Pelvic lipomatosis.

Pelvic lipomatosis. Although usually in the domain of the urologist, pelvic lipomatosis sometimes first may present to the general surgeon. Often called perivesical lipomatosis, this process of unknown etiology has been defined as a nonmalignant overgrowth of normal fatty tissue limited primarily to the perirectal and perivesical spaces in the pelvis. Typically it occurs in middle-aged, nonobese, men presenting with dysuria and sometimes with suprapubic fullness. High position of the prostate may be noted on rectal examination. Urinary tract roentgenograms show a high, gourd-shaped bladder with the surrounding radiolucency of fatty tissues. Elongation of the urethra usually makes cystoscopy difficult. Sigmoidoscopy and barium enema may reveal extrinsic pressure on the rectum. Pelvic venography rarely shows external venous compression; arteriography does not suggest neoplastic vessels. Fat metabolism studies are of little value. The absence of adequate cleavage planes renders direct surgical management difficult. The frequently progressive lower ureteral obstruction eventually may require urinary diversion. Four biopsy-proved cases from the Eastern Virginia Medical School Hospitals are reported, and the 57 previous cases from the literature are reviewed.


Role of the sympathetic nervous system in peptic ulcer production in rats. The role of the sympathetic nervous system in gastric acid secretion and in experimental duodenal ulceration (cysteamine induced) was studied in rats. The animals were divided randomly into seven groups: (1) control, (2) sham-operated, (3) surgical sympathectomy, (4) chemical sympathectomy (6-HODA), (5) vagotomy, (6) surgical sympathectomy plus vagotomy, and (7) chemical sympathectomy plus vagotomy. Results on gastric acid secretion were expressed as gastric acid output (GAO = micronEq of acid secretion in 1 hour). The means in the control and sham groups were 447.83 +/- 26.67 GAO and 399 +/- 36.4 GAO, respectively. The means in the sympathectomized rats (surgically = 562 +/- 27.21 GAO and chemically = 648.66 +/- 46.53 GAO) were higher (P less than 0.01) than those of the control and sham groups. In the vagotomized group the mean was 156.6 +/- 17.64 GAO, lower than those of the control and sham groups (P less than 0.001). The incidence of ulceration was 47.5% and 46% in the control and sham groups, respectively. Both the sympathectomized groups (surgically, 73%; chemically, 77%), had a significantly elevated incidence of ulceration as compared with the controls (P less than 0.01). The vagotomized group had a 14% incidence of ulceration. These results clearly indicate that sympathectomy has a definite effect on gastric acid secretion and on the incidence of experimental peptic ulceration in rats.


Prevention of deep vein thrombosis in urological patients: a controlled, randomized trial of low-dose heparin and external pneumatic compression boots. A prospective, randomized clinical trial in 83 patients undergoing open urological operations was performed to compare the relative prophylactic efficacy of low-dose heparin and external pneumatic compression (EPC) of the calves in comparison to no treatment in the prevention of deep vein thrombosis (DVT). The diagnosis of deep vein thrombosis was established by the I125 fibrinogen scan and contrast phlebography. The data indicate that EPC is more effective than no treatment (p less than 0.04) and more effective than low-dose heparin (p less than 0.04) in the prevention of DVT. There was one pulmonary embolus in each of the three groups, and in the treatment groups this occurred without evidence of DVT.


Renovascular hypertension following surgical repair of dissecting aneurysm of the thoracic aorta. A critically ill patient with refractory renovascular hypertension following successful intrathoracic repair of a type I aortic dissection was treated successfully with gelfoam embolization of the left kidney. Renal artery stenosis secondary to aortic dissection can exacerbate pre-existent hypertension in the preoperative or postoperative periods and can be diagnosed angiographically. Unilateral renal artery embolization may provide a safe alternative to nephrectomy for renovascular hypertension in cases where surgery is not feasible.


Parathyroid cysts: report of a case with ultrastructural observations. Parathyroid cysts are an uncommon cause of neck masses which are of uncertain origin. Electron microscopic observations reveal the cysts to be lined by a simple absorptive rather than secretory cell, which rests on a basement membrane. These are not cheif cells. Smooth muscle forms an integral part of the cyst wall. These findings of simple epithelial cells and mesenchymal tissue (smooth muscle) support the concept that these cysts represent persistent embryological remnants. A likely source is the third pharyngeal pouch.


[Veterinary herd management programme on a beef bull farm (author's transl)]. A report on herd management advice on a beef bull farm by a multidisciplinary committee over a three-year period. Eight groups, each consisting of approximately ninety-six bulls (781), were fattened and delivered. Fattening of the calves was started at the age of one week and they were delivered at the age of seventy weeks. For the first ten weeks, they were individually housed in rearing pens, then they were kept in groups of eight in housings with slatted floors. Studies were done to see whether waste matter of the potato-processing industry could be turned into useful material in this manner. This was found to be the case, provided sufficient attention was paid to the other constituents of the ration. Veterinary problems consisted in diseases of newborn animals, indigestion accompanied by tympanites, respiratory diseases, foul in the foot and injuries. Minor problems were lice, loss of cuds, infectious keratoconjunctivitis, trichophytosis, urinary calculi, cysticercosis, cerebrocortical necrosis and abscesses in organs. The total proportion of deaths and rejects was 7.8 per cent, 2.6 per being due to mortality. A classification by cause and age was established. Moreover, the relationship between differences in growth and particular forms of disease was studied. This relationships could be shown to be present in some cases but there also were marked differences which could not be accounted for on the basis of patient administration. On the whole, the state of health was highly satisfactory.


[Criteria for evaluation of methods, systems and interference procedures to which animals are submitted (author's transl)]. Veterinarians can be expected to play a particular role in the relationship between man and animals. Dutch laws and formal agreements on the subject are briefly reviewed. The following main points that should be taken into account are discussed. (1) detailed description of the method, system and interference; (2) their purpose, (3) consequences for the welfare of animals; (4) aspects relevant to human society: importance of purpose, international aspects, significance for public health and environment, public opinion; (5) alternatives, with description of points (1), (3) and (4); (6) considerations of usefulness and necessity from the practical point of view and acceptability from the point of view of ethics; (7) position of the veterinarian; (8) conclusion.


[Bacteriological features in evisceration of broilers (author's transl)]. The total aerobic bacterial count and the number of Enterobacteriaceae in the pericloacal skin of broilers did not show any fundamental changes resulting from the processes of evisceration studied, averaging 5.3 logN/gram and 4.0 logN/gram respectively. The interior organs such as the liver and heart were severely contaminated, particularly by the evisceration proper and manual removal of the intestines. There are fairly marked differences in levels of contamination between the portions of skin sampled, which differences are levelled out to some extent during the process of evisceration. Possible causes of the differences in levels of contamination are stated.


[Bronchial and subpleural lipoma (author's transl)]. Three cases of bronchopulmonary lipomas are reported, two sub pleural and one endobronchial. They represent 2,8% of all so-called benign bronchopulmonary tumours in our statistic. The two subpleural and asymptomatic lipomas were treated by thoracotomy and enucleation, the third, the endobronchial lipoma required lobectomy because of irreversible pulmonary damage.


[The importance of the cystic medio-necrosis of aorta and great arteries in cardio-vascular surgery (author's transl)]. Based on the experiences of 14 observations a correlation between clinical picture and histological damage of aortic wall in medio-necrosis Erdheim-Gsell is tried. In the preoperative phase the definitive diagnosis is seldom possible. Atypical pathological findings at the aorta or great arteries must be suspected to be caused by medio-necrosis Erdheim-Gsell.


[Autologous blood donation and transfusion in cardiosurgical high risk patients (author's transl)]. In an unselected group of patients undergoing a wide variety of cardiovascular operations, the possibilities of long-term preoperative autologous blood collection combined with oxygenator hemodilution were examined. The mean number of preoperative donations was 2.5 units of blood. It was 50 p.c. higher in men than in women. One third of the men, but no female patient, collected 4-5 units of autologous blood, thus equalling the mean calculated blood requirements. Short- or long-term disavantages of the donations were not seen. --The total amount of homologous blood required could be diminished by 50 p.c., in atrial septal defects even by 70 p.c. The percentage of patients without homologous blood increased from 3 to 25 p.c. of the total material, but in atrial septal defects from 13 to 67. Further improvements of these values may be expected from an earlier entry into the program of autologous donations and, correspondingly, by an earlier iron substitution. Only thus, without special methods of storage, roughly calculated one half of all cardiovascular surgical patients may come through without homologous blood. In view of the risks of homologous blood transfusion, already now no atrial septal defect and, with limitations, no valve replacement should come to surgery without adequate autologous blood collection.


[Clinical experience with the cage electrode EMT 588 K. Threshold--current consumption--postoperative complications (author's transl)]. The Lagergren cage electrode Elema EMT 588 K was implanted in 26 male and 21 female patients for permanent cardiac stimulation. 29 of the 47 cage electrodes were fitted with a platinum and 18 with an Elgiloy head. Acute threshold in the platinum group was 0,52 +/- 0,15 volts (x +/- s), the equivalent electrode resistance being 565 +/- 135 ohms. The threshold mean value for the Elgiloy cage electrodes was shown to be 0,36 +/- 0,11 volts, while the resistance values measured respectively 410 +/- 44 and 418 +/- 23 ohms depending on the method of measurement. In the postoperative period (up to 16 months) the following complications were observed: 3 dislocations (6,38%) and one case of rise in threshold (2,12%). The total correction rate (8,5%) corresponds almost exactly to that recorded by the author in a personal series of 400 electrode implantations of various designs. The cage electrode offers no advantages in comparison to other small surface electrodes, however, the relatively higher current consumption caused by low total electrode resistance must be regarded as disadvantages. Experience with the cage electrode has shown that the transitional resistance depends not only on the surface, but also essentially on the material and shape of the electrode tip.


[Early and late results after surgical treatment for pulmonic stenosis with intact ventricular septum (author's transl)]. From 1958 to 1975, 309 pts. were operated on for pulmonic stenosis (PSt) with intact ventricular septum. The lesion was of the isolated valvular type in 81,5%, of the infundibular type in 9,1%, and of the combined type in 9,4%. A closed transventricular valvulotomy (Brock) was performed in 33 cases, primarily in infants. 130 pts. underwent transarterial valvulotomy in inflow occlusion, and 146 pts. were operated with the aid of extracorporeal circulation. Hospital mortality was 3,9%. All three operating methods showed almost identical early results, whereas the long-term results indicated a superiority of the open techniques. The results were less satisfying in pts. more than 20 yrs. of age than in younger ones. In 10 cases (3,4%) follow-up revealed recurrent PSt requiring re-operation, mainly because of persisting infundibular hypertrophy and markedly thickened (dysplastic) valve cusps.--Indications for the different surgical techniques are discussed on the base of the results.


[Pathogenesis, clinical application and therapy of chylothorax (author's transl)]. With the growth of traffic density and the spread of thoracic surgery, the clinical picture of the chylothorax can be observed with increasing frequency. Above all, the spontaneous or symptomatic chylothorax presents diagnostic problems, since, in about 70% of the cases, it only represents the concomitant symptom of a malignant tumor. Only after exact diagnostics and the exclusion of a malignant primary disease can one be content with the cursory diagnosis of an idiopathic chylothorax. However, this requires strict postoperative control and observation of the patients. Two patients are presented in whom the genesis of the chylothorax still remained unclear 3 1/2 years after the successful ligature of the thoracic duct.


Dose dependent reduction of glucose utilization by pentobarbital in rat brain. A new method of determining the rate of glucose utilization in brain regions of individual rats has been used to measure the dose dependency of the reduction of the metabolic activity of the cerebral cortex by pentobarbital. Cerebral cortical glucose utilization is depressed to a basal level of 44% of the control rate when cerebral pentobarbital levels exceed 50 microgram per g of tissue. The major portion of this effect occurs between the cerebral pentobarbital range of 10--20 microgram per g, which can be achieved by 1/5 to 1/10 the normal anesthetic intraperitoneal dosage. If a depression of brain metabolism is responsible for the previously reported protection of the brain from ischemic damage, these data suggest a substantial reduction of brain metabolic rate is achieved in the rat at a barbiturate dosage which may be therapeutically relevant in the human after acute brain ischemia.


Dose dependency of the post-insult protective effect of pentobarbital in the canine experimental stroke model. In a canine stroke model, dose dependent protection by postocclusion pentobarbital was suggested from 10--40 mg/kg. In 28 dogs investigated (10 from a previous study) a distinct, significant reduction in right cerebral hemisphere infarction occurred in animals given 15--20 mg/kg pentobarbital intramuscularly 1 hour postocclusion. Increased dosages did not alter statistically the infarct size and 2 dogs at the 50 mg/kg and 80 mg/kg levels died of barbiturate-induced respiratory failure.


Intracranial hemorrhage and infarction in anticoagulated patients with prosthetic heart valves. In 1 year 6 patients with prosthetic heart valves (PHVs) treated with anticoagulants suffered intracranial hemorrhage. In 4, hemorrhage occurred into the site of a recent non-hemorrhagic infarction. In the others, both of whom had endocarditis, hemorrhages probably occurred as the result of rupture of a mycotic aneurysm. Five patients were treated with warfarin, 1 with heparin. In all patients the level of anticoagulant activity was greater than 1.5 times control. Five patients were in atrial fibrillation; 1 was hypertensive. The diagnosis of intracranial hemorrhage was made and its location and extent accurately determined by computed tomography (CT). Three patients underwent surgery and 2 are alive with only minor neurological deficits. Among the 3 patients who did not undergo surgery 2 died and 1 is alive with a moderate neurological deficit. The management of PHV patients with use of anticoagulants is discussed in terms of the mechanisms involved in intracranial bleeding. Emphasis is placed on prevention of emboli, discontinuation of anticoagulants once non-hemorrhagic infarction has occurred and the primacy of CT scan in diagnosis when hemorrhage is suspected. The special problems of anticoagulation in the presence of endocarditis are also discussed.


Analysis of the effect of bilateral sympathetic stimulation of cerebral and cephalic blood flow in the dog. Unilateral stimulation of the cervical sympathetic in dogs had no effect on cerebral blood flow (CBF) measured by the venous outflow technique. Since this technique measured CBF from both cerebral hemispheres, small changes induced by unilateral stimulation could have been masked by a large constant CBF measured from the contralteral hemisphere. To test this possibility the effect of simultaneous bilateral sympathetic stimulation was studied when the dog was breathing either normal air or a gas mixture of 10%CO2. During normocapnia, no changes in CBF occurred; during hypercapnia CBF increased 19% following passively the increase in blood pressure. These data indicate that bilateral stimulation of extracranial sympathetic nerves does not exert a significant effect on CBF. We show mathematically and experimentally that unoccluded anastomses will cause CBF to appear to decrease in response to sympathetic stimulation. This may explain why others have observed changes in CBF during sympathetic stimulation.


Cerebral infarction in young adults.

Cerebral infarction in young adults. The etiologic and prognostic features which characterize cerebrovascular disease in the later decades of life are not applicable in younger patients. The records of 58 patients who had suffered cerebral infarction between the ages of 15 and 40 were reviewed in order to study these features. Fifty-five percent of the patients were found to have had an identifiable etiology for their cerebral infarction, with nearly half of these suffering from embolic infarction of cardiac origin. In 45% no clear etiology could be established but hypertension was prevalent in those patients between 31 and 40 years of age. Follow up data were obtained on 68% of the hospital survivors; nearly 3/4 of them had completely recovered or had improved.


Modification of acute focal ischemia by treatment with mannitol. A simple implanted device was used to occlude acutely the left middle cerebral artery (MCA) of 16 conscious cats. Eight received no treatment and 8 were given intravenous mannitol (1.2 gm/kg) at the time of occlusion. The initial neurological findings in both groups were similar, that is, agitation, forced circling, and right hemiparesis. The treated cats remained alert but the untreated cats became lethargic and drowsy. Perfusion with a mixture of colloidal carbon and buffered paraformaldehyde was carried out from 30 minutes to 6 hours following MCA occlusion. Results of morphological examination of brains from the treated and untreated groups suggested that mannitol had a protective effect upon cerebral tissue during the primary phase of acute focal ischemia. Light microscopic analysis of neuronal alterations demonstrated considerable preservation of neurons in brains of treated cats. Beneficial effect of mannitol was attributed partly to prevention of capillary narrowing and suppression of ischemic cerebral edema.


Ultrasonic digital interferometer for investigation of blood clotting. The digital ultrasonic fixed path interferometer designed for testing small amounts of sample was used for the investigation of whole blood coagulation, retraction and clot melting processes. The ultrasound velocity and absorption are determined from the characteristics of an acoustic resonator consisting of an emitter, a column of liquid to be tested and a receiver. The measuring accuracy of the ultrasound velocity is 0.1 ms-1, resolution--0.01 ms-1; the absorption measuring error does not exceed 10%. The device operates automatically giving analogue signals in the output for the recorder and discrete ones for the tape puncher to process the results obtained by computer. This permits employment of the interferometer in complex investigation systems. The whole blood clotting characteristics obtained provide new information which correlates with the results of some biological tests.


Thromboendarterectomy for total occlusion of the internal carotid artery: a reappraisal of risks, success rate and potential benefits. Forty consecutive patients undergoing thromboendarterectomy for total internal carotid artery occlusion were studied in an attempt to determine a) whether careful case selection could be expected to reduce future postoperative mortality and morbidity, b) whether the achieved patency rate justified early operation and c) whether patients in whom patency was restored and maintained had a better long-term prognosis. The results show that a group of patients can be selected that will have low postoperative mortality and morbidity. The success rate for restoration of blood flow is high, particularly if the operation is performed soon after occlusion. The long-term prognosis in patients in whom patency of the internal carotid artery is restored and maintained appears to be better than in those with persistent occlusion of the carotid artery.


Cerebrovascular disease in sickle cell anemia: a clinical, pathological and radiological correlation. An opportunity to study cerebrovascular changes in sickle cell anemia (SCA) presented itself when a black child with this disorder died of bihemispheric strokes. Angiography demonstrated severe occlusive vascular disease involving primarily the circle of Willis and major bifurcations of both internal carotid arteries. Collateral circulation to the distal branches of the internal carotid arteries occurred through transdural anastomoses from the external carotid system and via the leptomeningeal route. Perfusion of the basal ganglia was accomplished by vessels arising from the proximal internal carotid arteries. These changes resembled those of Moyamoya disease. Autopsy showed old and recent cerebral infarcts. Two vascular processes were responsible for the arterial occlusions: (1) exuberant intimal hyperplasia, and (2) old and recent thrombi with partial recanalization. The former has been described only once before in SCA. Small vessels in the basal ganglia were exceptionally numerous and dilated. We conclude that intimal hyperplasia within large cerebral arteries may be responsible for infarction and small vessel prliferation in basal ganglia in patients with SCA.


Vascular spasm in cat cerebral cortex following ischemia. The reaction of brain parenchymal vessels in areas of no-reflow following ischemia in cats was evaluated. A method was devised by which brain biopsies following ischemia were quickly frozen at -170 degrees C, sections were cut and stained and vessel internal and external diameter measured. Vessels in the no-reflow areas had smaller internal and external diameters and thicker walls when compared to adjacent reflow areas as well as to normal control animals. By utilizing a 2-way analysis of variance in which reflow versus no-reflow vessel diameters were compared by region the differences were found to be statistically significant (p less than 0.05). The data raise the possibility that there may exist normal regional differences in the size of cerebral vessels.


Dilated episcleral arteries--a significant physical finding in assessment of patients with cerebrovascular insufficiency. Dilated episcleral vessels associated with ipsilateral internal carotid artery occlusions have been previously reported though not widely appreciated. These ocular changes have been presumed to be manifestations of ocular ischemia. The authors have recently encountered this sign in seven patients and in none was there evidence of ocular ischemia. In addition to an ipsilateral internal carotid artery occlusion, arteriograms demonstrated that the major source of blood supply to the homolateral cerebral hemisphere was by retrograde flow through markedly enlarged ophthalmic arteries filled in retrograde fashion from dilated external carotid collateral channels in the orbit. This association of dilated episcleral arteries as a sign of increased orbital blood flow and the major source of collateral blood supply to the homolateral cerebral hemisphere has not been previously reported. We reemphasize the importance of a careful examination of the episcleral vessels in patients suspected of having internal carotid artery occlusions.


Photostudies of urethral varices "hemorrhoids": a forgotten lesion. The clinical features, endoscopic findings, and management of urethral varices "hemorrhoids" are described. We also offer a preliminary pathophysiologic discussion of their genesis and their oversight.


Suprapubic wad suspension. Combined perineal-abdominal approach for correction of postprostatectomy urinary incontinence. A three-year experience with 20 patients who became incontinent after various types of prostatectomies is described. A new method of repair using a combined approach is presented. The perineal component allows the insertion of a pliable prosthetic "wad." The posterior edge of the wad is held in a position inclined 20 degrees toward the vertical plane of the recumbent patient's perineum by two heavy nylon sutures. The sutures are brought into the previously dissected retropubic space by the use of a 10-cm. long Keith needle which is passed through the urogenital diaphragm. The ends of the sutures are tied over small marlex pledges over the abdominal fascia. There were two failures and one case in which urethral stricture developed among the 20 patients undergoing surgery.


Torsion of spermatic cord.

Torsion of spermatic cord. A series of 198 cases of acute unilateral, painful scrotal swelling considered to be torsion is presented and an aggressive surgical management of this entity described. The results achieved, a high incidence of testicular salvage, justify this aggressive approach.


133Xenon inhalation method: significance of indicator maldistribution for distinguishing brain areas with impaired perfusion. An index for total flow. This paper introduces a new index for the assessment of regional cerebral blood flow. The index is proportional to total flow, and is obtained from the ratio of regional count rate to arterial indicator input to a region. This index is a more sensitive indicator of impaired perfusion than the traditional flow rate indices which express flow per unit mass of tissue per minute. It accounts for brain tissue partly or totally deprived of its blood supply. Examples of clinical application are reported. A good correlation with the findings of computer-assisted tomography has been found.


Isolated torsion of penis. Report of 6 cases. Torsion of the penis as an isolated anomaly has rarely been reported. Six such cases seen in a pediatric urologic practice within a two and one-half-year span suggest that it is not as rare as has been hitherto suggested. The embryologic abnormality appears to be an isolated skin and dartos defect, since the torsion is completely remedied by simply freeing the penile shaft of its investing tissue. The ease of achieving a normal appearance would appear to justify its surgical correction.


Evaluation of closed suprapubic cystostomy. Closed suprapubic cystostomy is an expeditious procedure for a variety of clinical conditions requiring urinary drainage. Its benignity is reflected by a low complication rate of 1.6 per cent and no deaths in this series of 244 consecutive patients. Nevertheless, major complications can occur if proper technique is not adhered to or contraindications are not observed.


Partial replacement of urinary bladder by autologous gallbladder. In an effort to find a more suitable method of partial urinary bladder replacement for those patients with either a damaged or contracted bladder, the use of the autologous gallbladder was studied. The urinary bladders of 6 female dogs were partially resected, and the defective portions were replaced by autologous gallbladder transplants. After six weeks, the gallbladder mucosa showed evidence of squamous cell metaplasia progressing toward transitional cell epithelium with minimal necrosis. The muscular layer showed extensive granulation tissue and revascularization. No changes were detected in the upper urinary tracts. No mortality or detectable morbidity was associated with the procedure. It appears that the gallbladder may have a role to play in partial urinary bladder replacement.


Hydronephrosis, renal agenesis, and associated genitourinary anomalies in ACI rats. The ACI rat provides a congenital mammalian model for the spontaneously occurring defects of renal agenesis and hydronephrosis. These anomalies appear to be part of a spectrum of abnormalities caused by a mesonephric duct defect. These same anomalies also exist in man probably more commonly than previously appreciated.


Intra-arterial streptokinase and renal artery embolization. An animal experiment was constructed to simulate the clinical entity of renal artery embolization. Because of the high morbidity and mortality rates associated with the current methods of treatment, percutaneous infusion of the renal artery with streptokinase was evaluated as a new method of therapy. Results were analyzed by the following criteria: (1) arteriography, (2) gross pathology, and (3) differential renal function studies. In 12 dogs whose left kidney was embolized without treatment, renal function was 38 per cent of the contralateral normal kidney twenty-one days later. Seven dogs were embolized but treated immediately with intra-arterial streptokinase for six hours; renal function was increased to 58 per cent of the contralateral normal kidney. Various fibrinolytic agents and their possible clinical application in embolism are discussed.


Urinary fistula into ureteral stump after ileal conduit diversion. Despite ileal conduit diversion for urinary incontinence, an adolescent male with meningomyelocele continued to void per urethram postoperatively. Urologic investigation disclosed spontaneous fistulization from a ureteroileal anastomosis to a ligated ureteral stump, with resultant urinary drainage to the bladder. This unusual complication of ileal conduit diversion has not been reported previously. More attention should be directed to securing a watertight ureteroileal anastomosis. A careful single layer anastomosis is recommended to minimize urinary leakage without increasing the risks of stenosis and obstruction.


Vesical endometriosis.

Vesical endometriosis. An additional case of endometriosis of the bladder is reported illustrating the classic clinical features of the disease; treatment was by partial cystectomy. Vesical endometriosis is then discussed with reference to its unusual features and management.


Abdominal aortic aneurysm presenting as retroperitoneal fibrosis. A case of abdominal aortic aneurysm which presented as retroperitoneal fibrosis followed by fatal disseminated intravascular coagulation is reported. A diagnostic aortogram should be considered in all cases of apparent idiopathic retroperitoneal fibrosis.


Use of ephedrine to control anal urinary incontinence. A case illustrating the use of ephedrine to control urinary incontinence from the rectum is reported. It is postulated that this successful treatment is due to the action of ephedrine on the smooth muscle of the anal sphincter.


Plasmacytoma of testis presenting as primary testicular tumor. Two cases of plasmacytoma of the testis presenting as primary testicular tumors are presented. This lesion may be confused both clinically and histologically with other more common pathologic conditions.


Pure leiomyoma of prostate.

Pure leiomyoma of prostate. This is a case of pure leiomyoma of the prostate replacing the entire prostatic tissue. On microscopic study no prostatic glandular elements were identified. The literature is also reviewed.


Polycystic kidneys without radiologic enlargement. Polycystic kidneys in adults usually appear in the middle years and are described as large kidneys with most of their parenchyma displaced by a large number of cysts. Often the diagnosis is excluded if the intravenous pyelogram reveals kidneys of normal size. This report describes a patient with normal sized polycystic kidneys discovered at an advanced age.


Detection of bone metastases in urogenital malignancies utilizing 99mTc-labeled phosphate compounds. A retrospective study of 99 patients with proved urogenital malignancies was done to determine the value of bone scanning versus roentgenographic skeletal survey in assessing the degree of metastatic involvement. Findings on bone scans were positive in 59 patients, and in 7 of these patients results of roentgenographic skeletal survey were negative; 11 additional patients had only minimal roentgenographic abnormalities in contrast to more extensive involvement demonstrated by bone scanning.


Discovery of a lectin with affinity for the HBs antigen. An extract of marguerite leaves was found to contain an agglutinin which has affinity for HBs (adr type) antigen-sensitized sheep erythrocytes and for pure HBs antigen. This agglutinin activity was inhibited by the plasma of hepatitis patients who were known to have circulating HBs antigen. The agglutinin activity was also inhibited by 0.03M N-acetylneuraminic acid.


Hepatitis B antigen and antibody among staff members of an Israeli hospital and a kibbutz population. Until recently, hepatitis type B was thought to be transmitted parenterally. However, much evidence has appeared regarding non-parenteral transmission. Hospital personnel are exposed both ways to this disease. We compared the incidence of hepatitis B surface antigen (HBsAg) and antibody (anti-HBs) among 388 workers at a major medical center in Israel with 203 kibbutz residents, using radioimmunoassay procedures. Of the hospital personnel, 1.8% were found to carry the antigen and 23.9% the antibody. In contrast, 0.5% of kibbutz personnel were antigen-positive and 11.8% carried the antibody. The highest incidence of antibody was found among people born in middle-eastern countries outside of Israel. These results show a significant increase in the exposure of hospital personnel to hepatitis B virus. A marked increase in the frequency of sera positive for anti-HBs occurred after the first year of hospital work.


An attempt at passive transfer of immunity to leprosy patients by transfusion of allogeneic lymphocytes, inactivated with mitomycin C. An attempt was made to repair cell-mediated immunity in 7 patients suffering from lepromatous leprosy and severe erythema nodosum leprosum by intravenous infusion of 400 million allogeneic blood lymphocytes on 3 occasions. The lymphocytes were obtained from lepromin and tuberculin-positive subjects and were inactivated in vitro by treatment with mitomycin C. Immunotherapy with inactivated lymphocytes only modified the severity of erythema nodosum leprosum, without altering other aspects of the disease.


Serum ferritin levels in male blood donors: relation to number of phlebotomies and iron supplementation. Serum ferritin estimation has been shown to be a reliable test to reveal iron deficiency. Such estimations have been made in groups of male blood donors with a varying number of previous phlebotomies and a mean interval between donations of 9.9 +/- 1.7 SD weeks. It was found that the mean ferritin level was significantly (p less than 0.001) lower in the blood donors than in nondonors. After 6-8 phlebotomies it was about 40% lower. Subnormal ferritin values were found in 10% of the donors, almost exclusively among those who had taken less than 1,000 mg of iron supplementation since the last donation. It is concluded that with a donation interval of about 10 weeks, there is a considerable risk for iron deficiency after about 6 donations. This risk is far less if more than 1,000 mg of iron supplementation is taken between phlebotomies. A role for serum ferritin estimation in monitoring donation intervals and/or iron therapy is suggested.


Variation of cold agglutinin levels.

Variation of cold agglutinin levels. Cold agglutinin levels were determined in 120 individuals ranging in age from 1 to 64 years using untreated and ficin-treated group O erythrocytes. The geometric mean titer for untreated cells was 5.7 +/- 1.1 SEM and for ficin-treated cells 18.7 +/- 1.1 SEM. The mean titers and scores for various blood groups were not significantly different. Titers and scores correlated significantly to total serum IgM concentration (p less than 0.001). Females had significantly higher cold agglutinin levels than males (p less than 0.001). A significant decrease of cold agglutinins occurred in the 26- to 64-year age group as compared to the 11- to 25-year age group (p less than 0.01). The data should contribute to a clearer understanding of the biological impact of cold agglutinins.


Anticore antibody screening of transfused blood. Aliquots of 130 HB8Ag negative units of blood which were administered to 26 recipients were tested under code for anti-HBc by a solid phase radioimmunoassay technqiue. 14 of the 26 recipients developed posttransfusion hepatitis (PTH), including 6 cases of hepatitis B. Anti-HBc was detected in 7 or 5.3% of 130 donor units. Of the 14 patients acquiring PTH, 6 received a unit of anti-HBc-positive blood. Type B hepatitis occurred in 4 of the 7 anti-HBc recipients, and non-type B hepatitis in 2. Only 1 of 12 recipients who failed to develop PTH had received a unit containing anti-HBc.


Di-2-ethylhexylphthalate (DEHP) content of blood or blood components stored in plastic bags. Di-2-ethylhexylphthalate (DEHP) is a plasticizer used in the manufacture of plastic bags for blood products, which may be toxic. No more than a trace (less than 0.1 microgram/ml) could be detected in anticoagulants in blood bags, or in the blood of healthy untransfused subjects. A mean of 23 microgram/ml was found in ACD whole blood after 2 weeks storage, and 46 microgram/ml after 3 weeks; the corresponding figures for packed cells were 39 and 45 microgram/ml. The level in CPD whole blood was similar. Fresh frozen plasma and cryoprecipitate contained 7 microgram/ml, while levels of 1.0 and 0.7 microgram/ml of DEHP were found in the blood of two patients who had received massive transfusions. Most DEHP in stored blood was associated with plasma lipoproteins.


Professional and voluntary blood: a preliminary study in Iran. Among professional and voluntary blood donors in Tehran HBsAg carriers and RPR positives were found more frequently in the former group. The levels of haemoglobin, serum total protein and serum immunoglobulins G, A and M were significantly lower in commercial blood. Measurement of transferrin saturation showed that one-third of professional donors were quite severely iron deficient. For fractionation purposes the maximum theoretical yield from commercial plasma is 16% less IgG than from plasma of voluntary donors, 21% less total immunoglobulins and 20% less albumin.


Genetic evidence for four common alleles at the phosphoglucomutase-1 locus (PGM1) detectable by isoelectric focusing. The existence of 4 alleles of phosphoglucomutase (PGM1) in human red cell lysates has been demonstrated by isoelectric focusing confirming earlier work by Bark et al. and Kuhnl et al. A survey of 101 red cell lysates and the inheritance of these alleles in 24 families are now described.


Morphology and physiology of the McLeod erythrocyte. I. Scanning electron microscopy and electrolyte and water transport properties. The McLeod phenotype is a rare condition characterized by deficiencies in the Kell blood group antigens of erythrocytes. The present study has defined some of the morphological and physiological characteristics of these red cells. Scanning electron microscopy reveals that approximately 27% of McLeod cells are morphologically abnormal. These aberrant forms resemble the acanthocytes of abetalipoproteinemia. Incubation experiments indicate that the morphology of McLeod erythrocytes is not due to a plasma factor. Biochemical studies reveal that the lipid composition and microviscosity of these erythrocytes are normal. In addition, isotopic tracer experiments indicate that electrolyte transport is also within the normal range. However, osmotic water permeability is approximately 30% below normal. The absence of a lipid abnormality and other experimental data suggest that the abnormal morphology and reduced H2O permeability of the McLeod erythrocyte may be due to defective membrane protein.


Change of oxygen affinity of hemoglobin in different conditions of blood preservation. Changes of oxygen affinity of hemoglobin were studied in blood preserved in different conditions. Changes in hemoglobin function were least in CPD blood in plastic bags, and more extensive in ACD blood in plastic bags, ACD packed red blood cells in plastic bags and ACD blood in glass bottles, respectively. These decreases are consistent with the changes of organic phosphates levels during storage found in earlier studies. When old erythrocytes were incubated with inosine, pyruvate and phosphate, defective oxygen transport function was completely restored even after 7 weeks storage in ACD.


Changes in the agglutinability of red cells and the inhibition of specific agglutination by plasma from human blood taken into ACD and stored at 4 degrees C. The effect of storage in ACD at 4 degrees C on red cell agglutinability and the inhibitory properties of the plasma to blood group reagents has been studied. It was found that the variability demonstrated was related to the origin of the reagent used, particularly between human and on-human sources. The significance of these findings with regard to biochemical and morphological changes in blood on storage is discussed.


Two Melanesian antisera reacting with SsU components. Two different Melanesian antibodies demonstrated, by blocking tests and their reaction patterns, steric interaction of S, s and U components. The antigen(s) detected, designated Ux and Uz, may represent differing conformations, genetically determined, of certain U, S and s structures. Of 1,000 Caucasian bloods, 3 had very marked enhancement of Ux. Family studies are presented. In one such blood, abnormal steric interaction of D with s and U was indicated. Melanesian population studies show that Ux and Uz are among the antigens depressed in recessive ovalocytosis. The linkage disequilibria affecting MNSs and SsUz are inter-related, the associations being of SUz with Caucasian M and Melanesian N.


e-Antigen and anti-e in two categories of chronic carriers of hepatitis B surface antigen. Screening for e antigen and anti-e was performed in 517 HBs antigen chronic carriers, 329 blood donors and 188 hemodialyzed patients. e antigen was detected in 35 blood donors (10.6 percent): 88 percent had a high titre of HBsAg, and 80 percent had a distrubed liver function. No difference was noted regarding sex and age of the carrier. Anti-e was detected in 33.7 percent of the bood donors. A significant difference (p less than 0.01) was noted between males (29 percent) and females (46.6 percent). Anti-e was found more prevalent in young people between 21 and 34 than in older people (p less than 0.05). Anti-e was rarely found when the titre of HBsAg was low or high. 88 percent of the anti-e carriers had an intermediate titre from 1/1 to 1/32 by CEP. Both e Ag and anti-e were more prevalent in ad subtype than in ay subtype (p less than 0.02 for both). Inside the ad subtype, anti-e is less frequent in adr (6 percent) than in adw2 (42 percent) and in adw4 (57 percent); p less than 0.01. The difference between the prevalence of e Ag in adr (31 percent) and in adw2 (17 percent) is not significant but the healthy carriers with e antigen are more numerous in adr than in adw2 subtype. e antigen was detected in 53.7 percent of HBs Ag-hemodialyzed patients and anti-e in 3.7 percent of these patients. These results are neither correlated with the liver function nor with the state of chronic carrier (27 percent of e Ag in transient HBs Ag carrier).


A rapid automated latex screen for tetanus toxoid antibodies. This report describes the sensitisation of latex particles and the use of this reagent on the Autotape system to select blood donations containing greater than or equal to 4 IU/ml of tetanus toxoid antibody. Plasma containing tetanus toxoid antibodies is processed to provide immunoglobulin for passive protection against tetanus. The techniques used for screening include immunoelectrophoresis [3], tetanus toxoid sensitised latex particles [5], haemagglutination [1] and automated haemagglutination [6]. The technique used by the Sheffield Regional Transfusion Centre until recently, was immunoelectrophoresis, selecting donors with 4 or more IU/ml. The Autotape system, previously described for brucellosis [4] and syphilis testing [2], provides a system for automated slide testing and a 5-min tetanus toxoid coated latex test has been developed to select suitable donations for the production of specific immunoglobulin.


[Inhibition in the spinal cord: a neuronal mechanism of hypalgesia produced by acupuncture (author's transl)]. Central nervous system mechanisms of nociception and pain were studied electrophysiologically in the spinal cord of cats. A great proportion of dorsal horn neurons respond to noxious skin stimuli, for instance to heating to 50 degrees C; such stimuli predominantly activate afferent C fibres. These spinal neurons participate in the transmission of nociceptive information to the brain. The heat-evoked discharges of dorsal horn neurons are effectively inhibited by repetitive electrical stimulation of large;, low-threshold cutaneous A fibres. The inhibition reaches its maximum effect after several minutes of nerve stimulation, and declines at a slow rate after the end of stimulation. This long-term suppression is considered to be a neuronal mechanism underlying hypalgesia produced in man e.g. by acupuncture and by transcutaneous nerve stimulation.


[Comments on epileptic psychosis (two case reports) (author's transl)]. Nosological interpretation and therapy of epileptic psychosis is difficult, since psychotic and epileptic activities are of quite different time relationships. Case reports of two patients suffering from psychosis and showing generalized spike-wave paroxysms, without evidence of clinical seizures, are presented. The problems of diagnosing epileptic psychosis under these circumstances and the therapeutic approach are discussed.


[Cerebral angiography with the contrast medium vasobrix 32 (ioxitalamate) (author's transl)]. On the basis of angiograms carried out 168 patients, the contrast qualities achieved with the contrast medium, Vasobrix 32 were compared with those of other contrast media used so far. In the case of carotid angiography, Vasobrix 32 allowed better visualisation in the arterial phase than achieved with the contrast media used so far. The superiority of Vasobrix 32 over other substances was even more evident in the venous phase. As regards visualisation of the branches of the small arterial vessels such as the striothalamic branches, the results achieved with Vasobrix 32 were better than with the contrast media used so far and, therefore, a general improvement in visualization can be expected from Vasobrix 32 (Ioxitalamate). Complications with neurological sequelae were not observed, subjective complaints occurring to a slightly lesser extent than in the case of contrast media with a high sodium salt content.


[Hepatic hypoglycaemia (author's transl)]. The case histories are reported of two patients with the relatively rare association of hypoglycaemia with liver cirrhosis. The recent literature on hypoglycaemia as a consequence of liver disease is reviewed and the frequent absence of typical clinical symptoms in this form of hypoglycaemia is pounted out.


[Regeneration of synovial tissue in rheumatoid arthritis following synovectomy (author's transl)]. A study was carried out on 83 knee joints which had been subjected to synovectomy for rheumatoid arthritis. The morphological changes in the synovial tissue were divided into two types, Type I or hypertrophic and Type II or hypotrophic. Type I (hypertrophic) exhibited oedema, hypervascularization, fibrinous layers, large amounts of villi and granulationlike tissue, lymphocytes and plasma cells. Type II (hypotrophic) contained all the above elements, but to a much lesser degree, and fibrosis was the dominant feature. Regenerated synovial tissue was removed one to three years after the original synovectomy by arthrotomy or biopsy in 26 patients who were symptom-free. The tissue was thinner and hardly any villi were seen. The typical inflammatory elements were seen, but were not as pronounced as in the original tissue, irrespective of type. A heavy fibrosis was most frequently seen, but apart from this the regenerated tissue greatly resembled the original.


[Histomechanical studies on test specimens from hyaline cartilage under compressive loading with regard to rheology (author's transl)]. Modified rheological methods from high polymer physics (biorheology, historheology) have been applied to the testing of hyaline cartilage histomechanics. The following histomechanical properties of cartilage are discussed: transient behaviour, the influence of the mechanical history on the subsequent force-deformation processes, viscoelastic equilibrium status (histomechanical steady state), and relaxation phenomena in the pressure and tension range under alternating pressure-tension loading. Pressure force-time input and output curves in a closed loop system and the amplitude-increasing phenomenon under uniform sinus deformations with increasing superimposed linear deformation input were also demonstrated. The results are discussed from the point of view of functional anatomy.


[Catamnestic studies on infections in granulocytopenias]. Granulocytopenias in insufficiencies of the bone marrow, haemoblastoses and other basic diseases led to an increased endangering by infections and frequency of infections. As a rule, here was decisive the scope of the decrease of the granulocytes, measured at the morbidity by infections, the degree of severity of the infection, the frequency and the duration of fever episodes. Despite improved possibilities of antimicrobial treatment the complications by infection in granulocytopenias increased, so that the prophylaxis of the infection is of particular significance.


[Cardiac function diagnosis in the hemodialysis practice using so-called Rentsch tension index]. The so-called tension index PI after Rentsch allows a frequently repeatable control of the degree of sufficiency of the heart with slight annoyance of the patient and moderate expenditure of time. In dialysis patients in whom the heart stress and the conditions of the interior milieu frequency acutely change with the help of the PI valuable hints for the treatment could be received.


[Evaluation of exposure level in the handling of explosives]. For the clarification of a supposed case of poisening by handling of explosives containing nitric acid ester in a man who was an expert in performing explosions the proof of the exposition was necessary. By the determination of free nitrite in the blood as well as by measuring of blood pressure and pulse in persons exposed in the same way the intake of nitrated constituents of the explosive could be made clear. The advantage of the determination of free nitrite in the blood in contrast to the determination of the met-Hb is discussed. It is referred to an additional potential endangering by gun fumes and the measures for the protection of labour which are to be derived from this.


[Comparative effects of ajmaline and lidocaine on hemodynamics in myocardial infarct]. Haemodynamic changes after single intravenous injection of antiarhythmic doses of ajmaline (50 mg) and lidocain (100 mg) were measured comparatively in 10 patients with acute myocardial infarction, stable cardiac rhythm and without manifest left heart failure. The effects of ajmaline were characterized by a significant decrease of systolic arterial pressure (9%), of left ventricular stroke work index (15%) as well as by an increase of the mean pressure of the pulmonary artery (7%) in the early phase after application. No significant changes in cardiac index, stroke volume index, systemic vascular resistance, right and left ventricular filling pressures and heart rate occurred. The effects of lidocain on the cardiac circulation were comparatively small. The intravenous administration of lidocain did not result in significant changes of the cardiac index or left and right ventricular filling pressures. Diastolic arterial pressure increased significantly (5%), while the heart rate decreased (5%).


[Esophageal manometry in Behçet's disease (author's transl)]. Esophageal function was investigated by quantitative intraluminal pressure measurements in three patients with Behçet's disease. All three had motility disorders partially resembling those described in diabetics and partially those from patients with scleroderma. These motility disturbances may be secondary to a neurological involvement in Behçet's disease.


[Ultrasound in the diagnosis of cystic lesions of the liver (author's transl)]. Possibilities and limitations of the use of ultrasound in diagnozing cystic liver diseases are discussed with reference to our own investigations. Solitary or multiocular liver cysts can be detected in the right proportion and in the correct anatomical position from about 1.5 cm in size; they are often coincidental findings after ultrasonography. The ultrasonic method is a simple investigation technique without any complications or contraindication and it now has a firm place as a screening investigation programme within diagnostic procedures especially before an intended liver needle biopsy or puncture during laparoscopy. By carrying out ultrasonic investigations on families of patients with cysts of the liver it has been possible to make an early diagnosis of hereditary cystic disease.


[A case of congenital double pyloric canal (author's transl)]. In the case of 47-year-old patient who had been suffering for several months from a duodenal ulcer disease, a so called double pylorus was traced by applying fiberoptic gastroscopy. At the same time proof was found for the ulcera duodeni. Owing to the fiberoptic result of two regularly pyloric canals it was already doubted, that this was only a question of a secondary pyloro duodenal fistula caused by peptic ulcer. A particular and differentiating pathological anatomical examination of the surgical specimen showed as a result, that the patient was suffering from a congenital duplication of the pyloric canal by a pyloric ligament. The duodenal ulcers, proofed by x-ray examination and gastroscopy, were recognised as a secondary disease of a locus minoris resistentiae.


HLA-antigens in idiopathic haemochromatosis (i.h.). preliminary report. Striking differences could be observed when the HLA-antigens of 11 unrelated idiopathic haemochromatosis (i.h.) patients were compared with healthy controls. Besides the increase of the antigens A3, A11 and B7 and the decrease of A2, the large number of homozygous antigens at the A or/and at the B locus was found to be the most interesting result. Taking the latter finding into account, the possible existence of a recessive "disease-susceptibility gene" closely linked to the major histocompatibility system, playing a basic role in the etiology of i.h. was assumed.


Actinomycosis and lumbar disc disease.

Actinomycosis and lumbar disc disease. The occurrence of isolated spinal lesions due to actinomycosis is rare. Nonetheless its presence in this case acts as another reminder of the variety of lesions that may present as a lumbar disc syndrome.


Acid- and alkaline phosphatase in amniotic fluid in normal and complicated pregnancy. 171 samples of amniotic fluid were obtained by abdominal amniocentesis from 67 women with complicated pregnancies (isoimmunization, diabetes mellitus or toxaemia). The levels of heat-labile alkaline phosphatase (HLAP), heat-stable alkaline phosphatase (HSAP) and acid phosphatase (AcP) were determined and compared to the enzyme levels in 179 samples from women with normal pregnancies of corresponding gestational ages. HLAP showed two "peaks" of activity, one in the 5th-22nd week and the other at term. HSAP and AcP showed increased activity at term. HSAP was decreased (p less than 0.01) in isoimmunization between the 36th and 40th week. 11 cases of toxaemia with placental insufficiency showed no differences in the levels of HLAP and HSAP compared with normal pregnancy. AcP showed no differences between normal and complicated pregnancy. Samples contaminated by blood showed no significant increase in the acid- and alkaline phosphatase levels. Samples contaminated by meconium showed a complex pattern. Some samples had normal enzyme levels, some had high levels of HLAP only and some had high levels of HSAP and AcP. The origin of the enzymes is not known with certainty. HSAP in amniotic fluid is most likely not of placental but intestinal origin. Determinations of acid- and alkaline phosphatase in amniotic fluid seem to be of little values in the clinical management of complicated pregnancy.


Premature labor treatment with ritodrine in multiple pregnancy with three or more fetuses. Modern treatment for anovulatory infertility increases the incidence of multiple pregnancies with three or more fetuses and predisposes to prematurity with high perinatal mortality and mortidity. Premature labor was successfully treated in four multifetal pregnancies with ritodrine hydrochloride, a beta-mimetic drug relaxing the uterus. Another patient misdiagnosed as false labor was not treated and lost three out of four premature babies. Beta-mimetic treatment is indicated in multiple pregnancies even in false labor, or when painless progress in cervical dilatation is observed, to avoid asymptomatic progression into true labor. In contrast to singleton pregnancies, advanced labor with more than four centimeters cervical dilatation should not preclude good chances for successful treatment. Persistence in treatment and repreated use of the most effective intravenous route combined with oral ritodrine administration is needed because of marked tendency to recurrences of premature labor. Progressive increase in the dose of oral ritodrine may be indicated by decrease in therapeutic response. Maternal tachycardia should be considered as an index of patient responsiveness to the beta-mimetic treatment. The therapy is most successful when the patient is hospitalized from the first episode of treatment until at least the 37th week of pregnancy. This is probably less expensive than prolonged hospitalization of several prematures in an intensive care nursery.


The thermogenic activity of exogenous E and F prostaglandins in humans. A basic understanding of the physiologic effects of the prostaglandins on the human reproductive system has been one of the diverse scientific interests of Professor Axel Ingelman-Sundberg (19). Although the obvious clinical ultility of these ubiqitous compounds directed early attention to their therapeutic aspects, more recently there has been renewed interest in the basic physiologic mechanisms of the prostaglandins in reproductive medicine. Undoubtedly, the work of Dr Ingelman-Sundberg has stimulated many of his colleagues, students, and fellow scientists to pursue such basic studies in greater details.


Therapeutic abortion in an out-patient clinic. A prospective investigation of complications and patient acceptability. The incidence of complications associated with therapeutic termination of pregnancy was analysed in 1349 patients, whose average age was 26.3 years. Of the patients, 51.8% were 25 years or under; 56.3% were seen in or before the 8th week of pregnancy, and 17.4% had previously had one or more legal abortions. All the operations were performed under local anaesthesia and by the same doctor, who was an experienced gynaecologist. Complications associated with the operation occurred in 14 patients (1%), viz. infections in the uterus and tubes, 9 cases; incomplete abortion necessitating repeat curettage, 4 cases; and profuse bleeding requiring blood transfusion, 1 case. No uterine perforations or cervical ruptures were encountered. Questioned about subjective discomforts of the opeation, 7.4% of the women answered that the discomfort had been considerable, whereas 62.6% described it as only slight; 4.8% would have perferred general anaesthesia. We conclude that therapeutic abortion can be performed safely and with an acceptably low incidence of complications in out-patients, provided the operations are performed by an experienced gynaecologist.


Follow-up studies in dysplasia and cancer in situ of the cervix uteri. In order to study when recurrences appear following conization for dysplasia or cancer in situ of the cervix uteri, a series of 477 patients has been investigated. They all underwent conization at Sabbatsberg 1965-1970. Among the 181 cases of dysplasia two developed recurrences one respectively three years after treatment. In the series of 296 patients with cancer in situ thirteen recurrences appeared. Eight of them were detected within the first three years. The other five were spread out during the next four years. About 50% of all patients had been followed-up for five years or more (Table I). The conclusion is reached that a yearly follow-up is necessary for at least ten years. As it is impossible to take care of such an accumulating number of examinations at the Swedish departments of obstetrics and gynecology without extra personnel, the following proposal is made. During the first three years after treatment the examinations are performed at the department where the conization has been performed. After that period the follow-up is limited to vaginal smears taken once every year in connection with the general gynecologic health control.


Organization of amniocentesis for antenatal genetic diagnosis. In spite of the rapid development of amniocentesis for genetic diagnosis, it is still only a small fraction of the mothers at risk who are having the procedure performed. The medical and public health problems associated with genetic amniocentesis are discussed on the basis of the experience gathered in a major medical center.


Regression of tumour growth after administration of alkoxyglycerols. A regression of tumour growth is observed when alkoxyglycerols are administered prior to radiation treatment of patient suffering from cancer of the uterine cervix. This regression has been demonstrated by a change in the quotient between the incidence of early and advanced stages.


ENT diseases of allergic origin.

ENT diseases of allergic origin. The author defines the following notions: allergy, atopy and allergic rhinopathy. The symptomatology, diagnosis, evolution and different clinical forms of the allergic rhinopathy are discussed.


Electron microscopic study of the normal and allergic nasal mucosa. Electron microscopic studies of the human nasal mucosa have complemented earlier histological and histochemical studies. In this paper, the fine structural details observed in different tissue components are described and discussed in relation to the function of the nasal mucosa under normal and pathological conditions. The physiological changes in the anterior part of the inferior turbinate which occur under the influence of air currents differ clearly from the electron microscopic picture of respiratory mucosa with typical ciliated epithelium. The fine structure of the allergic nasal mucosa differs according to the stage of the allergic reaction; the characteristic changes are described both after different time intervals following intranasal allergic testing with positive reaction as well as in patients with seasonal or perennial nasal allergy of longer duration.


The nose provocation and the passive anterior rhinometry (PAR). The authors describe an easy and fast way of nose provocation (aerosol provocation combined with passive anterior rhinomanometry). A comparative study between skin tests, lungprovocations and noseprovocations proves the usefulness of the method.


Indications, techniques and results of surgery in nasal allergy. The only surgical intervention that interferes in the mechanism of an allergic rhinitis reaction, is the vidian neurectomy. The reported results are excellent, also in severe cases resistant to medical treatment. In the present report we describe the autonomic innervation of the nasal mucosa, the indications, techniques and results of vidian neurectomy. Intranasal techniques to diminish the hypertrophic tissues in cases of hyperttrophic rhinopathy are also discussed. Special attention is paid to cryosurgery of the inferior turbinate.


Basic concepts in immunology.

Basic concepts in immunology. The immune system exhibits the capacity to react specifically towards antigens. This capacity depends on the activation of T and B cells. The cooperation between B and T cells is necessary for the production of IgG, IgA and IgE. The productions of these antibodies together with the formation of the other immune products (IgM and sensitized T cells) result in an altered state of reactivity towards the antigen. This becomes manifest in variety of ways: from protection to destruction. In the case of allergic rhinitis the tissue damage is caused by the presence of IgE and the subsequent release of vaso active amines by the mastcell after contact with the antigen.


Maxillofacial injury.

Maxillofacial injury. This chapter has emphasized the relative infrequency of severe skeletal maxillofacial injuries in children. When they do occur, it is extremely important that they be approached by a team of physicians, each of whom is competent to manage the injury and complications related to his specialty. Particular attention must be given to the issues of general facial bone growth as well as future dental development. All operative procedures must be designed to avoid further injury to unerupted teeth, and the traditional methods of immobilization must be modified in order to avoid the avulsion of deciduous teeth.


Hazards of ventilation tubes.

Hazards of ventilation tubes. Ventilation tubes are not the treatment of choice in serous otitis media. Conservative measures should be tried first, with simple myringotomy for the evacuation of thick, rubbery fluids. Autoinflation, well tolerated by most children above 3 years of age, should be practiced daily for months to years, under periodic check-ups. Tube insertion should be reserved for younger children, as well as for recurrent and non-responsive cases. These are the cases in which a calculated risk is worth taking, as otherwise the patient is on an ineffective treatment. In those hard-to-manage ears, tubes seem to be justified, as their potential hazards are apparently outnumbered by the complication of untreated or maltreated serous otitis media.


Mucocutaneous lymph node syndrome.

Mucocutaneous lymph node syndrome. Mucocutaneous lymph node syndrome (MLNS) is a recently described disease entity of unknown etiology that mainly affects children. The disease is characterized by fever, oral mucosal changes, cervical lymphadenopathy and a peripheral skin rash with induration of hands and feet and subsequent desquamation. Thromboarteritis of the coronary vessels causes death in 1 to 2 percent of the patients. Over 7,000 cases have been reported in Japan and increasing numbers are reported in the United States. No specific treatment is available.


Blunt and penetrating injury.

Blunt and penetrating injury. Personal injury may result from deceleration of the body or of missiles by the body, resulting in blunt or penetrating multiple trauma. The extent of the deceleration injury is determined by the amount of energy absorbed. Whether the injury is blunt or penetrating depends on factors of force, surface and time. Priorities in the management of the multiple-injury patient consist of rapid evaluation and control of breathing, bleeding and shock.


Preventing stroke after TIA.

Preventing stroke after TIA. Previous reports suggest the probability of stroke after TIA as 20 percent in the first year and 45 percent within five years. Forty-five TIA victims were treated in a stroke prevention program for an average of five years. Efforts were made to correct or control all risk factors. Eight of the 45 experienced further TIA'S, Three had subsequent strokes and two had myocardial infarctions. Two deaths were reported. This stroke prevention program offers an improved prognosis for victims of TIA.


Failed disk syndrome.

Failed disk syndrome. Over half the patients in most pain clinics in the United States are seeking relief from the "failed disk syndrome." Careful initial diagnostic evaluation and aggressive nonoperative therapy are essential to avoid poor results. Causes of continued pain after disk surgery include original pain syndromes not due to a disk, inadequate surgery, development of arthritis, additional disk disorders and nerve root fibrosis. Treatment demands precise diagnosis. Diagnostic injections and nerve blocks are helpful when other techniques fail.


Blunt and penetrating chest trauma.

Blunt and penetrating chest trauma. Blunt or penetrating trauma to the chest can cause several life-threatening conditions: open or closed pneumothorax, each with or without hemothorax; flail chest; pericardial tamponade, and injury to other structures in the chest--the esophagus, trachea or great vessels. Any trauma sufficient to compromise function of thoracic organs must also be suspect for extrathoracic injuries, especially to the spleen and other abdominal viscera.


Intravenous regional anesthesia--'Bier block'. The Bier block is ideally suited for management of many types of trauma to an extremity. Blood is removed from an injured extremity by elevation and wrapping, and then a pneumatic tourniquet is applied proximal to the site of injury. Lidocaine is then injected into a vein distal to the tourniquet. The tourniquet prevents entry of the lidocaine into the general circulation while anesthesia is obtained in the extremity; it also provides a bloodless surgical field.


Nonsteroidal anti-inflammatory agents in arthritis. Aspirin remains the agent of first choice, but ibuprofen, fenoprofen, naproxen and tolmetin are useful drugs in rheumatoid arthritis. Ibuprofen and fenoprofen are also approved for use in osteoarthritis. Each shares anti-inflammatory, analgesic and antipyretic properties with aspirin, phenylbutazone and indomethacin. The nonsteroidal anti-inflammatory agents have fewer minor side effects than aspirin and fewer major side effects than indomethacin or phenylbutazone. The patient must understand that drugs are but one part of a comprehensive management program.


Impotence--some causes and cures.

Impotence--some causes and cures. Transient organic causes of impotence include alcohol consumption, drug use or inflammatory genital disease. Many diagnoses of organic impotence, with diabetes, for example, have been premature and have resulted in iatrogenic, psychogenic impotence. After a stroke, heart attack or major surgery, depression may cause impotence. Anxiety and sexual ignorance are major etiologic factors. Thus, sex education and uncomplicated sex therapy can achieve a high percentage of cure. Penile plethysmography during sleep provides useful information. Penile prostheses are helpful for appropriately motivated couples when there is permanent impotence.


Keratosis pilaris.

Keratosis pilaris. This benign skin disorder is recognized by a characteristic appearance and a positive family history. Safe, effective treatment with urea creams and lotions is available.


Temporal arteritis.

Temporal arteritis. Temporal (giant cell) arteritis is a disease of older persons that has a variety of clinical presentations. It is a major cause of blindness. The erythrocyte sedimentation rate is almost always markedly elevated. Corticosteroidss in large doses are urgently required. The diagnosis is established by biopsy of an artery. In an 80-year-old women who sudddenly became blind, the signs had been masked by low doses of steroids given for a mistake diagnosis.


Sleep disorders and insomnia.

Sleep disorders and insomnia. Primary sleep disorders include narcolepsy, the Pickwickian syndrome, sleep apnea in infants and other rare conditions. Secondary sleep disorders occur in depression, alcoholism, endocrinopathies, heart failure and pregnancy. Medical symptomatology often increases during rapid-eye-movement (REM) sleep, when physiologic activity is high. Insomnia, the most common sleep disorder, requires careful work-up, attempts at environmental manipulation and judicious short-term pharmacotherapy. Pharmacologic manipulation of sleep is beset with complications. A basic understanding of properties and side effects of the sleep-inducing drugs is needed in order to select the optimal agent.


Clinical classification of Ebstein's anomaly. Twenty-six patients with Ebstein's anomaly were classified into three types according to their clinical features, heart catheterization data, angiocardiographic and anatomical findings which were obtained on surgery or autopsy. The hemodynamics in each type were discussed. 1. Tricuspid Stenosis Dominant Type. Eight patients, who were cyanotic and had severe symptoms, mild to moderate cardiomegaly, and the "double-ball sign" on angiocardiography were classified into this type. A pressure gradient across the tricuspid valve was demonstrated in 5 patients. 2. Tricuspid Insufficiency Dominant Type. Four cyanotic patients, who had mild symptoms despite the severe cardiomegaly were grouped into this type. The "double-ball sign" was found in all. In three patients, incompetent tricuspid valve was observed. Tricuspid insufficiency necessitates the volume overwork of the right atrium and the functioning right ventricle, resulting in severe dilatation. 3. Mild Type. Fourteen patients who showed no or mild cyanosis, no or mild symptoms, and mild to moderate cardiomegaly, were classified into this type. It is considered that the adequate cardiac output in these patients is attributable to the good function of the tricuspid valve.


Polymicrobial infective endocarditis: an increasing clinical entity. Polymicrobial endocarditis was very uncommon until ten years ago. However, since that time, at least 21 cases were reported, and 10 patients with this mixed infection were seen at our hospital. All, except one of these infections, occurred in patients who had undergone heart surgery or abused intravenous drugs. Although, generally clinically indistinguishable from mono-microbial endocarditis, these mixed infections carried a very high mortality rate (greater than 30 per cent), and an unusually large number of the patients (greater than 50 per cent) needed heart surgery either to control the infection or to repair cardiac defects resulting from the infection. The prognosis depended on the species rather than the number of organisms isolated and on aggressive antimicrobial and surgical therapy.


Post-extrasystolic potentiation of ischemic myocardium by atrial stimulation. The response of acutely ischemic myocardium to post-extrasystolic potentiation (PESP) was evaluated in 11 mongrel dogs. Mercury-in-silastic length gauges were sutured to the epicardial surface of the left ventricle; left ventricular pressure was determined via an apical large-bore catheter-transducer system and controlled by volume manipulation. The anterior descending coronary artery was then ligated, and single premature atrial contractions were introduced via an external stimulator. Thirty minutes after occlusion, shortening during ejection had decreased an average of 81 +/- 8 per cent, from 1.30 +/- 0.29 to 0.32 +/- 0.05 mm. PESP initially induced a marked restoration toward normal segmental contraction as systolic shortening increased significantly to 1.14 +/- 0.23 mm. Additionally, paradoxic systolic expansion, when present, reverted to a normal pattern of contraction during PESP. Responsiveness to PESP deteriorated progressively with time over 3 hours following occlusion until the muscle became essentially totally unresponsive to this stimulus. It is concluded that a single premature atrial beat may be used to induce PESP and provides an effective stimulus for contractile reserve of acutely dysfunctional ischemic myocardium. Loss of responsiveness to PESP may represent the progression to nonviability following acute ischemia.


The difference vector: assessment of effects of changes or interventions. Vector dipole moments were measured on young pigs before and one week after ligation of the left anterior descending coronary artery. Vectors were obtained for the three peaks of vector spatial magnitude, M. Preoperative, postoperative, and difference vectors were measured for each peak. If excitation is normal except through the infarcted tissue, the difference vector should be more closely related to the infarct because the normal excitation cancels out. It was found that the postoperative vector was changed by the infarct but that the difference vector was a better indication of infarction. This paper was designed to introduce the method using experimental data for a small number of pigs.


Effects of proximal intra-atrial Wenckebach on distal atrioventricular nodal, and His-Purkinje, block with special reference to the theory of alternating Wenckebach periods. Intra-atrial Wenckebach patterns of stimulus-to-response intervals coexisting with distal, A-V nodal, and His-Purkinje, blocks occurred in eight patients during high right atrial stimulation at rapid rates. In two patients with 2:1 St-H block and in two patients with 4:1 St-V block, an increase in the degree of block occurred when the proximal intra-atrial Wenckebach cycle was completed with the stimulus which otherwise would have been propagated to the distal levels. However, the degree of block did not increase when the intra-atrial Wenckebach terminated in distally blocked stimuli. In one patient progression of 4:1 into 5:1 St-V block was due to the association of intra-atrial Wenckebach with alternating 2:1 block at the A-V nodal, and His-Purkinje, levels. Contrasting with most reports dealing with the mechanisms of alternating Wenckebach in a single structure, this study permitted the determination of the boundaries between proximal and more distal levels. It also showed that alternating Wenckebach cycles (of St-H intervals) ending with two consecutively blocked stimuli could result from the association of proximal intra-atrial Wenckebach with distal, A-V nodal Wenckebach, or abortive AW, cycles. The electrophysiology of documented two, or three, level block in different structures has validated previously made assumptions regarding multilevel block in a single structure.


Misdiagnosis of atrial septal defect in patients with hereditary telangiectasia (Osler-Weber-Rendu disease) and hepatic arteriovenous fistulas. Two patients with hereditary telangiectasia (Osler-Weber-Rendu disease) and high-output congestive heart failure secondary to large hepatic arteriovenous malformations had preoperative heart catheterization and exploratory cardiotomy to correct presumed intracardiac left-to-right shunts at the atrial level. At operation, both patients had oxygen-enriched blood returning from the inferior vena cava. Subsequent hepatic angiography demonstrated large hepatic arteriovenous fistulas, and both patients underwent hepatic artery banding and ligation, with reduction of left-to-right shunting.


The role of the central nervous system in chronic congestive heart failure. Even though congestive heart failure is extremely common, the mechanisms responsible for the clinical manifestations remain a puzzle. The central and autonomic (sympathetic) nervous systems are responsible for a large part of the clinical manifestations. The role of the nervous system in CHF is discussed briefly. It is evident that there are many gaps in knowledge that remain concerning the role of the central, peripheral, and autonomic nervous systems in congestive heart failure. The peripheral vascular constriction, increase in venous tone and pressure, tachycardia, sweating, dermal pallor, and tension and anxiety in patients with CHF reflect generalized sympathetic nervous system activity and the influence of the central and autonomic nervous systems on the clinical syndrome of CHF.


Sequence of cardiac changes in Duchenne muscular dystrophy. Boys with Duchenne muscular dystrophy (DMD) rarely have clinical evidence of myocardial dysfunction during life. Nevertheless, congestive heart failure is a frequent terminal event and autopsy invariably shows dystrophic myocardial involvement. Little is known regarding the progression of heart functional abnormalities in boys with DMD from birth to death. Therefore we have examined the hearts of 18 DMD boys aged 4 to 15 years with the following non-invasive methods: cardiovascular physical examination, electrocardiography, chest x-ray, serum enzymes, and echocardiography. Control subjects were 25 normal boys matched to their DMD counterparts by age and by body surface area. The dystrophic patients were divided into early (N = 9) and late (N = 9) DMD according to manual muscle testing of skeletal muscles. In early DMD, six of 23 cardiac indices differed from control boys; in the late stage, an additional five indices became abnormal. Early DMD was characterized by these abnormalities: tachycardia, large ECG R/S ratio in V1, augmented q wave voltages in Leads I, II, and V5 of the ECG, diminished contractile excursion of the left venticular posterior wall (LVPW) and interventricular septum, and decreased rate of relaxation of the LVPW. In late DMD additional cardiac abnormalities appeared: enlarged heart volume by x-ray, reduced cardiac ejection fraction, diminished change in left ventricular diameter from diastole to systole, reduced maximal systolic endocardial velocity, and decreased rate of circumferential fiber shortening as detected in the echocardiogram. Most of the cardiac abnormalities were revealed only by echocardiography, which is thus shown to be a sensitive method for monitoring the progression of cardiac dystrophy during the life span of the DMD child.


Ondine's Curse: hemodynamic response to diaphragm pacing (electrophrenic respiration). The hemodynamic response to diaphragm pacing was studied in eight patients with Ondine's Curse. It was shown that such pacing could lower the pulmonary artery pressure while correction of hypoxemia alone could not. It was demonstrated that on pacing, calculated pulmonary arteriolar resistance decreased and there was normalization of arterial blood gases. The mechanism for these changes was improved alveolar ventilation.


Measurement of the circulatory effects of dobutamine, a new inotropic agent, in patients following cardiac surgery. The use of an extractable aortic electromagnetic flow probe to provide a continuous on-line display of ascending aortic flow and cardiac output following open heart surgery is described. Utilizing this equipment, the hemodynamic actions of dobutamine and isoprenaline are compared in 14 patients immediately following cardiac surgery. The study confirmed an inotropic action produced by dobutamine at a heart rate 10 to 15 per cent lower than isoprenaline, with less peripheral vascular action. Arterial and coronary sinus blood analyses revealed little difference in the myocardial metabolic actions of either drug. Because inotropic drugs produce only relatively small increases in stroke volume in this group of patients, the rise in cardiac output caused by these agents is more dependent on the effects upon heart rate rather than improved myocardial contractile state and consequently dobutamine has little advantage over isoprenaline in this situation.


Total effective compliance of the vascular bed in essential hypertension. Total effective vascular compliance, hemodynamic parameters, cardiopulmonary (CPBV) and total blood volumes (TBV) were determined in 31 men, including nine normotensive controls and 22 permanent essential hypertensive patients. The effective compliance was calculated from the changes in central venous pressure recorded simultaneously with the changes in blood volume obtained after a rapid dextran infusion. In hypertensives, compliance was significantly reduced (1.55 +/- 0.6 vs 2.25 +/- 0.11 ml./mm. Hg/Kg. in controls) (P less than 0.001) and negatively correlated with blood pressure (P less than 0.01), cardiac index (P less than 0.01), and the CPBV/TBV ratio (P less than 0.01). These results suggest that venous compliance contributes to the control of cardiac output in essential hypertension.


Effect of pentobarbital anesthesia on ventricular defibrillation threshold in dogs. The effect of pentobarbital anesthesia upon the minimal voltage and current required for electrical ventricular defibrillation (the defibrillation threshold) was investigated in dogs. Threshold current, energy, and charge in five dogs averaged 2 per cent, 13 per cent, and 6 per cent less under surgical levels of pentobarbital anesthesia than thresholds in the same animals in the awake, unanesthetized state. In dogs given sufficient pentobarbital to produce apnea and supported by mechanical ventilation, threshold current, energy, and charged averaged 3 per cent, 17 percent, and 2 per cent less than comparable awake values. These differences were far from statistically significant. In a second study, five dogs were kept for 8 to 10 hours at a surgical level of anesthesia with pentobarbital sodium. Defibrillation threshold current, determined at hourly intervals, did not drift outside +/-10 per cent limits. Arterial blood gas measurements revealed a stable, compensated metabolic acidosis in all animals (pH 7.36 +/- 0.06, pCO2 33 +/- 4 mm. Hg, pO2 71 +/- 9 mm. Hg). These data support the validity of defibrillation studies using animals anesthetized with pentobarbital and indicate the stability of the defibrillation threshold under controlled experimental conditions.


Creatine phosphokinase MB isoenzyme in hypothermia: case reports and experimental studies. Six patients with severe medical disorders and profound hypothermia are presented who had elevated total serum creatine phosphokinase (CPK) and CPK-MB isoenzyme activity without clinical or postmortem evidence of acute myocardial infarction. Experiments in dogs indicate that hypothermia reduces total CPK activity in both striated and myocardial muscle resulting in increased serum enzyme activity. These data suggest that profound hypothermia may result in diffuse striated and cardiac muscle cellular injury without evidence of discrete infarction with consequent release of CPK-MB isoenzyme into serum.


The prominent electrocardiographic conduction aspects of hypokalemia in a patient with periodic paralysis. This article documents striking atrioventricular and intraventricular conduction disturbances in marked hypokalemia, in a Negro male with periodic paralysis. The authors discuss cardiac conduction in hypokalemia.


Isolated T wave alternans.

Isolated T wave alternans. Two patients with isolated T wave alternans are reported, with their vectocardiograms, their response to carotid sinus stimulation, and the response to calcium infusion in one of them with documented severe hypocalcemia. Eleven cases of the literature are briefly reviewed. The alternans of the T wave appears with severe QT prolongation, QT alternans, and an increased tendency to ventricular fibrillation. The findings are consistent with the hypothesis that T wave alternans may be the electrocardiographic manifestation of the transmembrane action potential alternans and could be related in some cases to hypocalcemia.


The hypertension complex.

The hypertension complex. The complex of factors that operate in the genesis as well as the development of various types of hypertensive disease is discussed. Questions are asked and possible answers given to only a few of the unsolved problems of hypertension. The treatment of hypertension especially with drugs, is then discussed in the light of these complex mechanisms.


Valve origin of the aortic incisura.

Valve origin of the aortic incisura. The occurrence and magnitude of the incisura of the central aortic pressure were shown in 66 patients to depend on the functional state of the aortic valve. In normal subjects and children with congenital aortic stenosis (with thin flexible leaflets), the incisura ranged between 6 and 14 mm Hg. With aortic regurgitation, the incisura diminished as the severity of regurgitation increased. With calcific aortic stenosis, the incisura was smaller or absent. These observations imply a valve mechanism productive of the incisura. In vitro studies of human aortic valves confirmed these observations. Additional in vitro studies with high speed cinematography (2,000 frames/sec) of a stented normal porcine valve also showed that early diastolic stretch and recoil of the leaflets occurs. These results indicate that in the presence of a normal or diseased aortic valve the aortic incisura is produced primarily by valve distension or recoil, respectively. Distension and rebound of the aortic walls do not appear to contribute significantly in the presence of a normal or a diseased valve. Because acquired aortic valve disease affects the magnitude of the central aortic incisura, inspection of the incisura may be of ancillary valve in evaluating the pathologic state of the aortic valve.


Thallium-20 1 myocardial perfusion scintigraphy for the clinical clarification of normal, abnormal and equivocal electrocardiographic stress tests. Sixty-five patients were studied with stress electrocardiography and thallium-20 1 relative myocardial perfusion scintigraphy. Results were correlated with selective coronary angiography. Scintigraphy was more sensitive (85 versus 67 percent), more specific (89 versus 63 percent) and significantly more accurate (87 versus 65 percent) than stress electrocardiography for the diagnosis of significant coronary arterial lesions in patients with isoelectric S-T segments at rest. Stress scintigraphy helped clarify the equivocal stress test due to left bundle branch block, left ventricular hypertrophy, drugs, hyperventilation and other conditions and was more accurate than the stress electrocardiogram (89 versus 53 percent) even in the presence of a depressed S-t segment at rest. Thallium-20 1 scintigraphy is a safe and simple noninvasive method for identifying abnormal myocardial perfusion, stress-induced ischemia and, indirectly, significant coronary arterial lesions.


Abnormal platelet survival time in men with myocardial infarction and normal coronary arteriogram. Platelet survival time was measured in eight men who had an acute transmural myocardial infarction and were subsequently found to have a normal coronary arteriogram. Platelet survival (chromium-51 labeling) was shortened in all men (2.4 +/- 0.11 days; average half-time +/- standard error of the mean) and different from that in eight age-matched normal men (3.7 +/- 0.08 days) (P less than 0.001). Three patients had recurrent venous thromboembolism and one had had iliofemoral arterial thromboembolism. Platelet survival was shortened (2.9 +/- 0.12 days) in 11 of 16 age-matched men with transmural infarction who had arteriographic evidence of coronary obstructive disease. These results suggest that platelet survival time is shortened in patients with infarction who subsequently are shown to have a normal coronary arteriogram and that arterial thrombosis may be responsible for the infarction.


Bruce treadmill test in children: normal values in a clinic population. The Bruce treadmill protocol is suitable for children as young as age 4 years. Maximal endurance time may be used as the sole criterion of exercise capacity, and normal values were established with 327 children having an innocent heart murmur. Mean endurance time in boys increased from 10.4 minutes at age 4 to 5 years, to 14.1 minutes at age 13 to 15 years. Mean endurance time in girls increased from 9.5 minutes at age 4 to 5 years to 12.3 minutes at age 10 to 12 years. Mean maximal heart rate ranged from 193 to 206 beats/min. Age differences in mean maximal and submaximal heart rates were small. There were negative correlations between endurance time and the ratio of weight to height. There were negative correlations between heart rates at treadmill stages 1 to 3 and the endurance times. The correlation coefficient of endurance time with maximal oxygen uptake was 0.88, but for clinical purposes endurance time alone is a satisfactory indicator of exercise performance.


Surgical significance of the coronary arterial anatomy in truncus arteriosus communis. In truncus arteriosus communis, as in other anomalies of conotruncal development, the coronary arterial anatomy not only differs from that found in the normal heart but also is subject to unpredictable variations. A consistently distinctive pattern was found in roughly two thirds of 31 cases, a frequency approximating that with which a distinctive coronary arterial pattern occurs in complete transposition of the great vessels. Surgical injury to a major coronary artery was identified in 2 of the 30 hearts from patients with truncus arteriosus communis who died in the early postoperative period. Of particular significance are large branches of the right coronary artery crossing the upper anterior surface of the right ventricle to supply the anterobasal surface of both ventricles and the upper part of the interventricular septum. These arteries are at special risk in surgical procedures utilizing a conduit anastomosed to a right ventriculotomy.


Termination of ventricular tachycardia with bursts of rapid ventricular pacing. Bursts of rapid ventricular pacing used during 573 episodes of ventricular tachycardia in 23 patients terminated 5 12 episodes (89 percent), with burst rates averaging 56 beats/min above the ventricular tachycardia rate, for 5 to 10 captures. Tachycardia was accelerated by pacing bursts to rates below 300 beats/min in 16 episodes (3 percent); 10 of these terminated spontaneously or responded to further bursts. Acceleration of heart rate to more than 300 beats/min or ventricular fibrillation occurred six times (1 percent), each episode requiring direct current cardioversion. Pacing bursts had no effect in 38 instances (7 percent), mostly in patients with terminal cardiogenic shock. Implantable pacemakers delivering bursts of rapid ventricular pacing were placed in two patients who have used these units at home. No deaths were associated with bursts of rapid ventricular pacing, which is an effective, rapid, pleasant alternative to repeated direct current cardioversion and a useful tool during electrophysiologic testing in patients with recurrent tachycardia.


Tortuosity as an index of the age and diameter increase of coronary collateral vessels in patients after acute myocardial infarction. A possible correlation among increase in diameter, lengthening or tortuosity and age of bypassed obstruction was investigated in coronary arterial collateral vessels. In 35 autopsy patients with a myocardial infarct of known age, as determined from clinical history and pathologic demonstration of an infarct of consistent age in the distribution of an obstructed vessel, 140 collateral vessels were identified in postmortem arteriograms and measurements made of their diameter and tortuosity. Multivariable regression analyses showed that collateral diameter and tortuosity increase with greater time after the infarction. It is suggested that identification of tortuosity in a coronary vessel may provide an indication that it functions as a collateral channel and of the degree of its dilatation and the time it has been a collateral channel. The lengthening that produces tortuosity probably arises from the same relaxation of medial tension that induces dilatation as a result of increased blood flow.


Angiographic evaluation of the natural history of normal coronary arteries and mild coronary atherosclerosis. Between September 1966 and September 1976, a group of 48 patients with normal coronary arteries or nonsignificant coronary atherosclerosis documented in a first coronary arteriogram underwent a second angiogram because of persistent or recurrent chest pain. The interval between studies was 13 to 108 months (mean 42 months). The indication for the first angiogram was typical or atypical anginal pain. The patients were separated into two groups according to the results of the first angiogram. Group I included 22 patients, 9 men and 13 women, with normal coronary arteries (mean age 49 years, range 28 to 62). Group II included 26 patients, 18 men and 8 women, with coronary stenosis of less than 50% of intraluminal diameter (mean age 49 years, range 38 to 63). The second angiogram revealed normal coronary arteries in all 22 patients in Group I but showed progression of diseases in 7 (27%) of the 26 patients in group II. The coronary arterial narrowings were greater than 50% in four patients and greater than 70% in only two patients. The clinical course, coronary risk factors and interval between angiograms were not useful predictors of progression of disease. The data suggest that coronary artery disease is unlikely to developed in adults with normal coronary arteries and that roughly 75% of adults with nonsignificant atherosclerosis will not show progression of disease over a 3 to 4 year period.