Long-term prednisone followed by thymectomy in myasthenia gravis.

The present series of thirty patients has  led us to certain conclusions concerning the management and treatment of patients with myasthenia gravis. The use of cholinesterase inhibitors alone is reserved for those patients with purely ocular myasthenia whose deficits can be satisfactorily corrected with those agents. Some of those with  ocular involvement  may be disabled; and in light of our excellent results with that small group, as well as similar findings presented by Fischer et al., patients with disabling or refractory ocular myasthenia should be considered for treatment with prednisone. All other patients with myasthenia are given a course of  oral corticosteroids (prednisone) initially at high doses, with subsequent tapering to maintenance, alternate-day low-dose therapy. Cholinesterase inhibitors are used as needed while the patient is receiving corticosteroids. We now anticipate that patients will exhibit sustained improvement within the first  two weeks, reaching maximal improvement at about three months. Exacerbations of myasthenic weakness may occur in the early phases of treatment. Such exacerbations have been commonly mild and occur with a mean onset at 5 days, and have a mean duration of 6 days. Most patients have been able to tolerate an alternate-day schedule of prednisone therapy when maintenance levels were achieved. The effective maintenance dose has been determined as the smallest dose of prednisone which allows the patient to maintain maximal improvement. Following the establishment of maximal improvement, patients have been considered for thymectomy. In our experience, the sternum-splitting procedure has been tolerated extremely well by patients exhibiting marked imporvement or remission while on corticosteroids. In those patients where thymectomy is contraindicated, irradiation of the thymus might be considered. Patients are continued on maintenance steroid therapy following surgery for a period of time that has been arbitrary. Currently, we consider an attempt to discontinue steroids at approximately one year reasonable. Should the patient relapse after discontinuation of the medication, oral corticosteroid treatment is reinitiated. Consideration is given to the possibility of recurrent thymus in patients who repeatedly fail to maintain a remission when steroids have been stopped. Our experience has not permitted us  to draw firm conclusions concerning how long a time high-dose daily steroid treatment should be continued in patients who show no favorable response to that therapy. Other modes of treatment, such as courses of parenteral ACTH, methyl prednisolone, dexamethazone, or antimetabolites might be considered if there is no response after 12 weeks of high-dose, daily corticosteroid therapy.


Saccade fatigue and response to edrophonium for the diagnosis of myasthenia gravis.

Maximum velocity and amplitude of repetitive ( 1-per-second) 30 degrees saccadic eye movements were quantitatively assessed for 4 minutes before and after intravenous edrophonium chloride as a diagnostic test for myasthenia gravis. Atropine was given initially to suppress muscarinic side effects. Eye movements were recorded by electrooculography and a digital computer identified saccadic eye movements and plotted amplitude-velocity relationships. When compared with control subjects, eleven of twelve patients with proven MG had a significant increase in saccade amplitude and/or maximum velocity after edrophonium chloride. Only three of twelve proven MG patients had clinically apparent extraocular muscle weakness. The initial period of fatigue improved the sensitivity of the test in those patients who began with normal saccade amplitude and maximum velocity. Two of the patients with positive saccade fatigue tests had no change in optokinetic nystagmus amplitude before and after edrophonium chloride. It is concluded that, quantitative assessment of repetitive large angle saccades before and after edrophonium chloride is a sensitive test for extraocular muscle involvement in MG.


Kinetics of monocyte receptor activity for immunoproteins in patients with sarcoidosis.

Peripheral blood monocytes from patients with active sarcoidosis have increased ability to bind IgG-antibody-coated and C3-coated erythrocytes. Binding of monocytes from sarcoid patients is inhibited less than for normals with IgG1 and IgG3 in the fluid phase. Following phagocytosis of latex particles, monocytes from sarcoides patients retain the capacity to bind IgG-coated erythrocytes, whereas monocytes from normal individuals show disappearance of IgG receptors followed by recovery during a 6-8 hr period. Preliminary studies (8 patients) of monocytes from patients with Crohn's disease show some increase in binding of IgG-coated erythrocytes as compared with normals; this increase, however, is less than for sarcoidosis patients. Preliminary experiments with multistranded polynucleotides (poly I:C:U) show increased activity for normal monocytes and no detectable effect on IgG receptor activity for sarcoid monocytes. Thus peripheral blood monocytes of patients with sarcoidosis have increased IgG and C3 receptors sites, suggesting activation of monocytes in this disease and perhaps in other granulomatous disorders.


Evidence for circulating immune complexes in erythema nodosum and early sarcoidosis.

Twenty-two patients were investigated during acute attacks of erythema nodosum with a series of tests for circulating immune complexes. Nineteen had bilateral hilar lymphadenopathy and were considered to have sarcoidosis. Evidence of circulating immune complexes was found in 18, out of 22 patients (including 15 out of the 19 cases of sarcoidosis). The most frequent abnormality was the detection of elevated levels of C3 breakdown products (C3i), which were found in 14 out of 18 tests. The test results returned gradually to normal as symptoms subsided in 20-40 days, but 2 patients still showed abnormalities at 40 days despite the disappearance of symptoms. It is concluded that free immune complexes appear in the circulation during the early stages of acute sarcoidosis and gradually disappear as symptoms subside.


The nature and physical characteristics of a transmissible agent from human sarcoid tissue.

In controlled experiments normal and immunologically deficient CBA mice were inoculated in footpads, intraperitoneally, or intravenously with whole fresh, fresh supernatant, and fresh filtered supernatant (0.2 mu) or with each of these homogenates after autoclaving or their further exposure to 60Co irradiation (2.5 MR). As controls, mice were inoculated with identically prepared fresh nonsarcoid homogenates by these same routes. Epithelioid- and giant-cell granulomas were present in viscera of mice given each fresh sarcoid homogenate by any of these routes 15 months after inoculation, but were not present in mice given nonsarcoid autoclaved sarcoid, or 60Co-irradiated sarcoid homogenate. Successful passages were achieved following the inoculation of whole or filtered supernatant (0.2 mu) sarcoid mouse tissue homogenate into footpads, intraperitoneally, or intravenously. The epithelioid- and giant-cell granulomas evolved slowly over a period of many months following the inoculation of sarcoid tissue or passage homogenates and persisted thereafter in association with Kveim reactivity. The transmissible agent is inactivated when homogenate prepared from human sarcoid or mouse sarcoid tissue is autoclaved or 60Co-irradiated, can be repeatedly passaged, and has been shown to pass an 0.2-mu membrane filter. It is therefore presumably viable and must approximate to the size of  a virus or be capable of being deformed so as to pass a filter of such a pore size (0.2mu), L forms.


Transmissibility of sarcoid-specific granulomas in the footpads of mice.

Homogenate of 30 sarcoid lymph nodes was injected into the footpads of mice and 42% of the mice showed epitheloid-cell granulomas in the sites. However, the control lymph-node homogenates obtained from nonsarcoid patients also provoked similar granulomatous changes, although the positive rate was somewhat lower. In the granulomas a small amount of dust pigment remained, but no polarizing crystals were found in the sites or in the homogenate of either groups. No acid-fast bacilli, fungi, or other aerobic organisms were cultivated from the homogenate. Granuloma-formation activity remained after the homogenate had been sterilized in several ways and it existed in sediments of centrifugation of less than 2200 x g, but not in the supernate. The results seem to indicate that the granuloma formed in the footpads were the result of a local immunological reaction to the degenerated heterogenic protein of the injected and persistent homogenate.


Structure and function in sarcoidosis.

We have reviewed and compared our clinical, roentgenographic and histological material from 63 patients with sarcoidosis, berylliosis, and biological dust sensitivity. Among the histological features interstitial cellular infiltration proved to be the best for correlation with abnormal function, especially with arterial oxygen pressure and alveolar-arterial oxygen pressure difference at exercise, single-breath pressure and alveolar-arterial oxygen pressure differnce at exercise, single-breath diffusing capacity, forced vital capacity, and a composite index of overall functional impairment. There was also a significant correlation between pathological changes and a composite index of clinical severity. Some of the imperfections in these correlations may be related to strategic locations of granulomata that could alter ventilation-perfusion relationships, but part of the functional change remains unexplained by our histological measurements. Correlations of physiological and pathological features with radiographic parenchymal changes generally was poor except in the most severe cases. The finding of 4 cases with biological dust sensitivity or "allergic alveolitis" in this series reemphasizes that it is worth reviewing all cases of routinely labeled sarcoidosis in which the diagnosis has been based on the histological finding of granulomata. This is especially true in patients whose roentgenograms show no hilar  nodes and minimal or "groudn-glass" changes in the lung fields despite significantly abnormal lung function and also in patients who have rapid remissions and exacerbations without therapy. Almost all of the features of berylliosis overlapped those of sarcoidosis and no distinction could be made histologically. The mean values were worse in the berylliosis group and the long-term results in treated patients were not nearly as good as in the sarcoidosis group.


Pulmonary function in stage I and II pulmonary sarcoidosis.

Pulmonary function tests in 25 newly studied patients with Stage I and 19 with Stage II sarcoidosis revealed normal mean values in Stage I for all tests except DLCOSB. Mean values for VC, TLC, MMF, and exercise Pao, were abnormal in Stage II and significantly different from Stage I. There was a parallel difference in prevalence of impairment of these measurements and of DLCOSB as well. When the present results are compared with previously reported values for sarcoidosis patients with radiographic evidence of pulmonary fibrosis, progressive impairment is evident with later stages of disease. These findings indicate that extent and prevalence of impairment increase with progressive radiographic abnormality and that physiologic findings are useful in staging sarcoidosis.


Lung water and capillary permeability in pulmonary sarcoid-like granulomatosis.

The subject of our research was the use of multiple indicators to study the lungs of rats during a pathological process induced by complete Freund's adjuvant (CFA). The parameters studied were extravascular water (idQwl), the capillary permeability of [14C]sucrose, and the unrecovered fraction of [3H5glucose. We ascertained that idQwl gives a valuable estimate of total pulmonary water (r=0.91, n=30) and allows a satisfactory quantification of granulomatosis, as is shown by the comparison between the values of idQwl measured at different stages of the lesional process with average number of nodules per slice of right middle pulmonary lobe. The capillary permeability of sucrose is normal both at early and late stages of the CFA granulomatosis process. The fraction of [3H]glucose not recovered increases significantly (p less than 0.001) during the initial stage of the CFA process. This apparent loss of indicator can be explained by the existence of a slow cellular compartment.


Sarcoidosis in Europe: a cooperative study.

The data on the epidemiologic situation of sarcoidosis from 24 countries of Europe have been reviewed. The new facts seem to demonstrate that the differences between the frequency of this disease in the north and south are not real. The actual situation is dependent on the general knowledge of this disease and on the extent and intensity of the active detection of its asymptomatic stage. A new prospective cooperative study of the yearly incidence of all forms of sarcoidosis in the total population of at least some European countries would be desirable.


A cooperative study of sarcoidosis in Asia and Africa: descriptive epidemiology.

An eight-nation cooperative epidemiological study revealed the Asian and African features of sarcoidosis. Almost every country reported from several to less than 30 cases, except for Japan which had already collected over 3,000 cases. Not a single case was found in the mass x-ray surveys conducted by several countries on a large scale (Tables 1 and 2). Although the number of the cases included in this study were small, this information is the first of this kind for Asia and Africa.


A cooperative study of sarcoidosis in Asia and Africa: analytic epidemiology.

The characteristics of about 2,000 Japanese sarcoidosis cases collected by the Japan Sarcoidosis Committee during the 10-yr period, 1963-1972, were chronological increase with decreasing infectious diseases (represented by tuberculosis), north-to-south decline in sarcoidosis incidence in accordance with the Oxford Atlas Seasonal Climates, the age of cases shifting to the younger group in areas of high incidence, a local outbreak, and familial aggreagations. These results led the authors to an hypothesis that sarcoidosis is a disease induced by an infective agent or agents, prevalent in cold places, becoming influential in association with ecological changes, and affecting persons with predispositions.


Patterns of sarcoidosis in three population groups in New York City.

Caucasians in this study group presented in the chronic stage of sarcoidosis more frequently than the Blacks and Puerto-Rican-born. 2) Twenty-eight percent of the Caucasians and 26% of the Blacks who presented in the chronic stage of sarcoidosis, died of pulmonary insufficiency. 3) Puerto-Rican-born women are especially prone to present with erythema nodosum and Stage I radiographic sarcoidosis.  4) Sarcoidosis with extrathoracic organ involvement was more common in Black and Puerto-Rican-born patients than in Caucasians. 5) The size of the Kveim papules was larger in the Black and Puerto-Rican-born patients than among the Caucasians. 6) Two-thirds of all groups were insensitive to tuberculin. 7) The extent and duration of disease at presentation is a major determinant prognosis. 8) Ethnic factors influence the clinical patterns in sarcoidosis, but socioeconomic factors may preclude generalizations based solely upon clinic populations in New York City.


Familial sarcoidosis with multiple occurrences in eleven families: a possible mechanism of inheritance.

Among 80 Black patients with sarcoidosis, 11 families were identified as containing multiple cases. Monogenic modes of inheritance were reasonably excluded by informal inspection of pedigree patterns and by poor fit of corrected ratios within sibships to the expected ratio for all sibships at risk. The observed familial distribution conforms in several respects to properties that are descriptive of multigenic traits. Additionally, heritability based only on female probands was estimated to be between 60% and 70%. A larger sample size should permit analysis of additional multigenic properties.


The optic pathway in neurosarcoidosis.

A case is reported of a patient, age 40 yr, with progressive hypothalamic and visual failure. Autopsy revealed widespread multisystemic sarcoidosis with involvement of the central nervous system. The intracranial portion of the optic pathway was diffusely infiltrated by sarcoid granulomas. Comparison of this case with previously reported autopsy and biopsy findings leads to the following conclusions: 1) The intraocular, intraorbital, and intracranial parts of the optic nerves may be involved independently; 2) lesions of the nerve head and of the retrobulbar part of the nerve may be unilateral; and 3) involvement of the intracranial portion is usually bilateral and forms part of more widespread sarcoidosis of the central nervous system.


Sarcoidosis of the upper respiratory tract and its relation to lupus pernio.

The authors present a personally studied series of 32 patients with sarcoidosis affecting the upper respiratory tract and nose. Twenty-five of these patients had lupus pernio (LP), which in 8 instances was accompanied by sarcoidosis of the upper respiratory tract (SURT). The 7 other patients had SURT (mucosal disease) without LP. There was a female to male ratio of 7:1. SURT presented mainly in the third decade, whereas LP presented mainly in the fourth and fifth. Despite this, SURT was as much a chronic manifestation of sarcoidosis as LP. Five of 11 patients (45%) presenting with SURT progressed to LP within 2 yr. Overall 26 patients (81%) had intrathoracic sarcoidosis, 19 patients (59%) had skin lesions other than LP, 10 patients (31%) had bone sarcoidosis, 7 patients (22%) had ocular lesions, and 6 patients (19%) had peripheral lymphadenopathy. The Kveim-Siltzbach skin-test was positive in 12 of 12 patients with SURT, making it a useful aid in the differential diagnosis of sarcoid granulomas in the nose. Two patients had nasal perforations, both of which followed a submucous resection.


Hepatic granulomata: problems in interpretation.

Granulomata occur in the liver not only in patients with systemic granulomatous disease, but also in a variable number with underlying liver disease and in a heterogeneous group of disorders that appear to be neither hepatic nor granulomatous in nature. The hepatic granulomata found in association with liver disease are rarely attributable to complicating systemic granulomatous disease, and probably represent a nonspecific response to the underlying hepatic disease. In the heterogeneous group of diseases that appear to be neither hepatic nor granulomatous in nature, hepatic granulomata may (in some instances) represent a nonspecific response to such conditions as intraabdominal malignancy and ulcerative bowel disease. However, in others, particularly those with unexplained prolonged fever, hepatic granulomata may be attributable to specific agents that are overlooked or escape detection by currently available diagnostic measures. The etiology of hepatic granulomata can seldom be established on histological grounds alone, and usually requires collateral clinical and laboratory evidence for identification.


LP-X test in sarcoidosis patients with liver involvement: comparison with other liver function tests.

In the serum of many patients with sarcoidosis, alkaline phosphatase activity is increased due to sarcoid liver involvement. A study was carried out of various tests expressing intrahepatic cholestasis in 26 patients with sarcoidosis, 18 of them with a positive liver biopsy and 8 with a negative liver biopsy. SAP was elevated in 23% of the patients and its thermoresistance pointed to an hepatic origin. The predictive value of a positive test (PV-positive, the percentage of times that a positive test is in agreement with an involved liver) and the predictive value of a negative test (PV-negative, the percentage of times that a negative test will detect a nondiseased liver) were calculated. LP-X test is more reliable than SAP, which in turn is better than CB, BSP retention, and gamma-glutamyl-transpeptidase, in that order. LP-X seems to be more specific and more sensitive than alkaline phosphatase for predicting liver involvement in sarcoidosis.


Ocular sarcoidosis: evaluation of intraocular findings.

Intraocular lesions occurred in 55 of 70 sarcoidosis patients (78.6%) and their intraocular findings were biomicroscopically analyzed. Intraocular lesions were observed bilaterally in 54 of 55 patients (98.0%) and these various lesions occurred simultaneously or within a short period in almost all tissues of the eyeball. From these characteristics a new attempt was made to correlate the presence of sarcoidosis with intraocular findings. A gross positive correlation was revealed between the number of active intraocular lesions and the presence of sarcoidosis. Four to six active, bilateral intraocular lesions were found only in sarcoidosis. Although the correlation was not statistically tested, it should be clinically very useful in managing patients with suspicious intraocular lesions. Among the causes of visual disturbances secondary glaucoma was the most frequent. In 41 (37.2%) eyes various degrees of intraocular hypertension were observed. Impairment of aqueous outflow due to nodular infiltration of trabeculae was the fundamental mechanism in the rise of intraocular pressure. It should be emphasized that this peculiar trabecular finding can be identified only by a trained ophthalmologist and is very frequent in and characteristic of ocular sarcoidosis.


Clinicopathological study of fatal myocardial sarcoidosis.

Presented here was an outline of fatal myocardial sarcoidosis in Japan based on 42 autopsy cases. The incidence, clinical features, pathological findings (particularly the distribution of sarcoid lesions in various organs, and gross as well as histological patterns have been reviewed. The ratio of fatal myocardial sarcoidosis to the total number of sarcoidosis deaths is higher than that of other countries and it appears characteristic of Japanese sarcoidosis that the disease occurs here predominantly after the fourth decade in females. Only 12% of myocardial sarcoidosis cases are diagnosed exactly. Conduction disturbances and dysrhythmias due to myocardial damage are its most common manifestations. The modes of presentation or cardiac death are sudden death, 16 cases (41%); congestive heart failure, 9 cases (23.1%); Adams-Stokes syndrome, except sudden death, 7 cases (17.9%); death due to dysrhythmia, 6 cases (15.4%); and 2 pacemaker deaths among the application of pacemakers, 7 cases. As for the ECG findings, A-V block and bundle-branch block was observed in most cases and ectopic beats were also frequently observed. The difficulty in exact diagnosis of myocardial sarcoidosis appears to be due to the frequency of lack of manifestation of systemic sarcoidosis as well as insidious cardiac involvement. The gross findings on myocardial lesions showed 3 patterns and each of the localized patterns corresponded to the histological extension. The conglomerate-band-like pattern corresponded to expansive invasion, the dendrite pattern to interstitial extension. The histological findings on the myocardial lesions were classified into four types: 1) exudative type, 2) granuloma type, 3) combined type of granuloma and fibrosis, 4) fibrotic type. Two extreme cases showed the exudative and fibrotic type, respectively, and were discussed.


Bone sarcoidosis.

Sarcoidosis of the bone has been observed in 24 patients for up to 43 yr. It was always present in hands and/or feet and also elsewhere in 4 other patients. Soft-tissue swelling preceded the radiological abnormality for up to 4 yr in 9 patients accompanied it once, followed it once, and was absent in 13 (55%). Bone involvement was usually an incidental finding when sarcoidosis presented elsewhere, including lupus pernio (50%) and other chronic skin lesions (41%), lungs (75%), eyes (51%), lymph nodes (21%), liver (17%), spleen (13%), parotids (13%), facial palsy in 2 patients and erythema nodosum in 1. Pulmonary infiltration, with or without lymphadenopathy, was evident in three-fifths of the patients and hilar adenopathy alone in one-fifth. Sarcoid tissue was observed in the bone, but not in the surrounding soft-tissue swelling of 2 amputated fingers. There were 3 types of bone lesions: a) Lytic in 20 patients; minute 1-mm cortical defects or larger, usually rounded defects that on healing become corticated leading to punched-out "cysts". b) Permeative in 8 patients; these showed progressive cortical tunnelling with remodelling of trabecular and cortical architecture. c) Destructive in 3 patients, with secondary joint-surface involvement and in one a periosteal reaction.


Gallium scanning in sarcoidosis.

This study of 36 patients, 27 with sarcoidosis, confirms the avidity of mediastinal and pulmonary sarcoidosis for gallium-67. This procedure may prove useful in distinguishing enlarged hilar vessels from lymph nodes. Gallium scanning proved unsuccessful, however, in detection of clinically important extrathoracic sarcoidosis and appears to have limited applicability in the diagnosis of thoracic sarcoidosis.


Fine-needle aspiration biopsy of the spleen in diagnosis of sarcoidosis.

Splenic fine-needle aspiration is a simple, safe bedside procedure by which cells typical of the sarcoid granuloma can be rapidly detected. Not only does it appear to be a valuable diagnostic procedure, but it offers a reliable method for demonstrating multisystem involvement in sarcoidosis.


Flexible-bronchoscope biopsy of lung and bronchial wall in intrathoracic sarcoidosis.

1) Twenty of 25 patients (80%) with sarcoidosis had positive lung biopsies obtained by flexible-bronchoscope biopsy. 2) Three of the 5 negative biopsies were in patients with chronic sarcoidosis whose chest radiograph was unchanged for 1 yr or more. 3) Two insignificant pneumothoraces occurred as a complication of the bronchoscopic biopsy procedures. 4) Noncaseating epithelioid-cell granulomas found on fiberoptic bronchoscopic biopsy are no more specific for the diagnosis of sarcoidosis than similar findings in any other organ biopsy.


Comparison of clinical and laboratory findings of intrathoracic sarcoidosis between children and adults.

Children were different from adults in the following findings of intrathoracic sarcoidosis: All of the 69 pediatric patients studied had no complaints and were found by chest x-ray examinations, in contrast with 71% of the 62 adult patients studied. At the ages 10-14 yr there were far more boys than girls. In pediatric patients eye involvements were rare, blood eosinophilia was more frequent, biopsy of conjunctival follicles was more frequently positive, cold serum hemagglutinins were higher at first and decreased later, and the prognosis was far better than in adults.


Further observations on the transmissibility of Crohn's disease.

In controlled experiments normal and immunologically deficient CBA mice were inoculated with whole fresh, fresh autoclaved, fresh supernatant, or filtered supernatant (0.2 mu) of whole Crohn's or non-Crohn's homogenate into footpads, intraperitoneally or intravenously. Epithelioid and giant-cell granulomas were present in a substantial proportion the footpads and in bowel or mesenteric lymph nodes of a proportion of given each fresh Crohn's homogenate by any of these routes 15-17 months after inoculation, but were not present in mice given non-Crohn's or autoclaved Crohn's homogenate. Successful passages were achieved following the inoculation of Crohn's mouse tissue homogenates, including passage from mice receiving filtered supernatant (0.2mu) or whole Crohn's homogenate, into footpads or intravenously. The epithelioid- and giant-cell granulomas evolved slowly over a period of many months following the inoculation of Crohn's tissue or passage homogenates and persisted thereafter. The transmissible agent is inactivated when homogenate from Crohn's tissue is autoclaved, can be passaged successfully into footpads or intravenously, and has been shown to pass an 0.2 mu membrane filter. It is therefore presumably viable and must approximate to the size of a virus or be capable of being deformed to pass a filter of such a pore size (0.2mu).


The first seven cases of chronic beryllium disease in ceramic factory workers in Japan.

In the present paper the first 7 cases in Japan of chronic beryllium disease found in workers employed in a ceramic factory utilizing beryllium have been described. Immunological examinations of these cases showed changes similar to those observed in sarcoidosis, that is, negative tuberculin test and increase in serum gamma globulin and immunoglobulins. The fact that a considerable number of workers in the same factories as the patients showed negative tuberculin reaction may suggest that there may be further cases of chronic beryllium disease among them that are still in a latent period.


The Edinburgh spleen: source of a validated Kveim-Siltzbach test material.

Although it is true that some Kveim-Siltzbach test suspension may for reasons unknown behave in a totally nonspecific way and so be useless in the confirmation of active sarcoidosis, the experience with the Edinburgh spleen has shown that it is also true that a preparation can be made which acts specifically in the sarcoid context and fulfils all the Siltzbach criteria. The active principle probably resides in the membrane components of sarcoid tissue cells.


The Kveim test: analysis of results of tests using colindale (K 12) materials.

Results of an analysis are presented of the salient clinical, pathological, and Kveim-test data of importance in the diagnostic assessment of 839 patients in whom a Kveim test was made as part of their routine clinical investigation. From these analyses the following significant observations can be made: 1) The age distribution and negative tuberculin results in patients with sarcoidosis were in keeping with the diagnosis of sarcoidosis, whereas for those in whom a diagnosis other than sarcoidosis was made, they were not. 2) The findings of 64% positive tuberculin results in cases of confirmed sarcoidosis of less than 2 yr known duration and only 39% in those of greater than 2 yr duration are closely similar to those found in international Kveim-test studies reported by Siltzbach in 1966 and Hurley and Bartholomeusz in 1971. 3) The use of the material was helpful in confirming a diagnosis of sarcoidosis in patients with extrathoracic lesions, for positive results were obtained in 33% of those with uveitis 40% of those with erythema nodosum only (findings which are in keeping with those of other studies in the United Kingdom, and 60% among 27 patients presenting with lesions in various sites, including 2 with cranial nerve lesions and one with cardiac arrhythmia. 4) We found only 2 positive reactions (less than 1%) among 221 patients in whom a diagnosis other than sarcoidosis was reached. Clearly these findings show that the Kveim test material. Lots 19 and 22, of spleen K 12 exhibited not only a high degree of reactivity and selectivity for sarcoidosis, but also that they were of considerable practical value as an aid to diagnosis. The finding of only 2(0.9%) positive Kveim tests among 221 patients with diseases other than sarcoidosis is of special interest. Of the different diseases that were ultimately diagnosed only 6 patients tested had lymphoma, only 11 had either pulmonary or lymphatic tuberculosis, and only one had Crohn's disease. Although these numbers are small, it is relevant to compare the Kveim-test data of Lots 19 and 22 of K 12 with those of Lot 5 and of Lot 14 of the same spleen. In validation studies Lot 5 yielded the expected proportion of positive reactions at different stages of sarcoidosis and a negligible proportion of positive reactions with active or quiescent pulmonary tuberculosis or among healthy subjects. However, in subsequent studies in special groups of patients, those with Crohn's disease, ulcerative colitis, or lymphatic tuberculosis, a proportion of the Kveim tests performed with these lots were positive. Within the context of the present field  study, the results of these analyses confirm that the last lots of K 12 material exhibited a high degree of selectivity for sarcoidosis and that they emphasize again the practical value of the Kveim tests with suspensions that have undergone careful validation.


International Kveim histology trial.

An histological analysis of Kveim-test biopsies performed on a total of 306 patients including those with sarcoidosis, Crohn's disease, tuberculosis, and collagen disease is presented. Five main Kveim suspensions, "antigens," were used in the survey, Colindale K 12, Lot 5, Marburg 2 and 3, Commonwealth Serum Laboratory (CSL) early batches, 001/2/3 and late batches, 005/6. The biopsies were read blind by two observers (overall agreement 75%), the nature of the antigen and disease later disclosed, and the finding statistically analysed. It was agreed that focal epithelioid-cell collections remain as the essential criteria for the diagnosis of Kveim positivity. Diffuse epithelioid cells, Langhans' giant cells, lymphocytes, and necrosis are associated with focal epithelioid cells and hence Kveim positivity. Steroids were found to inhibit Kveim positivity. Observer disagreements were mainly due to difficulties in distinguishing macrophages from true epithelioid cells. We conclude that doubtful cells should be ignored in deciding Kveim positivity. Lymph-node-derived Kveim antigens were the most sarcoid-specific. They were more granulogenic and produced more necrosis, despite also producing the most foreign material. It is recommended that validation of new Kveim antigens must include adequate testing on patients with Crohn's disease, as the more nonspecific antigens were shown to give equal positive rates in sarcoidosis and Crohn's disease.


Comparative in vitro reactivities of leukocytes from sarcoids and normals to different Kveim preparations.

Comparative studies of in vivo and in vitro reactivities to Kveim preparations have been carried out in 45 sarcoid and 30 normal subjects. Lymphocytes of 14 of 45 sarcoids and 4 of 30 normals proliferated significantly in response to at least 1 of the 4 Kveim suspensions used for in vitro studies. The prevalence of positive responses were significantly greater in sarcoids than normals in cultures containing Kveim-CSL and Kveim-Edinburgh. The Kveim-reactive cells were less stimulated by PHA, but no other significant alterations were found, including the presence or absence of in vivo Kveim reactivity in the cell donors. Reactivity to more than 1 Kveim preparation occurred in 9 of 14 cases. Kveim-induced leukocyte migration inhibition occurred more commonly in sarcoids than normals, but differences were not as striking. There was not a precise correlation between proliferative and migration-inhibition responses to Kveim.


Experience with a Dutch kveim suspension in men and guinea pigs.

A Kveim antigen was prepared according to the Chase-Siltzbach method from the spleen of a patient with sarcoidosis. This antigen was tested in a number of patients with sarcoidosis or possible sarcoidosis and also in a number of non-sarcoid patients. Several lots prepared from this spleen were compared, yielding differences in reactogenicity. Maybe this can be explained by heterogeneity of the spleen. An animal model (the BCG-presensitized guinea pig) is presented that may be applicable for a preclinical evaluation of lots of Kveim antigen.


Extended experience in the long-term corticosteroid treatment of pulmonary sarcoidosis.

A 15-yr experience with symptomatic pulmonary parenchymal sarcoidosis treated with corticosteroids has included 250 patients. Within the past 5 yr 192 patients have been actively studied and these are reported in detail. Varied clinical observations are described. Serial measurements of vital capacity and steady-state carbon monoxide diffusing capacity were performed. All of these patients were sufficiently symptomatic and incapacitated to require treatment. Ninety-one percent were Black, 72% were female, and 72% were in the third and fourth decades. In response to treatment there was overall clinical improvement and an increase in vital capacity in 150 (83%) of 180 patients, although only a temporary increase in 12 of these patients. By contrast, only 82 (46%) showed an increase in carbon monoxide steady-state diffusing capacity and only temporarily in 19 patients. Changes in vital capacity correlate well with changes in symptoms and the radiographic appearance and are of great assistance in assessing the clinical course and need for continued treatment. The diffusing capacity is more difficult to interpret. Continued treatment was required in 74 patients (48%) because of recurrent clinical relapses as treatment was withdrawn. Such relapses were observed in 70% of the patients. Improvement and discontinuation of treatment was achieved in 66 patients (42%). In the 44 in whom there was no observed relapse, 34 were treated for less than 2.5 yr. In the total group, longer periods of treatment, 2.5-10 yr or more, were required in 104 patients (54%). In this series of 192 patients there were 7 deaths, with 22 deaths in the total 15-yr series of 250 patients. Of these, 18 were directly attributed to the sarcoidosis. Clinical improvement coincident with corticosteroid treatment and the frequency of relapse as treatment is withdrawn strongly support the benefits of corticosteroid treatment for symptomatic pulmonary sarcoidosis. When relapses occur and recur, retreatment is necessary and often long-term maintenance doses of prednisone (10-15 mg daily) are required for many years. The relatively infrequent problems related to this treatment are greatly exceeded by the clinical benefits.


The problem of the treatment of sarcoidosis: Report of the Subcommittee on Therapy.

Stage I: Hilar Adenopathy With normal lung function observe, as it often resolves. With reduced lung function observe for 6-12 months. Treat if there is progression or persistence. With erythema nodosum use mild anti-inflammatory agents such as salicylates or like drugs. Stage II: Adenopathy + Pulmonar Infiltrates With normal or slightly reduced lung function observe; treat if it worsens. Treat if there is no remission in 6-12 months. With reduced lung function treat, possibly for many years or a lifetime. Stage III: Pulmonary Infiltrates +/- Fibrosis Without Adenopathy There is reduced lung function. Treat, demonstrate improvement, follow patients with serial measurements of vital capacity at least. Other Indications for Treatment Other indications for treatment include myocardial sarcoidosis, cerebral sarcoidosis (although the outcome is less certain), serious hepatic or renal sarcoidosis, hypercalcemia, persistent systemic symptoms, or other serious organ or functional impairment. Assess each patient individually and completely. Use good clinical judgement. It is clear that treatment that is too little or too late is of little benefit. Even the statistical results form a perfectly controlled study cannot provide absolute direction for the individual patient. As clinicians we are frequently called upon to apply considered judgements without hard data to predict the outcome. We also maintain the flexibility to change our therapeutic programs when circumstances change, either in the patient or in our knowledge. We can be grateful we have a treatment as good as corticosteroids and must try to exercise our best judgement as to when it should be instituted.


Growth hormone deficiency after treatment of acute leukaemia in children.

Growth hormone (GH) secretion was studied in 15 children at various times after treatment for acute lymphatic leukaemia. Impaired GH responses both to hypoglycaemia and to Bovril were found in 4 children. 13 of the children had been given prophylactic cranial irradiation of either 2500 rads in 10 fractions or 2400 rads in 20 fractions. The reduction in GH responses in those given the former dose was highly significant compared with the reduction in those given the latter dose. However, other differences between the two groups included the length of time since cranial irradiation and the chemotherapy used. The main cause of the GH deficiency is not yet clear, but we conclude that it may occur in children treated successfully for acute lymphatic leukaemia.


Search for new treatment approaches in schizophrenia: in vitro studies of potential N-methyltransferase inhibitors.

Partially purified rabbit lung N-methyltransferase (NMT) was used in an in vitro assay to screen various amines and substrate analogs as potential inhibitors, N-Methyltryptamine (NMeT, 10(-3 M) and 14C-S-adenosyl-L-methionine (14C-SAM, 2.5 X 10(-5) M) were used as substrates to form 14C-N, N-dimethyltryptamine (14C-DMT). By thin layer chromatography the product was identified as having the same Rf as authentic DMT. Of 129 compounds studied S-adenosyl-L-homocysteine (SAH), 2-(2-aminoethyl)-5,6-dichlorobenzimidazole dihydrochloride (SKF No62817-A2), DMT, an equimolar mixture of adenosine plus DL-homocysteine, N-(2-aminoethyl)-pyrrolidine, and 2-(2-aminoethyl)-pyridine showed definite inhibitory properties. These constitute potential lead compounds for further research.


[Studies on the epidemiology of malignant tumors, systemic diseases and leukemia in children (author's transl)].

The analysis of statistical data on the incidence of leukemia in children in the German Democratic Republic between 1968 and 1973 gives no evidence for increasing risk of disease. Incidence in the G.D.R. is about the same as reported in literature. It seems that in the etiology and natural history of malignant tumors and hemoblastosis in children, constitutional and genetic as well as environmental factors are involved. They may work single or combined. Probably, malignant tumors or malignant systemic disease arise if the immune system fails to destroy endogenous or transplanted tumor cells.


Dominant inheritance of McArdle syndrome.

Myophosphorylase deficiency (McArdle syndrome) is an uncommon condition characterized by exercise intolerance, muscle cramping, and myoglobinuria. Although the original report by McArdle dealt with a sporadic case, subsequent cases reported in the literature show high familial incidence and consanguinity, implying that the defect is transmitted as a rare recessive gene or a possible sex-limited mode of inheritance. The present report describes the clinical, histoenzymatic, and biochemical findings in a 40-year-old woman with myophosphorylase deficiency. The family history reveals that four other members are also affected: an older sister, a younger brother, a 10-year-old son, and her 75-year-old mother, and possibly her maternal grandmother. Because of this particular pattern of direct transmission in this family, a dominant inheritance is postulated.


The first 15 years' experience with vagotomy and drainage for duodenal ulcer at the Royal Prince Alfred Hospital, Sydney.

The first 15 years' experience with vagotomy and drainage for duodenal ulcer at the Royal Prince Alfred Hospital, Sydney is summarized in a retrospective study. Proved ulcer recurrence in 16% of patients, a mortality rate of 2.6%, and a postoperative complication rate of 32% suggest that vagotomy and drainage as the procedure of choice in all patients with chronic and complicated duodenal ulcer should be reconsidered. The delay in recognition of ulcer recurrence and the increase in the number of patients with longer follow-up show disturbing similarities to the recurrence of ulcer after gastroenterostomy alone.


Postbulbar duodenal ulcer.

Postbulbar duodenal ulceration is not common, but when present is difficult to diagnose and treat. Between January 1965 and September 1971, 1,080 patients with duodenal ulcers were treated surgically at St James Hospital. Forty-one ulcers were found at operation to lie distal to the duodenal bulb. Pain was the most common indication for surgery. In six-patients it was clinically indistinguishable from biliary pain, giving rise to diagnostic difficulty. Twelve patients (29%) presented with haemorrhage, a percentage similar to the 25% of bulbar ulcers presenting with this complication over the period of this study. This is contrary to the finding in most other series, that postbulbar ulceration is more frequently complicated by haemorrhage than is bulbar ulceration. Perforation and stenosis are uncommon complications. Postbulbar ulceration is easily overlooked in conventional barium studies. Only one-third of the patients subjected to barium meal x-ray examination had their ulcers identified in the first study. In a further third the presence of an ulcer was suspected, and the remainder required multiple investigations for undiagnosed symptoms before the condition was demonstrated. Duodenoscopy was not performed in a sufficient number of patients for its value to be assessed, but other reports indicate that it should be a valuable manoeuvre. The technical difficulties and potential hazards of Polya gastrectomy are discussed and special reference is made to the surgical management of bleeding postbulbar ulcers.


Multiple hyperplastic inflammatory polyps complicating quiescent ulcerative colitis.

A patient with well-controlled and currently asymptomatic ulcerative colitis had II unusually large polypoid lesions in his colon demonstrated by barium enema X-ray examination and colonoscopy. Previous histological descriptions of inflammatory polyps did not adequately describe their morphology, and the term "hyperplastic inflammatory polyp" is suggested.


The Kock continent ileostomy: a preliminary report.

A review is presented of seven patients who have undergone a continent type of ileostomy, as described by Professor Kock. There has been no mortality. Two of the early patients had considerable difficulty with the functioning of the valve and required re-operation. No patient in the series now wears an external appliance. Six of the seven are fully continent; the seventh reports occasional leakage, but is satisfied with the operation. The operation is considered to be still under trial, but is regarded as having great potential and likely to be much more widely practised in the future.


Closure of colostomy.

A retrospective review of 110 patients who had their colostomies closed during the period from 1963 to 1973 has been undertaken. Their average age was 64 years. Diverticular disease and colorectal cancer had been the most frequent indications for the colostomy. Wound infection occurred in 36.4% and faecal fistula in 7.3%. These complications occurred less frequently in patients who had antibiotic bowel preparation. The overall mortality rate was 4.5%. Measures to reduce the morbidity and mortality are discussed.


Mesenteric venous thrombosis associated with oral contraceptives: a case report.

Small-bowel infarction resulting from mesenteric venous thrombosis is a rare but life-threatening complication to which young women taking oral contraceptives are liable. The patient characteristically presents with an "acute abdomen" after a variable prodromal period of vague abdominal pain. The correct diagnosis can be made from the macroscopic appearance at laparotomy, provided the surgeon is alert to the condition. An accurate diagnosis is important, as anticoagulation measures must be instituted early to counter the commonly associated thromboembolic phenomena.


Carcinoid tumours of the biliary tract.

Data on 13 patients, including two not previously reported, with carcinoid tumours of the biliary tract are reported. In ten of them the primary tumour was located in the gallbladder and in three in the biliary duct. No specific symptoms were recorded, and the carcinoid syndrome has not been reported in carcinoid tumours of the biliary tract. In five patients the tumour was first found at autopsy. Metastases were found in three patients at operation or autopsy. Cholecystography can show either a functioning or a non-functioning gallbladder. Some patients had concretions in the gallbladder. The prognosis appears to be good, and one of the patients reported survived 20 years with metastases.


The use of a posterior-based tongue flap for the closure of a pharyngocutaneous fistula.

The closure of a pharyngocutaneous fistula by the use of a posteriorly based tongue flap is described. The use of such a flap for this purpose has not been  previously recorded in the literature.


Needle biopsy of bone: a simplified technique.

By means of a slight modification of a commonly available needle, adequate amounts of bone for histopathology examination have been obtained from deep-seated bones, including vertebral bodies. Forty-one correct diagnoses were made in 51 consecutive cases in which the technique was used.


Occupational compression of the common peroneal nerve at the neck of the fibula.

Seven cases of common peroneal nerve compression were seen among farm workers. The symptoms followed working in a sitting position with forward advancement, a position commonly adopted in India for harvesting a crop and hoeing. Motor and sensory impairment was seen in the distribution of the common peroneal nerve, more marked in the distribution of the deep peroneal branch. Motor conduction time, estimated in two cases, was delayed. At exploration, the cause of the compression was found to be a tendinous arch extending along the posterior border of the peroneus longus, and curving backwards and upwards along the lateral border of the soleus. Excision of this arch, with elimination of the origin of the upper part of the peroneus longus, led to disappearance of the neurological deficits.


The management of vertebral artery insufficiency in cervical spondylosis: a modified technique.

Vertebrobasilar insufficiency may on rare occasions be caused by cervical spondylotic spurs. These can be cured by a minor procedure, and a plea is made for avoidance of fusion in such patients.


Chronic subdural haematoma in the elderly.

A series of 20 patients over the age of 60 years, all suffering from chronic subdural haemotoma, is reviewed. Factors leading to diagnostic errors are emphasized. Burr-hole aspiration supplemented by adequate measures to aid in reexpansion of the brain remains the primary choice of treatment in this condition.


Thymectomy for myasthenia gravis.

A group of 71 patients with myasthenia gravis is reviewed. All were initially managed medically, and 18 underwent thymectomy. Twenty-three responded poorly to drug treatment, and seven died from respiratory failure. In contrast, thymectomy was beneficial in 16 of the 18 who were subjected to operation. Seven patients had significant postoperative respiratory complications, and nine required a tracheostomy. Thymectomy appears to be effective and safe and to be indicated in young patients with early disease, and in patients who do not respond to drug treatment. The transcervical approach to thymectomy was satisfactory on two occasions.


Granulomatous mastitis.

Granulomatous mastitis is a benign mammary lesion, which clinically can closely simulate breast cancer. The condition has only recently been recognized, less than a dozen cases being recorded in the English literature. Two further cases are presented, the histological features are illustrated, and the literature is reviewed.


Primary rhabdomyosarcoma of the heart: a case report, with autopsy.

A case of rhabdomyosarcoma of the heart in a 45-year-old man is reported. The diagnosis was suspected because of refractory congestive cardiac failure, a bulge on the left cardiac border, and was confirmed histologically at necropsy.


Secondary hypertrophic osteoarthropathy. An unusual cause of arthritis in childhood.

Although an uncommon occurrence in childhood, hypertrophic osteoarthropathy secondary to tumors- most commonly to osteogenic sarcoma with pulmonary metastasis-may cause severe join pain and swelling. The syndrome should be considered in the differential diagnosis of acute arthritis in childhood


Granulocyte function in chronic granulocytic leukemia. II. Bactericidal capacity, phagocytic rate, oxygen consumption, and granule protein composition in isolated granulocytes.

The initial rate of phagocytosis, oxygen consumption rate during phagocytosis, bactericidal capacity against Escherichia coli, and the granule protein composition of isolated mature-appearing granulocytes were studied in 23 patients with chronic granulocytic leukemia (CGL) with the simultaneous use of normal controls. The initial rate of phagocytosis was decreased (p less than 0.05) in the CGL patient group, as were oxygen consumption rate (p less than 0.001) and bactericidal capacity (p less than 0.001). Kinetic analysis of the ingestion rate showed CGL granulocytes to have the same capacity to bind the particles as normal granulocytes. Both specific and primary granule protein deficiencies were shown for CGL granulocytes, and these deficiencies were more pronounced at or near blast cell transformation. Analysis of all different granulocyte function parameters showed an inverse correlation to white blood cell counts (p less than 0.01) and to the percentage of immature granulocytes in peripheral blood (p less than 0.001). The leukocytosis doubling time was progressively shortened during the chronic course of the disease. A correlation was found between granulocyte function parameters and leukocytosis doubling time (p less than 0.001), indicating that granulocyte function was progressively deteriorating during chronic phase CGL, and may be an expression of increasing disturbance of the differentiation process.


Contamination and resterilization of the Bain circuit.

Fifty Bain circuits were tested for contamination following single patient use. A contamination rate of 8 per cent was found. Two methods of resterilization were examined. Sterilization by activated glutaraldehyde proved unsatisfactory, while ethylene oxide sterilization was found to be an effective method which produced no detectable adverse physical or chemical alterations of the circuits.


Myophosphorylase deficiency (McArdle's disease): report of a family.

The clinical and biochemical findings are presented of two brothers suffering from McArdle's Disease (Myophosphorylase Deficiency). Tissue enzyme estimations and lactate levels were done in affected and non-affected members of the family. Affected members showed absence of phosphorylase enzyme by histochemical and quantitative estimation. No quantitative abnormalities were found in other enzyme systems of glycolytic pathways in the family investigated. Various other aspects of clinical features, biochemical abnormalities and inheritance are discussed.


Cephalometric comparisons of the results of the Wardill-Kilner and Von Langenbeck palatoplasties.

Two groups of individuals with isolated clefts of the palate were compared. One group had had the Von Langenbeck procedure performed at the University of Iowa and the other the V/W-Y (Wardill-Kilner) procedure performed in Denmark. All individuals in both groups were Caucasians. In order to avoid the influence of any possible ethnic differences on the interpretation of the results, each cleft group was initially compared to a matched non-cleft group from the same geographical area. Differences were then statistically evaluated using the Student t-test. The incidence of malocclusion in the two operated groups was compared using Chi Square. Different landmarks were pricked on duplicate cephalograms. Nine angular and four linear parameters were measured. Two ratios derived from these linear parameters were also computed. The results of this study tend to indicate that these two procedures have similar effects upon antero-posterior and vertical growth of the craniofacial complex as determined from cephalometric roentgenograms. While there were no statistically significant differences in the incidence of malocclusion, the need for a detailed study of the effects of different palatoplasties on dental occlusion was emphasized. Speech results and dental occlusion emerge as critical factors in the evaluation of the effects of these two surgical techniques.


A radioautographic study of chondrocytic proliferation in nasal septal cartilage of the prenatal rat.

Six pregnant female Sprague-Dawley rats were labeled with tritiated thymidine and killed, one each day, during the terminal six days of pregnancy. Nasal septal cartilages of five pups from each litter (a total of pups in all) were monitored radioautographically for cellular proliferation. It was found that chondrocytes were moderately active mitotically on gestational day 16, showing 12.1 grains per microscopic field. Activity increased sharply the following day (16.5 grains/field) then declined slightly on day 18 to a 16.1 count. There was a marked drop on both the 19th and 20th days (13.1 and 10.3 grains/field respectively) followed by a leveling off on the 21st day (9.3 grains/field). No specific location in the septal cartilage could be identified as a growth center. The area of highest proliferative activity varied from day to day, being seen in the nasal tip on day 16, centered in the middle two-thirds of the cartilage twenty-four hours later, then moving caudally to the posterior one-half the following day (day 18). On day 19, a final shift back to the middle of the septum was observed. It was impossible to identify an active zone anywhere within the septum of either the 20- or the 21-day prenatal rat.


Bilateral congenital choanal atresia and absence of respiratory distress.

Bilateral congenital choanal atresia is considered a lethal congenital malformation in an obligatory nasal breathing neonate. Described herein are two cases of bilateral choanal atresia associated with craniofacial anomalies who did not present respiratory distress in the neonatal period. Our first patient had a complete unilateral cleft lip which facilitated oropharyngeal respiration. The second patient presented wory distress in the neonatal period by providing an oropharyngeal airway.


"Basket suspension" as an adjunct to tongue flap closure of hard palate defects.

Proper suspension of a tongue flap is necessary to prevent detachment and allow proper healing when used to repair palatal fistulae. Our use of an aluminum suspension basket to prevent flap tension and motion has facilitated inset of the flap resulting in healing per primum in 31 consecutive patients.


Cleft palate and congenital palatopharyngeal incompetency in mandibulofacial dysostosis: frequency and problems in treatment.

In a series of 25 cases of mandibulofacial dysostosis, 7 patients had isolated clefts of the palate, 1 had a complete unilateral cleft of the lip and palate, and 8 had congenital palatopharyngeal incompetency (CPI). The CPI appeared in four forms: (a) complete agenesis of the soft palate, (b) foreshortening of the soft palate associated with a submucous defect of the hard palate, (c) submucous defect of the hard palate with adequate palatal length but inadequate elevation in speech, and (d) lack of adequate palatal elevation in the absence of a submucous defect or reduced length of the soft palate. Inadequate velopharyngeal function, whether congenital or subsequent to palatal repair, may be masked by the presence of other speech problems in this syndrome, particularly by the "muffled" voice quality which appears to be associated with an elevated and retracted tongue posture. Both prosthetic and surgical treatment of inadequate velopharyngeal function are complicated in patients with MFD by other structural anomalies, particularly inadequate oral opening and constriction of the airway.


The Peabody Picture Vocabulary Test as a measure of intelligence in children with palatal problems.

The Peabody Picture Vocabulary Test and the Wechsler Intelligence Scale for Children were administered to 33 children with palate problems. The correlations between PPVT and Wechsler IQ's ranged from .45 to .50 indicating that the Peabody is only a moderately good predictor of WISC scores in this population and suggesting that its utility in cleft palate children is limited. Additional data on the PPVT-WISC relationships are also presented and discussed.


Neonatal intensive care unit: basic equipment needs.

Intelligent selection and use of neonatal equipment are essential for quality care. Desirable features of monitors, ventilators, and diagnostic-therapeutic equipment are elucidated.


A 2-year retrospective study of demand for dental care from Scottish school leavers.

After leaving school young adults in the United Kingdom are no longer eligible to receive care from the School Dental Service. Patients who have previously been treated by the Service are obliged to seek care elsewhere. The aim of the study was to see how effectively a group of Scottish school leavers coped with the change. The study population was 912 school leavers. The method depended upon a retrospective study of clinical records relating to the year before leaving school and the following year. During the last year at school, 48% of the subjects received treatment from three sources: 30% were treated by a general practitioner, 19% by the school service and 2% by the hospital service. During the 2nd year of the study, 69% of those who had earlier been treated by a general practitioner again requested dental care compared with only 40% of those who had earlier been treated by the school service and 30% of those who had not sought dental care during their last year at school. Recommendations are made for encouraging an increased demand for care from those who have formerly been treated by the school service.


Public attitudes concerning water fluoridation in Denmark.

Attitudes towards water fluoridation were assessed in a national probability sample of 1,600 adult Danes. 23% favored and 48% opposed water fluoridation while 29% didn't know. Differences in opinion were found in relation to sex and age, occupation, residence, and dental behavior. Compared with an earlier Danish study, a shift towards more expressed opposition to water fluoridation seems to have taken place.


Effectiveness of a dental education program on oral cleanliness of schoolchildren in Israel.

The purpose of this study was to examine the effectiveness of a dental health education program providing dental health information and toothbrushing instruction on oral cleanliness. Two methods of instruction, individual and group instruction, are presented in this study. The plaque situation was assessed in a group of 175 children, 11-14 years of age, by the Patient Hygiene Performance (PHP) method at the beginning of the study and at 1, 2, and 12 months. It was found that immediately after instruction the dental health education program resulted in improved oral hygiene home care for the two experimental groups. However, the improvement noted was achieved regardless of the method of toothbrushing instruction (individual versus group). Moreover, it was demonstrated that maintenance of a satisfactory level of oral hygiene home care was dependent upon review of educational programs and toothbrushing instruction and not related to the method of instruction.


The effect of professional toothcleansing on gingivitis and dental caries in children after 1 year.

The purpose of this study was to determine the effects of professional mechanical toothcleansing on plaque, gingivitis, and dental caries in young children with a high caries experience. Seventy-eight children, 7 years of age, were stratified according to presence or absence of smooth surface lesions on the permanent teeth and subsequently randomly assigned to an experimental group and a control group. The experimental group was given a thorough mechanical toothcleansing every 2 weeks. After 12 months a statistically significant difference in plaque accumulation and a minor difference in level of gingival inflammation could be demonstrated between the two groups. The incidence of dental caries in permanent teeth present at both examinations was 70% lower in the experimental group. The effect on permanent teeth erupting during the study and on primary teeth present at both examinations was not statistically significant.


Retention and effectiveness of a chemically polymerized pit and fissure sealant after 12 months.

The aim of the present study was to evaluate the retention and effectiveness of a bis-GMA type of fissure sealant which polymerizes after conventional mixing of the two catalyst/activator components (Concise Enamel Bond System). Unilateral sealing of homologous pairs of permanent first molars was carried out by a dental hygienist. Of the 451 sealed sites sealant was present in 73%, partly missing in 8%, and completely missing in 18% after 1 year. The effectiveness of the treatment in preventing occlusal caries was highly significant and the caries reduction was found to be about 70%. A strong relationship between status of sealant and occlusal decay was demonstrated. The shortcomings of the half-mouth design when evaluating sealants as a caries-preventive measure in public dental health programs are discussed.


Reproducibility of response to a questionnaire on symptoms of masticatory dysfunction.

The aim of the present investigation was to check the reproducibility of answers to multiple-choice questions used in a questionnaire. The questionnaire was concerned with symptoms in patients with dysfunction of the masticatory system. Five main types of questions were tested by repetition within 1 week by 98 patients. Comparisons were also made between questionnaire data and clinical findings. The interval between the questionnaire and the clinical examination was 1 week. The best reproducibility was found for answers to a question about previous joint radiography, which was the simplest question with the fewest alternatives. The second best was found for a question about the duration of the symptoms referable to the masticatory system. The poorest reproducibility was noted for a question about masticatory muscle pain. The comparison between the questionnaire data and clinical findings showed the best agreement for joint sounds. The reported pain symptoms and palpatory tenderness seem to be different entities.


Associations between the total fluoride content of dental plaque and individual caries experience in Australian children.

Individual caries experience (DMFT) and the total fluoride content of dental plaque were determined for 72 schoolchildren, aged 9.7-13.0 years, lifelong residents in one of three New South Wales towns, where the fluoride levels of the reticulated water supplies were: Katoomba, less than 0.1 parts/10(6); Sydney, 1.0 parts/10(6) for 4 years; and Yass, 1.0 parts/10(6) for 16 years, prior to sampling. The mean fluoride content of plaque in Sydney (22.6, s.d. = +/- 16.8 parts/10(6)) and Yass (25.6, s.d. = +/- 16.4 parts/10(6)) differed significantly (t = 2.27, P less than 0.05 and t = 3.30, P less than 0.02, respectively) from that in Katoomba (13.5, s.d. = +/- 8.3 parts/10(6)). Significant inverse associations were demonstrated between total plaque fluoride and individual caries experience (DMFT) in Sydney (r = -0.45, P less than 0.025) and overall (r = -0.28, P less than 0.010). Inverse trends were established between plaque quantity (dry weight of plaque collected) and fluoride levels. No associations could be demonstrated between fluoride treatment (dentifrice, tablets or topical application) and plaque fluoride, DMFT or plaque quantity.


Treatment of adult acute non-lymphoblastic leukemia using intermittent combination chemotherapy with daunomycin, cytosine arabinoside, 6-mercaptopurine and prednisolone-DCMP two step therapy.

A regime of treatment of acute non-lymphoblastic leukemia in adult, employing DMCP protocol, especially two step method consisting of daunorubicin, cytosine arabinoside, 6-mercaptopurine and prednisolone is described. Out of 32 adult patients with ANLL treated with DCMP regime 26 (81.3%) achieved complete remission. The median durations of complete remission and survival were 53 weeks and 54 weeks, respectively. The longest duration of complete remission was more than 220 weeks, and 3 cases are still maintaining initial complete remission more than 3 years.


Unsuspected pulmonary alveolar proteinosis complicating acute myelogenous leukemia.

A patient with acute myelogenous leukemia developed pulmonary alveolar proteinosis in the terminal phase of the leukemia. The diagnosis of pulmonary alveolar proteinosis was unsuspected during life and was established only at autopsy. Other reported cases of the same association are reviewed. This report serves to stress the importance of considering the diagnosis of pulmonary alveolar proteinosis in malignant hematologic diseases and the need for hematologic evaluations in pulmonary alveolar proteinosis.


Tooth migration during the transitional dentition.

Posteruptive tooth migration between 6 and 14 years involves both total arch displacement and intra-alveolar tooth movement. Central incisors, canines, and permanent first molars all drift forward within the alveolar bone. The molars, and to a lesser extent the incisors, drift occlusally. With respect to lingual arch contour, lateral movement of molars and canines is negligible.


The motor system: a clinical appraisal.

A tongue thrust myofunctional therapy program has been presented which is uniquely successful because of proper timing, patient selection, and conceptual simplicity. A very small percentage of orthodontic patients should undergo myofunctional therapy. Tongue thrusters in the mixed dentition stage are not proper candidates for myofunctional therapy. The incident of tongue thrust in population samples decreases progressively until about the age of 12. Many openbite malocclusions are treatable without myofunctional therapy. Because a large number of tongue thrusters are only adapting to malocclusions, we do not become concerned until the tongue is interfering with mechanics. The percentage is usually quite small. Patients completing orthodontic treatment are easily motivated because they want their bands off. We are changing funcion at a time when mechanical therapy is changing form. There is a synergism between the effects of mechanical and myofunctional treatment. At this stage if the tongue does interfere with mechanics, myofunctional training is essential. Omission of such training will, in all likelihood, lead to partial or complete failure of the treatment program. When myofunctional therapy is necessary, the program should be simple and direct. The importance of bolus control in a peripheral seal during the voluntary movements in preparation for swallowing cannot be overemphasized. The myofunctional program presented teaches the patient the necessary bolus control in peripheral seal swallowing in a very direct manner. Myofunctional training really does not teach correct swallowing but instead teaches the voluntary movements of preswallowing. When the patient learns correct preswallowing, the involuntary movements of deglutition adapt to the new correct preswallowing movements and posture. Myofunctional therapy is essential for the successful treatment of a small percentage of orthodontic patients. If only those patients who really need it are treated, and if this treatment is kept simple and direct, then myofunctional therapy need not place a disproportionate drain on resources.


The maintenance system and occlusal dynamics.

We have discussed the maintenance system and its relationship to occlusal dynamics and occlusion function. The premise has been set forth that to avoid untoward sequelae post-orthodontically in the areas of relapse of tooth positions, occlusal wear, periodontal disease, and temporomandibular pain-dysfunction, it is best to have an occlusion free from centric and excursive interferences. The practical approach to the desired goal for the orthodontist lies in an understanding and familiarity of occlusal dynamics that allows him to look at detailing of tooth positions with insight into their ramifications from a functional standpoint. The insight can only be gained by hard work and self-discipline in the study of occlusion. A knowledge of these concepts will alert the orthodontist ot the true severity of the cases he is treating, allow him to position teeth so as not to create problems and , lastly, to be able to competently handle those cases that do develop posttreatment problems.


Abundancy and diversity of mRNA sequences in human leukocytes.

The messenger RNA populations in two haematopoietic tissues were compared with respect to number of different sequences present and their relative abundancies. This was accomplished by hybridising complementary DNA to the cytoplasmic polyadenylated RNA from which it was transcribed and to heterologous polyadenylated RNA. The hybridisation kinetics were essentially the same in the homologous hybridisation. However, in heterologous hybridisation some differences were observed in the high abundancy messengers.


[Percutaneous chordotomy for the treatment of pain. Technic, indications and results].

In the last 13 years, since the introduction of percutaneous chordotomy by Mullan et al. (1963),the method has been developed and has now a solid place in the neurosurgical management of pain problems. The lateral approach of the C1/C2 level with X-ray check, visualization of the spinal cord by means of positive contrast myelography, impedance measurement, and stimulation is the mostly used and the least complicated method. Percutaneous chordotomy should be mainly used in the management of intolerable pain in patients with malignancy. The results of 130 percutaneous chordotomies in 100 patients during the last 2 years are discussed.


The blood circulation of the tongue.

This article describes the gross anatomy of the vessels which supply the mammalian tongue. It shows that there is a rich vascular supply. Available data indicate that the lingual papillae are supplied with a true capillary circulation, which is more abundant in the papillae containing taste buds. The vessels of the tongue are innervated by adrenergic sympathetic vasconstrictor fibers and it is also very likely that a cholinergic parasympathetic vasodilator influence exists.


Physiology of salivary secretion.

The aim of the present work was to explain the mechanism of the acinar secretion of the salivary gland during stimulation. The following items were discussed and concluded. (1) The acinus is the majority of cells being the powerful transport system of the fluid from interstitial side to lumen. (2) Osmotic flow was clarified being a cause of water transport, in which the osmolality gradient across the acinus epithelium was initiated by a preceded salt transport. (3) The grades of osmotic gradient, of hydraulic conductivity, and of semipermeable property of gland epithelia were described. (4) On salt transport during stimulation, Na+ inflow across the basal plasma membrane and Na+ extrusion across the luminal membrane of the acinus cell were discussed with respect to the electrochemical gradient and ionic flow. From the electrophysiological work and the ionic distribution of the salivary gland, it is concluded that massive Na+ inflow and K+ outflow across the basal plasma membrane was a passive process due to an increase of permeability to those ion during stimulation, but the process of Na+ extrusion across the plasma membranes of the luminal side of the cell as well as of the secretory granules was active. (5) The electrochemical gradient for Na+ and K+ at the basal plasma membrane which had an important role for passive Na+ and K+ transport may be maintained by ouabain-sensitive Na+-K+ pump as most other cells. (6) A model for salt transport across the acinar cell was proposed. Intracellular Na+ due to passive Na+ inflow may activate cooperatively the Na(Cl) transport system at luminal plasma membrane and membrane of secretory granules in high levels of (Na+)in. Though it also activated the Na+ -K+ transport at the basal plasma membrane in any level of (Na+)in. (7) Energetics for the ion transport of gland was discussed with a transport-work rate equation as well as oxygen consumption in secretory state. It is assumed that the energy in active transport at the luminal plasma membrane requires more than the dissipated energy in passive process at the basal plasma membrane. The energy for active transport across the luminal plasma membrane may be corresponded to a main part of oxygen consumption for ion transport across the overall epithelium. (8) The phenomena of osmotic flow coupling with salt flow and of passive ionic flow coupling with electrochemical gradient which is maintained by Na+ -K+ pump may be an expression of production and utilization of negative entropy which is a characteristic of biological membrane.


Stimulus-evoked pain in teeth.

When pain occurs in teeth as a result of external stimulation it is more likely to be due to physical factors affecting the enamel and dentine than to pulp disease. The mechanisms are described, clinical conditions are mentioned and a speculative attempt is made to correlate them by introducing the idea of streaming potentials in the dentine and pulp. The pain perception threshold is considered in relation to different teeth, age, sex, lateral dominance, personality, and the area of electrode contact. The latter has proved interesting, for manipulation of it has led to possibly important findings on the nature of convergence in the trigeminal system, two-point discrimination, referred pain and somatopic representation of dental pulps in the medulla oblongata.


Evidence that chromosome band 22q12 is concerned with cell proliferation in chronic myeloid leukaemia.

A man and two of his three children carried an abnormally short chromosome 22 resembling the Philadelphia chromosome (Ph1). Giemsa banding showed that the abnormal chromosome resulted from a translocation t(11;22) (q25;q13). The breakpoint on chromosome 22 was at the q12/q13 band interface compared with the breakpoint of Ph1 at the q11/q12 band interface. The absence of leukaemia or haematological disorder in members of this family suggests that the critical genetic site on chromosome 22 concerned with abnormal myeloid cell proliferation in human leukaemia is contained in the 22q12 band.


Normal and locally induced oral pigmentations.

The classical description of normal gingivae as 'coral pink' in colour is both inadequate and misleading. The intra-oral soft tissues frequently exhibit pigmentation under normal conditions, the most commonly occurring pigmentations being of racial origin. A normal gamut of pigmentation of the gingivae may be said to range from pale pink to deep bluish purple and colour variations may be uniform, unilateral or bilateral, diffuse, mottled or macular. The distribution and amounts of melanin in the oral tissues can be affected by a number of abnormal and pathologic conditions, both local and general. A variety of possible causes of abnormal pigmentation--physical, chemical and biological--are described.


Effect of new technologies in the training and utilization of dental auxiliaries in the US Army.

The combat strength, readiness, and effectiveness of the US Army is dependent, in part, upon the health of the American soldier. The conservation of his oral health is the mission of the Army Dental Corps. Confronted with steadfast mission requirements, increasing demands for dental services, and a reduction of professional staff, the Corps has responded to challenge with the implementation of an alternative to the limitations of established and traditional concepts of practice. In 1972, the Army Dental Corps introduced a new system of care delivery, based upon the expanded utilization of its auxiliary personnel and the team mode of practice. In a six year period, approximately 900 expanded duty auxiliaries, known in the Army as Dental Therapy Assistants, or DTA's were to be trained to extend professional capability to the performance of a variety of reversible dental procedures. They were to operate as members of care delivery teams, and to perform their expanded functions only upon the direction and under the supervision of the responsible team dental officer. To date, more than 500 DTA's comprize this new para-professional force, with more than 300 trained and operationally employed. Interim assessments of this endeavor have confirmed the antecedent research, which identified the impressive potential of Team Dentistry. DTA's have been trained to perform previously professional dental functions to a professional standard of quality; their proper team utilization returns a marked increase in professional capability, enabling the delivery of a greater number of dental services to more of the patient community; and their expanded role in care delivery has been well received by both the patient and the professional. Team Dentistry and the expanded duty auxiliary have added a new dimension to dental care delivery, as well as a promising route to mission accomplishment by the Army Dental Corps.


Organization and administration of the United States Air Force Dental Service.

The United States Air Force was established as an independent department in 1947 and in 1949 became responsible for its own medical support. In 1951 the dental division was renamed the USAF Dental Service and 432 dental officers were transferred to it from the Army. The dental service now provides a world-wide oral health service from 286 fixed dental centers having a total of over 2200 treatment rooms. The backbone of the service is the general dental practitioner and great stress is laid on the preventive aspects of the service. Eight specialty areas are recognized and in-service training, supplemented by specialist training in civilian institutions provide the trained professional resources required. The facilities for the provision of dental services comprise clinics with multiple treatment rooms for each dentist and adequate space for oral hygienists and support and administrative services. Equipment follows the modern trend towards 4-handed seated practice by the dental team.


Some thoughts on dental malpractice.

Malpractice litigation is not new nor is it limited to the professions of medicine and dentistry. The number of dental malpractice claims is increasing in many countries though the percentage of cases in which the patient succeeds remains constant at about ten to twelve per cent. In successful cases however the monetary compensation awarded has increased substantially in the past few years. The increasing use of multi-chair dental offices and the employment of more auxiliary workers in dental practice may have contributed to the increase in litigation as has the widespread dissemination of knowledge of patients' rights by newspapers and television. It is unfair to blame the legal profession for this increase. There is evidence that the 'contingent fee' arrangement between plantiff and lawyer contributes to the number of cases brought. It has been suggested that the existence of malpractice insurance may make the dentist less careful to prevent untoward effects of dental treatment. In many states the law will not permit punitive damages to be paid by the insurance agency nor are fines imposed for criminal activities covered. It is important that the dentist should be fully informed about the details of the cover which his insurance does in fact provide.


Transactions of an international conference. Worldwide concern: better dental care for more people. An international collaborative study. How social surveys were conducted.

It is assumed that utilization of dental care services and hence the state of oral health is dependent on social and psychological characteristics of both consumers and providers. The sociological variables studied included the basic facts of age, sex, residence and socioeconomic status. Attitudes to general health care, past oral health care and self assessment of oral health status were also investigated. Accessibility of oral health care facilities in terms of cost, loss of time and distance travelled was assessed, as was the consumers estimate of the dentist's sensitivity and competence, his attitude to preventive care, aesthetic values and knowledge of oral health care measures. Sociologists from the participating countries cooperated in the formulation of questionnaires which could be applied with comparable results despite differences in language and culture. Adults were interviewed in their own homes while younger groups completed the questionnaire in school under the supervision of the researchers. In all cases the sociological survey preceded the clinical examination to reduce the introduction of bias. The data were collected in Geneva and analysed to determine the extent to which oral health status could be related to perception of need, personal oral health practices, availability, accessibility, acceptability and utilization of services. Further analysis may help to determine whether observed differences between populations relate more to the characteristics of the systems of dental care or to features inherent in the population of the country.


Transactions of an international conference. Worldwide concern: better dental care for more people. An international collaborative study. How the oral and social measures were compared.

This paper explains the statistical methods used to reach the conclusions regarding the relationship between selected social variables and oral health status reported in subsequent papers referring to specific countries. The procedure called 'stepwise regression' was employed in relation to each of the three clinical categories of data. The single social variable which explains the greatest variation in the oral data is identified as the most important predictor. Its influence is then removed by mathematical adjustment and the second and subsequent social variables are similarly identified until no further ones remain which are significant in explaining remaining variability in the oral data. The effect of utilization was always removed first regardless of its predictive power. The findings for each country were used to construct 'tree' diagrams on which the best and worst pathways are indicated to give a profile of those subjects having the fewest and the most decayed teeth.


Oral health care in Australia.

The study data on oral health status for this age group was consistent with previous recent studies. The sociological data added considerably to the knowledge of the charactistics of this group in the area sampled in New South Wales, Australia. The system of delivery of oral health services mainly through private practice appears to be providing comprehensive treatment to a segment of the student population fairly well defined by sociological variables reported in the analysis. However, only limited services appear to be reaching sizeable remainder.


Oral health care for Canterbury, New Zealand 13-14 year old students.

The study has demonstrated a high prevalence of dental caries and a uniformly high level of treatment across all major population groups of Canterbury 13-14 year olds. The treatment programme has the problem of dental caries under control but more attention should be directed to lowering caries prevalence and the need for treatment by increased use of preventive measures. While increasing the population coverage in respect of fluoridated water would give the greatest reduction in caries prevalence, alternatives should be considered, especially in areas not served by piped water supplies. As dental personnel appear to be important sources of health education information, advantage should be taken of this opportunity to emphasize the importance of preventive care. The early signs of periodontal disease are of concern and they, too, should be susceptible to a more concerted preventive programme. Previous studies have demonstrated a high prevalence of denture wearers amongst New Zealand adults. This, and these early results from the International Collaborative Study have focussed attention on the need for information on factors influencing the demand for treatment once adolescents have reached the maximum age covered by the Government programmes. Further investigation is needed to provide these data.


Features of oral health care across cultures.

This paper sets out to draw together the findings from the five individual studies and to draw tentative conclusions from them. It is pointed out that the comparisons made are between system factors and not between whole systems of oral health care. An attempt is made to evaluate the effectiveness of individual system features in the hope of being able to suggest ways in which those shown to be most beneficial might be incorporated into complete systems. In relation to caries experience, measured as DMF teeth, there is a wide variation, not only by each of the separate components to that total. In those studies where extensive school dental services exist, the F component accounts for almost all the score while in the other study groups it forms only about half the total, the proportion tending to be greater in the non-metropolitan than in metropolitan populations. In the same way treatment/need ratios and amounts of retreatment required show the benefits of the existence of the school dental service. The treatment/need ratio is then examined in relation to selected variables such as method of payment, utilization of auxiliaries, the existence of specified target groups etc. When the method of stepwise regression analysis is applied to the pooled samples utilization of services remains the most important predictor of treatment/need ratio. Others in order of importance are whether dental personnel decide on frequency of visits, whether the last visit was made for symptomatic reasons alone and whether lack of severity of symptoms had been a reason for avoiding oral health care. In relation to periodontal conditions no clear picture has emerged and this may demonstrate how systems of all types have failed to deal with this problem. Although much remains to be elaborated three main findings have already emerged from this study: (i) The need for reinforcement of preventive behaviour and services. (ii) The effectiveness of regulated contact between consumer and provider in meeting treatment needs. (iii) The need to concentrate on quality as well as volume of care in providing adequately for the needs of child and adolescent populations.


Osteosarcoma: A review of 345 cases.

345 cases of osteosarcoma are reviewed. The long term results are known in 240. The overall ten year survival rate was 5 per cent. This is analysed in relation to age, site of tumour, radiographic grading, and method of treatment. There were no survivors in patients under the age of fifteen; in tumours of the proximal half of the femur and humerus; or tumours of the trunk. If these cases are excluded, amputation gave a ten year survival rate in 11 per cent. The radiographic grading expressed in relation to expansion of the tumour has a significant relationship to the prognosis. In the authors' experience histological grading of the tumour is not feasible and probably has no bearing on the prognosis. The authors express their preference for treatment based on their analysis of this series.


Isolation of Haemophilus aphrophilus from an adult with acute leukemia.

During the course of treatment for acute myelocytic leukemia, Haemophilus aphrophilus was isolated from eight blood cultures associated with the clinical picture of bacterial endocarditis.


The histology of eclamptic lesions.

A brief description is given of the main lesion found in eclampsia. Emphasis is placed on the marked difference between the type of lesion found in the kidney and those found in other organs. It is suggested that they may be explained on the basis of increased coagulability of the blood, hypertension and possibly increased permeability of blood vessels. Hypertension may damage vessels and determine the sites of thrombus deposition. Increased permeabilithe mesangium of the glomerulus.


Genital mycoplasmal infections: their relation to prematurity and other abnormalities of reproduction.

The genital mycoplasmas, Mycoplasma hominis and Ureaplasma urealyticum eT-mycoplasmas) are common vaginal organisms. They are acquired primarily through sexual contact. There is evidence, some of it highly suggestive, linking the genital mycoplasmas to involuntary infertility, spontaneous abortion and low birth weight. Additional controlled treatment studies are needed in each of these areas to assess fully the role of the genital mycoplasmas. M. hominis has the potential to invade the blood stream and is responsible for some instances of fever following abortion and of postpartum fever.


An evaluation of proximal surface cleansing agents.

The effectiveness of the Interspace brush, Inter-Dens, and waxed dental floss as proximal surface cleansing agents was compared in 35 subjects. Each subject used all three methods of cleansing in random order of selection. Statistical analysis of the results showed that there was no difference in the effectiveness of any one of these three agents. However, proximal surfaces of anterior teeth where cleaned more effectively than posterior teeth. The coronal half of the proximal surfaces was cleaned more effectively than the apical half and the facial half more effectively than the lingual half when Inter-Dens was used. Comparison of cleansing effectiveness between facial and lingual halves of proximal surfaces for the Interspace brush and waxed dental floss showed no significant difference. Mesial and distal proximal surfaces were cleaned with similar effectiveness. Plaque control was only satisfactory on approximately half of the proximal surfaces, though a wide variation occurred. Significantly lower plaque scores were found 1 week after the initial instruction session, irrespective of the agent used. The majority of subjects preferred Inter-Dens whilst waxed dental floss was the least-liked method of cleansing.


Plaque-removing effect of a toothbrush, dental floss, and a toothpick.

The ability of three different oral hygiene devices to remove 2-day-old bacterial deposits was evaluated on 21 young adults with healthy periodontia. On buccal tooth surfaces, the cleaning effect of a multitufted nylon brush was superior to that of a wooden toothpick or unwaxed dental floss. On lingual surfaces, the toothpick was as effective as the brush. On the visible portions of proximal surfaces, all three devices were equally efficient. A combined cleaning exercise with all three instruments together yielded significantly better results than did the use of each single device. Eight subjects were able to remove all disclosable deposits.


Use of palatal mucosa and lyophilized dura mater to create attached gingiva.

Gingival extension procedures using free palatal mucosal autografts or homologous lyophilized dura were compared clinically. Palatal mucosa was transplanted in 68 cases and lyophilized dura in 16 cases. The width of the zone of attached gingiva was measured before surgery and at regular intervals up to 2 years postoperatively. The width of the attached gingiva remained relatively constant in the mucosal transplant group from 1 month postoperatively, with an average relapse of about 20%. In the dura group the width of attached gingiva showed a marked decrease until 3 months after surgery with an average relapse of approximately 63%. If a preset minimal width of the attached gingiva is considered to be the criterion of success, the superiority of the palatal mucosa grafting procedure is demonstrated.


The periodontal management of a patient with a profound immunodeficiency disorder.

A case of severe, uncontrolled periodontal disease in a patient with a profound immunodeficiency disorder is reported. The periodontal disease was noted before the age of 10 years and is generalized, with marked associated alveolar bone loss, even threatening a mandibular fracture. Severely involved teeth were allowed to exfoliate, and extractions were avoided. At the age of 17 years, the patient now has only nine remaining teeth. The management adopted and alternative approaches are critically reviewed. The implications of the dental findings for current concepts of the pathogenesis of periodontal disease and dental caries are discussed.


Specification test for the solubility and disintegration of dental cements: a critical evaluation of its meaning.

The specification test for solubility and disintegration is an essential screening test for the quality control of certain cement types. No cement fails it can be considered for use; however, the test has only a limited clinical significance because it does not give an indication of the stability of the fully hardened cement matrix either in oral fluids or water. Instead, it gives a measure of the content of the soluble reaction intermediate present in cements that are still hardening and where the matrix has not fully formed. The test relates, therefore, to early vulnerability to aqueous attack and hardening rate. The period of test is, in fact, an atypical one and the true extent of the erosion of the cement matrix is obscured by the presence of soluble reaction intermediates. Long-term extrapolations cannot be made and so test results for broadly satisfactory cements within a category cannot be used for valid comparisons of clinical excellence, and they can be used even less to compare different cement types with different setting reactions. For example, in general, the dental silicate cement has a higher solubility and distinegration figure than the zinc phosphate cement because it contains soluble sodium salt and hardens more slowly. However, it is more stable under oral conditiont an indication of the vulnerability of the forming matrix to attack. The test is not valid when applied to zinc oxide-eugenol cements because the products of decomposition are either virtually water-insoluble or volatile and therefore not measured under the conditions of the test. A method is suggested for overcoming this deficiency. The test needs to be supplemented by other tests done on fully hardened cements for longer periods of time and in mediums that can represent oral conditions. One example would be to stimulate acid conditions developed in stagnation areas. A total estimation of decomposition products, both soluble and insoluble, is called for rather than the determination of soluble materials only.