A prospective study of sudden death in "high-risk" bundle-branch block. We prospectively followed 257 patients with bifascicular and trifascicular conduction-system disease and intact atrioventricular conduction who had undergone His-bundle studies. Forty-seven per cent had associated coronary-artery disease, and 23 per cent primary conduction-system disease. His-ventricular interval was moderately prolonged in 43 per cent and markedly prolonged in 12 per cent. During an average follow-up period of 25 months 50 patients died. However, death was sudden in only 27, and 17 of the sudden deaths were not due to bradyarrhythias. Actuarial analysis showed an overall mortality rate (mean +/- S.E.) of 19 +/- 2.6 per cent at two years, mortality from sudden death being 10 +/- 2.6 per cent. Permanent heart block occurred in 12. No clinical symptoms (including syncope), electrocardiographic findings, electrophysiologic data or their combination identified patients at high risk of sudden death. Sudden death due to bradyarrhythmia is uncommon in patients with bundle-branch block and intact atrioventricular conduction. Therefore, routine prophylactic use of permanent pacemakers in all such patients is inappropriate. Pacemaker implantation should be reserved for those with documented symptomatic bradyarrhythmias.


Career choice and performance on state licensing examinations of "Fifth Pathway" students. Between 1975 and 1977, 340 American citizens trained in foreign medical schools (mostly Mexican) completed a year of supervised clinical training (Fifth Pathway) in New York State before beginning residency training. Analysis of 335 such students revealed a greater tendency to remain in the State for residency training as compared to graduates of New York State medical schools (P less than 0.01). A primary-care specialty was chosen by these students significantly less often than be American graduates (P less than 0.001). Their pass rate on state licensing examinations, although higher than that of other foreign-trained medical graduates, was significantly lower than that of American-trained students (P less than 0.001). Fifth Pathway programs can provide a source of United States-citizen house officers for hospitals currently staffed mainly by alien physicians. Such programs offer foreign-trained United States physicians an opportunity to improve their clinical skills before starting residencies, but evidently do not fully overcome their educational deficits.


Breast self-examination practices and breast-cancer stage. To determine the relation between breast self-examination performance and the clinical and pathological stage of breast cancer at first diagnosis, we studied 335 patients with breast cancer. Approximately one fourth of the patients reported that they had been practicing monthly breast self-examination, and half that they had never practiced breast self-examination. More frequent performance of breast self-examination was associated with more favorable clinical stage and fewer axillary-lymph-node metastases on histologic examination. On pathological examination, the age-adjusted maximum tumor diameter of patients practicing monthly breast self-examination was 1.97 +/- 0.22 cm (mean +/- S.E.M.) as compared to 2.47 +/- 0.20 for those performing self-examination less often than monthly and 3.59 +/- 0.15 for patients never performing breast self-examination. These data associating more favorable clinical and pathological stages of breast cancer with more frequent breast self-examination need to be extended by determination of the survival rates of the various self-examination groups.


Estimated effect of breast self-examination and routine physician examinations on breast-cancer mortality. We examined the effects of breast self-examination and breast examination by physicians on the stage of breast cancer at diagnosis. Clinical and pathological-staging information was compared to interview data on method of initial detection of 293 women. Tumors were detected in clinical Stage I 53.8% of the time when the detection method was routine physician examination, 37.7% when it was self-examination and only 27.0% when detection was accidental. Sixty-nine per cent of women practicing self-examination at the time of diagnosis discovered their tumor by this method. Differences were less apparent when pathological stage was considered. Tumors found during routine examination of the breast averaged 6.1 mm smaller in diameter than those discovered accidentally. We estimate that breast-cancer mortality might be reduced by 18.8% to 24.4% through self-examination or routine physician examination, respectively.


Decreased activity of hepatic uroporphyrinogen decarboxylase in sporadic porphyria cutanea tarda. To investigate the role of uroporphyrinogen decarboxylase in the pathogenesis of the sporadic form of porphyria cutanea tarda, we measured this enzyme in liver, erythrocytes and cultured skin fibroblasts, and also measured coproporphyrinogen oxidase and the total iron concentration in liver. The mean uroporphyrinogen decarboxylase activity was lower in liver from seven male patients (9.0 pmol of coproporphyrin per minute per milligram of protein) than in 12 controls, including seven with alcoholic liver disease (22.3 pmol per minute per milligram; P less than 0.05). Coproporphyrinogen oxidase activities were the same in each group. Liver iron concentrations were lower during remission, but uroporphyrinogen decarboxylase activities were not related to clinical activity for uroporphyrin excretion. Erythrocyte and fibroblast enzyme activities were the same as in normal subjects. A hepatic uroporphyrinogen decarboxylase defect is a prerequisite for the development of porphyria cutanea tarda, but other factors, which probably do not alter uroporphyrinogen decarboxylase activity, determine the clinical onset. In sporadic porphyria cutaneous tarda, the enzyme defect appears to be restricted to the liver.


Scintigraphic detection of pulmonary emboli by serial positron imaging of inhaled 15O-labeled carbon dioxide. Inhaled radioactive carbon dioxide is retained in pulmonary blood distal to embolic obstruction and appears as an area of increased radioactivity that delineates the site and magnitude of the affected zone. The scintigraphic detection of pulmonary emboli by serial imaging of inhaled carbon dioxide labeled with cyclotron-produced 15O2 was evaluated in 27 patients undergoing conventional pulmonary ventilation/perfusion imaging and pulmonary arteriography. Fifteen patients proved to have pulmonary emboli on arteriography. Sensitivity (87%) and specificity (92%) rates for inhalation imaging were superior to those of conventional ventilation/perfusion imaging (P less than 0.05). Clearance of 15O2 activity was markedly delayed over embolized pulmonary segments (mean half time of 47.0 +/- 11.1 seconds [S.E.M.]) in comparison to normal segments (mean of 3.6 +/- 0.08 seconds; P less than 0.001). Pulmonary imaging by this method provides an approach to the detection of pulmonary emboli that is relatively sensitive and specific and permits analysis of persisting perfusion in embolized pulmonary segments. A major practical limitation, however, is the necessity of a nearby cyclotron.


Role of cell shape in growth control.

Role of cell shape in growth control. Tissue culture plastic adhesivity was precisely varied by applying different concentrations of poly(2-hydroxyethyl methacrylate). The extent of cell spreading was thus accurately controlled so that cells cultured on these substrata could be held at any one of a graded series of quantitated cell shapes. Cell shape was found to be tightly coupled to DNA synthesis and growth in nontransformed cells. These findings suggest a mechanism that is important in growth control of mammalian cells, and provide a more fundamental interpretation of such phenomena as density dependent inhibition of cell growth and anchorage dependence.


Isolation by molecular cloning of a fragment in the split ovalbumin gene. An EcoRI fragment of chicken DNA (fragment 'a') containing a sequence complementary to the 3' half of ovalbumin mRNA has been isolated by molecular cloning. Analysis of the cloned fragment proves conclusively that the chicken ovalbumin gene is split. Fragment 'a' contains no extensive sequence repeated elsewhere in the genome and represents the only type of organisation of this part of the split ovalbumin gene in chicken genome.


The alpha-helix dipole and the properties of proteins. Phosphate moieties bind frequently at N-termini of helices in proteins. It is shown that this corresponds with an optimal interaction of the helix dipole and the charged phosphate. This favourable arrangement may have been discovered several times during evolution. In some enzymes, the helix dipole might be used in catalysis.


Binding of additional histones to chromatin core particles. Isolated nucleosome core particles from chick erythrocytes and calf thymus have been used in experiments to show that chromatin subunits can absorb more than an additional equivalent of the histones making up the nucleosome octamer with no significant alteration in external shape and structure.


Mapping of the residues responsible for the negative cooperativity of the receptor-binding region of insulin. Insulin binding to its receptor leads to negatively cooperative interactions among the receptor sites. Studies with 29 insulin analogues (animal insulins and proinsulin, insulin-like growth factor and chemically modified insulins) which vary 1,000-fold in their affinity for the receptor and in their biological potency, suggest that a discrete invariable region on the surface of the insulin monomer is responsible for including the negative cooperativity. This domain comprises some of the eight carboxy-terminal residues of the B-chain and the A21 asparagine. Burying of this 'cooperative site' in the dimerisation of insulin leads to a loss of negative cooperativity. A revised mapping of the insulin molecule is proposed, featuring distinct bioactive and cooperative sites.


Characteristics of successful natural enemies in models of biological control of insect pests. Biological control of insect pests is characterised by a persistent, strong reduction in the pest population following the introduction of a natural enemy. Analysis of mathematical models suggests that differential exploitation of patches of the pest in a spatially heterogeneous environment provides the most likely mechanism to account for known successes.


Principles of the eradication or control of tsetse flies. The success of attempts to control African trypanosomiasis afflicting both men and animals through the destruction of the tsetse vector depends on a realistic assessment of human and ecological factors in infested regions. The complete eradication of tsetse is at present possible only in limited areas, and elsewhere the advantages of periodic control campaigns have to be weighed carefully against their cost.


Antigenic variation in trypanosomes.

Antigenic variation in trypanosomes. In its mammalian host, Trypanosoma brucei is able to change the antigenic character of its glycoprotein surface coat and so evade the host's immune response. This phenotypic change seems to occur spontaneously in 1 in 10,000 individuals but is not due to genetic mutation: host antibody is not necessary for its induction but plays a selective part in bringing about the gross changes in parasite numbers and antigenic character observed in the bloodstream by destroying the main component of what is actually a heterogeneous population. The infecting trypanosome population injected into the mammalian host by the tsetse fly vector may also be heterogeneous. Such heterogeneity complicates plans to vaccinate cattle and people against the African trypanosomes based on the premise that the metacyclic trypanosomes of a clone bear the same surface antigen.


Immunity to intestinal parasites.

Immunity to intestinal parasites. Intestinal parasites are common in man and animals and can cause severe disease. Knowledge of immunity to such infections is limited and comes largely from studies using laboratory host-parasite systems. Understanding how immunity can operate, and why it often does not, is not only of intrinsic interest but necessary for the development of immunological methods of control.


Specific and nonspecific immunisation against parasitic infections. Parasitic diseases present major problems to man and his domesticated animals but do not respond easily to conventional vaccination procedures. Vaccines including attenuated stains, killed parasites, homogenates and soluble extracts all produce varying degrees of protection but controlled infections and immunisation with heterologous species or nonspecific antigens also induce protective immunity.


Sequence of chicken ovalbumin mRNA.

Sequence of chicken ovalbumin mRNA. The complete sequence of chicken ovalbumin mRNA is presented; it is 1,859 residues long, excluding its terminal 'cap' and poly(A). The region coding for ovalbumin lies close to the 'cap' but is separated from the poly(A) by an extensive 3' noncoding region of 637 nucleotides which may have no function that is precisely dependent on its sequence.


Extended X-ray absorption fine structure determination of iron nitrogen distances in haemoglobin. EXAFS spectra have been obtained of oxy and deoxy complexes of haemoglobin and of the 'picket fence' porphyrin, using synchrotron radiation as a source of X rays. The fluorescence data were Fourier filtered to obtain distances to the first shell and corrections applied to remove contributions from the axial ligands. In this way, the iron to porphinato nitrogen distances were determined to be 1.98 +/- 0.01 A for both oxygenated complexes and 2.055 +/- 0.01 A for both deoxy forms.


Potential for variability through multiple gene products of bacteriophage phiX174. The small single-stranded DNA phages phiX174 and S13 produce multiple products of certain phage genes, as observed by electrophoresis on SDS-polyacrylamide slab gels. Two A protein products, two A products and four G products are observed. The multiple gene products may arise from multiple sites for initiation or termination of translation, or by protein modification. Some of the variant products may provide a substitute for heterozygosity without a concomitant increase in the size of the genome.


Quantum jumps of conductance during formation of membrane channels at cell-cell junction. The cell-to-cell conductance of a nascent cell junction increases by stable quantal steps. The steps evidently reflect the opening of stable cell-to-cell channels, all alike and growing progressively in number.


[Medicine-man practice. Ritual therapy and drugs used by the Digo in Tanzania]. The strong activity of the patient is significant in traditional Digo ritual therapy. In contrast to Sharmanism, he, and not the healer, plays the main role. The Digo healer applies hypnosis, somatiic exercises, stimulating music, and drugs in his three-day ritual performed mainly for psychosomatic and chronic illness.


Field-focusing nuclear nuclear magnetic resonance (fomar). A technique, field-focusing NMR (FONAR), is described for doing NMR scans in large samples. The method utilizes a shaped D.C. magnetic field that confines the NMR-signal-producing region of the sample to a small volume called the resonance aperture. The aperture contains the required values of the Ho field to fully bracket the band of the r.f. pulse. The magnet system and r.f. pick-up coil that achieved the first human NMR can is discussed.


[Lectins, sugar-binding plant proteins]. Lectins are proteins which can bind to the surfaces of animal and human cells. They are widespread in the plant and animal kingdom. Though many lectins have been isolated and characterized, and though some are extensively used as cell surface "tools", their biological role is only subject to hypotheses.


Acetylcholine content of and release from isolated pelviureteral tract. Measurements were taken for the acetylcholine content of animal and human pelviureteral muscle and for the release of acetylcholine at rest and during field stimulation of the isolated renal pelvis and ureter. Release was frequency-dependent, with the maximum output obtained at 10 Hz. The release of acetylcholine from reserpine-pretreated and piperoxan-treated tissues remained unchanged, but tetrodotoxin (1.10(-6) g/ml) and noradrenaline (2.10(-6) g/ml) significantly reduced the output.


The interaction of rifamycin SV with hepatic transport of taurocholic acid in the isolated perfused rat liver. The effect of rifamycin SV on hepatic transport of taurocholic acid was investigated using isolated perfused rat liver technique. In all experiments, the perfused liver was maintained at taurocholic acid steady state by infusing constant amount of taurocholic acid. Infusion of rifamycin SV at various rates decreased biliary secretion of bile acids in a dose-dependent manner. Replacement of rifamycin SV by perfusion medium reversed this effect. To determine the site of action of rifamycin SV, kinetic experiments with 14C-taurocholic acid were undertaken. Rifamycin SV elevated the half-life of the medium disappearance of 14C-taurocholic acid. Furthermore, the antibiotic delayed the biliary appearance of 14C-taurocholic acid. The analysis of the results gave indications that the antibiotic interferred with hepatic uptake as well as biliary secretion of taurocholic acid.


Paradoxical decrease of brain 5-HT turnover by metergoline, a central 5-HT receptor blocker. Since metergoline (1-methyl-8-beta-carbobenzyloxy-aminomethyl-10-alpha-ergoline) is a potent 5-HT antagonist in peripheral organs, its possible blocking effects on 5-HT receptors in the rat brain were investigated. In vitro, metergoline inhibited both the specific high affinity binding of 3-H-5-HT onto synaptosomal membranes (IC 50 = 18 nM) and the stimulating effect of 10 micron 5-HT on the adenylate cyclase activity in colliculi homogenates from newborn rats (IC 50 = 12 micron. In vivo, the administration of metergoline (10 mg/kg i.p., 60 min before death) resulted in a significant decrease in the 3-H-5-HT binding capacity of synaptosomal membranes from the forebrain of adult rats. Taken together, these data clearly indicated that metergoline is a potent blocker of some serotoninergic receptors in the rat brain. Surprisingly, the changes in 5-HT turnover occurring in the brainstem and in the forebrain 1 h after metergoline (2-10 mg/kg) treatment were similar to those normally induced by a central 5-HT agonist: both the rate of 5-HT utilisation and that of 5-HT synthesis were significantly decreased. These changes were in contrast to the acceleration of 5-HT turnover induced by the administration of another potent central 5-HT antagonist, methiothepin. These results are discussed in relation to the possible existence of several types of serotoninergic receptors in the rat brain. It is possible that the positive feedback regulation of 5-HT turnover is triggered by the blockade of serotoninergic receptors sensitive to methiothepin, but not to metergoline.


Interaction of fusidates with bile acid uptake by isolated rat hepatocytes. The interaction of fisidic acid and two of its conjugates with carrier-mediated uptake of bile acids was investigated in isolated rat hepatocytes. All three fusidates inhibited the uptake of both cholate and taurocholate competitively suggesting a direct interaction of fusidates with bile acid carrier. The inhibition constants for all three fusidates for the inhibition of cholate uptake were significantly different from the respective inhibition constants for the inhibition of taurocholate uptake. This would indicate that both cholate and taurocholate are transported by more than one carrier into hepatocytes. The results may also indicate that taurine conjugated bile acids may be transported preferentially by one transport system while unconjugated bile acids may be preferentially transported by another transport system.


Metabolic fate of 3H-noradrenaline released from the mouse hypothalamus. In slices of mouse hypothalamus labelled in vitro with 3H-noradrenaline (3-H-NA), the deaminated metabolite 3H-3,4-dihydroxyphenylglycol (3H-DOPEG), represented 40.2 +/- 2.6% of the total outflow of radioactivity and was the main fraction in the spontaneous efflux. Inhibition of neuronal monoamine oxidase by exposure to 60 micron bretylium, reduced the outflow of 3H-DOPEG to 9.7 +/0 0.3%. At the same time, the proportion of 3H-normetanephrine (3H-NMN) was significantly increased. On the other hand, an increased outflow of 3H-DOPEG and a lower proportion of 3H-NMN was obtained in the presence of 2.9 micron of the reserpine like agent Ro 4-1284. It is suggested that in the mouse hypothalamus, the deaminated metabolite, DOPEG, is formed inside the nerve terminals, while the O-methylated metabolite, NMN, might result from the activity of extraneuronal catechol O-methyltransferase.


Nephrotic syndrome and focal glomerular sclerosis in aging man. Focal glomerular sclerosis (FGS) with the nephrotic syndrome is a disecades. Less than 2% of reported patients are older than 60 years of age, and to our knowledge no patients over 70 years of age have been described. The present report documents with renal biopsies the occurrence of FGS and the nephrotic syndrome in 4 patients with an average age of 70 years, 3 being septuagenarians. We suggest that FGS in these patients may represent a disease of senescence, and that FGS in younger patients may result from accelerated glomerulotubular senescence.


The morphologic basis of proteinuria in experimental chronic serum sickness glomerulonephritis. A light and electron microscopic study using horseradish peroxidase and ferritin as tracers. The morphologic basis of proteinuria in experimental chronic serum sickness glomerulonephritis in rabbits was studied by light and electron microscopy using horseradish peroxidase (effective radius 30 A; mol. wt. 40,000) and ferritin (effective radius 60 A; mol. wt. 480,000) as protein tracers. It was found that more ferritin, but paradoxically, less horseradish peroxidase gained access to the urinary space. Observations made by electron microscopy appeared to indicate a decreased permeability of most part of the damaged glomerular capillary wall to both tracers. These results favor the interpretation that proteinuria in chronic serum sickness glomerulonephritis is the result of focal rather than diffuse increase in permeability of the glomerular capillary wall. Lesions of segments of the nephron other than the glomerular capillary wall, may contribute to the leakage of proteins to the urinary space.


Relations between the cortico-papillary osmotic gradient and saline diuresis in normal and acutely hypophysectomized rats. The renal osmotic cortico-papillary gradient and those of sodium, potassium and urea have been determined in normal and hypophysectomized hydropaenic rats and in normal and hypophysectomized saline-loaded rats, hypophysectomy having been performed 2 h prior to the kidney excisions (acute hypophysectomy). Saline loading was found to depress the renal cortico-papillary gradients in both the normal and hypophysectomized rats, the decrease being more pronounced in the latter. Since the hypophysectomized rats excreted significantly less sodium than normals it is inferred that the depressed cortico-papillary osmotic gradient need not invariably be the decisive factor promoting renal sodium excretion as has generally been accepted.


Reduced hexokinase activity in renal medullary tissue from rabbits with inferior vena caval constriction. Caval constriction in rabbits results in reduced blood flow to outer cortical tissue but blood flow to juxtamedullary cortex and outer medullary tissue is increased. The present study indicates that this shift in tissue perfusion is accompanied by a reduction in hexokinase activity.


Hemoperfusion with uncoated amberlite XE-336 resin in normal and uremic dogs. Amberlite XE-336 is a pyrolized polystyrene resin with an adsorptive spectrum similar to activated charcoal. 5 normal (group I) and 5 uremic (group II) dogs had 6 h of hemoperfusion with a 400-gram column of Amberlite XE-336 resin with a blood flow rate of 300 ml/min. In group II during 0, 0.5, 1, 3, and 6 h of hemoperfusion the mean column clearances of creatinine were 273 +/- 10, 224 +/- 7, 177 +/- 8, 125 +/- 30, and 64 +/- 17 ml/min and the serum creatinine concentration decreased from 10.4 +/- 1.3 to 3.2 +/- 0.9 mg/dl. In one of the uremic dogs the column clearance of middle molecules measured at 0, 0,5, 1, 3, and 6 h of hemoperfusion was 273,258,101,109, and 23 ml/min. The side reactions in group I and II hemoperfusion studies included transient hypotension, hypocalcemia, leukopenia and a reduction in platelet count.


Nelson's tumour--two case reports.

Nelson's tumour--two case reports. Two cases of tumours of the pituitary gland, occuring in patients after bilateral adrenalectomy for Cushing's syndrome, were admitted to the Clinic and operated on during the period 1974 to 1976. The clinical and laboratory data are compared to those of similar, published cases. The aetiology is discussed in the light of recent neuroendocrine investigations.


Acute central and intermediate cervical cord injury. Six cases with cervical cord contusion are described. All were over 50 years old, had an hyperextension injury of their cervical spine, suffered from tetraparesis predominant in the upper limbs and showed no X-ray evidence of injury to the cervical spine. Marked cervical spondylosis was present in five cases, one also had a narrow spinal canal. Cases No. 3 and 4 had an atypical recovery pattern. Shoulder and elbow movements improved last or not at all, while in the classic cases the hand muscles recovered last. Upper motor neuron damage was thought to be the cause, a result of intermediate instead of central cord traumatic necrosis or ischaemia. Pathological findings in case No. 5 emphasizes the possible diagnostic importance of taking lateral X-rays of the cervical spine in hyperextension. It also shows why laminectomy and/or myelotomy cannot help. Case No. 6 shows the noxious effect of shock and the effectiveness of steroid therapy.


[The measurement of intracranial pressure (author's transl)]. A new method of measuring pressure extradurally was tested in 19 patients and compared in 14 patients with the intraventricular pressure which was also measured. When functioning satisfactorily the values for the extradural pressure were generally around 3-5 mm Hg lower than those which were recorded within the ventricles. The reason for this appeared to be the inadequate length of the adaptor screw which was used to fix the pressure recorder in the skull, so that a small part of the actual intracranial pressure was absorbed by the dura.


[Microsurgery of sphenoidal ridge meningiomas (author's transl)]. On the basis of 22 sphenoidal ridge meningiomas operated on in the last two years, the topographical relationship of these tumours to the brain and the base of the skull is described. The microsurgical technique which is used is described and its advantages discussed.


[Fronto-cranial remodeling for craniostenosis with mobilisation of the supra-orbital barr (author's transl)]. 33 cases of fronto-cranial remodeling by osteotomies are reported by the authors. Since 1973, 19 oxycephalies have been operated according to an original technique based on two principles:--rocking and advancement of the supra-orbital barr, with an easy lateral retention by a Z-bony cut.--transposition of free bone flaps to rebuild a forehead of the appropriate curvature. The good results obtained have encouraged the authors to operate on young children or even babies in order to solve simultaneously the functionnal and the aesthetic problems. Three plagiocephalies, two trigonocephalies have thus been treated, as well as 5 facio-craniostenosis for whom a 2 cm forehead advancement has been done, the following results being very encouraging.


[Mesodiencephalic level of severe head injuries (author's transl)]. From the study of 65 severe traumatic comas, the authors describe the syndrome of mesodiencephalic dysfunction, because of its frequency and its particular clinical signs. This peculiar level of loss of consciousness is characterized by a coma without mimic and without awakening after painful stimulation, by a stereotyped motor pattern in extension, by a perseverance of the photomotor reflex, while fronto-orbicular and vertical oculo-vestibular reflexes are lacking. This level of deterioration appears to be a critical point in the natural history of comatose patients. If this level is not surpassed, the probability of early death due to evolutive neurological lesion is low (18%). One half of these patients have a good prognosis, more than 75% have an excellent recovery. This high probability of recovery is decreased by a half when the level of mesencephalic dysfunction is reached.


[Pathogenesis of persistent subdural effusions in infants (author's transl)]. Current theories on the pathogenesis of persistent subdural effusions in infants are not supported by our clinical and operative data. In our more recent cases, a daily electrophoretic analysis of the fluid obtained by external subdural drainage has been performed and allowed to disclose the presence or progressive appearance of cerebro-spinal fluid. The relative concentrations, observed for some proteins present in the fluid collected in this way, cannot be explained by simple filtration, but enforces us to postulate the existence of a free communication between the subarachnoid and the subdural spaces. These first results support our initial hypothesis assuming that persistent effusions are supplied and even replaced by cerebro-spinal fluid, due to the occurrence of a communicating hydrocephalus ruptured in the subdural space. There is thus no sound physiopathological basis for treating these cases with membranectomy and we suggest instead that the treatment of choice should be a fluid derivation.


Extra-dural hematoma of the posterior fossa (author's transl). 10 cases of posterior fossa extra-dural hematoma are reported and 100 other published cases reviewed. It appears that the sole clinical evaluation frequently leads to wrong or delayed diagnosis. In only one out of five cases the cerebellar signs and the palsy of one or several cranial nerves (VII, IX, X, XI, XII) are prominent. In contrast, all other cases do not present specific signs. Furthermore, the presence of a concomitant supratentorial traumatic lesion may contribute to prevent the finding of evidences for cerebellar extra-dural hematoma. The possibility for such hematoma must always been kept in mind when an occipital fracture is shown by radiography. Venous phases in carotid arteriography permit to ascertain the extradural hematoma if there is a displacement of the torcular Herophili or of the transverse sinus. Data from carotid arteriography may be normal and the lesion may be ascertained by vertebral arteriography which will demonstrate: anterior displacement of the basilar artery against the clivus--anterior displacement of posterior inferior cerebellar and posterior meningeal arteries--crescentic displacement of brain substance from the inner table--displacement of the venous sinuses.


[Surgical posterior approach in spondylolisthesis (author's transl)]. The authors report their experience about 60 patients who suffered of a spondylolisthesis and who were treated by a surgical procedure. A posterior approach has been used for all the patients. After a brief review of the clinical and radiological features of the disease, the authors emphazise the advantages of the posterior approach; only this technique allows a correct access both to the bone and the nerve roots lesions. Two types of operations are proposed:--the ablation of the posterior arch of the concerned vertebra (Gill's operation).--a posterior arthrodesis by mean of an homograft, using one of the following technique: an Albee grafting a Bosworth grafting an ilio-transversary grafting. The results are considered from a clinical, and an anatomo-radiological point of view.


[Intra medulla oblongata and cervical ependymoma (surgery, apnea for two months and improvement) (author's transl)]. A 17 years old female was first seen in a neurology department in December 75. She was running a low grade fever; her general status was not good. At the physical examination she presented:--an amyotrophy of both arms, mainly proximal,--a thermo analgesic dissociation which was complete from C1 to C5 and incomplete from C5 to D4, and--a spastic quadriparesis (with a posterior spinal syndrome). The first physical disabilities appeared 15 months before. The myelography revealed an enlarged spinal cord in the upper part of the cervical region and the contrast media could not go through the foramen magnum. At surgery, a solid mass, localized on the right side, inside the medulla oblongata and the spinal cordal, with a cyst at each extremity, reaching C4 in the lower part and the recessus lateralis in the upper part. During surgery the patient was breathing spontaneously. After the removal of the mass, she presented an apnea. The quadriplegia following surgery was very short. She recovered rapidly a normal motor activity in both legs and in the right arm. Respiratory paralysis remained complete for 2 months. The right diaphragm recovered completely in 4 months, the left one only in part. 4 months after surgery, she went back home. One year later for security reason she still has a tracheotomy. The distal paralysis of the left superior arm is still present.


[Experimental cerebral infarction. Part 2: EEG change in experimental thalamus infarction in the dog--it's value and application (author's transl)]. Athough it has been generally believed that it is extremely difficult to prepare an experimental model of cerebral infarction in the dog with the use of temporary vascular occlusion, the procedure recently developed by one of the authors fascilitates the production of a localized infarction in the thalamus with a noticeably high rate of success. To obtain more reliability of this method, techniques of electroencephalography induced from depth electrode to the thalamus were applied in this experiment. Following a temporary vascular occlusion, a significant diminution of fast wave component of about 10 Hz occurred with attenuation of voltage in the ipsilateral thalamic depth electrode. In cases of 2 hour vascular occlusion done by this method, an obvious infarction in the thalamus was confirmed histologically 7 days later. The authors emphasised that when the experimental model of thalamic infarction in the dog are combined with EEG, not only can cerebral infarction be producted with more certainly but also the EEG changes can be followed. This analysis is important since it provides information on the chronological changes in the ischemic region or infarction lesion.


[Tethered cord syndrome--our three cases and the review of the literature (author's transl)]. Three cases of tethered cord syndrome are presented with reference of reported literatures. This syndrome is usually associated with spina bifida occulta and cutaneous manifestation such as subcutaneous tumor, skin dimple, hairy patch, and neavus. Presented symptoms are various progressive neurological deficits involving weakness and/or sensory disturbance of lower limbs, bowel and/or bladder dysfunction, leg and/or low back pain, and orthopedic pathological conditions such as scoliosis and/or foot deformities. Properly performed myelography is the only method of preoperative confirmation of this syndrome. As the surgical release of the tethered spinal cord is effective for these various symptoms except for foot deformity, early investigation and early surgery are recommended.


[A case of cerebral polyuric hyponatremia (author's transl)]. A case of cerebral polyuric hyponatremia was reported. A 64-year-old lady had complained of visual disturbance for 4 years. She was operated upon under the diagnosis of tuberculum sellae meningioma. Sever days following operation tremendous polyuria was senn, i. e. polyuria over 40 l/day, massive sodium wasting in the urine, hyponatremia and severe thirst feeling. These situations could not easily controlled by pitressin, and 2 days after the onset of polyuria the level of sodium in the serum decreased up to 112 mEq/l, the amount of excretion of sodium into urine increased up to 186 mEq/l, and the patient had finally a convulsive seizure followed by loss of consciousness. This hyponatremia was easily controlled by infusion of hypertonic NaCl. The pathogenesis of this condition could not be explained by applying the classical concept of "Diabetes Insipidus" nor "SIADH". This hyponatremia might be the result of massive sodium wasting in the urine. And from the results obtained in our patient, these conditions should be classified in the syndrome of "Cerebral Polyuric Hyponatremia" as reported by Oi et al. It should be emphasized that the measurement of osmorality and level of electrolytes in the serum and urine had to be performed frequently when the postoperative polyuric situation was found, so that the clinical diagnosis could be established in the earlier stage. The clinical diagnosis and differentiation of postoperative disorders in water and electrolytes of central origin were discussed.


[A case of colloid cyst of the third ventricle (author's transl)]. The authors report a case of colloid cyst of the third ventricle diagnosed preoperatively through CT scan, pneumoencephalography and carotid angiography. The patient was a twenty-six year old housewife with a history of two repeated episodic headaches followed by gait disturbance, vomiting and cold sweating. At operation, the colloid cyst which completely occluded the right foramen of Monro, was reached by anterior transcallosal approach and was partially removed with subsequent cure of her symptoms. The cyst fluid contained cholesterin crystals, cholesterol, protein (12.8 g/dl), and sugar (16 mg/dl). Histologically, the cyst wall consisted of a single layered cuboidal or columnar epithelium with many cilias internally and loose connective tissue rich in vascluar channels externally. Cytoplasm and cellular surface was partly positive at mucicarmine, PAS and alusian blue staining. The fact would confirm that there is mucin secreting function among the epithelial cells of the cyst.


Prolactin suppression by serotonin antagonists in man: further evidence for serotoninergic control of prolactin secretion. To further investigate the role of serotonin in human prolactin (Prl) secretion, serotonin antagonists have been administered to healthy volunteers in basal conditions and after pretreatment with the selective blocker of dopamine receptors, pimozide (Pim). Highly significant falls (p less than 0.001) in serum Prl were observed at 120, 180, and 240 min following the oral administration of metergoline (Met) (4 mg; N = 34) and methysergide (Meth) (3 mg; N = 20) in comparison with placebo. No significant difference was found in the degree of Prl suppression induced by these two serotonin antagonists and by hte dopaminergic drug bromocriptine (Br) (2.5 mg; N = 20). After Pim pretreatment (1 mg every 6 h for 7 days) the elevated serum Prl levels were reduced to 27.1% +/- 8.1 (SEM) of basal after Met and to 54.5% +/- 8.9 after Meth administration (N = 5 for each study). It is concluded that Met and Meth inhibit Prl secretion by mechanisms which are not or only partially related to dopaminergic receptors. These data are consistent with a stimulatory role for serotonin in human Prl release.


Plasma cortisol of conscious cats during cerebroventricular perfusion with adrenergic, cholinergic and gabanergic antagonists. Adrenergic (alpha and beta), cholinergic (m and n) and gabanergic (gamma) influences on the regulation of basal hypothalamo-hypophyseal-adrenocortical (HHA) activity, as assessed by plasma cortisol levels, were investigated in non-stressed conscious cats. Alterations in neurotransmitter activities were induced by perfusing the cerebroventricles for 60 min with mock cerebrospinal fluid containing alpha, beta, m, n and gamma antagonists given along or in various combinations. Neither gamma, m nor n blockers altered basal HHA activity, whereas both alpha and beta blockers given alone or together, or combined with m, n and gamma blockers markedly elevated plasma cortisol. These responses were inhibited by the addition of dexamethasone to the perfusion fluid. These data suggest that basal HHA activity in the cat is maintained by a central inhibitory action of the adrenergic system on spontaneously discharging corticotropin-releasing factor neurons, and not via an adrenergic-cholinergic-gabanergic neural chain.


Total dural calcification with secondary hyperparathyoidism: a rare entity. A case of total, dense dural calcification in an adult female patient with secondary hyperparathroidism is presented. The often reported feature in the skull is that of a combination of osteopenia and osteosclerosis giving a granular bone texture described sometimes as "grains of sand" or "salt and pepper" appearance [6]. Extensive dural calcification with this condition has very rarely been reported [2, 3]. The purpose of this paper is to document the existence of the latter in a patient followed up for 19 years.


The value of computed tomography in the evaluation of the enlarged head. The contribution of computed tomography (CT) in the assessment of macrocrania has been examined with reference to a consecutive series of 93 cases. In the great majority a definitive diagnosis could be made without resorting to more noxious procedures. Hydrocephalus was present in 46% of this group. The incidence of macrocrania with childhood hydrocephalus and its relationship to the aetiology and other CT features was examined with reference to 109 consecutive cases with hydrocephalus shown on CT. Macrocrania was present in only 11% of cases with an underlying tumour, but in 71% with other obstructing lesions.


Foreign body embolism of retinal arteries as a complication of carotid angiography. Two cases of foreign body embolism of the retinal arteries after percutaneous carotid angiography were encountered within a period of 7 months. Both patients were non-arteriosclerotic. Loss of visual function in direct relation to carotid angiography and the observation of a dark foreign body in a retinal arteriole indicated exogenous embolism. No or only slight remission occurred. Careful ophthalmoscopy in cases of visual complaints after carotid angiography is advised, and if foreign body embolism is suspected, treatment with vasodilators (e. g. amyl nitrite) should be given a trial.


Clinical testing of Amipaque for cerebral angiography. Amipaque 280 mg I/ml was compared to Isopaque Cerebral 280 mg I/ml for common carotid injection in twenty patients in a double blind trial. Simple comparison was also performed in examinations with selective external carotid injections. The reaction of the patients to the common carotid injection was mild on the whole but Amipaque caused significantly less discomfort than Isopaque. Selective external carotid injection of Amipaque caused very little discomfort while most patients complained of severe pain when Isopaque was used. No serious side-effect was observed.


Spontaneous closure of cerebral arteriovenous malformation demonstrated by angiography and computed tomography. Spontaneous disappearance of a cerebral arteriovenous malformation, presumably secondary to thrombosis, was demonstrated in a young female patient by angiography and computed tomography 11 and 13 years respectively after the initial radiographic demonstration of the lesion.


[Choledochal cysts. Clinico-radiological considerations and surgical technical notes]. A successfully operated case of neonatal common bile duct cyst is described. Cystoduodenostomy was employed. Whether or not this condition is attributable to obstruction dysembryogenesis or aganglia is discussed. Assessment of the anatomopathological features leads to the establishment of three clinical types: cyst properly so called, hernia and diverticulum. True choledochus cyst has three main symptoms: mass, icterus and pain. The other two forms constitute only 5% of the reported cases. They have no distinct signs and the few cases described have been encountered during surgery or necropsy. Diagnosis is complicated by cholostatic cirrhosis and portal hypertension. Treatment is necessarily surgical: excission of the cyst, reconstruction of the main duct by direct anastomosis of the hepatic duct to the duodenum or a jejunal loop prepared according to Roux; anastomosis by means of cystoduodenostomy.


[Indications, value and limitations of azygos-portal disconnection in the treatment of esophageal varices]. Satisfactory results obtained, lasting for years in some cases, following azygos-portal disconnection in selected patients with bleeding oesophageal varices, portal hypertension, splenopathy and gastroduodenal ulcer are referred to. It is suggested that wider use should be made of this technique, particularly in patients in poor condition, because the long-term picture does not include the hyperammoniaemic encephalopathy often associated with extensive portosystemic shunts.


[Rapid diagnosis of myocardial function after open-heart operations]. The Authors observed dynamical changes of ventricular pressure curves during prolonged catheterization. An analysis gave the opportunity to point out three main types of pressure curves. There were registrated pressure curves typical for the increased pulmonary pressure, while myocardial failure process look place in the background of normal values of the right ventricle pressures. Absence of pathological changes in the pulmonary blood flow gave the opportunity to show direct dependency of pressure curves due to myocardial function. Determination of pressure curves as a rapid method of obtaining vital diagnostic information of cardiac failure.


[Current status of surgery of nephro-vascular hypertension]. With current angiology, the chances of identifying and treating operatively and radically patients with nephrovascular hypertension are greatly increased. Extending indications and improving technique it has been possible to operate 84% of patients with verified diagnosis of stenosis of the renal artery, according to angiographic data. Positive results have been achieved in 78% of patients. Post-operative mortality with isolated lesions of the renal arteries was 5%. Advances have been made in the standardization of diagnostic tests in patients with high AD and as regards speedy operation in specialist angiological clinics.


[New method of simultaneous disobliteration of the visceral arteries and abdominal aorta]. Simultaneous correction of abnormal blood flow is necessary in the presence of combined lesions of various branches of the abdominal aorta. The problem can be solved comparatively easily by using transaortic endoarteriectomy, a technique proposed here, which consists essentially of longitudinal incision of the aortic lumen and simultaneous endoarteriectomy under the visual control of the abdominal aorta, the visceral branches and the renal arteries. Personal experience is based on 21 operations for cases of atherosclerosis and aspecific sclerotic aorta-arteritis. Simultaneous transaortic endarteriectomy is indicated in the presence of lesions localized at the proximal segment of more than two branches of the abdominal aorta. In 4 of the cases observed it was associated with resection and prosthesis of the lesioned segment of the artery and in 9 cases with resection of the abdominal aorta and aorto-femoral prosthesis. Clinical succe-s was achieved in 10 cases (90.5%).


[Annuloplasty with a semi-rigid supporting ring for correction of mitral insufficiency]. The paper presents an anatomic and physiologic substantiation and an analysis of the initial clinical experience of mitral annuloplasty with the aid of original semi-rigid metallic supporting rings. The authors' experience comprises 33 operations with 2 cases of hospital mortality (6.2%). The problems of diagnosis and surgical technique are discussed, with special reference to the rationale of annuloplasty in cases of combined mitral diseases (stenosis and insufficiency). The obtained results demonstrate the efficacy of the introduced method of annuloplasty ensuring a stable restoration of the function of the mitral valve.


[Carcinoma fo the gallbladder. Experience and proposals]. Poor survival observed in a series of 40 females and 44 males with cancer of the gallbladder treated over a period of about 16 years ar referred to in the formulation of three proposals designed to achieve better results: I) Earlier and more reliable diagnosis based on selective arteriography, echography and careful intraoperative examination; II) More rational management based on more radical surgery, including, for example, resection en bloc of the gallbladder, hepatic fossa and adjacent liver, and cysticocholedochic, posterior pancreaticoduodenal and coeliac efferent lymphatics; III) Prevention based on prophylactic cholecystectomy in classes of subjects most at risk, such as women over 50 with cholelithiasis.


[Neoplasms of the male breast. Case report and review of the literature]. Fourteen cases of breast cancer in males observed between 1950 and 1974 at the Busto Arsizio Hospital Surgery Divsion are presnted. The literature is reviewed and attention is given to the incidence of this form, its symptoms and treatments, and to the length of survival after surgical management.


[Personal experience with vagotomy in the treatment of duodenal ulcer]. Truncal vagotomy was employed in 120 cases of simple or complicated duodenal ulcer. Pyloroplasty was also performed in 98 cases, antroduodenostomy in 5, Billroth I or II in 12, and gastrojejunostomy in 5. No operative deaths were noted, even though the series included emergency situations and patients in poor condition. The incidence of complications and immediate sequelae was insignificant. Follow-up for 2-6 yr showed complete success in over 91%, with partial improvement in 3.8%. Poor results included 3 cases of recurrence, 1 of late scar stenosis on the pyloroplasty site, and 1 of intermittent gastroplegia.


[Biliary peritonitis. Clinical and statistical findings in 37 cases]. Following an aetiopathogenetic and physiopathological discussion of biliary peritonitis, a statistical analysis of the main clinical symptoms observed is presented on the basis of 37 personal cases with a view to highlighting diagnostic factors capable of identifying a disease process which may easily be confused with other acute abdominal diseases. The need to intervene as quickly as possible is finally noted.


[Intrathoracic goiters].

[Intrathoracic goiters]. Reference is made to the nosographical classification of intrathoracic goitre and the difficulties associated with its diagnosis. Particular attention is devoted to the correct surgical technique required. Surgery is mandatory in mediastinal cases on account of the slow and gradual progression of the swelling and exacerbation of the symptoms, and also because complications may supervene (cancer, intraparenchymal haemorrhage, etc.). The approach routes are discussed, along with the conditions requiring resort to a complementary route--usually median sternotomy--in addition to cervicotomy.


[Tumors of Meckel's diverticulum].

[Tumors of Meckel's diverticulum]. The presentation of a rare case of leiomyoma of Meckel's diverticulum in a boy of 5 yr forms the starting point for a discussion of such cancers. In adult age, the complication is not so rare as the sporadic publications would suggest, incidence of tumoral forms being around 1 : 50 M.D. with a high malignancy frequency. In paediatric age, on the other hand, the tumoral degeneration of a M.D. is an exceptional occurrence: a review of more than 1,200 reported cases and personal experience (48 cases of M.D. in 15 yrs) confirm the rarity of the observation. The need to seek M.D. on each occasion and remove it to prevent the risk of tumoral degeneration in adult age is stressed. M.D. surgical removal tecniques are commented on and emphasis laid on the desirability of ample intestinal resection in cases of cancer of the diverticulum.


[Diagnosis of megacolon in the neonatal period]. The importance of diagnosis in megacolon is underscored and an account is given of its radiological and histochemical aspects. If correctly performed, radiological examination enables the condition to be recognised. This was always the case in a personal series of 17 cases. Histochemical examination according to Meyer-Ruge is also useful. This is a simple method and demands minimal withdrawals from the submucosa. The findings are also more readily interpreted than those offered by conventional histological examination. Stress is laid on the possibility of false negatives in the newborn as described in the recent literature.


[Proteinuria in the aged].

[Proteinuria in the aged]. The Authors for a better knowledge of the senile kidney have studied the urinary proteins of a group of elderly people resident in a geriatric institute. For instance they have noted the percentage of proteinuria in the urine of 313 patients (M and F) with various pathology, making also an electrophoresis of the urinary proteins. They put in evidence that the subjects with proteinuria were older than others, without proteinuria, and noted the high incidence of the infectious diseases of the urinary tract in these patients. In a second time the urine of 247 apparently healthy elderly people has been studied. Through an accurate examination (that is comprehensive of some serum parameters and a comparison with subjects without proteinuria) the Authors discussed a way of growing old defined "with biological trouble".


[Alcohol, blood lipids and advanced age]. The problem of the alcohol induced hyperlipemia in men is still in discussion. The Authors have tested the plasma lipid values of elderly subjects, known as a "good drinkers" in relation to abstemious males of equal age. No significant differences were found in the plasma lipid values of the good drinkers compared with those of the abstemious patients.


[The electrocardiogram of the long-lived. Observations gathered from a study of 190 subjects over 80]. The Authors have examined the ECG of 190 older than 80 patients. The 5,78% have resulted "normal" and the 12,10% "border-line"; the disturbances of the excitability (67,36%) have been more than those of the conduction (31,04%) among which the Left Anterior Emi-block have been important (12,10%). The myocardial infarction has been infrequent (7,89%) where the Left Ventricular Hypertrophia has been the 20%; the left deviation of the ventricular complexes has represented the 61,57%, the synusal rhythm the 85,26%, the normal rate has been present in 79,47% of the cases.


[Various aspects of sleep in the long-lived]. The Authors through a set of questions have studied some qualitative and quantitative aspects of the sleep of 24 older than 80 patients. These results put in evidence that all the examined longevous people in the whole life, have gone to bed early in the night. Some particular habits in the sleep could be included among the environmental factors useful to a long life.


[On the subject of longevity. Study of a case of a 105-year-old man]. The Authors describes the case of male subjects who has got a very old age (105) with no particular "biological trouble". Some considerations about it are discussed.


[Adaptive physiopathology of advanced age]. We have considered the so-called "teleological" aspects in many senile diseases that is a kind of effort to compensate alterations due to the aging process, where that process takes place with biological trouble (which happens for most subjects since aging without biological trouble is a prerogative of a minority of privileged people who will have a longevous and healthy life). These "teleological" aspects represent the foundation of the phisiopathology of adaptation in advanced age and the key for a correct interpretation of it and therefore for a correct preventive and curative program.


[Etiopathogenetic considerations on so-called moderate thrombopenia in young women]. Twenty cases of moderate thrombocytopenia in young women were examined in an assessment of the nosological status of this form. Parameters enjoying pathogenetic significance were distinguished in some instances: 4 cases displayed dysendocrinopathy, 2 the signs of consumption coagulopathy, 3 an antibody situation attributable to compensated autoimmune thrombocytopenia, and 3 a probable central inhibition of thrombocytopoiesis due to drugs. Since no significant cause could be determined in the remaining 8 cases, it can be said that this syndrome occupies a special place among the forms of chronic thrombocytopenia.


[Blastic cytophagocytosis in acute leukosis]. The phagocytic activity of the blastic cells in the course of acute leukemias has been previously analyzed mainly by means of technical methods concerning the ingestion of inactive particles or foreign bodies. The spontaneous ingestion of cells (cytophagocytosis) has been studied to a minor extent, with reference to some occasional pictures, mainly in erythremic syndromes. The analysis of 104 cases of acute leukemias, classified according to cytochemical criteria, demonstrated the presence of cytophagocytosis pictures almost exclusively in non-lymphoid acute leukemia patients. The data are discussed with relation to similar findings in epithelial tumors as well as to the emperipolesis pictures.


[Raised glucagon levels of the blood induced by arginine: relation to blood sugar, blood insulin and STH in aged non-diabetics and diabetics]. In a group of aged nondiabetic and diabetic subjects and in a group of young subjects the glycemic, insulin, growth hormone and glucagon response to intravenous arginine was studied. A prompt increase in blood glucose, serum insulin and glucagon levels was observed, but glucose and glucagon peaks were significantly higher in older non diabetic and diabetic subjects. Growth hormone secretion did not show any difference between aged nondiabetic and young subjects, on the contrary it is lower in diabetics. These findings might suggest the hypothesis of the glucose intolerance during old age due to increased release of glucagon.


[Determination of antithrombin III (chromogenic substrates) and FDP in women in treatment with oral estroprogestin agents]. In 280 women, in fertile age, 133 of whom represented the control group, FDP and antithrombin III with the method of chromogenic substrates were determined. In 147 women, who were taking, for variable period of time, oral estroprogestinic drugs, a significant diminution of antithrombin III was found. No significant differences for FDP were observed.


[ Long-term evaluation of the effect of a chemotherapy protocol using vincristine, adriamycin, procarbazine and prednisone (VAPP) on advanced Hodgkin's disease]. A chemotherapeutic combination associating vincristine, adriamycin, procarbazine and prednisone (VAPP) was evaluated in Hodgkin's disease. Subjects were either far advanced cases or relapsing after MOPP and/or radiation therapy. 50 cases were evaluable. After 6 months of treatment 80% of the cases achieved a complete remission. After 30 months 87% of the patients still survive and 60% were still in complete remission. The good tolerance of this chemotherapeutic combination and the results described above, suggest that VAPP may be useful in all cases when MOPP is not well tolerated or is not active.


[Hemochemical data in the function study of the senile kidney]. A survey was made of 2426 serum creatinine (SC) values in subjects over 60 and free from kidney diseases or other conditions capable of influencing the renal function. SC values were higher in males than in females and showed a tendency to increase with advancing age. The study of the correlation between endogenous creatinine clearance and both urea and SC showed that the latter represents a more reliable index of glomerular filtration rate than the former.


[Human chorionic gonadotropin in the treatment of chronic peripheral obliterative arteriosclerotic arteriopathies of the lower limbs]. Personal experience with human chorionic gonadotropin in the treatment of chronic obliterating peripheral atherosclerosis of the lower limbs in various stages in a series of 54 persenile and senile subjects is reported. Following protracted i.m. administration, the product normalised blood lipid values and brought about the regression of attenuation of subjective and objective symptoms that had been disclosed instrumentally in many cases. It is felt, therefore, that this drug can be used as a further weapon in the treatment of these arteriopathies.


[Allergological study of subjects with chronic rhinitis]. The following parameters were considered in an allergological study of 362 subjects with chronic rhinitis unaccompanied by bronchial asthma: sex, age at onset, residence, familial allergy, personal history, season in which distrubances occurred, nasal polyps, concomitance of conjunctivitis, appear of chronic bronchitis, skin tests for dusts, vegetable fibres, skin derivatives, pollens and moulds. A positive allergometric response was noted in 60.77% and familial allergy in 30.93%. Skin manifestations were observed in 20.99%. Conjunctivitis was present in 55.24%, most of whom were skin-positive; nasal polyps were present in 4.69%, most of whom were skin-negative. 1.65% had chronic bronchitis. 79.54% of the skin-positive subjects were sensitive to pollens, 47.72% to "inhalants" (28.18% to household dust), and 30% to moulds.


[Importance of research on antibacterial substances in the study of bacteriurias]. A study was made of 1050 urine specimens from the Nephro-Urological and Geriatric Departments of the Malpighi Hospital to see how many percent contained antibacterial substances and the incidence of bacteria species. 26.5% contained antibacterial substances. Proteus rettgeri was significantly more frequent in specimens containing such substances, whereas staphylococci were significantly more frequent in the remainder.


[Non-secreting myeloma].

[Non-secreting myeloma]. On the basis of a personal observation, the cases of "non secretory" multiple myeloma reported in the literature are reviewed. A myeloma classification based upon the production and excretion of monoclonal proteins by neoplastic plasmacells is presented together with an evaluation of the different possible pathogenetic mechanisms. The diagnostic criteria of "non secretory" myeloma are discussed and its main clinical problems analyzed.


[Blood lipid disorders and chronic pancreatitis. 4 cases]. The literature dealing with the debated and not yet completely settled question of the causal relationship between dyslipidaemia and acute and chronic diseases of the pancreas is reviewed. Four personal cases of chronic pancreatitis associated with dyslipidaemia are presented and their possible pathogenetic relationships are discussed.


[Clinical onset of meningitis in chromophobe adenoma of the pituitary: 2 cases]. Two cases of purulent meningitis in subjects with misinterpreted chromophobe adenoma of the hypophysis are presented. Radiography in the acute stage revealed typical enlargement of the sella turcica and thus established the diagnosis, which was eventually confirmed histologically during surgery. The frequency with which this complication has occurred in a personal series is contrasted with its rarity in the literature, particularly neurosurgical works. It is felt, therefore, that the association of adenoma and meningitis is more common than is generally supposed. Routine cranial radiography is recommended in all cases of purulent meningitis, especially in young subjects and adults, from the outset. This will reveal hypophyseal involvement and enable replacement hormonal therapy with cortisone to be added to symptomatic and antibiotic management in cases of concomitant hypophyseal and adrenal insufficiency.


[Allergological findings in rhinitis-asthmatic subjects]. A comparison was made between skin-positive and skin-negative subjects in an allergological study of 404 patients with rhinitis and asthma. The two diseases had appeared simultaneously in 52.72% of cases, while rhinitis had appeared first in 35.14%. Respiratory disturbances had occurred more frequently before the age of 30 yr in allergic subjects and between 20 and 50 yr in skin-negative subjects. Familial allergy was noted in 34% and a personal history of skin allergy in 21%. Associations with conjunctivitis, chronic bronchitis and nasal polyposis were noted in about 50%, 13% and 4% respectively. Nearly all skin-negative subjects had disturbances the whole year round, as did 47.67% of the skin-positives, while 36.53% of the latter had disturbances in spring and summer only. A positive reaction to at least one allergen was noted in 79.95%. Pollens were positive in 70.58%, dusts, vegetables fibres and skin derivatives in 66.25%, and moulds in 33.12%. The allergens used and the number of positives obtained with each are listed. It is felt that reaction to pollen should be investigated in such subjects, even when their symptoms are not sea sonal.


[Data on a comparison between a rapid test and urine culture for the determination of bacteriuria]. A streep test has been employed for bacteriuria involving identification of nitrites in the urine and results are compared with those obtained with classical bacteriological techniques. Parallel performance of the nitrite test and urine culture showed that the latter cannot be replaced as far as diagnosis goes but it also proved the usefulness of the nitrite test for mass screening purposes.


[Surgical treatment of renvascular hypertension. Personal cases]. Authors analyze a personal series of patients surgically treated for renal artery diseases (177 cases). Criteria of screening and diagnosis of stenosis are discussed and also are referred the clinical data. Authors describe their own personal reconstructive technique on renal arteries. Early and late results are widely analyzed.


[Diagnostic value of retrograde cholangiopancreatography by transendoscopic route]. Endoscopic retrograde cholangiopancreatography (ERCP) is essential in the diagnosis of pancreatic disease, jaundice and in post-cholecystectomy syndromes, as well as in cases where cholecystography and i.v. cholangiography fail to explain disturbances that strongly suggest bile duct involvement. Its confirmation of clinically established pancreatic disease is much more positive than that given by scintiscanning and multiple superselective arteriography. Unlike the latter, it also permits the differential diagnosis of chronic pancreatitis, cancer of the pancreas, pseudocysts, etc. and distinguishes medical and surgical pancreatitis (stenosis, proteinaceous calculi, and obstructing pseudocysts). Differential diagnosis of progressive jaundice on clinical grounds or with the aid of ordinary means of examination is sometimes unsatisfactory. ERCP clearly distinguishes medical and surgical forms, so that exploratory laparotomy is not needed in subjects with liver-cell forms. It also shows the nature, site and extent of extrahepatic obstruction, and points to the organic cause in 79% of cases of postcholecystectomy syndrome. Right hypochondrial pain or intermittent jaundice and negative cholecystography and i.v. cholangiography is a further indication, since ERCP will reveal disease of the pancreas or bile ducts (cholelithiasis, choledocholithiasis, sclerosing cholangitis, etc). It is also useful in the diagnosis of cirrhosis, abscess, echinococcus cyst and primary or secondary cancer in cases where needle biopsy and-or arteriography are either contra-indicated or inconclusive.


[Local malignancy potential of basal cell and prickle cell epithelioma]. A series of over 300 cases of highly malignant basal and prickle-cell epitheliomas is presented as an illustration of the way in which due importance is not always given to forms that may well be deeply invasive, though these are only some of the epitheliomas that may be encountered. The particular nature of each formation is not always evident at first and may be the cause of its further progression. High malignancy is more common in cases of recurrence and poor management, so that ineffective attempts at treatment may be seen as a contributing factor. Of course, when treatment has been correct, failure and subsequent recurrence may point to primary "predisposition" to recur; this tendency cannot yet be detected in time or with precision. Local malignancy is often independent of the type of epithelioma involved. Indeed, it is more serious and difficult to combat in the case of basal cell forms on first recurrence and resistance to proper management, whereas in prickle-cell epithelioma, when distant metastasis is prevented, local invasiveness is frequently conquered by truly radical surgery.


[Evaluation of the bone marrow granulocyte reserve in patients with Hodgkin's disease during antiblastic polychemo- and radiation therapy]. The ethiocholanolone test was used to evaluate the granulocyte reserve in 22 patients with Hodgkin's disease before and during polychemical antiblastic and radiation therapy. Under basal conditions, the reserve was normal and its behavior was fairly constantly related to histological type. Stress is laid on the inadequacy of the simple leukocyte count as a guide to the planning of treatment by comparison with the more accurate picture offered by the granulocyte reserve.


[Becker's benign muscular dystrophy. Observations on 1 family]. Three males in a family had Becker's benign muscular dystrophy. In addition, there were five likely female carriers, three of whom presented altered biochemical findings. Agreement is expressed with the view of other workers that Becker's form can be distinguished from the serious form of the disease on the grounds of exclusive expression in males, late onset of the first symptoms, recessive transmission linked to the X chromosome, extremely slow progression, and long survival.


[Hemodynamics in venous diseases of the lower limbs]. Venous diseases of the lower extremities have been studied haemodynamically by analysis of variations in dynamic venous pressure, which is held to be a fundamental parameter. Pressure modifications point to the state of the deep venous system, the valves and the subfascial communicating veins or to the efficiency or otherwise of the muscular pump of the lower extremities. The venous pressure curve is a reliable indicator of the various clinical stages of chronic venous insufficiency and postphlebitis syndrome. As a clinical parameter, venous pressure is sensitive to all pathological changes in the venous system of the lower extremities. It presents variations proportional to the gravity of pure phlebopathies and of venous diseases secondary to congenital dysplasias (e.g. Klippel-Trenauny syndrome) and to congenital or acquired arteriovenous shunts. An attempt is made to classify venous diseases of the lower extremities on the basis of this parameter and examples are given of dynamic venous pressure curves encountered in the various disease pictures observed.


[The role of the physician in the preparation of adults for old age]. Loss of his social role and various other stresses result in a psychological feeling of impotence and nothingness in the aged. Physicians should make a close study of these aspects and not identify the aged with the end of finality and segregation. Adaptation to old age is determined by the years preceding it and doctors should help adults to improve the quality of their lives and no "die" in a metaphorical sense. This is not something that can be improvised, however. Adults must not only face up to problems concerning their health, but also those relating to aging and the attainment of a satisfactory life-style during their years of retirement. A doctor can do great deal to enable adults to discover new abilities to adapt for themselves.


[Massive pulmonary embolism. Clinical aspects and treatment]. The frequency of pulmonary embolization seems to be increasing. Venostasis, intimal damage and hypercoagulability of blood are the more recognized causes of pulmonary thromboembolism. It is especially threatening to the elderly, obese, immobilized (for an accident or an operation) patients. Pulmonary isotopic scans or angiograms are most often relied upon to establish the diagnosis. A properly performed pulmonary angiography is necessary to establish or refute the diagnosis in almost every case. With the exception of the patients suddenly dying for a massive pulmonary embolism, the period of time between onset of symptoms and death is usually adequate for substantiating a diagnosis and promptly beginning a fit anticoagulation therapy using continuous intravenous heparin or fibrinolytic agents infusion. Although it is not proper to separate surgical and medical treatment of thromboembolism, the Authors, on the ground of their experience on 5 patients affected by massive pulmonary embolism, in 3 of whom was performed a successful embolectomy, think that heparin anticoagulation treatment is at any rate to apply for treating pulmonary embolism, but in patients in whom the shock is unresponsive to vasopressors or in whom anticoagulation therapy is controindicated, the surgical removal of pulmonary emboly, with the support of a pump oxygenator, is the treatment of choice for the acute massive pulmonary thromboembolism.


[Polychemotherapy of advanced cancer of the breast]. Results obtained with a cyclophosphamide, methotrexate, vincristine, 5-FU and prednisone protocol in the treatment of advanced breast cancer are reported. The number of weekly courses proposed by Ansfield was varied. 53% remissions were noted. The effect of the variation introduced was assessed with reference to a much lower incidence of side-effects and a percentage of satisfactory results comparable with that of Ansfield. Nevertheless, it is felt that the treatment in question should be employed as a second choice when more efficacious protocols, such as those including adriamycin, cannot be used or have proved ineffective.


[Proposal for wound pinching of viper bites]. Wound pinching is suggested as a first aid measure for viper bites, the intention being to prevent absorption of the cutaneous component of the poison. This procedure is most indicated in bites in regions of the body where it is not possible to apply a tourniquet (trunk, abdomen, neck, face). It can also be useful in wounds to the extremities as a complement to the tourniquet. Finally, in all wounds, it offers the best conditions for cutting, scarification of the wound and perifocal infiltrative treatment with anti-ophidic serum.


[Preliminary findings on 2 groups of diabetics with regard to platelet aggregation in relation to retinopathy and ultimate relation to antidiabetic therapy]. Platelet clumping was examined in untreated insulin-dependent and insulin-independent diabetics, with and without retinopathy. Hyperaggregation was noted, particularly in subjects with retinopathy and longstanding diabetes. Metformin normalised clumping in the course of mild diabetes.


[Presence of Salmonella wien in Campania in 1974-75]. Salmonella wien was detected in various patients admitted to the D. Cotugno Hospital between May 1974 and June 1975. Strains isolated in Naples showed the same in vitro transferable resistance to antibiotics as those responsible for the recent epidemics in Algeria and France.


Liver glycogen synthesis and glucose tolerance in rats adapted to diets with a high proportion of fructose or glucose. Glucose tolerance and in vivo incorporation of glucose into liver glycogen were investigated in rats fed high carbohydrate diets containing glucose or fructose as the sole carbohydrate source. As compared with control glucose-adapted rats, a slight deterioration of the glucose tolerance was observed in fructose-adapted rats. The possivle cause of the deteriorated glucose tolerance in fructose-adapted rats seems to be among others reduced glucose incorporation into liver glycogen and a smaller depression of endogenous glucose production by exogenous glucose.


Comparative studies in obese subjects fed carbohydrate-restricted and high carbohydrate 1,000-calorie formula diets. 45 obese subjects were fed a high-carbohydrate, relatively low-fat, or a low-carbohydrate, relatively high-fat 1,000-calorie (4.14MJ) formula diet. The diet provided for an isoenergetic substitution of 170 g of carbohydrates for 75 g of fat. Weight reduction up to day 30 was significantly higher in the subjects on the carbohydrate-restricted diet. There were no significant differences between the water and electrolyte balances. The mean total weight reduction achieved on the high-carbohydrate diet was 9.8 +/- 4.5kg with a mean daily weight loss of 298 +/- 80g, while the corresponding values on the carbohydrate-restricted diet were 14 +/- 7.2 kg and 362 +/- 91 g/day, respectively.


Effect of the type and proportion of dietary carbohydrate on serum glucose levels and liver and muscle glycogen synthesis in the rat. The effect of the type of dietary carbohydrate on oral glucose tolerance and on in vivo incorporation of labeled glucose or fructose into liver and muscle glycogen in the rat were investigated. The intake of fructose or sucrose reduced, as compared with starch or glucose, glucose incorporation into liver glycogen and caused a slight deterioration of the glucose tolerance. These effects were observed already when 50% of the total dietary carbohydrate was substituted by fructose or sucrose. The incorporation of labeled glucose into muscle glycogen was not affected by the type of dietary carbohydrate. Specific radioactivity of liver and muscle glycogen and the concentration of muscle glycogen after administration of labeled fructose were higher in fructose-adapted than in glucose-adapted rats.


Placenta accreta. A clinicopathologic review of 67 cases. During a 20-year period 67 uteri removed from placenta accreta, among a population of 645,000 live births and stillbirths in Northern Ireland, were examined. Of the 37 involving the cavity, only 31 were placenta accreta vera; 14 of these were total and 17 partial. Three others showed invasion into the wall (placenta increta), and three penetration through the wall (placenta percreta). When any part of the placental adhesion involved the previa site the case was taken to be a placenta previa accreta; here adhesion was extensive in 10 and limited in 7. A further 11 were examples of placenta previa increta, and 2 more of placenta previa percreta. There were only two maternal deaths. These variants are described and illustrated, and the association with high parity and, especially in the previa cases, with previous cesarean section is emphasized. The histologic deficiency of maternal decidua at the implantation site and the recognition and behavior of cells of the nonvillous trophoblast are briefly described. Hysterectomy, which in placenta previa variants must be adequate to excise the area of cervical involvement, appears to be the rational treatment.


Inhibition of premature labor by terbutaline. Terbutaline was administered to 50 women, all diagnosed as being in labor prior to 36 weeks' gestation. In 47, uterine activity was initially arrested with intravenous therapy. The infusion rate required to arrest uterine activity ranged from 10 to 80 microgram/min and 21 of the 50 patients (42%) required more than one intravenous infusion. The average prolongation of gestation was 3.7 weeks in those successfully treated. Twenty-four delivered within 48 hours after the terbutaline was discontinued. Treatment failures occurred in 11 (22%). Not a single infant died of the respiratory distress syndrome. Side effects were mild and well tolerated.


Insulin levels in amniotic fluid. Management of pregnancy in diabetes. A correlation between high insulin levels in amniotic fluid and the appearance of diabetogenic fetal morbidity was found in radioimmunoassays of 487 samples of the fluid. The mean insulin level in metabolically normal pregnancies rose from 9 muU/ml (Week 27) to 15 muU/ml (Week 40). The insulin level in amniotic fluid of diabetic patients was elevated up to 27 times the mean. Insulin levels in the umbilical cord and urine of newborns of diabetic mothers were also elevated, to 29 and 21 times the mean, respectively. Elevation of insulin levels in amniotic fluid portends diabetogenic fetal morbidity. High and rising insulin levels at an early stage (26-28 weeks) may indicate a high risk of preterm onset of labor. Regular adjustment of metabolic compensation on the basis of amniotic fluid insulin made it possible to reduce the level in 12 of 17 pregnant diabetic women by increasing insulin dosage. The 12 women were thereby enabled to carry their pregnancies to term and to await the onset of spontaneous labor without diabetogenic fetal morbidity. Beta-stimulating agents affect glucose management and may cause elevated insulin levels in amniotic fluid.


The suspicious contraction stress test.

The suspicious contraction stress test. From a clinical service using the contraction stress test as an evaluator of fetal well-being, a 37-month review of the significance of the suspicious contraction stress test was performed. There were no antepartum losses in a group of 107 patients whose initial test was suspicious. Following each testing a number of patients delivered spontaneously or were delivered for other reasons. Results in 5 of 67 patients at the second testing changed from a suspicious to a positive test, 36 became negative, and 26 remained suspicious. There were no further conversions to a positive test after the second testing. There is a strong correlation between the loss of fetal heart reactivity and the repeated suspicious contraction stress test. The chief value of the suspicious test is as a marker in the high-risk pregnancy appraisal for consideration of additional fetal and maternal evaluation and possible clinical management alteration.


The nonstress test.

The nonstress test. Antepartum fetal evaluation by heart rate monitoring was carried out on a clinical service during a 1-year period utilizing the nonstress test as the primary screening device. Nonreactive nonstress tests were supplemented by the oxytocin contraction stress test. In this study, the use of the nonstress test appropriately led to the identification of all fetuses who were in jeopardy and, in the majority of instances, identified fetuses in good condition who did not require the administration of oxytocin to determine fetal well-being. In our experience, the nonstress test is a reliable, inexpensive, convenient, time-saving screening procedure which can be made available to a greater number of patients than the contraction stress test alone.


Assessment of fetal lung maturity by a microviscosimeter. A new method of rapid antenatal assessment of fetal lung maturity was evaluated in relation to the newborn outcome and two other accepted test. This method is based on fluorescence depolarization (FD) technique. The special instrumentation required for this method (the Microviscosimeter) was found to be simple and easy to handle even to nonprofessional personnel. Analysis of 47 samples of amniotic fluid received within 48 hours of delivery demonstrated that lung maturity threshold may be related to a numeric value (P value) measured by this technique. With a P value of less than 0.320 respiratory distress syndrome (RDS) is unlikely to develop. With a P value greater than 0.340, chances for RDS, usually severe, are high. With a P value of less than 0.340 but greater than 0.320, RDS may or may not develop. This method did not prove to be more reliable then the determination of L/S ratio by thin layer chromatography, but its advantage is that it supplies the results in less then an hour. The FD technique proved to be more reliable then the commonly used foam stability test.


Endogenous creatinine clearance during pregnancy. II. Variations in normal standards based on methodology. A comparison of the endogenous creatinine clearance (ECC) values by using creatinine levels measured by the autoanalyzer and the modified Jaffe reaction using Lloyd's reagent was performed in 108 normal ambulatory pregnant women at various stages of gestation. The mean ECC was found to be significantly lower when the former method was employed except between 39 and 41 weeks when the values became similar. The mean ECC when calculated from the autoanalyzer results did not vary during pregnancy since serum creatinine by this method remained fairly constant. The difference in serum creatinine level between the two methods observed during pregnancy was absent in the nonpregnant state.


Hormonal effects of wedge resection of polycystic ovaries. Plasma FSH, LH, estradiol, testosterone, and progesterone were measured serially before, during, and after bilateral ovarian wedge resection in 2 patients with polycystic ovaries. Preoperatively both were anovulatory with persistently elevated plasma LH values and 1 patient had high testosterone concentrations. Plasma FSH, estradiol, and progesterone were within the normal midfollicular phase range. The LH:FSH ratio was increased and no cyclic gonadotropic activity occurred. During surgery progesterone levels rose while estradiol concentrations fell. In both patients, the initial reduction in estradiol secretion was observed after unilateral wedge resection but testosterone concentrations only declined 6-24 hours postoperatively. During the first postoperative week the LH:FSH ratio fell significantly and cyclic gonadotropic activity, in the form of sporadic LH and FSH spurts, was noted. In the second week after surgery, and estradiol surge occurred followed by preovulatory LH and FSH peaks, ovulation, and a normal luteal phase. Spontaneous menstruation occurred by the end of the first postoperative month and both patients conceived within 4 months of surgery.


Design and preliminary observations of National Cooperative Diethylstilbestrol Adenosis (DESAD) Project. The National Cooperative Diethylstilbestrol Adenosis (DESAD) Project has completed the major portion of its enrollment phase with the examination of more than 3000 daughters of women taking synthetic nonsteroidal estrogens (denoted DES) during pregnancies occurring from the early 1940s to the mid-1960s. The aims of the Project are to fill urgent needs for information on the prevalence and incidence of structural and epithelial abnormalities or neoplastic changes and their complications in these young women. Participants are grouped by mode of entry as identified by prenatal record review (40.1%), documented as DES-exposed but walking in (25.1%), or referred (22.8%) to the DESAD Project for examination, and not documented as exposed but having gynecologic abnormalities typical of those associated with DES exposure (12.0%). This study cohort, in part having paired controls, will be examined annually for at least 5 years. Details of the design and selected preliminary findings are reported.


In utero exposure to DES. Evaluation and followup of 199 women. Among 199 women from 12 to 30 years of age who had been exposed to DES in utero, the colposcopic evaluation of the vagina and cervix was considered normal for only 13.6%. The incidence of colposcopically detected lesions was not related to the trimester of DES exposure, the patient's age, use of oral contraceptives, or presenting symptoms. Areas of punctation, mosaic patterns, white epithelium, and keratosis were not considered areas of adenosis. Cervical bands, hoods, cock's combs, etc., were considered as part of the cervix. Under this definition adenosis of the vagina was diagnosed in only 14.1% of the patients. Eight (4.0%) women were found to have cervical intraepithelial neoplasia (CIN), Grade 3 lesions, and an additional 36 (14.1%) women were found to have CIN, Grade 1 lesions based on the light microscopy evaluation of directed biopsies. There were no cases of clear cell adenocarcinoma. It appears that women with in utero DES exposure may be at a higher risk of developing squamous neoplasia compared with non-DES-exposed women.


Localization of 3H-estradiol-17beta in diethylstilbestrol-induced adenosis. Treatment of neonatal mice with diethylstilbestrol results in the appearance of adenosis in the uterine cervix and upper part of the vagina in later life. Using dry mount autoradiography, the uptake and distribution of [3H]-estradiol in the same regions were studied after in vivo injections with [3H]-estradiol. It was demonstrated that the adenosis cells have the ability of uptake and nuclear concentration of estradiol and are thus target cells for estrogens. The importance of this finding for the development of malignancy is discussed in relation to the clear cell adenocarcinomas in young women exposed to diethylstilbestrol in utero.


Uterine choriocarcinoma fourteen years following bilateral tubal ligation. A patient who developed choriocarcinoma of the uterus 14 years after bilateral tubal ligation and resection is presented. Non-patency of the fallopian tubes was demonstrated radiologically. The various mechanisms of occurrence of the clinical picture are discussed. Activation of dormant chorionic cells present since the patient's last known pregnancy (1960) appears to be the most probable explanation for the origin of the choriocarcinoma.


Mucinous cystadenocarcinoma of the ovary. Reports of 78 cases of mucinous cystadenocarcinoma of the ovary were collected from the Emil Novak Ovarian Tumor Registry and the files of the Gynecologic Pathology Laboratory of the Johns Hopkins Hospital between the years 1942 and 1966. Two-year and 5-year followups were available for 91 and 83% of the cases, respectively. The prognosis was related to the most aggressive area of the tumor as the histologic grade was based on the maximum number of mitoses per high-powered field. In view of the clinical and histopathologic differences between these lesions and the serous and endometrioid varieties, it is suggested that each tumor be considered on its own merits in order to offer an accurate prognosis.


Comparison of amniotic fluid optical density and foam stability test in predicting fetal lung maturity. The ability of optical density measurements and the foam stability test to predict the L/S ratio of amniotic fluid (AF) was examined. Optical density measurements and the foam test predicted the L/S ratio with a similar degree of accuracy; neither was able to replace biochemical measurement of the L/S ratio because both gave false negative and false positive predictions. Optical density measurements and the foam test did not combine to increase the accuracy of prediction.


Subspecialization manpower in obstetrics and gynecology. Growing interest in the emergence of subspecialties within obstetrics and gynecology prompted a survey of all Junior Fellows of the ACOG. That survey, representing the attitudes and expectations of 1702 housestaff and practitioners, disclosed that nearly 31% of obstetric-gynecologic residents planned to subspecialize as contrasted to 19.5% of postresidency obstetrician-gynecologists who either engaged in or plan to engage in subspecialty training/practice. The highest demand areas seemed to be in endocrinology and perinatology, and most subspecialists either limit or plan to limit their practice to the area specified. There was, in addition, a general feeling that subspecialists should confine their activities to major medical centers, and an unfavorable attitude was expressed toward subspecialty-board-imposed practice restrictions. Details regarding the factors influencing Junior Fellows' response to subspecialization are discussed.


Cervical pregnancy.

Cervical pregnancy. A case of cervical pregnancy is presented. The clinicopathologic criteria for the diagnosis are reviewed. Different modes of management are discussed. Our patient was a classic case of a woman with a cervical pregnancy who had had a pregnancy termination done in the antecedent pregnancy. The abdominal hysterectomy was performed as a lifesaving procedure when curettage could not control the hemorrhage.


Cesarean section in the massively obese. The case histories of 4 massively obese patients who underwent cesarean section are summarized. In all, a Pfannenstiel incision was made beneath the patient's huge panniculus, and a lower segment cesarean section was easily accomplished. There were no postoperative wound infections and all of the women had an essentially benign postoperative course.


Maternal and fetal outcome of Lamaze-prepared patients. To determine whether Lamaze childbirth preparation is harmless, harmful, or beneficial, 500 consecutive Lamaze-prepared patients were compared to 500 hand-picked controls, matched for age, race, parity, and educational level. Lamaze preparation was found to have a significant beneficial effect in almost every obstetric preformance category. The Lamaze-oriented patients had one-fourth the number of cesarean sections and one-fifth the amount of fetal distress (P less than .005). Postpartum infection, measured both by maternal febrile morbidity and by the incidence of antibiotic use, was one-third that of the controls (P less than .005). Similarly, the "prepared" patients had fewer perineal lacerations and those that occurred were not as serious as those in the control patients (P less than .005). The control patients had three times as many cases of toxemia of pregnancy (P less than .005) and twice as many of prematurity (P less than .05).


Modern management of hypertensive disorders of pregnancy. Hypertensive disorders of pregnancy contribute significantly to perinatal mortality. Successful application of modern tests of antepartum fetal status and appropriately timed delivery, with monitored labor and liberal use of cesarean section led to significantly improved fetal and neonatal salvage in 242 patients with hypertensive disorders of pregnancy between 1973 and 1975. The reduction in perinatal mortality to a corrected rate of 12/1000 in the years 1973-1975, compared to a previous rate of 75/1000 between 1970 and 1972, justifies the modern aggressive management of hypertensive disorders in pregnancy.


A new method of evaluating fetal growth. When fetal brain weight (BrW) is expressed as a modified exponential function of total body weight (BW), there is close agreement (p = 0.9841) between measured and calculated values (Sy = 6.16 g). Fetal BrW in utero can be determined from the neurocranial cross-sectional area (CSA) of the fronto-parieto-occipital plane. The standard error of the estimate is Sy = 8.03 g. The estimation of BW from the abdominal circumference and BrW from the CSA is the basis of two indexes which reflect the BrW:BW relationship. By definition, the brain size index (BSI) is 100 in the normally growing fetus. In a given case, a value greater than 100 denotes the amount by which measured BrW exceeds the BrW which is appropriately for a normal fetus of the same BW. The somatic retardation index (SRI) expresses as a percentage the amount by which total fetal weight lags behind normal ponderal growth in cases of IUGR. The indexes provide quantitative data on relative brain and body weights and serve as a ratio scale of the severity of the pathology in IUGR.


Fetal demise following negative contraction stress tests. The contraction stress test (CST) has become widely used to assess antepartum fetal well-being over the past 5 years. A summary of 14 reports in the literature revealed seven fetal deaths in 1739 patients within 1 week of a negative CST, an incidence of 0.4%. This prompted an investigation of our results for comparison. During the period January 1, 1975, to February 28, 1977, 746 patients underwent 1119 CSTs. Seven fetal deaths occurred in 680 patients within 1 week of a negative CST, an incidence of 1.0%. Although maternal conditions associated with fetal demise within 1 week of a negative CST include diabetes mellitus, prolonged pregnancy, chronic hypertension, and pre-eclampsia, fetal death in most instances resulted from factors other than uteroplacental insufficiency (UPI). Conditions commonly associated with fetal demise following a negative CST were umbilical cord accidents, severe congenital anomalies, and abruptio placentae. The low incidence of fetal death after a negative CST supports continued use of the CST in evaluation of high-risk pregnancies.


The management of high-risk obstetric transfer patients. Regionalization of perinatal care has demonstrated a definite improvement in perinatal mortality and morbidity. It has been shown that it is optimal to have high-risk neonates transferred in utero to tertiary perinatal care centers. In 1976 there were 1622 deliveries at Fort Carson Army Hospital, and 100 perinatal transfers to Fitzsimons Army Medical Center, including 73 in utero transfers and 27 neonatal transfers. An in-depth study of the obstetric management of in utero and neonatal transfers produced guidelines for the aggressive management of high-risk obstetric patients.


Prognostic value of the pregnancy zone protein during early pregnancy in spontaneous abortion. The concentration of pregnancy zone (PZ) protein in maternal serum during early normal pregnancy was followed in a prospective study of 261 pregnant women. A marked increase which followed an exponential function was found and a theoretic onset of induction at the time for implantation was calculated. Women with a later spontaneous abortion had low values. The prognostic relevance of PZ determinations was studied and values from women who later had a spontaneous abortion were compared to those from normal pregnancies. The prognostic value of PZ protein was compared to that of hCG and progesterone. PZ and hCG assays had the same prognostic accuracy concerning the outcome of pregnancy while determinations of progesterone were less valuable.