Outcome of severe damage to the central nervous system. Scale, scope and philosophy of the clinical problem.

The recovery process after acute brain damage has attracted little interest from either basic or clinical scientists who seem to be most concerned with the acute stage. Much might be learnt about the mechanisms of the nervous system from study of the recovery process. The number of patients with permanent brain damage is growing as the result of the increased survival rate  from such common conditions as severe head injury and non-geriatric stroke. Response to this problem has largely come from other disciplines, and in the form of supportive care rather than scientific enquiry. Such an enquiry might seek to answer three outstanding questions. (1) What is the nature of the persisting disability? (2) Can more scientifically based rehabilitation, including physical, mental and social components, either accelerate the rate of recovery or reduce the degree of ultimate disability? (3) Can the ultimate outcome be predicted in the acute stage; and can the amount of further improvement be estimated in the later stages of recovery?


Prognosis after severe head injury.

Prognosis depends on establishing a relationship between the patient's state in the early stages and the ultimate outcome. Both the severity of the initial damage (including early complications) and the degree of recovery need to be defined, but practical and statistical considerations impose a limit on the number of variables which can be manipulated. Variables chosen should be those likely to be relevant, and pilot studies are more reliable than intuition in indicating which items should be included. Data chosen should be of a kind likely to be readily available for most patients and should not therefore depend on complex laboratory investigation. The most reliable indicant of initial severity appears to be the depth and duration of coma or altered consciousness, and a scale has been devised for measuring these. Measures of outcome should include separate assessment of mental and physical disability as well as the overall social consequence of the brain damage. Prognosis should be expressed as the probability (mathematically expressed) that a patient will reach certain defined outcome categories, five of which are recognized in the present study. Predictions should begin only after initial resuscitative measures are complete (say six hours after ictus); they need not be limited to the early stages but can include estimates of the degree of further improvement expected in the light of progress in the early weeks after injuries. New methods of management cannot be critically assessed unless factors influencing prognosis are reliably identified and can be matched in comparative patient groups. An estimate of prognosis is also required for the selection of patients for intensive treatment, both in the acute and in the rehabilitation stage. Without such data there is a tendency to deploy an unduly high proportion of scarce resources on patients who have little prospect of recovery; this may deny the best chance of recovery to patients with severe, but less overwhelming, brain damage.


Signs of plasticity and reconnection in spinal cord damage.

Experiments on the thalamus, dorsal column nuclei and spinal cord in the adult cat and rat show that partial destruction of afferents to these regions leads to the immediate unmasking of certain types of activity which are normally inhibited. Chronic studies show that some cells begin to respond to afferent nerve impulses after a period in which the cell seems to have lost all inputs. Sprouting of terminals from remaining areas is one possible explanation for these late changes but one must also consider the possibility that the new connections result from axons which were already present but which normally were ineffective.


Cerebral blood flow and metabolism.

To date, regional measurements of cerebral blood flow in humans have not been especially helpful in predicting the outcome of acute brain injury. The recent appearance within the medical environment of biologically significant pharmaceuticals labelled with the positron-emitting isotopes 15O, 13N and 11C has made possible the quantitative regional measurement of cerebral metabolism in humans. This advance, coupled with the development of radically new detection systems, will allow the safe measurement of truly regional blood flow and metabolism in humans in the near future. Such information is basic to an understanding of the pathophysiology of acute injury to the brain and the rational prediction of outcome in the individual case.


Assessment of severe damage to the brain by multiregional measurements of cerebral blood flow.

Regional cerebral blood flow (rCBF) was measured with a 32-detector device in patients with severe injury to the central nervous system. Most suffered head injiries in traffic accidents. Many patients were severely demented. Several were comatose or in a so-called persistent vegetative state. Flow was measured at rest and during various forms of stimulation. The resting values were on the whole markedly reduced. The flow patterns often showed distinct correlations with the original brain injury. In the best preserved patients, mental activation caused increases in flow with a normal or near-normal distribution. Cutaneous electric stimulation gave rise to increases in cortical flow even in highly reduced patients with severe brain damage. Patients with total or less than total loss of telencephalic structures with retained brainstem reflexes and respiration ('apallic' patients) did not show any changes in flow on sensory stimulation. We conclude that the technique for measuring rCBF enables us to assess severe damage to the central nervous system quantitatively and also to estimate whether higher functions are retained in severely reduced patients in coma, stupor and apallic state--patients who more or less completely lack behavioural responses.


[Medical and social aspects of epilepsy (author's transl)].

A review of social aspects of epilepsy is given. Similar to the own experience the literature shows only little social prestige given to patients with epilepsy, an experience known from persons with psychiatric disorders. The prevalence rate for chronic epilepsy is 0.5%. So called genuine seizures decreased with diagnostic progress during the last years (about 50%). Lower social classes and negative social patterns are characteristic of employees with epileptic fits. Unemployed persons show normal social structure. A relation to social class and onset of epilepsy exists. Epileptics are socially immobile. Like other persons with chronic diseases epilepsy produces a special social attitude and often negative therapeutic motivation. In contrast to the literature non-hospitalized epileptics show normal intelligence. Neurotic symptoms are seen in many cases however (about 40%). Often social disturbances origin from broken home situations. There is no specific social and mental defect. According to the own experience social integration of epileptics depends upon the local economic structure. The common prejudice varies with the local area. Social drop-outs are not due to the seizures, but occur mainly in mentally retarded persons who are not able to follow therapeutic regimens. Delinquency is increased among the own patients (18%). The causes are psychoorganic syndromes, often in connection with negative therapeutic motivation and alcoholism. The tendency to specific crimes, known from the literature, could not be confirmed. Forensic problems in direct connection with epileptic fits are rare. Medical problems concerning ability to drive often occur. Many patients possess a driver licence (46.5%), gained after onset of epilepsy in 50%. But the accident rate is lower than in the general population. Special outpatient departments and therapeutic groups for epileptics--affiliated to neurological centers--can improve the exact diagnosis, therapeutic motivation and social integration.


[Experimental analysis of a perceptual disturbance in schizophrenia. Desynchronization of hand-movements with uniform acoustic frequency (author's transl)].

1. In contrast to healthy adult subjects many schizophrenics are unable to drum synchronically with a uniform acoustic frequency. 2. But many schizophrenics can do this when their full attention is diverted by additional light-stimuli. 3. Healthy subjects can be induced to desynchronization, when perception of acoustic frequency is blurred. 4. This desynchronization in healthy subjects can be abolished when their full attention is diverted by additional light-stimuli.


Antistaphylococcal activity of sisomicin and four other aminoglycosides against strains sensitive and resistant to methicillin.

Five aminoglycosides were tested for inhibitory activity on 91 strains of Staphylococcus aureus, 39 of which were methicillin-resistant. The antistaphylococcal activity of these antibiotics was independent of the methicillin-resistance. Their order of decreasing effectiveness was: gentamicin greater than tobramycin = sisomicin greater than amikacin greater than kanamycin. Resistant strains were only found for the latter.


A coordinated team approach to one health problem.

Rheumatoid arthritis, as a complex and chronic disease, requires the expertise of many disciplines working in a combined fashion with the patient as an active and responsible member of the health team. In-depth knowledge of the disease is vital to the nurse in assisting her in developing an effective and logical plan of care. The nurse must act as the liaison between patient and health team and coordinate the programme of treatment. The most important feature of the delivery of care to the rheumatoid patient at the Rheumatism Foundation Hospital is that the patient is involved in his plan of care from the beginning and has shared responsibility for its being carried out and its effectiveness. It is the cooperative effort between the health team and the patient which is the major feature in this very successful comprehensive approach to caring for the patient with rheumatoid arthritis.


Clinical application of electrocardiographic trend recording.

New electronic technology has made trend recording (R-R intervals versus time) feasible on a routine basis outside of acute-care units at nursing stations on regular hospital floors. The physician or nurse is able to monitor the rate and rhythm changes of his patient easily with this form of data compression which minimizes the scanning of reams of ECG paper. The information obtained from such electrocardiographic data results in improved surveillance of arrhythmias and leads to better patient care.


Description and uses of intracranial pressure monitoring.

Today, ICP monitoring is used to facilitate the diagnosis, treatment, and prognosis of abnormal ICP profiles. The level of ICP is made readily available and impending ICP abnormalities can be detected by evaluation of compensation mechanisms. ICP monitoring can also be used to evaluate methods of ICP reduction as shown in Fig 5. It can also aid in determining the prognosis. A poor prognosis is indicated by a CPP of less than 30 mm. Hg, rising ICP in spite of treatment, and loss of compliance. ICP monitoring is useful only in the experienced hands of a neurosurgical team which is better qualified to interpret data in association with the clinical picture and determine a plan of treatment. They are also fully aware of and can guard against possible infection, CSF leakage, hematoma, and its consequences.


Effect of family visits on the blood pressure and heart rate of patients in the coronary-care unit.

Conclusions that can be drawn from this study are: (1) the blood pressure and heart rate of CCU patients show no significant changes when the patients are awake and are not interrupted by stressful events. (2) A family visiting period of ten minutes every hour creates a stressful effect on the blood pressure and heart rate of cardiac patients in a CCU. (3) Since patients are particularly vulnerable to fatigue in the early stages of coronary illness, a ten-minute visiting period every hour for twelve hours appears to be a stressful event and indicates that the present visiting schedules are not conducive to good patient management. (4) Continuing studies should be done to determine what other type of CCU visiting time arrangements might be made to insure better patient care.


Injuries to major vessels: an overview of current concepts.

Injuries to major arteries and veins continue to result in loss of life and limb. Successful management of such injuries requires an integrated team approach with careful attention given to resuscitation of shock, technical aspects of surgical procedures, and adjunctive management. This review addresses current concepts relating to the problem of vascular trauma.


Arrhythmias in the coronary-care unit. V. Physiologic bases of paroxysmal bradycardia-dependent bundle branch block.

Bradycardia-dependent bundle branch block can occur during acute cardiac ischemia or infarction. Basic cellular electrophysiology helps in understanding the mechanisms involved. A review of the previous four vignettes of this series will be helpful in studying this vignette.


Anaerobic infections.

The treatment of anaerobic infection will be improved by: (1) having a high index of suspicion of anaerobic bacteria in all infections, (2) recognition of clinical signs characteristic of some of these infections, and (3) institution of antibiotics that are likely to be appropriate before the culture results become available 4 to 7 days later.


Metabolism during shock and sepsis.

The shock-induced changes in the cells of both peripheral tissues and vital organs apparently occur mainly in the energy pathways. The normal flow of these pathways is inhibited by the lack of oxygen; and both this anoxia and the consequent energy deficit inhibit the function of membranes. As a result, the active transport of gluconeogenic substrates, such as glucose, amino acid, and fatty acid, is blocked; this allows potassium efflux and sodium influx. Gluconeogenesis is inhibited either by a direct effect of endotoxin on the gluconeogenic enzymes or by the lack of ATP. Prolonged anoxia interferes with the oxidation of pyruvate and increases the intracellular and extracellular levels of lactate. The intracellular acidosis or the direct effect of endotoxin on the membranes finally causes the permeability or lysis of cellular and lysosomal membranes. Lysosomal hydrolases have been implicated in the cellular pathology of shock, the production of MDF, and the adverse effects on endothelial cells of the vascular system. Further ATP deficiency may alter protein biosynthesis.


The diagnosis and management of severe sepsis and septic shock.

Shock due to or associated with sepsis may present a clinical picture quite different from that usually seen in hypovolemic or cardiogenic shock. Any trend which suggests increasing sepsis should be treated aggressively as if shock were present. The earlier such therapy is begun, the better the results tend to be. Perhaps the greatest errors in the therapy of severe sepsis and septic shock are (1) delayed control of the primary septic process, (2) giving too little fluid in the early phases of therapy (and too much later), and (3) delaying ventilator assistance if the patient's ventilation or blood gases are deteriorating.


Intermittent pseudocomplete A-V block due to A-V dissociation in presence of 2:1 A-V block.

A false pattern of intermittent complete A-V block was seen in two asymptomatic patients when A-V dissociation was superimposed on a basic 2:1 A-V block. Although the conduction disturbance occurred at the A-V nodal level in both cases, in Case 2 it resembled A-V block due to bilateral or trifascicular disease. This arrhythmia was the end result of Type I (Wenckebach) block and apparently has a better prognosis than those emerging from a Type II (Mobitz) block.


Pulmonary fat embolism: a complication of fracture.

Medical personnel must be aware of the possibility of fat embolism as a complicating factor of fractures. Ambulance, emergency room, orthopedic, and intensive-care personnel may frequently be involved in the care of these patients. Fat embolism should be suspected any time a patient exhibits bizarre mental, pulmonary, or circulatory symptoms following a fracture. Prevention may be achieved by as near immobilization of a fracture as possible. When fat embolism does occur, the course of the illness may or may not be complex. The treatment is supportive and the patient should be made as comfortable as possible.


Arrhythmias in the coronary-care unit. VI. Physiologic bases for the use of antiarrhythmic drugs.

Classification of antiarrhythmic drugs based on their electrophysiologic and hemodynamic properties coupled with an understanding of the transmembrane action potential of the cardiac cell (see the first of this series of six vignettes) help in the appropriate choice of therapy in a given clinical setting.


Delayed conversion to sinus rhythm after direct-current countershock.

Elective cardioversion for supraventricular arrhythmias has been performed in 203 patients during a 30-month period beginning in May, 1972. In five instances conversion to normal sinus rhythm occurred well after the electric shock had been delivered. The interval ranged from 4 to 105 seconds after DC countershock. In one patient, atrial fibrillation clearly persisted for eight seconds after DC countershock, however, immediately after countershock the ventricular rate became regular and, in addition to the fibrillatory activity, apparent sinus P-waves became visible and the same regular rate persisted after disappearance of fibrillatory waves. This raised the possibility of atrial dissociation. Our experience suggests that if apparent failure of conversion is noted after DC countershock, a repeat shock at a higher level should not be administered immediately but only after observing the rhythm for up to two minutes. Other possible mechanisms of delayed conversion are discussed.


A system for controlled microwave heating of small samples.

A system for the controlled thawing and heating of small samples in a waveguide is described. A means of maintaining constant absorbed power within the sample over a wide range of sample parameters is a major feature of the system. Provision for sensing the melting point of immersed samples is include. Samples are continuously rotated to improve heating uniformity.


The transmission of reflexes in the spinal cord of cats during direct irradiation with microwaves.

The spinal of cats was directly exposed to 2450 CW microwave radiation in order to study the effect on reflex response and synaptic function. A small but statistically significant increase in the reflex response was detected in the first series of experiment, which indicates enhancement of the synaptic transmission. However, this effect was not observed in a second series of experiments in which the incident power density was increased from 10 mW/cm(2) to 20 mW/cm(2) and a more rigorous experimental design was employed. The slight changes that were observed in the second series could be attributed to small temperature variations during the experiment.


Fast fixation of brain in situ by high intensity microwave irradiation: application to neurochemical studies.

The levels of acetylcholine and choline were measured in various brain regions of the rat after fixation by microwave irradiation of the head and after decapitation and subsequent freezing in liquid nitrogen. Levels of acetylcholine were increased by approximately 50% after microwave irradiation, while choline levels were reduced. These biochemical findings were correlated with virtually complex loss of acetylcholinesterase and NADH-diaphorase activity after 1 s exposure to microwave irradiation at a level of 5 kW.


Coupling of Gaussian electromagnetic pulse into a muscle-bone model of biological structure.

The effect of angle of incidence on the transmission electromagnetic pulse with Gaussion character in biological material is studied. The model assumed is a layer of soft tissue over a semi-infinite medium of boney structure governed by alpha dispersion. The numerical results demonstrate that the transmitted pulse strength is the greatest when the pulse is incident normally on the air-tissue interface. The coupling efficiency for a one microsecond pulse is three times as big as that for a ten microsecond pulse.


Microwave auditory effect- a comparison of some possible transduction mechanisms.

When human subjects are irradiated with pulse modulated microwave energy they report the perception of a sound that appears to originate from within or slightly behing the head. Three of the possible mechanisms are examined using first order mathematical approximations and several simplifying assumptions. The results show that while all three (radiation pressure, strictive force and thermal expansion) are capable of producing the phenomenon, the stress resulting from thermal expansion may be so great that it masks the effect of the others completely.


[Distribution and changes of antibiotic susceptibility of genus Haemophilus (author's transl)].

We studied on the distribution and changes of antibiotic susceptibility of H. influenzae, H. parainfluenzae and H. parahaemolyticus isolated from clinical materials, mainly from sputum and pharyngeal swabs. In this study we used 132 strains of H. influenzae, 89 strains of H. parainfluenzae and 43 strains of H. parahaemolyticus isolated during January and June of 1975, and estimated the susceptibility for the following eighteen antibiotics by the agar plate dilution method: ampicillin, amoxicillin, ciclacillin, sulbenicillin, carbenicillin, cephalothin, cefazolin, ceftezole, cephalexin, streptomycin, kanamycin, gentamicin, dibekacin, tetracycline, doxycycline, chloramphenicol, thiamphenicol and colistin. We compared these with previously reported results and observed the changes of antibiotic susceptibility. Ampicillin has the strongest antibiotic activity on three species of Haemophilus and the activity of four cephalosporins was weakest. Among three species H. parahaemolyticus was most susceptible and H. influenzae least susceptible to cephalosporins. Antibiotic activity of cyclacillin was rather weak. Other twelve antibiotics have good activity on Haemophilus. We could not find any ampicillin-resistant strain, but found five (3.8%) streptomycin-resistant, one (0.8%) kanamycin-resistant, eleven (8.3%) tetracycline-resistant, and seven (5.3%) chloramphenicol-resistant strains of H. influenzae. Six years ago we found five (9.6%) streptomycin-resistant and one (1.9%) tetracycline-resistant strains, but no resistant strain to other antibiotics. Tetracycline- and chloramphenicol-resistant strains are supposed to have a tendency to increase. There were very few strains which were resistant to more than two antibiotics among H. influenzae. We found a few strains resistant to tetracycline or chloramphenicol among H. parainfluenzae and H. parahaemolyticus, and one strain of H. parainfluenzae was less susceptible to ampicillin.


An experimental nursing study: a behavior modification approach to nursing therapeutics in body positioning of spinal cord-injured patients.

Ten spinal cord-injured patients at a rehabilitation center were randomly assigned to two groups: one group received behavior modification training in body positioning, the other group received customary body positioning nursing care. Body positioning behaviors were modified through demonstration of body positions and shaping of body position moves with attention from the nurse as the positive reinforcer. Following treatment, the behavior modification group showed significant change in increased frequencies of daily changes of position and patient-initiated changes of position; in decreases assistance needed for change of position, and in decreased frequencies of intervals of prolonged skin pressure. There was no significant change in frequency of face lying or participation in ward activities of daily living. Replications of the study are needed for confirmation of findings.


Human sexuality course evaluation.

A three-day human sexuality program was offered in 1974 to medical, nursing, and graduate psychology students for the second consecutive year at the University of Cincinnati. The program was designed to cover a wide range of topics; supply accurate information; encourage participants to question, explore, and assess their own sexual attitudes; and help participants develop a more tolerant attitude toward sexual beliefs, attitudes, and behaviors of others. The Sexual Knowledge and Attitude Test and an evaluation form were used to measure students' pre- and postcourse knowledge, attitudes, and opinions. The total group of 186 subjects registered a significant difference between mean scores of the pre- and postcourse tests. When examined separately, nursing and medical students showed significant changes in attitudes and knowledge scores. Results of the three-day program were compared with those of a five-day program given the previous year. A profile analysis showed the differences in nursing and medical students in pre- and postcourse scores. An evaluation form demonstrated how each group of students felt about the course. This study documented that human sexuality content should be included in nursing and medical curriculums and demonstrated that an introductory concentrated course is an effective interdisciplinary experience for nursing and medical students.


Attitudes toward alternative models of unions and professional associations.

Within the occupation of nursing a synthesis of union and profession has been occurring so that "new" images of the profession and of unions are not as divergent as they traditionally were. To investigate whether nurses and nursing students are responding in terms of the traditional or the newer images of unions and professions, the relationship between motivations for entering nursing and attitudes toward unions and the profession were examined among 75 nurses and nursing students. Some support was given to the idea that nurses still respond to unions and the profession in terms of the traditional images although there was some suggestion, when comparing nursing students with nurses, that response patterns may be changing.


Changing perceptions of organizational communication: can short-term intervention help?

An intervention activity commensurate with specific organizational goals, directed to short-term change efforts to alter employee perceptions about their satisfaction, about such work activitiesas communication, and about opportunities to make job-related innovations was implemented for emergency room personnel in a large West Coast metropolitan hospital. When evaluated, using a research design which reduced validity threats in interpreting results, perceptions about some aspects of work were found to be more susceptible to change through short interventions than were others.


Patient responses to being transferred during hospitalization.

When eight clinical nurse specialists and a nurse research consultant studied within-hospital transfers of patients, they found that most patients knew the reason for transfer and were neutral in reaction about it. There were no differences for sex, previous hospitalizations, frequency of transfer, age, or clinical nursing unit from which they were transferred.


Professional autonomy and the work satisfaction of nursing educators.

The importance and satisfaction associated with 21 characteristics of a nurse faculty position were examined, using 1974 questionnaire data from schools of nursing at four major state universities. Teaching, supportive colleagues, keeping clinical knowledge current, and faculty autonomy were seen as the most important aspects of the job by the 154 nursing educators surveyed, while salary, fringe benefits, and other extrinsic rewards ranked substantially lower in importance. Satisfaction with the more important conditions was generally low, with lack of faculty participation in decision making a particularly noteworthy source of dissatisfaction. Importance and satisfaction ranking of the 21 characteristics remained fairly stable across the four schools and across groups broken down by martial status, experience, and other personal attributes. Increased professional autonomy, it was suggested, would benefit faculty morale, recruitment, retention, and overall effectiveness in nursing education.


The subjective aspects of coronary care.

An exit questionnaire to measure satisfaction with selected aspects of coronary care was given to patients following discharge from coronary care units in 11 community hospitals in the Intermountain West. Although overall satisfaction was found to be high, the responses indicated significant differences (p less than .01) in patient satisfaction among the dimensions examined. The central findings suggest the need for more attention to the nontechnical aspects of care, especially reduction of emotional trauman and improved interpersonal relations. Practical implicattions of these and other findings for the nursing profession as well as for coronary care are discussed.


Pulmonary embolism.

Despite the difficulty in diagnosis and the detailed care necessary in both the acute and long-term management of the patient with pulmonary embolism, expertise in this area is requisite for the primary care physician who may expect to encounter this problem with moderate frequency among patients in his clinical practice.


Immunization. A continuing need.

Many vaccines are available to prevent potentially fatal disease. It is especially important for all of us who provide care to review periodically the current recommendations, since they are not static. Changes are based not only on the availability of improved vaccines, but also on knowledge of the diseases and altering societal and epidemiologic circumstances. We owe it to all our patients to be meticulous in maintaining up-to-date immunization records as well as to be knowledgeable about the indications and contraindications for each vaccine. Finally, it is important to remember that the immunization status of adults has been overlooked too often. This is no longer justifiable in light of current knowledge.


Impotence.

The first and most important assistance the physician can give to the patient who complains of impotence is to take him seriously. In most cases organic causes can be ruled out. Primary or total psychogenic impotence is also a rarity, and most cases are secondary and amenable to appropriate therapy.


Evaluating the seriousness of adolescent adjustment reactions.

Adolescents can be expected to inflict some pain on their environment periodically, and complete conformity of an adolescent is not necessarily a sign of mental health. With the exception of some particular behaviors such as a suicide attempt, auditory hallucinations, or a school phobia, one cannot make a prediction about the existence of, or seriousness of, a psychological problem of an adolescent based solely on the occurrence of any one particular antisocial act. Such typical adolescent problems such as stealing, truancy, sexual involvements, and drug use can be either a normal part of adolescent growth, the manifestation of a situational stress reaction, or the indication of a serious personality disturbance or identity crisis. Only by putting this behavior into the framework of an adolescent's age, social situation, general stress factors and developmental history can one attempt to reach a true evaluation of the seriousness of his behavior. To put it simply, one must try to understand the individual, rather than judging the behavior itself. The type of evaluation outlined here is often difficult and time consuming, but in terms of the long range help that it can be both to the teenager who is using his behavior as a means of asking for help and for the normal teenager who just needs to be told that he is not carzy, this is time and effort well spent.


The noncompliant patient.

The failure of patient to follow recommendations is present in all practices and can have dire consequences. Prevention is possible if the factors which may contribute to noncompliance are recognized. If the physician is alert to the existence of poor compliance in his practice, successful intervention can be achieved.


Infectious mononucleosis.

Infectious mononucleosis is a unique disease in its hematologic aspects; it is different from the frequently occurring acute microbial diseases in that it affects primarily the reticuloendothelial system; and it is interesting serologically because of the heterophil antibody reaction, as well as the multiplicity of antibodies which may be produced. The diagnosis should be suspected clinically before hematology is reported - by remembering the prototypes. In fact, a patient between 16 and 25 years old who complains of sore throat and fever is more likely to have infectious mononucleosis than another disease; and if - in addition - he is jaundiced, a diagnosis of infectious mononucleosis is almost certain. Finally, a negative result of treatment with corticosteroid has the diagnostic significance mentioned above. Positive effect of treatment has no diagnostic significance.


Vegetarian diets.

A growing number of Americans are choosing to follow vegetarian diets. These diets can meet the nutritional needs of individuals of all ages. Vegetarians who eat eggs and/or milk and dairy products have no special problems in obtaining adequate nutrients. Pure vegetarians, who avoid all animal products, should pay particular attention to sources of protein, calcium, and riboflavin. Supplementation of vitamin B12 is indicated in these individuals. Guidelines for both good normal nutrition and therapeutic diets can be adapted for use with a vegetarian diet.


Medical management of the patient with renal stones.

Although the exact cause of renal stones is largely unknown, a greater knowledge of metabolic and other factors contributing to stone formation is the basis of current treatment. A practical program of medical management that is designed to prevent recurrent surgical procedures and the loss of renal function is outlined.


Practical prenatal care. I. Initial prenatal care.

Most factors which place the mother or fetus at risk are present at the time of the initial prenatal visit or develop during the pregnancy and before admission to the hospital. As many as 40 per cent of all high risk patients may be detected at the initial prenatal visit.


Hiring a new health practitioner.

Individuals are now being trained to function at varying levels of expertise as primary care practitioners, and the selection of a new health practitioner appropriate to the physician's individual practice can prove to be an asset professionally, personally, and economically.


[Uropepsin change in peptic ulcer after balneological treatment at Khisar].

The author followed uropepsin in ulcer patients before and after a complex balneo-therapy in Hissar, where the following therapeutic complex was applied: 1) Tub bath--36-38 degrees C; 2) Drinking of mineral water--"Momina Sălsa" spring (slightly mineralized, hydrocarbonate-sodium, slightly radioactive, fluor). Diet No 1 and physical excercises in hyperacidity. The author has established two-way changes in the values of the followed-up uropepsin, the high--decreased and the low--increased to normalization. The resulsts are statistically significant. Concluding he admits that uropepsin is a reliable method for investigation of the fermetformation function of gastric mucosa and for the assesment of the balneotherapy effect in sanatorium conditions.


[Resistance of the Staphylococcus aureus isolated from patients operated on for cardiovascular diseases to penicillins, cephalosporins and the salts of heavy metals, their lysogenicity and phagotype].

The analysis of the results obtained on the study of 55 strains of Staph. aureus isolated from purulent excretion in the patients operated under conditions of artificial blood circulation provided a conclusion that most of the clinical staphylococcal cultures were highly resistant to the beta-lactamase sensitive antibiotics. It was supposed that the above strains possessed penicillinase plasmids, since all the cultures tested had penicillinase activity and were resistant to benzylpenicillin, the resistance exceeding 1.0 Unit/ml, in 70 percent of the cultures these properties were complemented with resistance to heavy metals salts and mercuric chloride. These cultures possessing penicillinase plasmids belonged mainly to the phage group, III and were polylysogenic.


PC-904, a novel broad-spectrum semisynthetic penicillin with marked antipseudomonal activity: microbiological evaluation.

PC-904, sodium 6-{d(-)-alpha-(4-hydroxy-1,5-naphthyridine-3-carboxamido) phenylacetamido}-penicillanate, is a novel semisynthetic penicillin derivative that possesses a broad spectrum of in vitro and in vivo antibacterial activities. In low concentrations, PC-904 inhibits growth against large proportions of the gram-positive and gram-negative organisms susceptible to carbenicillin and gentamicin. In addition, PC-904 is several times more potent than carbenicillin against organisms such as Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Proteus vulgaris, Shigella, Salmonella, Neisseria gonorrhoeae, and Bacteroides fragilis. Most striking are the inhibitory effects of PC-904 against P. aeruginosa and K. pneumoniae. Against these two clinical isolates, PC-904 is, respectively, 35 and 100 times more active than carbenicillin. The minimum inhibitory concentrations of PC-904 against P. aeruginosa are comparable to those of gentamicin. PC-904 acts bactericidally. The effect of inoculum size on the antibacterial activity is often small and generally comparable to carbenicillin. The rate of binding to serum protein is high (88 to 98%), but the effect of the addition of serum on the drug's activity is not marked, because such binding is reversible. It is confirmed that PC-904 has a very potent in vivo antibacterial activity against gram-negative and gram-positive organisms. Against systemic infections with P. aeruginosa, K. pneumoniae, and E. coli in mice, PC-904 is 7 to 10 times, over 8 times, and 2 to 15 times more active than carbenicillin, respectively.


Association of a penicillin resistance gene with a tetracycline resistance plasmid (PTP-2) in Staphylococcus aureus.

On transduction with a lysogenic strain of Straphylococcus aureus isolated from a clinical specimen and having tetracycline (TC)-penicillin (PC)-chloramphenicol (CP)-resistant plasmids, the three-drug-resistant strain was frequently obtained. By repeatedly transducing from this strain, a strain (TP-2) having stable resistance to TC and PC could be obtained. In transformation with the deoxyribonucleic acid (DNA) of TP-2 as donor, all of the transformants obtained by selecting with either TC or PC were both TC and PC resistant. According to electron microscopy study of the covalently closed circular DNA of TP-2, the plasmid DNA size was 1.37 +/- 0.03 mum (2.84 x 10(6) daltons). The plasmid (P(TP-2)) is presumed to be a new plasmid in which the PC resistance gene was integrated into the TC-resistant plasmid.


Identification and antimicrobial susceptibility of 250 Bacteriodes fragilis subspecies tested by broth microdilution methods.

Broth dilution antimicrobial susceptibility tests and biochemical identification of Bacteroides fragilis subspecies were performed by micromethods, yielding results within 48 to 72 h of isolation. The subspecies had similar minimal inhibitory concentration end points.


Some determinants of psychological deficits associated with chronic cannabis consumption.

The present study was done in order to investigate the following general hypothesis: "Other conditions being equal, the lower the non-drug level of proficiency on tests of cognitive and psychomotor performance the smaller the size of function deficit associated with drug taking". Twelve objective tests generating 16 test variables were administered to 850 chronic cannabis takers and 839 comparable non-takers, all males ranging in age between 15 and 50 years and representing various positions on "literacy-illiteracy" and "urbanism-ruralism". Six specific predictions were formulated; (1) Performance on the test is expected to be correlated with the level of leteracy of the subject. (2) the lower the level of literacy the smaller the size of function deficit associated with cannabis taking. (3) Performance on the tests is expected to be correlated with the level of urbanism of the subject. (4) The lower the level of urbanism (i.e. more ruralism) the smaller the size of function deficit associated with drug taking. (5) Performance on the tests is expected to correlate inversely with age. (6) The older the subject the smaller the amount of function deficit associated with cannabis consumption. All our predictions were confirmed. The consistency of these results raises the possibility that a basic regularity governing the relationship between cannabis consumption and psychological-function deficit is being uncovered. The suggestion was made that our major hypothesis might prove valid with regard to the area of acute effects of cannabis taking as well. Our hypothesis was shown to provide a broad framework capable of integrating a number of conflicting reports both in the area of long term and that of short term cannabis use.


The epidemiology of self-reported drug misuse in the United Kingdom.

Self-report methods are, in general, the only feasible way of obtaining information of the prevalence of drug misuse, other than opiate misuse, in the population. The present review examines the results of surveys of self-reported drug misuse conducted in the United Kingdom between 1968 and 1972 and discusses the findings in terms of the uses of epidemiology. The evidence from the surveys suggests that by 1972, a higher proportion of students in higher education, particularly those following courses in the social sciences, admitted to having ever misused controlled drugs compared with the general population of similar age. There were considerable local and regional variations in the prevalence of self-reported misuse. The majority of those who admitted to having ever misused drugs in the samples surveyed since 1970 said they had misused cannabis. The only individual characteristics that were found to be consistently associated with admitting to having ever misused drugs were favourable attitudes to drugs and slightly elevated neuroticism scores.


Elements of tort liability as applied to athletic injuries.

It has been the purpose of this paper to stress the legal issues that could face physical education and athletic personnel in schools. A number of generalizations have been focused upon with the help of specific cases from legal records. The law is not always as clear-cut as many of the cases indicate. Gray areas are often present in defendent/plaintiff battles. Should a legal case grow out of your program, get a good lawyer. In the meantime, use foreseeability and take every reasonable precaution to prevent torts from occurring.


Loss of resistance to methicillin and other antibiotics in Staphylococcus aureus associated with a chronic empyema.

A chronic empyema was investigated in a patient during a period of seven years. A strain of Staphylococcus aureus resistant to methicillin and four other antibiotics was isolated and the loss of all these determinants was shown to occur in vitro. A similarly sensitive organism was obtained directly from the patient during the later stages of his illness and the homogeneity of the phage patterns indicate that the organism was a true variant which evolved from the highly resistant one.


The role of the nurse in patient education. Focus: the cardiac patient.

Although nursing perceives patient teaching as an essential function, there is significant disparity between policy and practice. The evidence cited shows that nurses are not doing effective, consistent patient teaching and are not perceived by patients and doctors as competent in patient teaching. It appears that nurses do not view patient teaching as a priority and that nurses are not held accountable for patient teaching. Patient teaching seems to be done only "if there is time." It is often done on an informal and largely voluntary basis by motivated nurses. Nurses must awaken to the fact that patient education is not a luxury, but a necessity if patients are to receive maximum benefit from today's knowledge of treatment, prevention, and control of disease. Multiple factors interfere with nurse's doing adequate patient teaching, including inadequate preparation to teach and discrepancies in acceptance of teaching as the nurse's role. These obstacles can be overcome; they must be overcome if nursing is to make a significant contribution toward quality health care.


A program for rehabilitation in coronary heart disease.

A practical, easily applied approach to coronary heart disease rehabilitation has been reviewed. Good rehabilitation is nothing more than total patient care that begins on admission to hospital and continues for the remainder of the patient's life. Optimization of medical care, psychosocial and vocational adjustment, activity progression, reconditioning, and patient education must be constantly sought at all stages of the program. Consistency and thoroughness can be assured through the use of a few helpful forms and handouts. The real and potential benefits of a comprehensive cardiac rehabilitation program amply justify the effort in all clinical settings.


The patient with congestive heart failure. Teaching implications.

If a decrease in hospital readmissions and a reduction in the length of hospital stays as well as an improvement in the general health and quality of life in patients with congestive heart failure can occur with an educational process, then efforts in this direction should continue and be constantly improved. There is no magic formula in helping patients learn. The success of the teaching will depend on the individual patient's ability, willingness, and understanding, but it also depends on the ability, knowledge, imagination, and effort put forth on the part of the nurse teacher. Organizing group classes and employing pre-printed instructions and information, instead of on-the-spot written instructions by each individual teacher, are ways to enhance the success of the teaching as well as increasing interest on the part of the patients. Although these methods were not discussed by this author here, their use needs to be explored.


Patient education and the prevention of endocarditis.

Bacterial endocarditis prophylaxis has received scant attention in nursing and medical literature in the past. Nurses must participate in prevention as well as in curative measures to enable patients to enjoy optimal health. Information about the manifestations, risk, and prevention of B.E. as well as successful patient approaches has been presented to assist the reader to recognize susceptible patients and to teach them protective measures.


Myocardial infarction and stress.

Some stress and adaptation are necessary in life. Scientific study is showing, however, a significant correlation between stress and coronary artery disease when the stress is continuous or extreme. It is becoming increasingly clear that although mortality has fallen to 8% in some of our CCU's no program for the reduction of morbidity and mortality of patients with coronary artery disease will be complete until we understand its relationship to stress and the difficulties of pre- and posthospital life. We, as nurses, hav a unique responsibility and challenge as we care for the whole person, his life, his faith, and his hope. Bodily effects of stress can be minimized by supportive interpersonal relationships and patient education.


Sexuality and the middle-aged cardiac patient.

Counseling for the resumption of sexual activity deserves as much attention in a cardiac rehabilitation program as walking or jogging. Research findings enable the counselor to give specific sexual advice. The energey expenditure during coitus for long-married couples is equivalent to that of climbing stairs, and consequently the risk of heart attack is low. However, clustering of psychosocial and physiologic demands, such as illicit affairs, outbursts of anger, alcohol, and hearty meals, may precipitate reinfarction or death. A sexual activities program is successful only if each partner is committed to give and receive pleasure. Knowledgeable and sensitive counseling will enable the couple to explore extra-coital options for lovemaking prior to the resumption of intercourse. This writer has observed that once couples are "turned on" to the pleasuring exercises, coital activity is attempted at an earlier date without untoward side effects in the cardiac patient.


Smoking and the heart patient.

It has been shown that inhaled smoke and its toxic constituents, specifically nicotine and carbon monoxide, are positively correlated with an increase in the incidence, progression, and lethal consequences of coronary heart disease. Smoking is a complex habit made up of both pharmacologic and psychosociologic determinants. Unlearning the habit may take time. The nurse is an ideal person to counsel the hospitalized smoker, since she is close to the patient and is seen by the patient as a credible health worker. Once the smoker has begun his relearning process the biggest problem will be staying off cigarettes in the months and years that follow. Family members should be included in the counseling process as they will be needed for support and encouragement. Follow-up is necessary either on a one-to-one basis or in a smoking clinic. In addition to counseling, the nurse has a responsibility to speak our publicly to maintain optimum smoking health standards.


Nursing responsibility in child abuse.

The major intent of this presentation was to demonstrate: nursing responsibility according to legal mandate, using the example of legislation signed into Michigan Public Law in September, 1975; components of child abuse and neglect services including identification, reporting, diagnosing, and treatment; and to identify for other health professionals providing services to families and children, the nurse's role in dealing with the child abuse and neglect phenomenon.


Peptic ulcer disease.

Commentary and update: X-ray diagnosis, gastric analysis, and endoscopic biopsy cytology; dietary therapy, antacids, and anticholinergics.


Abdominal pain in children.

Chronic vague abdominal pain is an extremely common complaint in children over 5 years, with a peak incidence in the 8 to 10 year group. In over 90 per cent of the cases no serious underlying organic disease will be discovered. Most disease states can be ruled out by a careful history, a meticulous physical examination, and a few simple laboratory tests such as urinalysis, sedimentation rate, hemoglobin, white blood count determination, and examination of a blood smear. If organic disease is present there are often clues in the history and the examination. The kidney is often the culprit--an intravenous pyelogram should be done if disease is suspected. Barium enema is the next most valuable test. Duodenal ulcers and abdominal epilepsy are rare and are over-diagnosed. If no organic cause is found, the parents must be convinced that the pain is real, and that "functional" does not mean "imaginary." This is best explained by comparing with "headache"--the headache resulting from stress and tension hurts every bit as much as the headache caused by a brain tumor or other intracranial pathology. Having convinced the patient and his parents that no serious disease exists, no further investigation should be carried out unless new signs or symptoms appear. The child must be returned to full activity immediately.


Potassium. The intracellular cation.

Normally the concentration of potassium in the extracellular space is maintained within relatively narrow bounds; in disease, these boundaries may be exceeded. Hyperkalemia and sometimes hypokalemia must be considered medical emergencies, to be treated promptly, effectively, and appropriately.


Abnormalities of extracellular fluid volume and sodium concentration.

Each of the five true hyponatremias is discussed as a defect in the free water-excreting mechanisms of the body, in order to formulate a rational approach to diagnosis and treatment. One artificial and three real causes of elevations in plasma sodium are also discussed.


Fungal infections of the skin.

Fungial infections of the skin can be diagnosed and treated in a simple, economic manner. They must first be properly identified so that specific, effective therapy can be instituted.


The current status of hip replacement.

Total hip arthroplasty, since the release of methylmethacrylate, is being performed in this country at the rate of about 15,000 per year. For the older patient, virtual absence of pain, improved function, and a short-term rehabilitative effort, make total hip arthroplasty the procedure of choice in the treatment of severe noninfected hip disease. For other patients, successful salvage of previously failed hip surgeries is now possible. Finally, there are those younger patients for whom no other form of therapy is possible to provide pain-free function. Although not a panacea for all hip disease, the total hip arthroplasty has provided pain-free existence with improved function and a return to a useful life for patients with previously inoperable hip disease, no matter what the etiology.


Evaluating suicidal risk.

Suicide is seldom, if ever, a comfortable subject to deal with. Medical school curricula, for various reasons, are too often unable to include the subject in a useful way, and consequently physicians feel unprepared when confronted with a severely depressed or desperate patient in practice. In addition, suicide is an unsettling reality because it relects and reminds us of our own frailty and humanity. Nearly everyone has had an experience of depression or some fleeting thought of suicide at some time in his life. Growing up can often be almost unbearably painful at certain times during adolescence. Middle age inevitably brings with it losses, possibly of loved ones, and with this uncertainties about whether it is really all worth the effort. And as age advances, health and vigor and aspirations slowly depart. Exactly when, at times of crisis such as these, suicidal thoughts take over and lead to action is difficult to define, but the physician must always be prepared for this possibility. Factors have been described which may be useful in alerting the physician to the possibility of suicide. Physical illness may give rise to feelings of hopelessness to which the physician must stay attuned; the patient may also use physical illness as a pretext for seeking help for deeper things that trouble him. As Havens points out, neither reassurance, nor criticism, nor abbreviating the interview will help the situation of a desperate patient. Clarification of the patient's feelings and thoughts are mandatory. Psychiatric consultation can be an important adjunct in achieving this goal and may at times be life saving.


Moles that cause concern.

It is strongly recommended that any pigmented lesion which cannot be diagnosed with certainty as benign should be excised and pathologically examined. In addition, any mole which is removed, no matter for what purpose, whether it is suspected of having malignant or premalignant changes or for cosmetic and functional purposes, should always be pathologically examined. If the lesion is suspected of showing malignant change, then if technically possible it should be completely excised. If the location is such, or if it is a sufficiently large lesion, that a simple complete excision cannot be performed at that time, then it is justifiable and good medical practice to do an incisional biopsy. However, if the pathological report shows that the tumor is malignant then the necessary radical surgery should be performed within 7 to 10 days of the initial biopsy. Under these circumstances, incisional biopsy does not adversely affect the prognosis. Under these circumstances, the incisional biopsy prevents unnecessary radical and sometimes mutilating surgery being performed for the treatment of a benign pigmented tumor.


Grief, mourning, and pathological mourning.

An individual may present with a multitude of symptoms following an acute loss. Helping the patient go through the essential "grief work" may prevent prolonged and serious alterations in social adjustment as well as potential medical disease.


Second thoughts on dementia. Evaluation and management of patients with mild dementia.

The early recognition of dementia along with consideration of differential diagnosis and elucidation of its underlying causes is of paramount importance because many of these conditions are remediable, given proper diagnosis and adequate treatment. The purpose of this article is to emphasize possible alternatives to the grim sentence of slowly progressive irreversible deterioration of personality and intellect when the verdict of dementia is pronounced.


Psychological aspects of family practice.

The double diagnosis is a tool which can be used to develop an expanding ecologic perception of the patient and his illness. Intrafamily relationships can be related to the development of recurrent physical illness among family members, and an increased understanding of the relevance of such data can clarify the epidemiology of many clinical syndromes, thus allowing the formulation of a more comprehensive plan of medical management.


Detection and control of hypertension: challenge to all nurses.

The Task Force members strongly recommend that every nurse become accountable to the hypertensive population- whether detected or undetected- to get them into the health care system. For concrete help with this major undertaking, every nurse should study the report of the Task Force when it become available.


[Method of determining the sensitivity of Staphylococcus aureus to methicillin].

The effect of the incubation temperature, i.e. 37 and 30 degrees and the effect of addition of 5 per cent of sodium chloride to the nutrient medium was studied with respect to the results of sensitivity determination of staphylococci to methicillin by 3 methods, such as serial dilutions in liquid and solid media and replica method applied to separate colonies. With the use of all 3 methods incubation of the samples at a temperature of 30 degrees increased the rate of staphylococcal cultures resistant to methicillin. Addition of sodium chloride to the solid nutrient medium increased the level of detecting methicillin resistant cultures in the samples incubated at a temperature of 37 degrees and decreased it in the samples incubated at 30 degrees.


Drugs and PGO waves in the lateral geniculate body of the curarized cat. IV. The effects of acetylcholine, GABA and benzodiazepines on PGO wave activity.

The possible involvement of cholinergic mechanisms and of GABA in the modulation and generation of ponto-geniculo-occipital (PGO) waves was studied using PGO waves induced by the benzoquinolizine derivative, Ro 4-1284 ( =PGO(1284)), and by p-chlorophenylalanine (=PGO(PCPA)), and continuously recorded and counted in the lateral geniculate bodies of unanaesthetized immobilized cats. Atropine had no significant effect on PGO(1284) but markedly depressed the density of PGO(PCPA) this effect of atropine was absent when the synthesis of noradrenaline (NA) was inhibited in addition to that of 5-hydroxytryptamine (5-HT). Arecoline and eserine at a low dose increased the density of PGO(PCPA). Both the stimulation of nicotinic receptors by nicotine and their blockade by mecamylamine reduced the amplitude of PGO(1284) and PGO(PCPA). Eserine, 0.3 mg kg(-1) i.v., had a similar effect. GABA injected into a lateral brain ventricle augmented the density of PGO(PCPA) but not the PGO(1284). Increasing the level of endogenous GABA by amino oxyacetic acid (AOAA) and by hydroxylamine affected PGO waves like GABA. Bicuculline tended to decrease the density of PGO(PCPA). Chlordiazepoxide increased the density of PGO(1284) and, more markedly, that of PGO(PCPA). The latter effect was prevented by atropine and by lesions placed in the amygdala, the septum and medial forebrain bundle several days prior to the acute experiment. It is concluded that synapse with nicotinic cholinergic receptors are prsent either in the neuronal network of the pontine reticular cells which trigger the PGO waves or within the pathway leading from this trigger area to the lateral geniculate body or within this structure. It is tentatively suggested that the noradrenergic neurones which depress the formaton of PGO waves, are under a modulating influence from limbic forebrain structures. The suggested pathway originating in the forebrain and projecting to the locus coeruleus seems to be inhibitory for the NA-neurones involved in the modulation of PGO waves and to contain muscarinic cholinergic and GABA-ergic synapse. Chlordiazepoxide might augment the density of PGO(PCPA) either by activating this pathway in the limbic forebrain or by enhancing GABA-ergic transmission at its ending.


Diagnosis and treatment of infections of the urinary tract.

Infection of the urinary tract is life-threatening, particularly in the patient who is already critically ill. Avoidance of instrumentation, meticulous catheter care, and frequent bacterial screening are required. Prophylactic antibiotics should probably be avoided in favor of rapid, adequate treatment with the indicated antibiotic when infection is identified. Suprapubic aspiration of urine is a significant advance in diagnosis, providing rapid, accurate information with no increased risks.


The diagnosis and treatment of acute respiratory failure in sepsis.

Early diagnosis is mandatory in the adult respiratory distress syndromes, particularly in sepsis, and therapy should begin as soon as there is a reasonable suspicion that this problem is developing. Blood-gas changes cannot usually be appreciated clinically until the respiratory problem is quite severe. Accordingly, serial blood-gas analyses should be performed in any septic patient who has an increased chance of developing ARDS. Any deterioration in the patient's condition, blood gases, or ventilatory effort should be considered as an indication for early ventilatory assistance. Control of the primary process, high tidal volumes, PEEP, and careful dehydration are the mainstays of therapy. Serial blood gases and careful observation of the patient's effective compliance are essential to determine the optimal ventilator settings and the optimal PEEP. Early administration of massive steroids should be considered if the patient fails to respond to correction of the underlying etiologic problem (particularly sepsis), careful progressive dehydration, and optimal expansion of the alveoli (using high tidal volumes and/or PEEP).


Enhanced transformability with heterospecific deoxyribonucleic acid in a Streptococcus sanguis mutant impaired in ribonucleic acid polymerase activity.

We have induced with nitrosoguanidine in Streptococcus sanguis a mutation conferring inability to grow and synthesize ribonucleic acid (RNA) at 42 C, the optimal temperature for growth and RNA synthesis in the parental strain. The mutation (ts) is transferable via transforming deoxyribonucleic acid (DNA) and is replaceable by its wild-type allele with fairly high efficiency in transformation reactions. The ts mutation is unlinked to the sites of mutation conferring resistance of rifampin (rifr) and streptolydigin (stgr), known to affect the beta subunit of DNA-dependent RNA polymerase. Extracts from strains carrying the ts mutation are more sensitive to elevated temperatures than are parental extracts when assayed for DNA-dependent RNA polymerase. The conclusion that the mutation causes a temperature-sensitive defect in some component of this enzyme (other than beta) is supported by the finding that the polymerase activity of a heat-inactivated ts stgr extract cannot be increased by addition of an unheated ts stgs extract, which is itself inactivated by streptolydigin. S. sanguis recipients carrying the ts mutation are highly transformable with heterospecific DNA, especially at the restrictive temperature.


Hepatobiliary complications of sepsis.

Jaundice developing in critically ill or injuried patients should probably be thought of as a manifestation of severe sepsis until proven otherwise. Septic jaundice occurs in about 50 to 60 per cent of patients with generalized peritonitis. Biochemically, jaundice associated with bilirubin (particularly the direct fraction) and liver enzymes (particularly the alkaline phosphatase) and a decrease in the serum albumin. Histologically there is intrahepatic cholestasis. The etiology of these changes in unknown, but they appear to be due to an end organ response to sepsis. Optimal treatment involves control of the sepsis and maintenance of a glood flow of well-oxygenated blood to the liver.


Pulmonary infections.

It is likely that nosocomial pneumonias will continue to be a problem in critical-care areas. If there are to be breakthroughs, they will probably come in the area of prevention, not treatment. Scrupulously sterile techniques when using inhalation therapy equipment, suctioning patients, and changing tracheal tubes remains the mainstay of prevention. Early recognition and aggressive therapy of nosocomial pneumonias have had limited success in decreasing morbidity and mortality rates.


Digitalis excess mimicking the sick sinus syndrome.

Symptomatic bradycardia-tachycardia is often a feature of sick sinus syndrome. However, when alternating brady-tachycardia results from excessive use of digitalis preparations or electrolyte imbalance, it is iatrogenic and therefore not considered to be SSS per se. Sick sinus syndrome is applied to the following arrhythmias providing they are not iatrogenically induced: (1) sinus bradycardia usually unresponsive to atropine therapy or exercise, (2) sino-atrial block or arrest with long pauses, and (3) alternating bradycardia or tachycardia.


Antistaphylococcal activity and beta-lactamase resistance of newer cephalosporins.

Four newer cephalosporins (cefazolin, cefamandole, SK&F 59962, and cefoxitin) were investigated for determination of their antistaphylococcal activity and relative stability to staphylococcal beta-lactamase (penicillinase). Crude preparations of beta-lactamase from recent clinical isolates of Staphylococcus aureus were used. Cefamandole and SK&F 59962 were highly active against both large and small inocula of staphylococci and were resistant to staphylococcal beta-lactamase. Cefoxitin, although resistant to beta-lactamase, possessed less antibacterial potency but was still approximately as active as methicillin. Cefazolin was somewhat more susceptible to staphylococcal beta-lactamase than the other three agents and resembled cephaloridine in this respect. With minor exceptions, a correlation was found between the susceptibility of different agents to beta-lactamase and the magnitude of the effect of inoculum size when the drugs were tested against large and small inocula of staphylococci.


Nafcillin-gentamicin synergism in experimental staphylococcal endocarditis.

The bactericidal rate of nafcillin and the combination of nafcillin and gentamicin against Staphylococcus aureus were compared in vitro and in experimental endocarditis. The combination proved synergistic against 8 strains of S. aureus in broth. In rabbits with S. aureus endocarditis, the organism was eradicated more rapidly from cardiac vegetations when animals were treated with the combination than with nafcillin alone. Gentamicin alone was ineffective. This combination is under study in the therapy of acute endocarditis caused by penicillinase-producing S. aureus.


Genetic and molecular characterisation of resistance determinants in methicillin-resistant Staphylococcus-aureus.

A genetic analysis of resistance to antibiotics in methicillin-resistant Staphylococcus aureus was performed. Demonstration of plasmid-specific DNA either in transductants that had received antibiotic-resistance markers from multiply-resistant strains, or in segregants of methicillin-resistant strains that had lost unstable determinants except the one under study, indicated that markers of resistance to penicillin, chloramphenicol and neomycin are present on separate, mutually compatible plasmids. Absence of covalently closed circular DNA was demonstrated in transductants that were resistant to methicillin, tetracycline, erythromycin and streptomycin, as well as in segregants that had lost the penicillinase, chloramphenicol and neomycin plasmid, but were still resistant to methicillin, tetracycline, erythromycin, streptomycin and the sulphonamides. Analysis of plasmid DNA either in a 5-20% neutral sucrose gradient or by electron microscopy revealed the presence of three readily distinguishable plasmids. The molecular weights of these plasmids were estimated by comparing the sedimentation rate constants with those of known reference plasmids and by contour-length measurements. The molecular weight of the penicillinase plasmid was estimated to be 20 X 10(6) daltons, that of the chloramphenicol plasmid 3 X 10(6) daltons and that of the plasmid carrying the neomycin resistance marker 37 X 10(6) daltons.


[Drug sensitivity of Yersinia enterocolitica and Yersinia pseudotuberculosis].

Drug-sensitivity of 70 strains of Y. enterocolitica and 24 of Y. pseudotuberculosis including reference strains and isolates from men or animals were determined by the agar plate-dilution method. All the strains of Y. enterocolitica were relatively resistant to penicillins and cephalosporins, while all of Y. pseudotuberculosis were sensitive to both of the agents. Most of the strains of both species excluding 13 resistant ones were sensitive to streptomycin. The resistant strains, however, were sensitive to other aminoglycoside antibiotics, i.e. kanamycin, paromomycin, gentamicin, tobramycin, dibekacin and amikacin. All of the strains were sensitive to chloramphenicol. Most of the strains excluding 3 resistant ones were highly sensitive to tetracycline. The resistant strains were also resistant to doxycycline and methacycline but not to minocycline. All of them were resistant to erythromycin, to lincomycin and to novobiocin. Most of them excluding 7 resistant strains were sensitive to sulfisoxazole. All of them were sensitive to nalidixic acid, piromidic acid, and also to dihydroxymethylfuratrizine. A new synthetic agent, fosfomycin showed a relatively wide range of activity to the strains, but none of resistant strains were noticed. These resistant strains were all found in the isolates from men and animals but not in reference strains. Among these resistant strains, resistance patterns were as follows; TC, SM, SA in 3 of Y. enterocolitica, SM, SA in 3 of Y. enterocolitica and in 1 of Y. pseudotuberculosis, and SM in 3 of the both species, respectively. As for polypeptide antibiotics, polymyxin B and colistin, some strains of the both species showed an uncontinous susceptibility, i.e. inhibited growth at a certain lower concentration but growth at a higher concentration.


Instructional change in health care education.

Faculty in the nursing, medical, and pharmacy schools of a midwestern university health sciences center responded to a two-part instrument intended to determine the extent of 1) their commitment to implement recommended changes in their teaching activities and 2) their perceptions of the extent to which such changes had been implemented throughout their respective schools. Factor analysis and analysis of variance revealed variable degrees of commitment to change in teaching activities, as well as perceptions that such changes had not been implemented widely throughout the schools. The data suggested that faculty adjusted traditional instructional practices to fit new resources and expanded programs, rather than implementing changes in their instructional methods and techniques as the overall programs changed.


Effect of acquisition of knowledge on self-evaluation and the relationship of self-evaluation to perception of real and ideal self-concept.

To investigate the effect of knowledge acquisition on self-evaluation and self-concept 69 graduate nursing students--25 in an experimental group, 18 in control group I, and 26 in control group II--enrolled in three nursing courses provided demographic data, self-evaluation of entering behavior, and personality test data. The latter two tests were given on pre- and posttest bases. Seven hypotheses were tested. Overall results showed: The experimental group which was taught by means of mastery learning acquired significantly more knowledge than the control groups which received the traditional lecture-discussion method of learning; there was an inverse relationship between knowledge acquisition and self-evaluation of entering behavior; positive correlation between "amount of overestimation or underestimation of previous knowledge'' and extremes of self-concept was partially supported; in general, single students were less able to evaluate accurately by what they thought they knew than were married subjects; employment was inversely related with knowledge acquisition and course grade. The relationship between self-concept and acquisition of knowledge was not significant.


Role, function, and decision making in community mental health.

In this study, opinions of 44 nurses who worked in urban community mental health settings were solicited in interviews that covered their role, functions, and part in the decision-making process. Most were found to have a limited view of their role and functions, one that was based more on their duties than on the possibilities in the field. Nurses with at least a baccalaureate degree and head nurses and clinical specialists believed they had a part in the decision-making process.


Community health nurses' preferences for systems of protection.

This study examined community staff nurses' and nursing students' preferences for escort protection in areas in which they would refuse to go alone and investigated the nurses' comfort in performing tasks in the presence of a protector. Influence of type of agency, student--staff status, role performance, and evasion on preferences were made for health care delivery based on the findings.


The process of clinical judgment in nursing practice: the component of personality.

An exploratory study of the relationship of personality in the process of clinical judgment in nursing practice pointed out that changes in the profession--the extended role of nurses and the increasing number of men and older women who enter nursing--necessitate reexamination of the nurses' personality profile, development of a device to measure "successful'' and "effective'' clinical judgment, and evaluation of the effect of personality on nursing process.


Movement tempo and the experience of time.

To test the relationship between preferred rate of movement and time estimation; to attempt to control for conscious compensation in relation to time estimation; and to determine whether a trend emerges relating slowed rates of walking to time estimation; and to determine whether a trend emerges relating slowed rates of walking to time estimation by incorporating an additional slower rate, 90 healthy volunteer subjects between 18 and 45 years of age, drawn from the student population of a large, metropolitan university, were tested while walking on a finely calibrated treadmill. Three rates of walking were utilized: the individual's preferred rate and two rates slower than his preferred rate--one 30% slower, another 50% slower. While the subjects walked at the imposed rates, they were added to estimate a 40-second interval by two methods: one designed to control for conscious compensation and one to allow for compensation. They estimated the interval by activating a buzzer at the beginning of the interval and again when they felt 40 seconds had elapsed. Auxiliary data related to body temperature, pulse, and time competence (a scale of Shostrom's Personal Orientation Inventory) were also collected. The entire procedure required approximately one hour. Relationships were analyzed by simple correlation and two-way analysis of variance for repeated measurements. The relationship between preferred rate of walking and time estimation was not supported. Controlled conscious compensation did not make a difference in time estimation, as indicated by F ratio. The difference in time estimation in relation to rate of walking was statistically significant (p less than .001), and the trend was in the direction hypothesized. The time ratio score of the POI did not correlate with time estimates, and there was a low negative correlation between age and time.


Faculty and student perceptions of effective classroom teaching in nursing.

The purpose of this three-stage study was to identify and validate constructs which students use in differentiating among teachers. In stage I, six theoretical constructs thought to be involved in teaching effectiveness were identified; these were revised through a faculty content validity study. In stage II, a known-groups validity study, all items and constructs were found to be used by students in differentiating between good and poor teachers. In stage III, students' ratings of current teachers were collected and factor analyzed. Two factors, individualized prescriptive approach and systematic theoretical presentation, were identified. An analogy was drawn between these factors and elements of nursing process. The category structure which had been derived through the faculty content validity study was not supported.


Predictive value of selected admission criteria for graduate nursing education.

To determine if there are admission criteria that predict success in graduate nursing education, an investigation was conducted of 193 graduates who had successfully completed the masters nursing program at a private eastern university. Admission criteria and other variables chosen were nursing, nonnursing, and cumulative undergraduate grade point averages (GPAs); verbal, quantitative, and combined Graduate Record Examination (GRE) scores; age at entrance; number of years intervening between attainment of the bachelors and completion of the masters degree; and, number of years intervening between the basic nursing education and the completion of the masters degree. Each variable was correlated with masters GPA for degree of association. Pearson's coefficient of correlation was used to analyze the data. Subgroups were analyzed in relation to the chosen area of clinical concentration: community health, psychiatric, medical-surgical, and maternal-child nursing; basic nursing education: diploma or generic baccalaureate; and, marital status: single or married. Nursing, nonnursing, and cumulative undergraduate GPAs were found to be weakly associated with the masters GPA except for the psychiatric subgroup which showed a moderate correlation between the cumulative under-graduate and the masters GPAs. Weak associations were found between verbal, quantitative, and total GRE scores and the masters GPA, with two exceptions: for psychiatric and community health subgroups there were moderate degrees of association between verbal GRE scores and the masters GPA. Age was not an effective criterion for predicting degree of success in the program. Both measures of intervening years were found to be weakly associated with the masters GPA.


Sexuality of nurses: correlations of knowledge, attitudes, and behavior.

In a study of relationships among knowledge, attitudes, and statements of nursing behavior about sexuality, degree of comfort with sexual situations was measured with a Professional Sexual Role Inventory (PSRI), using ridit analysis. The PSRI and the Sex Knowledge and Attitude Test were administered in groups to 107 professional family planning nurses and 64 senior nursing students. The major hypothesis--the more knowledge a nurse has of human sexuality, the more favorable will be her attitude toward it and the more comfortable she will be in professional situations with sexual overtones--was supported. Significant positive correlations between sexual knowledge and attitudes and written responses indicated comfort in handling sexual situations. Analyses of variance of the test scores--by age, race, marital status, religion, religiosity, frequency of church attendance, and urbanization--demonstrated areas of sexuality which might be incorporated into nursing inservice training and education.


The teenager with pubertal delay.

All adolescents are concerned about their growth and development, and 2 to 3 per cent may have a delay in pubertal maturation. In most cases this is constitutional, and careful evaluation and thoughtful management will help alleviate their anxiety.


Closed head injury: a simplified approach.

In early evaluation of the head-injured patient one must continuously be alert for signs requiring operative intervention. If a neurologic deficit is in evolution, it should manifest itself by producing a change which will not be missed by careful frequent clinical evaluation.


When adoptive families ask for help.

As the adopted child enters adolescence and becomes more acutely aware of the biologic link of the generations, he often manifests behavior which is confusing to his parents. He may need to know more about his natural parents or even begin a search for them. At other stages in his development, but particularly at this time when his dual identity presents a special form of the adolescent identity crisis, both parents and child may need help and support in dealing with the feelings that emerge.


Hyperlipoproteinemia: diagnosis and management.

The hyperlipidemias are fairly common and require proper understanding. They may cause major complications, they may present as secondary manifestations of a number of common diseases, and, finally, a diagnosis of primary hyperlipidemia has significant implications for the patient's family.


Is the cervix normal? How do you arrive at that conclusion?

It is the responsibility of practicing physicians to determine, at the earliest possible time, the presence or absence of neoplastic disease of the cervix. Modes of treatment for cervical cancer will vary according to geographic location, the expertise of those providing treatment, and current clinical trials.


Constipation.

Careful understanding of the multiple factors which play a role in constipation precedes successful treatment. A method is described which employs elimination of factors interfering with normal bowel function. Refraining of spontaneous defecation is described.


Weight problems in adolescence.

Even the normal adolescent must incorporate into his body image radical changes in size, body proportions, and sexual characteristics. Obesity and anorexia, which are commonplace, may be sensitive problems to deal with.


The effect of vasopressin upon the excretion of calcium by the sheep.

Vasopressin (140 muU/min) was infused intravenously into 12 conscious merino ewes for 2 hr. Urine flow rate and free water clearance were consistently reduced. There was no effect upon renal plasma flow, glomerular filtration rate or the rate of excretion of sodium, potassium, magnesium, chloride or phosphate. Although all animals received 75 mmol calcium chloride into the rumen on the previous day, five commenced the experiment with calcium excretion rates of less than 1 mumol/min. In these, vasopressin further decreased calcium excretion. In seven animals with calcium excretion rates between 2 and 20 mumol/min vasopressin had no effect upon either total calcium or free ionized calcium excretion rate.


Uncharted cholinergic nerves in the rabbit parotid gland.

Cholinergic nerves are shown to be left in the rabbit parotid gland after avulsion of the auriculo-temporal nerve: a cholinesterase inhibitor injected through the duct caused secretion, thereby revealing leakage of acetylcholine from cholinergic nerve endings, and acetylcholinesterase positive nerves were found histochemically. The incomplete cholinergic denervation offers an explanation to the fact that some choline acetyltransferase activity remains in the 'denervated' glands.


Taurine transport rates between plasma and tissues in adult and 7-day-old mice.

Transport rates for taurine from plasma to liver, kidney, heart, spleen and femoral muscle were evaluated in adult and 7-day-old mice in vivo. The mice were injected with [35S]taurine and the specific radioactivity of taurine was determined in the above tissues at varying intervals from 10 min up to 48 hr after the injection. A multicompartment model was fitted to the data and the transport rates with their confidence limits were estimated using a digital computer. The tissue-plasma exchange rate was generally faster in adult mice than in 7-day-old mice. The transport rates between the plasma and the brain or muscle were low, while taurine penetrated into the liver and kidneys very rapidly. There was no distinct correlation between the calculated transport rates and the tissue taurine concentrations. The metabolic breakdown of taurine in the tissues was slow, since only negligible amounts of radioactivity were recovered in the metabolites of taurine, isethionic acid and inorganic sulphate. It seems unlikely that either the magnitudes of the transport rates between the plasma and the tissues or taurine breakdown rates in situ act as the primary factor determining the taurine levels in tissues.


The effect of plasma potassium in determining normal rates of excretion of potassium in dogs.

Doses of 5-15 mmol KCl or KHCO3 (less than the daily intake in food) given by stomach tube or intravenous infusion, produced increases in plasma K and in K excretion, the time delay between change in plasma K and  rate of excretion being minimal. Without doses of K salts in control experiments, plasma K concentration was about 4 mmol/1 and K excretion about 5 mumol/min. After doses of KCl or KHCO3, plasma K and rate of excretion of K both increased, increase of 0-5 mmol/1 in plasma K being associated with an increase of about 35 mumo1/min in K excretion. Increased excretion of K was accompanied by a small increase in Na excretion. Excretion of both C1 and HCO3 increased, C1 more after HCO3 more after KHCO3. The results indicate that within normal ranges, plasma K is an important factor determining the rate of excretion of K.


Respiratory responses to CO2-rebreathing in Nigerian men.

In 36 young Nigerian men, ventilatory capacity and the changes in ventilation, tidal volume and tidal P CO2 during oxic CO2-rebreathing have been measured. CO2 response lines and breathing rhythms have been determined and analysed in relation to the anthropometric and lung function data. Previous findings that Nigerian men have a substantially lower ventilatory capacity than Europeans at a standard height and age are confirmed. Breathing rhythms in Nigerians appear to be the same as in other ethnic groups studied. CO2-sensitivity varies with FVC, as found previously in Europeans and New Guineans. However, at a standard FVC of 41, Nigerian men have the same CO2-sensitivity as Europeans, and not a lower value like New Guineans.


Salmonella typhi strain with transmissible multiple resistance.

A case of typhoid fever caused by multiple drug resistant S typhi by R factor was clinically and bacteriologically studied. The clinical course was weakly influenced by successive chloramphenicol (21 days) and ampicillin (7 days) therapy; recovery occured after 62 days of disease including 2 relapses) as a result of the combined effect of immunization by disease and septrin administration (9 days). Two strains of S. typhi were isolated, one of them from blood culture before treatment, being Vi A degraded, sensitive to antibiotics A, C, T (strain 221) and the other from stool culture, after 4 days chloramphenicol treatment, being untypable with adapted Vi II phages, resistant to A, S, C, T (strain 552). Resistance markers were transferred within 4 conjugation systems, from strain 552 - as donor - to E. coli K12, to S. typhi A and to S. typhi 221 - as recipient-, the resistance level found was equal to that of the donor for all the determinants. The fi- character of the resistance factor was established and its possible restrictive effect in explaining the presence of two lytic patterns was discussed. The importance of the occurence of multiple drug-resistant S. typhi in certain areas, as well as chemical and epidemiological consequences, is emphasized.


The microdilution antibiotic susceptibility test. Bacteroides fragilis.

A micro broth-dilution method was developed for the antibiotic susceptibility testing of Bacteroides frgilis. Eighty strains of B. fragilis were tested against six antibiotics using the agar dilution test as the reference method. The microdilution test yielded results in 24 hours, and agreement with the reference test was satisfactory. Certain subspecies-specific patterns of antibiotic susceptibility were observed. However, larger numbers of subspecies should be evaluated before subspeciation of B. fragilis can be used as a reliable predictor of antibiotic susceptibility.


Peters' anomaly with the fetal transfusion syndrome.

Of identical twins with the fetal transfusion syndrome, the second twin who was anemic and hypoxemic from early gestation had Peters' anomaly by histologic examination of the host cornea excised during corneal transplantation at 7 months of age. The absence of a normally positioned lens with the incorporation of lens epithelium, capsule, and cortex within the posterior corneal stroma suggested a developmental disturbance in the separation of the lens from the cornea. The severe lenticular disturbance, microphthalmos, and fetal growth retardation in this case reflected early anemia and the resultant hypoxemia. To our knowledge, this is the first time that the fetal transfusion syndrome and Peters' anomaly have been associated.


[Behavior of Vibrio cholerae strains of the biotype El Tor isolated in Apulia in 1973, in relation to various antibiotics and chemotherapeutics].

The tests carried out on the strains of Vibrio cholerae of the El Tor biotype, isolated during the epidemic in Apulia in 1973, brought to light the sensitivity of all the strains to various antibiotics and chemotherapeutic substances. Only one initially sensitive strain, when it was isolated again in the same patient, proved to be resistant to tetracycline. On the basis of this discovery and others communicated in published works, the Authors outline the problems posed by the emergence of antibiotic-resistant strains, especially when the resistance involves R factors.


In vitro and in vivo comparative evaluations of injectable cephalosporin derivatives and ampicillin.

The in vitro and in vivo activity of the 5 injectable cephalosporins, cefazolin, cephaloridine, cephalothin, cephapirin, cephacetrile, and ampicillin was compared. No gram-positive organisms resistant to any of the cephalosporin derivatives were encountered. The MIC of ampicillin for gram-positive organisms was distributed over a wide range. The antibacterial activity of cefazolin, cephaloridine and ampicillin was high against gram-negative organisms. Ampicillin was potently effective especially against P. mirabilis and cefazolin especially against K. pneumoniae. The protecting effect of the 5 cephalosporins on experimental infections in mice was compared. The effect of cefazolin and cephaloridine was more marked than that of the others. These results may be explained by the fact that the other 3 cephalospoirins are rapidly metabolized in the living body.


Effect of lung inflation on alveolar permeability to solutes.

The alveolar epithelium separates gas and liquid phases in the lung. Osmotic forces available for separating these phases will be determined by the solute permeability of the epithelium. The relative rates of diffusion of several simultaneously studied solutes of known molecular size have been used for measuring the equivalent pore radius across the alveolar epithelium in vivo in the perinatal period and in adult animals. In perinatal sheep, the equivalent pore radius increases from 0.5 nm in the fetal state to 1.5-4.5 nm during the first minutes of spontaneous ventilation. Postnatal animals, 12-60 hours of age, have pore radii of 0.7-1.4 nm. Static inflation of the lungs, in fetal lambs, produced pressure-dependent increases in pore radii. In adult sheep and rabbits the measured radius of equivalent pores across the epithelium in vivo was positively correlated with the degree of inflation of the lungs (P less than 0.005). Measurements varied from 0.5 nm at low levels of inflation to large leaks at high levels. These experiments indicate that solute permeability across the alveolar epithelium is a dynamic function of the inflation of the lung, rather than a static feature.


Comparative aspects of salt and water transport across lung.

Calculation suggests that the outward flux of water from the surface of the lung into the expired air could be driven by a relatively small standing osmotic gradient. The structure of this alveolar epithelium does not appear to possess the characteristics of a typical secretory epithelium. These considerations argue against the occurrence of active transport in the alveoli of the adult mammalian lung.


Mechanism of alveolar flooding in acute pulmonary oedema.

In severe pulmonary oedema, the alveoli fill rapidly with fluid of essentially the same protein composition as free interstitial fluid. The usual explanation is that the normally 'tight' alveolar epithelial intercellular junctions suddenly become freely permeable to proteins. But the pathophysiological basis for such a change is unknown. In seven anaesthetized dogs one lower lobe was filled with iso-osmotic fluid containing 125I-labelled albumin. The calculated alveolus-blood albumin permeability over three hours averaged 0.06 X 10(-7) cm/s. It decreased nearly 50% when the alveolar tracer concentration was tripled for three more hours. At autopsy, large interstitial free fluid cuffs around blood vessels and airways were found. Isolated lung lobes were filled with isosmotic fluid containing tracer albumin at 10 and 20 cmH2O (0.98-1.96 kPa) airway pressure. Free interstitial fluid cuffs developed within 30 and 10 minutes, respectively. The tracer protein concentration in the cuff fluid averaged 0.9 that of the alveolar fluid. It is postulated that the terminal airway epithelium is normally permeable to protein and water. In acute pulmonary oedema alveolar flooding may occur along the same pathway after the loose interstitial tissue space is fluid-filled and its pressure exceeds that in the airway. The anatomical site of the bulk fluid and protein leak has not been identified.


Intracellular and subcellular oedema and dehydration.

Changes in intracellular water content appear to be common abnormalities induced by a wide variety of pathogenic mechanisms. Such changes in cell water produce changes in the water in various subcellular organelles bound by semipermeable membranes. Cell and subcell functions then alter in their turn. In isolated alveolar macrophages (rabbit), intracellular and intramitochondrial oedema reduces mitochondrial O2 utilization. Metabolic control is maintained because lactate production reverses (Pasteur effect). On reconstitution, O2 utilization and lactate production return towards normal, indicating reversibility. Cellular and intramitochondrial dehydration also reduces mitochondrial O2 utilization but metabolic control is lost because lactate production also decreases. Osmotic reconstitution does not reverse the abnormality. Exposure to hypotonic media leads to release of lysosomal enzymes (beta-glucuronidase, EC 3.2.1.31) to the extracellular phase of isolated alveolar macrophages. Some of this release is caused by exocytosis although, at low osmotic concentrations, intralysosomal oedema ultimately ruptures lysosomes, with extensive discharge of enzyme. In turn, lysosomal enzymes may injure more normal cells. Impairment of energy metabolism caused by hypoxia leads to intracellular oedema, because Na+ accumulates in the cells when ATP is no longer available for the sodium pump. Continued studies of the disorders in cell physiology caused by changes in cell and subcell water should provide important new insights into a wide variety of disease states (including pulmonary oedema).


Clinical disorders of lung liquid.

Clinical pulmonary oedema is often persistent and of sudden onset, suggesting a vicious circle, i.e. positive feedback. It is difficult to produce in animals by any haemodynamic manoeuvres, but the important neurogenic component can be illustrated by acutely increasing cerebrospinal fluid pressure of rabbits to 300 mmHg (40 kPa). Breathing stops virtually at once, and restarts when cerebrospinal fluid pressure is again reduced. With cerebral ischaemia lasting for up to 2 min, all is well; with longer times pulmonary oedema is almost invariable and often eventually fatal, although the animals may otherwise apparently recover. Comparable events sometimes follow subarachnoid haemorrhage in man. A few hypotheses on the pathogenesis of pulmonary oedema in man are offered.


The permeability of lung capillary and alveolar walls as determinants of liquid movements in the lung.

The lungs of the exteriorized fetal lamb offer an unusually good opportunity for measuring the permeability of lung capillary and alveolar walls, because access to plasma, interstitial fluid and alveolar liquid can be obtained without seriously disturbing their physiological relationships. Although there are probably some differences in permeability between fetal and air-breathing lungs, the underlying pattern appears to be similar. Large water-soluble molecules, including proteins, can penetrate capillary but not alveolar walls. The latter appear to be impermeable to molecules with diffusion radii greater than 0.5-0.6 nm. Pore theory can be used to characterize these permeabilities and to obtain estimates of osmotic reflection coefficients for various water-soluble substances. From them, predictions can be made of the bulk movements of liquid to be expected in a variety of circumstances, including the adaptation of the lungs at birth, lung oedema and drowning in sea water or fresh water.