Differential distribution of small and large neurons in the sacrococcygeal dorsal root ganglia of the cat.

The differential distribution of small and large neurons in the sacrococcygeal dorsal root ganglia of the cat was disclosed by measuring the short diameter of the perikarya. The measured values were systematically charted along the rostro-caudal axis of the ganglion. This approach permitted to delineate small and large neurons; the short diameter of the former being less, that of the latter more, than 22 micrometers. Small neurons (69% of the population) are distributed along the entire length of the ganglions, while large neurons are clustered in the distal half. The same histological specimens were appropriate to show that if only every 8th section was used for counting the number of perikarya (the number of the nucleoli was interpreted as that of the perikarya) the result was not significantly different (less than +/- 5%) from that gained by a total count. The significance of the inhomogeneous distribution of ganglion cells was discussed within the emerging concept of the topological arrangement of the perikarya in the ganglion, on the one hand, and the termination of the central branch of the neurons in the spinal cord, on the other.


Effect of CH-123 on vascular cholesterol deposition in experimental atherosclerosis of rabbits.

The effect of CH-123, a new antiarteriosclerotic pyrido-1,2a-pyramide derivate was checked in experimental atherosclerosis of rabbits. Cholesterol deposition was found to continue after 4-week cholesterol feeding even after the cholesterol level had returned to normal. This allowed to study the action of drugs in a phase dominated by lipid apposition to the vascular wall. In the experiments, clofibrate was used for reference. As judged by the lipid values in serum and aortic wall, CH-123 reduced substantially the deposition of lipids, mainly of cholesterol, into the aortic wall.


The role of function in the formation of the skull.

Partial resection of the mandible, resection of the chewing muscles, amputation of extremities and ligature of the common carotid artery were performed in animals different in chewing type (dogs, sheep, rabbits and rats). These studies revealed a close relation between shape and function. It was shown that changes in function have a decisive effect on the development and shaping of the skull bones and musculature.


Localization of 3H-serotonin in the adrenal medullary cells of newborn rats.

In newborn rats serotonin was found to bind the membranes of adrenal medullary cells, to the wall of their vesicles and could be demonstrated also in the nucleus. The observations allowed conclusions concerning the cellular mechanisms of serotonin action.


Localization of 3H-histamine in the nucleus of Tetrahymena.

3H-histamine was incorporated by Tetrahymena partly into membrane-associated structures (cilia), partly into intra-cytoplasmic localizations, and above all into food vacuoles. A considerable amount appeared in the nucleus, in practically exclusive association with the heterochromatin.


Histological differential diagnosis of aseptic bone-necrosis.

Differentiation between traumatic and vascular aseptic bone-necrosis is a serious problem in everyday practice. This paper considers the theoretical background of differential diagnosis.


Occupational therapy and occupational medicine-a merger.

A working model for occupational therapy intervention in an industrial setting is presented. The model addresses both preventive and problem-solving aspects of practice. An overview of relevant industrial sociology, a discussion of the model, and implications for the therapist are given as well as the viability and benefits of a merger despite the disparate value systems associated with industry and the health services.


Structured learning therapy: development and evaluation.

This paper describes the procedures, materials, and evaluation of Structured Learning Therapy, one of several skill training therapies to emerge in recent years. A number of issues are considered in regard to enhanced outcomes for such therapies, particularly means for more successful transfer of newly learned skills from therapy to real-life settings, and prescriptive use of such psycho-educational treatments.


A light probe adapted for use in training the blind.

The application of modern electronics technology has produced a number of new sensory aids for the blind. Serious limitations are presented, however, by the high cost and sophisticated training and maintenance requirements some of the new aids demand. This paper describes the design and development of an economical light sensor. Construction notes, including complete parts requirements, are given. Prototype applications to blind rehabilitation training and suggested uses as a personal sensory aid are discussed and critically evaluated.


Feeding and toileting devices for a child with arthrogryposis.

Patients with arthrogryposis multiplex congenita have many problems with activities of daily living because of limited upper and lower extremity joint motion and muscle strength. Feeding and toileting are two activities frequently performed at home and at school that may require one or two people to assist the child. A feeding device and a toileting ramp made from readily available materials have improved a child's independence at home and at school, have been of cosmetic and psychological value, and have minimized the need for assistance by one or more people. The feeding device may also be used for writing and art activities. No future dental problems are anticipated with the use of the feeding device over a period of time. Fabricating and training time with the feeding device is about one hour for each process. The fabricating and training time with the toileting ramp is lengthier with several hours required for each process. Patients with extensive involvement from burns or muscular dystrophy can also benefit from use of the feeding device.


A classification of wheelchair seating.

Selecting a wheelchair cushion for a person with a physical disability can be confusing and difficult. Because many cushions are commercially available and because no single cushion will work for all patient categories, the therapist needs to be aware not only of the factors that influence the selection of the cushion such as patient activity level and lifestyle, but also of the differences that exist among all the cushions she or he might recommend.


Analysis of exercise-induced R wave amplitude changes in detection of coronary artery disease in asymptomatic men with left bundle branch block.

The exercise electrocardiograms of 44 asymptomatic men with acquired left bundle branch block were analyzed for changes in R wave amplitude. Results were correlated with findings on selective coronary angiography. There were two subgroups: 7 men with significant angiographic coronary artery disease (Group I) and 37 with normal coronary angiograms (Group II). Exercise induced an increase in R wave amplitude in all seven men with coronary artery disease but in only 10 of the 37 men without significant coronary artery disease. This criterion thus had a sensitivity of 100 percent but a poor specificity of 73 percent, a predictive value of 41 percent and an accuracy rate of 77 percent for the diagnosis of coronary artery disease. The greater the increase in R wave amplitude the greater was the likelihood of some degree of left ventricular dysfunction as measured by wall motion abnormalities and elevated left ventricular end-diastolic pressure. The increase in R wave amplitude with exercise appears to be a sensitive test in identifying coronary artery disease in asymptomatic men with acquired left bundle branch block.


Right ventricular diastolic pressure in coronary artery disease.

Right ventricular hemodynamics were evaluated in 179 patients with coronary artery disease to determine the effects of chronic ischemia on right ventricular diastolic pressure. Abnormal right ventricular filling pressures occurred only in patients with an abnormal right ventricular systolic pressure or an abnormal left ventricular end-diastolic pressure. Of the 63 patients whose right ventricle was stressed by an increased systolic load secondary to passive pulmonary hypertension, 44 (72 percent) had an abnormal right ventricular end-diastolic pressure. In this group obstruction of vessels serving the right ventricular free wall or septum, or both, was almost universal (43 of 44, 98 percent) and a significantly increased incidence of inferior infarction (P less than 0.05) was noted. Such obstruction was significantly less frequent in patients with normal filling pressures (10 of 17, 59 percent; P less than 0.001). Compared with patients with coronary artery disease, patients with passive pulmonary hypertension due to aortic stenosis or mitral stenosis had significantly greater degrees of pulmonary hypertension (P less than 0.05) yet slightly lesser elevations of right ventricular end-diastolic pressure. These data suggest that in patients with ischemic heart disease the right ventricle exhibits diastolic dysfunction at lower levels of afterload stress than it would with normal coronary blood flow.


Echocardiographic recognition of atrioventricular valve stenosis associated with endocardial cushion defect: pathologic and surgical correlates.

The association of either mitral or tricuspid stenosis with endocardial cushion defects has been well recognized pathologically but is infrequenctly diagnosed clinically. M mode echocardiographic features such as markedly disproportionate ventricular size, abnormal mitral or tricuspid diastolic echoes or failure to define adequately an atrioventricular (A-V) valve are strongly suggestive of associated stenosis of that valve. In this study mitral stenosis in association with endocardial cushion defect was correctly diagnosed in four of five patients. In the fifth patient (the first seen) the condition was easily diagnosed retrospectively. Tricuspid stenosis was similarly diagnosed prospectively in three of four patients. Significant stenosis was not overlooked or misdiagnosed in any patient with an endocardial cushion defect. Significant stenosis of an A-V valve in association with endocardial cushion defect carries a high mortality. It is important to recognize the combined lesion clinically because infants with it are not suitable for total surgical correction. Palliative surgical procedures with aggressive medical therapy probably offer the infant the best chance of surviving until ventricular growth may render corrective surgery feasible.


Echocardiographic evaluation of left ventricular function in children with congestive cardiomyopathy.

Echocardiography was used to study left ventricular function in 37 children with congestive cardiomyopathy. Left atrial and left ventricular diameters were approximately 1.5 times that predicted by body weight, whereas systolic decrease in left ventricular diameter (shortening fraction) and increase in posterior wall thickness were half that of normal children. The ratio of left ventricular preejection period to ejection time was increased in 25 patients and normal in 10. The mean velocity of circumferential fiber shortening was decreased in 30 of 34 patients and averaged 52 percent of that predicted by heart rate. The shortening fraction was higher in the 12 patients who were asympatomatic at the time of study than in the 25 who had symptoms of congestive heart failure (19.6 +/- 2.4 standard error of the mean versus 14.6 +/- 1.2) (P less than 0.05). In 11 patients whose condition improved after therapy with digoxin and diuretic drugs, serial echocardiograms showed significant increases in shortening fraction and posterior wall thickening and decreases in left atrial diameter and the ratio of preejection period to ejection time. However, one or more indexes of left ventricular function remained abnormal, despite the resolution of symptoms and a return of heart size to normal as judged from the chest roentgenogram.


Endocardial cushion defect associated with cor triatriatum sinistrum or supravalve mitral ring.

Clinical and angiographic or autopsy data, or both, on three children with a subdivided left atrium (cor triatriatum) and an associated endocardial cushion defect are reviewed. (One child had ostium primum defect, and two had complete atrioventricular [A-V] canal.) A fourth patient demonstrates the difficulties in differentiating subdivided left atrium from supravalve mitral stenosis in the presence of an endocardial cushion defect. The clinical findings are greatly influenced by the endocardial cushion defect. A pressure gradient between the pulmonary wedge and (left or right) ventricular end-diastolic pressures in patients with an endocardial cushion defect indicates pulmonary venous obstruction and should alert one to the possibility of these combined lesions. The exact diagnosis is made with injections of angiographic contrast medium into the proximal and distal left atrial chambers, to documented the respective relations of the pulmonary veins, left atrial appendage and A-V valves to these atrial chambers. All three patients with an endocardial cushion defect and a subdivided left atrium had an associated patent ductus arteriosus. The common association of subdivided left atrium with intracardiac, pulmonary venous and aortic anomalies is again demonstrated.


Electrophysiologic effect of digitalis on sinoatrial nodal function in children.

Despite the prevalence of digitalis usage in children, the electrophysiologic effects of digitalis on sinoatrial (S-A) nodal function is unknown in this age group. The purpose of this study was to determine the effect of digitalis on sinoatrial conduction time as well as on S-A nodal automatically. Ten subjects (mean age 10.5 years) underwent electrophysiologic assessment of S-A nodal function before and 30 minutes after administration of ouabain (0.01 mg/kg). Total S-A conduction time increased in each subject and the mean value after ouabain (182 msec +/- 13 standard errors of the mean [SEM]) was significantly higher (P less than 0.01) than before (149 msec +/- 11). The sinus cycle length was variable after ouabain (P greater than 0.1). The corrected sinus nodal recovery time also was variable (P greater than 0.1), decreasing substantially in three subjects. Mechanisms of the effect of digitalis on the S-A node and atrium are proposed and discussed. It is concluded that digitalis prolongs the S-A conduction time in children with normal S-A nodal function. By prolonging the S-A conduction time, digitalis may artifactually shorten corrected S-A nodal recovery time in some patients.


Hypovolemia and hypotension complicating management of acute cardiogenic pulmonary edema.

After the acute onset of heart failure and in the absence of acute myocardial infarction, plasma volume may occasionally be depleted to the extent that the patient presents with clinical signs of circulatory shock. In five patients, the acute onset of clinical and radiographic signs of cardiogenic pulmonary edema were associated with reduction in arterial blood pressure and cardiac output. The pulmonary arterial wedge pressure was within normal limits but a reduction in plasma volume was demonstrated, which is best explained by the rapid translocation of plasma water that represented pulmonary (and most likely also peripheral) edema fluid. The infusion of 5 percent albumin solution significantly increased cardiac output, mean arterial pressure and cardiac work, reversed lactic acidosis, enhanced furosemide-induced diuresis and was followed by a decrease in both clinical and radiographic signs of pulmonary edema. These observations confirm that volume expansion may constitute appropriate treatment for some patients with cardiogenic pulmonary edema who may present with hypotension and who are unresponsive to conventional therapy.


M mode and cross-sectional echocardiographic features of flail posterior mitral leaflets.

Seventeen patients with accepted M mode echocardiographic criteria for flail mitral leaflet were studied. M mode echocardiograms revealed characteristic disordered mitral valve motion: (1) 16 (94 percent) had chaotic diastolic mitral motion; (2) 14 (82 percent) had systolic mitral flutter; (3) 14 (82 percent) had systolic left atrial echoes; and (4) 12 (71 percent) had systolic mitral valve prolapse. In 8 patients (47 percent) all four findings were present, with three findings present in 16 (35 percent) and two findings present in 13 (18 percent); none had fewer than two findings. Cross-sectional echocardiographic studies in 10 patients revealed a systolic whipping motion of the posterior mitral leaflet into the left atrium in all, abnormal systolic mitral coaptation in all and an abnormal mass of systolic left atrial echoes in 4. None of the first three M mode criteria were observed in 230 patients with uncomplicated "mid systolic click-late systolic murmur" syndrome; cross-sectional echocardiography in 30 of 230 patients revealed normal systolic mitral coaptation and no systolic whipping of the tip of the posterior mitral leaflet into the left atrium.


Increased right ventricular wall thickness on echocardiography in amyloid infiltrative cardiomyopathy.

In six patients with clinically significant amyloid infiltrative cardiomyopathy, echocardiographic right ventricular anterior wall thickness was significantly increased (mean 7.5 +/- 2.3 mm; range 5 to 10 mm). This finding in conjunction with the previously described abnormalities of the left ventricle (symmetric increase in wall thickness, diffuse hypokinesia, and small to normal left ventricular diastolic dimension) is consistent with the findings of a diffuse myocardial infiltrative process and should minimize confusion with constrictive pericarditis.


Acquired cyanotic heart disease secondary to traumatic tricuspid regurgitation. Case report with a review of the literature.

A case of traumatic tricuspid insufficiency leading to right atrial enlargement and to a patent foramen ovale with right to left shunting is presented. Six similar cases previously reported are reviewed. The time course of clinical deterioration was related to the type of tricuspid valve damage incurred. Papillary muscle rupture led to surgery within a year, whereas less severe chordal damage allowed a more benign course that lasted from 10 to 25 years from the time of injury to the time of surgery. Surgical repair of the incompetent tricuspid valve and closure of the atrial septal defect led to significant improvement. The diagnostic usefulness of radionuclide imaging and echocardiography is demonstrated in this case. A mechanism of right to left interatrial shunting in the presence of normal pulmonary arterial pressures is proposed; this invokes phasic increases in right atrial pressure from tricuspid insufficiency and streaming of blood from the inferior vena cava into the left atrium across a patent foramen ovale in a manner that resembles conditions in the fetal circulation.


Alterations within the rat thyroid gland during vitamin A deficiency.

Thyroid glands from female rats kept vitamin A deficient for one, two, and three months were examined by electron microscopy. After one month on the diet, no consistent alterations were noted. After two months, the colloid in some follicles displayed a peripheral zone of decreased density. In addition, ultimobranchial follicles within the gland had become keratinized. After two to three months on the diet, cells were seen entering the colloid. Many of these cells were identified as follicular cells since they often occurred in groups and occasionally exhibited remnants of desmosomes. Often the cells within the colloid appeared vacuolated, and by light microscopy were thought to contain lipid. However, electron microscopy revealed that these cells contained many digestive vacuoles rather than lipid droplets. Quantitative and autoradiographic studies indicated that thyroids of vitamin A deficient rats took up less radioiodide than thyroids of control rats. The keratinization of ultimorbranchial follicles in vitamin-A deficiency has been suggested as preliminary in the histogenesis of squamous cell carcinoma. However, an effect of vitamin A deficiency on thyroid follicular cells has not heretofore been reported. It's possible that the presence of follicular cells in the colloid reflects an accelerated turnover of these cells and could indicate an early pathological sign.


An evolutionary view of the male reproductive tract and sperm maturation in a monotreme mammal--the echidna, Tachyglossus aculeatus.

In exploring the evolution and adaptive significance of epididymal function, we have studied the male excurrent duct and spermatozoa of a monotreme mammal--the echidna. Sperm maturation in the echidna excurrent duct appears simpler than that in most therians examined. Furthermore, neither the duct nor the spermatozoa of the echidna display specific therian characteristics; they bear a much closer resemblance to those of non-passerine birds. The echidna spermatozoon is filiform, the sperm tail has no distinctive features, and the anterior seventh of the undulating nucleus is covered by a modest acrosome. Immediately behind this a restricted apposition between plasma membrane and nuclear envelope constitutes a post-acrosomal ring. This is evident also in some reptiles and marsupials, whereas in Eutheria such a membrane association appears as the posterior ring at the base of the sperm nucleus. Maturation of spermatozoa in the Wolffian duct of the echidna appears to be expressed only in a changing capacity for motility and in loss of the cytoplasmic droplet. Neither surface, structural nor acrosomal changes that characterize sperm maturation in therian mammals have been detected in maturing echidna spermatozoa. The echidna duct displays little of the regional complexity of the epithelium that typifies this duct in the Theria. Of five regions distinguishable on the basis of epithelial morphology, the first two appear to be counterparts of efferent ducts by virtue of a low columnar, partially ciliated epithelium. The tall pseudo-stratified Golgi-rich epithelium of the major portion of the duct broadly resembles that of the therian epididymis, but it displays only two structurally distinguishable regions, the more distal being the site of a dense luminal secretion. The foamy epithelial cells of the fifth and terminal region, characterized by a mass of supra-nuclear vesicles and rough ER, suggest a secretory function that may in some way contribute significantly to the ejaculate, for accessory glands are poorly developed in monotremes. The possibility is considered that the relative complexity of epididymal function and sperm structure in therian mammals could have been determined by evolutionary change in the milieu of the female tract, and/or in the character of the egg vestments that the fertilizing spermatozoon must penetrate.


Fine structure of the liver in the larval lamprey, Petromyzon marinus L.; hepatocytes and sinusoids.

The ultrastructure of hepatocytes, bile canaliculi, and hepatic sinusoids of the larval lamprey, Petromyzon marinus, was examined using thin-sectioned and freeze-fractured tissues. The liver is a "tubular gland" with hepatocytes arranged in a tubular fashion around large bile canaliculi. Hepatocytes are roughly conical in shape, with their tapered apices facing a bile canalicular lumen. They possess extensive rough and smooth endoplasmic reticulum, a well-developed Golgi complex, abundant mitochondria, and varying numbers of large secondary lysosomes. Both secondary lysosomes and the Golgi complex are concentrated in the apical or peribiliary cytoplasm, indicating a possible role in bile secretion. The apical surfaces of the hepatocytes bear numerous elongate microvilli and occasional cilia, which project into the bile canaliculi. The hepatocytes are joined, apically, by junctional complexes composed of zonulae occludentes and adhaerentes. In freeze-fracture, the zonulae occludentes are of variable apicobasal depth and consist of honeycomb-like meshworks of fibrils. Spaces of variable width frequently appear in the P-face grooves, indicating that the zonulae occludentes are "leaky." Numerous communicating (gap) junctions join the hepatocytes laterally. Varying numbers of lateral microvilli project into the intercellular spaces and, basally, the plasma membrane is deeply infolded, resulting in the formation of apparently interdigitating basal processes resting upon a thin basal lamina. Sinusoids are composed of both a heavily-fenestrated, continuous endothelium, and phagocytic reticulo-endothelial (Kupffer) cells. Depsite the difference in arrangement of their hepatocytes, the mammalian and lamprey livers show similar ultrastructural features.


Morphogenesis of the truncus arteriosus of the chick embryo heart: tissue reorganization during septation.

Septation of the truncus arteriosus of the normal chick embryo heart was surveyed systematically with the light microscope. Tissue from replicate samples at successive periods of development was sectioned within an arbitrary coordinate system based on positional reference points along the external surface of the heart. Correlation of several aspects of tissue morphology within this spatial and temporal reference-frame yielded a new description of tissue associations and kinetics during septation. A stable complex of tissue structures appeared in the downstream, distal truncus at Stage 25 and persisted throughout the septation process. This complex consisted of (1) the cephalic margin of the myocardial sheath, and (2) the adjacent bifurcation of the vascular lumen, linked together by (3) the newly condensed Y-shaped strap of cells forming the aorticopulmonary septum. The apparent motion of this septation-complex toward the ventricle(s), the appearance within the thoracic cavity of the adjacent segments of the aortic arches, and measures of tissue length and width suggested that septation was accompanied, and perhaps initiated, by increased tension along the truncus. The truncal ridges remained upstream from the complex, with mesenchymal condensations beneath the endocardium differentiating into the definitive semilunar valves. Downstream from the bifurcation, mesenchyme in the aortic arch region condensed around the separate lumens to form the smooth muscular tunica media of the great arteries. The epicardium developed in a caudocephalic direction along the heart tube. Vagal innervation approached the heart cephalocaudally. Capillaries formed along the dividing truncus in both directions. Autoradiography following 3H-thymidine labelling demonstrated reduced DNA synthetic activity in the cephalic margin of the myocardium and aorticopulmonary septum, compared with the associated loose mesenchyme.


Involution of the female Mullerian duct of the fetal rat in the organ-culture assay for the detection of Mullerian Inhibiting Substance.

The study of Mullerian Inhibiting Substance (MIS) has been made possible because of the organ-culture bioassay devised by Picon ('69) for detecting MIS in vitro. We have studied the degeneration of the female Mullerian duct of the rat fetus, the target tissue of the assay, with electron microscopy. We have observed that the involution of the female Mullerian duct in the organ-culture assay follows a pattern of degeneration similar to the normal involution of the male Mullerian duct under the influence of MIS from the fetal testis (Price et al., '77). This involution involves alterations in the duct epithelium subsequent to a response of the mesenchyme surrounding the duct. The degeneration of a specific organ system under the direct influence of a specific factor, Mullerian Inhibiting Substance, represents an example of "programmed cell death."


Luteinizing hormone and follicle-stimulating hormone production in the pars tuberalis of hypophysectomized rats.

Luteinizing hormone and follicle-stimulating hormone were identified by immunocytochemistry in the same cells of the pituitary pars tuberalis, following hypophysectomy in the rat. A marked hyperplasia and hypertrophy of these cells occurred in response to hypophysectomy. These findings are discussed in light of the potential for hormone production by pars tuberalis gonadotropes following hypophysectomy performed as part of an experimental protocol, as well as that performed for palliation of human metstatic breast cancer.


Aglomerular pathways in intrarenal microvasculature of aged rats.

By means of silicone rubber injections, we confirmed the existence of several types of aglomerular arterial pathways within kidneys of aged rats. In superficial cortex some interlobular arteries divide to form aglomerular branches (Ludwig's arterioles) towards cortex corticis. In juxtamedullary cortex these pathways are relatively more numerous, they comprise: (a) Vasa Recta Vera, (b) glomeruli in which afferent and efferent arterioles form a continuous vessel and (c) glomeruli with two efferent vessels, one by-passing glomerular tuft. In addition, results obtained in the rat by the microsphere technique are in agreement with our morphological observations.


25 Hydroxycholecalciferol levels in Beduin women in labor and in cord blood of their infants.

25 Hydroxycholecalciferol levels were measured in eight Beduin mothers in labor and in the cord blood of their infants, and compared with values in 42 Sephardi Israeli women in labor and the cord blood of their offspring. Beduin baby cord blood had a mean 25 hydroxycholecalciferol concentration of 3.78 ng/ml +/- 3.22 (SD) being about half of their mothers' level in labor. Values in Sephardi women and cord blood were 3 times higher. PTH levels were lower and calcium concentrations were higher in cord blood (P less than 0.001) in both groups when compared to their mothers' blood. The relevance of these findings to the high incidence of infantile rickets and hyypocalcemia in Beduin children is discussed.


The effect of diet on echocardiographic left ventricular dimensions in normal man.

The effect of dietary sodium and potassium on echocardiographic left ventricular dimensions was studied in normal subjects. In 10 subjects, left ventricular end diastolic volume was found to be 18.8 greater, and systolic volume 17.1% higher with zoo mEq sodium diet than on a 1Omeq sodium diet (P less than 0.025). While receiving an ad libitum diet, the subjects were found to have an end diastolic volume of 107.9 +/- 6.4 ml SE and an end systolic volume of 45.2 +/- 2.7 ml SE. During sodium depletion, values fell to 101.3 +/- 5.7 ml SE and 38.6 +/- 2.9 ml SE, respectively, then on a high sodium diet rose to 120.3 +/- 7.0 ml SE and 45.2 +/- 2.7 ml SE, respectively. Heart rate fell during sodium repletion by 4.2% (P less than 0.05) while mean arterial blood pressure, cardiac output and peripheral vascular resistance did not change significantly. In contrast, seven subjects consuming a diet containing 25 and 200 mEq potassium in seqeucne, the sodium intake remaining constant, did not display significant changes in cardiac dimension, heart rate, blood pressure, cardiac output, or vascular resistance. It is concluded that dietary sodium significantly effects the size of a nonfailing left ventricle, an effect that must be considered when single or sequential echocardiograms are interpreted.


Hypocholesterolemic action of dietary fiber unrelated to fecal bulking effect.

Twenty-two healthy volunteers took approximately 20 g/day of concentrated dietary fiber from either carrot, cabbage, apple, bran, or guar gum or 31 g from pectin,  added for 3-week periods to controlled diets. Total serum cholesterol fell by 13% on both guar and pectin (P less than 0.01) with no significant change in high density lipoprotein cholesterol. Over the 3-week supplementation period, the other fibers were without effect with the exception of carrot, where both control and test high density lipoprotein levels fell (P less than 0.05 and less than 0.01, respectively). If, however, the 3rd week of the control was compared with the 3rd test week, the values for total cholesterol were 7% lower after apple (P less than 0.02) while after carrot the high density lipoprotein cholesterol level was 10% lower than the control (P less than 0.01). No significant change was seen in serum triglyceride or body weight either as judged by differences over the 3-week periods or by comparing test and control values at 3 weeks. Comparison of stool weights obtained in this study indicate that the fecal bulking action of dietary fiber is independent of its hypocholesterolaemic effect.


The effect of dietary fiber on postprandial serum digoxin concentration in man.

The postprandial digoxin concentrations in serum were measured for 4 hr by radioimmunological assay in six healthy volunteers who had received 0.8 mg beta-acetyldigoxin by the oral route. Digoxin was given together with a formula diet containing as admixture, respectively, wheat bran, microcrystalline cellulose, pectin, carrageenan, and carob seed flour. The various additions did not reduce the mean digoxin concentrations in serum. After carob seed flour, the concentrations were significantly (P less than 5%) higher, as compared to the control. After microcrystalline cellulose, pectin, and wheat bran the mean peak concentrations were reached later than in the control state.


Antipyrine pharmacokinetics and D-glucaric excretion in kwashiorkor.

Hepatic microsomal oxidation and glucuronidation were studied in 15 children with kwashiorkor on admission to the hospital and again after 3 weeks of nutritional rehabilitation. Microsomal oxidation as measured by antipyrine half-life and clearance was shown to be depressed in the acute phase of malnutrition (T 1/2 = 7.9 +/- 5.0 hr, clearance = 8.4 +/- 5.1 ml/min) improving with nutritional rehabilitation (T 1/2 = 4.3 +/- 2.3 hr, clearance = 15.5 +/- 8.7 ml/min). Urinary D-glucaric acid excretion increased from 60.6 +/- 42.2 mumoles/24 hr to 121.8 +/- 105.0 mumoles/24 hr over the same time period. Evidence is thus presented that both hepatic microsomal oxidation and glucuronidation are depressed in the acute phase of kwashiorkor but recover with nutritional rehabilitation.


Obligatory urinary and fecal nitrogen losses in young women, older men, and young men and the factorial estimation of adult human protein requirements.

Obligatory urinary and fecal nitrogen losses and urinary urea nitrogen and creatinine excretion levels were determined in 11 young women (four of whom used oral contraceptives), eight older men, and five young men. Values for obligatory nitrogen losses in the young women who did not use oral contraceptives were similar to those observed previously in young women and lower than those reported for young men. Our values for older men were lower than previously reported values for obligatory losses observed in young and elderly men, but similar to previously reported values for young women and to values for our women who did not use oral contraceptives. The four oral contraceptive users had significantly higher levels of total urinary and fecal obligatory nitrogen losses than the nonusers in our study. When values from our study and values from other recent studies are considered, variations in obligatory nitrogen losses appear to be larger among individuals within an age-sex group than the observed differences between groups. When the intakes of protein recommended as safe by the Food aculated from obligatory nitrogen losses per se, the recommended levels appear to be only marginally adequate.


Urinary sodium and blood pressure in vegetarians.

Urinary sodium, potassium urea, creatinine, uric acid, plasma urea, creatinine, cholesterol, blood pressures, height, weight, and skinfold thickness were measured in some or all of 106 matched pairs of vegetarians (mainly Seventh-Day Adventists) and nonvegetarians. Mean blood pressures were lower in vegetarians (141.9/88.9 mm) than nonvegeterians (148.0/90.9 mm) but the urinary excretion of sodium was higher, although not significantly, in the vegetarians (mean of 169.7 compared with 161.2 mmole/day). The vegetarians also had a higher urinary potassium excretion (62.9 mmole/day) than the nonvegetarians (54.8 mmole/day) thus giving them a lower mean sodium to potassium ratio (3.0 compared with 3.3). Both systolic and diastolic blood pressures correlated positively with plasma cholesterol levels which were less in vegetarians (6.0 mmole/liter) than nonvegetarians (6.6 mmole/liter). They also correlated positively with the urinary sodium to potassium ratio, but only in nonvegetarians. It was concluded that dietary sodium does not explain the blood pressure differences between vegetarians and nonvegetarians.


Calcium deficiency in rural black children in South Africa--a comparison between rural and urban communities.

The prevalence of biochemical abnormalities usually associated with rickets was investigated in three black school-going populations, one from a rural community, one from a small urban community, and one from a large urban area. A high prevalence of biochemical abnormalities was found in the rural community, where 13.2% of children were hypocalcemic and 41.5% had elevated alkaline phosphatase concentrations. No hypocalcemia was detected in the children from the large urban area. Urinary calcium excretion was lowest in the community with the highest prevalence of hypocalcimia and elevated alkaline phosphatase concentrations. Dietary calcium intake in those children with biochemical abnormalities was estimated at 125 mg/day, compared with 337 mg/day in those children with normal biochemistry. It is suggested that the pathogenesis of the biochemical abnormalities in the rural community is due to a low dietary intake of calcium.


Absorption of iron from breakfast meals.

The absorption of nonheme iron from nine common Western type breakfasts was studied in 129 subjects using extrinsic labeling with radioiron. In one group the iron absorption from a continental type of breakfast served with coffee was standardized against the absorption from a reference dose of derrous ascorbate (3 mg Fe). In all subsequent experiments the absorption from this breakfast was compared with one of the other breakfast meals served on alternate days and each labeled with a different radioiron isotope. The bioavailability of iron in the different breakfast meals varied markedly. There was almost a 6-fold idfference in absorption (0.07 to 0.40 mg) despite of the fact that the iron content only varied from 2.8 to 4.2 mg. The most marked effect was seen with tea which reduced the absorption to less than half and with orange juice which increased the absorption two and a half times. The present findings must be considered when giving dietary advice to groups of subjects who are known to have a critical iron balance. The present results also imply that an evaluation of the iron nutrition in a population cannot only be based on the daily dietary intake of iron but must also include the bioavailability of iron in frequently consumed meals.


Studies on the bioavailability of zinc in man. III. Effects of ascorbic acid on zinc absorption.

As ascorbic acid is known to enhance the absorption of dietary iron and to inhibit the absorption of dietary copper, studies were undertaken to examine the effect of ascorbic acid on the bioavailability of zinc in human subjects. The index of absorption was the change in plasma zinc concentration after a 110-mg aqueous dose of ZnSO4.7H2O (containing 25 mg of elemental zinc). Doses of 0.5, 1.0, and 2.0 g of ascorbic acid, representing a spectrum of Zn:ascorbic acid molar ratios from the dietary to the pharmacological range, failed to produce any significant change in the pattern of zinc absorption. Moreover, 2.0 g of ascorbic acid, equivalent to a Zn:ascorbic acid ratio of 0.145 failed to improve the absorption of 108 mg of elemental zinc incorporated into 120 g of black bean gruel. Ascorbic acid over a range of dosages commonly consumed by man had no demonstrable effect on the absorption of inorganic zinc.


Zinc nutritional status of young middle-income children and effects of consuming zinc-fortified breakfast cereals.

The effects of consuming zinc-fortified ready-to-eat breakfast cereals were determined in a double-blind controlled study. The 96 healthy young children who participated (mean age 58 months) consumed either zinc-fortified cereal, providing 25% United States Recommended Dietary Allowance per 1 ounce serving (test children) or nonzinc-fortified cereals (controls) for a 9-month period. The test children were calculated on average to receive an additional 2.57 mg of zinc per day from this fortification program. This increment increased their mean daily zinc intake to a level that approached the Recommended Dietary Allowance (10 mg) of the National Academy of Sciences for children less than 10 years of age. By the end of the period, the test children (combined sexes) had a mean increment of plasma zinc that was 6.5 micrograms/dl greater than that of the control children (P less than 0.02). The test girls had a greater increment (28.5 micrograms/g) in hair zinc content than controls girls (P less than 0.05). There were no significant differences in other biochemical parameters including plasma copper and serum cholesterol. No significant differences in food intake or growth velocity were associated with the consumption of the zinc-fortified cereal. Multiple sex and time related differences occurred in plasma, hair, urine, and parotid saliva zinc concentrations that were unrelated to the type of cereal consumed.


Serum cholesterol and diseases in Nigerians.

A study of 3451 cholesterol determinations in different diseases was carried out. The mean cholesterol levels for male and female adults and children with different diseases were compared with values for their healthy counterparts. Sickle cell anemia, leukemia, liver cirrhosis, hepatosplenomegaly, tuberculosis, and diabetic, nutritional, ataxic, and tropical neuropathies in male and female adults were associated with reduced cholesterol level while in children malnutrition and anemia were the main causes of low cholesterol levels. Obesity and hypertension caused an elevated level but the mean values were within the range for adult Nigerians in the high income group. Only nephrotic syndrome in both adult and children was associated with a markedly increased cholesterol level in Nigerians of low income status.


Nutrition survey of Finnish rural children. VI. Methodological study comparing the 24-hour recall and the dietary history interview.

The aim of the study was to evaluate and to compare the 24-hr recall method with the dietary history method as used in a food consumption survey of children. Information on the dietary intkake was obtained by 24-hour recall from 158 children and by the history method from 134. The interviews are repeated 7 months later. In addition, 741 children were interviewed by both methods on the same occasion. The repeatability of the results was analyzed both at the individual and at the group level. The correlation coefficients between the first and second interview in terms of the individual intakes of energy and nutrients were fairly low for both methods. At the group level the results of repeated 24-hr recalls were in good agreement. The dietary history method, however, gave significantly different mean intakes when repeated. The correlation coefficients between the values obtained by the 24-hr recall and the history method varied from 0.20 (vitamin A) to 0.50 (energy). The history method gave consistently higher mean values than the 24-hr recall. Neither of the methods can be considered suitable for the measurement of an individual child's dietary intake. The 24-hr recall is preferable for food consumption surveys of groups of children.


The effects of stimulation of ear acupuncture points on the body's pain threshold.

Six ear acupuncture points, one non-acupuncture ear point, and the body locus Ho-Ku (LI-4) were electrically stimulated in order to compare the effects of stimulation on the body's pain threshold at selected loci on various points on the body by measurement with a radiation heat-type Pain Meter on 5 subjects. The ear points, with the exception of the non-acupuncture ear point, were found to be effective even in peripheral body regions in varying degrees. Ear stimulation did not increase the threshold as rapidly as Ho-Ku. In all cases where the pain threshold was raised, the effect persisted after electrical stimulation had stopped.


The sedative effect of acupuncture.

Eight patients with diagnosis of anxiety neurosis were treated with acupuncture. Six of them showed good to moderate response while 2 had no change. The endorphin theory in applying acupuncture is discussed.


Traditional and modern medicine in Malaysia.

Malaysia has a large variety of traditional medical systems that are a direct reflection of the wide ethnic diversity of its population. These can be grouped into four basic varieties, namely, traditional "native," traditional Chinese, traditional Indian and modern medicine, examples of which are described. In spite of the great inroads made by modern medicine, the traditional systems are firmly established. Patients move from one system to another or use several systems simultaneously. The integration of the traditional Malay birth attendant into the health team is described. The forces influencing the development, acceptance and integration of the medical systems is discussed.


Eosinophilic cystitis. A study of 16 cases.

The authors describe 16 examples of eosinophilic cystitis. Cases were predominately in older men, and usually were associated with other conditions of the bladder or prostate. In contrast, most of the 21 cases reported in the English language were in women and children who had a low incidence of associated bladder conditions, but often had allergic disorders and eosinophilia. It appears that either bladder injury or allergy predisposes to eosinophilic cystitis. The bladder-injury type probably occurs fairly commonly and can be misdiagnosed both clinically and pathologically. In most of the present series, the clinical diagnosis was carcinoma of the bladder, and some biopsy specimens superficially resembled specimens from cases of nonspecific chronic inflammation. There was muscle necrosis in most examples, and significant replacement fibrosis of muscle in all the latter sometimes masquerading as mucosal fibrosis. Giemsa stain for eosinophils and trichrome stain for muscle fibrosis are helpful diagnostic aids. Also, eosinophilic cystitis appears related to allergic cystitis and interstitial cystitis.


Lipomatous hypertrophy of the cardiac interatrial septum. A report of 38 cases and review of the literature.

Thirty-eight cases of lipomatous hypertrophy of the cardiac interatrial septum are presented and analyzed, together with those previously reported. Available data indicate that this entity is more likely to be seen in the seventh to eighth decade of life, in Caucasians, and with age-associated increases of epicardial fat. It differs from cardiac lipoma, which is a true neoplasm occurring in a younger age group. It is probably more frequent than reported as it is usually not looked for. Atrial arrhythmias sometimetimes coexist with this lesion, but a cause-and-effect relationship would be difficult to prove. The lesion should be included in the differential consideration of atrial masses found by ultrasound, cineangiocardiogram, and gated radionuclide cardiac imaging.


Phencyclidine abuse. Clinical findings and concentrations in biological fluids after nonfatal intoxication.

Phencyclidine concentrations were measured in the plasmas of 22 patients with nonfatal phencyclidine intoxication using gas-liquid chromatography with a nitrogen detector. Concentrations found ranged from less than 10 to 812 micrograms/l, and except for the systolic blood pressure (r = 0.60, P less than 0.05), showed no significant correlation with the physical findings. The most common physical findings were combativeness-agitation (64%), depressed level of consciousness (50%), hypertension (43%), moiosis (43%), and tachycardia (43%). Phencyclidine concentrations measured in the erythrocytes of seven of the patients were generally higher than concentrations in the corresponding plasmas (erythrocyte:plasma concentration ratios ranged from 3.1 to 37.9), suggesting that the binding of phencyclidine to plasma proteins is low. Erythrocytic concentrations also showed no significant correlation with either the physical findings or the plasma concentrations of phencyclidine. For 15 unselected urines the concentrations of phencyclidine showed no significant correlation with urinary pH.


Selective IgA deviciency in Charcot-Marie-Tooth disease.

A selective IgA deficiency was found in five of 15 random patients with Charcot-Marie-Tooth disease. Immunologic studies of 32 members of the five families showed low IgA in 17 of the members, associated with elevated IgM in 20, without other significant immune abnormalities. The immunoglobulin pattern and the variability of symptoms in this familial peripheral neuropathy suggest that a thymic or gut-associated immune deficiency or both, may be causally related to the disease process.


Serum ferritin and bone marrow iron stores. I. Correlation with absence of iron in biopsy specimens.

Serum iron, total iron-binding capacity, and percentage saturation of transferrin have classically been used to demonstrate a hypoferremic state; however, these tests may not discriminate between depleted iron stores and conditions associated with defective reticuloendothelial release of iron. Estimation of stainable iron in the bone marrow biopsy specimen is then the most practical way to assess body iron stores. With the availability of a radioimmunoassay procedure for serum ferritin, we undertook a prospective study to determine whether serum ferritin concentrations might replace assessment of the marrow biopsy iron stores as an indicator of hypoferremia. Iron stores were absent from bone marrow biopsy specimens from 104 patients. A good correlation between low serum ferritin levels and absence of iron stores in biopsy specimens was found for 91 patients (87.5%). Thirteen (12.5%) had normal serum ferritin concentrations with absence of biopsy iron. These individuals had hematopoietic malignancies or active hepatic disease, or were receiving iron therapy. In this group, a bone marrow biopsy would still be necessary for evaluation of a hypoferremic state, even though the serum ferritin concentration might be normal.


Manual and computerized cumulative reporting systems for the clinical microbiology laboratory.

A manual and a computerized system that produce cumulative updated reports from the clinical microbiology laboratory are described. Each system gives the physician a report that is clearly formatted, cumulative, readily updated, and written in conversational terms with minimal abbreviations. The report formats and updating sequences are nearly identical, so that one system can easily replace or back up the other. The cost and complexity of the hardware and software for the computerized system are modest, so that these are suitable for the moderate-sized hospital laboratory processing fewer than 10,000 specimens per year. Also, the laboratory personnel in our community-based nonteaching hospital were able to develop, set up, and support these systems without external consultation or purchased services. Therefore, the improved quality of reporting based on these types of systems can now be available to all laboratories without regard to size or workload.


Leucomalachite green assay for free hemoglobin in serum.

A new colorimetric assay for the determination of serum free hemoglobin utilizing the noncarcinogenic compound leucomalachite green is described. The reaction is complete in 8 min, with the resulting color stable for at least 30 min. The absorption maximum for the leucomalachite green reaction product was observed at 617 nm. Precision studies at 50 and 300 mg/l free hemoglobin concentrations resulted in within-run variations of 1.9 and 1.7%, while the day-to-day variations were 6.9 and 4.0%, respectively. Accuracy studies at concentrations of 50, 150 and 300 mg/l resulted in recoveries of 88, 95 and 98% of theoretical values.


In-vitro activities of cefamandole and cephalothin against 1,881 clinical isolates. A multi-center study.

By use of an agardilution technic, 1,881 clinical isolates were tested against cefamandole and cephalothin. The isolates represented 18 genera, recovered in five geographically separate centers within the United States. The majority of strains were susceptible (MICs less than or equal to 8 micrograms/ml) to both drugs. Cefamandole showed greater activity against most of the bacterial pathogens. Enterococci, Serratia spp., and Acinetobacter spp. were resistant to both drugs. Cephalothin was more active against Staphylococcus aureus, and both cephalosporins were relatively inactive against methicillin-resistant strains of S. aureus. Enterobacter spp. and indole-positive Proteus spp. were susceptible to cefamandole but resistant to cephalothin.


Ultrastructure of myofibroblasts and decidualized cells in leiomyomatosis peritonealis disseminata.

A case of leiomyomatosis peritonealis disseminata studied by light and transmission electron microscopy is reported. The lesion, from a pregnant woman, was found to contain predominantly myofibroblasts and decidualized cells in a rich collagen stroma, while relatively few leiomyocytes and fibroblasts were observed. The development and fate of this entity are discussed in view of the present findings and those previously reported.


Septicemia caused by Pseudomonas paucimobilis.

A case of septicemia caused by Pseudomonas paucimobilis is reported. This represents the first definitive case of disease produced by this yellow-pigmented, nonfermentative bacillus.


Coping with poor prognosis in the pediatric intensive care unit. The Cassandra prophecy.

The intensive-care pediatrician who prophesies to parents that their child's illness is irreversible may encounter denial and hostility. The physician may compare his plight to that of Cassandra--the mythical Greek prophetess of doom, who was cursed to see into the future and not be believed. Four cases are reported in which parents rejected their child's hopeless prognosis, counterprophesied miraculous cures, resolved to obtain exorcism, criticized the care, or accused nurses of neglect. This produced a painful breakdown in the usually harmonious relationships between doctors, nurses, and parents. Parental denial as a coping mechanism is discussed. Guidelines are presented for the prevention and/or early recognition and management of the Cassandra Prophecy phenomenon. A miraculous recovery in one case is a potent reminder to physicians and nurses that they do not have the gift of divine prophecy and cannot see with certainty into the future.


The usefulness of lateral neck roentgenograms in laryngotracheobronchitis.

To evaluate the usefulness of lateral neck roentgenograms when laryngotracheobronchitis (LTB) is the suggested diagnosis, three pediatric radiologists were asked to examine a series of lateral neck roentgenograms of subjects with LTB and controls. In six of the group with LTB, the roentgenograms were unreadable. Given adequate roentgenograms, the radiologists diagnosed or excluded LTB with a high degree of accuracy (sensitivity, 93%; specificity, 92%). However, their predictions of severity based on the roentgenograms showed a poor correlation with measures of clinical severity. The clinical severity of those with unreadable roentgenograms was significantly greater.


Streptococcus bovis meningitis in a neonate.

Neonatal infections have been caused by Streptococcus bovis, a nonenterococcal group D Streptococcus. A recent case of neonatal meningitis caused by this organism prompted a literature review regarding appropriate antibiotic therapy. Although most reports suggested penicillin therapy alone for S bovis meningitis, isolates of this organism that were as resistant to the lethal effect of penicillin as the enterococcus have been recovered. Therefor, it was recommended that until the results of minimal inhibitory concentration and minimal bactericidal concentration tests are known both an aminoglycoside and a penicillin be used simultaneously. Proved susceptibility to the penicillin would justify discontinuation of the aminoglycoside therapy. Physicians caring for neonates with S bovis should be aware that some strains may be resistant to the lethal effect of penicillin.


Familial cirrhosis.

Three pairs of siblings with cirrhosis were investigated. The histopathological examination of the liver biopsy specimens and the laboratory findings did not give any clue about the cause of the disease. The presence of familial cirrhosis was considered.


Gallium 67 scanning for the diagnosis of infection in children.

Gallium 67 scintigraphy was studied prospectively in 26 children with clinically suspected abscesses. Scan interpretation agreed with the clinical outcome in 21 patients (81%). The true-negative rate was 71% and the true-positive rate was 92%. False-positive scans were related to bleeding and bone infarcts. False-negative scans were related to neutropenia (less than 500 neutrophils/cu mm) and to lesions smaller than 1 cm. Gallium scanning is a safe and reliable method of diagnosis of infection in children, except for patients with neutropenia or whose lesions are smaller than 1 cm. Two-hour scans may be useful in some patients, particularly those with osteomyelitis.


Diaphragmatic elevation in neonatal myotonic dystrophy.

In two infants born to mothers with myotonic dystrophy, chest roentgenograms showed elevation of the right sides of the diaphragms. These findings aided in the diagnoses of the neonatal form of myotonic dystrophy and the diagnoses were confirmed at autopsy. Diaphragmatic elevation in neonatal myotonic dystrophy is important to differentiate from diaphragmatic abnormalities that may be amenable to surgery. Accurate early diagnosis and appropriate genetic counseling is important in the management of this disorder.


Posterolateral (Bochdalek's) diaphragmatic hernia in sisters.

Two siblings with identical left posterolateral diaphragmatic (Bochdalek's) hernias are described. To our knowledge, there is one earlier description of siblings in which the diaphragmatic defects have been defined as posterolateral. The observation of these two families with a defect that is usually sporadic raises the possibility of etiologic heterogeneity among posterolateral defects of the diaphragm. Although overall recurrence risk is probably small, prenatal diagnosis by ultrasound should be possible and may improve perinatal management in familial cases.


Career dynamics of female heroin addicts.

Heroin use histories and related institutional involvements were obtained from 30 female heroin addicts. Presence of intimate (vs casual) companions at first heroin use strongly differentiated subsequent high vs low consumption patterns. Intimate others were precipitants in 60% of all treatment episodes; the duration of such episodes was nearly double that for self-precipitated admissions. Concurrent familial determinants were indicated in virtually all accounts of current consumption patterns. It is concluded that romantic/kinship units and liasons of female addicts are an important focus for research, policy, and therapeutic interest.


Alcohol and drug abuse treatment: perceived effectiveness of inpatient combined treatment programs.

The present study did not address directly the comparative superiority of treatment approaches for combined versus separate treatment. It reflects, instead, the perceptions of staff and clients from the programs visited, the available literature, information gathered in the search for combined programs, and program processes and outcomes. The primary hypothesis generated by the study proposed that, given a receptive treatment staff, it is probable that combined treatment has the flexibility to provide treatment to both drug and alcohol abusers that is at least as effective and probably more efficient than separate treatment. Until empirical evidence that clearly delineates problems associated with combined treatment is obtaned, it was suggested that the selection of a combined or separate treatment paradigm is best determined by the needs of the community and the attitudes of the treatment staff.


Fire deaths and drinking: data from the Ontario fire reporting system.

Data on recorded alcohol impairment of 264 victims of fatal fires in Ontario in 1976 are analyzed. Male victims were twice as likely to be impaired as females, and impairment was more common among those under 50 years of age. Alcohol impairment was most often noted in victims of fires at night and on weekends. Overall, 31% of adult victims were reported as alcohol impaired. The Ontario data suggests alcohol involvement in victims was not associated with smoking as a cause of the fire.


A twenty-year follow-up of narcotic addicts in Tucson, Arizona.

This preliminary report from an epidemiological study of heroin addiction in Tucson, Arizona, 1956-1976, examines the status of heroin addicts 20 years after they have been identified as narcotics abusers, focusing on the maturation hypothesis which holds that heroin addicts tend to cease use of narcotics spontaneously by age forty. A cohort of 51 subjects was identified from Public Records of Court Appearances for narcotic offenses during a 36-month period (1955-1957), located and, where possible, interviewed. Records from a minimum of two agencies (law enforcement, corrections, treatment, welfare) were used to establish current status of the individual with reference to the use of narcotics and/or other drugs. Demographic, ethnic, socioeconomic makeup of the sample, as well as criminal involvement and treatment episodes, is included. After 20 years, one individual is drug-free or abstinent. Twenty-three are considered still addicted to heroin, 16 of these are in prison; seven are addicted to methadone or alcohol. Thirteen are dead. Six could not be located; however, five could be traced well beyond 1956 through criminal activities. All but one person have passed their fortieth birthdays. For these 51 addicts, the maturation hypothesis does not hold.


The impact of Vietnam service on heroin-addicted veterans.

Age-matched samples of Vietnam veterans and veterans who did not serve in Vietnam were surveyed at the time that they applied for treatment of heroin addiction. Vietnam veterans were more likely to have begun using heroin during their military service, and they were more likely to say that their service experiences had affected their use of drugs, usually citing relief of fear and tensions of war. Veterans who had not been in Vietnam were somewhat more likely to have begun using drugs after service, and generally indicated that their military experiences had not affected their drug use. When they did cite an effect of service, the factors usually indicated were boredom and a lack of meaningful activity. Attitudes toward narcotic use were negative in both groups, but significantly less so among Vietnam veterans. However, these attitudes did not relate to patterns of current or past drug use. Groups did not differ in the extent of or reasons for current illicit drug use, but non-Vietnam veterans reported more alcohol use. The Vietnam war was mentioned by one Vietnam veteran and by no non-Vietnam veterans as a reason for continuing narcotic use. Few other differences were found. Notably, typical treatment course over a 5-year follow-up period was similar in the two study groups.


Reentry concerns of incarcerated substance abusers.

To facilitate planning of a state-wide reentry program for parolees with histories of drug and alcohol abuse, group interviews were conducted to determine the perceived problems and reentry service needs of 110 male and female inmates of Oregon correctional institutions. Expressed concerns about problems related to frustrations of prison experience, familial and peer relationships, parole supervision, and day-to-day survival skills point to significant gaps and biases in existing reentry services planned from an "objective" viewpoint that slights direct assessment of potential clients' needs.


Emergency room admissions for acute drug reactions in a VA hospital.

To determine the extent to which veterans used a VA Emergency Room (ER) for the treatment of acute drug reactions, the ER log of a VA Hospital was examined to ascertain the number of drug-related visits during the past 24 months. The low base rate suggests that veterans do not rely on a VA ER for the treatment of acute drug reactions and that proper medical supervision and medication management is maintained in the majority of cases. Those who did utilize a VA ER appear to be young (age range 25 to 34), used legally prescribed drugs in combination with alcohol or tranquilizers, and were often suicidal. More attention to the crisis state precipitated by the acute drug reaction is recommended.


The reliability of biographical information obtained from court-stipulated clients newly admitted to treatment.

An exhaustive test-retest reliability study was made of the intake interview used by Abraxas' residential drug program. The study is notable in that (1) 143 wide-ranging questionnaire variables were examined, (2) all tested clients were under court pressure, and (3) the second interview was given after an average of 8 months in treatment. Reliability coefficients for 50% of the 143 items were found to be greater than or equal to .70, 83 were greater than or equal to .50, and the lowest coefficient recorded was .24. Although the clients tended to suppress some sensitive material in the first interview, it was concluded that considerable self-reported information can be obtained from court-stipulated clients within a few days after admission.


Second-year alcoholism treatment outcome evaluation with a focus on Mexican-American patients.

This is an evaluation of an Alcohol Treatment Unit with a focus on a comparison of Mexican-American and Anglo-American outcomes. Social adjustment on a target cohort of 75 was measured on a standard rating instrument (SAI) 2 years after discharge from the hospital. The overall successfulness of the program was 39%; the validity of the Treatment Difficulty Scale (a composite index of anticipated treatment difficulty) was demonstrated for both ethnic groups and both first and second year outcome results; and the average stability of first year findings of SAI components as compared to second year results was shown to be 79%. Use of a standardized index of pretreatment patient characteristics was recommended to facilitate comparative program evaluation research.


Hypernephroma with nonmetastatic liver dysfunction (Stauffer's syndrome) and hypercalcemia. Case report and review of the literature.

A case of renal carcinoma with hepatic dysfunction and hypercalcemia is described. The literature on Stauffer's syndrome has been reviewed and the pathogenesis of this syndrome discussed. It is stressed that the presence of hepatic dysfunction should not be considered a contraindication to surgery since its manifestations have been observed to regress in many cases following removal of the tumor.


Hepatic sinusoidal dilatation related to oral contraceptives. A study of two patients showing ultrastructural changes.

Two patients who have been on oral contraceptives for five and six years developed sinusoidal dilatation. Hepatic enlargement, tenderness and pain disappeared after the discontinuance of steroid drugs. Ultrastructural changes included dilatation of endoplasmic reticula with accumulation of granular electron dense material, disruption of mitochondrial membranes and deposits of collagen fibers in the intercellular spaces between hepatocytes and in the spaces of Disse. Possible relationship of this condition to peliosis hepatis and focal nodular hyperplasia are discussed.


Abnormalities of the bile duct associated with chronic pancreatitis.

The association of abnormalities of the common bile duct with chronic inflammatory disease of the pancreas is described in this report in which the important diagnostic role of endoscopic retrograde cholangiopancreatography (ERCP) is emphasized in this disease entity. ERCP was utilized as a single diagnostic modality in 27 patients (15 females) in whom both the biliary tree and pancreatic ducts were demonstrated. Abnormalities of the pancreatic duct were noted in all patients while the associated changes of the common bile duct were noted in 12 (44%--7 females). The role of ERCP in confirming the diagnosis and its importance in planning specific therapy is emphasized.


Amelioration of pancreatitis with azathioprine.

An experimental method was developed for the production of acute hemorrhagic pancreatitis of uniform lethality in dogs, using the injection of a bile trypsin mixture into the major pancreatic duct. Fifteen of the 20 dogs treated with azathioprine survived as opposed to none of the ten treated conservatively.


Pneumatosis cystoides intestinalis following jejunoileal by-pass.

Four cases of pneumatosis cystoides intestinalis following ileojejunal by-pass in 37 patients are described and the literature reviewed. This complication is usually a self-limited condition, responding to conservative management.


Canidida infection of the upper gastrointestinal tract superadded upon chemical injury with acids.

Two male patients, who presented with Candida albicans infection of the upper gastrointestinal tract, superadded over local mucosal injury due to corrosive chemical agents and chronic alcoholism have been described. Such an association of prior local injury with this type of fungal infection has not been hitherto documented. One of these patients had a gastric antral stricture due to ingestion of concentrated sulfuric acid and Candida esophagitis, whereas the other had severe erosive gastritis and Candida gastritis following ingestion of thiocyanates.


Liver abscess. A complication of regional enteritis.

A patient with liver abscess in association with regional enteritis is reported. Liver abscess should be suspected in patients with regional enteritis who present with fever, elevated serum alkaline phosphatase, liver tenderness, right upper quadrant pain or hepatomegaly.


Conjugated hyperbilirubinemia in infants with erythroblastosis fetalis.

In an attempt to identify the incidence of conjugated hyperbilirubinemia in infants with erythroblastosis fetalis the records of 67 infants were reviewed. Twenty-two infants were found to have direct bilirubin concentrations greater than 1.0 mg./dl. Among 11 infants who underwent intrauterine exchange transfusion, nine (82%) had conjugated hyperbilirubinemia. Of the remaining 56 infants without the procedure, only 13 (23%) showed evidence of this complication. To predict infants at risk of developing conjugated hyperbilirubinemia, the ratio of hematocrit and total bilirubin concentration in cord blood (H/B ratio) was examined.


Suture granuloma of the stomach following splenectomy.

An unusual case of a suture granuloma developing four years after splenectomy and stimulating an intramural gastric neoplasm is presented. Radiologist should be aware of this entity and include it in their differential diagnosis of intramural gastric masses in postoperative patients.


Laboratory-based surveillance of influenza virus in the United States during the winter of 1977-1978. I. Periods of prevalence of H1N1 and H3N2 influenza A strains, their relative rates of isolation in different age groups, and detection of antigenic variants.

Influenza A (H3N2) viruses were isolated from outbreaks and epidemics of disease during the period December 1977 to March 1978. For the last two months of this period, H1N1 strains of influenza A were also responsible for epidemics. In some regions (e.g., Hawaii) co-circulation of H1N1 AND H3N2 strains occurred, whereas in other regions (e.g., Wisconsin) isolation of H3N2 strains had almost ceased prior to isolation of H1N1 strains. Few influenza B isolates were reported. Analysis of the ages of patients from whom specimens were submitted for influenza virus isolation confirmed that, whereas H3N2 strains were isolated from persons of all ages, greater than 97 per cent of H1N1 isolates in six states analyzed were recovered from patients less than 26 years old, although specimens were tested from older persons who were ill during the period of prevalence of H1N1 influenza. The majority of H3N2 isolates tested by hemagglutinin-inhibition reaction were similar to A/Texas/1/77, and the majority of H1N1 isolates were similar to A/USSR/90/77. Antigenic analysis of isolates, however, identified a small number of variants of H3N2 and H1N1 strains.


Laboratory-based surveillance of influenza virus in the United States during the winter of 1977--1978. II. Isolation of a mixture of A/Victoria- and A/USSR-like viruses from a single person during an epidemic in Wyoming, USA, January 1978.

At a time when outbreaks and sporadic cases of influenza caused a A/Victoria/3/75-like and A/Texas/1/77-like H3N2 strain of influenza were occurring in the Rocky Mountain region of the USA, about 60% of the students of a high school in Cheyenne, Wyoming, were involved in an outbreak of influenza-like illness. Six influenza A(H1N1) virus isolates were obtained from throat swabs collected from 12 of these students. Virus isolated from a seventh student, however, contained a mixture of H1 and H3 (A/Victoria/3/75-like) hemagglutinins and N1 and N2 neuraminidases, as shown by the ability to clone from the mixture viruses with antigenic components H1N1, H3N1, and H3N2. An antigenic hybrid virus with H3N1 composition was re-isolated from the original throat swab. The results show that one student was shedding a mixture of A/Victoria/3/75(H3N2)-like and A/USSR/90/77(H1N1)-like viruses at the time his throat swab was taken.


Estrogen use and blood pressure in later life.

Use of oral estrogens did not alter the blood pressure (BP) or BP lability of women aged 52--87. The effect was similar in normotensives and women who were hypertensive before starting estrogen. Compared with nonusers of estrogen, users had lower systolic pressures, but did not differ in diastolic blood pressure, lability, frequency of doctor visits or BP determination, obesity, smoking or use of alcohol or psychotropic medication. The data neither confirm a previously reported association between estrogen use and hypertension nor do they suggest pre-selection of users for hypertension or labile BP.


Familial aggregation of blood pressure and weight in adoptive families. I. Comparisons of blood pressure and weight statistics among families with adopted, natural, or both natural and adopted children.

Tests of homogeneity of means, variances and correlations for systolic blood pressure (BP), diastolic BP and weight among subdivisions of a smple of adoptive families are presented. The means and variances of either type of BP, but not weight, were not significantly heterogeneous among families grouped according to the number of parents and children, natural and/or adopted, in the family unit. Estimates of correlation between family members wree not heterogeneous among subdivisions for each of the three variables. Our results indicate that these data are suitable for a genetic analysis of familial aggregation. Pooled correlations suggest that the degree of resemblance of BP and of weight between family members varies within and across generations. Correlations involving the adoptees were significantly different from zero only for diastolic BP.


Familial aggregation of blood pressure and weight in adoptive families. II. Estimation of the relative contributions of genetic and common environmental factors to blood pressure correlations between family members.

An analysis of the familial aggregation of blood pressure (BP) was conducted to provide estimates of the role of genes and household environment in determining the phenotypic resemblance between biologically related family members. The biological model used for this analysis parameterizes the correlations between family members into the contributions of genetic and environmental variability shared within and across generations. Hypothesis testing about different parameters in the model suggests that shared environment explains larger fractions of the parent-natural child and the full sib correlations for diastolic BP than for systolic BP. For diastolic BP, children in a household share the effects of common environment in addition to the effects which they share with their parents. Dependence of the degree of resemblance between household members on the effects of environmental factors shared within and a-ross generations is not explained by the variability of length of cohabitation among individuals.


Measurement criteria for group echocardiographic studies.

This study reports the reproducibility achieved both within an observer and between observers measuring left heart echocardiographic dimensions using standard measurement criteria in school age children. These criteria define acceptable interfaces as: 1) a single dominant line; 2) continuity at the point of measurement of at least 5 mm in length; and 3) display of specific motion characteristics for the cardiac structure to be measured. The within observer intraclass correlation coefficient for interventricular septum, diastolic dimension, systolic dimension, left ventricular posterior wall, left atrium and aorta averaged 0.94 (range 0.87--0.98). The coefficient of variation averaged 3.6% (range 2--7.5%). The least reproducible dimension was left ventricular posterior wall. The day-to-day variability within a single subject of echocardiographic determined cardiac dimensions was small for all measurements. The standard deviation of error for all variables was no more than 0.3 mm. A system using screening criteria and standardized measurement techniques can provide the degree of precision necessary to begin investigating echocardiographic differences in group studies.


Isolation of Pseudomonas pseudomallei from clay layers at defined depths.

Twelve strains of Pseudomonas pseudomallei were isolated from the soil and water of a sheep paddock over a two-year period. The organism was recovered from the clay layer of the soil profile as well as from water that seeps into this layer during the "wet" season. Five isolates were obtained before the commencement of the "wet" season; environmental factors appear to play an important role in the survival of Ps. pseudomallei during the "dry" season. Lower isolation rates were recorded than those indicated by workers in southeast Asia and Iran.


Circulation and migration of small blood lymphocytes in the rat: II. Study of the lymphocyte selective migration by light and electron microscopic autoradiography.

Fourteen male Wistar rats were the recipients of labeled small lymphocytes (1.5 x 10(7) each) collected from the peripheral blood of syngeneic donors. The migrating labeled lymphocytes were traced in the various organs from one to 60 minutes following their transfusion. Sections from the lymph nodes, bone marrow, spleen, thymus, ileum, liver, lung, and kidney were analyzed morphologically by autoradiographic studies. The results showed that some of the labeled small blood lymphocytes migrate to the lymph node and bone marrow as early as one minute following transfusion; their exodus from these two organs occurs within three minutes. In the case of the spleen, the lymphocytes did not migrate selectively to the marginal zone of the lymphoid follicles until ten minutes following transfusion. The electron microscopic study of the spleen and lymph node showed that the labeled lymphocytes selectively migrate to certain areas which consist of reticulum cells, macrophages, unlabeled lymphocytes, and plasma cells. The term "immunocompetent zones" is proposed for these areas because of the biological significance of this selective migration with reference to immunity.


Chemical modification of nuclear proteins by erythropoietin.

The spleen of the exhypoxic polycythemic mouse was employed as a model system to study the effect of erythropoietin on enzymes that chemically modify nuclear proteins. At selected time intervals after in vivo administration of erythropoietin, acetyltransferase and methyltransferase activity were measured in nuclei isolated from the spleens of treated mice. In addition, the incorporation of labeled methyl and acetate groups into individual histone proteins was also examined. A 36% increase in nuclear acetyltransferase activity was observed eight hours after administration of erythropoietin, whereas nuclear methyltransferase activity increased by 42% 24 hours after administration of the hormone. Selective acetylation or methylation of individual histone proteins was not observed, and it is concluded that activation of transcription by erythropoietin is not the result of acetylation or methylation of nuclear proteins.


The aplastic anemia-paroxysmal nocturnal hemoglobinuria syndrome.

Occasionally it is difficult to differentiate paroxysmal nocturnal hemoglobinuria (PNH) from idiopathic aplastic anemia in patients who present with pancytopenia and an aplastic bone marrow. Patients with PNH may not have an abnormal acid hemolysis test, and patients with aplastic anemia may present with evidence of abnormal sucrose lysis, acid hemolysis, and antibody-mediated complement hemolysis. Demonstration of a population of red blood cells which are highly susceptible to antibody-mediated complement lysis makes a diagnosis of PNH probable. Donor red blood cell survival studies, which distinguish intracorpuscular from extracorpuscular hemolytic disorders, permit differentiation of the two disorders.


Bone lesions in primary amyloidosis.

Amyloidosis primarily involving bone is described in a 59-year-old male pateint. Well circumscribed lytic lesions of the skeleton raised the possibility of myelomatosis. The prolonged insidious course of the disease was uncomplicated by hypercalcemia, pathological fracture, or hematologic abnormalities. The clinical course, together with histological findings and strongly positive bone scan, were the distinguishing features. The osseous manifestations without plasma cell tumor appears to be a rare occurrence in amyloidosis.


Congenital universal muscular hypoplasia: evidence for autosomal recessive inheritance.

Congenital universal muscular hypoplasia has been confused with similar diseases in the past. Evidence presented in this paper distinguishes this disorder from other phenotypically similar ones and indicates that it is inherited as an autosomal recessive disorder.


Alpha-thalassemia in blacks is due to gene deletion.

We used molecular hybridization to test if alpha-thalassemia is due to gene deletion in the black. In 10 families with clinically well-defined alpha-thalassemia-1 (alpha-thal-1), hydribization of alpha-globin cDNA was reduced to the same level as that found in Asians with alpha-thal-1, where two of the four normally present alpha-globin genes are deleted. A black child with hemoglobin H (Hb H) disease also has three globin genes deleted, as do Asian patients with Hb H disease. We conclude that alpha-thalassemia in the black is most commonly due to gene deletion.


In search of non-random X inactivation: studies of fetal membranes heterozygous for glucose-6-phosphate dehydrogenase.

Extraembryonic membranes and fetal tissues were obtained from 55 specimens of 5--11 weeks conceptual age. The glucose-6-phosphate dehydrogenase (G6PD) electrophoretic phenotype was determined and correlated with that of maternal blood. Fifteen specimens were heterozygous for G6PD A, and for nine of these the maternal allele could be determined. In none of these specimens did the isozyme pattern of the membraneous chorion or chorionic villi differ significantly from that of fetal tissue. We have obtained no evidence of non-random inactivation in extraembryonic membranes of human fetal specimens at this stage of development.


Genetic linkage between hereditary hemochromatosis and HLA.

A large Mormon pedigree of a proband with hemochromatosis was studied, using transferrin saturation as the quantitative phenotypic trait. The analysis indicated that the inheritance of hemochromatosis was recessive, with partial expression in some heterozygotes. The lod score of 6.88 (theta = .0) was strongly indicative of linkage between the hemochromatosis locus and the human major histocompatibility (HLA) loci.


Normal adult with absent HEX A: immunoreactive HEX A is present.

Fibroblasts from a normal adult with absent hexosaminidase A (HEX A) activity were demonstrated to possess immunoreactive HEX A as measured by GM2 beta-D-N-acetylgalactosaminidase activity which precipitated with specific anti-HEX A antibodies. Possible explanations for the molecular defect are presented.


Medical paternalism and the rule of law: a reply to Dr. Relman.

In this Article, Professor Baron challenges the position taken recently by Dr. Arnold Relman in this journal that the 1977 Saikewicz decision of the Supreme Judicial Court of Massachusetts was incorrect in calling for routine judicial resolution of decisions whether to provide life-prolonging treatment to terminally ill incompetent patients. First, Professor Baron argues that Dr. Relman's position that doctors should make such decisions is based upon an outmoded, paternalistic view of the doctor-patient relationship. Second, he points out the importance of guaranteeing to such decisions the special qualities of process which characterize decision making by courts and which are not present when such decisions are made by doctors. Finally, he argues that Dr. Relman has overestimated the social costs of bringing Saikewicz-type cases before the courts and that those costs which are inevitable are more than offset by the qualities of process that the court system can offer in such matters.


Reconciling Quinlan and Saikewicz: decision making for the terminally ill incompetent.

One of the most perplexing problems in the medicolegal field concerns the criteria on which decisions not to treat terminally ill incompetent patients should be made. These decisions traditionally have been made by physicians in hospitals--sometimes with the assistance of the patient's family--on the basis of their perceptions of the patient's "best interests." Recently, two state supreme courts have ruled on this question. The New Jersey Supreme Court, in the Quinlan case, developed a medical prognosis criterion, and permitted the patient's guardian, family, and physicians to apply it with the concurrence of a hospital "ethics committee." The Massachusetts Supreme Judicial Court, in the Saikewicz case, adopted, on different facts, the test of "substituted judgment" to be applied by a probate court after an adjudicatory hearing. The two cases have been interpreted by many in the medical profession as representing conflicting viewpoints--one supportive of traditional medical decision making and the other distrustful of it. It is the thesis of this Article that Quinlan and Saikewicz are in fundamental agreement and can be reconciled by the next state supreme court that rules on this question. Both courts enunciate a constitutional right to refuse life-sustaining treatment, based on the right to privacy. They agree that incompetents should be afforded the opportunity to exercise this right, and that certain state interests can overcome it. They agree also that physicians should be permitted to make medical judgments, and that societal judgments belong in the courts. The differences in how the opinions are perceived result from the interplay of several factors: the differences in the facts of the cases; the inarticulate use of the term "ethics committee" by the Quinlan court; the literal interpretation of the role of such a committee by the Saikewicz court; a desire for 100 percent immunity on the part of physicians and hospital administrators in Massachusetts; and advice from their counsel on how such immunity can be guaranteed. It is the author's hope that this Article will help to dispel much of the misinformation surrounding these two cases, and to refocus the debate on how decisions should be made for the terminally ill incompetent patient on the real issues regarding criteria and the decision-making process that remain to be resolved.


Patient Compensation Funds: legislative responses to the medical malpractice crisis.

Fifteen states have created Patient Compensation Funds in response to the increased cost and reduced availability of medical malpractice insurance associated with the so-called "medical malpractice crisis." Patient Compensation Fund statutes limit health care providers' liability to a specified amount, and establish state-administered funds to compensate victorious malpractice plaintiffs for damage awards in excess of that amount. This Note examines the Patient Compensation Fund mechanism, evaluates its effectiveness as a compensation system for malpractice victims, and recommends particular provisions that might enhance its effectiveness. The Note concludes that the Patient Compensation Fund mechanism is an effective means of increasing the availability and of reducing the cost of medical malpractice insurance, and should be adopted by other states experiencing a "medical malpractice crisis."


Medical paternalism or legal imperialism: not the only alternatives for handling Saikewicz-type cases.

In 1977, the Supreme Judicial Court of Massachusetts held in the Saikewicz case that the probate court is the proper tribunal for making decisions whether to give or withhold "life-prolonging treatment" for terminally ill incompetent patients. This ruling provoked debate in the medical and legal communities. Dr. Arnold Relman, Editor of The New England Journal of Medicine, argues that Saikewicz encroaches on existing sound medical practice and requires decision-making machinery that is impractical and inhumane. Relman contends that treatment decision for terminally ill incompetents in Saikewicz-type cases should be made by the physician in consultation with the patient's family. Law professor Charles Baron, in contrast, defends Saikewicz's judicialization approach, arguing that such decision must bemade in an adversary framework that approximates the ideal of the rule of law. In the present Article, Professor Buchanan argues that Relman's criticism of Saikewicz rests on a defective, medical paternalist view of the physician-patient relationship, and that Baron's support of Saikewicz is based on an unjustifiable, legal imperalist view of decision making for incompetents. In Buchanan's view, Relman's approach fails to distinguish appropriately between the making of medical judgments and the making of moral judgments and wrongly assumes that the patient's family typically cannot understand the elements of the decision, while Baron's approach unjustifiably extends the sphere of the legal process by ignoring the special moral relationship that usually exists between the family and its incompetent member. Buchanan proposes an alternative decision-making approach that he believes incorporates the merits, while remedying the defects, of both Baron's and Relman's approaches. The alternative is based on three propositions. (1) The proper presumption in Saikewicz-type cases is that the family of an incompetent is to make decisions concerning treatment. (2) This presumption of the family's dominant role in decision making is defeasible: protection of the patient's rights requires that decisions be made within a framework that allows vigorous discussion and accoutability through impartial review and that provides for legal intervention when necessary. (3) The institutional framework for implementing the features listed in the preceding proposition will rely heavily upon an ethics committee that is neither an all-medical prognosis committee nor an administrative agency of the hospital. Besides evaluating and responding to the Relman and Baron approaches, Buchanan examines the contribution to the Saikewicz debate made by law-and-medicine professor George Annas. In essence, Buchanan rejects Annas's argument that, taken together, the Saikewicz opinion and the Quinlan opinion of the Supreme Court of New Jersey delineate a proper division of medical and legal decision-making responsibility concerning terminally ill incompetents. Buchanan concludes that, contrary to Annas's view, those two cases are not reconcilable.


Relationship of inappropriate drug prescribing to increased length of hospital stay.

The relationship of inappropriate drug prescribing to increased length of hospital stay was studied. The medical records of 77 cases of pyelonephritis were reviewed retrospectively. Appropriateness of antimicrobial drug therapy was judged by three types of explicit screening criteria: drug-specific, patient-specific, and match of drug to infecting organism. Patients whose therapy passed all the criteria were hospitalized, on the average, two days less than those whose therapy failed one or more of the criteria. This was a significant difference (p less than 0.05). Age, seriousness of the pyelonephritis, or method of payment appeared to have no significant moderating effect on this result. However, the increased length of stay may not have been associated with only inappropriate prescribing, because the inappropriately prescribing physicians kept their patients hospitalized longer beyond the point of symptom remission than did the appropriately prescribing physicians. The study suggest that successful interventions for improving drug therapy could result in large cost savings.


Administrative approach to disaster preparedness in the pharmacy.

Disaster planning for a hospital pharmacy department is discussed. During a crisis, the type of behavior exhibited by hospital personnel and the community can be used to predict the situation's severity and to prepare a response. During disasters, it is important to focus on accomplishing tasks by defining employees' roles, establishing chains of communication, delegating authority to competent persons, limiting decision-making by persons other than those in command and defining the boundaries of pharmacy's involvement in the disaster. A case study of pharmacy operations during a crisis is presented, with guidelines for assessing the situation, establishing priorities, identifying resources and executing a response. Hospital pharmacy administrators must display a high degree of creativeness and responsibility during disasters, but training in the principles of disaster management can be helpful.


Pharmacy practice in an operating room complex.

The steps involved in establishing a comprehensive pharmaceutical service in an operating and recovery room complex is described. Objectives of the operating room pharmaceutical satellite were to: (1) improve control of distribution, storage and charging for all drugs, especially Schedule II controlled substances; (2) reduce inventory costs and loss of revenue; (3) improve compliance with the drug formulary; and (4) establish patient-oriented pharmaceutical services. The pharmacy satellite improved inventory control and patient charging, assured continual access to all drugs and appropriate security for controlled substances, and expanded the pharmacy department's clinical, drug information and research activities.


Developing drug-use profiles from drug-charge records.

The potential for developing a drug-use profile from drug-charge records was studied at an 830-bed community hospital. Patient drug charges were reviewed retrospectively for one year (1975) to identify: (1) which key drugs accounted for a high percentage of cost and usage; (2) where key drugs were used within the hospital; (3) how they were used; and (4) who were the chief prescribers. Of the drugs used, 8% accounted for 80% of total drug product costs. Seven drug groups (10% of the total drug groups) appeared in the top 10 of both drug cost and quantity categories. Six individual drugs also appeared in the top 10 of both categories. According to cost, cephalosporin antibiotics were ranked first among drug groups but were sixth according to quantity. Analgesics-antipyretics were ranked first among drug groups by quantity and second by cost. Cephalothin was ranked first among individual drugs by cost and was not in the top 10 in quantity. Diazepam was ranked first among individual drugs by quantity and third by cost. Patients' drug-charge records can be used effectively to generate drug-use profiles for ongoing drug use review, quality assurance and cost containment programs.


Predicting warfarin maintenance dosage based on initial response.

The relationship between initial response to warfarin sodium, as measured by prothrombin time, and warfarin maintenance dose was studied. Hospital patients received 10 mg of warfarin sodium daily until the prothrombin ratio (patient's prothrombin time/control) was 1.5 to 2.5. Patients subsequently were maintained at that warfarin dosage which maintained prothrombin ratios within this range. Twenty-two patients completed the study. A correlation was found between maintenance dose and the logarithm of the prothrombin ratio on the third day after initiating warfarin therapy (p less than 0.01, r = -0.74). There was no relationship between maintenance dose and the number of days needed to reach therapeutic response. Patients with baseline prothrombin ratios of less than one took significantly longer to reach therapeutic response than did patients with baselines of greater than one (p less than 0.01y. A simple yet scientific approach to determining warfarin maintenance dosage would seem to be feasible. The correlation found between maintenance dose and prothrombin ratio in this study would have to be applied cautiously and only after further validation.