Urinary excretion of the cancer-related glycoprotein EDCl: effect of chemotherapy.

The effect of chemotherapy on the urinary excretion of a cancer-related glycoprotein labeled EDCl, recently isolated from the urine of a patient with acute myelocytic leukemia, has been studied by radioimmunoassay in eight cancer patients who were excreting 200 to 500 mg/day before treatment. In five patients, chemotherapy caused marked clinical improvement, and the glycoprotein disappeared from the urine within 10 days after chemotherapy began. In the two patients with solid tumor who responded to chemotherapy, disappearance of glycoprotein EDCl from the urine preceded clinical improvement by 1 to 2 months. Four of the five responsive patients relapsed within 6 months; in each instance, the glycoprotein reappeared in the urine (greater than 100 mg/day) 2 to 5 weeks before clinical relapse. Three patients were resistant to chemotherapy, and their urinary glycoprotein did not decline during chemotherapy. Measurement of urinary glycoprotein EDCl will be useful in rapidly ascertaining which drug will be effective in a cancer patient and in predicting relapse.


Regression of liver cell adenomas associated with oral contraceptives.

The regression of liver cell adenomas that follow the use of oral contraceptives when steroids are withdrawn was observed in three patients. At diagnosis by needle biopsy in patients without pain or evidence of hemorrhage, prompt cessation of steriod use is suggested as the preferable form of treatment. The same is true for the diagnosis made at surgery if the tumor or tumors are difficult to remove.


Aspirin hepatotoxicity and disseminated intravascular coagulation.

A 17-year-old girl with a clinical diagnosis of adult-type juvenile rheumatoid arthritis developed a severe hepatotoxic reaction to 3.6 g of aspirin per day. This was associated with a microangiopathic anemia and transient congestive cardiac failure. She responded well to steroids, and when all laboratory test findings were back to normal, she was "challenged" with five divided doses of aspirin (total, 3.0 g). This produced a salicylate level of 9.1 g/dl and was associated with an immediate deterioration in liver function test findings and a return of microangiopathic blood features with elevation of fibrin split products and a prolonged prothrombin time. These changes were again reversed by promptly starting steroid therapy. This case suggests that disseminated intravascular coagulation, and its rare association with hepatotoxicity, is a potentially fatal side effect of aspirin therapy.


The microbiology of evacuated blood collection tubes.

A collaborative study involving 20 clinical laboratories representing diverse geographical regions was organized to examine the microbiology of evacuated blooc collection tubes. Overall, 14% of the 1433 tubes examined contained microorganisms representing a variety of bacteria and fungi. Of note was the finding that nearly 9% of tubes with yellow closures, which are stated to be sterile by the manufacturers, contained bacteria, including Pseudomonas aeruginosa, enterococci, Serratia marcescens, and Acinetobacter calcoaceticus. Sterilization of these potential sources of infection is advisable.


Spontaneous retroperitoneal bleeding in patients on chronic hemodialysis.

Six patients developed spontaneous retroperitoneal bleeding while on maintenance dialysis (3% of all patients so treated). At the time of the bleeding episode, four patients were receiving Coumadin for prevention of recurrent clotting problems in external shunts. In three patients, including two who had not received Coumadin, bleeding developed while on dialysis. The presenting common symptoms and signs of retroperitoneal bleeding included sudden and progressive abdominal pain with blood pressure drop and subsequent development of an abdominal mass. These symptoms were associated with a falling hematocrit without any documented external blood loss and with suggestive X-ray changes, including absence of psoas shadow with soft tissue density. All six patients recovered. Treatment included blood transfusions, temporary regional heparinization, withdrawal of Coumadin, and bed rest. Surgical exploration was undertaken in two patients, but no obvious bleeding source was found. Anticoagulation therapy and functional platelet abnormalities may be contributory causes.


Hematologic aspects of systemic lupus erythematosus. Current concepts.

Anemia occurs in more than one half of patients with systemic lupus erythematosus and is usually attributed to "chronic disease." Approximately 10% of patients with a positive Coombs' test manifest clinically significant hemolysis. Leukopenia affects both granulocytic and lymphocytic lines and may be caused by autoantibodies. Nevertheless, enhancement of B lymphocyte function occurs in active disease, perhaps due to a loss of regulatory T cells. Most patients have increased production and increased peripheral destruction of thrombocytes, with a normal circulation platelet count. Thrombocytopenia is usually caused by increased destruction. Qualitative abnormalities of platelet aggregation also occur. Circulation anticoagulants are not rare; however, spontaneous bleeding is uncommon. The anticoagulants, immunoglobulins directed against clotting factors, assume importance for invasive procedures. Most clinically significant hematopoietic abnormalities can be suppressed by corticosteroids; however, splenectomy, or immunosuppressive agents, or both, may be indicated for patients who respond inadequately to corticosteroids.


Spinal fluid pleocytosis in acute posterior multifocal placoid pigment epitheliopathy.

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a disorder of the fundus frequently characterized by sudden onset of bilateral, marked visual loss associated with yellowish-white, ill-defined placoid lesions of the retina. Most cases show a rapid resolution with restoration of vision to normal or near-normal levels. We evaluated an 11-year-old boy with presumed APMPPE who showed a mononuclear cell pleocytosis on spinal fluid examination.


Eye findings in autonomic hyperreflexia.

Autonomic hyperreflexia is a phenomenon seen in quadriplegic patients involving hyperactivity and dysfunction of the autonomic nervous system. Unilateral lid retraction, mydriasis, and relative exophthalmos were observed in a young man having unilateral autonomic hyperreflexia, demonstrating that sympathetic discharge to the eye may be a part of this syndrome.


Transient angle-closure glaucoma in central retinal vein occlusion.

Two cases are presented in which unilateral transient angle-closure glaucoma accompanied occlusion of the central retinal vein. In both cases, the uninvolved eye had a wide-open angle and the involved eye demonstrated a marked anterior displacement of the lens-iris diaphragm. Short-term treatment with cycloplegics and carbonic anhydrase inhibitors resulted in a rapid and permanent deepening of both angles. The similarity of this picture to malignant glaucoma as well as possible causative factors is discussed.


Pharmacogenetics in keratoconus.

Genetic markers such as phenylthiourea (PTC) taste has been used as a simple test in genetically determined diseases. A solution of 8.1 mg PTC in 100 ml of water was used as the antimode. The incidence of nontasters in the 50 keratoconus patients tested was similar to that found in the normal population. Under the conditions of this study, a common genetic basis between PTC taste testing and keratoconus is definitely not present.


Further observations on eccentric perilimbal suction cup application.

Absence of an anemic, cystic bleb site, as well as reduced fluorescein fluorescence in this area after transcleral fistulizing surgery, infer failure. One method to create or augment bleb formation in suitable eyes is with the use of eccentric suction. This method creates localized ocular message, mobilizes conjunctiva and episclera, and provides a quantitative measure of bleb function.


Ocular oscillations.

A variety of abnormal ocular oscillations consequent to brain stem and cerebellar dysfunction are described. The brain stem eye signs include: see-saw nystagmus, convergence-retraction nystagmus, down-beat nystagmus, ocular myoclonus, ocular bobbing, and superior oblique myokymia. The "cerebellar system" eye signs discussed are five varieties of nystagmus, square wave and macro square wave jerks, macro saccadic oscillations, ocular dysmetria and flutter, and opsoclonus.


Exostosis of the mandibular coronoid process.

Abnormal enlargement of one or both mandibular coronoid processes may lead to a limited mandibular excursion. A case of unilateral coronoid process exostosis severely limiting mandibular function is described. A review of the literature pertinent to this uncommon abnormality is presented. The various entities of coronoid process osteochondroma, osteoma, exostosis, hypertrophy and developmental anomaly, all producing a similar picture of coronoid process enlargement are discussed. The proper use of the available radiographic techniques simplifies the diagnosis of these uncommon maladies, as long as a coronoid process abnormality is considered in the differential diagnosis of restricted mandibular movement.


Sensorineural hearing loss in chronic ear surgery.

The author's series of 3000 consecutive operations of tympanoplasty from 1960 to 1975 were reviewed in regard to the occurrence of sensorineural hearing loss as a consequence of the surgical procedure. Worsening of bone conduction thresholds by 10 dB through the frequencies 500 to 4000 cps, or a 10% reduction in speech discrimination scores were considered significant. Whereas in transcanal tympanoplasty the incidence of cochlear damage was greater in ears when initially the ossiculare chain was incomplete, by contrast in combined approach tympanoplasty the risk was greater when the chain was intact initially. It was concluded that cochlear trauma was usually due to 1) the hydraulic effect of excessive stapes manipulation during the removal of disease, and 2) the development of a perilymph fistula. The unpredictable predisposing threat of cochlear fragility due to genetic and inflammatory factors was emphasized and the poor results of tympanoplasty in tympanosclerosis were underlined. The current methods of treating sensorineural hearing loss after tympanoplasty were enumerated and discussed. It was concluded that although those aimed at improving labyrinthine circulation had theoretical backing, there is as yet little experimental or clinical evidence to support the claims of their protagonists.


Effect of various sensory stimuli on reflex laryngeal adduction.

Various types of sensory stimuli may influence reflex laryngeal adduction. The reccurrent laryngeal nerve responses evoked by single shock and repetitive electrical stimulation of a number of sensory nerves have been neurophysiologically observed in twenty-five adult cats. Stimulation of major cranial afferents produces strong adductor responses. The magnitude of these evoked responses is approached only by stimulation of the splanchnic nerve in the abdomen. On the other hand, comparable stimulation of special sensory and spinal somatic sensory nerves produces rapidly attenuated evoked adductor responses. We postulate that while these latter adductor responses may be insuffcient to produce strong glottic closure, they may effectively modify phonatory function of the larynx. We have, therefore, attempted to demonstrate the effects of various sensory elicitations upon reflex laryngeal adduction as they may compositely influence both protective and phonatory control of this organ system.


Microfissure between the round window niche and posterior canal ampulla.

The microfissure between the round window niche and the posterior canal ampulla was examined in fetal, child, and adult human temporal bones. The communication which was filled with mesenchymal tissue and blood vessels extending from the middle ear, was observed between the round window niche and the posterior canal ampulla in 10 to 15-week human fetuses. The mesenchymal tissue in the communication was replaced by cartilage with advancing age of the fetus. No communication was observed at birth. From newborn to 12 months of age, no microfissure was observed. After one year of age, the microfissure was first observed and the frequency of the observation increased with increasing age of the patient. After six years of age, the microfissure was observed bilaterally in 100% of cases studied. The microfissure has its origin from the communication between the round window niche and the posterior canal ampulla in fetal life, and is a normal developmental and anatomical structure, and not a pathological finding.


Clinical significance of asymmetrical vocal cord tension.

The effects of asymmetrical tension on the vibratory pattern of the vocal cords were studied in two kinds of experiments: 1) high speed motion picture photography of artificial voice production in excised canine and human larynges, and 2) computer synthesis of voice and vocal cord vibration via a theoretical model incorporating the physiological parameters required for phonation. In both approaches the asymmetrically tensed vocal cords consistently vibrated in three distinct modes which depend partly on the rest positions of the vocal cords; Type I. For rest positions at or near closure, the two cords vibrate at the same frequency with glottal closure every period, and with tense cord preceding the lax one in phase and with the line of contact moving toward the tenser cord during the closed phase. The voice produced is not hoarse; Type II. For wider rest positions glottal closure occurs irregularly, the vibrations become complex and less periodic, and the voice becomes hoarse; Type III. The glottis never closes and the vibrations become more periodic with reduced amplitude. Supplementary stroboscopic observations suggest a precedure for diagnosing tension asymmetry and the implications for surgical treatment for disorders of vocal pitch are discussed.


Response characteristics of cochlear nucleus neurons to vowel sounds.

Most studies in auditory neurophysiology have utilized tonal stimuli to determine the coding properties of neurons in the cochlear nuclei. In this investigation of the kangaroo rat, cochlear nuclei, neuronal responses to vowel sounds, as well as tones, were studied. The vowel sounds, each about 40 msec in duration were: see article. Five were linked together to form a 200 msec stimulus and various combinations of five vowel sounds provided us with 18 different stimuli. The results show that neurons in the cochlear nuclei are remarkably sensitive and selective to vowel sounds. Furthermore, the responses of these neurons to pure tones do not provide a complete basis to predict the types of responses to the vowel sounds. More significant is the finding that the neural discharge rate and pattern of discharge to a particular vowel may depend on where the vowel appears in the stimulus and what other vowel precedes it. This vowel positional effect is not the same for every neuron. We have called this phenomenon a neural "set".


Tetanus and tracheostomy.

Forty-one patients with tetanus in different stages of the disease on whom tracheostomies were performed are discussed in this paper. Out of these, 21 died, giving a mortality rate of just over 50%, which is about equal with those reported from other centers. It was found that patients in Stage III of the disease referred for tracheostomy hardly ever recovered. Patients in Stage II on whom tracheostomy was performed early stood the best chance of survival and recovery. However, if the operation was delayed in Stage II patients, there was a much greater chance for complications to develop, mostly due to aspiration of secretions into the tracheobronchial tree with consequent bronchopneumonia. There were four deaths, all in Stage III patients undergoing tracheostomy, where no definite or conventional identifiable cause could be determined. There were three deaths due to "technical failure" in tracheostomized tetanus patients, which underlines the difficulties and technical problems encountered in satisfactorily maintaining a totally paralyzed patient without any means of communication.


Pseudocellulitis of the orbit.

A case of retinoblastoma with secondary glaucoma, in which the initial clinical findings were indistinguishable from those of orbital cellulitis, is presented. Acute glaucoma, especially in childhood, may mimick suppurative disease of the orbit, and primary ocular pathology must be considered in evaluating apparent disease processes in other facial structures.


Joseph Toynbee Memorial Lecture, 1976. Tympanoplasty--four heterodox techniques.

Polarization between proponents of intact canal wall tympanoplasty and radical (modified) mastoidectomy in the treatment of cholesteatoma and other irreversible temporal bone lesions can be avoided in many cases by the use of one or more special techniques. These include (a) Gelfilm (no-graft) induction of tympanic membrane regrowth; (b) the use of tragal cartilage and perichondrium in columellization and in Type III neomyringostapediopexy; (c) the use of laboratory-prefabricated ossicular homografts to correct malleal-capitulum and malleal-footplate discontinuities more precisely; and (d) the circumferential approach (circumnavigation of patient's head) and anterior position of the surgeon in order to visualize the sinus tympani, retropyramidal, and retrofacial areas, obviating extensive posterior tympanotomy bone dissections. These techniques make possible a third alternative to the choice of either combined-approach tympanoplasty or radical or modified radical mastoidectomy in the treatment of a number of advanced temporal bone lesions.


Movement patterns of intrinsic minus fingers. Role of intrinsic and extrinsic muscles in finger posture control.

A detailed study of the patterns of two movements (pure metacarpophalangeal flexion and pure interphalangeal extension) in intrinsic minus fingers shows that the long extensors and long flexors produce simultaneous movement at the metacarpophalangeal and interphalangeal joints. A comparison of the patterns of these movements in totally intrinsic minus and interosseous minus fingers shows that in the latter the lumbricals are probably largely inactive during attempted pure metacarpophalangeal flexion and contribute to restrain metacarpophalangeal extension considerably during attempted pure interphalangeal extension. Active participation by the interosseous muscles appears necessary for completing these movements.


End-organ and drug-induced vestibular nystagmus.

The occurrence of spontaneous, positional and paroxysmal positional nystagmus was studied in patients with end-organ lesions, and in subjects with drug-induced central vestibular nystagmus. Repeated vestibular examination using electronystagmography for assessment of spontaneous and positional nystagmus in the standard head positions was carried out. The findings indicate that the paroxysmal positional nystagmus is the most frequently seen nystagmus prior to its disappearance in end-organ induced nystagmus and also the most frequently seen in drug-induced nystagmus. The direction changing type of nystagmus was very frequently encountered in end-organ lesions. These findings indicate that the type of horizontal vestibular nystagmus by itself is of no diagnostic value in localizing the site of the lesion and that the various types reflect different degrees of vestibular compensation that occur prior to their disappearance. The value of various classifications of positional nystagmus lies mainly in that they help describe the nystagmus clinically.


Management of acute intestinal ischaemia.

The acute abdomen due to a vascular catastrophe affecting the major splanchnic vessels is often a life-threatening condition that can be very difficult to diagnose. In this article the pathological and physiological changes found in large- and small-intestinal ischaemia are related to the clinical features of the illness. Radiological, biochemical, and haematological aids to diagnosis are discussed. The treatment of large- and small-bowel ischaemia and of their specific complications, such as malabsorption and gastric hypersecretion, is outlined.


Reversible sensorineural hearing loss with intravenous erythromycin lactobionate.

Three patients are presented who developed reversible sensorineural hearing losses during treatment with intravenous erythromycin lactobionate. A fourth patient treated with erythromycin gluceptate did not develop hearing loss. Ototoxicity with erythromycin lactobionate has been previously reported in only three patients, one of whom had medication orally. Withdrawal of the antibiotic resulted in prompt improvement in every case with return of hearing to pretreatment levels.


External rotational injury of tha ankle joint with displacement of the talus.

The mechanism of second-degree external rotational injury of the ankle, with fracture of the lower end of the fibula, is discussed with reference to experiments on an anatomical model. It is concluded that with this type of injury there is lateral displacement of the talus because the deltoid ligament is ruptured, but there is no diastasis of the inferior tibiofibular syndesmosis. The results of conservative treatment of 10 patients with second-degree external rotational injury of tha ankle are reviewed.


Eye-head coordination: an observation.

Voluntary or passive head movements in normal and awake individuals with or without visual clues other than prior visual fixation, produce an occular movement in the same direction as the head movement rather than the expected counter gaze movement.


Marlex mesh wrapping of abdominal aortic aneurysm.

While resection with grafting is now the operation of choice for the treatment of abdominal aortic aneurysms there is still a need for a less traumatic procedure suitable for the elderly, poor-risk patient. Such a technique is described, the aneurysm being mobilized and wrapped in a double sheet of Marlex mesh. Two illustrative cases are reported with survival for 3 years and 2 1/4 years respectively.


Catgut and polyglycolic acid. An evaluation in the human stomach.

The breaking tensions of catgut and polyglycolic acid (Dexon) sutures placed within and then recovered from the human stomach were compared on each of 5 postoperative days. A substantial difference was evident in the performance of the two materials under these conditions. The extreme variability of catgut degeneration contrasted with the constant performance of polyglycolic acid.


Anaesthesia for the neonatal pig--'the micropig'.

The use of spontaneous respiration of oxygen, nitrous oxide, and halothane via Jackson Rees's modification of Ayre's T-piece and a flexible 'snout' mask proved to be a simple and effective way of anaesthetizing neonatal pigs--'micropigs'--in the first few days of life without resorting to endotracheal intubation. No airway obstruction occurred as long as the head was extended with firm traction on the jaw and provided the nostrils were not pressed up against the wall of the mask. The anaesthetic technique described provided adequate muscle relaxation and analgesia for extensive abdominal surgery. The animals recovered rapidly and there were no postoperative complications.


Periodic (Pel-Ebstein) fever of lymphomas.

During lymphomatous diseases, bouts of intermittent or relapsing Pel-Ebstein fever occasionally repeat in remarkably regular tempo resembling the episodes of benign periodic fever. Febrile episodes alone, especially during acute lymphomatous disease, occasionally precede overt evidence of underlying disease for months. In that event, diagnosis and treatment of lymphomas are delayed. Regular febrile bouts are either uniquely characteristic of lymphomas or represent the imposition of periodic fever. Apprehension of malignant disease during benign periodic fever may induce intensive investigation. Malignant disease has not ensued in reported cases of periodic fever.


Dose-response and time-response study of erythrocytosis in rats after intrarenal injection of nickel subsulfide.

Erythrocytosis was induced in Fischer rats by intrarenal (ir) injection of nickel subsulfide (Ni3S2) in dosages ranging from 0.6 to 10 mg per rat. Measurements of blood packed cell volume (PCV) became increased by one month after ir injection of Ni3S2; reached maximum values at approximately two months; and gradually returned to control values by seven months. The duration and magnitude of erythrocytosis were related to the dosage of Ni3S2. Increases in hemoglobin concentrations and erythrocyte counts (RBC) in Ni3S2-treated rats were consistently proportional to blood PCV values. Blood hemoglobin concentration was 24.9 +/- 1.2 g per dl at two months after bilateral ir injection of Ni3S2 (10 MG PER RAT), VERSUs 15.8 +/- 0.5 g per dl in saline-injected controls (P less than 0.001). No significant changes occurred in leukocyte or platelet counts of Ni3S2-treated rats. Autopsy of rats killed two months after ir injection of Ni3S2 showed marked erythroid hyperplasia of bone marrow and fibrotic needle tracts in renal parenchyma with localized deposits of particles of Ni3S2. In contrast to the erythrocytosis induced by ir injection of Ni3S2, administration of Ni3S2 by intramuscular (im) injection (10 mg per rat) had no significant effect upon blood PCV, RBC or hemoglobin values or upon morphology of bone marrow.


Dermatomyositis: ultrastructure of abnormal mitochondria in the skeletal muscle.

The mitochondrial anomalies observed in the skeletal muscle of a patient with dermatomyositis included paracrystalline inclusions, dense bodies and stacks of lamellae. Virions were not found. These anomalies are similar to those noted in other myopathies.


Rapid analysis of cefazolin in serum by high-pressure liquid chromatography.

A high-pressure liquid chromatography (HPLC) method has been developed for the analysis of cefazolin in serum. Serum was deproteinized by the addition of 6% trichloroacetic acid and injected onto a reverse-phase column with a mobile phase of 10 to 15% methanol in 1% aqueous acetic acid. Cefazolin chromatographed without interference from ultraviolet-absorbing components of serum, with a retention time of 3.1 min. Standard curves comparing peak area with concentration prepared from dog or human sera were linear over a range of 1.6 to 200 mug/ml. Results from the HPLC assay were compared with microbiological assays (cylinder plate method) on both standard serum samples and sera from dogs and human subjects receiving intramuscular cefazolin. The HPLC method was somewhat more accurate in comparison with the microbiological assay performed on serum samples of known concentration. The comparison of results from an analysis of serum levels of dogs or human subjects receiving cefazolin indicated that the two methods would lead to identical conclusions concerning pharmacokinetics or the achievement of therapeutic serum levels. The HPLC assay method presents an alternative to conventional microbiological assays, with marked improvement in speed (30 min) and considerable potential for future development.


Quality control of gamma counters. I. Experimental evaluation of sources of error.

Errors of counting rate as large as 2 percent may occur through variations in instrumental parameters during the measurement of I-125 activity using a gamma counter. Much larger errors result from failure to maintain constant sample geometry; in particular, the slope of calibration curves depends on sample volume.


Radioimmunoassays for monitoring exposure to potential carcinogens.

As the numbers and production of environmental pollutants and hazardous industrial compounds increase, the necessity for monitoring the environment and workplace to avoid or to limit human exposure to toxic substances becomes more urgent. In support of the occupational safety program at the National Center for Toxicological Research, very sensitive and specific radioimmunoassays for measuring two known animal carcinogens, 2-acetylaminofluorene and diethylstilbestrol and their metabolites were developed. Radioimmunoassay (RIA) techniques offer unique advantages over ixisting methodologies in the field of toxicology; these include exquisite specificity and sensitivity, simplicity in sample handling and rapid analysis. These RIAs are currently being used for monitoring possible human exposure to carcinogenic compounds.


Comparative penetration of amikacin, gentamicin, and penicillin g into exudate fluid in experimental sterile peritonitis.

Using a rabbit sterile peritonitis model, we compared the penetration of intravenously administered amikacin, gentamicin, and penicillin G into peritoneal exudate. Peritonitis was induced with sterile normal saline, and the peritoneal exudate contained 23,751 +/- 3,039 granulocytes 8 h later. Antibiotics were administered intravenously 3 h after initiating peritonitis, and serum and peritoneal fluid concentrations were measured for 5 h. Peritoneal levels of each antibiotic exceeded simultaneous serum levels by 1 h after dose and remained above serum levels thereafter. The maximum peritoneal fluid concentration of amikacin reached 71.2% +/- 12.7 of the maximum serum concentration, whereas maximum gentamicin peritoneal concentration achieved 37.1% +/- 2.7, and penicillin achieved 23.2% +/- 4.5, of their respective maximum serum concentrations.


Measurement of digoxin by radioimmunoassay.

A sensitive, specific and precise procedure for the measurement of digoxin by radioimmunoassay is presented. The method is rapid, convenient and highly reliable for this very important measurement. Studies designed to evaluate the validity and reproducibility of the assay are presented and discussed.


Renal disease from exposure to solvents.

Exposure to a variety of solvents may result in renal disease. Tubular renal disease with anuria occurring fairly promptly after exposure is most commonly seen. There is evidence that some cases of glomerular disease, such as extra-capillary glomerulonephritis and membranous nephropathy, may be causally related to chronic solvent exposure. Their detection may be impeded by the prolonged latent period between exposure and onset of disease, the non-specificity of the glomerular lesions and the non-availability of a history of exposure.


Antimicrobial activity in vitro of netilmicin and comparison with sisomicin, gentamicin, and tobramycin.

The antimicrobial activity of netilmicin, a new semisynthetic aminoglycosidic aminocyclitol, was determined against 123 recent gram-negative clinical isolates susceptible to gentamicin and 60 isolates resistant to either sisomicin, gentamicin, or tobramycin. The minimal inhibitory concentrations and minimal bactericidal concentrations of netilmicin, sisomicin, gentamicin, and tobramycin against Pseudomonas, Escherichia coli, Klebsiella, Enterobacter, Proteus mirabilis, and indole-positive Proteus were, in general, quite similar. Gentamicin was the most active against Serratia. A total of 54, 67, and 88% of gentamicin-resistant Pseudomonas, Serratia, and Klebsiella, respectively, were susceptible to netilmicin. Strains of indole-positive Proteus, Acinetobacter, Providencia, and E. coli resistant to gentamicin were likely to be resistant also to netilmicin.


Pharmacokinetics of amoxicillin: dose dependence after intravenous, oral, and intramuscular administration.

Amoxicillin was studied in normal subjects after intravenous, oral, and intramuscular administration of 250-, 500-, and 1,000-mg doses. Serum drug levels were analyzed using a two-compartment open model, as well as area under the curve (AUC) and urinary recovery. The variations of these pharmacokinetic parameters were then examined using the three-way analysis of variance and linear regression equations. These results confirmed nearly complete oral absorption: AUC was 93% of intravenous absorption, and urinary recovery was 86%. The intramuscular administration of amoxicillin results in complete and reliable absorption with peak drug levels, AUCs, and urinary recovery equivalent to oral dosage. The absorption of lyophilized amoxicillin after intramuscular injection resulted in an AUC that was 92% of intravenous absorption and urinary recovery of 91%. The peak serum levels, time to peak, and other pharmacokinetic parameters for intramuscular injection were nearly identical to those for oral administration. Kinetics of both intramuscular and oral administration exhibited dose-dependent absorption (absorption rate constant, 1.3/h for 250 mg and 0.7/h for 1,000 mg). This resulted in relatively later and lower peak serum levels for increasing dose. Total absorption, however, showed no dose dependence, as indicated by urinary recovery and AUC, which changed by less than 10%.


Effects of amphotericin B on macrophages and their precursor cells.

The effect of amphotericin B (AmB) treatment on the mononuclear phagocyte system of mice was investigated. Peritoneal macrophages from mice that received AmB treatment showed a higher phagocytic and antibacterial activity than those from normal untreated mice. When the levels of macrophage precursor cells in bone marrow and spleen were followed in mice after AmB treatment, an eightfold increase in the splenic content of limited stem cells for both macrophages and granulocytes (colony-forming units in culture) and a threefold increase in the number of pluripotent hemopoietic stem cells (colony-forming units in spleen) were observed on day 4. These were also accompanied by a slight increase in the colony-forming units in spleen and in culture in femoral marrows. AmB was capable of inducing a large number of peritoneal colony-forming cells in the peritoneum, and caused a significant rise in the serum level of colony-stimulating factor. No significant change in the level of blood monocytes was noted, although a transient increase in the proportion of neutrophils was observed within 24 h after AmB treatment.


Inhibitory effects of ATP on platelet aggregation: cation interaction and shape change.

Adenosine triphosphate (ATP) has more than one effect in its inhibition of platelet aggregation. In addition to its direct competition with adenosine diphosphate (ADP), ATP may suppress the aggregation mediated via a cation interaction and a restoration of platelet shape.


Susceptibility of Propionibacterium acnes to seventeen antibiotics.

The in vitro susceptibility of 96 isolates of Propionibacterium acnes to 17 antibiotics was determined by utilizing an agar dilution technique. With the exception of the aminoglycosides, these organisms are susceptible to virtually all of the commonly used antimicrobial agents.


Mechanisms of gentamicin resistance in Staphylococcus aureus.

Three clinical isolates of Staphylococcus aureus resistant to gentamicin and other aminoglycosides have been examined for antibiotic modifying enzymes. The strains contain a number of these enzymes, most of them similar to those commonly found in aminoglycoside-resistant gram-negative strains. All three strains (and a transductant derived from one of them) contain two enzymes mediating gentamicin resistance, an aminoglycoside 6'-N-acetyltransferase and a novel enzyme, gentamicin phosphotransferase.


Laboratory evaluation of FR10024 a new cephalosporin derivative.

FR10024 is a broad-spectrum antibiotic. The in vitro antibacterial activity of FR10024 against clinical isolates of Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis is greater than that of any of the cephalosporins developed to date. Indole-positive Proteus, Enterobacter, and Citrobacter are resistant to FR10024, as is true for the other cephalosporins. However, more than half of the strains of Enterobacter and Citrobacter tested were susceptible to FR10024 at an inoculum of 10(6) cells/ml. A single subcutaneous injection of FR10024 to mice with peritoneal infections due to S. aureus and several species of gram-negative bacilli gave a protective effect inferior to that of cefazolin but appeared to be superior to that of cephalothin. When given in two divided doses, however, the protective effect of FR10024 was enhanced and almost equaled that of cefazolin. The serum levels and rates of urinary recovery of FR10024 varied in different animal species. The mean peak serum level of FR10024 in humans after a single intramuscular injection of 500 mg was two times higher than that of cephalothin. The serum half-life after intramuscular injections of 250 and 500 mg was slightly shorter than that of cephalothin. After receiving 250 mg of FR10024 intramuscularly the urinary recovery rate was 87.7% in healthy volunteers. The biliary excretion rate of FR10024 was particularly high. The 24-h excretion of FR10024 in rats was 63.3%, this being six to seven times higher than that for cefazolin, which has the highest biliary excretion of the other known cephalosporins. When FR10024 was injected intramuscularly (20 mg/kg), it was found that the hepatic levels of FR10024 in rats were the highest of all the cephalosporins, including cefazolin, but the levels of FR10024 in other tissues were not as high as those of cefazolin.


In vitro studies with netilmicin compared with amikacin, gentamicin, and tobramycin.

Netilmicin, a new semisynthetic aminoglycoside derived by ethylation of the 1-N position of the deoxystreptamine ring of sisomicin, was tested in vitro with 4,070 strains of gram-negative bacilli isolated at the UCLA Medical Center during 1975 to 1976, using the agar dilution technique and an inoculum of approximately 10(4) organisms. Results were compared with those simultaneously obtained for amikacin, gentamicin, and tobramycin. Using Mueller-Hinton medium, inhibitory concentrations in broth correlated with those obtained by the agar dilution method except for Pseudomonas aeruginosa, where a 2- to 16-fold difference in susceptibility was noted. For most clinically significant Enterobacteriaceae and P. aeruginosa, the activity of netilmicin in vitro was comparable or superior to that of gentamicin, tobramycin, and amikacin with respect to potency by weight and achievable blood levels. Against gentamicin-resistant strains (MIC > 16 mug/ml), the activity of netilmicin paralleled that of amikacin with the exception of Providencia stuartii, which was inhibited by amikacin but not by netilmicin.


Mezlocillin: in vitro studies of a new broad-spectrum penicillin.

Mezlocillin is a new semisynthetic penicillin that inhibited 71% of the isolates of Serratia marcescens, 67% of Escherichia coli, 50% of Enterobacter spp., and 49% of Klebsiella spp. at a concentration of 12.5 mug/ml. It is also active against both indole-positive and -negative Proteus spp. and gram-positive cocci, except penicillin G-resistant Staphylococcus aureus. At a concentration of 100 mug/ml, it inhibited 94% of the isolates of Pseudomonas aeruginosa. It is more active than ampicillin, carbenicillin, and cephalothin against some gram-negative bacilli.


Comparative in vitro activity of nafcillin, oxacillin, and methicillin in combination with gentamicin and tobramycin against enterococci.

The in vitro activity of nafcillin, oxacillin, and methicillin alone and in combination with gentamicin and tobramycin against 30 strains of enterococci was investigated. The penicillinase-resistant penicillins were less active than penicillin and ampicillin against the enterococci. Nafcillin was more active than oxacillin and methicillin. Sixty-six percent of strains were inhibited by nafcillin at 6.25 mug/ml, but none was inhibited by oxacillin and methicillin at the same concentration. At 12.5 mug/ml, 83, 16, and 0% were inhibited by nafcillin, oxacillin, and methicillin, respectively. By using a variety of criteria and analyses, it was shown that none of the antibiotic combinations studied demonstrated enhanced killing of all strains of enterococci. Nafcillin-gentamicin was the best combination, and enhanced killing was demonstrated against most strains. Oxacillin was more effective than methicillin when combined with gentamicin. Tobramycin was probably less effective than gentamicin in combination with the penicillinase-resistant penicillins against enterococci.


Evaluation of various analogues of tilorone hydrochloride against Venezuelan equine encephalitis virus in mice.

The antiviral activity of tilorone hydrochloride and three of its analogues (11,002, 11,567, and 11,877) was assessed by oral and intraperitoneal (i.p.) administration to Venezuelan equine encephalitis (VEE) virus-infected mice. Significant increases in the percentage of survival (P < 0.01) were apparent after oral administration of tilorone and analogue 11,877 at dosages of 250 and 500 mg/kg. Neither tilorone nor 11,877 increased percentage of survival when dosages of 31.25 to 500 mg/kg were given by the i.p. route. Orally administered analogue 11,002 was effective against 100 mouse intracranial median lethal doses (MICLD(50)) of VEE virus at doses at 250 to 1,000 mg/kg; doses of 31.25 to 250 mg/kg given i.p. were effective against 10 MICLD(50). Oral dosages of 250 to 1,000 mg of analogue 11,567 per kg were active against 100 MICLD(50) of virus. By the i.p. route, 250 mg of 11,567 per kg protected mice against 1,000 MICLD(50), and a dose of 125 mg/kg protected against 100 MICLD(50). Oral treatment of VEE infection with analogue 11,567 24 h after subcutaneous inoculation of VEE virus resulted in no significant increase in the percentage of survivors. All survivors of these studies were susceptible to rechallenge 21 days after the first inoculation of virus.


Enteropathogenicity of Vibrio parahaemolyticus in the ligated rabbit ileum.

The enteropathogenicity of Vibrio parahaemolyticus was investigated by contrasting the effects of whole cells, cell fragments, cell-free preparations, and media constituents injected into rabbit ileal loops. Three of 20 cultures utilized were Kanagawa-negative strains from seawater and sea fish. The remaining 17 cultures included both Kanagawa-positive and -negative strains from Japanese victims of gastroenteritis. Broth culture filtrates concentrated 10-fold by dialysis against 30% Carbowax were unreactive, whereas lyophilized filtrates, regardless of Kanagawa type, as well as all sterile broth preparations containing greater than or equal to 5% NaCl gave positive reactions in the rabbit gut. In contrast, crude lysates derived from broth cultures of Kanagawa-positive strains caused loop dilatation; lysate supernatants were unreactive. Lysates of cells washed from brain heart infusion agar were more reactive than lysates from Trypticase soy agar-grown cells. When agar-grown cell lysates prepared by disruption in saline were dialyzed against distilled water, they were devoid of gut reactivity. Reactivity was restored in dialysands resuspended in saline and in dialysates concentrated 10-fold. The agar-grown cell lysates exhibited Kanagawa-type hemolysis. Our data support the conclusion that the rabbit loop reactivity observed with lyophilized, cell-free culture filtrates may result from excessively elevated NaCl concentrations, and that a toxic factor associated with large-cell particles may be dialyzable, depends on saline for expression, and resembles the Kanagawa hemolysin.


Conidiogenesis and secondary metabolism in Penicillium urticae.

Submerged cultures of Penicillium urticae (NRRL 2159A) produced the antibiotics patulin and griseofulvin when grown in a glucose-nitrate medium. A high concentration of calcium (i.e., 68 mM) inhibited the production of both antibiotics while stimulating conidiogenesis. Conidial mutants that were defective in an early stage of conidiogenesis produced markedly less patulin, even under growth conditions that favored secondary metabolism. A mutant which lacked the ability to produce the patulin pathway metabolites m-cresol, toluquinol, m-hydroxybenzyl-alcohol, m-hydroxybenzaldehyde, gentisaldehyde, gentisyl alcohol, gentisic acid and patulin, as well as the pathway enzyme m-hydroxybenzyl-alcohol dehydrogenase, still produced yields of conidia that were equivalent to or greater than those of the parent strain. Other mutants which were blocked at later steps of the patulin pathway also produced conidia. These results indicate that patulin and the other related secondary metabolites noted above are not a prerequisite to conidiogenesis in P. urticae. Environmental and developmental factors such as calcium levels and conidiogenesis do, however, indirectly affect the production of patulin pathway metabolites.


Chemically defined medium for Rothia dentocariosa.

A chemically defined medium for Rothia dentocariosa has been established. All strains tested, including the type strain, grew well in this medium. Rothia strains had a generation time of 3.5 to 4.0 h, with a yield of 62 mg (dry weight) per 100 ml after 72 h of growth in the chemically defined medium.


Two plating media modified with Tween 80 for isolating Yersinia enterocolitica.

MacConkey agar modified with Tween 80, and deoxyribonuclease agar modified with Tween 80 plus sorbitol were used in differentiating Yersinia enterocolitica colonies from other lactose-negative bacterial colonies.


Microbial transformation of 8-chloro-10,11-dihydrodibenz(b,f)(1,4)oxazepine by fungi.

The microbial transformation of 8-chloro-10,11-dihydrodibenz(b,f)(1,4)oxazepine (compound I) was undertaken to obtain new derivatives. Compound I was transformed by Hormodendrum sp. (NRRL 8133) to 8-chloro-10,11-dihydrodibenz(b,f)(1,4)oxazepine-11-one (compound II) and 2-(2-amino-4-chlorophenoxy)benzyl alcohol (compound IV). Microbial cleavage of the nonaromatic ring to form compound IV was accomplished by several other fungi. Compound I was transformed to 8-chlorodibenz(b,f)(1,4)oxazepine (compound III) by Hormodendrum cladosporioides (NRRL 8132).


End products and fermentation balances for lactic streptococci grown aerobically on low concentrations of glucose.

Maximum acetate produced aerobically by Streptococcus diacetilactis and Streptococcus cremoris was 14% of 1 to 7 mumol of glucose/ml in a partially defined medium that contained lipoic acid. Y (glucose) values were 35.3 (S. diacetilactis) and 31.4 (S. cremoris) with low concentrations (1 to 7 mumol/ml) of glucose in the medium and 21 (S. diacetilactis) with higher concentrations (6 to 15 mumol/ml). Y (adenosine 5'-triphosphate) values for the bacteria, determined by taking into account the end products produced, were 15.6 and 13.9 for S. diacetilactis and S. cremoris, respectively, in the partially defined medium containing 1 to 7 mumol of glucose/ml and higher (21.5 and 18.9, respectively) in a complex medium that contained 2 mumol of glucose/ml. Addition of citrate in addition to glucose did not result in higher molar growth yields.


Isolation and identification of fecal bacteria from adult swine.

An examination of the fecal microflora of adult swine was made with regard to the efficiency of several roll tube media in enumeration and recovery of anaerobes, the effects of medium constituents on recovery, and the isolation and identification of the predominant kinds of bacteria. Total number of organisms by microscopic bacterial counts varied among fecal samples from 4.48 X 10(10) to 7.40 X 10(10) bacteria/g (wet weight). Comparison of different nonselective roll tube media indicated that about 30% of the fecal bacteria could be recovered with a rumen fluid (40%, vol/vol) medium (M98-5). Recoveries of 21 and 15%, respectively, were obtained with M10 and rumen fluid-glucose-cellobiose agar (RGCA) media. Rumen fluid, Trypticase, sugars, and CO2 gas phase were important components required for maximum recovery with this medium. Similar high recoveries of anaerobes were also obtained with M98-5 containing swine cecal extract of place in rumen fluid or M10 plus swine cecal extract. Significantly lower recoveries were observed with RCGA, media supplemented with swine fecal extracts, reinforced clostridial medium, brain heart infusion agar, and prereduced blood agar. Ninety percent of the bacteria isolated from roll tube media were gram positive and consisted of facultatively anaerobic streptococci, Eubacterium sp., Clostridium sp., and Propionibacterium acnes. The remainder of the flora (8%) included several other species of anaerobes and Escherichia coli. Rumen fluid (or volatile fatty acids), Trypticase, and yeast extract additions to basal media stimulated the growth of anaerobic strains. Variation in the relative proportions of the predominant fecal microflora was observed. This work indicates that satisfactory enumeration, isolation and cultivation of the predominant microflora in swine feces can be obtained when strict anaerobic culture methods and a rumen fluid medium are used.


Aerobic microbial flora of intertrigenous skin.

The incidence and density of intertrigenous microflora were determined in subjects using nonmedicated soap. The axilla, groin, toe web, and finger web were examined. The incidence of gram-negative rods was 17% for the axilla, 13% for the groin, 10% for the toe web, and 9% for the finger web. Klebsiella, Proteus, and Enterobacter were the predominant organisms, in that order. The highest incidence of Staphylococcus aureus was in the groin (12%) and toe web (11%). Lipophilic diphtheroids were the most prevalent bacteria in the groin (1.1 X 10(6)/cm2) and toe web (1.2 X 10(6)/cm2). Nonlipophilic diphtheroids were the predominant flora in the axilla (1.3 X 10(7)/cm. Micrococci had the highest counts in the toe web (7.6 X 10(5)/cm2). The incidence of coagulase-negative staphylococci was highest in the finger web, but the major flora were those of micrococci.


Fibrosing alveolitis in infancy and childhood.

Fibrosing alveolitis is a rare, diffuse lung disease characterized by varying combinations of two histological features: thickening of alveolar walls and the presence of large mononuclear cells in the alveolar spaces. Clinical details of 10 children with fibrosing alveolitis are reported. The main symptoms in children are tachypnoea or dyspnoea, cough, poor weight gain, and cyanosis. The condition is similar to that in adults, but it is usually a more acute illness, and if untreated, more predictably fatal. Respiratory failure, pulmonary hypertension, and cardiac failure are the major complications. Less commonly, superimposed bacterial infection and pneumothorax occur. Chest x-rays often show a sequence of changes with a ground-glass appearance and fine mottling in the early stage of the disease, progressing to a picture of mainly hilar linear markings in those children who recover. The histological features at lung biopsy or necropsy are described; these correlated poorly with the radiological features, steroid responsiveness, and clinical course. Lung function tests in 3 older children showed evidence of markedly reduced lung volumes in 2. Static lung compliance in 4 children in the acute stage of the illness was normal in 3 and diminished in one. The response to steroid therapy was analysed in cases from the literature and the 10 reported cases. No spontaneous remissions occurred, all the survivors having been treated with corticosteroids. In children fibrosing alveolitis is almost always a corticosteroid-responsive disease. An appropriate course of prednisolone would be of at least 4 week's, but preferably of 8 weeks' duration, at a minimum daily dose of 2 mg/kg. After improvement the steroid withdrawal should be cautious and protracted, comprising at least a year's continuous treatment.


Natural history of Hartnup disease.

Hartnup disease was diagnosed in 12 children and 3 of their 15 sibs in the course of routine urine screening of 6-week-old infants in New South Wales. These children were followed for up to 8 years, during which time there were only two clinical episodes which might be ascribed to Hartnup disease. The mental development of all the children was normal. 10 had height centiles less than the midparent height centiles, while 4 had centiles equal to or above the midparent centiles. The study shows that in children with Hartnup disease in Australia symptoms are very uncommon. Mental development is normal, and heights are possibly slightly below that expected. Hartnup disease has an incidence of approximately 1 in 33 000 in New South Wales.


Absorption and endogenous faecal excretion of calcium by low birthweight infants on feeds with varying contents of calcium and phosphate.

Low birthweight infants aged 4-41 days were given from birth one of three experimental milk formulae varying widely in content of calcium and phosphate. Ca and P in feed, urine, and faeces were measured between carmine markers corresponding to a metabolic period of 48 hours. Calcium enriched in 46Ca to provide a marker for the dietary Ca was added to one feed and 46Ca measured in urine and faeces. True absorption of Ca and endogenous excretion into the bowel could then be inferred. True absorption of Ca was proportional to Ca intake and independent of P intake. Endogenous faecal excretion seemed to be independent of both Ca P intakes, and varied widely between different infants in the range 4-150 mg/day. Urine Ca was low and retention was essentially the difference between true absorption and endogenous faecal excretion. Retention of Ca tended to be much greater on a high Ca intake, but the variability in retention between infants on a given intake was large, paralleling the variability in endogenous faecal excretion. The variability in plasma Ca concentrations in newborn infants may in part be a consequence of wide individual variability in endogenous faecal excretion. The 46Ca marker technique provides a means of investigating the factors determining this variability.


Urinary and faecal excretion of marker calcium (46Ca) by low birthweight infants.

Low birthweight infants were given calcium enriched in 46Ca in a single feed. The specific activity of successive urine samples showed that the absorption of the marker was largely complete in about 4 hours. The rate of decrease of urinary specific activity after 3 1/2 hours was exponential and very similar in 8 sets of observations in 6 infants. Its extrapolation backwards to 1 hour may indicate the size of the exchangeable calcium pool, usually about 200 mg/kg body weight. Completeness of faecal collection for estimation of 46Ca is essential for accurate determination of true absorption and endogenous faecal excretion of natural Ca. In 5 infants examined, nor marker was detectable in faeces excreted later than 48 hours after the first stool containing marker. Nevertheless, reasons are given why a collection period limited to 48 hours may sometimes involve error.


Peritoneal dialysis in children. Review of 8 years' experience.

During the years 1968-75, 59 periods of peritoneal dialysis were performed on 44 children aged from 2 days to 17 years. The commonest complication was peritoneal infection, which affected 68% of those under 2 years and 30% of older children. This was satisfactorily treated in all but one case which was due to Candida albicans. The use of combined intramuscular and intraperitoneal gentamicin therapy is described. 2 patients died as a result of massive intraperitoneal haemorrhage and one had a nonfatal intestinal perforation. In experienced hands peritoneal dialysis is a convenient, effective, and reasonably safe way of treating acute renal failure; it is best performed in centres capable of handling complex metabolic problems and investigating and treating the underlying renal disease.


Evaluation of a new mineral and trace metal supplement for use with synthetic diets.

In an earlier study (Alexander et al., 1974) it was shown that the mineral mixture used in association with a synthetic diet was deficient in zinc, copper, iron, and manganese. A new mixture containing appropriately increased amounts of these trace metals has now been evaluated by means of metabolic balance studies carried out on children with phenylketonuria. This new mixture was shown to be satisfactory for zinc, copper, and iron, but minor changes have been recommended for manganese.


Use of a simple duodenal capsule to study upper intestinal microflora.

The upper intestinal microflora was studied in 10 malnourished Indonesian children using the paediatric Enterotest Capsules. Trophozoites of Giardia lamblia were found in 2 specimens, profuse fungal mycelia in 3, and ascaris worms and eggs in 1. In 9 patients an abnormally profuse small intestinal bacterial flora was found. Provided precautions are taken to exclude artefactual contamination of the line on its withdrawal, this is a safe and simple method for studying the upper gut flora which could be applied to field conditions since it does not require radiological facilities.


Hepatic dysfunction in association with pancreatic insufficiency and cyclical neutropenia. Shwachman-Diamond syndrome.

A patient with pancreatic insufficiency and cyclical neutropenia is described who also has evidence of hepatic dysfunction. He and 3 other patients whose findings are given emphasize the wide range of abnormalities seen in this syndrome.


Velocity of head growth during the perinatal period.

Growth velocity of head circumference was studied longitudinally in different gestational age groups of 222 appropriate-weight-for-dates (AFD) and 94 small-for-dates (SFD) healthy infants during the first 5 months of life. Term AFD and SFD infants showed a steady slowing of growth rate of head circumference from birth. In contrast, preterm AFD infants of less than 36 weeks' gestation showed an increasing velocity of growth followed by slowing, with maximum velocity occurring between 30 and 40 days after birth. The shorter the postconceptional age at birth the later maximum velocity occurred. However, those preterm AFD infants of between 30 and 33 weeks' gestation who were given a high caloric feed showed a similar velocity curve to that of infants of 34-37 weeks of gestation. Cross-sectional data were used to estimate growth velocity of head circumference in the fetus. Two conclusions emerged. First, there is a slowing of head growth velocity from 31 weeks' gestation in utero, and second, term infants show a marked increase in volocity after birth. Though the occurrence of maximum velocity of head growth is delayed in the preterm infant, the net effect is such that at a given postconceptional age his head circumference is greater than that of the term infant, at least within the first 5 postnatal months.


Factors which influence the timing of maximum growth rate of the head in low birthweight infants.

The postnatal rate of head growth in 63 infants of less than 34 weeks' gestation was examined retrospectively, together with that of 7 other infants of between 34 and 40 weeks' gestation who had severe respiratory illnesses. From the serial measurements of head circumference the timing of maximum velocity of postnatal head growth was examined and related to the infant's gestational age, nutrition, and respiratory illness during the neonatal period. Within this group of infants the longer the gestation the earlier maximum head growth velocity occurred. For infants of similar gestational ages the presence of a severe respiratory problem was associated with a delay in the time of maximum head growth. Differences in caloric intake during the first week of life did not seem to affect significantly the timing of maximum head growth velocity.


The tall girl. Prediction of mature height and management.

The arrest of excessive tallness in girls with hormonal therapy has been reported to be useful, but lack of accuracy in the prediction of ultimate stature based on the tables of Bayley and Pinneau (1952) has allowed only a rough evaluation of its benefits. A series of 40 tall girls were treated with oestrogens and mature stature was evaluated by the method of Tanner et al. (1975). Results were compared with those obtained in a previous study made in 1966 where Bayley and Pinneau tables were used.


Choledochal cyst in infancy and childhood. Analysis of 16 cases.

Choledochal cyst was diagnosed before operation in 14 out of 16 infants and children by means of a combination of diagnostic tests. Ultrasonic echogram showed a cystic mass in all 11 patients examined. The characteristic displacement of the duodenum was noted in 9 of 14 patients by contrast studies of the upper gastrointestinal tract, and hepatobiliary scintiscanning confirmed choledochal cyst in 7 of 8 patients (88%). A cyst was shown by oral or intravenous cholangiography in 3 of 4 patients. Onset of symptoms occurred from 7 days of age to 9-5 years; in 10 patients  onset occurred under 12 months of age, in 3 from 13 to 24 months, and in the remaining 3 from 2 to 9-5 years. The first symptoms were jaundice, vomiting, acholic stools, and poor sucking. Obstructive jaundice and acholic stools were found in more than 80% of the patients, and abdominal mass in 60%. Vomiting occurred in 50% of the patients, one-third of whom showed failure to thrive, and 70% of patients over the age of 1-5 years had abdominal pain. About half of the patients had a mild to moderate degree of fever. In all patients primary excision of the cyst was followed by hepaticojejunostomy in Roux-en-Y fashion. The postoperative course was uneventful in 14 patients; 2 patients died, one from ascending cholangitis and one from hepatic failure.


Viruses and febrile convulsions.

In 276 children admitted to hospital with febrile convulsions a wide range of virus types was identified by means of nasopharyngeal secretions and cough/nasal swabs. The overall virus identification rate was 49%. Analysis of age, sex, family history, and past history showed no marked differences between the virus-positive and the virus-negative children. More than 80% had symptoms of respiratory infection in association with their convulsions, whether or not a virus was identified. Convulsions were not apparently more severe in the virus-positive group. Rapid virus diagnosis was found helpful in the management of children with febrile convulsions. The virus aetiology of many febrile convulsions has implications both for hospital cross-infection and for research into methods of prevention.


Infantile spasms and early immunization against whooping cough. Danish survey from 1970 to 1975.

113 cases of infantile spasms were diagnosed in the period 1 April 1970 to 31 March 1975 after Denmark changed her immunization programme. Previously whooping cough vaccine was given as the triple combination at 5, 6, and 15 months of age. From 1 April 1970 it was given as a monovalent vaccine at 5 and 9 weeks of age and at 10 months of age. A comparison with previous material of 86 cases of infantile spasms from 1957 to 1967 showed no change in the age at onset. Though there may be an occasional connection between immunization and infantile spasms, the most important factor is a time-coincidence between any immunization given at a certain age with the neurological disorders which are natural for that age.


Polypoidal organization of aspirated amniotic squamous debris(amnion nodosum) in middle-ear cavity of newborn infants.

The development of polypoidal structures, derived from organization of amniotic squamous debris, in the middle-ear cavity of 3 infants is described. The lesions mimicked the development of amnion nodosum lesions of the placenta and were attached to either the tympanic membrane or the head of the stapes. They were accompained by atypical metaplastic changes in the middle-ear epithelium. While the clinical significance of the structural changes is uncertain, they strengthen the case for histopathological examination of the middle ear in infant necropsies.


Powder aspiration in children. Report of two cases.

Two cases of powder aspiration are reported. A 7 1/2-month-old girl showed a classical course with an asymptomatic period of 3-4 hours, then severe respiratory distress developed. Acute respiratory insufficiency made tracheal intubation and mechanical ventilation necessary for 10 days. Complications included insufficient alveolar ventilation, atelectasis, pneumothorax, and superinfection. But the baby recovered with some residual radiological changes in the lungs. A 13-month-old boy was treated immediately after massive powder aspiration by tracheal intubation and bronchial wash-out. The postoperative course was unevetful and no respiratory distress developed. Powder aspiration leads to severe bronchiolar obstruction with a delay of several hours and has a high mortality rate. The best results in treatment are obtained by immediate intubation and bronchial wash-out, even in the absence of respiratory symptoms. Artifical ventilation may be necessary with the special problem of overcoming very high airway resistance. Corticosteroids and bronchodilators may be helpful.


Serum thyrotrophin determination on day 5 of life as screening procedure for congenital hypothyroidism.

In 327 newborns cord blood thyroxine (T4) was 11.8 +/- 0.4 mug/100 ml (SEM) (151.9 +/- 5.1 nmol/l), and serum thyrotrophin (TSH) 6.7+/-1.0 muU/ml. Variability was marked for both T4 and TSH. Remeasured in the same patients on the fifth day of life, the TSH level was 3.7 +/- 1.0 muU/ml, lower than at birth (P less than 0.001), while scattering of TSH values was much smaller, with 99.4 % of values less than 12 muU/ml...


Prognosis for infants weighing 1000 g or less at birth.

During the 10 years 1966-1975, 148 infants weighing less than or equal to 1000 g were admitted to the Neonatal Unit of University College Hospital. 48 (32%) survived the neonatal period. The neonatal survival rate for infants weighing less than or equal to 750 g was 8% and for infants weighing 751-1000 g, 41% 9 infants died later, leaving 39 (26%) long-term survivors, all of whom are being followed-up. The progress of the 27 older children, born in 1966-74 (median birthweight 899 g, range 648-998 g; median gestational age 28 weeks, range 24-35 weeks), was assessed at ages between 15 months and 8 years (median 3 years). No abnormalities were detected in 21 infants (78%): 2 (7%) had major handicaps and 4 (15%) minor handicaps. We conclude that provided intensive care methods are available, the prognosis for infants weighing less than or equal to 1000 g is now better than in the past.


The effects of prostaglandins E1 and F2alpha on epidermal growth.

The effects of prostaglandins E1 and F2alpha (PGE1 and PGF2alpha) on the growth of guinea pig epidermis have been studied in vivo. The prostaglandins were injected intradermally into guinea pigs, and tritiated thymidine was injected intraperitoneally prior to sacrifice. The autoradiographic labelling indices (L.I.) were assessed and  a significant increase was found 4 h after injection of PGE1 -an effect which lasted for up to 72 h. PGF2alpha injections had no significant effect on the L.I.


Psoriasis and insulin secretion. Preliminary results.

We have studied psoriatic subjects with normal weight and with overweight without inherited diabetic familiarity. The results seem to indicate the existence in psoriasis of an endogenous insulin-resistence. In this prospective the hypothesis that psoriasis carries a diabetogen risk is suggested.


The nature and frequency of the histological changes found in psoriasis vulgaris.

A total of 272 biopsies (from psoriatic lesions with a diameter of 2-10 cm) were performed on 178 psoriasis patients. Sections from these biopsies were stained with haematoxylin-eosin and by the PAS and trichrome techniques. Each section was investigated for the presence or absence of para- and hyperkeratosis, acanthosis, mitoses, intercellular edema and spongiosis of the epithelial ridges, edema at the top of the connective tissue-papillae, the number of leucocytes penetrating the epidermis at the top of these papillae, classical Munro abscesses, abscesses in the horny layer and Kogoj spongiform pustules, and the results were noted. It was found that the site of the biopsy in the psoriasis lesion, the location of the psoriasis lesion from which material for biopsy was taken and the moment of time during the course of the disease at which the biopsy was performed, had no influence on the histological signs observed in a given patient. In other words, the histological picture of psoriasis plaques from 2-10 cm found in a given patient exhibits a high degree of constancy. Some evidence was found indicating that signs of latent psoriasis may probably be present in the healthy skin of a psoriasis patient. It is generally assumed that the epidermis above the connective tissue-papillae in cases of psoriasis is thinner than normal. Our investigation showed that the reverse is the case: the thickness of the epidermis in the psoriasis efflorescences is significantly greater than in healthy skin nearby in the same patient.


Results of reflex photometric determinations of vasoconstriction after topical steroid application. Tachyphylaxis, relative and absolute refractory phase after single and multiple application of steroid.

After a repeated intensive topical application (4-h rhythm), there it is phase already after 28 h in which the cutaneous vessels are insensitive (refractory) to constrictor stimuli due to steroids. This refractory phase lasts for at least 68 h. A single local application of steroid likewise leads to a diminished vasoreactivity for a limited time. The relative refractory phase is limited to 96 h under the given experimental conditions.


The influence of fluocortolone treatment on the collagen content in guinea pig skin.

Specific pathogen free guinea pigs were treated with varying dosis of fluocortolone for 15 days. The treated animals showed the same per cent weight gain as the controls. The total hydroxyproline content of the skin and the hydroxyproline content in different collagen fractions was the same in treated and untreated animals. Thus fluocortolone seems to have no specific effect on the synthesis or the breakdown of collagen in the guinea pig skin. Also the physical development of the animals, kept under defined conditions, failed to show a catabolic effect of of fluorcortolone.


The role of acid esterase in the pathogenesis of xanthoma. A histochemical study in rabbits.

Previous studies of our group indicated that two types of cells are involved in the pathogenesis of atheroma. The one type, myocytes, are poor in acid esterase activity, store lipid droplets which they cannot hydrolyze and are transformed into foam cells. The other type, macrophages, are rich in this enzyme activity, can and do hydrolyze the esters with possible healing by fibrosis. In the present study the importance of acid esterase activity in experimental xanthoma in hyperlipidemic rabbits was studied. Perithelial cells of small blood vessels were found to be poor in acid esterase activity and to contain bulky lipid masses. With time, increasing numbers of cells with high enzyme activity were found mainly at a distance from the vessels. These cells, which mostly contained finely emulsified lipids are believed to be macrophages. Thus, in both atheroma and xanthoma, vessel wall cells take a "passive" part in formation of the lesion, while blood borne cells play a role in disposing of the lipid with eventual possibility of healing.


[Histopathology and histochemistry of psoriasis under photochemotherapy (author's transl)].

Fifty-two biopsies from involved and clinically normal looking skin of patients with psoriasis vulgaris and from normal control subjects, all being treated with 8-MOP-UVA (PUVA) were obtained between days 2 and 300. The following parameters were investigated: 1. initial PUVA effects; 2. initial regression of psoriasis under PUVA-therapy; 3. late effects of PUVA-therapy on regression of psoriatic lesions; 4. EFFects on melanocytes and pigmentation; and 5. long-term effects of PUVA-therapy. Paraffin embedded and cryostat sections were prepared with routine stains for light microscopy and enzyme histochemical special stains. The regression of psoriatic lesions following PUVA-therapy was separately assessed for epidermal and dermal components. The sequence of events was as follows: re-establishment of a continous stratum granulosum, re-establishment of a continuous normal appearing stratum corneum, regression of acanthosis and papillomatosis, and regression of inflammatory infiltration. During the initial phase of PUVA-therapy there is a sharp increase of melanocytes which leads to a foamy appearance of the basal cell area. Long term studies did not reveal actinic damage of the skin, neither in the epidermis (absence of actinic keratoses or squamous cell carcinomas) nor in the dermis (absence of actinic "solar" elastosis).


[Anastomoses and epitheloid vessel-wall cells of lymph nodes close to the skin (author's transl)].

A report is given on age-related changes found in special morphological areas of the hilus vessels. These vessels, together with the physiological involution of lymph node parenchyma, are of importance for the deposition of melanoma cells. The hyperplasia of epitheloid cells of the vessel walls in the lymph node capsule as well as their possible misidentification as micro-metastases of melanoma cells is discussed.


Daily variation in air quality.

We related year-round air pollutant concentration in three small U.S. towns, with considerable differences in population density and industrial activity, to air temperature, wind direction, wind speed, rainfall, sky conditions, and days of the week (workdays vs. pended particulates) concentrations can be explained by changes in weather conditions. During weekends, pollution did not decrease consistently and, in some instances, may have increased as a result of dense recreational traffic. We suggest that recognition of the multifactorial causation of high levels of air pollution may lead to more realistic, more effective, and less costly air pollution ocntrol programs.


Radionuclide assessment of LeVeen shunt patency.

Patients with an initially satisfactory result following placement of a LeVeen peritoneo-venous shunt for intractable ascites may reaccumulate massive ascites. Determination of the etiology of such is a difficult problem. We describe a simple method using intraperitoneal injection of Technetium--99m sulfur colloid and three gamma camera scintiphotos of the chest and abdomen to allow prompt determination of shunt occlusions as the cause.


Fluoride in treated sewage and in rain and snow.

The liquid effluent of a sewage treatment plan contained 1.21 ppm ionic and total fluoride, which was higher than 1.0 ppm fluoride in the fluoridated public water supply. The discharge of the effluent into a river did not greatly raise the fluoride content of the river water because of dilution and other factors. The semisolid waste of sewage treatment also contained fluoride, but very little was volatilized on burning. Rain and snow were found to contain detectable quantities of fluoride, and the fluoride content of snow increased markedly during exposure to an urban environment.


Biosynthesis of methylmercury compounds by the intestinal flora of the rat.

The contents of the rat cecum and, to a lesser extent, those of the small intestine, synthesized methylmercury from mercuric chloride labeled with Hg 203 in vitro under aerobic or anaerobic conditions. The rate of formation was approximately 18 ng/g cecal contents/20 hr. The synthesis of methylmercury was inhibited by antibiotics and by filtration of the cecal contents through membrane filters, indicating that the bacterial flora of the gut participates in the reaction. Pure cultures of bacteria, isolated from the intestinal tract of the rat, could methylate mercuric chloride. It was estimated that the total amount of methylmercury synthesized from ingested inorganic mercury in man in approximately 400 ng/day.


Reoperation for postsurgical peptic ulcer recurrence: appraisal of ten years' experience.

Between January 1, 1965 and December 31, 1974, 47 patients were treated at the University of Florida Affiliated Hospitals for peptic ulcer after a generally acceptable ulcer operation. Twenty-seven patients had had vagotomy and drainage, four patients had had vagotomy and antrectomy and 16 patients had had partial gastric resection. Forty-nine definitive operations were performed with a 4% operative mortality. Three patients (7%) had another ulcer recurrence following surgery. Left transthoracic vagotomy is the treatment of choice when recurrent ulceration follows subtotal gastrectomy or vagotomy and antrectomy. For ulceration following vagotomy and drainage, antrectomy, antrectomy is preferred. Synergism between hormonal and neural gastric stimulants causes a decreased parietal cell responsiveness to vagal stimulation after antrectomy. Exploration of the hiatus at the time of antrectomy increases the morbidity of the procedure. Should ulcers recur after antrectomy, vagotomy may be performed with a low morbidity through the transthoracic approach.


Thoracic outlet syndrome in whiplash injury.

Thirty-five cases of thoracic outlet syndrome complicating whiplash or cervical strain injury were studied. Thirty cases had confirmation by the demonstration of slowed ulnar nerve conduction velocity (UNCV) through the thoracic outlet. Two distinct groups of patients were found. An acute group, seen an average of 3 1/2 months post injury, had severe neck pain with often mild or incidental thoracic outlet syndrome. A chronic group, with symptoms persisting more than 2 years after cervical injury, often had thoracic outlet symptoms as the predominant complaint. This study suggests that the arm aches and parethesias seen in association with both acute and chronic cervical strain injury are most often secondary to thoracic outlet syndrome.


The reservoir ileostomy: early experience with 54 patients.

Reservoir and ileostomies were performed in 54 patients between 1972 and 1975. Primary colonic pathology included chronic ulcerative colitis in 47 patients, Crohn's colitis in one, familial polyposes in 5 and Gardner's Syndrome in one. Followup is complete and varies from 6 months to three years. All but three patients are completely continent to feces; only one of these three requires the occasional use of a stomal appliance. There were no mortalities. Complications included suture line dehiscences, small intestinal obstruction or prolonged paralytic ileus, and hemorrhage from the reservoir. All complications were successfully treated and removal of the ileal reservoir was not required in any patient. These complications and steps which may be taken to avoid them are discussed. In addition, indications and contraindications for surgery are enumerated. It is well documented that both the colonic polyposes and long standing chronic ulcerative colitis are premalignant diseases. The availability of a continent, reservoir ileostomy as an alternative to the standard, incontinent, stoma has significantly reduced patient resistance to colectomy, and permitted earlier surgery.


Evaluation of outdoor air quality in rural and urban communities.

A year-round air monitoring program for sulfur dioxide, sulfates, nitrogen dioxide, nitrates, ozone, and total suspended particulates was conducted in three towns with population densities ranging from 29/km2 to 1178/km2. The results showed significant differences in concentrations of several pollutants between the urban town and the two rural towns. However, site-to-site variation over distances of 1 mile or less within the urban area was considerable. To express pollutant loads in each town in a single number, we calculated a combined pollutant index on premises similar to those used for combined occupational exposures, but with U.S. primary air quality standards rather than threshold limit values as indices of minimal health effects. The combined index exceeded unity in all three towns, suggesting either that total pollutant loads may be excessive even in the sparsely populated town of Lebanon, Connecticut, or, more likely, that the U.S. primary air quality standards have been set at low levels without due regard for additive effects.


Cholecystostomy in the high risk patient with biliary tract disease.

The morbidity of complications and mortality following surgical operations for nonmalignant disease of the biliary tract is greatest among those 65 years and older. The reported overall mortality regardless of age ranges upward from 0.88%. At The New York Hospital-Cornell Medical Center for a 43-year period (1932-1975) it was 1.77%. For those 65 and older it was 5.1%. For patients with acute cholecystitis it was 3.5% and of those in this category 65 and older it was 9.2%. This experience and that reported from other comparable clinics is the basis for advocating that the procedure selected be within the capacity of the patient to tolerate it. Specifically a cholecystostomy, a compromise procedure, may be lifesaving for the presenting situation deferring cholecystectomy until  later. Admittedly the more effectual approach is undelayed definite surgery when calculous disease is demonstrated.


Collagen breakdown and nitrogen dioxide inhalation.

Measurements of urinary hydroxylysine glycosides indicate that considerable collagen degradation occurred during the reentry into the earth's atmosphere of the American astronauts of the Apollo-Soyuz mission. Since the crew accidentally inhaled nitrogen dioxide, a recognized pulmonary irritant, and showed clinical and roentgenographic signs of diffuse chemical pneumonitis, it is likely that collagen degradation occurred in the pulmonary parenchyma.


Cranial nerve injuring during carotid endarterectomy.

Injury to the greater auricular, hypoglossal and superior laryngeal nerves during carotid endarterectomy is preventable. A knowledge of regional anatomy and the mechanisms of such injury allows prevention of this complication. Unilateral individual nerve injury is generally well tolerated, but bilateral or combined nerve injuries can pose a serious threat to life. Minor modifications in technique aid greatly in avoiding nerve injury.


The surgically treated chronic gastric ulcer: an extended followup.

Since the overall results of the medical management of chronic gastric ulcer are discouraging, the records of 595 patients with chronic gastric ulcers who underwent surgical treatment at the Mayo Clinic from 1961 through 1965 were reviewed. Gastric and duodenal ulcer (or scar) occurred together in 18%. Partial gastric resection was the predominant surgical procedure employed. There was an uneventful postoperative course in 83.2% of patients. Early complications occurred in 16.8%, death in 1%, and early reoperation in 3.4% of patients. Followup extended from 1 to 14 years. Late complications occurred in 31.1% of patients. The overall results, graded according to a modified Visik classification, were excellent in 31.9%, good in 48.4% and unsatisfactory in 8.1%. In patients undergoing partial gastrectomy for "channel ulcers", the incidence of reo 1% recurrence rate for ulcers elsewhere in the stomach, with or without truncal vagotomy. For the majority of gastric ulcers, partial gastric resection, with or without vagotomy, remains theoretically advantageous and clinically proven.


Gastric fistula following splenectomy: its cause and prevention.

Gastro-cutaneous fistula following splenectomy, a rare but serious occurrence, may result in death or prolonged disability. Six previous cases have been reported in detail, while 8 others have been mentioned briefly. The current report reviews the literature and describes 4 additional instances of this complication. Two of the 4 patients died. Sever factors, acting singly or incombination, may predispose to the development of post-splenectomy gastrocutaneous fistulas. These include direct surgical trauma to the gastric wall, generalized arteriosclerotic disease, hematoma in the gastrosplenic omentum, and reflection of gastric muscle fibers into the gastrosplenic ligament. The usual site of rupture of stomach is along the greater curvature in the fundic portion. In circumstances in which splenectomy is associated with known or suspected compromise of the blood supply to this portion of the stomach, a method of enfolding the greater curvature is proposed to prevent the development of a gastro-cutaneous fistula. Awareness of the possibility of this uncommon but serious complication will aid in its early recognition and treatment.


Environmental air and airborne infections.

The results of a study on the epidemiology of airborne (aerobic) surgical infections are presented. The first phase of the study was carried out in a surgical suite which contained no environmental or traffic control systems. The second phase of the study took place within a modern "up to date" operating room suite containing multiple air screens as well as an elaborate ventilation system utilizing HEPA type filters which provided the operating room with clinically sterile air. One hundred and fifty-six patients were also studied. All patients underwent major procedures. The ratio of clean, clean-contaminated, and dirty cases was the same in both groups. Preoperatively, a nasal swab, clean voided urine (or vaginal swab) and a rectal swab were obtained on each patient. Daily nasal cultures and cultures of suspected sites of infection were obtained postoperatively. Daily nasal cultures and "glove sweat" cultures were obtained on all personnel attending the patient. Environmental cultures of the operating room, the operating room hallway, recovery room and patients' rooms were also taken. All samples were checked for the presence of staphylococci, streptococci, Escherichia coli, proteus species, enterobacter, klebsiella, and pseudomonas. In all, 15,000 cultures were taken during the study. The rate of infection was essentially the same in both phases of the study. Environmental air only occasionaly served as the source of infecting organisms. The results of the study support the conclusion that the most common source of infecting organisms in surgical infections is thepatient or those around him. The most common time of contamination is during the surgical procedure itself. Surgical infections can best be minimized by meticulous observation of fundamental principles of antisepsis rather than by dependence on elaborate and costly ventilation and air control systems.


Preoperative demonstration of pancreatic fistula by endoscopic pancreatography in a patient with pancreatic ascites.

Endoscopic pancreatography was useful in demonstrating pancreatic ductal obstruction, fistula, and pseudocyst in the preoperative evaluation of a patient with pancreatic ascites. Surgical exploration confirmed the preoperative findings and Roux-en-Y cystojejunostomy was performed. Some salient features of pancreatic ascites are discussed.


Hemobilia following percutaneous transhepatic cholangiography.

Percutaneous transhepatic cholangiography is a safe, effective diagnostic procedure for use in evaluating the jaundiced patient. As is the case with most invasive diagnostic procedures there is a risk: an overall mortality rate of 0.5% and morbidity rate of 3-10%. Fortunately hemobilia is an uncommon complication, encountered only four times in our series of 102 percutaneous cholangiograms. In every case of hemobilia the clotting parameters were normal. The one factor common to each case was distal obstruction of the extra hepatic bile ducts. However, this one factor may play an important role in the etiology and therapy of post cholangiographic hemobilia. The hemorrhage subsided spontaneously in every case following surgical decompression of the bile ducts and there was no further active bleeding postoperatively. The possible explanation for the cause of bleeding and the fact that it subsided following demcompression of the bile ducts is discussed. All four patients survived this complication and in the 102 patients there were no deaths attributable to percutaneous transhepatic cholangiography.


Preoperative intra-aortic balloon support in surgery for left main coronary stenosis.

Twenty-six patients with left main coronary (LMC) stenosis were operated upon with preoperative intra aortic balloon pump (IABP) support. There was no mortality, and no morbidity attributable to the balloon catheter. The most delicate facet of revascularization surgery in this entity is the pre-cardiopulmonary bypass phase including anesthesia induction during which blood pressure fluctuation may further diminish severely compromised coronary flow. Although systolic pressure dropped to below 100 mm Hg in 50% of patients during induction, there were only two patients with electrocardiographic evidence of perioperative myocardial infarction, and only one who needed rantic institution of cardiopulmonary bypass just after induction. Perioperative logistics were quite trouble free in all 26 patients, in marked contrast to 5 LMC patients operated upon prior to our preoperative IABP concent; 3 of these deteriorated upon induction, with two deaths resulting. Preoperative IABP is a reasonable supportive adjunct in surgery for LMC stenosis.


Carcinoma arising in the wall of a breast cyst during pregnancy.

A 23-year-old patient developed a carcinoma in the wall of a breast cyst during the second trimester of an otherwise uncomplicated pregnancy. A review of the literature revealed 7 reported cases of carcinoma of the breast arising in a cyst wall. However, none of these these cases has been associated with pregnancy. The relationship of fibrocystic disease and carcinoma of the breast is discussed. The possible influence of pregnancy and age on the prognosis of this patient are also considered.


Takedown and reconstruction of cavopulmonary anastomosis.

Takedown and reconstruction of a previous Glenn anastomosis at the time of repair was performed in 1 child with pulmonary atresia and ventricular septal defect and in 3 children with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis. All 4 survived and showed excellent clinical results. The surgical technique and postoperative hemodynamic and lung scintigraphic data are presented.


Coronary obstruction secondary to direct cannulation.

Four patients are reported with obstruction of the proximal left main coronary artery that developed following prosthetic replacement of the aortic valve. Angina pectoris and ventricular arrhythmias were the presenting clinical manifestations. Anterior descending coronary artery bypass was used in 3 of the patients and vein patch angioplasty in the fourth. One patient died in the hospital. The 3 survivors achieved reflief from angina and ventricular arrhythmias. One patient died from nephropathy 2 1/2 years later. Two patients remained asymptomatic 1 1/2 and 3 years later, respectively. This review emphasizes the need for prompt coronary angiography in patients experiencing angina pectoris after aortic valve replacement, and it shows that coronary revascularization can be performed with satisfactory results.


Resolution of surgically induced right bundle-branch block.

In a retrospective study, the serial electrocardiograms of all patients with surgically induced right bundle-branch block (RBBB) were reviewed. None of these patients had had RBBB prior to operation. Seven patients who had RBBB from 6 to 16 days after operation showed resolution in ECGs done 3 to 8 months later. Two patients are reported, with documentation by vectorcardiogram, in whom RBBB resolved by 3 and 12 years after operation. The origin of transient forms of RBBB may be different from the long-standing form. If RBBB of long duration is due to operative injury to the proximal right bundle, Purkinje fiber network, or distal branch or branches of the right bundle, or to combinations of these tracts, one may speculate about the possibility of regeneration of the right ventricular conduction system. Since no data are available concerning the long-term prognosis of RBBB and since a progressive conduction disturbance can occur, the resolution of RBBB after many years might carry a better prognosis than its persistence.


Pulmonary hydatid disease: report of 100 patients.

One hundred patients with pulmonary hydatid disease underwent thoractomy and operative removal of the cysts. Of the 60 men and 40 women, most were between 3 and 19 years old. Cough, fever, dyspnea, and chest pain were the prominent symptoms in the majority of cases. Intact hydatid cysts were found in 67 patients and infected or ruptured cysts in 33. The Casoni skin test, Weinberg reaction, and eosinophilia were found to be unreliable diagnostic criteria and therefore were not used routinely in our patients. Roentgenological examination was the most valuable diagnostic aid. A single lobe was affected in 72 patients. Unilateral multiple foci were present in 15 patients and bilateral multiple foci in 13. Cystectomy and capitonnage were the preferred operative procedures in most cases. Pulmonary resection was necessary to only a limited number of patients. We conclude that conservative surgical methods such as cystectomy (with or without capitonnage) are preferable, especially for children, whose residual lung parenchyma has great capacity for expansion. The mortality rate among our 100 patients was 2%; both died of cardiac arrest during operation.


How to shorten, lengthen, or untwist saphenous vein grafts.

A simple method is described to correct saphenous vein bypass grafts that inadvertently have been made too long or too short or have become twisted. The essential feature of the technique is the use of a Satinsky vascular clamp to hold the divided ends of the vein and maintain their alignment during the repair. The most accessible portion of the vein is used as the site for the repair, leaving the aortic and coronary artery ends of the graft intact. While we have not had need to use the technique frequently, we have found it to be a simple method and believe it to be useful when such instances arise.


Ventricular septal defect due to septal infarction after repair of tetralogy of fallot.

A case is reported of ventricular septal defect resulting from septal infarction following repair of a tetralogy of Fallot. The infarct probably resulted from division of a septal coronary artery during resection of the hypertrophied infundibulum. The superficial position of the septal artery on the right side of the septum in tetralogy makes it surprising that this complication has not been previously reported.


Candida albicans infection of sternum and costal cartilages: combined operative treatment and drug therapy and 5-fluorocytosine.

Two patients with candidal sternal osteomyelitis have been successfully treated by operative debridement and adjuvant drug therapy with 5-fluorocytosine. One patient had developed postoperative candidal wound infection after sternotomy, and the other acquired candidal sternal osteomyelitis following Candida fungemia. The diagnosis, suggested by culture, was confirmed by identification of Candida pseudohyphae in debrided tissue. Histological confirmation of candidal sternal osteomyelitis indicates the need for operative debridement and specific systemic antifungal therapy. The drug 5-fluorocytosine appears to provide effective oral therapy in this situation.


Oxalosis and chronic renal failure after intestinal bypass.

A 45-year-old man underwent a jejunoileal shunt procedure for obesity. Twenty months later he developed severe oxalosis and chronic renal failure, which required maintenance hemodialysis. The sequential observation of two biopsy specimens and the necropsy (over a span of 39 months) suggests that oxalate deposition caused tubular obstruction and destruction with subsequent atrophy of nephrons. This indicates that patients undergoing intestinal bypass are at risk for developing irreversible renal failure due to enteric hyperoxaluria.


Human chorionic gonadotropin (HCG) treatment of obesity.

After a nine-day control period, six hospitalized obese women were placed on 500 calorie diets and were given 125 IU of human chorionic gonadotropin (HCG) intramuscularly daily for 30 days. Another five obese women received injections of diluent only and consumed identical diets for the same period. Mean weight loss in the HCG-treated group was nearly identical to that achieved by women given the placebo. Reduction of triceps skinfold thickness or circumferential body measurements of the chest, waist, hips, and thighs were not different. Patters of change of a variety of plasma and urine substrates, electrolytes, and hormones were similar in the two groups and consistent with semistarvation and weight loss. These results indicate that HCG has no effects on chemical and hormonal parameters measured and offers no advantage over calorie restriction in promoting weight loss.


Multifocal atrial tachycardia.

Multifocal atrial tachycardia (MAT) was observed in 41 patients, 35 of whom were in acute respiratory distress. A hospital mortality of 37% reflected the seriousness of their underlying conditions. In no patient was the arrhythmia the primary cause of death. The MAT preceded and/or followed atrial fibrillation (AF) or atrial flutter (Af) in 19 patients (46%). The MAT simulated AF in several cases in which P-waves were inconspicuous. Our cases suggest that MAT is not a manifestation of digitalis intoxication. Quinidine sulfate, procainamide hydrochloride, lidocaine, and phenytoin (diphenythydantoin) did not affect the rhythm. Digitalis was usually not effective in slowing the ventricular response in patients with MAT. Propranolol hydrochloride was given to seven patients and was effective in slowing the atrial rate in all cases. An attempt at electrocardioversion was unsuccessful in one patient.


Familial atrial tachyarrhythmia with short PR interval.

A family had an unusual and perhaps unique familial dysrhythmia. The proband had a short PR interval with normal QRS and chronic recurrent paroxysmal atrial tachycardia (Lown-Ganong-Levine syndrome). The arrhythmia produced left ventricular dysfunction. Both paroxysmal atrial tachycardia (PAT) and left ventricular dysfunction were reversed with administration of digoxin and propranolol hydrochloride. Three family members had paroxysmal or chronic atrial fibrillation, first diagnosed at a relatively young age (23 years, 38 years, and early 40s, respectively). Five additional family members had short PR intervals with normal QRS, and eight other family members had borderline short PR intervals. The mode of inheritance appeared to be autosomal dominant with varying expressivity. We have described a familial syndrome characterized by PAT or atrial fibrillation in its advanced form with short PR interval as a possible identifying trait. The future course of members with isolated short PR is unknown.