Current concepts in synovial fluid analysis.

The systematic examination of synovial fluid confirms the noninflammatory nature of degenerative joint disease, is diagnostic of gout, pseudogout, and septic arthritis, and will usually allow the identification of rheumatoid arthritis, systemic lupus erythematosus and Reiter's syndrome.


Decompression of forearm compartment syndromes.

The diagnosis of forearm compartment syndrome by clinical findings alone has been difficult and inconsistent. This study was designed to assist in the diagnosis and treatment of forearm compartment syndromes. We evaluated several forearm incisions and determined their effectiveness by measuring compartment pressures using the wick catheter. The wick catheter is a simple, safe, and effective means of determining forearm compartment pressures. Preoperative and intraoperative measurements of the dorsal as well as the volar compartment pressures should be performed. Volar fasciotomy is effective in decompressing the volar compartment and may be effective in lowering the dorsal compartment pressure as well. Dorsal fasciotomy should be performed when that pressure remains elevated following volar decompression. The curvilinear volar and volar-ulnar incisions were equally effective in lowering compartment pressures experimentally, but the curved incision allowed beteer exposure to nerves and vessels and is preferred.


Cryosurgery in the treatment of giant cell tumors of bone: a report of 52 consecutive cases.

Fifty-two cases of giant cell tumor of bone have been treated by cryosurgery--an extensive freezing of residual tumor after curettage. Cryosurgery is performed by direct pouring of liquid nitrogen into the tumor cavity through a funnel. The cavity is filled with methylmethacrylate and corticocancellous onlay grafts until peripheral bone regeneration occurs to provide bone stability and prevent postoperative pathologic fracture. Patients with lesions in a weight bearing bone are placed in a long leg ischial weight bearing brace until sufficient healing has taken place. Rebiopsy (a second stage diagnostic procedure) is performed 3-6 months after the original cryosurgery. By comparison of pathology, results and complications between our first series of 25 cases and the additional 27, we have observed only one frank malignant giant cell tumor (1.9% incidence). This is much lower than the previously reported 16% fully malignant complication rate, and may be the result of the rapid elimination of the giant cell tumor by cryosurgery.


Rupture of the musculotendinous cuff of the shoulder.

Codman established the diagnostic criteria and treatment for musculotendinous cuff rupture over 40 years ago. Chronic shoulder pain after a history of trauma which is unresponsive to usual conservative treatment may indicate rotator cuff tear. Point tenderness, weakness of abduction and external rotation, atrophy, and palpable crepitus or a gap are confirming signs. X-rays may be negative in the acute injury but show definite changes with chronicity. An arthrogram confirms the presence of a tear. An electromyograph should be performed to rule out suprascapular nerve lesions. Surgical repair will result in good or excellent results in at least two-thirds of cases properly selected. Complications which can adversely influence the results include deltoid avulsion, residual impingement and ectopic bone formation. A successful repair is generally permanent.


A systemic lupus erythematosus-like syndrome induced by procainamide.

A syndrome that resembles Systemic Lupus Erythematosus both clinically and on laboratory studies may be induced by procainamide. It is associated with multisystemic involvement, positive Antinuclear Antibody titers (ANA), and positive LE cell preparations. In patients on procainamide therapy the syndrome must be differentiated from osteoarthritis, myocardial infarction, and pulmonary embolism. When procainamide  is discontinued, this Lupus-like syndrome is usually reversible. Other drugs, including hydralazine and isoniazid have also been implicated in provoking this Lupus-like syndrome.


Clear-cell carcinoma of the lung metastatic to the hamate: a case report.

Metastatic lesions of the hand are uncommon. A report of a solitary metastasis to the hamate seems not to have appeared previously in the literature. A 46-year-old factory worker presented a rare tumor, clear-cell carcinom of the lung, metastasizing to an unusual location, the hamate. The symptoms simulated sympathetic dystrophy and diagnosis was delayed because of the late appearance of radiographic changes over 6 months after symptoms first appeared. Early bone scanning in patients with chronic pain may provide useful information prior to the appearance of X-ray changes.


Chondrosarcoma of the hand.

A case of chondrosarcoma of the hand recurred 4 times over a period of 32 years. Forty-seven cases of hand chondrosarcomas have been found in the literature. Histological diagnosis is difficult in differentiating chondrosarcomas from benign chondromas. Pain and swelling are the main symptoms of recurrence. The diagnosis is established by arteriography and excisional biopsy. Extraskeletal hand chondrosarcomas do not metastasize and other hand chondrosarcomas do so only rarely. Block excision of localized amputation is the treatment of choice.


The presence of lining cells on surfaces of human trabecular bone.

Sixteen human trabecular bone biopsies were obtained from sites located in the ilium and in the area of the greater trochanter of the femur. Patients ranged from 19 to 85 years old and included men and women. All bone surfaces observed contained osteoid. Flat, branched fibroblastic-like cells were observed lining bone surfaces in all biopsy specimens. The presence of these cells was not dependent on age, sex, race, or disease state of the patient. Based on this study, we believe that the majority of human trabecular bone surfaces are covered with these thin lining cells.


Inhibition of human lymphocyte responses by methylmethacrylate.

The in vitro response of normal stimulated human peripheral blood lymphocytes to methylmethacrylate (MMA) was a dose related inhibition. Fifty per cent inhibition occurred at concentrations of 0.078-0.125%. MMA affected not only responses to soluble phytomitogens but also responses to specific antigens and allogeneic lymphocytes. Numbers of viable cells in cultures with and without mitogens and MMA were comparable at the beginning and end of experiments, excluding methacrylate-related cytotoxicity as the primary mechanism of inhibition of lymphocyte responses. Inhibition did not result from alteration of kinetics of lymphocyte responses. Inhibition was greatest when MMA was added during early phases of cellular activation. It also reduced the ability of T-lymphocytes to rosette with sheep erythrocytes. These data indicate that MMA causes noncytotoxic, incompletely reversible inhibition of nonspecific, specific, soluble, and insoluble stimulated lymphocyte responses and rosette formation in vitro.


The Paltrinieri-Trentani hip joint resurface arthroplasty.

The Paltrinieri-Trentani type of resurfacing the hip has been under clinical investigation for over 6 years. The prostheses consist of a metal cap, which is fitted to the head of the femur (no amputation of the neck and the head being required) and an acetabular cup made of high density polyethylene. Matched cups and caps are available in different sizes. The biomechanical preconditions upon which this hip resurfacing is based must be understood to successfully perform the operation. The series of patients reported here were aged between 32 and 70 years. The results after 6 years are 76% successful, and typical cases rate between 5 and 6 on the Charnley Scale; 12% rated between 3 and 4; 12% were failures owing either the fracture of the neck of the femur or to loosening of the femoral prosthesis. Further analysis of the cases demonstrated that: prostheses applied with the correct surgical technique gave satisfactory results; failures were attributable to errors of technique and indication.


Fluid space in bone.

This paper reviews the extraction of solutes through capillaries in bone, by means of outflow dilution techniques in the canine tibia. Solutes leave capillaries in bone by passive diffusion dependent on molecular size. The fluid space in bone is also examined by means of analyzing washout curves of radioactive substances. It is proposed that there are 4 definable compartments in bone; a vascular space, a perivascular fluid space a bone fluid space and a bone space. The relevance of these spaces is in bone mineral short and long term ion exchange activity.


Methylprednisolone in posttraumatic pulmonary insufficiency.

The effect of methylprednisolone, 30 mg/kg on the musculoskeletal trauma model in dogs were compared with the previously reported untreated models. The atelectasis, inflammation, and alveolar membrane thickening were ameliorated. There was a decrease in the coagulopathy of trauma as well as increased cardiac output, pulmonary vasodilitation and a decrease in the pulmonary shunt. Although these changes are salutory, the majority of patients with posttraumatic pulmonary insufficiency can be adequately treated by prompt adequate volume replacement, blood replacement, and appropriate use of cardiotonic drugs. Only in the resistant patient are steroids necessary.


Socket-cup arthroplasty.

Socket-cup arthroplasty gives a painless hip and allows a sufficient range of motion for the daily activities of the average patient. Arthrodesis and total hip replacement are clearly possible in the cases in which the operation is a failure. The procedure therefore is relatively conservative. There are 2 major causes of failure. One is atrophy and necrosis of the femoral head and neck covered by the cup. The other is loosening between the acetabular bone and cement in dysplastic hips. The results of clinical trials with socket-cup arthroplasty were disappointing. Reoperation by total hip replacement between 1--5 years after implantation (mean 3 years) was required for 7 of 12 cases. Failure was associated with fracture of the femoral neck secondary to osteonecrosis in one hip and with the loosening of the acetabular socket in 6 hips. To overcome these difficulties, improvements in materials, design and surgical procedure are necessary. The indication for the present designs and materials for socket-cup arthroplasty should be strictly limited.


Cemented double cup arthroplasty of the hip: a 5 year experience with the ICLH prosthesis.

The ICLH (Imperial College-London Hospital) total hip arthroplasty is a procedure in which a metal femoral component caps the proximal femur and a polyethylene acetabular component resurfaces the acetabulum with both components cemented in place. Between June, 1972, and November, 1974, changes were made in prosthetic design and in operative technique in response to 2 specific problems encountered. The loosening rate was high until the original polyethylene femoral component was redesigned so that it was metal. The incidence of femoral neck fractures was unacceptable until trochanteric osteotomy was discontinued. Since November, 1974, 116 hips have been replaced and neither the prosthesis nor the operative technique has changed. Pain relief has been comparable to that obtained with conventional Charnley-type hip replacement. All patients walk out of doors and no patient's walking capacity is limited by pain in the operated hip. No hip has lost motion and 36% have an effectively full range. No deterioration in the quality of these results is suggested when the first postoperative assessment is compared to those at 2 years and longer postoperative. Technical errors to be recognized and avoided are varus placement of the femoral component and excessive vertical placement of the acetabular component.


The glycosaminoglycans of human articular cartilage: molecular weight distribution of chondroitin sulphate in different layers in the adult individual.

Articular cartilage from 3 human femoral heads was sectioned serially, at 200 micron thickness, parallel to the articular surface. The morphologically normal cartilage was compared with superficially fibrillated cartilage. Sections from 5 or 6 defined layers representing the cartilage bulk were pooled and the sodium salt of chondroitin sulphate was isolated from each layer. The molecular weight distribution of the chondroitin sulphate was determined by either Sephadex G-200 or Sephacryl S-200 gel chromatography. For the normal articular cartilage from the 3 individuals a reduction of the average molecular weight of the chondroitin sulphate from the articular surface to the cartilage-bone junction was observed. In the superfically fibrillated cartilage superficial layer chondroitin sulphate had a smaller average molecular weight than the corresponding normal cartilage of the same femoral head.


Leg lengthening.

Two hundred eleven leg lengthening operations have been carried out at the Royal National Orthopaedic Hospital, London, in 192 patients between 1966 and 1977. The results were analyzed in the 143 patients who had reached skeletal maturity. A 5 cm gain in length using Anderson's modification of Abbott's lengthening machine was achieved in 21 femora and 122 tibiae. There was no significant difference in the sexes, 98 boys and 94 girls. Average difference in leg length before operation was 5.75 cm (11.7--3.0 cm). Average reduction in difference 3.06 cm (7.5--4.5 cm). Average difference at maturity 2.48 cm (9.5--0.5 cm). Fractures occurred in 30 patients all of which united, but some lost part of the length gained. Most serious was a decision to amputate in 2 patients due to severe discrepancy in one patient and foot deformity in another. There were no failures of union, no long-term sepsis and no deaths.


Socket and cup surface replacement of the hip.

To improve the surgical results of severe osteoarthritis of the hip, surface replacement of the hip using a double cup without cement was employed on 75 hips during the period from 1972 to 1977. The results of the procedures have been analyzed on 67 hips followed for more than 6 months. The most dramatic improvement following the procedure has been pain relief, observed in 58 of 67 hips (86%). Three reoperations were necessary. Failures were treated satisfactorily either by total hip replacement, or by arthrodesis and/or by placing a new cup on the head respectively. There was no operative death, pulmonary embolism, thrombophlebitis, nor deep infection. We do not think this procedure replaces more definitive surgery such as the Charnley-type total hip replacement, but it is a good adjunctive procedure particularly in patients younger than 60 years of age.


Experimental limb lengthening by epiphyseal distraction.

Kirshner wires were placed either side of the right distal femoral epiphysis and a constant tension device applied a distracting force across the plate in rabbits. Growth increase was measured between the wires and found to be about 150% greater than the concurrent normal growth between 2 control (undistracted) wires on the left; such growth increase can occur in the absence of fracturing. The forces required to do this were between 1/5 and 1/10 of those shown to cause fracturing in vitro. The growth increase was shown to be associated with hyperplasia and hypertrophy of the plate, as well as an increased rate of cell division and sulfated polysaccharide synthesis. This was in turn shown to be associated with an increase in new bone formation.


Conservative total hip arthroplasty: a procedure to conserve bone stock. Part I: analysis of sixty-six patients. Part II: analysis of failures.

Pain relief, function, and range of motion in surface replacement hip arthroplasty is comparable to the Charnley-type conventional arthroplasty. Patients with primary and secondary degenerative hip disease are the most suitable candidates for surface replacement. Previous operations, especially mold arthroplasty, increases incidence of failure. Osteopenia, obesity, or congenital deficiency of the acetabulum also increases the incidence of failure. Intraoperative preservation of abductor continuity and rigorous postoperative abductor strengthening are necessary to insure the success of the procedure. A minimum of 18 months is necessary to adequately evaluate the procedure. Acetabular loosening is avoidable. Hemispherical reaming of the femoral head did not contribute to femoral component loosening. Traumatic femoral neck fracture is a concern, but atraumatic femoral neck fracture can be avoided through improved operative technique, and by a program of rehabilitation of hip musculature. The procedure is indicated in the relatively young, well-motivated, non-obese patient with degenerative joint disease who has normal hip musculature.


Continuous transphyseal traction: experimental observations.

Observations of canine tibias lengthened by continuous transphyseal distraction (without osteotomy) reveals an acute fracture through the metaphyseal zone of primary trabeculae and rapid osseous healing. Long-term follow-up demonstrates normal subsequent growth.


Surface replacement of the hip joint.

A total hip resurfacing prosthesis consisting of a high density polyethylene socket and a stainless steel cup was devised in 1974. Bone cement fixes the socket in the acetabulum but is not applied between the cup and the femoral head. Four types of sockets and 3 types of femoral cups with different diameters are available. Between April 1974, and October, 1977, 57 total hip replacements using socket-cup prosthesis were performed in 54 patients with various hip disorders. In this series, 36 patients with 37 of these replacements ranging in age from 40 to 68 years (mean 50 years) were examined. The length of follow-up ranged from 6 months to 3 1/2 years and the overall subjective and objective results were excellent. Pain was relieved in 97.3%. Walking ability was improved in 86.1%. With 6 months in almost all patients, mobility and  the activities of daily living were significantly improved.


Cement-free bioceramic double-cup endoprosthesis of the hip-joint.

A cement-free bioceramic aluminum oxide double cup endoprosthesis is under investigation as an alternative to the cemented stem endoprosthesis. Nine patients with 11 operated hips are without complaints after an average of 20.8 months (range 8--28 months). Early loosening of 2 femoral components occurred because of technical mistakes during operation. In 3 patients loosening of the femoral component was seen 5--7 months after surgery. Mobilization of the hip joint and walking capacity are similar to the usually implanted stem endoprosthesis. Stable long-lasting anchorage is possible if the femoral component is implanted in valgus position and in contact with living bone. Failures are treated by a traditional type of endoprosthesis.


Operative lengthening of the femur.

Femoral lengthening with the aid of the apparatus described in this article can be accomplished safely and predictably. However, it is not without considerations and problems which must be fully understood and appreciated. The healing process requires months to years; with a cooperative patient and a diligent attentive orthopedist, the equalization of leg lengths is more than justified.


The significance of intraosseous pressure in normal and diseased states with special reference to the intraosseous engorgement-pain syndrome.

When investigating a patient whose main symptom is pain aggravated by activity, or rest pain in the area of the knee (and perhaps other joints as well) the intraosseous engorgement-pain syndrome should be kept in mind. This type of pain can also be present in patients with osteoarthritis. In such patients intraosseous angiography and intraosseous pressure measurement can be useful guides when deciding the type and site of treatment. As regards the knee joint, these investigations must always be made in both tibia and femur. A drainage time of 10 and more minutes after injection of 2 ml radiopaque dye in a prone patient, and retrograde filling of intramedullary veins from a metaphyseal injection is abnormal. Concomitant intraosseous pressure measurement may be useful when made under well controlled conditions. Pressure values of more than 30--40 mm of mercury above the venous pressure are probably pathological. Rest pain can successfully be treated by a simple fenestration operation.


An axillary approach for a Putti-Platt repair.

Eighty-seven Putti-Platt repairs for traumatic recurrent anterior dislocations of the shoulder have been performed, utilizing the anterior axillary approach. This approach facilitated the surgical repair so well that its use has been continued. The anterior axillary approach provides an excellent exposure of key anatomical structures. This is obtained by undermining the skin. The blood loss has been minimal. Infection is rare and wound healing is rapid. The surgical scar is minimal and inconspicuous. This exposure requires one assistant, which can significantly shorten the operative time.


Osteochondroma of the atlas: a case report.

An extremely rare case of osteochondroma arising from the right lateral mass of an atlas was successfully treated by a complete removal through an oblique high cervical incision coupled with a transection of the underlying sternocleidomastoid muscle and careful freeing and retraction of the adjacent vital neurovascular structures.


A calcified fibrocartilagenous nodule in the ligamentum nuchae. Presenting as a tumor.

Nodules of fibrocartilage, calcified fibrocartilage, or bone may be found in the adult ligamentum nuchae. These are generally asymptomatic but may mimic fractures or, as in the case presented here, tumors.


Metastatic cancer of the spinal column.

In an effort to determine the potential of radiotherapy or surgery in alleviating the symptoms and signs of metastic cancer to the spinal neuraxis, 77 cases with documented malignant disease in this area were studied retrospectively over a 2 year period. Emphasis must be placed on early diagnosis, and recognition of intractable day and night pain as a hallmark of cancer of the spine. This symptom was found to be present for many months before the diagnosis could be made on plain X-rays. Bone-scanning, tomography, and myelography were consistently found to be useful adjuncts to early diagnosis. This study points out that operative intervention is ineffective in relieving the signs and symptoms of cord compromise, and adds significantly to the general morbidity of the patient. This was a consistent finding in cases with metastases to the thoracic spine who had developed neurological dysfunction secondary to their tumors. Radiation therapy should be considered a useful form of palliation for the pain associated with metastatic cancer.


An ivory vertebra: monostotic Paget's disease of bone.

The roentgenographic scintographic and histologic features of an "ivory vertebra" are characteristic of monostotic Paget's disease. This case and condition are of special interest because Paget's disease is quite unusual in persons aged 30 or younger.


Acute patellar dislocation: results of immediate surgical repair.

Seventeen cases of acute, first time, lateral patellar dislocations without fracture treated by immediate surgical repair were reviewed and evaluated. Nine patellar tendon realignments and 8 medial side reefing procedures were performed. There were no recurrences of patellar dislocation. Twelve knees were painful, of which 8 were rarely painful. All but one patient were satisfied with their results and participated in any desired sport. Surgical repair of acute patellar dislocation is advocated in the young patient who anticipates future participation in athletics.


Bilateral spontaneous concurrent rupture of the patellar tendon without apparent associated systemic disease: a case report.

Patella tendon ruptures are an uncommon injury. Only 5 previous cases of bilateral patellar tendon rupture have been reported. Only 3 of these cases occurred simultaneously. All 5 previously described patients had systemic disease. This paper presents the only reported case of an individual with no known systemic disease who has suffered bilateral spontaneous concurrent patella tendon rupture.


Injuries of the anterior cruciate and medial collateral ligaments of the knee. A retrospective analysis of clinical records--part I.

The difficulty in diagnosing and subsequently treating lesions of the anterior cruciate ligament (ACL) is demonstrated in a review of 136 cases. Twenty-one patients noted a "pop" at the time of injury and each had a lesion of the ACL. The mechanism of injury may be helpful. The commonly seen valgus external rotation injury was noted in 60% of the cases but internal rotation with hyperextension and/or hyperflexion were also reported. The anterior drawer sign, if present, increases the accuracy to 92.1%. Failure of early cast treatment occurred if the ACL was torn but not in lesions confined to the MCL. Early meniscectomy in the cruciate deficient patient did not alleviate the need for further surgery in this group. At surgery the medial meniscus was torn in 93/124 ligament injuries but in addition 14 tears of the lateral meniscus were found. Wound complications were frequent with infection (4.8%) always being associated with hematoma formation (9.5%).


External rotation tibial osteotomy in clubfoot: adverse late effects.

In a review of 16 feet in clubfoot patients who had external rotation osteotomies to correct internal tibial torsion, 13 had the undesired effect of aggravating and increasing the varus deformity of the foot. External rotation osteotomy to correct internal tibial torsion seems contraindicated in the presence of clubfoot. If an indication does exist, the chances of late adverse effects can be decreased by deferring surgery until the child is over the age of 8, or by combining the procedure with lengthening of the long flexor tendons.


Chondrosarcoma of the talus: a case report.

Although malignant cartilage tumors of the foot and especially of the talus are uncommon, the treating physician must become suspicious when a "simple ankle sprain" is resistant to standard treatment. In such a case, the comparison of serial radiographs may reveal subtle changes and the use of a radioactive bone scan may be of diagnostic value.


The unreducible Lisfranc fracture. Case report and literature review.

In a lateral dislocation that is unreducible by closed methods, one should suspect that the tendon of the tibialis anterior muscle may be preventing reduction because of its interposition. In such a situation an open reduction is mandatory.


Chondrosarcoma developed in the distal phalangeal bone of the third toe. A case report.

A unique chondrosarcoma developed in the distal right middle phalangeal bone of the foot in a 38-year-old woman. In a review of statistics on the localization of 264 chondrosarcomas in the Bone Tumor Registry of Japan since 1964, 4 were in the foot and 11 were in the hand.


Musculoskeletal infections due to Mycobacterium kansasii.

Mycobacterium kansasii musculoskeletal infections are unusual. The infection presents as either a tenosynovitis, monoarticular arthritis or generalized systemic spread. In 2 patients, vigorous surgical and antimycobacterial medical regimens controlled the infection and produced full return of function.


Mycobacterium fortuitum infections: a review with two illustrative cases.

Two outbreaks of postoperative wound infections by organisms of the Mycobacterium fortuitum complex have focused attention on this notoriously drug resistant organism. In this report 2 cases are presented which developed infections with this organism, one of which responded to systemic antimicrobials despite discouraging in vitro sensitivities. Surgical debridement must remain the choice of treatment; however, systemic antibiotics may prove effective in some cases.


Tuberculosis joint infection.

A retrospective study of tuberculosis infection of joints over a 10 year period has identified 21 documented cases. The patients were, for the most part, of rural, middle-class background and usually in the fifth to seventh decade. Diagnosis was commonly missed with the exception of spinal lesions. Presentation was usually monoarticular with roentgenograms showing progressive joint destruction. Sedimentation rate elevation and positive skin testing were helpful, but the diagnosis depended on culture and histologic examination of tissue. Chemotherapy was very effective and urgent surgery was performed on spinal lesions for neurologic deficit.


Fat embolism in children.

Clinical fat embolism in children is rare. An 11-year-old myelodysplastic child with an apparently insignificant tibial fracture illustrates the risk of this potentially fatal complication in children with osteoporotic bone.


Effect of rigid plate fixation on structure and mineral content of cortical bone.

The effect of rigid plate fixation on the structure and mineral content of cortical bone were studied by light and fluorescence microscopy and by chemical analysis of calcium and hydroxyproline content in 27 rabbits from one day to 17 weeks after the attachment of a 5 hole ASIF-plate onto intact femur. Between the second and seventeenth postoperative weeks the plated cortical bone became progressively thinner and porotically transformed. Subendosteal resorption was partly offset by the formation of new subperiosteal bone that resulted in a slightly wider than normal, thin-walled tubular bone. At 17 weeks the mean calcium content of the tubular bone under the plate was 15% less than the initial postoperative content (p less than 0.05). The corresponding decrease in calcium content in the metaphyseal and epiphyseal areas of both the operated and the control bone was highly significant. The mean values for hydroxyproline in plated and control bones remained largely unchanged.


Radiation effects produced by the intra-articular injection of 32P.

Colloidal forms of radioactive isotopes are being used for the treatment of some articular diseases. The radiation effects of intra-articular injection of 0.25 mCi of 32P in the form of colloidal chromic phosphate were investigated in one of the knee joints of adult Wistar rats. The contralateral knee was used as a control. The animals were sacrificed one, 7, 14, 28 and 56 days later. Destructive changes were found after 56 days. The articular cartilage was atrophied and covered by a fibrous pannus. The growth cartilage was severely disorganized and there were deleterious effects on both cells and matrix.


Epiphysiodesis for limb length inequality: results and indications.

In view of the minimum morbidity, low incidence of complciations, and averall success rate, epiphysiodesis is an excellent method for correction of moderate limb length discrepancies. Skeletally immature patients with discrepancies between 2.5-8 cm with adult height predicted to be in the normal range (5 feet or greater) are good candidates for epiphysiodesis. Preoperative evaluation over several years prior to operation, utilizing the principles of Green-Anderson or the straight line graph, provide an accurate means of predicting future growth and determination of time of operation. Technique of epiphysiodesis is reliable and technical complications resulting from its use are few. Patient with a paralytic basis for shortening do best functionally with an end result undercorrection of 1.5 cm; equalization or overcorrection is to be avoided in these patients. Nonparalytic patients do best if limb lengths are equalized, with 1.5 cm of overcorrection or under-correction equally well tolerated.


Femoral shortening.

Femoral shortening is a well proven method of correcting a leg length discrepancy once growth has ceased. The discrepancy should be significant enough to justify the procedure, and should be ideally confined to the femurs. The musculature of the femur to be shortened should be normal. A segment of femur equal to the discrepancy is excised at either the midshaft, subtrochanteric, or supracondylar levels. Secure internal fixation of the osteotomy is essential. Equalization of the femurs (femoral shortening combined with femoral lengthening of the opposite leg) can be performed for femoral discrepancies of over 8 cm.


Closed intramedullary shortening of the femur.

Closed intramedullary shortening of the femur in the adult provides a method for leg length equalization that poses minimal operative risks, maximizes healing, and produces an excellent functional and cosmetic result. The etiology of anisomelia and any associated abnormalities must be carefully analyzed preoperatively. A series of 40 closed intramedullary shortenings of the femur were performed; shortening averaged 3.3 cm (range 2.0 to 5.0 cm). Three patients had significant complications: delayed union in one patient required renailing; two cases of symptomatic external rotation deformity required correction. The technique for the procedure is demanding in terms of experience and equipment. Otherwise, intramedullary femoral shortening is an excellent method for managing adult anisomelia.


Technical aspects of midshaft femoral shortening with Küntscher nailing.

Surgical shortening of the lower limb in adults with unequal leg length is a rare procedure making up about 0.05% of all orthopedic operations. Most often a subtrochanteric level and nail-plate fixation is used. Early weight-bearing with this technique can, however, result in metallic failure. As is illustrated in 11 cases, midshaft femoral shortening operations with intramedullary nailing are hazardous because of rotational or longitudinal instability. As a precautionary measure, extra reaming and locking osteotomy can be performed. This makes intramedullary nailing a relatively safe procedure, and allows immediate full weight-bearing.


One stage femoral lengthening in the adult.

One stage femoral lengthening procedures were performed in 9 adult patients. Eight patients had femoral shortening secondary to femoral fractures. The remaining patient had diffuse left hemiatrophy. The method of one stage lengthening has been modified from that described by Cauchoix. There were 7 males and 2 females with an average age of 23 years. The preoperative femoral shortening averaged 4.5 cm. The average lengthening at surgery measured 4.0 cm and 3.8 cm of this was maintained at follow-up. Complications included one case of serious sciatic and femoral nerve palsy, implant failure in 3 patients, a case of late femoral refracture following plate removal, and a case of acute femoral artery occlusion. There were no postoperative infections. Two cases required additional bone grafting of the osteotomy sites. There was no loss of preoperative hip or knee motion with this technique. One stage femoral lengthening by the method described is a major operative undertaking with several potential complications. The surgical technique is demanding and monitoring of the neurovascular status of the extremity during lengthening is mandatory. When properly executed, results are gratifying.


Staged femoral lengthening.

Lengthening of short femurs, including those with actual or anticipated shortening of several inches, has been carried out using serial lengthenings. Up to 5 individual lengthenings, each of approximately one inch, have been performed on involved femurs. In cases where shortening was due to epiphyseal injury, e.g. osteomyelitis of the distal femur, good results have been achieved. Congenital shortening has not been completely corrected because of subluxation of the hip during lengthening. The principle complication has been fracture through the plate and graft. Usually this fracture could be used as the indication for additional lengthening, thus minimizing the problem. It is believed that this approach offers advantages in terms of decreased total cost in time and money, making it suitable for private patients. An additional advantage is the lack of disastrous complications. Technical problems have been numerous, however. The procedure should not be undertaken casually or for minor leg length inequality.


Tibial lengthening.

Tibial lengthening as a means of correcting certain discrepancies in lower limb length has become a well-accepted, though rarely indicated, procedure. Success depends upon knowledgable evaluation of all factors involved in the problem, upon adherence to the indications and prerequisites, and upon strict attention to all details of the operation. Nearly all cases of tibial lengthening are accompanied or followed by problems and/or complications. Problems such as delayed union, inadequate union and failure of union must be anticipated and appropriately coped with. Complications such as fracture through the lengthened area, compartment syndromes, infection, and foot and ankle deformities must be prevented if at all possible, and aggressively treated when they occur. Utilizing the appropriate indications and meticulous technique, one can expect to achieve lengthening of 4--5 cm in nearly all cases. Bone grafting and internal fixation will be required in a significant number of tibial lengthenings in order to achieve strong, solid union. The technique currently employed by the authors utilizes the Anderson percutaneous osteotomy, accompanied by the Wagner apparatus. In critically analyzing the results of 73 personal cases of tibial lengthening, the authors conclude that the procedure is justified in carefully selected patients.


Usefulness of the posterior cerebral flow study in subdural hematoma.

Anterior and posterior radionuclide cerebral flow studies and brain images were performed on two patients with surgically proven subdural hematoma. In both patients, the posterior flow study showed perfusion defects corresponding in location to the static image abnormalities. The anterior radionuclide flow study was negative in both patients, even though the abnormality in one of the patients was more anterior than posterior in location. On the basis of these cases, it is suggested that the performance of a posterior radionuclide flow study in suspected subdural hematoma might provide useful information not obtained on the routine anterior study.


Cimetidine administration resulting in improved pertechnetate imaging of Meckel's diverticulum.

Administration of cimetidine prior to pertechnetate imaging in two patients with Meckel's diverticulum resulted in demonstrating the abnormality with unusual clarity. This is presumed due to the cimetidine-mediated retention of pertechnetate in the gastric mucosa. Pertechnetate imaging in two normal subjects with and without cimetidine administration disclosed a marked difference in retention of the radionuclide in the gastric mucosa and its subsequent transit into the intestinal tract. Pertechnetate imaging in conjunction with cimetidine administration appears to result in markedly improved identification of Meckel's diverticulum.


The use of nuclear medicine procedures in the diagnosis of Budd-Chiari syndrome.

The case history of a patient with Budd-Chiari syndrome (BCS) is described. The underlaying disease proved to be essential thrombocytosis. Congential elliptocytosis was also present. The value of the conventional liver scan, percutaneous splenoportoscintigraphy and isotopic phlebography of the inferior vena cava in the diagnosis of BCS is described. It is suggested that a combination of these three noninvasive techniques be used when BCS is suspected.


Granulomatous hepatitis: spectrum of scintigraphic manifestations.

Four cases of granulomatous hepatitis are presented. Hepatocellular disease in general and the clinical, histological and scintigraphic manifestations of granulomatous hepatitis are discussed.


Characteristics of red blood cell survival from subjects with hereditary elliptocytosis.

Hereditary elliptocytosis is an intrinsic red cell abnormality and 12% of elliptocytic individuals demonstrate hemolysis. Using tracer kinetic methodology (51Cr labeled RBC's) the destructive phase of erythropoesis was assessed in two healthy subjects receiving labeled donor red blood cells from individuals with hereditary elliptocytosis. The red blood cell survival time of transfused elliptocytes was significantly decreased in both recipients, with a survival half-time (T 1/2) of 19 days in one recipient and 20 days in the other (N 27 days). Abnormal splenic sequestration was also demonstrated. The decreased survival of transfused cells suggests that caution should be exercised in utilizing patients with hereditary elliptocyosis as donors in blood banking operations even in the absence of evidence of hemolysis.


Endogenous serum TSH levels and metastatic survey scans in thyroid cancer patients using triiodothyronine withdrawal.

Using a triiodothyronine withdrawal method to produce a hypothyroid state in 38 patients with prior thyroidectomies for differentiated thyroid cancer, 56 H-TSH and T4 levels were measured prior to metastatic survey scans performed with 131I. All the T4 levels were below normal and 55 of the 56 H-TSH levels were elevated. No qualitative differences could be observed in the eight patients who had scans performed after bovine TSH injections and later after triiodothyronine withdrawal. Triiodothyronine withdrawal does induce high endogenous TSH levels and under normal circumstances bovine TSH injections are not required for metastatic scans in patients with thyroid cancer.


Trauma in the Pagetoid: beware the non-specific scintigram.

Radionuclide brain scans and cerebral blood flow studies have become highly sensitive but they remain quite nonspecific diagnostic modalities. Previous reports have discussed similarities between Paget's disease of bone and subdural hematoma on radionuclide studies. We encountered a case in which Paget's disease produced all the described manifestations of subdural hematoma. The differential features of the two conditions and their pathophysiological bases are discussed.


Myelofibrosis presenting as hypermetabolic bone disease by radionuclide imaging in a patient with asplenia.

In a patient with myelocytic anemia, hepatomegaly, and metastases suggested by radiographic evidence of sclerosis throughout the pelvis and spine, a liver-spleen scan revealed mild hepatomegaly and an absent splenic image. A bone scan demonstrated diffusely increased activity in all bones, especially in the joint regions. A bone marrow scan showed only hepatic activity but no significant uptake in the bone marrow. Ultrasonography and contrast angiography failed to identify a spleen. The findings from a bone marrow biopsy and a peripheral blood examination indicated myelofibrosis. The implications of an increased concentration of radiopharmaceuticals in bone are briefly discussed.


Scintigraphy in pediatric urinary tract lymphoma.

Excretory urography is the standard examination used to evaluate structural abnormalities of the urinary tract in children. However, renal imaging offers advantages over excretory urography in the functional evaluation and in certain morphologic patterns of lymphoma.


Fenestrated sagittal sinus mimicking posterior cerebral infarction.

Two patients who presented with abnormal neurological findings and focal abnormalities on static brain imaging, were felt to have infarction in the distribution of the posterior cerebral artery. However, the posterior flow study delineated the cause of the abnormality as being a fenestrated anomaly of the sagittal sinus. The incidence of occlusive disease of the posterior cerebral artery, its clinical and scintigraphic presentation and the potential pitfalls for misinterpretation are reviewed.


Ventricular visualization on brain scan with intracranial hemorrhage in disseminated phycomycosis.

Infections with fungi of the class Phycomycetes result in distinctive tissue changes characterized by growth of hyphae in and around blood vessels, causing necrosis and hemorrhagic infarction of tissue. A brain scan on a patient with a phycomycotic intracranial aneurysm demonstrated ventricular visualization at a time when there was clinical and autopsy evidence of rupture of the aneurysm.


Demonstration of traumatic hepato-pleural-cutaneous defect by 131I-rose bengal.

A 19-year-old man was shot in the right chest about 2 cm below the nipple; bloody fluid was drained through a chest tube. Two days later sero-sanguineous fluid tinged with bile was seen to drain from the wound site. 131I-rose bengal, injected intravenously, collected in the dome of the liver and drained into a collection bag placed over the wound site, thus identifying a hepato-pleural-cutaneous fistula, which was confirmed at surgery.


67Ga-citrate identification of inflammation in the perirenal space.

Two patients are presented who had radiogallium (67Ga-citrate) studies which revealed focal abdominal accumulations identified as the perirenal space. These localizations, to a specific anatomical site, were confirmed surgically. The distinguishing features of the perirenal space on radiogallium scans include the relatively vertical axis, downward conical extension, and sharp cut-off ("sparing") medially to the midline.


Assessment of the utility of gallbladder imaging with 99mTc-IDA.

Cholescintigraphy was performed in 113 patients of whom 38 had normal gallbladders, 37 had acute cholecystitis and 38 had chronic cholecystitis. The radiopharmaceuticals used in the study were either 99mTc-dimethyl acetanilide iminodiacetic acid or 99mTc-paraisopropyl acetanilide iminodiacetic acid, both of which performed equally well. All patients with non-visualized gallbladders had cholecystitis, but visualization did not exclude disease. The rapidity of obtaining the results (within one hour), the complete absence of untoward reactions to the radiopharmaceuticals, the much lower frequency of subtle or indeterminate results, the ability to render useful information in the presence of moderate jaundice and the lack of interference from overlying intestinal contents establishes these radionuclide agents as superior to both radiographic oral and intravenous cholangiography in the investigation of the acute abdomen.


Orbital fractures and medial canthal reconstruction.

An attempt has been made to acquaint the surgeon with the basic principles in the evaluation and treatment of the patient with trauma involving the orbital area. Evaluation must include neurologic, ophthalmic, as well as radiologic examination of the traumatized area. The decision to operate must be based upon the findings in the individual case using sound clinical judgment. Treatment consists of the restoration of the integrity of the traumatized area and the repair of whatever defects may have been caused.


Surgical treatment of complications of cosmetic blepharoplasty.

The principles of repair of complications of cosmetic blepharoplasty are aimed at correction of the deformity present. Shortage of skin is usually corrected by skin grafting, lax lower lids by lid shortening procedures, and poor upper lid closure by releasing restricting tissues. Some unusual complications and their treatment are also described.


Advancements in ptosis surgery.

Ptosis has been treated in the past by vertical lid shortening, true levator resection or tucking, brow suspension, and superior rectus suspension. The last mentioned type of repair has all but been abandoned. Advances in vertical shortening procedures have been many. I have included those that seem to me to be significant. True levator surgery has not changed substantially, but the few changes have been good ones. Brow suspension material has been varied. Popularity is returning to autogenous fascia lata, as it should. Postoperative control of lid level when fascia lata is being used is discussed. Future advancements will probably center on the preservation of the effect of Müller's sympathetic muscle. This valuable asset to ptosis surgery has been largely neglected in the past.


Burn injuries of the eyelids.

Burns of the eyelid and surrounding structures are relatively uncommon in spite of a high incidence of thermal injuries involving the face. The etiologic factors, circumstances that precipitated the injury, and the anatomical features unique to the eyelid and adnexal area may conceivably account for the low incidence. The basic aims in reconstructing deformities must include primarily measures of protecting corneal exposure and relieving epiphora. Early reconstruction of other deformities such as epicanthal folds, palpebral stenosis, and missing eyebrows and eyelashes should be discouraged because of frequent recurrence of deformities due to contracting scars and scar hypertrophy.


Counseling juvenile offenders: an experimental evaluation of Project Crest.

Thirty randomly selected juvenile delinquents receiving a dual treatment approach of community outreach counseling services (Project CREST) and probationary supervision were compared over a 6-month period with a control group of 34 delinquents receiving only probationary supervision. The CREST group demonstrated significant improvements over the control group on total acts of misconduct (p less than .05)  and monthly misconduct rates (p less than .025). These findings are discussed in light of previous evaluations of the CREST model.


Preventive intervention programs for disadvantaged children.

This paper describes a 6-year effort aimed at developing educational interventions for a group of economically disadvantaged children. The program provided an opportunity for psychologists and student paraprofessionals to join with personnel at urban health care facilities in responding to a serious identified community problem--disadvantaged youngsters, ages 1 and 2, who are vulnerable to later school and life difficulties. The intervention succeeded in enhancing academic skills among six groups of disadvantaged toddlers. As ongoing research results indicated the need for new program elements, the university personnel piloted innovations and the health centers gradually incorporated effective components into the existing program.


Improving the evaluation of human services by separating the delivery of service from service.

The delivery of services has been receiving increased attention in recent years. Judicial action combined with budgetary constraints have focused on the need for greater scrutiny and accountability in service delivery. Although much is being written in this regard, there are at present few attempts to provide a conceptual base from which service delivery can be approached. Through this paper a framework will be provided from which various human services can be examined, with particular attention being directed to the need for separating the substance of service from the process of its delivery.


Applied anthropology and the concept of the underdog: implications for community mental health planning and evaluation.

Medical anthropologists have long been involved in health-program evaluation and have studied factors related to program acceptance in target communities. However, assessing the reasons for the success or failure of a program should not be an end in itself, but should be a process that generates guidelines for the development of similar programs elsewhere and more general suggestions about the appropriate roles that applied anthropologists can fulfill. This paper briefly summarizes the research of an anthropological team who investigated the apparent failure of a respite home facility for retarded children in a suburban neighborhood to generate requisite community support. The team was able to develop a series of recommendations in aid of a plan to establish such centers elsewhere in the county, and in the state of Florida as a whole. However, the paper is more broadly concerned with applied anthropological attempts to define the nature of target or client communities and at delineating the appropriate anthropological perspective on health care delivery transactions. New roles for the anthropologist as evaluator will be considered.


Do we really want a program evaluation strategy based solely on individualized goals? A critique of goal attainment scaling.

Goal attainment scaling is a program evaluation technique that measures program success using individualized client goals rather than the same measuring instrument for all clients. Although the reliability of the goal attainment scales is generally acceptable, such scales have not exhibited satisfactory validity. Also when clients have not been assigned to programs randomly, evaluations comparing two or more programs using goal attainment scales are potentially more biased than evaluations that use the same outcome measure for all clients. Thus since goal attainment scaling does have therapeutic value, program evaluators should adopt a multivariate assessment strategy combining goal attainment scaling with uniform measuring instruments.


Is there job satisfaction in community mental health?

After discussing the importance of job satisfaction, this paper presents data concerning current levels and sources of job satisfaction in community mental health centers. Data came from a survey completed by 164 staff members working in 22 different programs located in Michigan. The return rate was 94%. Results indicated that compared to workers in other occupations, the staff were about average in satisfaction with co-workers and supervision, but low in satisfaction with the work itself. The two major sources of job satisfaction reported by staff were the level of accomplishment experienced in the work and the degree of clarity in organizational goals and policies. The paper concludes by suggesting ways in which job satisfaction in community mental health could be increased.


Day treatment as an aid to mainstreaming troubled children.

Problem children who are diverted from public school programming into a private psychoeducational day facility in a community mental health center are followed up in a 10-year study to determine the rate of return to regular classes. The evidence points to a successful reintegration into public schools for the great majority of students. A philosophy for mainstreaming which supports the need for proper preparation of children for public school reentry is basic to effective management.


Evaluation of a remediation program using senior citizens as psychoeducational agents.

A remediation program for learning and psychosocially disabled pupils utilizing senior citizens as paraprofessional aides was evaluated. The senior citizens were effective in developing tutorial relationships conducive for the students' academic and psychosocial development, as indicated by pre- and posttesting. The disabled pupils improved their academic skills, as measured by standardized achievement and intelligence tests and by school grades. Statistical comparison with a control group further demonstrated the significance of the gains. The pupils' psychosocial adjustment also showed significant improvement on various personality assessment measures and behavior ratings by teachers and parents. Finally, self-reports by the senior citizen aides suggest that they also profited by their involvement in STEP.


Computerized cranial tomography of free intracranial fat in congenital tumors.

Three additional cases of free intracranial fat associated with congenital tumors are reported. The migration of fat with positional change is detailed. Free intraventricular fat may present without transcerebral rupture of the tumor. Our experience with these three patients, plus the two previously reported, suggest that two conditions must be present for oily material to enter the ventricular system through the outlets of the fourth ventricle: first, there must be a reversal of bulk flow of cerebrospinal fluid; second, the oily material must have a specific gravity less than that of cerebrospinal fluid. Also noted from our series is the absence of serious clinical sequelae associated with rupture or leakage of fatty tumors.


Computerized tomography of frontal sinus pneumatocele.

The radiographic feature and computerized tomography (CT) findings in a case of frontal sinus osteoma associated with pneumatocele are described along with the clinical history and surgical findings. CT gives useful information regarding the extent of air dissection and its relation with the ventricular system.


Computed tomography of the cervical spine and spinal cord.

A number of cases are presented to illustrate the diagnostic effectiveness of computed tomography in the cervical spine and spinal cord, specifically in syringomyelia, spinal stenosis, and fractures. Certain limitations in the examination are also presented, and problems related to interpretation, particularly in regard to spinal stenosis, are discussed.


The use of CT scanning in resolving "pseudo" lesions of the liver.

The authors have presented three cases in which bowel, fat, or fluid interposed between the liver and abdominal wall resulted in an equivocal or abnormal radionuclide scan of the liver. Ultrasound was useful in suggesting the etiology in only one instance. In all three cases, however, computerized tomography clearly demonstrated the etiology of the defect or "pseudo" lesion seen on the radionuclide scan.


Computed tomography of the pancreas: the use of intravenous contast to define the dorsal surface of the pancreas.

After a non-selective review of 80 abdominal CT examinations, it was found that the use of intravenous contrast markedly improves the recognition of the superior mesenteric vein and the splenic vein. These veins lie adjacent to the posterior surface of the pancreas. When the pancreas is poorly seen due to inadequate retroperitoneal fat, when pancreatic size is borderline, or when pancreatic ductal obstruction is suspected on scans prior to intravenous contrast administration, the use of contrast may resolve the uncertainty.


The influence of computed tomography on clinical decision making in the evaluation of a nonvisualizing kidney.

Nonvisualization of a kidney in an elderly man was investigated by computed tomography (CT). Simple low lying ureteral obstruction was excluded, multiple pathologic abnormalities were identified and causes for the nonvisualization are postulated. This case report demonstrates the important effect CT scanning produced on the clinical management of the patient in question.


Ethinyl estradiol in peripheral plasma after oral administration of 30 microgram and 50 microgram to women.

Plasma levels of ethinyl estradiol were measured by radioimmunoassay in five women after oral administration of 30 microgram and of 50 microgram of ethinyl estradiol. Peak levels of ethinyl estradiol were mostly observed within two hours after the tablet intake. The peak concentrations found were 50--90 pg and 95--135 pg for the two doses administered. Twenty-four hours after the administration of the tablets, the plasma concentration of ethinyl estradiol did not exceed the plasma blank values (25 pg/ml) in most women.


Effect of racemic and S(+) alpha-chlorohydrin-1-phosphate on glyceraldehyde-3-phosphate dehydrogenase in relation to its contraceptive action.

The phosphate esters of racemic (+/-) alpha-chlorohydrin and its S(+)-optical isomer have been prepared as cyclohexylamine salts. In vitro both inhibited glyceraldehyde-3-phosphate dehydrogenase by a competitive mechanism, whereas (+/-) alpha-chlorohydrin did not. The S(+)-isomer was approximately four times as potent as the racemate. These results correlate with data concerning the relative contraceptive activity in rats of racemic and S(+) alpha-chlorohydrin. They support the view that the antifertility mechanism involves in vivo formation of S(+) alpha-chlorohydrin-1-phosphate, with resulting inhibition of glycolysis in sperm.


Analysis of 100 cases of missing IUD strings.

In a study of 100 patients with missing IUD strings 69 women had their IUD in utero (4 were pregnant) and 17 had unnoticed expulsions (4 pregnancies); 9 devices were in the peritoneal cavity and one had perforated the cervix. Since the IUD was in the uterine cavity in the majority of these cases, most contraceptors whose IUD strings disappear can be managed in the office or clinic with relatively simple techniques to locate and remove the device.


Failure of withdrawal bleeding during combined oral contraceptive therapy: "amenorrhoea on the pill".

Serum follicle stimulating hormone, luteinising hormone and oestradiol-17beta concentrations have been measured in 21 patients with failure of withdrawal bleeding during combined oral contraceptive therapy and 21 matched controls with a normal bleeding pattern. Gonadotrophin and oestradiol-17beta concentrations were effectively suppressed in all patients during the phase of contraceptive ingestion. During the week between courses of treatment, there was a significant rise in the gonadotrophin (p less than 0.02) and oestradiol (p less than 0.05) concentrations in the patients but not in the controls. It is suggested that patients with failure of withdrawal bleeding during combined oral contraceptive therapy may have higher total oestrogen levels during the treatment-free week because of a less persistent suppression of hypothalamic-pituitary-ovarian function.


Norethisterone oenanthate as an injectable contraceptive: a study of patients discontinuing treatment.

Two hundred and ninety-five women were enrolled in a study of norethisterone oenanthate (NET-OEN) as an injectable contraceptive. One hundred and twenty-four patients who discontinued this contraceptive have been studied in detail. The main reasons for use-related closures of method were menstrual abnormality (22 patients), minor side-effects (23 patients), personal reasons (22 patients) with 18-month life-table net discontinuation rates of 14.7/100 women, 13.5/100 women, 14.2/100 women. There were no accidental pregnancies. The probability of discontinuing treatment was not affected by age, parity, time of starting treatment or previous contraception. Sixty-nine per cent of all discontinuations occurred in the first four months of treatment. There were no serious complications.


Comparative studies on two combination oral contraceptives, one containing synthetic estrogen, the other "natural" estrogens.

Two combined oral contraceptives, one containing ethinyl estradiol and the other micronized estradiol and estriol, were compared by measuring a variety of endocrine and renal parameters over nine months. Significant changes were observed in plasma renin activity (P.R.A.) on the synthetic estrogen. Much larger changes were observed in the total urinary estrogens on patients taking the "natural" estrogens reflecting the amount of estrogens required to be excreted in the urine.


Occurrence of ovulation in women receiving the injectable contraceptive norethisterone oenanthate.

Ovarian function was studied in ten women receiving a single intramuscular injection of 200 mg norethisterone oenanthate. Two of the ten women appeared to ovulate within 60 days of injection and a further four within 90 days. Follicular activity probably not followed by ovulation occurred in five subjects within 60 days of the injection and in a further subject within 90 days. Only one subject showed no evidence of follicular or luteal activity during the course of this study. There was wide variation in the rate at which the administered gestagen was metabolised and no correlation between the rate of metabolism of norethisterone and the return of ovarian function or the ponderal index, height or weight of the subjects.


Use of a radioreceptor test for HCG in women practicing contraception.

The importance of a simple, rapid and highly sensitive test for the diagnosis of early pregnancy cannot be overemphasized. In the present times when newer delivery systems of contraceptive agents and menstrual regulation procedures are increasingly used for fertility regulation, it is inevitable that confirmation of early pregnancy poses a severe problem. This radioreceptor test has been found to be very reliable even in early cases. A positive test was 100% accurate for pregnancy whereas the accuracy of a negative test was found to be 94.4%. Confirmation of these results was done by various other parameters like clinical, histological, radioimmunoassay for HCG and biological test for pregnancy.


The frequency of coronary heart disease and myocardial infarction in rheumatoid arthritis patients.

The authors studied the frequency of coronary heart disease (CHD) and myocardial infarction (MI) in 500 rheumatoid arthritis (RA) patients (116 men and 384 women). Almost 75% RA patients received 15.0-50.0 g of acetylsalicylic acid (ASA) monthly for above 4 years. The authors did not find significant differences in the frequency of CHD risk factors in the group of RA patients and in the Polish population of similar age. The authors noted only 2 cases of MI and 2 cases of CHD in 500 RA patients. All these patients received ASA irregularly and in small doses. The morbidity coefficient analysis showed that MI is 3-times less frequent in RA patients than in the Polish population. The authors suppose that long-term ASA treatment is one of the factors reducing the risk of CHD and MI probably by inhibition of the platelet function.


Effect of the stellate ganglion blockade upon the electrical systole (Q-T interval) of the heart.

The effect of the Novocain blockade of the stellate ganglion upon the duration of the electrical systole (Q-T) of the heart was studied in 38 patients. Basic Q-T was normal in 17 patients; in these cases stellate ganglion blockade did not influence the Q-T interval. Of the 21 cases with Q-T prolongation, in 10 the Q-T interval became considerably shorter upon the effect of blockade. In the 11 cases that did not respond to the blockade, ECG repolarization was regular, and there was no arrhythmia. Of the 10 responsive cases with Q-T prolongation, in 9 the repolarization was pathological, and in 6 there was no chronic arrhythmia. The authors discuss the role of the sympathetic nervous system in certain forms of Q-T prolongation.


Risk factors and survival prognosis in men younger than 40 years and men older than 60 years with myocardial infarction. (Retrospective clinico-epidemiological study).

In a clinico-epidemiological retrospective study there were examined 300 men younger than 40 years and 300 men older than 60 years with clinically or histologically diagnosed myocardial infarction (by WHO criteria). The study has confirmed that clinically unequivocal myocardial infarction in men younger than 40 years is significantly frequently connected with the presence of the following main risk factors: 1. Myocardial infarction or sudden death in next-of-kin aged less than 60 years.--2. Excessive cigarette smoking (greater than 20 cigarettes daily).--3. Hypercholesterolaemia (greater than 260 mg/100 ml, hypertriglyceridaemia (greater than 200 mg/100 ml), and hyperuricaemia (greater than 7 mg/100 ml). The time elapsed between the manifestation of the coronary accident and calling for medical aid was longer in the group of men older than 60 years. After 5 years the proportion of surviving patients was significantly higher in the younger group.


Reorganization of cardiac venous system in patients with atherosclerotic heart disease.

By angioroentgenography, macro- and microscopic examinations the authors investigated the plasticity of intramural blood drainage vessels and the histological structural lesions of venous walls in 50 heart preparations of patients suffering from atherosclerotic heart disease (AHD) that had developed on the basis of coronary sclerosis varying in degree and localization, and in 15 preparations from hearts of practically healthy persons. It was found that in AHD the myocardial capillary network gradually rarefied; the capillaries, postcapillaries, venules, and sinusoids distended, became varicose, and deformed. In the walls of individual segments of the cardiac draining system the authors observed collagenization, and in myocardial small veins, reduction of venous valvules. The degree of the described alterations in the venous system was proportionate to the degree of myocardial sclerotic changes.


Positive family history as a risk factor of obliterative atherosclerosis.

Clinical, angiological, and biochemical examinations were performed in 981 men and 30 women with organic afflictions of peripheral arteries, and in 411 men and 50 women without any signs of peripheral arterial lesions. Their family histories were thoroughly recorded with particular reference to the occurrence of myocardial infarction, cerebral accidents before and after the age of 60 years, and death of these causes; further, of hypertension, diabetes mellitus, obliterations and gangraenes, in each patient's siblings, parents, and all four grandparents. Furthermore, the significance of positive family history in combination with other risk factors was investigated. Family history can be considered positive with respect to obliterative atherosclerosis when in anyone of the patient's grandparents, parents, or siblings an obliteration of peripheral arteries is present or when anyone of them died of myocardial infarction or apoplexy, especially when aged under 60 years. Presence of several factors in the specified next of kin accelerates the obliterative process in the patient. A positive family history, however, plays no decisive role either alone or in combination with any other single risk factor, but only in combination with two or more other factors, one of which is always tobacco smoking; it is not significant in any combination with obesity.


Peripheral arterial reactivity in patients with peptic ulcers and in healthy subjects.

With an oscillograph according to Gesenius and Keller, the authors investigated the oscillographic waves in lower limbs and their reductions after exposition to cold and exercise in 27 men and 22 women with gastric or duodenal ulcer as well as in 18 healthy men and 12 healthy women. Both groups were subdivided into age categories from 19 to 30 and from 45 to 54 years. It was found that 1) peripheral arteries in men in the lower age category with duodenal ulcer reacted to cold stimulus by a more marked vasoconstriction than the arteries in healthy men in the same age category; 2) in women with duodenal ulcer the same observation was made in not only the younger, but also in the higher age category; 3) peripheral vasoconstriction after application of cold in women with duodenal ulcer, aged up to 30 years and 45-54 years was higher than in women with gastric ulcer in the corresponding age categories; 4) peripheral arteries of the younger men as well as of the younger and older women with duodenal ulcer reacted often more strongly to exercise and to exercise following application of cold in comparison with corresponding controls, and in the case of the women, in addition, with those with gastric ulcer.


Protein and polynucleotide metabolism in skeletal muscles in dogs with experimental myocardial infarction.

In experiments on 105 dogs it was found that at the onset and in the course of extensive myocardial infarction there regularly occur a specific set of shifts in the protein and nuclein metabolism in skeletal muscles. Besides changes reflecting a certain decrease in the functional capacity of muscles there also appear metabolic reactions of compensatory nature. Changes in nitrogen metabolism in striated muscles are most pronounced in the formation period of myocardial infarct but partially persist during the organization stages, some of them up to a period of a whole month. The intensities of changes are mostly expressed by values 20-35% higher than the initial ones, but in some indicators the alterations are still more intense.


Production of experimental occlusive myocardial infarction in mice.

A method is described for production of occlusive myocardial infarction in mice. The dynamics of development as well as the morphological changes in ischaemized myocardium of mice, large laboratory animals, and humans were identical. Polarization microscopy helped reveal myocardiocytic changes in the ischaemic zone already within the first minutes after coronary artery ligation. The method reported upon has the following advantages: feasibility of all stages of the operation by a single operator, low postoperative mortality of the animals and their modest requirements for postoperative care, and low consumption of isotopes and costly therapeutic remedies.


Functional reserve of the heart and catecholamines in experimental mitral valve incompetence.

In dogs with experimental mitral valve incompetence, by the end of the adaptation stage (2nd week) the cardiac functional reserve decreases; the decrement is correlated with the exhaustion of the reserve of catecholamine synthesis evident from the decrement of their precursors in the myocardium and adrenals as well as from the destruction of plentiful cells of the adrenal medulla, accompanied by development of necrosis, dystrophy, and disturbances of vascular permeability in the adrenal glands. In the initial period of the compensatory stage (1st month) a considerable activation of the catecholamine synthesis takes place, together with their increase in the right ventricular myocardium and in the adrenals.


Ultrastructural changes in dog myocardium in the early phase of endotoxin shock.

Initial ultrastructural changes were studied in dog myocardium in endotoxin shock. Lesions of fine structure of myocardial cells, intravascular coagulation, and increased permeability of the histo-haematic barrier were found.


Toward the engineering of photosynthetic productivity.

This article is a review of progress towards a general quantitative theory of photosynthetic productivity or autotrophy in plants. It is not intended to be an exhaustive review, but rather a perspective of the autotrophic puzzle and current approaches to its solution. The review describes attempts to quantitatively describe a generalized plant based on theoretical expressions for its component parts. Particular emphasis has been placed on the source-transport-sink continuum. This continuum can be broken into five subsections: 1. Stomal mechanics and physiology 2. Photosynthesis (within chlorophyllous cells) 3. Mass and energy exchange between the leaf and environment 4. Phloem translocation 5. Sink metabolism models Progress towards the development of physiologically based models in each of the above areas is assessed, relying heavily on the approach and findings of the authors and their colleagues. The problems and possibilities inherent in attempting to couple these components into a generic model of productivity are discussed. Finally, the potential benefits and hazards of genetic engineering of plants are discussed, and weaknesses in the current approach are highlighted.


Thoughts on cross-cultural studies on the epidemiology of depression.

A considerable number of studies have been conducted on the epidemiology of depression across cultures. These studies have relied on two basic research methods: treated cases and untreated cases. However, limitations in these two methods make it impossible to arrive at any substantive conclusions about ethno-cultural variations in the rates of depression. The treated cases approach fails to control for the fact that individuals in a culture do not have equal access to psychiatric facilities nor equal motivation to psychiatric care. The untreated cases approach, which is based on community surveys, is limited by differences in the definition of depression, the diagnostic signs used to identify depression, and variations in the degree of professional contact with the potential "cases.' In addition, current cross-cultural depression studies are faced with the problems of poor diagnostic reliability for depressive disorders and profound differences in the manifestation and experience of depression among different ethno-cultural groups. Many ethno-cultural groups do not demonstrate any of the psychological components of depression associated with its presence among Western groups. An entirely new approach to the cross-cultural study of depression appears warranted. Four steps are suggested to facilitate future studies: (1) An emic determination of disorder categories in different cultures; (2) The establishment of symptom frequency, intensity, and duration baselines, (3) Objective symptom pattern determination through multivariate data processing techniques: (4) Comparative studies using similar methodologies with culturally relevant definitions of disorder.


Witchcraft illness in the Evuzok nosological system.

The Evuzok nosological system is structured with respect to two frames of reference, one designating illness as an empirical reality (descriptive subsystem), the other designating it according to its religious, magical and social significance (etiological subsystem). The articulation of these two subsystems is brought about in the process of diagnosis. Having examined this system as a whole, the author devotes his attention to a particular set of etiological categories, those which associate illness with witchcraft (nocturnal illnesses). He attempts to define their distinctive traits and, from this, to determine their common elemental structure. This study, based on a number of years of fieldwork, is part of an ongoing research program on African folk-medicine pursued by the Laboratoire d'Ethnologie et de Sociologie Comparative of the Université de Paris X.


Prosthetic treatment and rehabilitation: use in patients with cancer of the head and neck.

Dental management of the patient with cancer, especially when the disease process involves the head and neck region, should be an integral part of the patient's overall treatment plan. By utilizing the team approach and detailed advance planning, stressing both immediate treatment to control the patient's disease and short- and long-term rehabilitation, the best possible treatment for each patient can be formulated with a minimum of posttreatment complications. If an institution is to make the commitment to treat patients with cancer, a comprehensive dental support program with a maxillofacial prosthodontist is a necessity. As the benefits of a dental department are recognized, the utilization of this service increases and the overall treatment and rehabilitation of the patient with cancer is improved.


Behavior therapy for autistic children: a study of acceptability and outcome.

An inpatient program for autistic children which used behavior modification methods is described, and a follow-up study of the first 15 children discharged from the program is reported. In general, the outcome results appear to be comparable to those of other treatment methods. A second main purpose of the study was to assess the acceptability of this program to parents and to document their impressions regarding their child's period of inpatient care. Overall, a high level of acceptability was found.


Mainstreaming psychiatry: some personal commentary.

The psychiatric education establishment is depicted as zealously searching for a set of educational principles that will allow maximum bandwagonry, maximum fundability. "Medical mainstream" is the current catch phrase selected for discussion. The contention of the author is that--instead-sound bio-social principles, easily available from child psychiatry as a field, would provide a dynamic substructure that would not be voguish and evanescent. Far from pursuing the medical mainstream, psychiatry might be more secure as an academic discipline were it to adopt an evangelical, illuminating attitude toward other medical specialties. In short, the proposal is made that general psychiatry and its fellow medical specialities ought to be brought into the child psychiatry mainstream. What child psychiatry could give to medicine and to general psychiatry is considered under these headings: a developmental perspective, a behavioral science sophistication, a medical foundation and lifestyle ("Aesculapian authority"), a humanistic attitude, and a stance of patient advocacy.


Parental reactions to children with congenital heart disease.

Informal discussions with 260 families of children with congenital heart disease are reported. Parents raised questions concerning etiology, timing of the diagnosis, pathophysiology and symptomatology, and need for restriction. Depending upon the stage and seriousness of the disease, common parental behavior was observed. A psychological process similar to mourning is required at the time of diagnosis and at the time of corrective surgery in order to promote the family's adaptation to the child with congenital heart disease. Management suggestions are included.


On the inter-relationship of cognition and affect: fantasies of deaf children.

A few projective studies focusing on the impact of cognition on affect in the deaf have reported strikingly disparate results with little systematic inquiry. A new and previously unreported play situation (with the deaf) was devised to elicit a detailed story. Fantasies were obtained in a uniform fashion from four groups of five-year-old boys comprising middle-class deaf and hearing children and lower socio-economic-class deaf and hearing children. Results suggest that: (1) The impact of deafness on cognitive functioning in these children is akin to--but apparently no worse than--the cultural deprivation phenomenon experienced by low socio-economic-status children. (2) There is no paucity of fantasy life in the deaf or deprived child, despite the absence or relative lack of verbal skills. (3) A problem common to both disadvantaged children and the deaf children tested in the intrusion of anxiety into autonomous ego functions, so that practice necessary for the firm development of cognitive schemata is interfered with. (4) The clinical impulsivity secondary to these emotional pressures may perpetuate itself by interfering with cognitive decentration in time and space in relation to others.


Long-term effects of high-carbohydrate, high-fiber diets on glucose and lipid metabolism: a preliminary report on patients with diabetes.

High-carbohydrate, high-fiber (HCF) diets have beneficial therapeutic effects for selected patients with diabetes mellitus. We have treated 10 patients with HCF diets on a metabolic ward and followed them for an average of 15 months while they were on maintenance diets at home. The HCF diets containing 70 per cent of calories as carbohydrate were accompanied by significant reductions in requirements for insulin or sulfonylureas. Fasting plasma glucose, serum cholesterol, and triglyceride values were significantly lower on the HCF diet than on a 43 per cent carbohydrate diet. On the HCF diet, insulin therapy was discontinued for five patients and sulfonylurea therapy for three. After an average of 15 months on the maintenance diet containing 55 per cent to 60 per cent carbohydrate, seven patients were still managed without insulin or sulfonylureas. Average fasting plasma glucose values during maintenance diets at home were identical to values on the HCF diets in the hospital. On the maintenance diet, serum cholesterol values were similar to initial values but serum triglyceride values were significantly lower than values on the 43 per cent carbohydrate diet. These studies indicate that moderately high-carbohydrate, high-fiber diets can be successfully followed at home and that improvements in glucose metabolism achieved in the hospital can be sustained outside the hospital.


Influence of indigestible fibers on glucose tolerance.

In eight patients exhibiting chemical diabetes mellitus with a poststimulative hypoglycemia, we observed that the pattern of the oral glucose tolerance test (OGTT) was improved when indigestible fiber was added to the oral glucose load. As compared with a standard OGTT, the peak blood glucose, expressed as per cent change from baseline, was particularly blunted by pectin or by cellulose phosphate but remained unchanged with cellulose supplementation. The time interval required to reach the blood glucose peak was significantly prolonged with pectin. The rate of blood glucose rise was reduced to a greater extent by pectin than by cellulose phosphate, which in turn was more efficient than cellulose. The blood glucose nadir expressed as per cent change from baseline was blunted by pectin, while the results were not significantly different after addition of either cellulose phosphate or cellulose. On the other hand, the plasma immunoreactive insulin did not show any significant change whether the glucose was given with or without one of the aforementioned types of fiber. From these results, it is concluded that an additional fiber intake may be of interest in the management of chemical diabetes. The use of pectin may diminish the poststimulative hypoglycemia.


Growth and maturation of children with insulin-dependent diabetes mellitus.

The purpose of this paper is to define criteria used for classifying patients into varying degrees of diabetic control and to verify that children with diabetes maintained in higher degrees of metabolic control do not have delayed growth and maturation. Growth records of 252 children with insulin-dependent diabetes who have been under continuous observation in our clinic at three- to five-month intervals for at least three years and up to 16 years have been individually reviewed and analyzed. All children received two daily injections of a mixture of two parts of an intermediate to one part of regular insulin and were instructed to eat structured meals of high-quality selected foods. An over-all rating for diabetic control based primarily on the frequency and degree of glycosuria was made for the time period between clinic visits. The over-all diabetic control rating and the size of the subgroups were "good"--20 per cent, "fair to good"--64 per cent, and "fair"--16 per cent. All children maintained in "good" and "fair to good" control (84 per cent), grew and matured at a normal rate regardless of the age at onset or duration of diabetes. All children in lower degrees of control coming under care for greater than 24 months after diagnosis had accelerated growth during the early months after attaining a higher degree of control.


Computerized surveillance of diabetic patient/health care delivery system interfaces.

DIASURV is a computerized surveillance program developed to monitor the interaction of a large cohort of diabetic patients with a tertiary care institution. The input of this simple program consists of a file of diabetic patients, the daily census of hospital inpatients, and the daily census of hospital outpatients. Written in COBOL, the program consists of edit and file-maintenance components and inpatient and outpatient search components. The output is a daily listing of all inpatient (x- = 60) and outpatient transactions (x- = 20) for the cohort of 1,800 patients. The output also summarizes previous exposures of patients to specific bedside and classroom activities in diabetes education. DIASURV has a variety of applications in terms of organization of teaching efforts and facilitated access to a limited amount of patient management information.


Cigarette smoking and prevalence of microangiopathy in juvenile-onset insulin-dependent diabetes mellitus.

In order to evaluate a possible relation between cigarette smoking and prevalence of diabetic microangiopathy, a series of 180 consecutive patients suffering from insulin-dependent juvenile-onset diabetes mellitus with different durations of disease (60 patients each with diabetes for 10 to 19 years, 20 to 29 years, and 30 to 39 years, respectively) were examined for clinical signs of retinopathy, nephropathy, and peripheral neuropathy. The results were compared with the patients' previous and actual smoking habits. Cigarette smoking was defined as daily smoking of at least ten cigarettes for one year or more. Smoking habits of the total diabetic sample were not significantly different from those of a nondiabetic control sample. However, a decline in the number of cigarette smokers and a rising number of ex-smokers were noted with increasing duration of diabetes. In comparing smokers and nonsmokers, no difference was found in the prevalence of peripheral neuropathy, background retinopathy, and proliferative retinopathy. However, the prevalence of nephropathy (persistent proteinuria) was significantly higher (p less than 0.05) among these patients who were or had been cigarette smokers. Thus, cigarette smoking might be considered a risk factor for the development of diabetic nephropathy.


Home blood glucose monitoring as an aid in diabetes management.

Home blood glucose monitoring, using Dextrostix and an Eyetone meter, has been utilized in several subcategories of patients with insulin-dependent diabetes mellitus. These include pregnant patients, anephric patients, patients undergoing weight reduction, patients with altered renal threshold for glucose reabsorption, and patients in whom diabetic regulation is difficult. Patients monitored home blood glucose continually (on a daily basis), intermittently, or only for particular problems or symptoms. Such monitoring can be practically accomplished in a manner acceptable to patients. Motivation, compliance with protocol, and an understanding of the objectives of the program are essential on the part of the patient. Home blood glucose monitoring, however, can provide an insight diabetes regulation that cannot be attained in any other way and can greatly facilitate regulation of diabetes. Such home blood glucose monitoring may increase the likelihood of achievement of a degree of control approximating euglycemia.


Remissions of diabetes mellitus after weight reduction by jejunoileal bypass.

Limited weight loss following jejunoileal bypass in 24 diabetic persons who were still distinctly overweight five to ten months after a mean weight decrease of 78 lbs. was accompanied by a return of normal fasting glucose and insulin levels, normal insulin responses, and a decrease in glucose intolerance. The glucose disappearance rate had improved in the majority of the subjects, but only three had attained values in the normal range. Concomitants of the undue hyperglycemia and/or obesity included labile and, rarely, sustained hypertension and/or cardiomegaly. The blood pressure returned to normal but heart size did not change. Electrocardiographic abnormalities noted in about one-half of the patients persisted after the operation. Triglyceride and cholesterol levels decreased. No patients had diabetic retinopathy visible on funduscopy. Proteinuria did not change in three patients. Neuropathy consisting of absent ankle reflexes and/or decreased vibration perception noted in one-half of the subjects persisted despite the improvement in carbohydrate metabolism.


Assessment of diabetic control: a comparison between home and clinic blood glucose levels.

A comparison between blood glucose levels in patients attending a diabetes clinic and in the same patients leading their normal lives showed that for maturity-onset diabetic patients on oral hypoglycemic therapy, the clinic levels were a poor guide to the patients' usual blood glucose. For insulin-treated patients and for those treated with diet alone, the clinic levels were not significantly different from those taken at home or work.


Effect of added fiber on the glucose and metabolic response to a mixed meal in normal and diabetic subjects.

10 g of guar was added to a test meal given to 11 subjects, six of whom had insulin-dependent diabetes, after an overnight fast. The addition of guar to the meal produced an overall decrease in the blood glucose concentrations after the meal in both normal and diabetic subjects. The insulin secretory response in the normal subjects was less when guar was included in the meal than when it was not. In normal subjects, but not in diabetic subjects, the addition of guar also resulted in a diminished response of lactate, pyruvate, and alanine to the test meal and a blunting of the fall in serum ketones. This is likely related to the fact that the same dose of insulin was given in the diabetic subjects with both test meals. Thus, in the normal circumstances, the diminished glycemic response to the guar-containing meal resulted in diminished insulin secretion, which was not the case with the diabetic subjects.


New evidence for the intermediate position of relaxed accommodation.

Experimental evidence is presented that the focus of the eye tends to return passively to an individually characteristic intermediate resting position or dark-focus whenever (1) the stimulus to accommodation is degraded or (2) when the quality of the image is independent of focus. Based on measurements of the dark-focus with a laser optometer, it is possible to predict the magnitude of night, empty field, and instrument myopia on an individual basis. The role of the intermediate dark-focus as a factor in accommodation also provides an explanation for the paradoxical variation of visual acuity with observation distance. Applications to night myopia and night driving are described, and implications for clinical practice are discussed.


Current patterns of neonatal morbidity and mortality in infants of diabetic mothers.

Recent advances in antepartum fetal evaluation have contributed to a marked reduction in fetal deaths in pregnancies complicated by overt diabetes mellitus. To determine the effect of these changes on neonatal morbidity and mortality, a retrospective analysis of complications in 322 infants of diabetic mothers (IDM) in White classes B--R was undertaken. The majority (89 per cent) of the IDM were delivered at term with a mean gestational age of 38 weeks. Neonatal morbidity correlated significantly with gestational age, occurring in 80 per cent of the preterm and 40 per cent of the term infants. The overall incidence of complications was: hyperbilirubinemia 37 per cent, hypoglycemia 31 per cent, hypocalcemia 13 per cent, polycythemia 8 per cent, and necrotizing enterocolitis 2 per cent. Respiratory distress syndrome (RDS) occurred in 9 per cent and congenital malformations in 6 per cent of the infants. Nine infants died, and four of these deaths were due to anomalies. These data indicate that (1) a reduction in fetal mortality has been accompanied by a reduction in neonatal mortality; (2) neonatal morbidity has been decreased but remains significant in the IDM; and (3) congenital anomalies have replaced RDS as a major cause of neonatal death for the IDM.


Metoclopramide for gastroparesis diabeticorum.

Three patients with uncontrolled diabetes mellitus and with symptoms due to gastric retention proved to have gastroparesis diabeticorum. The diagnosis was established by the beefsteak-barium meal. After the administration of metoclopramide, gastric emptying improved and the diabetes was easily controlled. Gastroparesis diabeticorum is one cause of uncontrolled diabetes mellitus and may be helped by the administration of metoclopramide.


Zero retinal image disparity: a stimulus for suppression in small angle strabismus.

Suppression was examined with binocular perimetry in patients with small angle strabismus. Suppression stimuli were presented to the fovea of the fixating eye or 5 degrees nasal or temporal from the fovea. Suppression was found in the deviating eye of patients with normal or anomalous correspondence at retinal points corresponding to the retinal locus of the suppression stimulus. Suppression was demonstrated on both the nasal and temporal hemiretina of the deviating eye. Results indicate that zero retinal disparity is a strong stimulus for suppression in the central and peripheral visual field of patients with small angle strabismus.


Neonatal morbidity among infants of diabetic mothers.

While the modern approach to management of diabetic pregnancy has reduced the perinatal mortality significantly, the neonatal morbidity remains high. This study has investigated factors which may account for the persisting high neonatal morbidity when birth trauma has been virtually eliminated and the incidence of respiratory distress syndrome (RDS) considerably reduced. Major congenital malformations emerge not only as the leading cause of perinatal losses but also as an important cause of morbidity. Delivery before 37 weeks increased the incidence of RDS and hypocalcemia, and it is suggested that, when strict metabolic control is used and with the help of facilities to monitor the fetus closely in the last weeks of pregnancy, the number of infants delivered at this early date can be further reduced. The present study also indicates that normoglycemia should also be encouraged on the day of delivery as maternal hyperglycemia at this stage increases the incidence of neonatal hypoglycemia. Jaundice, which very commonly affects newborn infants of diabetic mothers, is influenced by the use of oxytocin for vaginal delivery and by infant overweight (greater than 90th percentile) at birth, factors which are not beyond control. Finally, route of delivery per se may not be important in relation to neonatal morbidity.


[Indications for the location of trabeculotomy in simple glaucoma. I. The blood contents of Schlemm's canal].

Following trabeculotomy, about 30% of glaucomatous eyes are not normalized in pressure without additional therapy. In these cases, it was not possible to remove the resistance of outflow completely. Before deciding to perform trabeculotomy it is, therefore, necessary to localize the resistance of outflow. The inspection of the blood pattern in Schlemm's canal gives no indication where to localize the resistance of outflow. The same holds true for the haemorrhage deriving from Schlemm's canal, in the operating field (trabeculotomy window), which appears in 19.2% of cases. After trabeculotomy the blood outflow into the anterior chamber is significantly higher (63.6%) using the suction cup, then following pressure of the gonioscopy lens (28.1%). The differences between these findings are discussed. Our results indicate the necessity to search for other methods in localizing the resistance of outflow pre-operatively.


Cheiralgia paresthetica in diabetes mellitus.

Cheiralgia paresthetica is a sensory mononeuropathy of the superficial ramus of the radial nerve. A case is presented here in a patient with diabetes mellitus.