Saccular aneurysm of infancy and early childhood. A case of intracranial saccular aneurysm occurring in early childhood and presenting with sudden dysphasia and hemiplegia is reported. A review of the literature emphasizes the rarity of this lesion. Despite a significant preoperative neurological deficit, the patient tolerated aneurysm clipping and recovered well. The majority of reported cases involve males under 2 years old. Aneurysms in infants have a distribution different from that seen in adults. Microscopic examination of these lesions fails to show any evidence of inflammation or atherosclerosis. The data suggest that the pathogenesis of these rare childhool lesions differs from that of adult saccular aneurysms.


Lumbar disc disease in children.

Lumbar disc disease in children. The clinical experience with lumbar disc disease in 38 patients at a large children's hospital is reviewed. Thirty children underwent surgical treatment; eight patients were not operated upon. The surgical results were excellent, with 93% of the children cured or markedly improved on follow-up. The main differential aspects of lumbar disc disease between children and adults are emphasized.


Air embolism during trans-sphenoidal pituitary operations. Doppler ultrasonic cardiac monitoring of patients undergoing trans-sphenoidal pituitary operations in the semisitting position has revealed the occurrence of venous air embolism in 3 of 31 consecutive cases. One such case is presented. Air may be drawn into the venous system whenever a gradient exists between the site of operation and the right heart. During trans-sphenoidal operations the most likely portals of venous air entry include the intercavernous connections within the sella, venous channels through nonpneumatized bone, inadequately sealed subnasal vessels, and vascularized metastatic tissue in the pituitary. Because the potential for morbidity and mortality from air embolism is so great, rapid diagnosis with the Doppler unit and prompt treatment, including aspiration of air from the right atrial catheter, administration of 100% oxygen, performance of the Valsalva maneuver, saline irrigation of the wound, and hemostasis of open vessels, are essential. Technetium-macroaggregated albumin (TEMAA) lung scans are helpful in postoperative verification of venous air embolism.


Measurement of spinal cord blood flow by the microsphere technique. Differential spinal cord blood flow was measured in dogs by the radioactive microsphere injection method. The mean spinal cord blood flow was 10.8 +/- 0.53 (SE) ml/100 g/minute. The flow values for the white and gray matter were 7.1 +/- 0.65 (SE) and 26.3 +/- 2.2 (SE) ml/100 g/minute, respectively.


Melanotic schwannoma.

Melanotic schwannoma. Reports of melanotic nerve sheath tumors of Schwann cell origin are rare, only three having been found in the literature. Two new cases of spinal intradural melanotic nerve sheath tumors are reported and the literature is reviewed. Controversy has arisen in regard to the origin of melanin within these tumors. Electron microscopic study of one of our cases indicates that the Schwann cell is capable of producing melanin. The available evidence suggests that ultrastructural identification of the cell type in these pigmented tumors is essential in plotting the therapy and prognosis of patients with melanotic nerve sheath tumors.


Subdural hygroma of the spinal meninges: a case report. A case of a subdural hygroma or chronic subdural hematoma of the thoracolumbar spinal meninges is described. This became symptomatic 9 years after trauma. Terminological ambiguity is discussed, along with the detailed clinical, radiological, and operative presentations of this rare condition.


Intracerebral Ewing's sarcoma: case report. A case of intracerebral Ewing's sarcoma is reported. Neurosurgical intervention was required for treatment. The increasing incidence of central nervous system involvement by Ewing's sarcoma is discussed.


Combined cranio-orbital surgery for extensive malignant neoplasms of the orbit. Extensive, invasive neoplasms of the cranio-orbital region are generally considered to be inoperable and are treated with local radiation therapy and occasionally with chemotherapy. Upon local recurrence of these neoplasms, further treatment efforts are usually deemed futile. Over the past 4 years, 10 patients with extensive neoplasms of the cranio-orbital region that were previously thought to be inoperable were referred to us for further evaluation. Five of these patients had failed an intensive course of radiation therapy. Radical regional cranio-orbital resection was performed. The resection included the skin, globe, sphenoid wings, and orbitofrontal bone. The maxillary sinus and nasal septum were left exposed. The exposed dura mater and the frontal and temporal bones were resurfaced with split-thickness skin grafts. All patients in this series have survived free of local disease to date. Combined cranio-orbital resection offers both palliation and a possible cure for patients with extensive, invasive neoplasms of the cranio-orbital region. Reconstructive surgery can be performed using full-thickness flaps after 2 years of observation for local recurrence.


Comparison of the infratentorial and transtentorial approaches to the pineal region. During the past 10 years, two different operative approaches to the pineal region have been recommended by different authors. Numerous reports have appeared in the literature, indicating the safe use of one or the other of these two techniques for the excision of masses in the pineal region. This paper reports experience with both techniques in the treatment of 15 patients with mass lesions in this area. Four patients underwent a supracerebellar infratentorial approach and 11 patients underwent an occipital transtentorial approach to the pineal region. These two approaches are compared in terms of anatomical exposure, technical difficulties, and real or potential complications. The authors prefer the occipital transtentorial approach in dealing with lesions in the pineal region.


The lumbar shield: a preliminary report. Postoperative perineural adhesions between the lumbar nerve root and the partially removed intervertebral disc are thought to be a cause of failure of the standard operative procedure for the removal of a ruptured lumbar intervertebral disc. Attempts have been made to reduce postoperative perineural adhesions by the use of epidural muscle, fat, gelatin sponge, silicone, and steroids. The present communication introduces a new implantable silicone device, a lumbar shield, designed to: (a) provide a radiopaque marker on the dorsal perimeter of the excavated lumbar disc so that the presence or absence of a recurrent disc herniation can easily be determined on plain postoperative x-ray films, (b) provide ready access to the operative site in the event of a recurrent disc herniation, (c) prevent postoperative perineural adhesions between the lumbar dura and the nerve root and the partially removed intervertebral disc, and (d) prevent postoperative adhesions between the lumbar dura and the nerve root and the paraspinal muscles. Satisfactory results of lumbar disc surgery over the past 44 years have occurred in about 90% of routine patients. The value of the lumbar shield in 82 patients (59 routine and 23 workmen's compensation/medicolegal patients) followed for 6 months is described. A satisfactory result, i.e., relief of pain or the presence of occasional postoperative pain, occurred in 85% of routine patients at 1 month, 97% at 3 months, and 95% at 6 months.


Cerebral angiography in meningocerbral inflammatory diseases in infancy and childhood: a study of thiryt-five cases. The value of cerebral angiography in the diagnosis of intracranial infections is presented, and the differential diagnosis of the various angiographic appearances in meningocerebral infections is discussed. Specific angiographic characteristics permitting the diagnosis of vasculitis, cerebritis, meningitis, brain abscess, and subdural and epidural fluid collections are correlated with known concepts of the pathological anatomy of these entities. Angiography is recommended in those infants known to have a meningocerebral infection who show signs of an increase in intracranial pressure or focal neurological dysfunction.


Neural and vascular tissue reaction to aneurysm-coating adhesive (ethyl 2-cyanoacrylate). The effect of ethyl 2-cyanoacrylate (Aaron-2-Alpha) obtained from two different manufactures was evaluated in 37 cats divided into two groups. The first group (n = 28) received a 9-year-old preparation. The second group (n = 9) received recently acquired adhesive. Aaron-2-Alpha was applied to the left cruciate cortex and left femoral neurovascular bundle under barbiturate anesthesia. Normal saline was applied on the right side for control. Survival was allowed for 2, 4, 7, and 14 days after application of the adhesive. The 2-day survival was excluded in the second group. Neuropathological examination revealed meningeal necrosis, neuronal and axonal degeneration, vascular wall degeneration, thrombosis, and inflammatory reaction in both groups of cats. The compounds tested are far from satisfying the ideal requirements for their safe use. Chemical degradation may take place in the adhesives stored for prolonged periods of time. Adhesives obtained from two different sources may contain adjuvants of different toxicity. Severe local tissue reaction could produce marked neurological deficits when adhesives are applied in critical areas.


Scanning electron microscopic anatomy of the supratentorial basal cisterns. Arachnoid slips from the canine supratentorial basal cisterns were excised and studied by scanning electron microscopy. The inner face of the arachnoid membrane was examined, and two fundamental surface patterns, fenestrated and embossed, were observed. The remaining fibers and microfibers were anchored to these two surface sheets.


Significance of bilateral abnormalities on the CT scan in patients with severe head injury. One hundred forty head injured patients, managed by a standardized protocol of early diagnosis, surgical decompression, and intensive therapy, had computerized tomographic (CT) scans within 1 hour or arrival in the emergency room. Ninety of these patients had serial scans during the subsequent week. On admission, 26 patients had normal scans, 75 had unilateral lesions, and 39 had bilateral lesions. Thirteen who had unilateral lesions on admission developed contralateral lesions during the first week for a total of 52 patients with bilateral lesions. These 52 patients could be separated into two distinct groups: (a) those with small ventricles and no change or a slight, homogeneous decrease in density of the brain parenchyma, who had better neurological status on admission, lower intracranial pressure (ICP), and better outcome; and (b) those with bilateral increased density lesions, who had poorer motor response on admission, higher ICP, and worse outcome. The value of CT scanning in management, prognosis, and outcome is emphasized.


Cerebral revascularization: proximal external carotid to distal middle cerebral artery bypass with a synthetic tube graft. A right proximal external carotid to distal middle cerebral artery bypass with a prosthetic tube graft was performed in a patient with intermittent cerebral ischemia due to middle cerebral artery stenosis. The patient was relieved of his symptoms, and he was neurologically normal 3 months after operation. Angiography 3 months postoperatively revealed flow through the graft and excellent filing of the middle cerebral circulation, both retrograde and antegrade. Early results suggest that an expanded polytetrafluoroethylene graft may be useful as a vascular conduit if suitable autogenous vessels are unavailable or have failed.


Bilateral optic canal meningiomas: a case report. In the case presented, bilateral optic canal meningiomas produced binocular visual loss. Correct diagnosis was delayed because of inadequate and misinterpreted radiological studies. Careful radiological and surgical examination of the planum sphenoidale later suggested this as the source of both canalicular masses. The pertinent aspects of this case are reviewed in relation to information from similar cases reported previously. In the future, increased clinical suspicion and more accurate neuroradiological studies should improve the detection and afford earlier surgical treatment of meningiomas of the optic canal.


Extracranial-intracranial (EC-IC) arterial bypass: past performance and current concepts. The authors present a review of published experience with intracranial-extracranial arterial bypass grafting. The procedure is technically feasible and has a relatively low morbidity and mortality when performed by experienced microvascular surgeons. However, its therapeutic value is still unproven.


Metabolic disturbances after head injury: abnormalities of sodium and water balance with special reference to the effects of alcohol intoxication. Eighty-eight patients with craniocerebral trauma were studied prospectively to assess the effects of the injury on sodium and water balance. Abnormalities of serum sodium and osmolality occurred in 11 of the 76 patients who were on the study more than 24 hours, and the incidence of these abnormalities was directly related to the severity of the craniocerebral injury. Hyponatremic hypo-osmolar states were as frequent as were hypernatremia and serum hyperosmolality. The major cause of the hyponatremia was inappropriate antidiuretic hormone secretion; hypernatremia was due to dehydration and occurred predominantly in comatose patients with increased insensible fluid losses associated with pyrexia. We recommend that the initial fluid intake after craniocerebral trauma be kept between 1500 and 1800 ml/24 hours and that further fluid management be dictated by repeated serum electrolyte determinations. The electrolyte balance should be monitored continuously after a significant head injury for up to 2 weeks, because hyponatremic states sometimes develop more than 1 week after injury. The serum alcohol was measured on admission, and the level of serum alcohol correlated well with the serum osmolality on admission; thus, the degree of elevation of serum osmolality was a very good guide to the serum alcohol level. However, there was no statistically significant correlation between alcohol intoxication or chronic alcoholism and the late development of serum sodium and osmolality disturbances.


[Multiple carcinomas of the large intestine]. Authors stress that multiple carcinomas of the large bowel are not exceptional at all and report 5 cases of metachronous cancers and 1 case of synchronous cancers. They are 4,4% of all the colo-rectal neoplasms operated by the "Istituto di Semeiotica Chirurgica dell'Università di Trieste". The Authors discuss the most important pathogenetic, pathological and diagnostic problems and emphasize the usefulness of a very careful intra-operative evaluation of the entire colon and of a post-operative follow-up for the early discovery and treatment of a second cancer in another tract of the large bowel.


[Megarectum in childhood].

[Megarectum in childhood]. The criteria employed in the classification of megarectum in infancy are briefly reviewed and its diagnosis is discussed. Stress is laid on the importance of clyster radiology and rectal manometry. Biopsy extended to the point of true sphincteromyectomy may also prove resolutive. Lastly, infantile neuropsychiatry is unmistakably indicated in diagnosing the psychological origin of many of these forms. Aganglionic forms are quickly described and attention is directed to those due to fibrosis of the inner sphincter. Most of such cases are shown to be of secondary, reactive, rather than primary congenital, origin on histological inspection after surgery. Lastly, consideration is given to essentially psychogenic forms. The picture observed in a case treated by sphincteromyectomy with histological evidence of interstitial fibrosis with muscle and nerve regression suggested that affective disturbances lead first to persistent constipation, followed by abnormal distension of the last segments of the intestine. Subsequent regression results in an organic evolution independent of the original disturbance, so that surgery must be resorted to, as well as neuropsychiatric treatment.


[Personal approach in the surgical treatment of cancer of the gallbladder]. The part played by surgery in the treatment of gallbladder cancer is conditioned by the delay in diagnosis and the rapid spread of the disease to non operable structures rather than to any particularly intrinsic malignity. In the face of a clinically ascertained cancer or one recognized at surgical exploration, exeresis is essential if possible. Cholecytectomy completed by cuneiform hepatic resection and extensive locoregional lymphadenectomy offers adequate radicality with acceptable risk. Vaster operations have high operative mortality which is out of proportion to the results possible, 43 personal cases are reported.


[Endoscopic control of patients subjected to vagotomy and drainage for duodenal ulcer. Personal experience]. The usefulness of endoscopic examination of patients subjected to vagotomy and drainage for duodenal ulcer is stressed, since it permits recurrences and ineffective treatment to be detected, along with the control of other parameters, such as the appearance of the mucosa, the performance of gastric drainage, the features of peristalsis and gastric tone, and the performance of the cardial sphincter. Data from a series of 43 endoscopies performed after 192 vagotomy and drainage operations carried out between 4-1973 and 5-1976 are presented.


[Villose polyps of the duodenum].

[Villose polyps of the duodenum]. A case of villous polyps of the duodenum is reported, world-wide series also being considered. The various symptomatologies and percentages of malignant transformation and localization are described and stress laid on the superiority of endoscopy to radiography owing to the fact that it gave: 1) exact site and nature diagnosis of the lesion during the haemorrhagic phase; 2) exact histological and topographical diagnosis, following the haemorrhage, paving the way to the subsequent surgery.


[Treatment with monocomponent semi-lente insulin in diabetes of difficult compensation]. According to personal experience, good clinical effects may be obtained by monocomponent insulin treatment, independently from strict immunological indications (i.e. high plasma-anti-insulin antibody titers). The present paper reports on a two daily injection treatment with monocomponent Semilente insulin (SeLe MC) in comparison with an earlier management with conventional retard insulins, in a group of 16 insulin dependent diabetics, selected among the most poorly controlled patients with unstable diabetes and/or high insulin requirement. In 6 subjects, after transfer to SeLe MC, it was observed a reduction in M bs, delta, and M delta indices of the glycemic regulation, indicating lower mean glycemic profiles with fewer irregularities. In 11 cases a marked improvement in the subjective symptomatology was noticed. Some minor hypoglycemic reactions induced to a reduction in the high insulin requirement in 8 cases. All but two patients had significant values of insulin IgG antibodies. The period of observation was too short to take in consideration an immunological modification, as an explanation of the present clinical results. However, these could be hypothetically referred to an amelioration in the releasing of endogenous insulin and/or in the hormone-receptor interaction as a consequence of treatment with monocomponent insulin preparations, in comparison to non purified conventional preparations. Treatment with SeLe MC seems to be suitable in particularly difficult control of the diabetes and in emergency situations.


[Preliminary results of polychemiotherapy and immunostimulant treatment with Corynebacterium parvum in tumors of the breast in the postoperative phase and advanced phase]. Difficulties still encountered in the coordinated interdisciplinary management of solid tumours in hospitals are discussed. Preliminary results obtained with a polychemical and immunostimulating protocol based on Corynebacterium parvum (introduced in 1973) in breast tumours immediately after surgery and in the advanced stage are presented. Two out of eight subjects with advanced forms died. Partial regression or a steady state were noted in the remainder. No locoregional recurrences or metastases were observed from 1 to 2 yr after the commencement of treatment in 22 patients treated in the immediate post-operative phase. These results are considered satisfactory, though a final evaluation would be premature. Stress is laid on the importance of immunostimulating management in the avoiding the immunodepression caused by the administration of drugs.


[Clinical and statistical study of the use of alpha-MPG in the treatment of viral hepatitis]. Several workers have already employed alpha-MPG in the management of acute vital hepatitis as a sulphydrylating agent to combat viral poisoning of the liver cells. Its distinct features include the stability of its molecule, its biochemical attributes in the course of time, and its virtually similar oral and injectable LD(50) (2100 MG/KG). High doses, well above those possible with earlier sulphydrylating agents, were used in a trial of alpha-MPG against UDPG. The new drug proved more active and led to a particularly significant fall in SGPT. Subjective and biohumoral parameters returned to normal more quickly, though the differences were not significant. Tolerance was good. Subjective over-reaction with a slight rise in temperature and allergic exanthema was noted in 3 cases. This promptly regressed when the treatment was suspended.


[Amyotrophy caused by herpes zoster. Description of 5 cases]. Radicular paralysis is the most frequent, though usually less serious, complication of Herpes Zoster, being observed in rather less than 5% of patients. The site affected--leaving aside exceptional cases--it that of the gangliar and radicular district where the eruption occurs. A clinical and neurophysiological study was made of 5 patients with loss of strength and trophism on the part of muscles in the eruption site within 2 to 5 weeks after the onset of Herpes. Routine blood chemistry tests were run, together with spinal puncture in three cases. The EMG data pointed to variously severe neurogenic distress referable to myeloradicular involvement. Subsequent clinical and EMG controls demonstrated gradual, though slow improvement. This finding is in line with the literature data.


[Psychiatric (psychodynamic and psychotherapeutic) aspects of obesity]. An account is given for non-psychiatric physicians of the psychodynamic, psychiatric, and psychoterapeutic aspects of obesity. A primarily psychoanalytic explanation is presented of the unconscious meanings that the words involved assume in children and "fixed" obese subjects with regression to the "oral stage" of their libido development. The meanings associated with food and feeding are examined in an interpersonal, familial, social and environmental context. A summary psychopathological classification is made of obesity, together with an evaluation of what appears to be the direct opposite of obesity, i. e. mental anorexia. Lastly, the relevant prognostic and therapeutic criteria are considered. The latter are mainly centred on the various forms of psychotherapeutic intervention (individual, group, analytical and inspiration therapy, etc.).


[Warty dyskeratoma. Analysis and case reports]. Warty dyskeratoma (WD) may be observed in both whites and negros. It is usually small single isolated brown nodule with a prevalent localization of the head of aged males. During the last 4 1/2 years 20 cases were recognized at the Perugia Dermatological Clinic, representing 3.8% of 522 biopsied clinically similar skin tumors. The ratio of WD with keratoacanthoma was 1.3 and with squamous-cell carcinoma 1:5. In 4 cases a lesion clinically similar to squamous-cell carcinoma but with histological picture of WD was localized of the lower prolabium. The excision was the treatment of choice. On the basis of our findings and from a survey of the literature a clinico-pathological picture of the disease is described. Three points are emphasized: 1. WD is frequently localized on the head; when localized on the lower prolabium squamous-cell carcinoma mast be considered in differential diagnosis; 2. no clinical feature is peculiar of the disease; 3. surgical excision is essential for a correct diagnosis when histological examinations are performed on orthogonal and medial sections.


[The arterio-alveolar CO2 gradient. Physiopathological and clinical significance]. The arterio-alveolar CO(2) gradient was examined in 20 patients with various ventilation diseases. It increased or became negative in obstruction. The tendency to increase was attributable to distribution disturbances, particularly the marked increase in the "dead space" effect. The same picture, though to a lesser degree, owing to a smaller dead space increase, was even more frequent in restriction cases. The appearance of a gradient in healthy subjects is referable to uneven air and blood distribution in the alveoli under physiological conditions. The physiopathological significance of negative gradients is discussed in the light of the results and the findings of other workers.


[Clinical and statistical evaluation of the hypotensive effectiveness of 3 therapeutic plans in essential hypertension]. The analysis of variance and Student's "t" test were applied in an assessment of the hypotensive effectiveness of three hypotensive protocols: a) diazepam + amitryptiline; b) reserpine + chlorthalidone; c) all drugs in 57 and 32 patients with stabilised essential hypertension. Diazepam + amitryptiline proved effective, both alone and in protocol b).


[Physiopathological correlations between carbohydrate and lipid metabolicm and obesity]. Sugar and fat metabolism were studied in a group of obese women without diabetes. Blood triglicerides and cholesterol were, on average, within normal limits, though endogenous hypertriglyceridaemia was noted in a few cases. Triglycerides were significantly related to blood sugar (baseline and after glucose loading), whereas there was no significant connection with blood insulin. The meaning of these results is discussed.


[Dosimetric experience with mammography]. Dose measurements were carried out during mammography with both conventional films without a reinforcement screen and with Low-dose films, using hot press chip lithium fluoride meters on the breast, sternum, mons Veneris, and the glabella between the supraciliary arches. The results made it clear that there were no dosimetric objections to the large-scale employment of mammography in diagnosis. Value absorbed were lower than those given in the literature for both the conventional and the Low-dose system.


[Medullary plasmocytosis in urologically silent Grawitz' tumor]. Three cases of urologically silent Grawitz' tumour detected by a pathological blood picture marked by marrow plasmacytosis are presented. The importance of paraneoplastic syndromes in this tumour form is discussed. The association observed is common and its classification as a paraneoplastic syndrome is examined.


[Absenteeism and influenza. Analysis of relationship between the excess morbidity and the influenza phenomenon]. The results are reported of a survey on the influenza phenomenon made on a sampling of about 100,000 subjects from the FIAT working community. The study is based on the absenteeism information for both over and under three days absence, for the time period between October 1976 and April 1977. In addition, a tentative evaluation of the influenza phenomenon has been made not only for the overall working population but also for various age groups.


[Anti-platelet-aggregation drugs and atherosclerosis]. The relationship between hyperlipidaemia and thrombophilic state in atherosclerosis was appraised by evaluation of platelet aggregation according to Breddin in 20 patients with clinically established atherosclerosis, 10 normal controls, and 22 subjects taken from the average population of a medical department aged 12-58 yr with no history of atherosclerosis. Normal screening for the disease was carried out in all patients. Drugs inhibiting platelet-aggregation were given to all subjects in Breddin's 3rd or 4th stage. A relationship was noted between Breddin stage and the seriousness of atherosclerosis, while the former was a pointer to thrombophilic states. The drugs administered were able to reverse the aggregation stage.


[Viral neuraxitis. Epidemiological and clinical aspects]. Seven cases of acute neuraxitis due to Coxsackie B3, 2 to mumps, 1 to measles, and 1 to influenza B observed in the province of Alessandria between Jan. 1975 and July 1977 are described. In the coxsackie cases, blood chemistry and clinical examinations were coupled with determination of serum levels of complement fixing, haemagglutin-inhibiting and neutralising antibodies on two successive specimens, isolation of virus from cerebrospinal fluid and faeces, and, in one case, from a cerebral biopsy specimen, and determination of cerebrospinal fluid IgA, IgG, and IgM. Some particularly interesting epidemiological, immunological and clinical features of teh series are discussed more fully.


[Enviromental factors in the pathogenesis of thyroid cancer]. Local factors with a possible influence on the frequency and histological type of thyroid cancer are examined in the light of cases observed at the Mauriziano Hospital in the last 10 years. The overall number of cases has been increasing and papilliferous forms have been more common than follicular forms. Iodine deficiency and thyrotropin hyper-stimulation encourage onset and account for the higher frequency of thyroid cancer in endemic areas, where, however, follicular forms are more common. Ironising radiation is a direct cause, particularly of papilliferous forms arising after exposure during youth.


[Changes of plasmatic amino acids in various cases of acute hepatic necrosis and insufficiency in man]. Changes in total and individual plasma amino acid were examined in subjects with necrosis of the liver and acute insufficiency. Quantitative variations in single amino acids and their percentages were noted in all cases. The extent of such change and the number of amino acids involved were roughly proportional to the degree of insufficiency. A continuous and persistent increase in total blood amino acids can be regarded as a poor prognostic sign, especially if accompanied by a sharp fall in necrosis enzymes. Such an increase, in fact, was only observed in extremely serious cases.


[The quarantined dialysis room for Australia-antigen-positive patients. Theoretical, normative, structural, operational, organizational and management aspects]. The technical features of dialysis facilitate the transmission of hepatitis B virus and the outbreak of possibly serious epidemics among patients and hospital staffs. Statistical, epidemiological and clinical data have been collected on many occasions. They serve to emphasise the problem and the need for quarantined centres. The establishment of such a centre for HBsAg-positive patients is discussed in the light of personal experience in the design and setting up of quarantined rooms. The underlying technical and structural requirements are also examined. Reference is also made to two years' experience in the running of a room of this kind. Stress is laid on the importance of having a room for these patients, not only from the clinical standpoint (lessening of contagion), but also from teh social and exonomic standpoint (reduced costs and length of hospital stay, greater rehabilitation).


[A case of pure erythroblastic aplasia effectively treated with immunosuppressive drugs]. A case of PRCA, refractory to corticosteroids and androgenes is reported. The patient presented persistent remission when treated with Cyclophosphamide. The review of the cases treated with immunosuppressive drugs proves that this treatment is effective and emphasizes the probable autoimmune pathogenesis of PRCA.


[A case of the Ramsay-Hunt syndrome (herpes zoster of the geniculate ganglion) with concomitant C2 and C3 nerve involvement]. A case of Ramsay-Hunt syndrome (herpes zoster of the genicular ganglion with paresis of the facial nerve) presenting concomitant involvement of the sensitive nerve roots C2 and C3 is reported. The main aetiopathogenetic hypotheses as reported in the literature are presented and an attempt made to formulate a standard aetiopathogenetic theory comprising lesions to the motor nerve fibres and those of the sensitive nerve fibres.


Incidence of subclinical metastasis in stage I and II ovarian carcinoma. The incidence of unsuspected metastasis to the diaphgram, retroperitoneal lymph nodes, and omentum as well as malignant cytologic peritoneal washings in women with presumed localized ovarian cancer is presented. Of the women with presumed Stage I ovarian cancer, from our clinical experience and those reported in the literature, 11.3% were found to have diaphragmatic metastases, 13.3% had aortic lymph node metastases, 8.1% had pelvic lymph node metastases, 3.2% had omental metastases, and 32.9% had malignant peritoneal washings. In Stage II ovarian cancer, 23% were found to have diaphgragmatic metastases, 10.0% had aortic lymph node metastases, 0% had omental metastases, and 12.5% had malignant peritoneal washings.


Anaerobic bacterial recovery from two transport systems in a study of gynecologic flora. Several systems for transporting specimens to the laboratory to test for the presence of anaerobic bacteria are available to clinicians. To date, these have not been systematically compared, especially regarding cost-effectiveness. This study compares recovery of anaerobic organisms from genital cultures of gynecological patients under bacteriologic study for research purposes. Two transport systems for delivery of specimens to the laboratory were studied: 1) the commercially available Anaswab system, and 2) a modified Stuart medium (transport charcoal medium) with 0.2% added agar in addition to 0.2% added charcoal. Our data shows no significant difference in kinds of anaerobic organisms recovered using either system when specimens are transported to the laboratory within 24 hours. Although the sites of culturing compared in this study are not directly applicable to the problem of pelvic infection, nevertheless the potential for lowering cost by selecting alternative systems for anaerobic recovery should prompt further comparisons in clinical settings. Some practical suggestions are made for applying agar-modified transport charcoal medium, the less expensive alternative, to clinical situations.


Heating of metallic intrauterine contraceptive devices during ultrasound examination. Heating of metallic IUDs during ultrasound examination has been suggested as a possible hazard to surrounding tissues. Serial temperature measurements of such devices during insonation with commercially available ultrasound equipment show no temperature changes during prolonged exposure. The results indicate that the possibility of significant heating of metallic objects within the body may be disregarded in clinical practice.


Amniotic fluid copper and zinc concentrations in human pregnancy. Amniotic fluid concentrations of zinc and copper were measured in human pregnancy of 12 to 44 weeks' gestation. Although mean values for both metals are relatively flat throughout pregnancy, there appears to be a relative increase in copper levels between 26 and 33 weeks' gestation, and increasing levels of zinc after 34 weeks. Correlations with fetal age or fetal-maternal disease are not apparent in specimens from this heterogenous population.


Use of hPL in the diagnosis of intrauterine growth retardation. Measurements were taken of human placental lactogen (hPL) in 111 pregnant patients with subnormal uterine growth or complications often associated with IUGR and assessed as a measurement of growth retardation. The results of this study are presented here.


Management of premature rupture of the membranes. A 14-month prospective study of patients with premature rupture of the membranes was performed. The purpose of the study was to determine the effect of different therapeutic regimens for management of premature rupture of the membranes (PROM) on perinatal morbidity and mortality, as well as on maternal morbidity. Maternal and fetal risk factors and predictive factors in pregnancy outcome were prospectively defined. In patients with PROM whose gestational age was 34 weeks or more, induction within the first 12 hours of membrane rupture resulted in minimal maternal and fetal morbidity and mortality. Patients with gestational age of less than 34 weeks had an improved maternal and fetal outcome if left alone until spontaneous labor or 34 weeks' gestation was reached unless signs of sepsis developed. Respiratory distress syndrome (RDS) was the leading cause of morbidity and mortality in the infants of patients who delivered prematurely due to premature rupture of the membranes. Incidence of fetal infection was significantly less than that of RDS as a cause for fetal morbidity and mortality.


Hansen's disease in pregnancy.

Hansen's disease in pregnancy. Hansen's disease with pregnancy is an uncommon concurrence in the United States. The clinical courses of 62 pregnancies in 26 treated patients with various types of Hansen's disease are reported. In general, patients with Hansen's disease do well in pregnancy. However, the subgroups of active lepromatous and dimorphous types have an increased incidence of obstetric and disease complications. Additional important observations include a high incidence of false-positive biologic tests for syphilis, with the possibility that the FTA-ABS test may also be falsely positive in pregnant patients with Hansen's disease. Sulfone drugs may be used safely during pregnancy. There is a low incidence of congenital malformations, but an unusually high incidence of twinning in this small group of patients.


The large fetus. Management and outcome. In a 4-year retrospective review of 801 pregnancies that resulted in the delivery of an infant weighing 4100 g (9 lb) or more, increased incidence of both maternal and perinatal complications was noted. There were no maternal deaths, and ther perinatal mortality rate was 0.49%. The second stage of labor was prolonged in 9.7% of primigravidas and in 2.2% of multiparas. Shoulder dystocia and perineal lacerations were related to increasing birthweight. Difficult deliveries resulting in clavicle fracture or brachial plexus injuries, and facial trauma contributed to the 11.4% perinatal morbidity rate. Asphyxia was observed in 7.7% and hypoglycemia in 5.2% of the neonates. Congenital anomalies (1.5%) were not increased in the large fetus group. Close surveillance for diabetes mellitus and anticipation of the potential complications associated with delivery of a large infant may reduce maternal and neonatal morbidity rates and maintain low mortality rates.


Antibiotic therapy of endometritis following cesarean section. Treatment successes and failures. A prospective clinical and microbiologic study was carried out on 413 indigent patients undergoing cesarean section. Operative site infection developed in 160 (38.5%). Initial treatment with penicillin and kanamycin was successful in 125 of these 160 infections (78%). Thirty-five patients (22%) failed to respond to penicillin and kanamycin and were treated with clindamycin or chloramphenicol. Twenty-eight of the 35 responded promptly to the additional antibiotic therapy. The remaining 7 patients (4%) had either abscesses, hematomas, or presumed septic pelvic thrombophlebitis. Among patients with anaerobic cultures, B fragilis was isolated with 12% with a good response to penicillin-kanamycin, but from 53% with a poor response to penicillin-kanamycin and with a good response to clindamycin or chloramphenicol. Similar critical evaluations of other antibiotic regimens are needed.


Pregnancy specific beta1 glycoprotein in fetal and maternal compartments. Pregnancy specific beta glycoprotein is produced by the syncytiotrophoblast and secreted into the maternal peripheral circulation reaching levels of approximately 200 m/liter in normal pregnancy at term. In the present study the distribution of this newly defined placental protein was examined in maternal and fetal compartments in 12 patients at delivery.


The estriol/creatinine ratio in a random urine sample as a screening test. The estriol/creatinine ratio was determined in a first morning urine sample in 1808 pregnancies in the 32nd week of gestation. The ratio obtained correlated closely with birthweight and showed a linear increase with percentile birthweight group. There was a 25-fold increase in perinatal mortality in those pregnancies with a ratio below the tenth percentile; all pregnancies ending in stillbirths with birthweight below the tenth percentile gave such a ratio. The single estrogen/creatinine ratio allowed the early detection of a group of pregnancies at high risk of intrauterine growth retardation or major total abnormality without inconvenience for the patient.


Planned vaginal delivery following cesarean section. A program of trial labor by patients who had previously undergone one low cervical transverse cesarean section is described. Experience with 526 such patients shows that 49% delivered vaginally, doing so with slightly less morbidity and a shorter hospital stay than 108 similar patients not given a trial labor. Perinatal mortality and morbidity were unaffected by trial or route of delivery. Uterine rupture was encountered three times in the trial group and once in the nontrial patients but at no time resulted in a serious threat to the mother or child. Fertility was retained in 2 of the 4 patients. A significant increase in maternal morbidity was noted among patients whose trial labor resulted in a repeat cesarean section.


Continued pregnancy after failed first trimester abortion. Forty-six patients with unintentional continued pregnancy were detected among a series of 65,045 first trimester abortions. Patients at greatest risk are those with very early pregnancy and those with marked uterine anteversion or retroversion or with uterine anomaly. Attention to gestational duration and uterine size as related to the amount and character of the evacuated tissue, particularly stressing identification of villi and fetal tissues, may help avoid this problem.


Amniotic fluid transfer of meperidine from maternal plasma in early pregnancy. Concurrent samples of maternal plasma and amniotic fluid were collected from 40 subjects during the second trimester of pregnancy following a single intramuscular dose of meperidine (100 mg). Maternal meperidine plasma levels were highest in samples collected from 15 to 50 minutes after drug administration. Thereafter the level declined during the next 2 hours. Meperidine was not detected in amniotic fluid until 30 minutes after the intramuscular dose. We estimated that an apparent equilibrium was reached between plasma and amniotic fluid at 120 to 155 minutes after the drug was given to the mother. Normeperidine was not detected in either maternal plasma or amniotic fluid during the time course of this study.


Obstetric outcome before and after metroplasty in women with uterine anomalies. A review of 49 patients with uterine anomalies was made to determine the relationship of anomalies to infertility, to obstetric outcome, and to indications for surgical reconstruction (metroplasty). For 41 of the 49 patients with obstetric histories, the overall pregnancy wastage was 72%, with bicornuate and septate patients having 85 to 90% wastage. The 28% of pregnancies that were successful were largely accounted for by patients with didelphic anomalies. It was found that infertility was an uncommon problem in these patients and it should rarely be an indication for metroplasty. In 21 patients properly selected for metroplasty because of repeat pregnancy loss, the obstetric outcome improved from 7% successful pregnancies before surgery to 75% postoperatively. Patients with septate or bicornuate anomalies were found to be poor obstetric performers and likely candidates for repair, while patients with didelphic anomalies achieved obstetric satisfaction without surgical intervention.


Podophyllin poisoning. Systemic toxicity following cutaneous application. The toxicity of topically applied podophyllin in a 16-year-old girl is presented. Coma requiring respiratory support and major neurologic complications as well as hematologic and hepatic toxicity was observed. Therapy with a new modality, charcoal hemoperfusion, resulted in resolution of the acute toxicity, leaving a peripheral neuropathy which had not completely resolved after 4 months. The pharmacology and suggested treatment measures for the toxicity of this rarely reported agent are reviewed.


Syphilitic cervicitis. A report of a case. A case report of a young female who had a biopsy of a cervical lesion suspicious for malignancy is presented. After further evaluation, an initial diagnosis of Stage III sarcoma of the cervix was considered. The patient was eventually appropriately treated for a syphilitic chancre of the cervix. The pitfalls of diagnosis in this patient and other patients in the literature who have leutic cervicitis are stressed in order to alert the practicing gynecologist to this unusual location of a common veneral disease.


Douche-induced pelvic peritoneal starch granuloma. A case of granulomatous peritonitis occurring in a patient without previous surgical history is described. The patient was initially seen because of vaginal bleeding. Gynecologic examination disclosed an ovarian mass which, at laparotomy, grossly mimicked a carcinoma with peritoneal seeding. Histological studies revealed focal chronic granulomatous peritonitis with starch granules as determined by polarization microscopy. It is hypothesized that prolonged use by the patient of a suspension of powder in water as a douche introduced the offending agent into the pelvic peritoneum.


Acute visual loss during pregnancy after bromocriptine-induced ovulation. The elusive tumor. The evaluation of patients complaining of amenorrhea with or without galactorrhea has been greatly enhanced by the availability of serum prolactin determinations and advances in diagnostic radiology. Likewise, the treatment of these patients with ergot derivative has resulted in the return of normal menses, and many pregnancies have been reported. The present report is of a patient with hyperprolactinemic amenorrhea-galactorrhea successfully treated with bromocriptine. A pregnancy followed resumption of menses, and a suprasellar cromophobeadenoma became manifest by producing blindness of the patient. The case is presented with recommendations for diagnosis and treatment.


Acute necrotizing fasciitis of the endopelvic fascia. A patient with an extensive necrotizing infection of the endopelvic fascia is presented. Cultures and tissue sections revealed the organisms responsible to be a mixed infection of Bacteroides, Staphylococcus, and Streptococcus. Hypertension and diabetic vascular disease were felt to contribute to the initiation of the disease process in this unusual site.


Squamous cell carcinoma in situ of the vagina and cervix after intrauterine DES exposure. Two patients exposed in utero to maternal DES ingestion presented with adenosis. Each developed intraepithelial neoplasia in an area of active metaplastic change. The question is raised whether a continuum exists beginning with DES exposure and proceeding through the occurrence of adenosis and active squamous metaplasia to dysplastic alteration and finally squamous neoplasia. Since the cytologic smear is negative in 50% of cases during the dysplastic phase, it is recommened that all cases of adenosis be followed by colposcopy.


Endometrioid carcinoma of the fallopian tube. A case of endometrioid carcinoma arising in endometriosis of the fallopian tube is described. One case of tubal endometrioid carcinoma has been reported previously, but the entity has not hitherto been recognized among primary fallopian tube tumors. The clinical presentations, histopathology, and pathogenesis of this rare tumor are discussed.


Delayed interval delivery of a twin pregnancy. A twin pregnancy is reported in which a prolonged interval between delivery of twins was accomplished by the use of labor-inhibiting drugs and the placement of a cerevical cerclage. Infants weighting 690 and 1192 g were delivered from a mother with a normal uterus at 27 and 31 weeks' gestation, with survival of the second twin. Pathologic and sonographic findings in the case, philosophies of its management, and a review of the medical literature are presented. The case is apparently unique to obstetric literature.


A spinal cord neurolemmoma in pregnancy. A case of spinal cord neurolemmoma (Schwanoma) in pregnancy is described. A review of the literature fails to reveal any similar tumors in association with pregnancy. Diagnosis, treatment, and pathogenesis of spinal cord tumors in pregnancy are reviewed.


Barogenic rupture of the esophagus associated with hyperemesis gravidarum. Spontaneous rupture of the esophagus is associated with continuous nausea and vomiting in the chronic alcoholic. The following is a case report of a similar occurrence in a young, healthy, primigravida with hyperemesis gravidarum. To our knowledge, this has not previously been reported in the obstetric literature.


Pregnancy after jejunoileal bypass. A review and report of one case. A case of pregnancy after jejunoileal bypass is presented. Fifty-six full-term pregnancies among 44 patients reported in the literature are reviewed. Pregnancy is not contraindicated after jejunoileal bypass, as it is accompanied by few more problems than those normally encountered in the obese woman. Somewhat smaller babies are born from these pregnancies and some minor disturbances of glucose, protein, and minerals may have to be adjusted during the pregnancy. A two-year interval is suggested after jejunoileal bypass before pregnancy is undertaken, to allow a weight-loss plateau to be established. The 7% incidence of severe congenital anomalies among these 57 pregnancies is higher than normal and suggests an added risk.


Nonobstructive cecal dilatation and perforation after cesarean section. A case of nonobstructive cecal dilatation and perforation after cesarean section is reported with a review of the surgical literature on the management of this entity.


Antenatal diagnosis of Potter syndrome.

Antenatal diagnosis of Potter syndrome. A case is presented of bilateral renal agenesis (Potter syndrome) which was diagnosed before birth. The diagnosis was based on severe oligohydramnios, unrecognizable fetal kidneys and bladder on ultrasound, and failure to demonstrate a fetal bladder after administration of furosemide. Ultrasonic evidence of a hypoplastic thoracic cage provided further support for the intrauterine diagnosis.


Incompetent cervix in offspring exposed to diethylstilbestrol in utero. Five patients with malformation and hypoplasia of the cervix due to diethylstilbestrol (DES)-exposure in utero developed cervical incompetency during the second trimester. Four of the patients were managed successfully during pregnancy with a modified Shirodkar cerclage procedure which was performed at the first sign of cervical effacement and dilitation. The fifth patient, who had lost 2 pregnancies because of cervical incompentency, underwent a modified Lash procedure and permanent cerclage in the nonpregnant state and was delivered at term by primary cesarean section. In view of the large number of women exposed to DES who have grossly abnormal-appearing and hypoplastic cervices, it is important for obstetricians to be aware of this potential complication in order to avoid second trimester losses which could be prevented by prompt surgical intervention.


Amniotic fluid embolism and disseminated intravascular coagulation after evacuation of missed abortion. The combination of amniotic fluid embolism and disseminated intravascular coagulation in obstetrics usually occurs at term associated with tumultuous labor. Maternal death almost inevitably follows. That these two crises may occur associated with abortion in herewith reported for the first time. Prompt recognition and aggressive appropriate therapy were responsible for patient survival with virtually no residual sequelae. Diagnosis was established on the basis of serial chest x-rays, pulmonary function tests, sputum, and serial blood studies.


Ureterouterine fistula as a complication of elective abortion. A rare case of ureterouterine fistula following a uterine curettage for elective abortion is presented. Review of the literature and management of the present case outlines two different methods of managment of this complication of surgery. Attention is called to the possibility of this complication occurring following uterine curettage for elective abortion.


Thrombocytopenia in two patients treated with low-dose heparin. Two cases of thrombocytopenia, one resulting in bleeding, are reported in patients treated with prophylactic low-dose heparin. The evidence indicates that low-dose heparin was responsible. A review of the literature indicates that heparin-induced thrombocytopenia may be a common event. Since low-dose heparin has been shown to decrease the incidence of venous thrombosis and subsequent pulmonary embolism in patients undergoing major surgery, recommendations are made for monitoring platelet counts in such patients.


Local spread and lymph node involvement in cervical cancer. In 150 cases of carcinoma of the cervix the specimens obtained by radical hysterectomy and lymphadenectomy were examined by means of giant frontal section preparations which included adjacent parametria. Serial step sections of lymph nodes were performed. There were 44 cases of Stage IB, 13 of Stage IIA, and 93 of Stage IIB. Lymph node involvement was 16%, 33%, and 37%, respectively. The size of each cervical tumor was expressed in square millimeters as an "area-equivalent," the product of its vertical and horizontal diameters in the frontal plane. Cross relationships of tumor size, incidence of lymph node metastasis, border zone spread, and parametrial involvement were studied and are discussed. It is concluded that tumor size gives a better indication of tumor behavior than does clinical staging and constitutes an objective method of classifying tumors that the latter cannot attain.


The use of pelvic arteriography in assessing carcinoma of the cervix. Twenty-nine patients underwent pelvic arteriography as a part of their pre-radical-hysterectomy evaluation for cervical carcinoma. False-positive studies were as common as false-negative studies, not only in the assessment of tumor extension locally, but also in determining the presence of pelvic lymph node involvement. Twenty-one patients underwent preoperative irradiation, but the lack of correlation was similar in 8 patients who were treated by primary radical surgery a few days after arteriography. The clinical estimate of tumor extension corresponded more closely to the pathologic findings than pelvic arteriography.


Radioactive phosphorus and external radiation as an adjuvant to surgery for ovarian carcinoma. At the Johns Hopkins Hospital between the years 1967 and 1973, 40 patients with primary ovarian carcinoma were treated with radioactive phosphorus. Of these, 19 were treated with external radiation in addition. The morbidity from the radioactive phosphorus alone was negligible. Dosages of less than 5000 rads to the pelvis were usually well tolerated even when given in combination with the isotope. Pathologic changes in the bowel are discussed.


Unilateral ovarian abscess associated with the intrauterine device. Four cases of primary ovarian abscess associated with intrauterine contraceptive devices are presented. It is proposed that both their unilaterality and the fact that they were primary in the ovary rather than tuboovarian are due to the fact that bacteria from the intrauterine device are shed continuously through the fallopian tubes, resulting in the inoculation of the corpus luteum, a unilateral structure. Removal of the ovarian abscess without additional surgical therapy is sufficient for a patient with this type of pelvic infection.


Fetal activity determinations and oxytoxin challenge tests for assessment of fetal well-being. Fetal activity determinations followed by oxytocin challenge tests were performed in 101 patients. When fetal heart accelerations occurred following fetal movement, the oxytocin stress test was negative in 99.5% of the cases. An abnormal fetal activity determination was followed by a positive oxytocin challenge test in 12% of the cases. It is suggested that a normal fetal activity determination is indicative of good fetal reserve and therefore reduces the need for oxytocin challenge test. An abnormal fetal activity determination, however, is unreliable and requires that an oxytocin challenge test be performed.


Intensive care in adolescent pregnancy.

Intensive care in adolescent pregnancy. Adolescent pregnancy has long been considered high risk perinatally. It is also a symptom of social disorder. Older studies provided ominous portents of increased risk of toxemia, prematurity, anemia, cephalopelvic disproportion, and perinatal wastage. Studies during the past decade have shown more encouraging data, especially when representing a concerted effort toward this age group. The first 2 years of an intensive and individual approach to gravidas under age 17 are discussed. A total of 135 young women were studied and compared with 100 controls of similar age, treated routinely, and with 100 women of more nearly ideal childbearing age. Perinatal and social data are shown. The implications of the data are discussed in light of other studies. Few, if any, medical differences between the two groups of adolescents and the older women are noted. More important are the social and emotional factors in determining future difficulties.


Extraabdominal uterine exteriorization at cesarean section. A series of 386 consecutive cesarean sections is presented in which postpartum uteri were randomly exteriorized or left in situ for suturing the hysterotomy incision in an attempt to evaluate differences in morbidity. Both groups were shown to be similar with respect to overall morbidity, although a high-morbidity subgroup exhibiting increased blood loss was defined and included significantly more patients in the noneventrated group. Emesis occurred in 4 (3.4%) patients in the eventrated group and was directly related to fundal traction under regional anesthesia. Although a larger prospective series is needed to evaluate more serious morbidity, the data presented suggest that uterine eventration at cesarean section is not to be condemned.


Internal fetal monitoring and maternal infection following cesarean section. A prospective study. A prospective clinical and microbiologic study was performed on 419 patients undergoing cesarean section. A multivariant analysis revealed that labor, rupture of the membranes, and vaginal examinations each had a much greater relative importance than did internal monitoring in determining infection. In an alternative analysis, patients with internal monitoring had no increase in frequency or severity of infection, beyond that imposed by labor and rupture of membranes. Further, endometrial cultures from patients developing infection after internal monitoring were found to have the same bacteria as the cultures of patients developing infection without monitoring.


Fetal contribution to oxytocin in human labor. Fetal oxytocin contribution to the mother during spontaneous labor was investigated using a specific and sensitive radioimmunoassay to measure oxytocin in blood, amniotic fluid, and urine. In 26 subjects with spontaneous labor and vaginal delivery (Group I) and 18 subjects with cesarean section after labor (Group II), umbilical arterial plasma (UA) oxytocin concentrations were significantly higher than umbilical venous plasma (UV) ocytocin concentrations. With elective cesarean section (Group III), UA oxytocin concentration was 29.8 +/- 7.5 pg/ml and UV oxytocin concentration was 16.1 +/- 5.9 pg/ml (n = 14). In contrast, the mean UV oxytocin concentration was higher than the mean UA oxytocin concentration, when oxytocin was given to the mothen concentration in Groups I and II was significantly higher than in Group III. Amniotic fluid oxytocin concentrations in Group I and II patients were higher than in Group III. Oxytocin was also present in fetal urine. The findings indicate that during spontaneous labor, oxytocin is produced by the fetus and flows toward the maternal circulation.


Human placental lactogen levels in multiple pregnancies. Serum human placental lactogen (hPL) levels were measured in duplicate with a radioimmunoassay in 206 serum samples at 30 and 36 weeks' gestation from women with normal singleton pregnancies (75) or pregnancies with twins (37). One triplet pregnancy was also studied. The results show a significant elevation of hPL in the women with twin pregnancies at both the 30th (7.0 vs 6.0 microgram/ml) and the 36th (9.2 vs 7.4 microgram/ml) weeks. One-third of the twin pregnancies had values of hPL in excess of 8.0 microgram/ml at 30 weeks and more than half had values in excess of 9.0 microgram/ml at 36 weeks. The triplet pregnancy had an hPL value of 11.0 microgram/ml at 36 weeks' gestation. These data support the potential usefulness of serum hPL measurements in the screening profile for the detection of high-risk pregnancies.


Pregnancy after jejunoileal bypass and the SGA infant. Twenty-one pregnancies (19 patients) were studied, noting the effects of previous jejunoileal bypass on perinatal sequelae. A larger percentage of SGA infants (20%) were delivered to mothers after bypass surgery. Low birthweight appears to be related to maternal hypoalbuminemia. Twelve of thirteen (92%) infants born to multiparous patients after surgery had term birthweights less than any previous term infant's birthweight prior to the procedure. Postponement of pregnancy after ileal shunt until all metabolic parameters have returned to normal (up to 36 months) is advised.


Maternal and fetal plasma renin and dopamine-beta-hydroxylase activities in toxemic pregnancy. Toxemic and normotensive pregnant women were compared for plasma renin activity (PRA), aldosterone (PA), and dopamine-beta-hydroxylase (DBH). At term, hypertensive patients exhibited higher levels of PRA and PA, but similar levels of DBH, progesterone, and estradiol. Their elevated blood pressure was significantly correlated to their levels of PRA. During the delivery levels of PRA increased significantly in toxemic patients in spontaneous labor. Venous and arterial cord PRA levels were higher in babies born to hypertensive mothers than in babies born to normotensive mothers. Three days postpartum, maternal PRA level was lower than at term. Seven days postpartum, PRA levels remained higher in toxemic than in normal women. Maternal DBH levels did not change during and after delivery. Levels of DBH were undetectable in cord blood. We conclude that the renin-angiotensin system is involved in the pathogenesis of toxemia.


Aberrant breast tissue of the vulva. A case report and review of the literature. Aberrant breast tissue may occur anywhere along the embryonic milk line. Only 17 instances of breast tissue of the vulva have been recorded in the English literature between 1900 and 1976. Review of these cases, as well as features of the patient herein reported, serve as a basis for presenting a clinical profile of this interesting entity, its potential complications, and a rationale for appropriate management.


Skin changes and diseases associated with pregnancy. During the gestational period, the skin is among the many organs undergoing changes. Various endocrine changes occurring in pregnancy are thought to give rise to certain skin changes such as pigmentary alterations, abnormalities in hair growth, vascular anomalies, and striae. Also, there are several skin diseases unique to the pregnant woman. Whereas the physiologic skin changes are mainly of cosmetic importance, the various pregnancy-unique skin diseases have associated symptoms, and an increase in both fetal and/or maternal morbidity and mortality is associated with several of these skin diseases.


Rubella antibody titer. The significance of low-titered rubella antibodies. The hemagglutination inhibition (HAI) test is not mathematically precise and reproducible. Thus, it is critical to know whether or not the threshold titer (1 : 10) of detectable rubella antibody is indicative of true immunity. Three patients with a 1 : 10 HAI titer presented with subsequent rubella during gestation. Ninety postpartum patients with a HAI titer of 1 : 10 were vaccinated and the rubella antibody titers were reassessed. Seventeen percent of these patients responded to the vaccine challenge with an eightfold or greater rise in titer. Thus, we recommend that the patient with a low HAI titer (1 : 10) should be considered to have marginal immunity to rubella and should be vaccinated.


Fertility after cryosurgery of the cervix. Fertility in patients following cryosurgery of the cervix was evaluated in 412 women. Cryosurgery does not appear to have any effect on subsequent fertility when compared with the general population.


Continent vesicostomy. Application in a patient. Continent vesicostomy, as performed in the laboratory animal, allows the severely dysfunctional bladder to be emptied at predetermined intervals by transabdominal catheterization. The formation of a continent vesicostomy in a patient with markedly impaired bladder function secondary to an extended pelvic operation for the treatment of cancer is described. This technique provides a possible alternative to the construction of a urinary conduit in patients disabled from the treatment of a pelvic malignancy.


Intrauterine growth retardation. Antenatal diagnosis by ultrasound. Serial cephalometry is useful not only in defining the risk for intrauterine growth retardation (IUGR) in relation to each fetus' growth potential but also in identifying symmetric versus asymmetric undergrown fetuses. It is suggested that all fetuses with biparietal diameters falling below the 25th percentile or dropping to a lower percentile division undergo biophysical and biochemical monitoring for detection of the affected fetus. The value of the head-to-abdomen circumference ratio close to term in delineating asymmetric undergrown fetuses is discussed.


Respirator fitting: the key to protecting workers. How can you be sure that workers are being properly fitted with respirators? For now8 quantitative fit tests are the best way, unless hazards are minimal.


What steps must be taken to establish a respiratory protection program? The author discusses eleven 'commandments' for such a program, among them the need for written operating procedures, proper selection and storage, and training.


Employee education, management support can halt respirator abuse. Workers need to know why they wear respirators. And their use of protective equipment must always be supervised and governed by written procedures.


How do job-related problems contribute to child abuse? Many child abusing parents are unemployed, but others who work may bring their job-related frustrations home, where they explode into violent child abuse.


Nurses can 'take the heat' off of workers. The most serious danger is heat stroke, but cramps and exhaustion also afflict workers whose surroundings or physical makeup make them vulnerable to heat stress.


Nurse practitioner has a central role in hospital health service. As director of the hospital health service at George Washington Medical Center, this nurse practitioner has clinical, administrative, and educational duties.


A comparative study of physiologic intracranial calcifications. It has been the impression of clinicians that pineal calcification is infrequent in Shiraz, Iran. In order to evaluate this clinical impression 2000 consecutive skul X-rays taken at Saadi Hospital, Shiraz, Iran, were reviewed for the presence of physiologic intracranial calcifications. The incidence of these clasifications in male and female in consecutive age groups of 10 years from 0 to over 70 years of age were assessed and compared with previous reports from other countries. The average incidence of pineal calcification for those over 20 years of age was 18.29% in this study compared with 55% in the U.S.A. The incidence of calcification in the choroid plexus and the falx cerebri was also considerably less than previously reported. The literature is reviewed and the possible causes for the geographical differences in the reported frequency of physiologic intracranial calcifications is discussed. It is possible that racial and dietary factors may be significant in the variation in the incidence of pineal and other cranial calcifications noted in different countries. Within a population group, age and sex are additional factors.


Hypotensive agent from Cynomorium coccineum. The Iranian plant Cynomorium coccineum was investigated and found to possess significant blood pressure lowering activity in the dog. Extensive chemical isolation and fractionation has revealed that the depressor components were mainly present in the fresh juice of the plant. The fractions, by various organic solvents, of the dried powdered plant lacked significant depressor activity. However, the fresh juice of the plant as well as the water soluble fractions of the fresh juice exhibited strong depressor activity. Spectroscopic metal analysis and infrared and Mass spectra of the active fractions seem to suggest the inorganic nature of these fractions with very low carbon and hydrogen contents which are present, perhaphs, in some special molecular arrangement that becomes disrupted due to sensitivity to the analytical procedures employed.


Studies on concurrent  salmonellosis in dogs and man. Eight positive Salmonella cultures were obtained from 8 of 314 family dogs in Tehran. Attempts to isolate Salmonella organisms from the owners of the Salmonella infected dogs were successful only in one of eight instances. The Salmonella serotype isolated from the owner was the same as that from his pet dog.


The prevalence of intestinal helminthiasis among the Qashqai tribe in Southern Iran. The prevalence and the intensity of intestinal helminthiasis in the Qashqai tribe of Southern Iran were studied. Infection with Ascaris Lumbricoides and Trichuris Trichura was low (6.1 and 0.8 per cent respectively) while the prevalence of Trichostrongylus was 27.6 per cent of the total stool samples examined or 63.2 per cent of the total intestinal parasites found. This might be due to the mode of life of the tribe and the proximity of its people to domestic animals.


Hepatic versus pulmonary involvement by Echinococcus granulosus. In a five period, year 41 consecutive patients with echinococcosis were studied. Single organ involvement occurred in 34 (82.93%) and multiple organ disease in seven patients (17.07%). Single hepatic involvement, recorded in 15 patients (36.59%) was equal to single pulmonary involvement. This distribution appears to assume an intermediate position between the northern preponderance of hepatic and the southern prevalence of pulmonary echinococcosis in Iran.


The effect of ischaemia on the function and fine structure of the microvasculature of myocardium. Seventeen mongrel dogs were subjected to ligation of the circumflex branch of the left coronary artery. At intervals from 10 to 300 minutes after ligation, 10 ml of a sodium fluorescein and colloidal thorium hydroxide solution were injected via an intra-arterial catheter placed distal to the ligature. Up to 20 minutes after ligation this tracer solution evenly perfused the left ventricular wall including the posterior papillary muscle (PPM). During 25 to 50 minutes there was a progressive patchy loss of perfusion into the PPM although the sub-epicardial region was evenly perfused. After 60 or more minutes of ischaemia it was not possible to inject this tracer solution into the subendocardial region. Electron microscopic examination indicated that this loss of vascular competence was possibly due to vasospasm of some vessels in the marginal zone between the perfused and non-perfused areas and was unlikely to be due to intravascular thrombosis, endothelial cell swelling, or to compression of vessels due to cell or tissue oedema.


Mycobacterium avium associated with chronic pulmonary disease in a Queensland resident. Bacteriological investigation over an 11-year period has implicated Mycobacterium avium ser I as the most probable cause of chronic pulmonary disease in a resident of south-eastern Queensland. Although the patient had contact with domestic fowls and a pet budgerigar, the source of the organism is uncertain.


Pseudomyxoma peritonei et ovarii with an occult neoplasm of appendix: case report. Although pseudomyxoma peritonei is comparatively rare, the simultaneous occurrence in this condition of mucinous tumours of ovary and appendix is common and has been termed pseudomyxoma peritonei ovarii et appendicis. Four closely followed patients in a small series showed only 25% 6-year survival. This paper presents a further case with a 14-month follow-up.


Xanthogranulomatous endometritis: case report. A case of chronic endometritis with unusual histological features due to the presence of abundant foam cells and lipid material is described. The presence of foam cells, abundant intra- and extracellular lipid together with other inflammatory cells in the absence of endometrial hyperplasia or carcinoma warrants the diagnosis of xanthogranulomatous endometritis.


Systemic form of Weber-Christian disease. A case of systemic Weber-Christian disease, involving retroperitoneal adipose tissue with secondary damage to the associated organs and blood vessels is reported. The involved organs showed varying degrees of necrosis, lipogranulomata and fibrosis.


Malignant meningioma: ultrastructure and observations on histogenesis. A malignant meningioma was studied by light and electron microscopy. Histologically, the tumour was composed predominantly of spindle shaped cells arranged in interlacing bundles with numerous mitoses and much nuclear atypia. There were many necrotic foci as well as invasion of the cerebral cortex, dura mater and blood vessels. Ultrastructurally, the main findings included moderate plasma membrane interdigitation, many intracytoplasmic filaments, and junctional attachments of three kinds: desmosomes, hemidesmosomes, and zonulae adhaerentes. These subcellular features are suggestive of arachnoidal cell origin.


Invasion of the hepatic capsule by tumour metastases to the liver. Liver metastases of Waler 256 tumour in rats and of C3HBA tumour in mice were produced by mesenteric vein inoculation of tumour suspensions. Gross liver nodules were examined by light microscopy and by transmission and scanning electron microscopy. Subcapsular tumour nodules were seen to penetrate the hepatic capsule in all animals and to lodge on the peritoneal surface. Penetration occurred by stretching and attrition of the thin hepatic capsule in these animals. Studies done on human hepatic metastases revealed a different picture. In only a small number of such cases did peritoneal involvement occur from subcapsular nodules, and in these the penetration was limited, apparently by way of capsular veins and lymphatics. The thick fibrous capsule of human liver appears thus to form a barrier to peritoneal tumour dissemination.


Ethanol's influence on the stimulus level required to evoke an orienting response in goldfish. In goldfish the heart rate orienting response to periodic photic stimuli was measured by a specially designed computer that also regulated the intensity of the stimuli to maintain the response. When ethanol was administered, the fish then exhibited orienting responses to less intense stimuli; this increased excitability was maintained for the duration of all tests (i.e., a maximum of 26 hours). There also seemed to be a residual increase of excitability lasting as long as 7 days after the ethanol was administered.


An examination of the relationship between race, skin color and a series of autonomic nervous system measures. In the total population of 75 subjects, the skin albedo correlated significantly with skin resistance, a relationship which was not maintained when the total population was separated into its component subgroups of whites, blacks and Indians. The Indians, "anthropologically Caucasians" but skin color more akin to the blacks, exhibited mean skin reflectance and skin resistance intermediate to that obtained in the black and white groups respectively. Other differences and significant correlations between the autonomic functions in the three groups indicated a higher level of sympathetic tone in the Indians, although this could be attributed to the older age of this group. It was suggested from the results that skin color rather than race has a greater influence on skin resistance.


External inhibition in a goldfish (Carassius auratus) classical conditioning situation. Goldfish were classically conditioned with a light as the CS and shock as the US. The UR was a decrease in respiration. After 15 or 60 conditioning trials the fish were tested with novel stimuli (clicks) during the CS-US interval. High and moderate intensity novel stimuli produced a significant decrease in CRs (external inhibition) for fish with 60 conditioning trials (5.5 or 10.5 sec CS-US interval), but not fish with 15 conditioning trials. Low intensity novel stimuli produced no evidence for disinhibition (an increase in CRs). Control groups (e.g., groups with random presentations of the CS and US) showed that the external inhibition for fish with 60 conditioning trials was inhibition of a true CR.


Multivariate data analysis in empirical research. A look on the bright side. The interpretive benefits of employing multivariate analysis methods on experimental data with more than one dependent variable are described heuristically and illustrated on a set of data from a simply designed experiment in physiological psychology. Multivariate analysis of variance (MANOVA) is performed on the 9 dependent variables contained in the sample data and on the four composites derived from a principal components analysis (PCA) of the variability of the nine. A linear discriminant analysis (LDA) is conducted following both MANOVA results, and 5 methods of determining the "important" dependent variables in the experimental-control group difference are presented and discussed in terms of the data at hand.


Bone density in thalassemic children during the course of the disease. The study was carried out on 50 thalassemic children and 20 control subjects aged 5--15 years. The cortical thickness in thalassemic children was less than in control subjects. The bone loss was more obvious in girls (P less than 0.0005) than in boys (P less than 0.05). The greater bone loss in girls could not be explained by the level of blood hemoglobin because in both sexes the mean value was the same (7.3 +/- 0.5 g/dl). Of the 12 thalassemic children observed for 9--24 months, 9 showed no signficant bone change, 2 showed an improvement of cortical thickness and only 1 showed bone loss. Of the 11 thalassemic children observed for 25--48 months, 4 showed significant bone loss and 7 no change of the bone density. In both groups the mean value of pretransfusion blood Hb was 7.3 g/dl and the sex distribution was equal. A relationship was found in both control and thalassemic children between bone density and urine phosphorus to urine creatinine ratio.


Spermine and spermidine, modulators of the cell surface enzyme adenylate cyclase. Adenylate cyclase activity was measured in membrane preparations of cultured fibroblasts from controls and patients with cystic fibrosis. Enzyme activity increased as the transition from exponential growth to confluence occurred; sodium fluoride-stimulated activity more markedly displayed this relationship than basal cyclase activity. The in vitro addition of spermine (1 X 10(-6) to 2 X 10(-3) M) to membrane preparations caused inhibition of basal and sodium fluoride-stimulated enzyme activity, with 50% inhibition of basal activity occurring at 10(-6) M spermine. Spermidine (10(-4) M) caused 15--25% inhibition of adenylate cyclase activity. The increase in fibroblast adenylate cyclase activity during the transition from exponential growth was comparable in cells obtained from cystic fibrosis patients and control subjects. Basal and sodium-fluoride stimulated adenylate cyclase activity as well as inhibition of this enzyme activity by spermidine and spermine were undistinguishable between the different cell genotypes. A potential modulation of cellular proliferative activity through polyamine interaction with the adenylate cyclase system is postulated.


Stimulation of p-aminohippurate extraction in the maturing rabbit kidney. In vivo studies were performed to evaluate maturational changes in PAH extraction (EPAH) in the rabbit and to determine whether accelerated maturation of this process could be achieved. Fifty-four animals were injected with penicillin before study at 10, 14, 21, or 28 days of life. Forty-eight rabbits served as saline-injected controls. PAH extraction in controls increased from 29.3 +/- 2.4% at 10 days of age to 35.9 +/- 3.3% at 14 days, 59.7 +/- 3.5% at 21 days, 71.6 +/- 1.9% at 28 days, and 72.7 +/- 2.3% at 35 days of life. Penicillin injection on the 3 days before study resulted in enhancement of EPAH on days 10 and 14 to 42.7 +/- 2.4% and 65.0 +/- 3.2% (P less than 0.005). On days 21 and 28 less stimulation was noted (68.7 +/- 2.3%; 76.0 +/- 4.1%). Preinjection on days 6--9 with study delayed to day 14 also led to augmentation (46.7 +/- 3.7% P less than 0.05) but less than that achieved after injection on days 10--13. These data suggest that EPAH stimulation may be transient, descreases as maturation is approached and is likely related to substrate availability.


Perinatal nitrogen accretion in muscles and fingernails. Paired triceps muscle and fingernail samples were obtained at autopsy from 25 normally grown (NG) and 16 intrauterine growth-retarded (IGR) neonates who died within 28 days of birth. Gestational ages ranged from 21--46 weeks and birthweights ranged from 425--3750 g. Muscle samples were desiccated, defatted and ground to powder. Nitrogen content of muscle and fingernail were determined by a modified micro-Kjeldahl technique. Muscle nitrogen (MN) content averaged 12.1 +/- 1.89 g/100 g fat-free dry solids (FFDS) (mean +/- SD) and was similar for NG and IGR neonates and, within these two groups, for premature and mature babies. Fingernail nitrogen (FN) content averaged 13.8 +/- 0.95 g/100 g and no variations with duration and quality of intrauterine growth were identified. Fingernail nitrogen content correlated linearly with muscle nitrogen content in both NG (n = 0.48, P less than 0.002) and IGR (n = 0.67, P less than 0.005) neonates. The regression equation for the entire study population was: FN = 0.31MN + 9.96, Syx = +/- 0.778, r = 0.59, P less than 0.001. These data suggest the possibility of using simple, noninvasive fingernail "biopsies" to monitor protein economy and quality of perinatal growth.


Effect of uterine artery insulin infusions on umbilical glucose uptake in sheep. Although glucose is an important fuel for fetal oxidative metabolism, regulation of its availability to the mammalian fetus is poorly understood. This study was performed to determine the effect of infusions of insulin into the uterine arterial circulation on umbilical uptake of glucose in chronically instrumented, unstressed sheep. Twenty-eight determinations of umbilical glucose uptake and diffusion clearance of glucose by the placenta were made in four ewes. Immediately following a control study during which saline was infused into the uterine artery, porcine regular insulin diluted in saline was infused at 0.05 to 8.1 mU/min . kg uterine weight for 20--30 min and the determinations were repeated. Subsequent studies were performed at the conclusion of additional infusions of insulin to a maximum of 21.6 mU/min . kg. There was a significant increase in umbilical glucose uptake during initial insulin infusions (4.47 +/- 0.6 mg/min . kg fetus) compared to the control studies (3.08 +/- 0.6 mg/min . kg) associated with an increase in diffusion clearance (13.8 +/- 1.9 ml/min . kg fetus vs. 8.99 +/- 1.8 ml/min . kg). When the total cumulative dose of exogenous insulin, It, was 162 mU/kg uterine weight or less, the umbilical uptake of glucose, Q, may be expressed as a function of maternal arterial blood glucose concentration in milligrams per dl, [A], and of It.


Reaction of 4-methylumbelliferylguanidinobenzoate with cultivated human skin fibroblasts derived from patients with cystic fibrosis. Protease activity in cultivated human skin fibroblasts has been quantitated using 4-methylumbelliferylguanidinobenzoate (MUGB), an active site titrant of trypsin-like proteases (7). The reaction of the proteases with MUGB was complete in 1 hr, inhibited both by benzamidine and (p-nitrophenyl)-p'-guanidinobenzoate, but not by p-hydroxymercuribenzoate. The extent of reaction was proportional to protein concentration and independent of MUGB concentration. This activity was present in the particulate fraction of the cell. The mean "titre" values (nanomoles of 4-methylumbelliferone released per mg protein) of the proteases in fibroblasts from eight controls (N), 8 obligate heterozygotes (H), and 14 patients with cystic fibrosis (CF) were: N, 1.27 +/- 0.11; H, 0.82 +/- 0.12; CF, 0.66 +/- 0.10. The differences in the "titre" values for N:CF and N:H were significant (p less than 0.001) as were those for H:CF (p less than 0.01). The mean "titre" value obtained for cultivated control amniotic fluid cells was 1.29 +/- 0.17. These data indicate a reduction in the MUGB-reactive proteases in skin fibroblasts derived from patients with CF when compared either to control or to obligate heterozygotes. These data are consistent with our earlier suggestion (11, 15) that decreased proteolytic levels in the tissues and fluids of patients with CF may be a generalized phenomenon.


On the advantages of specific airway resistance. The specific airway resistance (SRaw) is a relatively precise parameter of bronchial quality and in normal children its relation with body length, although very significant (P less than 0.001), is so poor that it can safely be disregarded (Fig. 4). Also the dispersion around the mean value remains stable at any body size (Fig. 4). Contrasting with the inverse relation between airway resistance (Raw) and lung volume, SRaw does not show any systematic variation with lung filling (Fig. 5). These data are consistent with the new formulas: SRaw = tg beta (PB - PH2O) and Raw = SRaw/TGV in which tg beta stands for relation between the plethysmographic box volume and breathing flow fluctuations (Fig. 2); PB - PH2O represents the ambient pressure corrected for water vapor pressure at body temperature; TGV is the thoracic gas volume at mean expiratory level. In disease SRaw varies more rapidly and markedly with any alteration of the airways than does Raw (Fig. 6). Consequently, a normal value for SRaw would indicate that both Raw and TGV must be in a normal range.


Tap water scald burns in children.

Tap water scald burns in children. Tap water scald burns account for 7% to 17% of all childhood scald burns that require hospitalization. Often the burns are severe and disabling. Toddlers and preschool children are the most frequent victims. In 45% of the injuries, the unsupervised victim or peer turned on the tap water; in 28% the cause was abuse. Eighty percent of the homes tested had unsafe bathtub water temperatures of 54 C (130 F) or greater, exposing the occupants to the risk of full-thickness scald with 30-second exposure to hot water. Such burns may be prevented passively by limiting household water temperatures to less than 52 C (125 F). New water heaters could be preset at this temperature and families could be taught to turn down the temperature on existing units.


Mitigation of cretinism by breast-feeding. An athyrotic infant had hypothyroidism at 1 year of age. He had grown at an above-average velocity until age 10 months when breast-feeding was discontinued, yet his bone age remained that of a newborn. These observations suggested that breast-feeding had attenuated hypothyroidism by providing significant quantities of thyroid hormones in the milk. To test this hypothesis, thyroxine (T4), 3,5,3'-triiodothyronine (T3), and 3,3,5'-triodothyronine (reverse T3) were measured in breast milk samples collected serially from three months before to four months after delivery. Mean breast milk T4 content fell from 1.4 to 0.7 microgram/dl within 48 hours after delivery, while T3 content rose from 136 to 286 ng/dl. Reverse T3 content remained unchanged. The shift in the T4/T3 ratio after delivery was observed in samples of all five donors; the highest postpartum T4 level was 1.1 microgram/dl and the highest postpartum T3 level was 405 ng/dl. It is concluded that breast-feeding may deliver sufficient thyroid hormones to the athyrotic infant to mitigate severe hypothyroidism and to prevent impaired neurological development.


Interaction of maternal and neonatal obesity. Maternal weight and height before pregnancy and weight gain during pregnancy were recorded for each of 109 mothers who were delivered of normal infants after gestations of 37 to 43 weeks. Infant parameters obtained included gestational age, birth weight, bilateral mid-arm circumference, and eight skin fold thickness measurements. The eight skin fold thicknesses were summed (SSFT) for each infant. Infants with SSFTs greater than 40 mm (N = 8) for the group were classified as "fatter" infants. All of the fatter infants were large for gestational age (LGA), but accounted for only one third of the LGA infants in the study. Birth weight, length, and cross-sectional mid-arm fat area were significantly increased in the fatter LGA group when compared to other LGA infants. Cross-sectional mid-arm muscle area was not significantly different for the fatter LGA infants compared to the other LGA group. Mothers were defined as obese or nonobese according to pregnant weight for height. Obese mothers had infants with significantly increased SSFTs when compared with infants of nonobese mothers. Mulitple regression analysis showed that both prepregnant weight for height and weight gain during pregnancy were associated with increased subcutaneous fat in the neonate. Weight gain during pregnancy was associated with increased neonatal fatness and length, while  prepregnant weight for height was associated with neonatal fatness independent of neonatal length.


Studies of the cause and treatment of hyperammonemia in females with ornithine transcarbamylase deficiency. Assay of ornithine transcarbamylase (OTC) activity in multiple small bits of liver (approximately 5 mg) that were obtained from a single surgical biopsy in a patient with OTC deficiency revealed a 10- to 40-fold variation in enzyme activity. Similar studies with control autopsy liver specimens varied 2.5-fold at most. The greater variation in the patient with OTC deficiency probably is due to sampling of clusters of normal or abnormal hepatocytes that resulted from inactivation of either the abnormal or normal X chromosone. Enzyme activity assayed on small liver biopsy specimens may not be representative of the entire liver in female patients with OTC deficiency. The hyperammonemia in individuals heterozygous for OTC deficiency may be due in part to shunting of blood through multiple "metabolic portosystemic shunts." Treatment of a girl who has OTC deficiency with a low-protein diet, a low-protein diet supplemented with oral essential amino acids, and a low-protein diet plus oral ketoacids of essential amino acids, on a separate occasion, a low-protein diet was compared to a low-protein diet plus lactulose. The low-protein diet plus oral ketoacid supplementation resulted in the best metabolic control of the patient's disease. On the other hand, paradoxical transient hyperammonemia was observed after the intarvenous administration of ketoacids to two acutely ill female patients with OTC deficiency.


Amniotic fluid lecithin/sphingomyelin ratio: comparison between an African and North American community. One hundred nineteen samples of amniotic fluid obtained from healthy pregnant Nigerian women were analyzed for their lecithin/sphingomyelin (L/S) ratio. There was a gradual increase in the L/S ratio with increasing maturity from week 23 to week 42 when values of 0.69 and 5.73, respectively, were obtained. Compared with the ratios reported from San Diego, our ratios were significantly higher where numbers were adequate for statistical tests. The higher L/S ratio probably shows that pulmonary maturity occurs earlier in the African babies and might partly explain the low incidence of respiratory distress syndrome in our premature babies.


Pulmonary lesions in atypical measles.

Pulmonary lesions in atypical measles. Atypical measles is a well-described entity which has a high frequency of pulmonary involvement. Resolution and shrinkage of the pneumonic infiltrates into nodular mass-like lesions have been cited only once before. Three cases of atypical measles pneumonia are described which demonstrate these pulmonary nodular sequelae. In one of the cases examined a nodular residuum has now persisted for five months. Atypical measles pneumonia should be considered as a diagnostic possibility before invasive investigations are performed in a patient who has a pulmonary nodule.


Diagnostic dilemmas of Wilson's disease: diagnosis and treatment. Wilson's disease, an autosomal recessive disorder of copper metabolism, may defy diagnosis in children. The classical triad of Kayser-Fleischer rings, neurologic dysfunction, and hypoceruloplasminemia may be absent. Patients may be seen initially with acute or chronic hepatitis, hemolytic anemia, or neurologic dysfunction. Guidelines are presented for diagnosis of Wilson's disease based on a review of 25 pediatric and adolescent patients. A high index of suspicion in necessary so that therapy with penicillamine may be begun before irreversible liver or neurologic damage occurs. The prognosis is excellent when diagnosis and treatment are established early.


Segmental colonic gangrene: a surgical emergency in the hemolytic-uremic syndrome. A 2 1/2-year-old girl had rectal bleeding, an abdominal mass, and diffuse peritonitis. A segment of gangrenous colon was removed. Following surgery she developed the hemolytic-uremic syndrome (HUS), which is characterized by renal failure, hemolytic anemia, and the thrombocytopenia. The intestinal manifestations associated with the HUS are stressed. This case demonstrates that gangrenous bowel can occur in these patients, and that their survival may depend on resectional surgery.


Clinical usefulness of polymorphonuclear leukocyte vacuolization in predicting septicemia in febrile children. Vacuolization of the polymorphonuclear leukocyte (PMN) has generally been regarded as an indication of bacterial infection and has been particularly useful in diagnosing septicemia. In an effort to predict septicemia, peripheral blood smears from 69 febrile children were examined and systematically scored for severity of vacuolization. Thirteen children had remarkable vacuolization compared to the others. These 13 included only five children with bacterial illnesses and only one of the seven children with septicemia. Our finding that PMN vacuolization was neither diagnostic of septicemia nor predictive of bacterial infection suggests that the specificity of the link between vacuoles and bacteremia needs to be reassessed.


Nonsurgical management of renovascular hypertension in the neonate. Over an 18-month period nine infants in a neonatal intensive care unit developed hypertension (blood pressure, 115/88 to 280/140 mm Hg) at 2 to 45 days of age. Eight of the nine infants had indwelling umbilical artery catheters prior to onset of hypertension; six of the nine infants had evidence of a patent ductus arteriosus. Peripheral plasma renin activity was greater than 300 ng/ml/3 hr in six of eight infants. Angiograms were abnormal in six of seven infants and computerized renal scans were abnormal in all nine infants. One infant had congenital renal artery stenosis. Eight of nine infants had evidence of unilateral or bilateral renal artery thrombi which were felt to have emanated from an umbilical artery catheter or a ductus arteriosus. Hypertension in all infants was successfully controlled medically (follow-up of 3 to 27 months; mean, 14.4 months). Blood pressures remained normal when medication was discontinued. In our experience, neonatal renovascular hypertension is no longer uncommon, responds to aggressive medical management, and rarely requires early nephrectomy. Neonatal renovascular hypertension was usually associated with umbilical artery catheters positioned above the level of the renal arteries.


Initial urinary catecholamine metabolite concentrations and prognosis in neuroblastoma. Initial urinary catecholamine metabolite and amino acid excretion patterns were examined in 54 children with neuroblastoma. The relationships between prognosis and age at diagnosis, stage of disease, primary site, and histologic grade of tumor were similar in this population to those found in previous studies, but only age and stage were found to be independent prognostic variables. Prognosis in disseminated disease was found to correlate directly with the urinary vanilmandelic acid (VMA)/homovanillic acid (HVA) ratio but not with the absolute levels of HVA. The presence of the dopa metabolite, vanillactic acid, as well as increased amounts of cystathionine and/or low levels of VMA indicated poor prognosis. These results are consistent with the hypothesis that biochemically primitive neuroblastomas deficient in dopamine beta-hydroxylase are move virulent than their mature analogues which produce epinephrine, norepinephrine, and their metabolites.