Free-running circadian plasma cortisol rhythm in a blind human subject.

The plasma cortisol rhythm in man has been presumed to be an endogenous circadian rhythm, synchronized by some external stimulus to an exact 24-h period. Sleep/wake and 'social activity' cycles have been considered as candidates for this synchronizer. Previous studies have suggested that the dark/light phase shifts associated with the sleep-wake cycle may be the external synchronizer, rather than the sleep/wake cycle itself. A totally blind, but otherwise normal subject was studied for a period of 50 days. Her hourly sleep/wake status and hourly integrated mean plasma cortisol concentrations were determined, and the data were subjected to non-parametric mathematical analysis. The subject was found to have a free-running rhythm in plasma cortisol with a period of approximately 24.5 h. Her sleep/wake rhythm, determined by similar analysis, had a period of exactly 24 h. In addition to the dominant 24.5-h cortisol rhythm, there appeared to be a minor 24-h cortisol rhythm with a peak that coincided approximately with the time of awakening. It was not possible to determine whether this sleep/wake-related peak represented a minor component of the circadian rhythm, synchronized by some stimulus associated with sleep/wake activity, or merely an acute response to awakening itself. Nevertheless, the two rhythms exhibited 'beating' behaviour, resulting in maximal peak cortisol concentrations when they were in synchrony and minimal peak concentrations when they were not. It is concluded that environment dark/light phase shifts are the dominant synchronizer of the circadian rhythm in plasma cortisol concentrations in man, as they are for a variety of circadian rhythms in other living things.


Rapid conversion of carbimazole to methimazole in serum; evidence for an enzymatic mechanism.

Carbimazole (CBZ) is one of the major drugs currently used for the treatment of Graves' disease. It is a carbethoxy derivative of methimazole (MMI), originally developed in the hope of obtaining a longer acting drug than methimazole. In the present study we have demonstrated that carbimazole is rapidly converted to methimazole in vitro by serum from rats and humans, and we have obtained evidence that this conversion is enzymatic. Experiments with [35S] CBZ in rats showed that the drug is so rapidly transformed to MMI after i.v. injection (within 3 min) that very little of the unchanged drug would be expected to reach the thyroid gland. The antithyroid action of CBZ in rats, therefore, can be ascribed entirely to the MMI to which it is rapidly converted. Although no experiments were performed with human subjects in vivo, the very rapid conversion of CBZ to MMI by human serum in vitro suggests that the antithyroid action of CBZ in humans can also be attributed to MMI. The original expectation of a longer acting drug has, therefore, not been met by CBZ. On the basis of the studies reported here there appears to be no advantage in using CBZ in preference to MMI for the treatment of Graves' disease. Although the in vivo action of CBZ must be attributed to its rapid conversion to MMI, the drug does possess inherent antithyroid activity. This was shown in the present study by the finding that CBZ is as potent as MMI in blocking thyroid peroxidase-catalysed iodination of thyroglobulin.


Human growth hormone (hGH) stimulation tests: the sequential exercise and L-dopa procedure.

Forty-eight normal volunteers, thirteen subjects with short stature without apparent cause and thirty-one patients with delayed growth clinically highly suggestive of growth hormone deficiency (GHD), with chronological ages of 11.4 +/- 0.4 years (mean +/- SEM), 14.0 +/- 0.7 years and 12.8 +/- 0.8 years; height age of 11.0 +/- 0.4 years, 8.9 +/- 0.7 years and 6.3 +/- 0.4 years and bone age of 10.7 +/- 0.7 years, 9.9 +/- 0.8 years and 7.5 +/- 0.7 years respectively, were tested with provocative tests of human growth hormone (hGH) release-insulin-induced hypoglycaemia, arginine infusion, L-DOPA, exercise and sequential exercise and L-DOPA--in order to identify growth hormone deficiency. In the 'normal' subjects (control plus short stature) the sequential exercise and L-DOPA test induced the greatest peak and integrated secretion rates of plasma hGH (16.5 +- 1.2 ng/ml and 679 +/- 70 ng/ml/120 min respectively) when compared to other tests. This combined stumulus was the only one to which all 'normal' subjects responded: a similar degree of responsiveness has not been earlier described for other hGH-stimuli. The responses observed with all stimuli were significantly lower (P less than 0.001) in GHD group compared to the 'normal subjects'. Emphasis was given to the sequential exercise and L-DOPA test as an innocuous, sensitive and simplified procedure in the evaluation of children with growth retardation.


Deliberate hypotension in ENT surgery.

The development of deliberate hypotension for ENT surgery is described. A hitherto unrecorded case of paraplegia complicating hypotensive anaesthesia is reported. The use of sodium nitroprusside as a hypotensive agent is assessed. Indications and contraindications to deliberate hypotension are reviewed. Possible neurological damage is considered.


Otosclerosis and pregnancy: a study of the influence of pregnancy on the hearing threshold before and after stapedectomy.

In a retrospective study of 144 fertile women subjected to operation for otosclerosis by the method of Shea or House, we found a fall in the hearing threshold in the operated ear which seemed to be a little greater in the patients who became pregnant after the operation than in those who did not. However, the hearing loss was significantly greater in the non-operated ear in the patients who became pregnant after the operation than in those who did not.


The occurrence of secretory otitis media in allergic children.

One hundred and forty-four ears (72 patients), forming part of the computer controlled respiratory allergy group of the University of Turku, were analyzed with tympanometry and audiometry to diagnose secretory otitis media. Effusion  was found in 3 ears (2 patients) and a pathological tympanogram in a total of 15 ears (10 patients). The incidence of secretory otitis media was 3% and of pathological tympanograms 14%. This study supports the opinion that immediate allergy is not an aetiological factor in secretory otitis media.


Perineural spread in squamous cell carcinomas of the head and neck: a clinicopathological study.

Perineural spread of tumour has been demonstrated in 24% of an unselected series of 70 patients with squamous carcinomas of the head and neck treated by surgery. Slightly more than half the patients had primary tumours arising within the buccal cavity. Clinical features suggesting perineural infiltration were found in about two thirds of the cases; the symptoms and signs were usually sensory and occurred early in the disease. The mandibular division of the trigeminal nerve was most commonly affected. Perineural spread was more likely to occur with large carcinomas, moderate or poorly differentiated, showing local invasion and lymph node metastases. The associated pathological changes are described and a high incidence of damage to nerve fibres is recorded. The practical implications of perineural spread of tumour are discussed with reference to indications for more radical surgery or for more conservative measures supplemented with other modes of treatment.


The forehead flap: a modification in technique.

The use of the forehead flap for reconstruction within the oral cavity after tumour resection is discussed. A minor modification in technique is described. The sub-zygomatic route to the oral cavity is used and a piece of teflon or sialalastic sheet is sewn over the raw surfaces of the flap which lies within the tunnel in the cheek to facilitate retrieval of the pedicle.


Hallervorden-Spatz disease.

We had the opportunity to study a family, five of whose members were affected by the Hallervorden-Spatz disease (three males and twin girls). The characteristics of the condition were analyzed and compared with those cases considered by other authors to be affected by the condition. Intrafamilial and interfamilial variations were analysed, and it was the latter that contributed most to the overall variation of the condition. It was clearly established from the reported cases and our family that this is an autosomal recessive condition (P greater than 0.23 +/- 0.08). It is suggested that the condition probably originated in Europe and that it is caused by an inborn error of metabolism related to neuromelanin and the dopaminergic system. The condition affects the muscular tone and voluntary movements progressively, making voluntary coordinated movements, and chewing and swallowing almost impossible, and in the last part of its development mental deterioration, emaciation, severe feeding difficulties and visual impairment are common clinical manifestations. The ages of both onset and death are distributed in a unimodal curve. The mean survival time after diagnosis was 11.18 +/- 7.8 years.


Partial trisomy 12q associated with a familial translocation.

A case is described of a female infant, who was trisomic for the terminal bands of the long arm of chromosome 12. Congenital abnormalities were present. Cytogenetic analysis on the proband's parents revealed the father to have a rare, simple translocation involving chromosomes 12 and 18.


Counseling problems when twins are discovered at genetic amniocentesis.

With the increased use of routine ultrasonography at the time of genetic amniocentesis, twins are increasingly likely to be discovered at the time when the procedure is to be carried out. In the presence of twins the likelihood of finding an abnormality may be significantly increased, but at the same time problems such as discordance between the twins for the abnormality, or the inability to test both twins may occur. This altered situation may affect the parents' decision  as to whether or not to undertake amniocentesis, and the need for additional counseling prior to proceeding with the amniocentesis is stressed.


Alcohol metabolizing enzymes: studies of isozymes in human biopsies and cultured fibroblasts.

Rapid and sensitive micromethods for the study of alcohol dehydrogenase and adehyde dehydrogenase isozymes in skin extracts, cultured fibroblasts and other organs are presented. Possibilities for the application of these techniques to the study of interindividual variations in response to alcohol are discussed. While fibroblasts cultured from a skin biopsy from one Japanese individual revealed a heterodimer (ADH2 2-1) of alcohol dehydrogenase, skin extract from another Japanese showed a homodimer (ADH2 2-2). Up to four isozyme sets for aldehyde dehydrogenase (ALDH) were detected in various human organs and at least three sets were found in skin and fibroblasts extracts. Our preliminary data on liver, stomach, and skin indicate that ALDH is polymorphic and several loci are concerned in the determination of these isozyme sets.


Distal trisomy 17q.

A 3-year-old, male patient with trisomy 17q231qter due to a paternal t(5;17)(p151;q231) is compared to three other patients reported in the literature who are trisomic for the same segment due to a familial t(17;21)(q23;q22). The features common to the four patients are: profound mental retardation; dwarfism; frontal bossing and temporal retraction; narrow squinty eyes; thin lips with overlapping of the lower lip by the upper lip; very low-set and abnormal ears; cleft palate; and hyperlaxity of the ligaments. It thus seems possible to delineate a new cytogenetic syndrome.


Chromosomal variants in mentally retarded and normal men.

The possible phenotypic effect of chromosomal variants is as yet an unsolved problem. QM- and C-banded chromosomes of 100 male patients with idiopathic mental retardation were compared with chromosomes of 100 Royal Military College cadets, as controls. Increased size of 9qh seems to be a factor with possible negative effects. 9qh- was found to be more common in the control sample. Another variant found more often in the retarded subjects was 16qh-. Increased frequencies of Yq+ or small inversions in chromosomes 3 and 9 were not found in the retarded.


Catecholamine metabolism in familial amyloid polyneuropathy.

In order to evaluate the involvement of the peripheral autonomic nervous system in the pathogenesis of type 1 familial amyloid polyneuropathy, the urinary excretion rates of catecholamines and serum dopamine-beta-hydroxylase (DB/) activity were examined in 22 patients at various clinical stages. Changes in both indices were closely linked to the progression of the illness; urinary excretion rates of catecholamines were first decreased in patients suffering from moderate autonomic dysfunction, while serum DBH activity was significantly reduced only in patients with far advanced disease. These findings suggested that patients with advanced disease might be suffering from a chronic deficiency of catecholamines in the peripheral sympathetic nerves. Administration of L-dopa, however, failed to improve the clinical manifestations.


Evolutionary conservation of large chromosomal segments reflected in mammalian gene maps.

Conservation of genetic linkage over long periods of time is exemplifted. Comparisons are made between chromosomal regions in different species as well as within two species, man and the house mouse. Homologous regions are defined and the phenomenon of differential silencing of genes is described. The importance of conservation of particular sequences of genes is discussed in relation to medical genetics, animal breeding, evolutionary theory and genetic regulation.


Anthropometry in the Cri du Chat syndrome.

Anthropometric and cranial X-ray measurements of 35 individuals with a 5p- karyotype showed a general growth retardation. Height, weight, circumference of the thorax, pelvic breadth, and the size of the skull, face, hands and feet were all subnormal. Only the inner canthal distance was moderately increased, especially in young individuals, but there was no true hypertelorism. The palate was not high-arched. Large and small terminal deletions produced much the same anthropometric features; and the proband's sex did not have a major influence. Age variations within parameters examined followed the developmental pattern of normal individuals. A certain phenotypical variation in the Cri du Chat syndrome may therefore be attributed to normal changes or to intrapersonal conditions.


Immunological features of juvenile onset diabetic patients correlated to HLA type.

Ninety-six juvenile onset type diabetics showed an increase in the frequency of HLA B8 and B15 and a decrease in frequency of HLA B7 antigens. Sixty-four maturity onset diabetics showed no disturbance in the frequency of these antigens. Fifty-four of the juvenile onset type diabetics, with an average duration of disease of 3.2 years were tested for the presence of islet cell antibodies (ICAs). Thirty-two per cent were positive, the incidence decreasing from 70% in those patients tested within 1 year of diagnosis to zero in those patients tested within 1 year of diagnosis to zero in those patients tested more than 5 years after diagnosis. No correlation was found between the incidence of ICAs and either cell-mediated immune reactions or HLA type. B15 positive patients were associated with cell-mediated immune reactions to pancreatic antigens and with the presence of other tissue autoantibodies. HLA phenotypes were not associated with environmental data. Diabetic siblings had identical HLA A-B haplotypes more often than could be expected to occur by chance.


Goodpasture's syndrome--effects of plasmapheresis.

Two patients with Goodpasture's syndrome, who underwent plasmapheresis are presented. One patient received prednisone but the other patient received no concomitant cytotoxic therapy. Results indicate that plasmapheresis reduces morbidity in patients with Goodpasture's syndrome. The possible mode of action of plasmapheresis is discussed. The use of cytotoxic  therapy as an adjunct to plasmapheresis may not be necessary since the anti-GBM production appears to be a self-limiting process.


Intravenous immunoglobulin therapy for antibody deficiency.

Twenty patients with antibody deficiency were treated at random with either intramuscular immune serum globulin (ISG) or intravenous modified immune serum globulin (M-ISG). Fourteen patients received of 259 M-ISG infusions during 242 months of treatment. Catastrophic vasomotor reactions were not observed. A single dose of 150 mg/kilo M-ISG increased serum IgG values a mean 248 mg%. Intravenous M-ISG therapy was effective in reducing the incidence of acute infections. Subjects receiving M-ISG developed 0.103 acute infections per month of treatment. Patients injected with ISG had 0.295 acute infections per month of treatment. Seven subjects had separate courses of both intravenous M-ISG and intramuscular ISG. Acute infections per month of treatment for M-ISG and ISG were 0.104 and 0.406, respectively.


Transfer factor and hepatitis B: a double blind study.

A prospective, double blind placebo-controlled trial was carried out on twenty-nine patients with hepatitis B. Thirteen received transfer factor and sixteen placebo. There were no significant differences between the two groups in any clinical or laboratory measurements made, although a rapid early reduction of serum aspartate transaminase levels by transfer factor is possible. Similarly, no significant changes were delineated by the in vitro measurements of lymphocyte function. Transfer factor did not alter the natural course of hepatitis B.


A comparison of two 125I C1q binding tests to detect soluble immune complexes in serum of patients with malignant disease.

The 125I C1q deviation test and the modified 125I C1q PEG precipitation test were compared in their ability to detect soluble immune complexes in serum using a model system of HSA-rabbit-anti-HSA, and were then applied to sera collected from patients with malignant and non-malignant conditions. Despite close agreement in the model system, the two tests gave divergent results for the presence of C1q binding substances in individual serum samples collected from patients. The inherent complexities of interpreting C1q binding in serum, in terms of the presence of soluble immune complexes, makes it questionable whether either test can be relied upon to provide a means of identifying these complexes in the sera from patients with malignant disease.


Maternal smoking and cord blood immunity function.

Thymidine uptake in PHA-stimulated culture of cord blood cells from smoking mothers is greater than that from non-smoking mothers. There was no such difference when separated lymphocytes were studied; this suggests that smoking suppresses a suppressor cell. No difference was detected in haemoglobin, immunoglobulins, transferrin, cell counts, E-rosette counts and leucocyte mobility.


The effect of cortisone acetate on pulmonary lesions in a rabbit model of hypersensitivity pneumonitis (cortisone and hypersensitivity pneumonitis).

Rabbits were sensitized with Micropolyspora faeni by intratracheal inoculations and later challenged with the same antigen either with or without parenteral administration of cortisone acetate prior to challenge. Animals developed anti-M. faeni serum precipitins, M. faeni-induced alveolar macrophage migration inhibition, and positive 48-hr skin reactivity to M. faeni. Sensitized animals also demonstrated an augmented pulmonary histopathological response following respiratory challenge with M. faeni when compared to non-sensitized controls. Cortisone acetate abrogated this augmented pulmonary histopathological response following challenge with M. faeni. Cortisone acetate also abolished the positive alveolar macrophage migration inhibition found in sensitized animals.


Influence of supernatants from polymorphonuclear leucocytes on blastogenesis of syngeneic and allogeneic murine splenocytes.

Supernatant was produced from activated peritoneal polymorphonuclear leucocyte-rich cell populations from different strains of mice. These supernatants were studied for their ability to modify spontaneous and mitogen-induced blastogenesis of syngeneic and allogeneic splenocytes. Our results indicate that polymorphonuclear leucocyte-rich cell cultures from two strains of mice, A/J and BALB/c, produced a supernatant that could enhance PHA-induced blastogenesis of syngeneic and allogeneic splenocytes. Cells from a third strain C57B1/6, did not produce an active supernatant. In general, the response by splenocytes from these three strains paralleled the production of active supernatant that we observed. The response to the active supernatant was dependent upon the mitogen stimulation of the splenocytes, the mitogen dilution and the supernatant activity. These functions are believed to be genetically determined.


Electrophoretic behaviour of blood and synovial fluid lymphocytes in rheumatoid arthritis.

Probit analysis of the electrophoretic mobilities of human blood lymphocytes identifies at least three main subpopulations. According to their rate of movement in an electrical field, the subpopulations are referred to as the fast, intermediate and slow cell distributions. Lymphocytes of the fast and intermediate populations appear to be T cells, while the slow cell population includes cells with B cell characteristics. Compared with normal subjects, lymphocytes of intermediate mobility are significantly increased in the blood of rheumatoid patients and comprise a major fraction of the lymphocyte exudate in rheumatoid synovial fluid.


Impaired neutrophil chemotaxis in Pelger-Huët anomaly.

A family has previously been described in which four members with Pelger-Huët (P-H) anomaly suffered from recurrent attacks of abdominal pain and fever, while one member, whose polymorphonuclear leucocytes (PMNs) were also hyposegmented, was asymptomatic. We studied chemotaxis, chemokinesis and spontaneous locomotion of PMNs in the three surviving symptomatic sisters, in their asymptomatic brother and in two asymptomatic members of another family with P-H anomaly. The spontaneous migration of the PMNs of the three sisters was significantly slower both under agarose and in a membrane filter than that of the PMNs of the asymptomatic patients with P-H anomaly. Chemotactic and chemokinetic locomotion of the PMNs of the symptomatic sisters was also slow. Our results suggests that the impaired chemotaxis was due to a defect in the intrinsic locomotor capacity of PMNs rather than in their deformability or their responsiveness to the chemotactic stimulus.


Elevated serum levels of a biliary glycoprotein (BGP I) in patients with liver or biliary tract disease.

Human hepatic bile contains a glycoprotein (biliary glycoprotein I, BGP I) which cross-reacts with the carcinoembryonic antigen (CEA). A radioimmunoassay for BGP I was developed. The interference of CEA or 'non-specific cross-reacting antigen' (NCA) in the assay was small. The serum levels of BGP I were determined in healthy subjects, in patients with hepato-biliary diseases and in patients with various infectious or inflammatory disorders. Healthy individuals, including pregnant women, had a serum BGP I concentration of about 0.5-1 mg/l. Diseases of the liver or biliary tract (e.g. hepatitis A or B, cytomegalovirus hepatitis, obstructive jaundice or primary biliary cirrhosis) were associated with elevated serum levels of BGP I, as opposed to infectious diseases not affecting the liver mostly showing values within the normal range. Raised levels of serum BGP I activity may reflect biliary obstruction as a result of interference with normal BGP I secretion to the bile.


The time of day of antigen encounter influences the magnitude of the immune response.

Studies in the rat and in man have shown that the time of day at which an antigen is encountered has an influence on the expression of any subsequent cell-mediated immunity, when the response is measured after a fixed interval. This suggests that immune processes are modulated by intrinsic biological rhythms. Experiments are now reported in which sensitized rats were ear-challenged with oxazolone and studied at intervals during the delayed hypersensitivity reaction. These show that differences in the expression of immunity due to the clock time of challenge became apparent at an early stage and were still present after the maximum response, assessed by the change in ear thickness. The experiments also show that the circadian variations in antigen responsiveness are present during the second recall of immunity and can be manipulated by altering the lighting regimen. The light-dark cycle is often a synchronizer for biological rhythms, although its precise role in the oxazolone system remains to be evaluated. This study demonstrates that phase reversal of the lighting regimen alters the proportions of lymphocytes present in rat blood at two clock times, one of which is the time of day at which the maximum immune response to oxazolone is initiated.


Pseudohypoaldosteronism.

Three children, two of whom were siblings, had pseudohypoaldosteronism. The features of this condition include failure to thrive, hyperkalemia, metabolic acidosis, salt wasting, elevated peripheral renin activity, and increased plasma aldosterone concentration. Hyperplasia of juxtaglomerular apparatus was seen in a renal biopsy specimen from one of these patients. Administration of large quantities of salt normalized the serum electrolyte abnormalities and permitted normal growth. Furthermore, the serum electrolyte abnormalities were prevented by administration of increased amounts of salt to one of these children from birth.


Bicarbonate hemodialysis using a sorbent regenerative system.

In light of the concern about the use of acetate in dialyzate a simplified means of performing acetate-free hemodialysis has been developed using the sorbent regenerative system (RED). Fifteen sorbent bicarbonate hemodialyses free of acetate were performed on two patients for 4 or 6 hours. The initial dialyzate mixture contained 135 mEq/l NaHCO3 only. The infusate cations of K, Ca and Mg were in the form of chloride salts. A 30-minute titration of the sorbent cartridge with the bicarbonate dialyzate was necessary to release the excessive hydrogen ion from the cartridge which allowed the dialyzate bicarbonate to stabilize. The dialyzate Na fell during titration but rose during dialysis. The dialyzate Cl rose throughout titration and dialyses. The plasma bicarbonate rose significantly by the end of 4 and 6 hour dialyses. The blood pO2 and pCO2 did not change during dialysis and a significant rise in blood pH resulted. We conclude that bicarbonate dialysis is feasible and relatively easily accomplished in the sorbent system.


Serum C-peptide in renal failure patients following stimulation of pancreatic secretion.

We have demonstrated persistently elevated serum C-peptide concentrations in patients with chronic renal failure on chronic hemodialysis. A blunted serum C-peptide response to intravenous glucose, glucagon and tolbutamide was also found. However, the response to oral glucose stimulation was greater and more prolonged than in control subjects, probably related to the magnitude of hyperglycemia found in patients with chronic renal failure. These observations suggest the existence of a defect in the renal clearance of C-peptide although an abnormality in C-peptide secretion cannot be excluded.


The Ask-Upmark kidney in a premature infant.

A premature infant with segmental hypoplasia of one kidney is reported. Since 1929 when Ask-Upmark first reported this renal anomaly and its association with hypertension, the nature of the lesion has remained in doubt. The question whether it is acquired post-natally or whether it is a developmental mal-formation has not been resolved. The case which we now report clearly documents the prenatal development of the lesion as well as its association with arrested nephrogenesis and the presence of abnormal vasculature. The cause of these changes is not clear, but it is suggested that ureteral reflux was present.


Inconsistency in radiographic evaluation of progressive renal osteodystrophy.

Five radiologists graded 49 series of bone X-rays of 20 patients with chronic renal failure treated by hemodialysis. There was a high incidence of osteodystrophy which progressed identifiably over intervals exceeding 12 months. The severity grade of osteodystrophy was poorly reproducible among patients, among radiologists, and even between interpretations by the same radiologist after an interval of 10 months. Although the severity of osteodystrophy correlated with serum alkaline phosphatase values, the latter was not an accurate predictor of the severity of the bone lesions. Radiographic reassessment at intervals of one year or less in the asymptomatic patient has less reproducibility than the anticipated changes. More sensitive and reliable techniques are recommended.


Inadequate removal of methanol and formate using the sorbent based regeneration hemodialysis delivery system.

The sorbent based hemodialysis delivery system was shown to be ineffective for the treatment of methanol intoxication. Clinical and in vitro studies showed rapid saturation of the sorbent cartridge for methanol and formate adsorption. Methanol and formate clearances were four fold less than achieved with the recirculating single pass delivery system. The sorbent delivery system should not be used for methanol intoxication.


The influence of several factors that intervene in hemodialysis on serum levels of triglycerides and free fatty acids.

The effect of the administration of heparin and glucose, in doses and sequence similar to those of hemodialysis, on serum free fatty acids and triglycerides, was studied in eight patients with chronic renal failure who had not undergone hemodialysis. The results are compared with the action exerted by hemodialysis on the same parameters. During hemodialysis, the values of triglycerides are not significantly different from those obtained at similar intervals after the administration of glucose and/or heparin, with the exception that the values obtained five hours after beginning hemodialysis are lower than those obtained five hours after the administration of glucose (P less than 0.005). The levels of free fatty acids obtained during hemodialysis are higher (P less than 0.005) than those found during the other tests. The possible origin of these high fatty acid values is discussed, and the possibility that they originate from the acetate in the dialysis liquid is suggested.


Aluminum, zinc and copper concentrations in plasma in chronic renal insufficiency.

Plasma aluminium, zinc and copper were determined in 68 patients with chronic renal insufficiency and in 20 healthy individuals. In the renal insufficiency group 16 patients had received aluminium containing substances particularly phosphate binding drugs (aluminium hydroxide) for a long time. We observed that only the patients taking aluminium hydroxide showed elevated aluminium levels in plasma (controls: 0.86 +/- 0.27 mumoles/l; renal insufficiency: 3.05 +/- 1.63 mumoles/l). In two of these patients with symptoms of "dialysis dementia", plasma aluminium concentrations were markedly increased. The zinc concentrations in plasma of patients with renal insufficiency were slightly decreased (controls: 14.48 +/- 2.65 mumoles/l; renal insufficiency: 11.77 +/- 2.35 mumoles/l); the plasma copper concentrations were slightly increased (controls: 17.3 +/- 2.83 mumoles/l; renal insufficiency: 22.98 +/- 4.7 mumoles/l). There was a distinct decrease of plasma zinc concentrations in patients with raised aluminium levels. The clinical aspects of these changes are discussed.


Incidence and significance of rising blood acetate levels during hemodialysis.

Recent work suggests that rising arterial acetate levels occur in some patients undergoing hemodialysis and that they may be responsible for some dialysis problems, particularly cardiovascular instability. Blood acetate levels and acetate flux rates have been determined in 20 adult and 4 pediatric patients during hemodialysis as well as in 4 patients with combined renal and hepatic failure. Rising acetate levels occurred in 25% of the adult patients, although they were stable in the children and the patients with renal and hepatic failure. The occurrence of hypotension during dialysis was unrelated to a high blood acetate level.


Acute massive hydrothorax complicating peritoneal dialysis, report of 2 cases and a review of the literature.

Acute massive right-sided hydrothorax is a relatively rare but serious complication of peritoneal dialysis and may be responsible for the development of dyspnea during peritoneal dialysis. The pleural fluid appears to arise from the peritoneal dialyzate based on the time of its appearance and its chemical composition. It should be included in the differential diagnosis when a patient becomes dyspneic during peritoneal dialysis along with exaccerbation of congestive heart failure, pneumonia, atelectasis, and purulent bronchitis. Its occurrence is an indication to stop the peritoneal dialysis and contraindicates further use of this form of dialysis. Treatment may be conservative or aggressive (thoracentesis) depending on the clinical condition of the patient. Etiology is poorly understood. In some cases, there may be traumatic diaphragmatic fenestrations, but the majority of cases appear to be due to less well defined communications between the peritoneal and pleural spaces.


The antibody response in chronic pyelonephritis.

Serum antibodies specific for the bacteria isolated from the urines of 41 patients with chronic pyelonephritis and 14 with asymptomatic bacteriuria were assayed. Even though it is clear that infections which involve the kidney evoke higher antibody responses than do purely bladder infections, it is difficult to establish a cut-off level for distinguishing the two by this method. There is a greater probability that there will be an upper urinary tract infection without an antibody response than that there will be a good antibody response in cases with lower tract infections. In our case list, 49% of the patients with chronic pyelonephritis had titers equal to or greater than 1:400, and another 44% had titers between 1:50 and 1:100. Therefore it appears that the magnitude of the antibody response depends not only on the location of the infection but also on other factors, such as the intrinsic immunogenicity of the different bacterial strains and the properties of the immunological system of the patient.


Compression osteotomy of the tibia.

Compression osteotomy of the tibia is to allow knee motion postoperatively without case immobilization. Rigid internal stabilization by axial compression and tension band wiring enhances union. The rigid internal stabilization prevents loss of position of the osteotomy, often seen in other techniques. The benchmark for this osteotomy operation is no fractures of the osteotomy fragments, no position loss, no thromboemboli, and no deep wound infections.


The use of the Vidal-Adrey external fixation system. Part 1: The treatment of open fractures.

The average time for healing of open fractures treated by the Vidal-Adrey external fixation method was 9 1/2 months for the lower extremity and 4 months for the upper extremity injuries. In a series of 33 cases, the results were excellent or good in 21.


Computed tomography in the diagnosis of dislocations of the sternoclavicular joint.

Dislocations of the sternoclavicular joint can be easily characterized with computed tomography. Two typical cases, one demonstrating superior dislocation and the other showing posterior dislocation of the clavicle, illustrate the value of the method. Correlated anatomical observations demonstrate the proximity of the great vessels to the sternoclavicular joint.


The use of the Vidal-Adrey external fixation system. Part 2: The treatment of infected and previously infected pseudarthrosis.

A total of 23 infected or previously infected non-unions were treated by the Vidal-Adrey modification of the Hoffmann apparatus. The external fixators were applied after decortication and bone grafting either immediately in cases with no evidence of infection or later in cases of draining, infected wounds. The average healing time for these non-unions, that is time when no external support was required, was 12 months after the initial application of the Vidal-Adrey external fixators. The results were considered good or acceptable in 21 of 23 cases. Union occurred in 21, although union did not necessarily mean a good result overall when all other factors (shortening, etc.) were considered. This fixation device, when correctly applied and in conjuction with adequate debridement and bone grafting is an excellent method for the treatment of severe non-unions where infection is or was a problem.


Familial osteochondritis dissecans of the knee.

The autosomal dominant pattern of osteochondritis dissecans and association with mild dwarfism were observed during a study of 4 generations of one family. Twelve of 31 family members had proven osteochondritis dissecans and 8 others appeared to have or (now deceased) have had it; 10 of these 20 patients were of short stature (less than 5%). At the onset, children under 11 years of age had bilateral irregularities of ossification. Three of the 11 adolescents (13-19 years) had osteochondritis dissecans with development of the condition from irregularities of ossification that could be traced in the roentgenograph of one. Two of the 3 surviving adults now in their sixth or seventh decade have osteoarthritis (one moderate, one severe). The younger adults, now in the 20's and 40's, have minimal knee sysmptoms.


Late results of Hauser procedure for recurrent dislocation of the patella.

To determine whether the Hauser procedure for recurrent dislocation of the patella prevents repeated dislocation and provides a functional knee without late degenerative arthritis, 52 patients with 67 surgically treated knees were studied clinically and roentgenographically with an average follow-up of 17.1 years. Greater than 70% of patients had an excellent or good result up to as long as 30 years postoperatively. There appeared to be no predisposition to the development of degenerative arthritis. Recurrent dislocation persisted in 7% of cases and female patients with generalized ligamentous laxity had a high incidence of persistant, recurrent dislocation and poorer long-term results. Development of genu recurvatum is a definite risk in patients who have tibial tubercle transfer prior to epiphyseal plate closure.


Bilateral total knee replacement under one anesthetic.

The postoperative results and complications among 41 patients undergoing bilateral total knee arthroplasty were compared with 40 patients who underwent unilateral total knee replacement. Among the bilateral group, the most common diagnosis was rheumatoid arthritis (68%), while degenerative arthritis prevailed in the unilateral group (50%). Preoperatively, patients in the bilateral group exhibited generally a greater degree of physical disability and limitation of activity due to multiple joint involvement. Postoperatively, no change in the arc of motion was noted in either group, although flexion contractures were significantly diminished in both. The degree of postoperative pain relief was identical in both groups as was the decreased need for walking devices. The most commonly observed complication among the unilateral group was prosthetic loosening (12.%). This was felt explainable on the basis of the increased postoperative activity level of patients with degenerative arthritis and single joint disease. Patients in the bilateral group showed a higher incidence of wound problems, presumably secondary to the long-term use of steroids. The infection rate was identical in each group, but the bilateral group displayed a higher incidence of pulmonary emboli (9.7 vs. 2.5%). The postoperative need for rehabilitation services and the duration of time before dependent walking was achieved was not prolonged in the bilateral group. Hospitalization of the bilateral group was increased only 20%. No deaths were reported in either group. When the need for total knee replacement exists bilaterally, bilateral replacement with a single anesthetic would appear reasonable, provided careful patient selection and technical guidelines are followed.


GUEPAR knee arthroplasty results and late complications.

One hundred eight GUEPAR knee arthroplasties have been studied with a follow-up of one year on 41; 2 years on 22 and 3 years on 45 knees. Overall results were 17% excellent, 44% good, 10% fair and 29% poor. Excellent results were comparatively fewer in rheumatoid arthritis. There was a deterioration in the quality of results of arthroplasty with longer follow-up. The incidence of deep infection was 11%. There was a significant correlation between early wound drainage and deep infection. More than half of the infected knees have not required intervenition as yet. One knee was revised and 3 had attempted arthrodesis with one successful fusion. Two patients died with septicemia. Axle migration occurred in 8 knees and femoral stem breakage in 2 knees. Loosening was found in 27% of the knees with progressive reduction in quality of the arthroplasty. Incomplete cementing predisposed to loosening. Patellar symptoms were present in 28% of the knees. Patellar subluxation and dislocation occurred in 49% of the knees. More than half of these were symptomatic. With normal patellofemoral alignment, pain was more common in the osteoarthritic knee. Use of a patellar implant with GUEPAR knee prostesis should be restricted to severely disabled patients with major fixed deformities. Mechanical failure can be minimized by proper positioning of the implant, correct alignment of the extensor mechanism and adequate cement around the entire stem.


Mycobacterium abscessus (M. chelonei) infection of the knee joint: report of two cases following intra-articular injection of corticosteroids.

In 2 patients (3 knees) acute infectious arthritis of the knee developed following intra-articular injection of corticosteroids. The pathogenic organism responsible for the infection was found to be Mycobacterium Abscessus (M. Chelonei). Diagnostic difficulties were encountered due to the rarity of such infections and elusive identification of the organism with routine laboratory procedures. Therapeutic approaches necessitated combined radical surgical procedures together with antituberculosis drugs. Surgical treatment also afforded correct and definitive identification of the organism, from material obtained at operation. Although these mycobacteriae were found to be resistent to antituberculosis drugs, these same drugs proved effective clinically.


Chronic dislocation of the sternoclavicular joint: an operative repair.

Chronic spontaneous dislocation of the sternoclavicular joint occurs more frequently in athletes than nonathletes, causing weakness and sometimes pain during prolonged stress upon the arm. Five such joints were successfully treated in 4 patients by means of a dynamic method of repair--tenodesis of the sternal head of the sternomastoid muscle. The sternal origin of the sternomastoid muscle in continuity with its muscle belly and strip of sternal periosteum is looped under the first rib, back through a drill hole in the clavicle and sutured to itself to replace the damaged costoclavicular ligament. Dislocations of the joint should not be repaired for purely cosmetic reasons as the risk of keloid scar formation in this region is notoriously high. All the patients who were young and athletically inclined, recovered fully within 4 months of the operation and returned to their sporting activities. Follow-up has ranged from 12 to 38 months. There have been no late complications or failures of the technique.


Complete replacement of the peroneus longus muscle by a ganglion with compression of the peroneal nerve: a case report.

In a 38-year-old woman, the entire muscle belly of the peroneus longus was replaced by a ganglion. Signs of peroneal nerve dysfunction resulted from direct pressure of the ganglion. Excision of the ganglion required a tenodesis of the peroneus longus tendon to provide a normal gait pattern which was maintained during a 17 month follow-up period. This entity needs careful, prompt evaluation to avoid neurological damage and to distinguish it from compartment syndrome.


Surgical treatment of reruptures of the tendoachilles following nonsurgical treatment.

Nine patients who sustained a rerupture of their Achilles tendon after nonsurgical treatment were evaluated both subjectively and objectively with the Cybex isokinetic dynamometer. Subjectively, only 5 of the 8 patients were satisfied as compared to a 93% satisfaction rate in our previous series of patients with primary surgical repair. Cybex measurements were statistically inconsistent, unlike the primary repairs. This small series of patients in which the tendoachilles was reconstructed following failed nonsurgical treatment suggests that early surgical repair is the treatment of choice unless otherwise medically contraindicated.


The role of soft tissue reconstruction in flexible implant arthroplasty of the metacarpophalangeal joint.

In 116 hand metacarpophalangeal joint arthroplasties of the flexible type, the operative technique did not include reconstruction of capsular or ligamentous structures, but employed meticulous relocation of the common extensor tendons, and a modification of the metacarpal osteotomy plane and shape. A closely supervised program of splintage and therapy was instituted postoperatively. This series does not vary significantly with respect to range of motion or recurrence of ulnar drift (seen only when patients failed to wear splints as directed) in comparison to other reports. The results, therefore, fail to support the concept that radial capsular and ligamentous reconstruction is an essential part of this procedure.


A hand infection from A. calcoaceticus (M. polymorpha).

Acinetobacter calcoaceticus (Mima polymorpha) is not a well known organism, and its identification can be confusing due to its variable morphology and sensitivity pattern. In a joint infection, delay in identification or appropriate treatment can result in added morbidity. An A. calcoaceticus (Mima) infection in the hand seems not to have been previously reported. The present case involving a finger joint infection illustrates the pathogenicity of A. calcoaceticus (Mima) and problems of treatment. Minocycline is recommended as the drug of choice in subsequent A. calcoaceticus (Mima) and (Herella) infections.


Superior gluteal artery laceration, a complication of iliac bone graft surgery.

In the 2 cases cited, laceration of the superior gluteal artery occurred when removing bone from the posterior ilium. A review of the anatomy shows how the superior gluteal artery, as it exists the sciatic notch, can be compressed locally and exposed for clipping or ligation. The internal iliac artery can be occluded by embolization of a Fogerty catheter. The bony origin of the gluteus maximus is a good landmark to help avoid entering the sciatic notch and a special retractor provides the necessary exposure.


Acute bilateral anterior dislocation of the shoulders.

In 3 cases of simultaneous bilateral anterior dislocation of the shoulders, considering the forces which predispose to anterior dislocations, it is postulated that in each case forced abduction and external rotation or abduction with hyperextension causes these injuries to occur.


Calcium requirement and calcium therapy.

The mean calcium requirement of normal adults has been estimated from 212 calcium balances on 84 normal subjects and found to be 578 mg. The calcium allowance required to ensure that 95% of normal adults are in calcium balance is about 900 mg. Calcium requirement is relatively higher than that of phosphorus or magnesium because plasma calcium--and therefore urine calcium--is maintained at the expense of the skeleton in the presence of calcium deficiency, whereas plasma phosphate and magnesium--and therefore urine phosphate and magnesium--fall on phosphorus and magnesium deficient diets. Calcium requirement appears to rise at the menopause, and postmenopausal bone loss can be reduced by calcium supplements. In postmenopausal osteoporosis, the severe negative calcium balance can be corrected by giving calcium or calcium and vitamin D, but vitamin D alone is not beneficial. Similarly, bone loss, height loss and further vertebral compression can be reduced by calcium or calcium and vitamin D but not by vitamin D alone.


Compartment syndrome of the interosseous muscles: early recognition and treatment.

A compartment syndrome of the interosseous muscles can be a challenging diagnosis as there is generally no neurovascular compromise to the digits involved. The most sensitive clinical sign is pain with passive motion at the metacarpal phalangeal joint of the involved digit. In this report, a 31-year-old man developed a compartment syndrome of the first, second, and third dorsal interosseous muscles following an injection of heroin in the "snuffbox" area. Compartmental tissue pressure measurements were 80, 75, and 55 mmHg respectively, and were a significant aid in the early diagnosis as well as management.


Circulatory and vascular changes in the hip following traumatic hip dislocation.

An experimental study of the extraosseous and intraosseous vascular and circulatory changes following traumatic hip dislocation in dogs and rabbits is reported. The observations were made by dissection, angiography and histology following posterior dislocation and reduction at varying intervals. Traumatic dislocation of the hip causes extraosseous circulatory disturbance in the hip resulting in intraosseous circulatory deficiency in the femoral head. The sites of the vascular lesions are the extraosseous branches of the femoral circumflex arteries and their extraosseous branches of the epiphyseal and metaphyseal arteries and the retinacular artery of the circulus vasculosus articularis. The types of the vascular damage are irreversible tear of the minority of vessels along the ruptured capsule and teres ligament, and the compression, traction and spasm of the majority of intact vessels which are reversible by early reduction. In prolonged dislocation the circulatory disturbance persists or worsens due to additional pathological changes such as posttraumatic inflammatory changes, fixed deformity in the dislocated position, thrombosis, fibrosis and occlusion of vessels which may eventually cause an ischemic necrosis of the femoral head. Early reduction within several hours after dislocation restores nearly normal regional anatomy and relieves vessels from compression, traction or spasm and restores extra and intraosseous circulation. It also prevents or minimizes thrombosis, fibrosis and occlusion of vessels and avascular necrosis of the femoral head.


Conservative treatment of low velocity gunshot wounds.

A retrospective study of gunshot wounds of the extremities present 148 patients who had sufficient clinical and radiological follow-up data to assess the results. The routine treatment for this injury consisted mainly of cleansing the wound, introduction of systemic antibiotics in the emergency room followed by hospitalization. More extensive treatment and surgical debridement were done only when intraarticular or vascular injury occurred. Two patients developed infected wounds. In 6 displaced humeral shaft fractures, there were 2 non-unions and one delayed union. In 11 comminuted, displaced fractures of the femoral shaft, one non-union occurred.


Effects of ligamentous injury on ankle and subtalar joints: a kinematic study.

Using 10 normal fresh cadaveric legs, kinematic effects of ligamentous injuries around the ankle joint were studied while the ankle joint moved from maximum plantar flexion to maximum dorsiflexion in saggittal plane. A series of anteroposterior and lateral sequential roentgenograms was taken both in the normal and subsequently created injured condition, to evaluate instant center of rotation and horizontal rotation pattern in the hindfoot complex. Although the pattern of instant center of rotation of the ankle joint varied among normal condition, the majority fell in a prescribed area. The deviation of instant centers from those in uninjured condition was most evident in lateral ligament injury. The average horizontal rotation between the tibia and calcaneus was 8 degrees in the uninjured condition; 6 degrees in the subtalar joint and 2 degrees in the ankle joint. In both medial and lateral injuries, more rotation in the subtalar joint was noted in plantar flexion phase. In the ankle joint, the degree of excessive rotation in plantar flexion range was greater in lateral injury than medial injury, but that in dorsiflexion range was greater in medial injury. It appeared that while every component of collateral ligaments around the ankle was important in controlling rotation in plantar flexion range, the posterior portion of the deltoid ligament is most important in the forsiflexion range.


Experimental knee instability: early mechanical property changes in articular cartilage in a rabbit model.

Utilizing a knee joint instability model for traumatic osteoarthritis, quantitative measurements of the biomechanical properties of the articular cartilage demonstrate that the cartilage deforms and that the deformation rapidly occurs within 24 hours of injury. These changes in mechanical properties may be a more sensitive indicator of early degenerative changes in articular cartilage than the ordinary histological measurements.


Paramedian neuroma presenting as a ganglion.

Peripheral nerve tumors are rare, usually encapsulated and intraneural in location. A 33-year-old woman with a nonencapsulated paraneural neoplasm of the median nerve obtained pain relief without recurrence from surgical excision of the tumor. This represents an exceedingly rare disorder of peripheral nerves.


A quantitative sutdy of vertebral displacement and angulation in the normal cervical spine under axial load.

Cervical traction of one-third the person's weight was applied for 3 minutes to normal subjects. The mean and standard deviation of displacement and rotation between adjacent cervical vertebra was calculated in the sagittal plane. The average separation between adjacent vertebra was 0.7 mm with a standard deviation of 0.5 mm. The average angular motion between adjacent vertebra was 0.9 degrees with a standard deviation of 2.4 degrees.


Rattlesnake bites: current concepts.

The management of snake bites once the patient reaches the hospital should be to obtain the necessary blood parameters (type and cross-matched blood, complete blood count, platelets, PT, PTT, fibrinogen and fibrin split products, electrolytes and calcium), to evaluate the fang marks and the neurovascular status of the involved extremity and to monitor systemic signs and symptoms. These steps are extensively described in the literature, and are commonly agreed upon. We then start intravenous antivenom, after appropriate skin testing for horse serum allergy, beginning with 4--5 vials (8--10 in children) over the initial 30--60 minutes and titrating to cessation of the progression of the toxic signs. Concomitantly, we measure intracompartmental and subcutaneous tissue pressure in all clinically suspected areas. If intracompartment pressures are less than 30 mm Hg, surgical intervention is not necessary; antivenom is continued as necessary and the wick catheter measurements are repeated if indicated. If pressures are greater than 30 mm Hg,immediate surgical decompression is advisable.


Coccidioidomycosis of the spine: unusual roentgenographic presentation.

Vertebral osteomyelitis is a frequent consequence of disseminated coccidioidomycosis. In a 25-year-old man, the sequela was a single level unilateral osseous bridge between the second and third lumbar vertebra. A review of previous cases has disclosed one case with a similar roentgenographic picture. The occurrence of a single level unilateral reactive process should arouse suspicion of a localized chronic bone infection.


The spike procedure of Mumford: a simple technique is described for stabilizing open fractures of tubular bones.

The spike procedure is applicable as a substitute for a fixation device. In open tubular bone fractures, the spike procedure utilizes the open fracture bone ends to create an intrinsically stable situation in place of pins or extrinsic devices. One end of the tubular bone fracture is fitted into the medullary canal of the other end.


A histochemical study of alkaline and acid phosphatase activity in subchondral bone from osteoarthrotic human hips.

In order to analyze the presence of alkaline and acid phosphatase activity in osteoarthrotic subchondral bone frozen sections from 24 femoral heads were prepared for semiquantitative analysis, using the enzyme-histochemical methods described by Burstone and by Barka and Anderson. Different areas of the subchondral bone, viz. weight-bearing, nonweight-bearing and osteophytes as well as central regions were analyzed. Furthermore, the cartilagenous changes were determined by histological-histochemical grading. There were wide variations within the same femoral head with significantly greater activity of both alkaline and acid phosphatase in weight-bearing than in nonweight-bearing areas and in subchondral bone than in central regions. Osteophytes excluded, the enzyme activities correlated directly with the severity of the cartilage lesions. These enzyme activities presumably reflect the degree of bone regeneration and bone resorption respectively.


Mechanical stability of the greater trochanter following osteotomy and reattachment by wiring.

Greater trochanters of fresh and formalin-perserved cadaver femora were osteotomized, rewired using techniques described by Amstutz, Charnley, Coventry and Harris, and then mechanically tested. Force simulating abductor muscle pull was applied to the trochanter in the plane of section while its displacement was measured continuously with an extensometer. Although many trochanters appeared rigidly fixed when stressed manually, all displaced visibly when 27 kg load was first applied. When released, permanent sets averaging 0.1 mm (Charnley and Harris) to 3--4 mm (Coventry) were measured. Subsequent repeated loadings (0--27 kg) from this new "rest" position produced recoverable cyclic "functional" displacements averaging 0.7 mm (Charnley and Harris) to 2.3 mm (Coventry). With the exception of the specimens wired by the Coventry technique, results for a simulated 45 degrees anterior pull were generally comparable to those for a neutral pull. Ultimate failure loads of the trochanteric fixation were on the order of 110 kg for selected fresh specimens.


The mechanisms of severe arterial injury in surgery of the hip joint.

Vascular accidents occurring in the course of hip surgery may reach potentially catastrophic dimensions by posing an immediate and sudden threat to life and limb. This is a report of 15 cases with severe arterial injury representing 0.2--0.3% of all reconstructive hip operations performed during an 8 year period. In 6 cases perforation of either the external iliac artery, the common femoral artery of main branches of the lateral and medial circumflex femoral artery were caused by the tip of a narrow-pointed Hohmann retractor used to expose the hip joint. Other mechanisms were: intimal tear with appositional thrombosis, probably caused by mechanical strain imposed on atherosclerotic arteries, giving rise to complete limb ischemia (2 cases); the dangers associated with the entry of bone cement through a defective acetabulum into the pelvis causing thrombotic occlusion due to polymerization heat (one case) or intimate adhesion of artificial bone to the external iliac artery subsequently being ripped open during replacement of the cup (one case); the increased hazards of replacing firmly embedded hip prosthesis (3 cases of direct arterial injury with chisel, knife and cutting edge of protruding bone); and the complications associated with the development of a false aneurysm (2 cases). Fourteen of the 15 extremities were salvaged. Above-knee amputation was unavoidable in one case owing to delay of vascular repair. There was no immediate operative mortality. Knowledge of the causative mechanisms prevents arterial injury during hip surgery. The relatively low rate of vascular complications in spite of vicinity of main vessels gives credit to the well standardized technique of hip surgery, especially hip replacement. However, it is suggested that the surgeon should be sufficiently acquainted with the exposure of the main vessels above and below the groin to be able to control life threatening hemorrhage at all times. A McBurney incision with retroperitoneal exposure and clamping of the external iliac artery will suffice to diminish bleeding considerably. Thereupon careful dissection and placement of snares around the common femoral artery, the arteria profunda femoris, and whenever necessary, the lateral or medial circumflex femoral artery will enable closure of the lacerated artery. For hemorrhage resulting during replacement of firmly embedded hip prosthesis it might become necessary to ligate the internal iliac artery. Reconstruction of obliterated arteries should call for the cooperation of the vascular surgeon for eventual angioplasty. Angiologic examination of the lower extremities is mandatory whenever severe arterial trauma has occurred in the course of hip surgery and is best performed by measuring the ankle blood pressure with a Doppler ultrasound probe.


The efficacy of low-dose heparin--warfarin anticoagulation prophylaxis after total hip replacement arthroplasty.

The prime therapeutic objective of prophylactic anticoagulation for patients undergoing total hip replacement is to reduce to a minimum fatalities from pulmonary embolism. Our low-dose heparin-warfarin prophylactic anticoagulation protocol affords significant protection in this regard (one fatal pulmonary embolism in 796 cases) without the use of venography or other objective tests to check for deep venous thrombosis and for all patients including those with venous disease or a history of prior thromboembolic disease. The 13.1% hematoma rate (5.0% late major) is a small, nonlethal, and acceptable price to pay for this protection.


Total hip replacement following infection in the opposite hip.

Total hip replacements without ensuing infection were performed in 31 patients in the presence of infection in the contralateral hip. Infection in the opposite hip was proved bacteriologically in the follow-up in 19 cases averaged 5 years (2 years 3 months to 10 years). In another 12 hips in the same circumstances, without positive bacteriological evidence of active infection on the opposite side, healing occurred without infection.


Femoral shaft perforation: a complication of total hip reconstruction.

Perforation of the femoral shaft by the stem of the prosthesis is a rare, but serious complication following total hip replacement. It is a complication that is avoidable if meticulous attention is given to preoperative planning and intraoperative technique. The major predisposing factors for this complication are previous hip surgery, hip dysplasia, osteoporosis and poor exposure. Every attempt should be made to discover a perforation during surgery and to correct the alignment of the femoral stem. The patients who have experienced this complication have had a poor result suffering pain, loosening or femoral shaft fracture necessitating surgical revision.


Treatment of subacute sepsis of the hip by antibiotics and joint replacement. Criteria for diagnosis with evaluation of twenty-six cases.

Total hip replacement fixed with acrylic cement can be successful despite past or present hip infection. Recovery of the infecting organism must be vigorously pursued, either by repeated aspirations or open biopsies. Staging the reconstruction is determined by the pathogenicity of the infecting organism, gram stain, frozen section, and above all the surgeon's observations of the condition of the wound. If in doubt, treatment of infection must take precedence over the reconstruction. Adequate antibiotic coverage should begin as soon as the diagnosis is certain and the organism identified. Antibiotics should be continued postoperatively for one month intravenously, followed by 4--8 months oral therapy, though the length of oral antibiotics could be debated. A number of authors have based their diagnosis of hip infection on clinical, roentgenographic, laboratory and bacteriologic studies. However, they have not given specific guidelines for the determination of deep hip infection. The application of the criteria outlined in this paper can distinguish superficial from deep hip infection as illustrated in 40 cases with no evidence of recurrence of infection. For the present only relative guidelines may be drawn for the treatment of subacute or recently arrested sepsis of the hip. Considering some 80,000 total hip replacements done in the U.S. in the past year, a significant number of patients will require treatment of this type and appropriate programs should be established for the welfare of the patients.


Trochanteric osteotomy: analysis of pattern of wire fixation failure and complications.

Problems and complications following trochanteric osteotomy in 277 total hip replacements demonstrated that while the value of trochanteric osteotomy is obvious, the incidence of problems and complications in 277 total hip replacements was about 15%. Analysis was made of the location and sequence of wire failure following different techniques of trochanteric wiring. The usual method of wire failure was by fatigue fracture, although early fracture in the post-operative phase may be secondary to tensile failure, The incidence of wire tensile failure can be increased by inadvertent kinking or scoring of the wire during trochanteric fixation. An ununited trochanter should be protected against wire failure and its sequelae.


Precise identification of radiographic acetabular landmarks.

Accurate radiographic demonstration of pelvic anatomical landmarks is predicated on proper positioning of the patient. Interpretation of acetabular abnormality especially may be difficult when to the artifact created by pelvic asymmetrical positioning there is added true femoral head displacement. A radiograph of hip joint abnormalities in a child with congenital hip dislocation where positional distortion was present served to illustrate the problem. To clarify the direction and magnitude of acetabluar alterations with specific pelvic positions, radiographs and photographs were taken of anatomic models outlined by suitably placed lead markers. Clues to inappropriate pelvic positioning are loss of symmetry in the widths of the iliac alae, sizes of the obturator foramina, and positions of the "tear drop" figures.


The Giliberty bipolar prosthesis: a clinical and radiographical review.

An interim report of 65 Giliberty bipolar hip units followed for an average of 19 months shows excellent short-term results in regard to their clinical condition. Radiographic study of the prosthesis with special attention to cup movement portends a favorable long-term result. Nevertheless, the snap-fit mechanism of the prosthetic head in the cup and the moving cup justify a cautious attitude until a larger series of a longer term can be completed.


"Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening.

In view of the increasing incidence of stem-type femoral component loosening, a detailed retrospective radiographic zonal analysis of 389 total hip replacements indicated a 19.5% incidence (76 hips) of radiological evidences of mechanical looseness, i.e., fractured acrylic cement and/or a radiolucent gap at the stem-cement or cement-bone interfaces. Detailed serial radiographic examination demonstrated progressive loosening in 56 of the 76 hips and these were categorized into mechanical modes of failure. The 4 modes of failure characterizing stem-type component progressive loosening mechanisms consisted of stem pistoning within the acrylic (3.3%), cement-embedded stem pistoning with the femur (5.1%), medial midstem pivot (2.5%), calcar pivot (0.7%) and bending (fatigue) cantilever (3.3%).


Slipped capital femoral epiphysis long-term results after 10--38 years.

Thirty-four patients with chronic slipped capital femoral epiphysis (SCFE) involving 45 hips were followed over a period of no less than 10 years and as great as 38 years. Excluding those who had had intraoperative complications, 30 hips evaluated between 10 and 20 years follow-up were found to have good or excellent results. Fifteen hips followed greater than 20 years, however, showed fair to poor grading in 10 of 15 hips. This progessive change seemed to be related most closely to the bilateralism of the disease. These observations suggest that while follow-up of a 20 year duration may show good clinical results, over a longer period of time the prognosis of SCFE is guarded.


Intertrochanteric fractures of the hip treated with the hip compression screw: analysis of problems.

Seventy-five patients were treated for intertrochanteric hip fractures with the hip compression screw. There were 4 cases in which the lag screw was inserted twice into the femoral head. Three of these patients had a poor result due to superolateral migration and extrusion of the lag screw. The fact that the lag screw is large in comparison to the femoral head makes double placement dangerous. Satisfactory guide wire placement is essential for a one time, precise insertion of the lag screw into the femoral head. The use of a threaded tip guide wire minimizes the chance of it falling out when withdrawing the reamer or tap. If the position of a lag screw is unacceptable, it seems better to insert a flanged nail rather than a second screw in a second track.


Intertrochanteric fractures of the hip in the elderly: a retrospective analysis of 236 cases.

A series of 236 patients over the age of 80 with intertrochanteric fractures were treated on a protocol established basis in an attempt to decrease postoperative morbidity and mortality. Rigid fixation with interfragmentary compression using the compression hip screw permitted us to begin early mobilization and immediate weight-bearing. Vigorous pulmonary tiolette, prophylactic antibiotics, and aspirin "anticoagulation" were used as adjuncts. Three month mortality was 7%. Overall, 76% of the patients who ambulated in any manner before their fracture walked again after surgery. Many, however, lost one grade level of walking postoperatively. Effective treatment for a patient with an intertrochanteric fracture, regardless of advanced age, is surgery and early mobilization.


Clinical study on internal fixation of femoral neck fractures.

A clinical study on the results of internal fixation of femoral neck fractures treated by multiple Knowles pinning was undertaken and correlated with the results of an experimental study. Experimentally, failures were produced by downwards migration of the Knowles pins. This phenomenon accounts for the settling of the femoral head on the neck and the frequency of non-union or malunion in patients with subcapital fractures. The type of fracture, type of reduction and age correlate with failure rate. This has to be explained by biomechanical considerations based upon the mode of failure of the internal fixation. A Garden stage III and IV, a varus or anatomical reduction of the fracture and an old age predispose to failure of the internal fixation and consequent non-union.


Internal fixation versus nontreatment of hip fractures in senile patients.

Institutionalized senile patients with hip fractures have a high mortality regardless of whether treatment consists of internal stabilization or is non-operative. In an effort to select the best therapeutic approach in this type of patient, 150 patients were examined in 3 comparable groups. In the first group of 50 patients treatment consisted of surgical stabilization of the fracture. In the second group of 45 patients treatment was non-operative; mortality in these 2 groups was over 50% at the end of 16 weeks. In an effort to improve this degree of risk we transferred 53 patients from the psychiatric hospital to a general hospital for prompt internal stabilization of the hip fractures. There was a striking decrease in mortality to 28% in the third group. We have concluded that under optimal conditions, prompt surgical stabilization of hip fractures in elderly senile individuals offers them the best opportunity of surviving the injury and is preferable to nontreatment.


An uncemented total hip replacement: experimental study and review of 300 madreporique arthroplasties.

Mafreporique arthroplasty is not intended as a bustitute for acrylic cement stabilized arthroplasty but is available as an effective alternative. An experimental and clinical investigation including radiological analysis of 300 madreporique arthroplasties has convinced us of the reality and reliability of biological anchoring by endosteal osteogenesis. The madreporique method does not result in any local or general complications usually associated with the cement technique. Full weight-bearing is permitted at the same postoperative time as the cemented prosthesis. The results at early and interim follow-up periods compare favorably with cemented hip arthroplasties. Living bone that undergoes remodelling provides for long-term anchor of the prosthesis and eliminates the chemical intermediary which leads, more or less, with time to loosening of the implant in a significant number of cases.


Experimental study on internal fixation of femoral neck fractures.

The relative strength and the failure mode of internal fixation by multiple pinning and nailing was investigated on 35 specimens. Internal fixation consisted of 3, 5 and 7 Knowles pins, a Smith-Petersen nail or a sliding nail plate. The strength of a specimen with a triflanged nail is only half of that with multiple Knowles pins. There is no significant difference in strength of 3, 5, or 7 pin specimens. The strength of an internal fixation with a sliding nail plate is not superior to the strength of multiple pinning. The mode of failure for the different types of internal fixation is primarily a crush fracture of the supporting trabecular bone at the femoral neck with downward and outward migration of the pins or nail. Except with the fixation with 3 pins where an initial bending could be observed, failure is not a plastic deformation of the internal fixation device.


A review of fractures in the proximal femur treated with the Zickel nail.

The Zickel intramedullary fixation device was used to treat 26 patients with subtrochanteric or impending subtrochanteric fractures. The use of this device has advantages over traditional traction methods as well as nail plate fixation. Twenty-two patients were ambulatory within one month following surgery. Healing of the fracture by roentenogram required an average of 4.9 months and had a high union rate, 17 out of 18 patients was apparent with the use of the Zickel device. There is no classification of fractures at present which has a prognostic value when intramedullary fixation is used. Traumatic and pathologic fractures were treated with similar results. There was no appliance failure in this series.


Hip disease of Mseleni.

Mseleni in Northern Zululand is a remote geographically isolated improverished district in which about 2,000 persons suffer from a crippling joint disease similar to dysplasia epiphysealis multiplex and spondyloepiphyseal dysplasia. Eleven per cent of the men and 39% of the women in young adult life are seriously disabled and, with concurrent osteoarthritis, 90% of the population are grossly incapacitated in old age. Affected and unaffected control areas have been compared. Analysis of the climate, dietary factors, social taboos and soil and water does not implicate these as causes. Genetic studies, despite considerable field work, sociological surveys and laboratory investigations have not provided the answer. Despite a high incidence in the Mseleni area no disturbance of blood group percentages could be determined. The disease had dissimilarities from Kashin Beck disease in which fusarium fungus allegedly causes small joint polyarthritis. Fusarium sporotrichiella has not been grown in subtropical Zululand and thus could not be a causative agent. Mseleni disease also differs from Handigodu disease in Karnataka India, in which the hips are also destroyed in 80% of cases in the acute form of this disease which is brought on by environmental factors related to subtropical climate, low animal protein intake and intake of a variety of possibly toxic products of vegetable origin. Investigation of stored groundnuts in the affected districts has not revealed a fungus toxin in food which can as yet be implicated. A multifactorial genetic and environmental cause appears probable.


Penetration of gown material by organisms from the surgical team.

The routes by which viable organisms shed by the surgical team reach the wound are not yet fully understood. Bacteriologic studies show that shedding is greater in surgeons than their assistants or scrub nurses, and is increased by activity and temperature, but is primarily related to the individual's shedding characteristics. Comparison of the ability of 3 types of cotton gowns to contain the surgical team's bacterial effluent shows that the body exhaust system gowns developed by Charnley are superior to more conventional gowns. It is clear that viable organisms can penetrate very closely woven Ventile (pore size 10 microns) as well as balloon cloth (pore size 50 microns). Ventile used without a body exhaust system does not appear to increase gown efficiency. Penetration of gown material by organisms from the surgical team is responsible for 20% of wound contamination. The gown glove cuff junction is an important leakage point for organisms shed by the surgical team. A newly designed "mitt" cuff more effectively seals this area than the conventional stockinette cuff.


Internal derangement of the sternoclavicular joint.

Indirect injuries to the sternoclavicular joint can result in an internal derangement. The major injury is to the intra-articular disk. The condition is generally caused by indirect injury to the shoulder, and causes tenderness, mild swelling and a clicking sensation over the joint. An arthrogram may well prove helpful in diagnosis. The lesion is treated by simple disk excision.


Distal symphalangism: symbrachydactylism arising in a family with distal symphalangism.

A recent survey of congenital hand anomalies has revealed that symphalangism of the distal interphalangeal joint is more frequent than had previously been reported. To date, however, only 3 familial pedigrees have been documented in the literature. The family reported in this article had 9 individuals spanning 4 generations affected with symphalangism of the distal interphalangeal joint. In all cases, this was associated with ankylosis of the distal interphalangeal joint of the second through fifth toes. One child in the family also had brachyphalangism bilaterally as well as a bifid distal phalanx of the thumb. The world's literature does not seem to include a similar case. As with previous cases of fusion of the distal interphalangeal joint, there was little functional disability resulting from this anomaly and we do not recommend operative procedures to restore motion.


Morton's neuroma--pathogenesis and ultrastructure.

In an attempt to clarify the pathogenesis of Morton's neuroma, 106 documented cases were analyzed by multiple staining techniques and electron microscopy. The lesion was found to consist of a progressive fibrosis which enveloped and disrupted nerves and arteries. No evidence of a nerve proliferation nor of a specific inflammatory process was encountered. Based on these observations, it is concluded that repeated trauma in the connective tissue elements, including nerves and arteries in the interdigital clefts, lead to a reactive overgrowth of connective tissue (scarring) that disrupts the nerves and the arteries. Sclerosis of the arteries and the narrowing of their lumen contributes to ischemia and further nerve atrophy. The nerves and arteries caught in this reactive scar become more sensitive to pressure and cause characteristic pain.


Growth of osteoid osteoma transplanted into athymic nude mice.

An osteoid osteoma, excised from the neck of the femur of a 23-year-old man, was cut into four 1.5 mm3 fragments and immediately transplanted into muscle pouches in athymic nude mice. One fragment was devitalized by lyophilization before implantation. The viable tumor cell xenografts grew, differentiated into uncalcified osteoid, and retained the characteristics of the original tumor. The killed implants were resorbed, but both the surviving viable and nonviable tumor tissue induced the connective tissue cells of the mouse host bed to proliferate and differentiate into normal cartilage and calcified bone. The mouse new bone deposits were remodeled and colonized by bone marrow, a tissue not seen in osteoid osteomas. These observations suggest that the sclerotic bone shell characteristic of osteoid osteomas may be an inductive reaction of host bed tissue to an osteoma cell product that is comparable to bone morphogenetic protein (BMP) produced by normal bone cells and transferred by normal bone matrix.


Long-term follow-up of Charnley arthroplasty of the hip.

A review of 11.5 year (average interval) follow-up examination of 409 low friction arthroplasties performed included only 3 late failures. The excellent results of the successes have been fully maintained for as long as 14 years. This was true with regard to pain, function of walking and mobility. Resorption of the calcar femorale was rare and no correlation was found with the wear of the socket. The average wear of 1.5 mm was less than predicted by Professor Sir John Charnley. Although 10 patients (7.8%) had excessive wear no patient is at present near the stage of requiring replacement of the socket for this reason. No adverse reaction was found to the implant or the cement.


The ultrastructural localization of secretory acid phosphatase in giant cell tumor of bone.

Three cases of giant cell tumor of bone were studied with the light and electron microscopes to determine the histochemical and cytochemical distribution of acid phosphatase isoenzymes. Using beta-glycerophosphate as a nonspecific substrate, acid phosphatase was found in the giant cells as well as the stromal cells. Ultrastructurally, using this substrate, the enzyme was found to be associated with lysosomes in the stromal cells and giant cells and also with the profuse system of tubules and vesicles in the cytoplasm of the giant cells. Using phosphorylcholine and D-ephedrinephosphate, which are substrates for a specific secretory isoenzyme of acid phosphatase, activity was found only in the vesicles of the giant cell cytoplasm. Lysosomes did not show activity with these substrates. Multinucleated cells of giant cell tumor contain a specific secretory type of acid phosphatase which is not present in the stromal cells. This suggests that the giant cells are attempting to form a secretory system similar to osteoclasts and that the vesicles in the cytoplasm which contain this acid phosphates are the morphologic expression of an abortive secretory system.


The effect of calcitonin on fracture healing.

Corrective osteotomy of the long bones may be required in patients with Paget's disease. Experiments on rabbits suggest that the safety of the procedures is of concern while the patient receives Calcitonin. Twenty-four rabbits were divided into 4 groups of 6 animals. Half of each group received maintenance doses of Calcitonin subcutaneously. In all animals the left and right ulnae were osteotomized through middiaphysis. The right ulna was fixed with a "mini" dynamic compression plate. The left ulna was not immobilized. Each group of animals was sacrificed at successive intervals of 3 weeks. Histologically, no difference was found in the healing of the fracture of test or control animals. Radiographically, the fracture line persisted longer in animals receiving Calcitonin (6 weeks vs 3 weeks). All fractures healed by 9 weeks. The fracture line disappeared more rapidly in all the immobilized bones. Based on these observations, administration of Calcitonin is not a contraindication for corrective osteotomy in Paget's disease. Osteotomies should be rigidly fixed to maintain the correction achieved surgically until healing is established.


A method for determining success following total hip replacement surgery.

The success of a total hip replacement surgery, using the hip evaluation form, was investigated in 2 groups of surgical patients which differed in terms of relative success of surgery. For the men, the group which did not respond as well to surgery had less education and were more retired individuals; this group also had more pain, less ambulation, and greater functional handicaps prior to surgery. For the women, there were no significant differences between the groups with regard to the demographic variables and the hip evaluation measures prior to surgery. The Minnesota multiphasic personality inventory administered following surgery suggests that the women who did not respond as well to surgery had more physical symptoms, anxiety, depression, and difficulties in relating to people.


Risk factor assessment in 101 total hip arthroplasties: a medical perspective.

Our experience with 101 consecutive T.H.A.'s in 91 patients was examined in an attempt to identify preoperative risk factors for postoperative medical complications, especially pulmonary embolism and thrombophlebitis. Six per cent of patients developed postoperative clinical thrombophlebitis, and 8% a pulmonary embolism. Advancing age and previous venous thrombosis served as predictors for pulmonary embolism and thrombophlebitis, respectively (p less than 0.01), but obesity, venous varicosities, diabetes mellitus, cigarette smoking, previous pulmonary embolism, and length of surgery did not, for either. Fifty per cent of the patients with preoperative abnormal kidney function developed some form of medical complication postoperatively, a significant increase in risk (p less than 0.05) over patients with normal kidney function. We were unable to identify an increase in postoperative atelectasis or pneumonia associated with smoking or obesity in these patients. No consistent decrease in post-operative medical morbidity could be assigned to preoperative medical consultations, suggesting that we have not yet identified all significant risk factors. A thorough preoperative preparation and improvement in intra- and postoperative techniques and management may account for differences found in this study from traditionally held risk factors.


A method of management of the fractured stem in total hip replacement.

A method of removal of the fractured stem of a total hip replacement consists of drilling the distal fragment and extracting it through the open neck of the femur. Good exposure and careful preparation of the medullary canal to take a heavier stem in a well supported position will prevent stem fracture. Extended neck prosthesis may be indicated to ensure stability. Secure reattachment of the trochanter is essential.


Femoral component loosening after total hip arthroplasty.

To determine the long-term durability of total hip arthroplasty and to identify factors responsible for femoral component loosening, 106 total hip arthroplasties were reviewed in patients with a minimum postoperative period of 3 years. Seventy-four had Charnley-Müller prostheses and 32 had Charnley prostheses. Femoral component loosening occurred in 16 of 106 hips. Not all loose components were symptomatic. The femoral component at risk was the femoral Charnley-Müller type that had been inserted in varus position in a functioning active heavy patient who previously had had a femoral head prosthesis.


Methylmethacrylate metabolism in man. The hydrolysis of methylmethacrylate to methacrylic acid during total hip replacement.

Methylmethacrylate, the monomeric component of the polymethylmethacrylate cement used in orthopedic surgery, has been shown to undergo hydrolysis to methacrylic acid during hip replacement operations. Circulating levels of methacrylic acid were comparable with those of methylmethacrylate. Concentrations of both methylmethacrylate and methacrylic acid normally lay in the range 0--15 micrograms/cc. No correlation could be discerned between changes in the concentrations of methylmethacrylate and methacrylic acid, and changes in blood pressure.


Effect of gentamicin on shear and interface strengths of bone cement.

Antibiotic impregnated cement offers a potential method for salvage of infected total joint replacements. The addition of gentamicin in concentrations of .5, 1.0, and 2.0 per 40 significantly affects the shear strength of Palacos acrylic bone cement. The clinical significance of this strnegth drop is not clear. Large grained antibiotic additives have deleterious effect on shear strength. Measurements were made to determine the effect of gentamicin concentration on the bone-cement interface strength but no trend could be determined. The interface strength was much less than the strength of Palacos alone and suggested that bone strength is the limiting factor.


Differential diagnosis of jaundice by 99mTc-IDA hepatobiliary imaging.

The utility of 99mTc-IDA imaging in the differential diagnosis of jaundice was assessed. Although overall accuracy was 84%, this method is still inferior to the reported efficiency of ultrasonography and CT in making the correct diagnosis. Radionuclide imaging is a good alternative when these other modalities are not available and it functions well in an adjuvant capacity. The diagnostic limitations of 99mTc-dimethyl IDA imaging in cases of moderate to severe jaundice are largely overcome by the use of 99mTc-p-butyl IDA.


Successful visualization of cortical malignant lesions on renal scintigram using 99mTc-dimercaptosuccinic acid.

The early (dynamic) and late (static) renal images obtained with 99mTc-dimercaptosuccinic acid (DMSA) were utilized to evaluate renal cortical malignant tumors in 30 cases of renal cell carcinoma each of which had been confirmed by operation or autopsy. Early images, performed 20--50 seconds after radionuclide administration, demonstrated abnormal vascular pools in the cortex. A cold area without DMSA uptake was demonstrated on the 2-hour or late images, reflecting a non-functioning renal mass. Lesions demonstrated with combined early and late images showed a good correlation with those demonstrated by renal angiography in 25 out of 27 cases. However, when almost all the renal tumor was replaced by necrotic lesions, the early image did not reveal hypervascularity. When a highly vascular renal tumor extended to the perinephric tissues, the tumor area was sometimes overestimated on the early image. It is almost impossible to diagnose renal cell carcinoma using radionuclide imaging alone. However, 99mTc-DMSA renal studies, using both early and late imaging, have proven to be a useful, noninvasive adjunct in the detection of malignant cortical lesions.


The effect of diaphragmatic attenuation on 201Tl images.

The effect of diaphragmatic attenuation on 231Ti images of the heart was studied by intermittent recording with patients in inspiration and expiration. These studies suggest that the commonly observed posteroinferior defects in the left lateral projection can be explained by this mechanism. Possible effects on the anterior view are also suggested.


Adrenal gland imaging with multiplane tomography.

Multiplane tomography can be employed successfully to image the adrenal glands after the intravenous administration of 6 beta-131I-iodomethyl-19-nor cholest-5(10)-en-3 beta-ol (NP-59). The tomographic display allows separation of the adrenal glands from other organs that often obscure the adrenal image when gamma cameras are used and the depth of the adrenal glands may be determined without obtaining lateral views.


Cisternography and CT scanning with 111In-DTPA in evaluation of posterior fossa arachnoid cysts.

A patient with a large, long-standing posterior fossa arachnoid cyst was evaluated. Computed tomography was used to demonstrate the cyst. 1111In-DTPA cisternography demonstrated the communication of the cyst with the subarachnoid space, stasis of the 111In in the cystic space, and incomplete ascent of cerebrospinal fluid over the cerebral hemispheres.


Localization of bone-seeking agent within a desmoid tumor.

This is a case report of a patient who had a desmoid tumor which localized 99mTc-diphosphonate. The mechanism for this localization was felt to be the affinity of the bone agent for the immature proliferating collagen in this tumor.


Accumulation of 99mTc-methylene diphosphonate in an adenocarcinoma of the lung.

Increased accumulation of 99mTc-methylene diphosphonate (MDP) was observed in an adenocarcinoma of the lung during the performance of routine bone imaging.


Reliability of stress thallium-201 scanning in the clinical evaluation of coronary artery disease.

Stress thallium-201 scanning proved to be a highly sensitive and specific screening procedure for myocardial ischemia in 52 consecutive cases with coronary arteriograms. Stress thallium-201 scanning was considerably more accurate and more specific than the exercise electrocardiogram (ECG) as evidenced by a sensitivity of 83% compared to 55%, and a specificity of 94% compared to 82%. When submaximal stress tests were excluded, improved sensitivity of thallium scan to exercise ECG was 95% to 64% with no change in specificity. Factors producing negative thallium scans in the presence of coronary artery disease were: delay in obtaining the first post-exercise scan, positioning and observing variability, severe three-vessel disease uniformly affecting all myocardial segments, and failure to achieve maximal stress testing due to attenuation of the heart-rate response by propranolol or somatic complaints.


Accumulation of 201Tl-chloride in a parathyroid adenoma.

A 201Tl-chloride sacn was performed on a patient with primary hyperparathyroidism. 201Tl-chloride accumulated in the region of the right lower thyroidal pole and a diagnosis of parathyroid adenoma was confirmed intraoperatively. 201Tl-chloride imaging of a hyperfunctioning parathyroid gland seems to be useful for the detection and preoperative localization of a parathyroid adenoma.


The Anger camera and the pertechnetate ion in the routine evaluation of thyroid uptake and imaging.

The thyroid traps the pertechnetate ion and iodine in a similar manner. Thus, 99mTc-pertechnetate may be used for thyroid uptake studies (including stimulation and suppression tests)8 as well as imaging. Images are obtained after an intravenous administration of 2--4 mCi of 99mTc-pertechnetate, and the scan is preceded by a trapping index at 20 minutes, measured as the neck to thigh ratio. In 1973, we compared 99mTc-pertechnetate with 131I in diagnostic uptake and imaging studies of the thyroid gland in 100 patients. We have had experience with an additional 100 patients, and modified our procedure so that the Anger camera with pinhole collimator will adequately replace the standard scintillation probe. Using the camera alone, with the 99mTc-pertechnetate makes the study less expensive and briefer, with no loss of information. Routine use of the scan aids in distinguishing diffuse from localized diseases.


Primary tuberculosis diagnosed by gallium scan.

We report a case of tuberculosis which, although clinically unsuspected, was diagnosed on a 67Ga scan. It is well known that 67Ga scintigraphy may be used as an adjunct to radiography for assessing extent and localization of inflammatory activity and for follow-up and progression evaluation of diffuse granulomatous diseases such as sarcoid and tuberculosis.


Cranial cholesteatoma: unusual 99mTc-Sn polyphosphate and 99mTc-pertechnetate scintiphotos.

Results of the brain and bone scintigraphy in a case of cranial cholesteatoma are described and the differential diagnosis is discussed. With both techniques, the lesion is characterized by diminished central and increased peripheral activity.


Gallium scan in recurrent Hodgkin's disease in children.

In 18 of 88 children with biopsy proven and previously untreated Hodgkin's disease, recurrence developed during a period from four to 53 months after therapy (median period, 22 months). In 16 patients in whom gallium scans were performed, 21 positive gallium scans were obtained during 26 episodes of recurrence. Abnormalities were noted in half of them during a period from one to 10 months prior to physical, laboratory, radiographic or histologic confirmation of recurrence (median period about 5 months). We have concluded that the gallium scan is very useful in initial workup and is sensitive in detecting early recurrence in children with Hodgkin's disease. Such scans are indicated when there is clinical suspicion of recurrence, when other modalities are unavailable or when the results of other studies are equivocal.


Abnormal images of right heart disorders.

Increasing attention is being given to radioisotopic studies of the right heart. Measurement of right ventricular ejection fraction has become more common. We present examples of cardiac images which were obtained during the scintigraphic assessment of right sided cardiac disorders. Images of the first pass, of the gated cardiac study, and of the nongated cardiac blood pools offer complementary information to the overall radionuclide evaluation of right heart disease.


Brain scintigraphy in arteriovenous malformation.

Brain scintigraphy demonstrated an unusual image pattern which was associated with an arteriovenous malformation (AVM). A preoperative diagnosis of AVM was suspected on the radionuclide study and confirmed by contrast angiography and surgery. We review the criteria established for diagnosis of AVM by dynamic and static scintigraphy and discuss additional findings which can be helpful when noncharacteristic AVM presentations are encountered.


Hepatic adenoma: imaging with different radionuclides.

A case of a benign hepatic-cell adenoma studies with dynamic radionuclide angiography and static imaging with different tracers is presented.