Determination of protein allowances in human adults from nitrogen balance data.

The problem of predicting human protein requirements is examined in detail. Three methods from the literature are shown to represent a logical sequence wherin each takes into account more sources of variation than does the previous one. These are the single level method and two versions of the multiple level method, all of which assume a population response curve. A fourth method is proposed as the next step in this sequence. This method calculates a response curve for each individual and works with the individual requirements. Since each method makes fewer assumptions about the data and, therefore, about the biological situation of population protein needs, each method gives successively larger protein allowance values, while at the same time identifying the sources of variability and uncertainty in these estimates.


Effects of acute caloric restriction on cholesterol metabolism in man.

The effects of acute caloric restriction on cholesterol balance and kinetics of plasma cholesterol specific activity were investigated in five hyperlipemic subjects with varying degrees of obesity. Caloric restriction decreased plasma triglycerides by 41 +/- 12%, plasma cholesterol by 11 +/- 9%, and the ratio of esterified to free cholesterol by 12 +/- 7+. Immediately on institution of caloric restriction there appeared to be an influx of tissue cholesterol into plasma and a reduction in endogenous synthesis of cholesterol. The cholesterol balance decreased from 1,469 +/- 441 to 1,212 +/- 349 mg/day and the rate of decay of plasma cholesterol specific activity decreased 62 +/- 3%. The effect of caloric restriction on hepatic synthesis of bile acids was also very prompt. The total fecal bile acids were reduced immediately by 36 +/- 7%. Because the effect on fecal excretion of deoxycholic acid was greater than that on fecal lithocholic acid, it was suggested that hepatic synthesis of cholic acid was reduced more than the synthesis of chenodeoxycholic acid. Caloric restriction did not cause any change in the percentage of absorption of dietary cholesterol (40 +/- 2% versus 42 +/- 3%). These observations are in accord with our model relating cholesterol metabolism with the metabolism of plasma lipoproteins in man.


Nutritional management of the female with phenylketonuria during pregnancy.

This paper discusses a rational approach to appropriate nutritional management of the pregnant woman with phenylketonuria (PKU). Special food items, including new formulas and low-phenylalanine products, as well as allowable nutral foods are described. Particular emphasis is placed on the nutritional adequacy of this PKU diet during pregnancy. Such a diet should be palatable and tolerated well and should also take into consideration important economic, cultural, and psychological aspects. Clinics caring for PKU individuals should be so prepared because many otheir females are approaching childbearing age.


Vitamin A deficiency and anemia in Central American children.

In order to investigate the role of vitamin A nutriture in the prevalence of anemia in Central America, a retrospective evaluation of the data of the six Institute of Nutrition of Central Americal and Panama/Office for International Research nutrition surveys of Central America and Panama has been made. Three groups of children; 1 to 4, 5 to 8, and 9 to 12 years old, living between 0 and 2,5000 feet above sea level were studeid. Several biochemical and dietary parameters related to anemia were corrleated with plasma levels of retinol. Children between the ages of 5 and 12 years showed a significant positive correlation between hemoglobin and plasma retinol. Children aged 1 to 4 years did not show a similar correlation. In children of all age groups there were positive correlations between plasma retinol and serum iron. Percent saturation of transferrin was also found to be lower when plasma retinol levels were low. Children with an adequate intake of iron, as classified by both dietary information and socioeconomic level, showed a significant positive correlation between plasma retinol levels and iron in their serum. In contrast, no correlation was found when dietary iron was low. In the light of these findings, a possible relationship between vitamin A deficiency and anemia is suggested.


Normality and other statistical considerations as they relate to selected quantitative measures in the CAP survey.

Investigation of the CAP statistical reports for quantitative tests with respect to the assumption of normality and the method for detecting outliers was performed. Specifically, laboratory measurements of several constituents from the Comprehensive Survey for 1975 were examined. The findings indicate that the assumption of normality, while not exactly valid, is reasonable and not deleterious to the purpose of the Survey, but that the method of determining outliers may be too stringent. A less strict, simpler outlier procedure is suggested as an alternative. It is also observed that other evaluation procedures would be available if more significant digits were reported for the laboratory measurements.


Long-term stability of enzymes, total protein, and inorganic analytes in lyophilized quality control serum.

The stability of total protein and various enzyme and electrolyte analytes in numerous pools of lyophilized quality control sera is evaluated. Using data obtained between 1973 and 1976 from Regional Quality Control Programs utilizing the Quality Assurance Service of the College of American Pathologists, monthly group mean values are studied as a function of time, by means of linear regression analysis. In the 28 pools studied, unstable analyte-pool combinations were detected in approximately 35% of the cases. Total protein was the most universally stable. In a large percentage of pools, minimally increasing concentrations of sodium, chloride, and potassium were found, while inorganic phosphorus decreased in the majority of pools. In pools with changing enzymatic activiteis, alkaline phosphatase tended to increase and creatine phosphokinase generally decreased. Changes in levels of calcium, serum glutamic oxaloacetic transaminase, and lactate dehydrogenase were inconsistent. Changes in analyte concentration were judged in relation to the precision (SD) with which the analytes were measured. The ratios of rate of change in analyte value to SD were lower for electrolytes than for other analytes.


Analytical clinical chemistry precision. State of the art for fourteen analytes.

Relationships of concentration and coefficient of variation for 14 clinical chemistry analytes are described. Estimated mean regression curves and standard deviations of individual laboratory coefficients of variation about the mean regression are calculated. Two analytes, calcium and sodium, showed no relationship of concentration to precision. Twelve analytes showed significant relations between concentration and coefficient of variation. State-of-the-art precision is compared with medical goals. The average coefficient of variation for one analyte, calcium, fails to meet medical goals for automated or manual methods. Average precisions for 13 analytes meet medical goals. The distribution of individual laboratory precision above average state-of-the-art figures is discussed. The proportions of laboratories failing to meet medical goals are large for sodium, chloride and glucose, in addition to calcium.


Interlaboratory survey of enzymatic analyses. II. Intermediate studies.

A set of six interrelated specimens was analyzed for creatinine, urea, and five enzyme constituents by about 10 laboratories on two occasions. The results from each laboratory were subjected to linear regression analysis and the correlation coefficients, X and Y intercepts, and slopes were calculated. These parameters then were used in various ways to (a) evaluate the composition, linearity and stability of the specimens, (b) assess the analytic precision of each laboratory, (c) assess the accuracy of the laboratories relative to their peer group, and (d) identify systematic differences among peer groups. The results suggest that this technic is a viable approach to the evaluation of laboratory performance in enzymatic analyses.


Urinary chemistry. A new CAP program.

A pilot survey program for urinary chemistry was implemented by the College of American Pathologists during the year 1976. The nine analytes selected for the program were amylase, calcium, phosphorus, sodium, potassium, creatinine, osmolality, 17-ketosteroids and total protein. Data obtained from more than 230 enrolled laboratories indicate deficiencies in assay performance for amylase, 17-ketosteroids and total protein as measured by consensus evaluation. Acceptable performance was apparent for the remaining analytes.


Serum magnesium. A CAP survey--1975.

The results of the 1975 CAP Comprehensive Chemistry Survey of serum magnesium are presented. More than 1,260 laboratories participated in this survey. The most commonly used method for the measurement of serum magnesium concentrations is atomic absorption spectrophotometry. Colorimetric dye methods (Rapid-Stat (TM) kits, the Dupont ACA and titan yellow) follow in popularity. Variation in precision was lowest with atomic absorption and highest with titan yellow methods. All three of the dye-binding methods demonstrated either consistently negative or consistently positive biases when compared with the weighted mean concentration. The differences between the mean concentrations obtained by the dye-binding methods and atomic absorption spectrophotometry are statistically analyzed, and several conclusions are presented. As demonstrated by this survey and at the concentrations measured, the estimation of serum magnesium by any of the commonly used methods, except titan yellow, is clinically appropriate.


Serum lithium. A CAP survey perspective.

Lithium data from the 1975 College of American Pathologists Comprehensive Chemistry Survey program have been analyzed. The results have been organized into five method-dependent groups: four variations on emission flame spectrophotometry, and one group containing all manual atomic absorption methods. The bias observed between flame emission and atomic absorption methods was correlated with the sample mean. In addition, three paired specimens were analyzed by mean comparison. This study indicates that atomic absorption methods have a negative bias, but an apparent correlation with the sample mean indicates the probability of standardization error between the methods. This may be related to a protein depression effect and may be due to differences in viscosity between aqueous standards and serum-based samples. Both atomic absorption and flame emission methods demonstrate variability that is clinically satisfactory.


Serum osmolality. A CAP survey analysis.

Serum osmolality has been included as a constituent to the comprehensive Chemistry Series of the College of American Pathologists Survey Program since 1973. The data for 1975 are reviewed in depth and compared with those for the two previous years. The results show that the interlaboratory variation of osmolality analysis is minor and concurrence has shown progressive improvement each year. The mean concentrations of duplicate pairs of specimens circulated to participants in 1975 show very close agreement except for one pair of duplicates for those laboratories using the Advanced Instruments and Fiske osmometers. The source of this difference is unexplained. The mean concentrations achieved by the participants using the various osmometers were compared with the "all-methods" mean. The bias is greatest for those laboratories using the Fiske and Wescor instruments. The number of laboratories submitting osmolality data has increased each year. There has been some change in the relative popularities of the various osmometers used by the participants.


Proficiency testing for the radioimmunoassay of carcinoembryonic antigen. A one-year report.

Forty-three laboratories participated in an interlaboratory testing program offered by the College of American Pathologists for the radioimmunoassay (RIA) of carcinoembryonic antigen (CEA). Thirty correctly reported a sample with 1.9 ng of endogenous CEA per ml as less than 2.5 ng. For samples with added exogenous CEA at the 5.4 ng/ml level, 24 laboratories reported too low and six too high (more than 2 SD beyond the targe value). At the 8.9 ng/ml concentration, three laboratories underestimated the CEA, while 18 overestimated the sample's concentration. A similar proportion of the laboratories performed in the same manner when estimating CEA at a target concentration of 15.9 ng/ml (five underestimating and 27 overestimating the concentration). Although individual variations were large, the majority of participating laboratories can reliably distinguish normal concentrations of CEA from moderate, intermediate and large elevations.


The calibration of automated instruments for accuracy in hemoglobinometry.

The surveys of the College of American Pathologists indicate a consistent bias between the manual "reference" method for hemoglobin determinations and the Coulter S measurements. The Coulter S hemoglobin values are invariably lower; the difference averages 0.3 g/dl. The commonly used calibration methods for the Coulter appear to be subobtimal. The hemoglobin calibration and quality assurance method proposed by Bull and colleagues is advocated as the presently most acceptable method. Commercial hemoglobin control materials should not be used for hemoglobin calibration.


Calibration methods for automated hematology instruments.

Recent CAP survey data have documented marked improvement in the reproducibility of hematologic tests. The favorable outcome is attributable largely to the widespread use of automated whole-blood analyzers. Calibration variability, however, detracts from this enhanced precision, and there are clear indications that improvement is necessary. Primary calibration methods for hemoglobin, hematocrit and cell counting procedures are presented. The methods of applying these primary calibration methods to automated whole-blood analyzers are delineated. The use of both preserved reference blood and statistical control technics for the identification of calibration loss is described.


The prediction of prothrombin time system performance using secondary standards.

A method for the comparison of prothrombin time systems using single large lots of lyophilized plasma in the College of American Pathologists Surveys is presented. Systematic biases for prothrombin time methods as well as for thromboplastins have been measured, and their use allows a very accurate (within 2.25%) prediction of the prothrombin time for the great number of prothrombin time systems presently being used in the United States.


A critical analysis of platelet counting methods.

A careful analysis of platelet counting methods, including an assessment of accuracy, was done using data from the College of American Pathologists Comprehensive Hematology Survey preserved platelet suspension specimen (H-32-1976). Comparisons between methods suggest systematic biases probably related to the calibration methods used for automated instruments. Falsely elevated counts occurred with manual methods and one light-dispersion system. Methods for calibration and continuing quality assurance of platelet counting are proposed.


CAP interlaboratory survey of analytic balances.

An interlaboratory survey of analytic balances was performed using aluminum oxide spheres weighing about 525 mg each. Results in 82 of the 83 laboratories completing the survey suggest that for this weight level, the error would not exceed +/-0.3% in 19 of 20 weighings; or +/-0.4% in 997 of 1,000. Discussions concerning components contributing to the variance are included.


Results of HBsAg testing of AABB-CAP survey samples.

Participants in the AABB-CAP HBsAg Survey Program and the Comprehensive Blood Bank Survey currently use radioimmunoassay (RIA) as the primary test for hepatitis B surface antigen (HBsAg). In changing from counterimmunoelectrophoresis (CEP) to RIA, participants have maintained a high degree of proficiency, detecting 99.1% of all reactive samples. Both RIA and reversed passive hemagglutination (RPHA) show greater sensitivity than the second-generation methods. Proficiency with RPHA has been variable because of the occurrence of false-positive reactions and difficulty in detecting some samples with RIA ratios between 2.1 and 7.0.


Quantitation of vaginal acid phosphatase and its relationship to time of coitus.

In cases of alleged sexual assault a quantitative vaginal acid phosphatase determination may indicate not only the presence of seminal fluid but also the approximate time of coitus, even in the absence of spermatozoa. A method of obtaining and handling vaginal swabs allowing for acid phosphatase determination and examination for spermatozoa was developed. Postcoital samples were obtained from 26 women and analyzed for ACP activity. Quantitative levels of ACP were related to time since coitus. These levels were compared with those found in 104 cases of alleged sexual assault and in 27 women volunteers.


A slow-speed gravity delivery system for laboratory specimens.

A prototype system for the slow-speed transport of specimens by gravity was installed in New York University Hospital in May 1974. Blood, urine, body fluids and other specimens, except for 24-hour urines, are transported inside cylindrical containers that descend at constant velocities between 60 and 120 cm/sec, depending on the weight of the contents. Containers could be dispatched at six-second intervals, and each could carry as many as 15 blood specimens. Experience with the system has demonstrated that slow-speed gravity transport is practical and safe. No specimen has been lost, damaged or broken. Performance was acceptable, but some design modifications were needed. In February 1975, the system was expanded to provide service to the Intensive Care and Coronary Care Units.


The use of frozen, thawed erythrocytes in blood banking: a report of 28 months' experience in a large transfusion service.

A program of component therapy using largely frozen erythrocytes was initiated at Cook County Hospital in July 1973. Use of the three existing washing systems for routine preparation of frozen erythrocytes has shown that there are differences in the levels of free hemoglobin, hematocrit, and residual glycerol in the washed products. Adenosine triphosphate, 2,3-diphosphoglycerate, and extracellular potassium and sodium were found to be within acceptable limits. Some expired units were cultured and were found to be positive for Staphylococcus and Corynebacterium. The source of contamination has not been determined. Frozen blood, when available, has been given to all patients, regardless of age or clinical condition. The incidence of transfusion reactions has decreased from 0.57% prior to the inception of the component therapy program to 0.11% since that time. Two cases of possible posttransfusion hepatitis occurred in patients who had received non-frozen blood, and in three patients who received non-frozen erythrocytes and/or components as well as frozen blood. Although the goal of the program was the use of frozen erythrocytes exclusively, only 64% use was achieved, as sufficient quantities of blood for freezing were not available at all times.


Antithrombin III and Factor VIII in patients with neoplasms.

Possible increased activation of the coagulation pathway was measured in a group of patients with neoplastic diseases. In addition to standard tests, the thromboplastin generation test, thrombin generation test and immunologic and coagulant activities of both Factor VIII and antithrombin III were utilized in the evaluation. The correlation between immuno-Factor VIII (VIII-Ag) and its clotting activity (VIII-C1) was good (r = 0.83). In contrast, this was not the situation for antithrombin III-Ag and its clotting activity. Thromboplastin generation was accelerated in 60% and thrombin generation was accelerated in 40% of the patients. Fibrinogen was elevated in half the cases: in most of these patients, thrombin times were slightly prolonged. These results indicate that some patients who have cancer have abnormal clotting patterns and are often in a potentially hypercoagulable state that is reflected by the thromboplastin generation test, thrombin generation test, and high levels of Factor VIII (both VIII-Ag and VIII-C1).


Neutrophilic hypersegmentation as an indicator of incipient folic acid deficiency.

The authors have identified a group of subjects with neutrophilic hypersegmentation who are normal or near-normal with respect to other hematologic indices (hemoglobin, mean corpuscular volume). In a high proportion of these subjects, serum folate levels are abnormally low. In this group and a non-hypersegmented-neutrophil control group there was a significant negative correlation between average numbers of neutrophilic lobes and serum folate levels. In the subjects with hypersegmented neutrophils the predominant alteration is a shift from three-lobed to five-lobed neutrophils. It is believed that neutrophilic hypersegmentation can be a valuable adjunct in documenting and/or uncovering incipient folate deficiency.


Reassessment of a cytochemical test for differential diagnosis of leukemic reticuloendotheliosis.

Reports of negative tartrate-resistant acid phosphatase reactions in a few cases of leukemic reticuloendotheliosis prompted the authors to re-evaluate the diagnostic specificity of this test. As a result, they modified the test by (1) incorporating a dual-control system for excluding a false-negative test due to technical errors, and (2) instituting an objective grading system for assuring consistent interpretation of the test on blood smears. When these modifications were applied to materials of patients suspected to have leukemic reticuloendotheliosis, there was an excellent, although not specific, correlation between the positive test and the diagnosis of leukemic reticuloendotheliosis. Tartrate-resistant acid phosphatase reactions were positive, intermediate, and negative for 76, 21, and 3% of 29 patients who had leukemic reticuloendotheliosis, whereas the figures were 3, 32, and 65%, respectively, for 37 patients who had chronic lymphocytic leukemia and other hematologic disorders.


Latex agglutination in diagnosis of bacterial infections, with special reference to patients with meningitis and septicemia.

Antibody-sensitized latex particles were used to demonstrate specific bacterial antigens in cerebrospinal fluid, blood and urine. Difficulties with reported nonspecific agglutinations appear to have been overcome. The method seems to be sensitive, specific, and simple to perform, and shows a better detection rate than culture or countercurrent immunoelectrophoresis. Urinary excretion of Haemophilus influenzae antigens was followed. The diagnostic usefulness of demonstrating such antigens at a later stage of disease is discussed.


Isolation of Corynebacterium xerosis from clinical specimens: infection and colonization.

Eleven patients were colonized or infected with diphtheroids identified as Corynebacterium xerosis. All the patients were compromised hosts by nature of their underlying disease and/or therapy. Two patients developed bacteremia following colonization of the respiratory tract with C. xerosis. Other patients were colonized at various sites, which included the respiratory tract, abdominal and thoracic wounds, amputated limb, and arterial-venous shunt. Distinctive features for the identification of C. xerosis include negative reactions for hemolysis, urease, and motility, and positive reactions for catalase, glucose, sucrose and nitrate reduction. Antimicrobial susceptibility tests were performed by the disk diffusion method. In many instances the organisms were resistant to the antimicrobial regimens received by the patients. This was most frequent for nafcillin, gentamicin, kanamycin, clindamycin, and chloramphenicol. On the other hand, the organisms were highly susceptible to penicillin, ampicillin, cephalothin and carbenicillin.


Germ tube-positive Candida tropicalis.

The germ tube test is routinely used for the rapid identification of Candida albicans and its variant C. stellatoidea, and is generally thought to be specific for these organisms. Four cases in which yeastlike fungi were isolated, and, although they were germ tube-positive, further morphologic and biochemical examinations identified them as Candida tropicalis are presented.


Pulmonary allescheriasis: report of a case from Ontario, Canada.

A case of pulmonary allescheriasis in a 53-year-old woman residing in London, Ontario, Canada, is described. This patient entered the hospital complaining of dyspnea, a productive cough, and pains in the neck and left shoulder. Roentgenograms of the chest revealed a large cavity in the upper lobe of the right lung, and xerograms showed an intracavitary mycetoma. Monosporium apiospermum, the imperfect form of the fungus Allescheria boydii, was grown from her sputum and from the mycetoma as well. Treatment with amphotericin B had no effect on the infection, and the upper lobe of the right lung was resected. The cough cleared completely and the patient made an excellent recovery. This case of pulmonary allescheriasis once again emphasizes that the most satisfactory form of treatment available at present for this mycosis is surgical excision of the infected area.


Pseudomonas maltophilia bacteremia associated with a prolapsed mitral valve.

A 53-year-old man had had recurrent episodes of transient visual loss, malaise and a heart murmur. Blood cultures repeatedly grew Pseudomonas maltophilia, a frequent opportunistic pathogen, and echocardiogram documented mitral-valve prolapse. The risk of bacterial endocarditis is stressed.


Thymidine-dependent strain of Salmonella oslo selected by trimethoprim-sulfamethoxazole therapy.

A case report describing the isolation of a multiple-drug-resistant strain of Salmonella oslo from urine and stool specimens is presented. After ten days of trimethoprim-sulfamethoxazole therapy, a second strain of Salmonella oslo was isolated from another stool specimen. The second strain was determined to be a thymidine-requiring organism. The significance of this thymidine-requiring strain is described.


Osteolytic lesions following traumatic pancreatitis.

We present a case of osteolytic lesions secondary to medullary fat necrosis associated with pancreatitis. The bone lesions are usually secondary to pancreatic trauma and evaluation of possible child abuse is indicated. The roentgenographic findings may not be seen until three to four weeks after the onset of pancreatic disease, and must be differentiated from osteomyelitis and traumatic periostitis. The presence of multiple lesions in many bones without substantial clinical signs of infection should suggest the pancreas as the primary problem.


Echocardiographic diagnosis of bacterial endocarditis of the mitral valve in a neonate.

A full-term normal neonate had acute staphylococcal endocarditis. Serial echocardiograms demonstrated abnormal echos in the region of the posterior mitral valve leaflet and aortic outflow tract that were subsequently proved to be a bacterial vegetation. This represents, we believe, the first case reported of the echocardiographic diagnosis of bacterial endocarditis in a neonate. There was progressive functional impairment of the mitral valve despite appropriate antibiotic therapy. At necropsy, a 1-cm vegetation was found attached to, and eroding through, the posterior mitral valve leaflet. The remainder of the heart, including the mitral valve apparatus, was normal. Endocarditis is a rare, but devastating, disease in a neonate, and the echocardiogram is a safe noninvasive method of making an accurate diagnosis and following the course of the disease.


Right atrial myxoma in a child.

A 12-year-old girl with fatigability, dyspnea, variable murmurs, and chronic congestive failure was treated for chronic myocarditis with medical management for 16 months. Cardiac catheterization and angiography performed to rule out constrictive pericarditis disclosed a right atrial myxoma. Following removal of the mass, this patient became asymptomatic. Since right atrial myxoma rarely occurs in children and can mimic other diseases, the diagnosis depends on a high index of suspicion.


Neonatal renal papillary and cortical necrosis.

Renal papillary and cortical necrosis (RPCN) in newborn infants has been generally fatal. This report describes three survivors of neonatal RPCN who have been followed up from 23 to 57 months. The cause of RPCN was hemorrhage and asphyxia neonatorum in two patients and hemorrhage and shock in one. The diagnosis was confirmed in one patient by an excretory urogram at 3 weeks of age and in another by renal biopsy at 5 weeks of age. In the third, diagnosis was made retrospectively. Findings from subsequent examination showed that creatinine clearance was normal in one patient, slightly reduced in another, and moderately reduced in the third. Maximum ability to concentrate urine was decreased in all. Follow-up excretory urograms in all three patients showed dilated bizarre-appearing calices and renal cortical atrophy. These radiologic findings are similar to those found in segmental hypoplasia or chronic (atrophic) pyelonephritis.


Monocytosis in congenital syphilis.

We evaluated hematological findings, with special reference to the monocyte count, in ten infants with congenital syphilis. One patient had a monocytic leukemoid reaction and eight had absolute monocyte counts considerably higher than normal control infants. Monocytes appear to be an essential participant in the cellular reaction to treponema pallidum. To our knowledge, this is the first report of a monocytic leukemoid reaction in congenital syphilis.


Bacterial meningitis and septicemia in sickle cell disease.

A total of 422 patients with sickle cell disorders have been observed for 3,442 patient years. During this period, 53 episodes of septicemia or meningitis occurred, indicating a risk of 12.5% from these infections for each individual. If only patients with SS hemoglobinopathy (sickle cell anemia) (323 patients) are considered, the risk was 15.2%. The case fatality ratios for sepsis and meningitis were 35% and 10%, respectively. Disease due to Streptococcus pneumoniae occurred, almost exclusively, among children with SS hemoglobinopathy who were less than 5 years of age. After the first decade, illnesses among patients with all types of sickle cell disorders were frequently associated with an identifiable source of infection, a chronic course, and frequent involvement of Gram-negative organisms.


Cognitive evaluation of children with elevated blood lead levels.

Cognitive evaluation of children with elevated blood lead levels was compared with that of a control group similar in age, sex, race, neonatal condition, socioeconomic status, and presence of pica. No significant differences in cognitive functioning were found between the study and control groups. Implications of the present data and their relationship to those of previous investigations are discussed.


Content and emphasis of well-child visits. Experienced nurse practitioners vs pediatricians.

The content and emphasis of well-child visits conducted by nine randomly selected pediatricians was compared with those of five experienced pediatric nurse practitioners. Twenty one nurse visits and 43 pediatrician visits with 1-year-old to 2-year-old children were monitored. The nurses discussed developmental and child behavior topics in significantly (P less than .05) greater depth, they asked more open-ended questions, made more specific recommendations, provided more maternal support, and the parents spoke a greater proportion of the time during the nurses' visits. Efficiency (number and depth of topics considered per unit time) of both groups was similar. Nurse visits were more time-consuming (mean, 25.5 vs 17.6 minutes for pediatricians). A subgroup of four pediatricians conducted visits much like those of the nurses, scoring as well in less time. The other five pediatricians conducted shorter visits, with little emphasis on child development and provided less time for the parent to talk. Overall, after five years in practice, these nurses were in no way less complete in child health supervision than a representative sample of pediatricians and were considerably more comprehensive in their approach than the average pediatrician.


Prader-Willi syndrome. Variable severity and recurrence risk.

The families of 39 patients with Prader-Willi syndrome were examined for similarly affected individuals. The pertinent findings include (1) one sibling more profoundly affected than the patients usually described, (2) one first cousin more mildly affected than usual, (3) a suggestive history of increased frequency of spontaneous late miscarriage (17%) from the mothers of affected offspring, and (4) an occurrence rate of 1.6% in proband siblings.


Beckwith-Wiedemann syndrome in a mother and her son.

The Beckwith-Wiedemann syndrome--exomphalos, macroglossia and gigantism--occurred in a mother and her son. The clinical and metabolic features of this syndrome are described. We believe this is the first report of this syndrome affecting a mother and her son. An autosomal dominant pattern of inheritance is suggested.


Liver function and structure in survivors of acetaminophen poisoning. A follow-up study of serum bile acids and liver histology.

A series of 30 patients, hospitalized with acetaminophen overdose, were studied during initial admission and again three months later. The quantity of acetaminophen ingested varied from 5 to 50 g and 19 patients developed raised transaminase levels in the serum during the initial period. Liver damage, on the basis of needle biopsy findings, was categorized as severe in 5, moderate in 7, and mild or minimal in 18 patients. At three months' follow-up all but one of the biochemical indicants of liver damage had reverted to normal in all patients. The exception was the serum total bile acids. Residual changes found on liver biopsy at three months were minimal and nonspecific, apart from one previously severely affected patient in whom there was evidence of scarring. It is concluded that in the usual spectrum of acetaminophen poisoning requiring hospitalization there is no evidence of lasting liver damage.


Granulomas and cholestatic--hepatocellular injury associated with phenylbutazone. Report of two cases.

A combined cholestatic-hepatocellular injury and noncaseating granulomas occurred in two patients 1 and 4 weeks after phenylbutazone therapy. Both patients were jaundiced, one had a macular rash, and both had peripheral blood eosinophilia. Symptoms and signs subsided, and abnormal findings from tests of hepatic function rapidly returned to normal following withdrawal of the drug. Sections of liver biopsy specimens 6 months later showed no granulomas or other pathologic changes. Previously reported cases are reviewed.


Budd-chiari syndrome after taking oral contraceptives. A case report and review of 14 reported cases.

A case of Budd-Chiari syndrome in a young woman taking oral contraceptives is described. Her main complaints were abdominal pain and ascites without hepatosplenomegaly and the subsequent development of shock. Diagnosis was established by selective hepatic arteriogram and vena cavagram. She was treated with supportive measures, anticoagulants and neomycin. At the time of this report, the patient is slowly convalescing, taking coumadin, diuretics and Aldactone, as well as supplementary vitamins. Reviewed are 14 cases of Budd-Chiari syndrome occurring while patients were taking oral contraceptives.


Influence of carbon chain length of dietary fat on intestinal alkaline phosphatase in chylous ascites.

The long-term effects of chain length of dietary fat on intestinal lymphatic transport of alkaline phosphatase were investigated in two patients with chylous ascites due to leakage of intestinal lymph into the peritoneal cavity. Substitution of a medium-chain triglyceride diet for long-chain triglyceride resulted in a parallel fall in triglyceride and the intestinal isoenzyme of alkaline phosphatase in chylous ascites. The concentrations of lymph triglyceride were linearly related to lymph intestinal alkaline phosphatase levels, suggesting a positive relation between absorption of long-chain triglycerides and transport of mucosal alkaline phosphatase into lymph.


Ileal epithelial cell migration after 40% small-bowel resection. Autoradiographic studies in the rat.

Adaptation in the small bowel after resection is associated with increases in crypt cell proliferation and villus height. This paper gives the results of an autoradiographic investigation with [3H]thymidine of epithelial cell migration 60 days after 40% small-bowel resection in the rat. The mean number of cell positions between the crypt--villus junction and the leading labeled cell 30 hr after injection was increased by 19.4% in the resected group (P less than 0.02). The mean total number of cells per villus column was increased by 27.8% (P less than 0.002). Migration rate estimated in cell positions per hour was accelerated by 18.9% (P less than 0.001) after resection. The 8.1% lengthened life span of villus cells was not statistically significant. The increased number of cells per villus column and unaltered life span of villus cells would facilitate functional adaptation. The causal relationship between the larger villus cell population and accelerated migration after resection and increased crypt cell proliferation is unknown.


Pressure profile of esophageal peristalsis in normal humans as measured by direct intraesophageal transducers.

The pressure profile of esophageal peristalsis was studied in healthy young adult males using an intraesophageal transducer assembly. The amplitude of peristaltic contractions following wet swallows was determined at intervals along the esophagus from the lower esophageal sphincter (LES) to the upper esophageal sphincter (UES). The amplitude profile revealed a trough of significantly decreased (P less than 0.05) amplitude at 17.5-20.0 cm above the LES. The change in pressure per unit time (dp/dt) produced a profile also with a significant decrease (P less than 0.01) in the upper esophagus, having good correlation (r = 0.91, P less than 0.001) with the amplitude profile. Mean velocity of the peristaltic wave in the upper esophagus varied from 2.92 +/- 0.19 (+/- SEM) to 3.29 +/- 0.36 cm/sec. In the distal esophagus, mean velocity increased significantly (P less than 0.01) to 4.98 +/- 0.38 cm/sec at 7.5 cm above the LES, and then fell significantly (P less than 0.05) to 2.15 +/- 0.27 cm/sec at 2.5 cm above the LES. This report establishes amplitude and velocity profiles in the human esophagus. The profile of the first derivative of the primary peristaltic wave (dp/dt) is also described, and its possible importance discussed.


Detection of gallbladder disease in patients with normal oral cholecystograms. Results using a simplified biliary drainage technique.

An endoscopic biliary drainage technique was used in the study of 70 patients. All had histories suggestive of gallbladder disease but with normal oral cholecystograms. Of the 29 patients with abnormal drainage studies, 26 had cholecystectomy with all specimens showing cholecystitis, and cholelithiasis was seen in 46%. Five of the 41 patients with normal drainages underwent cholecystectomy, with no abnormality noted in any surgical specimen. Significant differences were seen when the mean WBC count, frequency of leukocytosis, and back pain were compared between the normal and abnormal drainage groups. Biliary drainage is a useful supplemental test when a false-negative oral cholecystogram is suspected.


Syphilitic proctitis.

Two adult male homosexuals with syphilitic proctitis and without any detectable anal lesions are reported. There was no history or evidence of an external primary chancre in either patient. Of note, one had extensive rectal involvement of the first 20 cm and the other had multiple sites involved. One patient developed severe rectal bleeding following biopsy and a Jarisch-Herxheimer reaction after the first penicillin injection. Salient features of the literature are reviewed and discussed.


Abnormal liver function in chronic hypervitaminosis A.

A case of chronic hypervitaminosis A is reported in a 57-year-old woman who took vitamin preparations for alopecia. Liver biopsy of the patient showed both an increase in the number and size of fat-storing cells on light microscopy and rapidly fading green autofluorescence of vitamin A. Electron microscopy confirmed the presence of engorged fat-storing cells in the space of Disse and minor toxic changes in hepatocytes. This case illustrates the early hepatic changes of chronic hypervitaminosis A and indicates a need for restriction of sales of vitamin preparations.


Phlegmonous gastritis diagnosed by endoscopic snare biopsy.

A case of phlegmonous gastritis, diagnosed for the first time without laparotomy and with spontaneous recovery, is described. The only procedure allowing nonsurgical diagnosis of this disease is endoscopic snare ("jumbo") biopsy of the giant folds in the diseased parts of the stomach. Snare biopsy includes submucosal tissue which is the main site of histological changes in phlegmonous gastritis.


Acute pancreatitis occurring in gastric aberrant pancreatic tissue.

The occurrence of acute pancreatitis in gastric aberrant pancreas is described. The patient presented initially with acute abdominal pain and a palpable epigastric mass. The symptoms were severe and recurrent, and laparotomy with antrectomy was required.


Mesenteric fibromatosis associated with familial polyposis.

This patient represents the 25th case report of mesenteric fibromatosis in patients with Gardner's syndrome. Her family genealogy reveals polyposis of the colon in nine members in four generations. In addition, one member has papillary carcinoma of the thyroid and one has newly discovered osteomas. To our knowledge, this family may be the first to manifest this combination of extracolonic lesions with familial polyposis, and the case supports a single-gene etiology for the complete syndrome.


The spectrum and causes of liver diseases in narcotic addicts.

Fifty charts of patients discharged with a diagnosis of liver disease from the acute care service of a hospital for the treatment of addiction were analyzed. Among 42 active heroin users or former heroin addicts maintained on methadone, 79% were heavy alcohol abusers. Seventeen cases of cirrhosis were encountered. All occurred in those abusing alcohol. Reversible liver disease was seen in both alcohol abusers and nonalcoholics. This study suggests that alcohol is a major factor in the development of irreversible liver disease in active heroin addicts and ex-addicts on methadone maintenance.


Abdominal tuberculosis. Experiences with 300 cases.

Problems in the management of abdominal tuberculosis are discussed with reference to 300 surgically verified cases. The protean clinical manifestations depend on the site and extent of the disease, and its complications. Operation was resorted to for complications when diagnosis was in doubt and when intrinsic intestinal disease was proved. Surgery was preceded by antituberculous drugs whenever possible. At operation, the disease was found to involve the alimentary canal in 196 cases; in the remaining 104, only the lymph nodes and/or the peritoneum were affected. Intestinal resection was carried out in 100 cases. Emergency surgery carries a high mortality (18/76) because of toxemia, hypoproteinemia, anemia, etc. Positive histology was obtained in 229 cases. One hundred and seventy-nine cases showed evidence of caseation. Caseation and peritoneal tubercles (103 cases) differentiate intestinal tuberculosis from Crohn's disease. Despite considerable progress made in therapy and prophylaxis during the last quarter of the century, tuberculosis of various sites continues to be a major health hazard in India. The precise prevalence of Koch's disease of the abdomen has not been determined due to lack of a survey in random samples of population. This common malady, however, with its protean profiles and varied complications continues to challenge the diagnostic acumen and therapeutic skill of clinicians practicing various discplines of medicine.


Augmented histamine test--diagnostic and prognostic values.

The results of the augmented histamine test in 107 controls, 48 patients with gastric ulcer and 141 patients with duodenal ulcer are presented. The mean basal acid secretion and maximal acid output (MAO) were significantly higher in duodenal ulcer patients than in normal subjects. Ulcers of the body of the stomach were associated with lower than normal levels of secretion, whereas ulcers of the prepyloric region were associated with higher than normal levels. In this study of 141 patients with duodenal ulcer, 101 patients or 72% had an MAO above the upper limit of normal (20.4 mEq./hr.). Conversely, a patient with an MAO of less than 12.4 mEq./hr. is unlikely to have duodenal ulcer disease. The use of the ratio of MAO to actual body weight did not increase the diagnostic discrimination between normal subjects and those with duodenal ulcer. Duodenal ulcer patients with complications had a significantly higher MAO to histamine than those without complication. The finding of an MAO greater than 40 mEq./hr. is highly suggestive of the presence or the imminence of a complication.


The pancreas and immunoglobulins. I. Immunoglobulin levels in pancreatic secretion of patients with normal function: preliminary studies.

Immunoglobulin levels of pancreatic juice following secretin administrations were determined in 35 normal patients. The variation of levels was high. The means and standard errors were as follows: Ig-A--7.2 +/- 7.0; Ig-M--1.5 +/- 0.97; Ig-g--21.44 +/- 16.10.


Differences in antral response to meat extract in duodenal ulcer patients.

Although acid secretion is important in the pathogenesis of duodenal ulcer formation, the antral phase of gastric secretion has not been adequately studied. In 60 duodenal ulcer and 12 normal patients, basal, antral and peak acid secretion was investigated. Antral function was assessed by instilling meat extract sodium and measuring acid and serum gastrin output. Two groups of patients were thus identified: 1. Antral responders in whom meat extract caused a significant increase in serum gastrin and acid output. 2. Antral nonresponders in whom meat extract did not significantly lead to an elevation in gastrin and acid output.


Esophageal perforation. An unusual presentation with a benign clinical course.

A case of esophageal perforation occurring in a 75-year-old man is presented. The clinical presentation was benign and the diagnosis of esophageal perforation was made incidental to an upper gastrointestinal barium examination. Conservative management consisting of nasogastric suctioning, antibiotics and antacids was effective in minimizing the clinical course. This represents a rare instance of a successful nonsurgical approach to esophageal perforation.


Multifocal malignant hemangioendothelioma presenting as acute hepatitis. A clinicopathologic study.

A patient with malignant hemangioendothelioma of the liver is described. The patient's clinical presentation and course were that of fulminant hepatic necrosis. Complications included upper gastrointestinal hemorrhage, hepatic encephalopathy, abnormal coagulation parameters and the hepatorenal syndrome. The duration of the illness from the onsetof symptoms to its fatal outcome was five weeks.


Indomethacin and canine lower esophageal sphincter pressure.

A total of 20 experiments were carried out on 10 dogs to investigate the effect of indomethacin, administered rectally, on the canine lower esophageal sphincter pressure (LESP). Indomethacin increases LESP. Its effect begins 60 minutes after rectal administration and lasts for about 120 minutes. It reaches its highest level 90 minutes after administration. Indomethacin has no effect on the canine fundal or esophageal pressure.


The radiology corner: Kaposi's sarcoma of the stomach.

Kaposi's sarcoma is a systemic, multicentric and slowly progressing vascular tumor which usually affects the skin. Visceral involvement is common, may follow or precede the cutaneous involvement and rarely, may be the only manifestation of the disease. Gastric sarcomatous lesions are characterized by the presence of multiple submucosal or intraluminal nodules affecting a part or the entire stomach and simulating large gastric rugae. A case of isolated gastric Kaposi's sarcoma affecting the greater curvature of the stomach is presented, illustrated and discussed together with a short review of the pertinent literature.


The Framingham Eye Study. I. Outline and major prevalence findings.

During the period 1973--1975, 2675 out of 3977 still-living members of the Framingham, Massachusetts, study population, who have been under investigation for coronary disease risk factors since 1948 and who were in 1973--1975 aged 52 to 85, were given an eye examination stressing cataract, diabetic retinopathy, macular degeneration and glaucoma. Of 2940 subjects who still lived in the local Framingham area, 2477 were examined. Local population prevalence for one or both eyes positive was: 15.5% for senile cataract, 3.1% for diabetic retinopathy, 8.8% for senile macular degeneration and 3.3% for open-angle glaucoma. The proportion of adults with poor "best" visual acuity may be much less than has been estimated by the National Health Survey and the proportion with open-angle glaucoma much more than currently suspected on the basis of foreign studies.


An estimate of the prevalence of epilepsy in a rural Appalachian population.

A descriptive study has documented what is felt to be a precise estimate of the prevalence of epilepsy in 1973 in the school-age population of Clay County, Kentucky, a rural Appalachian county. A 96% response rate was achieved from the target population of 5467. By utilizing an accepted definition of epilepsy, an experienced child neurologist and a carefully monitored survey method which required the cooperative efforts of school personnel, local public health nurses and community leaders, a prevalence significantly greater than that previously reported from other areas of this country was observed (p less than .05). The true prevalence of seizures in Clay County, Kentucky, children 6--16 years of age in 1973 is believed to have been between the observed rate of 27 cases per 1000 and the estimated rate of 35 cases per 1000. The prevalence rate of febrile seizures is believed to have been underestimated in the Clay County data. For comparative purposes, the authors are currently applying the same methodology to a non-Appalachian area.


Dual infection by "+" and "-" mating types of Ajellomyces (Blastomyces) dermatitidis.

A culture of Blastomyces dermatitidis isolated via bronchial washing from a patient with blastomycosis was studied intensively. The primary isolate was shown to have contained both the "+" and "-" mating type determiners of Ajellomyces dermatitidis. This was evidenced by the observations that both a first and a second subculture, when paired with itself produced fertile ascocarps typical of A. dermatitidis. Both these subcultures determined the production of ascospores when paired individually with each of six testers, these testers not producing fertile fruiting bodies when selfed. Isolation by micromanipulation of "+" and "-" ascospores from ascocarps produced by selfing a subculture established the mixed ("+", "-") nature of the clinical isolate and of the infection. The mixed infection was considered to have resulted from inhalation of both the "+" and "-" ascospores or conidia of A. dermatitidis or from the inhalation of one spore that contained both the "+" and "-" mating type determiners.


Protective effect of immune serum globulin (ISG) against hepatitis A infection in a natural epidemic.

Serologic evidence now confirms epidemiologic evidence that human immune serum globulin (ISG) protects susceptible patients from hepatitis A provided it is administered prior to exposure to the virus. In two wards of young patients housed at the Lynchburg (Virginia) Training School and Hospital for the mentally retarded, 44 out of 60 patients had no detectable antibody to hepatitis A prior to an epidemic which took place there in 1970; 12 of 19 non-immunized susceptible patients contracted the disease, while only four of 25 patients receiving ISG developed hepatitis. These four were probably infected with the virus prior to ISG administration. Of the 16 patients with pre-existing antibody, none showed any signs of symptoms of hepatitis.


Seroepidemiology of hepatitis B virus in Israel. Results of a pilot study in Jerusalem.

One thousand thirty-three native and immigrant Israelis, divided into 10-year age groups, were tested for the hepatitis B surface antigen (HBSAg) and antibody (anti-HBS). The prevalence of anti-HBS was 10.1%, increasing with age from the first (6.3%) through the fifth decade (16.2%) and declining slightly in the sixth and seventh decades. The age-adjusted prevalence of anti-HBS was higher for native Arabs (20.8%) compared with native Jews (4.8%), and for immigrants from North Africa (33.3%), compared with immigrants from the Middle and Near East (20.1%) and Western ("Ashkenazi") countries (8.5%). Acquisition of anti-HBS was not correlated with a past history of jaundice or of blood transfusion. Of the positive sera reactive for anti-HBS that were subtypable, 74% were anti-y and 26%, anti-d specific. The prevalence of HBSAg for the study population was 1.8%, resulting in a prevalence of hepatitis B virus (HBV) infection, past and present, of 11.9%. These findings indicate that, while HBV infection is prevalent in Jerusalem, the most common presentation is a non-icteric illness with an age distribution extending through early adulthood and not coinciding with the early childhood clustering characteristic of icteric hepatitis in the region. The serologic findings are consistent with other clinical and epidemiologic evidence that endemic hepatitis in Jerusalem is predominantly the result of infection by "non-B" viruses.


Consanguinity analysis in heterogeneous populations.

Consanguinity analysis can be performed in populations comprising collections of genetic isolates, and the resulting estimates can be valid and useful in phenotypes caused by numerous recessive genes, such as mental retardation and congenital nerve deafness. Maximum likelihood methods are presented for estimating gene frequency and proportions of homozygous cases of morbid phenotypes in such populations.


Consanguinity analysis in Israeli mental retardates.

Consanguinity rates were analyzed in 904 families of retardates studied in 11 Israeli Jewish ethnic groups. It was estimated that the representative recessive gene frequency is .00518, implying that a gene equilibrium maintained by mutation alone is improbable and that some other hypothesis should be considered. The proportions of homozygotes among the following idiopathic subgroups are estimated as follows: 18%-19% homozygotes among severe idiopathic retardates with nonconsanguineous parents and no affected siblings; 74%-76% homozygotes among severe idiopathic retardates with first-cousin parents and no affected siblings; 5% homozygotes among mild idiopathic and idiopathic-familial retardates with nonconsanguineous parents; and 41% homozygotes among mild idiopathic and idiopathic-familial retardates with first-cousin parents. The estimated number of major gene loci within ethnic groups is 17-21 for severe idiopathic retardation and 43-61 for mild idiopathic retardation. These findings provide a basis for genetic counseling of families with single retardates of unknown cause. They can also be useful in epidemiologic studies of nongenetic factors. The great prevalence of common gene defects causing retardation, coupled with the rarity of disorders of amino acid metabolism in the same series, seem to indicate that further emphasis on amino acid metabolism may be nonproductive in the scientific study of retardation and that other biochemical approaches should be encouraged.


Human hyperargininemia: a mutation not expressed in skin fibroblasts?

Arginase specific activity in the fibroblasts from three hyperargininemia patients is similar to that in controls. Kinetic features, pH-optimum, effect of Mn++, apparent Km values and DEAE- and CM-cellulose chromatography isozymes are identical in either cell type. The arginase gene functional in fibroblasts may be unrelated to the cause of hyperargininemia in humans. The latter mutation may solely affect the arginase of erythrocytes.


Partial trisomy 1 due to a "shift" and probable location of the Duffy (Fy) locus.

Transposition of 1q31-1q32 from the q to p arm in a parent followed by crossing over resulted in a child with a duplication of this region. Concomitant C- and GTG-banding and genotyping were used to position the single crossover and to localize Fy to 1q2.


Probable genetic linkage between autosomal dominant retinitis pigmentosa (RP) and amylase (AMY2): evidence of an RP locus on chromosome 1.

A linkage analysis is reported for three branches of a single family segregating for autosomal dominant retinitis pigmentosa. A statistically significant lod score of 3.9 is obtained for the RP locus and AMY2 at a recombination frequency of 1%. This linkage indicates that the RP locus is on the no. 1 chromosome since the AMY2 locus has been placed on the short arm of 1. Lod scores are reported for four other loci on chromosome 1; none of these achieve statistical significance. Analyses are reported for 23 additional autosomal markers and close linkage with RP can be excluded for a number of these.


Health care and hospital pharmacy in Denmark.

Health services and community and hospital pharmacy practice in Denmark are discussed. Topics covered include the education and training of pharmacists and technicians, pharmaceutical manufacturing by community and hospital pharmacies, hospital drug distribution, and drug information services. Pharmacy is unique in Denmark inthe 40% of the drug products on the market are manufactured by pharmacies, under the auspicies of the pharmacy proprietors' association. As in other Scandinavian countries, the number and location of community pharmacies are controlled by the state. Ninety pharmacists are employed in 13 hospital pharmacies; half of the pharmacists are occupied bb drug product manufacturing.


Health care and hospital pharmacy in Finland.

Health care services and community and hospital pharmacy practice in Finland are discussed. Specific topics covered include the education of pharmacists, national health insurance, health care services, community pharmacy practice and hospital pharmacy practice. The drug supply in Finnish hospitals is organized in one of three ways. Hospital pharmacies have a chief pharmacist who has a "proviisori" degree (comparable to M.S.). Central medicine supplies in hospitals without hospital pharmacies are under the supervision of the chief physician; the caretaker in larger hospitals is usually a pharmacist with a "farmaseutti" degree (comparable to a B.S.), and in smaller hospitals it is a nurse. In very small hospitals or nursing homes the medicines are kept in one place and cared for by a nurse.


Pharmacist impact on drug use in an institution for the mentally retarded.

Pharmacist involvement on a team developed to monitor drug use in an institution for the mentally retarded is described, and the results of the team's efforts are reported. The behavioral review committee consisted of a physician, pharmacist(s), nurses, psychologists, sociologists and therapists. The pharmacists reviewed the patients' charts and pharmacy records to compile a complete drug history on a special "drug calender" form. The pharmacist visited the patient to determine current problems, the effectiveness of therapy and the presence of adverse drug reactions. Recommendations were than made to the committee. During the two-year study period, the use of antipsychotic drugs was reduced 18%; antianxiety-antidepressant drugs, 50%; sedative-hypnotics, 58%; and miscellaneous agents, 65%. The net savings in drug expenditures was more than $10,000 per year, Maladaptive behaviorial test results implied that the decreased drug use did not change behavior significantly. The study shows that the pharmacist, through a team approach, can help reduce the overuse of medications in institutions for the mentally retarded.


Neonatal medication surveillance by the pharmacist.

Data on prenatal, labor and delivery, and postnatal medication exposure to neonates were collected. During an 11-week period, 100 neonates consecutively admitted to a hospital were studied. The pharmacist obtained a social and medication history from the mothers and reviewed maternal anesthesia records and the charts of the neonates. Fifteen definite and possible adverse medication reactions were detected in 13 neonates. The median number of different medications ingested prenatally was 4.7. The four most commonly ingested prenatal medications were vitamins (97%), iron preparations (90%), headache/pain/arthritis medications (68%) and antinausea/vomiting medications (40%). The most commonly used medications during labor and delivery were oxytocin (73%), meperidine (33%) and promazine (25%). The use of strong narcotics during this period produced neonatal respiratory depression in some cases. The four most commonly prescribed postnatal medications were vitamin K1 (100%), gentamicin (10%), ampicillin (8%) and Poly-Vi-Sol (6%). The maternal interview indicated that most mothers were unaware of the influence that many medications can play upon the fetus. It is recommended that the pharmacist conduct a maternal medication interview prior to labor and delivery.


Hemorrhagic shock.

The treatment of hemorrhagic shock is discussed, based on principles illustrated in a hypothetical case. The pathophysiology and clinical monitoring of hypovolemic shock are reviewed. A practical approach to volume replacement therapy in hemorrhagic shock is suggested.


Blood and blood substitutes for treating hemorragic shock.

Blood substitute products for the treatment of hemorrhagic shock are discussed with regard to their composition, physical and therapeutic characteristics, adverse effects, cost, and market availability. Commercially available plasma expanders discussed include blood derivatives (whole blood, packed red blood cells, plasma, normal human serum albumin, and plasma protein fraction), synthetic colloids (dextrans 40 and 70) and a balanced salt solution (lactated Ringer's injection). Plasma substitutes alone are administered until the hematocrit falls below 30% of coagulation difficulties develop. Normal serum albumin 5% and plasma protein fraction 5% are excellent colloidal plasma expanders without the potential hazard of hepatitis. Lactated Ringer's injection is the fluid of choice to replace lost blood up to 10% of the vascular volume.


Potassium hydroxide solution 10% for the fast hydrolysis of esters for analysis.

The applicability of a five-minute hydrolysis method with 10% potassium hydroxide in an alcohol-water (80-20) mixture was investigated for the quantitative determination of certain esters (aspirin, benzocaine, benzyl benzoate, methyl paraben, phenyl salicylate, procaine hydrochloride, propyl paraben, salicylanilide and 0-salicylsalicylic acid) and salicylamide. The results indicate that the method is satisfactory for all but methyl paraben and propyl paraben.


Pituitary apoplexy. Association of degenerative change in pituitary ademona with radiotherapy and detection by cerebral computed tomography.

In 14 of 300 patients with pituitary adenoma, apoplexy developed with pathologic evidence of hemorrhagic necrosis and cystic change in the tumor. In five patients, apoplexy was the initial manifestation; in eight patients, it was associated with radiotherapy. In 12 other patients with pituitary tumors, sudden clinical deterioration occurred; they had predominantly cystic tumors with minor foci of hemorrhagic necrosis. In five patients, this was associated with radiotherapy. Degenerative hemorrhagic, necrotic and cystic changes occur frequently in pituitary tumors and radiation may be potentially dangerous in these cases. To avoid precipitating episodes of sudded visual and neurologic deterioration, prior aspiration and biopsy may be performed through transphenoidal approach in those with intrasellar tumors, whereas in those with extrasellar tumors, cerebral computed tomographic scan may define pathologic features of the pituitary adenoma.


Crystal deposition disease. Diagnosis by electron microscopy.

The diagnosis of gout and pseudogout has traditionally been established by the identification, in synovial fluid, of monosodium urate and calcium pyrophosphate dihydrate crystals with compensated polarizing light microscopy. In this paper the utility of electron microscopy in establishing these diagnosis in two cases, when the conventional means of synovial fluid analysis had failed to do so, is discussed. The application of ultrastructural analysis of synovial fluid increases diagnostic capability in the crystal deposition diseases, and it is recommended for those patients in whom the more usual studies have not established a diagnosis.


Echocardiography in experimentally-induced myocardial ischemia.

Using an experimental canine model, we have employed echocardiography to study segmental dyskinesis produced by acute coronary occlusion. Characteristic alterations in posterior wall and septal motion occur after acute coronary ligation; these resemble clinical abnormalities described in acute and old myocardial infarction. The degree of dyskinesis produced is directly related to the severity of the perfusion deficit. Coronary reperfusion had variable effects on dyskinesis; most animals showed improvement but in some the myocardial contraction abnormalities became more severe. A vaviety of interventions were undertaken during ischemia. The elevated level of arterial pressure induced by the administration of methoxamine increased ventricular diameter and presumably oxygen requirements, and was deleterious to ischemic wall motion whereas the administration of norpinephrine reduced ventricular diameter and improved function. Intra-aortic balloon counterpulsation had little effect on either ischemic motion or perfusion. These experimental studies generally support conclusions drawn from clinical echocardiograms about the relationship of abnormalities of wall motion to coronary artery lesions and myocardial ischemia, and suggest further clinical uses for echocardiography in coronary disease.


Dynamic cardiac imaging using a focused, phased-array ultrasound system.

A two-dimensional ultrasound imaging system capable of producing high resolution, cross-sectional images of the heart in real-time has been developed. This system relies upon phased-array principles to rapidly steer and focus the ultrasound beam through the cardiac structures under investigation. A hand-held, linear array of 24 transducers is manipulated on the anterior chest wall to image various cardiac structures. Images of high line density are presented in selectable sector arcs to a maximum of 90 degrees. This imaging system has proved particularly useful for the detection of a variety of left ventricular and cardiac valvular disease.


Pulsed Doppler echocardiography: principles and applications.

A new recording and display system is described for use with pulsed Doppler blood flow velocity detectors in the diagnosis of valvular and septal defects. The principles of the pulsed Doppler device are described along with the methods used to analyze and display the Doppler shifted signal from flow jets resulting from various valve defects. An M-mode display is combined with blood flow display to provide a convenient record of the clinical procedure. Examples of aortic stenosis, aortic insufficiency, mitral stenosis and regurgitation are presented along with signals from other valves.


Medical laboratory personnel: clinical education and employment in Connecticut.

This paper presents the results of a survey of CLA, MLT, and MT graduates of clinical programs in Connecticut. It reports on characteristics such as educational background and employment history. Differences among the three professional categories are examined with respect to method of locating first job, setting, activities and tasks, job titles, and applicability of education to employment.


Urinalysis by modular learning.

A self-instructional approach to the entry-level presentation of urinalysis in a written modular format was used by a class of medical laboratory technician students. The course consisted of 13 modules based upon behavioral objectives. The modules used no audio or visual media but required "hands-on" performance of laboratory procedures. The achievements of a test sample of 12 students were compared with those of a previous class in which the same material was presented in lectures. Evaluation by written tests given to both classes showed no statistical difference. The self-instructed students performed adequately in their practical laboratory work, but the overall learning time was increased by 50 percent when self-pacing was used. A measurement questionnaire revealed that the students preferred instructor-led courses to self-instructional units for a variety of reasons which lead to some further considerations.


The effect of human chorionic gonadotropin and estradiol-17beta on the maintenance of the human corpus luteum of early pregnancy.

The effect of exogenous human chorionic gonadotropin (HCG) and estradiol valerate (EV) on the maintenance of the corpus luteum of early pregnancy, assessed by serial estimations of serum progesterone and 17alpha-hydroxyprogesterone (17-OHP), was studied in 35 subjects following therapeutic termination of pregnancy by suction curettage before the tenth week of gestation. Continuous intravenous infusion of 50,000 International Units (I.U.) of HCG for 24 hours following termination of pregnancy delayed the decline of serum HCG levels, and 17-OHP levels were maintained at preoperative levels for the 24 hours of the infusion. Single intramuscular injections of 5,000 or 20,000 I.U. of HCG were ineffective. Administration of 25 mg. of EV intramuscularly immediately following therapeutic termination of pregnancy slightly retarded the decline of serum 17-OHP levels. The same treatment when administered in combination with the intravenous infusion of 50,000 I.U. of HCG completely prevented the ability of HCG to maintain serum levels of 17-OHP. These finding susggest an antagonism between estradiol and HCG in maintenance of the human corpus luteum during early pregnancy.


Hematologic problems in pregnancy V. Obstetric transfusion therapy.

A study of 37,186 admissions, from 1970 through 1974, to a large southern charity hospital obstetrics service revealed a striking 63 per cent reduction in number of patients receiving blood transfusions. Analysis showed no change in patient population, bleeding disorders, toxemia, incidence of obstetric hemorrhage, serious febrile morbidity, or incidence of antepartum anemia. In the study period cesarean section rate increased 77 per cent and anemia at delivery markedly decreased. Transfusions associated with spontaneous abortion decreased by 70 per cent, and after the third study year no patient undergoing legal abortion received blood. The study demonstrated improvement in specific hematinic therapy of antepartum anemia and avoidance of transfusion therapy in the presence of uncharacterized antepartum or puerperal anemia. Despite the remarkable decrease in blood transfusions, obstetric outcome (including perinatal mortality rate, maternal mortality rate, and serious febrile morbidity) did not suffer but, indeed, improved.


Antenatal exposure to doxylamine succinate and dicyclomine hydrochloride (Benedectin) in relation to congenital malformations, perinatal mortality rate, birth weight, and intelligence quotient score.

In a prospective cohort study of 20, 282 gravidas and their offspring, congenital malformation rates were similar in the children of over 1,000 women exposed and those not exposed to two components of Bendectin (doxylamine succinate and dicyclomine hydrochloride) during the first four lunar months of pregnancy. In a cohort reduced to 41,337 mother-child pairs for technical reasons, mean birth weight and perinatal mortality rates were similar according to exposure or nonexposure to either drug, as were intelligence quotient scores measured at four years of age in 28,358 of the children. Control of potential confounding factors with a variety of multivariate techniques did not materially alter these findings.


Antenatal exposure to the phenothiazines in relation to congenital malformations, perinatal mortality rate, birth weight, and intelligence quotient score.

In a prospective cohort study of 50,282 gravidas and their offspring, over-all rates of congenital malformations were similar in 1,309 children of women exposed to phenothiazine drugs during the first four lunar months of pregnancy and in 48,973 children of women who were not exposed. There was a suspicion of association between phenothiazine exposure and cardiovascular malformations. In a cohort reduced to 41,337 mother-child pairs for technical reasons, perinatal mortality rates and mean birth weight were similar according to phenothiazine exposure or nonexposure, as were intelligence quotient scores measured at four years of age in 28,358 of the children. Control of potential confounding factors with a variety of multivariate techniques did not materially alter the findings.


Immunogestosis: a new etiologic concept of "essential" EPH gestosis, with special consideration of the primigravid patient; preliminary report of a clinical study.

Evidence for immunologic processes taking part in the pathogenesis of what until now has been called the "essential" form of EPH gestosis is cited. The name of immunogestosis (IG) is introduced. The data of this preliminary study suggest that regular "inoculation" of the female genital tract with allogeneic spermatozoal histocompatibility antigens reduces the incidence of IG. Information about preconceptional sexual habits and contraceptive measures was obtained from 83 selected primigravid patients. Twenty-eight women had mild to moderate IG (Group B);55 did not (Group A). Women in Group B had had less contact with spermatozoa of partners than did women in Group A. Oral contraceptive consumption was less in Group B than in Group A. Women in Group B were younger than women in Group A. All these differences were statistically significant. A new immunoetiologic hypothesis referring to IG, as well as the theoretic and clinical implications arising from it, are discussed. This hypothesis is based on the assumption that spermatozoal histocompatibility antigens can either induce immunologic tolerance or be responsible for the phenomenon of immunologic enhancement in the maternal immunosystem. As the fetus inherits paternal histocompatibility antigens, it is concluded that pre-existing tolerance (or enhancement) exerts an IG-preventive function in a subsequent pregnancy.


Vaginal prostaglandin E2 for missed abortion and intrauterine fetal death.

Vaginal suppositories containing 20 mg. of prostaglandin E2 (PGE2) were given to 50 patients with a diagnosis of either missed abortion or fetal death. A total of 94 percent of the patients (47/50) expelled products of conception, and 84 percent of these expulsions (42/50) were complete. The mean time to expulsion of the fetus was 11.3 hours with a mean dose of 3.6 suppositiries. A total 60 per cent of the patients experienced vomiting, diarrhea, and pyrexia. Four patients had a blood loss in excess of 500 ml., and two of these patients required blood transfusion. Vaginal administration of PGE2 suppositories appeared to be a rapid, safe, and reliable means of managing missed abortion and intrauterine fetal death.


Clinical experience in nonstressed antepartum cardiotocography.

The condition of the fetus during pregnancy was assessed by 1,763 antepartum cardiotocograms made in 386 patients with the use of fetal movements and physiologic uterine contractions. There appeared to be a significant correlation between the cardiotocograms and the obstetric outcome.


Amniotic fluid testosterone and follicle-stimulating hormone in the determination of fetal sex.

To determine whether hormone analysis could be used for accurate determination of fetal sex, we measured testosterone (T) and follicle-stimulating hormone (FSH) in 130 amniotic fluid samples at midgestation. The mean unconjugated T in amniotic fluid of 73 patients carrying male fetuses was 202 pg. per milliliter (95 per cent confidence limits [CL]: 70 to 580) and all but three had levels higher than 90 pg. per milliliter. The mean amniotic fluid unconjugated T for 49 patients carrying female fetuses of 41 pg. per milliliter (95 per cent CL: 11 TO 125) was fivefold lower than that for the male fetuses and all but three patients carrying female fetuses had amniotic fluid T levels of 90 pg. per milliliter or lower. The mean amniotic fluid FSH of 0.7 ml. U. per milliliter (95 per cent CL: less than 0.5 to 3.4) for subjects with male fetuses was tenfold lower than that for patients with female fetuses. Amniotic fluid FSH levels less than 2.0 ml. U. per milliliter were found in 88 per cent of patients carrying male fetuses and in only one patient with a female fetus, and levels greater than 10 ml. U. per milliliter were found in those with female fetuses only. In eight patients (7 per cent of cases), neither amniotic fluid T nor FSH determinations were indicative of fetal sex. Measurement of unconjugated T and FSH in amniotic fluid may be an adjunct to other methods of determining fetal sex.


An analysis of air transport results in the sick newborn II. Antenatal and neonatal referrals.

The neonatal intensive-care unit at Fitzsimons Army Medical Center admits approximately 350 infants each year. At least half of these infants are referred, and, since 1973, there has been a steady increase in antenatal referrals. In 1975, in utero referrals exceeded neonatal referrals. The entire perinatal population of two referring hospitals was retrospectively evaluated in order to compare neonatal and in utero transfers. The neonatal transfers had higher-than-predicted mortality rate, while the in utero referrals had not only lower-than-predicted mortality rate, but the survivors had a shorter hospital stay. The combined neonatal/perinatal regionalization program resulted in a perinatal mortality rate of eight and 7.6 per 1,000 births in the two hospitals during the study period.


Quantification of fetal heart rate variability by magnetocardiography and direct electrocardiography.

A computer method for quantification of fetal heart rate (FHR) variability from fetal magnetocardiography during pregnancy and from direct fetal electrocardiography during labor is presented. It is based on statistical analysis of the QRS interval sequences. Beat-to-beat variation is characterized by a differential index (DI) and long-term variation by an interval index (II). The effect of the sample time on the DI is minimal, and hence the DI can be calculated from rather short samples. The II is more sensitive to FHR trends and should be calculated from longer samples, but between the periodic changes, accelerations, and decelerations. Variable amounts of detection pulses are lost in both methods. The DI is sensitive to the missing intervals; no analysis result should be accepted if the number of lost intervals exceeds 10 per cent. The II is less sensitive to the number of missing intervals. The means and standard deviations of the variability indices for eight fetuses during pregnancy and for five fetuses during labor are presented.


Clear cell carcinoma of cervix and vagina in progeny of women who received diethylstilbestrol: three cases with scanning and transmission electron microscopy.

Three cases of clear cell carcinoma of the cervix and vagina in progeny of women administered diethylstilbestrol (DES) were studied ultrastructurally. The patients were young and had a positive history of maternal ingestion of DES during pregnancy. Similar ultrastructural features were observed in all cases. The neoplastic cells were arranged in solid nests or glands. Ultrastructural findings in these cases were similar to those of previously reported clear cell carcinomas of the ovary and endometrium, which seems to indicate a common Müllerian origin11, 16 as opposed to a mesonephric origin. 10 A transition between vaginal adenosis and the neoplasm was not observed.


Pelvic pain in women.

The clinical and psychological characteristics of 18 women with pelvic pain but no demonstrable pathology have been compared with those of 17 women with a similar complaint but some form of pelvic pathology and a control group of 9 women with no gynecologic problems. The results suggest that pelvic pain can have a psychosomatic origin which is amenable to short-term psychotherapeutic measures.


Cyclic changes in salivary activity of N-acetyl-beta-d-glucosaminidase; a possible efficient indicator for predicting ovulation and pregnancy.

Salivary activity of N-acetyl-beta-D-glucosaminidase showed a characteristic pattern of changes during the normal menstrual cycle with a distinct peak on Day 13, 14, or 15 before the next menstruation. This peak of enzyme activity occurred withing one day of the nadir of basal body temperature and was absent in women with spontaneous or iatrogenic anovulatory cycles. These results are stongly suggestive that the salivary determination of this activity may be convenient indicatior for determining the day of ovulation.


Hormones in amniotic fluid.

With increasing use of amniocentesis for high-risk pregnancies, measurement of amniotic fluid hormone levels could prove to be a pratical value. Protein steroid hormones as well as prostaglandins in amniotic fluid are reviewed. The source and entry of each hormone, their concentrations, and their possible physiologic role in pregnancy are discussed. Changes in the level of hormones in amniotic fluid or pregnancies with complications jeopardizing fetal well-being are referred to, and their significance is discussed. Since amniotic fluid is close to the myometrium, changes in some amniotic fluid hormones might be responsible for or associated with the onset of labor.


Surface tension of amniotic fluid lipid extracts: prediction of pulmonary maturity.

The surface tension (ST)-lowering properties of an amniotic fluid lipid extract can provide a rapid and reliable means of predicting pulmonary maturity. One hundred and eleven samples from 91 patients were analyzed. A surface tension of less than 56 dynes per centimeter at 120 microliter of extract and less than 46 dynes per centimeter at 220 microliter of extract denoted pulmonary maturity. Values greater than these indicated immaturity. Among fluid samples studied within 48 hours of delivery for the presence or absence of respiratory distress syndrome (RDS) in 71 patients, there were no false positive ST values, while 7 of 22 patients with immature values developed RDS. Surface tension correlates well with the lecithin/sphingomyelin (L/S) ratio but provides clearer definition than the L/S ratio when compared to outcome. Blood and meconium contamination make the surface tension of fluid from babies with pulmonary immaturity appear mature. Identical twins with dissimilar ST values and outcome, as well as serial samples from individual patients, are analyzed and discussed.


The prediction of fetal oxygenation by an on-line computer analysis of fetal monitor output.

The deceleration delay index (DDI) is a statistical parameter computed by an on-line system which analyzes fetal monitor output for the temporal relationship between each uterine contraction and any associated deceleration of the fetal heart rate. A similar parameter describing this relationship is known to be quantitatively predictive of fetal oxygenation in the rhesus monkey, a species for which the level of fetal oxygenation is also known to be directly and progressively related to aberrations in the vital signs, to brain damage, and to fetal death. Thus, the DDI should be of significant, practical value in predicting fetal hypoxia at a time early enough to avert severe neonatal depression and/or hypoxic brain damage. A blind clinical trial of 106 parturients is presented which supports this concept by showing the DDI to be highly correlated with another oxygenation-associated parameter, the one-minute Apgar score.


A modern approach to management of pregnant diabetics: a two-year analysis of perinatal outcomes.

Increased understanding of maternal-fetal carbohydrate homeostasis together with modern perinatal technology now provides a more rational basis for obstetric management of the pregnant diabetic patient. These concepts were applied at MacDonald House in the care of 96 diabetic pregnant women over a two-year period. Pregnancy outcomes were compared with prior experiences with the same group of women. The perinatal mortality rate was reduced from 13.5 to 4.2%, and the rate of macrosomia (infants large for gestational age) was reduced from 30.9 to 17.7%. Patients with gestational diabetes, with a prior loss rate of 8.3%, suffered no losses in the current series. Maternal age was not found to correlate with an untoward outcome in this subgroup.


The future function and fortune of ovarian tissue which is retained in vivo during hysterectomy.

Hysterectomy was performed for 2,132 private patients; one third were done vaginally and two thirds, abdominally. Ages ranged from the 20's through the 80's, but 55% were between 40 and 55 years of age. Ovarian function was retained at the time of hysterectomy in 1,263 patients; ovarian tissue was retained in 1,557. Based on clinical criteria, 525 patients had continued ovarian function until last examined (one to 23 years); 328 had continued ovarian function until the end of the study (one to 25 years); 410 patients had cessation of ovarian function during the study at ages ranging from 41 to 64 years. Fourteen patients required second operations: three for hemorrhagic physiologic cysts, two for adhesions, one for ovarian endometriosis, four for cystadenomas, and four for ovarian cancer. Two cancer patients died; two are alive and well, five and 15 years after the second operations.


Clinical application of high-risk scoring on an obstetric service.

Obstetric risk scoring is a formalized way of recognizing, documenting, and cumulating antepartum and intrapartum factors to predict later complications for mother, fetus, and infant. If simple, practical, and reliable, risk scoring can be clinically useful in determining appropriate levels of care. In this prospective study, antepartum and intrapartum risk scales were integrated into the clinical record, and the relationship of risk scores to outcome was evaluated for 1,275 consecutively delivered gravid women. The forms could be simply and quickly filled out by the staff. Increased risk on both scales was significantly related to lowered one- and five-minute Apgar scores. The perinatal mortality rate increased from 0 to 93.4 per thousand from the lowest to the highest risk group. More than 80% of all perinatal deaths occurred in the one quarter of patients in the highest risk group. These results suggest that this risk scoring system can be used effectively in a clinical setting to identify patients at increased risk for neonatal depression and perinatal death.


Uterotubal implantation and obstetric outcome after previous sterilization.

The liberalization of sterilization policies has resulted in an increased number of patients requesting tubal reconstructive surgery. From 1973 through 1975, a total of 18 patients were operated upon by the authors for tubal reconstructive surgery following sterilization. These patients had had either postpartum sterilization of the Pomeroy technique or interval laparoscopic cauterization and cutting. The operative technique with an open uterine approach is described in detail. This technique warrants further evaluation, particularly following laparoscopic sterilization when end-to-end anastomosis is precluded.


Fetal growth retardation associated with maternal administration of immunosuppressive drugs.

Since maternal-fetal immunogenetic disparity facilitates growth of the fetoplacental unit, nonspecific depression of the maternal immune system by immunosuppressive drugs could result in previously unrecognized adverse effects such as fetal growth retardation. To test this hypothesis, groups of 6 to 8 primigravid Fischer female rats mated with DA or Fischer male rats were treated with saline (controls) or either cyclophosphamide (Cytoxan) or azathioprine (Imuran) in doses similar to those used therapeutically in human subjects. It was found that these drugs caused an increased incidence of fetal death and produced fetal and neonatal growth retardation. Smaller placentas and fetuses reflected a decrease in cell number rather than cell size whereas water, fat, and protein content were only minimally affected. Analyses of mean maternal weight gain, spleen weight assays, and changes in the lymph nodes draining the uterus indicate that effects detrimental to the offspring are primarily the result of immunologic and cytotoxic mechanisms. Moreover, a review of the literature suggests that these immunosuppressive agents are also associated with small-for-gestational age infants in human pregnancies.


Perinatal mortality rate at a community hospital, 1956 to 1975.

This paper is a review of the perinatal mortality rate and its components stillbirths and neonatal deaths, for the years 1956 through 1975 at Memorial General Hospital, Las Cruces, New Mexico. It is an attempt to assess major medical factors, such as specialization and cesarean section, and weigh their effect on these indices of the quality of perinatal medical care. Other factors considered in the analysis were: ages of mothers, parity, birth weights, and socioeconomic, educational, and motivational factors. The apparent impact of direct medical care factors is considerably less than would be expected.


Incidence and spontaneous resolution of postpartum bacteriuria.

On the first postpartum day, 53 patients (17.2 per cent) had asymptomatic bacteriuria. Spontaneous resolution of bacteriuria occurred in 40 (75.5 per cent) of the 53 patients by the third postpartum day--the most appropriate time to identify patients with true asymptomatic bacteriuria.


Comparative study of amniotic fluid and maternal blood serum human placental lactogen in normal and prolonged pregnancies.

The levels of human placental lactogen (hPL) were measured in maternal blood and amniotic fluid in normal and prolonged pregnancies. Statistical analysis of the hPL levels showed that values rose in both blood and amniotic fluid, reaching maximum levels between Weeks 34 and 36 (6.70 microgram per milliliter in blood serum, 0.85 microgram per milliliter in amniotic fluid). Thereafter, there was a decline, a significant fall occuring between Weeks 40 and 42 and in the prolonged pregnancy group (43 weeks and more) (t = 6.9 and p less than 0.001 in serum levels; t = 3.9 and p less than 0.001 in amniotic fluid levels). There was also a very close correlation (r = 021; p less than 0.005) between maternal blood and amniotic fluid hPL levels in normal pregnancies before labor.


Interrelationship between glomerular filtration rate and renal transport of sodium and chloride during fetal life.

The maturation of the glomerular filtration rate (GFR) and the interrelationship between the GFR and the renal transport of sodium and chloride have been evaluated during the last trimester of gestation with the use of long-term experiments in fetal lambs. An increase in GFR (milliliters per minute) parallel to the increase in fetal body weight was demonstrated; however, no significant change was shown when the GFR (milliliters per minute per kilogram of fetal body weight) (1.141 +/- 0.079) was related to fetal body weight or gestational age. There was a constant increase in sodium and chloride reabsorption (microequivalents per minute) during the last third of gestation. This increase in sodium and chloride reabsorption was less than the increase in GFR (milliliters per minute) before 129 days but became higher than the rise of GFR (milliliters per minute) after 129 days of gestation.


Abruptio placentae and perinatal death: a prospective study.

Abruptio placentae caused 3.96 perinatal deaths per 1,000 births in a large prospective study. Intrapartum but not prepartum maternal hypertension was observed in the fatal cases. Decidual necrosis at the placental margin and large placental infarcts were the most characteristic placental abnormalities. The decidual necrosis was correlated with maternal cigarette smoking and low pregnancy weight gains in the abruption placentae cases. The fetuses and neonates who died had a pattern of growth retardation  characteristic of antenatal undernutrition, indicating that poor maternal nutrition during pregnancy may have contributed to the genesis of the abruptio placentae.


Oral contraceptives and cervical carcinoma.

In a case-control study, 689 consecutive patients with cervical carcinoma were studied for their use of oral contraceptives. The control patients were matched for age, ethnic origin, age at first pregnancy, age at first coitus, and socioeconomic status. There was no significant difference between case and control subjects in the duration or oral contraceptive use, the type of estrogen used, or the years in which oral contraceptives were used. The mean duration of oral contraceptive use was 30.9 months by the case subjects and 30.2 months by the control subjects.


Effect of progesterone and estradiol-17beta on nucleic acid synthesis in vitro in carcinoma of the endometrium.

Nucleic acid synthesis was studied in 26 tumor specimens, during a one-hour in vitro incubation with the addition of progesterone and estradiol-17beta. On the response scale used, deoxyribonucleic acid and ribonucleic acid synthesis decreased linearly as the logarithmic concentration of either hormone increased. Inhibition of nucleic acid synthesis was highly significant (P less than 0.001) at 80 microgram per milliliter of progesterone and at 40 microgram per milliliter of estradiol. No evidence of synergism was found when the two hormones were combined at these concentrations. In Grade I and II tumors, the effect when both hormones were combined approximated the sum of effects of the individual hormones. In Grade III tumors, little difference was seen between treatment groups.


Some observations on the value of endocervical curettage performed as an integral part of colposcopic examination of patients with abnormal cervical cytology.

A total of 259 patients underwent endocervical curettage as an integral part of colposcopic examination of patients with abnormal cervical cytology. The transformation zone was entirely visualized in 140 patients (54.1 per cent), and, in 8.6 per cent of this group, the endocervical curettings were abnormal. On no occasion did the endocervical curettage harbor the worst lesion when compared to the histology of the ectocervical biopsy, cone biopsy, and hysterectomy specimens. In 117 patients (45.2 per cent), the transformation zone could not be visualized in its entirety, and in 57.3 per cent the endocervical curettings were abnormal. In one patient of this group invasive carcinoma was present in the endocervical curettage, and in another patient invasive carcinoma was present in both the ectocervical biopsy and the endocervical curettage. Thus, when the entire transformation zone is not visualized in its entirety or at all, endocervical curettage appears to be of value since a frank invasive carcinoma may be diagnosed and a cone biopsy avoided.


A direct radioimmunoassay for estriol-16-glucuronide in urine for monitoring pregnancy and induction of ovulation.

Antibodies to estriol-16alpha-[beta-D-glucuronide] were raised in sheep with the use of keyhold limpet hemocyanin and bovine serum albumin conjugates of estriol-16alpha-[beta-D-glucuronide]. A simple, rapid method is presented for direct radioimmunoassay of estriol-16alpha-[beta-D-glucuronide] in urine with dextran-coated charcoal used for separation of free from bound and deionized water used for dilutions. The method is thrifty in its use of reagents. The assay has been evaluated in the pregnancy range, and the sensitivity has been extended into the range necessary for monitoring induction of ovulation with Pergonal.


Abdominal wound dehiscence.

Abdominal wound dehiscence is a surgical complication with a high morbidity rate but which is associated with predictable and preventable factors. During a 10 year period (1966 to 1975) at the New York Lying-In Hospital, 70 cases were found on the obstetric-gynecologic service, and these cases were analyzed to see why dehiscence remains a problem. Those factors contributing to dehiscence include obesity, pre-existing pulmonary and cardiovascular problems, vertical incisions, the triad of ileus, vomiting, and coughing, and, to a lesser extent, hypoproteinemia, fluid and electrolyte imbalance, and wound infection. The incidence of abdominal wound dehiscence would be much lower if high-risk patients were identified, adequate pulmonary toilet was used, ileus was promptly treated with abdominal decompression, and strict attention was paid to electrolyte and protein balance in the pre- and post-operative period. The management of abdominal wound dehiscence is also discussed.


Plasma concentrations of four pregnancy proteins in complications of pregnancy.

Toxemia of pregnancy was associated with an elevation of the pregnancy-associated plasma protein (PAPP)-A concentration, as compared to the level in normal pregnancy in the last month of gestation. The other pregnancy proteins measured were not altered in toxemia. In twin pregnancies, the PAPP-A, PAPP-C, and human placental lactogen levels were all increased, particularly PAPP-A. On the other hand, pregnancy zone protein was not affected by twinning. Pregnancy with diabetes showed normal levels of these proteins.