How physicians use laboratory tests.

How physicians use laboratory tests. The aim of our study was to measure the ways in which a physician perceives and reacts to a laboratory result. After reviewing a series of brief clinical problems, physicians were asked to indicate the change in test results that would alter the diagnosis or treatment. Although there were wide differences in attitudes, the pattern of responses from 125 internists offered estimates of what is a clinically important change. In selected clinical settings, the change in successive measurements chosen with the greatest frequency as indicators of a clinically important change in level were glucose, 35 mg/dl; BUN, 6 mg/dl; serum sodium, 4 to 6 mEq/liter; serum potassium, 4 to 6 mEq/liter; uric acid, 8 mg/dl; creatinine, 0.4 mg/dl; serum calcium, 4 to 5 mg/dl; triglycerides, 20 mg/dl; hemoglobin, 1 g/dl; and serum osmolality, 11 mOsm/kg. The responses were compared with estimates of laboratory precision drawn from a national quality control program. The quality of laboratory testing was rated as satisfactory for clinical use in four of five clinical settings. The study points out the need to correlate the activities in the clinical laboratory with the application of test results in the care of patients.


Chenotherapy for gallstone dissolution. II. Induced changes in bile composition and gallstone response. Changes in bile saturation and biliary bile acid composition in patients with gallstones who received chenodeoxycholic ("chenic") acid, cholic acid, or placebo were measured. Chenodeoxycholic induced bile desaturation; this effect was attributable solely to a decrease in the proportion of cholesterol. By gas chromatography, chenodeoxycholic acid increased substantially in the biliary bile acids of patients receiving it, and by mass spectrometry, no unusual bile acids were detected in appreciable amounts. Changes in bile saturation and biliary bile acid composition were then related to chenodeoxycholic acid dosage, and all of these variables were, in turn, related to gallstone response. In general, patients whose gallstones dissolved ingested a higher dose of chenodeoxycholic acid or had bile that contained a higher proportion of this acid and it was more unsaturated, but there were many exceptions, casting doubt on the value of a single analysis of fasting-state bile for predicting gallstone dissolutions. The major factor influencing response, provided dosage is adequate, appears to be gallstone type. Nonetheless, the proportion of chenodeoxycholic acid in biliary bile acids can probably be used to infer patient compliance.


Causes and consequences of placental growth retardation. Placental growth retardation caused 84 fetal and neonatal deaths per 100,000 births. Its frequency increased as mothers' diastolic blood pressure levels increased, an effect augmented by proteinuria. The perinatal deaths also increased with advancing maternal age, anemia, and poverty. Maternal weight gains were low in the involved pregnancies, and the fetuses and neonates who died had a pattern of growth retardation characteristic of fetal undernutrition. Microscopic abnormalities in the decidua and placenta were characteristic of inadequate perfusion of the placenta from the uterus. They included fibrinoid changes in the arteries and arterioles of the decidua, villous cytotrophoblastic hyperplasia, and an obliterative endarteritis in fetal stem arteries of the placenta.


Orbitofacial wounds and cerebral artery injuries caused by umbrella tips. Penetrating orbitofacial wounds inflicted by the sharp metal tips of umbrellas may go unrecognized. This type of injury is not generally appreciated as having fatal consequences. Immediate neurologic and radiologic evaluations are diagnostic. The value of computerized tomography and cerebral angiography is stressed.


What to do about tic douloureux.

What to do about tic douloureux. Tic douloureux is a common disease that causes excruciating pain. It is a central pain due to a lesion within the trigeminal nerve or brain stem. The majority of patients with tic douloureux are successfully treated by pharmacotherapy with phenytoin or carbamazepine. Those who fail under medical management should promptly be offered modern surgical alleviation of their pain: percutaneous radiofrequency gangliolysis or decompression of the trigeminal nerve at the brain stem (Jannetta procedure). The goal of surgical therapy should be pain relief with minimal sensory loss; the complications of surgery are usually due to denervation of the face or eye. Patients with tic douloureux should not be subjected to extraneous drug therapy or other procedures with a low likelihood of long-term success.


The extent and character of drug consumption during pregnancy. One hundred sixty-eight obstetrical patients' conditions were monitored prospectively throughout the prenatal, perinatal, and postpartum periods to obtain data on maternal drug consumption. In the prenatal period, all patients received at least two different drug products: 93.4% received five or more, while one patient reported taking 32 different products. The average number of drug products used in the prenatal period was 11.0. The mean perinatal exposure in patients undergoing vaginal delivery was 7.0. Analysis by therapeutic category was performed. Information gathered confirms the fact that pregnant women do take a large number of different types of medications, the consequences of which remain unknown.


The ethics of terminal care.

The ethics of terminal care. The widely used notion of dignity is questioned as an adequate ideal for care of terminally ill persons. Instead of dying with dignity, the essential ethical components of dying with a sense of worth are proposed as comprising truly humane and personal care.


A modified, simple device for the emergency administration of percutaneous transtracheal ventilation. Studies of percutaneous transtracheal ventilation with intermittent jets of oxygen under high pressure have demonstrated a tendency toward carbon dioxide retention and poor alveolar washout. A modification of the percutaneous transtracheal ventilation fevice to include an expiratory phase improves pulmonary gas exchange and minimizes the possibility of CO2 retention. The most common complication is subcutaneous emphysema caused by incorrect catheter placement. Although endotracheal intubation is unquestionably the treatment of choice, percutaneous transtracheal ventilation does offer a viable alternative when intubation cannot be rapidly accomplished.


Walk-out patients in the hospital emergency department. Four hundred twenty-six patients walked out of The Johns Hopkins Hospital Adult Emergency Department before being treated between April 1976 and March 1977. Of these, 179 were matched for sex, race, age, shift and presenting complaint with controls to identify the distinguishing characteristics of walk-out patients. Walk-out patients have recent onset of symptoms, report a great deal of pain and discomfort at the time of initial visit, and wait a relatively short period of time before walking out. They are, however, likely to report little continuing pain or discomfort one to two weeks after followup, although they believe that they still need care. Walk-out patients do not seem to be exposed to objectively worse treatment in the emergency departemnt but seem to have less subjective tolerance for waiting.


Evaluation of the emergency department as a site for hypertension screening. To see if the emergency department is an appropriate site for hypertension screening, the coverage, appropriateness of the target population and the adequacy of follow-up procedures were evaluated. The study was conducted in the Adult Emergency Department of The Johns Hopkins Hospital, which 61% of the community regard as their regular source of care. All patients had their blood pressure read in the emergency department. A reading of 95 diastolic or greater was used as the definition of hypertension. Data from the 1970 census and The Johns Hopkins outpatient department billing system were used to evaluate screening coverage. Data to judge the appropriateness of the target population and adequacy of follow-up were collected in a retrospective audit of a random sample of emergency department records. The overall prevalence rate of hypertensive blood pressure reading was 19.5%. Blood pressure was read in only 75% of sample cases. The potential screeining coverage ranged from 9.9% to 38.6% with an overall community coverage of 24.2%. Less than 10% of the detected hypertensives were referred for follow-up. Therefore, in some emergency departments, including the Adult Emergency Department of The Johns Hopkins Hospital, hypertension screening may be feasible.


Phencyclidine overdose: an emerging concept of management. Emergency physicians should be prepared to treat overdosage from phencyclidine, a common street drug abused throughout North America. A dearth of laboratory resources to establish the diagnosis makes it essential that diagnoses include awareness of symptomatology. A specific therapeutic approach utilizing ion-trapping by continuous gastric suctioning and acidification of urine and/or blood can be used successfully to treat these patients.


The EMS system and disaster planning: some observations. Disaster planning, one of the 15 essential components of the Emergency Medical Service System Act of 1973, should be the culmination of the establishment of other components. Regions have gone to varying lengths to describe disaster plans but how realistic the plans are is questionable. New York has planned for multiple casualty incidents (MCI) to care for victims of fires, explosions, structural collapses and major transportation incidents. The irrational emotional response in mass disasters conflicts with the rational disaster plans written by health planners. Drills of disaster plans are not realistic. One solution is to designate the next serious incident, such as a fire or traffic accident, a major MCI. The ability to handle an MCI is probably the best measure of an EMS system's effectiveness.


Zygomatic fractures in the emergency department: evaluation and treatment. Diagnosis of zygomatic fractures in the emergency department is possible by history and clinical signs together with a routine series of facial bone x-ray films. Three case reports are submitted to illustrate this approach, one case with obvious clinical signs and x-ray findings and two "unclear" cases where either the physical findings or the x-ray findings were equivocal. There may be pain, tenderness, cheekbone displacement subconjuctive hemorrhage and numbness, enophthalmos, and blurred vision. A Water's view is recommended for x-ray films. Zygomatic fractures are best treated in five to seven days; eye signs indicate earlier treatment. To treat, expose the probable fracture site and reduce under direct vision. The zygoma can be immobilized by passing a Kirschner wire through the body of the zygoma medially towards and through the lateral wall of the nose and into the bony nasal septum.


A descriptive study of nosocomial bacteremias at The Johns Hopkins Hospital, 1968--1974. Patient, infection and pathogen characteristics are analyzed for 935 cases of nosocomial bacteremia at The Johns Hopkins Hospital, 1968--1974. The overall nosocomial bacteremia attack rate was 4.1 cases per 1,000 hospital patients. Rougly 6% of all hospital deaths were among patients with nosocomial bacteremias. The case-fatality rate for the seven years was 37.1% compared with an overall hospital mortality rate of 2.7 deaths per 100 hospital patients. The mortality rate for the entire hospital and the case-fatality rate declined significantly (P less than 0.1) over the seven-year study period. There was a significant increase (P less than .01) in Gram-positive nosocomial bacteremias over the seven-year period. During the period, Bacteroides species and Escherichia coli bacteremias increased significantly (P less than .01) while Candida species and Klebsiella species bacteremias had significant decreases (P less than .01). The nosocomial bacteremia attack rate was high for infacts under one year of age, excluding newborns. The attack rates were low for young adults but increased markedly with age in adults older than 40. The cardiac surgery service had the highest nosocomial bacteremia attack rate of 12.4 cases per 1,000 patients. Hospital patients with infective diseases, neoplasms, digestive diseases, diseases of early infancy or circulatory diseases had a much greater risk of acquiring nosocomial bacteremias. Of the 935 cases, 9.5% had multiple episodes of bacteremia.


Association of blue rubber bleb nevus syndrome with chronic lymphocytic leukemia and hypernephroma. A male patient with clinical and pathologic features of blue rubber bleb nevus syndrome is described. Multiple hemangiomata were disseminated throughout the skin and gastrointestinal tract, and typical findings of B cell chronic lymphocytic leukemia and renal cell carcinoma were evident. This case demonstrates a unique instance of associated neoplasia in blue rubber bleb nevus syndrome.


[Clinical electrocardiographic diagnosis of the preinfarct state]. The management of 164 patients with a paroxysm of angina pectoris by a cardiologic emergency aid unit included, besides a clinical examination, the recording of the ECG in 12 commonly accepted and additional leads suggested by Neb, N.F. Gurevich, and Slapac--Partilla. The values of the atrial and the end portion of the ventricular complexes of the ECG were analysed. Three groups of patients were distinguished; group 1 with uncomplicated (stable) angina pectoris; group 2 with subacute and group 3 with acute preinfarction state. It was established that the severity of ischemic changes in the left ventricular myocardium and the pronounced character of changes in values charaterizing definite deficiency of left atrial bio-electric potentials correlate and grow successively from group 1 to group 3. Among the patients hospitalized with a state of preinfarction 53.9% developed myocardial infarction; in 89.9% of patients the localization of the necrosis coincided with the ischemic zones in the preinfarction state.


[Effectiveness of physical rehabilitation in myocardial infarct taking into account long-term observation data]. The article discusses the results of a one-year follow-up of 439 persons who had suffered from macrofocal or transmural myocardial infarction; aneurysm of the heart was suspected in 128 of them. Four to six months after recovery, 60.1% of patients with suspected aneurysm of the heart and 69.1% of those with transmural or macrofocal myocardial infarction were engaged in work involving small physical exertion. Mortality in the follow-up period after the end of the acute period of the disease was 8.6%, the incidence of recurrent myocardial infarction, 9.3%. Persons who had resumed work one year after recovery endured physical exertion better. There was no statistically significant difference in the frequency of recurrent myocardial infarction and in mortality depending on the size of the infarct suffered, while incapacity for work was encountered more frequently among persons in whom cardiac aneurysm has bee suspected.


[Intensive therapy and resuscitation of heart rhythm disorders in myocardial infarct patients and the role of express methods of controlling respiratory function]. The authors used a complex of express methods to examine respiration and acid-base equilibrium in the unit of intensive care and therapy. Examination by means of these methods during intensive therapy and resuscitation helps in individualizing the therapeutic measures. Various individual disorders of respiration were revealed during electroimpulse therapy in paroxysms of tachyarrhythmia, but the final effect of this treatment in restoration of the sinus rhythm had a beneficial influence on the dynamics of cardiogenic respiratory insufficiency.


[Prognosis in myocardial infarct complicated in the acute period by heart conduction disorders]. The influence of disorders of atrioventricular and intraventricular conduction, encountered in the acute period of myocardial infarction, on the immediate and remote prognosis of the disease was studied. In the acute period of myocardial infarction, III degree atrioventricular block and the right branch of the bundle of His block with the left posterior semiblock had a significant deteriorating effect on the prognosis. The remote prognosis was worse only due to the effect of III degree atrioventricular block.


[Hemodynamics in atrioventricular block in acute myocardial infarct and its changes under the influence of electric stimulation of the heart]. Hemodynamics was studied in the initial condition and against the background of electric stimulation of the heart in 18 patients with acute myocardial infarction complicated by complete atrioventricular block. It is shown that block promotes the development of circulatory insufficiency in patients with myocardial infarction. The marked character of hemodynamic disorders and the changes induced in it by electric stimulation are determined in many respects by the functional condition of the left ventricle. In most patients with acute myocardial infarction complicated by complete atrioventricular block, with the exception of those with a clinical picture of cardiogenic shock, the main values of hemodynamics demonstrated against the background of electric stimulation hardly differ from the corresponding values in patients with myocardial infarction and no disturbances of atrioventricular conduction. During electric stimulation of the heart in the contingent of patients examined, the external work of the heart and the "tension/time" index considerably increase which suggests a marked increase in the myocardium requirements in oxygen. The probability of unbalanced increase in the requirements of the myocardium in oxygen against the background of electric stimulation dictates the necessity for raising its parameters to optimum levels.


[Radioisotope studies in the practice of an intensive therapy department]. The article discusses the 10-year experience in the use of radioisotop diagnosis in the practice of an intensive therapy department. The results of the examination of over 300 patients who had been operated on under conditions of extracorporeal circulation are analyzed. With the use of radioactive indicators some new aspects of the pathophysiology of acute circulatory disorders were revealed, among others those related to the problem of blood deposition, the correlation between the functioning of the right and left parts of the heart; the diagnostic possibilities in appraising the causes of the disorders of circulation, functioning of the parenchymatous organs, and tissue blood flow were widened; the therapeutic tactics in the development of hypovolemia, acute cardiac failure, and disturbances in tissue perfusion could be elaborated.


[Procedural aspects and indications for using stimulation of the heart in the therapeutic clinic]. Temporary endocardial decelerating stimulation of the heart was conducted 151 times in 57 patients with various tachysystolic disorders of the rhythm. The values of central and intracardiac hemodynamics were studied in some patients against the background of decelerating stimulation. Definite groups of patients were distinguished according to the results of decelerating stimulation. In 17 patients decelerating stimulation of the heart served as an independent method of treatment of cardiac arrhythmias the underlying factor of which was the re-entry mechanism. In 11 patients paired and combined stimulation of the ventricles promoted the normalization of the values of hemodynamics and myocardial metabolism which had occurred against the background of severe disorders of the rhythm. In 14 patients with marked electric instability of the myocardium due to various causes, decelerating stimulation allowed time to be gained for choosing and carrying out adequate drug therapy.


[Stimulation of the heart in tachycardia]. The results of decelerating stimulation of the heart in 52 patients with tachysystolic complications of various etiology were studied. Paired and combined stimulation of the ventricles induced artificial rhythm in 41 patients (78.9%), in 5 patients (9.6%) the paroxysmus of tachycardia were arrested when the electrode was being inserted into the right ventricle. Favourable results were produced in 29 patients (70.7%).


[Transportation of patients with myocardial infarct complicated by cardiogenic shock and the use of countershock via an intra-aortic balloon]. The article deals with the first experience in the use of auxiliary circulation by contrapulsation with an intraaortic balloon during the transportation of patients with myocardial infarction complicated by cardiogenic shock from an unspecialized hospital to a cardiosurgical hospital. Transportation on the background of contrapulsation does not affect the efficacy of auxiliary circulation and does not lead to a recurrence. A conclusion is drawn on the experiency of using contrapulsation during transportation of patients with myocardial infarction complicated by cardiogenic shock to specialized cardiosurgical hospitals for continuation of auxiliary circulation and emergency revascularization of the myocardium.


[Clinical and pathogenetic characteristics of cardiogenic shock]. The clinical course of cardiogenic shock was studied in 441 patients with myocardial infarction. The incidence of this complication was found to be dependent on the variant of myocardial infarction and was 7.4% in primary, 14.2% in repeated myocardial infarction, and 22.2% in the recurrent variant. The duration of the shock was 3 to 4 days and its course indulant. Disorders of central and peripheral hemodynamics are of principal pathogenetic importance in cardiogenic shock; these were studied by the method of dilution of T-1824 dye. Of auxiliary importance are autoantigens entering the blood from the zone of myocardial infarction 6 hours after the onset of the disease and possessing depressor, negative inotropic and cardiotoxic properties. This was established in experiments on intact and sensitized dogs. One of the components of the shock in a second attack of myocardial infarction or in recurrent infarction may be anaphylactic shock due to reaction of autoantibodies, circulating in blood after the first myocardial infarction, with the autoantigens arriving from the focus of the fresh necrosis.


[Prolonged catheterization of the left atrium in assessing the circulatory state following the surgical correction of a mitral heart defect]. Left-atrial pressure was measured in 36 patients 24 hours to 6 days after surgical correction of the mitral valve under conditions of extracorporeal circulation. The interrelation of the average pressure in the left atrium and the pressure in the right atrium, the end-diastolic pressure in the pulmonary trunk, the cardiac index, and the circulation volume was studied. Normal relation between the average pressure in the left atrium and that in the right atrium was observed in only 1/3 of the patients. The end-diastolic pressure in the pulmonary trunk was close to the pressure in the left atrium in value only in patients with pulmonary-arterial resistance below 220 dyn.s.cm--5. Normal values of the cardiac index were in most patients encountered when the average pressure in the left atrium ranged from 12 to 15 mm Hg. On the basis of the measurement of average pressure in the left atrium, the value of the cardiac index, and the average arterial pressure the tactics in the management of patients after surgical correction of mitral heart disease have been developed.


[Lesion of the heart in exotoxic shock]. The functional condition of the heart in exotoxic shock, the most severe complication in the early toxicogenic form of acute poisoning, was studied in 230 patients in whom shock had developed on the background of severe acute poisoning with fluid caustics, dichloroethane, organophosphoric insecticides or soporifics. The results of the studies show that in the phase of compensated shock the revealed disorders are mainly due to the compensatory intensification of the cardiac activity in response to the "chemical trauma". Affection of the contractile myocardium in this period of shock does not play any noticeable role in the development of hemodynamic disorders, the only exception are cases in which the preparation that had caused the poisoning possesses a specific cardiotoxic effect ("primary specific cardiotoxic effect"). The increase of the general phenomena of disorders of microcirculation and hypoxia leads to diminution of the enzyme control of metabolic processes in the myocardium and the development of secondary dystrophic changes in the myocardial fibre ("secondary nonspecific cardiotoxic effect").


[Heart rhythm disorders and blood rehology in ischemic heart disease]. Blood rheology was studied in 92 patients with ischemic heart disease having cardiac rhythm disorders. The syndrome of high blood viscosity and increased blood platelets aggregation were observed in paroxysmal tachycardia. In patients suffering from myocardial infarction with arrhythmia there was noted higher blood viscosity and more intensive blood platelet aggregation than in atherosclerotic cardiosclerosis. Treatment of paroxysmal tachycardia by means of electric impulse and agents blocking beta-adrenergic receptors results in a decrease of blood viscosity, the blood platelets aggregation intensity being unchanged.


[Changes in the indications and techniques in the surgery of retrobulbar orbital tumours (author's transl)]. In the past 3 decades, surgery of retrobulbar tumours was mainly done by neurosurgeions (transfrontal orbital approach) or ENT surgeons (transethmoidal approach), especially in Europe. More recently, especially in USA this has changed and the majority of these cases, in an increasing number of hospitals, are now treated by a modified Krönlein operation, usually performed by ophthalmic surgeons. In this paper we tried to elucidate the background of this development. Ultrasound exophthalmometry (Fig. 3), ultrasound A- and B-scans of the orbital tissues (Fig. 4 and 5) and computerized axial X-ray-tomography of the orbits (Fig. 6) improved the preoperative diagnoses markedly. In the most cases it is now possible to decide preoperatively on the existence, size and location (and sometimes even on the nature) of a spaceoccupying lesion in the orbit. The technic and the instruments for Krönlein's operation have been improved (Krönlein-Berke, Fig. 8-11). The oscillating saw (Stryker) facilitates the resection of the bone, and microsurgical technics are now preferred for removal of the tumour from the orbit. The modified Krönlein operation is also recommended for orbital decompression in severe endocrine exophthalmos, provided the lateral orbital wall is removed to the described extent.


[Pigmented paravenous retino-choroidal atrophy (author's transl)]. A 22-year-old man presented a typical appearance of pigmented paravenous retino-choroidal atrophy. Fluorescein angiography demonstrated a profound loss of the choriocapillaris in the affected areas. The amplitude of the scotopic and photopic electroretinogramme response was reduced. The electro-oculographic light rise was normal.


[Macular haemorrhage in dengue fever (author's transl)]. During the course of a dengue infection a 25-year-old female patient developed intraretinal haemorrhage in the mucula region of both eyes. This complication is interpreted as a result of a generalized tendency to bleed, which is typical for this disorder.


[Multiple corneal foreign bodies after auto-scooter driving in a fair (author's transl)]. We have observed of numerous superficial corneal foreign bodies especially in young patients (22 cases) driving so-called auto-scooters at a fair.


[Postoperative fitting of soft contact lenses in aphakia. (A trial with Weicon 38 and Weicon 72) (author's transl)]. In a controlled clinical pilot study 48 aphakic eyes were fitted with HEMA soft lenses on the 3rd postoperative day. An optically satisfactory and wearable fit was obtained neither with the conventional hydrated Weicon 38, nor with the highly hydrophilic Weicon 72. The main reasons were centralizing and motility defects of the lenses, which might be eliminated by an improved lens design. A further 57 patients showed an increase in corneal thickness following cataract extraction. The early fitting of permanent soft aphakic lenses should be delayed until the 4th day postoperatively, by which time the oedema has reduced and the cornea has reached approximately its pre-operative thickness.


[Eye-symptoms in a case of lactate acidosis caused by Biguanide-therapy (author's transl)]. A report is given of a case in which visual disorders had preceded an excess lactate coma. In both eyes evolution of an intense papillary and retinal edema with, in a high degree narrowed vessels and retinal hemorrhages.


[Topographical diagnosis of orbital lesions with contact B-scan ultrasonography (author's transl)]. With contact B-scan ultrasongraphy it is possible, to determine the topographical relations of space occupieing lesions to the main orbital structures. This enables the examiner to answer three important questions: (1) In which part of the orbit the lesion is located? (2) Is the proptosis produced by a lesion separate from the muscles and the optic nerve or (3) are these structures themselves affected? Our results are compared with those made by A-scan ultrasonography. The existing range of echographical patterns known of orbital tumors is thus widened by the topographical diagnosis elicited by contact B-scan ultrasonography.


[Synthesis of glaucoma problems (author's transl)]. Author intends to unite the part results of the glaucoma research (viz. blood vessel system, blood chemism, chamber angle, vegetative reflexes, psychosomatic factors, central effects) in a synthesis. The outcome of this synthesis is displayed in a schematic table.


[The influence of healing on the long-term effect of trabeculotomy in primary open angle glaucoma (author's transl)]. 83 eyes underwent a re-examination 3-7 years after trabeculotomy. By surgery alone the diurnal curve in 58 out of 74 eyes (78 percent) was regulated. In the majority of the other eyes additional medication controlled the i.o. pressure. There was no secondary cataract or other late complication. In 5 eyes there was a moderate deterioration of glaucomatous field defects without a decrease of visual acuity. The average i.o. pressure increased 2 mm Hg during the first 6 months postop., later on it was constant. The scarring processes in the chamber angle known from experimental surgery seemed to come to an end usually 6 months postoperatively. To judge the final result of trabeculotomy a postoperative follow-up of 6 months is necessary.


[Direct ciliary body coagulation as a treatment for various forms of glaucoma (author's transl)]. At the University eye clinic in Mainz a new method was carried out on 40 patients to coagulate the ciliary body whereby this was laid open and directly coagulated. In the post operative stage within the first 4 weeks a further increase of pressure could be observed in 3 cases only. The other patients, who have been observed up to 15 months, did not show any further increase of pressure and are well. This operation method is commendable especially in the cases of hemorhagic and absolute glaucoma.


[Indications and limitations of fibrinolytic therapy for central artery occlusion (author's transl)]. Fibrinolytic therapy was started 90 min after central retinal occlusion in a 62-year-old male patient, but the retinal function did not recover. Another patient, aged 64 years, with occlusion of a retinal artery branch, had therapy started only 6 hours after the event and showed full recovery as was documented by angiography. General contraindications against fibrinolytic therapy are: hypertension over 200 mm Hg, arteriosclerosis, diabetes with retinal changes, previous cerebral insults, malignancy or ulcer, hepatocirrhosis, recent surgical or angiographic interventions, renal insufficiency, pregnancy, cogenital or acquired abnormal blood coagulation. If these contraindications do not apply, fibrinolytic therapy of central retinal arterial obstruction is recommended provided this therapy can be started not later than 6 hours after the event. Occlusions of the central retinal vein should have fibrinolytic therapy only if there are very few haemorrhages and if the occlusion is not older than 24 hours.


[A suggestion on the microsurgical treatment of the persistent hyperplastic primary vitreous body (PHPV) (author's transl)]. Three children suffering from PHPV are described, who originally had been sent to the hospital because of suspected retinoblastoma. Exstirpation of the PHPV after opening the anterior chamber with a corneal cut of 180 degrees under the microscope seems a recommendable treatment. The A. hyaloidea has to be observed carefully during the preparation. In order to avoid massive hemorrhage into the vitreous, it is necessary to ligate this vessel before cutting. The cosmetical results were good but the visual acuity was unsatisfactory. The problems arising after a successful operation of the PHPV are similar to those in children with unilateral cataract.


[Results of surgical treatment in intermittent divergent squint with deliberate overcorrection (author's transl)]. A review is given of 28 cases (39 surgical procedures) with intermittent exotropia. Prior to surgery a prismatic correction was prescribed and gradually increased to stabilize the objective angle. The amount of surgery was calculated to give a slight overcorrection (approximately 5 degrees). Follow up over a 6 months period revealed better results if overcorrection was achieved. Consecutive esotropia occured if the surgery did not make proper allowances for distance/near ratios of the objective angle. Secondary surgery was delayed up to 6 months. Spectacle occlusion followed by base-out prisms were prescribed in any case of overcorrection until bifoveal fixation could be maintained.


[Lens caused shifts in color co-ordinates measured on the ocular fundus (author's transl)]. Changes in certain areas of the ocular fundus are frequently accompanied by changes in the spectral distribution of the reflected light. In many diseases of the ocular fundus, it is desirable to have an objective difinition of the color of the fundus during a particular phase of the disease. An instrument designed by Carl Zeiss, Oberkochen, West Germany, provides a satisfactory solution to the problem of measuring color on the ocular fundus. Transformational equations make it possible to convert the measurement parameters obtained by visual comparison into standardized color measurment values. The measurement error is slighter than necessary for clinical examinations. The possible influence of the ocular lens's own color on the color co-ordinates measured on the fundus was examined. Measurement of fundus color in three suitable situations showed no differences in color coordinates on the fundus between aphakic eyes of younger patients and eyes containing lenses. Incipient cataracts cause only a slight shift of the color co-ordinates. More marked cataracts cannot lead to erroneous interpretation of the measurement results, since measurement with this method is no longer technically possible in such cases.


[Nuclear-technical diagnosis procedures in clinical ophthalmology (author's transl)]. Recently in nuclear medicine two diagnostic methods have been developed: the topographical diagnosis utilizing mobile probes or scanners and the advanced diagnosis of function with the scintillation gamma camera. A similar trend is encountered in ophthalmic nuclear medicine.


[The ultrastructure of the terminal segments of the human lacrimal gland (author's transl)]. Eleven human lacrimal glands of patients between the age of 13 months and 42 years were examined. The following results were obtained: 1. The human lacrimal gland shows a tubuloacinous structure. 2. The cells of the gland epithelium are high cylindrical to conical. The height of the cells depends on the functional state. 3. The secretory epithelium shows different cell types: Most cells have pale cytoplasm and different coloured prosecretory granules. Also there are cells with pale cytoplasm and few prosecretory granules, and cells with dark cytoplasm and many osmiophile prosecretory granules and finally a few cells with dark cytoplasm and very few prosecretory granules. 4. The different cell types represent most likely different stages of the cycle of secretion within the lacrimal gland. 5. The myopithelial cells show a dependence of the functional state of the gland epithelium.


[Studies of the lymph drainage of the eye. 4. Drainage of lymphotropic radioactive tracers (99mTc-Microcolloid) after intravitreal injection (author's transl)]. In 7 rabbits the drainage of 99mTc-labelled Micro-colloid from the vitreous body of the eye was studied. In vivo measurements with an Anger-type camera were undertaken as well as in vitro measurements after dissection and excision of tissue-probes. From the data followed that indicator's elimination half-life from the vitreous body was on an average 7.8 hours. The drainage occurred partially along structures which are associated to the optic nerve. Furthermore drainage to the ipsilateral retrobulbar space and to the regional cervical lymph nodes, mainly to the bilateral deep cervical lymph nodes could be observed.


[Impaired visual perception in progressive multifocal leukoencephalopathy; a clinical diagnosis based on sequential computerized axial tomography (author's transl)]. Progressive multifocal leukoencephalopathy (PML) is a viral illness affecting principally cerebral white matter of patients, who have diminished immunologic resistance. A patient is presented, whose initial complaint was blurred vision. Relentless progression over a period of seven months to left hemianopsia, prosopagnosia, alexia with agraphia and eventually cortical blindness was observed. Accompanying the visual impairment was a steady deterioration of mental function. Sequential computerized axial tomography defined low density lesions in the occipital white matter with sparing of the cortical ribbon. As hemianopsia progressed to cortical blindness, the scans confirmed the evolution of bilaterial occipital lesions. The diagnosis was made clinically and established on histological and cultural grounds. Computerized tomography seems to be valuable in diagnosis and monitoring progress of PML.


Sea blue histiocytosis. A clinical cytologic and nosographic study on 23 cases. The authors examine the main clinical, cytologic and nosographic aspects of conditions and syndromes associated with SBH on the basis of the literature data (about 40 cases) and 23 personal ones. It is necessary to distinguish between three nosological conditions of SBH: hereditary disease, hereditary asymptomatic, acquired per se asymptomatic. From the clinical viewpoint less a half of all SBH cases are hereditary and present a syndrome based on splenomegaly, periodic hemorrhagic diathesis (due to variable thrombocytopenia), not rarely associated with hepatomegaly and lung or nervous system changes (often eyes are involved). There is also a second SBH hereditary form, vary rare and clinically different from the former, determined by deficiency of plasma-lecitin-cholesterol acyltransferase. The peculiar features of SBH are discussed by means of optical, cytochemical, electron microscopical investigations which point out the polymorphous aspect of these "famished" macrophages. The material stored by SBH is heterogeneous and the enzymatic defect of the most frequent form still remains obscure. The presence of SBH in different haemopathies has an analogous significance as Gaucher's cells found outside Gaucher's disease. It is impossible today to deny the existence of two well-identified SBHS.


Effect of prolonged low-dose infusions of ile5-angiotensin ii on blood pressure, aldosterone and electrolyte excretion in sodium replete man. Two healthy young males on a constant normal sodium diet (135 mM/day) were infused for 132 h with 3 ng/kg/min of angiotensin II. Plasma angiotensin II levels were therby raised to the range of moderate sodium depletion. Plasma aldosterone and the urinary excretion rate of aldosterone-18-glucuronide were markedly increased during the whole infusion period and returned to control levels after the infusion was stopped. A slight tendency of aldosterone secretion to decrease towards the end of infusion was probably due to sodium retention (appr. 200 mM and 350 mM respectively) and to a fall in plasma potassium by approximately 0.5 mM/1. Plasma aldosterone during infusion, maintained circadian variations similar to those of cortisol. Plasma cortisol patterns were unaffected by angiotensin II. Blood pressure increased gradually during angiotensin II infusion, reflecting changes in sodium balance. The results, differing from those of studies in dog and sheep, support the assumption that angiotensin II is an important regulator of aldosterone secretion in man rather than a merely permissive factor.


[Amniotic fluid insulin content as a parameter in assessing fetal condition in diabetic pregnancy (author's transl)]. The average insulin level in the amniotic fluid rises between the 27th and 40th week of pregnancy from 8 muU/ml to 17 muU/ml (n equal to 62). In diabetic pregnancy, the insulin level in the amniotic fluid is in the average elevated to 488%. This indicates oversupply of glucose to the fetus. In the healthy fetus the intercellular apparatus reacts by overproduction of insulin. Part of this insulin reaches the amniotic fluid via the urine. The fetus is in the paradoxical situation of showing simultaneously elevated glucose and insulin levels. The resulting surfeit of insulin is the cause of diabetogenic fetal morbidity. Amniotic fluid insulin levels can be used both to evaluate diabetogenic fetal morbidity, and in order to allow metabolic compensation with insulin to be carried out in accordance with fetal parameters in pregnancy. Examination of the amniotic fluid at bi-weekly intervals from week 27 on thus provides a means of adjusting the metabolic compensation with insulin in the diabetic mother in such a way that diabetogenic fetal morbidity is prevented.


[Enteral absorption of high calcium doses determined by means of stable isotopes (author's transl)]. The calcium absorption was determined in 8 healthy test persons (average age 25.6 years) after oral administration of 500 mg and 1000 mg of this element. A double isotope method with enriched stable calcium isotopes was used which can be applied without any restriction as, unlike in radiotracer techniques, any exposure to ionizing radiation is avoided. The calcium administered orally was labelled with 48Ca, the CaCl2 injected intravenously with 46Ca. The determination of both isotopes in serum and urine samples was carried out by means of neutron activation analysis. Independent of the calcium dose given, an absorption of 30% was found. From the 46Ca content in the serum samples a mean value of 6.4 +/- 1.0 g calcium or 98.8 +/- 15.4 mg Ca/kg body weight was calculated for the 24 hr-exchangeable calcium body pool.


[Computer system for the automatic analysis of cath-lab data. Reliability of pattern-recognition and measurements (author's transl)]. The computer-system for the on-line-analysis of hemodynamic data developed in Aachen enables the clinical user to perform the immediate on-line analysis of ECG, pressure-curves and thermo- or dye-dilution-curves in a dialog mode. The procedure of pressure analysis as well as the calculations by the computer for the individual haemodynamic parameters are described. The comparison of the medical-manual evaluation of the pressure curves on paper-registration and the computer results of the same measurement shows a very good correlation for wave-recognitions and wave-measurements for this system, integrated in the daily routine since 24 months. As well in the application of various fluid-filled catheters used in praxis as in tip-manometers it could be proved for the pressure-analysis in the different positions of the heart, that the computer-system produced reliable evaluations for all catheter materials used. The flexible conception of the computer program with its fast adaption to new problems allows its use not only in the clinical routine, but also and especially in the handling of scientific questions in the frame-work of haemodynamic analysis.


[Plasma digoxin concentration in different age groups (author's transl)]. Plasma digoxin concentration during maintenance therapy with digoxin was determined in premature and mature newborns, infants, children and adults. The plasma digoxin concentration of newborns was significantly higher than in adults; in addition, in the group of premature newborns it also was higher than in infants and children. These differences in plasma digoxin concentrations may be explained by differences in dose, volume of distribution and excretion rate of digoxin in the various age groups.


Non-interaction of spironolactone medication and cortisol metabolism in man. In 5 healthy subjects and in 5 patients with decompensated liver diseases, the concentrations of cortisol, canrenone and canrenoate-K were determined after single doses and after a long-term treatment with spironolactone. The concentrations of the metabolites of spironolactone were determined fluorimetrically, those of cortisol by a highly specific radioimmunoassay with previous chromatographic separation. As a result, non-interaction between spironolactone medication and cortisol metabolism, even at high dose and long-term treatment conditions, was established neither in normal test subjects nor in patients with liver failure.


[Myasthenic syndrome during penicillamine treatment (author's transl)]. The clinical and electrophysiological findings in 2 men who had developed a myasthenic syndrome after taking penicillamine for rheumatoid arthritis will be described. The symptoms began with dysfunction of the eye muscles following a generalised muscle weakness. Course of illness after withdrawal of penicillamine was not uniform. In one of the patients a complete remission occurred within a year. The other became steadily worse and required continuous treatment with cholinesterase inhibitors. Electrophysiological examinations showed neuromuscular blockade, posttetanic exhaustion, posttetanic potentiation was found in one patient only. An immunopharmacological block of acetylcholine receptors induced by penicillamine is discussed from a pathogenetical point of view.


A possible mechanism of demyelination of the Syrian hamster with hindleg paralysis. Electron microscopic studies of the spinal roots and the sciatic nerves of mutant hamsters with hindleg paralysis and of similar age control animals are reported. Fibrillary accumulations, some of which showed a crystalloid organization, were found in the inner loops of the myelin sheath. These changes were severe in the mutant but only mild in the controls. Moreover, the mutant alone showed demyelination with apparent sparing of the Schwann cell perikaryon and subsequent remyelination. A possible mechanism relating the fibrillary accumulations to the demyelination is discussed.


[Drug treatment of primary hyperlipoproteinemia (author's transl)]. Cardiovascular disease has become the major cause of death in the Western countries. There is strong evidence that elevations of serum lipids contribute to the pathogenesis of premature atherosclerosis. The classification of the hyperlipoproteinemias has been most beneficial as a guide to development of dietary and pharmacological regimens for lowering serum lipid concentrations. The results of dietary and drug prevention trials are discussed. Insight into the mechanisms involved in lipoprotein metabolism as well as the mode of action and of side-effects of hypolipidemic drugs is reviewed. Using present knowledge of heart disease research, it is reasonable to suggest dietary and drug treatments for the high risk patient.


Early appearance and mitotic activity of multinucleated giant cells in mice after combined injection of talc and prednisolone acetate. A model for studying rapid histiocytic polykarion formation in vivo. Combined intraperitoneal injection of talc and particulate prednisolone acetate resulted in the formation of significant numbers of multinucleated giant cells within 48 hours. Neither one of these two agents had a comparable effect when injected alone. Evidence is presented showing that the multinucleated giant cells arose by cell fusion. Synchronous nuclear division could be observed in a considerable proportion of newly formed polykarions. Although the late prophases were usually normal, high proportions of abnormal mitotic figures were observed at later stages of mitosis, particularly in anaphase and telophase. The chromosome abnormalities were so severe that it is highly improbable that mitosis led to successful nuclear multiplication within a given syncytium. Similar to prednisolone acetate, prednisone elicited the formation of multinucleated giant cells when injected with talc. No polykarion formation was observed, however, when prednisolone acetate was substituted for other steroid preparations of similar particle size such as cortexon acetate, cortisone, or testosterone isobutyrate.


Systemic effects of the VX2 carcinoma on the osseous skeleton. A quantitative study of trabecular bone. The skeleton of rabbits bearing the transplantable VX2 carcinoma has been studied by a combination of radiographic and histomorphometric techniques. It has previously been shown that this tumor produces and secretes large amounts of prostaglandin E2. In vivo experiments, as well as cell and organ culture studies, have led to the conclusion that the hyerpcalcemia observed in tumor-bearing rabbits is due to excessive secretion of prostaglandin E2 by the tumor and its subsequent action on bone throughout the organism. Our new findings reveal (1) no evidence of local invasion of bone by the VX2 tumor or osseous metastases; (2) radiographic evidence of generalized osteopenia; (3) histomorphometric documentation in trabecular bone of reduced volume density of bone matrix, consistent with increased resorption in trabecular bone at sites distant from tumor; and (4) a marked generalized reduction in surface density of osteoblastic layers, volume density of osteoid, osteoid seam thickness, and surface density of osteoid. These findings in trabecular bone of iliac crest and vertebra offer quantitative data in support of the conclusion that VX2 carcinoma affects skeletal metabolism systemically.


Response of lymphoid leukemia L1210 in mice to implantable sustained release cytosine arabinoside capsules. The lifespan of BDF mice with ascitic L1210 leukemia is more than doubled when they are treated with a single subcutaneously or intraperitoneally implanted sustained release cytosine arabinoside capsule. These capsules are drug-polymer composites, with dimensions of 1.0 cm in diameter and 0.15 cm in thickness, and a drug content of 17 +/- 3 mg each. Blank silicone rubber discs implanted intraperitoneally or subcutaneously in the leukemic mice produced no beneficial effects. Control healthy mice receiving the ARA-C releasing capsules continued to live with no obvious signs of drug toxicity. In vitro release of ARA-C from the discs was measured. Drug release was maintained above 20 micrograms per day for more than 35 days. ARA-C extracted from discs recovered from implant studies showed that less than 16% of the total drug content was released in vivo.


Intraoral basal cell carcinoma.

Intraoral basal cell carcinoma. The evaluation and treatment of an intraoral lesion over a period of 8 years is presented. Clinical appearance and course, microscopic findings, and response to treatment were consistent with a diagnosis of basal cell carcinoma of the mucous membrane. Current theories of histogenesis and the biological behavior of basal cell lesions are discussed.


Experiences with intra-arterial chemotherapy for head and neck cancer. During the 10-year period from 1966-1975, 250 patients with various head and neck cancers were treated by intra-arterial chemotherapy using single agents or various combinations. Only 15 patients showed response of I-C category according to Karnofsky's criteria, and 100 patients had I-B response. Another 100 patients showed I-A category of response and 35 patient had progressive disease out of which 5 patients exhibited excessive toxicity to drugs, eventually succumbing to it. A majority of patients in nonresponding (O-O) category and I-A category were earlier treated by radiotherapy, and intra-arterial chemotherapy was given for recurrent disease. The responses were relatively good whenever chemotherapy was given as a primary treatment before surgery and radiotherapy. Again response was additive when chemotherapy was given concurrently with radiotherapy.


Serum fucose as a monitor for recurrent malignancy. Serum fucose determinations were performed on 19 patients with "stable" or "inactive" malignancies, 33 patients with "active" malignancies, and 14 "normals." A significant difference in the values between "normal" and "stable" patients and those with "active" cancer is shown. A role for this relatively simple serological test for diagnosing and following metastatic cancer is suggested.


Chemotherapy in recurrent noncystic low-grade astrocytomas of the cerebrum in children. Six children with grade II astrocytomas were treated with combination chemotherapy consisting of 1,3 bis(2-chloroethyl) 1-nitrosourea (BCNU). Vincristine (VCR), intrathecal Methotrexate (i.t. MTX), and Dexamethasone. Of the children, 3 showed a partial remission, and 1 other showed clinical improvement. Our data suggest that chemotherapy is effective in low-grade astrocytomas, and there is now a need for larger trials in low-grade astrocytomas to document the role of chemotherapy accurately in these tumors. It is suggested that trials of chemotherapy as adjuvant to surgery and radiotherapy should be initiated.


Needle biopsy of endothoracic neoformations: a five-year experience. We dwell upon the importance of percutaneous biopsy in the diagnosis of endothoracic masses, comparing the results of the cutting needles to those of the fine needle aspiration biopsy. We began utilizing the Vim-Silverman needle with good results (73.7% diagnoses) and a small number of complications, only 1 of which needed treatment, but in the light of the severe and lethal complications described in the literature, we came to prefer the use of the fine needle aspiration technique, which provided good results, too, (74% diagnoses) and enlarged the diagnostic range of the percutaneous biopsy of the lung in cases of deep, or mediastinal masses. We also hold that the use of cutting needles should not be given up: in fact when a technically good smear from an aspiration biopsy does not allow a diagnosis, we usually repeat the biopsy using a cutting needle, if there is no contraindication.


Excretory urography in evaluation of the surgical cancer patient. Excretory urography was performed routinely in 504 patients with sarcoma, melanoma, pelvic, head and neck, or other localized tumors over a 5-year period. There were benign abnormalities in 14.4% of the patients examined, tumor associated abnormalities in 10.7%, and 1.4% false positives. The diagnosis of a benign lesion did not change cancer therapy in any patient. Findings on excretory urography were valuable in the management of patients with pelvic and intra-abdominal tumors. In these patients ureteral obstruction was always caused by tumor. There was a high rate of false positively in non-abdominal tumors. No second primary tumors were found.


The effect of mixed distributions on the methods of survival analysis. A study of the effectiveness of preoperative radiation as an adjuvant for surgery for patients with invasive bladder carcinoma revealed a subpopulation of patients having advanced disease who could not benefit from radiation treatment. The effect of such a group of patients on the efficiency of 2 common nonparametric tests is investigated here. Both Gehan's tests and Greenwood's tests were shown to have a very low efficiency when compared with a parametric test when this group of patients is present.


The usefulness of pretreatment DNCB in 85 patients with squamous cell carcinoma of the upper aerodigestive tract. Pretreatment DNCB skin testing and absolute lymphocyte counts were studied in 85 consecutive head and neck cancer patients. All patients were treated primarily with radiation therapy alone or combined radiation plus surgery. The results of DNCB testing and absolute lymphocyte counts were not sufficiently predictive of outcome, (no evidence of disease after 2 years) to be useful in making treatment decisions on an individual patient. This applied to the good prognosis (T1, T2, N0-N3) and poor prognosis (T3, T4, N0-N3) groups.


Cryosurgical treatment of aneurysmal bone cysts. An aneurysmal bone cyst is a benign, locally aggressive bone process which frequently recurs after excochleation. Exocochleation can be extended without loss of bone tissue by making use of cryosurgery. This combined technique was used in the treatment of 5 patients, without complications. None of the patients described had a demonstrable recurrence 12-60 (average 35) months after this combined therapy.


Rest therapy for rheumatoid arthritis.

Rest therapy for rheumatoid arthritis. Rest therapy in rheumatoid arthritis has long been controversial. Available evidence indicates that exercise increases joint inflammation and destruction and rest reduces inflammation. Hospitalization may produce improvement in inflammation, which is sometimes marked. Fatigue, a frequent and often prominent symptom of rheumatoid arthritis, is a guide to therapy. Sufficient rest to prevent fatigue combined with appropriate physical therapy would be expected to improve the treatment of rheumatoid arthritis.


Infectious mononucleosis in the older patient. Six cases of infectious mononucleosis in patients more than 60 years old were reviewed. The geriatric patient with infectious mononucleosis often presents with nonspecific constitutional symptoms, without exudative pharyngitis. The disease may present as fever of obscure origin or mimic chronic lymphocytic leukemia in this age group. Diagnosis is established through characteristic findings on hematologic and serologic studies.


Fluorescent thyroid scanning. A method based on stable iodine measurements. Analysis by x-ray fluorescence allows in vitro determination of iodine content of the thyroid gland and a mapping of the regional distribution of iodine in the gland. The picture produced is similar to that of the conventional radioisotope thyroid scan. In 5 normal subjects and 70 patients with thyroid disease, the thyroid concentration of iodine varied between undetectable and 28 mg. With the exception of hypothyroid patients, who showed low thyroid levels of iodine, all patients showed iodine values overlapping the normal range. The fluorescent scan gave results similar to those of the isotope scan in most cases. Exceptions were noted in some hypothyroid patients, patients with flooded iodine pool, and patients receiving suppressive doses of exogenous thyroid hormone. Small cold nodules were best detected by the radionuclide scintigram. The value of the fluorescent scan is in its low radiation dose and in the possibility it affords of studying patients whose thyroid glands have reduced uptake of the radioactive tracer.


Deferoxamine-chelatable iron in hemochromatosis and other disorders of iron overload. Deferoxamine-chelatable iron was measured in 103 patients with known or suspected iron overload. All of 34 patients with untreated hemochromatosis had distinctly elevated values for deferoxamine-chelatable iron. The mean value in these cases was significantly greater than that in patients with cirrhosis, who had little or no stainable hepatic iron. In 15 patients with hemochromatosis who were tested sequentially during the course of phlebotomy therapy, deferoxamine-chelatable iron proved a reliable index of the degree of reduction of storage iron. In 22 additional patients with partially treated hemochromatosis and 14 with iron overload accompanying chronic anemia, this test correlated well with the magnitude of iron deposits in liver or bone marrow. In patients with unexplained elevations of serum iron, normal or only slightly elevated deferoxamine-chelatable iron correctly indicated that storage (hepatic) iron was not excessive. The test was more reliable than determination of serum iron or transferrin saturation as an indicator of increased storage iron. Elevated values could not be attributed to disturbed liver function. Determination of deferoxamine-chelatable iron is a safe, practical, and useful procedure for identifying persons with increased iron stores and for assessing the effect of phlebotomy therapy.


Rehabilitation techniques for patients with amyotrophic lateral sclerosis. Rehabilitation techniques for the management of patients with amyotrophic lateral sclerosis are aimed at maintaining the patients at their optimum functional levels for as long as possible and at preventing complications secondary to disuse of muscles and immobilization. A functional staging of patients is proposed which is helpful in categorizing them in reference to the type of rehabilitative techniques required and the kinds of assistive devices needed.


Medical fee and service advertising: a response from physicians. Restrictions on advertising about services performed by professional groups have recently been questioned by the government and consumerists. The purpose of this study was to determine physicians' attitudes about the use of advertising in their profession and also to compare these results with responses from dentists, attorneys, and accountants. While a survey of these groups in three metropolitan areas indicate mild support for advertising in general, there was a definite negative reaction to advertising in the respective professions. Participants also reported their attitudes about the effects of advertising on prices and fees, quality of services, and public expectation and governmental regulations. The concepts of social marketing and informative advertising are suggested as approaches that may meet the requirements of both the government and the professions.


Understanding the growth of emergency department utilization. Much research on utilization of hospital emergency departments has been published over the past 10 to 15 years. It has failed to yield a coherent view of why the volume of use has increased, however, because most of it has focused on users of one or more ERs, ignoring the nonusers, and has provided insufficient detail about the local context in which the ER operates. The result has been large quantities of data which, when compared, produce inconsistencies which cannot be resolved without additional data from different studies. Yet, a tentative explanation of ER growth can be presented if the question of why people use ERs, which is usually thought of as being similar to the question of why people use medical care services, is restated as, why do people who want to use medical care choose the ER as the site of care? That question can best be answered by paying greater attention to enabling and illness factors than to the predisposing demographic factors upon which much research has focused. A tentative explanation of the growth of ER utilization is offered. Then, the support from the literature for it is presented and the remaining questions are identified for future research.


An evaluation of the Illinois trauma system. The impact of the Illinois Trauma System is assessed in the Southernmost region of the state. A sample of vehicular injuries and deaths are compared for a four year study period: two years prior to system implementation (FY 1970-1971) and two years after system initiation (FY 1972-1973). Decreases in mortality rates are experienced at trauma hospitals in FY 1972-1973 while mortality rates at those hospitals which did not become trauma centers remained constant. Trauma hospitals also exhibit significant declines in mortality rates during weekends and for the age group 45 to 64. When examined on a statewide basis the Illinois Trauma System appears to have little impact on urban mortality rates but a substantial effect upon rural mortality rates.


The tides of rural physicians: the ebb and flow, or why physicians move out of and into small communities. To determine the characteristics of physicians who move into and out of rural areas, as well as their reasons for establishing or leaving such practices, we sent questionnaires to 67 physicians who began practice in selected rural counties in upstate New York and 88 physicians who left practices in roughly the same area. From the 52 physicians (77.6 per cent) who responded to the former survey we found that 1) good professional support is mandatory for maintaining a satisfying small community practice, 2) a predisposition to small community living is essential for physicians to be recruited for rural practice, and 3) there are substantial differences with respect to demographic characteristics among persons who share similar reasons for practicing medicine in this region. For the 68 physicians (72.0) per cent ) who responded to the latter survey, the reasons for leaving could be grouped in the following categories: economic, social, and professional logistic. Although all of these factors contribute to the decision to leave, physician geographical mobility seems to stem chiefly from an unsatisfactory professional situation. These findings suggest several strategies for improving the situations in which rural physicians practice, and thus altering the massive imbalance in physician:patient ratios in urban and rural areas.


Improving community hospital board performance. There has been little focus on improving hospital governance as an approach to controlling costs and improving the  quality of care in community hospitals. The author examines assumptions underlying such an approach, describes various proposals, and presents criteria to be used in evaluating them. The author recommends governing board involvement in goal setting and monitoring activities. This requires the development of standards on hospital performance and governing board performance, as well as methodology for external monitoring and external impact on the boards in these respects.


Market structure and advertising in the U.S. pharmaceutical industry: some implications for public policy. Distortions in market processes for pharmaceuticals raise the important policy problem of devising measures to improve industry performance. This paper first reviews the basic issues involved in formulating economic policy regarding the pharmaceutical industry. Methods for reducing structural market power and undesirable promotional expenditures are examined, and the impacts of four oft-suggested policy "reforms"--removal of trade names, removal of patents, relaxation of requirements for certification of new drug products, and increased enforcement of antitrust laws--are then analyzed. Finally, problems requiring additional research are identified.


[Animal experiments about chondrogenesis in allogenic (homologous) auditory ossicles (author's transl)]. After the transplantation of allogenic ossicular transplants chondrogenesis could be observed during the integration process. This chondrogenesis in the allogenic (homologous) transplants could be demonstrated mainly in the area of the joint between incus and malleus. It is probable that the contact with a cartilaginous transplant bed of the host is very important for the chondrogenesis in the ossicular homografts.


[A clinical study on allogenetic ossicle-implantation (author's transl)]. Here we report a first three years clinical experience with allogenetic ossicles in middle ear surgery. The several allogenetic implants in tympanoplasty type III are coordinated to symbolic abbreviations for documentation. The technique and biology of Cialit-preservation is summarized. Findings and results vindicate the application of allogenetic ossicles outside large ENT hospitals too.


[Clinical testing of impulse-gustometry as a new method of gustometry (author's transl)]. For the first time in clinical routine testings impulse-gustometry was used in comparison to normal chemical or electrogustometric methods. Loss of taste caused by tympanoplasty, radiation of tumors in head and neck and accompanying facial nerve palsies was tested. The exactly defined location of the stimulus is known advantage in electrogustometry. Impulse-gustometry, however, is able to stimulate different taste sensations like the chemical methods. The sensible sensation, therefore, is eliminated. The stimulating pulses ranged between 0,5 and 2,0 ms at frequencies of 10 to 300 cps. Like with Krarup's method in impulsegustometry there is not always a taste sensation.


[Comparison of different nystagmus-parameters with the measured so-called maximal velocity of the slow phase in connexion with caloric vestibular examination (author's transl)]. The adequate stimulus of the semicircular canals by a rotatory acceleration is producing a nystagmus, whose graph of the postrotatorius I is adequate to a decreasing e-function. The constants of the function are calculabe, the variance is very small. The inadequate stimulus of the semicircular canals by caloric stimulation effects a nystagmus, which shows an intensive  changing course of the graph with a large variance. Only smoothings and standardisations by counting of an individual coefficient of the reaction-intensity lead to a graph, which is nearly adequate to an increasing and decreasing e-function. The variance of the single nystagmus-parameters grows with its range of reaction. The velocity of the slow phase shows the largest variance. Each experimental arrangement, which enlarges the nystagmus-intensity, is enlarging the variance coincident. The experimental conditions are neither to form by illumination of the eyes nor by increasing of the mental activity in such a uniform way that the variance would be reduced. The valuation of the singular nystagmus-parameters for the clinic is only to confirm by the examination of otoneurologic syndroms.


[The influence of aging on middle ear function (author's transl)]. Aging does not only affect the sensory-neural region of the hearing organ but as well the middle ear and its mechanic acoustic function. To determine changes in friction and elasticity of middle ear function due to growing age impedance audiometric methods were used. Alterations of middle ear impedance correlating with age and sex were proved by tympanometry, compliance measurement, reflex-activity and Eustachian tube function. The audiological results confirm morphological data of the middle ear and prove that the hearing organ may be looked at as a sensitive indicator of human physiological aging process.


[The last ear (author's transl)].

[The last ear (author's transl)]. An operation of the last ear should not be rejected completely, neither from the clinical nor from the audiological point of view. The special pathology of the ear should be considered critically. Many factors can influence the success of the surgical intervention. An exact and adequate diagnosis taking into consideration all the risk factors has to precede each intervention on the last ear. The personality of the patient and his psychological structure have an important influence on the final decision. The surgeon must be very thorough and careful in explaining the possible consequences of an operation. The intervention should be carried out by an experienced surgeon using a tried and proven method. In the case of operations that are neither threatening the life of the patient nor absolutely necessary from the medical point of view he should stop the intervention when--during the operation--the risk for the remaining hearing capacity results to be too high. In this situation the ear should be dried up and prepared for an hearing-aid. We should ever keep in mind that the hearing-aid even if the communication is not fully-satisfying--is better than an understanding by only lip-reading. The medical principle "nil nocere" is particularly important for the last ear.


[The cancer of the middle ear (author's transl)]. In a histological point of view there is in the first line the squamous cell carcinoma. Mostly a chronic otitis media is important for the genesis. Because of the hidden place of the tumor there are usually late stages to be observed. The success of therapy therefore is not all convincing as are about 25% 5-year-survival-rate. The mono-bloc-resection of the temporal bone turns out to be more and more important. As this operation involves high risks, the partial resektion of the temporal is still used. Radio-therapy before or after the operation is widely contested in its value, although there are statistically ensured results. Sole radio-therapy is only convincing with very tiny tumors, in other cases it is only palliative. Because of the histological structure of the squamous cell carcinoma the results of chemotherapy cannot be better.


[Our way in the treatment of middle ear carcinoma (author's transl)]. The treatment of middle ear carcinoma is in first place surgical, completed electrocoagulation and post-operative irradiation. The first intervention should be as radical as possible. But we do not consider that a total resection of the temporal bone should be routinely performed in each case. The range of the operation should be adapted to the size and localisation of the tumours process. It is impossible and unnecessary to preserve the labyrinth with a radical operation. The facial nerve can be preserved only in singled out cases. The retroauricular incision should be left open whenever possible because it helps to discover a relapse in due time and to apply radium, i.e., radioactive isotopes. A radical neck-resection should be performed only in case of a clinically obvious metastasis.


[Protects stapedectomy from increasing otosclerotic inner ear deafness? (author's transl)]. The favourable influence--first shown by Shambaugh--of fenestration operation used in cases of the otosclerosis which cause a rapid sensorineural hearing loss can also be stated for stapedectomy. A negative influence of stapedectomy on inner ear stability was not determined. Especially the ears whose inner ear function is very bad were favoured by this operation.


Round window membrane rupture.

Round window membrane rupture. Round Window Membrane Rupture is a surgically correctable cause of sudden hearing loss and vertigo. Reported is a 19-year-old male who had proven round window membrane rupture secondary to barotrauma. Surgical exploration revealed an abnormally large round window niche and membrane, possibly predisposing him to this injury. Diagnostic and therapeutic modalities of this entity are presented.


Genesis of the round window rupture syndrome; some experimental observations. Clinical and experimental evidence has revealed that rupture of the round window membrane, by itself, is not a major cause of sensorineural hearing loss. Eighteen guinea pigs underwent removal of the round window. The status of cochlear function was determined by recording the cochlear microphonic. An average loss of only about 6 db was observed after surgery. It is felt that there must commonly be more cochlear damage concurrent with window rupture to explain the significant and often relatively immediate hearing losses seen in clinical practice. The site(s) of this primary trauma has not yet been discovered, but it would seen reasonable in the light of recent reports that the perilymphatic vessels, the vas spirale, the stria vascularis and/or the intergrity of the cochlear duct might be involved in the genesis of this hearing loss. We propose that the term "round window rupture syndrome" be used as a more accurate description of this entity. The round window damage provides evidence of more devastating trauma within the cochlea. Thus, the clinician, being alerted, should not stop his therapeutic efforts with surgical closure of the RW. Better prognosis for the patient, as well as leading into new avenues for the investigation of cochlear function, would be the result.


Treatment of severe tinnitus with biofeedback training. Tinnitus has long been a problem which has plagued patients with otologic problems. We have been using biofeedback as a method of treatment for patients with severe debilitating type tinnitus. Most of the patients had sensori-neural type hearing impairment while a few had conductive hearing loss and normal hearing. The patients were given 10-12 one hour sessions of biofeedback training. They have been followed from 6 to 12 months after this initial training period. Over half of thondition. A few of the patients were dramatically improved while none are worse. Biofeedback has been shown to be an excellent method of treatment for patients with severe tinnitus.


Tinnitus: a new management.

Tinnitus: a new management. Tinnitus Clinic was established at the University of Oregon Medical School and the result of treatment for 158 patients is discussed. Patients received three forms of masking as treatment: masking from hearing aids, masking from the Tinnitus Masker, and FM-Masking. Conditions leading to each kind of recommendation are discussed. The examination procedures used in the Tinnitus Clinic are presented. The phenomenon of residual inhibition is explained and discussed in relation to possible long-term or permanent relief of tinnitus. Future plans for the clinic and needs of tinnitus patients are presented.


Management of congenital ear abnormalities. Congenital malformation of the ear has a complex origin and the possibility of hereditary, viral and toxic etiologies. The authors require audiometric evaluation, using the objective brain stem evoked response in young children, and polytomography of the middle and inner ears in all patients with atretic external auditory canals. Unilaterally atretic ear canals can be repaired electively at the discretion of the family and the patient, while in bilateral cases reconstruction is ideally done at approximately age four years. Regular follow-up is recommended to be certain that no cholesteatoma develops medial to an atretic external ear canal. The authors propose a working classification for congenital malformation of the ear. In the author's series of 35 operations for the repair of congenital ear abnormalities, 55% were improved to adequate levels of hearing without the use of a hearing aid. Eight exemplary cases and comments are presented.


Epidemiology of head and neck cancer.

Epidemiology of head and neck cancer. The epidemiology of head and neck cancer can be accounted for largely in terms of known carcinogens introduced into the body through the mouth. Though there are many environmental exposures--such as asbestos, radon, nickel and arsenic--which have strong carcinogenic effects, most of these have only a small impact on the general population because exposure is limited, usually to small occupational groups. Two prevalent exposures, however, tobacco and alcohol, are strong risk factors for nearly all sites in the head and neck, and together account for about 80%-90% of all cancers of the head and neck. There is evidence for biologic interaction between some occupational exposures and cigarette smoking for cancer of the lung, and tobacco and alcohol for cancer of the mouth. Based on this evidence for biologic interaction and the prevalence of smoking, it seems likely that tobacco is related to about 80% of all cancers of the head and neck in the United States.


Spinal accessory lymph nodes: a prospective study of metastatic involvement. The traditional radical neck dissection involves excision of the spinal accessory nerve en bloc with the soft tissue of the posterior triangle in an effort ot remove completely all node-bearing tissue. The resultant decrease in range of motion of the involved extremity and subsequent pain have prompted some surgeons to seek alternatives. The purpose of this study is to review prospectively radical neck specimens with the specific intent of evaluating the frequency of metastatic involvement of the spinal accessory lymph nodes with head and neck malignancies. Fifty neck specimens were studied and the frequency of cancerous involvement of the spinal accessory nodes was not found to be significantly different from nodal involvement of the entire neck specimen. The location of accessory nerve involvement was predominantly in the proximal portion which is not within the posterior triangle. The results are further evaluated with the subsequent conclusion that preservation of the spinal accessory nerve cannot be justified on the basis of infrequent involvement with metastatic lymph nodes.


Computerized tomography in the evaluation of head and neck lesions. The development of computerized tomography (CT) has been called the most important contribution to medical diagnostic techniques since Roentgen discovered the X-ray in 1895. Over the past several years, the growth in technology and literature concerning computerized tomography has been rapid. CT is useful in evaluation of head and neck lesions such as lesions of the paranasal sinuses, the nasopharynx, base of skull, the larynx and neck areas. It is also useful in evaluation of intracranial complications of head and neck diseases. CT has added the horizontal plane in the evaluation of these lesions. The ease of obtaining CT scans and its non-invasiveness are advantages. The most important single feature of CT that distinguishes it from other radiographic techniques is the capability of imaging of soft tissue. CT demonstration of bone destruction is not superior to polytomography. The transaxial orientation of CT planes seems to be particularly useful in certain locations such as the pterygopalatine fossa. CT is an additional diagnostic tool, but it has limitations of other radiologic techniques in differentiating histologic types. In this series, one case of ethmoiditis resembled carcinoma. In another, radiation necrosis was indistinguishable from intracranial metastasis. As technology advances in the use of CT, its application in head and neck lesions will be increasing.


Hemangiopericytoma-like tumors of the nasal cavity: a comparison with hemangiopericytoma of soft tissues. This study compares the published clinical and pathological features of hemangiopericytoma-like intranasal tumors with those of the hemangiopericytomas of other sites. Hemangiopericytoma-like intranasal tumors often originate in a paranasal sinus and extend into the nasal cavity secondarily. They occur most commonly in adults in the sixth and seventh decades of life and clinically mimic allergic polyps. These patients most commonly present with symptoms of nasal obstruction and epistaxis. Microscopically, these tumors demonstrate a vascular architecture, are composed predominantly of spindle cells, and lack nuclear or cytoplasmic pleomorphism, mitotic activity, hemorrhage, or necrosis. Follow-up data suggest that these tumors are unaggressive and are of local consequence only. Hemangiopericytomas of soft tissues usually occur in the retroperitoneum or the thigh and are uncommon in the nasal and paranasal sinuses. They usually present as painless masses. Attention to certain microscopic features of these tumors has led to reasonably good predictions of their behavior based on strict adherence to microscopic criteria. These criteria include the presence or absence of mitotic figures, necrosis, anaplasia, and hemorrhage.


Diagnosis of palatal defects by trispiral tomography: a pilot study. A pilot study is presented in which 12 selected patients, ages 3-11 years, were evaluated for a palatal defect utilizing trispiral tomography. Each patient, because of speech and hearing abnormalities, was evaluated by a speech pathologist and an otolaryngolgist and voice recordings, audiometry, tympanometry and plain and cine radiographic X-rays were obtained. Those children with speech and hearing abnormalities in whom the question of a palatal defect was raised underwent trispiral palatal tomography. Nine of the 12 patients selected for tomography demonstrated a palatal defect that was not detected by other means. Trispiral tomography appears to be a useful tool in the diagnosis of suspected palatal defects in selected patients.


The growth of cartilage from a free perichondrial graft in the larynx. An attempt was made to promote the growth of new cartilage from a frlage. Three dogs had the perichondrial grafting alone, while two had both the perichondrial grafting and a full thickness buccal mucosal graft. In all these dogs new cartilage was found as early as four weeks postoperative.


Lipids of the antarctic sei whale, Balaenoptera borealis. The blubber, liver, and muscle of the Antarctic sei whale were analyzed for total lipid content, composition of lipid by classes and positional distribution of fatty acids in individual lipids. The major  glycerolipids (triglycerides, phosphatidylcholine, and phosphatidylethanolamine) were fractionated by silver nitrate thin layer chromatography. The phospholipid fractions were analyzed for fatty acid positional distribution. The whale stomach contained almost exclusively the amphipod Parathemisto gaudichaudi. Its lipids were also studied and compared with the lipids of the body tissues. The results indicate that the stomach content lipids are subjected to modifications before being deposited in the blubber, liver, and muscle. According to the silver nitrate thin layer chromatographic studies, liver and blubber triglycerides resembel each other in their patterns of positional distribution of fatty acids and in molecular species composition. The phospholipids of liver and blubber also exhibited closely related fatty acid distribution patterns. In general, while the proportions of lipid classes and their predominant fatty acids varied from tissue to tissue, the patterns according to which the lipids had been synthesized seemed to be common.


Nutritional and metabolic studies of distillable fractions from fresh and thermally oxidized corn oil and olive oil. A semisynthetic diet containing 15% by weight of dietary fat was fed to six groups of male wistar rats for 28 days. Two groups received the distillable fraction of fresh corn oil (DCO) or fresh olive oil (DOO), two groups the distallable fractions of the thermally oxidized fats (OCO,OOO), and two groups received the respective fresh fats as controls (FCO, FOO). Substantial changes in the fatty acid composition occurred in the fats upon thermal oxidation. Only the rats that received OOO showed overt symptoms of heated fat toxicity. This was reflected in the histological scores of these animals with the liver sustaining the most numerous and severe lesions. Tissue fatty acid changes of any significance were confined largely to the polar liver lipid of the rats that were fed OCO or OOO. The results of this study would suggest that the relatively greater toxicity of OOO, compared to OCO, may in part be due to the high oleic:linoleic acid ratio of the fresh olive oil and in part to a higher tocopherol content of the corn oil.


Composition and synthesis of three higher ganglioside homologs in bovine mammary tissue. Three higher gangliosides were identified as constituents of bovine mammary gland. The structures of these three gangliosides were shown to be ceramide-glucose-galactose-(sialic acid)-N-acetylgalactosamine-galactose, ceramide-glucose-galactose-(sialic acid)2-N-acetylgalactosamine, and ceramide-glucose-galactose-(sialic acid)2-N-acetylgalactosamine-galactose. These gangliosides accounted for only a small fraction (less than 20%) of the lipid-bound sialic in mammary gland. White fatty acids with even carbon numbers from C14 to C26 were predominant in these gangliosides, they also contained C23 and C25 fatty acids. Mammary gland Golgi apparatus-rich fractions had all glycosyltransferases required for synthesis of these gangliosides starting with ceramide.


Linolenic acid deficiency: changes in fatty acid patterns in female and male rats raised on a linolenic acid-deficient diet for two generations. Rats were fed for two generations a purified, linolenic acid-deficient diet in which the only source of lipid was purified methyl linoleate. This diet contained about 38 mg linolenic acid/kg diet. Control rats were given the same diet supplemented with methyl linolenate (2,500 mg/kg diet). Male and female rats ranged in age from weaning pups to adults. Lipids were extracted from liver, brain, kidney, spleen, heart, muscle, gastrointestinal tract, lung, ovary, testis, adrenal, plasma, erythrocytes, retina, and adipose tissue. Fatty acids of major phospholipid classes (choline phosphoglycerides, ethanolamine phosphoglycerides, and mixed serine phosphoglycerides plus inositol phosphoglycerides) or of total lipid extracts were measured by gas liquid chromatography. Growth rates and organ weights were similar in control and linolenic acid-deficient rats. The major effect of the deficiency was to lower the proportions of n-3 fatty acids, especially 22:6 n-3, in all the organs analyzed. Docosahexaenoic acid (22:6 n-3) was mainly replaced by 22:5 n-6 in deficient rats. The greatest changes in composition were found in brain, heart, muscle, retina, and liver.


Triglyceride synthesis from dihydroxyacetone phosphate and palmitate by microsomes from mammary glands of lactating mice. Both di- and triglycerides were synthesized when microsomes isolated from mammary glands of lactating mice were incubated with dihydroxyacetone phosphate (DHAP), 1(-14)C)palmitate, ATP, CoASH, GSH, KF, MgC12, and NADPH. When NADH replaced NADPH, glyceride synthesis was very low. In the absence of either NADPH or NADH, DHAP was acylated to palmityl-DHAP. Since microsomes do not have glycerol 3-phosphate NAD:oxidoreductase activity , we inferred that glycerol 3-phosphate (GP) is not an intermediate in triglyceride biosynthesis from DHAP. This reductase, present in the cytosol, was active only with NADH. With the same concentration of either GP or DHAP, microsomes yielded essentially similar amounts of di- and triglycerides. Mitochondria, while capable of synthesizing palmityl-DHAP, did not produce di- and triglycerides.


Comparative intestinal and colonic absorption of [4-14C] cholesterol in the rat. [4(-14)C] Cholesterol was administered as an aqueous emulsion with triolein and dry non-fat milk either directly into the upper duodenum or into the ileocaecal junction of lymph duct cannulated rats. Lymph flow rates were similar in the two groups of animals. Whereas ca. 53% of the administered tracer dose of cholesterol was absorbed when introduced into the upper small intestine, only 0.06% appeared in lymph when administered into the caecum. Furthermore, less than 0.01% of the administered isotope was detected in urine and blood. The data demonstrate that the large intestine does not contribute significantly to the absorption of exogenous cholesterol in the rat.


Inhibition of fetal growth and survival by testosterone administration to pregnant sheep. Testosterone (as testosterone enanthate, 250 mg i.m. every 2 wk) was administered to pregnant ewes (n = 16), and injections of vehicle were used in 10 control pregnant ewes between days 75 of gestation and term (day 147). Fetal survival (7 of 16 in the treated group versus 10 of 10 in the controls) and growth (birth weights 4.00 +- 0.51 kg in the treated group versus 5.79 +- 0.93, mean +- SD, in the controls) were markedly impaired by testosterone administration. The mechanism of the testosterone effect is unknown, but could be through metabolism to estrogens by the feto-placental unit. These results imply that alterations in the production or metabolism of androgens by the mother or the feto-placement unit may exert important effects on fetal growth and survival.


Growth hormone response to propranolol and L--dopa in obese subjects. Oral administration of propranolol and L-dopa produced a marked increase in plasma growth hormone values in 12 obese subjects who had failed to respond to L-dopa alone. GH values after propranolol and L-dopa in obese subjects were not significantly different from those of normal subjects after L-dopa at 60, 90, and 120 min. Association of propranolol and L-dopa appears to be a simple means of investigating GH response in obese subjects.


A rapid method for the determination of glycosylated hemoglobins using high pressure liquid chromatography. Hemoglobin (Hb) Alc is a minor component of Hb found in normal individuals but elevated two or threefold in patients with diabetes mellitus. Limited studies have suggested that the level of Hb Alc is proportional to the integrated concentration of glucose over time. Thus it could serve as an index of hyperglycemia. Its measurement may enable a more objective approach to assessing whether or not the control of hyperglycemia can be correlated with the severity of complications of diabetes. Large scale clinicab studies of Hb Alc have not been undertaken for lack of a rapid assay system. This article describes a method of high pressure liquid chromatography (HPLC) which enables the isolation of Hb Alc in 27 min using only 12 microgram of Hb (100 microliter of blood) and a second method for the isolation of total fast Hb components (also elevated in diabetes) in 11 min. Using the first method, a total of 36 assays were performed on the blood of a single normal volunteer over a one month period. the mean level of Hb Alc was 4.95 +/- 0.12% (SD) +/- 0.02% (SEM), while the coefficient of variation (C.V.) was 2.4%. The mean Hb Alc & b level was 1.65 +/- 0.06% +/- 0.01% (C.V. = 3.6%). Values for Hb Alc in 10 normal individuals were 5.06 (mean) +/- 0.32% (SD) +/- 0.01% (SEM). Hb Alc values in 15 patients with diabetes mellitus ranged from 6.8 to 20.0%. The second method was designed to assay Hb Ala, Hb Alb, and Hb Alc as a single peak and yielded results identical to the sum of these components as determined by the first method ( r = 0.98; p less than 0.001).


Effect of exercise on glucose and insulin utilization in the forearm. Glucose and insulin utilization by forearm muscle was examined at rest and during exercise. Care was taken to have a steady state with regard to arterial plasma concentrations for 1 hr prior to as well as during the measurements. At rest, insulin uptake was linearly related to arterial insulin concentration. During exercise with no change in arterial plasma concentration of either glucose or insulin, there was an increase in uptake of both substances, and the relation of insulin uptake to concentration became exponential. It is hypothesizes that the latter phenomenon is due to an increase in cellular uptake of insulin by a mechanism independent of membrane receptors.


Plasma insulin patterns in the unanesthetized rat during intracardial infusion and spontaneous ingestion of graded loads of glucose. Rats were provided with double permanent heart catheters, allowing simultaneous infusion and rapid blood sampling in the freely moving animals. Intracardial glucose infusion (75, 150, and 300 mg) over 15-min periods induced biphasic plasma insulin responses, their onset and magnitude being correlated with the blood glucose increments. The insulin-ogenic index decreased at increasing infused loads. After spontaneous oral ingestion of 75, 150, 300, and 750 mg glucose over 2 min or less, plasma insulin increased rapidly during the initial 4 to 8 min. At the highest leads this was followed by a gradual further increase until 15 min. The rapid insulin response increased with the ingested load. About half of this response had occurred already at 2 min, i.e., prior to the first rise of blood glucose at 3 min. Maximum blood glucose levels (125-135 mg/dl) occurred between 8 and 15 min and did not correlate with the ingested loads. The insulinogenic index increased at higher oral loads. It is suggested that the plasma insulin response to glucose ingestion results from successive and cumulative operation of anticipatory nervously triggered insulin secretion, anticipatory loaded-dependent potentiation of secretory stimulation by rising blood glucose, and further adjustment of the secretion rate until blood glucose declines. The possible mechanisms are discussed.


[Diagnosis and therapy of acute penetrating myocardial injury (author's transl)]. Clinical signs of an acute penetrating wound of the heart not always are clear. Because of hemorrhage and reduced cardiac output during heart tamponade venous pressure not necessarily must be increased. If by pericardiocentesis an aspiration of blood is possible, diagnosis of a penetrating heart wound is of high probability; otherwise there is no diagnostic value of a negative pericardiocentesis. Only in a case of a very small cardiac wound pericardial drainage can be used as a sole therapeutic proceeding; clinical observation is mandatory and an emergency operation at all time must be possible. In most cases immediately thoracotomy with suture of the cardiac wound should be performed. Attention is necessary because of an injury of a coronary artery. Following this principle prognosis is good if the patient is reaching clinical treatment alive. Lethal outcome in 2 of our 12 reported cases in one of them is caused by refusing immediate surgical intervention by the patient himself, in the other by development of ischemic cardiac necrosis involving a papillary muscle after suturing a cardiac wound.


[Symptoms, signs and therapy of the septate gallbladder (author's transl)]. The septate gallbladder probably represents a congenital anomaly of form, that can be proven by X-ray in 3,8% of hospitalized patients. Only in 25% of these cases it has an own symptomatic significance. Here it does lead though, more or less distinctly, to the typical painful discomfort, comparable to the cholelithiasis, especially augmented by dietary sins, up to the state of colics. The symptoms intensify during the clinical course. Because the gallbladder remains in most cases without the finding of concrements, the misjudgement in these cases often leads to an unnecessary prolongation of the interval between diagnosis and operative treatment.