Factors determining dosages of amide-type local anesthetic drugs.

The physical status of the patient (sex, age, weight, height, and underlying disease) has been thought to influence the dosage of local anesthetic drugs that can be injected without causing a systemic toxic reaction, but this belief is not supported by statistically significant data. Furthermore, previous studies of plasma levels of bupivacaine and mepivacaine showed no correlation between dosage and physical status, even when maximum dosages recommended by pharmaceutical companies were exceeded. This study of 9,287 regional blocks, using the statistical tests of multiple regression and chi square, substantiates that the occurrence of systemic toxic reactions in adults does not correlate with dosages and/or physical status of the patient when 400 mg or less of bupivacaine, 450 mg or less of etidocaine, or 500 mg or less of mepivacaine is used. Therefore, the study questions the maximum dosages established for certain local anesthetic drugs, as well as the method by which such dosages were established.


Experience and progesterone in ring dove incubation.

Doves were tested for progesterone-induced incubation after they had acquired previous experience with from one to five different phases of their initial breeding cycle. A sixth group had no previous breeding experience. Previous breeding experience inclusive of at least the nestbuilding phase of the cycle is a significant facilitator of incubation behaviour induced by injected progesterone, but previous experience with only the courtship phase was not sufficient. Experience with phases additional to nestbuilding increased overall nest-responsiveness without significantly increasing the number of birds incubating. The nature of a ring dove's previous experience is therefore an important influence in its behavioural response to exogenous progesterone.


Compensatory responses of goat mothers to their impaired young.

The behaviour of a mother goat towards her young normally compensates for differences between them in their vigour at birth. Weakening the first-born with drugs still does not prevent its getting equal access to the udder, though weakening the second-born may render it so much less vigorous that maternal compensation does fail. When the mother is unable to distinguish her kids by sight or smell, she is unable to modulate her responses to the kids and then the more vigorous kid always establishes priority of access to the bladder. We conjecture that this is what normally occurs under harsh environmental conditions where the mother's milk supply is occasionally inadequate for two kids.


Social subordination and scent-marking in male Mongolian gerbils (Meriones unguiculatus).

Mongolian gerbil (Meriones unguiculatus) readily attacks an unfamiliar gerbil intruding into its territory. After several attacks, subordinated intruders seldom scent-mark in the occupied area. This inhibition of scent-marking is a response to stimuli associated with the defended territory, since subordinated males mark normally elsewhere. Previous research suggested that olfactory cues were primarily responsible, but data presented here do not support this. Subordinated males scent-marked as often as controls in a neutral arean contaminated with the dominant animals' bedding odours. Moreover, subordinate males seldom scent-marked in an area resembling the defended territory, even though defeat-related odours were absent. Repeated exposure without attack to the visually similar, but clean, test area did not enhance marking in subordinated males.


Relationships between exploratory behaviour and genic heterozygosity in the oldfield mouse.

Exploratory behaviour by adult male oldfield mice (Peromyscus polionotus) from mainland and beach localities in the southeastern United States was examined in relation to mean genic heterozygosity. Heterozygosity was estimated from allelic variation in 31 proteins detectable by starch-gel electrophoresis. Mean latency to enter the open field decreased and mean ambulatory behaviour gel mainland samples of mice increased with increasing mean genic heterozygosity. Ambulatory behaviour was realted to the number of heterozygous loci per mouse in mainland mice as a group. The exploratory behaviour of beach mice diverged from relationships between behavioural performance and heterozygosity observed for mainland mice.


Pheromonal regulation of male mouse ultrasonic courtship (Mus musculus).

Biochemicals from several sites on the body of female house mice (Mus musculus) were found to elicit 70-kHz ultrasonic calls from male mice. Experiment 1 demonstrated that an anaesthetized female wrapped in an odour-impermeable plastic bag elicited ultrasounds from males when either the front or rear of their body was left exposed. In experiment 2 cotton swabs rubbed on the face and cheeks of females but not from males elicited ultrasonic calls from males. The results of experiment 3 suggested that female vaginal odours also elicit calls. Experiments 4 and 5 demonstrated that males will also emit ultrasounds in response to female but not male urine. The source and chemical nature of this 'ultrasound-releasing pheromone' remain to be discovered.


On the analysis of rates of behaviour.

Formulas are developed for calculating the expected frequency of behaviour and of social interactions in each age-sex category or other class, particularly when the study population changes composition during the study, given the null hypothesis either of constant but unknown rates of behaviour that are independent of class, or of class-specific rates per individual.


A re-evaluation of song development in the song sparrow.

Song sparrows were hand-reared from the egg in auditory isolation from adult conspecifics and maintained either together with other species or individually in sound chambers. Songs developed by the males contained several normal species-specific characteristics, but on the whole differed both qualitatively and quantitatively and were therefore readily distinguished from wild-type songs. The data are largely consistent with those of Mulligan (1966), but the normal aspects of song development have been over-emphasized in recent literature.


Dominance in a human adolescent group.

Primatological concepts and methods are applied to a 5-week, naturalistic observational study of six 13-year-old boys in a summer camp. The purpose is to illustrate similarities between a human adolescent group and other primate groups in the establishment and stability of a dominance hierarchy, indices and frequencies of dominance interactions, and characteristics of dominance relations. A hierarchy was evident after 3 days of camp and remained operative throughout the 5 weeks, becoming more stable over time. The dominance rank-order was significantly related to athletic ability, leadership, and bed position but not to trail position, popularity, body surface area, and physical maturity. The possible social effects of the dominance hierarchy are also discussed.


Testosterone and persistence in mice.

In view of previous studies showing that testosterone increases persistence of food searching in chicks, a single factorially-designed experiment was carried out to investigate whether a similar phenomenon occurs in male mice. Using a runway test, it was found that testosterone, injected into castrated mice, did increase persistence. It was also shown that intact males resembled more the testosterone-injected than control-injected castrates, and that females resembled neither intact males nor either group of castrates. A larger number of training trials was found to affect feeding latencies in a similar way to testosterone. Comparison of two strains differing in emotional reactivity (BALB/c and Porton) showed differences consistent with their reactivity levels.


Intradermal administration of bivalent and monovalent influenza vaccines.

Intradermal (ID) administration of 0.1 ml of a bivalent influenza vaccine containing 40 CCA units each of influenza A/New Jersey (Hswine 1N1) and A/Victoria (H3N2) virus antigens and of a monovalent vaccine containing 100 CCA units of influenza B/Hong Kong virus to 70 adult volunteers produced no serious reactions and only 7% bothersome side effects. Excluding persons with high (1:64 or greater) initial antibody titers, then 90% and 85% of persons had fourfold or greater rises in HAI antibodies to A/New Jersey and B/Hong Kong antigens, whereas 53% had rises to A/Victoria. The authors feel the ID route deserves further consideration for giving killed influenza vaccines to adults. However, an influenza virus type that was prevalent for many years may fail to give sufficient rise in HAI to consider the patient protected.


Transfer factor for the practicing allergist-immunologist.

As continuing research elucidates the underlying mechanisms of immunological disease at the cellular level the need for the clinical allergist-immunologist to have available tools for the manipulation of cellular mechanics in the form of immunosuppression and immunostimulation becomes more apparent. An immunostimulant of perhaps wide application in the future is transfer factor derived from human lymphocytes. This presentation outlines in general the characteristics of transfer factor and a detailed method of production of transfer factor in a crude form is described. The procedure does not require specialized equipment and is simple enough so that interested clinical allergist-immunologists can produce transfer factor in their own laboratories and thus augment their armamentarium with an immunostimulant agent for use in selected cases.


The use of beclomethasone diproprionate inhaler complicated by the development of an eosinophilic pneumonia reaction.

As an insoluble steroid aerosol, beclomethasone diproprionate was recently made available in the United States. Only minor complications have been reported previously. A more serious development of adrenal insufficiency may occur upon the improper replacement of systemic steroids. We report on a patient who developed the clinical findings of pulmonary eosinophilia. The possible mechanisms for this complication in out patient are discussed. While a lower systemic steroid dosage may have been the provoking factor, we feel that an adverse reaction to oleic acid, a dispersing agent in the aerosol freon vehicle, is a strong possibility.


Immunoglobulin changes in SLE.

In 39 patients serum total protein and albumin concentrations were stable throughout the course of systemic Lupus Erythematosus. While IgG concentrations were increased at diagnosis and returned to normal during follow-up, IgM concentrations followed the reverse pattern. IgA dynamics differed from IgG and IgM. IgA was normal at diagnosis and its concentrations rose throughout the disease.


Relationship between acute respiratory illness and air pollution levels in an industrial city.

A retrospective study relating air pollution levels to hospital admissions for acute exacerbations among adults with chronic respiratory illness and children with acute respiratory disease was carried out in a highly industralized Canadian city. A total of 1,780 patient records were collated, and daily, weekly, and monthly hospital admission rates were related to a standard air pollution index that took into account floating particles and sulfur dioxide. A correlation coefficient of 0.77 (P less than 0.01) between number of admissions and level of air pollution was found for the city as a whole, and the strength of the association varied inversely with the distance of the hospital from the industrial area.


Arterial oxygenation differences with carbon dioxide-induced versus voluntary increases in minute ventilation in chronic airway obstruction.

Two groups of patients with similar degrees of chronic airway obstruction exhibited different degrees of increased arterial oxygenation with CO2-induced hyperpnea versus voluntary increases in ventilation matched for ventilatory pattern. Patients who failed to increase arterial PO2 as much with voluntary hyperventilation as with CO2 challenge also had a lower dynamic compliance with the voluntary maneuver, whereas those with similar increases in arterial PO2 had similar dynamic compliances during the 2 periods of increased minute ventilation. The differences between the 2 groups are believed to be related to different effects of hypocapnia on collateral ventilation.


Regional lung function in pleural effusion.

In 6 seated subjects with small unilateral pleural effusion without other radiographic abnormality, we measured regional lung function using xenon-133, comparing the function of the lung on the side with the effusion to the function on the contralateral side. When both lungs were equilibrated with Xe, count rates were lower at the base with the effusion, indicating either collapse or displacement of lung in these regions. Regional lung expansion was measured as fractions of regional total lung capacity: regional functional residual capacity/regional total lung capacity and regional residual volume/regional total lung capacity. The distribution of boluses inhaled slowly from residual volume was also measured, In all subjects the results were the same on the side with the effusion as on the other side. These findings were compatible with effective static pleural pressure being the same on both sides and suggest that the reduction in count rate at the base with effusion was due to displacement rather than compression of lung. We also measured regional washout half-times during dynamic breathing and found them prolonged in regions underlying effusion, indicating that dynamic ventilation of these areas was reduced. We postulated that the dynamic pressure swings applied to these regions were decreased by the effusions.


Spirometric lung function tests in normal men and African ethnic origin.

Measurements of forced vital capacity, forced expiratory volume in 1 sec; and peak expiratory flow were carried out in 623 normal Northern Sudanese, Soutehrn Sudanese, and Tanzanian men 17 of 70 years of age. The widely used prediction formular of these parameters for American, British, and Swedish subjects gave significantly higher values than the observed values in this study. From the results in Northern Sudanese subjects, prediction formulas and nomograms were constructed. They were found to provide accurate predictions for subjects from Southern Sudan and Tanzania. It is therefore confirmed that racial variations in the values of these parameters occur. The present prediction formulas and nomograms are recommended for subjects who are of African ethnic origin.


Diagnostic lavage and occult pulmonary hemorrhage in thrombocytopenic immunocompromised patients.

Twenty consecutive thrombocytopenic immunocompromised patients with pulmonary infiltrates underwent diagnostic bronchopulmonary lavage. Nine patients were found to have occult pulmonary hemorrhage as evidenced by increased stainable hemosiderin within alveolar macrophages. Other diagnoses established included Pneumocystis carinii pneumonia in 2 patients and metastatic carcinoma in 1. No hemorrhage was precipitated by the procedure, even in 7 patients whose platelet counts were less than or equal to 20,000 per mm3. We concluded that bronchopulmonary lavage is a safe and effective diagnostic procedure in thrombocytopenic immunocompromised patients and that occult pulmonary hemorrhage is a common cause of diffuse pulmonary infiltrates in such patients.


Lung function in infants and young children: functional residual capacity, tidal volume, and respiratory rats.

Functional residual capacity was measured by the closed-circuit, helium-equilibration method in 121 normal children 3 months to 6 years of age. Prediction equations for functional residual capacity for normal children of this age range are presented for the first time. This study demonstrates that some aspects of lung functiok can be studied relatively conveniently in young children.


Acute effects of an aerosol hair spray on tracheal mucociliary transport.

The acute effects of a commercially available aerosol hair spray preparation and a Freon propellant on various pulmonary function tests and tracheal mucociliary transport were studied in 12 normal nonsmokers. Tracheal mucous velocity was estimated by a roentgenographic method. In 7 subjects exposed to hair spray by directing the aerosol to the hair for 20 sec, no significant changes occurred in any of the various pulmonary function parameters, whereas mean tracheal mucous velocity decreased by 57 per cent (P less than 0.001) 1 hour after exposure. This effect was transient and could no longer be demonstrated after 3 hours. No significant changes in tracheal mucous velocity or pulmonary function tests were observed in the 5 control subjects exposed to the Freon propellant alone. These observations suggest that acute exposure to aerosol hair spray produces a transient impairment of a pulmonary defense mechanism, and that measurements of mucociliary transport is a more sensitive indicator of this type of airway irritation than conventional pulmonary function tests.


Serum creatine phosphokinase activity in asthma.

Serum creatine phosphokinase activity was measured in 2 groups of asthmatics. The first group consisted of 12 asthmatics followed as outpatients for periods of up to 16 months. Serum creatine phosphokinase activity increased in 8 patients and correlated with the severity of subjective symptoms and objective measurement of airway obstruction, as represented by the forced expiratory volume in 1 second. In the second group, consisting of 5 asthmatic patients studied during hospitalization for acute exacerbations of asthma, serum creatine phosphokinase activity was increased on admission in all the patients and decreased as symptoms and airway obstruction improved and alveolar ventilation decreased. Analysis of creatine phosphokinase isoenzymes showed the increase in every instance to be due entirely to skeletal muscle isoenzyme. The results of additional laboratory tests and further evaluation suggested that the increased serum creatine phosphokinase activity was not derived from the myocardium and was not related to parenteral therapy, specific drugs, hyperthermia, or hyperkalemia. The increase in serum creatine phosphokinase during exacerbations of asthma is probably derived from respiratory muscles, owing to the increased work of breathing.


Urinary tract cancer and isoniazid.

A case control study was conducted in Washington County, Md. to assess the possibility that isoniazid might be associated with the production of malignant neoplasms of the urinary tract. One hundred and forty-two cases of bladder cancer and 48 cases of renal cancer were found in the follow-up of a 1963 census population. Each case was matched to two other persons of the same race, sex, and age enumerated in the census. The tuberculosos register for the county was searched to see whether any case or control subject had ever received isoniazid. Two members of the entire study group had a record of isoniazid administration; both were control subjects. No evidence was found to associate isoniazid with cancers of the urinary tract.


HL-A and silicosis.

The search for a link between HL-A antigens and silicosis among 75 patients revealed no significant association. However, we did note a decrease in the frequency of B7; This change could be linked to a greater sensitivity to silicosis among persons who carry this antigen. There was also an increase of B8 among those silicotic patients with tuberculosis, although only a small number of patients were affected.


Instability of the carbon dioxide stimulus under the "mixed venous isocapnic" conditions advocated for testing the ventilatory response to hypoxia.

Meaningful and reproducible ventilatory responses to hypoxia cannot be obtained from the mixed venous isocapnic test reported by Rebuck and Campbell if it is not recognized that the CO2 drive increases progressively for at least 6 to 10 min after the PCO2 step.


Colonoscopy in a community hospital.

Colonoscopy is a valuable diagnostic and therapeutic tool. In the present series, 12 polyps, a villous adenoma, and three new cases of ulcerative colitis were found in symptomatic patients with negative barium enemas. Surgical intervention was avoided in two patients suspected of having carcinoma. This study proves the safety and the value of colonoscopy to the community hospital surgeon. It also affords a better means of evaluating the patient with inflammatory disease, and avoids the genetic effects of repeated x-rays.


Vascular injuries to the extremities.

The treatment of vascular trauma is a challenging and increasingly successful endeavor. Improvement in patency rates and limb salvage have occurred through advances in diagnostic methods, materials for vessel replacement and techniques of repair. Several principals have evolved. An aggressive diagnostic approach is indicated with early arteriography in all suspicious injuries. Distal blood flow should be established as soon as possible. Associated venous injuries should be repaired if possible. Unstable orthopedic injuries shoud be stabilized conservatively with minimal internal wire fixation of fragments and the use of traction. Fasciotomy should be used in treatment of any injury involving prolonged ischemia of distal tissues.


Correction of late aortic-bifemoral graft failures.

Our recent experience in reconstruction of late thrombosis of Dacron aortic-femoral graft is presented along with initial evaluation and treatment. It is suggested that a particular patient population is prone to this complication, and that aggressive restoration of limb flow is essential. This frequently involves ingenious techniques of deep femoral artery reconstruction done concomitantly with various inflow procedures as illustrated.


Dermoid cysts of the pancreas.

Pancreatic dermoid cysts are very rare. They are congenital abnormal growths arising from embryonic rests, usually appearing as a nontender abdominal mass. Abdominal pain and backaches are the usual symptoms, with or without signs of gastrointestinal obstruction. However, they may be totally asymptomatic. The treatment is surgical extirpation.


Abdominoperineal resection for carcinoma in the community hospital.

Stimulated by a report in 1974, we have reviewed all abdominoperineal resections in a Univeristy-affiliated community hospital. From 1964--1973, 67 such procedures were performed. There were 65 adenocarcinomas, one squamous cell cancer, and one carcinoid tumor. Dukes' classification was A-4, B-22, C-39, D-4. Postoperative complications occurred in 55.1% of patients. Late complications occurred in 22% of patients. Five-year follow-up was possible in 34 patients with an overall survival of 50%.


Eosinophilic granulomas of the gastrointestinal tract.

Three patients with eosinophilic infiltration of the stomach and one with eosinophilic granulomatous polyp of the ileum are described. We believe that eosinophilic granulomatous lesions of the gastrointestinal tract comprise a distinct clinical and pathologic entity which should be considered in the differential diagnosis of obstructing or ulcerating lesions.


One-stage cure of infected pilonidal cysts.

Twenty-five patients with infected pilonidal cysts were treated by wide incision and drainage with curettage of the cyst lining. Twice-daily peroxide irrigations and permanent hair removal were advocated. General anesthesia was used in all but three patients. These also represented the only recurrences. Two of these had an inadequate initial surgical incision.


Clinical experience with autogenous ascitic fluid infusion for cirrhotic ascites.

Autogenous ascitic fluid infusion was found to be a safe and practical method in dealing with patients suffering advanced liver cirrhosis complicated by massive ascites.


Spontaneous perforation of bile ducts.

The rarity of spontaneous perforation of bile ducts in the absence of trauma or previous biliary surgery is apparent by the few reports in the literature. In a review of the available literature, only 23 perforations of the common duct and 10 perforations of the common hepatic duct were found. This report adds two cases--one occurring in the distal common hepatic duct and one in a small superficial hepatic duct radical on the inferior surface of the liver. Choledochal calculi associated with infected bile and increased pressure in the proximal ductal system are the most common etiologic factors in spontaneous perforation of biliary ducts. Free bile or bile stained fluid in the peritoneal cavity with an intact gallbladder should alert the surgeon to the possibility of bile duct perforation. Recognition and proper surgical treatment as outlined are essential for successful management of this rare occurrence.


Abdominal aortic aneurysm and horseshoe kidney in a 91-year-old man.

A 91-year-old man had a symptomatic, enlarging abdominal aortic aneurysm in association with horseshoe kidney. He underwent successful surgical resection. Difficulties, secondary to the inter-relationship of the renal artery supply and the aneurysm, are discussed. This patient is 15 years older than the previously oldest reported patient with these two associated anomalies.


Sputum cytology: a valuable addition to the investigation of hypercalcemia.

In this paper we report two patients with asymptomatic hypercalcemia, one with primary and the other with ectopic hyperparathyroidism, in whom cytologic examination of the sputum led to the diagnosis of carcinoma of the lung despite the presence of normal chest roentgenograms. Sputum cytology is a simple, inexpensive and accurate test which should be included in the diagnostic regimen for hypercalcemia.


Antimicrobial therapy of vitamin B6-dependent streptococcal endocarditis.

Vitamin B6-dependent viridans streptococci were isolated from two patients with microbial endocarditis. Because of their unique requirement for pyridoxal hydrochloride, these organisms did not grow normally in the media usually used in diagnostic laboratories. When tested in supplemented media, both strains were resistant to penicillin G and relatively sensitive to streptomycin. Penicillin-streptomycin synergy was demonstrated in vitro as well as in experimental endocarditis. These laboratory findings confirmed the clinical observations in these two patients that penicillin-streptomycin therapy should be used in vitamin B6-dependent streptococcal endocarditis. Nutritionally varient streptococci may be important pathogens in microbial endocarditis and must be considered in patients with suggestive clinical findings but negative blood cultures.


Transient postpartum hypothyroidism: fourteen cases with autoimmune thyroiditis.

Twenty-five episodes of postpartum primary hypothyroidism were observed in 23 patients without thyroid hormone treatment: three were cases of irreversible hypothyroidism and the others were of transient hypothyroidism. The characteristics of transient postpartum hypothyroidism deduced by serial observations on 14 patients were [1] a high incidence of previous goiter; [2] thyroid enlargement at 1/2 to 4 months postpartum; [3] hypothyroidism at 3 to 5 months postpartum; [4] spontaneous recovery at 5 to 10 months postpartum; [5] high titers of antithyroid microsomal antibodies; and [6] persistence of small goiter. Transient postpartum hyperthyroidism before the occurrence of hypothyroidism and the recurrence of transient postpartum hypothyroidism were observed during two consecutive postpartum periods in two patients. Transient hypothyroidism was also observed in two patients after abortion. Fourteen of the 23 patients first noticed thyroid abnormality after delivery. These changes seem to be induced during the course of autoimmune thyroiditis by the immunologic changes occurring after delivery.


Salivary gland neoplasms as a late consequence of head and neck irradiation.

An increased occurrence of salivary tumors was observed in 1922 patients who received radiation to the tonsils and nasopharynx. Twenty-seven tumors, 19 benign and eight malignant, were found in this group as compared with an expected 0.2 malignant and less than 1 benign tumor. The latent period between the initial radiation treatment and diagnosis ranged from 7 to 32 years. After the first 15 years the incidence (77 cases/10(5) subjects/year) has remained constant and shows no indication of declining. Continued observation for salivary gland tumors is therefore indicated for subjects who received childhood irradiation.


Renin, sodium, and vasodepressor response to saralasin in renovascular and essential hypertension.

Saralasin (1-sar-8-ala-angiotensin II), a competitive inhibitor of angiotensin II, was administered to 32 patients with renovascular or essential hypertension before (Day 1) and after (Day 2) they were mildly sodium depleted by furosemide (1 mg/kg body weight). A blood pressure lowering effect of saralasin was observed in 16 of 17 patients with renovascular hypertension on Day 2, but in only 10 of the 17 on Day 1. Of the 15 patients with essential hypertension, only the four with high renin levels exhibited a vasodepressor response on Day 2; three responded similarly on Day 1. The Average net sodium loss between the 2 days was greater for patients who responded to the drug on Day 2 (170 meq) than those who did not (129 meq) (P less than 0.05); however, there was no correlation between blood pressure response and either net sodium loss or urinary sodium excretion at the time of testing. Plasma renin activity correlated with saralasin responses (r=-0.74, P less than 0.01). Saralasin testing during a state of modest sodium depletion compares favorably with renin measurements in the detection of renin-mediated hypertension.


Diuretic therapy and response of essential hypertension to saralasin.

Thirty-four patients, most with a low-renin "essential" hypertension, and seven normal subjects were placed on diuretic therapy for 4 to 5 weeks. In the normal subjects, infusion of a highly specific, competitive angiotensin II analogue (1-sar-8-ala-angiotensin II, saralasin) did not significantly change recumbent blood pressure either before or after diuretic administration. In contrast, the hypertensive patients as a group had a low stimulated plasma renin activity before diuretic therapy and a rise in blood pressure during saralasin infusion. After therapy, the stimulated plasma renin activity was higher and saralasin produced a fall in blood pressure in some patients who were still hypertensive. The results suggest that short-term diuretic therapy, which is thought to act through its natriuretic effects, can convert some patients with essential hypertension, many with a low or a low-normal stimulated plasma renin activity, to individuals whose hypertension is supported by angiotensin II. The fall in blood pressure to saralsin infusion after diuretic therapy was directly proportional to the height to which diuretics elevated the stimulated plasma renin activity.


Cystic fibrosis diagnosed after age 13. Twenty-five teenage and adult patients including three asymptomatic men.

Cystic fibrosis was diagnosed after age 13 in 25 patients. All had an elevated sweat chloride and either a sibling with cystic fibrosis or typical pulmonary infection or digestive symptoms caused by exocrine pancreatic deficiency. Fourteen had long-standing pulmonary or digestive symptoms. In contrast, four of eight patients whose symptoms began after age 13 presented with biliary cirrhosis. Three male patients were asymptomatic at diagnosis. Opacification of all paranasal sinuses was found in all patients examined radiologically. At diagnosis, pulmonary-function testing showed obstructive changes in 19 patients and sputum cultures showed Pseudomonas aeruginosa in 15 patients. Delayed menarche in five of seven female patients and infertility in the asymptomatic male patient (two of whom were found to have aspermia) could have led to earlier diagnosis. Teenagers and young adults with long-standing pulmonary or digestive symptoms, unexplained cirrhosis, aspermia, or a sibling with cystic fibrosis should be sweat-tested by pilocarpine iontophoresis.


Sternocostoclavicular hyperostosis: painful swelling of the sternum, clavicles, and upper ribs. Report of two new cases.

Five patients had persistent, pulling pain in the sternum, clavicles, and upper ribs that was exacerbated by cold and dampness. Clublike, symmetrical enlargement of the clavicles was seen and, in two patients, venous congestion of the upper half of the body. All patients had a constantly elevated erythrocyte sedimentation rate. Radiologically there was symmetrical hyperostosis of the sternal and middle portions of the clavicles, synostosis of the sternoclavicular joints, a widened and thickened sternum, and varying degrees of involvement of the upper ribs. X-ray findings did not change over several years. Phlebography showed bilateral subclavian vein occlusion in three patients and unilateral occlusion in one. Biopsies of the clavicles showed a characteristic hyperostotic sclerosis of the spongiosa. The cause of this sternocostoclavicular hyperostosis is unknown, but clinical, radiologic, and histologic findings indicate that it may represent a distinct, hitherto undescribed entity.


Major trends in psychosomatic medicine. The psychiatrist's evolving role in medicine.

Three developmental lines are identifiable in psychosomatic medicine: (1) psychodynamic investigations, (2) psychophysiologic and psychosocial research, and (3) consultation-liaison psychiatry. Although psychodynamic understanding of medical patients remains important, "psychogenesis" is no longer the principal concern of psychosomatic medicine, which has shifted emphasis to a holistic understanding that includes the biologic, psychologic, and social systems of medical and psychiatric patients. Recent investigations along the second line indicate that all medical and psychiatric illnesses can be regarded as "psychosomatic," in that comprehensive understanding and care cannot be achieved without considering the three interrelated systems. Consultation-liaison psychiatry is the practice of this holistic approach in the general hospital. The essential role of the consultation-liaison psychiatrist as a bridge between the biologic and behavioral disciplines may become a major part of the role of the general psychiatrist in the future.


Cystic lesions of the petrous apex: transsphenoid approach.

The transsphenoid approach to cystic lesions of the petrous tip has been made possible by the advances in techniques for diagnosis. These include polytomography, improved angiography, and computer tomographic (CT) brain scanning. The results of these studies can determine the size, shape, and thickness of the cystic lesion, as well as its exact relationship to the sphenoid sinus. A number of surgical approaches have been used to reach the cystic lesion of the petrous apex. Most notably, these include the middle fossa extradural craniotomy and posterior fossa craniotomy. These surgical techniques allow the cyst to be biopsied but do not establish permanent drainage. The translabyrinthine approach accomplishes wide access to the petrous apex, but cochlear and vestibular functions are sacrificed. The transsphenoid approach to cystic lesions of the petrous apex should be the ideal operation provided that the anterior aspect of the cyst abuts against the posterior wall of the sphenoid sinus. The cyst can be completely evacuated and permanent fistulization established into the sphenoid sinus using a septal mucosal flap and a silicone drainage device. The operation is accomplished without destruction to the inner ear.


Limitations of computed tomography in the investigation of acoustic neuromas.

Seventy percent of 80 surgically proven acoustic neuromas were visualized on preoperative computed tomography (CT) scans. Many more tumors were seen on contrast enhanced scans than on unenhanced scans (55 vs 25). No intracanalicular tumors and only one of 15 tumors less than 2 cm in size were visualized on CT scan. Most medium size tumors (2.0-3.0 cm) and all large tumors (greater than 3.0 cm) were visualized on CT scan when optimal technique was used. Positive CT scans often replace more invasive diagnostic studies in the investigation of acoustic neuromas. Negative scans do not rule out tumors as intracanalicular, and small tumors are usually not visualized with current techniques. If there is clinical suspicion of an acoustic neuroma, positive contrast posterior fossa cisternography should be done when the CT scan is negative.


Cholesteatoma surgery: residual and recurrent disease. A review of 1,024 cases.

This is an analysis of 1,024 primary cases of mastoid surgery for cholesteatoma operated upon during a ten-year period at the Otologic Medical Group, Inc. Our philosophy of management of the mastoid in these cases has been as follows: 1) avoid an open mastoid cavity when possible; 2) perform the operation in two stages if necessary; 3) reexplore the mastoid and middle ear for residual cholesteatoma when indicated. One-third of 380 revised cases had residual cholesteatoma, disease left by the surgeon. In 260 cases in which the surgeon felt it unlikely that there was residual disease he found it in 23%. In 4% this residual cholesteatoma was found in the mastoid. The incidence of residual cholesteatoma was higher in children and in planned, as opposed to unplanned, revisions. Residual cholesteatoma was detected in the middle ear more frequently than in the epitympanum, and in the epitympanum more frequently than the mastoid. Indications for, and timing of, the reexploration are discussed. Recurrent cholesteatoma refers to a retraction pocket and must be differentiated from residual cholesteatoma; the causes, prevention and treatment are different. Recurrent cholesteatoma was detected in 5%. The most common complication of the disease was a labyrinthine fistula (10%). Operative facial nerve damage occurred in one case. The most common postoperative complication was graft failure (3%). Intact canal wall tympanoplasty with mastoidectomy should be performed as a two-stage procedure in most cases when used in the treatment of aural cholesteatoma.


Natural history of sudden sensorineural hearing loss.

This is a prospective in-depth study of patients with sudden idiopathic sensorineural hearing loss. We found that 65% recover completely to functional hearing levels spontaneously and independent of any type of medical treatment. The majority do so within 14 days and many within the first few days. Prognosis can be predicted according to the slope of the initial audiogram (low-frequency losses do better than high-frequency losses), hearing at 8 kHz, erythrocyte sedimentation rates, in some select instances spatial disorientation symptoms, and speech discrimination scores. There was a very poor correlation between hearing and vestibular test abnormalities, except hypoactive calories. There were no correlations with age (excepting the very elderly), with antecedent respiratory infections, hypertension, diabetes, or other chronic diseases. We conclude that there is a fundamental difference in the behavior of apical and basal cochlea losses, that hearing recovery is always better at low than at high frequencies, that because of the high spontaneous recovery rates, tympanotomies seeking peri-lymph fistulas should be delayed ten days unless there is a progressive hearing loss, and that none of the current recommended treatments, especially histamine, have any effect on the outcome.


Endolymphatic sac obstruction. Biochemical studies.

Inner ear fluids were studied biochemically in guinea pigs from 1 to 16 weeks after producing endolymphatic hydrops by obstructing the endolymphatic duct. Fluid collected from beneath the footplate showed changes of 50% of the animals indicating distension of the saccule. There was an increase in potassium concentration and decrease in sodium concentration of the collected fluid, indicating a traumatic mixing of endolymph and perilymph produced by rupture of the saccule during collection of the fluid. The smallest changes occurred at one week, and the greatest changes were found four months after endolymphatic sac obstruction. Similar findings were observed in studying inner ear fluids obtained from patients with Ménière's disease. Cochlear endolymph showed biochemical alterations after endolymphatic duct blockage. There was a two- to three-fold increase in sodium concentration and a decrease in potassium concentration with the total ionic concentration remaining approximately the same. Some guinea pigs showed similar changes in vestibular endolymph. This study indicates that in the guinea pig, endolymph obtained in the distended endolymph compartment has a slightly different sodium-potassium ratio as compared to the normal ear. In patients with Ménière's disease there may also be an elevation of endolymph sodium concentration. The significance of this change and hearing loss observed in experimental endolymphatic hydrops and Ménière's disease is open to speculation at the present time.


Electron microscopic observations in a case of long-standing profound sensorineural deafness.

The ultrastructural pathology in an ear with long-standing profound deafness is presented. Endolymphatic hydrops was present, although there had been no vestibular symptoms. Although hair cells were absent, the intercellular junctional complex at the endolymphatic surface of the organ of Corti was maintained, suggesting "healing" by migration or proliferation of supporting cells to fill the empty spaces. Severe atrophy of the stria vascularis was present, and crystalline deposits were found within the strial remnant. An encapsulated tectorial membrane was interpreted in light of ultrastructural findings as either herniation of the fibrillar connective tissue of the spiral limbus into the scala media or alternatively demonstrating abnormal continuity between the connective tissue of the spiral limbus and the remnant of tectorial membrane. Neural degeneration was severe in all cochlear turns. However, more nerve fibers were seen in the proximal portion of Rosenthal's canal than at the habenula perforata or in the organ of Corti, and central processes from the ganglion area were more numerous than peripheral processes. The ganglion cell population was reduced to approximately 10% of normal, and only unmyelinated cell bodies were found. Few recognizable neural fibers were seen within the organ of Corti, although bizarre collections of apparent cellular debris and cell processes containing many mitochondria or vesicles were seen in regions normally containing neural fibers.


[Ultrastructural study of the Dego's disease (report of a new case and literature review) (author's transl)].

An observation of a new case of Degos' disease in a 42 year old woman presenting a merely cutaneous symptomatology, enabled to perform a detailed ultrastructural study of vascular lesions, nerves, infiltrate and perivascular fibroblasts. The episodic clinical evolution with various formation periods of vascular lesions, the frequency of virus-like inclusions in the endothelial cells and fibroblasts, as well as C3 deposits and the presence of intracytoplasmic cylinders in the histiocytes, suggest a common physiopathologic mechanism with the autoimmune diseases. A bibliographic review accompanies the clinico-pathological study.


Inner ear hemorrhage and endolymphatic hydrops in a leukemic patient with sudden hearing loss.

Several significant histopathological findings were noted in a case of sudden hearing loss in a patient with chronic lymphocytic leukemia. The major pathological findings were leukemic hemorrhage into both perilymphatic and endolymphatic spaces in the cochlear and vestibular systems, endolymphatic hydrops in the cochlea and sacculus, and a relatively narrowed and straightened vestibular aqueduct and endolymphatic sac. Additional interesting findings include: loss of hair cells in the organ of Corti and vestibular end-organs; destruction of the stria vascularis (possibly the origin of the blood); fibrosis in the perilymphatic spaces in the cochlea and the vestibule, and in the endolymphatic space in the vestibule; and new bone formation in the perilymphatic spaces in the vestibule. The leukemic infiltrate observed in both the cochlea and the vestibule was not considered to be significant. Hemorrhage into the cochlea is thought to be the most reasonable cause of the sudden hearing loss in this case. Also discussed are fibrosis and osteogenesis as a late consequence of hemorrhage, and the coexistence of endolymphatic hydrops with an anomaly of the vestibular aqueduct and endolymphatic sac.


[Interest and justification of general corticosteroid therapy in suppurative tinea (kerion) (author's transl)].

Persistency, especially in country people, of kerions (Trichophyton of animal origin with pus formation) led the authors to propound the use of general corticosteroid treatment as an original therapy. This concept is emphasized by many concordant features showing the importance of immune alterations in the pathogenesis of kerions. Six cases are reported according to this concept.


Sudden deafness with severe loss of cochlear neurons.

We report our postmortem findings in the temporal bones of a patient who, at the age of 13, after having had a cold, experienced a sudden and profound hearing loss in her right ear. She died of nasopharyngeal carcinoma at 41. The patient's right temporal bone showed a complete loss of cochlear neurons, but the organ of Corti was well-preserved. These findings indicate a primary degeneration of the cochlear nerve. The authors speculated that the possible cause of this sudden deafness was severe neuronitis of the cochlear nerve.


[Ectodermal anhidrotic dysplasia (author's transl)].

The E. A. D. is a genodermatosis characterised by absence or important diminuation of sweat glands. The study of 3 children of different families allows us to identify the diagnostic elements: typical facial signs, anhidrosis, rarity of teeth "buds", abnormalities of dermatoglyphes. This diagnosis must be established early, to protect the newborn from accidents of overheating caused by perspiration insufficiency. The sweat glands are not affected alone: exocrine glands also, explaining the fragility of the upper respiratory tract in such patients. The teeth abnormalities are important and need replacement by false teeth, carefully done at an early date and continued later on. Genetic investigation is indispensable to discover women who carry the disease, with a high risk of transmission to their children.


Pathogenesis of Bell's palsy. Retrograde epineurial edema and postedematous fibrous compression neuropathy of the facial nerve.

The pathogenesis of Bell's palsy is presented as retrograde epineurial compression edema with ischemia of the facial nerve. Although the etiology is unknown, an attractive theory is vasospasm, from any cause, along any facial nerve branch, with the chorda tympani, perhaps, the usual primary involvement. Retrograde vascular distension and edema, within the epineurium of the bony facial canal, compresses the nerve from outside its perineurial sheath. The compression force may be mild or severe, resulting in varying degrees of reversible or irreversible ischemic degeneration of myelin sheaths and axons, with varying degrees of cellular reaction to myelin breakdown. The edema may be resorbed, leaving reversible or irreversible nerve damage, or may stimulate collagen formation within the epineurium, with persisting fibrous compression (entrapment) neuropathy of the facial nerve. This concept is consistent with the varying results of Bell's palsy, and depends on the severity and duration of edema, and whether fibrosis occurs within the epineurium of the facial canal. Epineurial fibrosis also results in disturbance of metabolic exchange through the epineurial-perineurial-endoneurial tissues, and may ultimately result in obliteration of vascular drainage. Two temporal bone cases of Bell's palsy, one occurring ten years before death, with residual paralysis, and one two years before death, with clinical recovery, are added to the previously described four cases in the literature, three of early Bell's palsy, and one of remote palsy with almost complete recovery.


[Axial dermatoses (author's transl)].

In the vast group of linear dermatoses a very particular topographic type can be distinguished, i.e., the axial dermatoses which very electively follow the linear course of Scherington's axial lines. This feature can be found in several dermatoses and particularly in lichen striatus and acantholytic linear naevus. Topographically, the axial dermatoses are quite similar to the pigmentary demarcation lines which also follow the same course. Despite numerous patholgenic unknown facts, the concept of axial dermatoses certainly contributes to a better knowledge of the still obscure linear dermatoses.


["Pagetoid reticulosis" (Woringer and Kolopp disease). A disease of the Merkel cell (author's transl)].

A case of Woringer and Kolopp disease "Pagetoid reticulosis" is described. Clinical features include a ring of a target pattern of erythemato-squamous infiltrated skin lesion. The characteristic histological aspect of dense epidermal infiltrate by abnormal cells with a spared dermis has been observed. Ultrastructural findings include cytoplasmic granules with a found electron dense core and close relationship to neurites, two features of the Merkel cell of human normal epidermis. By comparing our patients with the already reported cases of Woringer and Kolopp disease it seems likely that this is a unique disease with no relationship with cutaneous lymphoma but which is defined by a Merkel cell proliferation.


Production of refusal factors by Fusarium strains on grains.

Corn fermented with strains of Fusarium culmorum NRRL 3288, F. poae NRRL 3287, F. moniliforme NRRL 3197, and F. nivale NRRL 3289 at 28 degrees C for 13 days was refused when fed to 30- to 60-pound (about 13.6- to 27.2-kg) swine. Analyses of the refused corn for trichothecenes (T-2, HT-2, acetyl T-2, fusarenon-X, and vomitoxin) showed that only the corn fermented with F. culmorum contained vomitoxin. None of these five trichothecenes could be detected in the other refused corn.F. culmorum grown on rice at 28 degrees C for 13 days also produced vomitoxin.


Epoxidation of 1,7-octadiene by Pseudomonas oleovorans: fermentation in the presence of cyclohexane.

A very efficient conversion of 1,7-octadiene to 7,8-epoxy-1-octene and 1,2-7,8-diepoxyoctane was achieved by incorporating a high concentration of cyclohexane into the conventional fermentation medium. In the presence of cyclohexane, a 90-ml% conversion of substrate to product was accomplished within 72 h, compared with an 18,5-mol% conversion in the absence of cyclohexane. Furthermore, the products were simultaneously separated and concentrated in the organic phase.


Stereospecific sulfur oxidation of 7-methylthioxanthone-2-carboxylic acid by Calonectria decora.

Thin-layer chromatography was used to determine the ability of three microorganisms capable of sulfur oxygenation, including Aspergillus niger, Streptomyces armentosus subsp. armentosus, and Calonectria decora, to oxidize 7-methylthioxanthone-2-carboxylic acid to the corresponding sulfoxide in growing cultures. In addition, optical rotary dispersion, circular dichroism, and nuclear magnetic resonance analysis in the presence of chiral shift reagent were used variously to access reaction stereoselectivity, absolute configuration, and optical purity of isolated products. The data indicated that C. decora produced the sulfoxide in high yield (69%) and optical purity (97%), most probably in the S-configuration.


Numerical taxonomy and ecology of petroleum-degrading bacteria.

A total of 99 strains of petroleum-degrading bacteria isolated from Chesapeake Bay water and sediment were identified by using numerical taxonomy procedures. The isolates, together with 33 reference cultures, were examined for 48 biochemical, cultural, morphological, and physiological characters. The data were analyzed by computer, using both the simple matching and the Jaccard coefficients. Clustering was achieved by the unweighted average linkage method. From the sorted similarity matrix and dendrogram, 14 phenetic groups, comprising 85 of the petroleum-degrading bacteria, were defined at the 80 to 85% similarity level. These groups were identified as actinomycetes (mycelial forms, four clusters), coryneforms, Enterobacteriaceae, Klebsiella aerogenes, Micrococcus spp. (two clusters), Nocardia species (two clusters), Pseudomonas spp. (two clusters), and Sphaerotilus natans. It is concluded that the degradation of petroleum is accomplished by a diverse range of bacterial taxa, some of which were isolated only at given sampling stations and, more specifically, from sediment collected at a given station.


Spatial relationship of the vaginal microflora to the vaginal epithelium of female rats: scanning electron microscopy.

The vaginal mucosa of ovariectomized female rats has been examined by scanning electron microscopy before and after estrogen [1,3,5(10)-estratriene-3,17beta-diol] treatment. Without estrogen stimulation vaginal colonization is minimal and the epithelium is characterized by a layer of epithelial cells covered with small microvillous-like projections. Progressive changes that were consistent with estrogenic cytoproliferative effects were seen after estrogen treatment. By post-treatment day 3 bacterial colonization was maximal and the epithelium was comprised of flat squamous cells that tended to become detached from the underlying tissue layers. Bacteria were seen in association with the intercellular borders of this tissue and occurred singly or as microcolonies. No distinct physical attachment structures were identified, although an amorphous extracellular material that may serve to attach the bacteria to the squamous epithelial cells was frequently seen.


Sublethal cold shock in Vibrio parahaemolyticus.

Exposing Vibrio parahaemolyticus populations to temperatures of 2 degrees C results in membrane damage, rendering cells incompetent to grow on media containing 5% NaCl.


Photochemotherapy for mycosis fungoides.

Twelve cases of cutaneous mycosis fungoides (MF) with erythroderma, plaques, and tumors were treated with photochemotherapy. Methoxsalen followed two hours later by ultraviolet light (UVA) resulted in clinical clearing of skin lesions in seven patients with plaque stage MF and one patient with erythrodermic MF. Four patients with both plaque and tumor stage MF showed clearing of plaques but not the tumors. Phototherapy units consisted of boxes with 16 to 64 UVA lights. The mean numbers of treatments to clear was 17.4. The mean total dose to clear was 134.8 joules. The mean dose of maintenance UVA was 5.6 joules/sq cm. Histopathologic clearing of mycosis fungoides was demonstrated with the clinical clearing.


Keratinizing dermatoses. Combined data from four centers on short-term topical treatment with tretinoin.

In four medical centers, 40 patients with keratinizing dermatoses were treated with topical tretinoin (vitamin A acid) 0.1% cream and salicylic acid 2% cream in a short-term, double-blind study. Tretinoin was the more effective treatment for several of the keratinizing dermatoses with the exception of palmar-plantar hyperkeratosis, for which it was not effective in the concentration and method of application used. The most striking clinical responses occurred in patients with lamellar ichthyosis and ichthyosis vulgaris. Local adverse reactions-chiefly pruritus, erythema, burning, excoriation, and irritation-were not severe and could be controlled by modification of the treatment regimen.


Allergic contact dermatitis to topical fluorouracil.

We designed a prospective and retrospective study to determine the incidence of allergic contact dermatitis to topical application of fluorouracil. Intracutaneous and epicutaneous skin tests of various fluorouracil concentrations were given to patients who were to be treated with the drug for actinic keratoses (group A) and to patients who had previously been treated with fluorouracil for actinic keratoses (group B). Six patients in group B had allergic contact dermatitis to topical fluorouracil. The common clinical characteristic of the six patients was a severe pruritic eruption at the site of fluorouracil application. Allergic contact dermatitis should be suspected in the presence of severe pruritus or a severe eczematous response in patients treated with topical fluorouracil.


Systemic argyria secondary to topical silver nitrate.

A case of generalized argyria secondary to topical silver nitrate use on the oral mucosa is described, and the nature and history of argyria reviewed. The patient has extreme pigmentation of her skin and abdominal viscera, as seen on physical examination, gastroduodenoscopy, and laparotomy. Her use of silver nitrate applicators was uncontrolled by her dentist and pharmacist, and the diagnosis of argyria was not made until 2 1/2 years of heavy usage had passed. Avoidance of similar cases requires the careful scrutiny of silver-containing medicinal usage by all health practitioners and pharmacists. Although the systemic distribution of silver in both elemental and ionic forms can be linked with no systemic toxicity, the resultant pigmentation can be devastating to the patient.


Eosinophilic fasciitis.

A detailed evaluation of the clinical and histologic manifestations of eosinophilic fasciitis is described in a 22-year-old woman. Scleroderma-like skin involvement is associated with eosinophilia and hypergammaglobulinemia. Visceral and serologic manifestations of a generalized scleroderma are lacking. Results of a biopsy showed severe thickening of the deep fascia accompanied by an infiltration of lymphocytes and plasma cells. This syndrome must be differentiated from generalized scleroderma because eosinophilic fascitis has a benign course and may benefit from systemic corticosteroid therapy.


Xanthoma disseminatum. Clinical, metabolic, pathologic, and radiologic aspects.

A 55-year-old man with the classical mucocutaneous lesions of xanthoma disseminatum has been followed up for a period of 13 years. The special features of this case, which make it unique, are as follows: (1) the availability of histologic data on multiple lesions for more than a ten-year period; (2) the progressive nature of the multiple osseous lesions; (3) the metabolic studies that show no evidence for accumulation of abnormal sterols in a xanthoma, the blood, or intestinal aspirate; (4) the development of hypothyroidism and symptoms or signs, or both, of an intracerebral and an intraspinal lesion; (5) the partial regression of the cutanous symptoms and lesions while receiving clofibrate, in spite of progression of the mucous membrane and osseous lesions, and (6) the failure to develop diabetes insipidus to date.


Congenital cutaneous candidiasis.

Three newborn infants are described in whom a generalized maculopapular rash was observed at birth or soon after. The eruption rapidly became vesicular, and in one infant it became bullous, and was followed in each case by extensive desquamation. Candida albicans was demonstrated on direct smear and on culture from the skin vesicles, and evidence of an intrauterine infection with this organism was detected on histologic examination of the placenta in at least two of the cases. Agglutinating antibodies to Candida were present in the sera of all three infants, though these may have reflected transplacental passage of maternal antibody.


Epithelioid sarcoma. A distinctive clinical presentation.

A case of epithelioid sarcoma occurred in an adult black man. The neoplasm recurred after 15 years in the form of multiple nodules and distinctive annular plaques. To our knowledge, this latter clinical manifestation has not been reported previously.


Choosing dermatologic instruction for students in family practice.

Sixty-three family practitioners responded to a special questionnaire designed to determine their judgment of what is most important to teach medical students and those residents headed toward careers in family practice. The ranking of emphases and specific diseases should be helpful to dermatologists responsible for the instruction.


Fifteen year experience with subcutaneous bypass grafts for lower extremity ischemia.

A 15-year experience with 92 subcutaneous arterial bypass grafts for lower extremity revascularization has been reviewed. Fifty-nine AF and 33 FF bypass operations were performed on 89 patients whose average age was 66 years. The overall five-year survival was 33% compared to an expected survival of 80%. 88% of the AF, and 76% of the FF operations were performed for limb salvage, bypass of an aortic aneurysm, or replacement of an infected aortic graft. The remainder were performed for intermittent claudication on patients who were too ill to withstand an intra-abdominal operation. 75% of the patients with AF grafts and 64% of those with FF grafts experienced complete relief of lower extremity ischemia, including all of the patients with claudication. Graft patency was analyzed by the life table method. In the FF series, 74% of the grafts remained patent for one year; 73% for two years; 66% for three years; and 53% for four years. A 50% incidence of thrombosis occurred at the end of two years in the AF group. The patency rate of the AF grafts was also studied with regard to the type of graft material employed: a 50% incidence of thrombosis was reached at 36 months with knitted Dacron; at 18 months with weave-knit Dacron; and at 9 months with woven Dacron. THESE DATA INDICATE THAT: (1) contrary to our previous report, weave-grafts provide adequate blood flow to the lower extremities but do not remain patent as long as more conventional types of reconstruction; (2) subcutaneous grafts should be performed only when an intra-abdominal procedure is contraindicated or life expectancy is limited.


Sources of lead in blood. Identification by stable isotopes.

The isotope ratios of lead in the blood of ten subjects resident in Dallas, Texas, were measured from April 1974 to June 1975. During the same period, the ratios in the city's air changed linearly by 6%. One subject gave erratic results, but the remainder yielded ratios that changed systematically--some linearly, others cyclically with turning points occurring in August to October and February to April. Two South African subjects were 6 months out of phase with their U.S.-born wives and the other U.S.-born subjects. Since the South Africans are presumed to have in their skeletons lead that is isotopically distinct from that in the U.S. environment, the cycles are attributed to the mixing of skeletal and dietary lead. The dietary component is inferred to be greatest in August to October, which correlates with the time at which 25-hydroxyvitamin D is reported to have maximum concentration in blood. On the assumption that the isotope ratios of dietary leads remained constant, the proportion of airborne lead in the blood of those subjects whose ratios changed linearly could be calculated, and values between 7 +/- 3% and 41 +/- 3% were obtained.


Interactions of lead, calcium, vitamin D, and nutrition in lead-burdened children.

This study was undertaken to evaluate relationships between blood or serum levels of lead (Pb), calcium, and 25-hydroxyvitamin D (25-OHD), within the framework of a nutritional survey of lead-burdened children. The results demonstrate that: regardless of blood Pb concentration and season of the year, serum 25-OHD concentration reflects vitamin D intake; high blood Pb (greater than or equal to 60 microgram/dl) was associated with decreased levels of 25-OHD (18+/--1 ng/ml vs. 32+/- in controls, P less than .001); concentrations Pb and calcium were inversely correlated in control and lead-burdened children; and children in the high blood Pb group (greater than or equal to 60 microgram/dl) had lower mean daily intakes of both calcium (610 +/- 20 mg vs. 770 +/- 20 in controls, P less than .001) and vitamin D (210 +/- 17 IU vs. 325 +/- 20 in controls, P less than .001). These data indicate that, in Pb-burdened children, multiple factors modify the absorption and toxicity of Pb, and relative vitamin D deficiency, not excess, is associated with high blood Pb levels. Assessment of nutrition, calcium metabolism, and vitamin D status is recommended in evaluating children known to have undue absorption of Pb.


Chemical pneumonitis secondary to inhalation of epoxy pipe coating.

Two patients with chemical pneumonitis secondary to inhalation of an epoxy curing material used in the coating of pipes had similar patterns of cough, hemoptysis, and dyspnea associated with diffuse bilateral alveolar infiltrates shortly following the exposure. Pulmonary function studies showed a volume-restrictive defect with severe hypoxemia, but an elevated diffusing capacity. All lung function studies returned toward normal within 1 month of exposure. One patient underwent an open lung biopsy which showed changes consistent with a nonspecific injury to the alveolar wall. This epoxy curing material, trimellitic anhydride, represents another cause of diffuse lung injury that can result in pulmonary edema.


Is axillo-bilateral femoral graft an effective substitute for aortic-bilateral iliac/femoral graft?: an analysis of ten years experience.

During the past ten years, 88 aorto-bilateral iliac/femoral grafts and 56 axillo-bilateral femoral grafts were electively performed for occlusive disease of the abdominal aorta or iliac vessels. The results of this retrospective study indicate that the axillo-bilateral femoral graft, although performed in an older population and more frequently for limb salvage, has a lower operative mortality than does conventional aortic bypass surgery with similar patency (76%) and survival (67%) at five years. However, axillo femoral grafting requires more frequent remedial surgery to obtain long term patency.


Parathyroid re-exploration. A clinical and pathological study of 112 cases.

In a series of 112 patients who underwent reoperation for primary hyperparathyroidism at the Massachusetts General Hospital between 1930 and 1975, all but 10 were treated successfully. Seventy-five initial explorations had been performed elsewhere, and 37 in our hospital. A total of 110 diseased parathyroids were uncovered-89 (81%) via re-exploration of the neck and 21 (19%) via mediastinotomy. In operation via the neck, the missing glands were most frequently found in the superior posterior mediastinum at the thoracic inlet (34, or 38%) and in mediastinal exploration, in the upper anterior mediastinum (14, or 67%). There were 66 patients with adenoma, 7 with carcinoma, and 29 with primary hyperplasia. Four had a hyperfunctioning fifth gland. One patient had an intrathyroidal and one, an ectopic gland. Reoperation was unsuccessful in 10 patients. Four died, and 6 are living. Unsuccessful exploration resulted from failure to understand the widespread distribution of normal parathyroids and the way they were displaced when diseased, error in diagnosing the pathologic entity of hyperparathyroidism at surgery, and technical incompetence. Reoperation of the neck was generally performed first. A mediastinotomy was undertaken only if the missing gland was clearly excluded from the neck or if localization studies had demonstrated its presence beyond doubt in the mediastinum. Reoperation was rarely performed simultaneously on the neck and the mediastinum, and it was seldom indicated in asymptomatic cases with a mild degree of the disease.


Tooth lead levels in Birmingham children.

The mean lead content of deciduous teeth from children living in the city of Birmingham (U.K.) has been shown to be 11.8 ppm dry weight, irrespective of the sex of the donor. Lead content varies according to type of tooth, and there is a gradient from incisors, with the highest level, to second molars, with the lowest. A relationship was shown between age of donor and lead content of canines and (when lognormalized data were considered) first molars. We were not able to demonstrate a correlation between tooth lead levels and residence near a potential industrial lead source, and we conclude that pollution from a general source is responsible for the body burdens we found.


Cancer mortality in relation to asbestos in municipal water supplies.

The mortality experience of twenty-two municipalities in Quebec grouped by evidence of exposure to asbestos fibers in water supplies (known high, possible high, and probable low exposures) was evaluated. Excess mortality due to cancer of the stomach (males), pancreas (females), and lung (males) was observed in the two municipalities with known high exposures. The excesses among males have been due to occupational exposure to asbestos. The absence of excess mortality due to pancreatic cancer among males suggested that the excess among females was not due to waterborne asbestos. The study therefore did not reveal evidence of excess cancer mortality that could be attributed to exposure to asbestos in drinking water.


Anatomic arterial-venous shunting in endotoxic and septic shock in dogs.

Shunting of radionuclide labeled 9 micron diameter microspheres by the systemic circulation, and 6 body regions was measured in two dog shock models: endotoxic shock (1 mg/kg  E. Coli endotoxin intravenously) and sepsis and septic shock (5 days after cecal ligation). Mean systemic arterial blood pressure was significantly lower than control in both the endotoxic and septic shock groups. Mean systemic shunting was 7.7% in the control group and 7.3% and 4.3% respectively in the endotoxic and septic shock groups. Regional shunting of the head, heart, and skeletal muscle were not significantly different in the three groups. However, mean shunting in the splanchnic circulation was 36.5% in the septic shock group as compared to 18.6% in the control group (p less than 0.05). Mean kidney shunting in the endotoxic group was 15.1% compared to 4% in the control group (p less than 0.05). During resuscitation with crystalloid, mannitol, blood, and cortiocosteroids mean aterial blood pressure and cardiac index increased but systemic arterial-venous shunting was 3.8 and 4.3% in endotoxic and septic shock respectively. These data show that systemic anatomic arterial-venous shunting is small and not different from control in both dog shock models, and regional arterial-venous shunting is increased only in the splanchnic circulation in the septic model and in the kidney in the endotoxin model.


Rapid onset of hand ischemia of unknown etiology: clinical evaluation and follow-up of ten patients.

Ten patients presenting with a history of the acute onset of hand ischemia have undergone detailed clinical, immunologic, and arteriographic evaluation. The disease is characterized by the acute onset of hand ischemia proceeding to fingertip ulceration, in the absence of recognized systemic disease. None of the patients had any evidence of large artery obstruction. Arteriography showed diffuse obstruction of the palmar and digital arteries. No evidence was found in any patient of any systemic disease process associated with small artery obstruction. These patients are suspected of having a previously unreported variant of hypersensitivity angiitis. Patients are left with permanent obstruction of the palmar and digital arteries. Follow-up suggests the disease in non-recurrent and is characterized by progessive clinical improvement associated with the development of collateral circulation. Conservative management of the condition is recommended.


The cerebrovascular Doppler examination in patients with non-hemispheric symptoms.

The cerebrovascular Doppler examination indicated a significant stenosis in only 19 of 53 patients with non-hemispheric TIA'S. There were no false negative or false positive examinations. Fourteen of 19 patients with an abnormal examination and 23 of 31 patients with a normal examination became asymptomatic after a carotid endarterectomy. Eleven patients were improved and two were unchanged. Therefore the cerebrovascular Doppler examination can not be used to predict therapeutic success or failure of carotid endarterectomy for non-hemispheric TIA's.


A fluorometric study of oxidative metabolism in the in vivo canine heart during acute ischemia and hypoxia.

Optical techniques for monitoring the fluorescence of intramitochondrial nicotinamide adenine dinucleotide (NADH) were employed to allow an on-line, non-invasive study of the metabolic state of healthy and ischemic cardiac tissue in the intact dog. Acute interruption of blood flow to the area of myocardium studied resulted in an immediate rise in NADH, indicating impairment of oxidative metabolism due to limitation of oxygen availability. Release of the coronary artery occlusion resulted in an oxidation of NADH to preocclusion baseline and signaled repayment of incurred O2 debt. Collateral flow produced a spontaneous fall in NADH levels towards preocclusion baseline. Hypoxic tissue was recognized by an oxidation of NADH on ventilation with 100 per cent O2, while in normal hearts no oxidation indicated the O2 was not rate limiting. Ischemic NADH increases preceded the onset of epicardial EKG changes, suggesting that an inability to rephosphorylate ADP to ATP is the primary cause of the EKG changes. Fluorometry of the in vivo heart provides a sensitive, continuous technique of monitoring cardiac cellular mitochondrial NAD;NADH redox levels and, therefore, the adequacy of high energy phosphate production and allows localization of cardiac tissue with marginal oxygen supply.


Results of treatment of 269 patients with primary cutaneous melanoma: a five-year prospective study.

A prospective protocol for the management of primary cutaneous melanoma was initiated at the University of Illinois in October 1968 and continued through June 1974. Over this period 269 cases were treated: 42 of the head and neck region, 75 of the trunk, 94 of the lower extremities and 58 of the upper exremities. The levels of invasion ranged from II to V, according to Clark's classification; level I melanomas were excluded. The status of the regional nodes was correlated with the level of invasion. Preliminary exploratory celiotomies were performed on all patients with lower extremity melanomas and on all those with level IV or V melanoma with clinically positive regional nodes. All patients were treated with wide excision and elective regional node dissection except those in whom celiotomy showed disseminated disease. Of the 150 patients now eligible for five-year analysis, 33 had level II disease, three with positive nodes. None had local recurrence or intra-abdominal metastasis. All 33 (100%) were cancer-free at five years. Of 56 with level III, 23 had positive regional nodes, two had local recurrence within two years, and two with melanoma of the lower extremities had intra-abdominal metastases. At five years 53 (95%) of the 56 were cancer-free. Of the 42 with level IV, 31 had positive regional nodes, five had local recurrence and five had intra-abdominal metastases; 21 (50%) survived for five years. Of the 19 with level V, 17 had positive nodes, three had local recurrence and five intra-abdominal metastases; 7 (37%) were five-year survivors. Of the 150, 114 (76%) were cancer-free at five years. On the basis of these findings, it was concluded that wide local excision is adequate for level II and probably for thin level III. But for thick level III and levels IV and V the best salvage rate is obtained by an aggressive surgical approach.


Ascending aorta to bilateral femoral artery graft via a ventral subcutaneous route.

Two patients were treated for grossly ischemic legs by a graft from the ascending aorta to both common femoral arteries. After leaving the mediastinum, the graft lay in the subcutaneous position throughout its course. In both patients, standard aorto-femoral repair was considered unduly hazardous because of gross obesity, large incisional hernias, previously unsuccessful vascular procedures, impaired renal function, emphysema, and complete occlusion of the abdominal aorta to the level of the renal arteries. Both patients had evidence of bilateral subclavian artery stenosis or occlusion. The technique of the operation is described and its assets and liabilities discussed. Within strict limitations, it is an alternative to axillo-femoral bypass.


Clinical vascular laboratory diagnosis of deep venous thrombosis.

The accuracy of our clinical vascualr laboratory was evaluated. Sixty-nine limbs (55 patients) were examined clinically for thrombophlebitis. All of these patients were then evaluated using segmental plethysmography and Doppler ultrasound techniques. Each limb was then studied with venography. In 57 of the 69 (82.6%) limbs evaluated, measurement of the maximum venous outflow accurately reflected the venographic  findings. Doppler augmented venous sounds were correct when compared to venography in 77.6% of limbs. In the 59 limbs that exhibited clinical signs of deep venous thrombosis, only 35.6% had venographic confirmation of the diagnosis. The clinical vascular laboratory provides an accuracy of diagnosis of deep venous thrombosis not achieved by clinical examination. If both segmental plethysmography and Doppler ultrasound were negative, it was very unlikely that deep venous thrombosis had occurred.


Splanchnic blood flow in patients with abdominal angina before and after arterial reconstruction. A proposal for a diagnostic test.

The diagnostic value of determining the splanchnic blood flow (SBF) and oxygen uptake before and after a test meal in patients suspected of abdominal angina was investigated in 15 patients with unexplained abdominal pain. Six patients with typical abdominal angina and occlusive lesions of two or three splanchnic arteries were investigated before and after successful arterial reconstruction. Five patients with less severe arterial lesions were classified as suspected of abdominal angina and four patients with eventual normal arteriography served as controls. No significant difference was found in fasting SBF between the three groups. Postprandial SBF rose in the controls and in the abdominal angina suspected group, but not in the patients with abdominal angina. After arterial reconstruction fasting SBF was higher than before and postprandial SBF rose to the level of the controls. No difference in oxygen uptake before or after test meal was seen in any of the groups or after arterial reconstruction.


Experience with reduction clitoroplasty for clitoral hypertrophy.

A technique for reduction clitoroplasty has been devised which provides an excellent cosmetic appearance for female patients with clitoromegaly due to virilizing CAH. Contrary to previous views, total clitorectomy should rarely, if ever, be considered as an initial method of management of children with clitoral hypertrophy. One of the 4 patients who has undergone reduction clitoroplasty using the described technique has achieved sexual gratification on several occasions postoperatively without discomfort.


Studies of the modified venous allograft.

Segments of rat inferior vena cava were modified by proteolytic digestion and dialdehyde starch tanning in an attempt to alter their antigenic nature and increase their tensile strength. These tissues were found to retain their ability to sensitize allogeneic recipients in both the intradermal and intra-aortic positions in all 50 experimental animals. Furthermore, these grafts had a very high aneurysm formation (100%), and aneurysm rupture (54%) rate even in isogeneic recipients, suggesting that the modification procedure so damages the structural integrity of venous tissue that its use in clinical situations may have disastrous consequences. Histologic evidence of intimal thickening, elastic disruption, and often severe acute and chronic inflammation supported the gross evidence of mechanical and immunologic damage and suggests that a mild brief course of immunosuppression may be indicated in clinical trials in situation in which autogenous saphenous vein in unavailable. Although the use of prosthetic mesh support for the graft may help to avoid structural changes, the introduction of synthetic materials may offset the theoretical advantages of the venous tissue.


Preoperative oral antibiotics reduce septic complications of colon operations: results of prospective, randomized, double-blind clinical study.

The effectiveness of short-term, low-dose, preoperative oral administration of neomycin and erythromycin base combined with vigorous purgation in reducing the incidence of wound infections and other septic complications of elective colon and rectal operations has been studied in a prospective, randomized, double-blind, clinical trial. One hundred and sixteen patients completed the study; all received mechanical preparation; 56 received neomycin-erythromycin base while 60 received an identical appearing placebo. The two patient groups were comparable in age distribution, clinical diagnoses, associated systemic diseases, types of operation performed and similar clinical features. The overall rate of directly related septic complications was 43 per cent in the placebo group and 9% in the group receiving neomycin and erythromycin base. The wound infection rates were 35% in placebo and 9% in antibiotic treated patients. Oral administration of neomycin and erythromycin base together with vigorous mechanical cleansing reduces the risk of septic complications after elective colo-rectal operations.


The child with ambiguous genitalia: a neonatal surgical emergency.

Although many birth defects pose a real threat to life if left uncorrected, the problem of ambiguous genitalia, if poorly or incorrectly handled, leads to a lifetime of unhappiness for both parent and child. The evaluation of these defects must be attended to with the same dispatch as any life threatening anomaly. A total of 18 children with ambiguous genitalia have been evaluated and treated in the past two years including nine females with virilizing adreno-genital syndrome, three infants with mixed gonadal dysgenesis, two infants with dysgenetic male pseudohermaphroditism, two males with severe perineal hypospadias, bifid scrotum, and undescended testicles, and two females with cloacal deformities. Precise diagnosis and most importantly proper gender assignments were made in 11 neonates by cytogenetic, biochemical, and miniaturized endoscopic techniques. Subsequent surgical reconstruction is governed by existing anatomy, not genetic sex, and has been completed in six children two to two and half years of age. Most are reconstructed as females with recession of the enlarged clitoris and vaginoplasty. Males with hypospadias are handled by standard techniques. Seven previously evaluated patients had been lost to follow-up for up to 13 years and were recently reconstructed. Surgical treatment in five older children with extreme virilization and moderate to severe gender confusion was technically successful but associated with pronounced emotional difficulties. Worse than delay in gender assignment, is making the wrong gender assignment, or failing to follow through with the original plan at an early age. Sample cases from each of these categories are presented in detail to illustrate the innovations in the diagnostic and therapeituc management of these children.


Long-term results in 1375 patients undergoing valve replacement with the Starr-Edwards cloth-covered steel ball prosthesis.

The two principal considerations with prosthetic valves are durability and thromboembolism. With the widespread interest in recently developed prosthetic valves (porcine, tilting disc, Cooley), the long-term results at one institution with a single prosthesis were considered of particular importance. Accordingly, a 97% follow-up has been completed on 1375 patients (pts) undergoing prosthetic valve replacement with the Starr-Edwards cloth-covered steel ball prosthesis at New York University between October 1967 and December 1975. Operative procedures were as follows: aortic valve replacement (AVR): 470 pts; mitral valve replacement (MVR): 362 pts; combined AVR and MVR: 129 pts; other combined procedures: 414 pts. Overall operative deaths were 13.7%, 9% for AVR, 10.8% for MVR, and 18.6% for combined AVR and MVR. At seven years, AVR survival was 64%, and MVR survival 64.5%. There has been widespread pessimism, usually without significant data, about the cloth-covered prosthesis, because of concern of cloth wear, hemolysis and other complications. Therefore, a particularly significant finding by actuarial analysis was that 85% of surviving patients with isolated AVR remained free of emboli for five years. In pts surviving isolated MVR, 80% remained free of emboli for five years. Of those having embolic episodes, 33% were not on anticoagulants. Fatal hemorrhage from anticoagulants occurred in 0.8% of pts. Endocarditis occurred in 5.7% of the entire group, with 1.3% requiring reoperation. Clinically significant hemolysis occurred in 5.1% of the group, with only 0.2% requiring reoperation. Hence, the total frequency of clinically significant cloth-wear was less than 0.5%. These data indicate both the reliability and the limitations of the Starr-Edwards cloth-covered steel ball valve and can be used in comparing experiences with the more recently developed prostheses.


Familial polyposis coli in black patients.

We have presented our experience with 19 black patients who had familial polyposis coli, seven of whom had associated cancer. Four of the seven had multiple cancers. Seventeen of the 19 patients were female but most of the patients at risk in our series were female. Sixteen of the 19 had extracolonic manifestations which have been described as part of Gardner's syndrome. Although our series was quite small, larger series do not report as high an incidence of extracolonic manifestations. Follow-up was too short to make any statements concerning the development of cancer in the retained rectal stump.


Improved results with carotid endarterectomy.

Two hundred ninety patients undergoing carotid endarterectomy were reviewed. From 1968 to 1972, 188 patients had carotid endarterectomy under general anesthesia with use of a shunt and hypercarbia. Stump pressures were not recorded in this group. There were three deaths, three postoperative hemiplegias and two complications of transient limb weakness. From 1973 to 1975, 102 patients were operated on under local anesthesia with systemic Innovar and Sublimaze, normocarbia and intra-operative assessment of stump pressure. In this group there was one death, no hemiplegia, and no complications of transient limb weakness. Twenty of the 102 were shunted either on the basis of stump pressure or the loss of motor ability or consciousness on carotid clamping. Those shunted had stump pressures ranging from 10 to 70 mm Hg with a mean of 20 while those not shunted had stump pressures ranging from 20 to 85 mm Hg with a mean of 53 mm Hg. Five patients lapsed into unconsciousness despite internal carotid stump pressures of 30, 30, 34, 36 and 70 mm Hg respectively, thus requiring intraoperative shunting. This experience seriously questions the reliability of carotid stump pressure as the sole determinant to identify those patients who require intraoperative shunting. We have come full circle, back to operation under local anesthesia, since intraoperative assessment of the patient's motor ability and consciousness alone provide the only absolute criteria for assessing the need for intraoperative shunting. Since the operation can be performed with greater technical efficiency without a shunt and without the potential complications of shunting itself, it behooves the surgeon to have a reliable method of knowing when it is not required.


Screening for breast cancer.

Mammography is of real assistance to the surgeon in evaluating breast problems not associated with a breast mass. Use of mammography in the detection of early breast cancer in breast demonstration projects has brought forth the time honored value judgement of benefit vs risk. This report introduces an additional aspect in the consideration of benefit vs risk, the interval cancer. From the demonstration project at KUMC, 326 biopsies were performed and 65 proved to be cancer. However, 24 additional women developed cancer before their next recommended screening date. This reduces the accuracy of mammography and physical examination by trained nurses in screening for breast cancer to 73%.


An evaluation of bone scans as screening procedures for occult metastases in primary breast cancer.

Preoperative bone scans were obtained in 104 patients with operable breast cancer. Areas of increased radioactivity detected by the bone scan were correlated with appropriate radiographs. One of 64 patients (1.5%) with clinical Stage I and Stage II breast cancer had a metastatic lesion detected by the preoperative bone scan. In contrast, 10 of 41 patients (24%) with Stage III breast cancer had occult metastatic lesions detected by the preoperative bone scan. The majority of patients with abnormal bone scans and no radiographic evidence of a benign lesion to explain the cause of the increased radioactivity proved to have metastatic breast cancer on follow-examination. Even though 20% of patients with operable breast cancer will eventually develop bone metastases, our results indicate that preoperative bone scans are not an effective means of predicting which patients with Stage I and Stage II disease will develop metastatic breast cancer. Because of the considerably increased frequency of detection of occult metastases in patients with Stage III breast cancer, bone scans should be obtained routinely in the preoperative assessment of these patients.


The contribution of a bacterially isolated environment to the prevention of infection in seriously burned patients.

A new system of patient protection from bacterial crossinfection called the Bacteria Controlled Nursing Unit (BCNU) is described, based on strict environmental control of a 6 x 10 foot area surrounding the patient's bed rather than the entire patient room or isolation ward, plus the ability to deliver all medical care without entering the protective environment and maintaining all monitoring, life support, and i.v. equipment outside the controlled environment. The clinical effectiveness of this system in the treatment of burn patients has been studied and compared with the effectiveness of single room isolation on a burn isolation ward and conventional isolation techniques on an open burn ward. The studies show that the BCNU is significantly more effective in preventing bacterial cross-contamination than conventional precautions (3.8% vs. 13.1%, P < 0.001; and 8% vs. 22.8%, P < 0.001) over a two and four week period. The studies also indicate that there was a significant increase in the probability of infection occurring following cross-contamination than occurring after auto-contamination (65% vs. 39%, P < 0.005), emphasizing the importance of preventing cross-contamination in reducing the overall infection rate in seriously burned patients. Clinical evaluation of the unit proved it to be compatible with intensive nursing and medical care without increasing the nurse to patient ratio. The unit provided sufficient control of bacterial cross-infection to allow reduction in mortality and improvement in the effectiveness of burn care through routine prompt excision of burn eschar and immediate wound closure to be carried out in severe and massively burned patients without a limiting threat of bacterial burn wound sepsis.


The potential of organizations of fee-for-service physicians for achieving significant decreases in hospitalization.

Because hospitalization is a key factor in controlling health care costs and because fee-for-service remains the predominant mode of physician payment, a study was undertaken of the hospitalization experiences of open panel fee-for-service health maintenance organizations (IPA-HMOs) and Foundations for Medical Care (FMCs). Ten open panel plans were surveyed as to characteristics of their programs, physicians, and enrollees and their hospitalization rates. Although data were incomplete, three IPA-HMOs, described as case reports, did achieve striking reductions in hospital use relative to a comparison group or period. Salient characteristics of these plans that may influence hospital use are prepayment by enrollees, sharing by physicians of some financial risk, and effective peer review. Further study is needed, but preliminary indications are that IPA-HMOs have a role to play in reducing health care costs.


Proton translocation in intack cells of Thiobacillus denitrificans.

Proton translocation assessed by the quinacrine fluorescence technique was compared with oxygen uptake during thiosulphate oxidation by cells of Thiobacillus denitrificans. The addition of thiosulphate to cell suspensions resulted in an outwardly directed proton translocation as reflected by an increased quinacrine fluorescence. Compared to the O2 uptake activity, the proton translocating system was much more sensitive to proton conductors, other ionophores and inhibitors of electron transport. The results indicate that (a) the proton-translocation activity (membrane energization) is enhanced in aged cell suspensions, (b) intactness of the cytoplasmic membrane is essential for establishing a protonmotive force in cells, (c) the fluorescence increase and proton translocation are reversible processes, (d) inhibitors of electron transport may also act as proton conductors by altering the integrity of the cytoplasmic membrane.


[Energy-dependent 63Ni-uptake by Alcaligenes eutrophus strains H1 and H16 (author's transl)].

Kinetic studies of the uptake of 63Ni were undertaken with two strains of Alcaligenes eutrophus, known to require nickel ions for chemolithotrophic growth. Using carbon dioxide as sole carbon source, growth is stimulated by low concentrations of nickel with optimum concentration for growth stimulation at about 0.3 micron nickel. Higher nickel concentrations were inhibitory. Heterotrophic growth on fructose was not stimulated by nickel ions.--Upon transfer into phosphate buffer freed of heavy metal ions, autotrophically grown cells exhibited rapid uptake of 63Ni which was dependent upon the presence of hydrogen, oxygen and carbon dioxide. Within 60 min nickel was accumulated from the medium, reaching 280-fold concentration in the cells. The observed uptake exhibited a temperature optimum at about 29 degrees C and was markedly inhibited by metabolic inhibitors such as arsenite, iodoacetate, methylene-blue, sodium azide and sodium cyanide. Other heavy metal ions (Zn, Co, Mn and Cu) only slightly inhibited 63Ni-uptake. The efflux of 63Ni from the cells was stimulated by 58NiCl2 and by toluene. These data indicate that nickel ions are accumulated by an energy dependent mechanism in chemolithotrophically grown cells of these strains.


Nutrition and factors limiting the growth of a methanogenic bacterium (Methanobacterium thermoautotrophicum).

The purification of Methanobacterium thermoautotrophicum from a culture contaminated with a heterotrophic organism is described. A defined inorganic medium under H2/CO2 (80:20 v/v) has been developed to support growth of M. thermoautotrophicum up to a concentration of at least 1.7 g dry weight/l. In a conventional medium iron and nitrogen sources were found to be growth-limiting factors. Throughout most of the culture period the rate of transfer of hydrogen or carbon dioxide from gas to liquid was the factor which controlled the growth rate. The growth yields of bacteria were in the range of 0.6-1.6 g dry weight/mole CH4.


The carotenoids of Flavobacterium strain R1560.

The main carotenoid of Flavobacterium strain R1560 has been identified as (3R,3'R)-zeaxanthin. Also present were small amounts of 15-cis-phytoene, phytofluene, "zeta-carotene" (7,8,7',8'-tetrahydro-psi, psi-carotene plus 7,8,11,12-tetrahydro-psi, psi-carotene), neurosporene, lycopene, beta-zeacarotene, gamma-carotene, beta-carotene, beta-cryptoxanthin, rubixanthin, 3-hydroxy-beta-zeacarotene and several apo-carotenals. Zeaxanthin production was inhibited by nicotine (10 mM), and lycopene and rubixanthin accumulated. The biosynthesis of zeaxanthin is discussed in terms of pathways and also of "half-molecule" reaction sequences. The presence of zeaxanthin may be a characteristic of a group of Flavobacterium species, and may thus be useful in the taxonomic classification of these organisms.


The photosensitivity of the malate oxidase system of a pigmented strain and a carotenoidless mutant of Sarcina lutea (Micrococcus luteus).

The effect of white light on the malate oxidase of Sarcina lutea (Micrococcus luteus) membranes has been examined using a carotenoid-containing and a carotenoidless mutant. At least three photosensitive sites have been detected. Two of these are associated with the malate dehydrogenase complex (malate-menaquinone reductase) and are unaffected by membrane carotenoid. A third site which has been detected beyond the dehydrogenase complex, is protected by carotenoid since it can only be demonstrated in carotenoidless systems. A repair mechanism has been found for one of the two sites in the dehydrogenase complex.


Lack of peptidoglycan in the cell walls of Methanosarcina barkeri.

Neither muramic acid and glucosamine nor D-glutamic acid or other amino acids typical of peptidoglycan were found in cell walls of two strains of Methanosarcina barkeri. The main components are galactosamine, neutral sugars and uronic acids. Therefore, the structural component of the cell wall most likely consists of an acid heteropolysaccharide, resembling that of Halococcus morrhuae. It is, however, not sulfated.


The effect of gamma radiation on breaking of dormancy in Phycomyces spores.

Dormant sporangiospores of Phycomyces blakesleeanus were activated by Cs-137 gamma rays. After a dose of about 300 krad, between 80 and 90% of the spores germinated normally. However, further development of the mycelium was inhibited. Even with dry spores a partial activation was obtained. Activation by gamma rays was not accompanied by an increase in trehalase activity.