Premature interruption of psychotherapy: continuation of contact by telephone and correspondence.

The author collected data on 15 patients for whom therapy was interrupted because of a move to a distant city by the analyst or the patient. He found that 14 of these patients refused to accept transfer to another analyst as urged by their analyst; instead, they continued contact by phone and/or correspondence with the analyst for long periods of time. Continuation of contact was not related to diagnosis but perhaps to a basic inability of these patients to face and work through separation or to some type of special patient-therapist relationship.


Abortion applicants: characteristics distinguishing dropouts remaining pregnant and those having abortion.

This study, of two groups of women who applied for induced hospital abortion, compares 100 women who had the abortion with 100 women who dropped out to carry to term. Dropout applicants who elected to carry to term had less education, had partners with less education, tended to be indecisive, and when they told their partners tended to receive negative responses toward abortion. In addition, these women expressed greater concern about the procedure and about the moral implications of abortion. Implications of this study for further research on women's and their partners' decision-making about abortion using the Janis-Mann model are discussed.


Injuries, crashes, and construction on a superhighway.

Crash and injury-crash rates increased significantly on segments of an Illinois superhighway undergoing major construction, compared to crash rates of preceding years and to crash rates on segments not undergoing construction. Maintaining separation of traffic on segments under construction resulted in smaller increase in injury-crash rates than crossover diversion of traffic from lanes under construction into previously one-way roads.


Nutrition surveillance in Arizona: selected anthropometric and laboratory observations among Mexican-American children.

A nutrition surveillance system in public health clinics is providing data for patient care and program planning. Through this system, Arizona's Mexican-American population has been shown to differ from other ethnic groups seen in clinic. Anemia and low height-for-age are significant problems in the Mexican-American population. Over-nutrition, in the form of overweight and high cholesterol, is also a problem among the Mexican-American clinic population.


Operative choledochoscopy. Results of a prospective study in several institutions.

A prospective study from six surgical units utilizing choledochoscopy in conjunction with primary choledocholithotomyand cholangiography resulted in an incidence of less than 2 per cent unsuspected residual biliary calculi. Total reliance on choledochoscopy without associated operative cholangiography is not justified and fraught with error. When there are no calculi in the common duct, the choledochoscope allows the surgeon to shorten exploration time with confidence that the postexploratory cholangiogram will confirm his negative findings. The choledoschoscope is of additional value in the extraction of calculi. Certain considerations in the management of biliary tract tumors also can be helped by the addition of choledochoscopy. The simultaneous presence of calculous disease and biliary tract neoplasm can coexist can be brought to light by the use of the choledochoscope. The incorporation of choledochoscopy, using a rigid Berci-Shore choledochoscope, as part of routine common duct exploration, appears to be warranted.


Hepatobiliary scanning using 99mTc-pyridoxylideneglutamate.

Technetium 99m-pyridoxylideneglutamate (99mTc-PG) administered intravenously is excreted by hepatocytes into the bile canaliculi and enters the gallbladder through the cystic duct and consequently, can be used for scanning the hepatobiliary ductal system. A total of 166 patients representing 27 normal subjects, 84 patients referred for investigation for pain in the upper right quadrant of the abdomen and 55 jaundiced patients were evaluated with 99mTc-PG. In normal human volunteers, the agent reached the liver in five minutes, and the common bile duct, gallbladder, and duodenum within 15 minutes. Satisfactory images of the hepatobiliary tract were obtained using small dosages of 99mTc-PG. The gallbladder was not visualized when the cystic duct was occluded. In the presence of acute cholecystitis, cystic duct obstruction, or in chronic cholecystitis where other roentgenographic studies showd a nonfunctioning gallbladder, there was no concentration of 99mTc-PG in the gallbladder. In partial common bile duct obstruction is distended common bile duct was visualized along with delay in transit of radioactivity into the duodenum. Complete common bile duct obstruction was associatedwith no radioactivity in either the biliary or the gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of biliary and gastrointestinal tracts. 99mTc-PG scanning proved capable of differentiating between hepatocellular disease and extrahepatic biliary tract obstruction.


Computed tomography: a valuable aid to the abdominal surgeon.

The application of computed tomography (CT) for diseases of the liver, pancreas, kidney, and retroperitoneum has been described. The diagnostic accuracy of CT when compared with angiography, radioisotope scanning, endoscopic pancreatography, and transhepatic cholangiography is now being studied prospectively. The attractive features of CT include low risk, wide applicability, noninvasive technics, high diagnostic accuracy, and patient acceptance.


Enhancement of biliary phospholipid radioactivity by intestinal administration of labeled precursors of hepatic lecithin synthesis.

An animal model is used to study the effects of different radioactive precursors of lecithin, administered intestinally, upon biliary lecithin synthesis. Choline caused greater biliary lecithin radioactivity than choline-labeled lecithin or palmitic acid. The clinical application of this finding is discussed with relation to patients with gallstones or potentially lithogenic bile. Oral administration of choline may increase biliary lecithin concentration and, thus, cholesterol-holding capacity in this patient group, thereby changing the character of the bile to a non-lithogenic state.


Cellulose granulomas and their relationship to intestinal obstruction.

Cellulose foreign body was initially described by the authors as a cause of granulomatous peritonitis implicating disposable surgical fabrics. The purpose of this study was to establish the incidence, origin, and clinical significance of the lesion. Of 7,500 surgical specimens and autopsies from surgical mortalities reviewed by one pathologist during a two and a half year study period, forty-five cases of cellulose foreign body granulomas were identified by light microscopy. They were examined with polarization technics and scanning electron microscopy in an attempt to determine the source of the cellulose fibers as either cotton or a wood product. The forty-five cases were identified in patients who had at least one previous surgical procedure involving the same area. Twenty-seven cases were extraperitoneal. Eighteen were located in the peritoneal cavity of which five were found at autopsy and thriteen were identified at laparotomy. Two patients had granulomatous peritonitis and six had mechanical small bowel obstruction associated with the granulomas. During the study period there were sixty operative patients of small bowel obstruction; forty-nine were due to adhesions of which thirty-seven had lysis of adhesions without biopsy. Of the twelve patients with surgical specimens, cellulose granulomas were present in six. This suggests that cellulose foreign body granuloma may be a significant cause of intestinal obstruction. The origin of the cellulose could not be definitively established in most cases because of loss of morphologic characteristics. However, fibers were positively identified as wood in two of ten cases (20 per cent) examined with scanning electron microscopy, which supports the thesis that they were derived from disposable surgical fabrics.


Release of VIP by calcium stimulation.

Calcium has been shown to be a reliable releaser of VIP, as has been observed with most peptide hormones. VIP is released throughthe gastrointestinal tract. The challenge of VIP release by calcium could reveal different "potentials" in the production of the hormone, that are not appreciated in the basal state. Calcium stimulation thus showed a slightly greater level of VIP release from the pancreaticoduodenal vein than from the portal radicals. But although the significance of this finding remains to be defined, calcium release could have a clinical applicability in the challenge of equivocal VIPomas.


Human gastric pacesetter potential. Site of origin, spread, and response to gastric transection and proximal gastric vagotomy.

Gastric electrical activity was recorded from twenty-six patients at celiotomy. The human gastric pacemaker was localized to an area in the midcorpus along the greater curve. Pacesetter potentials were generated regularly by the pacemaker at a mean frequency of 3.2 cycles/min and were propagated circumferentially and aborally from the pacemaker, increasing in amplitude and velocity as they approach the pylorus. The pattern of pacesetter potenitals in patients with gastric ulcer, gastric cancer, and duodenal ulcer was similar to that of patients without such diseases. Complete transection of the gastric corpus isolated the distal stomach from the natural pacemaker and resulted in the appearance of a new pacemaker in the distal stomach with a slower frequency. The fact that proximal gastric vagotomy did not greatly alter the frequency of generation or the pattern of propagation of the pacesetter potential provided further evidence that both are myogenic phenomena.


Effect of abdominal surgery on intestinal myoelectric activity in the dog.

The effect of cholecystectomy and small bowel transection on the myoelectric activity of the small intestine was determined in conscious dogs. Three animals were implanted with electrodes spaced approximately 25 cm apart along the serosal surface of the small intestine. Recordings were made with dogs in the unanesthetized fasted state. After completion of control recordings, the gallbladder was removed from each animal. Recordings were made each day after surgery for a period of one week and then periodically during the next two weeks. At the end of three weeks, transection and end-to-end anastomosis of the mid-ileum was done. Once again recordings were obtained each day for one week and periodically for two subsequent weeks to insure return to normal fasted patterns. Neither cholecystectomy nor transection and anastomosis had an inhibitory effects of the myoelectric activity of the small intestine.


Prevention of hypocalcemia by administration of homologous plasma during experimental hemorrhagic pancreatitis in the pig.

Pancreatitis was induced in fifteen immature pigs while five additional pigs underwent sham laparotomy. Animals with pancreatitis were separated into three groups of five each with respect to fluids administered after pancreatitis was induced. Each pig in group A and the control group received normal saline, 300 ml/hour for 8 hours. Pigs in group B received pig plasma at 150 ml/hour plus normal saline at 150 ml/hour for 8 hours. Pigs in group C received pig plasma at 50 ml/hour plus normal saline at 50 ml/hour for 24 hours. Values for serum hematocrit total protein, and total calcium, were measured preoperatively and 4, 8, and 24 hours postoperatively. Control animals and group B animals experienced no change in any parameter. Group A, animals sustained transient severe hemoconcentration, permanent severe hypoproteinemia, and hypocalcemia. Group C animals displayed a transient moderate hemoconcentration and a moderate but sustained decrease in calcium concentration. It is concuded that the hypocalcemia occurring during experimental hemorrhagic pancreatitis is directly related to the early hypovolemia and can be prevented by preventing the hypovolemia.


The effect of nephrectomy on the catabolism of secretin.

Previous studies have shown the kidney to be an important site for the catabolism of secretin. We have investigated possible sites within the kidney for secretin uptake in four intact anesthetized dogs. The disappearance half-time of an intravenous infusion of secretin, measured by a sensitive and specific ratioimmunoassay in four intact anesthetized dogs was 2.84 minutes. After ureteral ligation (to arrest glomerular filtration), the half-time of a similar intravenous dose of secretin was 2.78 minutes. Finally, the renal vascular pedicles were ligated to totally exclude the kidneys from the circulation and the half-time was found to be 5.43 minutes. These findings demonstrate that the efficient renal mechanisms for secretin degradation are not dependent upon glomerular filtration but upon some other mechanism, presumably located in renal tubular cells.


The intestinal mucosal barrier to intact antigenic protein. Difference between colon and small intestine.

The integrity of the normal mature intestinal mucosal barrier to unaltered proteins was evaluated with tritiated bovine albumin in rats. Intact H3-BSA placed into either colon or small intestinal lumen regularly reached the bloodstream in quantities sufficient to be antigenic or toxigenic, although the fraction of H3-BSA absorbed from the colon (0.13 per cent) was significantly smaller than that absorbed from the small intestine (1.7 per cent). These studies support the possibility that uptake of ingested or bacterial antigens from the normal gut may be involved in the pathogenesis of local intestinal and systemic disease in man.


Adjuvant chemotherapy with 5-fluorouracil after surgical resection of colorectal carcinoma (COG protocol 7041). A preliminary report.

In a prospectively randomized study the effect of adjuvant chemotherapy with 5-FU on survival and recurrence was analyzed in 274 evaluable patients with colorectal carcinoma who either underwent a curative or a palliative resection. In the treatment group, chemotherapy consisted of the intravenous administration of 5-FU 12 mg/kg daily for four consecutive days, then 6 mg/kg/per day on alternate days to the point of toxicity or to a maximum of 5 doses, followed by 12 mg/kg/week for one year. Drug toxicity was rarely severe and consisted of nausea and vomiting, diarrhea, stomatitis, leukopenia, and thrombocytopenia in slightly more than half of all patients. There have been no drug-related deaths. Analysis of the survival curves and disease-free interval curves reveal some evidence of drug benefit in both the curative group of resections and the palliative group of resections. However, this benefit is not significant except in those treated to toxicity. The disease-free interval after curative resection is significantly longer in patients treated with 5-FU to the point of toxicity with a white blood count less than 4,000 cells/mm3. We conclude that a preliminary analysis of the Central Oncology Group data in this trial does not make a convincing case for the use of 5-FU as an adjuvant to the surgical treatment of colorectal carcinoma.


Resection of the perforated segment. A significant advance in treatment of diverticulitis with free perforation or abscess.

As a result of improved medical management of chronic diverticular disease, perforation has become the most common indication for surgical intervention. During the past five years sixty-three patients underwent operation for colonic diverticular disease, of which forty-six were for perforation (generalized peritonitis in 8, abscess in 30, and fistula in 8). The eight patients with generalized peritonitis underwent emergency exploration for spreading peritoneal signs and were managed by resection of the perforated segment, end colostomy, and mucous fistula or Hartmann's pouch. Treatment of thirty-eight patients with abscess or fistula has also stressed primary resection of the perforated segment of colon. Resection and end colostomy without anastomosis was performed in three. Primary anastomosis with proximal diverting colostomy was performed in four. Primary anastomosis alone was done in thirty-one patients. There were no deaths. These results support primary resection of the involved colon with immediate or delayed anastomosis in the operative management of perforated diverticular disease.


Primary arterial ligation in resection of cancer of the colon. Rational and technic.

The dynamics of arterial, venous, and lymphatic flow in the mesentery were studied in dogs, using an electromagnetic flowmeter for the blood and cannulation and gravimetric measurement for the lymph. Ligation of veins caused an increased venous outflow in adjacent veins and a marked increase in lymph flow. When marginal vessels were ligated, eliminating the major collateral flow, venous flow decreased, but elevated lymph flow persisted. Simultaneous ligation of arteries and veins resulted in increases of both arterial and venous flow in adjacent vessels. Lymph flow decreased unless excessive arterial collateral flow persisted. When collateral marginal vessel flow was occluded, adjacent venous and arterial blood flow decreased to control levels. With arterial ligation, collateral arterial blood flow increased slightly, but venous and lymph flow decreased sharply. When collateral marginal vessels were eliminated, adjacent arterial blood flow decreased to control levels and venous flow virtually stopped. As a result of these studies, the technic of early primary arterial ligation followed by marginal vessel ligation appears to be the most satisfactory procedure for decreasing venous and lymphatic outflow and hopefully avoiding dissemination of cancer cells during the operation. This technic is now being used as a modification of the "no touch" technic for cancer of the colon.


Effect of different absorbable sutures on healing of gastrointestinal anastomoses.

Studies were performed in dogs to determine whether the newer absorbable sutures would be preferable to catgut in the gastrointestinal tract. Dissolution times of plain and chromic catgut were compared with those of polyglycolic acid (Dexon) and polyglactin 910 (Vicryl) sutures exposed to gastrointestinal contents in vitro and in vivo. Strength and healing of gastric, jejunal, and colonic anastomoses performed with each suture were compared in dogs. Catgut sutures proved susceptible to rapid proteolytic digestion throughout the gastrointestinal tract, whereas Dexon and Vicryl were invulnerable. Type of suture did not affect microscopic healing in the stomach jejunum, or colon. However, gastric anastomoses of Dexon were stronger at four and seven days and jejunal anastomoses of Dexon and Vicryl were stronger at seven days than anastomoses of catgut. Dexon and Vicryl may be superior to catgut for use in gastrointestinal anastomoses.


Prevention of accidental trauma to the iloinguinal nerve during inguinal hernoirrhaphy.

The sensory component of the iloinguinal nerve normally courses through the inguinal canal and supplies the upper thigh, pubis, inguinal crease, and the anterior and lateral aspect of the scrotum or labia majora. In 424 inguinal dissections a normal course of these nerves was found in 60 per cent. In 35 per cent an aberrant origin, course, and position were found, in which the nerve was behind and within the cremaster covering of the spermatic cord or round ligament. In 5 per cent both a normal and aberrant course was encountered on the same side. Both normally or aberrantly positioned nerves may be compromised during operation by retraction or by accidental division during the exposure of the inguinal canal structures and the isolation and dissection of the hernial sac. However, an aberrant nerve has a greater risk potential since it is behind and within the cremaster layer of the spermatic cord or the homologous covering of the round ligament. Accurate identification of these nerves and the awareness of their variable course and position during operation should minimize the risk of postoperative peri-inguinal cutaneous changes. This aberrant course of the ilioinguinal nerve has not been previously reported in the literature.


Significance of pneumatosis cystoides intestinalis after jejunoileal bypass.

In 148 radiographs taken two weeks to twenty-seven months postoperatively in a series of 402 jejunoileal bypass patients at the University of Minnesota, twenty-four patients demonstrated roentgen evidence for pneumatosis intestinalis on twenty-eight separate episodes. This primarily involved the right colon. Clinical signs and symptoms were reviewed in association with the roentgen findings. Symptoms of nausea, vomiting, fever, and abdominal stress were noted but were not universal. Six patients had no significant change in abdominal complaints at the time the pneumatosis was seen and seven patients had similar clinical findings without roentgen evidence for pneumatosis. Thus, the radiographic findings of pneumatosis intestinalis do not represent a specific sign for bypass enteritis.


The acalculous gallbladder.

There is a definite clinical entity of chronic acalculous cholecystitis that can be cured by cholecystectomy. More research needs to be done on how this condition could be more accurately and earlier diagnosed. The majority of chronic gallbladder symptoms are not dependent on the presence of calculi. Gallbladder x-ray films are subject to significant diagnostic error, as are all other diagnostic tests. There is a need for more uniformity among pathologists as to what microscopic findings substantiate a diagnosis of chronic cholecystitis.


Experience with amphotericin-B in the treatment of systmeic candidiasis in burn patients.

Systemic candidiasis has emerged as a major cause of death in burn patients. An increase both in the incidence of systemic candidiasis and its increase as a cause of death has been observed. Treatment with systemic amphotericin-B prior to 1971 at our institution was rarely successful. This was felt to be in part due to lack of sufficiently early recognition of the infection and to delay in the initiation of appropriate systemic therapy. From 1971 to 1975, fifteen patients have been treated with systemic amphotericin-B with one death. There have been no fatalities from candidiasis since 1972. No serious complications attributed to the use of amphotericin-B were observed. Prompt initiation of therapy with intravenous amphotericin-B is advised for burn patients in whom systemic candidiasis is present.


Preoperative administration of fluids.

A study by questionnaire was sent to 134 Surgical Services at Veterans Administration Hospitals to ascertain the prevalence of the practice of preoperative hydration during the period of hydropenia preceding surgery. A 92.5 per cent response was noted and the following conclusions are drawn: (1) The majority of Veterans Administration Surgical Services do not routinely provide intravenous fluids during the immediate preoperative period. (2) Affiliation with a medical school-based postgraduate training program does not alter significantly the proportion of Surgical Services providing preoperative intravenous therapy on a routine basis. (3) These observations suggest a need for Surgical Services to assess the desirability and indications of preoperative hydration. (4) However, in the case of chronic renal failure patients there is little question of the necessity for careful preoperative, intraoperative, and postoperative hydration.


Mesenteric infarction.

The most common etiologies of mesenteric infarction in fifty-one patients were arterial thrombosis (in 42 per cent), bowel infarction without major vessel occlusion (in 28 per cent), and arterial embolus (in 22 per cent), but the etiology also included some very rare vascular diseases--two cases of the malignant atrophic papulosis of Degos. In the group of forty-four operative patients the mortality was 70 per cent. All the patients treated medically died. Mesenteric infarction should be suspected in all elderly cardiac patients with symptoms of acute abdomen. The value of an early diagnosis, fast resuscitation, and aggressive operative treatment cannot be overstated. Bowel resections yielded the best results in this series. However, the operative treatment of the mesenteric infarction should be individual, depending on the etiologic factors and the time which has elapsed from the onset of the symptoms.


Evaluation of hematologic abnormalities in the nonbleeding postoperative patient.

With a seriously ill postoperative patient, selecting the best course of action may be difficult when laboratory data suggest hematologic abnormalities. If an Afro-American is to undergo major surgery, simple postoperative screening procedures are available for certain hereditary erythrocyte abnormalities. Acute hemolysis, from any cause, may mimic advanced liver disease. Bleeding into closed body spaces, with erythrocyte destruction secondarily, may mimic generalized hemolysis. One basic premise is always to review the medications being administered; many drugs may induce granulocytopenia or anemia. Because there is a compensatory increase in erythrocyte 2,3-diphosphoglycerate content that increases oxygen release to the tissues in the normovolemic anemic patient, less frequent use of blood transfusion is possible in these patients. Healing will continue even when the packed red cell volume is 25 per cent.


Hyperparathyroidism in thyrotoxicosis.

The frequency of hypercalcemia in 295 patients treated for thyrotoxicosis was 2 per cent. The combination of thyrotoxicosis and hyperparathyroidism is rare and only twenty-seven well documented cases could be found in the literature. Among ninety-two patients operated on for hyperparathyroidism, ten of them had thyrotoxicosis. In the present study, data on thirty-seven patients are reported. Hypercalcemia was found in all the patients and four of them had acute hyperparathyroidism. Hypophosphatemia was recorded in 60 per cent and hypercalcuria in 75 per cent of the patients. In ten patients there were renal concretions. Skeletal roentgenograms showed abnormalities in 65 per cent of the patients. In no instance had hyperparathyroidism commenced before thyrotoxicosis. Other recent reports on the etiology of hyperparathyroidism are discussed and it is concluded that hyperparathyroidism in thyrotoxicosis is a secondary disease. If a thyrotoxic patient with hypercalcemia still has elevated calcium values when becoming euthyroid after thyrostatic treatment, an operation should be performed. Because of a high recurrence rate in such patients with adequate follow-up, "near total parathyroidectomy" is recommended.


Thyroid cancer. Twenty-three years' experience at Baptist and St. Thomas Hospitals.

One hundred fifty-six patients with thyroid cancer were diagnosed and treated at Baptist and St. Thomas Hospitals from 1952 through 1955. Papillary carcinoma, representing 65 to 70 per cent of the total, occurs in all age groups and is the most readily curable of all carcinomas. Slightly more than 50 per cent of our series presented with multinodular goiters. When a male patient has nontoxic nodular goiter, it is three times more likely that he will have cancer of the thyroid than a female patient with a similar goiter. Definitive thyroid surgery was performed by over fifty different surgeons in 143 patients and simultaneous neck dissection in twenty-five. The histologic types ranged from papillary (9 per cent mortality) to anaplastic carcinoma (nearly 100 per cent mortality). Age and sex were shown in our series to affect survival. The female survival figures were better than the male, and older patients fared far worse then younger ones. Survival rates are much improved in patients with cervical node metastases when radical neck dissection is done. Patients reoperated for enlarged nodes located lateral to posterior triangle were found not to have metastatic cancer. Hyperthyroidism was confirmed in 0.25 per cent.


Indications for neck dissection in carcinoma of the lip.

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initally had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supramohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.


Scalp as a donor site.

Our experience in twenty-six patients suggests that the scalp is an excellent source of split thickness skin grafts. Healing is rapid, infection is rare, and the regrowth of hair conceals the donor site.


Regional perfusion for recurrent malignant melanoma of the extremities.

Seventeen patients with a local recurrence or intransit metastases of a malignant melanoma of the arm or leg were treated by normothermic regional perfusion with phenylalanine mustard. Seven of these patients had regional lymph node metastases as well. The follow-up period was with five to eight years or until the time of death. Two years after treatment, eleven of the seventeen patients were still alive. After a five year follow-up, six patients were still alive without demonstrable recurrence or metastases. Only three patients had a recurrence in an extremity; two of these three patients simultaneously showed general metastization.


Abdominal decompression: increased efficency by esophageal aspiration utilizing a new nasogastric tube.

Gastric aspiration alone utilizing either a Levin-type nasogastric tube or a gastrostomy tube is inefficient. The esophagus proved to be a more efficient supplemental site for aspiration of a swallowed bolus. For thirty-one patients, esophagogastric aspiration proved to be approximately twelve times as efficient as aspiration via a Levin-type tube for twenty-four patients or a gastrostomy tube in five patients (residual activity, of 3,35, and 42 per cent, respectively). Radiographic studies of a volunteer swallowing barium with each type of nasogastric tube in place showed efficient removal of the contrast agent by esophageal aspiration. With the Levin-type tube, the bolus promptly traversed the stomach and entered the duodenum along parallel channels remote from the x-ray -visualized gastric tube. Efficient postoperative exclusion of swallowed air clinically and experimentally by esophageal aspiration permits more rapid return of gastrointestinal function and full nutrition and perhaps shortened hospitalization.


Cushing's syndrome associated with bronchial adenoma.

A case of Cushing's syndrome associated with a bronchial adenoma treated eight years before with bilateral adrenalectomy was cured by surgical excision of the bronchial adenoma. A discussion of clinical and hormonal features of this lesion is presented. It is concluded that this tumor manifested a capability of synthesizing and releasing substances which are chemically and biologically similar to adrenocorticotropic hormone andmelanocyte-stimulating hormone (MSH). Stimulation of the adrenal cortex by this material results in hyperplasia and hypersecretion, and stimulation of the melanocytesy MSH resulted in excessive pigmentation. Acknowledgment: We are indebted to Doctors Wendell Nicholson, David N. Orth, and Grant W. Liddle of Vanderbilt University for determinations of ACTH and MSH levels and to Mrs. E.P. Jessup for assistance in preparation of statistical data for this manuscript.


Giant duodenal hamartoma consisting mainly of Brunner's glands.

A successfully treated case of a duodenal hamartoma is presented. A review of the literature has shown that this is the largest such tumor so far described, and the first time a mass was palpable on abdominal examination. Its large size resulted in pyloric obstruction, and its wide attachment to the duodenum necessitated a Polya-type partial gastrectomy during its removal. The pathologic controversy which has led to the classification of these Brunner's gland proliferations as duodenal hamartomas is briefly presented.


Total pancreatectomy for carcinoma of the pancreas.

Survival after partial pancreaticoduodenectomy (Whipple procedure) for carcinoma of the pancreas is uniformly poor. In the absence of nodal metastasis this may be due to extension of tumor beyond the line of resection of the pancreas or to a multicentric origin of the tumor. The material reviewed contained an illustration of the latter circumstance and provides a logical reason for recommending total pancreatectomy as the procedure of choice in resectable pancreatic carcinoma.


Pseudomembranous colitis associated with cephazolin therapy.

This is the first reported case of cephazolin-associated pseudomembranous colitis. The disease followed a relentless course from its onset to twelve days later when the patient underwent total colectomy for multiple perforations and then died of sepsis. Recent reports indicate that the incidence pseudomembranous colitis is higher than initially appreciated. Early recognition of this entity with confirmation by proctosigmoidoscopy and immediate discontinuance of of antibiotic therapy may reduce the morbidity and mortality of this disease.


Cryosurgery for pilonidal disease.

Pilonidal disease was treated by a new conservative technic, featuring opening the sinus tracks, removal of imbedded hairs and granulation tissue by gentle curettage, and freezing the opened wound with liquid nitrogen. The goal was to conserve tissue yet improve the chance of cure by a simple operation. Cryosurgery was used in twenty-nine patients with pilonidal disease invaried forms, including recurrent disease after previous operation in seventeen patients. The results, in terms of hospital stay, patient acceptance, and wound healing, compare favorably with alternate treatment methods. The slow healing time of the cryogenic wound, especially at the skin level, appeared to be an important factor in the success of the technic.


Nonoperative management of fingertip pulp amputation by occlusive dressings.

Nonoperative management of fingertip pulp amputations has been employed in eighteen adults. After wound cleansing and debridement, the wound was covered by an occlusive dressing. Healing of the amputated fingertip occurred within four weeks. The healed fingertip had an excellent sensory perception, normal range of motion and an acceptable cosmetic appearance. This satisfactory outcome was realized with less than ten days lost from work.


Below-knee amputations.

Below-knee amputations are commonly performed for peripheral vascular disease. To be successful, the technic must be exacting, and it is crucial to bevel carefully the anterior and medial tibial surfaces to permit successful prosthetic rehabilitation.


[Effect of urethane (DAB-6 product), hexobarbital-Na and pentobarbital-Na on the amino acid concentrations in blood serum of rats. I. Communication (author's transl)].

Free amino acids were determined quantitatively in serum from the fasting blood of rats before and after treatment with urethane (n = 20), hexobarbital-Na (n = 20) and pentobarbital-Na (n = 20). Serum was deproteinised by adding an equal volume of 5% sulphosalicyclic acid and the amino acids were separated by ion exchange column chromatography. 1.24 h after treatment with urethane the rats showed only a statistically significant higher concentration of ornithine in serum. - 2.24 h after injection of hexobarbital-Na the rats had statistically significant higher concentrations of arginine, isoleucine, leucine, lysine, methionine, phenylalanine, taurine, tryptophan and tyrosine in serum - 3.24 h after application of pentobarbital-Na the rats showed statistically significant higher concentrations of aspartic acid, glutamic acid, histidine, lysine, phenylalanine, serine, taurine, threonine, and tyrosine and statistically significant lower concentrations of argine and citrulline in serum.


[Symptomatology and treatment of post-hypoxemic myoclonisms].

After a brief description of the complex symptoms of myoclonias reference is made to the different systems of classification, and mention is made of the particular areas in which myoclonias appear after hypoxemic cerebral damage and which can be observed more frequently as a result of modern intensive therapy techniques. The 12 cases observed here form the basis for a description of the clinical and electronencephalographic symptoms and a discussion of the differential diagnosis; additionally, 2 autopsy results are discussed. In the cases at hand the myclonias seem to arise from subcortical areas. Finally, reference is made to the therapeutic measures quoted in recent literature and to the experiences gained by the authors, primarily with benzodiazepine.


[Report on an emergency of alveolar leakage following lung decortication (author's transl)].

A case of respiratory distress is reported following lung decortication. Of a 331/min applied respiratory volume 90% was lost due to the multiple alveolar leakage. The lung could be inflated only when the chest was closed and several Bülau drains with powerful suckers were inserted. When the lung surface came in contact with the chest wall, the lossof tidal volume could immediately be reduced and respiration was possible again.


[Respiratory mass spectrometer in the intensive care unit. Possibilities of application (author's transl)].

The respiratory mass spectrometer has now reached such a high degree of technical perfection, that the instrument can be used in the intensive care unit without any problems. Simultaneous and continuous analysis of respiratory and non-respiratory gases is possible. Thus a great amount of informations concerning the respiratory situation of patients can be obtained noninvasively. Simple monitoring of respiratory gases as well as lung function analysis can be performed. Problems in the field of mechanical ventilation can be solved more effectively with the help of the instrument.


[On spinal anaesthesia with isobaric bupivacaine 0,5% (author's transl)].

Clinical experiences of 5001 subarachnoid blocks using isobaric bupivacaine 0.5%, with and without adrenaline, for surgery are reported. The clinical results are satisfactory and no neurological sequelae are known to the authors. In vivo studies of C.S.F. after subarachnoid injection of bupivacaine 0.5% in an isobaric solution showed no changes in pH or precipitation. According to these results the authors see no contraindication in the use of bupivacine 0,5% for subarachnoid injection. The use of higher concentrations (e.g. 1%), however, can not be recommended.


[Is there an indication for the use of "micropore-blood filters"? (AUTHOR'S TRANSL)].

Recently "micropore" blood transfusion sets have been advocated to replace the traditional transfusion sets. Because of the higher cost it is important to review critically the data which would justify their clinical use. The filters eliminate microaggregates as they occur during blood storage. The question is wether micropore filters are able to reduce the incidence of posttraumatic or postoperative respiratory insufficiency. We have analysed all controlled in vivo studies. We found only one clinical study where in massively transfused polytrauma patients a decrease in the number of cases of respiratory insufficiency was documented. However, due to the small number of patients investigated, a significant difference in favour of the micropore filters could not be demonstrated. Animal experiments reveal more: Exchange transfusions carried out in dogs through micropore filters do not lead to functional or morphological pulmonary changes. Using traditional transfusion sets, a significant increase in pulmonary artery pressure and resistance was found together with a decrease in arterial pO2, pH and oxygen consumption. All these results correlate well with morphological changes in the lung. On the basis of our literature review, we conclude that there are no clear data which would make it mandatory to use micropore filters in clinical practice. On the other hand, there are several indirect hints than large amounts of microaggregates are not ideal for pulmonary function. The expensive micropore filters could therefore perhaps be used with advantage in massive tranfusions.


Tridimensional reconstruction and histology of the intratesticular seminal pathway in the hamster.

The present work reports a tridimensional reconstruction of the intratesticular seminal pathway in the hamster as studied with light microscopy of serial sections of the proximal pole of the testis. It has three portions: a "terminal segment" of the seminiferous tubules; the tubuli recti with three parts; and the rete testis with two parts, intratesticular and extratesticular. Experiments using ductuli efferentes ligation show a marked dilation of the rete testis and tubuli recti without a corresponding dilation of the seminiferous tubules. This may be due to a valve-like action of the cells in the terminal segment of the tubules.


The fatty ridge and fatty cushion of the human pulmonary trunk.

Presence of a ridge of fatty tissue running obliquely upwards and backwards over the left aspects of the pulmonary trunk was observed. It started from the left end of the infundibulo-trucal junction and after running parallel adjacent to free anterior border of the left auricle, terminated into an expanded oval and discoid structure, a little above the level of the tip of the left auricle. The structure was found to be of constant occurrence, position and form.


The fine structure of the interstitial tissue of the testis of the nine-banded armadillo.

The interstitial tissue of the testis of the nine-banded armadillo is composed of blood vessels, clusters of Leydig cells, the usual connective tissue elements, and a network of lymphatic sinusoids. The endothelial walls of the sinusoids are separated from the peritubular contractile cell layer surrounding the seminiferous tubules by a thin layer of collagen. The pertibular contractile cell is characterized by filaments and dense bodies within the cytoplasm, whereas the endothelial cells lack these structures. Within each cluster, several Leydig cells surround one or more blood vessels. Adjacent Leydig cells are jointed by 2- to 3-nm wide gap junctions and desmosome-like specializations. The Leydig cell is polygonal in shape with an ovoid nucleus. The cell is characterized by an abundance of smooth endoplasmic reticulum which appears as sheets of membranes, concentric whorls around vacuoles, and a random tubular network. Only a few short cisternae of rough endoplasmic reticulum are observed. Centrioles are closely associated with the Golgi apparatus. Rod-like mitochondria with tubular cristae are scattered throughout the cytoplasm. In addition, the cells contain vacuoles resulting from lipid extraction, filaments, microtubules, and glycogen. The surface of the cell exposed to the intercellular spaces exhibit numberous pinocytotic vesicles and cell processes which indicate active movement of material across the plasma membrane. In comparison to other mammalian species, the ultrastructural organization of the interstitium and the fine structure of Leydig cell of the armadillo resemble those of the guinea pig.


Spermatogenesis in the Chinese hamster.

In this article a description of the process of spermatogenesis in the Chinese hamster is given. Spermiogenesis could be divided into 16 steps. The cycle of the seminferous epithelium was divided into 12 stages, coinciding with the first 12 steps of spermiogenesis. The relative and absolute duration of the stages was determined. The duration of the cycle of the seminiferous epithelium was found to be 17.0 days. The morphology of the spermatogonia was studied in seminiferous tubules mounted "in toto." Four classes of spermatogonia could be discerned; undifferentiated A spermatogonia (Ais, Apr, Aal), differentiated A spermatogonia (A1, A2, A3). In spermatogonia and B spermatogonia (B1, B2). It is interesting to note that the last generation of spermatogonia (B2) arises at the beginning of stage 7 and divides to give rise to primary spermatocytes in the second half of this stage; in most other species the last generation of spermatogonia arises in stage 4, giving rise to primary spermatocytes in stage 6. The unidifferentiated A spermatogonia were counted in six stages of the cycle, together with the differentiated A, In or B spermatogonia present in the same stages. The results of these cell counts are discussed in detail. One of the conclusions that could be drawn about the behaviour of the Ais and Apr spermatogonia during the cycle of the epithelium was that there is mitotic activity in these cells in several stages of the cycle. It is suggested that this mitotic activity serves to generate the Aal spermatogonia, which after one or more divisions transform into Al spermatogonia between stages 2 and 8.


Proteolytic dechorionation of annual fish embryos.

Incubation of early embryos of Nothobranchius korthausae in sterile Tris-buffered pronase with added salts and EDTA results in complete dechorionation, after which development proceeds normally and at the same rate as in control embryos. The time required for dechorionation varies according to the age of the embryo and the concentration of pronase employed.


Sex differences in Necturus urinary bladders.

We describe morphological sex differences in urinary bladders of the urodele amphibian Necturus maculosus. The mucosal epithelial cells of bladders from males were tall and contained considerable PAS-positive material. In scanning electron micrographs of the mucosal surface, epithelial cells from male bladders were well demarcated and were capped with microplicae or with long cilia. The mucosal epithelial cells of bladders from females were low and contained only a small amount of PAS-positive material; in scanning electron micrographs cell boundaries could not be distinguished and no cilia or microplicae were present. Bladders from males had higher transepithelial potential difference and lower water content than bladders from females. Urine analyses were not significantly different in the two sexes. It is suggested that response to androgens in the male accounts for the observed differences.


Quantitative analysis of cell turnover in the enamel organ of the rat incisor. Evidence for ameloblast death immediately after enamel matrix secretion.

During renewal of the enamel organ in the rat incisor cohorts of epithelial cells are transported sequentially through presecretory, secretory and maturation zones to the gingival margin where the life cycles of these cells terminate. This process was examined kinetically by determining the absolute flux of cells within each of these zones of amelogenesis. It was found that the efflux of ameloblasts, stratum intermedium and papillary layer cells from the presecretory zone was about equal to the efflux plus expected growth within the secretory zone. However, between the secretory and maturation zones about 50% more ameloblasts entered the maturation zone than were required to account for the egress at the gingival margin and the expected growth. Since there was no similar imbalance between these zones for papillary layer cells, it was concluded that this discrepancy must represent a 50% reduction in the size of the ameloblast population during the maturation stage of amelogenesis. It was calculated that a little over 25% of the loss occurred immediately at the start of maturation within the region of postsecretory transition and the remaining 25% of the loss occurred throughout the subsequent regions of the maturation zone. In addition to the kinetic analysis graphic reconstructions, or surface maps, of ameloblast nuclei were prepared. These maps illustrated the characteristics of ameloblast nuclear packing within the three zones of amelogenesis and they provided quantitative confirmation that as ameloblasts progress through the maturation zone, there is a loss of cells in an amount predicted by the kinetic analysis.


Cultured neuroblastoma cells and halothane: effects on cell growth and macromolecular synthesis.

Cultured mouse neuroblastoma cells were grown in air-CO2 or air-CO2-halothane-gassed incubators. In the presence of halothane the growth rate of the cells was inhibited in a dose-dependent manner; 2 per cent halothane completely inhibited cell growth, while at 0.3 per cent halothane, the growth rate was 74 per cent of the control rate. The biosynthesis of protein and RNA in cells grown in the control atmosphere and that in cells grown in 1 per cent halothane were compared by several techniques. No significant difference between the rates of synthesis of these two macromolecules could be detected. Furthermore, a comparison of labeled protein and RNA by SDS-polyacrylamide gel electrophoresis revealed no qualitative difference. From this and previous work it is concluded that halothane affects the morphology and growth rate of cultured mouse neuroblastoma cells by disrupting cytoplasmic actin-like micro-filaments.


Lithium carbonate and neuromuscular blocking agents.

The effects of lithium carbonate on the responses to five neuromuscular blocking agents were evaluated in dogs anesthetized with halothane (1 per cent) and N2O (60 per cent) in O2. Latency (time from first twitch-height depression to maximal blockade), maximal twitch-height depression, and times to return to 50 per cent and 100 per cent control twitch tension were measured before and after intravenous infusion of lithium carbonate (1 mg/kg/min for one hour) during neuromuscular blockades produced by succinylcholine, decamethonium, gallamine, d-tubocurarine, or pancuronium. Lithium prolonged the latencies of neuromuscular blockades produced by 0.1 mg/kg succinylcholine and 0.1 mg/kg decamethonium by 248.1 per cent and 49.0 per cent, respectively, but had no effect on latency produced by 0.02 mg/kg pancuronium. The times for return to 50 per cent of control twitch height were prolonged by 69.5, 40.0, and 120.1 per cent, respectively. Lithium had no effect on latency or duration of blockades produced by 0.15 mg/kg d-tubocurarine and 0.6 mg/kg gallamine, but enhanced maximal twitch-height depressions produced by 0.9 mg/kg gallamine and 0.02 mg/kg pancuronium by 22.9 and 9.9 per cent, respectively. Twitch tensions decreased 5-10 per cent over three hours in three dogs receiving lithium infusion without relaxants. Twitch tension was depressed 0-2 per cent in three dogs after five hours of anesthesia in the absence of lithium or relaxants. Lithium prolonged the time required for neostigmine to reverse neuromuscular blockade produced by pancuronium in two of three dogs from a mean of 60 seconds to 135 seconds.


Autoregulation of renal blood flow during halothane anesthesia.

Renal blood flow, when not affected by humoral or neural influences, remains relatively constant over a wide range of renal arterial perfusion pressures. This phenomenon, referred to as "autoregulation," is an important mechanism allowing kidneys to maintain homeostasis of the internal milieu over a wide range of arterial pressures. The present study showed that 0.9 per cent halothane had no effect on autoregulation in an isolated, perfused dog kidney as renal arterial perfusion pressure was varied between 75 and 125 torr.


Thiopental inhibition of tumor immunity.

The ability of leukocytes to kill tumor cells appears central to the defense against neoplastic growth. The authors determined the effect of thiopental on this phenomenon in vitro by incubating 51Cr-labelled YAAC-1 tumor cells obtained from the peritoneal cavities of syngeneic A/JAX white mice with immune leukocytes from the peritoneal cavities of allogeneic C57/black mice. Tumor-cell death was quantitated by the amount of 51Cr released into the medium following tumor-cell lysis. Thiopental, in concentrations used during routine anesthesia, inhibited tumor-cell killing in a dose-related manner. Inhibition of cytotoxicity ranged from 8.6 per cent at 2.8 x 10(-5) M thiopental to 38.1 per cent at 8.5 x 10(-5) M thiopental. Moreover, this inhibitory effect was additive to that previously demonstrated with halothane, and was related to the duration of exposure to the anesthetic. It is postulated that thiopental and other anesthetics contribute to the inhibition of leukocyte responsiveness observed in patients with malignancies who have undergone surgical procedures.


Allergic evaluation of cereal smuts.

Weekly atmospheric sampling in the Pocatello, Idaho, area and skin testing with a standard inland smut mixture of the smuts of common cereal grains and grasses have shown that smut is a prominent antigen and, used rationally in a mixture of related antigens, is useful in all seasons in the treatment of allergies. The history, agricultural aspects and medical significance of smuts are discussed.


Allergy and pregnancy and birth complications.

There is a positive relationship between presence of allergic disease and occurrence of pregnancy and birth complications. It is suggested that this relationship is mediated by underdevelopment of the thymus or impairment of central nervous system mechanisms of immunological response due to anoxia often associated with pregnancy and birth complications.


Vascular reactivity of the bovine foot to neurohormones, antigens, and chemical mediators of anaphylaxis.

Three preparations were made of the bovine digit: isolated, spirally cut digital arteries and veins; pump (Ringer's)-perfused, isolated digit; and pump (blood)-perfused digit of the intact anesthetized calf. Administration of histamine, serotonin (5-hydroxytryptamine), phenylephrine, bradykinin, and prostaglandin F2alpha in general caused vasoconstriction. Preparations vasodilated in response to isoproterenol and prostaglandins E1 and E2. Epinephrine and isoproterenol caused biphasic effects in the isolated vein, but consistently produced only vasoconstriction in the perfused systems. Preparations taken from calves previously sensitized to horse serum mounted antigen-specific vasoconstrictor responses upon antigenic challenge. Responses of hoof vasculature to neurohormones and to antigen are consistent with a specific local allergic vascular response as a pathologic entity and may contribute to the understanding of the vascular changes implicated in laminitis.


Drug interactions in the horse: effects of chloramphenicol, quinidine, and oxyphenbutazone on phenylbutazone metabolism.

The plasma half-life of phenylbutazone in horses was not increased after pretreatment with chloramphenicol or quinidine, but was increased after oxyphenbutazone. This increased plasma half-life after oxyphenbutazone is consistent with observations in other species and suggests that oxyphenbutazone inhibits the metabolism of phenylbutazone in horses. Lack of inhibition of phenylbutazone metabolism in the horse by chloramphenicol and quinidine is inconsistent with results obtained in other species.


Use of bacteriophages as an adjunct in the identification of Pasteurella multocida.

Bacteriophages were used as an adjunct to biochemical reactions in the identification of Pasteurella multocida. With the use of bacteriophages, rapid definitive identification of 52.4% of 61 P multocida isolates was made.


Citation characteristics of periodical literature in veterinary science.

The usage of periodical literature in veterinary science was measured by means of citation analysis. Eighty-two percent of the citations in the source of this study, Advances in Veterinary Science and Comparative Medicine (1970-1974), were from periodicals, and 70 of the 743 periodical titles cited (9.4%) contributed 66% of the total periodical citations. Periodical literature cited in the source of the study appeared to have a half-life of 6.1 years, and to double its size approximately every 20 years. The aging patterns of the periodical literature seemed to vary with the publishing age of the periodical, i.e., the literature in the periodicals which have been in publication for more than 40 years showed a more gradual aging pattern than did that in the newer periodicals.


Toxoplasmosis in a California sea lion (Zalophus californianus).

Disseminated toxoplasmosis was diagnosed in a female California sea lion that had been used in thermoregulation studies for about 4 years while housed in a small enclosure with a fresh-water pool at the University of Hawaii, Honolulu. Toxoplasma gondii was demonstrated in and around necrotic lesions of the heart and the stomach. Source of the infection was not established; however, studies on toxoplasmosis in cats were being conducted at the institution, and common caretakers attended both groups of animals.


Effect of 2-mercaptoethanol on the in vitro response of sensitized bovine peripheral blood lymphocytes to Anaplasma antigen.

Sensitized lymphocytes from 3 cows vaccinated with anaplasma antigen were isolated and caused to react in vitro with antigen in a microculture lymphocyte transformation test. The addition of 2-mercaptoethanol at a concentration of 25 mul of 4 X 10(-3) M solution/well significantly (P less than or equal to 0.01) increased [3H]thymidine incorporation compared to microculture without 2-mercaptoethanol.


Effect of imidocarb dipropionate and hemicastration on spermatogenesis in pony stallions.

The effect of imidocarb dipropionate [3, 3' bis-(2-imidazolin-2-yl) carbanilide dipropionate] on spermatogenesis in 3 pony stallions was studied. The drug alone had no deleterious effect on spermatogenesis when given intramuscularly 4 times at a dosage level of 4 mg/kg at 72-hour intervals. Hemicastration, with or without subsequent drug treatment, caused almost complete cessation of spermatogenesis 30 days after the operation.


Cellular immunity demonstrated in pigs infected with African swine fever virus.

Twenty-two pigs infected with African swine fever virus (ASFV) were used to demonstrate delayed hypersensitivity (DH) in vitro by the leukocyte migration-inhibition test. The results indicated that ASFV-infected pigs developed DH against ASFV antigen (ASF antigen) as early as 20 days after inoculation, and the presence of viremia did not interfere with the leukocyte migration-inhibition test. Three ASFV-infected pigs that were also sensitized to mycobacterium developed DH against both ASF antigen and mycobacterium. The conclusion was that the cellular immune system is not impaired by ASFV infection in pigs.


Immunogenicity of experimental Streptococcus equisimilis vaccines in swine.

The protective and complement-fixing antibody immune responses to Streptococcus equisimilis vaccines were evaluated in young, surgically derived, colostrum-deprived swine. Comparable levels of protection against live S equisimilis challenge exposure developed in response to sonic-extract, acid-extract, and whole-cell vaccines combined with incomplete Freund adjuvant. The extract vaccines induced higher levels of complement-fixing antibody than did killed, whole cells. Protection, as well as complement-fixing antibody immune responses, were comparable when swine were given doses of vaccine beginning at 3 or 8 weeks of age.


Comparative study of the dorsal motor nucleus of the vagus nerve.

Quantitative studies were made of cells in the dorsal motor nucleus of the vagus nerve in the horse, dog, cat, pig, sheep, goat, and calf. This nucleus was larger in ruminants than in nonruminants. Some cells in all parts of the nucleus supplied visceral structures in the head, cervical, thoracic, and abdominal regions; however, a definite topographic localization did exist within the nucleus. Eighty percent of the cells which supplied the abdominal viscera were in the rostral and rostral-middle regions. The cells which supplied the thoracic viscera were distributed almost equally within the rostral three-quarters of the nucleus. Seventy-three percent of the cells which supplied viscera in the head and neck regions were in the caudal-half of the nucleus. The rostral region of the nucleus was much larger in ruminants than in nonruminants. It is proposed that cells in the rostral region of the nucleus supply the highly developed rumen and reticulum.


Pathology of subacute methylmercurialism in cats.

Clinical signs of toxicosis, neurologic lesions, and increased tissue residues of methylmercury (MM)were produced in 9 cats by oral administration of 1.29 and 0.86 mg  of Hg/kg of body weight/day as methylmercuric hydroxide. Clinical signs, which began after 15 days of exposure, included anorexia, ataxia, hypermetria, proprioceptive impairment, blindness, vertical nystagmus, and grand mal convulsions. Significant lesions occurred in cerebrum, brainstem, and cerebellum and correlated well with clinical signs. Microscopic central nervous system lesions consisted of neuronal degeneration, necrosis and loss of neurons, swollen axons, demyelination, loss of nerve cell processes, vacuolation of neuropil, gliosis, neuronophagia, perivascular cuffs, endothelial hypertrophy and hyperplasia, leptomeningitis, and infrequent vascular necrosis. Overall distribution of central nervous system lesions was unrelated to daily dose, but more advanced lesions were produced by the smaller daily dose. Mean tissue residues of MM were generally directly related to daily dose, and the average distribution among tissues was constant, with highest concentrations in liver, followed by kidney, spleen, muscle, and brain. In utero exposure of kittens to MM, revealed transplacental accumulation.


A new technique for evaluating nitrogen washout efficiency.

Nitrogen washout curves resulting from open circuit N2 washouts of unsedated human and canine subjects were constructed by plotting the breath-by-breath end-expiratory N2 fraction (Fn2) against breath number on a semilog scale. Curves were analyzed graphically, and the slope of the 2nd of the 3 components was expressed by B 1/2, the number of breaths required to reduce Fn2 to half of its original value. The magnitude of B 1/2 was directly proportional to the value of functional residual capacity (FRC) divided by tidal volume (Vt). The quantity B 1/2 (FRC/Vt) was relatively constant within an individual regardless of FRC or Vt and was named the nitrogen dilution constant (NDC). Means and ranges of Vt, FRC, B 1/2, and NDC were determined for normal human subjects and Beagle dogs. The NDC varied less among and within subjects than other simple indices of washout efficiency. It was also more sensitive than other indices in detecting age-related loss of washout efficiency. The use of NDC in evaluating N2 washout of subjects with interstitial lung disease was demonstrated.


Bone-methyl methacrylate interfacial shear strength: an experimental study of dogs.

Bone-methyl methacrylate interfacial shear strength at failure in chronically implanted hip prostheses was studied. Gorman total hip prostheses fixed with methyl methacrylate bone cement were implanted in 6 large dogs. Interface shear strength studies were performed at 8, 16, and 24 weeks. Mechanical testing determined that the mean interfacial shear strength was 15.2 +/- 13.0 kg/cm2. Variability of the data was too great to allow conclusions to be drawn from statistical analysis, but trends in the data were observed. It was concluded that the interfacial bond had sufficient strength to withstand axial loads 3 to 6 times greater than those applied under normal physiologic conditions.


Lymphocyte transformation in the dog: response of lymphocytes from normal and immune dogs to phytohemagglutinin, coccidioidin, and purified-protein derivative.

Antigen- and mitogen-induced in vitro transformation of dog lymphocytes was quantitated by pulse labeling with 3H-thymidine (3H-TdR). Dosages of antigen and duration of incubation were varied to determine the dose and incubation time that would allow a clear distinction between sensitized and nonsensitized dogs. Each of the 2 antigens tested, coccidioidin and purified protein derivative of tuberculin, induced a higher rate of 3H-TdR incorporation in lymphocyte cultures from dogs immunized to the homologous antigen than in lymphocyte cultures from dogs immunized to either the heterologous antigen or no antigen. Lymphocyte cultures from all dogs showed a high rate of 3H-TdR incorporation in response to phytohemagglutinin stimulation. Sequential lymphocyte transformation tests were done on 4 dogs immunized with either Calmette-Guérin bacillus alone or Calmette-Guérin bacillus in Freund's complete adjuvant. A positive response to purified protein derivative became evident in all 4 dogs 11 days after immunization and peaked at 18 days after immunization.


Effects of bretylium tosylate on the in vivo fibrillating canine ventricle.

Chemical ventricular defibrillation of the heart by intravenous or intracardiac administration of bretylium tosylate (6 to 24 mg/kg of body weight) did not occur in any dog (n = 30) given the drug 5 minutes before, immediately after, or 75 seconds after electrical induction of ventricular fibrillation. The bretylium did not appear to stabilize ventricular irritability nor  facilitate resuscitation by electrical defribrillation when compared with the control group of dogs. Significant dose-dependent chronotropic or systemic pressure effects were not seen following bretylium administration.


Diffuse pulmonary disease after therapy with nitrogen mustard, vincristine, procarbazine, and prednisone.

Pulmonary reactions may follow therapy with nitrogen mustard, vincristine, procarbazine, and prednisone. Two patients with Hodgkin's disease are described who were treated with nitrogen mustard, vincristine, procarbazine, and prednisone and developed diffuse lung disease. Their disease processes were evaluated with serial pulmonary function studies, chest radiography, and open lung biopsy. Hypersensitivity reactions appeared to be responsible, and treatment with corticosteroids was successful. Procarbazine may have been the responsible agent.


Morphometric study of elastic fibers in normal and emphysematous human lungs.

The length of elastic fibers and the distribution of fiber diameters was determined by morphometry in the parenchyma of human lungs. Studies were done on 33 lungs from male subjects 1 to 85 years of age, including 9 lungs with mild emphysema. These studies suggest that the total length of elastic fibers is present early in life, possible by 10 years of age, and thereafter remains constant. Average fiber diameter increases between infancy and adulthood but probably does not change further beyond the third decade of life. No significant differences could be detected in either total fiber length or fiber diameter in the lungs with mild emphysema compared to normal lungs of the same age.


Diagnostic problems in pulmonary-renal syndromes.

A 25-year-old woman survived a fulminant epidose of rapidly progressive renal failure with severe hemoptysis initially suspected of being Goodpasture's syndrome. Four years later the patient was diagnosed as having Wegener's granulomatosis.


Lymphoid interstitial pneumonia with associated chronic active hepatitis and renal tubular acidosis.

Various combinations of diffuse interstitial fibrosis, chronic liver disease, and renal tubular acidosis have been recorded. The patient we report is unique in that the features of chronic liver disease and renal tubular acidosis were discovered while the patient was being treated for lymphoid interstitial pneumonia. This sequence of events has not been previously described.


Construction of an improved tracheal pouch in the ferret.

A surgical technic is described for the construction of a subcutaneous tracheal pouch in the ferret and for sampling undiluted tracheal secretions at daily to weekly intervals during a period of many months. This technic is applicable to other species.


Crossover PO2, a measure of the variable effect of increased P50 on mixed venous PO2.

The effect on mixed venous Po2 of a shift to the right in the oxygen hemoglobin equilibrium curve, without a change in either arterial Po2 or oxygen uptake, depends on the difference between the arterial oxygen saturation differences and the venous oxygen saturation differences of the shifted and standard curves. For every rightward-shifted oxygen hemoglobin equilibrium curve there is a Po2, which I call the crossover Po2, at which mixed venous Po2 is the same for the standard and shifted curve. Crossover Po2 depends upon the hemoglobin concentration and the arteriovenous oxygen content difference. I demonstrate that in hypoxemic patients, especially if anemia and shock are present, the arterial Po2 may be less than the crossover Po2; thus, an increased blood P50, the Po2 at oxygen saturation of 50 per cent (pH 7.40, temperature 37 degrees C), cannot increase the mixed venous Po2.


Analysis of a community hospital employee tuberculosis screening program 31 months after its inception.

The employee tuberculosis screening program for this 450-bed, medical-surgical hospital was evaluated as of November 30, 1975. On that date, there were 1,488 employees, excluding physicians and medical and nursing students. Of the 626 employees tested at least twice with purified protein derivative, 28 converted their test from negative (zero induration) to positive (greater than or equal to 10 mm of induration), and 20 converted their tests from weakly reactive (3 to 9 mm of induration) to positive (greater than or equal to 10 mm of induration and showing a 6-mm or greater increase in induration over that resulting from the first test). The rate of conversion (tests with purified protein derivative going from negative to positive) was no different between the groups with high and with low degrees of exposure to tuberculous patients, suggesting the possibility of nonhospital-acquired infection in the latter group. A direct relationship existed between increasing age and increasing rate of conversion, suggesting that some of the convertors were not newly infected, but were persons with boosted reactivity. These data illustrate some of the practical problems of monitoring for tuberculous infections and subsequently offering preventive therapy to convertors.


Deposition of 2- and 7-mu m particles in the rabbit lung.

Depostion of 2- and 7-mu m polystyrene particles tagged with scandium-46 and gold-198, respectively, was studied in 6 rabbits. Deposition was estimated in the 3 major bronchi and their extensions in the right lung by dissecting free the bronchial tree and measuring the radioactivity in the various sections. The rabbits were exposed to a mixture of 2- and 7-mu m polystyrene particles. The particle content among bronchi was highest in the lower lobe and lowest in the upper lobe. The average particle content per unit of bronchial surface did not differ among the bronchi or among different locations in the lobe bronchus and its extension. The ratio of 7- to 2-mu m particles was greater in all bronchial sections than in the whole lung.


Adverse effect of a cigarette smoke component, acrolein, on pulmonary antibacterial defenses and on viral-bacterial interactions in the lung.

Intrapulmonary antibacterial activity in normal mice and mice with viral pneumonia was determined after continous exposure to the pure tobacco smoke component, acrolein. After inhalation challenge with Staphylococcus aureus and Proteus mirabilis, exposure to 1 to 2 ppm of acrolein significantly suppressed the intrapulmonary killing of the organisms in normal mice compared to control mice not exposed to acrolein. Sendai virus pneumonia depressed pulmonary antibacterial defenses in a virus dose-related fashion. Exposure of the mice infected with virus to acrolein resulted in a further suppression of intrapulmonary bacterial killing to the extent that, in most instances, the bacteria proliferated in the lungs. These data demonstrate that the cigarette smoke component, acrolein, not only depresses pulmonary bactericidal activity, but can also act as a stressor in aggravating an underlying disease process, resulting in an additional impairment of pulmonary antibacterial defenses.


A new roentgenographic method for estimating mucous velocity in airways.

A new roentgenographic method is described for the estimation of mucous velocity in airways. Radiopaque discs of teflon mixed with bismuth trioxide were deposited in the trachea, and their motion was observed by a fluoroscopic image intensifier. Simultaneous measurements of disc movement were obtained by a previously reported cinebronchofiberscopic method and by the roentgenographic method in 6 anesthetized dogs. Mean +/- SD tracheal mucous velocity was 8.5 +/- 7.3 mm per min by the roentgenographic method, and 7.6 +/- 7.1 mm per min by the cinebronchofiberscopic method. Discrepancies between the 2 methods for individual disc velocities could be accounted for by the cumulative errors of both methods. The roentgenographic method was also used in 7 normal volunteers who did not have topical anesthesia of the tracheobronchial tree. The discs were blown through the inner channel of a bronchofiberscope, the tip of which was located just above the vocal cords. Placement of the discs on the tracheal mucosa generally did not produce coughing. Tracheal mucous velocity ranged from 7.4 to 19.4 mm per min as estimated from videotape recordings of the image intensifier images. There was no consistent difference in velocity between the erect or supine position, or after topical anesthesia with lidocaine.


Alveolar multiplication in the contralateral lung after unilateral pneumonectomy in the rabbit.

Four weeks after left pneumonectomy in 10-week-old rabbits, the right lung increased in weight and volume to match the weight and volume of both lungs in control and sham-operated rabbits. Alveolar multiplication occurred in the right lung of the pneumonectomized animals resulting in approximately 60 per cent more alveoli than in the right lung of the control or sham-operated animals. Alveolar size was the same in all animals. The total number of alveoli in the right lungs of the pneumonectomized animals was almost identical to the calculated number of alveoli in both lungs of the control animals.


Effects of flow-resistive loading on mouth occlusion pressure during CO2 rebreathing.

To evaluate mouth occlusion pressure as an index of neural drive to the respiratory muscles that is independent of lung mechanics, the occlusion pressure response to rebreathing was studied in 7 normal subjects under control conditions and during flow-resistive loading. Inspiratory, expiratory, and combined inspiratory-expiratory flow resistances of 5 and 17 cm H2O per liter per sec were studied in 7 normal subjects. Pressure at the mouth was measured 150 msec after the onset of inspiration against the occluded airway. In all subjects, the ventilatory response to CO2 rebreathing was consistenly decreased by the 3 types of resistive loads, and this decrease was often greater with the higher load. In contrast, the occlusion pressure response was usually increased with inspiratory and inspiratory-expiratory resistance, indicating increased inspiratory muscle output due to these loads. With expiratory resistance, the occlusion pressure response was decreased in most of the subjects, suggesting a decrease in muscular output with expiratory loading. The inspiratory muscle pressure response to resistive loading could have been mediated by neural reflex and/or intrinsic muscle mechanisms. Occlusion pressure, therefore, appears to reflect over-all inspiratory neuromuscular output of the respiratory system during CO2 rebreathing, even with the addition of flow-resistive loads. Measures of mouth occlusion pressure provide a distinct advantage over ventilatory parameters in studies of respiratory control mechanisms during mechanical loading.


Pulmonary tissue concentrations of ethchlorvynol after intravenous injection.

Noncardiogenic pulmonary edema has been reported to follow the intravenous use of ethchlorvynol (Placidyl) in both human clinical and animal experimental situations. In a further attempt to define ethchlorvynol-pulmonary tissue inter-relations, we measured ethchlorvynol concentrations in venous and arterial blood and lung and liver tissue of dogs after intravenous injection of 15 to 25 mg of the drug per kg of body weight. In 10 dogs, the mean +/- SEM lung concentrations 1, 3, and 5 min after injection were 70 +/- 20, 50 +/- 13, and 24 +/- 9 mug per g of tissue, respectively. Simultaneous mean +/- SEM venous contrations were 75 +/- 40, 29+/-5, and 22 +/- 5 mug per ml of blood, respectively. During minutes 1 and 3, the liver concentrations were lower than those found in the lung. In an additional 3 dogs, injection of ethchlorvynol into the portal vein led to higher concentrations (at all sample times) in the liver when compared to the lung. In vitro lung slice studies using ethchlorvynol labeled with iodine-131 revealed no active energy-dependent uptake. Intravenously administered ethchlorvynol rapidly fluxes into and out of lung tissue, apparently following the laws of diffusion.


Granulocyte recruitment to airways exposed to endotoxin aerosols.

Guinea pigs were exposed to aerosols of 0.1 mg of Salmonella typhosa endotoxin per ml for 2 or 4 hours, and white cells in blood and in bronchopulmonary lavage were counted at 2, 4, and 6 hours. The lungs of a second group of guinea pigs and hamsters exposed in the same manner were fixed in inflation with osmium tetroxide in fluorocarbon, which retains cells on luminal surfaces of airways. The polymorphonuclear leukocyte counts in cardiac blood were significantly increased, and lymphocyte counts were decreased at 6 hours (P less than 0.05). The number of cells obtained by bronchopulmonary lavage, which were mostly polymorphonuclear leukocytes, increased at 4 hours to 28 million, and at 6 hours, was 26.5 million (P less than 0.01), compared to 5 million cells at the same times in air and in water aerosol control preparations. The polymorphonuclear cell counts on airway cross sections, i.e., (polymorphonuclear cells/epithelial cells) x 100, showed a mean +/- SD peak of 53.9 +/- 10.9 after 4 hours in guinea pigs and a peak of 99.7 +/- 11.0 after 6 hours in hamsters. Alveoli showed no cell recruitment. Platelets were aggregated on surfaces of arterioles facing bronchioles, although counts in blood were unchanged. Neither leukocytes nor airway cells showed damage to their ultrastructure. The time course for airway recruitment and leukocytosis matches that for symptoms after exposure of workers to dusts from natural fodder or fibers. This suggests that leukocyte recruitment to airways by inhaled endotoxin may be part of the mechanism for the fever and chest tightness in occupational disorders.


Experience with the jejunal loop interposition in the treatment of postgastrectomy disorders.

In the past 10 years 115 patients has revisional gastric surgery at the University of Florida. Twenty-seven patients had jejunal loop interposition to treat the different postgastrectomy disorders. While this procedure may provide relief of symptoms when used to treat several types of post-gastrectomy disorders, its best application is in patients with the severe form of postprandial dumping syndrome. When used in isoperistaltic fashion with an anti-dumping diet, the results are excellent.


Ciliated epithelial esophageal cyst: case report and review of the literature.

A brief review of the world literature on esophageal cysts is presented and a new case of ciliated esophageal cyst is reported. Emphasis is put on roentgenography and endoscopic examination as essential for diagnosis and on exploratory thoracotomy for definite diagnosis and treatment.


Fibrinogen uptake test. Criteria for interpretation of results in patients with venous thrombosis.

Accurate detection of active deep venous thrombosis with the fibrinogen uptake test (FUT) requires adherence to rigid criteria for interpretation of results of the tests. In a series of 56 patients, only detection of serial increase of per cent uptake at the same position correlated with presence of active venous thrombosis in all cases. Other investigated criteria, which were based on the analysis of single FUT results, showed a 21% incidence of false positive results. Accordingly, active venous thrombosis investigation by FUT requires performance of serial tests and analysis of the curve of uptake at each position to detect serial increasing per cent uptake.


Ectopic kidney: an unusual indication for extra-anatomic bypass grafting.

This case illustrates an unusual application of axillofemoral bypass grafting in a patient with a pelvic ectopic kidney. Application of this technique resulted in complete relief of the patient's symptoms of intermittent claudication and allowed us to avoid a larger procedure which might have jeopardized the survival of the ectopic kidney and which would have resulted in increased morbidity for the patient.


Large nonfunctioning adrenal cortical tumor: a case report.

A case of large nonfunctioning adrenal cortical tumor treated surgically is reported, with a short review of the relevant literature. The pathologic findings, including light and electron microscopic features, are described.


Complications of cardiac pacemakers.

Ten consecutive patients with complications of cardiac pacemakers seen in the past year are discussed. Electrode problems included displacement, fracture, erosion and exit block. Pulse generator complications included impending erosion, extrusion, runaway and a new complication due to faulty sealing. Possible causes and management of these complications are discussed.


Malignant melanoma: correlation of long-term follow-up with clinical staging, level of invasion and thickness of the primary tumor.

Sixty melanoma patients were followed 20 to 30 years after primary therapy, and survival rates were reviewed with reference to clinical and histological staging. All but one of the patients with clinically positive regional nodes died of metastatic disease. Two of nine patients with nonenlarged nodes that were clinically negative but histologically positive are alive 25 years after node dissections. Ten of 17 patients with negative nodes survived their operations by 20 to 30 years. Another series of 138 patients with stage 1 cutaneous melanoma were reviewed at the George Washington University Medical Center and tumor thickness was found to be a better measurement of prognosis than clinical or histologic staging, or the tumor's level of invasion. Prophylactic lymph node dissection appeared to double the survival of patients with lesions greater than 1.5 millimeters thick, but had no effect on those with thinner lesions. Thirty-nine per cent of the patients had lesions less than 0.76 mm thick, and all survived free of disease for five or more years. Of the tumors in the intermediate range of 0.76 to 1.50 mm thick, 33% metastasized or recurred; no clinical or pathologic discriminant could be detected that differentiated those patients who would have the recurring lesions from the others with tumors in this range of intermediate thickness who did well.


Selection of treatment regimens for women with potentially curable breast carcinoma.

Five-year survival rates for all Iowa breast cancer patients diagnosed in 1969 are substantially better than most published figures. Partly, this is because more Iowa patients came to treatment early before they developed diagnosable metastases. There also, however, were particularly good results for radical mastectomy compared to modified operations and when axillary metastases were present the results were much the best when supervoltage radiation followed the radical operation.


Mortality and morbidity after esophagogastrectomy for cancer of the esophagus and cardia.

Forty-eight esophagastric resections performed for cancer of the esophagus and cardia resulted in a five-year survival rate of four per cent. An operative mortality rate of 23%, comparable to that reported by others, diminishes the value of esophagogastrectomy even for palliation. Nutritional depletion, commonly found in these patients, contributes significantly to the unacceptably high mortality. A review of the recent literature indicates that the routine use of preoperative hyperalimentation and prophylactic antibiotics can significantly reduce morbidity in these high-risk patients and thereby result in better palliation.


Transabdominal proctopexy (Ripstein procedure) for massive rectal prolapse.

Transabdominal proctopexy (Ripstein procedure) for correction of massive rectal prolapse has greatly simplified the complicated problem of managing procidentia. The operation secures the rectum into the hollow of the sacrum by a Teflon sling. This restores and maintains the normal posterior curve of the rectum and prevents intussusception with subsequent prolapse. There has been no recurrence of rectal prolapse and no mortality in 36 patients, half of whom have been followed from five to ten years. Posterior proctopexy is a simple, safe and effective operation to repair massive rectal prolapse.


Unidentified gram-negative rod infection. A new disease of man.

A Gram-negative bacillus that defies identification was isolated from blood cultures of 17 patients with fever. Fifteen patients were male adults, and 14 patients had underlying diseases, including previous splenectomy in five, which impair host defenses against infection. Illnesses occurred in the summer and autumn in 14 cases and had been recently preceded by dog bites in 10 cases. Clincal syndromes included cellulitis in seven cases, primary bacteremia without localization in four, purulent meningitis in four, and endocarditis in three. Three patients died. The organism grows slowly on blood or chocolate agar in 10% CO, is oxidase- and catalase-positive, and is negative for nitrate reduction, indole production, and urease. It produces acid from glucose, lactose, and maltose. These features distinguish it from all previously described and classified bacteria. Furthermore, the epidemiologic features of the patients suggest that this organism is an opportunistic invader and may have an animal reservoir in nature.


Decrease in postprandial insulin and glucose concentrations by guar and pectin.

Postprandila glycaemia and rise in serum insulin after carbohydrate-containing meals were reduced by the addition of guar flour or pectin, or both. After a liquid test meal (four subjects) the 30-min blood glucose was reduced from 6.33 +/- 0.19 mmol/litre (114 +/- mg/dl), mean +/- SEM, in the control subjects of 4.77 +/- 0.17 mmol/litre (86 +/- 3 mg/dl) by addition of guar gum (P less than 0.05). The mean insulin level was also significantly lower at 15 min. A breakfast test meal (bread, butter, marmalade, and tea) resulted in a mean 15-min blood glucose of 6.18 +/- 0.21 mmol/litre (111 +/- 4 mg/dl) in eight subjects; 10 g of pectin added to the marmalade reduced this level to 5.64 +/- 0.17 mmol/litre (102 +/- 3 mg/dl) (P less than 0.01). The insulin levels were significantly lower at 15, 30, and 45 min. A similar meal in which guar was added to the bread and pectin to the marmalade resulted in significant reductions of blood glucose at 15 min (P less than 0.002) and 30 min (P less than 0.01). The insulin values were also significantly lower throughout the first 90 min of the test. This action of unavailable carbohydrate may prove useful in the dietary control of diabetes.


Plasma thyroglobulin in detecting thyroid carcinoma after childhood head and neck irradiation.

The level of thyroglobulin in plasma was measured in 904 subjects with a history of head and neck irradiation during childhood to evaluate its potential value in screening for and differentiating thyroid neoplasms. Mean plasma thyroglobulin level was significantly elevated in subjects with nodular thyroid disease versus those without evidence of nodules (49.8 versus 27.0 ng/ml). However, the overlap with normal subjects does not allow thyroglobulin assays to serve as the only screening procedure. The mean levels in subjects with benign and malignant thyroid nodules were indistinguishable (48.8 versus 53.9 ng/ml). Thirteen percent of otherwise normal-appearing subjects had elevated values that may represent clinically inapparent thyroid disease. It is concluded that in screening large numbers of persons at risk for thyroid neoplasia, thyroglobulin assays are useful in combination with other modes of evaluation. The assay is without value in distinguishing benign from malignant disease.


Screening for organic mental syndromes in the medically ill.

A brief mental status questionnaire adapted specifically to diagnose diffuse organic diffuse organic mental syndromes on busy medical words is developed and tested for reliability and validity. When the 30-item questionnaire was given to 17 medical patients diagnosed by consultation spychiatrists as having a diffuse organic mental syndrome, all score 20 or less. With hospitalized psychiatric patients the questionnaire was able to differentiate between the "functional psychoses" and diffuse organic brain syndromes. When administered to 69 consecutive medical admissions, fully one third showed marked cognitive limitations. A sample of normals suggested that results may be contaminated by severe cultural or educational variances. We discuss the role of cognitive dificiencies in medical patients, and suggestions are made regarding the broad usefulness of this questionniare to a medical service.


Correction of postoperative metabolic alkalosis and renal failure by hemodialysis.

Three postoperative patients with oliguirc renal failure and hypochloremic metabolic alkalosis were treated with hemodialysis using a specailly prepared high-chloride, low-acetate dialysate. This mode of therapy corrected the metabolic abnormalities and was significantly more effective than treatment with commercially available high-acetate dialysate at increasing the serum chloride and hydrogen ion concentration. Furthermore, hemodialysis with high-chloride, low-acetate dialysate corrected the clinical sequelae of hypoventilation, cardiac arrhythmia, and neuromuscular irritability associated with metabolic alkalosis while treating uremia simultaneously.


Coronary angiography and acute renal failure in diabetic azotemic nephropathy.

Thirteen juvenile-onset diabetics with azotemic diabetic nephropathy (mean serum creatinine level, 6.8 mg/dl) being evaluated fro renal transplantation underwent cardiac catheterization with angiography. All were followed for development of acute renal failure. Twelve (92%) developed some evidence of acute renal failure. Two required potassium exchange resin therapy. Six required dialysis acutely. There were no deaths. All patients who received greater than 65 ml/m2 of iodinated contrast developed acute renal failure. No patient with a hemoglobin value greater than 9.9 g/dl required dialysis or potassium exchange resin. The single patients without acute renal failure received less than 50 ml/m2 of iodinated contrast and had the highest hemoglobin value (12.0 g/dl). No cardiac or angiographic variables were predictive of acute renal failure. In this group at high risk for acute renal failure, radiographic contrast procedures should only be done if the information to be obtained is weighed against the potential for injury.


Immune neutropenia.

A patient with hyperthyroidism and severe neutropenia had a clinical course and family history that suggested an immune cause. Neutrophil-binding IgG was demonstrated in serum using the Fab-anti Fab assay. The antineutrophil factor bound specifically to either homologous or autologous neutrophils and could be adsorbed by the target neutrophils. The quantity of IgG required to saturate the neutrophil-binding sites (175 000 molecules per neutrophil) and the serum concentration (1.3 mug/ml) were determined. It was estimated that at the time that blood and marrow neutrophils were markedly reduced, serum contained sufficient neutrophil-binding IgG to saturate the binding sites of 1.2 times the total blood neutrophil pool.


Systemic therapy for metastatic breast cancer.

The data reviewed in this conference suggest that initial therapeutic decisions for patients with metastic breast cancer be based on the presence or absence of an estrogen receptor in the tumor. Patients with estrogen receptor in their original primary breast cancer or in a subsequent metastitic lesion are candidates for hormonal manipulation, whereas patients lacking estrogen receptor in their tumor are treated for their metastic disease with nonhormonal chemotherapy. Nonhormonal therapy usually consists of a combination of cytotoxic drugs including cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). Other programs of combination chemotherapy are under active study, especially programs that include nonspecific immune stimulation with Corynebacterium parvum or bacillus Calmette-Guérin (BCG). Inasmuch as patients with Stage II primary breast cancer frequently have "micrometastatic" disease, combination chemotherapy is also under study as an adjuvant to surgery. Preliminary results strongly support the use of such therapy.


Short dialysis, middle molecules, and uremia.

The cause of the uremic syndrome remains unknown; the success of dialysis therapy suggests that retained, dialyzable, but unidentified toxic solutes may play a role. Since chronic peritoneal dialysis seems to prevent or improve uremic neuropathy as well as does hemodialysis, it has been suggested that retained solutes of "middle molecular weight" (500 to 5000 daltons) may be major toxins. Only body fluid concentrations of these larger solutes are presumed to be reduced by peritoneal dialysis as well as with hemodialysis, whereas small solute concentrations are relatively poorly controlled. There have been numberous hemodialysis studies to examine the toxic potential of "middle molecules" as compared with that of smaller solutes. Although the importance of "middle molecules" as toxins remains unproved, numberous factors influencing their concentrations in body fluid have been discovered. Studies have also shown a surprising tolerance of patients to many variations in dialysis strategies. Difficulties in defining adequate dialysis have been intensified.


Chronic congestive heart failure in coronary artery disease: clinical criteria.

Congestive heart failure is a frequent and important manifestation of cardiovascular disease, but no uniform clinical criteria are available for use in epidemiologic studies. To develop diagnostic criteria, we related pertinent clinical findings to physiologic measures of left ventricular function in patients with coronary artery disease. When left ventricular end diastolic pressure or arteriovenous oxygen difference was used as the physiologic criterion, the following variables contributed significant (P less than 0.01) information: heart volume, ventricular gallop, heart rate, and blood pressure. The most reliable and valid set of descriptors determined in one group was tested in a second group of 1306 patients who had been followed for 6 to 36 months after initial evaluation. The validity of the descriptors was confirmed, and patients identified as having heart failure by these criteria experienced a worse survival rate (P less than 0.001). These criteria characterize patients likely to have impaired left ventricular function and a greater risk of death.


Plasma glucose levels: long-term effect of diet in the Chicago Coronary Prevention Evaluation Program.

In 150 middle-aged men prone to coronary disease, long-term data based on the Chicago Coronary Prevention Evaluation Program's diet showed that there was a favorable effect on fasting glycemia level and glucose tolerance. This diet for reducing obesity and hypercholesterolemia was low in cholesterol and saturated fat and moderate in polyunsaturated and total fat, with replacement of some fat by carbohydrate. At 2 years, decreased weight and serum cholesterol values of normoglycemic men were accompanied by a modest but significant fall in fasting and postload glycemia; at 4 years. fasting glycemia levels remained slightly below baseline. For men with suspect fasting hyperglycemia at baseline, sustained fall in weight and serum cholesterol value was associated with sizeable long-term reductions in fasting glycemia and improvement of glucose tolerance. Decrease in plasma glucose was significantly related to decrease in weight. No evidence of impairment of glucose tolerance with years-long consumption of this diet was recorded.


Abdominal pain caused by diabetic radiculopathy.

In diabetes mellitus, pain and weakness in a lower extremity can result from lumbosacral radiculopathy. However, abdominal pain caused by a similar type of thoracic nerve root disease is not generally recognized. Four diabetic patients with abdominal pain were studied. In none of the patients was the actual cause--radiculopathy--suspected until after extensive negative diagnostic investigation, which frequently included invasive procedures. Their clinical features were suggestive of malignant disease. Electromyographic examination revealed the correct diagnosis, and all four of the patients had a spontaneous and complete recovery.


Acetazolamide-induced weakness in paramyotonia congenita.

Acetazolamide has been shown to be effective prophylaxis for both hypokalemic and hyperkalemic paralysis. A patient with paramyotonia congenita, a related disorder with myotonia and episodic weakness, was studied during treatment with acetazolamide. Athough the patient's myotonia was virtually abolished, severe quadriparesis was produced during each trial of acetazolamide. This response distinguished this patient's condition from other forms of familial periodic paralysis and suggests that acetazolamide may be deleterious to some patients with periodic paralysis.