A sign of subarachnoid bleeding on cranial computed tomograms of pediatric head trauma patients. Of 109 children examined by cranial computed tomography soon after an acute head injury, a density in the region of the falx was identified in 24 patients, but disappeared on subsequent studies. The density measures in the range of blood and is thought to represent subarachnoid blood. It can be confused with falx calcification in adolescents and adults, but falx calcification is normally not seen in the pediatric population.


Computed tomographic evaluation of the diaphragmatic crura. The diaphragmatic crura have a variable appearance on CT body scans. They can at times appear quite prominent and be easily confused with other anatomical or pathological structures. Analysis of the CT scans of 100 patients revealed certain characteristic features of the diagphragmatic crura that help distinguish them from other structures, especially enlarged para-aortic lymph nodes.


Spinal arachnoid cysts in children.

Spinal arachnoid cysts in children. Five cases of benign spinal arachnoid cysts in children are described with their clinical, neuroradiological, surgical and pathological findings. Intraspinal benign arachnoid cysts may be confidently diagnosed myelographically when there is complete or partial obstruction with multiple oily contrast/cerebrospinal fluid levels as in 3 cases in this series. The multiple fluid levels are probably produced by multiple cysts or a cyst loculated due to partial compression by arachnoid bands either related to the normal septum posticum, congenital or acquired adhesion rather than to trabeculations within the cyst. In this series, the origin of the cysts is considered to be congenital.


The choroidal artery to the fourth ventricle and its radiological significance. The choroidal artery to the fourth ventricle has been studied in 25 brain specimens and 100 normal posterior fossa angiograms, including 25 angiotomograms. Its variable origin, course and radiological significance have been stressed.


Diatrizoate enemas: facts and fallacies of colonic toxicity. Rats were given enemas of Gastrografin in two strengths, Renografin--76, and Tween--80 in a 10% dilution. There were no deleterious effects on the colons with these media used in volumes to fill the colon. Severe changes resulted from volumes which produced overdistention.


The VATER Association.

The VATER Association. The VATER association is a group of congenital anomalies with a nonrandom tendency for concurrence. Defects include vertebral, vascular, anorectal malformation, tracheoesophageal fistula with esophageal atresia, radial-limb, and renal abnormalities. The critical period of organogenesis is at or before the sixth or seventh week of gestation. The VATER assoication is important in the evaluation of newborns with major congenital anomalies.


Intraluminal calcifications in the small bowel of newborn infants with total colonic aganglionosis. Intraluminal calcifications were found in the small bowel of 4 newborns with total colonic aganglionosis. Abdominal radiography demonstrated circular aggregations of small punctate calcific densities in the right lower quadrant and evidence of bowel obstruction. There was a microcolon in each case. The calcifications, which resemble those seen in small intestinal atresia and stenosis, are probably related to fetal intestinal stasis, and may be differentiated from those due to meconium peritonitis.


Retroperitoneal lipoma in a child.

Retroperitoneal lipoma in a child. A case of retroperitoneal lipoma in a child is presented. A lucent retroperitoneal mass was seen displacing the kidney and ureter without intrinsic renal involvement.


Anal agenesis with rectobulbar fistula.

Anal agenesis with rectobulbar fistula. Anal agenesis with a rectobulbar urethral fistula is an uncommon type of male imperforate anus. Six cases are presented with a review of the main features of the disorder, the possible embryologic origin, and the surgical management.


Histiocytic medullary reticulosis in childhood. The clinical, radiographic and pathologic findings of two children (ages 6 months and 5 1/2 years) with histiocytic medullary reticulosis are reviewed. Chest radiographs, excretory urograms, and skeletal survey revealed involvement of the mediastinum, lung parenchyma, pleural space, liver, spleen, kidneys, retroperitoneal lymph nodes, and long bones. This condition has rarely been reported in children and never during the first year of life. Histiocytic medullary reticulosis can occur in the very young; familiarity with its presentation at an early age helps to differentiate it from other infiltrative disorders of childhood.


Diagnosis of hepatobiliary disease by 99mTc-HIDA cholescintigraphy. 99mTc-HIDA is concentrated by the hepatocytes and excreted into the biliary system; the gallbladder, common bile duct, and early accumulation in the duodenum are visualized within 30 minutes of intravenous administration. The authors studied the utility of 99mTc-HIDA imaging in both acute and chronic cholecystitis and hepatobiliary disease in the presence of jaundice: (a) all normal gallbladders exhibited filling, (b) absence of visualization indicated gallbladder disease and/or cystic duct obstruction, (c) visualization of the gallbladder after cholecystokinin-induced emptying excluded an obstructed cystic duct and acute cholecystitis, and (d) a definitive diagnosis of hepatocellular disease, partial and complete obstruction, is possible in jaundiced patients with hyperbilirubinemias up to 5 mg%. Beyond that level, 99mT-HIDA imaging was of qualified value. The technique is useful in assessing biliary drainage in jaundiced patients with surgically altered biliary tract anatomy.


The dilated pancreatic duct: ultrasonic evaluation. Eight patients with signs and symptoms of obstructive jaundice were evaluated by gray-scale echography. In each, ultrasonic identification of a dilated pancreatic duct was helpful in confirming the diagnosis of an obstructing lesion at the level of the ampulla of Vater. In only 3 could the tumor mass itself be seen on ultrasound. With the recognition of pancreatic duct dilatation, it is no longer essential for a tumor in the region of the ampulla of Vater to be large or contour-deforming before it can be identified by ultrasound.


Biological effects of diagnostic ultrasound: a review. Biological effects from experimental ultrasound studies, such as chromosome aberrations and retardation of growth, have been recorded but mostly at levels far in excess of diagnostic intensity. The data surveyed in this review suggest that there is apparently little or no danger associated with diagnostic ultrasound exposure at clinical levels.


Dose distribution around an 125I seed source in tissue. Dose distribution about an 125I source in tissue has been calculated using absorbed dose constant and point isotropic source buildup factors. The effect of encapsulation material has been included. Depth-dose values have been verified by measurements with thermoluminescent dosimeters. Present data gives a value for absorbed dose constant of 1.32 rads cm2/mCi-hr. compared to the presently used value of 1.7. Depth-dose values are compared with other published data.


Measurements of reciprocity law failure in green-sensitive X-ray films. Reciprocity law failure was measured for four brands of medical x-ray films exposed with intensifying screens. Three of the films are green light-sensitized for use in combination with green light-emitting rare-earth screens. These films showed larger reciprocity failure effects than one conventional blue-sensitive film, Dupont Cronex-2. Development conditions had a small effect on reciprocity failure. As part of the investigation, a detector was constructed with a response that accurately monitors the light emission from the double screen-cassette combination over a wide range of x-ray photon energies.


Biplane angiographic volumetry using the right anterior oblique and half-axial left anterior oblique technique. Half-axial biplane left ventriculography was performed using the right anterior oblique view and a left anterior oblique projection obtained by angling the lateral image intensifier in a caudo-cranial direction so that the long axis of the left ventricle was more nearly perpendicular to the horizontal beam. Cardiac output showed a linear correlation with outputs determined by the thermodilution method.


Therapeutic embolization with detachable balloons. Physical factors influencing permanent occlusion. Twenty-one detachable Silastic 3  balloon embolizations were performed in 12 swine. Late balloon rupture was associated in vivo with increased size and decreased radiopacity of the balloons. Variables affecting the permanency of occlusion by the Silastic balloons were the osmolarity of the contrast medium and the size of the balloon relative to its uninflated size.


A simple catheter curve for cerebral angiography. A simple catheter curve for use in cerebral angiography is discussed. A shorter length of guide wire is needed before the catheter tip will enter the vessel.


Simplified outpatient lower extremity venography. Improved lower extremity venography has been achieved by a distally directed superficial foot venipuncture. Supine position and short procedure time afford excellent patient acceptance. Dilute contrast is believed responsible for eliminating venospasm and postvenography phlebitis; the low sodium concentration permits safe evaluation of cardiac patients. Sequential imaging (and the use of anteroposterior and lateral projections) eliminates false positive and negative interpretations. Skip areas are avoided by the use of 90-cm (36-inch) cassettes.


Studies of pulmonary vasculature using chromatoroentgenography. The authors describe a method of obtaining two images on a single film, using color to distinguish them. The technique is described, using pulmonary angiography as an illustration.


Influence of pulmonary hypertension on pulmonary diffusing capacity in patients with mitral stenosis. The pulmonary diffusing capacity (DLCO--steady state method according to Bates and coworkers) was measured at the time of heart catheterization in 12 patients with mitral stenosis without mitral incompetence. DLCO correlates with the tidal volume at rest and during exercise and with pulmonary vascular resistance during exercise only. DLCO and left atrial pressure exhibit a positive correlation up to 22.5 mm Hg only. In patients with mitral stenosis DLCO depends on the alveolar surface area and DLCO is influenced by regional changes in the pulmonary vascular resistance.


Closing and opening pressures in the intrapulmonary airways of rats. Pressures at which the peripheral airways (PA) and terminal bronchioles (TB), open and closed, were studied in rats' lungs in vitro. Airway luminal diameter was directly measured at diminishing transbronchial pressure (closing) and increasing transbronchial pressure (opening) by means of a stereomicroscope with a calibrated eyepiece. The PA and TB had internal diameters at 100 mm H2O ranging from 173 to 306 micrometer and 122 to 204 micrometer, respectively. Most of the airways closed suddenly in the pressure range between 75 and 5 mm H2O and only a few were still open at zero pressure. Closure began in the distal portion of the PA and mid-portion of the TB usually in a concentric manner. Terminal bronchioles and PA that initially were prepared at room temperature instead of at 0 degrees C often contained air at zero pressure and showed a decreased response to acetylcholine. Subthreshold concentrations of acetylcholine increased the critical closing pressure by more than 100%. The critical opening pressure was considerably higher than the corresponding closing pressure. It is proposed that bronchiolar closure depends on the tone of the airway smooth muscle, the elasticity of the airway wall and probably on the surface tension of the liquid lining the mucosal membrane.


Physiological assessment of severe chronic asthma in children. Measurements of maximum expiratory flows and lung volumes were made on 6 occasions at weekly intervals in 14 children who were known over several years to have severe chronic asthma. 11 of the 14 had persistent lung hyperinflation and marked reduction in maximum expiratory flow rates although there was considerable variability in individual measurements. The other 3 usually had hyperinflation and reduced expiratory flow rates. 3 times daily measurements at home of peak expiratory flow rate did not contribute further to assessment. The results of the study indicated that one or two measurements of maximum expiratory flow calculated from a maximum expiratory flow volume curve and of lung volumes recorded in a body plethysmograph are of value in identifying the child with severe chronic asthma.


Peripheral chemoreceptor insensitivity in chronic severe anaemia. Ventilatory response to central and peripheral chemoreceptor stimulation by carbon dioxide was assessed in 15 severely and chronically anaemic subjects before and after the correction of anaemia. Whereas the central CO2 responsiveness was found to be normal in the anaemic state, the peripheral response to CO2 was remarkably depressed. This blunted peripheral response to CO2 was restored to normal with the correction of anaemia.


Carbon monoxide, nicotine and the 'safer' cigarette. 15 healthy adults (5 women, 10 men) have been exposed to each of four experimental conditions: rebreathing of air or carbon monoxide, and the smoking of two low-nicotine (0.3 mg) or medium-nicotine (1.2 mg) cigarettes. The dose of carbon monoxide selected (80 ml) had no effect on resting heart rate or electrocardiogram, nor did it modify the exercise heart rate, ventilation, oxygen consumption or electrocardiogram. Both types of cigarette produced variable changes in the blood carboxyhaemoglobin level, increments being greatest in heavy smokers, and least in former smokers, pipe and cigar smokers, Gains of carboxyhaemoglobin were less with low-nicotine than with medium-nicotine cigarettes. Both types of cigarette produced some increase of resting heart rate, but the smoking of two cigarettes was insufficient to modify the exercise heart rate, ventilation, or oxygen consumption. The electrocardiogram also showed no signs of ischaemia during either rest or effort. It is suggested that, for the light and moderate smoke, the 'safest' cigarette may be one with a low tar and a very low nicotine yield. On the present data, this would also induce only small increments of blood carboxyhaemoglobin levels.


Indications for pulmonary function testing. Pulmonary function testing is needed to determine the pathophysiology present in the patient with cardiopulmonary disease. Blood gases and pH should be obtained during emergency situations and during cranial, thoracic, and extensive cervical or abdominal surgery. Lung function tests can be divided in global such as spirometry and diffusing capacity which study the ventilation and transfer of gases and regional determinations of ventilation and perfusion. Both types of tests complement each other and should be used together. The spirometry should consist at least of determination of the vital capacity and is determined in the first second to ascertain if there is obstructive lung disease. Some tests such as flow-volume curves, alveolar-arterial gradients and closing volume are very useful to detect early pulmonary disease before any symptoms or findings are present. This is probably one of the most important medical indications for pulmonary function testing. Before certain types of surgery pulmonary function testing is indicated; if the spirometry and diffusing capacity tests are normal, there is no pulmonary contraindication for the planned surgery. In chest surgery if there is significant compromise of the spirometry and diffusing capacity regional lung function tests are indicated to study the pathophysiology at regional level, thus trying to circumscribe the lung resection to the diseased areas.


[Polarographic measurements of PO2 with a 95% response time of 7-10 msec (author's transl)]. A fast PO2 tracing with 95% delay times of 15-20 msec in routine is necessary for measurement of the PO2 jumps in the expired air, particularly for the precise measurement of the so-called dead-air plateau. A Clark type PO2 electrode has been developed which has the demanded property. This electrode has four characteristic features: (1) a glasscoated Pt cathode with a tip diameter of 0.3 mm (diameter of the Pt wire = 0.1 mm); (2) a differential screwdrive for feeding the cathode 50 micrometer per turn; (3) a 0.2- to 0.3-micrometer-thin polytetrafluorethylene membrane, and (4) a special polishment of the surface of the cathode. The electrode has a 95% response time of 15-20 msec in routine when tracing PO2 changes from 150 to 750 mm Hg. About 30% of the prepared electrodes have response times of 7-10 msec. The output of the electrode in air is stable within the first 3 h (deviation smaller than 0.2%) and then decreases within 10 h approximately 1% per hour. The response times are constant for more than 48 h. The output of the electrode is linear from 0 to 760 mm Hg PO2. Within the accuracy of measurement the output is independent of PCO2.


Regional esophageal pressures with lobar obstruction in dogs. The right lower lobes (RLL) of intact horizontal dogs were obstructed at FRC during spontaneous breathing and artificial ventilation (IPPB). At end inspiration, pressure within the RLL became less than tracheal pressure, and pressure in the lower esophagus declined to a greater extent than in the upper esophagus. Tidal pressure swings in the obstructed RLL were larger than in the esophagus during spontaneous breathing but smaller during IPPB implying that the elastic recoil of the RLL decreased during inspiration at the mediastinal side. All these changes were intensified during RLL atelectasis and counteracted by strapping of the lower chest wall. These results indicate that: (a) around a lobe moving out of phase with the rest of the lung, a force is created tending to minimize the lobar volume differences; (b) the obstructed lobe is deformed during inflation of the rest of the lung; (c) esophageal (and hence pleural) pressure gradient is modified by this localized intrapulmonary pathology apparently due to shape interactions between chest wall and lung.


Comparison of 133Xe washout curves after bolus inhalation, perfusion, and equilibration. In 6 healthy subjects and 13 patients with chronic obstructive lung disease, 133Xe washout curves after bolus inhalation, perfusion and equilibration were compared, using a gamma camera and computerized data handling. In healthy subjects the washout after equilibration was significantly slower than after the two other procedures. As this phenomenon occurred at the basal zones, it was attributed to the presence of airway closure in some units. In patients, the three washouts were significantly different from each other. This indicated the existence of intraregional inhomogeneity in ventilation, perfusion and ventilation-perfusion ratio. Our conclusion is that comparison of these different washout methods yields valuable information not only on absolute values of pulmonary function but also on the intraregional distribution, which cannot be obtained by other examinations.


Sputum eosinophilia in chronic bronchitis and asthma. The occurrence of sputum eosinophilia was investigated in 115 patients with chronic bronchitis and asthma. They were clinically divided into four groups; those with asthma only, those with asthma of equal or greater duration than chronic bronchitis, those with chronic bronchitis recently complicated by asthma and those with chronic bronchitis only. Although sputum eosinophilia was more common in the asthmatic groups there was no significant difference between the groups in the degree of sputum eosinophilia. When the groups were subdivided on the basis of methacholine and isoprenaline response (asthma subgroup, greater than or equal to 20% response to isoprenaline or greater than or equal to 40% response to methacholine; chronic-bronchitis subgroup, less than 10% response to isoprenaline plus less than 20% response to methacholine), there was a significant difference between the groups in the degree of sputum eosinophilia. However, sputum eosinophilia still occurred in the chronic bronchitics. In the asthmatic patients, there appeared to be no difference in the degree of sputum eosinophilia in those with positive skin tests, or on steroid medication, compared with those with negative skin tests or not on steroids.¿


Lung mast cells and hypoxic pulmonary vasoconstriction in cats. An attempt was made to reduce or eliminate lung mast cells in order to determine the involvement of mast cells in hypoxic pulmonary vasoconstriction. Anesthetized cats were exposed to acute hypoxia (10% O2) 20-24 h after no pretreatment, after total lung irradiation (3,000 r), after intravenous nitrogen mustard, or after combined lung irradiation and nitrogen mustard. None of the treatments reduced total or perivascular lung mast cell density, or reduced the pulmonary vasoconstrictor response to hypoxia. However, an inverse relationship between lung mast cell density and the pulmonary pressor response to hypoxia was observed. These results suggest that the presence of more lung mast cells may oppose hypoxic pulmonary vasoconstriction.


Influence of low concentrations of allergens on bronchial system. The influence of Ascaris extract, applied during 1 h in low concentration as aerosol and intravenously, on the bronchial system and the potentiation of increase of airway resistance to acetylcholine (ACH) and histamine challenge caused by this kind of allergen exposure were studied in 13 dogs. All the animals presented no reaction by the allergen exposure itself but developed an increased response to ACH and histamine after this kind of allergen exposure. A control group of 4 dogs was submitted to saline solution aerosol and intravenous application. No change in response to the substances mentioned was observed. The airway response to cold air after concentrated and diluted Ascaris suum extract (AE) aerosol application was tested on 7 dogs. The response to cold air was only influenced after concentrated AE-aerosol exposure.


[Xeroradiography for cervical myelography using metrizamide (amipaque) (author's transl)]. Xeroradiography, particularly in addition to conventional tomography, for cervical myelography using water-soluble Metrizamide has been tested. Xerography was done in 30 of a total of 96 examinations and could be compared with conventional X rays. In the sagittal plane there was no advantage, in the lateral plane detail was clearer, especially at the cervico-dorsal junction and in establishing the extent of osteochondrotic changes narrowing the subarachnoid space. Xeroradiography should not be used routinely, but has its merits for certain problems, when higher radiation will be justified.


[Radiologic examination of the larynx with exposures around 180 kV (author's transl)]. The roentgenexamination of the larynx with high voltage permits to recognize functional and morphological disorders of the larynx. In seven out of ten patients with laryngeal diseases the subglottic space altered its shape. The method gives similar results as tomographic, but should be easier to apply to serious diseased patients.


[Examination of the size of the heart (author's transl)]. Linear size of heart and its volume were determined in 230 healthy individuals. A classification: small, normal and large, was applied. The various groups were correlated, so as to assess the radiologic findings and their assessment. The radiologic findings of the heart have only limited value, even if metric investigation is added.


[Accuracy of triple-diagnosis of the "small" carcinoma of the mamma (author's transl)]. Mammography was carried out in 3,500 patients. Of these 1,800 were examined with plate-thermography and in 450 cytology was done. 12 cases of "small" (10 mm) Ca were found, in 3 cases with thermography. In 4 cases thermography was negative, in one case for technical reasons. Mammography is the method of choice, thermography and cytology are valuable aids.


[Remarks on the paper: present means of lokalising intra-ocular foreign bodies, by M. Severin (author's transl)]. It is pointed out that the technique of Holzknecht can and should be considered one of the most important routine-measures for measuring radiologically visible foreign bodies in the eyes. This technique is as good as that of Comberg and has the great advantage that it only needs a ruler and compass, no other aids. It can be carried out by all radiologists. The technique of exposure and of measurement are discussed.


[Clinical experiences with the new contrast medium iodamide 420 (author's transl)]. Iodamide 420 is a high concentrated, water solubile contrast medium of 420 mg/ml iodine content. Clinical observations were made on 31 patients, following 68 contrast injections. The administered iodine solution amounted to 3 to 100 ml pro injection, i.e. 0.6 to 2.0 ml/kg body weight and a total of 12 to 160 ml, i.e. 0.8 to 5.0 mg/kg pro angiographic study. Tests of sensitivity were not done. Iodamide 420 is characterized by a strikingly good tolerability. No severe complication was observed. The side effects were rare and negligible. The use of this high concentrated contrast medium improves the quality of angiograms, especially in cases, where the injection of the necessary amount is troublesome due to the high flow/small catheter lumen ratio.


[On the description of the compton-effect (author's transl)]. The short paper presents a comparative description of the Compton-, Photo-, and Pair Creation Effect, respectively, for Non-Physicists. The cause for this note is the fact that the Compton Effect is nearly always incorrectly described in (German) "Introductions in Radiation Protection" and similar semi-popular publications.


[The diagnosis of tumours of the paranasal sinus (author's transl)]. Radiographic appearances of tumours of the paranasal sinus are often equivocal. One must try to differentiate the main radiologic signs--shadow, and changes in the walls (tumour, inflammation?). A few important data are given. But examples also show the sources of error. The need for immediate diagnostic-surgical measures in all cases of even minimal suspicion of malignancy is obvious.


[Influenza vaccination in dialysis patients]. 50 stabilized long-term hemodialysis patients were randomly selected to receive one intramuscular injection of a new influenza subunit vaccine containing only the surface antigens hemagglutinin and neuraminidase, or of an adjuvant containing whole virus vaccine. Both vaccines contained strains A/Victoria/3/75 and B/Hongkong/8/73. Both vaccines were very well tolerated and caused significant rises in the antibody titers within 4 weeks against both strains. The subunit vaccine produced significantly higher antibody titers against strain A than the whole virus vaccine.


[Multiple recurrence of Cushing's syndrome after bilateral adrenalectomy and pituitary gland surgery. Cure with o,p'-DDD]. A pituitary-dependent Cushing's syndrome in a young woman had an unusually protracted course and was extremely resistant to therapy. After unsuccessful pituitary irradiation, bilateral total adrenalectomy was performed. A piece of an excised adrenal gland was reimplanted into a buttock. Nevertheless, the patient went into adrenocortical failure and had to be given replacement therapy. After three years the Cushing's syndrome reappeared, this time combined with general hyperpigmentation. The implanted adrenal tissue was no longer to be found. Neither stereotactic pituitary coagulation nor implantation of 90-Yttrium into the pituitary resulted in remission of Cushing's syndrome. All attempts to localize the--very probably ectopic--cortisol-producing adrenocortical tissue failed. However, complete remission was finally achieved by treatment with o,p'-DDD.


[Pancreatic function after injury to the pancreas and traumatic pancreatitis]. Endocine and exocrine pancreatic function were investigated in 10 patients after pancreatic trauma or traumatic pancreatitis. There were no cases of overt diabetes mellitus. Three patients had subclinical diabetes. In the secretin-pancreozymin test 5 patients had normal exocrine pancreatic function after trauma, whereas in 3 patients bicarbonate and/or enzyme secretion was diminished, to normalize during an observation time of several years. In the remaining 2 patients a secretin-pancreozymin test could not be performed; one of them had slight steatorrhoea. These results are evidence of a good reserve capacity of the endocrine pancreas, and a good regeneration capacity of the exocrine pancreas, after trauma.


[The Bjoerk-Shiley and the Lillehei-Kaster valve in aortal position. A hemodynamic comparison]. Thirty-two patients with tilting disc valves in the aortic position were evaluated by left heart catheterization and cineangiography. 24 patients had Björk-Shiley valves (B-S group) and 8 Lillehei-Kaster valves (L-K group). At the postoperative hemodynamic evaluation, left ventricular peak systolic pressure was significantly (p less than 0.001) higher in the L-K group (174 +/- 22 mm Hg) than in the B-S group (140 +/- 22 mm Hg). The mean systolic pressure gradient across the prosthesis was significantly (p less than 0.001) higher in the L-K group (34 mm Hg) than in the B-S group (12 mm Hg). The calculated valve area at a similar average tissue annulus diameter was significantly smaller in the L-K group (0.9 cm2) than in the B-S group (1.5 cm2). It is concluded (1) that in the aortic position at similar external prosthesis dimensions the B-S valve exhibits superior hemodynamic performance of the L-K valve and (2) that aortic valve replacement by L-K valve is associated with significant postoperative left ventricular pressure load.


[Indications and costs of long-term oxygen therapy]. Nowadays, domiciliary long-term O2 therapy is given to certain patients with chronic arterial hypoxemia (PaO2 less than 55 mm Hg). However, it is important to exclude cases with severe CO2 retention (PaCO2 greater than 55 mm Hg). Hypoxemic and only slightly hypercapnic patients chiefly suffer from COLD and sometimes from a severe restrictive ventilatory disorder such as chronic bilateral pleural effusions or advanced kyphoscoliosis. The most important precondition for long-term O2 therapy is correct adjustment of all other procedures of pulmonary treatment, as well as total abstention from smoking. Common sources for domiciliary O2 therapy are bottles delivered to the patient's home weekly by the O2-producing firm. A new machine which appears to offer for greater facilities is the O2 concentrator of Rimer-Birlec (Cardiff, Wales). 2 liters O2/min are given via a naso-pharyngeal tube for 15 h per day. Without O2 during 9 h per day, the patient is able to follow appropriate employment. In domiciliary long-term O2 therapy the cost of O2 supply by the O2 concentrator is half that of bottles delivered to the home weekly. The new O2 concentrator for domiciliary  long-term O2 therapy is recommended as by far the most economical source of O2. Other sources of O2 such as liquid O2 or chemically produced O2 are uneconomical for domiciliary use. Only hospitals will benefit from supplying their pipelines from a container with liquid oxygen instead of using gaseous O2 from bottles. The cost of the former is 3/4 that of the latter.


[Diagnosis and therapy of chronic active hepatitis]. Chronic active hepatitis (CAH) as an entity covers a histologically, biochemically, and clinically heterogenous group of patients. Hence, there is no justification for treating all patients with this diagnosis with corticosteroids. On the basis of histological, biochemical, and clinical criteria, different degrees of severity of CAH can be distinguished. While corticosteroids appear to be indicated in severe CAH, they should, in general, not be administered in mild CAH. However, the course of disease must be carefully followed in these patients. In moderate CAH, the risk should be carefully weighed against the benefit of therapy in every individual patient, taking into account the severity of symptoms. In HBsAg-negative cases, a therapeutic trial of at least 6 months' duration is worthwhile. In HBsAg-positive patients, treatment with corticosteroids should be delayed and the course of the disease followed. Once the decision for corticosteroid therapy has been made, administration of 10 mg prednisolone and 50 mg azathioprine daily as a maintenance dose represents the therapy of choice. This combination is approximately as effective as 15--20 mg prednisolone alone, but is associated with a lower incidence of side effects.


[Diets for patients with kidney diseases]. Dietary treatment is indicated in the conservative management of chronic renal failure and in patients on maintenance dialysis. Water, sodium and potassium warrant chief consideration. The principles and different forms of protein-restricted diets are discussed.


[Indications for bandaging of the legs]. Study of the literature on the prevention of deep vein thrombosis shows the inefficacy of calf bandaging in the ambulation phase. Since thrombosis starts soon after or during operation, prophylactic measures are successful only if performed from the beginning of hospitalization. Orthostatic disturbances are not a general problem in the mobilization phase, as is shown in a study on 20 patients after myocardial infarction or heart surgery in whom leg compression did not influence circulatory regulation. In chronic venous or lymphatic insufficiency, however, compression therapy is of proven value. Such patients should be identified and treated. On the other hand, leg bandaging as a general preventive measure in the mobilization phase is no longer justified, but is indicated in individual patients with venous or orthostatic problems.


[Development of intestinal and bladder control from birth until the 18th year of age. Longitudial study]. The development of bowel and bladder control from 0 to 18 years of age in 321 Swiss children of the Zurich Longitudinal Study (1955-1976) is described. 3% of the children had started toilet training by the age of 1 month and 96% by 12 months. Bowel control was completed in 32% at age one, in 75% at age two and in 97% at age three. Complete bladder control by day and at night was established in none of the children at age one, in 20% at ages two and three and in 90% at age five. About one quarter of the boys and one tenth of the girls had a period of incomplete bowel or bladder control between 6 and 18 years. During the prepubertal period, the annual incidence of enuresis was 7-15% in boys and 7-10% in girls, and that of encopresis 2-4% and 1-2% respectively. Some combination of enuresis diurna, enuresis nocturna and encopresis were found in 7% of all children, although in most children, these events did not occur simultaneously. With the exception of primary diurnal enuresis, the different types of enuresis and encopresis were more frequent in males than in females. By the onset of puberty, encopresis resolved in all children and enuresis persisted in only a few children. The role of toilet training and the etiologies and pathogenesis of enuresis and encopresis are discussed from a development point of view.


[UV-fluorescence-bronchoscopy].

[UV-fluorescence-bronchoscopy]. In UV fluorescence bronchoscopy the patient inhales 5 ml of a 5% aqueous solution of fluorescein by compressed air spray, together with a beta2-stimulator, 10-15 min before the bronchoscopy. After the dyestuff which has collected in the secretion has been coughed up or drawn off, only carcinomata, nonciliated metaplastic forms of the mucous membrane, macroscopically non-visible tumour infiltrations into the mucous membrane, and lymphangiosis carcinomatosa remain stained. Under UV illumination, these areas can be visualized for location of points to be examined by biopsy. Interested readers are called upon to form themselves into a study group.


[Urinary Staphylococcus epidermidis: a pathogen or contamination?]. The alleged pathogenity of Staphylococcus epidermidis for the human urinary tract has been investigated statistically. The finding of this microbe in the urinary bladder punctate (678 suprapubic bladder aspirations) or in conventional urine sampling in the concentration greater than or equal to 10(4) microbes/ml (416 urine samples) shows no statistically significant correlation with the clinical signs of urinary tract disease.


[Surgical and endocrinological results after the removal of hormonally inactive pituitary adenomas by means of frontal craniotomy]. The pre- and postoperative endocrinological findings are evaluated in 128 patients suffering from pituitary adenoma without endocrine activity, undergoing surgery in the Department of Neurosurgery, University Hospital, Zürich, in the 10-year period between 1962 and 1971. The preoperative examination showed hypothyroidism in 24% of all cases. 59% of the males showed primary or secondary hypogonadism. All females in the age between puberty and menopause complained of menstrual disturbances. One patient complained of preoperative diabetes insipidus. The postoperative examination showed that the function of a partially insufficient pituitary may improve after surgery. Hypothyroidism and adrenal insufficiency became normal in 2/3 of the cases. Male hypogonadism improved in 33% of the cases. One female gave birth to a normal baby after an uncomplicated pregnancy 6 years after pituitary surgery. 16% of the cases suffered from postoperative permanent diabetes insipidus. The operative complication rate (brain edema, intracranial bleeding, epilepsy) was 32%. The immediate surgical mortality was 7% (9 patients). Recurrent adenomas were found and operated on in 9% of the cases (11 patients). Three patients had two recurrences.


[D-xylose absorption test. A pharmacokinetic and statistical study]. D-xylose pharmacokinetics has been studied in 6 healthy subjects by serial measurement of blood and urinary levels following oral and intravenous administration of two doses of D-xylose (5 and 25 g successively). Furthermore, patients with obesity, renal or hepatic insufficiency, or with a T-drain after cholecystectomy, are also investigated. Both the rate and completeness of D-xylose absorption and the apparent distribution volume of D-xylose present noteworthy interindividual variations, so that the time and value of the peak blood level are highly variable as between healthy subjects. Renal insufficiency increases the apparent elimination half-life of D-xylose and notably reduces D-xylose renal excretion. This study provides pharmacokinetic evidence of the very wide range of blood and urinary levels observed in the D-xylose tolerance test, and emphasizes the fact that D-xylose urinary excretion alone is not a reliable index of intestinal absorption.


Testing toxic substances for protection of the environment. The Toxic Substances Control Act requires pre-production testing of chemicals for potential hazards to human and environmental health. Effective control of chemicals requires evaluations of chemical hazard that go beyond determinations of toxicity to humans to include the effects, transport, and fat of chemicals in the environemnt. Formulation of meaningful hazard evaluations depends on integrating information from tests of chemical effects, transport, and fate or by developing testing tools that integrate these factors during experimentation. Chemical effects may be acute or chronic and they may be observed individual organisms, populations or organisms, or in total ecosystems. Chemical transport through the environment depends on physico-chemical characteristics of the chemical and the medium (soil, water, or air) as well as environmental factors and biotic processes. The ultimate fate of chemicals (persistence, transformation, or degradation) is determined by numerous physical and biological processes occurring in the environment, and must be acknowledged to effectively determine the hazard. Many techniques are available for the separate and routine evaluation of the effects, transport and fate of environmental contaminants. However, separate identification of the importance and magnitude of each of these factors limits their utility in assessments of chemical hazard. The microcosm (model ecosystem) method integrates many of these tests in replicable experimental units, and may provide substantial information on chemical hazard in ecosystem context.


Leupeptin, a protease inhibitor, decreases protein degradation in normal and diseased muscles. The protease inhibitor leupeptin decreases protein degradation in rat skeletal and cardiac muscle incubated in vitro, while protein synthesis remains unaltered. Leupeptin also lowers protein breakdown in denervated rat muscles and affected muscles from mice with hereditary muscular dystrophy. Leupeptin may thus be useful in retarding tissue atrophy. Since homogenates of leupeptin-treated muscles had decreased cathepsin B activity, this lysosomal protease may play a role in protein turnover in normal and diseased muscles.


Double-stranded RNA is present in extracts of tobacco plants infected with tobacco mosaic virus. Serologically specific electron microscopy was used to detect double-stranded RNA in extracts of tobacco infected with tobacco mosaic virus. Assays were made immediately after extraction, without purification, concentration, or treatment with phenol or detergent. This indicates that the double-stranded RNA is native and is not an artifact induced by purification methods.


Cyclopropanecarboxylic acid: chain elongation to omega-cyclopropyl fatty acids by mammals and plants. Rats dosed orally which [carboxyl-14C]cyclopropanecarboxylic acid (or its hexadecyl ester) retain radioactivity in tissue as novel triacylglycerols. The most abundant 14C-labeled metabolites were identified by gas-liquid chromatography-mass spectrometry as 13-cyclopropyltridecanoic and 15-cyclopropylpentadecanoic acids. Similar omega-cyclopropyl fatty acids are produced by beagle dogs and a lactating cow, as well as by apple and orange trees.


Lichen myxedematosus serum stimulates human skin fibroblast proliferation. Serum from patients with lichen myxedematosus, when added to exponentially growing normal human skin fibroblasts, stimulates DNA synthesis and cell proliferation. The degree of response in vitro is correlated with the extent of the disease in vivo and is specific for fibroblasts. The results suggest that there is a systemic factor (or factors) which may play a role in the etiology of diseases affecting the connective tissue.


Structure of collagen in cartilage of intervertebral disk. Small-angle x-ray and neutron diffraction patterns have been obtained from the annulus fibrosus of porcine intervertebral disk. These show that the collagen in this tissue is modified compared with that in tendon.


Durations of unitary synaptic potentials help time a behavioral sequence. Recordings in identified neurons and muscles that mediate crayfish tailflips reveal inhibitory postsynaptic potentials of two distinct durations. Those of long duration are recorded in five classes of cells in the flexion circuit, while those of short duration are recorded in three classes of cells in the extension circuit. The durations of the inhibitory postsynaptic potentials are matched to the durations of inhibition required by the different phases of the behavior.


Pitch memory: an advantage for the left-handed. In an auditory or musical task, subjects made pitch recognition judgments when the tones to be compared were separated by a sequence of interpolated tones. The left-handed subjects performed significantly better than the right-handed and also had a significantly higher variance. Further analysis showed that the superior performance was attributable largely to the left-handed subjects with mixed hand preference.


Newborn minor physical anomalies predict short attention span, peer aggression, and impulsivity at age 3. From a 5-to 10-minute newborn examination, behaviors of males at age 3 could be predicted. The number of minor physical anomalies, assessed soon after birth, was significantly related to a cluster of behaviors that are frequently labeled hyperactivity.


Interaction of critical periods in the visual cortex of kittens. The critical period for modifying the preferred direction in cat cortical units occurs earlier than that for monocular deprivation. The independence of the effects of these two types of deprivation from each other was tested by rearing six kittens with both reverse suture and reversed directional deprivation. The kittens were placed in a drum rotating in one direction with one eye open at ages 2 1/2 to 5 weeks; the drum rotation was reversed and the other eye opened when they were 5 to 12 weeks old. Recordings were then made in the visual cortex. The results were the sum of the effects of reverse suture and reversal of directional deprivation: most cells were driven by the eye that was open second, and most unidirectional cells preferred the direction to which the animals were exposed first. Consequently, many unidirectional cells preferred the first direction but were driven by the eye open second--a combination that the animal never saw during rearing. There was also an effect of ocular deprivation on directional properties and vice versa: reverse suture reduced the overall percentage of unidirectional cells, just as directional deprivation has been shown to affect the ocular dominance histogram. This result suggests that the same cells may be affected by both forms of deprivation.


L-Dopa methyl ester: prolongation of survival of neuroblastoma-bearing mice after treatment. L-Dopa has has been shown to demonstrate enhanced toxicity toward melanoma cells in vitro. Since melanocytes arise from the neural crest embryologically, the effect of L-dopa methyl ester, a soluble analog, on the murine C1300 neuroblastoma was studied. There was significant antitumor activity against the neuroblastoma, which was enhanced by combination with a dopa decarboxylase inhibitor, Ro4-4602. In vitro studies suggested inhibition of DNA synthesis as the principal site of action. A mechanism involving sulfhydryl compound scavenging is postulated.


Binding of benzo[a]pyrene 7,8-diol-9,10-epoxides to DNA, RNA, and protein of mouse skin occurs with high stereoselectivity. The formation, stereostructure, and cellular reactions of the 7,8-diol-9,10-epoxide metabolites of the carcinogen benzo[a]pyrene have been examined after topical application of benzo[a]pyrene to the skin of mice. In this known target tissue, polymer adducts from diastereomeric diol epoxides, (+)-(7S, 8R, 9R, 10R) and (+)-(7R, 8S, 9R, 10R), were formed stereospecifically from their corresponding 7,8-dihydrodiols. Both diol epoxides bind with proteins, RNA, and DNA in vivo. For the nucleic acids, binding occurs preferentially at the 2-amino group of guanine in cellular RNA and DNA in vivo. Methods for establishing the structure of the cellular adducts as well as the possible biological implications of their formation are discussed.


Chronologic and physiologic age affect replicative life-span of fibroblasts from diabetic, prediabetic, and normal donors. Cultured skin fibroblasts from subjects with clinically apparent diabetes mellitus and from subjects genetically predisposed to diabetes have a replicative lifespan that is inversely related to donor age. Fibroblasts from carefully defined normal subjects not predisposed to diabetes fail to show this correlation. The data support the idea that physiologic status of the tissue donor is a more precise determinant of fibroblast replicative lifespan than chronologic age.


Saturnine gout: lead-induced formation of guanine crystals. Intravenous injection of a sublethal dose of lead acetate into a domestic pig resulted in a 4.5-fold increase of guanine in the urine, indicating an impairment in the conversion of guanine to xanthine. This impairment is probably due to the inhibition of guanine aminohydrolase (guanase), since the activity of this enzyme is inhibited by Pb2+ (the inhibition constant being 3.0 X 10(-6)M). Postmortem histological examination revealed concretions of crystalline material in the epiphyseal plate of the femoral head. Extraction of the section containing the concretions showed that they were guanine. The relation of these findings to saturnine gout is discussed.


Human breast cancer: androgen action mediated by estrogen receptor. Growth of the human breast cancer cell line MCF-7 is enhanced by androgens, but only at pharmacological concentrations. Although physiological concentrations of androgens translocate the androgen receptor into the nucleus, no mitogenic effects are observed. By contrast, pharmacological androgens translocate not only the androgen receptor but also the estrogen receptor, and at these high doses significantly increase both DNA and estrogen-dependent protein synthesis. We therefore propose that androgens stimulate MCF-7 cell growth not through the androgen receptor but rather through the estrogen receptor.


Amantadine: neuromuscular blockade by suppression of ionic conductance of the acetylcholine receptor. Amantadine hydrochloride decreases the sensitivity of denervated mammalian muscle to iontophoretically applied acetylcholine. The drug depresses the amplitude of the end-plate current and reverses the slope of the relation between half-decay time and membrane potential suggesting that it alters the ionic conductance that is mediated by the acetylcholine receptor. Binding studies confirm that amantadine acts on the ion conductance modulator rather than the acetylcholine receptor.


Command neurons in Pleurobranchaea receive synaptic feedback from the motor network they excite. Command neurons that cause rhythmic feeding behavior in the marine mollusc Pleurobranchaea californica have been identified in the cerebropleural ganglion (brain). Intracellular stimulation of single command neurons in isolated nervous systems, semi-intact prepartions, and restrained whole animals causes the same rhythmic motor output pattern as occurs during feeding. During this motor output pattern, action potentials recorded intracellularly from the command neurons occur in cyclic bursts that are phase-locked with the feeding rhythm. This modulation results from repetitive, alternating bursts of excitatory and inhibitory postsynaptic potentials, which are caused at least in part by synaptic feedback to the command neurons from identified classes of neurons in the feeding network. Central feedback to command neurons from the motor network they excite provides a possible general physiological mechanism for the sustained oscillation of neural networks controlling cyclic behavior.


Neural correlate of behavioral plasticity in command neurons of Pleurobranchaea. Food stimuli normally excite the command neurons of Pleurobranchaea that cause feeding. In contrast, the same food stimuli selectively inhibit these neurons in specimens that have been trained to suppress feeding and withdraw from food by means of an avoidance conditioning paradigm consisting of paired food and conditional shock. Food stimuli excite the feeding command neurons of yoked control specimens exposed to unpaired food and shock, but inhibit the feeding command neurons of untrained specimens that have been satiated with food. These results suggest that the command neurons serve as a neural locus at which an animal's behavior is modulated by past experiences. These results also establish a neural correlate of behavioral plasticity, in the form of synaptic inhibition of the command neurons.


Legionnaires' disease: structural characteristics of the organism. The Legionnaires' disease organism was isolated from lung tissue taken from two fatalities of the Legionnaires' disease epidemic that occurred in Philadelphia during 1976. In yolk sac tissue the agent grew as a small coccobacillary microorgansim, which was Gram variable and Giménez positive. Intracellular coccoid and bacillary forms, detected by electron microscopy, within and without vacuoles, underwent multiplication by septate binary fission. Some of the intracellular forms resembled obligate intracellular pathogens. On defined bacteriologic media, the organisms were predominantly bacillary. The organism conforms to the morphologic criteria of a prokaryocyte.


Detection of bityrosine in cataractous human lens protein. Bityrosine was isolated from the insoluble protein of human cataractous lenses. Identification was based on correspondence with synthetic bityrosine with respect to chromatography, fluorescence, and ultraviolet and mass spectra. It is suggested that the compound may form cross-links with polypeptide chains in old and cataractous lenses, causing significant alteration in native protein structure.


Sulfhydryl groups and the monodeiodination of thyroxine to triiodothyronine. Sulfhydryl reagents exert a profound influence on the monodeiodination of thyroxine to triiodothyronine by rat and sheep tissues in vitro. A marked dithiothreitol-induced increase in the monodeiodination by fetal sheep liver homogenates suggests that the characteristically low conversion in fetal tissues is related more to the status of sulfhydryl groups than to a deficiency of the monodeiodinating enzyme.


Supplemental lighting stimulates growth and lactation in cattle. Sixteen hours of light daily (114 to 207 lux) increased weight gains and milk yield 10 to 15% in Holstein cattle in comparison with cattle exposed to natural-length photoperiods (39 to 93 lux) of 9 to 12 hours. The weight gain was accomplished without increased consumption of feed. Manipulation of supplemental light may thus cause dramatic increases in food supplies from animals.


Phase sensitivity in electroreception.

Phase sensitivity in electroreception. The gymnotoid electric fish Hypopomus artedi discriminates between electric stimulus pulses with identical spectral amplitudes but different spectral phase functions. Behavioral results can be explained on the assumption that electroreception is based on a linear filter, approximately matched to the species' electric organ discharge. The impulse response of the appropriate matched filter, in fact, resembles the known impulse response of the electroreceptors involved.


Relative risks of saccharin and calorie ingestion. The risk of a person getting cancer from ingesting saccharin is compared with the risk of ingesting additional calories which cause excess body weight. It is found that, for a person who is 10% overweight, the risk of ingesting one diet soft drink, which would cause a decrease in life expectancy of 9 seconds, is approximately equal to the risk of ingesting one additional kilocalorie; that is, if ingesting a diet drink inhibits ingestion of more than 1 kilocalorie, its benefits exceed its risks.


Contact-mediated bone resorption by human monocytes in vitro. Human circulating monocytes in tissue culture are capable of resorbing devitalized adult and fetal bone. An important component of this process is the adhesion of the cells to the mineralized substrate and the localized removal of matrix from beneath the attached cells. The process appears to involve both release of lysosomal enzymes onto the substrate and intracellular accumulation (transport) of resorbed matrix.


Cyclic polyether-protonated organic amine binding: significance in enzymatic and ion transport processes. The cyclic polyether, 18-crown-6, reacts with protonated amines in methanol to form complexes whose formation constants (log K) decrease in the order NH4+, RNH3+ greater than R2NH2+ greater than R3NH+. In the case of the organic amines, this stability order is identical to the earlier observed permeability sequence for protonated organic amines in glyceryl dioleate bilayers treated with valinomycin, nonactin, or gramicidin, and in bullfrog and rabbit gallbladder membranes. The decrease in log K values in the above series is primarily a result of decreased enthalpy change (deltaH) values, the entropy change (TdeltaS) term being essentially constant for the systems studied.


Directional selectivity in hamster superior colliculus is modified by strobe-rearing but not by dark-rearing. Visual response properties of superior collicular neurons of normal hamsters were compared with those of animals reared from birth to adulthood in either total darkness or with stroboscopic illumination. Directional selectivity was markedly reduced only in the strobe-reared animals, thus demonstrating visual plasticity in a system that develops apparently normally without visual experience.


Pelvic displacement osteotomy in young myelodysplastic patients with dislocatable hips. This prospective study of the role that pelvic displacement osteotomy may have in the management of dislocatable hips in patients with myelomeningocele defines the technical points to be considered and gives preliminary results for ten hips in eight children. The procedure may salvage failed posterior iliopsoas transfers or, in patients not operated on previously, it may limit cephalad displacement of the femoral head. Both control of muscle imbalance and improvement of acetabular contour appear essential to a high rate of success in these patients. Eight of ten hips in this series were stable upon short-term review. All patients were less than 7 years of age.


Immediate spica cast system for femoral shaft fractures in infants and children. From August 1973 through August 1976, 55 femoral shaft fractures in children were treated by manipulative reduction and immediate application of a double hip spica cast. All had satisfactory results and none had serious complications. Data from the study support our opinion that the immediate spica system is the treatment of choice for these fractures and that traction methods should probably be abandoned as definitive treatment of a femoral shaft fracture in a child.


Pyrah technic for ileal conduit diversion: a 16-year experience. At our institution, 100 patients had ileal conduit diversion using the Pyrah technic between 1959 and 1975. The results of this technic compare favorably with those of other ileal conduit diversions, and it has the advantage of being somewhat shorter than the standard Bricker procedure. Sixty-seven were done because of benign lesions of the urinary tract and 33 were done as part of the planned treatment of various malignant conditions. We did 56 diversions in patients with neurogenic bladder dysfunction. There were 67 early and 69 late complications, and the complication rate was much higher in patients having preoperative irradiation. The most common complications were wound infections, pyelonephritis, ureteroileal anastomotic leaks or stricture, and stomal stenosis. The upper urinary tracts showed signs of progressive deterioration after diversion in 19% of patients. The operative mortality was 6%. The mortality was four times greater in the group with malignant conditions.


Management of patients with glaucoma and cataract. The recent rise in the number of patients with both glaucoma and cataracts has increased the controversy over the management of these concurrent problems. Visual acuity, strength of medication, and previous surgery must be considered when determining whether to do cataract extraction alone, glaucoma surgery alone, or a combined procedure. We have found that the type of glaucoma the patient has influences our choice of surgery. The combined procedure is reserved for patients who have had repeated attacks of angle-closure glaucoma and those whose open-angle glaucoma is difficult to control. Thermal sclerostomy with cataract extraction was successful in maintaining intraocular pressures of 18 mm Hg or lower without medication in 48 of 58 patients.


Coordinated metabolic and obstetric management of diabetic pregnancy. Diabetes during pregnancy is associated with insulin resistance, an increase in insulin requirement, and a greater tendency to ketosis and ketoacidosis. Increased perinatal mortality is related to maternal hyperglycemia and can be decreased dramatically with strict control of plasma glucose during pregnancy and a smooth-working obstetrician-internist-neonatologist team. Bad prognostic signs include pyelonephritis, ketoacidosis, toxemia, and poor prenatal care. Timing of delivery is no longer arbitrary at 36 or 37 weeks, but is based upon signs of fetal lung maturation and estimates of fetal risk. Abnormalities in the infant, including congenital abnormalities, biochemical abnormalities, respiratory distress syndrome, and large body weight must be managed in a well-equipped newborn intensive care unit under the care of experienced neonatologists. Strict attention to these principles has resulted in viable infants in the last 36 pregnant diabetic patients delivered at Vanderbilt University Hospital. Therefore, close medical supervision, use of modern obstetric technics, and the availability of a well-equipped and staffed neonatal intensive care unit can result in a good outcome in this group of patients. Finally, the decision for pregnancy must be carefully considered by the diabetic patient, her husband, and her physician long before pregnancy occurs.


Role of sodium intake in the antihypertensive effect of propranolol. Twelve hypertensive patients had measurements of body weight, blood pressure, plasma renin activity, and plasma volume during periods of normal sodium intake and acute sodium depletion. After receiving propranolol orally for four to 14 weeks, repeat measurements were obtained under identical conditions of sodium intake. During normal sodium intake, propranolol therapy was associated with a decrease in plasma renin activity, a variable tendency to an increase in body weight and plasma volume, and a decrease in mean arterial pressure of 5 mm Hg (NS). During sodium restriction, blood pressure was decreased significantly from that observed during normal sodium intake and propranolol added a further significant decrease of 8 mm Hg (P less than .01). Blood pressure reductions obtained with sodium depletion and acute diuretic therapy were approximately the same with or without propranolol. The increase in plasma renin activity expected with sodium depletion and diuretic therapy was not blunted by propranolol.


Normal hematologic values obtained with a Coulter counter, model S. A survey was made of hematologic values obtained with the Coulter Counter, Model S, at American Medical Laboratories, Inc. Blood specimens from 6,887 outpatient men, women, and children were analyzed according to age and sex. Patients being seen by nephrologists, hematologists, and oncologists were excluded from the study. The mean values for white blood cell counts, mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration correlated well with values frequently quoted as normal. However, the mean values for hemoglobin, hematocrit, and red blood cell counts were slightly lower than the commonly accepted normal mean values. This may be a result of newer and more accurate methods of hematologic analysis.


Influenza, respiratory distress and clear chest films: report of four cases. Four patients developed severe wheezing and dyspnea with clear chest films during the course of an influenza epidemic. A variety of factors appeared to play a role in the pathogenesis of the respiratory distress. Standard bronchodilator therapy produced no appreciable response. All patients did well with supportive care.


Round window rupture secondary to acoustic trauma. Perilymph fistulas are a known cause of sudden hearing loss. The two cases presented illustrate round window ruptures secondary to acoustic trauma. The important considerations are early diagnosis and treatment, the possibility of associated congenital anomalies, and future protection against sound.


Removal of a common duct stone with a "filet" T-tube. In a patient who had had cholecystectomy, a common duct stone was removed with a filet T-tube, the open limbs of the tube closing around the stone so that it could be pulled out along the track of the T-tube stem. The maneuver was successfully repeated in a dog. The use of the filet tube is recommended when a T-tube is to be placed in the common duct.


Calcified mesenteric cyst.

Calcified mesenteric cyst. Reported is a case of a calcified mesenteric cyst that was causing obstruction of the small bowel. Because only roughly one case occurs per 100,000 hospital admissions, mesenteric cysts are rarely thought of and may be difficult to diagnose. The differential diagnosis includes such critical lesions as aortic aneurysm, pancreatitis, ovarian cysts, omental cysts, and lipomas of the mesentery. The proper treatment of these rare lesions is somewhat influenced by causative factors: embryonic, traumatic, neoplastic, infectious, or degenerative. Surgical excision or enucleation is preferred to internal or external drainage. Ultrasonography is becoming increasingly valuable as a diagnostic tool.


Pregnancy complicated by thoracolumbar scoliosis. Pregnancies complicated by severe thoracolumbar scoliosis may be affected by obstetric and cardiovascular complications. This case report of a pregnant woman with severe thoracolumbar scoliosis includes extensive documentation of complications by pulmonary function studies and peripartum arterial blood gas analysis. The differences between the physiologic changes of normal pregnancies and those of pregnancies with scoliosis are described.


Nonotosclerotic ankylosis of the stapedial footplate. A woman with a long history of chronic otitis media had a stapedectomy after a surgical diagnosis of otosclerosis. In the histologic study of the temporal bones, done after her death four years later, the main portion of the stapes footplate was present but fractured and no otosclerosis was present. New celluluar bone which simulated otosclerosis filled the anterior oval window niche and was continuous with the middle ear surface of the footplate fragments. The new bone extended anteriorly to overlie a tympanosclerotic focus and inferiorly was continuous with the periosteum of the middle ear. At least part of the new bone formation occurred after stapedectomy. This may explain the poor long-term results frequently encountered when a stapedectomy is done on patients with tympanosclerotic fixation of the stapes footplate.


Acute appendicitis in a child associated with prolonged appendiceal retention of barium (barium appendicitis). An instance of acute appendicitis in a child associated with prolonged retention of barium by the appendix and formation of a barolith was presented. Previous reports have implicated barium in the etiology of appendicitis and suggest routine roentgenographic follow-up of all cases in which barium enters the appendix. Considering the frequency of this observation and the lack of an established relationship between prolonged retention of barium and appendicitis, this suggestion seems unwarranted.


Carbenicillin nephrotoxicity.

Carbenicillin nephrotoxicity. A patient with biopsy-proven interstitial nephritis associated with nafcillin and dicloxacillin therapy developed fever, hematuria, pyuria, and renal insufficiency after the administration of carbenicilin five months later. Cephalosporin therapy was given to this patient without signs of renal toxicity. This is the first reported case of probable carbenicillin-induced interstitial nephritis and serves to emphasize the danger of giving any penicillin analogue to patients with a history of pencillin-induced interstitial nephritis.


Deafness associated with oral furosemide. A patient with Hodgkin's disease and renal insufficiency became deaf while being treated with high dose oral furosemide. Cessation of furosemide was associated with improvement in his hearing. However, at the time of his death, 11 days after stopping the furosemide, significant hearing impairment was still present. It is suggested that oral furosemide be considered potentially ototoxic, particularly in patients with compromised renal function.


Fibroleiomyomatous hamartoma: a rare benign pulmonary "coin lesion". A discussion of pulmonary hamartomas is presented along with a case presentation of a rare form, the fibroleiomyomatous variety. The need to differentiate these tumors from primary or even secondary malignant neoplasms always requires tissue diagnosis, necessitating surgical excision.


Bronchial carcinoids and hormonal disorder. The relationship between bronchial carcinoids and hormonal disorder is reviewed in the light of a study of 24 patients with carcinoid tumors of the bronchus. In this series, two patients presented with manifestations of the polyendocrine disorder. The common origin of carcinoid tumors and other APUD cells from neural crest ectoderm provides a common denominator in the association of carcinoid tumors of the bronchus and adenomas, or carcinoma of associated endocrine organs.


Supraglottic laryngectomy.

Supraglottic laryngectomy. This paper describes the experience with subtotal supraglottic laryngectomy for laryngeal carcinoma at the Department of Otolaryngology of the Tulane University School of Medicine. Of 36 patients, 32 (89%) had local control of diseases at one year. Of 27 patients followed up for at least three years, 22 (81%) are free of disease. Postoperative aspiration was the most frequent complication, but was a serious problem in only one patient. Because of the significant functional advantage of partial laryngectomy, the high rate of disease control, and an acceptable complication rate, we believe supraglottic laryngectomy is the procedure of choice for laryngeal carcinoma in selected patients.


Nasal masses in infants and children.

Nasal masses in infants and children. Nasal or perinasal masses in children may be classified as congenital or developmental masses, inflammatory lesions, or benign or malignant neoplasms. Because of a possible connection with the central nervous system, nasal masses may be difficult to manage. A premature biopsy, or even a noninvasive palpation, may precipitate intracranial infection, meningitis, or severe bleeding. The indolent nature and benign appearance of these lesions shold not lead to deferral of complete evaluation and appropriate treatment.


Bronchoscopy in the community hospital.

Bronchoscopy in the community hospital. A new Pulmonary Medicine-Thoracic Surgery service was established in a community hospital in July 1974. This report details the experience of 409 bronchoscopies performed from July 1, 1974 through Dec 31, 1976. There were no deaths and four complications--one aspiration and three pneumothoraces resulting from transbronchial lung biopsy. Final diagnoses for which bronchoscopy was done were as follows: cancer--141; infectious disease--97; interstitial disease--33; obstructive lung disease--58; hemoptysis--35; miscellaneous--45. In the cancer group, a cytohistologic diagnosis was made in 82 patients by bronchoscopy alone, 31 additional diagnoses were made by scalene node biopsy or mediastinoscopy, and the remainder by surgical exploration and/or resection. In 268 patients with benign disease, bronchoscopy established the diagnosis in 87% of the cases. Pulmonary Medicine tended not to repeat nondiagnostic bronchoscopy but rather to refer immediately for a definitive surgical procedure. Thoracic Surgery tended not to reduplicate bronchoscopy for the purpose of "confirmation." A conjoint medical-surgical approach to bronchial disease, at the community level and based on a mutual understanding of capability and limitation, is feasible, productive, and economical.


Gastroscopy in surgical practice.

Gastroscopy in surgical practice. We reviewed the records of 100 consecutive patients who had gastroscopy. All endoscopic work was done by our four-man surgical group. Roentgenographic and endoscopic diagnoses are compared with reference to degree of accuracy. The expanded uses of gastroscopy in surgical practice are illustrated and a plea is made for increased involvement of surgeons in the rapidly expanding field of endoscopy.


Approach to the management of pleural effusion in malignancy. The diagnostic and therapeutic approaches to malignant pleural effusions are reviewed, and data on the retrospective study of 37 patients are presented with respect to diagnosis and management. All patients with stable effusions should be managed with systemic therapy for the primary tumor when an effective agent is available. When it becomes necessary to use local therapeutic measures, thoracostomy tube drainage with local instillation of tetracycline is recommended.


Carpal tunnel syndrome in pregnancy.

Carpal tunnel syndrome in pregnancy. Occurrence of the carpal tunnel syndrome in pregnancy was studied by examining 100 consecutive obstetric admissions. Twenty-one patients reported paresthesias or hypesthesia in the median nerve sensory distribution of the hand during the pregnancy; eight of these had decreased sensation subjectively at the time of examination one to three days after delivery; two had trophic changes, loss of sudomotor function, thenar atrophy, and decreased two-point discrimination; and one had a delay in motor conduction time across the carpal tunnel. Of the 21 patients, 18 became asymptomatic before or shortly after delivery. The remaining three were asymptomatic three months after delivery. We conclude that the incidence of symptoms is probably greater than usually appreciated, but that few patients require treatment. Steroid injection may occassionally be necessary, but the need for surgical intervention is rare.


Zickel nail: a retrospective study of subtrochanteric fractures. Nineteen subtrochanteric fractures were treated at Charlotte Memorial Hospital and Medical Center between March 1973 and March 1976 by open reduction and internal fixation using the Zickel nail. Postoperative roentgenograms showed the cross-nail exiting the femoral neck in three of the cases, but this later proved not to be significant. Of the 16 patients available for follow-up all were ambulatory unassisted or with a walker within two months of surgery. Radiographically evident healing averaged 4.1 months. There were no non-unions and no infections. Our data support the use of the Zickel nail in the treatment of subtrochanteric fractures.


On defining microcardia: application in pulmonary emphysema. Pulmonary emphysema was the disease entity from which we derived a definition for microcardia in males. After the fourth decade, a cardiothoracic ratio of 38% or less is considered to represent a small heart. Among male Veterans Hospital patients between the ages of 41 and 83, the probability of an individual without emphysema having a cardiothoracic ratio of 38% or less was under 1%. Microcardia, even as an isolated sign, should make one suspect strongly the presence of subclinical emphysema and to consider instituting a prophylactic regimen. Hearts should be measured to judge not only increased size but decreased size in both patient and examinee groups.


Intraoperative patient monitoring: a method of analyzing esophageal phonocardiograms. The value of esophageal phonocardiography as a noninvasive monitor during anesthesia was studied in dogs. Esophageal phonocardiograms were analyzed using fast Fourier transform and least squares linear regression technics. This method has demonstrated that it is feasible to estimate two parameters of cardiac contractility--1/(PEP)2 and stroke power--and one parameter that demonstrates the state of the vasculature--total peripheral resistance. A continuous time (analog) processor that will accomplish this task is described.


Hair transplantation using local hypothermia. The frequency of hair transplantation for treatment of male alopecia is increasing, and much time is consumed in free scalp plug removal and implantation. The amount of time depends upon the number of grafts required. Plugs ranging in diameter from 2 to 4 mm are recommended since larger sizes have increased fibrosis and decreased hair growth. Composite grafts show greater survival when cooled; therefore, a method of local hypothermia and 5.5 mm scalp plugs were used in this study. The lowered temperature of the recipient site during the early postoperative days permitted the use of the larger grafts without fibrosis, hematoma, or infection and with improved hair growth. This technic allows better quality of hair growth, requires fewer hair plugs, and decreases operating time.


Oxygen concentrations received from commonly used delivery systems. The mean inhaled oxygen concentrations received from five devices commonly used for delivering supplemental oxygen to spontaneously breathing patients were determined. The ideal technic for the determination would require direct measurement of mean alveolar oxygen concentration. Since this is not feasible, we plotted arterial oxygen tensions against known inhaled oxygen concentrations in volunteers. The fitted equations were then used to determine mean inhaled oxygen concentrations received by the volunteers while breathing from each device. The volunteers received accurately determined oxygen concentrations from those devices employing the Venturi principle at settings of 40% or less. The concentrations received did not coincide with the settings with the Venturi devices above 40%, and highly variable with the non-Venturi devices. Variability in the concentrations received was related to the fact that the volunteers' peak inspiratory flow rates exceeded total gas flows delivered by the devices.


Angiography of the pancreas.

Angiography of the pancreas. The diagnostic potentials of pancreatic angiography are discussed on the basis of four illustrative cases and a review of the pertinent literature. It is concluded that selective visceral angiography properly applied is of great value in diagnosing carcinoma of the pancreas and in determining resectability of pancreatic tumors.


Preoperative oral antacid therapy for patients requiring emergency surgery. Preoperative oral antacid therapy has been used effectively to reduce the number of emergency obstetric patients "at risk" of developing acid-aspiration syndrome. Thirty-three nonobstetric adult patients requiring emergency surgery were selected to determine whether the protective effects of antacid therapy could also be derived in this high-risk group. Maalox-treated patients had a mean gastric pH of 6.46 +/- 0.5 and gastric volume 21.5 +/- 3.6 ml, with none at risk, whereas control patients had mean pH of 3.71 +/- 0.43, gastric volume 71.5 +/- 16.5 ml, and 42.1% at risk. This report suggests that preoperative antacid therapy should reduce the incidence of acid aspiration and subsequent morbidity and mortality in patients requiring emergency surgery.


Blastomycosis of fronto-ethmoid complex. Blastomycosis in children is relatively infrequent. Further, osteomyelitis of the frontal bone, which prior to the antibiotic era occurred more frequently and was mostly due to pyogenic cocci, is rare today. We described a case of frontal osteomyelitis in a child due to blastomycosis which occurred in the absence of frontal sinuses. To our knowledge this rare combination of factors has not previously been reported.


Gonococcal arthritis in the elderly.

Gonococcal arthritis in the elderly. A 60-year-old women presented with an acute, suppurative, monoarticular arthritis due to N gonorrhoea. Appropriate therapy was delayed because of failure to consider gonococcal infection in the differential diagnosis of pyoarthritis in the elderly. We suggest that this entity should be considered in the managment of acute, suppurative arthritis regardless of the age or physical diability of the patient.


Squamous cell carcinoma of the common bile duct. Squamous cell carcinoma of the common bile duct in a young woman was treated with pancreatoduodenectomy and chemotherapy. She died eight months after diagnosis. Clinical presentation and aggressiveness of the tumor are similar to adenocarcinoma. Radical resection is the treatment of choice, particulary in young patients.


Retropharyngeal abscess after endoscopic retrograde cholangiopancreatography: an uncommon but potentially fatal complication. Diagnostic cholangiopancreatography is a useful procedure which is attended by a relatively low incidence of immediate or delayed complications. Perforation of the esophagus or gut, myocardial infarction, hemorrhage, cholangitis, and pancreatitis are the most commonly reported morbid or fatal events. This paper reported a case of retropharyngeal abscess which led to tracheal compression requiring an emergency tracheostomy and antibiotic therapy after a routine ERCP procedure. This dramatic case pointed out an unusual but potentially fatal complication of diagnostic ERCP.


Long term results of Roux-en-Y hepaticojejunostomy. One hundred and twenty-three patients with benign diseases involving the bile ducts, curable by biliary bypass, underwent a Roux-en-Y hepaticojejunostomy, and the long term results of this operation were evaluated to ascertain if hepaticojejunostomy is a safe and durable procedure. There were no operative deaths. A peptic ulcer developed postoperatively in two patients. Only one instance of anastomotic stenosis was observed at follow-up study, averaging 5.5 years. Six of the 11 patients with postoperative biliary symptoms had intrahepatic lithiasis, a possible indication that the symptoms were due to temporary obstruction of the anastomosis by residual stones. A refined operative technique has improved the results which over-all are highly satisfactory.


A clinical evaluation of impedance rheography in peripheral arterial disease. The impedance rheograph has been shown to give values of blood flow consistent with a history of vascular insufficiency; normal limbs having a mean flow of 6.9 +/- 1.6 milliliters per minute per 100 milliliters of limb volume and diseased limbs having a proportionately reduced flow. The most reduced flow was found in those with rest pain or severe claudication, 1.7 +/- 0.8 milliliters per minute per 100 milliliters of limb volume. It is suggested that this technique may be useful clinically in assessing patients before treatment and, subsequently, as an objective evaluation of that treatment.


The clinical basis for a simplified classification of anorectal agenesis. Sixty consecutive patients with anorectal agenesis were seen during a ten year period. Among 41 boys and 19 girls, there were 35 supralevator and 25 infralevator abnormalities; associated anomalies were present in 38 patients. The over-all mortality was 23 per cent. A simplified classification of anorectal agenesis, based on therapeutic considerations, is proposed. It consists of four basic groups: male high and low and female high and low. A low lesion is defined as having a visible opening or membrane covered opening in the perineum in the male or a visible opening in the introitus or perineum in the female. These infants are managed with simple dilations of the fistula; definitive perineal anoplasty, if necessary, is deferred until the child is six months of age or older. All other lesions are defined as high lesions and are treated in the newborn period with a colostomy. Sacroperineal or sacroabdominoperineal rectoplasty is deferred until the infant is six to 12 months of age. The use of this classification as well as the judgments it implies in the timing of operative procedures will avoid dangerous perineal dissections in the newborn.


The rational use of drains after cholecystectomy. A study of patients who had a cholecystectomy compared the use of sump drains and Penrose drains. Sump drains were removed as soon as the indication for the presence of the drain no longer existed. Penrose drains were managed in the traditional way. The safety of early drain removal in selected patients was demonstrated. This technique offers most of the advantage and little of the risk of omitting drains entirely. The length of hospital stay for those patients who underwent a cholecystectomy can be significantly shortened by this technique;


The role of ischemia in the pathogenesis of stress induced gastric lesions in piglets. Ten conscious piglets were subjected to hemorrhagic shock for three hours. Nine surviving piglets showed severe stress induced gastric mucosal lesions in the gastric fundus and corpus. Total as well as regional gastric blood flow was measured, 8 micron radioactive microspheres, in the same piglets before--control--and during hemorrhagic shock. Total gastric blood flow fell almost 90 per cent uring shock. There was a significantly higher flow reduction in the mucosa of the corpus and fundus, where almost all of the stress lesions were found. Measurement of blood flow within these lesions demonstrated a fall approximately to zero. Ischemia seems to be an important pathogenetic factor of gastric stress lesions. This may possibly render the gastric mucosa more susceptible to other injurious factors.


Carcinoma in situ of the distal part of the colon and of the rectum. One hundred and three patients with carcinoma in situ in the rectum, rectosigmoid and sigmoid colon were evaluated retrospeactively. The majority of the lesions occurred within an adenomatous polyp. A synchronous invasive carcinoma of the colon was present in 43 patients, whereas 42 patients had carcinoma in situ unassociated with another malignant neoplasm or major medical illness. In the latter group of patients, adequate treatment of carcinoma in situ resulted in cure, while two patients who refused treatment died of invasive carcinoma of the colon. Adequate treatment could be obtained by local excision or intestinal resection, depending upon the size and the location of the lesion.


Adjuvant chemotherapy and immunotherapy in high risk patients with melanoma. Thirty-one patients with Stage II cutaneous melanoma received adjuvant chemotherapy or immunotherapy after radical excision of the primary and regional lymph nodes. Vaccinations with bacille Calmette Guérin produced minimal systemic reactions and was better tolerated by the patients than was chemotherapy. A higher survival rate and disease-free interval were noted in patients treated with bacille Calmette Guérin than those receving dimethyl Triazeno-imidazole carboximide. These results suggest that adjuvant chemotherapy with dimethyl Triazenoimidazole carboximide alone is not beneficial in the treatment of high risk patients with melanoma. In this study, adjuvant bacille Calmette Guérin therapy appears to be more advantageous than does chemotherapy.


Vascular trauma observed at an urban hospital center. The records of 50 patients with 67 major civilian type vascular injuries treated in a large urban center from 1967 to 1975 were reviewed in terms of nature of the injury, form of surgical management and early and late results. Civilian injuries differ in many aspects from those of their military counterparts and often require different treatment. In both, however, treatment protocols should be periodically re-evaluated for a number of reasons, chiefly among which are changing patterns of delivery of the injured patient to the medical center and advances in technical skills. Notable in the presently reported series were the low mortality and the absence of a need for amputation, with a limb salvage rate of 100 per cent. Despite modern advances in technical proficiency in vascular reconstruction, there is still a place for careful vascular ligation in the definitive surgical management of major vascular trauma.


Long term behavior of reversed saphenous vein grafts for advanced femoropopliteal disease. Fifty consecutive long saphenous vein graft operations for limb salvage performed between 1958 and 1965 were observed by periodic arteriography. Of 50 grafts, 11 failed within two years, and at the time of the final review, two patients had defaulted. Extended observations of the remaining 37 grafts up to 15 years showed three main complications. First, graft degeneration affected seven grafts with earliest evidence of elongation, tortuosity, irregular dilation or aneurysmal formation at four years. It did not affect any graft after eight years. One graft required replacement because of degeneration. Second, proximal dilation was seen in six grafts, but it did not compromise patency or function and had a maximal incidence at four to six years. Third, the site of the distal anastomosis was narrowed in eight patients, but the narrowing was severe in four. This complication occurred at six to eight years and affected 25 per cent of the surviving patients. The narrowing was caused by thrombus formation within the area of anastomosis and was amenable to further arterial reconstruction.


Alterations in serum lipid concentrations following skeletal trauma. Serial studies of 118 patients following fractures of the pelvis or lower extremity demonstrated a significant association between hypoxemia and the serum concentration of nonesterified free fatty acids. Serum lipase levels were similar but not as significant. No differences were noted in the serum concentrations of either triglycerides or cholesterol.


Surgical experience with craniopharyngioma in adults. It is proposed that the term craniopharyngioma of the adult be employed only for tumors presenting after the successful completion of puberty. The contrasts with the current practice of arbitrary distinction on the basis of age at the time of operation. Of 48 patients over 20 years of age at the time of operation, 38 fulfilled the criteria for "craniopharyngioma of the adult". Clinical characteristics of these 38 are analyzed. In contrast to generally accepted ideas, the course of patients with incompletely excised tumors is unfavorable, with frequent early and serious recurrences. A complete excision is therefore recommended for craniopharyngioma of the adult.


Extracerebral cavernous hemangioma of the middle fossa. Two cases of extracerebral cavernous hemangioma in the middle fossa are reported. Cerebral angiography showed a large avascular mass lesion in each case, but the tumors were very vascular at operation. Recovery of vision occurred in one case postoperatively. Diagnosis and treatment of these tumors are discussed.


Fluent aphasia after closed head injury. A case of post-traumatic, contre-coup Wernicke's aphasia resulting from left posterior temporal hemorrhagic contusion localized by angiography and CAT scan is reported. Categorization of aphasia is reviewed, emphasizing that a fluent language disorder can be elusive to laymen and non-neurologically oriented physicians.


Intraorbital ophthalmic aneurysms and arteriovenous fistulae. Angiographically documented aneurysms and arteriovenous fistulae of the intraorbital segment of the ophthalmic artery are extremely rare. A unique patient is presented who had both lesions within the same orbit. History of this disease entity is traced briefly, pertinent anatomy and embryology are reviewed, and an explanation is offered on the pathogenesis of these lesions based on embryology.


Ipsilateral subclavian to external carotid and STA-MCA bypasses for retinal ischemia. The surgical treatment of a patient with retinal ischemia in the left eye and occlusion of the left common and internal carotid and right internal carotid arteries is presented. After demonstration of filling of the left external carotid artery from vertebral collaterals, as saphenous vein graft from the left subclavian to the left external carotid artery was performed prior to a left superficial temporal artery to middle cerebral artery bypass. This case demonstrates the feasibility of revascularization in the presence of occlusion of the ipsilateral common and internal carotid arteries.


Cerebral metastasis from a malignant thymoma. A 14-year-old girl was found to have a solitary metastatic thymoma in the occipital lobe of the brain eight years following thoracotomy for removal of a malignant thymoma. Histologically, the lesions appear identical. Initial neurological examination was normal. The metastatic lesion was surgically removed followed by radiation therapy. No neurologic deficits related to the metastasis to the brain were evident nine months postoperatively.


Schistosomiasis of the spinal cord.

Schistosomiasis of the spinal cord. Schistosomiasis of the spinal cord is a rare presentation of a disease involving over 200 million people. A patient from an endemic area presenting as a transverse myelitis or a spinal cord tumor, and with eosinophilia, should alert the physician to the possibility of schistosomiasis of the spinal cord. Diagnosis is based on finding the characteristic eggs in the stool or urine, or if necessary, by rectal, bladder or liver biopsies. Myelography is performed to determine if decompressive laminectomy is necessary.


Breast cancer in 3,558 women: age as a significant determinant in the rate of dying and causes of death. The forces of mortality created by cancer of the breast have been examined utilizing data collected during the past 19 years by the Syracuse, N. Y., Upstate Medical Center Cancer Registry on 3,558 women. Except for 15 lost to follow-up, all have been contacted annually through 1974 or until death. Time and cause were recorded for all deaths. In April, 1975, 1,883 remain alive and in the registry and 1,660 women have died. Using life-table analyses and considering deaths due only to breast cancer, mortality rates were calculated for three age groups--21 to 50 years, 51 to 70 years, and 71 to 100 years. Breast cancer expresses its lethality most vigorously in the oldest group. The half-death time (50% mortality rate) for the youngest group was 13 years, for the middle group 8 years, and for the oldest group 5 years. The rate of dying was a function of both age and stage at diagnosis. At 16 to 18 years after diagnosis, deaths due to breast cancer begin to disappear. Eighty-eight percent of the women who died following a diagnosis of cancer of the breast have died of their breast cancer. Age as well as stage at diagnosis are significant determinants on the length of survival and cause of death.


Selective arterial embolization for control of traumatic pelvic hemorrhage. Operative techniques for control of massive extraperitoneal bleeding after pelvic trauma have been disappointing. Extensive blood supply by ample collaterals alledgedly is responsible for the failure of proximal ligation of hypogastric arteries. Angiography has proved to be a valuable technique in the diagnosis and treatment of pelvic vascular injuries. Three patients are reported in which the diagnostic and therapeutic applications of angiography with subsequent embolization enabled the surgeon to avoid a difficult and possibly frustrating exploration. In addition, it provided an accurate indication for surgical intervention in one patient.


Platelet function abnormalities in a family with recurrent arterial thrombosis. Three young family members with recurrent arterial thrombosis underwent investigation for lipid or coagulation abnormalities. Lipoprotein electrophoresis, cholesterol, triglyceride levels, and routine coagulation studies were unremarkable. By contrast, testing of platelet function showed enhanced platelet aggregability to epinephrine and collagen in two of the subjects. In addition, release of 14C-serotonin by adenosine diphosphate and epinephrine was increased over control values in these same two patients. The third subject demonstrated decreased platelet aggregation and lowered 14C-serotonin release, but was symptomatic with rest pain at the time of testing. The ongoing in vivo thrombosis in the third subject may account for hypocoagulable platelets by in vitro testing. These abnormally sensitive platelets identified by platelet function testing may be associated with a familial "hypercoagulability" syndrome. Definition of the hemostatic abnormality in these individuals provided a rational basis for pharmacological therapy with antiplatelet drugs, which appeared to be successful.


Division of the left renal vein: a safe surgical adjunct. Ten patients have undergone surgical division of the left renal vein (LRV) during operations on the abdominal aorta. Nine were elective procedures performed during the resection of a complicated abdominal aortic aneurysm (six patients) or treatment of complete infrarenal aortic occlusion (three patients). The first patient in this series underwent emergency LRV ligation at the renal hilum for the control of hemorrhage incurred during an elective aneurysmectomy. This patient survived postoperative renal failure and myocardial infarction, but died 21 months later from another myocardial infarction. At the time of death, he had moderate renal insufficiency. None of the remaining nine patients undergoing elective LRV division experienced any apparent renal dysfunction, as measured by urine sediment, serum creatinine, blood urea nitrogen, and intravenous pyelography. Although not recommended as a routine maneuver, division of the LRV is advocated as a safe adjunct for surgical exposure in difficult aortic procedures.


Graft interposition splenocaval shunt for total or selective decompression of portal hypertension. A new operation for selective or total decompression of the portal venous system in cases of intrahepatic portal hypertension is described. It involves interposition of a large-caliber Dacron graft between the splenic vein and the inferior vena cava. The graft-interposition splenocaval shunt is performed readily and quickly, satisfying the variable hemodynamic needs of patients with portal hypertension. It can be either selective (S-SCS) or total (T-SCS) from the beginning, or a T-SCS may be converted subsequently to a S-SCS should surgically induced hepatic decompensation supervene. It is less demanding technically than distal splenorenal shunt (D-SRS). The S-SCS conserves portal venous perfusion of the liver, preserves hepatocellular function and architecture at the preoperative levels, avoids precipitation of postshunt portal-systemic encephalopathy, and decompresses gastric-esophageal varices with prevention of further variceal bleeding even better than D-SRS. One hundred percent graft patency has been obtained, and the surgical results have been superior to those following portacaval shunt in patients with large liver blood flow and relative benignity of the liver disease, be it cirrhosis or noncirrhotic portal fibrosis. In patients with advanced cirrhosis, variceal bleeding, and small liver blood flows, T-SCS would be indicated. Patients of this category obtained inferior surgical results and had operative deaths (16.7%) following S-SCS. The concept of the operation has merits and deserves further evaluation.