Safety of oral vancomycin in functionally anephric patients.

Administration of a vancomycin oral solution, 2 g daily for 16 days, to functionally anephric patients without inflammatory bowel disease resulted in assayable but low (</=0.66 mug/ml) serum levels in two of the five volunteers.


A study of the practice of dermatology in the United States. Initial findings.

A nationwide study of the practice activities of dermatologists reports that dermatology is a predominantly outpatient specialty, with 97% of patient encounter occurring outside of the hospital. The average dermatologist cares for approximately 7,000 patients a year and functions almost exclusively as a specialist, with only 2.2% of his cases related to nondermatologic problems. The dermatologist performs a type of primary care, however, with seven out of ten patients being self-referred. Eighty-seven percent of dermatologic encounters can be categorized into 25 disease conditions. This study serves to increase the understanding of how the dermatologist cares for his patients.


Interdigital athlete's foot. The interaction of dermatophytes and resident bacteria.

Quantitative cultures in 140 cases of interdigital "athlete's foot" established the following clinical-microbiological correlations. In 39 cases of mild, scaling, relatively asymptomatic variety, fungi were recovered in 84% of cases. As the disease progressed to maceration, hyperkeratosis, and increased symptoms, recovery of fungi fell to 55% in moderately symptomatic and to 36% in severe cases. Symptomatic cases had increasing numbers of resident aerobic organisms, particularly large colony diphtheroids. Experimental manipulations of the interspace microflora in volunteers, monitored with quantitative cultures, demonstrated that symptomatic, macerated, hyperkeratotic process results from an overgrowth of resident organisms if the stratum corneum barrier is damaged by preexisting fungi, while overgrowth of the same organisms in normal, fungus-free interspaces does not produce lesions. These experiments support the conclusion that athlete's foot represents a continuum from a relatively asymptomatic, scaling eruption produced by fungi to a symptomatic, macerated, hyperkeratotic variety that is caused by an overgrowth of bacteria.


Concurrent localized scleroderma and discoid lupus erythematosus. Cutaneous 'mixed' or 'overlap' syndrome.

Four patients with concurrent, chronic, progessive, localized scleroderma and discoid lupus erythematosus were studied; the condition originated as linear scleroderma in three of them. Three of the four patients were young females at the onset of the first skin disease. Dermatopathologic study confirmed the scleroderma and lupus erythematosus (LE). Direct immunofluorescence showed a positive band test in three cases. Unusual serological results included a positive LE clot test in three cases, a positive extractable nuclear antigen test in one case, and a negative antinuclear antibody test on repeated occasions in all four cases. Rare cutaneous disease similar to systemic, "mixed," or "overlap" connective tissue disease exists and offers an opportunity to study unusual immunologic and pathological events in both scleroderma and LE.


The genetics of follicular atrophoderma.

Follicular atrophoderma apparently does not occur alone but is associated with other abnormalities. It is present in three groups: (1) If it is associated with chondrodystrophia calcificans congenita, it occurs only in girls and is due either to an X-chromosomal gene causing the changes in the heterozygote (ie, in the female sex) and penatal death in the hemizygous state (ie, in the male sex), or to an autosomal dominant gene with expression almost wholly limited to the female sex; (2) If it is associated with Bazex's syndrome, it occurs in male and female persons in successive generations and is due either to an autosomal dominant gene or to an X-linked dominant gene; and (3) If it occurs in association with keratosis palmoplantaris dissipata, keratosis follicularis, and hyperhidrosis palmoplantaris, it may be due to a recessive gene or a mutation.


Corticosteroids in the treatment of alopecia totalis. Systemic effects.

Fifteen patients with alopecia totalis (AT) or alopecia universalis (AU) were treated with combined topical, intralesional, and oral corticosteroids. All or virtually all scalp hair regrown on seven patients, and they have been able to discontinue oral corticosteroids without recurrence of AT or AU for periods of three months to 7 1/2 years, with an average remission of 32 months. Two additional patients are currently receiving 5 mg of prednisone every two days. Using topical and intralesional corticosteroids in more resistant areas allowed for more rapid lowering of oral doses and thus side effects were minimized. In view of the usually nearly hopeless prognosis for AT and AU and the results reported here, a trial course of topical, intralesional, and oral corticosteroid treatment would seem to be reasonable for highly motivated patients.


Surgical therapy for basal cell epitheliomas by curettage only.

Thorough curettage alone was used to treat 214 basal cell epitheliomas (BCEs) of 152 patients who were followed up from six months to 13 years (the initial three were treated 19 years ago). One hundred sixty-four treated sites have been followed for at least two years, 132 for at least four years, and 121 for five years or longer. There were six treatment failures in the 214 lesions followed to date. Two recurred at ten months, one at 12 months, two at 20 months, and one at 25 months after treatment. If it is carefully done, the curettage alone cure rate compares favorably with other forms of treatment. Curettage is simple, effective, and inexpensive treatment of BCEs.


Pilar sheath acanthoma.

A newly recognized, benign follicular tumor occurred in nine patients who ranged in age from 46 to 75 (median, 55) years. The neoplasms were solitary, asymptomatic, skin-colored nodules with a central pore-like opening plugged with keratin. All lesions had been present for years. Eight were on the skin of the upper lip and one was on the forehead. Histologically, a central cystic cavity showing epidermoid keratinization extended from the surface into the deep cutis. Multiple tumor lobules that were composed of hair sheath epithelium extended from the cyst wall into the surrounding corium. This neoplasm, which we have named "pilar sheath acanthoma," must be differentiated from trichofolliculoma and dilated pore.


Combined immunotherapy of malignant melanoma. Unusual survival following cerebral metastasis.

An 18-year-old woman was found to have solitary cerebral, choroidal, and pulmonary metastases of malignant melanoma three years after excision of a primary malignant melanoma. The cerebral metastasis was excised, and the patient's condition was treated with CNS irradiation followed by combined immunotherapy with transfer factor and Bacille bilié de Calmette-Guérin. The transfer factor donor was her father, who showed cellular immunity to melanoma extracts on in vitro testing. Histologic examination of the pulmonary nodule, which was excised after the initiation of immunotherapy, revealed a dense lymphocytic infiltrate associated with the metastatic melanoma. The patient is currently free of detectable melanoma more than three years after the cerebral metastasis. Studies in a second patient also demonstrated the appearance of inflammatory infiltrate in metastatic melanoma following transfer factor therapy.


Acquired zinc deficiency dermatosis in man.

We encountered two cases of acquired zinc deficiency. In one of the patients the state was due to alcoholism with liver cirrhosis and pancreatitis, and in the other patient it was attributed to a small intestine bypass operation for obesity. The skin symptoms included hair loss, acrodermatitis, and widespread eczema craquelé (asteatosis). The cutaneous manifestations of zinc deficiency seem to constitute a characteristic syndrome that might be helpful in recognizing manifest zinc-deficient states in man.


Proliferating systematized angioendotheliomatosis of a 5-month-old infant.

Proliferating systematized angioendotheliomatosis occurred in a 5-month-old infant and persisted for five months. On the basis of the clinical course and the results of histological examination, the inflammatory type of proliferating angioendotheliomatosis was found. The condition is characterized by the proliferating reaction of the vascular endothelium owing to an allergic process as a result of immunological mechanisms by bacterial infection or protein of cow's milk in this uncommon disease.


Percutaneous paraquat absorption. An association with cutaneous lesions and respiratory failure.

Striking cutaneous lesions and death owing to respiratory failure occurred in a middle-aged woman eight weeks after initial cutaneous contact with the herbicide paraquat (1,1'dimethyl-4,4'dipyridylium dichloride). While similar changes have been described in animals, to our knowledge, serious morbidity or mortality owing to percutaneous absorption has not been described in man. This case report illustrates the extreme toxicity of this herbicide and demonstrates that lethal quantities of the drug may be absorbed from apparently trivial skin wounds. Stricter precautions, including the mandatory use of protective clothing, should be recommended whenever this material is used.


Carcinoma of the inframammary crease.

Carcinoma of the inframammary crease is an uncommon but distinctive manifestation of carcinoma of the breast. This report of a case illustrates the clinical and histophathologic features. The patient's tumor was exophytic and fissured, and the initial biopsy specimen mimicked basal cell epithelioma.


Diffuse fasciitis with eosinophilia.

The recently described syndrome of diffuse fasciitis with eosinophilia consists of scleroderma-like cutaneous changes in the absence of Raynaud's phenomenon and without visceral involvement. Peripheral blood eosinophilia and hypergammaglobulinemia occur in the majority of patients. The biopsy specimen is characteristic and shows a diffusely thickened fascia with a noticeable inflammatory infiltrate. The etiology and pathogenesis of the entity are unknown. The majority of the cases have been reported to respond to corticosteroids. Pulmonary function abnormalities and rheumatoid factor elevation in one of our patients suggests that this syndrome may be a variant scleroderma or may have previously unrecognized systemic manifestations. The patients' objective responses to corticosteroids were minimal.


Larva migrans complicated by Loeffler's syndrome.

A husband and wife contracted larva migrans while vacationing on the Gulf of Mexico. Subsequently, migratory pulmonary infiltrates and peripheral eosinophilia (Loeffler's syndrome) developed in both patients. Their cutaneous lesions were treated with topical thiabendazole and resolved within two weeks. The pulmonary complication was treated symptomatically and resolved during the next eight weeks.


Impetigo herpetiformis or generalized pustular psoriasis?

Impetigo herpetiformis was diagnosed in a primigravida woman on clinical, laboratory, and histopathological grounds. This disease should be considered as a rare and serious variant of generalized pustular psoriasis. After initiating prednisone therapy, antepartum registration of fetal heart rate patterns appears necessary to evaluate fetal well-being. Subsequent pregnancies of the patient were not recommended.


Papular acrodermatitis of childhood and hepatitis B infection.

A case of papular acrodermatitis (PAC) associated with acute anicteric type B hepatitis occurred in a 2-year-old child. Immunocytochemical studies failed to detect the presence of viral antigens in the involved skin lesion. Current knowledge of the hepatitis B viral antigens and of their possible role in PAC is discussed.


Metastasizing atypical fibroxanthoma. Coexistence with chronic lymphocytic leukemia.

Atypical fibroxanthoma (AFX) is one of a group of cutaneous lesions with a malignant histological appearance but a generally benign clinical course. A 79-year-old white man had AFX of the cheek that recurred and metastasized to buccal and cervical lymph nodes three months after initial diagnosis. When careful physical and and laboratory examinations were done, the patient was found to have concomitant chronic lymphatic leukemia, "null cell" type. In view of the low incidence of metastasizing AFX and the increased occurrence of tumors in patients with lymphomatous disorders, an important association is suggested. Before establishing the prognosis for patients with pseudomalignancies of the skin, an evaluation of their general health and immunological status should be made.


Favus: twenty indigenous cases in the province of Quebec.

Twenty indigenous cases of favus in two families residing in the province of Quebec were studied. Importantly, the disease, although active, remained undiagnosed for many years in most of the cases. The finding of active cases suggests that the disease is still endemic in regions previously described as harboring cases, namely the province of Quebec and possibly Kentucky.


The correlation of indoor solar simulator and natural sunlight: testing of a sunscreen preparation.

To determine the equivalence of xenon arc solar simulator and natural sunlight test results, the sun protection factor (SPF) for an experimental sunscreen preparation was determined using each light source. The minimal erythemal doses (MEDs) were shown to be equivalent on unprotected skin. It was necessary to supply additional heat to the treated skin prior to solar simulator exposures to obtain comparable SPFs. By careful control of the subjects' environment, natural sunlight effects can be duplicated with a solar simulator.


Dermal duct tumor: a histochemical and electron microscopic study.

The histochemical and electron microscopic findings in seven cases of dermal duct tumor are described. All seven of the patients were elderly, and five were women. The tumors were small flesh-colored or red papules located most often on the head and neck region. Intense phosphorylase and moderate respiratory enzymes characterized the histochemical reaction of the tumors. The following three types of tumor cells were recognized ultrastructurally: clear, dark, and luminal. The tumor was principally composed of clear cell proliferation around a regular ductal lumen. In addition, melanocytes, Langerhans' cells, and lymphocytes were occasionally seen within the tumor masses. An intact basal lamina and few hemidesmosomes with no detectable actin-like microfilaments were the features of the tumor-stroma interface. Our study results showed that the dermal duct tumor is a benign tumor with eccrine dermal ductal differentiation.


Rhinophycomycosis entomophthorae.

Rhinophycomycosis entomophthorae is a variant type of subcutaneous phycomycosis of the face that is caused by Entomophthora coronata. The case we describe was the first patient reported in the world literature, to our knowledge. His infection reappeared after an extended dormant period. Although his condition exhibited an early partial response to surgical and medical management, the condition became refractory to treatment.


Mucha-Habermann's disease in children: treatment with erythromycin.

Safe therapeutic measures for Mucha-Habermann's disease in children are lacking. Three patients with the disease were treated with erythromycin for systemic effect. Although the series is small and uncontrolled, this approach seemed effective. An anti-inflammatory mechanism related to inhibition of chemotaxis is speculated.


Mobile encapsulated lipomas. Formerly called encapsulated angiolipomas.

Lipomas with true capsules are rare. Those that move about, cause pain, and show no permanent attachment to a blood supply deserve special consideration. In this report of two cases, I have designated this entity "mobile encapsulated lipoma".


Malignant atrophic papulosis: treatment with aspirin and dipyridamole.

On electron microscopy of the endothelial cells of a patient with cutaneous and CNS symptoms of malignant atrophic papulosis, paramyxovirus-like particles could be seen in the cytoplasm. These particles were interpreted as degenerative changes that were due to ischemia. Coagulation studies showed increased thrombocyte aggregation, and treatment with the platelet-suppressive drugs, aspirin and dipyridamole, was instituted. This treatment resulted in a normal thrombocyte aggregation after eight months and complete clinical remission, which still persisted four months after cessation of therapy.


Angioendothelioma: report of an unusual case in an American black.

Angioendothelioma is a rare malignant vascular tumor occurring on the face or scalp in an elderly individual or in an area of antecedent radiotherapy or chronic lymphedema. We are reporting the second fully documented case of angioendothelioma occurring in a black patient. The case is also of interest because initially the tumor mimicked kerion, both clinically and histopathologically.


Treatment of cutaneous Kaposi's sarcoma with intralesional vincristine.

A 68-year-old man had lesions of Kaposi's sarcoma that developed continually in a localized area after excisional surgery, electrosurgery, and radiotherapy of previous lesions. His lesions cleared with intralesional injections of vincristine sulfate without any systemic and only minor local side effects. Newly developed lesions, which did not occur on the sites of previous treatment, were also responsive to this form of therapy.


Cutaneous involvement by IgD myeloma.

Multiple, firm, nontender, violaceous, cutaneous and subcutaneous nodules of the abdomen and thighs developed in a 53-year-old man with proven IgD myeloma. A biopsy specimen showed dermal infiltration by large atypical undifferentiated cells similar to those previously found on bone marrow aspiration. Despite intermittent improvement with radiotherapy and chemotherapy, the patient died and an autopsy showed multiple osteolytic lesions and massive involvement with tumors that encased the pelvic organs, infiltrated and replaced portions of the psoas muscles, infiltrated the kidneys and intestines, and replaced the bone marrow by small and intermediate-sized malignant lymphoid cells. IgD myeloma is a rare hematologic malignancy that occurs at a  younger age than other forms of myeloma, has a high incidence of involvement of soft tissues, and is a particularly dedifferentiated and vicious form of myeloma.


Treatment of acute viral croup.

Total respiratory resistance (RT) was measured before and after nebulised alpha-adrenergic stimulant therapy in 8 children aged 4 to 18 months who had the clinical symptoms of acute viral croup. In 7 children there was a mean fall in RT of 30% after treatment, associated with an improvement in their clinical condition. This improvement was shortlived, the resistance returning to pretreatment levels within 30 minutes. The remaining child showed no improvement after phenylephrine but was subsequently found to have acute epiglottitis. Nebulised water did not produce any change, indicating that the response was not due to moisture alone.


Alpha and beta adrenergic stimulants in bronchiolitis and wheezy bronchitis in children under 18 months of age.

Total respiratory resistance was measured before and after nebulised phenylephrine in 5 babies (age range 7 to 17 months) with wheezy bronchitis, and in 2 babies (aged 2 and 6 months) with bronchiolitis. None showed a change in resistance after treatment. Total respiratory resistance was measured before and after nebulised adrenaline in another 14 babies (age range 4 to 13 months) with bronchiolitis. No fall in resistance was noted in any baby after treatment whether or not it was given by a conventional or an ultrasonic nebuliser. We conclude that alpha- and beta-adrenergic stimulants are ineffective in bronchiolitis and wheezy bronchitis in children under 18 months of age.


House dust mite sensitivity in childhood asthma.

The clinical features of perennial asthmatic children with a skin or bronchial reaction to the house dust mite (Dermatophagoides pteronyssinus) were compared with those of asthmatic children without mite sensitivity. Mite sensitive asthma was characterised by an early age of onset of symptoms, these being predominantly nocturnal. A history of wheezing precipitated by dust exposure, during vacuuming, bedmaking, or dusting was present in 52% of cases. Asthmatic children with mite sensitivity were more likely to have been born at the time of the year when mite counts were highest. This was consistent with the idea that allergy may be associated with a period of susceptibility to sensitisation in early infancy.


Severe ventilatory failure in asthma in children. Experience of 13 episodes over 6 years.

During the 6-year period from 1 October 1971 to 30 September 1977, 13 (about 1%) of 1225 admissions to hospital with asthma developed severe ventilatory failure (peak arterial PCO 2 greater than 8 kPa). Mean age was 4.1 years (2.3--7.9), and on average each patient had been admitted to hospital on 5 occasions during the preceding year. 11 gave a family history of asthma or a personal history of associated allergies. A viral upper respiratory tract infection was the commonest precipitant of wheeze, and in 7 patients the duration of wheeziness before admission to hospital was 12 hours or less. Six (0.5%) patients were treated by mechanical ventilation and all survived. The changing patterns of management during the study period are reviewed.


Nonstructural heart disease in the newborn. Observations during one year in a perinatal service.

One-third of 327 newborn infants referred to the perinatal service of the Hospital for Sick Children during 1975 with suspected cardiopulmonary disorders proved to have nonstructural heart disease. Most of these were term infants with transient tachypnoea or cyanosis who recovered. A history of fetal distress or difficult delivery was commonly associated. The haemodynamic disorder for most was a delay in the normal progress of the transitional circulation. Evidence of myocardial ischaemia was present in 40%, and about half of these developed congestive heart failure. Aids to diagnosis of the ischaemic complication included echocardiography and myocardial perfusion scanning. For a small proportion specific metabolic disturbances, myocarditis, or dysrhythmia seemed the primary cause but even for these there were reasonable grounds to suspect a prenatal origin. Current general supportive measures were of value in treatment.


Metabolic and endocrine events at the time of the first feed of human milk in preterm and term infants.

The first feed of breast milk given to a group of 12 term infants was previously shown to increase the levels of blood glucose and plasma insulin, growth hormone (GH), gastrin, and enteroglucagon. We have now studied the effects of the first feed of breast milk in two similar groups of preterm infants, to compare the results with those obtained for the term infant. One group of 8 preterm infants received a bolus (2.5 ml/kg) of breast milk via a nasogastric tube; the other group of 5 infants received a continuous intragastric infusion (2.5 ml/kg per hour) of breast milk. No change occurred in the concentrations of blood glucose, lactate, pyruvate, or ketone bodies, or in plasma insulin, GH, pancreatic glucagon, or enteroglucagon in either the 'bolus fed' or the 'infusion fed' group of preterm infants. Thus the marked metabolic and endocrine changes in term infants after the first feed do not occur in preterm infants with standard methods of feeding.


Case of tumour rickets.

A 10-year-old boy, with widespread soft tissue tumours of bone, developed hypophosphataemic rickets due to impaired renal tubular reabsorption of phosphate. Biopsy of the largest tumour showed a nonosteogenic fibroma. We believe this boy is another example of 'tumour rickets', as other causes of rickets were excluded clinically and biochemically. Cases of rickets or osteomalacia associated with a tumour, have generally been reported to be cured by surgical removal of the tumour, implicating it as the cause of rickets or osteomalacia. Owing to the large number of tumours in this boy, surgical removal was not possible, and he required large doses of vitamin D, together with oral phosphate, before his rickets healed. It is suggested that the tumour produces a phosphaturic hormone.


5-alpha-Reductase deficiency causing male pseudohermaphroditism.

An infant with male pseudohermaphroditism due to deficiency of 5-alpha-reductase is described, the elder of two affected male siblings. These patients, who come from Pakistan, are the first to be described outside America.


Congenital dyserythropoietic anaemia type I in two brothers presenting with neonatal jaundice.

Two brothers with congenital dyserythropoietic anaemia type I are described. Both presented with neonatal jaundice, required transfusion for anaemia at 8 weeks of age, and have subsequently remained well with only mild anaemia. Peripheral blood findings and bone marrow morphology on light and electron microscopy are discussed.


One-hour blood-xylose in cystic fibrosis.

One-hour blood-xylose concentrations after an oral xylose load were measured in children with cystic fibrosis (CF) and healthy controls. The mean of the 1-hour blood-xylose values was significantly increased in the group with CF. The finding confirms an earlier observation by Rolles et al. (1973). Its significance is not at present understood but it suggests that small intestinal function should be further investigated in CF.


Theophylline toxicity in a neonate.

One of a pair of preterm twins treated with theophylline (2 mg/kg per day) for apnoea developed episodes of hyperglycaemia in glycosuria.


Aortic homograft valve replacement for postendocarditis aortic incompetence in early childhood. A case report.

A case of postendocarditis aortic incompetence with congenital ventricular septal defect in a 21-month-old child, treated successfully by homograft aortic valve replacement and closure of the ventricular septal defect, is reported. It appears that no similar case has previously been reported in the UK.


Pharmacokinetics and metabolite-pattern of 8-methoxypsoralen in man following oral administration as compared to the pharmacokinetics in rat and dog.

Following oral administration of 14C labelled 8-methoxypsoralen (8-MOP) in man the plasma level course, the metabolite-patterns and the elimination of the parent compound and its metabolites have been investigated. Additionally the results discovered have been compared with the data of pharmacokinetics on dog and rat. In man and rat the plasma protein binding of 8-MOP has been determined. Maximal levels of the total radioactivity in the plasma were achieved 2 h after dosing. At this time 8-MOP represents 50% of the radioactivity in the plasma. The plasma protein binding in vitro of 14C 8-MOP valued from 88% to 91% in man, and between 75% and 83% in the rat. Urinary elimination of the total radioactivity as a measure of the extent of absorption varies greatly and depends on the therapeutic formulation being employed. Following the administration of the solution 74% is recovered within 48 h. Faecal elimination of the total radioactivity reached 14% within 3 days. The metabolite-pattern does not show the unchanged 14C 8-MOP. Several polar metabolites occur in the urine among which biochemical conjugates have been recognized. Only polar metabolites are observable in the faeces from which the radioactivity is incompletely extractable. From a comparison of the metabolite profiles, the rat as well as the dog seem to be a useful animal species for experimental investigations with 8-MOP.


Serum and skin lysozyme activity in non-diabetic and diabetic subjects.

Lysozyme activity was significantly reduced in the skin of patients with clinical diabetes, but not in the skin of other diabetics or in serum of all these patients. Sex and age had no influence on serum or skin lysozyme activity in either nondiabetic or diabetic subjects. The reduction of cutaneous lysozyme activity is suggested as a factor for the seriousness and the relapses of cutaneous infections in subjects with clinical diabetes.


Pagetoid malignant melanoma and lentigo maligna melanoma of toe. A study with the fluorescence method (Falck and Hillarp).

Two cases of malignant melanoma on the toe of middle-aged women were examined chiefly by the fluorescence method of Falck and Hillarp. In one of the patients, histopathology of the pigmented tumor on the left middle toe was a Pagetoid (superficial spreading) melanoma in situ, and the subungual granulomatous lesion on the right great toe in the other patient was a lentigo maligna melanoma. On fluorescence microscopy, characteristic findings of the pigment cells lying in the epidermis of both types may be summarized as follows: In the Pagetoid melanoma, the melanoma cells are ovoid, lack dendritic processes, and emit specific yellow fluorescence. In the lentigo maligna melanoma, the pigment cells clearly show dendritic processes, and emit specific green fluorescence.


An ultrastructural study of localized lymphangioma circumscriptum.

An electron microscopic study was performed on the lymphatic vessel (lv) of localized lymphangioma circumscriptum (Lc), which was found clinically typical but histologically not associated with hemangioma and inflammation. The lv of Lc was morphologically divided into two types. The first type was situated at the upper dermis of the lesion and the other, at the deep dermis. The former had certain similarities to lv of experimentally induced lymph-stasis, whereas the latter was morphologically similar to lv of the normal skin. From the findings of the present study and those reported in literature, Lc could not be considered as a mere benign overgrowth of lv, but as one of pathological results induced by a long-standing lymph-stasis.


Comparative electron microscopic study of clear cells in epidermodysplasia verruciformis and flat warts.

Are Epidermodysplasia verruciformis (E.V.) and disseminated flat warts different diseases? Are there any diagnostic criteria between them? In order to attempt answering these 2 questions, fundamental for prognosis and nosology, a comparative ultrastructural study was made of epidermal clear cells of 2 cases of E.V. and 4 flat warts from 4 patients of whom 3 were under immunosuppression drugs. The reason of cytoplasmic electron translucency was mainly a reduction in tonofilaments and keratohyalin amounts in E.V. and a centrifugal edema and vacuolization in flat warts. On the other hand, the number of ribosomes was raised in E.V. and reduced in flat warts. These findings allow differentiation between the 2 diseases and suggest a possible different host-virus relationship.


The effect of systemic treatment with 5-fluorouracil on the epidermis of the guinea pig.

The thymidine labelling index and the mitosis rate (blocked by colcemid) in the basal cell layer of the guinea pig were determined before and during treatment with 5-fluorouracil (1 mg i.p. in 2 day's interval/100 g body weight). Additionally, the epidermal area and thickness and the number and size of cells were measured. 5-Fluorouracil equally reduces the thymidine labelling index and the mitosis rate with the full effect after treatment of at least 22 days. From these findings it is concluded that the S-phase--calculated from the end of the thymidine synthesis--is not altered. Furthermore atrophy of the epidermis runs parallel with the reduction of the 3H thymidine labelling index and the mitosis rate.


Acute effect of 8-methoxypsoralen and ultraviolet light on sister chromatid exchange.

The acute effect of 8-methoxypsoralen (8-MOP) and 8-MOP + long wave ultraviolet light (UVA) on sister chromatid exchange (SCE) has been examined in an in vitro experiment. The SCE count was significantly increased by 8-MOP without light, but the effect was substantially greater (50%) by 8-MOP + UVA. In addition, mitoses with banded staining of the chromosomes were seen after 8-MOP and UVA. These changes were dose dependent, and they might be responsible for the reduced cell turnover in psoriasis plaque after PUVA.


Acidic glycosaminoglycans in skin and urine of a patient with wide-spreaded lichen sclerosus et atrophicus.

Changes of dermal and urinary acidic glycosaminoglycans in Lichen Sclerosus et Atrophicus (LSA) were investigated with the following results: 1. Hyaluronic acid (HA) was excreted in urine of a patient with LSA. 2. HA and low sulfate chondroitin were eluted with 0.5 M NaCl by Bio Rad AG 1- X 2 (Cl- form) column chromatography. 3. Involved dermal tissue contained only about 50% of HA in the skin of a healthy adult.


Faecal porphyrin excretion in various types of porphyria. Thin layer chromatographic study.

A new method of thin layer chromatography was used for the study of faecal porphyrins in 31 porphyric patients (20 cases of porphyria cutanea tarda, 5 cases of porphyria variegata, 2 cases of hereditary coproporphyria, 1 case of acute intermittent porphyria and 3 cases of erythropoietic protoporphyria), 14 of their clinically normal relatives and 5 controls. The pattern obtained was characteristic of each type of porphyria and compared to previously published data.


Effect of vitamin A acid on the growth of keratinocytes in culture.

The effect of vitamin A acid on the culture of guinea pig ear keratinocytes was investigated. Use of this agent and treatment of the plastic dishes with collagen solution facilitated attachment and growth. Vitamin A acid elicited a wave of DNA synthesis which was studied by incorporation of tritiated thymidine and quantitation of cellular DNA, particularly during the period 24--45h after plating. During this period, thymidine incorporation into DNA was increased ten-fold by vitamin A acid and showed a complex pattern of peaks and shoulders which may represent the S phase of synchronous keratinocytes.


[Comments on the surgical treatment of hydronephrosis].

The author first recalls that the first operation to correct hydronephrosis due to ureter stenosis was performed by Trendelenburg. He then defines the causal lesion of hydronephrosis and describes its etiology. He stresses that the only procedure for correcting hydronephrosis caused by stenosis of the juxtapyelic ureter is the removal of this portion, the lesion of which it is impossible to repair or correct. He criticizes the numerous operations proposed by different authors and even the partial removal of the renal pelvis. He points out that most of the operation procedures described as new, have already been published. He finally stresses that the best operation is the removal of the stenosed ureter followed by direct pyelo-ureter anastomosis and kidney draining by means of a tutor probe placed from the pelvis to the bladder during the operation and kept in place for a few days.


[Cytology of urine in eosinophilic cystitis. Apropos of 19 cases].

A retrospective, cytological study has been carried out on the urine of 19 patients diagnosed by means of an endoscopic biopsy as suffering from eosinophilic cystitis. The authors have assessed the erythrocytes, the urothelial cells and the inflammatory ones, by means of a percentage count on 1,000 of the latter. In all the cases there was found to be a percentage rate of polynuclear neutrophils of more than 90% as well as the constant presence of eosinophils although in a very limited percentage and the conclusion is reached that it is impossible to diagnose eosinophil cystitis by means of the cytological study of the urine alone.


The arthritis of mixed connective tissue disease.

Twenty patients with mixed connective tissue disease were followed for 5 years. Arthritis occurred in all 20 patients, being the presenting complaint in 11 patients. The joints most frequently involved were the proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrists, metatarsophalangeal (MTP), and knee; the distribution tended to be symmetrical, mimicking early rheumatoid arthritis. Joint deformities occurred in 6 patients, but apart from 1 patient with arthritis mutilans, significant functional impairment was not encountered. Radiologically small punched out bone erosions, asymmetrically distributed, were the most characteristic finding; other notable changes were aseptic necrosis, tuft erosions, and periarticular calcification. Joint effusions were non-inflammatory, the cellular content was predominantly lymphocytic and the C3 level was normal. Most cases were controlled with non-steroidal anti-inflammatory agents and invariably responded to prednisone less than or equal to 7.5 mg/day.


Markedly raised synovial fluid leucocyte counts not associated with infectious arthritis in children.

Synovial fluid leucocyte counts greater than 50 000 cells/mm3 (50 X 10(9)/1) are usually associated with infectious arthritis. Six children, 3 of whom meet the criteria for juvenile rheumatoid arthritis (JRA), are described with synovial fluid white blood cell counts greater than 88 000 cells/mm3 (88 X 10(9)/1). Two had synovial fluid leucocyte counts greater than 100 000 cells/mm3 (100 X 10(9)/1). The diagnosis of infectious arthritis was unlikely in these 6 children since the synovial fluid smears and cultures for infectious agents were negative and their histories atypical for infection. While in most instances such markedly raised synovial fluid leucocyte counts indicate infection, this finding is not diagnostic of septic arthritis.


[Vesico-ureteral reflux].

We review the current problem of vesico-ureteral reflux, commenting upon the etiological factors and the physiopathology of the same. We describe the exploratory methods (analysis, urography, cystourethrography, cystoscopy) and assess the data obtained in order to establish the indication of medical or surgical treatment.


Lymphocyte studies in rheumatoid arthritis. II. Antibody-mediated and mitogen-induced lymphocyte cytotoxicity in synovial fluid and peripheral blood.

A comparison was made of the activity of synovial fluid (SF) lymphocytes with peripheral blood lymphocytes in antibody-mediated and mitogen-induced lymphocyte cytotoxicity in patients with a variety of inflammatory joint diseases. SF lymphocytes consistently showed little or no antibody-mediated cytotoxicity (AMC) although mitogen-induced cytotoxic activity was comparable with that of the peripheral blood lymphocytes. Blocking substances on the cell surface were not responsible for the lack of AMC by SF lymphocytes as preincubation at 37 degrees C and enzyme treatment (trypsin, neuraminidase) of the cells did not restore activity. The lack of AMC by SF cells from a variety of inflammatory joint fluids demonstrates that this may be a consequence of inflammation in the joint and excludes the possibility that this is a specific property of fluids from certain conditions such as rheumatoid arthritis. Lymphocytes thought to be involved in AMC have a characteristic surface morphology (Fc receptor positive, E rosette negative, surface immunoglobulin negative). Such lymphocytes are present in synovial fluid in comparable proportions to those in blood. Hence the absence of AMC indicates that functional assays must be used in determining the presence or absence of cells with special functions.


[Morphogenesis of the renal glomerulus in relation to fetal weight].

The author studies the development of the kidney glomerulus during the foetal period. He establishes four, well-defined stages in the morphological development of the same, in relation to the weight of the foetus. He thus obtains the average decreases and increases in each of the forms.


SOluble and insoluble immune complex-platelet interactions in rheumatoid inflammation.

The interactions of soluble and insoluble immunoglobulin G (IgG) complexes with macromolecular rheumatoid factor (RF) and platelets were examined in an in vitro system permitting observation of platelet activities which may contribute to rheumatoid inflammation. Studies of the aggregation phenomenon by the nephalometric technique and by selective sedimentation of 51Cr-labelled platelets revealed no aggregation by platelets exposed to heat aggregated IgG (HAIgG) complexes or their RF precipitates in a plasma test system. Release of serotonin was demonstrated by the increasing radioactivity of platelet supernates to 45 min by 14C-serotonin labelled platelets exposed to insoluble IgG heat aggregates. Significantly less release was shown with saline, native IgG, and soluble IgG complexes. When RF was added to soluble HAIgG complexes, the resulting precipitate caused significantly higher release than controls. No concomitant release of the lysosomal enzyme beta-glucuronidase was detected. Thus, although soluble complexes do not cause significant release of biologically active amines, conversion of soluble complexes to insoluble immune precipitates by RF is associated with this activity which is independent of platelet aggregation and/or lyosomal enzyme release in our test system. Release of biologically active amines from platelets exposed to insoluble complexes may be important in the initiation and propagation of inflammation in rheumatoid arthritis.


[Sarcomatoid renal carcinoma].

The authors present a case of sarcomatoid kidney adenocarcinome of the fibrosarcomatoid kind. They stress the importance and difficulty of making a differential diagnosis between the sarcomatoid type of kidney adenocarcinomas and pure sarcomas of the kidney, this being an entirely histopathological and extremely complex diagnosis. They comment upon the possible histogenesis in the sense that they may be sarcomatoid areas deriving from the stroma or from a cellular metaplasia of the adenocarcinoma.


On the relationship between gastrin, gastric secretion, and adjuvant arthritis in rats.

The elevation of plasma immunoreactive gastrin known to occur during the induction of adjuvant-induced arthritis (Rooney et al., 1973) has been shown to be maximal at 7 days after injection. Gastrin administered exogenously accelerated and exacerbated the inflammatory joint disease. Some evidence has been presented that the endogenous immunoreactive gastrin had biological activity in terms of gastric acid secretion.


Proximal interphalangeal arthroscintigraphy in rheumatoid arthritis.

Quantitative scintigraphy of proximal interphalangeal joints was performed by a reproducible method using 99m-Technetium in the hands of 40 normal controls and 20 patients with rheumatoid arthritis (RA). The range of the mean uptake varied considerably between proximal interphalangeal (PIP) joints in normal subjects. The mean uptake over PIP joints was not significantly different either between normal controls and RA patients, nor between those rheumatoid arthritis patients with and those without clinical signs of inflammation in the PIP joints. However, the variation in the PIP counts was significantly greater in the rheumatoid hands than in the normal hands. There was no clear correlation between the technetium uptake and the clinical parameters of inflammation in the PIP joints.


Rapid cryoglobulin screening: an aid to the clinician.

A rapid screening method for serum cryoblobulin is reported. It requires only common laboratory equipment and is based upon the detection of light scattering (500 millimicron) in the early phase of cryoaggregation. All of 28 sera negative for cryoglobulins by the conventional 5-day incubation method were negative by the screening method. Conversely, all sera containing 60 microgram/ml or more of mixed cryoglobulins were positive by the screening method. The initiation phase of cryoprecipitation in mixed cryoglobulins was found to be prompt, as reported previously for monoclonal cryoglobulins. This sensitive method of cryoglobulin detection provides results to the clinician within 2 hours, a helpful insight where consideration of possible immune complex vasculitis exists.


Isolated epiphyseal chondrocyte allografts into joint surfaces. An experimental study in rabbits.

Isolated epiphyseal chondrocytes from 5 week old female New Zealand white rabbits were transplanted as allografts into drill holes in the tibial articular surface of adult male New Zealand white rabbits. The grafts were examined after 8 weeks. Fresh chondrocytes which were partially separated from their matrix were more successful (47%) than completely separated cells (20%) and were significantly more successful (P greater than 0.05) in skeletally mature (58%) as opposed to immature recipients (20%). Storage of the cells at -79 degrees C for 2 to 9 days or at -196 degrees C for 36 to 58 weeks gave successful results of 23% and 33%, respectively. Control defects showed fibrocartilage filling the defect in 25%.  The factors affecting survival of chondrocyte allografts require further study before clinical application of the method.


A family study of Behcet's syndrome.

The first-degree family members of patients with Behcet's syndrome were investigated to determine (1) whether there was a familial aggregation of Behcet's syndrome or of its component features, (2) whether there was an increased incidence of sacro-iliitis in these families, and (3) whether a link exists between Behcet's syndrome and spondarthritides in first-degree relatives. Of the 226 relatives and patients seen, 21 patients with definite Behcet's syndrome and their 71 relatives were analysed in some detail. Orogenital ulceration was found in 2 mothers of probands; 1 patient had psoriasis and Behcet's but neither disease featured in the pedigree. Another family showed numerous manifestations of psoriasis and psoriatic arthritis, 1 member having severe sacro-iliitis but the proband had Behcet's syndrome only. Family trees including HLA pedigrees, where known, are presented. Spouses suffered few of the complaints found in patients, and to a less extent in relatives, but showed a high incidence of backache, perhaps of psychogenic origen.


A prospective study of gout in New Zealand Maoris.

Results are reported from the first prospective study of gout in New Zealand Maoris based on a sample of 388 males and 378 females. At baseline, high mean levels of serum uric acid (SUA) were found, 0.422 +/- 0.092 mmol/1 (7.05 +/- 1.54 mg/100 ml) in males and 0.350 +/- 0.091 mmol/1 (5.85 +/- 1.52 mg/100 ml) in females. On the basis of traditional criteria (SUA above 0.42 mmol/1 (7.0 mg/100 ml) in males and above 0.36 mmol/1 (6.0 mg/100 ml) in females) the prevalence of hyperuricaemia was 49% in males and 42% in females. The baseline prevalence of gout (8.8% for males and 0.8% for females) and the subsequent 11-year incidence rates (10.3% for males and 4.3% for females) are discussed in relation to specified SUA classes. When traditional, sex-specific criteria for hyperuricaemia were used, no relationship was found between the prevalence of hyperuricaemia and the incidence of gout. There was, however, a sharp increase in the incidence rate of gout in both sexes when SUA levels were above 0.48 mmol/1 (8.0 mg/100 ml). In subjects with a baseline SUA above this level, the age-standardised 11-year incidence rate of gout was 29.1% for males and 37.2% for females. A previously unreported relationship linking muscle size to the incidence of gout in males is presented as a major finding of the study. Other risk factors associated with gout were body mass and blood pressure.


Costovertebral and costotransverse joint involvement in rheumatoid arthritis.

Lesions of the costovertebral (CV) and costotransverse (CT) joints are distinctly unusual in rheumatoid arthritis. The patient presented had dramatic changes in these joints with destruction, ankylosis, and bony overgrowth. This led to a moderate respiratory impairment and a distinctive radiological presentation.


Systemic lupus erythematosus, repeated abortions, and thrombocytopenia.

A case is described of severe thrombocytopenia in a pregnant patient with mild SLE. Three previous pregnancies had ended in abortion. Attempts to reverse the thrombocytopenia with steroids, plasmapheresis, and splenectomy failed, the platelet count returning to normal immediately after the death of the fetus at 20 weeks gestation.


Joint amyloid presenting as 'polymyalgic' rheumatoid arthritis.

A patient presenting with 'polymyalgic' rheumatoid arthritis was shown to have synovial amyloid at an early stage of his illness. It is suggested that such patients merit early synovial biopsy and investigation.


Management of penetrating carotid arterial injury.

A review of the experience with penetrating wounds to the carotid artery was undertaken in an effort to establish concise clinical criteria for surgical management. These results were compared with similar cases from the literature reported since 1963. In these 233 cases, the presence or absence of preoperative neurological deficits was correlated with vascular repair or ligation of the carotid artery. The presence of coma preoperatively was the single most influential factor in determining operative management and prognosis. Patients without a neurological defect should have restoration of vascular continuity (0% mortality, 0.6% morbidity), which produces significantly better results than carotid ligation (p less than 0.002). Patients with all grades of neurological deficit, short of coma, should also have primary vascular repair. Morbidity and mortality rates are significantly less than those following ligation (15 vs. 50%, p less than 0.05). In comatose patients, neither repair nor ligation appear to influence the poor prognosis. At the present time, ligation of the carotid artery is only indicated in the comatose patient who has no evidence of prograde flow or if repair is technically impossible.


Use of the stomach as an esophageal substitute.

Esophagoplasty with isoperistaltic stomach is a useful and satisfactory means of reconstruction of the esophagus. It is simpler and there is no necessity for using a reversed gastric tube. The most essential points of technique for the modelling of the stomach, is taking advantage of the ample intramural vascular network and adequate selection of the highest point of the stomach for the site of the esophago-or pharyngogastrostomy. To utilize the intramural vascular network, sufficient width of the stomach is necessary. This also allows stretching of the stomach. Esophageal resection and reconstruction using the isoperistaltic stomach above the level of the neck was performed on 130 cases. Among them 40 cases were pharyngogastromies and 90 cases were cervical esophagogastromies. There was one operative death due to alcoholic liver cirrhosis (operative mortality rate 0.8%). If the stomach is properly handled, esophageal replacement by the isoperistaltic stomach gives constant success.


Fasting and postprandial serum gastrin levels in infants with congenital hypertrophic pyloric stenosis.

Recently attempts have been made to demonstrate the possible role of hypergastrinemia in the production of congenital hypertrophic pyloric stenosis in infants. Eleven infants with congenital hypertrophic pyloric stenosis, ranging in age from three to 11 weeks, were evaluated for fasting and postprandial serum gastrin levels. Two to ten weeks following successful pyloromyotomy, a similar evaluation was undertaken to demonstrate the possible role of elevated serum gastrin levels in the etiology of congenital hypertrophic pyloric stenosis. The average fasting and postprandial serum gastrin levels in infants with congenital hypertrophic pyloric stenosis did not differ significantly from levels noted in control infants. Similarly, no statistically significant difference was noted between the pre- and postoperative levels of serum gastrin in the affected infants. Several experimental studies have been reported within the past few years describing the production of hypertrophic pyloric stenosis in the offspring of dogs injected with pentagastrin during pregnancy. The results of our study minimize the direct importance of serum gastrin in the production of congenital hypertrophic pyloric stenosis. The role of the hormone secretin in the etiology of this condition is hypothesized.


Hyperbilirubinemia in inflammatory pancreatic disease: natural history and management.

Of 868 patients admitted with pancreatitis between 1971 and 1976, coexisting hyperbilirubinemia was noted in 125 (14%). The patient population was primarily composed of alcoholics (84%) with chronic pancreatic disease (75% Marsielles Class H or higher) which was of moderate severity (77% fewer than three prognostic signs). The hyperbilirubinemia in these 125 patients was due to extrahepatic obstruction in 22%, hepatocelluar disease in 31%, and was idiopathic in 47%. Transient hyperbilirubinemia (< 10 days duration) occurred most commonly in the idiopathic group. Transitory periductular pancreatic edema may account for the elevated bilirubin in some of these cases. Liver biopsy should be done whenever hyperbilirubinemia persists longer than ten days in patients with pancreatitis. If hepatocellular disease is not found, transhepatic or endoscopic retrograde cholangiography are indicated. If common bile duct obstruction is demonstrated, a brief trial of medical therapy is in order. Persistent conservative treatment, however, exposes the patient to the risk of cholangitis and biliary cirrhosis. In 13 of the 125 cases (10%), persistent extrahepatic obstruction proved to be due to compression of the common bile duct by inflammatory pancreatic tissue. In these circumstances, choledochoduodenostomy is recommended as the procedure of choice. In patients requiring biliary decompression, concommitant procedures upon the pancreas are occasionally indicated.


Colonoscopy and the management of polyps containing invasive carcinoma.

Experiences with 565 colonoscopic polypectomies and 91 colonic and rectal resections containing infiltrating carcinoma in polyps are reviewed. A plan of management based on pathologic study of resected polyps is formulated to avoid further unnecessary surgery. It was concluded that: (1) Tubular adenomas containing invasive carcinomas have a low incidence of metastatic node involvement. This incidence is related to the depth of carcinomatous involvement. Resection of these polyps with a margin free of carcinoma constitutes definitive and adequate treatment and that (2) Villous adenomas containing invasive carcinoma have a high incidence of metastatic nodal involvement, and operative resection of the involved area of the colon is recommended, and that (3) Pedunculated tubulovillous adenomas containing invasive carcinoma behave like tubular adenomas, and the recommendations for further surgery in the patient with tubular adenomas with carcinoma apply equally well for these lesions. Sessile tubulovillous polyps tend to behave like villous adenomas, and if invasive carcinoma is demonstrated, further operation is recommended.


Iliac-mesenteric-atrial shunt procedure for Budd-Chiari syndrome complicated by inferior vena caval thrombosis.

A 33-year-old woman had a diagnosis of idiopathic Budd-Chiari syndrome complicated by inferior vena caval occlusion. Conservative medical therapy failed to control the symptoms of both portal hypertension and vena caval stasis. Therefore, a prosthetic shunt was placed from the right common iliac vein to the right atrium with a side-arm to the superior mesenteric vein. She exhibited almost complete relief of symptoms and the graft was documented to be patent two weeks postoperatively. In many instances aggressive surgical therapy may help these patients who, in the past, would have been relegated to symptomatic therapy.


Effect of proximal gastric vagotomy on feeding stimulated Heidenhain pouch acid secretion and gastrin release.

Truncal vagotomy (TV) is known to increase the feeding stimulated acid output of Heidenhain pouches. A series of experiments were performed in dogs to see if proximal gastric vagotomy (PGV) also had this effect. Dogs were prepared with gastric fistulas (GF) and Heidenhain pouches (HP). Gastric function testing included three categories of tests: (1) serum gastrin determinations and Heidenhain pouch acid secretion after feeding, (2) gastric emptying and simultaneous Heidenhain pouch acid secretion, and (3) gastric and Heidenhain pouch acid secretion and serum gastrin levels after insulin. Compelte testing consisting of two control and two post-PGV tests was accomplished in five dogs in each category. Insulin testing confirmed that an adequate PGV was performed because GF peak acid output in response to 0.5 U/kg insulin IV was reduced 88% by PGV (p less than .01). In response to two separate meals peak acid output (PAO) from the HP's was not increased significantly after PGV: Meal I pre-PGV 450 +/- 112 vs post-PGV  400 +/- 99 muEq/15 min; Meal II pre-PGV 256 +/- 62 vs post-PGV 304 +/- 150 muEq/15 min. This finding may represent an important physiologic difference between PGV and truncal vagotomy.


Preoperative estimation of run off in patients with multiple level arterial obstructions as a guide to partial reconstructive surgery.

Preoperative measurements of direct femoral artery systolic pressure, indirect ankle systolic pressure and direct brachial artery systolic pressure were carried out in nine patients with severe ischemia and arterial occlusions both proximal and distal to the ingvinal ligament. The pressure-rise at the ankle was estimated preoperatively by assuming that the ankle pressure would rise in proportion to the rise in femoral artery pressure. Thus it was predicted that reconstruction of the iliac obstruction with aorta-femoral pressure gradients from 44 to 96 mm Hg would result in a rise in ankle pressure of 16--54 mm Hg. The actual rise in ankle pressure one month after reconstruction of the iliac arteries ranged from 10 to 46 mm Hg and was well correlated to the preoperative estimations. In conclusion, by proper pressure measurements the run-off problem of multiple level arterial occlusions can be evaluated. Thus the result of successful partial reconstruction can be assessed preoperatively.


Alimentary tract duplications in children.

This report reviews the experience with 78 alimentary tract duplications found in 64 patients over a 40 year period at the Children's Hospital of Pittsburgh. Ten patients had the duplication discovered at autopsy. Multiple duplications were found in 15% of patients. The symptoms and physical findings of a duplication varied with location, size and mucosal pattern. About one-fifth of the duplications contained ectopic mucosa, usually gastric. Two-thirds of the patients were diagnosed prior to one year of age. Vertebral anomalies, as a clue to the presence of the lesion, were present in 15% of the patients. The most common indications for surgery included a mediastinal or abdominal mass, intestinal obstruction, and gastrointestinal bleeding. The results of surgery were favorable, with a mortality of 20%. Surgical complications accounted for six deaths, while four children died of severe associated anomalies. Three others died without surgical treatment, but with symptoms from the duplication.


Treatment of caustic injuries of the esophagus: a ten year experience.

The methods of managing 32 patients sustaining caustic injuries to the esophagus are assessed. Treatment of these patients must be individualized according to the type of caustic ingested, the degree of burn and other clinical signs. While an aggressive approach is favored for second and third-degree burns in the form of early esophago-gastrectomy with subsequent colon interposition, operation is not necessary. In all patients, particularly those with first-degree burns. The use of antibiotics is recommended as soon as the diagnosis of esophageal injury is established. The efficacy of steroids in preventing stricture formation, especially with third-degree burns, is questioned.


A clinicopathologic study of 21 cases of pancreatic cystadenocarcinoma.

Cystadenocarcinomas are rare tumors of the pancreas. They are half as common as their benign counterpart--the cystadenoma. A review of 21 cases, including eight reported since 1963, revealed that most patients presented with upper abdominal pain and a large palpable upper abdominal mass. All patients had evidence of malignant degeneration occurring in a mucous cystadenoma. None had evidence of a serious cystadenoma. Grading revealed a predominance of low-grade tumors: 20 of the 21 lesions were grade 1 or 2. Cystadenocarcinomas were slightly more frequent in the head of the pancreas. Four patients had metastasis. Complete excision by distal or total pancreatectomy or Whipple pancreaticoduodenectomy is recommended. The five year survival after complete excision is 68%, and for patients with grade 1 lesions, and five year survival is 64%.


Sequential femoral-tibial bypass grafting for limb salvage.

Bypass grafting to distal lower extremity vessels continues to be associated with a high rate of graft occlusion. By utilizing a sequential side-to-side anastomosis between saphenous vein and popliteal artery in femoral-tibial bypass grafts, runoff can be increased and graft patency thereby improved. Sequential femoral-tibial grafts were employed in seven patients with gangrene, trophic changes, or restpain, all of whom had single-vessel runoff by arteriography. All seven sequential grafts established to a distal vessel in addition to the popliteal artery have remained open for periods of five to 27 months as determined by palpable graft or foot pulses. Two patients undersent below-knee amputation within six months of operation but had patent grafts at the time of amputation. In three patients ischemic ulcers resolved and in two patients toe amputations healed successfully. Sequential bypass grafting is a technique aimed at improving the patency rate of femoral-tibial bypass grafts by augmenting runoff.


The stapled gastrointestinal tract anastomosis: incidence of postoperative complications compared with the sutured anastomosis.

Performance of gastrointestinal anastomosis by means of surgical stapling devices has achieved popularity in the last decade even though no detailed study has been reported comparing complications following the stapled anastomosis with those following hand sutured procedures performed by the same surgeons. We have reviewed 812 operative procedures on the gastrointestinal tract performed in one hospital over a four year period. Stapled anastomoses were performed in 472 with 13 (2.8%) complications related to the anastomosis; in 296 sutured anastomoses there were nine (3.0%) related complications. Comparison did not disclose any significant difference in the number of complications in these two groups. In 44 instances wherein the anastomosis contained both staples and sutures, there were no related complications. Further analysis of the patients in each group disclosed that stapling procedures were utilized in a much higher percentage of those operations which were performed under emergency conditions or in the presence of intra-abdominal sepsis, intestinal obstruction, and carcinomatosis. If the technical details of surgical stapling are mastered, this technique appears to be as safe as suturing in the performance of anastomoses in the gastrointestinal tract.


Intestinal bypass: a modification.

Six hundred sixty-four patients who have had metabolic intestinal surgery for the treatment of morbid obesity are reviewed. Particular attention is directed to difference in weight loss, morbidity and mortality in end-to-side and end-to-end shunts, the former performed in 300 patients and the latter in 262 patients. Unsatisfactory weight loss was observed in 20% of patients with end-to-side shunts, while only 8% of patients with end-to-end shunts failed to lose a sufficient amount of weight. Morbidity and mortality were significantly increased in this latter group. This led to adoption of a modification of the end-to-side operation by developing a plication ?REVENT REFLUX. Our preliminary observation indicates that in 102 patients who have had this operation, similar weight loss is attained to that of end-to-end shunts with no greater morbidity or mortality than the end-to-side type.


Temporary loop ileostomy in the treatment of Crohn's disease.

The use of a temporary loop ileostomy for fecal diversion in 15 patients with Crohn's disease is discussed. The indications for the use of ileostomy included both emergency and nonemergency situations. Emergency indications included cases of acute peritonitis secondary to perforated bowel or abscesses, and intestinal obstruction. In nonemergency settings ileostomy was used either in conjunction with other surgery that was thought to have a significant risk of anastomotic leakage or to prepare a patient for major resectional surgery. It was the impression of the author's that temporary loop ileostomy was a helpful adjunct in the management of certain difficult cases of Crohn's ileocolitis.


Familial occurrence of hyperuricemia, gout, and medullary cystic disease.

We observed hyperuricemia, acute gouty arthritis, and renal medullary cystic disease in three members of a family over two generations. Two of these individuals were women who developed gout by age 20 years. Two teenage sons of one of these patients had severe hyperuricemia, which appeared due to underexcretion of uric acid. To our knowledge the occurrence of hyperuricemia, gout, and renal medullary cystic disease has not been reported previously.


Ticarcillin disodium in anaerobic infections.

Twenty-five patients were treated with ticarcillin disodium, 18 of whom had anaerobic infections that included pleuropulmonary infections (seven), mandibular osteomyelitis (four), perirectal abscess (two), sepsis, primary site unknown (one), liver abscess (one), pelvic abscess (one), decubitus ulcer (one), and synergistic gangrene (one). Seven had no anaerobic infections. Three had anaerobic septicemia. Culture results included anaerobes: peptococci (ten), peptostreptococci (ten), Bacteroides fragilis (six), Bacteroides not fragilis (ten), eubacteria (three), fusobacteria (two), Clostridium (one), Veillonella (one), and acidaminococcus (one); aerobes: Proteus (three), Klebsiella (two), Escherichia coli (two), and streptococci (two). Six patients with mixed aerobic infections initially received gentamicin sulfate in addition. The serum levels were 110 +/- 20 microgram/ml one hour after intravenous infusion of 5 g of ticarcillin disodium. All anaerobic isolates were susceptible at less than or equal to 100 microgram/ml and 85% by less than or equal to 25 microgram/ml of ticarcillin. Sixteen patients responded well to ticarcillin and two failed to respond. Our study suggests that ticarcillin is useful in the treatment of anaerobic infections.


Natural history of radiation-associated thyroid cancer.

The clinical courses of 91 patients with radiation-associated thyroid cancer were compared with courses in a control population. Radiation-associated carcinoma appears to be a disease of younger persons, and 90% of the tumors are papillary. No anaplastic or medullary tumors were observed. Ninety percent of the tumors were larger than those found in an autopsy series that surveyed for "biologically benign" thyroid tumors. There was a higher incidence of multicentric disease, locally invasive disease, and distant metastases in the population that had had x-ray exposure. Although the population with x-ray exposure had had more aggressive treatment, more recurrences were present in patients who had had radiation therapy. The death rate was similar in both groups. Parathyroid adenoma occurred more frequently in the population that had radiation exposure than in controls and appears to be a radiation-associated illness.


Anemia and secondary hyperparathyroidism.

Anemia has been recognized recently as a possible complication of primary hyperparathyroidism. If the hyperparathyroid state can induce anemia in patients with normal kidney function, the extremely high levels of circulating parathyroid hormone usually observed in hyperparathyroidism secondary to chronic renal failure may have an unfavorable influence on the anemia of uremic patients. We investigated the influence of subtotal parathyroidectomy on the severity of the anemia of 18 uremic subjects undergoing long-term hemodialysis therapy. Subtotal parathyroidectomy resulted in a significant increase of mean hematocrit value. RBC count, and hemoglobin level. Serial bone biopsies suggested a relationship between the amount of marrow fibrosis and the improvement of anemia after surgery, but the precise mechanism of this phenomenon is still unknown.


Staphylococcus aureus carriage rate of patients receiving long-term hemodialysis.

We studied the carriage rate of Staphylococcus aureus in patients receiving long-term hemodialysis and also noted the incidence of shunt infections, bacteremia, and septicemia in colonized patients. Thirty-one of 50 patients (62%) carried S aureus in the nose, throat, or on the skin, of whom 20 patients developed shunt infections; nine infections resulted in episodes of bacteremia. Patients with chronic renal failure not undergoing hemodialysis had a 21% carriage rate. Thus, there is a high carriage rate of S aureus in asymptomatic patients receiving hemodialysis that is probably related to an increased incidence of shunt infections and bacteremia.


Gallium citrate Ga 67 imaging in noninfectious interstitial nephritis.

Gallium citrate Ga 67 has been reported to be of value in the diagnosis of both malignant and infectious intra-abdominal diseases. The drug may also be taken up by mononuclear phagocytes in noninfectious tubulo-interstitial disease of the kidney. Positive renal scans from patients with these diseases either become negative or show decreased uptake following treatment. With further support of these findings, gallium citrate Ga 67 may become a valuable tool in both diagnosis and follow-up of noninfectious interstitial nephritis.


Pseudomonas maltophilia causing heroin-associated infective endocarditis.

The association of Pseudomonas maltophilia endocarditis in three patients with recent history of intravenous drug abuse is reported. All three patients had abnormal heart valves (two prosthetic and one rheumatic). A prominent characteristic of this uncommon pathogen is its in vitro resistance to the commonly used antimicrobials. Cure was achieved in all three cases. In two cases, synergistic antibiotic combinations were used. In one case, plasmid-mediated resistance to amikacin sulfate (Amikan, British; no comparable US product) emerged during therapy. The two patients with prosthetic valves received combined surgical and antibiotic therapy.


Familial systemic lupus erythematosus.

Pedigrees were obtained from 340 patients with systemic lupus erythematosus (SLE). Two hundred ten (62%) of the patients were from the wards of Lupus Clinic at the Los Angeles County-University of Southern California Medical Center, and 130 (38%) were from a private practice. Forty-one (12%) of the 340 patients with SLE had affected relatives: five had two and 36 had one affected relative. Ten (30%) of the 33 male patients and 31 (10%) of the 307 female patients had relatives with SLE. Examination of the individual pedigrees included examples of possible autosomal dominant, autosomal recessive, and sex-linked dominant and recessive inheritance. When all the pedigrees were considered as a group, multifactorial inheritance was suggested.


Adenocarcinoma of the stomach with common variable immunodeficiency syndrome.

Two patients had adenocarcinoma of the stomach in association with common variable immunodeficiency syndrome. There has been an increased prevalence of malignancy in this late-onset immunodeficient state. Similar to five previously reported cases, our patients had gastric carcinoma as a late complication. Further documentation of this association stresses the need for long-term follow-up in this premalignant condition.


Hemodialysis clearance of cimetidine.

Hemodialysis clearance of cimetidine was determined in three patients and was found to range between 41.34 to 75.91 ml/min. Notwithstanding its substantial dialyzability, the amount of cimetidine removed by four hours of hemodialysis constituted only 8% to 14% of the administered dose. Accordingly, major dose adjustment on the days of dialysis treatment, as suggested in the available literature, may not be necessary.


Fixed-bed charcoal hemoperfusion. Treatment of drug overdose.

Fixed-bed activated charcoal cartridges were used for hemoperfusion in the treatment of 54 patients with overdose of one or more drugs, including barbiturate, glutethimide, ethchloryvnol, meprobamate, methyprylon, methaqualone, salicylate, and diazepam. The most dramatic improvement was noticed in patients with phenobarbitol intoxication; they were admitted in stage 3-4 coma and were either awake or arousable by verbal communication at the end of 1 1/2 to 3 1/2 hours of hemoperfusion. Other intoxications improved slowly and required longer duration of treatment. The clearance rates of the drugs with hemoperfusion were greater than those usually achieved with hemodialysis. The data demonstrate the efficacy and usefulness of charcoal hemoperfusion for the management of drug overdose.


Focal sclerosing glomerulopathy with adverse effects during pregnancy.

Exacerbation of focal sclerosing glomerulopathy (FSGN) during pregnancy was noted in the three patients. All had antecedent asymptomatic proteinuria. Toxemia developed in two of the women during pregnancy and progressed rapidly to renal failure. Severe nephrotic syndrome developed in one patient with pregnancy and remitted after delivery. These cases suggest a deleterious effect of pregnancy on the course of FSGN and indicate the necessity for doing renal biopsy in women of childbearing age with asymptomatic fixed proteinuria or nephrotic syndrome so that those patients with FSGN can be properly counseled about future pregnancies.


Exacerbation of phenylbutazone-related renal failure by indomethacin.

A patient experienced a transient deterioration of renal function induced by indomethacin during recovery from idiosyncratic phenylbutazone-associated renal failure. Since both drugs inhibit prostaglandin synthesis, this patient may illustrate a unique enhancement of the more common and clinically unimportant effect of altered glomerular filtration rate induced by such drugs. The renal insufficiency per se associated with the idiosyncratic reaction to phenylbutazone may have also enhanced this patient's reaction to indomethacin. Careful observation of patients during administration of such drugs in this and other settings of acute renal failure appears warranted.


Severe electrolyte abnormalities in a pregnant patient with a jejunoileal bypass.

A pregnant patient with a jejunoileal bypass developed hypokalemic paralysis and severe hypocalcemia and hypomagnesemia. She also had hypokalemic myopathy with elevation of muscle enzymes, which was corrected by potassium administration. This case emphasizes the severe metabolic complications that may be encountered during pregnancy following jejunoileal bypass.


The syndrome of inappropriate antidiuretic hormone secretion in multiple sclerosis.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) occurred during an excerbation of multiple sclerosis (MS). Rapid symptomatic improvement occurred with correction of the hyponatremia. Although the pathophysiology responsible for development of the SIADH in this patient is unknown, CNS involvement by MS is a likely explanation.


Necrotizing fasciitis associated with Haemophilus aphrophilus. Report of a case.

Necrotizing fasciitis, a serious infection requiring prompt antibiotic and surgical therapy, previously has not been associated with Haemophilus aphrophilus. We report a case of necrotizing fasciitis associated with methylphenidate abuse from which H aphrophilus was isolated. Surgical and antibiotic therapy based on in vitro susceptibility testing resulted in eradication of the infection.


False-positive Sternberg-Reed cells present in pericardial effusion. Report of a case.

Recent reviews have emphasized the value of cytodiagnosis in the evaluation of malignant effusions from patients with lymphoproliferative disorders. We present a case in which the presence of Sternberg-Reed-like cells in pericardial fluid was related to prior radiotherapy and not to recurrent Hodgkin's disease.


Pneumococcal bacteremia diagnosed by peripheral blood smear in multiple myeloma.

A patient with multiple myeloma and a normal spleen died with high-grade pneumococcal bacteremia diagnosed by routine examination of a Wright-stained peripheral blood smear. In earlier reports, this finding has been described only in patients with abnormal or absent spleens. We review the proposed mechanisms of high-grade pneumococcal bacteremia in these patients and the immunologic abnormalities in patients with multiple myeloma that may result in increased susceptibility to this infection.


Cyclophosphamide-induced urticaria. Occurrence in a patient with no cross-sensitivity to chlorambucil.

A patient receiving adjuvant chemoimmunotherapy for breast carcinoma developed urticaria secondary to cyclophosphamide, one of the drugs of the chemotherapy regimen. Chlorambucil, another alkylating agent, was substituted with no cross-sensitivity noted.


Granulomatous colitis and ileitis complicating jejunoileal bypass.

There are many complications of a jejunoileal bypass for obesity. I report what is, to my knowledge, a previously unrecognized complication--granulomatous colitis and ileitis. Caution is urged in recommending this procedure for the treatment of obesity.


Bone marrow granulomas and neutropenia associated with procainamide. Report of a case.

Bone marrow granulomas and neutropenia occurred in a 77-year-old man following the ingestion of procainamide hydrochloride for 50 days. Although neutropenia has occasionally occurred following procainamide therapy, granulomas in the bone marrow have not previously been associated with the use of this drug. There was no other apparent agent that could have been responsible for the granulomas. Eighteen days after administration of the drug had been discontinued, the WBC count returned to normal and there were no granulomas present in the bone marrow.


Cerebrovascular occlusion in a transsexual man taking mestranol.

The Collaborative Study Group for the Study of Stroke in Young Women studied 598 women from age 15 to 44 years with cerebrovascular disease. They found that the use of oral contraceptives was significantly more prevalent in women who had suffered a thrombotic stroke than in women who had not had strokes. The risk of thrombotic stroke was estimated to be nine times greater in users of oral contraceptives than in nonusers. We report a case in which a previously healthy man who was using an oral contraceptive drug developed middle cerebral artery occlusion. In the absence of other predisposing factors in this case, it appears that the cerebrovascular occlusion was related to estrogen administration. The occurrence of persistent severe headaches in patients using estrogenic hormones may be a clue to impending cerebrovascular occlusion.


Spontaneous regression of breast carcinoma.

Spontaneous regression of breast carcinoma occurred in a patient with a malignant pleural effusion and bone metastases. The patient did not receive any form of hormonal manipulation or systemic chemotherapy. It is postulated that the spontaneous regression of the carcinoma may have been caused by immunological factors.


Pituitary apoplexy following chlorpromazine stimulation.

Chlorpromazine is frequently administered to patients with hyperprolactinemia to stimulate an increase in the serum levels of prolactin. A patient with a prolactin secreting adenoma is described in whom pituitary apoplexy developed in association with a hypotensive episode following the administration of 25 mg of chlorpromazine. Prolactin levels fell from more than 2,000 ng/ml to 340 ng/ml following infarction of the pituitary tumor. Pituitary apoplexy should be considered as a rare complication of chlorpromazine stimulation in a patient with a pituitary tumor.


Allopurinol-induced arteritis in partial HGPRTase deficiency. Atypical seizure manifestation.

A 17-year-old boy with partial hypoxanthine-guanine phosphoribosyl transferase deficiency developed a hypersensitivity reaction to allopurinol. The reaction was manifested by the development of bizarre, atypical seizures. The patient had been neurologically normal prior to the reaction. Seizures disappeared following discontinuation of allopurinol therapy. Allopurinol apparently can cause a diffuse vasculitis involving cerebral vessels after many year of therapy, resulting in atypical seizures.


An assessment of intermediate coronary care.

The effect of intermediate coronary care, with and without ECG monitoring, was compared with general medical ward care on the basis of mortality, resuscitation, and detection and treatment of arrhythmias from days 3 to 14 after admission in 2,095 cases of acute coronary heart disease. Mortality was significantly reduced (P less than .02), and number of successful resuscitations for ventricular fibrillation was increased (P less than .05) but only in the unit with monitoring. Number of arrhythmias detected was significantly increased, particularly incidence of ventricular ectopics and heart block (P less than .02). Number of arrhythmias corrected to sinus rhythm was increased, but not significantly. Death from pulmonary embolism fell (P less than .01). Review of causes of death and autopsies showed an increased proportion of deaths due to intractable heart failure and cardiogenic shock. Not only specially trained nurses, but also ECG monitoring, were necessary to obtain the benefits of this treatment.


Nosocomial infections in a community hospital: 1972 through 1976.

Of 78,057 patients discharged from a community hospital from 1972 through 1976, nosocomial infections developed in 3.58 per cent. Nosocomial infections of all types were 13.2 times more frequent for patients with rapidly fatal underlying illness and 3.4 times more frequent for patients with ultimately fatal underlying illness than in cases of nonfatal underlying illness. Outbreaks of epidemics or clusters of infections caused by the same organism were distinctly uncommon. These outbreaks accounted for only 49 of the 2,798 nosocomial infections found. No distinct trends, either increases or decreases, of infection rates by pathogen, site of infection, or service were noted during the study period. Sensitivity of the common pathogens to antibiotics also remained stable.


Pain of terminal cancer patients.

The belief that cancer inevitably leads to a painful death is widespread. This may contribute to society's "cancerophobia" with subsequent frequent delays in seeking medical attention for suspected malignant neoplasms. We evaluated the degree of pain experienced by dying patients, with and without cancer, at a large medical center. Patterns of analgesic administration and physician and nurse progress notes demonstrated that patients dying with cancer had significantly higher preterminal daily pain ratings and significantly fewer pain-free days than patients dying without cancer (P less than .01). Nevertheless, approximately one quarter of cancer patients died without any pain or analgesic administration. A painful death from cancer is thus not inevitable.


Frequency and morbidity of invasive procedures: report of a pilot study from two teaching hospitals.

The medical services of two teaching hospitals were assessed for the frequency of and complications from invasive procedures. There were 231 procedures performed on 303 patients. The frequency of procedures was significantly higher at one hospital (62% vs 39%, P less than .01). Twenty-nine complications occurred in 20 cases: 14% of patients who underwent procedures had at least one complication. Left-sided cardiac catheterization was the most common procedure. Procedures with more than one complication included the following: left-sided cardiac catherization (18% probability of complication); arteriovenous shunt (60% probability); thoracentesis (19%); bronchoscopy (25%); and percutaneous liver biopsy (8%). While no permanent damage or deaths were observed, over three fourths of the complications either required specific therapy or prolonged hospitalization or both. This study suggests invasive procedures are common and carry appreciable risks of serious complications. Appropriate clinical decision making and medical-legal protection require accurate estimates of those risks.


Clinical usefulness of susceptibility testing of anaerobes.

We have studied the clinical usefulness of antibiotic susceptibility testing of fresh clinical isolates of anaerobes (primarily from blood cultures). Analysis of 65 patients showed that susceptibility reports were used in only 13 instances (20%), representing mainly orothopedic and CNS infections. Of the 47 patients whose susceptibilities were not used, 20 received therapy (appropriate in each case) based on the culture report, and 27 were treated empirically. Only six patients in the empirically treated group received inappropriate treatment, but four of those six died, and patients in this group as a whole had a worse outcome than did patients in the other groups. However, these empirically treated patients also had a somewhat worse prognosis. We suggest that susceptibility testing of anaerobes be reserved for bacteremic patients and for managing severe, chronic anaerobic infections, such as septic arthritis, osteomyelitis, and brain abscesses.


Familial hyperpotassemia and hypertension accompanied by normal plasma aldosterone levels: possible hereditary cell membrane defect.

Hypertension and hyperpotassemia that were accompanied by normal plasma aldosterone and low renin levels and were responsive to chlorothiazide administration were found in a 29-year-old patient and two decades later in his 21-year-old son. Their renal function is normal, including response to sodium sulfate, mannitol, and aldosterone infusions. Adrenal insufficiency was excluded. The renin-aldosterone system was proved intact by physiological and pharmacologic stress and angiotensin-II infusion. Also normal were values for blood counts, blood volumes, and erythrocyte and exchangeable body potassium. The postulation of a defective cell membrane impeding potassium influx is supported by the failure of glucose and insulin infusions to substantially reduce hyperpotassemia. In the context of a hereditary disorder (the pedigree, compatible with autosomal dominant inheritance, includes five affected in two generations), hypertension is a second phenotypic character of a single defective pleiotropic gene although its pathogenesis remains unclear.


Proximal renal tubular acidosis: association with familial normaldosteronemic hyperpotassemia and hypertension.

Further investigation of a family with normaldosteronemic hyperpotassemia and low-renin hypertension showed seven members from three generations, who ranged in age from 4 to 56 years, to be affected. Results of earlier studies had established a normally functioning renin-aldosterone system and normal renal handling of potassium. Constant, albeit mild and asymptomatic, metabolic acidosis in all those affected prompted bicarbonate loading in both the propositus and his brother, which revealed a maximal renal tubular excretory capacity for bicarbonate reabsorption at serum levels of 18 mmole/liter and proved proximal renal tubular acidosis (PRTA). Further, a linear increase in urinary fractional potassium excretion accompanied that of bicarbonate in both, as in normal individuals. Dextrose-insulin infusion in the brother failed to reduce hyperpotassemia. These data support the hypothesis that a generalized cell membrane defect that specifically impedes potassium influx (as opposed to an isolated renal tubular defect) underlies this autosomal dominant disorder.


Hypertensive encephalopathy: recognition and management.

Hypertensive encephalopathy is a dramatic syndrome characterized by severe elevation of blood pressure, headache, visual disturbances, altered mental status, and convulsions. Although the syndrome is uncommon, to recognize and treat it promptly is important or the condition may prove to be fatal. Hypertensive encephalopathy should be distinguished from other cerebral complications of severe hypertension by obtaining careful history and performing thorough physical examination. The only definitive criterion for the diagnosis of this syndrome is its prompt response to therapy. If the patient's condition does not improve with hypotensive therapy, the physician should immediately search for alternate diagnoses. Potent drugs are available for prompt reduction of blood pressure. There are few medical emergencies in which the objective response to therapy is so strikingly apparent as in hypertensive encephalopathy.


Kayser-Fleischer-like ring in a cryptogenic cirrhosis.

A patient with cryptogenic cirrhosis was found to have corneal pigmentation rings indistinguishable from Kayser-Fleischer rings on slit-lamp examination. Although she had hepatic encephalopathy that included confusion, tremor, and slurred speech, diagnosis of Wilson's disease was ruled out because urinary cooper excretion and hepatic copper concentrations were below the range found in symptomatic Wilson's disease. The exact nature of these rings could not be determined, and they were considered as Kayser-Fleischer-like rings.


Screening for lignin degrading bacteria by means of 14C-labelled lignins.

Several Nocardia and Pseudomonas spp., as well as some unidentified bacteria, isolated from lake water containing high loads of waste lignin, were tested for their capacity to release 14CO2 from specifically 14C-labelled dehydropolymer of coniferyl alcohol (DHP) or corn stalk lignins. The bacteria were selected according to their ability to degrade phenolic compounds. However, only some of them could release significant amounts of 14CO2 from the labelled lignin. The tested Nocardia spp. were more active than the Pseudomonas spp. and the unidentified bacteria. The most active strains belonged to N. autotrophica. These strains released CO2 significantly from the methoxyl group and transformed the other carbons from the phenylpropane skeleton of lignin also into CO2. Other less demethylating strains also released little CO2 from the other carbons of the lignin molecule. From corn stalk materials which were specifically labelled in the lignin part, only small amounts of labelled CO2 were released.


Calcium uptake and survival of Bacillus stearothermophilus.

The calcium transport in resting vegetative cells of Bacillus stearothermophilus was studied by determining the retention of 45Ca in a membrane filter assay. The kinetics of death by vegetative cells, when suspended in buffer at 55 degrees C, was also investigated. The calcium influx required the presence of an energy source, e.g. glucose-1-phosphate and the system exhibited saturation kinetics. The requirements for survival of the thermophilic cells reflected those of the calcium transport system. Thus, cells treated with nitrogen gas showed an increased thermal stability and a decreased efflux of calcium. The initial velocity of calcium influx correlated linearly with the survival of the cells after 1 min heating at 55 degrees C. Lanthanum inhibited calcium influx and reduced survival. Magnesium did not inhibit calcium influx and could replace calcium as a stabilizing agent. The results suggest that the thermophilic cells are not intrinsically heat stable but survive due to a high cellular concentration of divalent ions.


Regulation of flavoprotein synthesis studied in vivo in a riboflavin-requiring mutant of Arthrobacter oxidans.

The biosynthesis of two flavoproteins, 6-hydroxy-D-nicotine oxidase with covalently bound FAD and 6-hydroxy-L-nicotine oxidase containing non-covalently bound FAD, was studied in wild-type cells and in a riboflavin-requiring mutant of Arthrobacter oxidans. In the mutant cells, the rate of synthesis and the maximal activity level of both enzymes after induction by nicotine depended on the amount of added riboflavin. The low rate of synthesis in the presence of 2 micron riboflavin could be enhanced during the induction phase by further addition of riboflavin (33 micron). Inhibitors of translation (chloramphenicol or streptomycin) completely blocked the synthesis of both flavoproteins. Inhibitors of transcription (rifamycin S or actinomycin D) stopped the synthesis of both enantiozymes in wild-type cells and in the mutant grown in the presence of a saturating supply of riboflavin (15 micron). Under conditions of restricted flavoprotein synthesis (2 micron riboflavin in the medium), however, the mutant cells continued to synthesize the enzyme for 2--3 h after the addition of the transcription inhibitors. It appears, that in these cells a rather stable m-RNA accumulated during riboflavin-limited flavoprotein synthesis. The dependence of the effect of transcription inhibitors on the extracellular supply of riboflavin suggests that the regulation of the synthesis of both flavoproteins occurs not only by control of gene expression (induction by nicotine), but also at the level of translation through the availability of FAD.


Carotenoids of rhizobia. II. The effect of nicotine on the carotenoid pattern of Rhizobium lupini.

With increasing concentrations in the growth medium of the cyclization inhibitors nicotine or 2-(4-chlorophenylthio)-triethylamine hydrochloride (CPTA) the previously identified bicyclic carotenoids of Rhizobium lupini (2,3,2',3'-tetrahydroxy-beta,beta-caroten-4-one and 2,3,2',3'-tetrahydroxy-beta,beta-carotene) were successively replaced by hitherto unknown monocyclic carotenoids. By application of mass and nuclear magnetic resonance spectroscopy 3 carotenoids were identified as 2,3-trans-dihydroxy-beta,psi-caroten-4-one, 2,3-trans-dihydroxy-beta,psi-carotene, and 3-hydroxy-beta,psi-caroten-4-one. A further compound was tentatively established as (2- or 3-)monohydroxy-beta,psi-carotene. It was found that other inhibitors such as diphenylamine or 4-chloro-5-(dimethylamino)-2-alpha,alpha,alpha(trifluoro-m-tolyl)-3-(2H)-pyridazinone (San 6706) did not affect the pigment pattern. The results are discussed in relation to carotenoid biosynthesis in Rhizobium lupini.


Aerobic and anaerobic growth of Paracoccus denitrificans on methanol.

1. The dye-linked methanol dehydrogenase from Paracoccus denitrificans grown aerobically on methanol has been purified and its properties compared with similar enzymes from other bacteria. It was shown to be specific and to have high affinity for primary alcohols and formaldehyde as substrate, ammonia was the best activator and the enzyme could be linked to reduction of phenazine methosulphate. 2. Paracoccus denitrificans could be grown anaerobically on methanol, using nitrate or nitrite as electron acceptor. The methanol dehydrogenase synthesized under these conditions could not be differentiated from the aerobically-synthesized enzyme. 3. Activities of methanol dehydrogenase, formaldehyde dehydrogenase, formate dehydrogenase, nitrate reductase and nitrite reductase were measured under aerobic and anaerobic growth conditions. 4. Difference spectra of reduced and oxidized cytochromes in membrane and supernatant fractions of methanol-grown P. denitrificans were measured. 5. From the results of the spectral and enzymatic analyses it has been suggested that anaerobic growth on methanol/nitrate is made possible by reduction of nitrate to nitrite using electrons derived from the pyridine nucleotide-linked dehydrogenations of formaldehyde and formate, the nitrite so produced then functioning as electron acceptor for methanol dehydrogenase via cytochrome c and nitrite reductase.


Utilization of hydrogen and formate by Campylobacter spec. under aerobic and anaerobic conditions.

A free-living aspartate-fermenting Campylobacter spec. was shown to utilize hydrogen produced in mixed culture by Clostridium cochlearium from glutamate. Resting cells of Campylobacter were shown to reduce aspartate, fumarate and malate as well as nitrate, nitrite, hydroxylamine, sulphite, thiosulphate and elemental sulphur with molecular hydrogen. Growth of Campylobacter spec. was demonstrated with formate as electron donor and nitrate, thiosulphate, elemental sulphur or oxygen as electron acceptor in the presence of acetate as carbon source.


Fine structure of the Kupffer cell in the bat, with special reference to the worm-like bodies.

The livers from normal bats captured in summer and autumn (active period) and in winter (hibernating period) were electron microscopically examined with reference to the worm-like bodies. 1) The worm-like bodies were numerous in bats captured in the active periods, while they were few in hibernating bats. The development of this body varied considerably from cell to cell. 2) The worm-like body seemed to develop from a short and straight tubular invagination of the plasma membrane, whereas the fully developed unit of the body comprised a twisted and complicatedly branching tubule extended in the cytoplasm, the end of which seemed to be retained as the orifice to the extracellular space. The contents of the tubule continuous with the cell coat showed faint transverse striation and a median dense line. A large worm-like body was presumably composed of a number of the units tangled complicatedly with each other, showing a large accumulation of abundant profiles of closely packed tubules. In some Kupffer cells a long tortuous tubule with a median dense line penetrated the cytoplasm transversely and communicated at both ends with two opposite surfaces facing the sinusoid. 3)The cytoplasmic area of the worm-like bodies was almost completely devoid of organelles; no communication between the worm-like bodies and other organelles was recognized. This finding suggested the resemblance of the area of the worm-like bodies to the ectoplasm. This assumption also was supported by frequent occurence of large coated vesicles along the worm-like bodies often communicating with them. 4)The worm-like bodies did not show any signs of enlargement even in Kupffer cells ingesting blood cells in their phagocytic vacuoles. Their profiles were found abutting on the phagosomes, but direct communication between both structures was not found. 5)It was proposed in this study that the worm-like bodies might possibly represent a membrane reservoir and contribute to the enlargement of the Kupffer cell surface.