The role of transbronchial lung biopsy in diffuse pulmonary disease.

Forty consecutive patients underwent flexible fiberoptic transbronchial lung biopsy for diagnosis of diffuse nodular or infiltrative lung disease. Biplane fluoroscopic examination with image intensification greatly facilitated accurate placement of the biopsy forceps near the pleura; Specimens of lung parenchyma were obtained for culture and histological study in every  case. A pathological diagnosis was correctly established in 34 of 40 patients. Transbronchial biopsy was helpful in the clinical management of an additional 4 patients. Biopsy results were not accurate in 2 patients. No significant morbidity was associated with the procedure. Fiberoptic transbronchial lung biopsy is a safe and useful adjunct to the diagnosis of parenchymal lung disease.


Aortocoronary vein graft flow in response to peripheral venous administration of sodium nitroprusside or diazepam.

Vein graft flow (VGF) in response to peripheral venous administration of sodium nitroprusside (SNP) or diazepam was studied in 13 anesthetized patients following cardiopulmonary bypass for aortocoronary vein bypass graft operations. SNP (0.5 microgram/kg/min) significantly reduced mean arterial pressure (p less than 0.05). VGF paralleled the decreased blood pressure, but the reduction was not significant (p greater than 0.05). Diazepam (0.1 mg/kg) did not significantly alter blood pressure or VGF. We conclude that peripheral venous administration of SNP or diazepam is not a pharmacologically reliable method by which to increase VGF in the period immediately following a graft operation.


A recommended protocol for pacemaker follow-up: analysis of 1,705 implanted pacemakers.

This study, developed for the purpose of establishing an appropriate protocol for general follow-up of the paced patient, is based on clinical experience with patients derived from diverse specialties, geographical locations and protocol preferences. The analysis represents a four-year study of the transtelephonic follow-up of 1,705 implanted cardiac pacers, which represents 44,616 pacer-months of experience. There were 340 system malfunctions, 41% (141) due to battery exhaustion and 59% (199) due to other causes. Of all observed system failures 9.7% (33) occurred within 1 month of implantation, with the rate declining sharply thereafter until battery failures began to occur at approximately the twenty-fourth month. Only 10.9% (37) of all system failures were accompanied by clinical symptoms. Of the clinical failures, 62% (23) occurred in patients who were tested at intervals greater than 10 weeks. Our analysis indicates that testing should be performed weekly for the first month following lead manipulation. Thereafter, tests should be performed at 8- to 10-week intervals for the first 24 months of pacemaker life. During the third postimplant year tests should be conducted more frequently, depending on the energy source of the generator.


Traumatic aortic rupture: an additional roentgenographic sign.

Esophageal displacement to the right at the level of the aortic arch and isthmus, as marked by an opaque nasoesophageal tube on anteroposterior chest roentgenogram is a useful sign in diagnosing traumatic aortic rupture. Finding this esophageal displacement in patients with blunt chest trauma warrants an immediate thoracic aortogram for demonstration of possible aortic injury.


Acute clonidine withdrawal syndrome following open-heart operation.

A patient who underwent cardiopulmonary bypass developed a syndrome of malignant hypertension with agitated delirium, unresponsive to antihypertensive agents, following abrupt withdrawal of clonidine. The literature on this syndrome is reviewed with emphasis placed on prompt recognition. The syndrome can be reversed by resumption of clonidine administration and can be prevented by maintenance of clonidine levels through the perioperative period.


Primary pulmonary sporotrichosis.

A patient with primary pulmonary sporotrichosis with infiltration and cavitation is reported. Treatment for one year with potassium iodide resulted in marked resolution of the inflammatory lesions but persistent cavitation and fungal infection. Cure followed bisegmental lung resection with no recurrence during eight-year follow-up. Excellent results are reported in 10 patients treated by resection despite less then optimal preoperative iodide therapy. Surgical treatment of primary sporotrichosis with cavitation is indicated and should be unattended by complications or recurrence.


Subclavian subtleties.

Several helpful technical features are presented that reduce the morbidity associated with subclavian vein catheterization. These techniques include percutaneous insertion through an indwelling catheter, repositioning the catheter without a second puncture, and securing the catheter without kinking or dislodgment. Use of these techniques will spare the patient the risks attendant to multiple subclavian punctures.


Pledget- and patch-holding clamp: a new instrument.

A new clamp designed to facilitate the handling and placement of various shapes and sizes of cardiac patching materials is described.


Gastroesophageal reflux and ascorbic acid insufficiency.

The incidental discovery of scurvy in a patient with a symptomatic hiatal hernia has led to the identification of 9 other individuals with chemically proved vitamin C deficiency secondary to an expressed aversion to "acid" food in any form. These patients were screened with capillary fragility tests and serum ascorbic acid determinations from approximately 200 hiatal hernia and reflux patients. With resumption of a normal vitamin C intake, scattered deficiency symptoms disappeared and both capillary fragility tests and serum ascorbic acid levels returned toward normal. There were no wound healing problems.


Diaphragmatic eventration in infancy and childhood.

Eventration of the diaphragm, although a relatively rare clinical entity, should be considered in all patients with respiratory distress during the neonatal period, particularly in babies born after difficult delivery by breech presentation or forceps extraction. The diagnosis can be made in the majority of spontaneously breathing patients by chest roentgenography or by fluoroscopy. The treatment initially should be supportive, including assisted ventilation if needed. If the infant cannot be weaned off the respirator after a week to ten days of respiratory support, surgical correction of the elevated diaphragm should be carried out. The results of surgical treatment in these desperately sick infants is usually most gratifying.


A rational approach to total thymectomy in the treatment of myasthenia gravis.

Thymectomy is important in the treatment of myasthenia gravis. Total removal of the gland is considered indicated. Although median sternotomy has been the accepted surgical procedure, the transcervical approach has been advocated as a safer method of achieving total thymectomy. A surgical-anatomical study of the thymus was made in 22 patients. A high incidence of surgically important variations in thymic anatomy was found in the neck and in the mediastinum. We believe wide exposure by way of median sternotomy with direct vision is required to remove all of the extracapsular mediastinal thymus in many patients, and good cervical exposure is required to remove the anomalous tissue in the neck. If a total thymectomy is to be achieved, we recommend a median sternotomy and a cervical incision, using the meticulous dissection described.


Late evaluation of patients undergoing valve replacement with the Björk-Shiley prosthesis.

This study analyzes 484 patients who survived mitral, aortic, or mitral and aortic valve replacement using the Björk-Shiley prosthesis from January, 1970, through December 31, 1974. Long-term follow-up of 1 1/2 to 6 1/2 years (mean, 3.67 yr) was done on 435 patients (98.2%). Eighty to 85% of the patients have improved noticeably. Thromboembolic problems occurred in 6.9%, representing 1.5 emboli per 1,000 patient-months. Anticoagulant bleeding problems occurred in 6.4% of the patients; late mortality was 15%. Actuarial survival curves showed patients at risk to 6 years having a 79% chance of survival. The same analysis according to preoperative New York Heart Association Functional Classification showed a striking reduction in survival in class IV patients. The Björk-Shiley prosthesis is a good choice for valve replacement today. Earlier diagnosis and treatment are needed to obtain better long-term survival.


Feasibility of closed-chest left ventricular bypass using unilateral retrograde transpulmonary flow.

A method for closed-chest left heart bypass using retrograde unilateral transpulmonry blood flow originating from the left atrium and retrieved by a cuffed cannula wedged in a pulmonary artery branch is described. Technical feasibility and physiological implications were tested in 12 anesthetized sheep and 4 awake calves. Retrograde transpulmonary flow showed a curvilinear relationship to the left atrial pressure, with the highest rate of rise occurring when left atrial pressure approached levels of pulmonary edema (25 to 35 mm Hg); at this point retrograde transpulmonary flow became equal to control cardiac output. The intervention and the bypass were well tolerated for short periods by these healthy animals. The possible advantages of the method are discussed, with emphasis on self-regulation of bypass flow by the filling resistance of the left ventricle.


Control of heparinization by activated clotting time during bypass with improved postoperative hemostasis.

Heparin and protamine dosages monitored during open-heart operations by activated clotting time (ACT) have been reported to be superior to dosage schedules based on body weight or body surface area. To evaluate the automated ACT, 114 consecutive open-heart operations performed between October, 1974, and December, 1975, were studied. Fifty-eight operations prior to April, 1975, using a standard heparin-protamine protocol (Group I) were compared with 56 operations from April to December, 1975, monitored with an automated ACT (Group II). The two groups were similar with respect to surgical procedures, pump time, and perfusion techniques. The protamine/heparin ratio was 25% less in Group II compared with Group I, and the 12-hour postoperative blood loss was 48% less in Group II. The automated ACT is a reliable, rapid, and simple test that has resulted in improved hemostasis following cardiac operation.


Late cardiac tamponade following open-heart surgery: detection by echocardiography.

Late cardiac tamponade following open-heart operation is a potentially lethal complication that is often difficult to diagnose. A case of cardiac tamponade occurring two weeks after left ventricular aneurysmectomy and coronary bypass surgery is reported. Despite opening of the anterior pericardium during operation, echocardiography revealed characteristic findings, which permitted prompt recognition of this disorder.


Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma.

Recent literature suggests that pulmonary embolus secondary to renal cell carcinoma may by more common than previously suspected. Renal tumors are known for their ability to metastasize early, often before the primary lesion is apparent. A patient with renal cell carcinoma and having massive pulmonary tumor embolus is presented. Attention was called to the occult tumor by the identification of clear cell carcinoma in the pulmonary embolic material. Pulmonary embolectomy and surgical extirpation of the primary tumor resulted in long-term survival.


Oral bronchodilator effect of 16(S)-methyl-20-methoxy-PGE2 (YPG-209) in guinea-pigs.

The bronchodilator activity of synthetic 16(S)-methyl-20-methoxy-PGE2 (YPG-209) was investigated in guinea-pigs. The potency of YPG-209 in relaxing the isolated trachea contracted by histamine was 10 times smaller than that of PGE2, and was not reduced by propranolol, while in the anesthetized animals YPG-209 given by an intravenous route was 230 times as potent in inhibiting an increase in the airway resistance induced by histamine as PGE2. When administered either intraduodenally to the anesthetized animals or orally to the conscious ones, YPG-209 showed a pronounced protection against histamine-induced bronchoconstriction, in contrast to PGE2 which had no significant protecting effect. Neither hypotension nor diarrhea could be observed at the doses of YPG-209 exhibiting a considerable bronchodilator effect. The hydroxyl group at carbon-15 of YPG-209 was little oxidized by 15-hydroxy prostaglandin dehydrogenase which was purified from the lung of guinea-pigs, consistent with the comparably long lasting bronchodilator activity of YPG-209 in vivo.


Sodium sensitive active transport of bretylium into adrenergic neurons for the development of blockade in rabbit ileum.

Transport of bretylium into adrenergic neurons was studied, using rabbit isolated periarterial nerve ileum preparations, by determining the effects of various incubation procedures, which inhibit noradrenaline uptake, to prevent or reverse the blockade. Adrenergic neuron blockade by bretylium 5 X 10(-5) (g/ml) was prevented but not reversed by incubation with sodium free and low temperature (10 degrees C) media. Ouabain 2.2 X 10(-8) and anoxia prevented bretylium-induced blockade. Noradrenaline 5 X 10(-6) and 8 X 10(-5) prevented and also reversed the blockade, but the reversing effect was transient. High calcium (totally 10 mM) readily reversed the bretylium-induced blockade, the recovery being complete and long-lasting. In light of the results, a sodium sensitive active transport of bretylium into adrenergic neurons is apparently necessary for development of adrenergic neuron blocking action in rabbit ilea.


A characterization of the effects of acetylcholine on the rabbit oviduct.

The effect of acetylcholine (ACh) on the perfused oviduct of the rabbit was investigated. The response of the oviduct to ACh during early gestation was variable, i.e., biphasic (contraction followed by slight relaxation) greater than contractile greater than relaxation. The responsiveness of the oviduct to the contractile effect decreased progressively during early gestation, similar to that previously reported for norepinephrine (NE). The contraction produced by ACh was antagonized by chlorisondamine and atropine and also by phentolamine and pretreatment with reserpine. It was concluded that the response produced by ACh may be mediated in part through the release of NE.


In vitro metabolism of nicotine in liver of ageing mice.

14-C-nicotine was incubated with 10000 X g supernatant fraction of liver homogenate from female mice (C3H/TIF/BOM) 2, 12 and 18 months old. The rate of metabolism was measured by the determination of the oxidative nicotine metabolite continine and by determining the disappearance of nicotine. No significant changes between different ages were found either in the continine formation or the rate of disappearance of nicotine.


A comparison of actodigin and ouabain in cats.

The effects of actodigin and ouabain at infusion rates which produce death in equivalent times were compared in anesthetized cats. Actodigin-induced ventricular tachycardia occurred sooner than that induced by ouabain. However, in animals in which the infusion of drug was stopped one minute after the onset of ventricular tachycardia, the arrhythmia terminated sooner in cats given actodigin than in those given ouabain. Actodigin produced a slower heart rate and greater prolongation of the PR interval than did ouabain suggesting a greater increase in vagal tone in the actodigin treated cats. Left ventricular pressure was not changed by either drug while peak dp/dt was increased after 30 min of the ouabain infusion but not significantly more than changes produced by actodigin. Thus, the use of actodigin may be limited by the early appearance of ventricular arrhythmias.


Inhibition by cinnarizine of the properdin-dependent activation of complement.

Cinnarizine (1-benzhydryl-4-cinnamylpiperazine dihydrochloride), a well-known antagonist of vasoactive agents, has previously been shown to inhibit the activation of complement at the level of the fourth component. Cinnarizine was now tested in a system of complement activation by the properdin-dependent alternative pathway. At the concentration of 7.10(-5) M the compound completely inhibited the hemolytic reaction, which is the consequence of human complement activation in the presence of inulin or zymosan. This in vitro effect of cinnarizine was abolished by the addition of 1 mM MgCl2. These findings extend the anticomplementary activity of cinnarizine to the properdin pathway and support its interaction with the magnesium-dependent steps of the activation sequence.


Anti-arrhytmic and general pharmacological properties of some 1,3-benzodioxole derivatives.

Seven 1,3-benzodioxole derivatives have been found to be effective against certain types of experimentally induced arrhythmias. Among them, 2-[2-(5-chloro-2-methyl-1, 3-benzodioxol-2-yl)ethoxy]-N, N-diethyl-ethanamine (LR 529) showed to be the most active. LR 529 prevented arrhythmias induced by CaCl2 intoxication in anaesthetized and conscious rats, by benzene-epinephrine in anaesthetized guinea-pigs, and by direct electrical stimulation either at increasing intensity of the ventricles of anaesthetized cats or at increasing frequency of the rabbit isolated atria. The new compound reversed to sinus rhythm the arrhythmias provoked by intoxication with aconitine and ouabain respectively in anaesthetized rats and dogs. LR 529 (and the other 1,3-benzodioxoles as well) showed scant local anaesthetic activity, short-lasting hypotensive effects, not accompanied by any change in heart rate, and discrete anti-aggregating activity on rabbit platelets "in vitro". In general, the new compounds showed weak or no effect on autonomic and central nervous systems, neither influenced other pharmacological parameters (at least within the range of doses active on experimental arrhythmias). Acute toxicity studies have indicated that even if some of the 1,3-benzodioxoles were more toxic than quinidine and procainamide, their anti-arrhythmic indexes (especially those of LR 529) were greater than those of the two reference drugs.


The influence of pentobarbital upon a cortical epileptogenic focus in rats.

Three subsequent doses of pentobarbital (5, 15, and 40 mg/kg) were applied intraperitoneally in acute experiments in rats with a cortical epileptogenic focus. Histograms of intervals between individual focal discharges were shifted towards longer intervals even after the smallest dose of pentobarbital; the prolongation of intervals was clearly visible after the third dose also in the EEG recording. Shape of primary as well as projected cortical focal discharges after pentobarbital resembled that seen after local application of GABA. Barbiturate spindles which were present after the first and second dose of pentobarbital were regularly triggered by focal discharges. The mechanism of this triggering was probably a thalamocortical one, because marked projected discharges were recorded from various thalamic nuclei from the very beginning of focal activity.


Inhibitory effect of fumaric acid and dicarboxylic acids on gastric ulceration in rats.

Production of gastric ulcerations in rats by pyloric ligation was found to be inhibited by either intraperitoneal or oral administration of fumaric acid in a dose of 50 mg per kg. The antiulcer action was also exhibited by the four-carbon dicarboxylic acids, maleic acid, oxalacetic acid, succinic acid and malic acid. The studies on fumaric acid indicated that the acid's antiulcer action was based on its ability to inhibit the gastric juice secretion and to dilate the stomach muscle.


Altered sensitivity to acetylcholine during chronic administration of organophosphorus anticholinesterase (fenthion) in albino mice.

Tissue sensitivity to acetylcholine during chronic administration of fenthion was assessed in mice. Fenthion was injected intra-muscularly every fourth day and experiments were carried out at various intervals. The parameters selected for testing cholinergic effects were, acetyl choline-induced contraction of isolated ileum and salivary secretion in vivo. In both types of experiments an initial supersensitivity followed by tolerance to acetylcholine  were observed. The underlying mechanisms are discussed.


Hyporeninemia and hypoaldosteronism in diabetes mellitus.

The changes in plasma renin activity (PRA) and plasma aldosterone concentration (PA) in response to postural stimuli were evaluated in 12 patients with stable diabetes mellitus and in five volunteers. Seven diabetic patients had hyperkalemia, and several had renal insufficiency and neurological complications. Five diabetics and had normal serum potassium concentration, a mean creatinine clearance within the normal range, and few complications. PRA and PA were measured in these patients and in the control subjects, all of whom were receiving a diet containing 10 mEq of sodium and 50 mEq of potassium while they were in a supine position, after they were tilted to a 90 degrees position, and after upright posture for two hours. The results indicate that impaired responsiveness of PRA and PA may occur in patients with complicated and those with uncomplicated diabetes and may be responsible in part for a relatively high prevalence of hyperkalemia especially in those diabetic patients with reduced renal function.


Staphylococcal septicemia and disseminated intravascular coagulation. Staphylococcus aureus endocarditis mimicking meningococcemia.

Two patients with acute endocarditis attributable to Staphylococcus aureus had a clinical syndrome similar to meningococcemia with meningitis. That fulminant S aureus septicemia may on occasion be associated with hemorrhagic skin lesions, thrombocytopenia, coagulation abnormalities, and meningitis is emphasized.


Hypertension in radiation nephritis. Report of a patient with unilateral disease, elevated renin activity levels, and reversal after unilateral nephrectomy.

A patient received intensive radiation to the right renal area for abdominal Hodgkin's disease and approximately ten years later severe hypertension developed. The presence of radiation nephritis with a severely shrunken right kidney was demonstrated and this was accompanied by a substantial increase in renin activity from the right kidney. Treatment with propranolol hydrochloride temporarily lowered the blood pressure and peripheral renin activity levels. Subsequent right nephrectomy resulted in a decrease in renin activity and a reversal of the hypertension. The data implicate a renin angiotensin mechanism as probable cause of hypertension in radiation nephritis.


Bone marrow necrosis. Diagnosis and assessment of extent of involvement by radioisotope studies.

In two patients with extensive marrow necrosis, the diagnosis of marrow necrosis was established by morphologic and radioisotopic studies, and the extent of involvement was accurately assessed by marrow scanning with technetium Tc 99m sulfur colloid while the patients were still alive. The literature on marrow necrosis was briefly reviewed and the clinical features of this condition were characterized. It was found that patients with this condition often have malignancies, underlying marrow disorders, sepsis, bone pain, and pancytopenia. Their marrow is often difficult to aspirate and they may require frequent transfusions to maintain a stable hemoglobin level. Radioisotopic studies are useful in the diagnosis and assessment of extent of involvement of this condition. They should be used in patients with clinical findings suggestive of marrow necrosis.


Carcinoembryonic antigen titers on effusion fluid. A diagnostic tool?

Carcinoembryonic antigen (CEA) has been demonstrated in tumors and body fluids, suggesting that effusion fluid (EF) CEA titer might separate benign and malignant EF. Plasma and EF CEA titers were determined on 141 patients with either benign (86) or malignant (55) EF. Although plasma CEA titers separated patients with either a benign or malignant EF 56% of the time, this separation was better accomplished (90% of the time) using EF CEA (P less than .0001). A malignant EF was associated with an EF CEA titer greater than or equal to ng/ ml or when, in the range 5.0 to 9.9 ng/ml, the EF CEA titer was greater than twice the plasma CEA. Paired plasma and EF CEA titers may aid in determining the benign or malignant origin of an EF.


Morbidity in alcoholics. Evidence for accelerated development of physical disease in women.

The physical disease profiles of 135 female and 736 male inpatient alcoholics, similar in age, social class, and referral pattern, were compared to further clarify the widespread clinical impression that female alcoholics are more illness-prone. Although the women had been drinking hazardously for fewer years, at admission the prevalence of most diseases was similar in men and women. There was, however, an excess of anemia in women and of fatty liver and chronic obstructive lung disease in men. Furthermore, the average duration of hazardous drinking before the first recorded occurrence of almost all illness events was shorter in women, the sex differences being statistically significant for fatty liver, hypertension, obesity, anemia, malnutrition, gastrointestinal hemorrhage, and an ulcer requiring surgery. These findings suggest that the development of physical morbidity in relation to hazardous drinking may be accelerated in women.


Prognosis in steroid-treated idiopathic nephrotic syndrome in adults. Analysis of major predictive factors after ten-year follow-up.

This long-term study analyzes the prognostic value of the quantitative urinary protein excretion during and following steroid administration, the renal functional status three years after the onset of disease, and the degree of histologic damage in adult patients with steroid-treated idiopathic nephrotic syndrome (INS). No patient who had a complete (proteinuria less than 0.1 gm/day) or partial (proteinuria less than 2.0 gm/day) remission during steroid administration progressed to renal failure. Furthermore, no patient in whom urinary protein excretion subsequently fell to below 2.0 gm/day ever progressed to renal failure. Only 3 of 49 patients in whom renal function was normal three years after the onset of INS developed renal failure. Finally, renal failure occurred in only 2 of 28 patients with mild abnormalities by light microscopy, compared with 12 of 21 patients with more advanced glomerular abnormalities. Thus, a partial, as well as a complete remission during steroid administration, subsequent reduction in proteinuria to below 2 gm/day, persistence of normal renal function beyond three years, or the presence of mild histologic abnormalities auger a favorable long-term prognosis in patients with INS.


Aplastic anemia associated with submassive hepatic necrosis. Report of four cases.

Four cases of fatal aplastic anemia were associated with submassive hepatic necrosis. The subjects were males, ranging in age from 20 to 33 years. Pathogenesis remained obscure.


Special report: dysoxia. Abnormal tissue oxygen utilization.

The ultimate cause of the clinical abnormalities associated with changes in oxygen supply and oxygen utilization is the development of abnormal tissue oxygen metabolism. Until now, there has been no satisfactory term to describe abnormal tissue oxygen metabolism. We propose the term "dysoxia" to fill this gap. There are a number of causes of dysoxia. One of the most interesting is that form of dysoxia related to abnormal mitochondrial structure and function. In this group of disorders, there is abnormal tissue oxygen metabolism, although oxygen supply is normal. Another interesting cause of dysoxia is exposure to high oxygen concentrations. High oxygen concentrations are involved in producing abnormal tissue oxygen metabolism under a number of different circumstances. The concept underlying dysoxia provides a unified approach to a large and important group of disorders involving most branches of clinical medicine.


Combined calcitonin and oral phosphate treatment for hypercalcemia in multiple myeloma.

Hypercalcemia of multiple myeloma has been discussed widely in the medical literature. The role of calcitonin and phosphate in the treatment of hypercalcemia of multiple myeloma has not yet been studied to our knowledge, although experimental animal models have been pointing to the role of phosphate supplement to calcitonin treatment in multiple myeloma. A patient had multiple myeloma and hypercalcemia. The usual medical treatment for hypercalcemia failed; however, the treatment with combined orally administered phosphate and calcitonin was successful. The role of phosphate depletion in this setting is brought up as an important factor in the failure of calcitonin therapy.


Aspergillus terreus osteomyelitis.

Aspergillus terreus infection limited to the L1-2 disk space and first and second lumbar vertebrae developed in a patient not predisposed to invasive aspergillosis. The observation of morphologically distinct secondary spores (aleuriospores) on microscopic examination of open biopsy specimens permitted a preliminary identification of A terreus, which was confirmed by culture. The infection was eradicated with amphotericin B in a total dose of 3 gm. Aspergillus terreus is usually a saprophyte. The present case and four others collected from the literature establish this species as an invasive pathogen.


Propionibacterium acnes meningitis in a previously normal adult.

A 25-year-old man was previously healthy until he contracted acute Propionibacterium acnes meningitis. Comparison with previous reports of de novo diphtheroid meningitis suggests that this entity can appear with features that are not characteristic of acute bacterial meningitis, including (1) stroke-like syndromes, (2) an afebrile course, and (3) a cerebrospinal fluid with a mononuclear pleocytosis and normal glucose level. The appropriate choice and dosage of antimicrobial agent must be guided by more than in vitro sensitivity data to prevent relapse and possible chronic meningitis. Although diphtheroids are as a rule exquisitely sensitive to penicillin, predictably high tissue levels of drug in diphtheroid meningitis are best achieved with chloramphenicol treatment. In the appropriate settling, the isolation of diphtheroids from cerebrospinal fluid should not be discounted as a "contaminant."


Pancreatitis with coexistent pancreatic duct stone and carcinoma. Early diagnosis by endoscopic retrograde pancreatography.

We had a patient with cancer of the pancreas that was diagnosed by endoscopic retrograde pancreatography where conventional diagnostic methods (including arteriography) were negative. Pancreatic resection was possible and examination of the surgical specimen showed microscopic adenocarcinoma coexistent with an intraductal stone and pancreatitis.


Hypomagnesemic hypocalcemia. Early serum calcium and late parathyroid hormone increase with magnesium therapy.

A patient with short-bowel syndrome developed severe hypomagnesemia (0.2 mEq/liter) associated with symptomatic hypocalcemia (6.1 mg/100 ml). Parathyroid hormone (PTH) levels were normal but inappropriately low. During therapy with magnesium sulfate, an initial hypocalcemia was followed by a calcemic response without a change in PTH levels. This indicates improved bone responsiveness to circulating low levels of endogenous PTH with magnesium replenishment, which appears to be related to the restoration of magnesium-dependent cellular mechanisms. The additional observation of a slow and delayed increase in PTH, despite normal calcium levels, indicates improvement of hormone synthesis.


Sudden death in patients with chronic bifascicular block.

Prospective follow-up studies of 277 patients with chronic bifascicular block showed that 30 patients developed sudden cardiac death (SCD). Cumulative one-, two-, and three-year SCD mortality was computed. The patients that developed SCD were compared with the remaining patients (209 alive and 38 dead). The groups were similar in regard to age, sex, AH, and HV intervals. The following were more frequent in the SCD group (P less than .05): angina, previous myocardial infarction, heart failure, cardiomegaly, left bundle-branch block, premature ventricular beats, and ventricular tachycardia. Ventricular fibrillation was the cause of death in four cases of SCD where terminal ECG documentation was available. We concluded that SCD is a major cause of mortality in patients with chronic bifascicular block. The association of SCD with coronary disease and ventricular dysrhythmia suggested ventricular fibrillation as a frequent mechanism.


Acetazolamide-accelerated anticonvulsant osteomalacia.

Severe osteomalacia was present in two epileptic patients who were under long-term treatment with congeners of phenytoin, phenobarbital, and acetazolamide. These patients showed slightly low serum calcium, normal or low serum phosphate, and normal parathyroid hormone concentrations. Discontinuation of acetazolamide produced an immediate threefold drop in the level of urinary calcium excretion and a slight rise in tubular reabsorption of phosphate, with no dectectable change in serum calcium or phosphate concentrations. Acetazolamide may have accelerated the development of osteomalacia by several mechanisms, including increased renal calcium excretion.


Hepatitis B miniepidemic in a peritoneal dialysis unit.

Two staff nurses in a peritoneal dialysis unit developed type B viral hepatitis while caring for a patient with persistent Hb Ag antigenemia. Peritoneal dialysis fluid from the patient contained surface Hb Ag antigen and was the probable mediator of the viral transfer. Hb Ag testing should be routine in peritoneal dialysis programs, and special precautions should be taken with dialysate of patients affilcted with hepatitis and/or Hb Ag antigenemia.


Sternoarticualr pyoarthrosis due to gram-negative bacilli. Report of eight cases.

Of eight patients with Gram-negative bacillary sternoarticular pyoarthrosis, seven were long-term intravenous heroin abusers. Clinical onset was insidious and a long delay (one month or more) in seeking hospitalization was usually noted. Anterior chest discomfort and painful, restricted homolateral shoulder motion were the chief complaints. Fever and monoarticular arthritis were universally present, Open synovial biopsy examination was frequently required for etiologic diagnosis. Pseudomonas aeruginosa was the most common pathogen isolated. Roentgenographic evidence of associated osteomyelitis was usually seen, but tomography was often necessary to delineate this lesion. Intraoperatively, associated osteomyelitis of the clavicular head and/or sternum was present in all eight cases and a perisynovial and/or retrosternal abscess was found in five patients. Early surgical exploration and prolonged antimicrobial therapy yielded excellent results.


Acute cyanide poisoning complicated by lactic acidosis and pulmonary edema.

Massive cyanide poisoning occurred in a 21-year-old man who had ingested 600 mg of potassium cyanide. The clinical course was marked by acute pulmonary edema and lactic acidosis. Because the poison was unidentified until nine hours after ingestion, the patient received only supported treatment which included diuresis, oxygen, bicarbonate, and assisted ventilation. A review of the literature shows that many case reports are poorly documented and do not provide a firm basis for evaluating therapy. To our knowledge, only four patients, including ours, have had blood levels of cyanide measured. In the absence of a suitable history, diagnosis of cyanide poisoning is difficult. A simple chemical test which can be performed on gastric aspirate is available. Hydroxocobalamin may be used as a nontoxic specific antidote. Nonspecific supportive therapy is of great importance.


Reversible crescentic glomerulonephritis following an acute exacerbation of chronic relapsing pancreatitis.

A patient had recurrent episodes of acute glomerulonephritis following exacerbations of chronic relapsing pancreatitis. Light microscopy of the renal biopsy performed during the episode of acute glomerulonephritis showed fibroepithelial crescents involving 70% of the glomeruli. The patient recovered without specific therapy. The time interval involved and the presence of subendothelial deposits with mesangial deposition of C3 complement and IgM suggest immune complex injury.


Erythrocytosis associated with the nephrotic syndrome.

A 23-year-old-man had true erythrocytosis and the nephrotic syndrome. A renal biopsy specimen showed focal sclerosing glomerulonephritis and nephrosclerosis. Both serum and urinary erythropoietin levels were increased, and plasma renin activity was in the high normal range. The association of erythrocytosis and glomerulonephritis with the nephrotic syndrome is reviewed, and the uniqueness of this association is proposed. Finally, a dissociation between these hormones was demonstrated using water immersion to the peck as a suppressive maneuver.


Avasucular necrosis of pheochromocytoma followed by spontaneous remission.

Following an acute spontaneous hypertensive crisis and shock a patient with pheochromocytoma was found to have an exceedingly high catecholamine excretion rate. After this episode, the patient remained normotensive and urinary excretion of catecholamines returned to normal. During surgery, a large pheochromocytoma was found and removed that showed avascualr necrosis. In phenochromocytoma, a sudden and exceedingly high rate of catecholamine release may cause intense vasoconstriction both generally and within the tumor itself. In this patient, avascular tumor necrosis led to a spontaneous remission of clinical symptoms.


Spontaneous remission of accelerated (malignant) hypertension in renal infarction.

Malignant hypertension occurred in a young man who also was found to have a left renal infarct and higher renal vein renin levels on the left side. His hypertension was controlled with drugs and subsequently treatment with these medications was gradually discontinued over a period of nine months. He remained normotensive when no longer receiving medication, and another intravenous pyelogram demonstrated a persistent cortical defect in the left kidney.


Encephalopathy induced by oral hypoglycemic drugs.

Three patients experienced severe hypoglycemic encephalopathy during oral therapy of adult-onset diabetes mellitus. Disabling residual neurological deficits were observed in two of these patients. The insidious time course of drug-induced hypoglycemia appeared to prevent patient recognition of sustained hypoglycemia. These cases indicate the need for further caution in the administration of oral hypoglycemic agents.


Operable lung cancer associated with fever, anemia, and hepatomegaly.

A 26-year-old man, acutely ill with fever, anemia, and hepatomegaly, was found to have an epidermoid carcinoma by percutaneous needle biopsy of a left apical lung mass. Following resection of the necrotic tumor, fever, anemia, and hepatomegaly disappeared. The patient is alive with no evidence of cancer 30 months later.


Nephropathy associated with methicillin therapy. Prevalence and determinants in patients with staphylococcal bacteremia.

The nephropathy associated with methicillin sodium therapy is considered to be rare, but its prevalence is unknown. We reviewed the antibiotic therapy of 81 cases of Staphylococcus aureus bacteremia to establish the frequency and determinants of methicillin nephropathy in that disease. Fifty-two patients received methicillin; nine (17%) experienced the characteristic clinical signs previously associated with drug-induced acute interstitial nephritis. This nephropathy uniformly subsided after methicillin was withdrawn, and did not always include deterioration of renal function. Factors that correlated with methicillin nephropathy were endocarditis and prolonged treatment, but not intravenous drug abuse. There was only one adverse reaction among 29 patients treated with a cephalosporin. It was similar to the nephropathic reactions to methicillin. Thus, reversible renal abnormalities are prevalent during methicillin therapy, particularly among patients with staphylococcal infections such as endocarditis. When prolonged therapy with methicillin is required, the urinary sediment and renal excretory function should be monitored.


Further evidence for the regulation of bacterial populations in soil by protozoa.

After the addition to soil of large numbers of a cowpea Rhizobium strain, the population declined steadily until the numbers reached about 10(7)/g, and the protozoa rose to about 10(4)/g. When indigenous protozoa were suppressed by the addition of actidione to the soil, the density of the test rhizobium did not fall initially, but its abundance declined to about 10(7)/g when actidione-resistant protozoa arose in significant numbers. The addition to actidione-treated soil of an antibiotic-resistant strain of Paramecium led to a rapid decrease in the population of the rhizobium, the density reaching essentially the same value as in soil receiving neither the drug nor the paramecia. The same changes occurred with Xanthomonas campestris as test prey except that its numbers fell to about 10(5)/g of soil. These data provide further evidence for the key role of protozoa in controlling the abundance of populations of certain bacteria introduced into soil.


Dorsal-ventral differentiation in Simonsiella and other aspects of its morphology and ultrastructure.

The morphology and ultrastructure of the aerobic, Gram-negative multicellular-filamentous bacteria of the genus simonsiella were investigated by scanning and transmission electron microscopy. The flat, ribbon-shaped, multicellular filaments show dorsal-ventral differentiation with respect to their orientations to solid substrata. The dorsal surface, orientated away from the substrate, is convex and possesses an unstructured capsule. The ventral surface, on which the organisms adhere and glide, is concave and has an extracellular layer with fibrils extending at right angles from the cell wall. The cytoplasm in the ventral region contains a proliferation of intracytoplasmic membranes and few ribosomes in comparison to the cytoplasm in other parts of the cell. Centripetal cell wall formation is asymmetrical and commences preferentially in the ventral region. Quantitative differences in morphology and cytology exist among selected Simonsiella strains. Functional aspects of this dorsal-ventral differentiation are discussed with respect to the colonization and adherence of Simonsiella to mucosal squamous epithelial cells in its ecological habitat, the oral cavities of warm-blooded vertebrates.


Heterotrophic growth of Thiobacillus A2 on sugars and organic acids.

Thiobacillus A2 grew on a number of organic acids, pentoses, hexoses and alpha-linked disaccharides, but not on beta-linked disaccharides or galactosides. Growth was slow on glucose, although fast-growing strains were selectively isolated. Additive growth rates occured on glucose and galactose; growth on glucose with fructose, pyruvate or gluconate was biphasic rather than diauxic; fructose was used preferentially over glucose;  slow growth on glucose was accelerated by some disaccharides; growth on acetate, fumarate or succinate with glucose gave diauxic growth with preferential use of the acid and repression of glucose incorporation. Acetate and succinate tended to be used preferentially even with cultures grown on them in mixture with fructose or sucrose.


A series of mutant strains of Scenedesmus obliquus with abnormal carotenoid compositions.

Several mutant strains of Scenedesmus obliquus (Chlorophyta) have been isolated which, when cultured heterotrophically, are pale green or yellow, in contrast to the dark green of the wild type. On the basis of their carotenoid compositions, four groups of pale-green strains have been delineated. These accumulate, respectively, no carotenoid, phytoene, mainly zeta-carotene and mainly zeta-carotene together with some neurosporene and lycopene. All these strains synthesized no chlorophyll b and only small amounts of chlorophyll a. A further group of yellow strains produced the normal Scenedesmus obliquus range of cyclic carotenes and xanthophylls, but no chlorophyll. Most of the pale-green strains were killed by exposure to light, but two strains, PG1 and 1E, which accumulated predominantly zeta-carotene when grown in the dark, survived exposure to the light and developed photosynthetically active chloroplasts containing the normal pigments. The possible biosynthetic implications of the carotenoid composition of these mutant strains, and the relationshp between the carotenoid composition and protection of the cells from photooxidative destruction are discussed.


Simultaneous operation of three catabolic pathways in the metabolism of glucose by Thiobacillus A2.

Enzymes essential to the operation of the Embden-Meyerhof glycolytic pathway, the Entner-Duodoroff pathway and oxidative pentose phosphate pathway were present in Thiobacillus A2 grown on glucose and other sugars. Radiorespirometry under various conditions with Thiobacillus A2 oxidising glucose specifically labelled with 14C in carbon atoms 1, 2, 3, 3 + 4, 6 or universally labelled demonstrated the simultaneous operation of the Embden-Meyerhof (48%), Entner-Doudoroff (28%), and pentose phosphate (24%) pathways in release of carbon dioxide from glucose. Growth on succinate, or autotrophically on formate or thiosulphate resulted in repression of most enzymes of the pathways, but high aldolase levels were retained indicating its role in gluconeogenesis and the Calvin cycle. Different fructose diphosphatase activities were found in succinate- and thiosulphate-grown organisms. The results indicate that all three major catabolic pathways for glucose function in Thiobacillus A2 grown on sugars. Thiobacillus acidophilus showed a different radiorespirometric pattern and apparently used the Entner-Duodoroff (64.5%) and pentose phosphate (35.5%) pathways, but showed unusually high release of carbon atom 6, as was also found for T. ferrooxidans.


The effect of illumination on the pigment composition of the zeta-carotenic mutant, PG1, of Scenedesmus obliquus.

Dark grown Scenedesmus obliquus strain PG1 accumulated zeta-carotene and phytoene as its major carotenoids. On illumination of dark-grown cultures in air/CO2, cyclic carotenes and xanthophylls were formed, apparently at the expense of the accumulated phytoene and zeta-carotene. This interconversion of carotenoids was accompanied by chlorophyll synthesis. In an atmosphere of nitrogen/CO2 the light-induced changes occurred more slowly and in nitrogen alone the changes were incomplete. No massive production of cyclic carotenes from the accumulated zeta-carotene was observed in cultures illuminated under anaerobic conditions.


Alcoholism and depression in adopted-out daughters of alcoholics.

Forty-nine daughters of alcoholics were compared to 47 daughters of nonalcholics; both groups of women (average age, 35 years) had been adopted by nonrelatives early in life. Two women in each group were alcoholic or problem drinkers. Although this is above the expected rate of alcoholism among women, the numbers are too small to draw definite conclusions. Almost all were light drinkers. Daughters of alcoholics had no more depression than controls, indicating that alcoholism in the biological parents did not increase the risk of depression in daughters raised by foster parents. Environmental factors may be important in both alcoholism and depression in women, since both tended to be correlated with psychopathology in the foster parents.


Differentiation of alcoholics. Childhood history of minimal brain dysfunction, family history, and drinking pattern.

Alcoholics were differentiated into two subgroups on the basis of drinking patterns and subjective response to alcohol. Severe drinkers (primary alcoholics) retrospectively reported more symptoms of childhood minimal brain dysfunction than less severe drinkers (secondary alcoholics), psychiatric patients, and normals. The alcoholics as a group reported a greater incidence of familial alcohol abuse than the psychiatric subjects, but a difference on this factor was not observed between the primary and secondary subgroups. In terms of clinical status, the primary alcoholics presented Minnesota Multiphasic Personality Inventory profile more indicative of normality than the other groups, but scored significantly higher on the MacAndrew Alcoholism Scale. These findings are discussed in light of further delineating a specific subtype of alcoholism that may have a genetic-constitutional relationship with other pathological disorders.


Schizophrenics' adopting parents. Psychiatric status.

With the exception of one finding in one experiment, adoption studies have demonstrated that genetic and not rearing factors play an etiological role in the schizophrenias. In that one study, clinical evaluations showed the biological parents of schizophrenics as more disturbed than the adopting parents of schizophrenics, who were, in turn, slightly more disturbed than the adopting parents of normal persons. Both the biological and the adopting parents of schizophrenics showed an equivalent degree of Rorschach pathology, suggesting the possible role of a learned communication disorder in the schizophrenic disorders. A replicative study were performed, employing the same design but utilizing a systematic sample. Structured interviews and tests were administered to the biological parents of nongenetic retardates. Structured clinical evaluation showed the biological parents of schizophrenics to be more disturbed than the other two groups, between whom there was no difference in psychopathology. With analysis of the Rorschach tests, the biological parents of schizophrenics showed significantly more Rorschach pathology than found in the other two groups, whose degree of disorder was the same. This study again confirms the role of genetic factors and fails to show an environmental component in the etiology of the schizophrenias.


The offspring of schizophrenics. II. Perinatal factors and IQ.

Within a sample of 60 children of schizophrenic parents, IQ and the correlates of IQ were examined. The Wechsler Intelligence Scale for Children was administered at age 7. The offspring of parents with schizophrenia were found to have a slightly lower IQ than their matched controls. This deficit could be attributed entirely to the male offspring. Using a second comparison group numbering several thousand, we computed correlations for various perinatal and socioeconomic factors with seven-year IQ. These correlations were also computed for the children of schizophrenics, and the difference in correlations was examined. IQs for the offspring of "continuous schizophrenics" (chronic, borderline, and chronic schizo-affective schizophrenics) were found to have lower correlations with socioeconomic indices and higher correlations, in a negative direction, with certain perinatal events. The findings were found to a lesser, nonsignificant degree among the small sample of offspring of acute schizophrenics. If these perinatal events are more negatively correlated with IQ because the children of continuous schizophrenics are specifically susceptible to them, it is possible that these factors are also influential in the later development of schizophrenia.


Platelet methylene reductase activity in schizophrenia.

A case of a folate-responsive psychosis that was associated with a defect in N5-10-methylenetetrahydrofolate reductase (methylene reductase) suggested the need to examine whether abnormally low activity of this enzyme might be of etiological importance in schizophrenia. We now report that there were no statistically significant differences in the platelet methylene reductase activity of chronic schizophrenics, compared with either hospitalized or nonhospitalized age-matched control subjects. Although it is possible that a larger survey might reveal a subpopulation of schizophrenics who are characterized by abnormal methylene reductase activity, this study suggests that chronic schizophrenia is not generally associated with such changes.


Failure of methadone and levomethadyl acetate (levo-alpha-acetylmethadol, LAAM) maintenance to affect memory.

Memory tests were administered to 30 patients taking methadone hydrochloride and 31 taking levomethadyl acetate (levo-alpha-acetylmethadol, LAAM) both prior to treatment and after one and three months of continuous treatment. A group of nonopiate using matched control subjects was administered the tests at similar intervals. No statistically significant difference in test performance was found among these groups at any of the three sessions. The methadone and control groups also did not differ significantly in the frequency of subjective reports of decreased memory function. Previous reports of memory deflicits during long-term methadone administration may be a result of comparing methadone and control groups at a single point in time and assuming that prior to methadone maintenance the groups were equivalent.


Symptom patterns in primary and secondary depression. A comparison of primary depressives with depressed opiate addicts, alcoholics, and schizophrenics.

The primary-secondary distinction in affective disorders has been proposed to reduce the heterogeneity of depression. An investigation of the frequency of secondary depression and its nature in depressed opiate addicts, alcoholics, and schizophrenics was undertaken. Findings show that secondary depression in ambulatory patients with other psychiatric disorders is relatively common. The sociodemographic characteristics of the secondary depressive are consistent with the population from which they derive but differ from primary depressives. The symptom patterns of secondary depressives are similar to primary depressives but are overall less severe. These findings give further support to the value of separating out secondary from primary depression in future research studies.


Model studies in tumor incidence.

Two models of tumor incidence predicting the latency period as a function of the applied dose of a carcinogenic compound yield the same relationship as it has been empirically stated by Bryan and Shimkin (1,2). One model is based on a single-cell damage, the other one on a disturbtion of proliferation control within the cell population. The observed latency periods compared to the predicted values show that the tommunication model is a better basis for understanding chemical carcinogenesis than the single cell incidence.


What's wrong with the theoretical research on molecular mechanisms of the chemical cancerization process.

The theoretical research on molecular mechanisms of chemical cancerization process is essentially a statistical problem in nature. Failing to have this notion in mind, many researchers in this field have engaged sterilizing controversies on the existence or the non existence of a correlation between the carcinogenic potency of a substance and some of its molecular properties. The following report is an example showing how the statistical concept and methods are necessary to resolve these problems.


Stability of the antigen expression in the spontaneous mammary adenocarcinoma during cultivation and absorbtion with immune serum.

Transplantable spontaneous mammary adenocarcinoma cells were cultivated in vitro under standard cell culture conditions, in presence of extracellular protease, in cottonstoppered bottles, and in presence of antitrypsin. At time intervals, aliquots from each were removed and examined for transplantability, response to humoral antibody, and to cytotoxic activity of spleen cells from immune animals. Under standard conditions, cells cultivated for 300 days or more became non-transplantable and 74% survived the killing effect of immune spleen cells. In presence of an extracellular protease, the cells maintained their transplantability and 23% survived the cytotoxic effects of the immune spleen cells. In cotton-stoppered glass bottles without HEPES, the cells maintain their transplantability and they survived the killing effect of the immune spleen cells. Finally, in presence of antitrypsin, the cells became less transplantable, remained sensitive to the toxic effects of the immune spleen cells. When absorbed with adenocarcinoma anti-serum, cells cultivated under standard cell culture conditions, or cultured in presence of antitrypsin became less transplantable, whereas, cells grown in cotton-stoppered glass bottles or in presence of the extracellular protease maintained their transplantability.


[A method for determining the biological effectiveness of ionizing irradiation by evaluation of mitotic depression of Ehrlich-ascites-tumour cells (author's transl)].

In the present paper there are given the conditions for evaluating the biological effectiveness of Co60-gamma-irradiation by determination of mitotic depression at a defined time after irradiation. Using the model of Ehrlich-ascites-tumour of mice the mitotic index was determined four days after inoculation and one hour after irradiation for doses of 50, 100, 200 and 300 rad. The dose-effect curve- show in the given range of doses an unambiguous dependence of the mitotic depression on the applied dose which can be clearly represented semilogarithmically by regression analysis in an analytical manner. Hence, this dependence may be useful for comparative studies of biological effectiveness of radiation with different LET.


A very significant correlation between carcinogenic activity of polycyclic hydrocarbons and certain properties of their transition states in the range of the lowest triplet states of the DNA.

A very significant correlation between carcinogenic power of polycyclic aromatic hydrocarbons and their probability of photoinduced double resonance transitions in the UV-range of about 3 to 3.5 eV is shown. The resonance can be interpreted in terms of the lowest triplet state energy of thymine at 3.25 eV and the energy difference between the triplet states of A--T and G--C base pairs. The correlation has been predicted from a hypothesis which describes cell communication by photon interaction within a cell population.


The passage of thiamine across the rat placenta and its uptake by the fetal organs. I. The transport of thiamine across the placenta.

It is well known that thiamine is highly soluble in water. However, if chloroplatinic acid (H2PtCl6) is used during fixation, an insoluble, electron-dense thiamine-PtCl6 precipitate is formed. Using this method we performed electron microscope autoradiography of the placental labyrinth of rats in their 15th day of pregnancy after injection into the maternal bloodstream of 3H-thiamine, and we also measured the radioactivity of the tissues, in order to study the transport of the thiamine across the placenta. Both developed silver grains and radioactivity were found in the largest amounts 30 min after injection; the amounts of both declined after 2 hrs and declined further after 5 hrs. The majority of the developed silver grains were localized in the smooth-surfaced endoplasmic reticulum, which is generally thought to be the vehicle for the transport of materials in the cell, while in the mitochondria, Golgi apparatus, etc. the grains were few. Considering the substantial depletion of the amounts of both sivler grains and radioactivity after the relatively short time of 5 hrs, we conclude that the greater portion of the thiamine passes quickly across the placenta to the fetus, where it is used in the metabolism of the fetal organs, and that only a small part of the thiamine is retained in the placenta for its own metabolism.


The passage of thiamine across the rat placenta and its uptake by the fetal organs. II. The uptake of thiamine by fetal organs.

Having injected 3H-thiamine into the maternal bloodstream of rats in their 15th day of pregnancy, the uptake by the fetal organs (liver and cardiac muscle) of the 3H-thiamine which had been transported across the placenta was studied by electron microscope autoradiography and by measuring the radio-activity of the tissues, using the same methods reported in the first paper of this series. In the fetal liver both developed silver grains and radioactivity were found in greates amounts in specimens collected 5 hrs after injection. Developed silver grains were abundant in the mitochrondria, Golgi apparatus, rough-surfaced endoplasmic reticulum, glycogen area, and nucleus, indicating that these cell organelles take up thiamine and utilize it for the cell metabolism. In the fetal cardiac muscle, the developed silver grains and radioactivity were found in greatest amounts 2 hrs after injection. The silver grains were abundant in the glycogen area, Golgi apparatus, and myofibrils, but they were especially abundant in the mitochondria. This indicates that thiamine is taken up by these organelles and employed in the cell metabolism.


Scanning electron microscopy of the third ventricular wall in the lamprey, Lampetra japonica.

The third ventricular wall and its adjacent region of the arctic lamphrey, Lampetra japonica, were studied by scanning electron microscopy to elucidate their surface fine structures. The specimens were caught in the mouth of the river during their anadromous migration. The ventricular wall is covered entirely with the cilia of ependymal cells, with the exception of the ventral side of the lateral wall, the floor of the recessus infundibuli and a portion of the recessus posteriosus. In the ependymal layer covering the ventral side of the lateral wall, numerous protrusions of neurons are found equipped with microvilli and cilia. These neurons seem to correspond to the liquor-contacting neurons. Ependymal cells identified as tanycytes occur in the posterior portion of the floor of the recessus infundibuli. The apex of the tanycyte is provided with numerous microvilli and a bundle of cilia, while its basal projection extends towards the outer layer of neurohypophysis to make contact with the capillary wall. A small spherule considered to be a secretory substance is observed near the root of the ciliary bundle. tthe recessus posteriosus consists of a layer of ependymal cells and neurons with an apical projection into the ventricular cavity. Possible intraventricular macrophage (Kolmer cell) is found in the lamprey.


An electron microscope study of the intestinal absorption of medium chain and long chain triglycerides in the rat.

The ultrastructural changes in the intestinal absorptive cells of the rat during the absorption of triglycerides, Particularly medium chain triglyceride (MCT), were studied by electron microscopy. In the absorptive cell of rats fed with MCT, the agranular endoplasmic reticulum in tubular form was remarkably proliferated throughout the cytoplasm as compared with that of fasting rats. The granular endoplasmic reticulum was mostly transformed into the same tubulo-vesicular form as the agranular endoplasmic reticulum. Chylomicra, which were consistently observed in the endoplasmic reticulum of the intestinal absorptive cell of rats fed with long chain triglyceride (LCT), did not appear in that of MCT-fed rats, although small lipid particles were noticed within it. The Golgi lamellae decreased in number and length. During the absorption of MCT, the central lacteal contained some lipid particles which were smaller in size than the chylomicron which appeared in the LCT-fed rats. These evidences might suggest that the majority of MCT administered was transported through the absorptive cell without reesterification in the endoplasmic reticulum into the portal vein system, and only a minor part of the MCT given was transported via the central lacteal after reesterification.


Rat interferons. IV. Sialoproteins in rat serum.

Introduction of virus as inductor of interferon into rats caused a decline in serum levels of sialic acid in blood taken at the time of maximum interferon activity. Differences in the acute phase proteins were dependent on the type of virus used for induction. NDV injected intravenously did not lower serum levels of seromucoid, but given together with DMSO markedly depressed the content of this protein in the serum. Stimulation of interferon production by Sindbis virus was accompanied by a significant rise in levels of seromucoid. The same virus given together with DMSO had no effect on protein level, which remained normal, but lowered the content of sialic acid in proteins.


Surface glycoprotein components in isolated melanotic melanoma cells in the golden hamster.

A study of glycoprotein components in trypsin-digested material from the surface of isolated melanotic melanoma cells showed presence of amino sugars, protein-bound hexoses, fucose and sialic acids. The high content of fucose and low content of sialic acids in the surface material from the cells were striking.


Actinomycetes of the genus Streptomyces in soil from Syria.

Species identification and antagonistic properties of 55 actinomycete strains isolated from Syrian soil were studied. The actinomycete strains belonged to 22 species, of which most abundantly represented were Streptomyces antimycoticus, S. rubiginosohelvolus, S. macrosporeus and S. coerulescens. Actinomycetes belonging to 16 species exhibited antagonism in relation to Gram-positive and Gram-negative bacteria, fungi and neoplastic cells.


Regulation of growth and DNA synthesis in mouse lymphoma L5178Y cells under conditions of nutrient depletion.

The effect of cultivation of L5178Y lymphoblasts to high density and in two kinds of nutrient-depleted medium on their growth was observed. It was found that in cell population grown to stationary phase the mitotic index and labeled thymidine incorporation dropped about 3 times in comparison with exponential control. Upon dilution with fresh medium the cells resume traverse the life cycle in partially synchronized manner. Cultivation of the cells in medium with 0-5% serum induced very rapid loss of their viability. Cultivation of the cells in medium without asparagine and with dialyzed serum caused significant slowing of their growth-rate and upon dilution with complete medium the cells entered the exponential rate of division in an asynchronous manner.


Surface immunoglobulins and lymphocyte adhesiveness in materno-neonatal pairs.

Surface immunoglobulins and lymphocyte adhesiveness were studied at birth in 20 materno-neonatal pairs. The percentages of B lymphocytes and spontaneous adhesiveness of lymphocytes were higher in the mothers than in the newborns.


Surface immunoglobulins and lymphocyte adhesiveness during development.

Surface immunoglobulins and lymphocyte adhesiveness were studied in 86 children divided according age into six groups. The percentages of B lymphocytes in newborns and older children were similar, but spontaneous lymphocyte adhesiveness in newborns was much lower. The group of one-year-old children had distinctly lower percentages of lymphocytes with surface immunoglobulins of the I gA + IgM / IgG classes compared with all the other developmental groups.


Surface immunoglobulins and lymphocyte adhesiveness in dystreptic children.

Surface immunoglobulins and lymphocyte adhesiveness were studied in 32 malnourished children. Percentages of lymphocytes carrying surface immunoglobulins showed marked dispersion in dystreptic children. Compared with the group of healthy children of the same age groups dystreptic children showed no significant differences in the percentages of lymphocytes with surface immunoglobulins of different classes or of their sum. The morphologic composition of lymphocytes in dystreptic, compared with healthy children, was similar, but adhesiveness of small lymphocytes was higher in dystreptic children.


Osmotic fragility of erythrocytes and lymphocytes labeled with chromium 51.

Osmotic fragility of lymphocytes and erythrocytes isolated from the same blood sample was studied. Release of 51Cr from lymphocytes and erythrocytes under the influence of distilled water and solutions (NaC1 from 0-1% to 4% and 0-83% NH4C1) was compared.


Serologic relationship of fimbriae among Enterobacteriaceae.

The existence of serological relationship of fimbriae among serotypes of the same genus and among genera of Enterobacteriaceae was determined by agglutination and absorption procedures. It was found that fimbriae of different serotypes of the same genus and among the genera a) Escherichia, Shigella and Klebsiella, and b) Salmonella, Arizona and Citrobacter were more or less antigentically related. No relationship was found among fimbriae of the Edwardsiella, Enterobacter, Hafnia, Serratia, Proteus and Providencia. It was also found that in Klebsiella, MS and MR fimbriae differed antigenically. On the basis of the results obtained nine antigentically distinct types of fimbriae were distinguished.


Lymphocyte response in in vitro cultures to some mitogens, and serum immunoglobulin levels in aged subjects.

Capacity of lympocytes for blastic transformation in in vitro cultures under the influence of PHA and PWM was studied in 40 subjects aged 20--60 years and in 43 aged 60--100 years. In the higher age group, in about 25% of cases, low percentages of blasts in cultures stimulated with PHA and PWM were observed. In 101 subjects aged 65--100 years, the mean level of IgA in serum was significantly higher compared with the 20--40-year age group. In some cases, levels of two or three immunoglobulin classes were raised. The unexplained changes in the reaction of lymphocytes to PHA and PWM and in levels of serum IgG were attributed to the old age of the subjects.


Intermittent bladder emptying via urethral catheterization or suprapubic cystocath: a comparison study.

A prospective study was undertaken to compare patients with recent spinal cord injuries undergoing bladder training by conventional intermittent urethral catheterization with a similar group treated with the Cystocath. Our present information suggest there are no differences with respect to episodes of bacteriuria encountered or for time spent by the catheter team for each procedure. Paraplegics tended to reach balanced bladder status more easily without surgery while quadriplegics did not. The bladder training program was shorter on the average for the Cystocath group. Further investigation is necessary to determine whether this is significant. Problems encountered were minimal and fewer than reported in the literature. We find no reason not to employ the Cystocath in bladder training programs in spinal cord injured patients.


Chemonucleolysis: evaluation of effectiveness by electromyography.

Findings in 97 consecutive patients who had undergone chemonucleolysis were analyzed. The purpose of this prospective clinical study was two-fold: (1) to provide a comparison of preoperative findings of electromyography, myelography and discography and (2) to evaluate postoperative electromyography as an objective test of recovery. All the patients had complete history and physical examination, five-view roentgenographic study of the lumbosacral spine, electromyography preoperatively and again at three months postoperatively, myelography and discography. Computer analysis of the results was done for the multiple cross-correlations in the study. All patients had had at least three months preoperative conservative care without relief of symptoms. The study shows that electromyographic study three months postchemonucleolysis is of value for corroboration of clinical improvement only if the EMG becomes completely normal. A greater percentage of patients recovered clinically after chemonucleolysis when the preoperative EMG was normal as compared to those for whom the preoperative EMG was abnormal. We were surprised to find no significant correlation between end result and the existence of pending litigation.


Diabetic peripheral neuropathy: a correlation of nerve conduction studies and clinical findings.

The electrophysiologic and clinical characteristics of diabetes were studied in 56 patients having diabetes of adult onset. Historical data including age, duration of diabetes, treatment type, family history and clinical symptoms were noted. Nerve conduction studies of the median, ulnar, peroneal, tibial and sural nerves were performed, and the H reflex was determined. Clinical sensory function of vibration, light touch, and two-point discrimination, muscle stretch reflexes in all four extremities and skin temperatures in the lower extremities were recorded. The data indicated a close correlation of clinical and electrophysiologic findings. The data supported the concept that diabetic peripheral neuropathy is progressive. It was concluded that diabetic peripheral neuropathy was present if two of the following three determinations were abnormal: median motor or sensory latency, ulnar sensory latency and sural latency.


Anal sphincter stretch: a technique to overcome detrusor-sphincter dyssynergia.

Intermittent catheterization has become a well-accepted method of management of the neurogenic bladder following spinal cord injury. Frequently, the presence of detrusor-sphincter dyssynergia interferes with the attainment of acceptable residual urine volumes in patients with upper-motor-neuron bladders. We have recently reported success in overcoming the problems of dyssynergia in some patients utilizing a technique called anal sphincter stretch in which relaxation of the external anal and urethral sphincters is produced by sustained distention of the anal sphincter. This has lessened the need for other measures that usually produce incontinence and has met with good patient acceptance. An update on the results of using this technique is presented. Although we have previously encountered quadriplegics who might have benefited from sphincter stretch, the lack of hand intrinsic muscle function required for the patient to perform it independently has precluded its use. We herein present a device that circumvents inadequate hand function, and which has enabled four C-7 quadriplegics to achieve satisfactory bladder emptying.


Carpal tunnel syndrome or trigger finger associated with neck injury in automobile accidents.

Among 450 patients examined for neck pain following automobile accidents, carpal tunnel syndrome (CTS) was diagnosed in four and trigger finger (TF) in three. All seven patients sustained cervical sprains and were drivers or passengers in automobiles which received impacts from the rear. All seven patients reported the onset of hand symptoms during or shortly after the accident. This unusual occurrence, not previously reported, appears to be related to the events which occurred at the time of the accident. The mechanism of injury for CTS is hypothesized to be median nerve compression by momentary acute hyperflexion or hyperextension of the wrist(s), while tightly grasping the steering wheel or bracing for impact. The cause of TF is suspected to be direct trauma to the flexor tendon and sheath by compression against bony prominences when the finger is hyperflexed or hyperextended. This can occur during the accident while forcefully grasping the steering wheel with acutely hyperflexed fingers.


Evoked brain potentials and disability in brain-damaged patients.

Various measures of evoked brain potential abnormality (EPA) were correlated with disability ratings (DR) for 35 brain-damaged patients. EPA data consisted of judgements of abnormality of ipsilateral, contralateral and bilateral responses to auditory and visual stimuli reflecting activity in the brain stem, subcortex and cortex. DR data were obtained from a scale developed for this study to quantize and categorize patients with a wide range of disabilities from coma to normal functioning. EPA scores based on visual and auditory cortical responses showed significantly positive correlations with degree of disability. Visual response correlation was .49, auditory .38 and combined visual and auditory .51. It was concluded that EPA measures can reflect disability independently of clinical information. They are useful in assessing brain function in general and, specifically, in assessing impairment of sensory function. The evoked potential technique was particularly useful in patients who were not able to participate fully in their own examination. There were indications that the technique may also be valuable in monitoring progress and in predicting clinical outcome in brain-damaged patients.


Stroke rehabilitation: maintenance of achieved gains.

Gains made during rehabilitation following stroke were maintained or improved by the majority of rehabilitants when assessed 2 to 12 years later. Five measures of rehabilitative activity studied were self care, mobility, amount of time spent at the rehabilitant's major daily activity, vocational status, and over-all rehabilitative status. Independent variables that correlated positively with these rehabilitative functions were living at home, rather than in a nursing home, and the rehabilitant's having an accepting, rather than non-accepting, attitude about his present status. The functional levels of rehabilitation are maintained as well through education of the rehabilitant and his family as through the use of public health nursing and community resources. The interviewed rehabilitants in this study maintained the gains in function achieved during stroke rehabilitation throughout the long survival time, averaging seven to eight years; and functional loss, when it did occur, was usually secondary to a superimposed health problem. This study shows that the gains in the level of functioning achieved during stroke rehabilitation presist in long-surviving stroke patients and that the quality of life is enhanced from the perspectives of the patient and his family.


Adult aphasics: relationship between convergent and divergent semantic behavior.

The purpose of the present study was to empirically evaluate the relationship between the ability of 30 aphasic subjects to produce a number and a variety of semantic responses with their ability to produce highly, knowledge-oriented, automatic responses. That is, the relationship between divergent and convergent semantic behaviors was explored. Use of both types of tasks will more adequately reflect the semantic strategies needed for spontaneous communication in day-to-day life situations. Results of the present study show that divergent and convergent behavior seem to require separate and distinct abilities for aphasic subjects. The strong and significant correlations between subject performance on the verbal, gestural and graphic convergent variables and subject ability to produce a number and a variety of relevant semantic responses confirms the fact that aphasia is both a divergent and a convergent semantic disorder. The findings of the present study therefore indicate the need to create diagnostic and therapeutic paradigms with divergent tasks that emphasize a variety, quantity and relevance of output from the same source, as well as the more traditional convergent tasks that are more highly knowledge oriented.


Exercise effect on strength and range of motion of hand intrinsic muscles and joints.

The intrinsic muscles of the hand are largely neglected in training, mainly because certain biomechanical principles must be applied in order for these muscles to be involved in hand exercises. Following these principles, a system of stretching and isometric exercises was developed. Twelve men exercised for four weeks, three times daily. Significant improvement in seven out of the 12 strength measurements was noted. Exercise seemed to affect just the metacarpophalangeal joints range of motion, while distal and proximal interphalangeal joints remained largely unaffected.


Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity.

Two series of bypass operations performed to bring about weight reduction in morbidly obese patients are compared. The same criteria determined patient selection, and all patients were operated on and followed up by the same surgeon. The first group of 100 patients underwent a 14-4 jejunoileostomy, and the second group of 100 underwent a modification of the gastric bypass procedure, in which 90% of the stomach is bypassed. The safety and operating time of the two operations were about equal, but long-term complications of the jejunoileal bypass were greater in frequency, duration, and seriousness. For this reason, the modified gastric bypass described here is preferred.


Isolated small bowel obstruction as the presenting feature of colonic disease.

Small intestinal obstruction without colonic dilation can be the mode of presentation in a variety of colonic diseases, including carcinoma, diverticulitis, and colitis. Plain abdominal roentgenograms may lead the unwary physician into errors of diagnosis and treatment by suggesting primary small bowel disease. Barium enema examination of the colon will keep the wary physician out of such traps. We describe five patients with small bowel obstruction who had a variety of colonic diseases diagnosed by barium contrast studies. If the reason for intestinal obstruction is not apparent and the need for emergency surgery is not compelling, we recommend an immediate contrast study of the colon to aid in evaluating possible colonic pathology.


Anterior spinal artery syndrome following abdominal aortic aneurysmectomy. Case report and review of the literautre.

Paraplegia developed in a 70-year-old man after resection of a ruptured abdominal aortic aneurysm during which aortic occlusion time was 45 minutes. Between one and three months postoperatively, he progressively recovered motor function to the point where he could walk unaided. Only four patients have previously been reported to recover from paraplegia produced in this manner. A review of the literature on the anatomy of the arterial supply to the spinal cord indicates the importance of the anterior spinal artery and the artery of Adamkiewicz (arteria magna radicularis). Paraplegia is more common in patients with hypotension and when backbleeding from the lumbar arteries has been poor.


Grey-scale ultrasonography in the differential diagnosis of jaundice.

One hundred fifty patients with cholestatic jaundice were studied prospectively by grey-scale ultrasonography. All patients had a diagnosis established by subsequent biopsy, autopsy, or surgery. Using the presence or absence of a dilated biliary tree as the criterion, the intrahepatic or extrahepatic nature of the jaundice was correctly differentiated in 145 of 150 patients, an accuracy of 97%. All 64 of the patients with intrahepatic jaundice were correctly identified. Five of the 86 remaining patients, each of whom had gallstones, were misdiagnosed. In eighty-two patients (54.7%), the specific etiology was diagnosed. Ultrasound is an accurate method for the evaluation of jaundice and would appear to have a definite value as a screening procedure before proceeding to more invasive studies.


Traumatic popliteal arteriovenous fistula. Diagnostic methods and surgical management.

The popliteal vessels rank second only to the external iliac system as the most frequent site of acquired arteriovenous communication. Direct trauma to the popliteal space is by far the most common cause, and surgical intervention is usually required to manage the defect. We present a recent illustrative case following meniscectomy. To our knowledge, the occurrence of an arteriovenous fistula complicating knee surgery has not been reported previously. This case outlines the potential value of B-mode ultrasound in diagnosis and the use of intraoperative angiography in assessing the adequacy of primary vascular reconstruction. Earlier experience of this vascular abnormality--six additional cases since 1941--is reviewed.


Internal retrovesical hernia producing intestinal obstruction. Report of a case.

A patient with clinical signs of complete intestinal obstruction was found at celiotomy to have a loop of small intestine caught in the narrow opening of a defect located in the transverse peritoneal fold of the urinary bladder and extending into the retrovesical space. This report aims at bringing attention to internal retrovesical hernias, an entity scarcely mentioned in the literature, as a possible cause of small bowel obstruction.


Saccular atherosclerotic aneurysm of the superior mesenteric artery.

We report on the successful surgical resection of an aneurysm of the superior mesenteric artery. The saccular nature of the aneurysm and evidence of celiac axis occlusion in this patient posed an additional challenge in the successful surgical treatment.


Diagnostic, prognostic, and therapeutic nerve blocks.

During the past three quarters of a century, nerve blocks have been used with varying success as a primary treatment technique for patients with acute and chronic pain. However, practicing dolorologists soon realized that, in certain individuals, anesthetic blocking of noxious, peripheral afferent sensations did not always amelliorate pain complaints and at times even exaggerated them. The recent advent of the multidisciplinary approach to the management of pain, including neurosurgical procedures, new drugs, electrical stimulation and psychosocial intervention, has helped to clarify the indications for, limitations of, and disadvantages of the use of nerve blocks. The purpose of this article is to place nerve blocks in proper perspective and to define their role among the many methods currently available for the evaluation and control of severe pain.


Neurosurgical control of chronic pain.

The neurosurgeon can play a significant role in the management of chronic pain. This potential is all to often unrealized or distorted by a lack of knowledge about patients who are suffering from chronic pain. Patient selection is the most important determinant of successful surgical therapy. Patients with chronic pain due to a neoplasm should be offered prompt, definitive neurosurgical intervention. Neurosurgical therapy is less likely to be successful if the pain is secondary to benign disease; tic douloureux is an exception to this rule. If chronic pain behavior is not primarily due to noxious peripheral input, surgery is unlikely to yield any long-term benefit. Augmentation of input by skin stimulation or electrical stimulation of various regions in the peripheral and central nervous system may become important therapeutic procedures for the neurosurgeon.


Obturator hernia: an elusive diagnosis.

Obturator hernia is an uncommon problem that occurs predominantly in elderly, debilitated women. The diagnosis should be suspected in such patients who have evidence of small bowel obstruction, often initially intermittent, and who complain of pain along the anteromedial aspect of the thigh. We present experience with three patients that characterizes the difficulties in diagnosis and treatment. Most patients require resection of the incarcerated bowel. Mortality is variable and is related to the condition of the patient.


Mediastinal masses in infants and children.

In a group of 93 pediatric patients with mediastinal masses, three quarters of them were diagnosed because they were symptomatic. Approximately one half of the masses were malignant, and of neurogenic or lymphomatous origin. Neurogenic tumors predominated before the age of 4 years, while lymphomas were most common beyond age 4. Two thirds of the malignancies were potentially curable by surgery, irradiation, and chemotherapy; 54% of the patients were salvaged. Enteric duplications, ganglioneuromas, bronchogenic cysts, hemangiolymphangiomas, thymic cyst, and teratomas were the most frequently occurring benign masses. Simple excision was uniformly effective in these lesions.


The profunda femoris-popliteal artery bypass.

The profunda femoris artery can be used for the origin of a femoropopliteal bypass in cases of previous aorto femoral bypass graft, short saphenous vein, and other less common conditions that render the common femoral artery unsuitable for proximal anastomosis. Fourteen profunda-popliteal bypass procedures were performed in 12 patients between 1973 and 1976. The indications for surgery were incapacitating claudication in seven, and rest pain or tissue necrosis in five patients. Electromagnetic flow measurements at operation in ten patients indicated a mean graft blood flow of 146 +/- 51 ml/min. The mean Doppler ankle/wrist pressure ratio improved from 0.48 +/- 0.11 preoperatively to 0.87 +/- 0.14 postoperatively, while the plethysmographic mean pulse volume increased from 1.1 +/- 0.6 microliter to 2.4 +/- 0.4 microliter. Thirteen of the 14 grafts remain patient at one to three years' follow-up. The profunda-popiteal bypass is an effective alternative to standard femoropopliteal bypass in cases where the common femoral artery is not available for proximal graft anastomosis.


Treatment of carcinoma of the sigmoid colon and upper rectum. A comparison of local segmental resection and left hemicolectomy.

We report a retrospective study of 107 cases of carcinoma of the sigmoid colon and upper rectum treated for primary cure at the University of California at Los Angeles Hospital between 1955 and 1970. Excluded from this analysis were patients treated by abdominoperineal resection, local excision, fulguration, or abdominoperineal pull-through procedures. Ninety-one patients were treated by local segmental resection and 16 by left hemicolectomy. Both groups were similar in regard to patient age and general health, lesion size, location, and pathological Duke's classification. Five-year survival was 70.3% after local segmental resection and 56.3% after left hemicolectomy. Hospital mortality was 1% after the former and 6.2% after the latter. Rate of recurrence after local segmental resection was 41% of that seen after left hemicolectomy, while complications were one-third as great. The present results after local segmental resection are comparable to the results reported in the literature when hemicolectomy was the procedure used. The data presented suggest that local segmental resection is an effective cancer operation for carcinoma of the sigmoid and upper rectum, and is fraught with a lesser morbidity and mortality than a radical left hemicolectomy.


Ipsilateral blindness: a complication of carotid endarterectomy.

We report on three patients in whom ipsilateral blindness developed following carotid endarterectomy. Fundoscopic examination of the retina documented ischemia and the visual field defects were permanent. In one patient, the internal carotid artery was patent and thought to be the conduit for embolization to the eye. Two patients had chronic occlusion of the internal carotid artery, and blindness resulted from atheromatous emboli to the eye through the external carotid artery in one and from postoperative thrombosis of the external cartoid artery in the other. Our experience calls attention to this infrequently reported complication of carotid endarterectomy and emphasizes the importance of the external carotid artery, especially when the internal carotid artery is occluded.


Control of hepatic bleeding with microfibrillar collagen.

Microfibrillar (Avitene) is a new absorbable topical hemostatic agent whose mechanism of action is platelet entrapment and activation of platelet clotting factors. It adheres to moist tissue surfaces to form a firm, flexible hemostatic coagulum. It has been used clinically in 36 patients with hepatic bleeding of diverse etiology, including bleeding from the gallbladder fossa, lacerations, resectional surfaces, biopsy sites, capsular denudations, and hepatic tumors. Although not intended to control major hemorrhage were major vessel ligation or resection is properly indicated, its topical use for diffuse small vessel bleeding may be life-saving. It is exceptionally useful in such conditions as cirrhosis and in thrombocytopenic or thrombasthenic coagulopathies. One treatment failure out of 36 occurred.


Noninvasive methods for evaluation of extracranial cerebrovascular disease. A comparison.

Sixty-five patients with clinical evidence of carotid occlusive disease were evaluated by the Doppler ophthalamic test, ophthalmodynamography, and oculopneumoplethysmography prior to angiography. Clinical assessment was accurate 68% of the time, with 32% of patients having no arteriographic evidence of significant disease. The sensitivity of the noninvasive tests was dependent on the extent of the carotid stenosis. When the extent was greater than 60% of the cross-sectional diameter, the Doppler ophthalmic test was accurate 54% of the time; the ophthalmodynamography test, 61% of the time; and the oculopneumoplethysmographic test, 97% of the time. In lesions encompassing 50% to 60% of the vessel diameter, the Doppler ophthalmic test was accurate 15% of the time; the ophthalmodynamography test, 17% of the time; and the oculopneumoplethysmographic test, 10% of the time. With less than 50% stenosis, none of the noninvasive tests detected atherosclerotic lesions. Although many diseased vessels were missed, the low incidence of false-positive tests enhanced the usefulness of these methods in augmenting the accuracy of clinical evaluation.


Subphrenic abscess. The new epidemiology.

Recent changes in the etiology, topography, and bacteriology of subphrenic abscess are identified in 93 patients treated between 1955 and 1975. Gastric and biliary tract operation account for 52% of abscesses. Appendicitis is now responsible for only 8% of subphrenic infections, in contrast with the 40% of previous reports. Colonic surgery (19%) and trauma (8%) are increasing in importance. Left-sided abscesses occur in 40%, and multiple space abscesses in 20% of patients. The bacterial flora consists of multiple strains of aerobic and anaerobic organisms. Since 1970, the aerobes have been Escherichia coli (96%), Klebsiella (21%), and Proteus (38%); anaerobes include Bacteroides (83%), cocci (50%), and clostridia (50%). The mean interval from the preceding operation until drainage of the subphrenic abscess was 5.5 weeks. Overall mortality was 31%, with higher mortalities for multiple space involvement (39%) and for abscesses developing after emergency procedures (35%). Recommendations based on this data are: (1) antibiotics selected should be effective against anaerobes, and (2) transperitoneal drainage is frequently indicated because of the increase in multiple abscesses and the need to evaluate the first operation.


Staging laparotomy for Hodgkin's disease in children. Evaluation of the technique.

The evaluation of a technique of laparotomy for the staging of Hodgkin's disease in childhood, including 52 operative procedures, is reviewed. A standard protocol, including splenectomy, multiple hepatic and bone marrow biopsies, and the routine sampling of at least six designated lymph node groups, was employed. It was demonstrated that the surgeon is unable to identify Hodgkin's disease by gross inspection and that the biopsy of node groups previously not included in routine laparotomy studies, ie, mesenteric and porta hepatis nodes is essential to staging in childhood. Stage was altered from stages I and II to stages III and IV in 35% of the patients. The incidence of abdominal recurrence following a negative laparotomy was 7%, and the incidence of post-splenectomy hyperacute infection was 4.5%. This study included minimal use of the lymphangiogram (33%), which accounted for the relatively larger group of patients in clinical stages I and II.


Bile leakage following percutaneous transhepatic cholangiography with the Chiba needle.

Percutaneous transhepatic cholangiography (PTC) for jaundice of undetermined etiology was performed with the Chiba needle in 30 patients. Successful visualization of the biliary ductal system was accomplished in 26 patients (86.7%); two of six patients (33.3%) with normal biliary systems had ducts visualized, and the ducts were visualized in the 24 patients (100%) with obstruction. Bile leakage of 50 to 500 ml (average, 200 ml) was observed at laparotomy or autopsy in 12 patients (40%), nine (30%) of whom had symptoms of peritonitis. Six (20%) of these were transient and three (10%) progressed to an acute abdomen. Bacteremia occurred in seven patients (23.3%), in three (10%) it progressed to septic shock, with one death (3.3%). There were no complications in patients with nonobstructed ducts. This study suggests that PTC with the Chiba needle has little advantage over the larger sheathed needles, and surgical standby is indicated in suspected cases of obstructive jaundice.


'Routine' liver biopsy in upper abdominal surgery.

Liver biopsy was done at the time of operation in 125 consecutive upper abdominal procedures to assess the incidence of unsuspected or undiagnosed hepatic abnormalities. Specifically excluded were hepatic lesions unexpectedly identified at laparotomy. Sixty-seven percent of the liver biopsy specimens were abnormal, the most frequent findings being fatty metamorphosis, cholestasis, triaditis, fibrosis, inflammatory infiltrate, cholangitis, cirrhosis, and hepatitis. The most frequent operation performed was cholecystectomy. In 63 patients with chronic cholecystitis, there was a 51% incidence of abnormal liver histology, while in nine patients with acute cholecystitis, the incidence was 78%. In 83% of all other operations, abnormal liver biopsy specimens were identified. Bile leakage, hemorrhage, and infection did not occur in this series, despite inclusion of patients with severe biliary obstruction, abnormal clotting factors, and intra-abdominal sepsis. New techniques of histochemical enzyme analysis and electron microscopy are expected to enhance the clinical correlation of occult hepatic lesions. We conclude that liver biopsy in a safe, informative adjunct to all upper abdominal procedures.