Long-term contraception with norethindrone subcutaneous capsules.

Norethindrone (NET) contained in silicone rubber, for slow release, was implanted subcutaneously. The rate of release of NET was 10-12 mug/day/10 mm length of the silicone rubber. The total length of the implants used varied from 100 mm to 200 mm. During the whole observation time 562 women months, 14 a-cidental pregnancies occurred. The pregnancy rate decreased with increasing length of implants. The implants produced a transient ovulation suppression, which subsided in four to five cycles. The plasma levels of NET stabilized at a level which was less than that reached by daily oral administration of 350 mug of NET. The high pregnancy rate and the great number of implants required render the method impractical for contraception. However, the active life-span of implants is three years and because there were few minor side-effects, the method was well accepted.


Immunosuppressive effect of radiotherapy on patients with lung cancer.

The immunoglobulins A, E, G and M of 25 patients with lung cancer were determined (by radial immunodiffusion) before, during and after radiotherapy. No significant change in any immunoglobulin were noticed overall. In the group with a  poor prognosis (survival less than 12 months; 15 patients), there was a significant decrease of IgA and IgM one month after the irradiation. In the group of patients with pulmonary infection (14 patients), the level of IgA, IgG and IgM were lower than in the group without infection throughout the examination period. Cellular immunity measured by the PPD skin test, showed no significant differences between the groups by survival.


Parietal cell vagotomy without drainage for the treatment of duodenal ulcer.

PVC without drainage for the treatment of duodenal ulcer is a safe procedure. There are fewer gastrointestinal complaints of the type frequently observed after more orthodox gastric surgery. Diarrhea and dumping may be noted after PCV but the incidence of both is less, and when they do occur they are milder and more easily controlled than after other types of operations. The ultimate recurrent ulcer rate remains unresolved because insufficient time for observation and follow-up has elapsed. Since most recurrent ulcers that occur after other gastric procedures present within the first two years after operation, the documentation by several authors of a recurrent ulcer rate of 2-4% in patients followed two to four years after operation suggests that PCV is a highly effective procedure. Yet the high recurrence rates of 22% reported by one group indicates that the operation is not highly effective for everyone. The factors responsible for the discrepancy between the high and low recurrence rates reported by different authors are not evident at this time.


Fate of antibodies bound to lymphocyte surface. II.--Degradation and release of immune complexes.

The fate of horse anti-human lymphocyte globulins, rabbit anti-human beta2 microglobulin antibodies and anti-HL-A alloantibodies radiolabelled with 125I and complexed to their corresponding lymphocyte surface antigens, was investigated. During prolonged incubation at 37 degrees C, part of these antibodies were actively released into the surrounding medium after enzymatic degradation occuring either intracellularly or at the cell surface. Metabolism of the antibodies was temperature-dependent and involved only antibodies able to react with antigens on the cell surface. Sephadex G200 filtration of the small percentage of non dialysable radioactive products in the supernatant revealed that all the 125I-anti-human lymphocyte globulin was recovered as a macromolecular structure in the void volume. Similar experiments were performed with 51Cr labelled lymphocytes coated with anti-lymphocyte globulins: treatment with anti-horse immunoglobulin precipitated part of 51Cr activity in the void volume which was therefore associated with anti-human lymphocyte globulin as an immune complex. The same protocol applied to the other two antibodies studied showed that anti-beta2 microglobulin antibodies were recovered both as macromolecular and 7 S immune complexes, whereas anti-HL-A antibodies were recovered as macromolecular, 7 S and still smaller immune complexes.


Inhibitory effect of interferon on DNA and RNA synthesis in murine spleen cells stimulated by lectins.

Spleen cells from mice inoculated with partially purified preparations of interferon (Sp. Act. 1 X 10(7) i.u./mg protein, 0.2 ml i. v./mouse) were stimulated in vitro with phytohemagglutinin, concanavalin A or lipopolysaccharide. After 2 days of stimulation, the incorporation of 3H-thymidine into TCA-insoluble radioactivity was inhibited 50-90% when compared with cells from animals inoculated with mock interferon. Maximal inhibition, with optimal doses of lectins was obtained when interferon was;inoculated 18 hours before. This effect of interferon on DNA synthesis was preceeded by inhibition of the incorporation of 3H-uridine into TCA-insoluble material. When cells were pretreated in vitro with interferon for 24 hours and subsequently stimulated with PHA, RNA synthesis was inhibited by 30-40%, whatever was the dose of the mitogen. The synthesis of 4S tRNA, 18S and 28S ribosomal RNAs were inhibited to the same degree by interferon. The incorporation of methyl groups into cytoplasmic sRNA was unaltered.


Implications of mass automated instruments on medical practice.

The clinical laboratory is in a stage of change which has been the direct result of an influx of technology and the current demand for lower costs and increased productivity. There is no significant trend anticipated in the future which would forestall this particular process. The practicing physician can anticipate a fairly marked reduction in the cost of individual tests and, likewise, a marked increase in the amount of available information. There will be a larger clerical function involved in the review of such information along with a series of relevant problems related to the actual size of the new data base. One of the most significant problems related to this increase in numerical reporting will be the statistical problem of the "abnormal-normal." Statistical misclassification must be considered with each abnormal test and a specific approach must be taken to these tests to minimize the inconvenience to the patient. It is recommended that any unsuspected abnormal test(s) that is discovered be repeated as a single test(s) through a reference method. Reordering of the test battery or screen will only offer another possibility for statistical misinterpretation. If the test on isolated evaluation does appear abnormal, then this should call for the routine evaluation of this particular condition. Multivariate statistical analysis could eliminate this probability dilemma, yet is presently experimental and is not in routine use within any clinical setting. We can look forward to the evolution of such a process through the mechanism of a hospital and laboratory communication system which will allow the physician to work with an evaluation process capable of handling these large volumes of numbers (22). Such programs are on the horizon and should be anticipated within the next five years in some of the larger centers that have this new instrumentation.


Inactivation of gentamicin by penicillins in patients with renal failure.

Kinetics of gentamicin inactivation by carbenicillin and ticarcillin were studied in vitro and in 17 patients with renal failure. In vitro, the half-life of carbenicillin in human serum at 37 C is longer (19.2 +/- 0.7 h) than ticarcillin (7.2 +/- 0.6 h). Thus, incubation of gentamicin with equal concentrations of ticarcillin or carbenicillin results in greater inactivation of aminoglycoside activity by the latter. If concentrations of the two penicillins are held equal by repetitive addition, rates of gentamicin inactivation are the same. The serum half-life of gentamicin in patients serving as their own controls was significantly reduced by administration of either penicillin. After carbenicillin, the half-life decreased from 46 +/- 8 h to 22 +/- 3 h (P < 0.02). The constant for inactivation of gentamicin (k(i)) by carbenicillin was 0.02 h(-1). The results indicate that gentamicin requirements are underestimated by methods currently employed to calculate dosage for patients with renal failure who receive carbenicillin concurrently. Adjustment of gentamicin dosage in such cases by application of the k(i) for gentamicin is suggested.


Tetracycline-resistant T-mycoplasmas (Ureaplasma urealyticum) from patients with a history of reproductive failure.

The susceptibilities of T-mycoplasmas (Ureaplasma urealyticum) to minocycline, demeclocycline, doxycycline, tetracycline, and erythromycin were determined by a direct tube dilution test. T-mycoplasma-positive urine sediments of 105 patients with a history of reproductive failure were used as inocula. Minocycline was found to be the most active of the group of antibiotics commonly used to eradicate T-mycoplasma infection. Based on the median initial minimum inhibitory concentration, minocycline was the lowest with 0.03 mug/ml, followed by demeclocycline and doxycycline with 0.125 mug/ml, tetracycline with 0.25 mug/ml, and erythromycin with 2.0 mug/ml. Six T-mycoplasma isolates which had been cloned three times were also tested for susceptibility to the same five antibiotics. The same susceptibility pattern was found. Strains resistant to high concentrations of all antibiotics occurred. Strong positive correlation was seen in 21 patients between in vitro highly resistant strains and positive posttreatment cultures. These results indicate that empirical treatment of genital mycoplasma infections is not justified. Cultures should be taken pretreatment, susceptibility testing performed prior to treatment, and follow-up cultures done posttreatment.


Carbenicillin in the treatment of infections involving anaerobic bacteria.

Twenty-one patients with serious infections involving anaerobic bacteria were treated with carbenicillin. Multiple anaerobes were involved in 8 cases, and in 10 cases, facultative anaerobes were also isolated. Bacteroides fragilis was isolated in 10 cases. Results were judged excellent in 7 cases, good in 8 cases, and fair in 5 cases. These data suggest that carbenicillin may be an effective antibiotic for the therapy of infections due to anaerobic bacteria, particularly those involving B. fragilis.


Comparison of in vitro antimicrobial activity of cefamandole and cefazolin with cephalothin against over 8,000 clinical bacterial isolates.

Antimicrobial susceptibility to cefamandole versus cephalothin and cefazolin versus cephalothin was compared by the broth microdilution method against 3,000 and 5,895 clinical bacterial isolates, respectively. Cefamandole and, to a lesser degree, cefazolin showed greater activity than cephalothin against Enterobacteriaceae, but the three drugs were comparable against gram-positive cocci.


Concentrations of gentamicin and amikacin in human kidneys.

High kidney concentrations of gentamicin or amikacin, measured by an enzymological assay, were found in 9 of 10 patients who died during therapy with these aminoglycosides. Renal cortical concentrations of gentamicin ranged from 140 to 540 mug/g of tissue, with medullary levels of 128 to 230 mug/g. Concentrations of amikacin ranged from 365 to 1,030 mug/g in the cortex and from 270 to 718 mug/g in the medulla. The only patient with low kidney concentrations was an infant who received a single dose of gentamicin. Tissue levels were high in patients with both normal and abnormal renal function. Our results indicate that gentamicin and amikacin are concentrated in renal cortical and medullary tissue.


Relative inactivation by Staphylococcus aureus of eight cephalosporin antibiotics.

These studies extend the recent observation that cefazolin is inactivated to a greater extent than cephaloridine by some strains of penicillinase-producing Staphylococcus aureus, whereas cephalothin undergoes little if any inactivation. In Mueller-Hinton broth (inoculum, 3 x 10(6)) 100 recently isolated strains had minimal inhibitory concentrations (MICs) </= 2 mug/ml for cephalothin and cephaloridine, whereas in Trypticase soy broth (TSB) 50% had MICs > 2 mug/ml and 10% (designated "resistant" strains) were >8 mug/ml for cephaloridine but remained </=2 mug/ml for cephalothin. A large inoculum (3 x 10(7)) of strains with high MICs in TSB almost completely inactivated 50 mug of cefazolin per ml in 6 h, with progressively less inactivation, in the following order, of cephaloridine, cephalexin, cephradine, cephapirin, and cefamandole; cefoxitin and cephalothin underwent little if any inactivation. The greater inactivation in TSB than in Mueller-Hinton broth appeared to be due to a greater production of beta-lactamases by each colony-forming unit, since the inoculum size in the two broths was not significantly different. In contrast, "susceptible" strains (MICs </= 2 mug/ml in both broths) inactivated cephaloridine more than cefazolin, and equal amounts of powdered bacterial extracts confirmed the fact that qualitatively different beta-lactamases were produced by the susceptible and resistant strains. Disk diffusion tests were unreliable in separating the two groups of staphylococci. The clinical significance of inactivation by strains with high MICs is not known but, unless susceptibility can be clearly established, cephalothin appears preferable for severe staphylococcal infections, since it undergoes little if any inactivation by any strains of staphylococci.


Ototoxicity of amikacin.

Amikacin was used in 77 treatment courses at a dosage of >/=7.5 mg/kg every 8 h, and patients were monitored for ototoxicity by following serial audiograms, serum creatinine, and amikacin blood levels. Patients were leukopenic (58), were infected by gentamicin-resistant organisms (11), or had cystic fibrosis (8). Three patients developed tinnitus, but none had vertigo or nystagmus. Of 55 courses with pre- and post-treatment audiogram, 13 (24%) were associated with development of high-frequency hearing loss, which was usually bilateral. No patient had conversational hearing loss, and audiograms reverted to normal in three patients. Onset of cochlear damage occurred in one patient after therapy was stopped. The group with high-tone hearing loss, in comparison to the group without audiographic changes, received a larger mean total dose (24 versus 9.6 g), were treated for a longer duration (19 versus 9 days), and more frequently had previous aminoglycosides. Fifty-seven percent of patients with a "peak" serum level exceeding 32 mug/ml and 55% of patients with "trough" levels exceeding 10 mug/ml developed cochlear damage. There was no difference between the groups in age, body weight, previous cochlear damage, renal disease before or during therapy, or average daily dose. Both monitoring of blood levels and limiting duration of therapy may prevent amikacin ototoxicity.


Susceptibility of Staphylococcus aureus and Staphylococcus epidermidis to 65 antibiotics.

The susceptibilities of 36 recent isolates of Staphylococcus aureus and 35 recent isolates of Staphylococcus epidermidis were determined against each of 65 antimicrobial agents and against two of them in combination. Rifampin was the most active of all the agents tested against both S. aureus and S. epidermidis. Among the penicillins, cloxacillin, dicloxacillin, and nafcillin were most active, although benzylpenicillin and phenoxymethyl penicillin were more active against susceptible strains. Cephaloridine was the most active of the cephalosporins, and sisomicin was the most active aminoglycoside. Minocycline was more active than the other tetracycline analogues tested. Among the macrolide-lincomycin compounds in clinical use, clindamycin was more active, and lincomycin was less active than erythromycin. The synergy of trimethoprim-sulfamethoxazole was more striking against S. aureus than against S. epidermidis. The median minimal inhibitory concentrations of the penicillins, cephalosporins, and aminoglycosides were lower against S. aureus, whereas the minimal inhibitory concentrations of the tetracyclines were lower against S. epidermidis.


Susceptibility of Enterobacter to cefamandole: evidence for a high mutation rate to resistance.

Cefamandole minimum inhibitory concentrations (MICs) of 10 strains of Enterobacter were determined by the ICS agar dilution and broth dilution procedures. Agar dilution MICs ranged from 1 to 8 mug/ml, with an inoculum of 10(4) organisms/spot. Broth dilution MICs were consistently higher, with an inoculum of approximately 7 x 10(5) organisms/ml. Seven strains showed MICs of >/=64 mug/ml. There was a marked inoculum effect in broth, and skipped tubes were often observed. Variants resistant to 32 mug/ml or more were isolated by direct selection and were shown to occur at a frequency of approximately 10(-6) to 10(-7). A mutant showing a 16-fold increase in agar dilution MIC was also isolated by indirect selection. These variants and others isolated from broth in the presence of cefamandole were tested for ability to inactivate the antibiotic, using both a biological and a chemical procedure. Two distinct classes of variants were seen. Twelve of 28 were shown by both methods to inactivate the antibiotic, whereas the others, including the indirectly selected mutant, did not. The wild types were also negative by both tests. The higher cefamandole MICs of Enterobacter in broth, thus, appeared to reflect a high frequency of resistant variants that were not detected with the inoculum and end point criteria usually used in agar dilution methods. The ability of some variants to inactivate cefamandole may have resulted from a mutation that extended the activity of Enterobacter cephalosporinase to include this antibiotic.


Laboratory studies with a new broad-spectrum penicillin, pirbenicillin.

Pirbenicillin {6-[d-2-phenyl-2(N-4-pyridylformimidoylaminoacetamido) -acetamido]-penicillanic acid} showed broad-spectrum antibacterial activity in vitro and also in the treatment of experimental infections after parenteral administration to mice. Against Pseudomonas aeruginosa, a three- to fourfold potency advantage over carbenicillin was seen both in vitro and in vivo. The in vitro antibacterial spectrum of pirbenicillin includes Escherichia coli, Serratia, Citrobacter, and Enterobacter isolates, against which it exhibited minimal inhibitory concentration values comparable to those of carbenicillin. However, mice infected with E. coli and Serratia were protected at doses of pirbenicillin that were two to four times lower than those required of carbenicillin. Pirbenicillin was more active than carbenicillin against gram-positive bacteria, especially Streptococcus faecalis. It was less active than carbenicillin against Proteus spp. and was inactive against ampicillin-resistant E. coli strains. Pirbenicillin was bactericidal at concentrations generally equal to or only two-fold higher than the minimal inhibitory concentration. With appropriately buffered media, pirbenicillin demonstrated eight- and fourfold better minimal bactericidal concentration values towards Pseudomonas isolates than those of carbenicillin and ticarcillin, respectively.


Cephalosporin-aminoglycoside synergism in experimental enterococcal endocarditis.

Despite in vitro demonstrations of synergism against enterococci, combinations of cephalosporin and aminoglycoside antibodies have been ineffective in the therapy of enterococcal endocarditis. Penicillin-gentamicin, cephalothin-gentamicin, and cefazolin-gentamicin were used to treat enterococcal endocarditis in rabbits. A direct relation was observed between the rate of cure and the degree by which the peak serum concentration of penicillin and the cephalosporins exceeded the minimal inhibitory concentration of the enterococcus. Thus, cephalosporin doses which produce serum concentrations which exceed the minimal inhibitory concentration of the enterococcus by several orders of magnitude may, in combination with aminoglycosides, be effective in treating human enterococcal endocarditis.


In vitro comparison of cefoxitin, cefamandole, cephalexin, and cephalothin.

The in vitro effect of cefoxitin, cefamandole, cephalexin, and cephalothin was tested against 645 strains of bacteria recently isolated from clinical sources. Against gram-positive organisms cephalothin and cefamandole were the most effective, generally being three- to fourfold more active than cephalexin or cefoxitin. Enterococci were not inhibited by less than 25 mug of any of the antibiotics per ml. Against Enterobacteriaceae, cefoxitin and cefamandole were the most active. An exception was the Enterobacter strains, against which cefoxitin was the least effective. None of the Pseudomonas aeruginosa strains were susceptible to 100 mug of any of the cephalosporins per ml. Cefamandole was the most active agent against Neisseria meningitidis and Neisseria gonorrhoeae. It was also the most effective agent against Haemophilus influenzae, even when taking into account a threefold inoculum effect.


Sensitivity of environmental microorganisms to antimicrobial agents.

The sensitivity of different microorganisms, considered as typical representatives of the microflora of soil and water, was established to evaluate the influence of the nonmedical use of antimicrobial agents on bacterial ecology. Only seven strains, six chemoorganotrophs and one chemolithotroph, could be considered as relatively sensitive to the 21 antimicrobial compounds tested. The other 29 microorganisms may be regarded as resistant to most antimicrobial agents. Streptomyces were sensitive to high concentrations of active substances. Broad-spectrum antibiotics showed an effect on environmental bacteria similar to that on human pathogens. Cephalothin stimulated the growth of a Chlorella sp. From these experiments, it appears that spilled antimicrobial agents have little chance of causing an alteration in the microbial ecology.


Production of ochratoxin A by Aspergillus ochraceus NRRL-3174 before and after exposures to 60Co irradiation.

Spores from the toxigenic organism Aspergillus ochraceus NRRL-3174 were exposed to specific levels of gamma irradiation and then allowed to germinate on selected media. Increases in ochratoxin A production by irradiated, compared to non-irradiated, spores were observed after inoculation of spores onto a cracked red wheat or into a synthetic liquid medium. Variations in daily ochratoxin production were also observed for control and irradiated spore-derived cultures developing on both media, with maximum toxin production varying from 7 to 11 days of incubation. The most notable increases in ochratoxin A production occurred from cultures developing from spores having been irradiated with 10, 25, or 50 krad. Exposures to 400 or 600 krad resulted in complete inhibition of spore germination and, consequently, no ochratoxin production. Of the two substrates used, wheat and synthetic, the quantities of ochratoxin A produced were significantly lower in the synthetic media than on the natural substrate. Higher and more rapid toxin production occurred from spores having been irradiated with 10, 25, 50, and 100 krad than occurred from the non-irradiated control spores when grown on synthetic media. Cultures derived from spores having been exposed to 10, 25, 50, and 100 krad produced significantly higher levels of ochratoxin A after 8 days of incubation on natural substrate than did the controls. Analysis of variance revealed that substrate, length of incubation, as well as irradiation levels all affected the time required to produce maximum levels of ochratoxin A.


Human fecal flora: variation in bacterial composition within individuals and a possible effect of emotional stress.

Data are presented on the distribution of 101 bacterial species and subspecies among 1,442 isolates from 25 fecal specimens from three men on: (i) their normal diet and normal living conditions, (ii) normal living conditions but eating the controlled metabolic diet designed for use in the Skylab simulation and missions, and (iii) the Skylab diet in simulated Skylab (isolation) conditions. These bacteria represent the most numerous kinds in the fecal flora. Analyses of the kinds of bacteria from each astronaut during the 5-month period showed more variation in the composition of the flora among the individual astronauts than among the eight or nine samples from each person. This observation indicates that the variations in fecal flora reported previously, but based on the study of only one specimen from each person, more certainly reflect real differences (and not daily variation) in the types of bacteria maintained by individual people. The proportions of the predominant fecal species in the astronauts were similar to those reported earlier from a Japanese-Hawaiian population and were generally insensitive to changes from the normal North American diet to the Skylab diet; only two of the most common species were affected by changes in diet. However, one of the predominant species (Bacteroides fragilis subsp. thetaiotaomicron) appeared to be affected during confinement of the men in the Skylab test chamber. Evidence is presented suggesting that an anger stress situation may have been responsible for the increase of this species simultaneously in all of the subjects studied. Phenotypic characteristics of some of the less common isolates are given. The statistical analyses used in interpretation of the results are discussed.


Survey of aflatoxicosis in farm animals.

Over a 22-month period, 278 submissions of farm animals were made to the North Carolina Diagnostic Laboratory for suspected aflatoxicosis, and 94 cases were confirmed on the basis of finding aflatoxin in the feed and the occurrence of bile ductule proliferation. There was an annual variation in the incidence of aflatoxicosis, as well as a seasonal variation: the peak incidence occurred in the winter, and the minimum incidence occurred during the summer. The annual increase coincided with the corn harvest. All confirmed cases occurred on farms that raised and stored their own corn, and 88% were in swine. The cases were geographically localized in the eastern section of North Carolina (94% of the total cases) where 82% of the swine and 79% of the corn are produced. Mean concentration of aflatoxin in feed samples from the confirmed cases was 3,890 mug/kg, and the mean value for corn used in making the feed was 5,180 mug/kg. Only aflatoxin B1 was found in the samples. These data were interpreted to mean that the incidence and severity of aflatoxicosis is greater than previously suspected, that poor on-farm storage of corn is a primary contributing factor, that aflatoxin formation continues during and after the milling process, and that mycotoxicoses other than aflatoxicosis may cause equal or greater problems.


Relationships between heat resistance and phospholipid fatty acid composition of Vibrio parahaemolyticus.

Vibrio parahaemolyticus was grown in tryptic soy broth (TSB) containing NaCl levels of 0.5, 3.0, and 7.5% (wt/vol). Cultures incubated at 21, 29, and 37 C were harvested in late exponential phases and thermal death times at 47 C (D47 c; time at 47 C required to reduce the viable population by 90%) were determined in phosphate buffer containing 0.5, 3.0, and 7.5% NaCl. At a given NaCl concentration in the growth medium, D47 c values increased with elevated incubation temperatures and with elevated levels of NaCl in the heating menstrua. Differences in thermal resistance of cells cultured at a particular temperature were greater between those grown in TSB containing 0.5 and 3.0% NaCl than between those grown in TSB containing 3.0 and 7.5% NaCl. D47c values ranged from 0.8 min (grown at 21 C in TSB with 0.5% NaCl) to 6.5 min (grown at 37 C in TSB with 7.5%, heated in 7.5% NaCl buffer). Methyl esters of major phospholipid fatty acids extracted from cells were quantitated. The ratio of saturated to unsaturated fatty acids in cells grown at a given NaCl concentration increased with elevated incubation temperature. At a particular growth temperature, however, saturated to unsaturated fatty acids ratios were lowest for cells grown in TSB containing 3.0% NaCl.


Physiology and ecology of bacteriophages of the marine bacterium Beneckea natriegens: salinity.

The effects of variation in ionic levels on the stability and replication of two bacteriophages (nt-1 and nt-6) host specific for the marine bacterium Beneckea natriegens were examined. Monovalent cations influenced the adsorption of the nt-1 but not the nt-6 phage; however, one-step growth studies showed that NaCl was required for replication of both phage. The NaCl optimum for nt-1 production was 0.25 M NaCl, the same as the growth optimum for B. natriegens. However, the optimum for nt-6 production was 0.16 M NaCl. These NaCl optima for host and phage are at estuarine rather than oceanic levels. The nt-1 phage was better suited to replicate at NaCl levels typical of higher salinity areas (18-35%) and the nt-6 phage was better suited to replicate at lower salinities (5-18%). The nt phage were more resistant to low NaCl levels than their host bacterium and appeared limited to marine waters by the lower survival salinity of B. natriegens coupled with phage inactivation processes occurring in natural estuarine waters.


In situ morphology of nitrifying-like bacteria in aquaculture systems.

The in situ microbiota from several aquaculture facilities with active nitrification was examined by transmission electron microscopy of thin sections for the presence of bacteria that contained intracytoplasmic membranes characteristic of the nitrifying bacteria. Colonies of bacteria with the cellular morphology of a species of Nitrosomonas were found to be present in both the culture water and in the biological filter slime of a freshwater chinook salmon (Oncorhynchus tshawytscha) culture system. bacteria in the water possessed the normal nitrosomonas type of ultrastructure, whereas similar bacteria in the slime had an aberrant morphology due to multiple invaginations of the cell wall and cyto-membranes and a significantly greater number of ribosomes. These nitrosomonas-like bacteria lysed during enrichment in commonly used media. Bacteria with the morphology of species of Nitrosomonas and Nitrosococcus were also observed in colonies in the surface slimes of marine culture systems for striped bass (Morone saxatilis) and quahaug (Mercenaria mercenaria).


Method for estimating the decomposition of hexadecane in the marine environment.

A method, based on quantitating 14CO2 produced from [14C]hexadecane, has been developed for estimating the rate of hexadecane decomposition in seawater of Tokyo Bay during the summer stagnation period. The rate of hexadecane decomposition was from 0.1 to 1.3 mug/h per liter of seawater at the surface layer in the polluted gyre of the inner part of Tokyo Bay during the summer of 1974. A similar horizontal distribution pattern was seen for the density of hexadecane-decomposing bacteria.


Production of antibody against ochratoxin A.

Antibody against ochratoxin A was obtained after repeated injection of different protein-ochratoxin A conjugates to rabbits. Among many protein-ochratoxin conjugates tested, bovine serum albumin-ochratoxin A was found to be the best antigen. The antibody is specific for ochratoxins A, C, and T, but is not specific for ochratoxins B, alpha, and other coumarin derivatives. The sensitivity for ochratoxin A detection using a binding assay is in the range of 0.5 to 10 ng/0.5-ml sample. Detailed methods for the preparation of protein-ochratoxin conjugates, preparation of immune serum, and methods for antibody titers are described.


Co-metabolism of fluorobenzoates by natural microbial populations.

Co-metabolic degradation of monofluorobenzoates was carried out by a mixed soil population in a basal salts medium. The monofluorobenzoates did not support growth of microorganisms but were shown to be subject to ring cleavage as a result of microbial activity. Rate of ring cleavage was increased by use of the co-substrate enrichment technique using glucose as the co-substrate. Results indicate that the monofluorobenzoates were subject to an initial co-metabolic attack with glucose, providing the energy necessary for co-metabolism to proceed to a point where complete metabolism became possible.


Viscometric assay of bacterial alginase.

Equations defining the reaction of microbial alginase on commercial sodium alginate are presented with respect to the viscometric assay of enzyme activity. The negative log of K was found to be linearly related to the concentration of algin, where K is defined as the change in the reciprocal of relative viscosity with time. The negative log of K was also found to be linearly related to the amount of enzyme in reaction mixtures when the substrate concentration was held constant.


Metabolism of acetonitrile and propionitrile by Nocardia rhodochrous LL100-21.

Six nitrile compounds and two amide derivatives were degraded by Nocardia rhodochrous LL100-21. Acetonitrile, hydroacrylonitrile, and propionitrile were the best sources of carbon and nitrogen for growth, whereas butenenitrile, succinonitrile, and acetamide supported less growth. Acrylonitrile and acrylamide supported growth but only as a source of nitrogen. Gas chromatography of the culture medium revealed a decrease in acetonitrile with the sequential formation of acetamide and acetic acid. Ammonia was also detected by colorimetric procedures. The enzyme system responsible for the hydrolysis of acetonitrile was shown to be intracellular and inducible. The breakdown of acetonitrile by a crude bacterial extract was a two-step enzymatic hydrolysis with acetamide as the intermediate product and acetic acid and ammonia as the final products. Product formation was stoichiometric with substrate disappearance. When propionitrile was the growth substrate, there was complete conversion of the nitrile to propionic acid and ammonia as the major products. The enzymatic breakdown of the propionitrile, although slower than acetonitrile, yielded the corresponding carboxylic acid and ammonia. Propionamide was produced in very small amounts as an intermediate product.


Anaerobic bacteria from the large intestine of mice.

Anaerobic bacteria from the colon of laboratory mice were enumerated and isolated using strict anaerobic techniques. Direct microscopic counts revealed 4.4 X 10(10) organisms in each gram (wet weight) of colon contents. Actual cultural counts averaged 3.2 X 10(10) organisms, which was 73% of the direct microscopic count. The tentatively identified genera were Bacteroides, Eubacterium, Fusobacterium, Lactobacillus, Peptostreptococcus, and Propionibacterium. Strains of Fusobacterium, Lactobacillus, Peptostreptococcus, and Propionibacterium were biochemically homogeneous. Strains of Bacteroides and Eubacterium, on the other hand, were biochemically heterogeneous and were subdivided into several distinct groups. The data indicate that many of the isolates are different from previously described species of the respective genera and may belong to new species.


Carbon metabolism in model microbial systems from a temperate salt marsh.

The metabolism of a saltwater leachate of 14C-labeled Spartina alterniflora was examined in laboratory systems using mixed, salt marsh microbial communities and, by addition of appropriate antibiotics, communities with bacteria or eukaryotes inhibited. Label uptake was more rapid in the systems with bacteria alone and with the mixed microbial community than with fungi alone. Mineralization of the added label was more extensive in the mixed and bacterial systems, whereas the fungi appear more efficient at converting the label into particulate biomass. Particulate biomass production efficiencies ranged from a high of 0.82 for the fungal system to 0.21 in the mixed community, with the bacterial system giving an intermediate value of 0.54. The presence of protozoa and microcrustaceans in the mixed system appears to account for an increase in the mineralization of the label assimilated. Additional experiments with whole labeled Spartina, a leachate from Spartina, and Spartina after leaching revealed that the seawater-soluble portions of the plants were attacked most rapidly by the microbial community.


Liberation of sulfate from sulfate esters by soils.

When incubated with acid, alkaline, and neutral soils, a variety of synthetic sulfate esters representing the various classes of these compounds was hydrolyzed by enzymes, probably of microbial origin. The appearance of sulfate in the soil water occurred immediately after introduction into the soils with some esters, whereas with others it occurred only after lag periods. Heat treatment destroyed the hydrolytic acitivity in the soils. The ester sulfate groups present in humic acid extracted from the soil appeared to be resistant to hydrolysis by a variety of sulfohydrolases extracted from bacteria and other organisms.


Treatment of complete prolapse of the rectum by the vaginal approach.

Complete prolapse of the rectum is essentially an enterocele which emerges through the anus as a sliding hernia of the rectum. In women, this condition can be operated radically by a simple technique which causes only little stress to the patient, entirely in conformity with the principles of the hernia operation, as advocated by Graham (Ann. Surg., 1942, 115 (1007), by the abdominal approach.


A simple surgical method of treating pilonidal sinus.

A simple surgical method of treatment was used in 63 patients with pilonidal sinus. Adequate block excision with primary closure is the basis of this technique. The problem of closure and obliteration of the dead space was solved by using absorbable sutures to unite fascia and subcutis in the midline, after mobilization of the skin and subcutaneous layers of the wound edges. In 59 (93.6%) of 63 patients treated, primary healing was obtained; in 4 (6.4%) disturbances of wound healing occured; and in 3 (4..8%) recurrences developed. The average stay in hospital was 10.4 days and the average healing time 10 days. The follow-up period was between 1 year and 6 years. The scars were sound, supple and painless. Our results include 6 patients, treated several days before the definitive procedure by incision and drainage for a pilonidal abscess. Antibiotic or chemotherapeutic agents were not used.


Necrotic colitis in the presence of normal vascularization of the colon.

Necrotic colitis in the absence of organic obstruction of the mesenteric vessels is an extreme and fulminant form of ischemic colitis. This calamity with its high mortality rate usually occurs in patients with pre-existent cardiopathy. It is rare for necrotic colitis to occur as a complication of hypotension, hypovolemia or sepsis. A report is presented of a case of total gangrene of the colon in a patient with hemorrhagic shock. Certain concepts are presented concerning the etiology of non-occlusive intestinal infarction. It is postulated that the fulminant gangrene of the colon is co-induced by Gram-positive rods which are demonstrable even in the deep layers of the colonic wall.


Subungual keratoacanthoma.

Subungual keratoacanthoma is a rare tumor with some features at variance with keratocanthoma elsewhere. It is a painful or tender lesion that shows little or no tendency to spontaneous involution. The terminal tuft of the distal phalanx is destroyed by pressure erosion. Clinically, subungual keratoacanthoma and subungual squamous cell carcinoma have many features in common. A distinction must be made histologically.


Rudimentary polydactyly presenting as a claw.

A patient with a congenital claw-like lesion of the finger was studied to determine the nature of the tissue. A variety of biochemical techniques and histological examinations indicated that the lesion was an example of rudimentary polydactyly covered with stratum corneum rather than an accessory nail.


Allergic contact dermatitis from TEA-Coco hydrolyzed protein.

A 21-year-old woman developed a severe dermatitis of the face after using a proprietary skin cleanser. Patch testing showed delayed hypersensitivity to TEA-Coco hydrolyzed protein (the triethanolamine salt of the condensation product of coconut fatty acids with a complex of polypeptides and amino acids derived from collagen), but not to other ingredients of the cleanser. Further patch testing revealed positive results with other condensates of fatty acids and protein hydrolysates.


Mucous membrane involvement in generalized pustular psoriasis: Report of three cases and review of the literature.

Pustular eruptions on both skin and mucous membranes occur in the various forms of generalized pustular psoriasis. Three patients with generalized pustular  psoriasis also had an eruption on the tongue resembling geographic tongue; one patient had sterile conjunctivitis. Histologically, the spongiform pustule of Kogoj is common to lesions of both skin and mucosa. We suggest that generalized pustular psoriasis be considered one of the mucocutaneous syndromes.


Patch test reactions to human dander in atopic dermatitis.

Patch tests reactions to human dander were positive in 120 of 181 (66%) patients with atopic dermatitis, in two of 28 (7%) patients with allergic contact dermatitis, and in one of 31 (3%) normal controls. The frequency of positive reactions was significantly higher in patients with atopic dermatitis. The reactions consisted of erythema and papules, which histologically showed an eczematous change at the upper parts of hair follicles. There was significant correlation between patch test reactions to human dander and delayed intradermal reactions to the same substance in atopic patients. It is suggested that certain patients with atopic dermatitis exhibit contact hypersensitivity to human dander. Whether or not the hypersensitivity has any relationship to the pathogenesis of the dermatitis was not determined in this study.


Pathogenesis of Woronoff ring in psoriasis.

As a result of ultraviolet light and coal tar therapy, a white ring (Woronoff) may develop in the normal skin adjacent to psoriatic plaques. Injection of prostaglandin E2 (PGE2) 1 cm outside of Woronoff ring produced redness in the ring, demonstrating that vessels within the ring were not unresponsive to PGE2. Whole skin homogenates from Woronoff ring contained an inhibitor of prostaglandin synthesis that was not found in uninvolved skin that was obtained from either psoriatics or normal controls. Prostaglandin E2 levels in the ring were one third of those in uninvolved skin from either psoriatics or normal controls. These findings suggest that the white ring that surrounds ultraviolet-light-treated psoriatic plaques is produced by a local inability to synthesize PGE2 in response to an ultraviolet light stimulus, resulting from the presence of an inhibitor of prostaglandin synthesis.


Treatment of Kaposi sarcoma with vinblastine.

Five cases of Kaposi sarcoma with vinblastine sulfate treatment were compared with 18 cases reported in the literature. Our experience with a low-dosage schedule emphasizes that toxicity is not necessary for a favorable result. Vinblastine seems to be an effective treatment for Kaposi sarcoma and, in selected cases, may supplement radiation therapy or be used alone.


Physiatrics for deforming linear scleroderma.

When linear scleroderma traverses several joints, severe and mutilating deformities and contractures, with loss of limb function, can result. Drugs and surgical procedures are usually of little benefit in ameliorating the deformities. Physiatrics on the other hand, is a readily available modality than can restore much useful function and reverse the contractures and is probably the most effective means of treating patients with deforming linear scleroderma. This type of therapy should be instituted at the inception of the disease process so that the development and progression of any contraction can be minimized or prevented.


15-Year developmental study on effects of severe undernutrition during infancy on subsequent physical growth and intellectual functioning.

This third 5-year follow-up on the effects of severe undernutrition during infancy on subsequent brain growth and intellectual development confirms the level of gross retardation of intellect in the undernourished group when compared with the controls. As the subjects are now 15-18 years of age this must be permanent. All but 5 of the undernourished group are now living in conditions comparable to the controls. Improved nutrition is manifest by catch-up in height, in that the mean difference between undernourished subjects and controls has decreased by 2-73 cm. Remarkably, the difference in head circumference has increased by 0-5 cm, the mean head circumference of the undernourished now being 2-8 cm less than that of the controls. The Bender Gestalt and Human Figure Drawing tests did not correlate with the intelligence tests, indicating a separate deficit of a marked disturbance of visual-motor perception in 17 of the undernourished subjects, in 9 of whom these tests were highly significant of minimal brain dysfunction (5 of the controls). In retrospect there is much evidence to suggest the controls were also suboptimal; 8 controls had abnormal electroencephalograms as did 6 of the undernourished group.


Congenital nephrotic syndrome of Finnish type. Study of 75 patients.

Seventy-five patients with congenital nephrotic syndrome of Finnish type were identified in Finland in the period 1965-1973, giving an incidence of 12-2/10(5). A large placenta and proteinuria from birth are the hallmarks of the disease. About one-quarter of the patients had oedema and/or abdominal distension at birth and in all cases the full nephrotic syndrome was documented before 2 months. More than half of the patients died before 6 months and none lived longer than 2 years 3 months. A slight rise in blood urea nitrogen or serum creatinine levels occurred in 14 cases, but in none of these did a frank uraemia develop before death. Infection appeared to be the immediate cause of death in 31% of the cases; in 43% no cause of death other than congenital nephrotic syndrome could be shown. Thrombi in large vessels were found in 11 out of 58 necropsies.


Neonatal pulmonary hypoplasia after prolonged leakage of amniotic fluid.

The clinical, radiological, and pathological features of the 'oligohydramnios tetrad' (Potter's facies, limb malpositions, pulmonary hypoplasia, and growth retardation) resulting from chronic amniotic fluid leakage are described in 2 infants who died of respiratory failure within 12 hours of delivery. A third infant with a partial form of the syndrome had prolonged respiratory symptoms and survived the neonatal period: the course of the disease and the radiological findings were compatible with a hypothetical diagnosis of partial pulmonary hypoplasia. Pulmonary hypoplasia should be recognized as a cause of chronic respiratory symptoms in viable infants.


Serum immunoglobulins in multiple pregnancy.

The concentrations of immunoglobulins (Ig) G.A.M. and E were determined in paired umbilical cord and maternal sera in 50 twin pregnancies. Mean IgG levels were higher in cord than maternal sera and in most cases the cord IgG level related more closely to that of the other twin than to either maternal level or birthweight, and was in the range for singletons of the same gestational age. The three cases of fetofetal transfusion syndrome were exceptional in the large difference between IgG concentrations in recipient and donor twins. The discrepancy was much greater than that found between the levels of proteins produced by the fetus, suggesting a disturbance in maternofetal placental transfer. IgM was detected in all cord sera, with one exception, and the level was not related to order of birth. IgA was detected in 16% of cord sera, 13% in sera from first borns. IgE was detected in only 8% of cord sera and there was no evidence of placental transfer.


Gentamicin dosage in children.

The results of 49 serum gentamicin assays from children of 2 weeks to 11 years of age are presented. The dose of gentamicin given 8-hourly intramuscularly ranged from 0-7 mg/kg-4-9 mg/kg. Doses of 1-7 mg/kg or less did not give adequate serum concentrations. As a result of these observations it is suggested that an intramuscular dose of 2-5 mg/kg given 8-hourly is suitable for most children in the absence of renal failure, but that adjustment of the dose according to serum gentamicin concentration is necessary.


Chloride losing diarrhoea and metabolic alkalosis in an infant with cystic fibrosis.

A case of hypochloraemic metabolic alkalosis in an infant with chloride losing ileostomy drainage and cystic fibrosis is described. It is speculated that intestinal loss of chloride played a major role in the development of metabolic alkalosis.


Immunoglobulin E in erythema nodosum.

Twenty-two children aged from 3 years 6 months to 12 years with erythema nodosum (EN) were grouped according to aetiology into streptococcal, tuberculous, and those whose aetiology was undetermined. Serum IgE levels were determined in all by the radioimmunosorbent technique. Levels were higher (mean value 991 units/ml) in streptococcal EN than in those of the other two groups (mean value 68 units/ml and 97 units/ml, respectively) and healthy age-matched controls (mean value 60 units/ml). Increase of IgE levels in individual cases of streptococcal EN did not correlate with severity of the clinical manifestations characteristic of that group.


Gastric pneumatosis in infancy.

Gastric pneumatosis (gas in the wall of the stomach) is an uncommon but characteristic plain-film radiographic sign. In infancy it is associated either with gastric outlet obstruction, usually hypertrophic pyloric stenosis, or necrotizing gastroenterocolitis. Differential diagnosis is mainly based on associated clinical findings, as exemplified by the 2 cases reported here. Both infants had isolated gastric pneumatosis as the principal radiographic finding. Correct diagnosis was greatly aided by recognition of this x-ray sign so that appropriate therapy was started without delay.


Hemodynamic consequences of femoral arteriovenous bovine shunts.

Seventeen patients with femoral arteriovenous bovine shunts (FAVBS) were evaluated to delineate the cardiovascular consequences of the procedure. The resting cardiac index (CI), as estimated by echocardiography, was increased in 8 patients (47%). Twelve of the 17 patients (71%) had more than a 20% reduction in CI after 5 minutes of shunt occlusion. In 6 of these, the CI returned to normal from an abnormally high value. As a group, the decrease in CI was significant (P = 0.001). This was accomplished mainly by a significant decrease in stroke volume (P less than or equal to 0.004). Signs and symptoms of congestive heart failure developed in 10 of the 17 patients during the year following FAVBS. Because of the marginal cardiac reverse in patients with renal failure and the significant increase in cardiac index resulting from FAVBS, alternative forms of vascular access should be used whenever possible.


Isotope angiography: technique, validation and value in the assessment of arterial reconstruction.

Isotope angiography performed by intravenous injection of technetium 99m pertechnetate has been demonstrated to be of value in the diagnosis and management of a variety of disorders of the large arteries. An improved technique of isotope angiography is described and the technique validated (53 cases) in normal and diseased arteries by correlating it with conventional contrast arteriography and/or operative findings. Peripheral arteries as far distal as the wrist or mid-calf have been accurately visualized and quantitation of isotope arrival times and total isotope activity in different parts of the arterial tree has provided a means of evaluating the hemodynamic significance of stenosing lesions. Thirty-nine arterial reconstructions were studied by this technique. Seven of 27 (26%) clinically patent arterial reconstructions were found to be harboring significant and potentially dangerous imperfections which were clinically unsuspected. Nine of 12 (75%) arterial reconstructions thought clinically to be occluded were demonstrated to be patent, obviating the need for invasive contrast arteriography. Isotope angiography may be used with no risk for the immediate postoperative and long-term evaluation of arterial reconstructions. Only those patients with abnormalities identified on isotope angiography need have conventional contrast arteriography for further delineation of the abnormality so that it may be repaired before it causes failure of the reconstruction.


Unresolved problems of pancreatic pseudocysts.

The treatment of 54 patients with pancreatic pseudocysts was reviewed. The operative mortality was 11% and after an average followup of 3 years the recurrence rate was 3.8%. Hemorrhage was the most significant complication of pseudocysts and occurred in 4 patients preoperatively and three patients postoperatively. The patients who developed recurrence or died had been operated within one day after the diagnoses of pseudocysts were made. The deaths were due to the conditions that necessitated the emergency operations rather than to the fact that the cyst wall had not adequately matured. Ideally, operation should be performed when the patient has reached an optimal clinical condition and the walls of the cyst are sufficiently thick. Currently there is no guide for estimation of the state of cyst maturation, although this may develop with the use of ultrasound. Since complications can develop during a prolonged observation period it was our policy to proceed with surgery as soon after diagnosis as the patient was in satisfactory clinical condition. It is evident from this study that internal drainage can be performed safely in less time than the 6 weeks frequently recommended. Morbidity and mortality were not adversely affected by a short interval between diagnosis and operation if the timing was a matter of election rather than a condition of emergency.


Survival from acute hepatorenal syndrome following splenorenal shunt.

Acute aggravation of chronic hepatorenal syndrome following angiography is described in a patient with recovery and long-term survival following splenorenal shunt. It is believed that this patient represents a type of hepatorenal syndrome which can be expected to tolerate shunt and recover from hepatorenal syndrome. Possible mechanisms of the pathophysiology are discussed and recommendations made on this basis for the selection of such patients for portal decompression.


Hemorrhagic necrosis of pheochromocytoma associated with phentolamine administration.

A case of ruptured pheochromocytoma is presented, the pathophysiology discussed, and the literature reviewed. Evidence is presented that the use of alpha-adrenergic blockade in general, and phentolamine in particular, may predispose to this complication. Twelve cases of massive hemorrhagic necrosis with or without rupture were found in the literature, including the present case. Six had no operation; one survived. Six had immediate operation; 4 survived. An additional case of hemorrhage into a small pheochromocytoma following phentolamine is presented. This tumor was neither ruptured nor massively necrotic, but the case supports the hypothesis that alpha-adrenergic blockade may cause hemorrhage within the pheochromocytoma.


Aorto-left renal vein fistula: an unusual complication of abdominal aortic aneurysm.

A patient with an abdominal aortic aneurysm with a preaortic left renal vein fistula is presented. Review of the 7 reported cases of aorto-left renal vein fistulae demonstrates many similarities in the clinical presentation with aorto-caval fisulae. However, in addition to the triad of pain, pulsatile abdominal mass and bruit, commonly found in aorto-caval fistulae, the presence of hematuria, proteinuria, and azotemia suggests a renal vein fistula. Radiographic studies often demonstrate a large non-functional left kidney. Operative management of the fistula may be performed by a variety of maneuvers. All 7 patients survived. When repair was undertaken without delay, function in the left kidney returned to normal within two months postoperatively.


Intraoperative arterial oxygenation in obese patients.

Although obese patients have been shown to represent a particularly high risk group with respect to hypoxemia both pre and postoperatively, no data exist to delineate the intraoperative arterial oxygenation pattern of these patients. Furthermore, no one has studied the effects of a change in operative position or a subdiaphragmatic laparotomy pack on arterial oxygenation (PaO2). Sixty-four adults undergoing jejunoileal bypass for morbid exogenous obesity, with a mean weight of 142.0 +/- 31.4 kg and a mean age of 33.3 +/- 10.4 years, were studied. Twenty-five patients (Group I) were maintained in the supine position throughout the operative procedure, while the remaining 39 patients (Group II) were changed to a 15 degrees head down position 15 minutes after a control blood sample was taken. Four additional markedly obese patients were studied to determine the effect of an abdominal pack of PaO2 values. The following findings were demonstrated: 1) 40% oxygen did not uniformly produce adequate arterial oxygenation for intra-abdominal surgery in otherwise healthy obese patients; 2) placement of a subdiaphragmatic abdominal laparotomy pack without a change in operative position resulted in a consistent fall in PaO2 in each patient to less than 65 mm Hg even though 40% oxygen was being administered; and 3) a change from supine to a 15 degrees head down operative position resulted in a significant (P less than 0.001) reduction in mean PaO2 (73.0 +/- 26.3 mm Hg). Seventy-seven per cent of these patients demonstrated PaO2 values of less than 80 mm Hg on 40% oxygen. Because of these findings, serious consideration should be given to the routine use of the Trendelenberg position intraoperatively in obese patients. However, if one elects this posture, prudence would dictate careful monitoring and maintenance of arterial oxygenation. Certainly, in obese patients, the intraoperative combination of the head down position and a subdiaphragmatic laparotomy pack should be avoided. In addition, since our data were collected in obese but otherwise healthy, young patients free of cardiorespiratory disease, special attention should be directed at the continuous measurement of arterial oxygenation in the older obese patient with either intrinsic dysfunction of vital organs (heart, lung, liver, kidney) or surgical disorders (peritonitis, sepsis).


The effect of hemorrhagic shock on disseminated intravascular coagulation.

Experiments tend to confirm the hypothesis that a thromboplastic substance in the blood stream causes little DIC if blood flow is normal. However, if the same quantity of thromboplastic material is present in a slow capillary flow, it will produce DIC and possible death, with a marked clotting defect.


The plastic surgical adhesive drape: an evaluation of its efficacy as a microbial barrier.

A microbial evaluation was made of adhesive plastic surgical drapes and cloth surgical drapes. These studies were done both during surgery and in the laboratory. The plastic drape does not allow bacterial penetration, lateral migration does not occur, skin bacteria do not multiply under the drape within the time periods studied and the patient drapes are held in place with their use. When wet, cloth drapes showed profuse bacterial penetration. Dry cloth showed less bacterial penetration as compared to wet cloth. Lateral migration under cloth drapes was not possible to assess due to a high level of penetration. The surface of cloth showed a higher level of bacterial contamination during the surgical procedures. Deep wound cultures collected just prior to closing showed 60% contamination when cloth was used compared to 6% when plastic was employed. The micro-organisms recovered from the various sites sampled were identified. Finally, in addition to the positive aseptic benefits afforded by plastic adhesive drapes, aesthetic features such as a more delineated operative field and elimination of towel clips make this product a useful adjunct to the surgeon's armamentarium.


The role of surgery in primary syphilis of the anus.

Surgery has no role in the treatment of primary (infectious) syphilis of the anorectum. In this paper, we describe four patients who presented directly to the surgeon complaining of localized anal lesions. In three patients, the chancre was excised and in one patient the correct diagnosis was made prior to surgery. Rectal pain, which we attributed to secondary infection, was the chief complaint in three patients. Two patients also complained of tender lymphadenopathy. Darkfield examination is the most important diagnostic technique and penicillin remains the drug of choice. When treating diseases of the anorectum, the surgeon must maintain a high index of suspicion and a constant awareness of the manifold presentations of primary syphilis.


Suppression of gastrin release and gastric secretion by gastric inhibitory polypeptide (GIP) and vasoactive intestinal polypeptide (VIP).

Five dogs prepared with Heidenhain pouches received infusions of saline, GIP and VIP before and after a standard meat meal. Blood samples were obtained under basal conditions and at subsequent intervals for measurement of gastrin, insulin, GIP and VIP by radioimmunoassay. GIP and VIP infusions had no effect on basal levels of gastrin. GIP and VIP (in common with secretin and glucagon) were found to suppress food-stimulated release of gastrin and gastrin-stimulated acid secretion from the Heidenhain pouch. Insulin levels were significantly elevated during GIP and VIP infusions. Food released GIP (and perhaps VIP.


The immune response of zebu cattle infection with Trypanosoma congolense and T. vivax.

Zebu cattle were infected with Trypanosoma congolense and T. vivax and changes in the levels of serum immunoglobulins were measured during infection and after treatment. Increases in the levels of IgM occurred within 14 days of infection coincidentally with the first appearance of trypanosomes in the peripheral blood. IgM levels rose to 2-10 times preinfection levels and remained high until the animals were treated with diminazene aceturate. Levels then declined to approximately pre-infection levels within 25 days. IgG levels showed little change. In one animal infected with T. congolense which died of trypanosomiasis, there was an initial increase in IgM levels but subsequently both IgM and IgG levels declined until the animal died. The neutralizing activity of whole serum, and serum IgM and IgG fractions from an ox infected with T. congolense were examined. High levels of neutralizing antibodies against trypanosomes isolated on the eighth day after infection were found in sera collected 12-29 days after infection. Most of the antibody activity was located in IgG fractions which showed a peak in neutralizing activity between day 17 and 22. IgG fractions of the sera showed only  slight antibody activity.


Kala-azar in Ethopia I: Leishmanin skin test in Setit Humera, a kala-azar endemic area in northwestern Ethopia.

Leishmannin skin test surveys were carried out on 1057 farmers and non-farmers in the low-lying Setit Humera area of northwest Ethiopia, a region known to be endemic for kala-azar. The population of the Humera area is composed mainly of new migrants, and the mean time of residence for the entire population is only 4-4 years. The corresponding periods for the urban and farm-owning population are 6-3 years and migrant farm labourers 2-6 years. Most of the population comes from the highland provinces of Begemdir, Tigre, and Wollo, areas where kala-azar is virtually unknown except for two recent cases (Ashford et al., 1973b). 45-6% of farmers were skin test positive, but only 8-3% of non-farmers. Women in this area are only rarely involved in farming, hence there is a concommitant  marked sex difference. The skin test results seem to be correlated with the results for sex, age, and occupation of known kala-azar patients. The percentage of skin test positivity increases with age and, particularly among farmers, with the length of time spent in the Humera lowlands. This correlation is lacking among non-farmers. The annual rate of infection to Leishmania sufficient to result in skin test conversion is around 7% per annum in agricultural workers in the Humera area, but less than 1% per annum in the non-farming population. The infection rate for farm workers to Leishmania prior to coming to Humera is around 2%, compared to less than 1% for the non-farmers. There appears (significant at 10%) to be a weak correlation between the induration of positive skin test and the length of time spent in Humera, suggesting that the degree of induration is related to the degree of exposure to Leishmania. The positive skin test in kala-azar endemic areas is probably the result of (a) nonpathogenic Leishmania species, (b) L. donovani of low virulence and/or (c) human host resistance to L. donovani.


Study of growth of Biomphalaria glabrata Say and other Planorbidae in Guadeloupe West Indies.

The growth of Biomphalaria glabrata, B. schrammi, Drepanotrema lucidum and D. kermatoides was studied in three habitatis on Guadeloupe. Theortical growth curves were calculated for each species by applying the Walford method and the von Bertalanffy equation. On Guadeloupe, the growth of B. glabrata was faster in the ponds of Grand Terre than in the small high altitude streams of Basse Terre. There is good correlation between the observations made in Guadeloupe and previous data obtained on Pureto Rico and St Lucia.


A preliminary study of the health of a populaltion staying in apartments of varying sizes in Singapore.

A study was made of the health of 438 households living in high-rise flats in three public housing estates in Singapore. These households were selected by serial sampling from a total sample of 594 households; 156 (26%) were non-respondents. The study used personal interviews to collect data. Respondents questioned directly indicated a low but positive effect of high-rise living conditions on their physical health. The perceived health status of most of these flat dwellers remained unchanged after moving into their present accomodation. The major findings with regard to mental health were: (a) worry and anxiety were associated with the socio-economic status of the respondents; (b) the recreational activities of the respondents were related to their socio-economic status, although the majority spent most of their spare time at home; (c) living conditions in flats tended to affect the patterns of social contacts of the residents with their extended families and primary groups. Three factors (income, education and ethnic group) affected the social behaviour of the respondents with regard to health: (a) the preference for, and selection of, the first source of medical treatment varied for the different soci-economic and ethnic groups; (b) self-medication was associated with ethnic group; (c) the level of education affected the decision on when to receive antenatal care.


Pulmonary aspergillosis: an analysis of 41 patients.

During the period 1969 to 1974, 41 patients having cultures positive for aspergillus were seen on the thoracic surgical services of the University of Maryland and Mt. Wilson State Hospitals. Intracavitary mycetoma was present in 36 patients. In 32 the underlying disease was chronic cavitary tuberculosis, 5 had decreased immunity due to other diseases, and in 3 no underlying disease was noted. One final patient developed a mycetoma following repair of tetralogy of Fallot. Hemoptysis, the predominant symptom, occurred in 23 patients, all of whom were from the group with intracavitary mycetoma. Hemoptysis was life-threatening in 8 patients, severe but not life-threatening in 12, and minimal in 3. Fifteen patients underwent pulmonary resection with 2 deaths. Both patients who died had undergone emergency resection for life-threatening hemoptysis; the fungus ball had developed following a previous resection for tuberculosis, and both had poor pulmonary reserve. Of 10 patients with hemoptysis who were not treated surgically, chiefly because they were poor operative risks, 4 died. This study suggests that pulmonary aspergillosis, particularly of the intracavitary type, is a potentially life-threatening disease. Because of the suddenness with which massive hemoptysis may occur, pulmonary resection is recommended for all patients with intracavitary mycetoma who do not constitute prohibitive operative risks.


Segmental lung resection in the first year of life.

Segmental lung resection was performed in 5 infants with congenital lung disease. The lesions were cystic adenomatoid malformation in 2, congenital cystic disease in 2, and congenital lobar emphysema in 1. A higher than expected incidence of major segmental bronchovascular anomalies was encountered (3 of 5 patients). Other than prolonged air leak in 1 patient, complications were negligible. All patients were well from one to six and one-half years after operation. Segmentectomy is a sensible operation for congenital pulmonary disease and ultimately may have as its greatest virtue the preservation of normal lung tissue.


Indications for early thoracotomy in the management of chest trauma.

Trauma to the thorax represents a significant portion of injuries seen in an inner-city emergency room. Although most of these patients may be successfully managed without thoracotomy, a certain percentage require operative intervention either immediately or within several hours. The records of more than 380 patients with major chest trauma seen in recent years have been reviewed. Three hundred twenty-one of these patients (84%) required only good supportive measures such as correction of hypovolemia, temporary ventilatory support, tube thoracostomy, and careful observation. Forty-four additional patients (12%) required immediate operation following preliminary resuscitative treatment. Indications included hemorrhage, cardiac tamponade, injury to a great vessel, and rupture of the diaphragm. There were 10 deaths in this group. In 15 other individuals (4%) delayed operation was undertaken following careful reappraisal of initial injuries by continued examination, monitoring of vital signs, and appropriate roentgenographic and laboratory studies. Indications for delayed operation included continued or recurrent bleeding, widening of the mediastinum, hemoptysis, and recurrent hemothorax. There was only 1 death in this group. Thus, although it may be clear which patients require immediate operation, only careful and continuous monitoring can identify those who initially appear to be in stable condition but eventually will require exploration.


Pulmonary complications in primary acquired hypogammaglobulinemia: surgical considerations.

With the discovery and routine use of antibiotics, a virtually new disease--primary acquired hypogammaglobulinemia--was recognized. More precise clinical, genetic, and laboratory endeavor has proved, in fact, that it is really one of a whole host of individual disease entities, all with the common feature of inadequate production and marshalling of gamma globulin to combat infection. Although the condition has been recognized in children's medicine for two decades, the survival of these early victims into adolescence and adulthood is now bringing them to the attention of surgeons as candidates for drainage or resection of suppurative disease of the lung, air tubes, and pleura. In fact a triad has emerged, with some of these patients having infectious disease in the lungs and sinuses associated with enlargement of the spleen when first seen. Often it is the radiologist who first suspects the diagnosis when he recognizes one or more features of this diagnostic triad. Three personal cases are presented together with a technique of management that appears successful. As with the recognition of any new disease, occult and subclinical presentations become more common as suspicion progresses, and ease of confirmation is afforded.


Corticosteroids and prevention of pulmonary damage following cardiopulmonary bypass in puppies.

A technique of inducing hypothermia using surface cooling and rewarming with a pump oxygenator has been applied clinically in infants with satisfactory results. Respiratory problems postoperatively, however, are reported to be among the complications contributing most to mortality and morbidity. Prednisolone sodium succinate (Solumedrol) has helped to obviate pulmonary damage in hemorrhagic and endotoxic shock and therefore may be effective in preventing pulmonary damage following hypothermia. This hypothesis was investigated in 12 mongrel puppies, 6 that had hypothermic cardiopulmonary bypass and circulatory arrest but were not given Solumedrol, and 6 that were treated preoperatively with Solumedrol. In lung biopsies taken immediately after bypass the pathological changes in both the group treated with steroids and the control group were similar. At six hours, however, lung biopsies from the control group showed further signs of progressive damage, while in the steroid-treated group there was a striking improvement with some lung biopsies showing a normal appearance. Thus, Solumedrol did not prevent initial lung damage, but the progressive and probably permanent changes were reduced.


Free-water clearance and the early recognition of acute renal insufficiency after cardiopulmonary bypass.

The predictive value of free-water clearance measurements for the early recognition of acute renal insufficiency was evaluated in 59 patients immediately following cardiopulmonary bypass. Blood urea nitrogen and serum creatinine measurements were taken before and after operation. Intraoperatively, immediately after completion of bypass, urine and serum samples were obtained for osmolality. Duration of bypass, urine output, degree of hemolysis, and quality of perfusion were recorded. Fifty-four patients developed no signs of renal insufficiency following bypass, and all had free-water clearance values equal to or less than -20 ml per hour. Five patients who had free-water clearance values equal to greater than -8 ml per hour developed manifestations of an acute renal insufficiency state. There were no false-negative or false-positive determinations. Consequently, free-water clearance measurements appear to be a reliable indicator of those patients who will develop renal insufficiency following cardiopulmonary bypass. Early recognition provides an opportunity immediately after operation for initiating treatment consisting of administration of diuretics, potassium restriction, and oliguric fluid regimens.


Urinary osmolal changes in renal dysfunction following open-heart operations.

Forty consecutive patients who underwent open-heart procedures using a hyperosmolar perfusion prime were studied to determine the significance of free-water clearance and urinary osmolality early after bypass in predicting the likelihood of postoperative renal dysfunction, defined as a blood urea nitrogen (BUN) level over 50 mg/100 ml. Urinary osmolality increased in all patients during the first 18 hours after bypass, but the increase was substantially less for those who subsequently developed renal dysfunction. Free-water clearance, which was significantly less negative in the patients with renal dysfunction by 2 hours after bypass and remained so throughout the 18 hours of this study, served as an early postoperative indicator of impaired renal function in the patients who eventually developed BUN elevation. Moreover, it was more sensitive as an index of renal dysfunction than was osmolality alone. Early recognition of renal impairment is important, as it may prevent dangerous fluid overloading and allow for corrective measures to be undertaken before frank renal failure develops.


A comparison of the hemodynamic effects of inotropic agents.

This experimental study was conducted to compare and contrast the cardiovascular effects of the drugs most commonly used to alleviate low-cardiac-output syndrome. Twenty-five adult mongrel dogs were infused with sodium pentobarbital (60 mg/min) until their cardiac output fell to 50+/-5% of the average control values determined by thermodilution technique prior to pentobarbital infusion. The dogs were then divided into six groups, and one of the following agents or combinations of agents was administered to each group: isoproterenol, glucagon, dopamine, dobutamine, levarterenol and phentolamine, or levarterenol and nitroprusside. All drugs, except for glucagon and the combination of levarterenol and nitroprusside, produced an increase in cardiac output above the nonfailure baseline values. However, this increase was accompanied by an undesirable, pronounced tachycardia except when levarterenol was used simultaneously with phentolamine. Both dopamine and the combined infusion of levarterenol and phentolamine proved the most effective in restoring systemic arterial pressure to near baseline values, and both were able to increase renal blood flow above the failure baseline values. While renal blood flow remained elevated with all dosages of levarterenol and phentolamine, it tended to decrease with larger doses of dopamine. These experiments demonstrate that there are major advantages in the use of simultaneously infused levarterenol and phentolamine for control of low-cardiac-output syndrome: increased cardiac output without elevated peripheral vascular resistance, restoration of systemic arterial pressure and consequent improved coronary flow, absence of tachycardia, and augmented renal blood flow.


Preferential atherosclerosis at the aortic junction of the ligamentum arteriosum: clinical significance and pathological correlation.

Clinical experience with 5 patients who had complications of atherosclerosis within the aorta at the site of the obliterated ductus arteriosus suggested the occurrence of clinically significant preferential atherosclerosis at this location. To examine this hypothesis, the clinical findings in these patients (4 with saccular aneurysm and 1 with systemic emboli from an ulcerated plaque at this location) were correlated with postmortem examination of the aortic isthmus in 40 consecutive cadavers. The point of ductal closure was the area of most severe atheromatous involvement in 32 of the 40 cadavers, and 25 of the 40 specimens demonstrated ulcerated plaques at this location. Microscopical examination consistently demonstrated intimal irregularity or disruption and thinning of the aortic media in this area. These studies indicate that preferential atherosclerosis occurs at the aortic end of the obliterated ducts arteriosus and that these atherosclerotic changes can be a clinically significant development.


Permanent cardiac pacemakers: twelve-year experience with 287 patients.

Our total pacemaker experience was evaluated to determine survival, complications, effectiveness of follow-up techniques, and future goals for surveillance. A retrospective review of 287 patients with 570 pulse generators revealed 164 alive and 104 dead; 3 recovered normal conduction, 14 transferred care, and 2 have been lost to follow-up. Average age at initial implantation was 67 years. Overall mean generator life has been 22 months. The one-, three-, five-, and ten-year survival is 84, 71, 60, and 39%, respectively. The 738 operations performed averaged 2.6 procedures per patient. Of the total survivors, 108 (66%) had no complications; 56 (34%) have had at least one complication, 70% during the first year of the initial implantation. Fifty episodes of premature interruption of pacing service were detected. Ninety-one patients (32% of the group) have required an operative procedure on their pacemaker system more frequently than every two years. Of the replacements, 89 (29%) were for reasons other than end of generator life; 66 (63%) of the deaths occurred before replacement of the first generator. Mortality in the first two years was 23%. Once survival exceeded two years the average annual death rate was 3.7% (expected, 3.2%). Survival in our series compares favorably with that of other groups who report by the actuarial method. These data suggest that some deaths, reduced patient productivity, and the high cost to health care providers may be due in part to inadequate follow-up after the first pacemaker implantation. If follow-up observation is done frequently during the first year after initial implantation and once minimum generator longevity has passed, the goals of pacemaker therapy may be achieved.


Treatment of malignant pleural effusion: a method using tube thoracostomy and talc.

Our experience with a simple bedside method for controlling recurrent symptomatic malignant pleural effusion is presented. The method consists of intercostal tube thoracostomy, instillation of a suspension of talc, and waterseal suction drainage. Based on our experience, we believe certain criteria should be met before undertaking talc pleurodesis. In properly selected patients the results with tube thoracostomy and talc pleurodesis have been uniformly good in preventing fluid recurrence and return of disabling symptoms. The technique and results are discussed.


The sutureless electrode: comparison with transvenous and sutured epicardial electrode placement for permanent pacing.

Consecutive series of 50 transvenous and 50 sutureless pacemaker insertions were reviewed and compared with a nonsimultaneous series of 50 patients who received sutured epicardial pacemakers. It is concluded that: (1) the sutureless electrode has a lower initial stimulation threshold than the transvenous type; (2) complications from sutureless electrodes are greater than with transvenous electrodes and similar to the incidence with sutured epicardial pacemakers; (3) initial pacing is more satisfactory with the sutureless electrode compared with the transvenous model; and (4) late electrode failure due to threshold rise is greater with the sutureless electrode than with the transvenous or sutured epicardial type.


An electric cutter for all surgical prostheses.

A new electric cutter for surgical prostheses has been developed and was compared with surgical scissors for efficacy. This comparison of the two methods was done by cutting the edges of nine popular prostheses. It was concluded from gross and microscopical results after pulling both edges of the grafts cut by the two methods that the electric cutter is much more effective for surgical prostheses.


[Partial distortion of the great vessels in dextroposition and intrapulmonary continuity (Taussig-Bing variety)].

A case of partial distortion of the great arteries in a patient with dextroposition and mitropulmonary continuity is described (Taussig-Bing variety). The embryogenesis and anatomy in comparison with others similar cases found in the literature is analyzed and discussed. The cardiac defect is a partial distortion of the great arteries and its analysis permit to conclude that the conal muscle is not an important anatomic feature; its presence does not play a important roll in the genesis of the heart malformation. This case is compared with the so called "transposition of the great arteries with posterior aorta" and it is concluded that these heart defects have the same embryogenesis and that the relation of the great arteries themselves and with the ventricles depend of different grades of incorporation of the conus. It can be said also that this group of cardiac defects are not true transpositions of the great vessels, because the aorta does not arise anteriorly to the crista supraventricularis.


[Determination of the real value of the ventricular volume using angiographic methods].

The developing of cuantitative angiographic procedures for evaluating the left ventricular efficiency have displaced most of the simple hemodynamic methods. The calculation of the left ventricular volume by usual ventriculography yields, as a rule, magnified values. The purpose of this paper is to determine the equation of the regression line means of which the real left ventricular volume can be calculated. A series of 12 normal hearts obtained from accidentaly deceased adult individuals (this necropsy material was afforded by the Forensic Medicine Department of México City). Previously measured amounts of a contrast substance were injected into the left ventricular cavity. The heart was filmed in a position equivalent to the chest RAO. The volume of the left ventricle was calculated using monoplane Sandler and Dodge cineventriculographic method. The results were submitted to statistic analysis. Confrontation of calculated and real values rendered a significative "r" (0.7374) and a non-significant "p" (0.001) the regression equation obteined was: y=36.97 + (0.39 x) in which: y=real left ventricular volume. x=calculated left ventricular volume.


[Scintillography of the adrenal medulla].

The "nerve growth factor" is a polipeptide isolated from salivary glands of some mammals. Its main physiological effect is on the autonomic nervous system. The injection of antiserum in newborn  animals leads to nearly total destruction of the sympathetic ganglia (immunosympathectomy). Anti-nerve growth factor labelled with Iodine-131 was injected in rats for the determination of organ distribution at different times (2,4,6,8 and 24 hours). A selective concentration in the adrenal medulla was obtained at 4 hrs. after intravenous administration of 50 uCi of anti-nerve growth factor with an specific activity of 0.001 g/mCi that permits, for the first time, the scan of the adrenal medulla. No intolerance or radiotoxicity was observed in the animals during a six-month follow-up period. The results are very encoragin, and the application of this new method in humans is at present under study.


[Echocardiographic evaluation of ischemic cardiopathy].

We studied a group of patients with ischemic heart disease divided into two groups: Group I coronary insufficiency. Group II myocardial infaction. We centered the work on the following aspects: analysis of the contractility; evaluation of the movement of the ventricular wall and of the septum; movement of the mitral valve; diagnosis of ventricular dyskinesias, akinesias, and hypokinesias. The patients in group I did not show significant alterations in the values of the ejection fraction and speed of circunferential shortening. The mean values of these parimeters are significantly less than the group of patients with infarcts, and 41% of these patients have EF less than 50% and Vcf less than 0.9. We did not find a correlation between these perimeters and the localization of the infarct. The velocity of the posterior ventricular wall was disminished in both groups of patients. The amplitude of movement of the posterior wall was reduced in the group of patients with infarctions. These parimeters were more altered in the posterior infarcts than in those with anterior localization and they are more an index of the state of the posterior wall than of the ventricular contractility considered overall, contary to mitral descriptions. In 3 cases of acute infarct we found paradoxical movement of the septum, which normalized itself in one patient in 6 months. In 6 other patients with old infarct we observed localized dyskinesias of the septum and of the free wall of the left ventricle. The mitral valve appears altered in a great proportion of coronary patients the most notorious characteristics being: a decrease in the EF pendent; an increase of the F index. These findings are considered in relation with the ventricular pressures and with the degree of distensibility of the left ventricle.


[Further cases of Ehlers-Danlos syndrome of the renovascular dysplasic variety].

One hundred and twenty patients with arterial hypertension and 3 cases of fibromuscular displasia of the renal arteries (FDRA) (group D) were studied; besides the usual arterial hypertension work up, a search of Ehlers-Danlos syndrome stigmata was carried out in all patients. The population of 120 hypertensive patients were classified in 3 groups: group A, fromed by 104 subjects without EDS stigmata; group B, constitued by 7 cases with hypermobility of one to three metar-carpophalangic joints and group C in which 9 subjects with hipermobility of more than 3 metacarpophalangic joints were included. Neither case of groups A and B showed arteriographic signs of FDRA. In 4 cases of group C there were arteriographic evidence of FDRA (3.3% of the whole population) and stigmata of SED (2 cases with skin biopsy positive for this entity). Two cases of group D showed stigmata of SED and a positive skin biopsy; the other case had a normal histology of skin and no clinical signs of SED. The presence of SED stigmata in a patient with arterial hypertension should alert the clinician in the diagnosis of FRDA; in such a case it is recommended that a renal arteriography be performed. In this paper similarities of SED of the arterial type and some cases of FDRA are remarked and it is proposed the both entities share the same or a very closed molecular collagen defect.


[Trans and postoperative myocardial infarct in heart surgery].

1. A study was made of 34 cases (33%) of myocardial infarction trans and immediately postoperative which occurred in 11,210 surgical interventions with and without extracorporeal circulation. 2. This presents a statistical relation of the frequency of myocardial infarction in realtion to the heart disease acquired with or without extracorporeal circulation with the mitral, aortic, and double prosthesis of the mitral and aortic valves. A correlation was also made with the ischemic heart disease subjected to revascularization. The same analysis was carried out in the congenital heart disease with or without extracorporeal circulation. 3. In all cases the antecedents, precipitating factors, and the clinical picture were studied and in 12 cases the necropsy was analized. The principal finding was transmural myocardial infarction with electrocardiographic proof and serial enzymes. 4. The group was divided into two sub-groups; Group "A" with acute myocardial infarction transoperative, and Group "B" with acute myocardial infarction in the first eight postoperative days. The electrical and mechanical complications were analized. 5. A correlation was made of the causes of mortality related to the type of congenital or acquired heart disease with or without extracorporeal circulation. 6. The frequency of this entity was studied with the total time of aortic clamping, and the complications such as the low cardiac output syndrome, rupture of the wall, aneurysms, acute pulmonary edema, and with the disturbances of rhythm and conduction. 7. The presence of 33.3% of normal coronaries in these of necropsy was emphasized. 8. The importance of the coronary profile of this group in relation to the consequences of a stress from anesthesia, surgery, extracorporeal circulation, and aortic clamping is mentioned. 9. The diagnostic parameters such as arterial hypotension with or without the low cardiac output syndrome, enzyme levels, and the action of the potassium ion are mentioned. 10. An analysis is made of the possible etiological factors of the precipitation of the myocardial necrosis in the cases with normal coronaries and those in which there was no important obstruction of the coronary macrocirculation. 11. In the subgroup "A" it was found that the frequency of myocardial infarction was less than in the subgroup "B", but there was greater mortality in group "A". The possible causal factors are analized.


[Factors influenceing the activity of oral anticoagulants].

Anticoagulants are drugs capable to retard or even cancell the process of blood coagulation. They are many factors who influences the intensity and duration of oral anticoagulant acitivity, such as drugs, body constitution, physical agents, diseases, etc. The oral anticoagulants interacts with other drugs at differents levels: at the gut, at the plasma, modiffing the protein binding or the metabolism of such drugs, at the enzimatic induction or inhibition, or at unknown places with many other drugs. These paper deals with the description of such interactions.


Left anterior fascicular block concealing anteroseptal infarction.

Fascicular blocks may modify electro-cardiographic morphologies and signs of necrosis may be masked. This report concerns the case of a patient with an anteroseptal myocardial infarction who developed a transient left anterior fascicular block. An explanation for the concealment of the signs of necrosis is proposed, based on an analysis of the modified activation process by means of a vectorial representation.


[Aneurysm of the membranous portion of the interventricular septum].

The membranous portion of the interventricular septum represents the final phase of the ventricular growth. It is situated between the orifice of the coronary sinus and the supraventricular crest; immediately below the right aortic semilunar valves and not the coronary. Four cases of aneurism of the membranous portion of the interventricular septum are presented; in two, the diagnosis was made by angiocardiography study and in the rest it was made with the findings of an autopsy. All were of the female sex. Two patients presented a systolic murmur in the low mesocardia; three had heart failure, two of which were secondary to an arteriovenous short circuit through an interventricular communication, and the other due to alternations in the automatism and in the atrioventricular circulation. One case had W-P-W, type A and during its evolution presented paroxysms of atrial fibrillation and flutter, variable degrees of atrioventricular block with Stokes-Adams syndrome and ventricular fibrillation. In one case an obstruction at the level of the outflow tract of the right ventricle was suspected through phonocardiographic studies, and was confirmed subsequently with hemodynamic study. This same case presented a protosystolic aortic snap, at 0.13-0.14 sec. of the q wave of the electrocardiogram, described as of value for the diagnosis of this malformation. In two cases the angiocardiographic study showed the presence of the aneurism in the membranous portion of the interventricular septum, in one, it was visualized in the posterioanterior projection and in another in the lateral. One of the specimens had the aneurism adhered to the tricuspid septal valve, and also a fissure which communicated the left ventricle with the right atrium. In the other, the aneurismal sac was located below the septal valve of the tricuspid, producing a distortion in the anatomical architecture of the atrioventricular orifice.


[Intermediate syndrome: electrocardiographic, angiographic and clinical characteristics and their development under medical treatment].

An emphasis is placed on the definition and separation of the acute coronary insufficiency from the other "status anginosus", because the natural history and its physiopathology is of a distinct nature and actually still not very precise. A group of 19 patients was studied which filled all the clinical, electrocardiographic and enzymatic requisites of the genuine acute coronary insufficiency. Among these a subgroup of 13 patients was found with the classic Prinzmetal syndrome. In all cases the following were studied: antecedents, risk and coronary profile, the pain syndrome, electrocardiographic alterations, enzymatic modifications, coronariographic findings modifications, coronariographic findings and the ventricular function through ventriculography. The frequent occurance in the female sex is pointed out as well as the importance of the social and sensorial stress. We effected and described the correlation between the number and intensity of the pain crises and coronariographic findings. The electrocardiographic and coronariographic findings were correlated in the Prizmetal variety as well as in the entire group. An analysis was made of the correlation between the number and degree of coronary obstructions and the areas of ventricular diskinesia. The apparent paradox between an important number of cases with ventricular diskinesia and the limited number of cases with clinical and radiological left ventricular failure was mentioned and discussed. An analysis is made of the theoretic models of the ischemic heart disease in relation to the coronary macro and microcirculation and the possible influence of the catecolamines and the collateral circulation. The different physiopathological mechanisms introduced in this entity whose genuine world wide ocurrence is not very elevated. The evolution and morbi-mortality of those cases placed under medical care is analyzed.


[The bradycardia-tachycardia syndrome].

Disorders of the heart rhythm which consist basically of sinus bradicardia or sinus arrest correspond to a syndrome which has been named the sick sinus syndrome. Within the framework of this syndrome, there is a subgroup of alternating atrial bradycardia with episodes of atrial tachyarrhythmia. Generally known as the bradycardia-tachycardia syndrome, this subgroup is both electrophysiologically interesting and therapeutically challenging. This report is concerned with the experience obtained at the emergency ward and coronary care unit of the Instituto Nacional de Cardiología de México on the diagnosis and management of 8 patients with this syndrome. Various underlying heart conditions were present with predominance of ischemic heart disease. The clinical picture was dependent upon the hypoperfusion of vital organs secondary to the cardial arrhythmia. The most common symptoms were derived from cerebral circulatory deficit and coronary insufficiency. Half of the patients had moderate cardiac failure. All patients had spontaneous and transient loss of sinus function which lasted more than 2,000 msec. in seven. The bradycardia had a rate below 50 beats per minute in all cases except one. The tachyarrhythmias observed were atrial flutter, atrial fibrillation and paroxysmal supraventricular tachycardia. Three of the patients had more than one of these these tachyarrhythmias during the period of study. A discussion is made on the diagnosis of this syndrome by means of atrial pacing and interventions which modify either vagal or sympathetic tone. Considerations are also made on the frequent associated abnormality of the A-V functional tissues. Emphasis is placed on the problems encountered in the management of these patients. It is concluded that, in most cases, a satisfactory result may be obtained by the implantation of a permanent demand pacemaker associated to the administration of antiarrhythmic drugs.