Platelet and fibrinogen survival in coronary atherosclerosis. Response to medical and surgical therapy.

Survival times of chromium-51 platelets and iodine-125 fibrinogen were determined in 58 men with documented coronary atherosclerosis. Compared with findings in a control group of 28 men of similar age, mean platelet survival time was selectively shortened (6.8 +/- 1.8 [standard deviation] days versus 9.0 +/- 1.0 days; P less than 0.0001) without a decrease in fibrinogen survival time. More than half of the patients (31 of 58) had a platelet survival time of less than 7.0 days (2 standard deviations from the mean survival time in control subjects). Mean platelet survival time improved toward normal in nine patients after coronary revascularization (preoperative 5.1 +/- 0.9 days, postoperative 7.1 +/- 1.5 days; P less 0.001) and in 13 patients after administration of dipyridamole and acetylsalicylate (4.8 +/- 0.5 days versus 7.0 +/- 0.8 days; P less than 0.001). We conclude that selective platelet consumption occurs in atherosclerotic coronary vessels of some patients and that medical or surgical intervention may inhibit this process.


The human coronary microcirculation: an electron microscopic study.

The ultrastructure of the terminal vascular bed of human coronary arteries was studied in the myocardial tissue obtained at surgery from different locations in the heart in five patients. The following vessels were identified: (1) Arterioles; slender and prolonged endothelial cells, flat nuclei and two to three layers of smooth muscle cells. (2) Precapillary sphincters: short endothelial cells, large nuclei bulging into the lumen, close myoendothelial junctions and a single layer of circular smooth muscle. (3) Capillaries: composed of one or more slender endothelial cells. (4) Venules: flat endothelial cells and nuclei, no muscular layer, rich collagen tissue. The function of these structures is believed to be as follows: the arterioles are the smallest blood-distributing arteries in the heart. The precapillary sphincters control blood flow to the capillaries; pressor substances present in the blood are picked up by endothelial cells, pass rapidly through the myoendothelial junctions and cause contractions of the smooth circular muscle layer; the bulging nuclei of endothelial cells then passively obstruct the lumen almost completely. The main exchange of gases and nourishing substances takes place in the capillaries. We postulate that in some pathologic conditions, abnormal constriction of the sphincters may cause diminished flow and be the basis for some well defined or unclear ischemic events.


Aortic implantation of anomalous left coronary artery arising from pulmonary artery.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare and usually fatal congenital malformation. Most surgical attempts to correct this anomaly have been unsuccessful, particularly those in infants. Recently, four patients underwent reimplantation of an anomalous left coronary artery into the aorta; all four survived the operation and are asymptomatic. This technique of reimplantation of the aberrant vessel into the aorta appears to be prefereble to other methods of repair, especially since it can be applied in any patient with the anomaly regardless of age or size. Because of the poor prognosis for patients with anomalous left coronary artery, surgical intervention should be made as soon as the diagnosis is made.


Formation and turnover of plasma membrane glycoproteins in kidney tubules of young rats and adult mice, as shown by radioautography after an injection of 3H-fucose.

The formation and turnover of the glycoproteins of the plasma membrane have been investigated by quantitative radioautography in the kidney tubules of young rats and adult mice killed at various time intervals after an intravenous injection of 3H-fucose. In young (40 g) rats killed five to ten minutes after the injection, radioautographs of distal tubule cells show that the Golgi apparatus contained about 85% of the cell label. By 30 hours, only 8% of the label remained in this organnele, whereas 67% was in the plasma membrane, indicating that most of the label had migrated from Golgi apparatus to this membrane. Similarly, in proximal tubule cells, about 82% of the label was initially in the Golgi apparatus, but less than 2% remained at 30 hours, at which time 78% was in the plasma membrane. In the latter cells, the apical tubules and vacuoles became heavily labeled before the apical microvilli did and, therefore, may be involved in the transit of label from the Golgi apparatus to the microvillous membrane. The results are interpreted to mean that, in kidney tubule cells, the Golgi apparatus is the site of a continuous incorporation of fucose into glycoproteins and that these migrate to the plasma membrane. In fully formed cells, such a conclusion would imply a continuous turnover of plasma membrane glycoproteins. However, in the rapidly growing kidney of young rats many new cells are added daily, the growth of which might involve net addition as well as turnover of glycoproteins. Accordingly, the experiment has been repeated in adult mice, in which the cells are assumed to be fully formed. Furthermore, since turnover implies eventual decrease of incorporated label, some of the animals have been killed at longer intervals, up to 27 days after injection. In these adult mice, as in young rats, prompt Golgi uptake and subsequent migration of label to the plasma membrane were observed in distal and proximal tubules cells. With time the label content of the plasma membrane decreased gradually, and by 27 days had virtually disappeared. From grain counts, it is concluded that the mean half-life of glycoproteins in the apical membrane of distal tubule cells is about two days, whereas in both the apical and basal membranes of proximal tubule cells, it is slightly over three days.


Freeze-fracture study of the carotid body.

Replicas of freeze-fractured rat carotid body chief (Type I) cells reveal the normal complement of cytoplasmic organelles. En face fractures of the chief cell plasmalemma exhibit occasional sites of fusion of the amine-containing vesicles which characterize the carotid body. The endothelial cells lining the capillary network of the carotid body display numerous pinocytotic vesicles often oriented in linear arrays, and occasional fenestrae. The endothelial cells are joined together by tight junctions which appear as grooves (B face) forming a continuous network over the membrane.


Phytochemical properties and hypotensive mechanism of extracts from Gardenia jasminoides seeds.

An improved extraction method was used to obtain hypotensive principles from seeds of Gardenia jasminoides Ellis (Rubiaceae). The crude extract contained mainly glycosides and had minimal direct cardiac depressant effects. The hypotensive action was attributable to a reflex phenomenon, involving both the parasympathetic and the sympathetic vasomotor centers. It was shown that the hypotensive and bradycardiac properties of Gardenia extract were entirely abolished in a tropinized and vagotomized rats, but only partially attenuated in carotid sinus denervated rats, and that low cervical spinal transection in rats did not inhibit the hypotensive responses. Accordingly, the afferent limb of this cardiovascular reflex are consisted of both vagus nerves and baroreceptor afferents, whereas the vagi alone constituted the efferent limb.


Therapeutic effect of acupuncture for chronic pain.

The purpose of this report concerned with the activities of the acupuncture clinic at UAB during the past 2 years and 3 months, is to objectively assess the role of acupuncture in the treatment of various pain disorders for which conventional pain relieving methods had failed to yield satisfactory results. In carefully analyzing the data provided by the patients through completed questionnaires, an attempt was made to look at the results obtained as unbiased as possible and to determine whether it is justified to continue the acupuncture activities at UAB or terminate them. From the data presented it appears that acupuncture helped in more than 50 percent of the patients by either completely or partially controlling the suffering from painful disorders. Patients helped by acupuncture received 8.55 treatments on the average, while patients not helped by acupuncture only received 4.75 treatments. There is little difference between the male and female patients as to the response to acupuncture. However, we noticed that the younger the patient and the shorter the duration of their problems, the better the response. Patients who had not had surgery to treat the pain syndrome responded better than those who had previous surgery. Patients with backache who had previously had laminectomy showed better response to acupuncture than the patients who had spinal fusion. It appears that good general health plays an important role in favorably responding to acupuncture treatment. It is apparent from this survey that acupuncture may be a valuable extension of a conventional pain clinic and an alternative in patients who are desperate in their desire to get relief from pain which they failed to obtain from other methods.


Lidocaine injection of auricular points in the treatment of insomnia.

By combining knowledge in modern medicine and traditional Chinese medicine, auricular points were selected for treatment of insomnia. Instead of the placement of needles, injection of small amounts of Lidocaine into these sites was employed. Fifteen out of 16 patients obtained substantial improvement and one patient received moderate improvement. The therapeutic effect was maintained three months after the end of the treatment series. The physiological and clinical implications of this study in terms of modern medicine and traditional Chinese medicine are also discussed.


Treatment of cluster headache by acupuncture.

The case history of a thirty year-old woman with cluster headache is reported. After various methods of treatment had failed, she was treated by acupuncture.


Acupuncture in two cases of peripheral nerve paralysis.

This is a report on a case of peripheral paralysis of the right side of the larynx. The patient was a 34 year-old male who became completely aphonic following a grippal infection. After 3 weeks of conventional treatment by a well-known specialist, he underwent acupuncture treatment. After 4 months the voice was again normal; however, the laryngoscopy showed a completely normal larynx only 7 months after the illness. The loci used and the reasons for their selection are discussed in detail. The second case was a 62 year-old male with facial paralysis. This patient underwent acupuncture treatment shortly after he was stricken. After 6 days distinct improvement was seen; he was completely healed after 2 months. The loci and the reasons for their selection are discussed. The cases are compared.


Infection in newborn siblings.

Two newborn siblings, one with meningitis and one with sepsis due to Listeria monocytogenes, were born to a healthy, 33-year-old woman. She had had a spontaneous abortion prior to the birth of these infants. In spite of negative cultures, persistence of this bacterium in the mother's genital tract and perinatal acquisition of infection is suspected.


Regional planning of hospital facilities for children.

The quest for constraint of health care costs has combined with the quest for better distribution of specialized child health services to emphasize the need for facility planning that considers the needs and resources of an entire region. This article describes the guidelines derived through one such planning effort and the process through which they were derived. The process can, we believe, be replicated or modified for planning pediatric hospital facilities or other health care facilities in other regions of the country.


General revenue sharing funds for the health care of mothers and children.

In a study of the use of General Revenue Sharing (GRS) funds by the states and by cities of 100,000 and over in the United States for fiscal years 1973 and 1974, we found that few states and large cities allocated or requested GRS funds for Maternal and Child Health (MCH), Crippled Children (CC), and related services. One third of the states and cities reported suggestions for use of GRS funds for MCH, CC, and related services.


Quadriceps contracture as a result of multiple intramuscular injection.

Quadriceps contracture in children can result from multiple intramuscular injections. We describe here seven patients with this complication. These patients were unable to completely flex the involved knee. At surgery, extensive fibrosis of the quadriceps muscle was found. Lengthening of the scar and contracted muscle and tendon restored a good deal of flexion. If long-term antibiotic treatment is anticipated, the intravenous route should be employed if possible.


Pneumoperitoneum in the extremely low-birth-weight infant: successful nonoperative treatment.

Pneumoperitoneum without associated pulmonary air leak occurred in two extremely preterm, low-birth-weight infants. These infants were considered too critically ill to tolerate surgical exploration. Accordingly, they were treated medically and supportively, with excellent results.


Defective neutrophil chemotactic responses in patients with recurrent episodes of otitis media and chronic diarrhea.

Fourteen patients who had repeated episodes of otitis media and diarrhea were evaluated to determine if a defect in the host defense mechanism could account for the unusual incidence of infection. Each of the patients with recurrent otitis media and diarrhea had a profound defect in neutrophil chemotactic responsiveness. The mean chemotactic index of the patients was 21 +/- 6, while that of 25 controls was 62 + 10. Other neutrophil functions, lymphocyte T-cell populations, immunoglobulins, and complement components were normal in the patients. Serum IgE levels were also normal. The presence of a defect in neutrophil chemotaxis in these patients with recurrent otitis media and chronic diarrhea suggests that the phagocyte may play an important role in protection of the mucosal surfaces of the respiratory and gastrointestinal tracts.


Oculocraniosomatic neuromuscular disease with hypoparathyroidism.

During a six-year period, an adolescent girl developed a polyglandular disease characterized by hypoparathyroidism, chemical diabetes, growth failure and pubertal delay, hypercholesterolemia, and hypomagnesemia. A slowly progressive neurological disorder occurred simultaneously, consisting of progressive external ophthalmoplegia, mitochondrial myopathy, ataxia, neural deafness, mental subnormality, atypical retinitis, corneal dystrophy, cataract, and increased protein level in the cerebrospinal fluid. An intracardiac conduction defect was also found. This disorder, the cause of which is uncertain, is termed oculocraniosomatic disease. Our patient is apparently unique in that there was an associated hypoparathyroidism.


The Tromso heart study: risk factors for coronary heart disease related to the occurrence of myocardial infarction in first degree relatives.

In a population survey for risk factors associated with coronary heart disease among 6595 men aged 20-49 years of age, a family history of myocardial infarction (MI) was obtained by interview. A high degree of concurrence (78%) was found between the reported and confirmed diagnoses. Subjects who had evidence of a previous MI had a significantly higher frequency of first degree relatives with MI compared to healthy men of the same age. In subjects with first degree relatives of either sex suffering from MI before age 50, the mean serum cholesterol concentration was found to be slightly but not significantly elevated. However, when the relatives were females below age 50, the subjects had significantly elevated mean systolic blood pressure (0.05 greater than p greater than 0.01). The differences between subjects with a positive and negative family history of MI were surprisingly small. Correspondingly, there was no difference in the frequency of MI relatives in subjects belonging to the upper and lower quintiles of the serum cholesterol and blood pressure distribution. The slight elevations in serum cholesterol and blood pressure contribute only to a very small extent to the increased risk to subjects with a positive family history.


Work-energy level, personal characteristics, and fatal heart attack: a birth-cohort effect.

In a 22-year followup of 3686 San Francisco longshoremen, a cohort analysis assessed job activity and six personal characteristics in relation to 395 fatal heart attacks. Four cohorts aged 35-44, 45-54, 55-64, and 65-74 in 1951 were studied annually for job shifts affecting energy output and for sudden or delayed death from heart attack by age 75. All subjects underwent multiphasic screening for heavy cigarette smoking, higher blood pressure, history of prior heart disease, obesity, abnormal glucose metabolism, and higher blood cholesterol. The first three of these characteristics added risk of fatal heart attack. The amount of risk varied in the four cohorts. Higher energy output on the job reduced risk of fatal heart attack, especially sudden death, in the two younger cohorts, where less active workers were at threefold increased risk. Lack of this effect in the two older cohorts could imply real differences in their work habits, such as being less energetic in heavy jobs or more energetic in light jobs than the younger cohorts. Or, before the study began, early deaths may have winnowed susceptibles from the two older cohorts. Combined low-energy output, heavy smoking, and higher blood pressure increased risk by as much as 20-fold. By elimination of these adverse influences, this population might have had an 88% reduction in its rate of fatal heart attack during the 22 years.


Effect of relative weight on familial blood pressure aggregations.

Because of recognized associations between body build and blood pressure in individuals, along with familial clustering of these variables, a study was undertaken to determine whether parent-child blood pressure resemblances reflect parent-child similarities in body build. Adolescents were selected to serve as propositi for the parental study from a large school population. To maximize the liklihood of demonstrating existing associations between blood pressure and the body build in family members, blood pressures and weight status of parents whose adolescent children had high blood pressures (Group I parents) were compared with similar observations in parents whose children had low blood pressures (Group II parents). Group III adolescent propositi were selected for high weight status but blood pressure below the mean for their sex group. Group I parents had higher blood pressures and body weight than did Group II parents, similar to the differences in the groups of children. Parents of Group III propositi had high body weight but blood pressure that was intermediate between the other two parent groups. Differences in Group I and III parental blood pressures, despite similar body weights, suggest that familial blood pressure resemblances cannot be solely attributed to familial similarities in body weight.


Variola minor in Braganca Paulista county, 1956: a trend-surface analysis.

Trend-surface analysis (TSA), a form of polynomial regression used in geology, ecology and geography, was applied to analysis of the spread of an epidemic of variola minor in a small Brazilian city. Cubic surfaces gave a generalized map of the space-time distribution of the epidemic, allowing those parts of the city to be identified where variola minor was spreading rapidly or slowly. The epidemic spread relatively quickly over the core area of the city, especially to the peripherally located household dwellings in a northeast to south-west direction. The dwellings of adults and pre-school children introducing the disease into their households broadly followed the overall pattern. School child introductory cases from a southern-located school yielded a saddle-shaped contour pattern, centered about the school; but this pattern was not repeated for the school serving the northern half of the city, which showed a ridge-shaped pattern dipping toward the west. Cubic surfaces for the influence of certain household and individual characteristics were investigated, but showed only week trends. The nearest match to the bowl-shaped overall pattern of introductory dates was provided by the vaccination level of the households. From this application, it appears that TSA permits the identification of regional trends in an objective manner and gives a quantitative measure of the importance of these regional trends in terms of the overall variation in the spatial pattern.


Estimation of the possible effect of interventive measures in the area of ischemic heart diseases by the attributable risk percentage.

In epidemiology the concepts of relative and attributable risk are used to describe the statistical association between the incidence of a disease and the presence of possible risk factors. If the association is due to a cause-effect relationship, the attributable risk can be considered as an estimate for the reduction in incidence as a consequences of intervention. In order to get unbiased estimates these risks must be standardized for the influence of confounding variables. From data of the Framingham Study these risks, standardized for the confounding influence of age, are estimated for three risk factors related to the incidence of coronary heart disease (CHD)--hypertension, hypercholesterolemia and cigarette-smoking--both marginally and jointly. Under very optimistic assumptions a theoretical reduction in 12-year CHD incidence of a maximum of about 20% is estimated from the male Framingham sample by assumedly lowering systolic blood pressure and serum cholesterol. If only cigarette-smoking could be totally eliminated, the reduction is estimated at about 37%.


Evidence for lower susceptibility to multiple sclerosis in Japanese-Americans.

A search for cases of multiple sclerosis (MS) was carried out among the 120,066 Japanese-American residents and the 3,060,366 Caucasian residents native to state of residence in King and Pierce Counties, Washington, and Los Angeles County, California. Although 48 cases would have been expected among Japanese-Americans in both areas (on the basis of the prevalence among Caucasians in these two areas), only eight cases were found who were residents on prevalence day -- all were American-born residents of Los Angeles County. The age-, sex-adjusted prevalence of MS among Japanese-Americans in both areas was 5.9 per 100,000. The lower prevalence of multiple sclerosis among Japanese-Americans than among Caucasians has been interpreted as evidence of a lower susceptibility to factors causing multiple sclerosis.


Alcohol consumption among white, black, or oriental men and women: Kaiser-Permanente multiphasic health examination data.

Alcohol consumption habits as recorded on health checkup questionnaires by 91,659 white, black, or Oriental men and women were studied. Substantial age, sex, and race differences in alcohol consumption were reported. Generally, men drank more than women, drinking was most prevalent among whites and least prevalent among Orientals, and the highest proportion of drinkers was found in the age decades 20-29 and 30-39 years. Consumption of 3+ drinks per day was most prevalent in the age decades 40-49 and 50-59. The proportion of nondrinkers diminished with increasing educational attainment. Alcohol use showed a strong positive assocaition with cigarette smoking, a weaker positive association with coffee use, and no relation to blood group within race. A complex relation was observed between alcohol use and adiposity, which differed for the various sex-race subgroups. It is concluded that age, sex, race, educational attainment, smoking, and adiposity are potentially significant confounders of studies of alcohol use and health.


The relation between physical, psychological, and social morbidity in a suburban community.

Questionnaire scales of physical, psychological, and social morbidity were utilized to discover the relation between these indices in a representative Australian suburban sample of 863 adults aged 20-69 years. The physical and psychological morbidity of the sample was considerable and comparable to that revealed by other health surveys. There was a positive association between the occurrence of physical and psychological illness. The level of social isolation was low and in this residentially stable sample there was no association between social isolation and either physical or psychological morbidity.


Giardiasis in Colorado: an epidemiologic study.

A one-year retrospective laboratory survey in Colorado revealed that 691 (3%) of 22,743 stool examinations for ova and parasites were positive for Giardia lamblia, a higher percentage than that reported from surveys outside of Colorado. The majority of infected residents who were surveyed had experienced an episode of chronic watery diarrhea (median duration 3.8 weeks) with bloating, flatulence, and weight loss (averaging 5.1 kg), and had responded to a course of metronidazole or quinacrine. A statewide telephone survey of 256 cases and matched controls identified: 1) and increased incidence of giardiasis in persons between the ages of 16 and 45, p less than .001, with males and females equally affected; and 2) a higher proportion of cases than controls who visited Colorado mountains (69% vs. 47%), camped out overnight (38% vs. 18%), and drank untreated mountain water (50% vs. 17%), p less than .001. Also identified was a correlation between the seasonal distribution of cases and degree of fecal contamination of mountain streams. These results indicated that  G. lamblia is endemic in Colorado and that drinking untreated mountain water is an important cause of endemic ifection.


Cholera in Portugal, 1974.I. Modes of transmission.

In April-November 1974, Portugal had a cholera epidemic caused by Vibrio cholerae El Tor Inaba with 2467 bacteriologically confirmed hospitalized cases and 48 deaths. Most of the country was affected, with 17 of the 18 districts reporting cases. V. cholerae was isolated from 42 per cent of shellfish tested during the epidemic, and an epidemiologic study found that a history of consumption of raw or poorly cooked cockles was significantly more common among cholera patients than among paired controls. Water from a spring and a brand of commercially bottled water were also found to be vehicles of transmission of cholera. Although night soil was sometimes used on gardens, consumption of raw fruits and vegetables was not associated with illness.


Cholera in Portugal, 1974. II. Transmission by bottled mineral water.

During a cholera epidemic, Vibrio cholerae was isolated from two springs which supplied mineral water to a spa and to a commercial water bottling plant. Epidemiologic investigation found that cholera attack rates were 10-fold greater among visitors to the spa than among non-visitors. A subsequent matched-pair case-control study which excluded persons who had visted the spa showed that a history of consumption of the bottled non-carbonated water was significantly more common among bacteriologically confirmed cholera cases than among paired controls.


Cholera on Guam, 1974: epidemiologic findings and isolation of non-toxinogenic strains.

In August 1974, six cases of cholera occurred on Guam. The index case had severe diarrhea and metabolic acidosis and died from pneumonia on the ninth day of illness; the other five cases had only mild to moderate diarrhea. Fish caught in Agana Bay and home-preserved was found to be the vehicle most likely responsible for the cases. Vibrio cholerae, El Tor Ogawa, was isolated from two patients, the Guam sewerage system, and a river emptying into Agana Bay. V. cholerae, El Tor Inaba, was isolated from the sewerage system, three storm drains imptying into Agana Bay, and Agana Bay. The Ogawa and Inaba isolates differed in their sucrose fermentation and hemolysis reactions, phage type and ability to produce toxin. Although this was the first reported cholera outbreak on Guam, the isolation of differentV. cholerae strains suggested that multiple introductions of V. cholerae had occurred on the island.


Determination of significant relative risks and optimal sampling procedures in prospective and retrospective comparative studies of various sizes.

Methods are given for determining the relative risks which it is possible to demonstrate as statistically significant with given probability in prospective and retrospective studies of a particular size. Also considered is the ratio of the sample sizes in the two groups being compared which will provide the most precise estimate of relative risk for a given total sample size.


Inheritance of low erythrocyte catechol-o-methyltransferase activity in man.

Catechol-O-methyltransferase activity was measured in blood obtained from 373 randomly selected subjects aged 16-18, 262 consecutive adult blood donors, and 201 first-degree relatives of subjects with RBC COMT activity of less than 8 U. The distribution of RBC COMT activity in a randoly selected populations was apparently bimodal with a nadir at approximately 8 U. Of a randomly selected population, 23% had low RBC COMT activity (less than 8 U), Because of previous reports of a significant sibling-sibling correlation of RBC COMT activity and because of the presence of a subgroup of subjects with low enzyme activity, RBC COMT activity was measured in blood from first-degree relatives of probands with low erythrocyte enzyme activity in 48 families. The results of segregation analyses of the data were compatible with autosomal recessive inheritence of an allele for low RBC COMT activity. RBC COMT in blood samples from siblings of probands inthese families also showed an apparent biomodal distribution.


Mental retardation associated with "balanced" chromosome rearrangements.

Balanced chromosome rearrangements were found in seven of 455 retarded children vs. four of 1,679 nonretarded, psychiatric children (P less than .05). The combined incidence of non-Robertsonian balanced rearrangements from this and reported surveys of the mentally retarded was five times greater than that from newborn surveys, whereas Robertsonian translocations were not increased among the retarded. The combined data show an increase in de novo rather than familial rearrangements among the retarded; the increase in de novo rearrangements is specifically for non-Robertsonian translocation.


Electrophoretic abnormalities of lysosomal enzymes in mucolipidosis fibroblast lines.

Electrophoretic properties of eight lysosomal hydrolases and 36 nonlysosomal enzymes were investigated in cultured fibroblasts from children with the inherited storage disease mucolipidosis II (ML II); fibroblasts from a child with a related disorder, mucolipidosis III (ML III); and two obligate heterozygous cell lines from parents of a ML II child. Cell homogenates of ML II fibroblast lines showed altered mobilities for lysosomal beta-hexosaminidase, acid phosphatase2, and alpha-mannosidase and deficient activity for the esterase-A4 and lysosomal alpha-mannosidase-B electrophoretic phenotypes. Altered mobility was also detected for the nonlysosomal enzyme adenosine deaminase-d. Deficient activities of other lysosomal enzymes were observed as previously reported. In a single ML III fibroblast line, only beta-hexosaminidase showed an abnormal electrophoretic pattern suggesting a difference between these cells and ML II fibroblasts. Thirty-five nonlysosomal enzymes associated with other cellular organelles and metabolic pathways were electrophoretically normal in all mucolipidosis cell lines. Heterozygous ML II cells showed normal expression for all enzymes. Two major patterns of altered lysosomal enzymes and adenosine deaminase were demonstrated in ML II cell lines, suggesting that at least two genetic forms of this disorder may exist. Neuraminidase treatment of ML II homogenates converted altered forms of acid phosphatase2 and adenosine deaminase-d and in two ML II lines, recovered the previously undetected lysosomal alpha-mannosidase band. These results are consistent with the mucolipidosis defect(s) being associated with abnormal post-translatinal processing of multiple lysosomal enzymes and adenosine deaminase-d.


Population genetics in the province of Ferrara. II. Survival of children with Cooley's anemia.

The demographic data of children with Cooley's anemia seen at the thalassemia center in Ferrara were analyzed. Survival was studied as a function of several variables, the most interesting being the distance between birthplaces of the parents of affected children. This distance was considered an indicator of genetic distance, and therefore an indicator of residual hybridity of the children. The significant regression of survival on interparental distance might be interpreted as an indicator of increased survival due to residual hybridity. The significant correlation of survival with expected hybridity supports this interpretation.


An improved turbidimetric method for plasma fibrinogen.

Our experience in the use of Ellis' and Stransky's turbidimetric technique for the determination of plasma fibrinogen is presented. We standardized the test using a plasma pool whose fibrinogen content was determined by a weighed clot technique. The turbidimetric-fibrinogen test is accurate, sensitive, specific, reproducible, convenient, and inexpensive. Correlations between the turbidimetric method and the weighed clot reference method was shown. The assay is sensitive to as little as 25 mg/dl plasma fibrinogen, and the results are not affected by samples with a high content of lipids, bilirubin, fibrin split products, lymphangiogram dye, or therapeutic levels of heparin. Day-to-day replicate determinations on a plasma pool yielded a coefficient of variation of 3.4 percent. Results from as many as 10 plasma samples can be obtained in 30 minutes (10-minutes working time). Reagent cost is less than one cent per test.


Pathogenesis and epidemiology of opportunistic mycotic infections: a review.

The pathogenesis, epidemiology, and ecology of pathogenic and opportunistic systemic infecting fungi are reviewed. The pathogenic fungi including the etiologic agents of histoplasmosis, blastomycosis, coccidioidomycosis, and paracoccidioidomycosis are limited geographically, can establish an infection in a normal host, and exhibit thermal dimorphism. In contrast, the opportunist fungi (Asperigillus sp., Candida sp., Cryptococcus sp., Mucor sp., and Rhizopus sp.) are widely distributed in nature, require altered host defenses for infection, and do not exhibit thermal dimorphism. Mechanisms of pathogenesis are also discussed.


Nonparametric percentile estimate of clinical normal ranges.

In this study, the nonparametric percentile estimate (PE), a statistical procedure requiring no previous assumption regarding the distribution of the underlying population, was used to determine adult normal limits for fasting plasma glucose, serum alkaline phosphatase, and urine amylase. Comparisons to the gaussian distribution were performed with histograms, symmetry calculations, plots on probability paper, and the chi-square test. The nonparametric and traditional PEs agreed perfectly when the glucose data fit the gaussian and log-gaussian curves. The nonparametric PE varied from the gaussian PE but was identical to the log-gaussian PE when the alkaline phosphatase activities followed the log-gaussian form. It differed sharply from the gaussian PE and was similar to the log-gaussian PE when the amylase values did not follow either the gaussian or log-gaussian model. The non-parametric PE was as efficient as its gaussian theory competitors when the assumed distributions were correct and, in most instances, was more accurate when the assumed distributions were incorrect.


Factors affecting T3 and T4 proficiency testing.

Problem areas within a proficiency testing (PT) program are performance evaluation and sample stability. The different units used in the various T3 uptake methodologies make performance evaluation complex. To facilitate this evaluation, a normalization method for T3 uptake performance evaluation has been developed. Sample stability studies for T3 uptake indicate that, at room temperature, sample values increase after storage for about seven days. Room temperature sample stability studies for T4 using a competitive protein binding (CPB) method indicate that the apparent T4 content of pooled serum increases after about one week. Fatty acids are shown to be an interfering substance in the T4 CPB method as well as the T4 radioimmunoassay (RIA) method. This interference increases with a decrease in carbon chain length from C18 to C12 and with an increase in unsaturation of fatty acids. The B/B0 ration for arachidonic acid at a concentration of 0.48 micronMoles per tube is 17.4 in a CPB method and 87.1 in a radioimmunoassay method indicating that the greater effect is in the CPB method. The increase in T3 uptake values are probably also due to the interfering effect of fatty acids.


Mycological culture media and its quality control.

The need for control of the quality of media used in the isolation and identification of fungi is an important aspect of the overall quality control of laboratory culture media; however, guidelines for such controls have not been available. In this paper, primary isolation media with and without appropriate drugs are suggested for use on a variety of specimens. Positive and negative quality control organisms that indicate clear-cut postiive and negative results on the fungal media to be tested are listed. Several alternative procedures for maintenance of fungi are discussed.


Comparison of the classical ASO titer, a microtiter method and streptozyme.

The classical ASO titer method was compared to the microtiter method of Edwards and to Wampole's Streptozyme kit. With the microtiter method, an 88.9 percent agreement with the classical method was obtained. A 94 percent agreement was found with the Streptzyme kit when used as a screening method.


A plea for consideration of ecological validity in the experimental psychology of mental retardation: a guest editorial.

The point was raised that, despite considerable experimental effort, laboratory research concerning learning, memory, and cognition, more generally, has not produced a very remarkable increase in our understanding of retarded behavior. Our principal contention in this paper is that the experimental psychology of mental retardation, while basically seeking causal relations between theoretical constructs and retarded behavior, is suffering from some metatheoretical and methodological shortcomings. These include, basically, a prevalent failure to consider the ecological aspects of the phenomenon of mental retardation. Implications of ecological validity are important with respect to the basis upon which subjects are selected for experimentation, the rationale underlying manipulation of independent variables, the choice of dependent variables, and the definition of the boundaries that limit generalizations. Some suggestions were offered for the purpose of guiding experimental research toward more meaningful and socially relevant goals.


Hyperuricosuria in the Fanconi syndrome.

A patient with asymptomatic adult Fanconi syndrome with glycosuria, amino-aciduria, hypophosphatemia, and renal tubular acidosis was found to have hypouricemia (serum uric acid, 1.5-1.8 mg/100 ml) secondary to increased renal clearance of urate (urate clearance/glomerular filtration rate, 32 per cent). Increased urate clearance in this patient with multiple reabsorptive defects probably represents diminished urate reabsorption. Consistent with this, the uricosuric response to probenecid was diminished. Reabsorption of filtered urate appeared to be intact. Inhibition of urate secretion with pyrazinamide completely suppressed the uricosuria in this patient, suggesting that increased urate clearance was due to either enhanced secretion or diminished reabsorption of secreted urate. There was no direct evidence for increased urate secretion. The response of urate excretion to pharmacologic inhibitors of tubular transport of urate differs in various clinical states associated with hyperuricosuria. The responses may reflect different mechanisms of hyperuricosuria.


Experimental evaluation of classroom environments: scheduling planned activities.

Scheduling of planned activities in a classroom for TMR adolescents was investigated. Ten classroom activities were scheduled in either a predictable (fixed) or unpredictable (random) order using an ABAB design. Relative to fixed scheduling, random scheduling resulted in significantly lower rates of activity completion and higher rates of disruptions. Lower rates of task completion also generalized to two unmanipulated activities. Activity completion and rate of disruptions, while generally inversely related, were significantly correlated for only 2 of 11 students. Students with lower levels of task completion under fixed scheduling showed the largest decrements in performance under random scheduling. Higher rates of disruptions under fixed scheduling were also associated with greater increments in disruptive behavior under random-scheduling conditions. Factors relating to the generality of these findings were discussed.


Enterobacter hafnaie infection: report of two cases and review of the literature.

Two of 255 wounded soldiers developed nosocomial infection with Enterobacter hafniae. This species is rarely associated with urinary or gastrointestinal disease, and had not been heretofore reported in the setting of localized or bacteremic wound infection. Difficulties in nomenclature and identification have obviated accurate assessment of the importance of E. hafniae as a pathogen. Nevertheless, in view of the relative sensitivity of this species to antibiotics one should be careful to distinguish E. hafniae from other members of the genus Enterobacter.


Categorical encoding in short-term memory by retarded and nonretarded children.

The use of consonants and digits as encoding categories in short-term memory by 32 EMR children and 32 nonretarded children of the same CA was investigated. The task employed was a modification of the release from proactive inhibition technique similar to that used by Wickens, Born, and Allen (1963). Results indicated that digits and consonants are significant categories used for encoding in short-term memory by 10- to 12-year-old EMR and nonretarded children but that nonretarded children more effectively utilize consonant material as an encoding dimension than do CA-matched EMR children.


Adaptive increase of respiratory enzymes in the mitochondria from cirrhotic livers of patients and rats, and its relationship to glucose tolerance.

Oxidative phosphorylation and respiratory enzyme concentrations of liver mitochondria and glucose tolerance were studied in 12 cirrhotic patients and CCl4-induced cirrhotic rats. The cirrhotic patients with normal or higher concentrations of cytochrome a(+a3) showed parabolic glucose tolerance test (GTT) patterns having return of blood glucose level somewhat toward normal within two hours and tolerated major operations well, while three patients with cytochrome a(+a3) concentrations less than 60 per cent of normal (0.81 +/- 0.02 (mean +/- SEM) X 10(-10) moles/mg protein) could not tolerate even minor operations. In CCl4-induced cirrhotic rats, cytochrome a(+a3) concentrations varied from 1.5 to 3.0 X 10(-10) moles/mg protein as compared with 1.8 +/- 0.1 of controls. In mitochondria with normal or higher concentrations of cytochrome a(+a3), the oxidative and phosphorylative activities per unit of cytochrome a(+a3) were negatively correlated with cytochrome a(+a3) concentrations. These rats tolerated partial hepatectomy well. However, in cirrhotic rats with subnormal cytochrome a(+a3) concentrations there was a high mortality following  hepatectomy. The former showed parabolic GTT patterns, while the latter showed nonparabolic GTT patterns.


Identifying profoundly mentally retarded subtypes as a means of institutional grouping.

While the profoundly mentally retarded social group is behaviorally heterogeneous, this knowledge appears to be of more theoretical than practical interest. The behavioral identification of functional profoundly retarded subtypes derived from ethological analysis may supply the structure necessary to utilize this behavioral variability. Institutional groupings based on dominant and subordinate subtypes may prove to be efficacious in increasing programming efficiency. A study of profoundly retarded persons' territoriality was discussed as it relates to new grouping procedures based on behaviorally identified subtypes. Implications with respect to the control of aggression, stereotypic activity, and behavior modification for functional subtypes were discussed.


Prediction of hearing sensitivity from acoustic reflexes in mentally retarded persons.

The ability of the sensitivity prediction from acoustic reflex (SPAR) technique to estimate hearing loss in mentally retarded subjects was investigated by comparing measured pure-tone thresholds determined through tangible-reinforcement operant-conditioning audiometry with predicted sensitivity from the SPAR procedure. Measurements were completed on a total of 32 retarded individuals having hearing levels ranging from normal to profound hearing loss. With minor exception, absences of the acoustic reflex were always accompanied by clearly abnormal tympanometry findings in the probe ear; therefore, the problem of unexplained absences of the reflex appeared to be minimal. Hearing loss never was present in those subjects for which SPAR predicted normal hearing, and the SPAR procedure never failed to detect an existing sensorineural hearing loss. On the other hand, there was some tendency for hearing loss to be predicted in normal-hearing subjects and for extent of hearing loss to be overestimated in subjects having a hearing loss.


The effect of hemodialysis on lung function, gas exchange, and response to carbon dioxide stimulation in chronic uremia.

Little is known of the effect of chronic hemodialysis on lung function. In six patients with chronic uremia, we performed pulmonary function tests, sampled arterial blood, and measured the ventilatory response to carbon dioxide inhalation before and after routine hemodialysis. Patients were in the seated position throughout the study period. Routine pulmonary function was normal in all but one patient; a restrictive ventilatory defect was seen in a patient with prior pleuropericarditis and this was independent of fluid status. All patients showed improvement after dialysis in maximum flow rate at 25 per cent vital capacity corrected for changes in vital capacity (V max 25% VC/VC) supporting reversible obstruction of small airways. Hypoxemia was not precipitated by dialysis and all patients showed a small improvement in alveolar-arterial oxygen gradient. Although resting hyperventilation was documented in these patients, the ventilatory response to carbon dioxide inhalation was not consistently enhanced before or after hemodialysis.


Transfer of associative-clustering tendencies in borderline mentally retarded and nonretarded adolescents.

Twenty-four sixth graders, 24 seventh graders, and 24 special-education students with MAs roughly equivalent to the sixth graders were randomly assigned to the cells of a 3 (grade level) X 2 (list novelty) X 2 (list organization) factorial design. In the list-novelty condition, subjects were immediately transferred to either a same-categories or a new-categories list on the third and fourth trials. In the list-organization condition, subjects received the lists on the first two trials in either a random or blocked format. For all subjects, the last two trials were presented randomly and contained new words. The results of the analyses revealed that there was significant negative transfer over trial blocks for the same-categories transfer condition. In addition, the new-categories group clustered significantly more on the second than the first trial block. There was no significant interaction between subject and treatment factors, suggesting that the processes involved in recall were similar for nonretarded and borderline retarded subjects.


Manipulation of stimulus features in vocational-skill training of severely retarded individuals.

Fifty-one severely retarded adults were taught a difficult visual discrimination in an assembly task by one of three training techniques: (a) adding and reducing large cue differences on the relevant-shape dimension; (b) adding and fading a redundant-color dimension; or (c) a combination of the two techniques. There were significant differences between training conditions in both trials- and errors-to-criterion performance. These were attributed to differential establishment of stimulus control in the first phase of training, with the combined procedure being the most effective, the color coding/fading next, and the relevant-dimension cue-disparity method the least powerful. These results demonstrated that substantial differences may exist in the efficacy of various vocational-skill training procedures involving manipulation of stimulus features.


Reaction time in retarded and nonretarded young adults: sequential effects and response organization.

Two types of sequential effects can occur in 2-choice reaction-time (RT) tasks. In an alternation effect, the RT for a response that differs from the previous response is faster than that for a response that is the same. In a repetition effect, the opposite is the case; i.e., the RT for a response that is the same as the previous response is faster than that for a different response. These effects were investigated in a comparison of retarded and nonretarded subjects in a 2-choice RT task. There were three conditions that differed in the degree of response organization required. For the retarded subjects, both a significant increase in the overall mean RT and a change from alternation to repetition effects were found with increasing degree of response organization. Neither result was found for the nonretarded subjects. For both groups there was a tendency for alternation effects to decrease and repetition effects to increase witwh decreasing intelligence. Overall, sequential effects were found to correlate more consistently than mean RT with both degree of response organization and intelligence.


Perceptual decentering in EMR and nonretarded children.

Perceptual decentering was examined in nonretarded children, EMR children equated for CA, and EMR children equated for MA. Perceptual decentering was measured by the number of part, whole, and integrated responses to a modification of the Picture Integration Test. MA peers (nonretarded and EMR children of equated MA) produced a significantly greater number of decentered (integrated) responses than did EMR children equated with the nonretarded children for CA. The results indicated that perceptual decentering is more fundamentally related to MA than to CA in EMR children.


Evaluation of paintings of nonretarded and retarded persons by judges with and without art training.

Correlations between creativity and intelligence are generally reported to be low. In the present investigation, we examined whether judges with and without art training (N = 40 for each group) would evalute the paintings of nonretarded and retarded persons differently. Five paintings each were obtained from 15 nonretarded persons, 11 moderately retarded persons, and 11 severely retarded persons. Judges who had art training did not differentially rate the art of nonretarded and retarded persons, but they gave significantly higher ratings than did non-art-trained judges to the paintings of retarded persons.


Effects of instructional set and self-awareness on task performance of retarded female adults.

The effects of success, failure, and neutral instructional sets on the task performance of retarded female adults were studied under varying conditions of self-awareness. A significant Set X Self-Awareness interaction was found where subjects in the neutral-set condition under high-awareness assembled more pens than subjects under the medium- or low-awareness conditions. The results were discussed in light of the expectancy of failure hypothesis.


Developmental analysis of outerdirectedness in noninstitutionalized EMR children.

Outerdirectedness has been found in nonretarded and institutionalized retarded children to be related inversely to cognitive level and directly to history of failure experiences. The developmental nature of outerdirectedness was investigated among noninstitutionalized EMR children using two independent measures of outerdirectedness. Forty subjects, comprising two MA levels, were given a block-design task that was equally difficult for both MA groups. Glancing from the task was found to be related inversely to MA. On a task in which subjects were scored for the amount of imitation of the experimenter's behavior, imitation was also found to be related inversely to MA. However, imitation and glancing were not correlated, suggesting that they may tap different aspects of outerdirectedness.


Reproductive counseling in patients who have had a spontaneous abortion.

A detailed morphologic study was made of spontaneously aborted embryos and fetuses from 472 patients. These patients were followed through 638 subsequent pregnancies. The patients were divided into four groups, depending on their previous obstetric history. The outcome of the subsequent pregnancies was correlated with the previous obstetric history of the patient and the developmental status of the aborted specimen. Patients who had never had a live child in the previous obstetric history were identified as a high-risk group. Patients who had had live births and pregnancy loss previously were found to be at significant risk of a subsequent premature infant following the late abortion of a fetus.


Treatment of epithelial carcinoma of the ovary: operation, irradiation, and chemotherapy.

This paper presents an interim analysis of 279 patients with epithelial carcinoma of the ovary who were entered into a prospective study started in April, 1971. One hundred and three patients were available for analysis three years after diagnosis. Apart from the survival differences by stage and treatment method, this study has shown that the completeness of the initial pelvic operation, in Stages II and III, is of greater prognostic importance than the stage. The importance of the features of the pelvic disease which interfere with the removal of all pelvic organs led the authors to conclude that factors other than stage should be considered in prescribing postoperative treatment. To date, the disease-free survival trends in Stages IB, II, and asymptomatic Stage III show that physicians should place much greater emphasis on the initial operative features when they are seeking the most effective combination of irradiation and chemotherapy. Analysis of failures shows that upper abdominal irradiation is more effective than daily chlorambucil  in preventing progression of disease to that area. However, early evidence indicates that chlorambucil added to pelvic irradiation improves the control of pelvic disease. Improved methods of treatment have not yet been identified for early Stage I (IA) and advanced presentations (symptomatic Stages III and IV).


The use of delayed primary wound closure in preventing wound infections.

Delayed primary wound closure was performed in 146 patients considered at risk of developing wound infection according to established criteria. These patients were matched individually for age, weight, diagnosis, and the use of prophylactic antibiotics with 146 patients undergoing immediate wound closure during the same time period. The matched pairs were subdivided into five categories depending on the indication for delayed closure; obesity, cancer, "above and below" procedure, infection, and opened bowel. In all categories the incidence of wound infection was significantly lower in the patients with delayed closure. The over-all infection rate was reduced from 23.3% in the control group to 2.1% in the study group. Hospital stay was unaffected. Delayed primary wound closure provides a safe, simple, effective means of reducing the incidence of wound infection.


Effect of elective induction of labor with prostaglandins F2alpha and E2 and oxytocin on uterine contraction and relaxation.

Prostaglandins F2alpha and E2 and oxytocin were used to induce labor in 101 patients at risks. The data show that the three drugs are efficient labor inducers. The success rate of induction is the highest in primiparous patients receiving oral prostaglandin E2. Uterine contractility patterns and base line are similar with all drugs. The relaxation phase of the uterine contraction is skewed consistently in each investigated labor. This suggests an unequal relaxation time for the uterine fibers. It is concluded that prostaglandins E2 and F2alpha and oxytocin are safe drugs for induction of labor if monitoring is used in order to avoid an overdose of the medication. The three drugs must be synergistic because of their identical action on the uterine muscle.


Intrapartum fetal heart rate profiles with and without fetal asphyxia.

Fetal heart rate profiles for periods up to 12 hours prior to delivery have been reviewed in 515 patients with a fetus at risk. Mechanisms other than fetal asphyxia will cause fetal heart rate decelerations, and fetal asphyxia may in some instances develop in the absence of total or late decelerations. However, an increasing incidence of total decelerations and late decelerations and particularly a marked pattern of total decelerations and late decelerations are of value in the prediction of fetal asphyxia. Fetal heart rate deceleration patterns can predict the probability of fetal asphyxia at the time of initial intervention, while a progression of fetal heart rate deceleration patterns in the individual fetus can be of assistance in the subsequent scheduling of serial acid-base assessments during labor.


Surgical management of carcinoma of the cervix.

Three hundred and fifty-two cases of carcinoma of the cervix which required some surgical procedure are reviewed. In Group I (primary treated), the lymph nodes were positive in 9% with Stage I and 45% with Staqe II disease. This group had an 88% five-year survival rate; patients with positive lymph nodes had a 60% two-year survival rate. One or more surgical complications occurred in 16.5% of patients treated for recurrent disease. The five-year survival rate in patients treated for recurrent disease was 35%. The Schauta-Amreich procedure is being used more commonly for poor-risk patients with recurrent disease confined to the cervix or with superficial vaginal involvement.


Dexamethasone treatment of the guinea pig fetus: its effects on the incorporation of 3H-thymidine into deoxyribonucleic acid.

Pregnant guinea pigs of 50 to 53 days' gestation (term 63 days) were anesthetized with ether, and their fetuses were injected intramuscularly with 30 mg of dexamethasone or sterile saline. One week later, the fetuses were injected with 3H-thymidine intramuscularly under direct vision at laparotomy; after one hour, the incorporation of thymidine into deoxyribonucleic acid (DNA was analyzed in various fetal tissues. The relative labeling of DNA was significantly depressed in the cerebral hemispheres, cerebellum, medulla oblongata, and midbrain of the treated fetuses compared to their littermate controls. The relative labeling of the DNA of lungs, kidneys, heart, and adrenals was also significantly reduced. Increasing the dose of dexamethasone produced a progressive inhibition of the incorporation of 3H-thymidine into DNA. A variable recovery from the inhibition became apparent by 14 days following exposure to dexamethasone. The evidence suggests that exposure of the fetus to dexamethasone may exert a potentially deleterious effect on fetal tissues.


Definition of sleep state in the newborn infant by heart rate analysis.

The relationship of heart rate variability to sleep state was examined in 9 term newborn infants at one to three days of age. Spectral density plots of rhythmic variations in heart rate during active sleep and quiet sleep were characteristic and always distinct from each other. Heart rate and heart rate variability were significantly higher during active sleep than during quiet sleep. It was always possible to identify quiet sleep and active sleep during sleep periods by inspecting spectral density plots of the variations in heart rate. Similar relationships between heart rate variability and sleep states may exist in utero. Spectral analysis of heart rate variations may provide an indirect measurement of fetal sleep states, and such measurements might become useful in assessing fetal brain maturity and fetal well-being.


Statistical analysis of first-trimester pregnancy terminations in an ambulatory surgical center.

From June, 1973, to December, 1974, 12,219 women requested elective termination of pregnancy at the Concord Medical Center, a private outpatient clinic in Chicago, Illinois. Suction curettage with local anesthesia was performed for 10,890 of the women; the remaining 1,329 (10.9%) women were rejected for the following reasons: not pregnant, 1.9%; estimated duration of pregnancy over 12 weeks, 7.3% medical reasons, 1.6%; and other reasons, 0.1%. For the aborted patients, the immediate complication rate was 6.9 per 1,000. Complication rates were directly associated with length of gestation (whether determined on the basis of the patient-reported last menstrual period (LMP) or on the basis of the physical examination) and with the experience of the physicians. This study adds further evidence that first-trimester termination of pregnancy by suction curettage, with local anesthesia, in a nonhospital setting is a safe procedure when high medical standards are maintained.


Circulatory effects of magnesium sulfate in normotensive and renal hypertensive pregnant sheep.

We have studied the effects of magnesium sulfate (MgSO4) administration in chronically instrumented normotensive and hypertensive pregnant sheep. Animals of 90 to 144 days' gestation were divided in two groups; those with normotensive arterial pressure and those in which renovascular hypertension had been produced. Our results show that bolus injection of 2 or 4 Gm. of MgSO4 caused a transient decrease in systolic and diastolic pressure which returned to control values within 5 to 10 minutes. The continuous infusion of MgSO4 in doses of 2 or 4 Gm. per hour produced a slight increase in uteroplacental blood flow but did not alter the blood pressure. Heart rate showed a slight increase. Because MgSO4 produced no significant hemodynamic changes, we feel that: (1) its use in obstetrics must be based on its anticonvulsant action and (2) MgSO4 in either normotensive or hypertensive patients is not associated with impairment of uteroplacental blood flow.


Serum calcium concentrations in human pregnancy.

Total and ionic calcium concentrations were measured in maternal serum from nonpregnant (N=30), pregnant (N=137), and early puerperal (N=17) women. In this cross-sectional study, total calcium levels (measured by atomic absorption spectrophotometry) exhibited the previously described pattern of a decline beginning in the first trimester and continuing until approximately 32 weeks, with a slight terminal rise from thence to term. Mean (+/-SD) values for the three trimesters were 4.80 (+/- 0.13), 4.56 (+/- 0.14), and 4.46 (+/-0.16) mEq. per liter, respectively, with all differences statistically significant. Ionic calcium levels (measured by calcium flow-through electrode) declined to a lesser (though still statistically significant) degree; mean (+/- S.D.) values for the three trimesters were 2.33 (+/-0.07), 2.28 (+/-0.08), and 2.24 (+/-0.06) mEq. per liter, respectively. Because of the differential rates of fall, the proportion of total calcium represented by the ionic component increased progressively during gestation. The results indicate that the major portion of the characteristic decline in maternal serum total calcium concentration with pregnancy reflects changes in the nonionized (albumin-bound) fraction while the ionic portion declines only slightly. The concentration of calcium ions in serum is maintained within a very narrow physiologic range throughout gestation.


The abortifacient and oxytocic effects of an intravaginal silicone rubber device containing a 0.5% concentration of 15(S)-15-methyl-prostaglandin F2alpha methyl ester.

Abortion was successfully induced by intravaginal insertion of a silicone rubber device impregnated with an 0.5% concentration of 15(S)-15-methyl-prostaglandin F2alpha methyl ester in 20 of 25 patients by prostaglandin alone and in an additional three patients by prostaglandin with a concomitant oxytocin infusion. The mean abortion time for the 23 successful abortions was 15.46 hours. Uterine activity was monitored in six patients and uterine response to the vaginal insertion of the prostaglandin-impregnated device was characterized by a gradual rise in amplitude of contractions and intrauterine baseline tonus accompanied by a rapid increase in the frequency of contractions. Induction of abortion by intravaginal administration of a silicone rubber device impregnated with prostaglandin eliminates the hazards associated with intra-amniotic instillation and offers the advantage of a single administration with the option of reversibility if a patient should be hypersensitive to the drug.


Trial of intravenous therapy in women with low urinary estriol excretion.

Estriol excretion in pregnancy is favourably improved following administration of 25% dextrose to patients with persistently low estriol excretion. A double-blind controlled trial was undertaken in 60 patients to assess the efficacy of other regimens of infusion therapy with Hartmann's solution, aminofusin, 10% dextrose, or ritodrine in Hartmann's solution. Estriol excretion rose above the lower limit of normal in 69% of the patients treated. There was no significant difference in success rates between the four solutions studied when subjected to analyses of variance and covariance. Fetal and placental weights were directly related to estriol excretion. Influences of the various therapeutic regimens on metabolic acidosis have been considered and possible reasons for therapeutic success discussed.


Vitelliform lesions developing in normal fundi.

Two patients with Best's macular dystrophy, photographically documented, developed vitelliform lesions in previously normal or nearly normal fundi. The patients were studied prospectively because their brother had Best's disease. The first patient, a 6-year-old boy, had normal-appearing fundi in February 1974, but in October 1974 he had developed a vitelliform lesion in the left macula. His electro-oculogram (EOG) was severely abnormal in both eyes. His 12-year-old syster had an essentially normal fundus appearance and an abnormal EOG in both eyes in November 1971. In October 1975, she had an extramacular vitelliruptive lesion in the right eye and a typical Best's lesion in the left macula.


Surgical repair of leaking blebs.

To repair a ruptured filtering bleb, we used the conjunctiva alone, or combined with its undissected Tenon's fascia, to cover the sclerostomy site. We used mattress sutures to thread the new flap into a vertical corneal groove anterior to the sclerostomy, creating a firm, nonretracting but still sufficiently "porous" cover that maintained filtration and resisted infection and perforation. Seven of eight cases of ruptured filtering blebs have been successfully repaired in this manner with the maintenance of adequate filtration.


Cataracts as an epidemiologic problem.

Cataracts are an enormous medical, financial, and social burden. At least 300,000 to 400,000 new, visually disabling cataracts occur yearly in the United States, and 5 to 10 million worldwide. Complications of modern surgical techniques alone probably result in at least 7,000 irreversibly blind eyes annulally in the United States, and a potential 100,000 to 200,000 worldwide. These figures must be refined through well-standardized prevalence surveys and careful monitoring of indications and results of surgery. Senile cataracts probably result from many, possibly compound, obscure causes. Race, altitude, dietary habits, and deranged carbohydrate metabolism are some that have been suggested. There is little basis for the common belief that senile cataracts are more prevalent, or mature more rapidly, in diabetics. Carefully conducted case control and long-term studies are needed to assess the importance of each of these factors and to identify additional ones. The rapid increase of intraocular lens implantation raises serious questions of safety and efficacy. Implantation increases the risk of corneal and macular edema, iritis, and reoperation for lens dislocation and membrane formation, while complicating the treatment of retinal detachments and retinovascular disease. They require controlled clinical evaluation.


Progressive bilateral essential iris atrophy.

Bilateral progressive essential iris atrophy, more advanced in one eye than in the other, occurred in a 24-year-old white man. Histopathologic examination of the iris from the eye with the more advanced iris atrophy disclosed no vascular abnormalities in that the vessels were patent and appeared normal except for accumulated perivascular connective tissue. Fluorescein angiographic examination of the fellow eye that was undergoing the earliest changes of iris atrophy failed to reveal any vascular abnormalities. However, tonographic examination indicated a markedly decreased outflow facility. There does not appear to be any vascular abnormality involved in the pathogenesis.


The association of HLA-B7 and HLA-B12 antigens with cup/disk ratio, family history of glaucoma, and intraocular pressure.

The presence of either HLA-B7 or HLA-B12 antigens was associated with a higher prevalence of cup/disk ratios greater than 0.3 in the GG responders (intraocular pressure greater than 31 mm Hg after six weeks of topical dexamethasone 0.1%, four times daily) and in the combined NN-NG (intraocular pressure less than or equal to 31 mm Hg) groups. The presence of either antigen was associated with a higher prevalence of a family history of glaucoma in the GG group. N association was noted between the antigens and age, sex, race, or mean intraocular pressure in either of the groups studied.


External ophthalmoplegia, ataxia, and areflexia complicating acute infectious polyneuritis.

A 13-year-old girl suddenly experienced ataxia, bilateral external ophthalmoplegia, and areflexia. She was previously healthy but several family members had had a flu-like illness. Cerebrospinal fluid punctures demonstrated a persistent lymphocytosis and protein elevation. Clinical improvement occurred in several months. These findings represent a variant of Guillain-Barré-Strohl syndrome (infectious polyneuritis), a systemic illness rather than a primary ophthalmologic entity.


Mitochondrial abnormalities in progressive external ophthalmoplegia.

Three cases of chronic progressive external ophthalmoplegia demonstrated ragged-red fibers. Histochemical stains showed that the ragged-red fiber appearance was produced by abnormal mitochondria in the muscle. Electron microscopic studies demonstrated the ultrastructural origin of the intramitochondrial inclusions seen in ragged-red fibers. The associated abnormalities in lactic acid metabolism possibly represent an underlying generalized defect in metabolism. This evidence suggests that chronic progressive external ophthalmoplegia is a diffuse disease of the mitochondria.


Retinal degeneration without pigment alterations in progressive external ophthalmoplegia.

A 56-year-old black man had annular visual field defects and retinal electrophysiologic dysfunction with chronic progressive external ophthalmoplegia and no pigmentary abnormalities in the fundus. Because the association of retinal disease with neurodegenerative states has generally been based on the observation of pigmentary changes, the patient's fields were erroneously interpreted as the nerve fiber bundle defects of glaucoma.


Retinal phlebitis in the Irvine-Gass syndrome.

We reviewed the pathology records from January 1965 through July 1975 for aphakic eyes. After exclusion of unsuitable cases, ten eyes (nine patients) with cystoid macular edema and 142 eyes without cystoid macular edema were studied. Clinical ophthalmic records were available for five of the ten eyes with the Irvine-Gass syndrome. Histologic sections were examined, revealing a significant correlation between the Irvine-Gass syndrome and retinal phlebitis, which has not been reported previously, as well as cyclitis and vitritis. Anterior segment operative complications tended to be more prevalent in eyes with the Irvine-Gass syndrome than in those without the Irvine-Gass syndrome, although the assocation was not statistically significant (P less than .1). Retinal trypsin digestion showed the phlebitis to be distributed posteriorly within primary and secondary retinal veins, frequently occurring near points of bifurcation. The changes in permeability seen in the Irvine-Gass syndrome may be due to this retinal phlebitis and to a generalized inflammation-induced increase in capillary permeability. The case of the phlebitis is not known.


Peripheral retinal neovascularization in sarcoidosis and sickle cell anemia.

A 30-year-old black woman with biopsy-proven sarcoidosis and sickle cell anemia had peripheral retinal neovascularization. Elevated fibrovascular proliferations and distal retinal ischemia with nonperfused ghost vessels passing through the area of neovascularization were found at the temporal periphery. No signs of intraocular inflammation were present. Both diseases occur in black patients and should always be considered in the presence of peripheral retinal neovascularization.


Penetration of topically administered prednisolone acetate into the human aqueous humor.

A single standardized drop of 1.0% prednisolone acetate labeled with tritiated thymidine was administered topically to one eye of 58 patients shortly before elective cataract extraction. An aqueous humor sample was aspirated at varying intervals and its corticosteroid content was determined. Peak drug concentration in aqueous humor was 1.13 mug/ml, which occurred 30 to 45 minutes after instillation of the medication. Substantial quantitites of corticosteroid were found in the aqueous humor five minutes after drug administration. The area under the drug concentration in aqueous humor-vs-time curve (a measure of the drug's bioavailability in aqueous humor) was 88 mug min/ml, and its half-life in human aqueous humor was 28 minutes. None of these values were significantly different from the comparable values in rabbit eyes.


Regional differences in ocular concentration of gentamicin after subconjunctival and retrobulbar injection in the rabbit.

We compared the penetration of radioactive carbon (14C) labeled-gentamicin into ocular tissues and fluids of albino rabbit eyes after subconjunctival (anterior subtenon's) and retrobulbar (posterior subtenon's) injections. In both normal and infected (Staphylococcus aureus endophthalmitis) eyes, higher levels of drug were produced with subconjunctival rather than with retrobullar admininistration in cornea, sclera, choroid and retina (as a unit), and iris; levels in the aqueous and vitreous humors of infected eyes were similar with the two routes of injection. Marked regional variations in the concentrations of gentamicin were noted in cornea, sclera, and choroid-retina after subconjunctival therapy. The pattern of these variations suggests that subconjunctival antibiotic penetrates the eye by direct diffusion. The low levels of drug after retrobulblar injection may be due to systemic absorption through the highly vascular orbital plexus of the rabbit.


Severe persistent inclusion conjunctivitis in a young child.

A 14-month-old girl had inclusion conjunctivitis although there had been no signs or symptoms that required medical attention in her first year. By 2 1/2 years of age, the child had extensive pannus and corneal scarring that severely reduced vision. The infection was caused by a genital strain of Chlamydia trachomatis, TRIC type E, that was probably acquired at birth. Although genitally transmitted chlamydial strains normally cause a self-limiting inclusion conjunctivitis in areas where trachoma is not endemic, this case illustrates that they may occasionally cause severe trachoma. Possibly local idoxuridine (IDU) treatment (administered to this patient before the correct diagnosis was made) contributed to the severity of this infection.


Histamine in human tears.

Tear samples from 13 normal volunteers and nine patients with vernal conjunctivitis were assayed for histamine. Tears in both groups contained histamine. The normal subjects had values ranging from 2.2 to 36 ng/ml with a mean of 10.3 ng/ml. The vernal patients had histamine values ranging from 0 to 125 ng/ml with a mean of 3,.2 ng/ml. The presence of histamine in tears indicates a role for this important mediator in both the physiologic and immunologic processes of the external eye.


An introduction to the proficiency examination.

The public's right to quality health care requires that health practitioners be competent to carry successfully the responsibilities of the positions they seek to fill, and that individuals seeking to practice must be evaluated as possessing the required expertise. The proficiency examination is used to judge the possession of such expertise. This article describes the proficiency examination, its characteristics, the basis upon which it is developed, and how it contributes to the assurance that practitioners are competent. Common misconceptions that practitioners may have about the proficiency examination are also discussed. The proficiency examination is defined as a criterion-referenced appraisal of the individual's possession of the performance knowledge and skill competencies required to execute the role responsibilities of the given practitioner generic position.


Temporal adaptation: a conceptual framework for occupational therapy.

The concept of temporal adaptation was introduced into the field of occupational therapy early in its development; however, it has not been developed as part of the theoretical backing of the field. This paper re-introduces the theme and provides both a general prospective for the clinician in thinking about patients' temporal behavior and a preliminary framework for application. Temporal adaptation when applied in clinical practice should add a wider perspective to existing clinical interventions. It is proposed as a generically applicable theoretical perspective appropriate across all dysfunctional categories of patients. Two case histories are presented to demonstrate the application of the theoretical framework to intervention.


Occupational role acquisition: a perspective on the chronically disabled.

Occupational therapists are aware that chronic disability restricts not only physical and mental skills, but also social skills and the resulting ability of the patient to function in society. The issue of quality of life for the chronically disabled requires assisting them in the acquisition of new, although not always remunerative, occupational roles. The occupational role defines daily activity and appropriation of time, as well as the contribution to society and societal worth. This article presents the sociological concepts of role, three critical points in conceptualization of the occupational role acquisition process, a model for evaluating and monitoring a patient's progress, and a case study.


Play: the arena for acquisition of rules for competent behavior.

Play is acknowledged as a critical, complex arena of learning. In play, individuals process information about their location in space, time, and personal relationships. One mechanism for organizing this information is the rule. This paper defines the rule as a symbol and its relationship to skilled action. With this perspective of rules, preliminary questions about play are posed. The occupational therapist can organize the observation of play based on the yield from these questions.


A clinical perspective on motivation: pawn versus origin.

Occupational therapy is founded on the principle of "actively engaging" the patient in tasks of therapeutic benefit. This method of treatment necessitates matching a patient's needs with interests and abilities in an attempt to motivate the individual to perform. A lack of motivation is often the most difficult and most unsuccessfully overcome obstacle in the occupational therapy clinic. Classical drive-reduction theories of motivation prove inadequate for therapists to arrest and reverse the behavior of an unmotivated individual. This article offers the concept of personal causation as an alternative means of understanding human motivation. This notion is examined in two modes of behavior, namely pawm and origin, in an attempt to further the understanding of the complex process of self-initiated and self-guided behavior. Four perspectives are proposed for therapeutic intervention that will promote motivated behavior in patients. They include a consideration of the following factors: expectancies of success or failure, internal versus external orientation, belief in skill, and sense of efficacy.


Congenital defects of the upper lateral incisors (ULI): condition and measurements of the other teeth, measurements of the superior arch, head and face.

We surveyed a French male population for the incidence of missing or reduced upper lateral incisors (ULI). In 5,738 subjects, we observed an incidence of 1.59% with one or two reduced ULI (the other normal) and 1.90% with one or two missing ULI (the other normal or reduced), altogether, 3.49% affected subjects. Furthermore, 250 random controls were observed. Agenesis of other teeth is more frequent in propositi. Missing thir molars were 12.4% in controls, 24.0% in propositi with reduced ULI and 39.6% in propositi with two missing ULI. Furthermore, agenesis of incisors, canines and premolars ranges from 0.4% in controls to 1.3% in propositi having reduced ULI and 5.0% in propositi with two missing ULI. So, propositi with reduced ULI are intermediate between the controls and the propositi with missing ULI with respect to the freeuency of agenesis of other teeth. On the other hand, a different ranking is observed with respect to the teeth measurements: reduction of tooth size is more marked in propositi with reduced ULI than in propositi with missing ULI. The reduction mainly affects canines, incisors and to a lesser degree, premolars. Arch length and interpremolar diameters are smaller in propositi with missing ULI, compared with controls.


Congenital defects of the upper lateral incisors: multivariate analysis of measurements of the other teeth, the superior arch, head and face.

The survey of a French male population allowed us to ascertain 75 propositi with one or two missing ULI, 59 propositi with one or two reduced ULI and 99 controls on whom measurements (mesiodistal and buccolingual diameters) of all of teeth of the superior arch are available. Principal Component Analysis gave a first estimated principal component highly correlated with each of the dental measurements of arch measurements. This size factor was eliminated by observing the plane of the second and third principal components. Strikingly different clusters of MD diameters or BL diameters were observed for the controls, the propositi missing one or two fo the ULI and the propositi with reduced ULI. For the controls, the arch length is correlated with the MD molar diameters and the MD incisor diameter, the arch width being isolated from the other measurements. For the propositi with missing ULI, among the dental measurements the MD and BL diameters cluster, the arch length is isolated as are the arch widths. For the propositi with reduced ULI, the rich length is closer to the dental measurements while the widths, especially the first one, are isolated. The best discriminant measurements are the diameters of the first premolars and the canine, the first arch width and the arch length. Among controls, the arch is narrowed and shorter for the propositi with absence and wider for the propositi with reduction. Teeth measurements are always smaller in propositi.


Influence of maternal nutritional status on prenatal growth in a Peruvian urban population.

Anthropometric measurements were made on 4,952 mothers and their neonates from a Peruvian urban population. Based on age-specific percentiles, the mothers were separated into categories of short and tall stature, high and low fat, and high and low muscle. The study indicates that: (1) tall and short mothers characterized by similar subcutaneous fat and upper arm muscle area (whether high or low) had newborns with similar birth weight and recumbent length; (2) mothers characterized by high subcutaneous fat had heavier and fatter, but not longer, newborns than mothers with low subcutaneous fat; (3) mothers characterized by high upper arm muscle area had heavier, leaner and longer newborns than mothers with low upper arm muscle area; (4) mothers characterized by high muscle and high fat had heavier and longer newborns than mothers with high muscle and low fat; but (5) mothers characterized by high muscle and low fat had heavier and longer newborns than mothers with low muscle and high fat. Considering that subcutaneous fat and arm muscle area reflect calorie and protein reserves respectively, it is concluded that an increase in maternal calorie reserves results in increased infant fatness, but a lesser increase in linear growth. In contrast, an increase in maternal protein reserves does enhance both birth weight and prenatal linear growth.


Aging and secular change in adult stature in rural Colombia.

Age-associated changes in adult stature of a cross-sectional sample of 634 adults from rural Colombia were estimated by multiple regression of stature and age controlling for subischial length, and from equations predicting maximum attained stature from subischial length. From these analyses the estimated rate of loss in stature due to aging per se for men was 0.12 cm/yr, while for women it was 0.03 cm/yr. When corrected for aging, several secular trends in adult stature were evident, although none were statistically significant.


Probable malignancy in a Sadlermiut Eskimo mandible.

The mandible of a Sadlermiut Eskimo woman, age at death 28 to 30 years, displays numerous well-formed formamina concentrated bilaterally around the mental foramina. Differential diagnosis identifies this lesion with highest probability as a metastatic cancerous lesion: of less likelihood are sarcoma, hyperparathyroidism, hemangioma, and osteomyelitis. The specimen deserves attention because identification of malignancy in paleopathological material is uncommon and difficult, and because malignancies in aboriginal Eskimo populations are reputed to have been rare or absent.


The evolution of molar occlusion in the Cercopithecidae and early Catarrhines.

Those Eocene prosimians which are possible catarrhine ancestors have four blade-like crests on each lower molar. Each crest shears in sequence across two upper molar crests. Occluding crests are concavely curved to hold the foods being sheared. Each of two medial lower molar crests bordering the principal crushing surface shear past single upper molar crests at about the same time the lateral lower molar crests contact the second rank of upper molar crests. Grinding and crushing areas are restricted to hypoconid, trigonid, and protocone surfaces. Oligocene catarrhine molars have increased crushing-grinding capacities and maintained but modify their shearing. As the crushing surface of the protocone expands and a crushing hypocone is added, the "second rank" upper molar shearing crests are functionally reduced. At the same time medial crests are increasingly emphasized so that the total shearing capacity remains virtually unchanged. Marginal shearing blades are straight edged; leading edges of occluding blades are set at different angles to the occlusal plane so that blades contact at only one point at any given time. Early Primates have separate crushing basins surrounded by shearing blades. Catarrhines tend to link explanding crushing surfaces anteroposteriorly into a continuous surface between all molars. A cladistic analysis based on both new and previously recognized characters indicates that: 1. Apidium may be more closely related to Aegyptopithecus than to Parapithecus; 2. cercopithecids are derived from a Parapithecus-related stock; 3. Oreopithecus could equally well have come from an Apidium or Aegyptopithecus stock.


Stress and the etiology of osteoarthritis.

Although degenerative joint disease is an old and exceedingly common problem, clinical investigators have not reached a consensus regarding the etiology of this disease. Comparative osteological analysis of the knee, hip, shoulder, and elbow joints of 789 individuals from four human skeletal populations (Black and White Americans, Pueblo Indians, and Alaskan Eskimos) indicates that age of onset, frequency, and location of degenerative changes are directly related to the nature and degree of environmentally associated stress, as reflected by the variable life styles of the populations sampled. Eskimos have the earliest onset and most severe involvement for all four joints studied, the right side is usually more affected than the left, and Blacks are more frequently involved than Whites in the knee, shoulder, and elbow. Functional stress, when constant and severe in nature, becomes the primary focus of degenerative disease, but other background contributing agents such as age, sex, and hormonal influence must not be ignored.


Brief hospitalization: a two-year follow-up.

The author present two-year follow-up data of a controlled study of 175 newly admitted inpatients who lived with families, comparing the relative efficacy of brief hospitalization (with and without transitional day care) and standard hospitalization (with all patients offered outpatient aftercare). The long-term results confirm the preliminary finding that brief hospitalization is preferable to longer term hospitalization for most patients. Briefly hospitalized patients spent significantly less time as inpatients and showed less psychopathology and impairment in role functioning. In contrast to preliminary findings, the long-term results indicate that use of day care reduced the number of inpatient days.


Dangerousness, confidentiality, and the duty to warn.

The Tarasoff decision, by imposing on psychiatrists an obligation to warn the intended victim of threats made by a patient, but only under certain vaguely specified circumstances, may stampede psychiatrists into issuing such warnings to avoid possible legal liability no matter how remote the risk of harm may actually be. The authors suggest that the ill effects of such a reaction by psychiatrists--breach of confidentiality and the attendant erosion of trust and harm to the therapeutic alliance--can often be easily avoided by taking less drastic steps, some of which are illustrated by case presentations.


Platelet monoamine oxidase activity in schizophrenic patients.

The authors studied platelet monoamine oxidase (MAO) activity in 29 schizophrenic inpatients and 26 schizophrenic outpatients during a 4-week double-blind trial of chlorpromazine with imipramine or thiothixene with placebo. The found that significantly more schizophrenic patients than normal control subjects had low platelet MAO activity after 4 weeks. Outpatients with low MAO activity were distinguished by increased behavioral activity and reduced social apathy. Inpatients with low MAO activity were distinguished by severity of illness and symptoms. Hallucinations were significantly more frequent among patients with low MAO activity. The authors suggest that platelet MAO activity might decline in some actively schizophrenic patients as part of the psychotic process.


Postsynaptic supersensitivity in schizophrenia.

In the context of the dopamine hypothesis of schizophrenia, the authors examined postsynaptic dopamine (DA) receptor sensitivity in schizophrenic patients by means of a neuroendocrine strategy using the DA receptor agonist apomorphine and growth hormone (GH) release as the measurable postsynaptic event. The activity of platelet adenylate cyclase, an enzyme intimately associated with catecholamine receptor activity, was also studied following stimulation by prostaglandin E1 (PGE1). Patients diagnosed as having acute schizophrenia had significantly higher GH responses and adenylate cyclase activity than normal control subjects and patients diagnosed as having chronic schizophrenia. Chronic schizophrenic patients with and without tardive dyskinesia showed GH responses slightly lower than but not significantly different from those of control groups.


Psychiatric consultation: concepts and controversies.

There are two major models of consultation in the field of psychiatry, differing in their goals, participants, settings, and methods. The psychiatric-therapeutic model entails provision of optimal care for the individual patient; the community mental health model involves provision of assistance to mental health caregivers. The author believes that to enhance the value of consultation the consultation should restrict his or her role to that for which he or she has been trained. Current social needs, coupled with a limited supply of consultants, suggest that psychiatric consultation should be provided within comprehensive health care systems. There is a pressing need to clarify the concepts of formulations concerning the criteria of outcome of psychiatric consultation so that evaluation of its effectiveness can be advanced.


Psychotherapy and pharmacotherapy: conceptual lenses.

Of the many difficulties in maintaining an integration of psychotherapeutic and pharmacotherapeutic treatment, one of the most important is "the problem of bimodal relatedness", that is, the distinction between relating to the patient as a diseased organ or object of study and as a disturbed person. The authors identify the forces that act to inappropriately emphasize one mode or the other and discuss major difficulties that arise because of failure to maintain a bimodal relatedness. In a setting of combined therapy, maintaining and safeguarding the optimal relationship of collaborative subject-subject relatedness can prevent the emergence of problem destructive to effective psychiatric treatment and research.


Catecholamine metabolism during heroin use.

The authors examined urinary levels of catecholamines and metabolites during a 10-day period of heroin use in 9 subjects. Catecholamine and metabolite excretion increased over baseline values on the first day of heroin use, but markedly different patterns of change emerged later. In contrast to the significant increase in normetanephrine and decrease in metanephrine excretion in all 9 subjects during heroin use, only 4 subjects showed an increase in 3-methoxy-4-hydroxyphenyl glycol (MHPG) excretion. Moreover, it appeared that the increase in MHPG excretion in this subgroup began on the day before heroin administration, which suggests the possibility of an anticipatory or conditioned response.


Ten years of inpatient programs for alcoholic patients.

The author reviews the progress made during the past decade in making acute hospital facilities available to the alcoholic patient. He also describes the advances that have been made in the level of care provided by increasingly available detoxification centers. However, he finds that the needs of chronically and permanently disabled alcoholic individuals are still not being met by the mental health system.


Prognostic implications of various drinking patterns in psychiatric patients.

The authors examined the drinking patterns of 198 first admission nonalcoholic psychiatric patients to determine the relationship among drinking behavior, severity of pathology, and prognosis. Heavy drinking in the psychiatric sample was not associated with increased levels of pathology and poor prognosis. To the contrary, among these nonalcoholic patients the abstainers and occasional drinkers showed the most severe pathology and poorest prognosis of all drinking groups.


Cognitive and interactive aspects of splitting.

The author discusses splitting, the segregation of multiple inner schemata of self and others, from the points of view of cognitive structure, cognitive process, anad interpersonal transaction. A case example illustrates how one borderline patient shifted fluidly during therapy among four isolated and sometimes incompatible representations of the doctor-patient relationship. The author concludes that therapists working with borderline patients must be aware of atypical transference patterns and may have to introduce, as a special nuance of therapy, work to stabilize patients' realistic self- and therapist images before offering interpretations.


Voluntary and involuntary treatment of aggressive patients.

The author describes his experiences in treating violent patients in group therapy. Problems include the divergent goals of therapist, patient, and society; the environmental limitations on incarcerated patients; countertransference issues; and magical expectations on the part of patients. Therapeutic goals must be somewhat limited with patients who are forced into therapy. It may be dangerous to "open up" such patients, especially when they face lengthy prison terms. The author suggests that distancing tactics be avoided with violent patients, who need to encounter another person who has dealt successfully with hatred, fear, and limitations.