[The hip in vertebral hyperostosis].

[The hip in vertebral hyperostosis]. The study of two series of cases affected by vertebral hyperostosis allows the authors to underline the frequency with which the hip joint is affected and to describe the destructive forms seen in hyperostosis of the hip. In a first series of 101 cases the authors picked up 145 pathological hips which were probably or surely associated with hyperostosis. These hip disorders presented in three types: Type I (already described by J. Forestier et al.) with peri-articular proliferation and radiological integrity of the joint space; Type II with hyperostotic proliferation and narrowing of the joint space; Type III with epiphysial destruction. The study of a second series "of the development of 58 cases of hyperostotic hip disease" followed for 2-16 years raises the consideration that these three types are in fact three stages in the evolution of the condition.


[Anatomical study of the lumbosciatic area]. This study of 75 anatomical specimens and their comparison with contrast metrizamide radiography of the terminal dural sac reveals the exact topography, height, volume and morphology of the dural sheath and for the nerve roots their disposition in the terminal sac, the level of the root emergence and anatomical and radiological views of the foramina above and below the emerging roots.


[Vitamin-resistant osteomalacias of hepatic origin in the adult]. The authors report two cases of vitamin resistant osteomalacia in an adult connected with an apparent inability of the liver to hydroxylate vitamin D. One of the cases showed a case of pseudo-hypo parathyroidism of type II, reversible by the administration of calcium. The other case demonstrated vertebral hyperossification. Treated with 25 hydroxycholecalciferol in physiological dosage an improvement in the clinical, biochemical and histological states resulted.


The inhibitory effect of crinofizin (pineal peptide extract) on adrenalin-induced hyperglycemia in rabbits. The effect of crinofizin--a pineal peptide extract with clinical use--on adrenalin hyperglycemia was tested in the rabbit. Administered subcutaneously one hour before an i.v. hyperglycemic dose of adrenalin, crinofizin significantly reduced the hyperglycemic effect of this hormone. The results reveal the functional antagonism between adrenalin and hypoglycemic pineal peptide(s) called "pinealine".


Urinary, plasma and adrenal tissue steroids in a male patient with Cushing's syndrome due to adrenal carcinoma. The dynamics of urinary and plasma steroids (CPB and RIA) were simultaneously studied in a 36-yr-man with Cushing's syndrome due to adrenal carcinoma. The markedly increased basal excretion of 5-pregnenetriol, PG, PGT, DHA, THS and corticosteroids with nonsignificant changes during the endocrine tests decreased to normal levels after tumour removal. The basal low level of plasma testosterone, with nonsignificant changes during the endocrine tests, rose progressively after surgery. The steroid content of adrenal carcinoma tissue determined by CPB and RIA after LH-20-Sephadex CC separation revealed important proportion of unconjugated 17-OH-P.


Cortisol circadian rhythm in 70--100-year-old subjects. The circadian rhythms of plasma cortisol was examined in 25 persons aged between 70 and 100 years by comparison with 5 adults aged between 17 and 38 years. The blood samples were drawn at 16 hundred, 20 hundred, 00 hundred, 04 hundred and 08 hundred hrs. Cortisol was assayed by the fluorimetric method. The experimental data were analyzed by Halberg's mean-cosinor method. The results showed that the circadian rhythm in plasma cortisol changes with age. The characteristic phenomena found were the following: a tendency towards reducing the hourly quantitative differences, comparatively more marked between 90 and 100 years; anticipation of the cortisol maximum level of 08 hundred at 04 hundred hrs in the group of 71 to 80 years, and at 00 hundred hrs in some of the subjects older than 80. A normal circadian rhythm was found in 2 of the 25 cases examined. These changes imply variations of the same kind in the CRF and ACTH levels. The changes in the circadian rhythms of cortisol show that the regulation systems are also implied in the aging process. It is possible that early-morning insomnia of the aged be due to this anticipation in cortisol secretion.


A histopathological, cytochemical and morphometrical study of the androgenic polycystic ovary. The authors studied histopathologically, cytoenzymologically and morphometrically 64 cases of androgenic polycystic ovaries. The distinctive sign disclosed was a marked hyperplasia of theca interna. The mean values of this latter in the androgenic polycystic ovaries was of 87 mu +/- 19 as compared to that of 75 mu +/- 18 found for theca interna in the ovarian follicular cysts unaccompanied by endocrine symptoms. Large lipid-rich cells--the so-called androgenic cells--were often present in the polycystic ovary. Cytoenzymologically a high activity of glucose-6-phosphate dehydrogenase was assayed in theca interna and in the androgenic paralutein cells, while the lowest activity was shown by the 3beta-ol-hydroxysteroid dehydrogenase.


The action of chlorpromazine upon the serum and hypophyseal variations of growth hormone, prolactin and TSH in the male adult rat under continuous-lighting stress. The influence of chlorpromazine (CPZ) on the serum and hypophyseal levels of growth hormone (GH), prolactin and TSH was studied in the male adult rat occurring under normal light-dark-rhythm conditions and under continuous 24-hour lighting, respectively. The serum and hypophyseal concentrations of GH decreased significantly (p less than 0.01 and p less than or equal to 0.02) one hour after the administration of 1.0 mg of CPZ in the animals under continuous light by comparison with the animals maintained on the same conditions. In the animals under normal light-dark rhythm, CPZ did not influence the peripheral or central concentrations of GH. The animals maintained either in normal or in continuous lighting conditions released prolactin under the influence of CPZ. The increased values of circulating TSH in light-exposed animals by comparison with the diurnal group (p less than 0.001) were some more augmented under the influence of CPZ, while this drug remained unefficient in the animals under normal light-dark-rhythm conditions. The mechanism of CPZ action upon the secretion of GH and prolactin, which are hormones lacking target gland, is discussed.


The biochemical prerequisites for preventing pathogenic lysolecithin activity in the human gallbladder. II. Studies on the subcellular localization of lysophospholipase. The subcellular localization of lysophospholipase activity in the human gallbladder epithelium was studied by differential and density gradient centrifugation. The highest relative specific activity was found in the microsomal fraction, although the enzyme appeared in mitochondria and lysosomes as well. The cytosol did not contain any significant lysophospholipase activity, but large amounts of enzyme were solubilized during centrifugation in sucrose gradients. These findings are discussed in relation to the distribution and properties of lysophospholipase in other cells and tissues and with regard to physiological implications. The possible relevance to the pathogenesis of aseptic cholecystitis is inferred.


The effect of thiazolidin carboxylic acid (ThCA) on the redox equilibrium maintaining in the rat hepatocyte with streptozotocin-induced diabetes. The variation of the activities of glutathion peroxidase, glutathion reductase, glucose-6-phosphate dehydrogenase, as well as of the concentrations of lipid peroxides and -SH groups of nonproteic nature, was followed up in the hepatocyte of normal rats, of those with, streptozotocin-induced-diabetes, and of diabetic rats treated with thiazolidin carboxylic (ThCA) acid. Free peroxides and glutathion peroxidase were increased in the diabetic animals as against the normals, whereas glutathion reductase, glucose-6-phosphate dehydrogenase and the -SH groups of nonproteic nature had lower values. A return to normal of these parameters was noticed in the animals treated with ThCA.


Experimental studies on fluid pathophysiology in small intestinal obstruction in the rat. II. Effects of intraluminal hyperosmolality and simultaneous intravenous infusions. Using an experimental model in rats a hyperosmolal glucose solution was introduced into the intestinal lumen to simulate and magnify the accumulation of fluid seen in simple small intestinal obstruction. Efforts to modify the extent and rate of this fluid flux by administering parenteral solutions of varying osmolality produced no result. When hypoosmolal or iso-osmolal infusion solutions were used, the intraluminal dilution process displayed mathematical characteristics in agreement with those of a simple dilution process, while at the same time normal blood volume was maintained. On the other hand, when a hyperosmolal glucose solution was infused, very great demands were made on the extravascular compartment, because a severe diuresis equal in volume to the fluid given parenterally took place, while at the same time there was marked hemodilution. Despite this the organism delivered as much fluid to the intestine as when hypo-osmolal or iso-osmolal infusions were given. Thus in principle the flow of fluid into the intestinal lumen could not be modified by giving parenteral solutions of any osmolality.


Portography of normal and regenerating dog liver. The angiographic appearance of the portal vein in the dog before and after major hepatic resection is described. An increased diameter and length of the lobar vein and their ramifications were found following resection. The appearance both in the portal and sinusoidal phase indicated a diffuse growth of the liver remnant. One week after resection a portal hypertension was recorded, which had usually receded after six weeks. Major hepatic resection seems to imply a higher risk for fatal toxic effects from the contrast medium.


Hepatic venography of normal and regenerating dog liver. Total and selective hepatic vein angiographies were performed preoperatively and 6 weeks after 70 per cent liver resection in 6 dogs. The alterations in the hepatic vein system, increased diameter and elongation of the remaining lobar veins and their major tributaries plus increased angle between the radicles, are consistent with the findings earlier described by angiography of the hepatic arterial and portal venous system after major hepatic resection in dogs.


Serum gastric inhibitory polypeptide (GIP) in duodenal ulcer disease: relationship to glucose tolerance, insulin, and gastrin release. Serum immunoreactive gastric inhibitory polypeptide (IR-GIP), gastrin (IRG), and insulin (IRI) were estimated in 41 normal weight patients with duodenal ulcer (DU) and 25 age-matched controls in response to a high calorie liquid test meal. 28 out of 41 DU patients had a hyperglycaemic glucose response during the test meal, and 15 had a pathological oral glucose tolerance test. Fasting and food-stimulated IR-GIP and IRG levels were significantly elevated in the DU patients. Serum IRI also increased to significantly higher levels in DU patients after the test meal. The degree of the greater hormone response was dependent on the glucose increase after the test meal in the case of insulin and GIP, but not in the case of gastrin. It is concluded: firstly, that a faster glucose absorption (possibly due to rapid initial gastric emptying or increased intestinal motility) is responsible for the high and short-lasting glucose peak and the increased GIP and insulin secretion; secondly, that the GIP response could well be causally related to the insulin response; thirdly, that hyposcretion of GIP is ruled out as a possible factor in the pathogenesis of gastric acid hypersecretion of duodenal ulcer patients.


Experimental studies on fluid pathophysiology in small intestinal obstruction in the rat. I. Effects of intraluminal hyperosmolality. An experimental model is described which is intended to simulate and accentuate the movement of fluids across the intestinal mucosa resulting from simple small intestinal obstruction as well as to provide a means for measuring these fluid shifts. Working on the hypothesis that the increase in fluid in the obstructed small intestine is a consequence of increased osmolality resulting from enzymatic breakdown of the intestinal contents, a solution of high osmolality was introduced into an intestinal segment of known size and position. Under these conditions the intestinal mucosa functioned in the manner of a semipermeable membrane and permitted only fluids of low osmolality to enter the intestinal lumen, thus tending to normalize its hyperosmolal contents. The process of dilution followed a simple dilution curve. At the same time hemoconcentration and increased serum osmolality reflected the mobilization of fluids from the extravascular and vascular compartments. The transfer of fluids into the intestinal lumen continued throughout the test period, despite the fact that there was a linear increase in intraluminal pressure to a relatively high level, indicating increased smooth muscle tone probably due to the hyperosmolal provocation. The observed accumulation of fluid was well reproducible and associated with predictable effects on the vascular and extra-vascular compartments.


Giant pseudopolyposis causing colonic obstruction. Report of a case seemingly associated with Crohn's disease of the colon. Gian pseudopolyposis is uncommon and only one obstructive case has previously been reported. In that case the underlying disease was ulcerative colitis while the present case seemed associated with Crohn's disease. Clinically this condition imitates a malignant tumour, and because of the rarity we failed to reach the right preoperative diagnosis in spite of correct colonoscopy and biopsy findings.


Skin reactivity and phagocytic function of neutrophil leucocytes in Crohn's disease and ulcerative colitis. A decreased capacity of the leucocytes to phagocyte yeast particles was found in patients with Crohn's disease of the ileum. Patients with lesions only in the colon showed normal phagocytic activity as did patients with ulcerative colitis (U.C.). Intradermal injection of killed Strep. pyogenes produced an increased erythrmatous reaction after 48 hours in patients with U.C., and the reaction was pustular in half of them. None of the controls or the patients with Crohn's disease of the ileum had such a reaction. An increased erythematous reaction to streptokinase-streptodornase was also more common in patients with U.C. than in those with Crohn's disease and a control group. No such difference was seen to other bacterial antigens. The reactivity to kallikrein, prostaglandin E1, histamine or bradykinin did not differ from that of normal subjects.


Serum bile acids in patients with viral hepatitis. Total and individual serum bile acid concentrations were studied in 18 patients with viral hepatitis. The initial high values returned to the normal range at approximately the same time as the conventional liver function tests. Chenodeoxycholic acid was the predominant bile acid initially, but cholic acid predominated as the disease resolved. All patients had proportionately less doexycholic acid than controls. It is concluded that the measurement of serum bile acid does not provide added information of value in the management of patients with viral hepatitis.


Calcium malabsorption and absence of bone decalcination following intestinal shunt operation for obesity. A comparison of two types of operation. Calcium absorption was studied in 23 patients before and one year after intestinal shunt operation for obesity. It decreased from 23 to 12% (p less than 0.02) after surgery, when the jejunum/ileum ratio was 36cm/12cm [type I], and only from 19 to 16% (p greater than 0.05), when the ratio was 12cm/36cm [type III]. It is suggested that the difference is due to variation in absorptive surface in the distal half of the small intestine and to a minor degree to change in external pancreatic function, bile acid metabolism, and fat digestion. Bone mineral content was lower in 37 obese than in normal subjects and underwent only minor changes (p greater than 0.01) 3 and 12 months after surgery, possible because of postoperative daily calcium and vitamin-D substitution.


Properties and subcellular distribution of acyl-CoA: cholesterol acyltransferase (ACAT) in guinea-pig liver. The optimal in vivo conditions for measuring liver acyl-CoA:cholesterol acyltransferase, EC.2.2.1.26 (ACAT) activity in cytoplasmic extract from guinea-pigs have been examined. ACAT in liver from ordinarily fed guinea-pigs is very low. The effect of different compounds on ACAT activity was evaluated. Sodium fluoride, oligomycin, divalent cations, oleyl-CoA, and bile acids were all shown to inhibit ACAT activity markedly. Albumin stimulated the cholesterol esterification independently of the presence of fatty acids. Subcellular distribution of liver ACAT in relation to different marker enzymes shows that the bulk of ACAT activity is present in the microsomal fraction. By comparing the esterification of exogenous and endogenous cholesterol, the results indicate that these two substrates are not esterified to the same extent. Both the 'enzyme" level and substrate quality are of importance for the high ACAT activity found in rat-liver homogenates compared to guinea-pig.


Red blood cell transketolase activity and the effect of thiamine supplementation in patients with chronic liver disease. Biochemical evidence of thiamine deficiency was found in 58% of patients with chronic liver disease, the incidence being higher in alcoholic than in non-alcoholic patients. Daily supplementation with high doses of thiamine hydrochloride (200 mg/day) for one week restored levels of thiamine pyrophosphate (TPP), the active co-enzyme form of thiamine, to normal in all cases. Such supplementation also stimulated synthesis of the TPP dependent enzyme transketolase. Because of the essential role of TPP as a co-factor in intermediary metabolism, it is concluded that high doses of thiamine should be included in the routine nutritional management of patients with severe chronic liver disease.


Gastric and duodenal peptic ulcer disease in a well-defined population. A prospective necropsy study in Malmö, Sweden. In a necropsy series from Malmö of 2,218 subjects above 20 years of age, and composing 88.2% of all Malmö residents above 20 who died during the period of investigation, the frequency of gastric and duodenal peptic ulcer disease (ulcer, scar or surgically treated peptic ulcer) was studied. The total frequency of peptic ulcer disease was 17.9% (20.9% in men and 14.7% in women). The condition was most common (25.4%) in men in the 50-59 year age group, after which the frequency declined. In women a constant high frequency (15-16%) was seen in all age groups above 60 years. Gastric ulcer (ulcer or scar) was found in 10.7% and duodenal ulcer in 5.5%. 16.1% of subjects with peptic ulcer disease had been subjected to surgical treatment, 22.8% of the men and 5.8% of the women.


Somatostatin inhibits gastric motility in response to distention. Gastric motility and plasma gastrin concentration have been measured in 6 healthy volunteers before and after stepwise gastric distention. Distention was performed by filling a flaccid thin-walled bag, which was connected with a low pressure transducer for measuring intragastric pressure variations. Stepwise increase in gastric volume from 0-600 ml caused graded increases in gastric motility. No significant change was seen in the plasma gastrin level. When gastric distention was performed concomitantly with constant infusion of somatostatin (0.05 mg/h and 0.50 mg/h) in the same individuals on different days, motility was significantly reduced, without any changes in the plasma gastrin concentration. It is concluded that somatostatin, which probably plays a role in the gastro-intestinal tract, may have a physiological effect in the regulation of gastric motility too. This motility effect of somatostatin seems to be independent of any effect on the gastrin concentration.


Oesophageal peristalsis. A simple system for the recording of oesophageal peristalsis, and the influence of bolus volume on peak peristaltic pressure amplitude. Peak oesophageal peristaltic pressure amplitude was recorded in 8 healthy subjects at points 5 and 15 cm proximal to the gastro-oesophageal sphincter, by using an in situ tip-transducer simultaneously with a continuous flush (Intraflo) perfused catheter system with external pressure transducer. Dry swallows and wet swallows of 2.5, 5 and 10ml, respectively, were made in random succession. In all cases the pressures recorded by either system correlated well. In all cases the peristaltic pressure amplitude was significantly higher after the wet swallows. The catheter and flow system used in this study is simple and makes recording of peristaltic pressures independent of the shape of the in situ transducer, and its therefore well suited for measuring the amplitude of oesophageal contractions.


Metabolic changes after jejuno-ileal bypass for obesity. Metabolic parameters were studied in 6 patients before and for 18 months after jejunoileal bypass for obesity. The postoperative changes in plasma concentration of amino acids were characterized by a decrease in essential amino acids, while the non-essential amino acids were unchanged or elevated, indicating a state of protein-caloric malnutrition. The pattern of fatty acids in serum the first year after operation: an unchanged sum of unsaturated and saturated fatty acids accompanied by a significant fall in linoleic acid and a corresponding increase in oleic acid, showed that even during this period the patients were in a state of essential fatty acid deficiency. The oral glucose tolerance test and the levels of serum immunoreactive insulin activity indicated a general improvement in glucose tolerance and a normalization of preoperative hyperinsulinism. A 40-50% reduction was found both in serum triglycerides and cholesterol levels. Serum iron was reduced by approximately 30%, whereas TIBC levels remained unchanged. The Schilling test showed a significant fall in vitamin B12 absorption postoperatively with subnormal values at 6 and 12 months. Vitamin B12 in serum dropped, but remained within the normal range, suggesting that the preservation of 25 cm of distal ileum is sufficient to secure adequate absorption of vitamin B12. Folic acid levels in serum fell after the bypass, demanding supplementation in 5 of the 6 patients at 6 months postoperatively.


Evidence for excessive absorption of oxalate by the colon in enteric hyperoxaluria. This work was designed to investigate the site of oxalate hyperabsorption in malabsorption syndromes. 1) Urinary oxalate excretion was measured in 27 patients with ileal resection (IR) and steatorrhea. Mean urinary oxalate excretion was high in 13 patients with IR and intact colon and in 9 subjects with IR and right hemicolectomy (90.2 +/- 11.9 and 108 +/- 18.6 mg per 24 hours; mean +/- S.E.M.), whereas it was normal in 5 patients with IR and ileostomy (21.9 +/- 4.4 mg per 24 hours). Steatorrhea was similar in the three groups. 2) On one patient of the last group in whom the colon had not been removed initially but excluded closure of the ileostomy resulted in the development of frank hyperoxaluria. 3) Intracolonic perfusion of calcium (1.93 g per day) abolished or greatly reduced the hyperoxaluria in 3 patients. These results indicate that the colon is the major site of oxalate hyperabsorption, and the right colon is not necessary for the development of hyperoxaluria in malabsorption syndromes.


Gastric emptying in patients with reflux esophagitis or benign strictures of the esophagus secondary to reflux compared to controls. Quantitative measurements of gastric emptying of fluids were performed in 11 controls, 12 patients with reflux esophagitis, and in 7 cases with benign strictures of the esophagus secondary to reflux. The method for measuring gastric emptying was the double-sampling test with phenol red as an inert marker. No significant alterations in gastric emptying were noted in reflux patients or in stricture patients compared to controls, although a tendency to a slower emptying was noticed in the latter group. The importance of these findings is discussed.


Effects of intraduodenal acid on gallbladder net water absorption and motility in the cat. A recently described perfusion technique has been used in the study of gallbladder function during acid infusion into the duodenum in the anaesthetized cat. The method allows simultaneous measurements of the net water absorption, and thereby the concentrating function of the gallbladder, as well as the motility of the organ. Duodenal acidification, which is known to release several gastrointestinal hormones, was found to reduce the net water absorption and induce a contraction in the gallbladder. The results are discussed in relation to earlier studies of gallbladder function as influenced by gastrointestinal hormones.


The development of mucosal changes after gastric surgery for ulcer disease. The development of morphological changes in the body mucosa after partial gastrectomy for ulcer disease according to Billroth I and II was studied early (within 3 years) and late (10-24 years) postoperatively with gastroscopy and forceps biopsies. The morphological findings in the body mucosa of the operation specimens and biopsies from the stomas were compared. The effect of time, ulcer disease, operation procedure, sex, and age was studied. In duodenal ulcer patients, with significantly less pronounced inflammatory mucosal changes in the operation specimen, partial gastrectomy caused acute and chronic gastritis to the same degree as seen in gastric ulcer patients within 3 years postoperatively. Duodenal ulcer patients also developed mucosal atrophy, cystic dilatation of the gastric glands, and intestinal metaplasia by time to an extent not significantly different from what was found in gastric ulcer patients. No correlation could be found between the mucosal changes and factors like age, sex, or operation procedure. Mucosal atrophy, chronic gastritis, and intestinal metaplasia are regarded as possible features of malignant transformation. If this concept is true, our findings may explain why stump carcinoma is frequently reported with the same incidence independent of preoperative ulcer disease or anastomotic procedure.


Experimental studies on fluid pathophysiology in small intestinal obstruction in the rat. III. Effects of intraluminal iso-osmolality and simultaneous intravenous infusions. The introduction of a hyperosmolal glucose solution in the intestinal lumen in an experimental model using rats resulted in the accumulation of large quantities of fluid in the lumen, resembling the situation in simple obstruction of the small intestine. To establish whether the osmotic strength of the glucose solution caused this influx of fluid, or whether the volume of the fluid per se is a contributory factor, an identical amount of an iso-osmolal and largely non-resorbable substance was introduced in place of the hyperosmolal glucose solution. No influx of fluid into the intestinal lumen could be demonstrated even when large infusions of varying osmolality were given intravenously. The osmolality of the intestinal contents remained unchanged as well as the intraluminal pressure. Despite the massive infusion of fluids, the hematocrit remained relatively stable, thus indicating stable blood volume and demonstrating the enormous storage capacity of the extravascular compartment.


Encephalopathy in patients with cirrhosis of the liver. A neuropsychological study. Neuropsychological tests and clinical ratings of the level of consciousness were performed in 30 patients with encephalopathy due to cirrhosis of the liver. Compared to the test norms for patients with diffuse cerebral lesions, the state of encephalopathy in patients with cirrhosis has a qualitatively different pattern of cerebral affection, since disturbances of attention were found independently of general intellectual function. Eight cirrhotic patients without portacaval anastomosis were matched in clinical rating with 8 patients with portacaval anastomosis. The course of cerebral affection after portacaval shunts showed defects characteristic of intellectual impairments in diffuse cerebral lesions, which were not found in the non-operated matched controls.


Determination of the faecal excretion of labelled bile salts after i.v. administration of 14C-cholic acid. An evaluation of the bile salt malabsorption before and after surgery in patients with Crohn's disease. By measuring total faecal radioactivity, correlated to 24-hour enterohepatic circulation, following i.v. administration of 14C-cholic acid, bile salt malabsorption was evaluated before and/or after surgery in 80 patients with Crohn's disease localized to the ileum and/or the colon and the results related to the length of ileum diseased or resected. Before operation bile salt malabsorption was observed only in patients with inflammation of the terminal ileum, but no significant correlation was found between bile salt excretion and the extent of ileal disease. In patients subjected to ileal resection with sacrifice of the ileocaecal valve, bile salt malabsorption correlated strongly to the length of ileum resected. This correlation was about the same in ileostomy patients and in patients subjected to restorative operation. We concluded that determination of 14C in faeces is a more sensitive test than the Schilling test and the faecal fat excretion test in reflecting ileal dysfunction, at least in patients with ileal resections.


Relations between surface charge and in vitro lysis of red blood cells in paroxysmal nocturnal haemoglobinuria. The effects of neuraminadase on the electrophoretic mobility and in vitro lysis of PNH, glutathione treated and normal erythrocytes was determined. Neuraminidase strongly affected the in vitro haemolysis of PNH and glutathione treated erythrocytes by substantially elevating the lysis in the Ham acid test while virtually eliminating lysis in the sucrose test. Findings suggest that membrane bound sialic acid or the level of cell surface charge may have a role in the susceptibility of PNH erythrocytes to complement mediated lysis.


Sustained haematological remission after bone marrow curettage in a case of primary myelofibrosis. This brief case report describes a sustained haematological remission obtained in a patient with primary myelofibrosis treated by bone marrow curettage after previous therapy with androgens was unsuccessful. The patient remains in haematological remission 5 years after the procedure. It is suggested that this procedure be attempted in more cases of myelofibrosis.


Clinico-pathological correlations in the Kiel classification of non-Hodgkin's lymphomata in children. The rapid development of chemotherapy and radiotherapy during the last decade makes an increasing demand for a reliable classification of malignant non-Hodgkin's lymphomas. This is especially important in children since in this age group the lymphomas show a much worse prognosis than in adults. An attempt at a modern classification is offered by the so-called Kiel classification. 38 children with non-Hodgkin's lymphomas previously classified according to Rappaport were re-evaluated according to the Kiel system. Reclassification was technically feasible in 26 patients. There was good agreement on typing between the two independently working cytopathologists. 3 patients proved to be cases of histiocytic medullary reticulosis. Among the remaining patients, a much larger variety of histological subgroups was seen than in the one published paediatric series of Lennert. 17 patients had high-grade malignant lymphomas with lymphoblastic lymphomas predominating. Some clinical correlations not detectable with the Rappaport classification were found using the Kiel system. 6 patients were judged as having low-grade malignant lymphomas but in this group the survival was poorer than expected and 1 patient showed leukaemic transformation. The Kiel classification makes high demands for adequate surgical techniques and preparatory routines. It seems to represent a step forward in the classification of non-Hodgkin's lymphomas but much more experience is needed, especially in children, in order to evaluate its role as a guide to differentiated therapy.


Migration pattern of splenic lymphocytes after local labelling of the pig spleen with 3H-cytidine. In normal young pigs splenic lymphocytes were selectively labelled by injecting tritiated cytidine into a splenic artery. 10 h later several lymphoid and non-lymphoid organs were investigated for spleen-derived lymphocytes by autoradiography. The relative and absolute organ distribution of the labelled cells was determined. Labelled lymphocytes appeared rapidly in the peripheral blood reaching a mean labelling index of 4.8%. More splenic lymphocytes were found in thymus dependent areas than in thymus independent areas of lymphoid organs. Nearly 40% of all emigrated lymphocytes homed to lymph nodes and only about 1% in the thymus. A surprisingly high number of splenic lymphocytes were located in the bone marrow and the lung.


Difference in the effect of immobilized ligands on the Fc and C3 receptors of mouse peritoneal macrophages in vitro. The function of the Fc and C3 receptors on the free surface of normal and endotoxin activated mouse peritoneal macrophages seeded on glass bound antibody--antigen (AbAg) complexes or complement was examined. We found that the glass bound AbAg complexes interfered with attachment and internalization of particles recognized by the Fc receptor. The C3 receptor function in these cells was not affected. On the other hand, normal and activated macrophages seeded on glass bound complement showed no change in the function of the C3 and the Fc receptors.


Circulating immune complexes, complement activation kinetics and serum sickness following treatment with heterologous anti-snake venom globulin. Consecutive serum and plasma samples, from a patient receiving 100 ml polyvalent horse anti-venom globulin after a rattlesnake bite, were analysed for circulating immune complexes (IC) and activation of complement factors. IC were determined by two independent methods, a complement consumption assay and a Clq-binding assay. Rapidly rising levels of complement-fixing circulating IC were detected as early as 4--5 days after the serum treatment and distinct IC-activity was recorded in both assays on day 8 when clinical symptoms of serum sickness were observed. The IC remained in circulation for at least 5 weeks. Signs of intravascular C-activation in the form of low C3, C4 and C5 values was noted on day 1 after treatment. Factor B was demonstrable 3--4 days after the snake bite and this factor and C3c attained a peak around day 8, just before maximal suppression of native C3 and C4. 14 days after the globulin treatment C3c and B were declining rapidly while C3 and C4 approached normal values first 36 days after treatment. An increase in heterophilic antibodies to sheep erythrocytes was observed after treatment with anti-venom globulin.


Complement lysis: the ultrastructure and orientation of the C5b-9 complex on target sheep erythrocyte membranes. The C5b-9 complex derived from human serum and assembled on target sheep erythrocyte membranes is a thin-walled cylinder rimmed by an annulus at one end. The total height of the cylinder is 150 A, towards which the annulus contributes 30 A. The cylinder has an apparently uniform internal diameter of 100 A. The external diameter of the annulus is 200 A. The classical complement 'rings' visualized on membranes after complement lysis represent such C5b-9 cylinders perpendicularly oriented on the membranes. The thin-walled cylinder is anchored in the membrane matrix and the annulus located in the exterior membrane glycocalyx. At the sites of attachment of the C5b-9 complexes, the continuity of the membrane bilayer is disturbed and the presence of trans-membrane pores is indicated. The data essentially support the 'doughnut' theory of complement lysis.


Ultrastructure of effector--target cell interaction in secondary cell-mediated lympholysis. The ultrastructure of the secondary cell-mediated lympholysis (CML) reaction and the effects on interacting lymphocytes of colchicine, cytochalasin B, and effector cell-specific antisera were examined using transmission and scanning electron microscopy. Surface labelling of cytotoxic secondary effector cells with cationized ferritin allowed them to be distinguished from unlabelled target lymphocytes. Effector--target interactions were characterized by intercellular junctions involving extensive areas of membrane apposition and interdigitation and extension of pseudopod-like processes by the effector cell. The abolition of such interactions when effector populations were pretreated with anti-Ly2 sera plus complement demonstrated target cell destruction in secondary CML to be dependent on the activity of restimulated cytotoxic T lymphocytes. Cytochalasin B and colchicine dramatically decreased the numbers of specific effector--target cell interactions observed. Although the data presented do not allow the possible activity of soluble lytic factors associated with the effector cell surface to be ruled out, they suggest that target cell lysis in the secondary CML system examined results from immune-specific binding of alloantigen-sensitized effectors to targets and osmotic effects which follow localized disruption of the target cell membrane.


Tracheobronchial clearance 5-15 months after infection with Mycoplasma pneumoniae. Tracheobronchial clearance was studied in 17 non-smokers who had suffered from a serologically verified Mycoplasma pneumoniae pneumonia 5-15 months earlier. The subjects inhaled 6 micron teflon particles tagged with 99mTc. The retention of the particles in the lungs was measured for 2 h. The retention after 2 h in this group was significantly higher than in a control group of healthy non-smokers. The results suggest that some impairment persists 5-15 months after the infection or that persons with slow clearance contract a mycoplasma pneumonia more easily than do those with fast clearance.


Group A meningococcal polysaccharide vaccine and course of the group A meningococcal epidemic in Finland. A group A meningococcal epidemic started in Finland in 1973 and had its peak in 1974. Its rapid decline and end after large scale vaccinations in 1975-76, involving approximately one quarter of the population, is described. It gives further proof of the clinical efficacy of the group A polysaccharide vaccine. No corresponding increase in the other serogroups has been seen in the 1 1/2 years elapsed after these vaccinations.


Relative concentrations of albumin and IgG in cerebrospinal fluid in health and in acute meningitis. IgG and albumin were determined in cerebrospinal fluid (CSF) and plasma by electroimmuno assay in 90 control patients. The curve for the ratios between concentration of IgG in CSF and in plasma versus the ratios between concentration of albumin in CSF and in plasma was practically linear (r=0.95). The scatter diagram of these ratios was used to investigate the occurrence of synthesis of IgG within the central nervous system in 55 cases of acute meningitis. No unmistakable intrathecal synthesis of IgG was demonstrated. No difference was found between the relative concentration of IgG in CSF early in the course of the disease and that observed later.


Prognostic value of blood platelet counts, coagulation factors and serum fibrin/fibrinogen degradation products (FDP) in acute infections. Platelet counts, P&P, factor V and fibrin/fibrinogen degradation products (FDP) in serum were determined in 96 patients with 100 episodes of acute infections. The aim of the study was to evaluate the possible correlation between the tests, separately and in combination, and the outcome of the patients. The prognostic value was found to be dubious (0.05 greater than P greater than 0.01) as regards both a low platelet count and a decreased level of P&P and very low (P greater than 0.2) as regards factor V. On the other hand, the demonstration of a raised S-FDP as well as the presence of more than one pathological test was of distinct prognostic value (P less than 0.001). It is concluded that coagulation tests are useful as supportive aids in the prognostic evaluation of patients with acute infectious diseases.


Prevalence of hospital-associated infections in five Swedish hospitals in November 1975. The prevalence rate of hospital-associated infections in 5 Swedish hospitals on November 4, 1975 is reported. In all, 4246 patients were included in the study, 3657 in acute disease clinics and 589 in chronic disease clinics. The overall prevalence rate was 17%, 11% in acute disease clinics and 59% in chronic disease clinics. The highest rate was found in intensive care units (72%), while in ophthalmological units it was 1%. 50% of all hospital-associated infections were urinary tract infections, 68% of which occurred in patients with an indwelling urinary catheter. 25% of all infections in acute disease clinics were postoperative wound infections, and 20% in chronic disease clinics were skin infections, including infections in varicose and decubital ulcers. 58% of the bacterial isolates from hospital-associated infections were gram-negative rods, while 12% were Staphylococcus aureus. Also in postoperative wound infections the gram-negative rods dominated over Staph. aureus, 35 vs. 23%. A prevalence study of this order of size seems adequate to assess the overall rate of hospital-associated infections in Sweden as compared to other countries. However, differences in prevalence rates between hospitals and clinics should be interpreted with great care. The seriousness and effect of reported infections must be evaluated otherwise, as well as the day-to-day infection control and the evaluation of prophylactic measures need other methods.


Treatment of anginose infectious mononucleosis with metronidazole. 16 patients with the anginose type of infectious mononucleosis were treated with metronidazole, and another 3 patients were given clindamycin. Most of the patients had been given penicillin or erythromycin before admittance to hospital. Treatment with metronidazole had a favourable effect on the course of the disease; the body temperature was normalized, signs of tonsillitis disappeared and cervical lymph nodes decreased in size within 3 days in 10 patients and in the remaining 6 within 4 or 5 days. Difficulty in mastication and swallowing was usually relieved within 1 to 2 days of treatment. The period before normalization was significantly shorter than in 10 controls. Two of the 3 patients who were given clindamycin developed exanthems, but otherwise a similar favourable effect as in the metronidazole-treated patients was observed.


Bladder irrigation in patients with indwelling catheters. The effect of intermittent bladder irrigation on the bacterial counts in urine samples was studied in patients with indwelling catheter and pre-existing urinary tract infection. Four different irrigating solutions were used. Irrigation with saline or 0.25% acetic acid had no effect on the urinary bacterial count. The bacterial counts were effectively reduced during intermittent irrigation both with 0.02% chlorhexidine and with 0.25% silver nitrate. Silver nitrate gave the greatest reduction of bacterial counts but chlorhexidine is preferable due to fewer side effects and greater convenience.


Chronic granulomatous disease in three siblings. A family of 7 persons is described in which one male and two female siblings have chronic granulomatous disease (CGD). The CGD diagnosis was established by histories of recurring infections, typical histopathology, deficient nitroblue tetrazolium (NBT) reduction and deficient neutrophil killing of Staphylococcus aureus. Noteworthy infections were liver abscesses, pneumonia, pleurisy, lymphadenitis, skin pustules, urinary tract infection and dental abscesses. The affected boy was the most severely ill with liver abscesses. One sister also had liver abscesses with Staph. aureus and both were treated with cloxacillin in combination with fucidin and surgical intervention. A survey of the closest relatives with the NBT test disclosed no further cases. In this family in the heredity seems to be of the recessive type.


Electrolyte distrubances after jejunal conduit urinary diversion. The use of jejunum in conduit urinary diversion may lead to electrolyte disturbances, characterized by hyponatremia, hypochloremia, hyperkalemia, acidosis, and azotemia, and a clinical picture of nausea, vomiting, dehydration, anorexia, and lethargy. Four out of six patients deviated with a jejunal loop developed this syndrome, the cause of which is discussed. It is concluded that the use of jejunum in urinary diversion should be avoided.


Effects of terbutaline and isoproterenol on hyperkalemia in nephrectomized rabbits. Terbutaline, an adrenergic beta2-receptor-stimulating substance, resembled isoproterenol in its hypokalemic effect on rabbits made hyperkalemic by nephrectomy three days prior to the experiments. Both agents lowered the serum potassium values. The duration of the terbutaline effect was longer and had less influence on the cardiovascular system than had isoproterenol.


Grading of human renal adenocarcinoma.

Grading of human renal adenocarcinoma. One hundred and thirty-eight adenocarcinomas of human kidney were assessed histologically with special reference to the tumor malignancy as indicated by the 5-year survival of the patients. Four different grading systems were used; the classification based on the histologic type of tumor growth, the grading of malignancy according to Arner et al., the grading based on the nuclear structure of carcinoma cells and finally a combined grading system based on the nuclear structure and the demarcation of the tumor from the surround tissue. The histologic type of growth was observed to be an inappropriate basis for grading of renal carcinoma. The grading system of Arner et al. was an appropriate method of malignancy grading despite its somewhat low reproducibility. The grading system based on the nuclear structure of the tumor cells was an accurate measure of the intrinsic malignancy of renal carcinoma and gave an excellent correlation between tumor grade and the 5-year survival rate of the patients. The combined grading system was an equally accurate method in estimating the 5-year prognosis of ranal carcinomas and indicated that the poor demarcation of the tumor from the surroundings in an unfavorable prognostic sign.


Ultrastructural characteristics of human renal cell carcinoma in relation to the light microscopic grading. Twenty-two consecutive cases of renal adenocarcinoma were graded histologically according to the nuclear structure of the tumor cells. The ultrastructural characteristics of these tumors were then evaluated and the findings were compared with the results of the nuclear grading. No ultrastructural characteristic was found which would have been specific for either Grade I, II, III or IV carcinomas. There was no ultrastructural features that could have been used as a basis for malignancy grading. The results show that electron microscopy has nothing to add to the nuclear grading system of renal adenocarcinoma and the value of this grading system is to be emphasized.


Urinary infection and transurethral prostatectomy. Positive preoperative urine cultures were obtained from 31 of 107 patients who underwent transurethral prostatectomy (TUR). The incidence was 59% among the patients who had had indwelling catheter and 15% in the non-catheterized cases. Of the 76 patients whose urine was sterile before TUR, 24 (32%) became infected in connection with the operation or in the immediate postoperative period. The length of hospital stay after TUR averaged 7.2 days for the patients with sterile urine postoperatively and 10.3 days for those with infected urine, a non-significant difference, partly explained by circumstances other than the infection. The postoperative urinary infections were not associated with serious complications. Postoperative epididymitis occurred in three patients. The mortality was nil.


Rupture of the penis.

Rupture of the penis. A case of acute penile rupture in a 32-year-old man is reported. The treatment was non-surgical. The symptoms subsided and sexual function was restored to normal within 8 weeks. The aetiology, pathology and symptomatology of penile rupture and the therapeutic possibilities are briefly surveyed.


Double vas deferens and epididymis associated with ipsilateral renal agenesis simulating ectopic ureter opening into the seminal vesicle. A 26-year-old man presented clinical, radiographic and, at operation, macroscopic signs of an ectopic opening of the left ureter into the seminal vesicle and agenesis of the left kidney. However, histological examination of the surgical specimen revealed that the supposed ureter was actually a vas deferens, and the structure removed from the renal site showed a histological composition like that the epididymis. The anomaly observed was thus a retroperitoneal duplication of the vas deferens and epididymis and failure of development of the ipsilateral kidney and ureter.


Müllerian duct cyst. Report of a case and review of the literature. Stranguria in a 35-year-old man was caused by an orange-sized cyst of the Müllerian duct. The case is reported and the literature is reviewed. The most reliable diagnostic method is cystoscopic tubulation through the prostatic utricle. The simplest form of treatment is subsequent evacuation of the cyst through the tube. Alternatively, marsupialization of the posterior cyst wall at laparotomy is preferable to attempted extirpation, which is always difficult and usually gives rise to complications.


Prognosis of survival in a geriatric population. With the aim of demonstrating prognostics as regards death in a geriatric population, the mortality among 1 486 patients (516 men and 970 women) in De Gamles By, Copenhagen, was observed over a 2-year period. The mortality curves for the groups examined were found to be rectilinear in logarithmic form and could therefore be described with sufficient certainty by one value, viz. the probability of death in any one year. The probability of death was just over 20% and was the same for both sexes. Of the parameters examined, particularly high mortality was found where there was urinary incontinence, severe mental abnormality, a great need for nursing, and poor physical mobility (especially inability to walk). On the other hand, there was no particular relationship with age. Where the degree of the handicapping factors was severe, there was generally greater mortality among the men than among the women, but this was not so in the less severe cases. The length of stay in the institution had no effect on the mortality. The results of the present study are in good agreement with previous findings reported from New York (7).


Minimum need for care in geriatric institutions. On the basis of a study from De Gamles By, Copenhagen, concerning the mortality and changes in the patients' need for nursing care over a 2-year period, calculation is made of the time-related changes in the care status, using a special model for homes for elderly persons. This model is based on a policy that only independent persons are received into such homes and that they remain there until they die. It is found that the need for care becomes stabilized after a period of 5-6 years and remains at a level corresponding to about 45% independent, 36% slightly dependent, and 17% heavily dependent patients (the "minimum need for care"). Using the model, a few examples are given to illustrate the changes which would arise in the need for care in De Gamles By if, on the basis of the primary care status on January 15, 1969, (A) only independent patients were admitted, and (B) the current admittance policy was continued.


A model for the estimation of change in knowledge between two interview occasions with unreliable responses. If a person gives the right answer to a question of yes/no type concerning a certain fact, the answer is correct either because the person knows the truth or because he/she happens to guess the right response alternative. Suppose that such a question is given to the same persons on two occasions, and that between these occasions, a campaign is undertaken, the aim of which is to raise the level of knowledge in the population. A model is introduced for this situation, making it possible to estimate the proportion (PB) of persons who know the answer before the campaign, the difference (D=PA-PB) in knowledge after (PA) vs. before the campaign, and the rate (g) of persons who guess the correct answer without having the actual knowledge. Asymptoic variances for the estimates are also given. The method is illustrated by means of data from a socio-medical survey in Addis Ababa, were the spread of knowledge concerning various vaccinations was investigated.


Frequent users of doctor services in a small rural community. Thirty-six per cent of the visits to doctors in a small rural community were made by the 6% of the population having the most diseases or symptoms. About 90% of the population accounted for about one-half of the medical services provided by the Kuusamo doctors; the other half was taken up by the 10% of the inhabitants in greatest need of medical attention. Adults consulted a doctor 2.1 times a year on the average. The most common reasons for consultations were respiratory diseases (23%), diseases of the genito-urinary system (16%) and accidents (14%).


Pregnancy and delivery among immigrants. Risk factors during pregnancy and delivery of immigrant women are analysed. Individual birth delivery records of 1 235 immigrant women and of 412 Swedish women are studied. Most of the immigrants--65%--were Scandinavians, while 10% had come from Southern Europe and 4% were non-Europeans. The immigrant groups differed somewhat amongst themselves, and also vis-à-vis the Swedes in some social and demographic respects. Participation in antenatal care was not lower among the immigrants than in the control group, but the former did not attend antenatal exercises to the same extent. The perinatal mortality and prematurity rates were 1.5% and 5%--about the same as among the Swedish women. The rate of premature delivery was found to be related to the duration of residence in Sweden. Women who had lived less than one year in this country more often delivered prematurely than did the more settled immigrant women. Further studies on the emotional reactions of immigrant women during pregnancy and delivery are proposed.


Plans for epidemiologic research in primary health care in Denmark. In Denmark health policy as well as research priorities are undergoing a gradual change. Increased emphasis has been placed on primary health care in the future. Routine epidemiologic registers in Denmark are presented briefly as well as some plans for future epidemiologic research in primary health care.


Early retirement pensions in Sweden: trends and regional variations. The total number of early retirement pensiones has risen sharply since the end of the 1960s. The increase was greatest during the early 1970s following a reform in 1970 which extended the right to early retirement pension to older workers because of labour market considerations. This article discusses various conceivable explanations for the growth in the number of early retirement pensioners and regional variations of this phenomenon. The following explanatory factors are considered: (a) The prospects of getting (keeping) a job. (b) Work capacity. (c) The nature of the pension scheme. (d) Alternative possibilities of support. (e) Preferences concerning early retirement pensions. The discussion focuses on two explanations highlighted in the public debate in Sweden: changes in pension legislation and the role of the solidarity wages policy. An empirical analysis of variations at the provincial level reveals a definite correlation between the proportion of early retirement pensioners and various indices of unemployment and underemployment.


[The little observed ions: magnesium and phosphorus]. Signs and symptoms of phosphorus and magnesium deficiency are recognized with increasing frequency. More and more clinical settings are known to favor P and Mg depletion. The clinical aspects of the P and the Mg depletion syndrome and are briefly summarized and a list is provided of papers describing the pathophysiologic mechanisms which may lead to clinically relevant loss of phosphorus and magnesium.


[Certain and disputed indications of immunosuppressive therapy in kidney diseases]. The effect of immunosuppressive agents in different glomerulopathies is reviewed and some guidelines for their use in clinical practice are proposed. The immunological aspects of pyelonephritis and interstitial nephritis are studied to evaluate future possibilities of either therapeutic immunosuppression or immunization in these diseases.


[Indications and contraindications of liver biopsy]. In each individual case the indication for liver biopsy depends on assessment of the risks relative to the potential benefits of the procedure. Besides hepatological risk factors, hemostasis and overall health problems must be considered. The benefit of liver biopsy is dependent on recognition of the pathognomonic lesion within the tissue sample obtained. Size and distribution of the different histological features and the size of the biopsy cylinder are, therefore, important determinants for the success of the examination. Whether or not a histological diagnosis may be useful for optimal management of a patient can best be judged if the clinical question has been well defined before the biopsy is performed.


[Transfemoral embolus aspiration from both renal arteries]. In a 50-year-old female patient who had suffered from coronary heart disease for about 3 years, a cerebral embolus resulted in left-sided hemiparesis. Four days later she became anuric. Acute thromboembolis occlusion of the renal arteries was assumed and renal angiography was performed. The angiography showed complete obstruction of the left renal artery and partial obstruction of the right renal artery. Due to the poor general condition of the patient it was not possible to carry out renovascular surgery or streptokinasetherapy. An attempt was therefore made to remove the emboli from the renal arteries by a new technique (transfemoral embolus aspiration). The subsequent angiography showed normal circulation in the right kidney and improved circulation in the left kidney. Ten days of dialysis treatment were required until urine production started again. Death then occurred from other causes. The autopsy confirmed free permeable renal vessels and absence of permanent sequelae in the parenchyma.


[Genetic radiation burden of the population in the canton Basel-City due to nuclear medicine]. The genetically significant radiation dose is defined as the gonadal dose which, if received by every member of the population, would produce the same genetic hazard to the population as do the actual doses received by the individuals. PORETTI et al. published a value of 42.9 mrad for Switzerland as the result of X-ray diagnostic examinations in 1971. The contribution from nuclear medicine was determined with reference to special circumstances in the Canton of Basle City: the annual genetically significant dose amounted to 0.5 mrad in 1976. This value represents about 0.5% of the annual annual background radiation.


[Fat embolism syndrome without fractures]. Report on an 18-year-old patient who developed a respiratory distress syndrome after trauma without bone fractures and with only minimal soft tissue contusion. Twelve hours after the accident fever and dyspnea appeared, accompanied later by hemoptysis, microhematuria, a fall in hemoglobin and in platelet count, petechiae on the skin and in the conjunctiva, cotton-wool lesions in the retina and micronodular shadows in the lungs. Various pathogenetic mechanisms other than bone marrow fat embolism are discussed in the light of this case.


[Treatment with high-dose beta-pyridylcarbinol: results in patients with hypercholesterinemia]. The effect of lipid-lowering therapy with high-dose beta-pyridylcarbinol was studied in 16 patients with primary hyperlipoproteinemia of type IIa and type IIb. After a controlled dietary pretreatment period of at least 3 months, the patients received 900 mg beta-pyridylcarbinol (Ronicol 300) per day for 12 weeks. The patients were then given only dietary treatment for a further 6 weeks. Clinical and laboratory controls were carried out every month and included measurement of cholesterol and triglycerides in whole serum and in the isolated lipoprotein fractions after ultracentrifugation. In 2 patients the treatment had to be discontinued due to side effects (flush). The numerous "safety parameters" were not affected by the treatment. Total and LDL cholesterol were lowered by about 15% and total triglycerides by about 25%. The HDL cholesterol levels remained unchanged.


Clinical attitudes to the autopsy.

Clinical attitudes to the autopsy. An enquiry into the attitudes of clinical consultants to autopsies was conducted by questionnaire. Responses indicate that most of the consultants accept that the autopsy is important in hospital practice and in teaching. There are, however, marked differences of view on the reasons for doing autopsies, and on the results of autopsies (e.g. in altering diagnoses or revealing unsuspected pathology), differences which influence the freqeuncy with which autopsies are requested. Some clinicians believe that increasing resistance by relatives to granting permission contributes to the falling rates, but this is a minority view. Clinicians also vary in their reactions to the falling rate, some regarding it as worrying while others are not concerned.


Morbidity and mortality in salmonella food poisoning. A review of 47 in-patient cases. Forty-seven new patients with salmonella food poisoning were admitted to the Infectious Diseases Unit at the City Hospital, Edinburgh, during 1975. Although all the patients had diarrhoea at some stage of their illness, the wide variety of presenting symptoms caused some diagnostic difficulties prior to the isolation of the organism. A probable predisposing factor to serious disease was recognised in 15 patients. Twenty patients (42.5%) were seriously ill and 4 patients (8.5%) died. This series stresses the potential severity of this common disease.


Non calculous cholecystitis: an 8 year review of cases treated by elective cholecystectomy. From a total of 248 cases of cholecystectomy, 36 were found to be without stones. These cases of acalculous cholecystitis have been reviewed with regard to signs, symptoms and radiological investigations. The complications of operative treatment have been documented and the etiology of the condition discussed. As a result of favourable outcome of operative treatment in these patients, it is suggested that surgery should be considered even in the absence of positive radiological findings at an earlier date.


Post-partum cardiomyopathy.

Post-partum cardiomyopathy. A report is presented of a patient who developed signs of cardiac failure 6 weeks after the birth of her fourth child. Detailed cardiac investigation indicated the diagnosis to be post-partum cardiomyopathy, a condition more commonly encountered in Negro women and comparatively rare in this country. The aetiology and mode of presentation are discussed.


Digoxin therapy: a clinical pharmacokinetic approach. Within certain limitations, digoxin can be prescribed for individual patients on a sound scientific basis. The use of pharmacokinetic principles and digoxin radioimmunoassay can improve the overall quality of treatment with this drug and reduce the incidence of adverse reactions. Variations in bioavailability and intestinal absorption are important factors in the determination of dosage and should be reduced to a minimum by improved pharmaceutical formulations.


The treatment of gout: a case of medical audit? An assessment of quality of drug control of hyperuricaemia in gouty subjects is reported. Twenty seven of 40 patients were found to be hyperuricaemic. Factors influencing compliance with drug therapy included awareness of the nature of gout and excessive alcohol consumption.


Trace-metal concentrations in normal human liver: methods to cope with marked variability. Concentrations of trace elements in human tissues characteristically vary widely, and the distributions of most concentrations are skewed to the right. Examination of some of the factors which contribute to the marked variability and skewness of the concentrations revealed that: (1) distributions of concentrations are satisfactorily normal (Gaussian) after logarithmic transformation, (2) ash weight is the best frame of reference in which to report results, (3) the distributions of metal concentrations are not further normalized by adjustments which assume that tissue lipid or collagen contains a fixed fraction of the metal found in the parenchyma, and (4) the choice of sample site within the liver is of minimal significance.


The glycosylation of hemoglobin: relevance to diabetes mellitus. Glucose reacts nonenzymatically with the NH2-terminal amino acid of the beta chain of human hemoglobin by way of a ketoamine linkage, resulting in the formation of hemoglobin AIc. Other minor components appear to be adducts of glucose 6-phosphate and fructose 1,6-diphosphate. These hemoglobins are formed slowly and continuously throughout the 120-day life-span of the red cell. There is a two- to threefold increase in hemoglobin AIc in the red cells of patients with diabetes mellitus. By providing an integrated measurement of blood glucose, hemoglobin AIc is useful in assessing the degree of diabetic control. Furthermore, this hemoglobin is a useful model of nonenzymatic glycosylation of other proteins that may be involved in the long-term complications of the disease.


Muscular dystrophy: inhibition of degeneration in vivo with protease inhibitors. The protease inhibitors leupeptin and pepstatin were used in vivo in genetically dystrophic chickens to determine their effects on the histological and biochemical changes observed in this disease. These compounds appear to delay the degeneration of muscle tissue which is characteristic of this disorder and thus may have potential therapeutic value in the treatment of muscular dystrophy.


Size and shape of the lateral intercellular spaces in a living epithelium. The lateral intercellular spaces of Necturus gallbladder epithelium were seen and measured while the living tissue was perfused in a new chamber. The compliance of the lateral cell membranes was calculated from the measured pressure-volume characteristics of the lateral intercellular spaces.


Murine lymphoma-induced immunosuppression: requirement for direct tumour cell contact. The FBL-3 lymphoma cell line caused impaired antibody formation in vivo when injected into mice intraperitoneally, and in vitro when added to normal syngeneic spleen cells immunized in vitro with sheep erythrocytes. Immunosuppression occurred only when intact viable tumor cells were cocultivated with the normal spleen cells. As few as 10(5) FBL-3 cells, when added to 5 X 10(6) normal cells, impaired antibody formation. However, cell-free extracts of filtrates from even much larger numbers of tumor cells did not affect antibody formation, either in vitro or in vivo. Heating the tumor cells at 56 degrees C or irradiation with as little as 1000 rads completely abolished immunosuppressive activity, both in vitro and in vivo. Separation of viable tumor cells from target antibody-forming cells by cell-impermeable membranes prevented immunosuppression, showing that direct cell-to-cell contact is required for immunosuppression.


Immunoassay of androgen binding protein in blood: a new approach for study of the seminiferous tubule. Androgen binding protein, a secretory product of seminiferous tubules, was isolated by means of affinity chromatography. A radioimmunoassay was developed and used to identify androgen binding protein in rat plasma. The ability to measure a testicular protein in blood provides a new method for investigation of seminiferous tubular physiology.


Bioluminescence: dual mechanism in a planktonic tunicate produces brilliant surface display. Luminescent flashes emanate spontaneously and on mechanical stimulation from the bodies of Oikopleura dioica (Urochordata, Larvacea); flashes also emanate, on mechanical stimulation only, from both their occupied and discarded mucous houses. The luminescence is intrinsic to the animals and their houses. Field observations suggest that, because of this dual method of light production, larvaceans may contribute substantially to surface coastal displays of marine bioluminescence.


Behavior and phylogeny: constriction in ancient and modern snakes. Comparative analyses of behavior have an underappreciated potential for revealing the role of ethoecological factors in the origins of higher taxa. Twenty-seven species (13 genera) in the advanced family Colubridae exhibited 19 patterns of coil application; one or two patterns were usually consistent within a genus. Forty-eight species (26 genera) in the primitive families Acrochordidae, Aniliidae, Boidae, and Xenopeltidae usually used a single pattern, despite differences in age, size, shape, habitat, and diet. This implies the shared retention of an action pattern used by their common ancestor no later than the early Paleocene. Constriction must have been used as a prey-killing tactic very early in the history of snakes and might have been a behavioral "key innovation" in the evolution of their unusual jaw mechanism.


Development of sensitivity to pictorial depth. Sensitivity to static pictorial information for depth develops between 22 and 26 weeks of age. When conflicting binocular and surface-texture information was minimized, 26- to 30-week-old infants directed their reaching to the apparently closer side of a photograph of a window rotated in depth. Younger infants, from 20 to 22 weeks of age, did not direct their reaching to the pictorially nearer side of the display but did reach with a high degree of directionality when presented with a real window rotated in depth.


Behavioral thermoregulation: orientation toward the sun in herring gulls. Orientation toward the sun combined with postural changes minimized the net radiation gain on the adult herring gull during the breeding season. The decrease in absorbed solar radiation was due to reduced surface area exposed to direct sunlight and to reduced absorptivity since, when the bird orients toward the sun, the angle of incidence is such that only the white surfaces receive direct sunlight. At low wind velocities (0 to 0.6 meter per second) and ambient temperatures above the lower critical temperature, the birds rotated 180 degrees during the day, always facing the sun.


Attenuation of amnesia in rats by systemically administered enkephalins. The pentapeptides methionine-enkephalin and leucine-enkephalin are both able to reduce experimentally induced amnesia in rats. In contrast to the possible analgesic activity of these peptides, the anti-amnesic effect is seen after systemic administration of dosages of 30 micrograms or lower. The nature of the anti-amnesic effect is different for the two peptides.


Polyribosomes associated with forming acrosome membranes in guinea pig spermatids. Ribosomes, some of which are arranged in polyribosomal configurations, are attached to specialized regions of the acrosomal membrane in guinea pig spermatids. This finding indicates a new functional dimension for the acrosomal membrane, that of protein synthesis, and suggests that during acrosome formation, proteins of the acrosomal membrane or acrosomal contents need not be synthesized before or during passage through the Golgi apparatus.


Gyrate atrophy of the retina: inborn error of L-ornithin:2-oxoacid aminotransferase. Cultured fibroblasts from a patient with gyrate atrophy of the retina do not convert L-ornithine, uniformly labeled with carbon-14, to proline. This metabolic block is caused by deficient L-ornithine:2-oxoacid aminotransferase activity in the patient. Her heterozygote father has intermediate activity of this enzyme.


5-Thio-D-glucose selectively potentiates hyperthermic killing of hypoxic tumor cells. To investigate the mechanisms by which heat affects cancer cells, we used 5-thio-D-glucose, an inhibitor of glycolysis in HeLa S-3 cells, under aerobic and hypoxic conditions at temperatures ranging from 37 degrees to 43 degrees C. Drug alone or heat alone killed a minimum number of cells under aerobic or hypoxic conditions. Exposure to drug and hyperthermia selectively increased the number of cells killed under hypoxic conditions at temperatures as low as 40.5 degrees C but had little effect on cells incubated under aerobic conditions. These results suggest that the glycolytic pathways is a primary site of hyperthermic damage leading to cell death.


Frog perspective on the morphological difference between humans and chimpanzees. The body shapes of humans and chimpanzees were compared quantitatively by criteria chosen for their capacity to discriminate well among the body shapes of frogs. By these criteria, the difference in body shape between humans and chimpanzees was found to be greater than that between the most dissimilar pairs of frogs examined--that is, frogs classified in separate taxonomic suborders. Even though the morphological diffference between the two primates is large by frog standards, the biochemical differences between the structural genes of these two species are small. The results of this study give quantitative support to the proposal that morphological evolution and biochemical evolution in structural genes can proceed at independent rates.


Improving cognitive ability in chronically deprived children. Beginning at different ages in their preschool years, groups of chronically undernourished children from Colombian families of low socioeconomic status participated in a program of treatment combining nutritional, health care, and educational features. By school age the gap in cognitive ability between the treated children and a group of privileged children in the same city had narrowed, the effect being greater the younger the children were when they entered the treatment program. The gains were still evident at the end of the first grade in primary school, a year after the experiment had ended.


delta9-Tetrahydrocannabinol and 17beta-estradiol bind to different macromolecules in estrogen target tissues. delta9-Tetrahydrocannabinol (delta9-THC), added to the limit of its solubility, did not compete with tritiated 17beta-estradiol for binding to estrogen receptor sites in mouse mammary or uterine cytosols. On sucrose density gradients of low-ionic strength, mammary cytosol labeled with [3H]estradiol exhibited a binding peak near the "8S" region typical of estrogen receptor whereas in cytosol labeled with delta9-[3H]THC binding was limited to the nonspecific 4- to 5S region. Differences in sedimentation properties and reciprocal competition studies strongly refute previous claims that delta-9-THC binds to estrogen receptor and that by so doing it directly acts as an estrogen.


Activity patterns of human skeletal muscles: relation to muscle fiber type composition. The muscle activity of normal ambulatory individuals was recorded continuously for 8-hour (working day) periods. Parameters of activity patterns were defined and numerical outcomes for these parameters were compared across a diverse population of muscles. Several pattern parameters, such as the average percentage of time active, were highly correlated with the percentage of type I fibers of a muscle.


3-Methoxy-4-hydroxyphenylglycol in cerebrospinal fluid and vanillylmandelic acid in urine of humans with hypertension. 3-Methoxy-4-hydroxyphenylglycol (MHPG) was measured in lumbar spinal fluid of 20 subjects with hypertension of varied etiology and severity. There was a significant correlation between the concentration of MHPG and the severity of hypertension. However, changes in the concentration of vanillylmandelic acid in the urine of these subjects were insignificant. In six subjects, administration of clonidine or alpha-methyldopa, two centrally acting antihypertensive drugs, was associated with a significant lowering of MHPG concentrations. These data support the hypothesis that central catecholamines are involved in clinical hypertension.


Myotonic muscular dystrophy: altered calcium transport in erythrocytes. Erythrocytes from patients with myotonic muscular dystrophy accumulate calcium at a significantly higher rate than normals do. This increased rate of net accumulation appears related to an enhanced permeability of the membrane to calcium, rather than to an impairment in its active outward transport.


Aflatoxicol: major aflatoxin B1 metabolite in rat plasma. Aflatoxicol, a carcinogenic metabolite of the foodborne carcinogen aflatoxin B1 previously known only as a bioreduction product in vitro, was identified as the major aflatoxin metabolite in the plasma of Sprague-Dawley rats, a susceptible species, that had been doses orally or intravenously with aflatoxin B1 labeled with carbon-14. Alfatoxicol, however, was not detected in the plasma of similarly dosed mice and monkeys, which are both resistant to aflatoxin B1-induced cardinogenesis. The formation of aflatoxicol both in vitro and in vivo may be an indicatory of species sensitivity to aflatoxin-induced carcinogenesis and may be useful in the prediction of human susceptibility.


Crankcase oils: are they a major mutagenic burden in the aquatic environment? Fractions from used crankcase oil enriched in polyaromatic hydrocarbons induced revertant colonies in Salmonella typhimurium strain TA 98 when activated by rat or trout liver extracts. The mutagenic activity was not due to benzopyrene or benzanthracene. Fractions from various crude and refined petroleums were nonmutagenic. Among various petroleum hydrocarbons entering inland and coastal waters, used crankcase oils may represent a major mutagenic burden.


Psychophysical functions for perceived and remembered size. Separate groups of people estimated the sizes of perceived or of remembered objects. In three independent experiments, both sets of data were well fit by power functions, and the exponent was reliably smaller by remembered than for perceived size.


Neurotrophic protein regulates muscle acetylcholinesterase in culture. Skeletal muscles lose acetylcholinesterase in culture as a result of denervation. A protein fraction isolated from peripheral nerves maintained the level of acetylcholinesterase in cultures of aneural embryonic muscle or denervated adult chicken muscle. These results indicate that trophic regulation of muscle acetylcholinesterase might be mediated by a protein produced by nerves.


Aural representation in the Doppler-shifted-CF processing area of the auditory cortex of the mustache bat. In the mustache bat (Pteronotus pamellii rubiginosus) the frequency and amplitude of an acoustic signal are represented in the coordinates parallel to the surface of the Doppler-shifted-CF (constant frequency) processing area ofthe primary auditory cortex. In this area all cortical neurons studied were excited by contralateral stimuli, and almost all of them were either excited or inhibited by ipsilateral stimuli. These are called E-E (ipsilateral and contralateral excitatory) and I-E (ipsilateral inhibitory and contralateral excitatory) neurons, respectively. The I-E neurons are directionally sensitive, while the E-E neurons are not. The E-E neurons are equally sensitive to echoes between 30 degrees contralateral and 30 degrees ipsilateral. Of the electrode penetrations orthogonal to the Doppler-shifted-CF processing area, 57 percent were characterized by either E-E or I-E neurons. Thus, there are at least two types of binaural columns: E-E columns, mainly located in a ventral part of the Doppler-shifted-CF processing area, where neurons are tuned to weak echoes; and IE columns, mainly distributed in a dorsal part, where neurons are tuned to moderate to intense echoes. Therefore, neurons tuned to weaker echoes integrate or even multiply faint signals from both ears for effective detection of a distant small target, while neurons tuned to moderate to intense echoes are suited for processing directional information and are stimulated when a bat approaches a target at short range. The Doppler-shifted-CF processing area may be considered to consist of two functional subdivisions.


Adrenal imaging agents: rationale, synthesis, formulation and, metabolism. In this introductory paper on radionuclide adrenal imaging, the rationale, synthesis, formulation, and metabolism of two clinically well-established and one promisinmg adrenocortical imaging agents are reviewed. Their present clinical utility is reviewed in a separate presentation in this issue. Progress to date in developing a positive imaging agent of the adrenal medulla and tumors of chromaffin tissue will be given brief consideration because there is, as yet, no clinically successful radiolabeled adrenal medulla imaging agent.


Precursor lesions in familial melanoma.

Precursor lesions in familial melanoma. Familial occurrences of malignant melanoma may be related to an inherited syndrome of precursor cutaneous lesions with distinct clinical and histologic features. Recognition of the syndrome in the relatives of melanoma patients identifies a subset of family members at high risk for melanoma, facilitating their early diagnosis and treatment. Further studies of these families may provide insight into the biology of malignant melanoma and the pathophysiology of malignant transformation in benign nevi.


Carcinoma of the ampulla of Vater.

Carcinoma of the ampulla of Vater. Adenocarcinoma of the ampulla of Vater represents about 10% of periampullary neoplasms. This tumor is slow-growing, often amenable to radical surgical resection, and associated with a better prognosis than the other neoplasms which arise in the periampullary area. Correct identification of ampullary carcinoma may be difficult but is essential because of its better prognosis. A review of 31 patients with adenocarcinoma of the ampulla of Vater treated at our institution reveals that the classical history of fluctuating jaundice and the well known findings of a palpable gallbladder and occult blood in the stool may not be present. The treatment of choice for ampullary carcinoma in the absence of hepatic or distant metastases is pancreaticoduodenectomy. Our operative mortality for pancreaticoduodenectomy is 16%, and the five-year survival rate is 32%. The role of palliative procedures, the operative complications, and the survival rates are discussed.


Verrucous carcinoma of the vagina.

Verrucous carcinoma of the vagina. The case histories of three women with verrucous carcinoma of the vagina are presented. Verrucous carcinoma, in the female genital tract as elsewhere, is a relentlessly growing, destructive, but generally nonmetastasizing neoplasm of stratified squamous epithelium with a characteristic gross and microscopic appearance. It should be recognized and segregated from the usual type of squamous carcinoma so that appropriate therapy can be administered. Surgical excision is the treatment of choice. Radiotherapy is usually contraindicated. Two of the patients described here were treated by surgery alone with good results. The other received radiation only and died within a year with persistent disease.


Unusual incidence of testicular tumors.

Unusual incidence of testicular tumors. Although carcinoma of the testicle is a rare lesion, one family physician saw three cases in 18 months. He diagnosed all correctly and referred the patients for treatment immediately. All three patients are living and well. We believe his alertness is worthy of note because, given the rarity of the lesion, a low index of suspicion and delayed diagnosis often occur, with less than desirable results.


Hodgkin's disease in pregnancy.

Hodgkin's disease in pregnancy. Two cases of Hodgkin's disease associated with pregnancies are presented. Review of the literature failed to show that pregnancy had any deletorious effect on either the course or survival of patients with Hodgkin's disease; nor did therapeutic abortion alter the survival curves of these patients. There is only one report of Hodgkin's disease metastasizing to the products of conception. Both chemotherapy and irradiation are used to treat Hodgkin's disease, and both are potentially harmful to the growing fetus. Therefore, if therapy can be delayed without detriment to the patient, is should be postponed until after termination of the pregnancy.


Localization of bronchogenic carcinoma in tuberculous lobes. The pronounced predilection of bronchogenic carcinoma for tuberculous lobes of the lungs is not generally recognized. In this plus 11 other series of patients with coexisting disease, an average of 52% had the neoplasm in a tuberculous lobe. In the present study, tuberculosis was confined to one or two lobes in 24 of 27 patients (89%) with coexisting disease; 21 (88%) of these patients had the neoplasm in a tuberculous lobe. Diagnosis required an average of 1.8 months (one week to 18 months). A low index of suspicion can delay diagnosis of the carcinoma until hilar enlargement, tumor, or metastasis is apparent radiologically, By then, often the tumor has become inoperable. Our data suggest that carcinoma should be suspected in a tuberculous man of cancer age who smokes and who has a lesion which is enlarging, is in an unusual location, or is drug resistant. Cytologic study of sputum, bronchoscopy, and early thoractomy are advocated.


Severe electrolyte disturbances associated with metolazone and furosemide. In two patients with severe hypertension and moderately severe renal insufficiency, metolazone and furosemide were used in combination with propranolol, methyldopa, and hydralazine to augment control of blood pressure. This combination of diuretics also was used in five patients with refractory congestive heart failure. The patients developed severe electrolyte disturbances with a general pattern of hyponatremia. disproportionate hypochloremia, alkalosis, and phyokalemia. These abnormalities were transient in the patients with severe hypertension and moderately severe renal insufficiency. Effective long-term control of blood pressure was obtained. In the patients with heart failure, edema persisted. Due to the severity of the electrolyte derangements, metolazone and furosemide were discontinued. Because of potential untoward effects, this combination of diuretics should be used with caution.


Acute renal failure in patients with acute leukemia. Acute renal failure may be a contributory cause of death in patients with acute leukemia. The purpose of this study was to define the causes and course of acute renal failure in group of patients with acute leukemia in order to identify preventive measures and reversible aspects of the renal insufficiency. Among 88 patients with acute leukemia whose courses were followed to the time of death, ten developed acute renal failure. Etiologic factors of the renal failure were uric acid nephropathy, sepsis with complicating hypotension and hypovolemia, and the administration of nephrotoxic antibiotics. In one patient ureteral obstruction from clots was responsible for renal failure, while in another patient disseminated aspergillosis led to renal failure. Other causes of acute renal failure in persons with acute leukemia, but not observed in this patient group, are hypercalcemia and leukemic infiltration of the kidneys.


Vascular access for chronic hemodialysis: use of bovine xenografts to create arteriovenous fistulas. Adequate vascular access is the hallmark of successful chronic hemodialysis for end-stage renal disease. Between May 1975 and August 1975, it was necessary to use a bovine xenograft in 91 instances to create an arteriovenous fistula for vascular access in patients receiving chronic hemodialysis at the Vanderbilt University Affiliated Hospitals. Forty-two patients had one xenograft, 14 patients had two, and seven had three xenografts. Of all fistulas created with the xenografts, 53% were patent six months after the operation, 36% were patent at 12 months, and 15% have remained patent for 24 months. Thirty-seven percent of the xenografts failed during the first three months after operation. The most common reason for failure was thrombosis of the xenograft. Other complications encountered were false aneurysms, infection of the graft, ischemia of the extremity, and bleeding. Amputation of the lower extremity due to ischemia from septic emboli was necessary in one case. There was no deaths directly related to the use of these xenografts. It is out current opinion that the bovine xenograft should be reserved for use in patients who have had failure of the more conventional type of internal fistula (Cimino type). In selected patients in whom it is not possible to create a Cimino shunt, the xenograft offers adequate primary vascular access.


Liver-kidney relationship in radioisotopic localization of retroheptic and subhepatic masses. Combined liver-kidney scintigrams in 46 patients were obtained by administering two radiopharmaceuticals labeled with 99mTc. A mass in the right adrenal or subhepatic area was demonstrated as a void or absence of activity between the organs. Normally, the activity in the liver and right kidney blends together so visual separation of organs is not possible. Two clinical cases, including ultrasonic and angiographic studies for comparison, are presented.


Effects of acupuncture on tissue oxygenation of the rat brain. Acupuncture has been claimed to be effective in restoring consciousness in some comatose patients. Possible mechanisms to explain alleged acupuncture-induced arousal may include vasodilatory effects caused by smypathetic stimulation which leads to an augmentation of cerebral microcirculation and thereby improves oxygen supply to the brain tissue. Experiments were performed in ten albino rats (Wistar) employing PO2 microelectrodes which were inserted into the cortex through small burholes. Brain tissue PO2 was continuously recorded before, during, and after acupuncture. Stimulation of certain acupuncture points (Go-26) resulted in immediate increase of PO2 in the frontal cortex of the rat brain. This effect was reproducible and was comparable to that obtained with increase of inspiratory CO2 known to induce arterial vasodilatation and thus capillary perfusion pressure. The effect was more significant as compared to tissue PO2 increases obtained after increase in inspiratory oxygen concentration from 21% to 100%. It appears that acupuncture causes increased brain tissue perfusion which may be, at least in part, responsible for arousal of unconscious patients.


Neural and dural optic nerve measurements with A-scan ultrasonography. Ultrasonography has been shown to be of great value in studying drusen, cupping, and elevation of the optic disk, as well as mass lesions of the orbital optic nerve. We have found A-scan ultrasonography to be an accurate and simple method of measuring both the diameter of the retrobulbar optic nerve and the size of the subdural perineural space. We have found the intervaginal space of the retrobulbar optic nerve to be uniformly enlarged in papilledema, optic nerve lesions, and endocrine orbitopathy.


Initial evaluation of patients with hypertension: an office procedure. Traditionally the initial evaluation of a patient with high blood pressure has focused on exluding secondary correctable causes of hypertension. Such all-inclusive evaluations are expensive, time-consuming, and expose the patient to some risk. A complete history, physical examination, and relatively simple laboratory procedures such as CBC, urinalysis, SMA-6 and 12, and ECG yield sufficient information to detect damage to target organs caused by elevated blood pressure and to exclude the presence of secondary causes fairly adequately. In that small number of patients in whom clues for correctable causes of hypertension are uncovered, or if patients fail to respond to appropriate treatment for essential hypertension, a more extensive evaluation can be undertaken.


Interesting approaches to the diagnosis of angina pectoris. Twelve different approaches to laboratory diagnosis of angina pectoris are reviewed here. They employ no fewer than seven different means of intentionally provoking a disparity between myocardial requirement and supply: dynamic exercise, hypoxia, prandial stress, raised systemic vascular resistance, paced tachycardia, mental stress, and exposure to normal environment. Of these, only dynamic exercise and the diverse combinations of stresses in the normal environment are capable of altering the heart's oxygen requirement-supply ratio threefold or more, accounting for the successful results from tests using these means of stress. The reviewed tests use three different means of detecting myocardial ischemia provoked by stress: electrocardiography to indicate impaired ventricular repolarization, indirect graphic records sensitive to impairment of mechanical ventricular function, and detection of insufficient myocardial perfusion patterns by radioactive tracer. The latter approach is particularly appealing because it directly reflects the pathophysiologic anomaly of interest. It should be remembered, however, that the basic differences in these methods of detecting ischemia make them complementary to each other and encourage their use in combination for improved diagnostic sensitivity.


Laboratory Diagnosis of sickling hemoglobinopathies. Sickle cell trait is present in about 8% of black Americans, and clinically significant sickling disorders are common in this population. These disorders can be accurately defined by combinations of quantitative hemoglobin electrophoresis at alkaline pH, citrate agar electrophoresis, solubility tests for sickle hemoglobin, fetal hemoglobin measurements, blood counts, erythrocyte indices and family studies. Unusual types of sickling hemoglobinopathies may require more extensive, specialized study. An unquestioned diagnosis should be prerequisite for any subsequent genetic counseling.


Posterior dislocation of the shoulder: report of six cases. Posterior dislocation of the shoulder is a rare lesion. We have seen six of these dislocations in recent years. Review of these six cases indicated that posterior dislocations of the shoulder have consistent causes and physical and roentgenographic findings. Recent dislocations can be treated conservatively with closed reduction. Recurrent or unreduced dislocations can be treated successfully with the McLaughlin technic of open reduction and suturing of the subscapularis tendon into the defect in the humeral head. Our results were satisfactory with either closed or open treatment.


Complete spontaneous resolution of bilateral subdural hematoma. Complete spontaneous resolution of bilateral subdural hematoma overa period of 17 months was documented by both radioisotopic brain scan and cerebral angiogram. It is suggested that the favorable response to the medical treatment in some cases should be interpreted with caution.


Chylothorax and lymphangiomas of bone: unusual manifestations of lymphatic disease. A patient with chylothorax, mediastinal lymphangiomatous malformation of the thoracic duct, and multiple lymphangiomas of bone is reported. If a patient has radiographic findings of increased pleural fluid with multiple lucent lesions of the skeleton, the possibility of a generalized abnormality in the lymphatic system should be considered. Early diagnosis and treatment can prevent a protracted course and wasting of the body due to the loss of essential body nutrients in the chylous fluid.


Mitral valve prolapse syndrome with early diastolic click. An instance of mitral valve prolapse syndrome demonstrating early diastolic click was reported. From the phonographic analysis of the cardiac sounds with simultaneous recording of apexcardiogram or echocardiogram, the production mechanism of the diastolic click was discussed.


Disseminated actinomycosis.

Disseminated actinomycosis. A case of pulmonary actinomycosis with dissemination to skin, subcutaneous tissue, and bone is described. The cutaneous lesions were characterized by tender swellings and fluctuant nodules and were the presenting manifestation of the disease. Typical sulfur granules were present in the skin and pleural biopsies. Actinomyces israelii and its synergistic bacteria Actinobacillus actinomycetemcomitans were cultured from skin and pleura. Clinical improvement, with resolution of lung and disseminated skin lesions, was prompt with parenteral penicillin therapy.


Enchondromatosis with hemangiomas (Maffucci's syndrome). Maffucci's syndrome in a 17-year-old girl is reported. Since the entity was first described in 1881 by Maffucci, 105 additional cases have been recorded. Several series have reported a small but significant percentage of cases (up to 18%) with malignant change. Our case, although not particularly unique in comparison with other cases of this syndrome, is presented because of the infrequent occurrence of this syndrome.


Snake-to-human transmission of Aeromonas (Pl) shigelloides resulting in gastroenteritis. A healthy young man developed acute gastroenteritis after handling an infected bao constrictor. The animal died after contracting "mouth-rot disease", a progressive ulcerative stomatitis of snakes charactistically caused a Aeromonas species. Stool cultures from the patient yielded a heavy growth of Aeromonas (Plesiomonas) shigelloides but no other enteric pathogens. Treatment wit sulfamethoxazole-trimethoprim resulted in rapid relief of clinical symptoms. Aeromonas species are not considered part of the normal human fecal flora and gastroenteritis due to this organism is rare. Furthermore, this case appears to represent a new zoonosis: human Aeromonas (Plasiomonas) gastroenteritis derived from contact with an infected animal host.