) and free T4 index. To unravel the resultant diagnostic problems, we have studied several variables of thyroid function in the sera of 47 patients hospitalized with nonthyroidal illnesses and seven hypothyroid patients encountered during the same period. Of the 47 euthyroid sick patients, 18 had low T4. Among these 18, free T4 index was normal in only five, whereas free T4 concentration measured by equilibrium dialysis was normal or high in 15 and 3,3',5'-triiodothyronine (reverse T3) normal or high in all 18. Reverse T3, free T4 concentration, and free T4 index were subnormal in all seven hypothyroid patients. Thus, measurement of free T4 index may be misleading in evaluation of thyroid function in patients with nonthyroidal illnesses, whereas measurement of serum concentration of reverse T3 and free T4 is quite discriminating.


Heat intolerance in former heatstroke patients.

Nine young men who had suffered from heatstroke on previous occasions (heat-intolerant subjects) and 10 young volunteers (control subjects) were examined to determine their physiologic responses to exercise in temperate (23 degrees C) and hot environments (40 degrees C). The tests included an orthostatic test, work loads of 40 W and 80 W, and oxygen consumption (Vo2) determination. Although all the control subjects completed the exercise under severe heat load (3 h), none of the heat-intolerant subjects succeeded in completing this test due to high rectal temperatures and high heart rates. Sweat rates were similar in both groups, with Vo2 slightly higher in the control subjects. Orthostatic responses were similar in each group. The results suggest that inefficient thermoregulation, possibly due to decreased heat conductance from core to periphery, contributes to heat intolerance in former heatstroke patients.


Bromocriptine and endocrine disorders.

Bromocriptine, a dopaminergic agonist, has been used to treat many endocrine disorders. In hyperprolactinemia associated with galactorrhea, amenorrhea, oligospermia, and impotence, bromocriptine reduces prolactin levels to normal and allows for satisfactory return of sexual and reproductive function in 90% of patients. In acromegaly, bromocriptine brings about subjective improvement in 75% of patients with reduction in growth-hormone levels to normal in 22% of patients. Bromocriptine has been used in premenstrual tension, functional infertility, Nelson's syndrome, and Cushing's disease with variable benefit. In low doses, side-effects are minimal. In higher doses, digital vasospasm and gastrointestinal bleeding have occurred. Although bromocriptine has been used in a wide variety of endocrine disorders, it appears to be most useful in treatment of male and female infertility associated with hyperprolactinemia.


Sociologic influences on decision-making by clinicians.

Recent articles on clinical decision-making have proposed sophisticated quantitative methods for improving the physician's clinical judgment. Actual clinical decisions, however, are influenced by interactions between the clinician, the patient, and the sociocultural milieu as well as by biomedical considerations. This paper explores these sociologic influences on the decision-making process. Four types of sociologic factors influence the clinician's judgment: the characteristics of the patient; the characteristics of the clinician; the clinician's interaction with his profession and the health care system; and the clinician's relationship with the patient. To illustrate sociologic influences on clinical decision-making, this paper presents observations from the literature of sociology, clinical psychology, psychiatry, and medicine. Further studies are needed to provide additional empirical information.


A national study of internal medicine and its specialties: I. An overview of the practice of internal medicine.

A nationwide study of 24 medical and surgical specialties has been conducted by the University of Southern California School of Medicine, Division of Research in Medical Education. This article is the first in a series reporting findings for general internal medicine and 10 subspecialties of internal medicine. Populations for these 11 specialties are defined and enumerated, and the specialties are compared in terms of demographic and geographic distribution. Practice comparisons are presented based on characteristics such as workload, allocation of professional time, location of encounters with patients, distribution of primary problem diagnoses, and projections of annual patient encounters. Forthcoming specialty-specific articles will present highly detailed information for general internal medicine and for the subspecialties of cardiology, gastroenterology, pulmonary disease, allergy, hematology, endocrinology, nephrology, medical oncology, rheumatology, and infectious diseases.


Minute perilymph fistulas: vertigo and Hennebert's sign without hearing loss.

The clinical entity characterized by episodic vertigo and a positive Hennebert's sign in patients without hearing loss is described. The history of perilymph fistulas is reviewed. Minute perilymph fistulas of the oval window were documented surgically in five consecutive patients with this syndrome. All experienced relief of their symptoms after surgical correction.


Completion laryngectomy.

From 1965 to 1975, 452 total laryngectomies were performed at the Washington University Medical Center, St. Louis, Missouri. Forty-two or 9.4% were completion laryngectomies. Completion laryngectomy is defined as the removal of the remaining larynx following an antecedent partial laryngectomy. These 42 cases are retrospectively analyzed in regards to original conservation surgery, clinical presentation, histopathology and salvage rate. The most common indications for completion laryngectomy were : 1) local recurrence, 2) local recurrence with associated severe upper respiratory obstruction, and 3) fistula control. The overall salvage rate following completion laryngectomy was 55% (23 patients). The highest rate was in patients with previous hemilaryngectomy (69%), followed by subtotal supraglottic laryngectomy (44%), and partial laryngopharyngectomy (14%). There is a high incidence of stomal occurrences (24% or 10 patients) associated with completion laryngectomy, particularly in patients with anticedent hemilaryngectomy. Most indications for completion laryngectomy present early, however, all patients must be carefully followed. Both the patient and the otolaryngologist must be ever vigilant following conservation surgery.


Treatment of syphilitic hearing loss. Combined penicillin and steroid therapy in 29 patients.

Twenty-nine patients with presumed syphilitic hearing loss, either congenital or acquired, were treated on one or more occasions according to a three-month protocol using penicillin and prednisone. Changes in hearing were carefully followed during treatment and for at least one year thereafter. Of 58 ears studied in 29 patients, 19 demonstrated significant partial improvement in hearing during treatment. However, 11 ears returned to pretreatment hearing levels after therapy, and only 8 ears, or 15%, maintained the hearing gains one year later. Enhanced discrimination occurred more commonly than gains in pure tone threshold. Long-term alternate day prednisone therapy was required to sustain hearing improvement in a small number of patients.


Intralabyrinthine schwannoma.

Two cases of unsuspected intralabyrinthine schwannoma are reported and the literature is reviewed. The mean age of the patients was 56 years, with the most common symptoms being hearing loss, dizziness, and tinnitus. All patients demonstrated a profound sensorineural hearing loss with low discrimination scores, and recruitment was elicited in two patients. A radiographic evaluation was negative in all but one case. Five of the six patients had a preoperative diagnosis of Ménière's disease. Transcanal labyrinthectomy was employed to remove tumor in all patients. This review suggests that a patient, presenting with symptoms of atypical Ménière's disease and negative radiographic evaluation, should alert the surgeon to the possibility of an intralabyrinthine schwannoma.


Malignant transformation of tracheobronchial juvenile papillomatosis without prior radiotherapy.

Squamous cell carcinoma of the trachea and bronchi developed in a 19-year-old male with recurrent laryngeal papillomata since age four, who had received no prior radiotherapy, but who was tracheotomized for obstructive laryngeal papillomata. Treatment with intravenous cytosine arabinoside, "moderate dose" methotrexate, topical 5-fluorouracil and irradiation failed to alter tumor growth, and the patient succumbed to recurrent arterial tumor emboli.