Skills and procedures in emergency medicine: room for controversy.

To examine patterns of consensus and divergence of opinion about whether, and under what conditions, residency-trained emergency physicians use certain skills and perform procedures, directors of 35 emergency medicine, 28 surgery and 30 internal medicine residency programs were surveyed. The directors reacted to a list of 30 skills modified from the condition/skills list compiled by the Certification Task Force of the American College of Emergency Physicians representing a consensus on the core-knowledge for emergency medicine, as determined by both practicing and university-based emergency physicians. The responses indicate a wide variation of opinion about which skills are within the realm of residency-trained emergency physicians, and under what circumstances a procedure should be performed. The skills of greatest concern among emergency medicine directors include axillary and intravenous lidocaine blocks, bronchoscopy, burr holes, closed reduction of dislocated hips, Swan-Ganz catheterization, and cardiopulmonary by-pass. In contrast, slightly more than one third of the procedures on the modified list were clearly agreed upon by over 80% of the directors as procedures performed by trained emergency physicians.


Toxicity of acetaminophen overdose.

Symptoms of toxicity following overdose of acetaminophen (APAP), now a common household medication, occur 24 to 48 hours following ingestion. Toxicity is mainly to the liver but, while data has implicated a minor metabolite, the precise mechanism is not known. Toxicity is likely to occur after a minimum ingestion of 140 mg/kg, but the toxic dose may vary as a function of individual glutathione levels. Since the early clinical picture is not diagnostic, APAP plasma levels must be measured. Supportive care alone has resulted in a 5% to 10% mortality with a high incidence of hepatic toxicity. Treatment within 10 to 12 hours following ingestion with any therapeutic agent reduced mortality to zero and diminished liver toxicity. N-acetylcysteine is an investigational new drug for treating APAP toxicity and can ethically be used if the patient is first enrolled in the current nationwide evaluation. Recommended treatment steps in a suspected APAP poisoning are 1) emesis or lavage; 2) plasma APAP determination; 3) obtain treatment protocol from the Rocky Mountain Poison Center; 4) history of use of other pharmacologic agents, and 5) diuresis, alkalinization or hemodialysis, as in aspirin poisoning, are contraindicated.


Emergency management and sequelae of acid ingestion.

Because it causes immediate pain when taken into the mouth, strong mineral acid is less often swallowed than corrosive alkali, but psychotic, inebriated or determined individuals may consume lethal amounts. Burns of the oropharynx and glottis may lead to asphyxial death. Acid has only superficial effects upon the esophagus but, upon reaching the stomach, flows along the lesser curvature, induces pylorospasm, and pools in the distal antrum. Pyloric stricture is the most common late complication among survivors. Due to the rapidity with which acid acts, local and systemic therapy must be expeditious. Neutralization and demulcification are recommended but no time should be lost if weak alkali is not readily available. Lavage has limited applicability and induced emesis is strictly contraindicated. Aggressive intravenous fluid therapy, antibiotics, and opiates for pain are needed in most instances. Immediate gastrectomy and steroids are controversial but operative intervention is eventually required following most significant ingestions.


Fasting plasma free amino acids of infants and children consuming cow milk proteins.

We have analyzed the fasting plasma aminograms of 165 infants and small children. Mean age was 17 months (range, 3-42 months). The majority had been consuming a diet in which all protein was supplied by calcium caseinate, the remainder a modified cow milk formula. Protein provided less than 6.4% of energy for 8 children, 6.4%-7% of energy for 81 children, 8% of energy for 42 children and greater than 8% of energy for 34. Only the values for the concentrations of total essential amino acids, valine, and taurine at less than 6.4% of energy as protein were significantly lower than corresponding values at higher intakes of protein. Analysis of the remainder of the data revealed no significant differences in either absolute concentrations or molar fractions among differing levels or sources of protein intake. Interindividual variation in concentrations of amino acids was greater than that resulting from changes in the level of intake of high quality protein when 6.4% or more of energy was provided as protein.


Severe methicillin-induced renal failure treated with hemodialysis.

We describe the clinical course of a patient who developed anuria following prophylactic methicillin administration. To the best of our knowledge, this is the first report of prolonged anuria following administration of this drug. The patient's nephropathy developed as a result of routine perioperative antibiotic prophylaxis for cardiac surgery and resulted in a two-week period of complete anuria. Following discontinuation of methicillin the patient was supported throughout this period by intermittent hemodialysis and eventually had an excellent recovery of renal function without concurrent use of corticosteroids. Thus methicillin may occasionally cause severe and prolonged anuric renal failure, but maximal supportive measures, including dialysis when necessary, should nonetheless be used, since the renal failure is reversible once the antibiotic is discontinued.


Candida meningitis in newborn infants: a review and report of combined amphotericin B--flucytosine therapy.

Meningitis due to Candida albicans was successfully treated in a 1.1 kg premature infant using combined antifungal therapy of amphotericin B for three weeks and 5-fluorocytosine for four months. Hydrocephalus and profound psychomotor retardation were present one year later. Psychomotor retardation, aqueductal stenosis and hydrocephalus were found to be common in a review of 16 previously reported cases of central nervous system (CNS) candidiasis in newborn infants. The diagnosis and institution of therapy were frequently delayed, and the mortality rate was 29% in the 17 patients reviewed here. The subacute course, lack of clinical findings, variable cerebrospinal fluid (CSF) findings, negative CSF cultures due to low concentrations of organisms, slow in vitro growth of C. albicans and misinterpretation of positive cultures as contaminants are factors frequently leading to delayed diagnoses. Using combination therapy, it should be possible to use lower doses and shorter courses of amphotericin B therapy for C. albicans meningitis in the newborn infant.


Changes in the kinetics of muscle contraction in vitamin D-depleted rats.

Using an in situ rat soleus neuromuscular preparation, changes in the muscle contraction kinetics in response to vitamine D depletion were studied. For a single isometric contraction, the time-to-peak tension (Tp) and the time-for-recovery-half-way-to-resting tension (T1/2r) were recorded. For a 150 Hz, 300 msec tetanus, the T1/2r was determined. Animals raised on high-calcium, high-phosphate, vitamin D-depleted diets showed prolongation of all parameters. Repletion of vitamin D returned Tp and T1/2r values to normal. Neither dietary calcium deficiency nor thyroparathyroidectomy produced an prolongation of Tp or T1/2r values. Therefore, based upon the experimental data, it appears that vitamin D or one of its metabolites, independent of any effect on the serum calcium or serum phosphate concentration, is necessary for normal muscle relaxation.


Glomerular C3 receptors in human renal disease.

The relationship between glomerular C3 receptor activity and intraglomerular C3 deposition was studied in 73 cases of various forms of renal disease. C3 receptor activity was measured by enumeration of complement-coated sheep red blood cells (IgM EAC) that adhered to glomeruli in frozen sections and expressed as a percentage of the mean number present in control kidneys. Adjacent sections were studied for the presence and distribution of C3 deposits. The precise location of corresponding dense deposits was determined through 1-mu sections or electron micrographs. Marked depression of C3 receptor activity was found in most cases in which there was accumulation of C3 along the glomerular basement membrane, irrespective of whether the deposits were in a subepithelial, intramembranous, or subendothelial location. In contrast, when C3 was not detectable or was found exclusively in the mesangium, C3 receptor activity was affected only moderately, if at all. These data are consistent with the hypothesis that the interaction of C3 with podocytes is a major determinant in the loss of C3 receptor activity in glomerular disease, but do not exclude the possibility that interaction with mesangial or endothelial cells may also influence C3 receptor activity.


Effect of hypertonic dialysate and vasodilators on peritoneal dialysis clearances in the rat.

A model for performing peritoneal dialysis in the rat was established which permitted the consistent measurement of dialysis clearances. The effects on urea and inulin clearances of interperitoneal vasodilators and 4.25% dextrose were compared. Isoproterenol, nitroprusside, histamine, and bradykinin, when added to 1.5% dextrose dialysate for three consecutive exchanges, all produced approximately a 20% increase in urea and inulin dialysis clearances. These increases in clearances persisted in the three subsequent exchanges when no drugs were added to the dialysate. The addition of isoproterenol, nitroprusside, or histamine to six consecutive exchanges did not produce a further increment in clearances. The use of 4.25% dextrose dialysate for three exchanges produced approximately a 50% increase in urea and inulin clearances. Clearances remained about 35% greater than control values in the subsequent three 1.5% dextrose exchanges.


Glomerular filtration of proteins: clearance of anionic, neutral, and cationic horseradish peroxidase in the rat.

Glomerular permeability to horseradish peroxidase, a protein slightly smaller than rat albumin but similar in shape, was studied in Wistar-Furth rats by using a purified neutral isozyme (HRP; molecular radius, a(e) = 29.8 A) as well as an anionic succinyl-derivative (sHRP a(e) = 31.8 A) and a cationized enzyme (cHRP, a(e) = 30 A). The clearance rate of the proteins was determined over a 20-min period using the amounts of enzyme actually filtered (i.e., protein in the urine and protein reabsorbed by tubules). Fractional clearance of cationic HRP (0.338 +/- 0.019) exceeded that of neutral HRP (0.061 +/- 0.005) by a factor of 5.5 and that of anionic HRP (0.007 +/- 0.000) by a factor of 48. Tubular reabsorption was less than 10% of the filtered load. The experimental results indicate marked charge dependency of the filtration of proteins across the glomerulus. Fractional clearances for these proteins are significantly lower than those reported in the literature for dextrans of similar molecular radii. Other molecular properties such as shape and deformability may explain these differences.


Mechanism of blood pressure reduction by teprotide (SQ 20881) in rats.

The mechanism by which the angiotensin converting enzyme inhibitor, teprotide (SQ 20881), lowers blood pressure was assessed in anesthetized normotensive and spontaneously hypertensive (SHR) rats. Teprotide always was administered at a maximally effective dose of 1 mg/kg. In six normal Wistar rats, teprotide lowered blood pressure only after sodium depletion, an effect which was abolished by bilateral nephrectomy. Saralasin infusion (5 microgram/kg/min) into salt-depleted normal rats induced a blood pressure effect similar to that of teprotide. When administered in addition to saralasin infusion, teprotide did not reduce blood pressure further in normal rats or in SHR. When blood pressure of normal rats was raised by angiotensin II infusion (200 ng/kg/min), teprotide did not affect the induced blood pressure increase. In contrast, the pressure rise induced by angiotensin I infusion (230 ng/kg/min) was reversed by saralasin, but again concomitant administration of teprotide did not induce further blood pressure reduction. Thus, under the particular conditions of the present study, teprotide did not appear to exert its hypotensive effect by any mechanism other than inhibition of the renin-angiotensin system. Furthermore, given at a maximally effective dose to the rat, it produced no greater vasodepressor effect than did saralasin.


Electroencephalographic and radionuclide studies in dialysis dementia.

Six maintenance hemodialysis patients with dialysis dementia (severe mental deterioration, speech disturbances, apraxia, facial grimacing, and myoclonus) were studied. They were matched with respect to age, duration of dialysis, and underlying renal disease with six patients who had no dementia and who acted as controls for the electroencephalographic (EEC) studies. The dementia patients had marked slowing of the EEG rhythm to 5--7 Hz with high voltage biphasic or triphasic spikes, and were clearly separated by frequency distribution analysis from the controls. Radio-iodinated serum albumin (RISA) cisternography in dementia patients demonstrated ventricular reflux, prolonged stasis, late appearance of the parasagittal strip, and persistence of RISA for up to 72--96 hr, which suggest an alteration in cerebrospinal fluid (CSF) dynamics.


Skeletal X-ray findings and bone histology in patients on hemodialysis.

X-ray films of the hand skeleton (mammography technique), serum chemistry, and quantitative bone histology (micromorphometry of undecalcified sections, iliac crest spongiosa) were compared in 25 patients on maintenance hemodialysis. The X-ray findings correlated better with serum PTH levels than with bone histology. Of all radiological signs of renal osteodystrophy, pronounced subperiosteal resorption (radial aspect, second finger, middle phalanx) and periosteal new bone formation (middle phalanx) correlated best with histological indicators of osteitis fibrosa. These signs were never seen in control patients. Acroosteolysis (endphalanx) and intracortical or endosteal resorption (middle phalanx) were less specific (i.e., seen even in the absence of metabolic bone disease) and correlated less with bone histology. Osteosclerosis in iliac cancellous bone was paralleled by abnormal texture of spongy bone in the proximal metaphysis of the middle phalanx (second finger).


Hepatitis B surface antigen in urine of hemodialysis patients.

As part of an extensive epidemiological survey of chronic hemodialysis patients in Michigan, hepatitis B surface antigen (HBsAg) was identified in the sera of 79 of 701 (11%) patients. Of these patients, 59 were carriers of HBsAg for three or more months. Urine samples were collected from 36 of 39 HBsAg carriers having urinary output. Of these samples, 19 (52%) were positive for HBsAg by radioimmunoassay; this was confirmed by specific antibody neutralization. The HBsAg was not identified in the urine of seven hemodialysis patients who were lacking serum HBsAg or in urine samples from three HBsAg sero-carriers who had normal renal function. Patients undergoing maintenance hemodialysis appear to constitute a large reservoir of HBsAg chronic carriers. This study indicates that a minimum of 50% of persistent HBsAg carriers who are producing urine have detectable HBsAg in single, randomly timed, unconcentrated urine specimen. These data suggest that urine may represent a potential vehicle for transmission in nonparenterally acquired hepatitis B.


[Nystagmus (author's transl)].

In 37,500 patients 291 cases of nystagmus were found. Jerky nystagmus of latent typ was the most frequent form, pendular nystagmus the next. Jerky nystagmus of gaze paretic type, micronystagmus, nystagmus amblyopicus and endpoint nystagmus are compared and contrasted.


[Partial palpebral myotarsectomy (author's transl)].

In cases of senile entropium we prefer an operation method, which attempts to exclude the aetiologic factors of these senile alterations. The tension of the tarsus must be increased and the muscle of the orbicularis at the palpebral margin must be reduced and retightened over the convex margin of the tarsus. It is not of less importance to correct the reduced elasticity of the fascia tarsoorbitalis. These corrections are achieved by a perforating rhomboid excision of the lower eyelid. The operation is performed with the use of a Chalazion forceps (Desmarres) which steps all bleeding. The method of operation was successful in all 34 cases and achieved good functional and cosmetic results. Recurrences were not observed.


[Complications and their prevention before, during and after the implantation of intraocular lenses (author's transl)].

The complications and their prevention during and after the implantation of iris clip- and iridocapsular lenses are evaluated. The follow-up period varied from 6-72 months. A careful selection of the patients and optimal conditions during the operation in endotracheal intubation are essential. Secondary cataracts (6%) and the lack of capsular synechiae to the haptic portion of the iridocapsular pseudophakos (7%) are the major complications.


[Long term observations after irradiation of the iris by the argon laser (author's transl)].

Eleven pigmented rabbit irides were irradiated with the argon laser and were examined electron-microscopically at several intervals between 15 minutes and 256 days after exposure. It was shown that cells start to migrate into the area of the lesion already on the fourth day. After 32 days the area of the lesion is completely closed. 256 days after exposure only a slight impression remained on the anterior surface of the iris.


[Retinal circulation time in diabetic retinopathy treated with photocoagulation (author's transl)].

A preliminary report is given on studies of the retinal circulation in diabetic retinopathy before and after photocoagulation treatment. The local retinal circulation time RCT of selected retinal areas was calculated by means of a fluorescein long-term infusion technique. In 7 eyes with diabetic retinopathy (DR) the mean RCT was significantly higher (2.0 +/- 0.58 sec. range 1.27-2.6) than in 15 control eyes (1.11 +/- 0.34 sec, range 0.50-1.82, Niesel 1976). Assuming an increase of blood flow in DR (L'Esperance 1971, Kohner 1975) the increase of RCT by a factor 2 would imply an increase of the vascular volume by a factor hardly less than 3 indicating the marked impairment of retinal hemodynamics in DR. After photocoagulation, the mean RCT was significantly shortened only in eyes with preoperative RCT values above 2 sec. The reduction of local RCT correlated with the extent of treated retinal areas. The cross-sectional area of the retinal veins measured near the optic disc was generally reduced independently of the extent of coagulation treatment. Taking also the obvious postoperative reduction of the total retinal vascular volume into account, photocoagulation resulted in a marked decrease of blood flow not only in extensively treated but also in areas with little coagulation effects. In DR the disturbed retinal circulation in general tends to normalize following extensive photocoagulation.


[The metabolic regulation of the retinal blood flow and the role of prostaglandins (author's transl)].

The microioptophoretic injection of PGE1 close to the retinal arterioles procedures a segmental vasodilatation of 40%. The inhibition of prostaglandin synthesis with indomethacin or aspirin blocks the vasodilatatory effect of hypercapnia and, to a lesser extent, of hypoxia. These results suggest that prostaglandins play a role in the regulation of retinal vasomotor activity.


[The role of the glial cells in the maintenance of the ionic environment of the photoreceptors of the retina of the drone (author's transl)].

A double-barrelled potassium sensitive microelectrode was used to record electrical potentials and K+ activities in the retina of the drone Apis Mellifera during stimulation with trains of flashes, 1 per sec, intense enough to produce receptor potentials of near maximal amplitude. During the stimulation photoreceptors lose about 25% of their intracellular potassium concentration. During stimulation the potassium activity in the extracellular space increased transitorily up to 20 mM and then fell to a plateau. By this time the potassium concentration increased by about 20% in the glial cells. These results suggest that the glial cells may participate in the regulation of K+ activity in the extracellular space. The increase of potassium activity in the glial cells may be a stimulus for activation of cellular metabolism.


[Study on the tissue compatibility of intracorneal horn lenses in experimental animals (author's transl)].

Horn lenses, manufactured from human toenail donor material were implanted intracorneally in 15 rabbits. The thickness of the lenses ranged 0.08 to 0.2 mm, the diameter from 4.5 to 7 mm. 13 lenses were fenestrated, two were not. Within 6 months, growth of corneal tissue into fenestrations of the lenses occurred but no signs of aseptic necrosis were seen histologically. The boundary layer between stroma and horn lens revealed apposition as well as ingrowth of tissue in electron-microscopic studies. Unguinal tissue may be useful in keratoprosthesis on the basis of its permeability to glucose, lack of foreign body-activity and hydrophilia.


[Practical experiences with the Octopus automatic perimeter (author's transl)].

A statistical analysis comparing the results of more than 1000 visual field examinations carried out with the automatic perimeter Octopus and with a conventional Goldman-perimeter, clearly demonstrates the superiority of the automatic instrument in many respects: Apart from a higher precision of the perimetric measurements (smaller fluctuations), a better reproducibility of the results (larger correlation coefficients) is noticed. Due to great ease of operation of the automatic perimeter, the ophthalmologist is discharged from the time-consuming task of perimetric examinations.


[The effect of lens opacities on the visual field (author's transl)].

The stray light effect on the visual field was quantitatively studied in normal subjects under experimental conditions. Stray light comparable to that caused by lens opacities was produced by means of selective occluders or diascleral illumination. The results derived from this model were compared with the statistical evaluation of the visual fields of 123 eyes with glaucoma followed for a minimum of 10 years. As expected lens opacities resulted in a concentric constriction of the peripheral fields and a loss of the inner isopters. The light difference sensitivity as determined by static perimetry was generally reduced preferentially in the central fields. These calculations provide a measure to anticipate the degree of lens opacifications from a depressed visual without knowledge of the visual acuity.


[Problems in the implantation of permanent magnets of the treatment of lagophthalmos (author's transl)].

We tried to implanted permanent magnets in the eye lid to cure lagophthalmos. But severe complications occurred very often, mainly decubitus with expulsion of the magnet through the skin. We think that it is necessary to change the system to get better results with permanent magnets in the treatment of lagophthalmos.


[Degenerative ocular retinal albinism in a girl ten years old (author's transl)].

Ocular albinism with myopia and impaired vision (R.E. 0.2; L.E. 0.6), but without nystagmus, were observed in a 10-year-old girl. The electrophysiological tests indicate, in addition, the presence of a tapetoretinal degeneration. It is assumed that the patient is carrier of two genes, a sex-linked one responsible for albinismus solum fundi and a second one of autosomal-recessive type, responsible for the tapetoretinal degenerartion.


[Eye movement disorder in albinos (author's transl)].

Recent studies have shown misdirected optic fibres in albinotic animals to the lateral geniculate body, to the visual cortex and to the superior colliculi. Since a similar anomaly was found anatomiclly and neurophysiologically in human albinos, an oculography was performed in 10 albinos. The results were identical to those found in the so called congenital nystagmus. It remains doubtful that the misdirection is an explanation for the nystagmus in albinotic humans.


[The role of bulb echography in the diagnosis of malignant melanoma of the choroid (author's transl)].

The combined A- and B-scan echography reliably separates intraocular melanoma from other intraocular lesion. This is showed by the analysis of 79 cases with clinically certain or possible melanoma during the last three years. In all 33 enucleated eyes the histology proved the echographic diagnosis of melanoma to be correct.


[Stimulation specific visual evoked responses (V.E.R.) in clinical use (author's transl)].

Out of the many different kind of stimuli used to elicit V.E.R., two classes are of practical clinical use. Luminance V.E.R. give information on the macular area and can be used through opaque media and in infants. Pattern stimulation may give information on visual acuity (foveolar function) or on conduction disturbances in the optic nerve. Pattern stimulation can be used in children under 1 year of age.


[Empty sella turcica and papilloedema (author's transl)].

In a 49-year-old patient bilateral papilloedema with an empty sella turcica was observed. A summary of the literature references to this syndrome and its pathogenesis and its eye complications are given and discussed.


[On the differential diagnosis of bilateral retrobular optic neuritis (author's transl)].

Two cases of optic nerve neuritis are reported. The first had typical clinical symptoms and the other had an atypical course. In the case of the first patient an astrocytoma was found in the right frontal lobe. The aetiology of the second case was a meningioma of the tuberculum sellae. The clinical findings in our cases are discussed with regard to 58 cases in the literature. In all cases of optic neuritis with typical and atypical course a tumor of the central nervous system must always be taken into consideration.


[Posttraumatic Horner's syndrome (author's transl)].

A report is given of 2 cases of Horner's syndrome caused by trauma. Pharmacological pupillary tests are mentioned. Traumatic Horner's syndrome occurs most often in injuries of spinal nerve roots. In rare instances it is reversible. Traumatic oculopupillary syndrome was first described in 1864.


[Thygeson's superficial punctate keratitis (author's transl)].

Thygeson's keratitis is characterized by a coarse punctate epithelial keratitis with almost no hyperaemia of the conjunctiva. It is a bilateral disease with frequent recurrences. The prognosis is good.


[Corneal and conjunctival deposits in the eyes of patients treated with periodic haemodialysis. Study of 47 patients (author's transl)].

The study of 47 patients with terminal renal failure treated in the centre for haemodialysis of Geneva shows that 66% present corneo-conjunctival deposits. These deposits do not produce symptoms nor diminution of the vision. Their pathogenesis, linked to the important variations of calcaemia and phospho-calcic product, is not a function of duration of haemodialysis. Similarity seems evident between these deposits, other soft-tissue calcifications and experimentally induced topical calciphylaxis.


[Dyskeratosis of the corneal epithelium (author's transl)].

Three patients presented an unilateral whitish cloudiness of the corneal epithelium which reduced the vision considerably. In two cases, radiotherapy was carried out previously (because of pterygium and because of teleangiectasia of the conjunctiva). In the eye of one patient, a superficial corneal lesion developed during general anesthesia. The corneal epithelium was scraped off in all cases, but the opacities reappeared. Histologically, the epithelium showed dyskeratosis with signs of malignancy. --7 illustrations (3 sketches of the corneas, 4 histological photographs).


[Problems of conjunctival closure after fornixplasty (author's transl)].

In plastic operations of the fornix the most important part of the reconstruction in cases without defect of the subconjunctival planes is to cover the defect with a plastic to make impossible the formation of symblepharon and to permit the spontaneous epithelialisation of the fornix. We operated on seven patients with this method and we always obtained very good fornix.


[Results of the surgical therapy of exotropia (author's transl)].

An analysis of 113 exotropia operations showed a reduction of the evodeviation for distance to a residual angle of -9 and -12 delta. In 67 cases with unilateral surgery (recession-resection) each additional millimeter beyond two millimeters produced a reduction of angle of about 3 delta for distance, the variance, however, was considerable. The operation of 58 cases with intermittant exotropia improved the manifestation for distance significantly in 71%.


[On the indications for treatment of intermittent exotropia (author's transl)].

The most decisive factors for surgical intervention in intermittent exotropia are the frequency of manifest deviation, the motor disturbancies and the degree of binocular functions present. The disturbance of binocular function may be characterised primarily by the extent to which binocular vision is convergence-dependent. We prescribe increasingly strong correcting prisms preoperatively. The aim is to attain and stabilise the divergent position of rest, to approximate the near and distant angles in cases of pseudodivergenceexcess, and to eliminate convergence-dependency of binocular vision.


[The surgical treatment of superior oblique paralysis (author's transl)].

The line of treatment drawn out by Malbran more than 20 years ago has lost none of its standing. However, although the main principles are still valid, the surgical protocol should be modified in view of the evolution of the surgical concept and technique for which we are indebted to Cüppers. The so-called "thread operation", which the author proposes to call the "Retroequatorial Myopexy of Cüppers" brings a decisive progress. Combined with the primary effect on the paralysis muscle, it also elegantly solves the three problems of this paralysis, namely hyperphoria, excyclophoria, and muscular incomitance. The ideal surgical plan includes now a Superior Oblique Tuck of the affected muscle, with a Retroequatorial Myopexy of the Inferior Rectus of the sound eye, either in the same operation or separately. The muscle weakening procedures by the traditional recession should be avoided.


[Retinal dysplasia with hydrocephalus (author's transl)].

A Study is described of a family in which four children of the same generation died during early childhood; three of them had an obvious hydrocephalus. Two of the latter could be examined clinically, and their eyes removed for pathology. One of them presented clinically bilateral leucocoria; histology showed a total detachment of a dysplastic retina, with absence of development of the vitreous. The other child had apparently normal eyes. Yet on microscopical examination there was a discrete retinal dysplasia without retinal detachment in both eyes, and a persistent hyaloid artery, in one. This association of hydrocephalus with retinal dysplasia is clinically and genetically different from other types of retinal dysplasia.


[Trabeculectomy-iridencleisis combined with cataract extraction].

On 31 eyes (23 patients, average age 74 years) with cataract and primary open-angle or chronic angle-closure glaucoma modified trabeculectomy with lobelike iridencleisis was performed combined with cataract-extraction. They were followed up for periods between 6 months and 3 years. In 84% of cases the i.o. pressure continued to be normalized without further antiglaucomatous therapy, in 16% additional treatment with drugs achieved sufficient lowering of i.o. pressure. In nearly all of the cases I observed a diffuse, very flat filtering bleb. Gonioscopy shows, that filtering channels stay open along the margin of the imbedded iris flap. Complications were rare and demanded no further surgery.


[Trabeculectomy and trabeculotomy (author's transl)].

A retrospective study was made of 319 cases operated upon between 1970 and 1975 with evaluation of the postoperative results (average period of observation 34.4 months, never less than 2 years). When compared to fistulisating interventions according to the Scheie procedure, we found the pressure lowering effect to be comparable, however the intra- and postoperative complication-rate and the tendency to develop cataract definitely less. This may be due to a) covering of the fistula by a scleral lamella and b) the use of the operating microscope.


[The meteorological influence on cases of acute glaucoma in French-speaking Switzerland in the years 1971-1976 (author's transl)].

The authors present a meteorological study of 45 cases of acute closed-angle glacuoma. Frontal type weather, especially that associated with an invasion of maritime air from the north-west following the passage of a cold front appears able to trigger off an attack in an anatomically predisposed subject.


[Postural glaucoma (author's transl)].

Three patients with different eye problems show pathological intraocular pressure in the supine position, while the pressure in the seated position was normal. In all three cases normalisation of intraocular pressure in the supine position could be achieved by treatment with Pilocarpine and other antiglaucomatous agents. Unfortunately one cases showed an aggravation of the visual acuity and visual fields. The term low tension glaucoma is discussed.


[Early results with scleral flap by Preziosi's operation (author's transl)].

The antiglaucomatous Preziosi operation leads within some months in a relatively high percentage of cases to a cataract necessary operation. The main cause for the seems to be a flat anterior chamber lasting several days. Posterior synechaie are frequent. Two out of 55 patients developed an infection of the filtration bleb. By additional preparation of a scleral flap over the sclerectomy complications were obviously rarer, and the regulation of the pressure was very good. There was no difference if the operation was done with or without scleral flap. High pressures during the first days after operation normalize themselves spontaneously or by massage of the eye ball, and have no significance the prognosis. In the cases with scleral flap the filtration blebs show good vascularisation, only in a few cases we saw cystic areas without vessels within filtration blebs with good vascularisation. Moreover the anterior chamber is formed much quicker and complications such as cataract are rare.


[Coats' disease: early detection and early treatment (author's transl)].

With regard to visual prognosis Coats disease can grossly be divided in 3 different stages: If the disease is confined to the periphery of the fundus, complete recovery can be achieved by appropriate treatment. If there is already a severe macular involvement central visual acuity hardly improves, but blindness can be prevented. In case of a widespread, exsudative retinal detachment, the prognosis is unfavourable. Early diagnosis and early treatment of Coats' disease are therefore very important.


[Spotty fatty retinal degeneration (author's transl)].

The author describes the macroscopical, microscopical and ultrastructural features of a peculiar form of snail track degeneration, which was found in 3 eyes with absolute glaucoma. The snowflakes are concentrated to scattered patches in an extensive frosted area of the peripheral retina. The glittering points consist of neutral fat in a gliotic and atrophic retina. Electron microscopy examination shows fat droplets within the astrocytes and Müller cells. These findings are believed to be the expression of a "in situ break down" of a very slowly atrophying retina by the macroglia.


[Reticular cystoid degeneration (author's transl)].

This is the first description of the biomicroscopic appearance of reticular cystoid degeneration (RCD). The case with exceptionally large RCD illustrates the difficulties of diagnosis in the living eye of this rather common condition. There is no scotoma in the visual field and the pillars transgressing the cystoid spaces obviously contain nervous elements. Morphologically the RCD are not very conspicious and are easily confounded with typical cystoid degenerations. Differential diagnosis between these two cystoid alterations of the retina is therefore difficult and possible only if vessels on the outer layer of the cystoid spaces are found.


[Eye a symptoms in relapsing polychondritis (author's transl)].

This is a rare auto-immune illness with necrosis of cartilages. Palpebral oedema, conjunctivitis, episcleritis, iridocyclitis and proptosis belong to this syndrom. But the cataracts often described are iatrogenic, due to the intense corticotherapy required. A report is given of one personal observation and discussion of new therapeutical possibilities.


[Annular detachment of the chorioretina of vascular origin (author's transl)].

This paper relates the case of a 54-year-old woman with spontaneous annular detachment of the chorioretina in the right eye. Through examination and evolution confirm that it is an "uveal effusion", most probably in relation with choroïdal circulatory troubles and an affection of the pigment epithelium.


[Conservative treatment of malignant intra-ocular tumours seen in Lausanne. First report (author's transl)].

Conservative treatment of malignant tumours situated within the eye, was begun in Lausanne eight years ago. Although the period of observation has been short and the number of patients limited, we can already note the first results, insisting particularly on the dangers and difficulties encountered during this plan of treatment.


[Pneumatically driven instruments for microsurgery (author's transl)].

In recent years motor driven hand instruments for especially difficult microsurgical manipulations have come in use. Under certain conditions the electric low volt systems presented difficulties with regard to power or reliability. Therefore trials were made with pneumatic systems which with same dimensions produce much more power. In this way also totally different functions can be remote-controlled in quite a new way.


[Neurinoma of the oculomotor nerve (author's transl)].

Three cases of histologically verified neurinomas of the oculomotor nerve are reported. The preoperative diagnosis in all three cases was not made; on the contrary all cases were diagnosed as sphenoid ridge meningiomas. The oculomotor neurinoma manifests itself in the beginning with a discrete progressive palsy of the oculomotor nerve leading in later stages to complete ophthalmoplegia. Proceeding the oculomotor nerve paresis or going parallel to it is a functional loss of the homolateral optic nerve sometimes progressing to amaurosis. Unilateral exophthalmos as well as frontal or orbital neuralgic pain with or without sensory disorders in the area of trigeminus-I are characteristic for the clinical picture in later stages, all symptoms characteristic for the syndrome of the apex orbitae, resp. the superior orbital fissure, resp. the anterior cavernous sinus. The differential diagnosis has to consider above all the sphenoid ridge meningioma, the trigeminal neurinoma and the numerous tumors within the cavernous sinus (aneurysmas, meningiomas, chondromas, metastases of carcinomas, pituitary adenomas etc.) or the middle cranial fossa. Plain X-ray, carotid angiogram and computer tomogram are essential diagnostic means for localization and extension of the tumor but not for histological diagnosis. Oculomotor neurinomas are very seldom. The three observed cases did not have any relation to a possible generalized neurofibromatosis.


[The random dot test as a screening method for the visual acuity in children (author's transl)].

The Random Dot Test was used for a screening of the visual acuity of children of 6 to 10 years of age. The testing time is reduced by 50% as compared with the examination by means of illiterate E images on cardboard charts. Children with refractive errors of up to 3 delta but normal visual acuity after correction are not detected at the examination distance of 1.30 m used in this study. None out of 672 children with severe eye diseases gave false negative results with the Random Dot Test. Disturbances of the binocular vision could also be detected with the Random Dot Test.


[A simplified radioimmunoassay for digoxin determination using a 125-j-labelled, solid-phase kit (author's transl)].

Our experience with a commercially available kit (Radioimmunoassay DIGOXIN, Boehringer, Mannheim) using (125J)-labelled digoxin and antibody-coated tubes is reported. This simplified method requires only two pepetting steps per sample and results can be obtained in 70 min. The intra- and interassay coefficient of variation ranged between 7% and 8%. The specific digoxin antibody gave no clinical relevant cross-reactions with spironolactone or prednisone (less than 0.0007%). Of the digoxin metabolites the aglucone digoxigenin showed 31% cross-reaction while the more important cardioactive metabolites digoxigenin-bis- and mono-digitoxide had the same binding affinity to the antibody as digoxin, beta-methyldigoxin and beta-acetyldigoxin. Cross-reaction with digitoxin was 6.8%. More than double-fold dilution of serum protein concentration showed little influence on the digoxin values measured. The results obtained by this new kit compare closely with those obtained by our tritium-labelled kit (r = 0.94, p less than 0.001). Therefore, the upper therapeutic limit of 1.9 ng/ml can be adopted for this method.


[Plasma concentrations of digoxin in patients under intensive care conditions and in patients undergoing anesthesia and operation (author' transl)].

Pharmacokinetic behavior of digoxin or beta-acetyldigoxin was examined in 66 patients (27 patiets under intensive care conditions, partially with controlled breathing, 22 patients undergoing extirpation of the uterus and 17 patients treated with radium or chemotherapeutics; 19 males and 47 females) by determining plasma concentrations of digoxin (PDC). After intravenous and oral application with a maintenance dose of 0.20--0.50 mg/day blood was taken daily during a 2 to 3 week period, resulting in 510 determinations. 24 hours after the first application of 0.50 mg digoxin i.v. the mean values of PDC amounted to 0.62 +/- 0.08 ng/ml. After 0.40 or 0.25 mg digoxin per day i.v. therapeutical concentrations could be observed at the third vs fifth day. An equilibrium of PDC was reached on the 6th day after starting digitalization using maintenance doses. Intravenous application of 0.25, 0.40 or 0.50 mg digoxin per day resulted in a mean steady state of 0.68 +/- 0.37, 0.86 +/- 0.33 or 1.27 +/- 0.49 ng/ml PDC, respectively. The results were significantly different (p less than 0.01--0.001). Serial measurements indicated a great variation of PDC. In patients without renal failure the intraindividual variation of the plasma concentrations was maximal 37.4% referring to the mean steady state, interindividual 37.1% and the evaluation of the inter- and intraindividual differences amounted to 54.1%. After oral administration of digoxin (maintenance dose: 0.50 mg/day) or beta-acetyldigoxin (maintenance doses: 0.20--0.40 mg/day) differences in PDC of 38.3% and 29.7% were obtained. Body weight, age and serum creatinine concentration were partly responsible for the variance of PDC. Multiple linear regression between stead state PDC and dose, age, body weight and serum creatinine concentration revealed 62.1% of the variance of the PDC after intravenous administration of digoxin. After oral administration of beta-acetyldigoxin 39.9% were obtained. Thus, 40% of the variance were caused by differences in distribution and elimination of digoxin after i.v. application. After oral application additional 20% of the variance could be attributed to resorption and possible disturbances.


[Vascular effects of digitalis in human extremities (author's transl)].

The effect of lanatosid C on the peripheral vascular system was studied in a randomized double-blind cross-over study. 1 mg lanatosid C in saline or a corresponding volume of saline were applied intravenously for 30 min to healthy subjects. A significant drop of 28% in blood flow and an increase of peripheral vascular resistence at rest of 44% during and after the application of the cardiac glycoside could be seen while the placebo effect was minimal.


Antigenic relationship between Chang liver cells and human hepatocytes.

Using monospecific antisera against human liver specific protein (LSP) it could be demonstrated that Chang liver cells bear LSP on their membranes. Chang liver cells can therefore be used as in vitro system to study immune reactions against LSP in human inflammatory liver diseases.


[Circadian rhythms in the endocrine system (author's transl)].

In four sections, the contribution reviews data on 24-hour variations of cortisol, growth hormone, prolactine, testosterone, LH and FSH in the human plasma. 1) Experiments on isolated subjects show that the 24-h variation of cortisol is based on an endogenous circadian rhythm which can be independent from the rhythm of sleep and wakefulness. 2) The various pattern each of which has been described in good correspondence by several groups of authors, suggest a series of hormones with a strong circadian component (e.g. cortisol) to those with a weaker (testosterone) or even without a circadian component (FSH). 3) The sleep-wake-cycle influences the phase of hormone rhythms by various degrees; therefore, a uniform reference to sleep time seems preferable to a reference to local time in order to compare several rhythms. 4) The rhythms of cortisol and growth hormone as described in man agree satisfactorily with those in other vertebrate species.


[Autologous 131J-tagged human fibrinogen for early detection of venous thrombosis (preparation, biological and in vivo properties) (author's transl)].

A method for preparation of autologous 131J-tagged human fibrinogen is demonstrated. In vitro the preparation is characterized by content of fibrinogen, protein, plasminogen, clottability and molecular weight. Total plasma radioactivity, specific radioactivity, non-protein-bound radioactivity, biologic half-life and the local activity at the thrombus define the properties in vivo. With the above criteria autologous 131-J-tagged human fibrinogen was shown to be useful for early diagnosis of venous thrombosis.


Serum iron and total iron binding capacity in leprosy patients.

Serum Iron and Total Iron Binding capacity were estimated on the sera collected from 45 leprosy patients attending the out-patient department of the Central JALMA Institute for Leprosy, Agra. The Sera from 15 healthy subjects were included in the study as controls. Hypoferraemia was observed in lepromatous leprosy and was particularly marked during the reactive phase. Further investigations to elucidate the pathogenesis of anaemia in leprosy are being planned.


Haematological profile in leprosy. Part II--Relationship to severity of disease and treament status.

321 adult male lepromatous leprosy patients were studied for relationship between haematological findings, severity of disease and duration of treatment. Significant changes were noticed in relation in haemoglobin concentration, serum vitamin B12 and serum folate levels, serum albumin and globulin. No significant changes were observed in serum iron levels in relation to disease and treatment status. With rising bacterial load, there was a trend towards lower haemoglobin concentration, higher vitamin B12 level and lowered serum folate levels. Serum albumin showed a significant decline, while serum globulin showed a significant rise. The findings are discussed in relation to replacement of bone marrow by lepromatous tissue as well as possible interference in the metabolism of haematinics by M. leprae. The exact mechanism of neurlogical deficit in leprosy in relation to deficiency of vitamin B12 and folic acid need to be further elucidated.


Irregularity of Dapsone intake in infectious leprosy patients attending an urban treatment centre--its magnitude and causes.

The Dapsone/creatinine ratio in random samples of urine was determined in 910 infectious leprosy patients attending the outpatient department of the Acworth Leprosy Hospital, Bombay during the period 20-9-76 to 20-11-1976. It was found that 48.7% of them were not taking regular treatment. The patients who were detected to be irregular in treatment were interviewed when they next attended the clinic to find the reason behind their irregularity. It was noticed that the majority of them (63%) attended the clinic for DDS treatment but could not come regularly for valid reasons, e.g. no time to attend, no money to travel to the clinic and absence from Bombay to go to native village.


Serum calcium and magnesium in different types of leprosy.

Serum calcium and magnesium were studied in 200 leprosy patients and 25 apparently healthy individuals. Serum calcium was found to be significantly decreased in all types of leprosy except tuberculoid. The decrease in serum magnesium was highly significant in tuberculoid, lepromatous and borderline lepromatous cases.


Persistence of Australia antigen in leprosy--a frustrating puzzle in immunology.

This paper deals with the relationship of Australia antigen (Au) to various sub-groups of leprosy, in a total of 200 cases. Au was found to be present up to 4% in lepromatous leprosy, 2% in tuberculoid leprosy and lepra reaction, and 3% of antibody in lepromatous leprosy. Presence of antibody denotes past antigenemia. The quantitation of the antigen is done using the new technique of Electro-immuno-diffusion (EID) of Laurell, synonymous with rocket technique. The persistence of the antigen is explained in the light of deranged immunological mechanisms.


The distribution of consumption model of prevention of alcohol problems. A critical assessment.

The conceptual framework and empirical basis of the distribution model are examined, and it is concluded that a more satisfactory model is required.


The single distribution theory of alcohol consumption. A rejoinder to the critique of Parker and Harman.

It is concluded that the central element of the theory, that the mean and rate of heavy consumption are closely related, is irrefutable, and recommendations for a prevention program are outlined.


Comparison of alcoholism prevalence rates obtained by survey and indirect estimators.

Prevalence rates obtained by the Ledermann consumption model and the Jellinek estimation formula are similar to the rate of "heavy--escape drinking" obtained by a suvey using a quantity--frequency index and questions about "escape drinking".


Evaluating implementation of a job-based alcoholism policy.

Implementation of the alcoholism policy of the U.S. Civil Service Commission could have been improved by canvassing supervisors and unit directors for their views, diffusing information more widely and providing more support to alcoholism coordinators.


Relationship between blood alcohol concentration and self-reported drinking behavior.

Men having a high blood alcohol concentration when arrested for drunken driving reported more drinking and more alcohol-related impairment than did men with lower concentrations.


Difficulty of follow-up and outcome of alcoholism treatment.

Patients who are difficult to follow up after alcoholism treatment have poorer treatment outcome than do patients who are followed up more easily.


Self-esteem of women alcoholics.

The self-esteem of women alcoholics was lower than that of men alcoholics and of "normal" women nonalcoholics but was similar to that of women in treatment for psychiatric disorders not related to the misuse of alcohol or drugs.


Alcohol-induced drowsiness and vigilance performance.

Detection of signals in a visual vigilance task decreased significantly after drinking 1.2 g of alcohol per kg. Two mechanisms for the detection decrement are discussed.


Rate of onset of drunkeness. A preliminary study.

Of eight moderate drinkers drinking until they became intoxicated, four left relatively sober prior to a rapid increase in sensations of intoxication, and four experienced a gradual progression to intoxication.


Effect of alcohol on emotional responses to stress.

When participating in tasks involving various probabilities of receiving an electric shock, men who had previously drunk alcohol maintained high levels of anxiety while anxiety decreased in men who had previously drunk a placebo.


Communication deviations in alcoholics; a pilot study.

Impairments in speech, language, voice and hearing were observed in 14 of 15 alcoholics in treatment.


Violence, alcohol problems and other problems in disintegrating families.

Violence is more than twice as likely to occur in families with rather than without alcohol problems.


Synchronized sipping in alcoholics and social drinkers; a preliminary investigation.

In a laboratory setting, social drinking couples synchronized a greater proportion of their sips of alcoholic beverages than did alcoholic husbands and their wives.


Factors affecting survival following radical mastectomy.

Data on 17 potentially useful factors from 152 women undergoing radical mastectomy for operable breast cancer were analyzed in order to determine the effect of each on survival and their relative importance. Only four, clinical stage, clinical and pathological lymph node involvement, and appearance of recurrence and metastases, proved to be of significant prognostic value. Axillary nodal involvement was the main single determinant of survival. Multiple regression analysis, based on factor analysis of the original input variables, was able to account for 34% of the variance in survival and is thus of only very limited use as a predictive instrument in the clinical management of prospective patients.


Alveolar soft part sarcoma.

This paper presents the case history of a 22-year-old woman with an alveolar soft part sarcoma of the scapular region. Treatment consisted of resection. Cytostatic medication with adriamycin and dacarbazine (DTIC) failed to prevent rapid general metastatic growth.


Angiographic features in tubular-papillary adenocarcinoma of the kidney.

Angiography and nephrotomography are essential in evaluation of avascular or hypovascular space occupying lesions of the kidney. Ultrasound adds another dimension in differentiating solid from cystic masses. Two cases of tubular-papillary adenocarcinoma were reported. Their angiographic findings consisted of a few neovascularities. Nephrotomography and ultrasonography in the second case showed a solid mass.


Intermittent occlusion of the abdominal aorta: a conceptual approach in treating below-diaphragm tumors (a preliminary report).

A modified form of tumor strangulation as a possible treatment modality is considered. Intermittent intra-aortic occlusion by means of specially designed catheters and equipment is described. As a preliminary feasibility study, occlusion in non-tumor-bearing animals has begun, with projection for future human cases anticipated. Theoretical concepts of substances from the occlusion process resulting in cure and specific immunity in experimental animals are evaluated, and the belief in the development of modified antigens and antibodies as a consequence of restriction of a growing tumor's proliferating blood supply is discussed.


Effect of phenylhydrazine pretreatment on splenectomized Rauscher leukemia virus-infected mice.

The protective effect of phenylhydrazine pretreatment seen in Rauscher leukemia virus-infected intact mice is not observed when splenectomized mice are used. Such mice succumb to infection even earlier than viral potency controls. Since phenylhydrazine is known to increase both splenic erythropoiesis and hematopoietic stem cell numbers, the results suggest that these two events may be involved in phenylhydrazine prophylaxis.


Visualization of breast lesions with an advanced ultrasonic device: results of a pilot study.

A pilot study is described in which a new design of a sensitive ultrasonic device was used to visualize breast lesions in nine patients. The results were in general accord with clinical, histologic, and x-ray examinations, although ultrasound was superior to x-ray mammography in the visualization of discrete cysts in breasts having a "dense" background. As the device provides an indication of the capabilities of ultrasonic equipment which will be generally available within the next two years, projections are made on the impact of this equipment on the earlier diagnosis and prognosis of cancer, together with a discussion of the negligible radiation bio-hazards posed by devices of this type, in the light of present knowledge.


Carcinoembryonic antigen follow-up and selection of patients for second-look operation in management of gastrointestinal carcinoma.

A long-term postoperative carcinoembryonic antigen (CEA) follow-up study is carried out with patients having undergone primary resection of histologically proved adenocarcinomas of the gastrointestinal tract. Up to now, 122 patients who underwent curative resections, as judged from the situs and the results of histologic examinations, were followed up for tumor recurrence by computerized CEA surveillance diagrams and clinical diagnostic methods. In the cases of tumor recurrence the rise of the CEA level preceded a positive clinical diagnosis by a mean of 4 months. On the basis of the CEA time course, we selected 28 patients for second-look surgery. In all cases proof of recurrence of the disease was obtained. A local recurrence correlating with a slow CEA rise was generally resectable, metastases correlating with a rapid CEA rise were only in some cases resectable, provided that second-look surgery was carried out without delay.


Dumbbell neurogenic tumors of the mediastinum. Diagnosis and management.

Among 706 collected cases of mediastinal neurogenic tumors were 69 patients (9.8%) with extension through an intervertebral foramen, so that the composite neoplastic mass was dumbbell-shaped. Although only 10% of these dumbbell tumors were malignant, the majority of the patients presented with neurologic symptoms of spinal cord compression. In about 40% of reported cases, the intraspinal component, although present, was not clinically apparent. Such cases of asymptomatic intraspinal extension should be suspected when special roentgenologic views of the spine demonstrate erosion of the vertebral pedicle or enlargement of the intervertebral foramen adjacent to the posterior mediastinal mass. Workup of these patients should include myelographic studies to determine whether a dumbbell tumor is indeed present; if it is, surgery should be carried out by a team of thoracic surgeons and neurosurgeons in a one-stage combined resection of both the intraspinal and the mediastinal component of the tumor. With early diagnosis and surgical intervention, long-term survival is the rule. When the patient is in the pediatric age bracket, an orthopedic surgeon should be included on the team to help minimize subsequent skeletal growth deformity.


Class of immunoglobulin deposition and prognosis in lupus nephritis.

In the three major morphologic groups of lupus nephritis--diffuse, focal proliferative, and membranous--glomerular deposition of immunoglobulins is usually a combination of IgG, IgM, and IgA and is not a good indicator of initial renal severity or outcome. In this study of 60 patients with systemic lupus erythematosus and nephritis, patients with exclusive or predominant glomerular deposition of IgG did not have more severe renal disease or a worse prognosis than those with combined IgG-IgM deposition.


Renovascular hypertension. Relationship of surgical curability to renin-angiotensin activity.

Fifteen patients whose renovascular hypertension was cured or improved by renal artery reconstructive surgery or nephrectomy (or both) underwent studies of their renin-angiotensin systems preoperatively. These studies included measurements of peripheral venous renin activity in the erect position without diuretic preparation, blood pressure response to blockade of endogenous angiotensin II with a saralasin infusion in the acutely sodium-depleted state, and levels of renal venous renin activity, also after sodium depletion. In 13 of these 15 patients who had benefitted from surgical intervention for relief of renovascular hypertension, at least one index of renin dependency was positive. Two patients had negative results in all of the tests. On the basis of these findings, we concluded that cure or improvement of renovascular hypertension is possible even though these three parameters of renin-angiotensin overactivity are negative.


Hemolytic transfusion reaction. Recent experience in a large blood bank.

Data on 47 cases of hemolytic transfusion reactions are presented along with a review of the literature. Human error and limitations of current techniques of compatibility testing remain the major causative factors of hemolytic transfusion reactions.


Treatment of diminutive mucosal lesions of the terminal colon by nurse endoscopists.

The efficiency of a supervised nurse endoscopist having been established, the role of nurse endoscopists has been extended to the treatment of diminutive colonic mucosal lesions. One nurse endoscopist, under supervision by a physician mentor, has carried out more than 6,000 sigmoidoscopies in a recent 1-year period and has fulgurated one or more diminutive polyps in almost 500 patients. Larger lesions detected by the nurse endoscopist were treated by the physician.


Consent forms--how, or whether, they should be used.

If written consent forms are to be used--their use normally is not mandatory--care should be taken that their use is proper and, hence, beneficial. To be of benefit to the physician, the consent forms must help him in meeting his duty to inform the patient or in protecting him from a patient's claim that his was not an informed consent (or both). Consent forms are of no benefit to the physician or the patient if they are worded poorly or put to poor use. Suggestions are provided to help the physician in considering his or her use of written consent forms.


Thrombotic occlusion of Hancock conduit due to severe dehydration after Fontan operation.

Six months after undergoing a Fontan procedure for tricuspid valve atresia, a 7-year-old child experienced thrombotic occlusion of the Hancock conduit coincident with an acute gastroenterologic illness that produced sudden, severe dehydration. Recovery from this complication was possible only by virtue of pulmonary blood flow through a Glenn anastomosis, which had been constructed at 1 year of age and which was left in place at the time of the Fontan procedure. At subsequent reoperation, the Hancock conduit, which was completely occluded with organized thrombus, was replaced with another Hancock conduit, and the patient is now doing well 10 months after this last operation. The relatively nonpulsatile flow characteristic of blood passing through the prosthetic conduit after the Fontan operation predisposes the patient to the possibility of the potentially lethal complication, previously unreported, of thrombotic occlusion of the conduit, and care must be taken to avoid severe dehydration in such patients.


Plasmaperfusion for the treatment of intractable pruritus of cholestasis.

A patient with primary biliary cirrhosis and intractable pruritus was treated with plasmaperfusion of charcoal-coated glass beads on two occasions. The procedures were well tolerated and resulted in the removal of about 70%  (494 mumol) of the estimated chenic acid pool. There was, in addition, pronounced amelioration of the pruritus which enabled the patient to sleep through the night without awakening because of itching. The pruritus, however, did not disappear and gradually returned to its preperfusion intensity by the end of the third week after perfusion.


Treatment of acute central retinal artery occlusion.

Central retinal artery occlusion very often leads to irreversible visual loss and seldom responds to treatment. Retrograde cannulation of the supraorbital artery followed by irrigation with anticoagulants and vasodilators may be of value in the early management of this problem. A case in point is described.


Fidelity of histone synthesis in cultured human fibroblasts.

The results in the literature to support Orgel's general error hypothesis of ageing only provide indirect evidence that errors in protein synthesis increase during senescence. This study attempts to provide direct evidence of errors in protein synthesis by measuring the misincorporation of 35S-methionine into histone H1 obtained from young and old fibroblasts (MRC-5). The conclusions that can be drawn from this study are: (a) the error level for the misincorporation of methionine into histone H1 is less than 7 methionines/10(5) amino acids and 2-3 methionines/10(4) amino acids in young and old cells respectively; (b) a methionine containing fraction associated with H1 is obtained after the final purification. The amount of this fraction increases with the age of the cell culture as does the number of methionine residues; (c) there is a variation in the complexity of H1 polypeptide chains, the complexity increasing with the age of cultured cells.


Structural and replicative forms of mitochondrial DNA from human leukocytes in relation to age.

The structure and replication of human leukocyte mitochondrial DNA (mtDNA) was investigated in healthy young adult males (23--37 years old), middle-aged males (42--52 years old) with secondary polycythemia, and elderly males (80--89 years old) who exhibited different degrees of age-related disease syndromes. The distribution of the various cell types within the white cell population was within normal limits in all samples. Total mtDNA was isolated in ethidium bromide--CsCl gradients and examined by electron microscopy after spreading by the aqueous and formamide techniques. The individual frequencies of catenated forms ranged from 2 to 6% but showed relatively little change (declining slightly) with age. The individual frequencies of circular dimers varied from 0 to 0.1% in the young adult and polycythemic groups and in 10 out of 12 elderly individuals. One elderly individual had a circular dimer frequency of 0.3% (including a circular molecular of tetramer size) and another had 4.5%. This finding suggest that agerelated cellular pathology may exist in the blood-forming system in some cases. The mode of replication of leukocyte mtDNA agrees well with that described for mouse L cells. There was no evidence of aberrant mtDNA replication as a result of aging.


The use of health services by civilian beneficiaries of the military health care system. A comparative study.

The military Health Care System provides comprehensive health care to entitled beneficiaries in a dual system consisting of hospitals and clinics at military installations, and an insurance like program (CHAMPUS) which pays for care in civilian facilities. Utilization by civilian beneficiaries was studied and compared with utilization by members of the Kaiser-Permanente Plan in Northern California, and the Non-Institutionalized Population of the United States. Hospital use rates for beneficiaries under CHAMPUS and in military facilities were calculated, and rough order of magnitude data were developed for utilization of hospitals outside of the Military Health Care System. Rates within the system were found to be lower than those of the noninstitutionalized population of the United States, partly because of utilization of hospitals outside of the Military Health Care System by entitled beneficiaries. However, rates were generally higher than those of Kaiser-Permanente (northern California) enrollees, despite the high use of hospital care by beneficiaries outside of the Military System. Systems factors impinging on hospital utilization rates are discussed. Ambulatory visit rates for beneficiaries in northern California to all types of providers were found to closely approximate those of the Kaiser-Permanente system, when all sources of care (within and outside of the system) are considered. Utilization within the Military Health Care System, however, is less than utilization by Kaiser beneficiaries. In general, civilian beneficiaries of the Military Health Care System were found not to be taking full advantage of their entitlement to health care.


Financial incentives to perform medical procedures and laboratory tests: illustrative models of office practice.

Financial return is one of several factors that may affect a physician's decision to order services for a patient. The extent of financial incentives to perform in-office medical procedures and laboratory tests is illustrated by four hypothetical models of general internal medicine office practice. The model practices consist of fixed ratios of history and physical examinations to return visits, with numbers and types of medical procedures and laboratory tests increasing stepwise through the four models. The procedures and tests included are an electrocardiogram, urinalysis, complete blood count, sigmoidoscopy, tuberculin skin test, two-view chest x-ray, cardiovascular treadmill stress test, and an automated 12-channel blood chemistry test. Charges and office expenses are estimated at 1977 Northern California levels. Net incomes derived for the four models are as follows: $31,000, $55,000; $60,000; and $90,000. The demonstrated financial incentives, which apply not only to internal medicine, but to all fields of medical care, are in conflict with policies that would emphasize personal rather than technical services. National health insurance proposals should include a continuing review of medical services valuation.


The demand for primary health care.

Data about the demand for primary health care, collected in a group practice of more than 10,000 individuals, were analyzed by Probit and Tobit techniques. With respect to the number of GP-contacts the results indicate, besides the well-known impact of age, sex, social class and morbidity, serious Interdoctor Variation, important influence of Problem Behavior and significant differences due to the Insurance System.


A causal model of health services for diabetic patients.

A causal model of health services which includes patient and provider variables, perceived access to care, utilization of services, continuity of care, technical quality of the care process, technical quality of the care outcome, and patient satisfaction is applied to a group of diabetic patients enrolled in the Seattle Prepaid Health Care Project. The enrollees received comprehensive health services at zero out-of-pocket cost from either a prepaid group practice plan or an independent practice plan. Surveys were periodically conducted to determine health status, satisfaction, and demographic characteristics of the enrollees; utilization of services was monitored throughout the experiment. The causal model is operationalized through the use of path analysis. Significant relationships (p less than or equal to .10) were established between satisfaction and perceived access to care, family size, sex, and professional qualifications of the provider; between outcome of care and health status, female education, and physician performance; between physician performance and professional qualifications; between continuity of care and health status and female education; between utilization and perceived access, specialty of provider, and provider system; and between access to care and provider system. The policy implications of the results are discussed.


Effects of acquiescent response set on patient satisfaction ratings.

This paper summarizes the results of three studies of bias in patient satisfaction questionnaires due to acquiescent response set (ARS), a tendency to agree with statements of opinion regardless of content. Three independent surveys (N = 1,280) were fielded using the Patient Satisfaction Questionnaire. Across the three field tests, 40 to 60 per cent of respondents manifested some degree of ARS and from 2 to 10 per cent demonstrated noteworthy ARS tendencies. Occurrences of ARS accounted for significant upward bias in satisfaction scores computed from favorably worded questionnaire items and scales constructed from those items and significant downward bias in scores computed from unfavorably worded items and scales constructed from those items. These biases were greatest for groups reporting lower educational attainment or less income. An example was presented to show that mean satisfaction scores for groups differing in education were biased by ARS to such an extent that group differences in satisfaction were overestimated by favorably worded items and were missed entirely by unfavorably worded items. Balanced satisfaction scales, i.e., those containing both favorably and unfavorably worded items, were not correlated or correlated only slightly with ARS; therefore, group means for balanced scales were not biased by ARS or were biased only slightly.


Measurement of work satisfaction among health professionals.

This paper describes a three-year research project that investigates the concept of occupational satisfaction of health professionals and suggests a method of measuring their level of occupational satisfaction. Additionally, the research examines factors defining occupational satisfaction important to health professionals. This process involves the development of a scale that measures the relative importance of various components of satisfaction, attitudes toward these components, and a weighted Index of Work Satisfaction. The methodology utilized in the development of this scale in an institutional setting with a sample of nurses is described, along with the transfer of this scale to three categories of health professionals involved in an outpatient setting. Responses from the physicians, nurses, and support staff in the ambulatory setting and responses from the hospital nurses indicate that the scale does measure occupational satisfaction of health professionals both in institutional and noninstitutional settings. Finally, statistical analysis of the original scale is reported and a revised scale is suggested for wider use.


Urgent care in the HMO: evolution of a system in Washington, D.C.

In 1961, Group Health Association, a large, non-hospital based, prepaid group practice in Washington, D.C. established an after-hours walk-in clinic on its premises for the care of medical problems requiring prompt attention. Within a year, this clinic's operation was extended to daytime hours for the use of the consumer-member at his own discretion. After 10 years, in the plan's main health center, the volume of adult visits to the acute care/walk-in center exceeded the number seen in the Department of Internal Medicine; most were of a routine rather than urgent nature. More visits to the acute care service were made during the day, when the full range of ambulatory services were available by appointment, than were made after hours. The choic of immediate first-come, first-served care over the conventional care-by-appointment by so many members was felt to have resulted in discontinuous suboptimal care, segregation of the membership along socioeconomic lines, as well as unnecessary and very costly duplications of service. The background of organizational behavior and community medical practices contribuing to this pattern of utilization are explored. Compared to traditional fee-for-service medicine, demands for outpatient services in the HMO tend to be greater. Acceptable alternatives to off-line channeling of patients with unexpected or acute conditions can be designed. In the general community today, utilization of medical services is strongly influenced by imbalances in available resources and by financial factors which are under no central control. In the HMO, all costs are prepaid and services are planned for a membership of known size. Even so, consumers' use of services in prepaid plans tends to follow the patterns seen in the community. More appropriate distribution of demands requires an active and ongoing system of patient education. A commitment by the HMO's providers and managers toward this goal is indispensable.


Identification of patients in need of psychiatric intervention: visiting an emergency facility.

The utilization of the emergency room (E.R.) at a small community hospital located in a black inner-city area is investigated. Patients are classified according to a criterion for psychiatric intervention for the purpose of making staffing pattern recommendations. Psychiatric patients and non-psychiatric patients are classified by age, marital status, previous admissions to the E.R., time of arrival and time spent in the E.R., and circumstances of mode of arrival in the E.R. The criterion of psychiatric intervention is viewed as providing an additional dimension in the study of the emergency room, a hospital service which is providing increasing routine and non-routine medical care to the general population.


The effects of outpatient psychiatric utilization on the costs of providing third-party coverage.

Although previous studies conducted in prepaid group practice settings have indicated that the cost of providing coverage for outpatient psychotherapy may be offset by lower utilization of medical/surgical services among those who receive the benefit, no such studies have been conducted in a fee-for-service setting, nor have actual before and after claims costs been compared. This study establishes a methodology for using routinely collected Blue Cross claims data to show how the acquisition and use of a given benefit affects total utilization patterns and the overall costs of providing third-party coverage. The use and cost of outpatient psychiatric coverage in one subscriber group is the particular application given to this methodology in this report. Blue Cross claims records of 136 subjects who utilized outpatient psychiatric benefits over a 48-month period were analyzed. Results indicate that overall medical/surgical utilization is reduced for that subgroup who used the outpatient psychotherapy benefit and that average costs dropped by $9.41, from $16.47 per patient per month before outpatient psychotherapy to $7.06 after contact, with costs being adjusted to reflect parity with the base year. Factors other than psychiatric intervention which may have brought about this cost reduction as well as policy implications of these results are discussed.


An index of hospital performance.

The purpose of this paper is to describe a simple index for computing relative hospital performance. An analysis of 33 short-stay general hospitals in New South Wales was used to develop the index. The index is based on patterns of admissions for each hospital, adjusting the hospital's crude death rate for the age distribution of patients treated and variations in the severity of their diagnoses. The index is relatively simple to calculate, but is nevertheless a valid indicator of hospital performance.


Examining physicians' drug order recording behavior.

The study reports the impact of a computer-based drug profile upon physicians' drug order recording behaviors. The drug profile system, including information about both drugs ordered and prescriptions received, was implemented for a randomly selected group of Kaiser Foundation Health Plan members during 1973. The monthly updated profile was made readily accessible to physicians. Drug order notations entered by physicians on outpatient medical records were examined to determine if the availability of the profile influenced the completeness of drug-related data being recorded by physicians. Using an experimental design, the results indicated the availability of the profile did not influence the completeness of drug-related data recorded. Also, observation of the data generated for analysis suggests caution in assuming drug notations or prescriptions reflect complete and reliable drug use data.


The Aroman food crisis: a fable with a lesson for national health insurance.

An analogy is always imperfect. Nevertheless, at times it is an effective way to communicate an insight. This paper uses an analogy to examine the consequences of attempting to achieve health sector efficiency through regulation, instead of consumer cost-sharing. It is suggested that as long as hospital care continues to be virtually "free" to patients at the time of use, such regulation may well do more harm than good. Moreover, a national health insurance plan that would make all medical care "free" to patients, and would pay for all health care through taxes (the proposed Health Security Act), would not only generate significant inefficiency; but, in contrast to the intentions of its supporters, would prove harmful to the poor and the elderly, by shifting scarce Federal tax dollars away from the programs that assist them in order to pay the medical bills of middle and upper income households. It is therefore urged that we enact income-related catastrophic national health insurance, that would place a ceiling, which varies with household income, on the financial burden a household must bear; but at the same time, would require most families to pay part of their own medical cost out-of-pocket, so that consumer cost-consciousness can help promote health sector efficiency.


Attitudes toward mental disease in a sample of Israeli urban residents.

A random sample of 463 residents of the Tel Aviv Metropolitan area in the 30 to 59 age group were interviewed in order to evaluate their attitude toward mental health. The image of mental disease among the respondents was vague and a general rejection of the ex-mental patient was observed. This is in contrast with findings of several similar studies conducted previously in the U.S.


Coordinated home care: the Massachusetts General Hospital experience.

The problem of post-hospital care remains a continued challenge, as many patients who no longer require expensive acute care facilities continue to occupy these beds, awaiting appropriate placement. The Massachusetts General Hospital Coordinated Home Care program, under the central administration of the Boston Visiting Nurse Association, has demonstrated that home care can be a viable, economically feasible alternative to institutionalization for carefully selected patients, when the appropriate medical and social needs can be met. Three major groups of patients have been effectively cared for: 1) patients with multi-system chronic illness; 2) patients with terminal malignancies; and 3) patients with catastrophic neurologic disease. The organization of the Coordinated Home Care program, the criteria for patient selection, and the issue of funding are reviewed. The impact of this program is examined in terms of its potential for better utilization of the Massachusetts General Hospital facilities, as well as the more appropriate coordination and use of existing health care resources in the community.


Validation of a patient classification through evaluation of the nursing staff degree of occupation.

The instrument of evaluation of the degree of occupation of nursing staff is centered on the activities of the staff. It generates an index indicating how "busy" the staff is during a given shift on a particular unit. It can be used to validate a patient classification system by level of nursing resources requirements.


Assessing the quality of care for urinary tract infection in office practice: a comparative organizational study.

As part of a comprehensive evaluation of care received by enrollees in a prepaid community health care project, we studied the process of care for enrollees reported to have a urinary tract infection. The care given to 98 patients enrolled in a large prepaid group practice (PGP) and 69 patients seen by 45 physicians in the independent practice setting (IPP) was analyzed. We found the process of care to be significantly better in the PGP, with a large part of the difference due to more appropriate utilization of urine cultures. This occurred despite a higher visit rate to internists in the IPP, and suggests that the organization of practice strongly affects the process of care received by patients even when all care is fully prepaid.


[Frequency of tonsillectomy in bronchial cancer patients (author's transl)].

Among 1415 bronchial cancer patients were 84 (5.94%) tonsillectomized observed. In an equal number of controls, selected according to the strictest criteria, there were 265 (18.7%) tonsillectomized. The latter figure corresponds to the lower limit for the frequency of tonsillectomies in the Federal Republic of Germany in the second half of the seventies. Thus these results show that bronchial cancer patients were subjected to tonsillectomy 3 times less than individuals not suffering from bronchial cancer. These results are in perfect agreement with previously obtained findings on the incidence of tonsillectomy in ENT tumors as well as in leukemia in children and adults.


[Système International d'Unités = SI-units. Temporary prescriptions are finished now (author's transl)].

After a description of the legal basis for the use of the so-called SI-Units the problems of changing into the new system are discussed. The essential changes, especially in the ENT--field are demonstrated. According to the present international recommendations the new legal units should be used in medicine as soon as possible.


[The problems of simultaneous tympanoplasty and adeno- tonsillectomy (author's transl)].

The effect of adento-tonsillectomy on tube function and middle-ear ventilation was measured by tympanometry and manometry. It was found, that after adenotomy considerable negative pressure values may develop in the middle ear. In about one third of all cases five to six days after operation the tube function was not yet normal again. After tonsillectomy alone only a few of the operated children has slight negative pressure values. Adenotomy and tympanoplasty should not be achieved simultaneously.


[Our experience, with the tube manometry in chronic otitis media. I: Equipment and methodology (author's transl)].

A simple method for clinical routine to check tube function in perforated tympanic membranes using an additional set developed by us for an impedanceaudiometer is reported. Before the possibilities to check tube function by tympanometric methods in normal tympanic membranes are discussed.


[Symptoms of the experimental auditory tube blockage in man (author's transl)].

The sound of an inhaling apparatus with a vibrator, introduced in both meatusses of the nose, is better heard in both ears during deglutition. This demonstrates a permeability of the Eustachian tubes. The same principle is used in the sonomanometry. We examined this phenomenon in five test persons, in whom we blocked by a pomphus the pharyngeal ostium of the tube during 90--150 min. On this occasion we found the following results: a ) The sound of the vibrator is always heard though the unblocked tube. b) There is a lateralisation in the Weber's hearing test immediately after the blockage of the tube, whereas the Rinne' test mains positive. c) The middle ear pression falls 1 mm H2O per min.


[Adenoid-cystic carcinoma of the larynx (author's transl)].

Report on 5 cases of adenoidcystic carcinoma of the larynx and review of the literature, containing about 60 further reports. About 80% of these tumors arise in the subglottice laryngo-tracheal transition region, 20% in the ventricular cord and the epiglottis. The vocal cords containing no mucus glands are never the origin of adenoid cystic carcinomas. These tumors grow under an intact mucosa and reach very often an enormous extension until dyspnoea, dysphagia and recurrent never paresis lead to diagnosis. The clinical course of these tumors ist not preditable--even not by their histological structure. In some cases the outcome is rapidely fatal by local growth and metastases, in others a many year long survival can be reached, but there exists no reliable report on a "cured" adenoid cystic carcinoma of the larynx. By radical surgery only better results can be expected. Irradiation produces long lasting remissions in some cases.


[Sarcomalike patterns in laryngeal carcinoma (pseudosarcoma, carcinosarcoma, spindle-cell-carcinoma, pleomorphic carcioma (author's transl)].

Report on 5 cases of so called carcinosarcomas of the larynx and hypopharynx and review of literature. These polypoid tumors have a small epidermoid carcinomatous part and a major part with sarcoma like appearance. The sarcomatoid tissue resembles to fibrosarcomas or some undifferentiated pleomorphic sarcoma. Observations of a gradual transition from the epithelial tumor cells to cells with a mesodermal appearance show that these tumors are varieties of squamous cell carcinomas (spindle cell or pleomorphic variety) and not "combination"--or "collision-tumors", "carcinosarcomas" or "seudosarcomas". These tumors appear in the larynx predominantly in man, at the same sites and in the same ageclasses as common squamous cell cancers and are not less malignant. The sarcomatoid tissue can arise at the beginning of the disease or at a later stage it can appear or disappear after operation or irradiation. The reason for this change of cellular structure is unknown.


[Endolaryngeal microsurgery. A report of our experiences in the years from 1966 to 1976 (author's transl)].

The total of 1420 mikrolarynagoscopic operations during the past 11 years have been epicritically evaluated by the authors. Besides obtaining a disclosure of the various diseases, the question of an early diagnosis of glottis cancer an its preceeding illnesses was discusses. With available case histories, the authors could determine a definite increase in the early stages of the comprehensive glottic carcinoms. The observed optimation of an early diagnosis has been related back to a reduction of the prediagnostic ailment intervals and the consequent prognomatic use of the endolaryngeal microdiagnoses. Considering the possibility of complication during the microlaryngological operation, a critical position was taken to the question of indications, and the diagnostical value of microskopic laryngoskopic as well as the stroboskopic in reference to the early diagnosis of malignant glottic changes were discussed. The authors have come to the previously presented interpretation that with malignantly suspicios appearance a histomorphological clarification by process of endolaryngial microdiagnosis cannot be waived.


[Transposition of the lingual thyroid gland (author's transl)].

A lingual thyroid gland was transposed below the skin of the neck with the main vessels remaining intact. Metabolic parameters did not change during the control period of 21/2 years. This procedure could be an alternative to resection of free transplantation of lingual thyroid.


[Ventilation measurings before, during and after treatment of tracheal stenosis due to long term intubation (author's transl)].

17 patients with post-intubation stenosis of the trachea were studied. By the extrathoracic stenosis the relative forced expiratory volume in the first second (FEV1,0) and in and expiratory flow were decreased, total airway resistance (Rt) was increased. After implantation of an endoprothesis the obstruction was significantly lowered (p less than 0,05). After removal of the tracheal endoprothesis further improvement occurred as was demonstrated by an increase in FEV1,0 an flow and by a decrease in Rt.


[Comparability of lung and nasal resistance. possibilities of comparison of rhinomanometry and bodyplethysmography (author's transl)].

Only a harmonical balance between the lung and nasal resistance garant an optimal respiratory mechanism. Therefore both resistances should not be judged separately. Up to now different methods of measurement of both resistance have been used. The substruction method has certain drawbacks in determining nasal resistance. On the other hand nasal resistance determined by rhinomanometry only becomes comparable to lung resistance if registered by a special simplified method. The problems of comparing quantitively both resistances are discussed and a solution is proposed.


[Controlled hypotension anaesthesia in ENT surgery (author's transl)].

Based on an experience over two years with 316 cases the principles of general anaesthesia with controlled hypotension in ENT surgery are described and discussed. Indications, contraindications and methods of application are outlined. The method reduces bleeding considerabley and proved to be useful for rhinoplasties, major sinus surgery as well as parotid gland and necksurgery.


[Advantages of blood gas analyses of an improved ventilation bronchoscope (author's transl)].

During bronchoscopy in elder patients the development of respiratory acidosis is a hazard. A new and improved ventilation bronchoscope decreases the risk, which was demonstrated by blood gas analyses. This bronchoscope differs from those normally used in the following ways: 1. An inflatable cuff on the outer tube seals the bronchoscope like a breathing tube against the trachea. 2. This bronchoscope, although in the endobronchial position, improves the ventilation of the contraleateral lung aided by wider side holes lying above the bifurcation. 3. Jet-ventilation can be employed.


[Flow rate, amylase and protein content of parotid saliva in sialadenosis (author's transl)].

Flow rate, protein concentration and amylase activity of parotid saliva were investigated in 17 patients with sialadenosis. The results were compared with the data obtained from 90 healthy controls. Total protein and amylase concentrations of saliva did not change although, under the influence of sialadenosis, the parotid gland clearly shows ultrastructural signs of disturbed protein secretion. Also the flow rates of parotid saliva were the same in sialadenosis patients and the control group. This can be explained by the patho-physiology of parotid secretion from the sialadenotic gland.


[Surgery of extensive tumors of the petrosal bone and the lateral skull base region (author's transl)].

Report on the problems in total removal of extensive tumors of the petrosal bone and the skull base in this region. These problems are: 1. Freeing of the tumor involved internal carotid artery from the carotid foramen to the cavernous sinus. 2. Covering the resulting large defects of the dura and covering the new ostium of the Eustachian tube to protect the posterior fossa from infection. 3. Stopping the blood flow during the removal of extensive glomus jugulare tumors. 4. Reconstruction of swallowing and voice in paralysis of the involved vagal nerve. Operative measures for the solution of these problems are described.


[Anomalies of the stapes (author's transl)].

Reported are four cases of anomalies of the stapes and the oval window niche. Their diagnostic and operative problems are discussed. The report includes one case of spontaneous cerebrospinal otorrhea. Surgical exploration of the middle ear demonstrated a fluid leak from a fistula in the stapes footplate. Two cases presented combined congenital anomalies of the stapes and facial nerve as a cause of hearing loss. Additionally one case of "columella" shaped stapes was observed. The embryological aspects of the middle ear structures are discussed.


[Stapes fixation and proximal symphalangism caused by autosomal dominant transmission (author's transl)].

A family showed in four generations the syndrome of stapes fixation and proximal symphalangism with changing expressivity caused by autosomal dominant transmission.


[The efficiency of computer-tomography and conventional tomography of processes of the skull and of the skullbase (author's transl)].

In 12 patients with tumorous or chronic-inflammatory diseases of the skull and the skullbase the results of conventional and computer-tomography were compared with the operative findings. The computer-tomography of the most important regions is demonstrated by individual examples. The preliminary results indicate, that computer-tomography is reliable in evaluation of the extend of pathological processes. Therefor follow-up data after treatment were obtained by computer-tomography only.


[Our experience with tube manometry in chronic otitis media. Part II: clinical use (author's transl)].

The appliance of tube manometry in clinical routine is reported as a simple and valuable method to judge tube function. By tube manometry treatment, conservative and operation, of both tube and middle ear, may be judged. Examples are given for the application of tube manometry in clinical routine.


[Sudden deafness: the audiometric profile (author's transl)].

34 cases of unilateral idiopathic sudden deafness were subjected to an intensive audiometrical examination programme. The average hearing loss in percent (calculated on the basis of the pure tone audiogram according to D. Röser, 1973) amounted to 71.6% prior to treatment, the average sound audiogram corresponding to a pantonal hearing defect. The percent gain in audition due to the treatment averaged 24.3%. The pretherapy hearing defect is greater in older patients, and therapy is much less successful in older than in younger patients. If treatment is started within 7 days, it is considerably more successful than in those cases where it is started a long time after the beginning of the disease. This, however, is no proof of the effectiveness of early treatment, but might also be due to the high rate of spontaneous remissions. The final stage of healing or partial recovery is reached, on the average, 20 days after the onset of the illness. In nearly all patients a recruitment was proved to exist; this means that most cases were cochlear hearing defects. The results are compared with the statements contained in medical literature, and an attempt is made to interpret diverging results.