Uterine tumors resembling ovarian sex-cord tumors. A clinicopathologic analysis of fourteen cases.

Uterine tumors with histologic resemblances to ovarian sex-cord tumors were encountered in 14 women in the fourth to sixth decades of life, most of whom had abnormal vaginal bleeding and enlarged uteri suggesting leiomyomas. The tumors in six cases (Group I) were identical to one or another form of well-recognized endometrial stromal tumor except for focal epithelial-like differentiation resembling that seen in sex-cord tumors. These tumors were mostly poorly circumscribed large mural masses. The focal sex-cord-like differentiation was manifested by cords, trabeculae, nests and tubules of epithelial-like cells; eosinophilic bodies resembling Call-Exner bodies were seen in one case. Five of the six patients with tumors of this type have been followed for postoperative intervals of 22 months to 15 years, and pelvic recurrences have developed in three. The tumors in eight cases (Group II) differed from those in Group I by having a predominant or exclusive pattern reminiscent of an ovarian sex-cord tumor. These tumors, most of which were single, well-circumscribed, yellow to tan, mural masses 4 to 10 cm in diameter, appeared benign, with no recurrence during postoperative periods of four months to seven years. The relations of the two groups of tumors to one another and to previously described similar tumors. including so-called granulosa-cell tumors and "plexiform tumors" of the uterus, are discussed, and an origin from endometrial stromal cells is postulated.


Brain-stem and adrenal abnormalities in the sudden-infant-death syndrome.

Fourteen of 28 sudden-infant-death syndrome (SIDS) victims had an abnormal proliferation of astroglial fibers in their brain stems and an enlarged mass of chromaffin cells in their adrenal medullas. Both of these abnormalities were associated with greater than normal muscle in the small pulmonary arteries, abnormal brown fat retention, and retained extramedullary erythropoiesis. These latter three findings are probably evidences of chronic alveolar hypoventilation and hypoxemia. The brain stem and adrenal abnormalities are probably also secondary to chronic hypoxemia.


Subacute myelo-optico-neuropathy (SMON) following pneumonitis. Serologic confirmation three and a half years after death.

A case of fulminant subacute myelooptico-neuropathy that occurred in a native American women following pneumonitis instead of the usual gastrointestinal dysfunction is reported. After the acute stage, which left the patient paraplegic and partially blind, she suffered an exacerbation which resulted in her death 11 months after the onset of illness. Autopsy disclosed symmetric optic and spinal demyelination. Neutralizing antibody titer against subacute, myelo-optico-neuropathy virus was determined on postmortem serum 3 1/2 years after death and found significantly elevated.


Hodgkin's disease in American Negroes. Histologic classification of the disease in 143 untreated patients, and age distribution.

The Rye histologic classification of Hodgkin's disease has been applied to 143 previously untreated cases of Hodgkin's disease in Negro patients seen in four hospitals in Washington, D.C.,during a 16-year period (1959-1974). The frequencies and age distributions of histologic subtypes were compared with those in American and two African series. Those histologic subtypes associated with poor prognoses (mixed-cellularity and lymphocytic depletion) predominated in American Negroes and in Negroes from Ibadan, Nigeria, and Kampala, Uganda. In an American series from Connecticut (approximately 98% Caucasian) the histologic subtypes lymphocytic predominance and nodular sclerosis were preponderant. There were statistically significantly less of the nodular sclerosis subtype (P less than 0.005), and more of the mixed-cellularity subtype in American Negroes compared with the Connecticut series (P less than 0.001). In contrast to findings in predominantly Caucasian populations, there was a predilection of the nodular sclerosis subtype for males in American and in African Negroes. This study showed that Hodgkin's disease in American Negroes epidemiologically corresponds to the so-called "intermediate pattern" of the disease.


The significance of focal glomerular sclerosis in children who have nephrotic syndrome.

This study was undertaken to learn the significance of focal glomerular sclerosis in children who have nephrotic syndrome. Tissue obtained by percutaneous renal biopsy 10-15 years previously was re-examined. Initially, two of the 29 biopsy specimens contained focal segmental hyalinosis or sclerosis and five of the 29 had focal glomerular obsolescence. The paraffin blocks were serially sectioned and examined. Following this procedure, seven of the 29 biopsies had focal segmented hyalinosis and 16 of the 29 had focal glomerular obsolescence. The percentages of focal segmental hyalinosis and focal glomerular obsolescence were recorded. Only those patients whose focal segmental hyalinosis exceeded 2% progressed to renal failure. Age-matched autopsy material from patients dying without renal dysfunction was used as a control. Focal glomerular sclerosis was seen in 75.8% of the control specimens, although few glomeruli within each specimen were involved. Focal glomerular sclerosis may be found normally; it may be found in nephrotic children who do not develop renal failure. The quantification of sclerotic lesions may be of prognostic significance in childhood nephrosis.


Sparganosis in the United States. Report of a case.

A 20-year-old Philadelphia woman (recently moved from South Carolina) had sparganosis of her lower anterior abdominal wall. In the United States sparganosis occurs when man enters the life cycle of dog or cat tapeworms of the genus Spirometra. Most of the American cases have been reported from the southeastern United States, and the most probable source of infection is contaminated drinking water. Sporadic cases have also been seen in other parts of the country. If the pathologist is familiar with the morphology of spargana, the gross and histologic features are sufficient for identification of genus Spirometra.


Ultrastructural changes in aspirin hepatotoxicity.

A percutaneous liver biopsy was obtained from a 9-year-old boy who had elevated serum transaminase levels while receiving aspirin treatment for rheumatic fever. Electron microscopy showed extensive fine-structure changes of the hepatocytes, similar to those induced by hepatotoxic drugs. These included marked dilatation of rough endoplasmic reticulum, proliferation of smooth endoplasmic reticulum, and mitochondrial abnormalities. These ultrastructural changes could be considered evidence that aspirin is hepatotoxic. The morphologic observations reported confirm the need for monitoring patients receiving systemic aspirin treatment transaminase measurements.


An evaluation of the usefulness of amylase isozyme differentiation in patients with hyperamylasemia.

Amylase assays measure total activity without differentiating the relative contributions of pancreatic- and salivary-type amylase isozymes. Since polyacrylamide electrophoresis allows identification of salivary-and pancreatic-type isoxymes and their respective variants, serum and urine specimens from patients with the clinical diagnoses of mumps (4), pancreatitis (16), or undiagnosed hyperamylasemias (5) were compared with specimens from control subjects. Patients with mumps had elevations of salivary-type isozymes, while those with pancreatitis had elevations of pancreatic-type isozymes. Elevation of salivary-type isozymes was identified in the five patients who had undiagnosed hyperamylasemias; among these, the isozymes of two originated in neoplastic ovarian tissue and those of three, probably in the salivary glands. Amylase isozyme differentiation cannot unamibiguously identify the tissue source of hyperamylasemia. However, in patients whose hyperamylasemia is of unknown etiology or who respond atypically to therapy, amylase electrophoresis provides identification of the elevated isozyme type, thus providing the basis for the rational selection of further diagnostic procedures.


Simultaneous determination of plasma aldosterone, corticosterone, 11-deoxycorticosterone, 18-hydroxydeoxycorticosterone, cortisol, and 11-deoxycortisol. Methods and applications.

A method for the simultaneous determination of aldosterone, corticosterone (B), 11-deoxycorticosterone (DOC), 18-hydroxy-11-deoxycorticosterone (18-OH-DOC), cortisol, and 11-deoxycortisol in a single 1-ml sample of plasma is described. The method is applicable to both man and experimental animal. After extraction and purification by thin-layer chromatography (TLC), aldosterone was determined by radioimmunoassay (RIA) employing antibodies to aldosterone: B, DOC, cortisol and 11-deoxycortisol were determined by RIA employing antibodies to corticosterone; 18-OH-DOC was obtained colorimetrically using the Porter-Silber reagent. Recoveries after extraction and chromatography were: aldosterone 71% +/- 9.4 SD; B 81% +/- 10.2; DOC 73% +/- 8.4; cortisol 65% +/- 7.2; 11-deoxycortisol 74% +/- 6.3 using labeled steroids; 18-OH-DOC 82% +/- 8.7 using inert steroid. The method has a high specificity and is reproducible and accurate.


Changes in serum chemical values as a result of prolonged contact with the clot.

Changes in serum biochemical values as a function of serum-clot contact time were investigated. Time extending to 48 hours were studied by drawing sets of six specimens from ten subjects. Glucose, lactic dehydrogenase, the transaminases, potassium, alkaline phosphatase, and iron showed significant changes. Other common tests, including electrophoretic separations, were not affected.


Pneumonia and pleural effusion. Association with influenza A virus and Staphylococcus aureus.

An 8-month-old infant with severe pneumonia and massive pleural effusions was found to have concurrent infections due to Staphylococcus aureus and influenza A virus. This was proved by the isolation of both agents from the pleural fluid. We believe this is the first case of isolation of an influenza virus from pleural effusions.


Empty sella syndrome secondary to intrasellar cyst in adolescence.

A 15-year-old boy had growth failure and failure of sexual development. The probable onset was at age 10. Endocrine studies showed hypopituitarism with deficiency of growth hormone and follicle-stimulating hormone, an abnormal response to metyrapone, and deficiency of thyroid function. Luteinizing hormone level was in the low-normal range. Posterior pituitary function was normal. Roentgenogram showed a large sella with some destruction of the posterior clinoids. Transsphenoidal exploration was carried out. The sella was empty except for a whitish membrane; no pituitary tissue was seen. The sella was packed with muscle. Recovery was uneventful, and the patient was given replacement therapy. On histologic examination,the cyst wall showed low pseudostratified cuboidal epithelium and occasional squamous metaplasia. Hemosiderin-filled phagocytes and acinar structures were also seen. The diagnosis was probable rupture of an intrasellar epithelial cyst, leading to empty sella syndrome.


A case of gonococcal osteomyelitis. A complication of gonococcal arthritis.

Gonococcal osteomyelitis is a rare complication of gonococcal infections since the advent of antibiotics. It is important that physicians be aware of this potential complication so that it is recognized and appropriate therapy promptly instituted.


"Bridging bronchus". A previously undescribed airway anomaly.

This report describes the clinical features and pathologic anatomy seen in an infant with anomalous bronchial branching and other congenital anomalies. The patient died of respiratory insufficiency and infection, possibly fostered by the malformed airway and a coexistent partial anomalous venous return. At autopsy, bronchial drainage of the right middle and lower lobes was provided by a large bronchial branch that originated in the left main-stem bronchus and bridged the mediastinum before entering the contralateral lung. Since crossed anatomic airway relationships after formation of primary branches are imcompatible with current concepts of embryologic lung development, a brief critical review of the pertinent literature is undertaken.


Ocular manifestations of subacute sclerosing panencephalitis.

We report a case of subacute sclerosing panencephalitis (SSPE) with severe peripheral chorioretinal pigment changes in addition to the more typical pigment clumping in the macula. The differential diagnosis of peripheral inactive chorioretinitis, the typical ocular findings, and clinical course of SSPE are discussed.


Teratogenic effect of anticonvulsant drugs.

Multiple malformations in all four children of a mother taking anticonvulsant drugs are reported, along with the extended family pedigree.


The prognosis of childhood systemic lupus erythematosus.

A retrospective analysis of 50 patients with childhood systemic lupus erythematosus seen during the past 13 years shows 35 living patients, 13 dead, and 2 lost to follow-up. Fourteen patients were males and 36 females, with the median age of onset 14 years. Clinical presentation was multisystemic in 31, primarily renal in 12, hematologic in 5, and atypical in 2. Renal involvement occurred at some time in all 50 patients. Central nervous system symptoms were present in 22 of 50. Survival in the present series is compared with previously reported survival models in the pediatric age group.


Transient hepatomegaly and hypoglycemia. A consequence of malicious insulin administration.

On two occasions, a 3 1/2-year-old black girl had severe hypoglycemia associated with transient hepatomegaly. The plasma insulin level during the second hypoglycemic episode was excessive and led to a diagnosis of malicious insulin administration. We suggest that plasma be obtained for insulin determination in children with hypoglycemia, and that transient hepatomegaly may be a helpful sign in cases of insulin overdose.


Gastric inhibitory polypeptide (GIP). Intestinal distribution and stimulation by amino acids and medium-chain triglycerides.

Radioimmunoassayable gastric inhibitory polypeptide was measured in extracts of canine antrum, duodenum, jejunum, and ileum. The highest GIP concentrations were found in the duodenum (347 +/- 53 ng/g) and jejunum (300 +/- 68 ng/g). An immunochemical similarity was demonstrable between porcine GIP and canine GIP. Dogs prepared with Mann Bollman fistulae were given an amino acid (AA) mixture or medium-chain triglycerides (MTC) by intraduodenal perfusion. With AA, a peak mean serum concentration of 672 +/- 106 pg/ml was reached 15 min after starting the perfusion. MCT resulted in a peak mean serum GIP concentration of 504 +/- 55 pg/ml 30 min after beginning the perfusion. When compared to results previously reported from this laboratory, AA and MCT are not as potent as corn oil (long-chain triglyceride) or glucose in stimulating GIP release. We conclude: (1) Immunoassayable GIP concentrations are highest in the canine proximal small intestine. (2) AA and MCT are weak stimulants of GIP release in the dog.


Comprehensive formal models for pancreatic calcium secretion. With reference to "exchange-diffusion," "two-component," and "unicellular" models of electrolyte secretion.

This is a theoretical paper in which comprehensive formal models are developed for all possible modes of entry of calcium into pancreatic juice. The 15 models include entry via: (1) the chloride-rich secretion, (2) the bicarbonate-rich secretion, (3) protein-bound calcium, and (4) interstitial fluid (ISF), plus the various possible combinations of these. Equations are presented for both calcium-volume and calcium-bicarbonate relationships. Each equation is modified as necessary to conform to the three current models for sodium, chloride, and bicarbonate secretion: (1) "exchange-diffusion," (2) "two-component," and (3) "unicellular" models. We believe the models provide a sound theoretical framework on which to build an understanding of pancreatic calcium secretion. Subsequent papers will be concerned with the physicochemical state of calcium in the juice, the relative contribution of ISF, and the development of an overall model for pancreatic calcium secretion. The long-term objective is to provide a rational approach for the understanding of pancreatic calcification and stone formation.


A new model of stress ulcer in the rat with pylorus ligation and its pathogenesis.

Water-immersion stress for 7, 14, or 20 hr consistently induced linear or punctate stress ulcers (mucosal erosions) in the corpus of the stomach in intact rats. When the pylorus of the stomach had been ligated prior to stressing, the stress ulcers changed their morphological feature (mainly punctate and in one place elongated) and location (both in corpus and antrum). Histologically, the stress ulcer developed in the proximal antrum of pylorus ligated rats and penetrated into the muscularis mucosa. Sodium bicarbonate, chlorpromazine, hexamethonium, atropine, metiamide, and bilateral vagotomy markedly inhibited the stress ulcers which developed in the pylorus-ligated rats. Phentolamine and propranolol hardly affected the development of stress ulcers. Amylopectine evoked a new type of stress ulcer in the corpus when it was given to the pylorus-ligated rats.


Myxedema ascites.

A 74-year-old man presented with mental obtundation and massive ascites without evidence of significant impairment of liver function. Thyroid function studies suggested hypothyroidism. Aspirated ascitic fluid had the characteristics of an exudate. Thyroid replacement therapy resulted in rapid clinical improvement with resolution of the ascites. Prompt recognition of myxedema ascites may prevent the inappropriate use of diuretic agents, therapeutic paracentesis, and sometimes unnecessary laparotomy.


Filiform polyposis of the colon. First report in a case of transmural colitis (Crohn's disease).

Filiform polyposis of the colon is characterized by multitudinous wormlike projections of mucosa and submucosa, and it has only previously been reported to be an unusual sequel to a prior limited episode of ulcerative colitis. The first reported instance complicating a 16-year course of typical transmural colitis (Crohn's disease) suggests that this benign proliferation may be a nonspecific submucosal response to two separated, but closely subadjacent zones of submucosal inflammation in either type of colitis. Although few cases of filiform polyposis are available for review, there has been no instance associated with carcinoma. The entity in itself does not represent an indication for colectomy.


A new substrate for the rapid evaluation of enteric microbial overgrowth.

The possibility of a new approach to diagnosis of intestinal bacterial overgrowth has been evaluated in laboratory animals. The diagnostic test involves oral administration of an enzyme-labile substrate consisting of para-aminobenzoic acid (PABA) conjugated to a bile acid. In the presence of enteric bacteria, PABA is split from the bile acid and is rapidly absorbed and excreted in the urine. The amount of PABA recovered during the 6 hr following the administered dose of the conjugate may be used as an index of bacterial overgrowth in the upper-gastrointestinal tract. The procedure has been shown to be a reliable index of this condition in laboratory animal models.


The asymptomatic HB6-Ag carrier: auto- and heterologous perils.

The asympatomatic carrier--usually discovered on offering to be a blood donor--presents a complex health problem which to date has received only "guarded" attention. These carriers may be dangerous, because they can transmit the HBs-Ag not only by parenteral but also by "nonparenteral" means, due to its presence in urine, feces, saliva, tears, semen, vaginal discharge, menstrual flow, breast milk, joint, ascitic and cerebrospinal fluids. The transmission by sexual contact is well established. Inapparent transmission may also occur from insufficient sterilization of instruments, by tatooing, ear piercing, by barbers, manicurists, dentists and by mosquitoes and bedbugs. Some of the characteristics of an asymptomatic HBs-Ag carrier seem to be: a young male, most often black, from a poor social and hygienic environment with a possible gene dependent immune deficiency state. Our experiences suggest that all newly admitted patients to the hospital personnel should have determinations of the presence of HBs-Ag in their blood, so that adequate steps can be taken to protect their contacts from infection.


Retrograde pancreatography: new contributions.

The standard technic for pancreatography was modified by using a metallic guide wire in the proximal half of the cannula so as to regulate pressure independently from that applied manually. The maximum pressure obtained by this method was measured in a polyethylene teflon cannula constructed to correspond to the Wirsung duct. Pressure was five times less when the guide wire was used. Our results in 33 patients correspond to experimental data. Only in 28% of our cases did the amylase rise slightly to a maximum of 290 Somogyi units. Acinar opacification was attempted by adding NaCO3 to a standard dye solution and was obtained in 20% of the cases (5 of 25). Maximum amylase elevation in this group was 263 Somogyi units. No complications resulted from the pressure measurements during pancreatography.


Endoscopic observation of the gastric mucus in vivo stained with azure A.

Gastric mucus was stained with Azure A, a cationic dye, which had the highest affinity with macromolecular constituents of the mucus, under such conditions as 0.2% Azure A-0.5% NaHCO3 solution (pH 8.1) in dye concentration, staining for ten minutes, 37 degrees C in reaction temperature and the salt concentration and ionic strength below 6.0 x 10(-2). In rat and resected human stomachs, gastric mucus was clearly stained under these conditions. In human subjects, the in vivo stained muscu was observed endoscopically. The pyloric gland region. The difference was seen in the pattern of the gastric area between the fundic and pyloric gland region. Histological examination revealed that only the mucous layer was stained with Azure A. The stained macromolecules in the mucus and factors affecting the staining were discussed.


The role of coloscopy in the differential diagnosis between idiopathic ulcerative colitis and Crohn's disease of the colon.

The authors point out the striking significance of coloscopy in establishing a correct diagnosis of inflammatory diseases of the colon. In particular, the most valuable endoscopic features are indicated which may permit distinguishing between idiopathic ulcerative colitis and Crohn's disease of the colon. Differentiation between these two diseases cannot always be achieved by means of available diagnostic procedures other than coloscopy. Moreover, the endoscopic findings enable an assessment to be made of the extent, stage, severity and course of either disease. The authors' experience encompass 2,478 coloscopy examinations: the observed cases of idiopathic ulcerative colitis are 182, those of Crohn's disease of the colon are 104.


Acute yersinial ileitis: a distinct entity.

A case report of documented Yersinial acute ileitis is presented. A review of the literature reveals that progression to Crohn's disease is uncommon. Yersinosis can present as several symptom complexes. Mesenteric lymphadenitis and terminal ileitis, however, appear to be the most common. The diagnosis is usually made during laparotomy for possible appendicitis, because the symptom complex may be very similar. If the only finding at laparotomy is a thickened edematous ileum, postoperative titers for Yersinia should be taken. A greater awareness is necessary before the true incidence and epidemiology can be ascertained.


Systemic sclerosis and regional enteritis occurring simultaneously.

A 58-year-old white female who had regional enteritis for many years insidiously developed scleroderma. A review of the literature failed to reveal any previous reports of this combination of diseases. The possible etiologies of both diseases are discussed along with their overlapping clinical manifestations.


Acculturation and coronary heart disease in Japanese-Americans.

Among men of Japanese ancestry, there is a gradient in the occurrence of coronary heart disease (CHD). It is lowest in Japan, intermediate in Hawaii, and highest in California. This gradient appears not to be completely explained by differences in dietary intake, serum cholesterol, blood pressure or smoking. To test the hypothesis that social and cultural differences may account for the CHD differences between Japan and the United States, 3809 Japanese-Americans in California were classified according to the degree to which they retained a traditional Japanese culture. The most traditional group of Japanese-Americans had a CHD prevalence as low as that observed in Japan. The group that was most acculturated to Western culture had a three- to five-fold excess in CHD prevalence. This difference in CHD rate between most and least acculturated groups could not be accounted for by differences in the major coronary risk factors.


Influenza detection: a prospective comparison of surveillance methods and analysis of isolates.

Several prospective methods for surveillance of influenza were compared for the speed and efficacy with which they identified cases of influenza in metropolitan Atlanta during 1972-1975, a period in which two outbreaks of influenza occurred. In a large city-county hospital's outpatient clinics, systematic collection of pharyngeal cultures for virus isolation provided a rapid means for discovering the presence of influenzal illness and for monitoring the extent of the outbreak. Both obtaining cultures and determining the percentage of patients with respiratory complaints indicated an outbreak 3-5 weeks before epidemic disease was confirmed by a rise in the number of deaths due to pneumonia and influenza. Antigenic analysis of influenza A strains isolated during this three-year period showed that influenza A strains recovered in Atlanta in 1973-1974 (a non-epidemic year) were identical to the strains recovered in the 1974-1975 epidemic. Why no epidemic occurred in 1973-1974 in the presence of the epidemic strain of the virus is unknown, and the lack of an epidemic suggests that the role of virus persistence in the epidemiology of influenza requires further evaluation.


A study of hepatitis B antigen carriers among schoolchildren in Netanya, Israel.

In the town of Netanya 9162 elementary schoolchildren (age 6-14 years) were tested for hepatitis B antigen (HBsAg) by the counter-electrophoresis method. The overall prevalence was 1.8% with a higher rate for males (2.2%) than for females (1.4%). Higher rates were observed among children born in the autumn and winter, particularly among the boys. This seasonal trend and male-female difference may partially be explained if infection occurs at circumcision. The ethnic distribution showed highest rates among children of Libyan and Yemenite origin (3.9% and 2.6%, respectively), and lowest rates among children of European and Israeli born parents (0.4% and 0.2%, respectively). Prevalence of HBsAg among children from large families and those from families living in poor and crowded quarters was very significantly higher than among children from smaller families living in richer areas and in less crowded conditions. These variables, which are closely associated with social class, remain significant after adjustment for ethnic origin and seem to account for a large proportion of the variation among the Israeli schoolchildren. The variation due to ethnicity is markedly reduced when adjusted for five other pertinent variables: age, sex, season of birth, crowding and family size. Assuming that prevalence of HBsAg in a population reflects the rates of infection (past or present), the results of this study strongly support the hypothesis that type B hepatitis in Israel behaves essentially as a contagious infection manifested primarily as a subclinical disease of early and mid-childhood.


Pharyngeal isolations of adenovirus 31 from a family population.

During a 14-month period in 1965 and 1966, adenovirus type 31 was isolated from 26 pharyngeal swabs obtained on a routine schedule from children and adults during a study of respiratory viruses among members of a family population. Eighteen isolations were made in a four-day period, seven within the preceding five months, and the last, eight months earlier. A significant association between the isolation of adenovirus 31 and respiratory or gastrointestinal illnesses was not demonstrable. Limited tests demonstrated neutralizing antibody increases in a few paired sera of infected adults. The virus is antigenically related to adenoviruses 12 and 18 and is capable of inducing soft tissue tumors in mice.


Nosocomial infection with highly resistant, Proteus rettgeri. Report of an epidemic.

Over 22-1/2 months an epidemic of at least 127 cases of nosocomial infection developed from a strain of Proteus rettgeri resistant to all antibiotics commonly tested in hospital laboratories. Although there were at least four cases of septicemia and one related death, the majority of cases consisted of asymptomatic bacteriuria or clinically mild urinary tract infection. Indwelling urinary tract devices and antibiotic therapy were important predisposing factors. Data supported an association between increasing use of gentamicin and increasing rates of resistant infection. No common source was found, and contact spread appeared more likely. Control measures included efforts to reduce unnecessary exposure to the incriminated risk factors and to improve asepsis in the management of catheterized patients. An additional 36 cases and one related death were identified in the 7-1/2 months following the investigation and institution of control measures. Nosocomial infection with extremely resistant organisms may pose a serious hazard wherever indwelling urinary tract devices and antibiotics are used together intensively.


Distribution of suspected tick vectors and reported cases of Rocky Mountain spotted fever in California.

Evidence is presented for an area of human risk to Rocky Mountain spotted fever (RMSF) in California extending beyond the range of its classic tick vector, Dermacentor andersoni. Geographic, seasonal, and host distributions of Dermacentor variabilis and Dermacentor occidentalis suggest these species as potential vectors of RMSF in California outside the range of Dermacentor andersoni.


Oral rabies vaccine: evaluation of its infectivity in three species of rodents.

The safety of oral rabies vaccine was evaluated in 3 species of rodents, animals which might inadvertently consume field-distributed vaccine baits intended for foxes. The potentials for infection from bait ingestion and transmission through cannibalism were evaluated. Results indicate that ingestion of the vaccine baits used in these experiments will result in infection and disease of some rodents. Of 64 rodents which ate baits, 19 (30%) died of clinical rabies; the diagnosis was confirmed in 11 (17%), and 2 (3%) had demonstrable rabies virus in their salivary glands. Only 3 of 112 (3%) rodents that ate vaccine-infected rodents contracted rabies, and none had demonstrable virus in their salivary glands.


Effect of immunosuppressants on dogs exposed two and one-half years previously to Blastomyces dermatitidis.

Observation of 33 dogs exposed to Blastomyces dermatitidis over a  2 1/2 year period is reported. During the first 1 1/2 years six dogs died and 23 (77%) developed skin lesions. Clinical evidence of disease in all the animals then subsided and remained so through another year of observation. Nine animals were sacrificed after 120 weeks and several tissues were cultured from each one. The remaining 18 were given immunosuppressants--azathioprine, prednisone, and cyclophosphamide--for eight weeks prior to autopsy. About one-half of the dogs were found to be infected with Histoplasma capsulatum and all were negative for B. dermatitidis by culture. The dogs were thought to have been inadvertently exposed to H. capsulatum during the first eight weeks of observation from a nearby soil plot before being moved to a more remote shelter. Skin testing with histoplasmin and blastomycin and complement-fixation (CF) tests, performed at various intervals after exposure to B. dermatitidis, appeared to reflect the course of disease with the number of reactors to the H. capsulatum antigens remaining relatively high while the number of reactors to B. dermatitidis antigens fell with the passage of time. The blastomycin skin test results in these dogs, however, persisted far longer than positive Blastomyces CF results. These data suggest that most dogs exposed to B. dermatitidis exhibit clinical symptoms of disease after about 12 weeks, persisting for about one year. The majority of animals recover spontaneously and completely. With H. capsulatum, however, the infection can be subclinical for at least a two-year period.


Sepsis associated with decubitus ulcers.

Among 21 patients with sepsis attributed solely to decubitus ulcers, bacteremia was documented in 16 (76 per cent)9 Bacteremia involved obligate anaerobes in eight patients (50 per cent) and was polymicrobial in eight patients (50 per cent). Twelve of 17 patients who received antibiotics had persistent bacteremia; in five patients, bacteremia was terminated only after surgical debridement. Ten of these 21 patients died, eight despite appropirate antibiotics. Among 14 patients who underwent surgical debridement, only four patients died. Surgical debridement and antibiotics effective against aerobic as well as anaerobic bacteria are both important in the treatment of this serious complication.


The cardiac conduction system in progressive systemic sclerosis. Clinical and pathologic features of 35 patients.

Progressive systemic sclerosis may be associated with focal myocardial fibrosis. Electrocardiographic abnormalities including conduction block are common in progressive systemic sclerosis but whether they are due to direct destruction of the specialized conduction tissue of the heart is uncertain. The conduction systems of 35 patients with progressive systemic sclerosis were studied. Of these 35 patients, 17 (50 per cent) had myocardial fibrosis of the type seen in progressive systemic sclerosis. In 10 of the 17, it was severe. Sinus node fibrosis was present in 13 patients and was nearly as frequent in those with as in those without the progressive systemic sclerosis myocardial lesion. Overlying pericarditis may have contributed to the fibrotic changes within the sinoatrial nodes in seven of the 13 patients. The atrioventricular node and main His bundles were normal. However, fibrotic changes were found in the proximal bundle systems in six patients. In three of the six, severe myocardial progressive systemic sclerosis was present, two had focal fibrous atrophy of the left bundle, and one had complete interruption of the right bundle. In only the latter patient was this reflected in the electrocardiogram which showed a right bundle branch block. Three patients without progressive systemic sclerosis myocardial lesions also had fibrous atrophy of a portion of the proximal left bundle branch, and in one the electrocardiogram showed an isolated left anterior hemiblock. Thus, morphologic abnormalities within the conduction system in our patients are difficult to attribute to progressive systemic sclerosis per se. Furthermore, although conduction abnormalities were more frequent in patients with myocardial disease, specific conduction system disease was not the cause in most patients. As has been noted in ischemic heart disease, the conduction system appears to be relatively spared from the myocardial changes of progressive systemic sclerosis, and the high incidence of conduction disturbances in this condition may be a consequence, rather, of damage to working myocardium.


Immunodeficiency, xanthomas and obstructive liver disease.

Chronic obstructive liver disease and secondary hyperlipidemia developed in an immunodeficient boy. Sequential addition of cholestyramine and phenobarbital to his medical regimen, following an initial response to bile drainage, resulted in the disappearance of xanthomas and pruritus, and the restoration of normal serum concentrations of lipids and bile acids. This improvement may result from shifting the bile acid pool from the peripheral blood compartment to the enterohepatic circulation.


Goodpasture's syndrome in a patient with the Nail-Patella syndrome.

A patient with the nail-patella syndrome in whom end-stage renal failuure developed as the result of Goodpasture's syndrome is described. Lesions characteristic of both rare diseases were seen on renal morphology. It is postulated that the glomerular membrane alteration of the nail-patella syndrome predisposed to the development of antiglomerular basement membrane antibody and hence Goodpasture's syndrome. A review of the incidence of renal failure in the nail-patella syndrome suggests that renal involvement can no longer be regarded as benign and that immune mechanisms may be related to progressive renal disease in some cases.


The appearance of nonlinear deposits of immunoglobulins in Goodpasture's syndrome.

A twenty year old woman presented with pulmonary hemorrhage and glomerulonephritis with linear deposition of IgG on the glomerular capillary basement membrane, and high titer of antiglomerular basement membrane antibody in her serum. Without treatment, renal function, which was transiently impaired, has improved, pulmonary hemorrhage subsided, and repeat renal biopsies have revealed the appearance of nonlinear in addition to the linear deposition of IgG on the glomerular capillary basement membrane in the face of diminished serum antiglomerular basement membrane antibody titer.


Splenosis: autotransplantation of splenic tissue.

Splenosis is the autotransplantation of splenic tissue that usually follows traumatic rupture of the spleen. Generally, the splenic implants are numerous and are located within the peritoneal cavity; however, extra-abdominal splenosis does occur. The implants are rarely clinically significant and are incidental findings at autopsy or at abdominal operation, unrelated to and distant from the splenic trauma and splenectomy. Splenic implants retain their ability to function, and recurrence of a hematologic disease for which the spleen was previously removed should alter the  clinician to the possibility of splenosis. The differential diagnosis includes accessory spleens, endometriosis, hemangiomas and metastatic cancer. We report three cases, two of which represent unusual complications of splenosis: a twisted pedicle of a splenic implant, which apparently caused abdominal pain, and recurrent Felty's syndrome associated with splenosis and an accessory spleen.


Regression of atherosclerotic stenosing lesions of the renal arteries and spontaneous cure of systemic hypertension through control of hyperlipidemia.

We describe a 49 year old woman with impressive regression of renal artery stenosing atherosclerotic lesions in response to sustained excellent control of hyperlipidemia. Initially, she had high blood pressure necessitating combined drug therapy with chlorothiazide, methyldopa and propranolol, with only moderately satisfactory control. Renal arteriography revealed a 90 per cent stenosing lesion of the right renal artery and 75 per cent narrowing of the left renal artery. Peripheral vein plasma renin was markedly increased at 32 ng/ml. With a combination of cholestyramine and clofibrate, serum lipids were maintained at normal values for several years. Increased blood pressure diminished spontaneously, and the patient has maintained normal blood pressures after discontinuation of antihypertensive therapy. Repeat renal arteriograms showed almost complete regression of the right renal artery lesion and a possible decrease in left renal artery disease. Peripheral vein plasma renin became normal at 3 ng/ml. This case illustrates that sustained control of hyperlipidemia could lead to regression of atherosclerotic nodules and impressive clinical improvement in certain patients.


Arthritis with an inflammatory dermatosis resembling Sweet's syndrome. Report of a unique case and review of the literature on arthritis associated with the inflammatory dermatoses.

A patient with a unique case of chronic episodic arthritis coincident with flares of acneform, pustular, nodular and ulcerating skin lesions was observed over a five-year period. This patient and a review of the literature on arthritis associated with the inflammatory dermatoses provide evidence which may interrelate several of these nosologically confusing skin conditions, e.g., the family of leukocytoclastic angiitides with the newly posited acute febrile neutrophilic dermatosis of Sweet. Systemic manifestations and a variety of acneform, pustular, nodular and ulcerating cutaneous lesions in the inflammatory dermatoses are best explained by small vessel involvement, with individual syndromes being determined by the type and degree of vascular change. Perivascular neutrophilic infiltration is the unifying histologic feature of these small vessel diseases. Neutrophil infiltration differentiates these entities, and our patient, from the histologically nonspecific inflammations of the skin, e.g., Behcet's disease and pyoderma gangrenosum, which, although capable of causing identically appearing skin lesions, consist predominantly of lymphocytic dermal infiltrates even in the earlier stages. It appears important to recognized these morphologically varied acute inflammatory dermatoses with perivascular neutrophilic infiltration in view of their systemic features and the dramatic efficacy of corticosteroid therapy.


Absence of imune deficiencies in a case of progressive multifocal leukoencephalopathy.

Progressive multifocal leukoencephalopathy (PML) is a rare disease related to a slow virus infection of the central nervous system; it is usually seen in patients who have impaired immunologic function. The present patient with biopsy-proved PML was found to have no demonstrable defects in either cellular or humoral immunity as assessed by multiple parameters. Thus, it appears that PML may occur in the presence of intact immune responses.


Sickle cell--betao thalassemia variant with high hemoglobin F and mild clinical course.

A 70 year old Black woman had chronic hemolytic anemia without recurrent painful crises. Hemoglobin pattern by electrophoresis was hemoglobin S (69 to 71 per cent), hemoglobin A2 (4.6 per cent) and hemoglobin F (24 to 27 per cent). No hemoglobin A was detected, and the hemoglobin F was distributed heterogeneously in the red cells. Reticulocyte alpha/nonalpha globin chain synthetic ratios were 1.44 to 1.62. Thus, the patient had a high hemoglobin F variant of S-beta zero (betao) thalassemia which has not been described previously. Her clinical course has been mild in comparison with S-betao thalassemia patients who do not have extremely elevated hemoglobin F levels.


Enterobacteriaceae identification compared by MORLOC (a new system) and API 20E.

Identifications of 201 Enterobacteriaceae isolates were compared by MORLOC (a new system) and the API 20E system. Identifications agreed for 192 isolates (95.5 per cent). Of the nine discrepancies, MORLOC was correct for four, API for three; neither for one; and for one, MORLOC agreed with the reference laboratory but apparently all three systems were incorrect. The MORLOC system requires an extra day for a TSI but is smaller and simpler and can be recommended as easier to use, more reproducible, less expensive, and, in this study, more accurate than the API 20E.


Experimental studies on cataract.

I have discussed five aspects of lens metabolism and their possible relationship to cataract in man, and this has left me with five fundamental questions to be answered. 1. Are the fluorescent tryptophan derivatives, found only in the lens of man and higher primates, involved in the development of brown nuclear cataract? 2. Is naphthalene cataract in rabbits a model for any type of cataract in man--i.e., are quinones ever formed in the human eye? 3. Is diabetes the only cataract in which osmotic swelling is important? 4. Does self-digestion of protein in the human lens contribute to cataract development? 5. Are the consequences of the abnormal maturation of lens fibers, which occurs in tryptophan deficiency cataract in rats, ever seen in man?


Hyperkalemia: diagnosis and treatment.

We have considered a differential diagnosis of clinical hyperkalemia. The clinical signs and symptoms of patients with hyperkalemia are manifold and can involve many organ systems. The nonoliguric chronic renal failure patient with hyporeninemia and hypoaldosteronemia may have as one of his principal problems recurrent hyperkalemia. Treatment of this condition includes well-known modalities such as administration of calcium salts, NaHCO3, removal of potassium with resin or dialysis as well as placement of a transvenous pacemaker in anticipation of bradyarrhythmias or asystole.


Primary retinal degeneration: evidence of normal phagocytosis in the retinal pigment epithelium.

In rats with primary retinal degeneration, lens extraction combined with total retinal detachment provided a model for injection of a tracer of colloidal carbon into the subretinal space. Electron microscopy and acid phosphatase cytochemistry were subsequently used to analyze the ingestion of tracer by the retinal pigment epithelium. It was found that the attachment, ingestion, and digestion phases of the phagocytic process were apparently preserved. From this evidence it is suggested that there is no lack of phagocytic power in the retinal pigment epithelium of affected rat strains.


Sodium and water: an overview.

The renal regulation of sodium is intertwined with the extracellular fluid volume (ECFV). Most adjustments in sodium elimination in man are accomplished via alterations in tubular reabsorption. The latter is sensitive to change in ECFV. An expanded ECFV results in less reabsorption and more excretion of sodium, and a contracted ECFV has the converse effect. There are direct and indirect mechanisms whereby ECFV influences sodium reabsorption. Patients with nephrotic syndrome, heart failure, and cirrhosis "behave" physiologically as normal individuals with a contracted ECFV. Water balance is normally determined by intake and losses in sweat which is always hypoosmotic to plasma, by evaporation from skin and lungs, and through renal excretion. The major factors that determine the ability to concentrate the urine are (1) the establishment of a concentrated environment around the collecting ducts, and (2) the elaboration and effects on the kidney of antidiuretic hormone. The evaluation of a patient with abnormalities of sodium and water rests initially and largely on clinical information. The clinical setting provides clues to anticipating, preventing, and interpreting distortions of body sodium and water. The laboratory can detect an abnormality, confirm or refute clinical assessment, and assist in the quantitative aspects of treatment and its efficacy.


Fluid and electrolyte disturbances in cirrhosis.

Glomerular filtration rate and renal plasma flow may be normal, reduced or increased in cirrhosis. The mechanism of departures from normal is not known. Other renal functional changes in cirrhosis include avid sodium reabsorption, impaired concentrating and diluting abilities, and partial renal tubular acidosis. Fluid and electrolyte disorders are common. Sodium retention with edema and ascites should generally be treated conservatively because they tend to disappear as the liver heals and because forced diuresis has hazards. The indications for diuretics are (1) incipient or overt atelectasis; (2) abdominal distress; and (3) possibility of skin breakdown. Hyponatremia is common and its mechanism and treatment must be assessed in each patient. Hypokalemia occurs and requires treatment. Respiratory alkalosis and renal tubular acidosis seldom need therapy. The hepatorenal syndrome is defined as functional renal failure in the absence of other known causes of renal functional impairment. The prognosis is terrible and therapy is unsatisfactory. The best approach is not to equate the occurrence of renal failure in cirrhosis with the hepatorenal syndrome. Rather the physician should first explore all treatable causes of renal failure, eg, dehydration, obstruction, infection, heart failure, potassium depletion, and others.


Histopathology of experimental ethambutol intoxication.

Ethambutol was administered to albino rats in their drinking water in doses of 105 to 2,500 mg. per kilogram per day for 18 to 102 days. Sixteen per cent developed bilateral lesions consisting of focal axonal swelling without demyelination, in their optic chiasms and the intracranial portions of their optic nerves.


Effects of mechanical agitation on endothelial function of preserved corneas.

Corneas from adult albino New Zealand rabbits were stored in either MK medium or moist chambers at 4 degrees C. for 18 to 24 hours. During that time, half the corneas from each group were agitated for 8 hours to simulate the motion that might occur during long-distance shipment. The corneas were then placed in specular microscopes and perfused for 4 hours with a modified Krebs-Ringer solution at 34 degrees C. Serial measurements of corneal thickness made during temperature reversal showed that agitation had no effect on endothelial viability of corneas stored in either solution. Electron microscopy of selected corneas confirmed this finding.


Corneal water and electrolyte content following storage in moist chamber and MK medium.

Rabbit corneas were subjected to MK-medium or moist-chamber storage for periods up to 7 days. Sodium, potassium, and chloride concentrations and hydration were measured. The hydration of corneas stored in MK medium was less than that of those stored in moist chambers. The sodium concentration of MK corneas remained stable for up to 7 days; the potassium concentration, however, decreased with increasingly longer periods of storage. Chloride concentrations quickly equilibrated with the high chloride level of MK medium. The concentration of sodium and chloride in moist chamber-stored corneas fell with progressively longer storage periods. Potassium showed an initial decrease in concentration followed by an increase in concentration that paralleled, and equilibrated with, the increasing acqueous humor concentration.


An improved model of experimentally induced ocular hypertension in the rabbit.

A model of experimentally induced ocular hypertension for the evaluation of antiglaucoma drugs in the unanesthetized rabbit is described. It is based on the intravenous infusion of suitable amounts of 5 per cent glucose solution, and advantageously substitutes the oral water load. The method is sensitive to drugs acting both on the outflow facility (2 per cent pilocarpine) and an aqueous humor formation (10 per cent guanethidine).


The WISC may not be a valid predictor of school performance for primary-grade minority children.

In the present investigation we studied the validity of the Wechsler Intelligence Scale for Children (WISC) for predicting several criterial teachers' ratings for primary-grade black, Anglo, and Mexican-American children. The results were rather striking: although validities for the combined groups were good (rs near .6), the validities calculated within each group presented a different picture. Validities were good for the Anglo children but near zero for the black and Mexican-American children. These results suggest that the WISC may be of little value in the assessment of the educability of minority children. The implications of these results for educational placement and the heredity-environment controversy were discussed.


Transfer of categorial clustering set in mildly retarded adolescents.

The relative effectiveness of instructions to adopt an organizational strategy vs. exposure to category labels was investigated. Twenty-four retarded adolescents were assigned to each of three conditions (blocking plus instructions, blocking plus labels, and blocking) for pretraining and training. Immediately after training, all subjects received a transfer task consisting of a new randomly organized list containing words from the same (training) categories for one-half of the subjects and from different categories for the other half. When exposure to category labels accompanied blocking, results indicated increased clustering and recall during the training phase and a trend toward increased clustering during the transfer phase.


Modifying maternal teaching style: effects of task arrangement on the match-to-sample performance of retarded preschool-age-children.

Twenty-one mothers and their retarded preschool-age children were observed during six teaching sessions. Following the first three sessions, each mother-child dyad was assigned to one of the three groups. Groups were matched on measures of mother and child behavior and on measures of various mother and child background factors. Prior to the last three teaching sessions, mothers received instructions to modify certain aspects of their teaching style. The results indicated that children of mothers who had been instructed to present the materials of the task systematically obtained significantly higher performance scores during training than did children of mothers who either received no instruction or had been told to increase positive feedback for correct responses. Further, 6 of 7 children whose mothers had altered the manner in which they presented the task materials showed improvement on a test administered after training. These results suggest that nonverbal activities which precede responding are critical aspects of teaching style and deserve more attention than they have received in the past.


Acquisition of concepts by TMR children as a function of type of modeling, rule verbalization, and observer gender.

A four-factor repeated measures design was established in order to determine (a) whether or not TMR children could acquire a novel rule-governed concept via modeling and (b) the effects of type of modeling demonstration, verbal rule provision, and observer gender on concept matching and transfer by TMR children. Twenty-four male and 24 female TMR children (mean IQ=44 and mean MA=5.67 years) were divided into four groups each equated by stratified assignment on IQ and MA. One male and one female group were randomly selected to observe a live female model present (a) massed-demonstration trials while verbalizing the concept, (b) massed trials without the concept being verbalized, (c) distributed-demonstration trials with the conceptual verbalization, and (d) distributed trials without conceptual verbalization. Subjects were then presented with three transfer tasks, each subsequently requiring a greater degree of generalization from the demonstration task. It was found that TMR children could acquire and transfer the complex concept via modeling. Distributed demonstrations yielded better initial response matching, while massed demonstrations led to better transfer. Rule provision facilitated transfer for massed-demonstration groups and facilitated matching for the male distributed-trials groups.


Assessment of the physical work capacity of institutionalized mentally retarded males.

Educable and trainable mentally retarded males (N=37) were examined for physical work capacity. Analysis of results indicated that the physical work capacity of the test population was 20 to 30% below that cited in the literature for nonretarded subjects of similar age and sex. Evidence also suggested that developmental and maintenance programs of physical fitness were required in order for mentally retarded persons to qualify for and maintain employment on most of the manual occupational tasks cited.


Eye movements and conservation acceleration in mildly retarded children.

Thirty mildly retarded elementary-school children, 15 of whom had received perceptual/attentional training, were tested on four Piagetian conservation tasks (number, length, and continuous quantity solid/liquid) presented on 16 mm movie film with taped instructions. Eye movements were recorded during the response period for each task. Subsequent analyses of eye-movement patterns showed clear differences between the training and control groups. Trained conservers showed more visual exploratory activity and less perceptual centration than control group subjects. Moreover the eye-movement patterns of trained conservers closely approximated those shown by natural (i.e., untrained) retarded conservers in a previous study. The findings were discussed in terms of possible cognitive structural changes resulting from training and possible cognitive structural differences between mildly retarded and nonretarded children.


Nurses' expectations for accomplishment of mentally retarded patients.

As part of a larger study into the pattern of care delivered to hospitalized mentally retarded adults, an attitude survey was undertaken. Factor analysis on questionnaires returned by 696 nurses yielded a three factor solution. One factor, concerned with the expectations that nurses hold of the potential level of patient accomplishment, was examined. Different grades of staff were found to hold significantly different views on a scale ranging from "optimist" to "pessimist". Results from 30 hospitals showed that, after correcting for this grade effect, there were substantial institutional differences.


Life expectancy of mentally retarded persons in Canadian institutions.

Data obtained from Statistics Canada were presented on the mortality level and expectancy of life for profoundly retarded and severely and moderately retarded persons in Canadian institutions for the years 1966 through 1968. Previous studies of mortality statistics were reported in mortality rates, average age at death, and crude death rates which are affected by the age distribution of the population involved. The very young and the very old are underrepresented in institutions, and thus these measures are not as accurate as life expectancy tables, which present the number of years expected to live, are independent of age distribution, and provide a reliable statistical measure for future replication and international comparisons. Retarded persons in institutions are living longer than previously, but their life expectancy does not meet that of the general population. Estimates of life expectancy for this population are vital for planning purposes.


Utility of the Uzgiris and Hunt seales of sensorimotor development with severely and profoundly retarded children.

The reliability and validity of the Uzgiris and Hunt (1975) scales of sensorimotor development were examined with severely and profoundly retarded children. The subjects were 63 severely or profoundly retarded children between 42 and 126 months of age. Thirty of the subjects were living in residential facilities, and 33 were living at home and attending day schools. All of the subjects were assessed on all six scales of the Uzgiris and Hunt instrument. Interexaminer and test-retest reliabilities were computed. Scalogram analyses were also computed for all but the Schemes scale. The findings were that the scales were reliable and, as theorized by Piaget, ordinal with the present sample. These findings were interpreted as indicating that these scales could be used reliably and validly with severely and profoundly retarded children. This was discussed in terms of the present and potential uses of these scales.


Sensory reinforcement of eyeblink rate in a decorticate human.

An unusual case of hydranencephaly was reported. The child survived for 19 years and showed evidence on three occasions of an increase in eyeblink rate with tactile reinforcement. Diagnosis was confirmed by an autopsy which revealed no preserved cortex in either hemisphere.


Role-taking ability and the interpersonal tactics of retarded children.

The relationship between social role-taking ability and preferences for interpersonal control tactics was assessed in 50 mentally retarded children. Feffer's Role-Taking Task and two hypothetical interpersonal control episodes were used as experimental measures. Results were that role-taking proficiency was associated with the development of alter-directed tactics or tactics by which the subject appeared to take into account the needs, motivations, or expectations of others. Neither MA nor IQ were significant predictors of interpersonal tactic choice. Controls for IQ and MA did not alter the significance of the association between role-taking and general tactic preferences.


A new approach to patients with suspected anaerobic postpartum pelvic infections. Transabdominal uterine aspiration for culture and metronidazole for treatment.

Oral metronidazole was given as therapy in 25 women with the clinical diagnosis of a postpartum anaerobic soft tissue pelvic infection following a vaginal delivery. There was a good clinical response in 80 per cent of these women. No anaerobic organisms resistant to metronidazole were recovered in the treatment failures. Different specimen collection techniques were evaluated, with anaerobes recovered in 4 per cent of the blood cultures, 26.3 per cent of the transabdominal endometrial aspirations, and 88 per cent of the transcervical endometrial samples. The aerobic recovery of organisms was 4 per cent from blood cultures, 15.8 per cent from transabdominal endometrial aspirations, and 96 per cent from the transcervical approach. The significance of these findings is discussed.


Carcinoembryonic antigen in intraepithelial neoplasia of the uterine cervix.

Carcinoembryonic antigen (CEA) was elevated (greater than 2.5 ng. per milliliter) in 29 of 100 patients with cervical intraepithelial neoplasia (CIN). CEA concentration was related to the amount of intraepithelial neoplasia and to the presence of glandular extension. Lymphoplasmacytic infiltration of tumor cells was unrelated to CEA levels. CEA values returned to normal within 8 weeks following surgery in 77 per cent of patients. A persistently elevated (greater than 5.0 ng. milliter) plasma CEA value following conization was associated with residual CIN in the cervix. These results suggest that sequential CEA determinations may be of value in the follow-up of those cervical cancer patients who initially have high plasma antigen levels.


A hypothesis: the role of a high-risk male in the etiology of cervical carcinoma: a correlation of epidemiology and molecular biology.

Certain impressive epidemiological evidence appearing in the last few years leads to the conclusion that some males are more prone to have a spouse with squamous cancer of the cervix than others. Advances in knowledge in other fields, especially at the molecular biological level, enable speculation on reasons for this curious conclusion. These readily testable theories, together with an outline of the evidence on which they rest, form the substance of this hypothesis.


Outpatient evaluation of patients with atypical Papanicolaou smears: contribution of endocervical curettage.

A series of 603 patients referred with atypical Papanicolaou smears was evaluated by repeat smears, colposcopically directed cervical biopsies, and endocervical curettage. These techniques as a unit can establish an accurate outpatient diagnosis superior to any of these modalities used alone and comparable with findings in conization and hysterectomy specimens. Endocervical curettage has made a unique contribution to the evaluation of such patients; these curettings have allowed examination of tissue fragments and are more reliable in diagnosing neoplasia than are endocervical smears. Invasive carcinoma and its precursors confined to the anatomic endocervical canal can be recognized by this technique, and conversely the absence of neoplastic epithelium in adequate endocervical curettings rules out occult carcinoma. Indications for conization of the cervix are discussed in reference to the other biopsy and cytologic findings, and guidelines are presented for patient management, stressing clinicopathologic correlation and cooperation.


Volatile constituents of human vaginal secretions.

Vaginal secretions were serially studied for 44 ovulatory cycles from 12 patients by means of combined gas chromatograph--mass spectrometry to identify small organic volatile compounds. In 10 of these cycles ovulation was documented with plasma radoioimmunoassays for progesterone, estrogens, and LH. These secretions contain a complex mixture of acids, alcohols, hydroxyketones, and aromatic compounds. Lactic acid, acetic acid, and urea were found to be present in all patients and underwent sharp cyclical variations in concentration with maxima in all patients occurring at midcycle. Small-chain, volatile C2-C5 aliphatic acids which have been shown to induce mating behavior in male rhesus monkeys were found in only four patients. In these patients the above acids were found predominantly at midcycle and during the luteal phase.


Primary prostaglandins in amniotic fluid in pregnancy and spontaneous labor.

Primary prostaglandins have been measured by radioimmunoassay in the amniotic fluid of 80 patients. In late pregnancy, PGE2 was higher than PGF2alpha with an increase around 36 weeks (378 +/- 71 pg. per milliliter) without significant modification until term. PGF2alpha increased too, but only significantly at term. During spontaneous labor, PGE2 and PGF2alpha were higher than before the onset of labor. Through serial determinations in five patients, two steps can be distinguished: the first one with stable levels but large oscillations of PGE2 and PGF2alpha and the second one starting at a variable stage of cervical dilatation with inversion of PGE2/PGF2alpha ratio (less than 1 and followed by an increase of both compounds more pronounced for PGF2alpha. It appears that PGE2 is concerned with the initiation of parturition while both PG's and mainly PGF2alpha are in relation to the contractions and the duration of labor.


Placental prostaglandin levels in pre-eclampsia.

Pre-eclampsia is characterized by uteroplacental ischemia. Prostaglandins can alter systemic blood pressure as well as regulate blood flow to the fetoplacental unit. In the present study, levels of prostaglandin E were significantly decreased in placental tissue from pre-eclamptic patients. Prostaglandin F, a potent vasoconstrictor, was markedly elevated. These observations indicate that altered placental metabolism of prostaglandins is an important factor in the pathophysiology of pre-eclampsia.


Oral contraceptives--induced hypertension--nine years later.

Nine years have gone by since oral contraceptive hypertension was first recognized as a clinical entity. In that time it has become apparent that what at first was thought to be a rare disorder is extremely common. Indeed, overt hypertension develops, in time, in about 5 per cent of Pill users. Increases in blood pressure, albeit within the normal range, are still more common. Pill hypertension may develop gradually. It is sometimes quite severe, and it is characteristically reversible within a few months after therapy is stopped. Oral contraceptives produce changes in the renin-angiotensin-aldosterone system, particularly a consistent marked increase in the plasma renin substrate concentration which may be associated with increases in plasma renin activity and aldosterone excretion. The estrogenic component of contraceptive pills appears to be the more important factor in producing abnormalities in the renin system. The mechanisms for the hypertensive response are not entirely clear since normotensive women using the pill may exhibit similar or even more marked changes in the renin axis. The pressor response could have both volume and vasoconstrictor components mediated by the sodium-retaining effects of the estrogen in the presence of a relatively, if not an absolutely, higher plasma renin activity, with the latter being held abnormal by the high plasma renin-substrate levels. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. Our in vitro experiments support the idea that the increased substrate is involved in pathogenesis because they indicate that in normal subjects plasma renin substrate is not present in "excess". Thus, a doubling of the physiologic levels of substrate by oral contraceptives leads to an almost twofold increase in the capacity for angiotensin production as indicated by studies of the initial reaction velocity. These observations define certain guidelines for applying oral contraceptive therapy. At least one base-line blood pressure measurement should be obtained, and blood pressure and weight should be followed a two- or three-month intervals during treatment. Furthermore, oral contraceptive therapy may be contraindicated in women with a history of hypertension, renal disease, toxemia, or fluid retention. Others in whom oral contraceptives are relatively contraindicated include those with a positive family history of hypertension, younger women in whom a longer term commitment is likely, and groups, such as blacks, especially prone to hypertensive phenomena.


Systolic time intervals in normotensive and hypertensive human pregnancy.

Systolic time intervals were measured in 10 nonpregnant, 37 normotensive, and 18 hypertensive pregnant women in both supine and lateral positions. With all the subjects in the supine position, left ventricular ejection time (LVET) was shortened; the pre-ejection period (PEP) lengthened, and the PEP/LVET ratio increased in normotensive late pregnancy compared with the nonpregnant state. Similar alterations in systolic time intervals were observed in hypertensive women in both early and late pregnancy in the supine position. In normotensive women in early pregnancy, alterations in systolic time intervals were inconclusive. When normotensive women in late pregnancy were turned from the supine into the left lateral position, a prolongation of LVET and a decrease in the PEP/LVET ratio were observed. When hypertensive women in late pregnancy adopted the left lateral position, no significant alterations in systolic time intervals occurred. Isovolumetric contraction time (ICT) was prolonged only in the hypertensive pregnant women in the supine position. The study suggests that left ventricular performance is diminished in normotensive women in late pregnancy when supine but improves when they adopt the lateral position. In addition, hypertensive pregnant women show evidence of diminished left ventricular performance which is not improved in late pregnancy by assumption of the left lateral position.


The relationship of hospital-acquired infection to invasive intrapartum monitoring techniques.

A 6 month survey of hospital-acquired uterine infection was done on the obstetric service of the Los Angeles County-University of Southern California (LAS-USC) Medical Center to determine the impact of the duration of monitoring upon the incidence of maternal infection. There were significantly more infections among the population monitored and in women undergoing cesarean section. In diminishing order, the incidence of infection was: cesarean section monitored, 90 of 223 (40.4 per cent); cesarean section not monitored, 56 of 271 (20.4 per cent); elective repeat cesarean section, 1 of 21 (5 per cent); vaginal delivery monitored, 33 of 1,236 (2.7 per cent); and vaginal delivery not monitored, 49 of 3,445 (1.4 per cent). In comparing those patients with infection and those free of infection following equivalent routes of delivery, there was no statistical difference in the duration of monitoring. These results suggest that the interval of monitoring alone is not a significant clinical factor in the development of maternal soft-tissue pelvic infection in a high-risk obstetric population.


Renal clearances of estriol conjugates in normal human pregnancy at term.

In late human pregnancy more than 90 per cent of the total estriol (E3) in body fluids consists of four conjugates, estriol-3-sulfate (E3-3S), estriol-16-glucosiduronate (E3-16G), estriol-3-glucuronide (E3-3G), and estriol-3-sulfate-16-glucosiduronate (E3-3S-16G). Since the relative amounts of E3 in blood and urine would be determined by the kidney, the renal clearance of each conjugate was determined and compared with inulin and p-aminohippuric acid (PAH) clearance, as measures of glomerular filtration rate (GFR) and the effective renal plasma flow. Five women were studied in the lateral decubitus position with inulin and PAH infusion. Samples of blood and urine were collected at 40 minute intervals and analyzed. The method for E3 conjugates involved separation of the four conjugates on Sephadex LH-20, enzyme hydrolysis, and radioimmunoassay. Renal clearances for E3-3S and E3-3S-16G were below inulin. E3-3G approximated inulin; E3-16G exceeded inulin and approached PAH. In plasma E3-3S-16G represented 48.4 +/- 7.2 per cent; in urine E3-16G represented 69.5 +/- 7.3 per cent of total E3. Thus, different conjugates predominate in blood and urine.


Neonatal respiratory distress following elective delivery. A preventable disease?

Twelve per cent of all infants with respiratory distress admitted to our neonatal intensive-care unit from November, 1973 to April, 1974, were born after elective intervention (15 cesarean sections and four vaginal inductions). All were white and 18/19 were private compared to yearly admissions of white (56 per cent) and private (57 per cent). Eighteen of 19 were admitted from the region via the transport service. Mean birth weight was 2.69 kilograms, with 18 infants over 2 kilograms. Pediatric gestational age from a physical and neurological evaluation ranged from 32 to 39 weeks (mean 36.2 weeks) in contrast to obstetric dating which ranged from 38 to 44 weeks (mean 39 weeks). The obstetric dating was 3 or more weeks greater than the pediatric age in 11 infants. Pulmonary disease included transient tachypnea (5) and respiratory distress syndrome (14). No prior documentation of pulmonary maturity had been obtained in any of these infants. Mean hospitalization was 23 days (range 1 to 140), with estimated costs of $3,421 per baby. Two infants died. Respiratory distress following elective delivery remains a potent source of on-going perinatal morbidity. Regional programs must direct increased educational efforts to eliminate this preventable disease.


The response of the human Fallopian tube to ergonovine and methyl-ergonovine in vivo.

Ergonovine maleate (EM) is a powerful stimulant of human tubal motility. It has been therefore thought that EM could interfere with normal ovum transport and serve as a contraceptive. The tube activating effects of EM and methyl EM were evaluated in 14 women and results confirmed that both are powerful stimulants of the human Fallopian tube. EM immediately post coitus significantly reduces the conception rate.


Suboptimal pregnancy outcome among women with prior abortions and premature births.

Data from 25,958 consecutive UCLA deliveries were analyzed to determine the effect of prior abortions and premature births on current pregnancy outcome. Perinatal death rate, combining stillbirths and neonatal deaths, increased more than threefold among women with at least one prior premature in birth and at least one prior abortion and approached 18 per cent of current deliveries when there were three or more prior premature births. Abnormal live births, defined as infants with either birth weight under 2,501 grams, gestational age less than 37 weeks, or congenital anomalies, significantly increased as the number of prior abortions and premature births increased, each in a range of 0 through 3 or more. For example, among women with at least three prior premature births, there were greater than 50 per cent abnormal live births. The risk was mostly that of low birth weight and low gestational age, although there was a slight increase in congenital anomalies. The risk was reduced considerably when there were previous term births and was influenced variably by race, clinic classification, maternal illness, and prior pregnancy complications. This empirical data on pregnancy outcome should be useful in reproductive counseling among women with pregnancy losses and premature births.


Antepartum fetal heart rate and uterine activity studies: I. Preliminary report of accelerations and the oxytocin challenge test.

A series of 344 antepartum fetal heart rate studies in 209 high-risk patients is described. The importance of evaluation of accelerations of the fetal heart rate as well as periodic decelerations associated with uterine activity is demonstrated. Our data suggest that the absence of accelerations of the fetal heart rate during the recording period may be associated with increased perinatal morbidity. Late decelerations may occur in the same recording session as accelerations of the fetal heart rate. The association of late decelerations of the fetal heart rate with no accelerations during the recording session is highly suggestive of increased perinatal morbidity. In high-risk patients, accelerations of the fetal heart rate and no late decelerations with uterine activity are a reassuring finding, with 91 per cent of patients showing no increased perinatal morbidity.


Colonic pseudo-obstruction following termination of pregnancy and uterine operation.

Colonic pseudo-obstruction refers to a condition in which physical and radiologic findings identical to those associated with mechanical obstruction of the large bowel are found but in which no organic cause of the colonic distention is present. Cases of this condition have been reported in the world literature, of which 40 per cent have followed the termination of pregnancy or uterine operation. Three cases of this syndrome are presented. One followed normal vaginal delivery; one followed cesarean section, and the third followed elective abdominal hysterectomy. The literature on the subject is reviewed, and a possible anatomicophysiologic explanation, based upon a sympathetic-parasympathetic neurostimulatory imbalance, is put forward.


Classification of human fetal movement.

A study of fetal activity was undertaken as the first step in a series of physiologic fetal movement studies. A simple, safe, noninvasive, clinically applicable method for studying fetal movement with a tocodynamometer is described. Four basic types of fetal movement have been seen and defined in terms of their durations, recorded patterns, and descriptive terminologies for identifying each movement.


Reported live births following induced abortion: two and one-half years' experience in Upstate New York.

Thirty-eight live births following induced abortion were recorded in Upstate New York between July, 1970, and December, 1972. Twenty-six followed saline-induced abortion; twelve of these occurred at one hospital, and eight were associated with one physician. Underestimation of gestation and exchange of inadequate volumes of amniotic fluid and hypertonic saline produced concentrations insufficient to cause intrauterine death. Viable infants with iatrogenic central nervous system damage from salt poisoning are a possible consequence of improperly planned saline-induced abortions. These births provide further evidence for encouragement of contraception and early termination of unwanted pregnancy.


Ovarian morphology in women with anosmia and hypogonadotropic hypogonadism.

Ovarian biopsies from five women with the syndrome of hypogonadotropic hypogonadism and anosmia who had not previously received exogenous gonadotropins were evaluated with special emphasis on follicular morphology. Follicular development past the primordial stage was rarely observed, suggesting that early stages of follicular maturation require amounts of gonadotropins in excess of those secreted in these women.


Excision of submucus fibroids with hysteroscopic control.

Hysteroscopy offers a new option in the diagnosis and management of submucus fibroids. The hysteroscopic excision of submucus fibroids in five cases is described. The problems and potentials of this approach are discussed.


Rational management of perinatal hydrocephalus.

Hydrocephalus of prenatal origin, which may be hereditary, is likely to be discovered more frequently and earlier in gestation with ultrasonic diagnosis. It is suggested that each case be analyzed according to a protocol which includes a full obstetric evaluation, complete genetic pedigree, determination of familial cranial size, and complete neuropathologic study. Destruction of the aqueductal area may deprive the investigator of much of the information needed for the thorough study of the case which is vital to counsel the parents concerning future pregnancies.


The effect of L-dopa and chlorpromazine on prolactin and growth hormone secretion in normal women.

The time course of simultaneous changes in prolactin (PRL) and growth hormone secretion in response to a single dose of L-dopa and chlorpromazine was determined in normal women. L-Dopa induced greater, but shorter (30 minutes), growth hormone release than concomitant suppression of PRL secretion. The PRL peak following chlorpromazine occurred at the same time as the nadir of PRL after L-dopa (3.5 hours). The quantity of PRL release inhibited by L-dopa equaled the amount of PRL secretion during the period of rebound, suggesting L-dopa inhibits PRL release, but not synthesis, by the pituitary.


Vasomotor symptoms, serum estrogens, and gonadotropin levels in surgical menopause.

Hormonal parameters of young women who developed vasomotor symptoms in the immediate postoperative period following castration are compared to those who remained asymptomatic. Only 37.5 per cent of 16 premenopausal women developed "hot flushes" after operation. Perimenopausal women with vasomotor symptoms and elevated follicle-stimulating hormone levels demonstrated normal luteinizing hormone and estrogen values preoperatively. There were no statistically significant differences in total serum estrogen, follicle-stimulating hormone, or luteinizing hormone concentrations between the group of patients with symptoms and the group withoyt symptoms. The results of the study indicate that rising gonadotropin or declining estrogen values appear to have no direct correlation to the onset of vasomotor symptoms in the immediate postoperative period. Thus, the precise etiology of the "hot flush" remains to be elucidated.


Scanning and transmission electron microscopic studies of vaginal adenosis and the cervical transformation zone in progeny exposed in utero to diethylstilbestrol.

Much attention has recently been focused on vaginal adenosis and other cervical and vaginal alterations occurring in female offspring exposed to diethylstilbestrol (DES) in utero. These alterations consist of heterotopic glandular epithelium in the vagina, a characteristic cervical transformation zone, and the frequent presence of a cervical collar, or hood. It is believed that these changes occur during embryonic differentiation of the lower genital tract following failure of squamous epithelium to migrate in a cephalad direction to replace columnar epithelium which normally lines the vagina and ectocervix. A number of cases clear-cell carcinoma have occurred in DES-exposed girls who also had adenosis. In an attempt to characterize the cellular populations of these areas of adenosis, we have made an ultrastructural study which is herein reported.


Response of human uterine arteries to local anesthetics.

The in vitro effects of local anesthetics and norepinephrine upon strips of early gestation and term pregnancy uterine arteries were studied in eight cases. In another case, the effect upon uterine veins was studied with a standard organ bath used to record isometric contractions. Histologic preparations were made to verify the type of vessel studied. An artery obtained from an eight-week gestation did not respond to either lidocaine or mepivacaine. All other arterial specimens (radial and helicoidal strips) responded with slow, rising, strong contractions to diluted concentrations of both of these substances. Likewise they responded with rapid contractions when exposed to norepinephrine. Alpha blockers were unable to prevent the contractions triggered by the local anesthetics. The vein specimens did not respond to local anesthetics but contracted when stimulated by norepinephrine. Based on these observations and after brief review of some hypotheses advanced to explain post-paracervical anesthesia fetal bradycardia, it is postulated that this bradycardia is probably due to uterine artery spasm, causing decreased intervillous space blood flow and fetal hypoxia.


Reduction of the stretch modulus of human cervical tissue by prostaglandin E2.

Samples of cervical tissue were obtained from women immediately following term delivery from spontaneous labor or oral PGE2-induced labor and from a small nunber of nonpregnant women in the reproductive years undergoing hysterectomy for benign gynecologic disease. The measured strips were placed in a well-oxygenated bath at 37 degrees C. containing Ringer's solution and stretched at a constant rate while continuously recording length and tension. The data were converted to stress-strain diagrams. Each curve contained a long linear portion which allowed one to compute a stretch modulus for each sample. A total of 71 strips from 23 patients was used. The average stretch modulus from the oral PGE2-induced patients was significantly lower than the spontaneous labor group (p less than 0.005), which, in turn, was significantly lower than the stretch modulus of the nonpregnant cervical tissue. It was also noted that the yield point was lower in the PGE2 series when compared to the spontaneous labor series (p less than 0.05). The effect of the PGE2 at a bath concentration of 10(-5) to 10(-6)Gm. per cubic centimeter was to materially reduce the stretch modulus within 5 to 15 minutes of the drug addition in both the PGE2-induced and spontaneous labor series. The results of these experiments indicate that PGE2 has the effect of reducing cervial stiffness.


Spontaneous contractility and the response of the human uterine cervix to prostaglandins F2alpha and E2 during the menstrual cycle.

The effect of prostaglandins E2 and F2alpha on the contractility of the uterine cervix was investigated in nonpregnant women throughout the menstrual cycle. PGF2alpha was found stimulatory to the cervix at all phases of the menstrual cycle, whereas PGE2 was inhibitory. The relaxing effect of PGE2 was most marked during midcycle.


Abnormal adolescent primiparous pregnancy: association of race, human chorionic somatomammotropin production, and smoking.

Abnormal pregnancies (33 per cent) were studied in 417 consecutive, unmarried, primiparous women, age 12 to 18 years (black, 54 per cent; white, 46 per cent). Black patients had no increase in abnormal pregnancies but had more infants weighting less than 2,500 grams (p less than 0.01). Black patients with pre-eclampsia gained less weight than white patients (24 versus 34 pounds, p less than 0.05) and had smaller infants (2,834 versus 3,316 grams). In white patients, the mean age at menarche was earlier in women who lost their infants (11.0 versus 12.7 years; p less than 0.01). Smoking was more prevalent in normal pregnancies (47 per cent) than abnormal pregnancies (38 per cent). Spontaneous abortion and fetal loss occurred more often in smokers (p less than 0.01). White women smoked more than blacks (60 versus 37 per cent). In mothers of infants weighting less than 2,500 grams, there were fewer smokers. Unexpectedly, smokers had less hypertension and pre-eclampsia. Human chorionic somatomammotropin values correlated with infant size. Levels of less than 4 mug per milliliter after 30 weeks' gestation were identical in normal and abnormal pregnancies (4.4 per cent). They were associated with small infants but no fetal deaths and did not predict outcome of pregnancy.


Measurement of the pre-ejection period during labor with the use of arterial pulse time.

A new fetal parameter, the arterial pulse time, is described. It is the time from the onset of the fetal electrocardiographic recording to the arrival of the arterial pulse wave recorded at the fetal head. Since arterial pulse time differs from the pre-ejection period by only an apparently constant value, it is proposed as a potential method for obtaining the pre-ejection period during labor.


Observations on maternal oxytocin release during human labor and the effect of intravenous alcohol administration.

Serial blood samples were obtained from 97 women in spontaneous labor, and oxytocin levels were determined by a sensitive and highly specific radioimmunoassay. The following observations were made: (1) The hormone is released in a series of "spurts"; (2) the peak levels achieved are usually 2 to 5 muU per milliliter and never exceed 12.5 muU per milliliter; (3) the frequency of spurt release increases as labor progresses, reaching a maximum in the second stage; (4) the frequency of spurt release is reduced during intravenous infusion of alcohol at levels which produce no obvious effect on uterine activity.


Needle puncture of fetus: a complication of second-trimester amniocentesis.

Needle puncture of the fetus has rarely been reported with midtrimester amniocentesis. This paper contains the report of five cases of needle scars in infants born after second-trimester amniocentesis for prenatal diagnosis of fetal genetic disorders. Since this complication may be more frequent than has been previously believed, there is the possibility that damage to the fetus may occur. It is suggested that the products of all abortions and all live-born and stillborn infants delivered following amniocentesis should be examined for evidence of injury.


In vitro perfusion of human placenta. V. Oxygen consumption.

02 consumption by human term placenta has been measured during perfusion in vitro, with a technique that permits perfusion of the intervillous space as well as the umbilical circulation. The rate at which 02 was consumed was directly related to the rate at which it was supplied, within the limits studied. Previous estimates of 02 consumption yielded figures approximating 3 ml. per minute per kilogram of placenta, but these estimates were attained under conditions of limited oxygen supply. When oxygen was delivered to the placenta at rates believed to be those achieved in vivo, oxygen consumption approximated 10 ml. per minute per kilogram. This rate of 02 consumption is similar to those obtained from studies of animal placentas in vivo and is more consistent with that of an active metabolic organ. If one were to accept estimates of 02 consumption by the human fetus in utero, the present studies indicate that approximately one fifth of maternal oxygen supplied to the conceptus is diverted to support placental metabolism.


The significance of fetal electrocardiography in the diagnosis of intrauterine bradyarrhythmia.

From 11 cases of fetal bradycardia diagnosed by monitoring of 130 fetal electrocardiograms (ECG's) in high-risk pregnancies we have presented our experience in three selected cases of fetal bradyarrthythmia. Case 1 revealed on ECG blocked atrial premature beats simulating an extreme sinus bradycardia sequentially followed by conducted atrial premature beats. In case 2 we diagnosed ventricular premature beats in the form of persistent bigeminy which was controlled by intravenous propranolol. The last case illustrated the phenomenon of aberrant ventricular conduction known to occur in adult cardiology. The electrophysiologic basis of the variable arrhythmias was discussed. Detailed analysis of repeated direct fetal ECG's provided us with the diagnosis and understanding of the electrophysiologic mechanisms underlying the rhythm disturbances. This consequently determined the pharmacologic therapy and the obstetric approach relevant to each case. We have shown that by direct fetal electrocardiography it is possible to analyze accurately the rhythm disturbances. Persistent fetal bradycardia does not always signify fetal distress. We hope that this will lead to closer teamwork between the obstetrician and the cardiologist which will give an impetus to the future development of "fetal cardiology," thereby enhancing our understanding of the electrophysiology of the fetal heart.


Moderate fetal bradycardia.

Fetal heart rates in the range of 100 to 119 beats per minute have been defined as moderate bradycardia. Twenty-five of 1,386 patients monitored during a 1 year period have manifested persistent moderate bradycardia. Moderate bradycardia is apparently related to fetal head compression, often in situations of relative cephalopelvic disproportion. It is alleviated by rotation of the vertex and does not appear to adversely affect the newborn infant.


Human uterine artery responses to lidocaine.

Uterine arteries from pregnant and nonpregnant patients were studied to define their responses to lidocaine. Although local anesthetics usually are considered vasodilators, these data indicate that the human uterine artery constricts when exposed to 1,000 mug of lidocaine in vitro. Furthermore, those arteries from pregnant patients exhibited significantly greater responses than did those from nonpregnant patients.


Repeat aborters.

In an attempt to learn more about the phenomenon of repeat abortions, 116 women seeking a repeat abortion were compared in various ways with three groups of women not seeking a repeat abortion but otherwise similar. From this study it is apparent that postabortion women become, over time, less persistent users of contraception than sexually active nonpregnant women. However, they are more likely to use contraception continually than are women seeking a first abortion. The abortion experience, with or without concurrent family-planning guidance, does not create universally sufficient long-lasting motivation to use of contraception. Some other factors which might contribute to this motivation are presented.


Fetal immune response following prematurely ruptured membranes.

Concentrations of immunoglobulins (Ig)A1, and IgA2, IgD, IgE, IgG, and IgM have been determined in cord blood, amniotic fluid, and maternal serum in a group of patients with a history of prematurely ruptured membranes (PRM) prior to the onset of labor and in a control group of patients undergoing normal delivery and without a history of infection during pregnancy. IgA and IgD were determined by sensitive hemagglutination-inhibition tests; IgG and IgM, by radial immunodiffusion; IgE, by a radioimmunoassay. There was evidence for an immune response in 10 of 16 cases of PRM: five of 16 had increased IgA but normal IgM; three of 16 had increased IgA and IgM; two of 16 had high IgM and normal IgA in cord blood. In patients with significantly increased levels of either IgA or IgM or both, there was a decreased level of IgD. These changes are most likely the result of the immune response to ascending infection from the maternal genitals. The sensitive testing method employed could demonstrate the presence of IgD in 53 per cent of normal cord blood samples and 72 per cent of amniotic fluid samples obtained at term. IgE was found in all normal cord blood and amniotic fluid samples tested. By concentrating the amniotic fluid up to 180-fold, IgM was demonstrated in all normal samples tested. The potential importance of IgA determinations in cord blood in addition to IgM determination for detection of intrauterine infections is stressed.


Abnormality in metabolism of 15N-labeled nitrate in toxemia.

The urinary excretion of 15N-labeled ammonium nitrate was studied during the last few weeks in patients with normal pregnancy and in those with toxemia. Marked diminution of the 15N label was found consistently in patients with toxemia in the urinary fraction consisting of nitrogenous compounds other than urea and ammonia. The possible significance of this finding is discussed.


Effect of ritodrine infusion on uterine and umbilical blood flow in pregnant sheep.

The effect of ritodrine upon uterine artery blood flow (UtBF) and umbilical vein blood flow (UmBF) was investigated in near-term chronic sheep preparations. During intravenous ritodrine infusions to the ewe in sequential dose rates from 100 to 800 mug per minute, UtBF fell progressively to 43 per cent below control levels and mean maternal arterial pressure (MMAP) declined 20 per cent. During constant infusions of 100, 400, or 800 mug per minute of ritodrine to the ewe for 120 minutes,, UtBF decreased 10, 37, and 31 per cent, respectively, and MMAP decreased 6, 20 and 25 per cent respectively. Dose-related maternal tachycardia and hyperglycemia occurred. There were no significant changes in UmBF, mean fetal arterial pressure, or fetal heart rate. During all infusions, maternal and fetal arterial pH, PCO2, and PO2 remained within normal physiologic limits. Simultaneous infusion of ritodrine (400 mug per minute) and propranolol (100 mug per minute) blocked the maternal tachycardia, but decreases in UtBF, MMAP, and UmBF were observed. Ritodrine infusions to the fetus (25 mug per minute) resulted in fetal tachycardia and a variable increase in UmBF.


Placental cultures for cytogenetic assessment in saline-aborted fetuses.

Confirmation of cytogenetically abnormal fetuses following saline abortion has been shown to be possible with the placenta as the source of viable fetal cells. The method is described in detail. In one third of cultures, only female cells were present. Differentiation between maternal and female fetal tissue when no numerical or structural cytogenetic disorder is present requires detailed analysis of fluorescently stained chromosomes for polymorphisms.


Incorporation of 14C-1-palmitate into rabbit fetal lipids in vivo.

14C-1-palmitate was injected into rabbit fetuses in utero. Fetal liver, blood, carcass, and placenta collected after 15, 60, 180, and 360 minutes were analyzed for radioactivity in lipid classes. Incorporation differed with tissue and lipid. Highest total early specific activity was detected in plasma but later liver displayed the most extensive incorporation. Phospholipid incorporation was more rapid in all tissues than that of other glycerides. Plasma triglycerides did not display any radioactivity for 3 hours. Results point to multicentric origin of plasma lipids. Ready utilization of the palmitate indicates that maternal fatty acid transfer plays an important role in fetal lipid hemeostasis.