Isolation information booklet stimulates dialog, allays fears. Isolation for nosocomial or community-acquired infection can be a bewildering and potentially stressful situation for the hospitalized patient and his family. Proper education is essential in order to minimize these fears and provide optimal medical care. A booklet has been designed to supplement the verbal explanations that should be given by hospital staff about the rationale and details of the isolation procedures. The booklet integrates the concerns articulated by isolated patients with the perceptive solutions suggested by an interdisciplinary group of health care professionals.


Study shows how to measure energy use, costs in food service. The cost and the availability of energy resources affect the cost of food service operations. Food service managers need to know the energy consumption and costs associated with preparation of various food products using various types of equipment. One study offers a technique that can enable them to measure these data.


Surgeons question future of surgical training, second opinions. Surgeons who attended the October 1978 meeting of the American College of Surgeons questioned the future of their specialty in an era when government agencies are emphasizing primary care. What will the role of future surgeons be? How will they be trained? Will they find themselves competing with family practitioners for hospital privileges? These questions were posed, but answers were scarce.


Flexible designs are key to reuse projects. New and more flexible design alternatives result when architects use the planning/program/design model for reuse/reconfiguration projects.


Two HMOs retrofit buildings in historic and commercial downtown areas. Renovation of nearby mill and warehouses provides HMOs with convenient locations, additional space at lower costs, and unusual, attractive, and functional facilities.


Rebuilding for the future: a forward-looking master plan. A 10-state redevlopment plan will provide a new structure with minimal interruption of service and loss of revenue.


Renovation saves hospital landmark.

Renovation saves hospital landmark. Architects restore a 57-year-old hospital facility without destroying its traditional and unusual characteristics.


Abandoned Air Force base redesigned as rehabilitation center. Renovation of a three-story hospital and construction of new one-story units consolidated scattered services and provided a barrier-free design for patients.


Is recycling of buildings a healthy alternative for the hospital industry? Recycling, or reuse as it's called in the construction industry, works for paper and aluminum--then, why not for entire buildings?


Hospitals must follow strategy to lead regional sharing efforts. A hospital that wants to initiate or expand service sharing with other institutions in its service area must analyze and act on many considerations that affect the success of such relationships. For example, the hospital must identify its resources and goals for sharing as well as those of the other participants, eliminate personal and institutional 'ego needs' from the relationship, and promote effective interpersonal relationships among the key individuals from the participating institutions.


An engineer's approach to data collection and planning. The hospital planner should imitate the engineer in his approach to gathering data on which planning programs must be based. The information must come from all groups involved in the hospital's operation, and each piece of data must then be evaluated for its individual contribution to the overall project.


Fellowships offer expanded views of the health care world. The authors briefly describe three fellowships that are currently available to health administration graduates. They also make some important observations about the usefulness of such fellowships and offer suggestions regarding fellowships in various key areas of the field of health care administration.


Hospital financial managers are central to management team. The hospital financial manager must play an increasingly larger role in the development of overall hospital policy. Human resources, as well as physical assets and capital must be considered, and the financial manager needs to establish programs that not only create a sound economic base, but that also show management's commitment to people.


Dietitians improve patient care with computerized selective menu. A computer-based system provides a selective menu that meets the dietary prescriptions of each patient; reduces food, printing, and personnel costs; and frees clinical dietitians to spend more time in rendering direct patient care through nutrition assessment and education and in auditing their department's operations.


Revised fire safety system cuts emergency response time. As Margaret R. Pardee Memorial Hospital, Hendersonville, NC. expanded, fire safety plans had to be reevaluated. With each new addition, fire safety responsibilities for hospital personnel multiplied and overlapped. Confusion resulted, and a revised, simplified, and coordinated fire safety system was devised. Seventeen false alarms within one year, caused by a faulty sprinkler system, gave hospital personnel ample opportunity to test the system and iron out unexpected problems.


Would you listen to what they're saying. Particularly at a children's hospital, the views and comments of patients and other publics can be a useful source of ideas in the creation of films, brochures, and other materials used to promote and explain the hospital. The words are frequently there; only the background needs to be provided.


Medical staff helps set priorities for equipment purchases. Through participation on a medical equipment priority committee, medical staff members have become more aware of the problems that their hospital's board and administration face in containing costs. In reviewing individual requests for equipment purchases, they not only apply their own expertise but also consider maintenance, personnel, planning, financing, and other implications of the proposed purchases.


Three-year growth of a pastoral care department. Three years ago, setting up a pastoral care department combining tradition with a contemporary thrust was an administrative dream at St. Mary's Hospital, Streator, IL. Now such a department is in full operation, offering a variety of services to patients, their families, hospital staff, clergy, and the community.


Abortion: a changing morality and policy? Emotions are excellent companions but not always good guides. It is essential, therefore, to submit one's loyalties and value judgments to constant scrutiny and questioning and to those theological criteria that make abortion also (though not only) a theological question, a task not without its risks.


Administrator burnout--causes and cures. Psychological "burnout" among administrators arises from frustrating life "scripts" and/or organizational pressures. Burnout may lead to termination, emotional withdrawal, fighting back, or corrective action. Strategies for prevention or cure include: developing space from work, determining intrinsically meaningful goals, setting up feedback systems, exploring self-actualizing activities.


How a hospital attracts MDs.

How a hospital attracts MDs. While statistics indicate the nation is producing more physicians than it needs, administrators of rural or inner city hospitals still may have difficulty recruiting the physicians they need. Suggestions are given for assessing a hospital's medical staff needs, organizing a search committee, locating physician resources, evaluating candidates, and conducting recruitment visits.


Refining a patient-acuity system over four years. Four years ago St. Joseph Hospital, Albuquerque, developed a patient acuity system to be used in staffing and budgeting for the hospital's nursing service. Since then the service has continuously maintained and refined the system; and nursing management thinks the system has raised staff morale, clarified budgeting and saved money within the service, and helped maintain consistently high-quality patient care.


Temporary arterial shunt in the severely injured limb. Silicone rubber tubing and matching vessel tips are available in any hospital with a renal dialysis unit. These materials may be used as a temporary measure to restore distal circulation in the severely injured limb. The operative technique and postoperative management of a case in which this manoeuvre was used are presented.


Snowmobile accidents in Northern Sweden. A total of 129 snowmobile injuries occurring in 117 persons was registered during the winter of 1976-7 in Jämtland, a county of northern Sweden. During that period about 6600 snowmobiles were in use in the district. In 92 cases speed contributed to the cause of the accident. Seventy-five persons were injured when falling off the vehicle or getting caught beneath it. The accidents are analysed and suggestions are made for their prevention.


Intertrochanteric displacement osteotomy in the treatment of femoral neck fractures. A total of 51 patients with displaced femoral neck fractures of Garden grade III or IV was treated by intertrochanteric displacement osteotomy. Of these, 42 patients had complete follow-up and 31 fractures (73.8%) united. The results were satisfactory in 66.6% and poor in 33.4%. The poor results were mainly due to non-union, chronic osteomyelitis and stiffness of the hip or knee. A high intertrochanteric osteotomy with adequate displacement is recommended in fresh, displaced femoral neck fractures.


Fatal cervical dislocation related to wearing a seat belt: a case report. A case of fatal cervical dislocation in a front seat passenger restrained by a retractable three-point belt is described. A biomechanical and technical analysis is given.


Alterations of the basal serum insulin and blood glucose in brain-injured patients. Serial fasting blood glucose and basal serum insulin were measured in brain-injured patients. The endocrine changes were compared with the level of consciousness. Evaluating the serial examinations of 92 brain-injured and 31 control patients we came to the following conclusions. There is a quantitative correlation between the alterations in the level of consciousness and the fasting blood-glucose and serum-insulin levels in brain-injured patients. Deep coma is connected with a high blood-sugar level, clear consciousness with a normal glucose level. The insulin level is, however, decreased in the comatose state and normal in the state of clear consciousness. According to the alterations in blood-glucose and insulin levels, brain-injured patients can be divided into four groups. The alterations in the insulin level cannot give a proper explanation of the blood-sugar changes. Some changes in the levels of both blood glucose and serum insulin may have prognostic significance. According to our results it can be supposed that certain cerebral structures take part in the regulation of the basal insulin secretion.


Flexor tendon healing and adhesion formation after Sterispon wrapping: a study in the rabbit. The influence of Sterispon (Allen & Hanbury) wrapping on the healing of the rabbit flexor digitorum profundus tendon sutured within the digital sheath was studied. Control tendons healed in 2 weeks in association with thick adhesions. The wrapped tendons were surrounded with fewer adhesions, but 50% separated. Healing was delayed until adhesions reached the suture site. A sheath of a single layer of mesothelial cells formed on the surface of the Sterispon opposite the tendon and this markedly reduced adhesions at the suture site. The cellular reaction was bland. Sterispon wrapping had a similar effect on tendon healing and adhesion formation as wrapping with other non-absorbable substances and the results support the theory that healing in the digital sheath is necessarily mediated through the formation of adhesions. Sterispon wrapping has been helpful after tenolysis operations.


Symptoms at one year following concussion from minor head injuries. Of 131 patients with mild concussion, 19 (14.5%) still had symptoms after 1 year. Of these 19 patients, 10 had some symptoms of which they had not complained at 6 weeks. Symptoms at 1 year were more common among women and among patients who had had positive neurological findings at 24 h. Of the 19 patients who had symptoms at 1 year, 8 were involved in law suits and 6 had been suspected of malingering 6 weeks after their accident. Five of these patients were both involved in law suits and suspected of malingering.


Intravenous regional anaesthesia in upper limb trauma. Practical experience in the use of Bier block anaesthesia of the upper limb is described. The revival of this well-tested technique is particularly relevant in circumstances where, for a variety of reasons, the administration of a general anaesthetic is impracticable. The quality of surgery, the safety of anaesthesia and the patient's comfort can be well maintained by following a few simple rules. We have satisfied these criteria in this series by using low doses which are safe and sufficient in a busy accident department.


The use of Kiton Fast Green to measure the viability of the head of the femur after fractures of the neck of the femur. An intravital staining method was used to predict the viability of the femoral head at operation in 36 patients with fractures of the neck of the femur. Life was predicted in 18 heads, death in 16 and in 2 there was some doubt. In the group which was predicted to be live, 15 fractures united uneventfully, 1 developed late collapse and 2 became infected and died. Of the heads predicted to be dead, 3 united without evidence of necrosis, four had radiological changes suggesting that necrosis had been followed by revascularization and 10 required further operations. Histological evidence was later obtained in 19 cases. Of 6 heads predicted to be live, 4 had united without evidence of necrosis, 1 showed necrosis and collapse and 1 was infected and dead. Of the heads predicted to be dead, 8 were dead, 4 showed revascularization taking place and 1 showed no evidence of bone necrosis. Intravital staining is a relatively easy technique but has limitations as a means of predicting the clinical outcome.


Cancer progression and monocyte inflammatory dysfunction: relationship to tumour excision and metastasis. In a longitudinal study performed before and after surgical resection of a chemically-induced, transplanted rat tumour we found that a monocytosis- and tumour-induced anti-inflammatory effect directed against macrophages was promptly corrected by tumour excision but recurred with metastasis. These observations indicate that the monocyte abnormalities are acquired and related to cancer progression. The anti-inflammatory effect required relatively large primary or metastatic tumour burdens. Our findings support the clinical impression that monocyte abnormalities are associated with a poor prognosis.


Effect of Corynebacterium parvum on hemopoietic stem-cell kinetics. The intravenous administration of 548 microgram of killed Corynebacterium parvum (C. parvum) into C57BL mice leads to a significant decrease in the number of bone-marrow colony-forming-units in spleen (CFUs) as early as 12 h after the injection of the bacterium. This decrease persisted in varying degrees for 3 weeks. After an initial fall at 24 h, the splenic CFUs exhibited a rapid expansion and reached values 10 times higher than the control range on the ninth day. A significant rise in the number of circulating CFUs, reaching a first peak at 2 h and a second one on the fifth day, was also observed. The proliferative status of femoral CFUs was increased at 48 and 72 h, while that of splenic CFUs presented a significant increase only 48 h after the injection of C. parvum. The sequence of events which were observed in these experiments indicates that an accelerated migration of hemopoietic stem cells from bone marrow to spleen via the blood circulation has to take place.


Carcinogenic potential of hycanthone in mice and hamsters. Hycanthone was administered to Schistosoma mansoni-infected and non-infected Syrian golden hamsters and Swiss mice by intraperitoneal and intramuscular injection of amounts up to the maximum tolerated dose. No tumors attributable to treatment were observed in hamsters. In infected mice, the overall incidence of hepatomas and hepatocellular carcinomas increased from 3.4% in untreated mice to 10.6% in those treated with hycanthone. Non-infected control mice developed 0.8% of these tumors compared to 10.2% in mice treated with hycanthone. Despite the use of high dose levels of hycanthone, statistical significance was attained only with non-infected female mice injected intraperitoneally and intramuscularly with hycanthone and then only at confidence levels of 92 and 95% respectively.


A standard large wound of the corneal epithelium in the rabbit. A method of iodine vapor cautery was applied to rabbit eyes. The cautery produces an approximately circular area denuded of epithelium of uniform size. The eye is not inflamed, and the very rapid mean healing rate of 1.42 mm2hr-1 was observed.


Long-term perfusion of human corneas.

Long-term perfusion of human corneas. In twelve isolated human corneas (cadaver time 2 to 16 hr) stromal thickness could be maintained within 0.50 to 0.66 mm up to 20 hr by the use of an endothelial bathing medium consisting of glutathione-bicarbonate Ringer's solution, HEPES-buffer, and 20% human serum. During the first 3 to 5 hr of perfusion, temperature reversal occurred in all corneas. Wound healing processes were observed in nine corneas throughout the experiments after scraping off a 2.5 mm area of central epithelium, which was kept in a moist saline-saturated atmosphere.


An electron microscopic study of macrophages in rats with inherited retinal dystrophy. In retinas of rats (RCS) with inherited retinal dystrophy, cells interpreted as macrophages infiltrate the outer nuclear layer and subsequently appear in the interphotoreceptor space, where they accummulate during the course of the disease. The morphology and distribution of these cells and their relations to the pigment epithelial cells were investigated. Macrophages, regardless of their location, possessed morphological features that distinguished them from the pigment epithelial cells. Premelanosomes and melanosomes, typical of pigment epithelial cells, were never observed in macrophages. There was no evidence to indicate that, during the period studied, the pigment epithelial cells had become dedifferentiated or had migrated from Bruch's membrane. Macrophages, like pigment epithelial cells, phagocytized little or no outer segment material. The findings indicate that, at least during the interval studied, the cells that infiltrate the retina and interphotoreceptor space are macrophages rather than pigment epithelial cells.


Quantitative evaluation of photopic ERG waveforms. Quantitative, computer-based ways of representing photopic ERG waveforms are investigated and related to over-all retinal condition in a group of normal subjects and a group of patients with diagnosed retinitis pigmentosa. Sinusoidal stimulation and a Fourier series response representation have been selected. This combination provides a few parameters which facilitate waveform comparison, and it naturally lends itself to generalization if more detailed features of ERG recordings are to be included. On the basis of this type of waveform characterization, the over-all photopic retinal condition of any individual eye can be represented by a single number or by its location in various cluster diagrams and its distance from the normal cluster. As exemplified by the results herein described, such an automated approach can be particularly useful in screening large populations for retinal degenerations or in quantitatively following the progression of retinal degeneration over long periods of time.


Effects of prostaglandins and norepinephrine on ocular pressure and pupil size in rabbits following bilateral cervical ganglionectomy. We wish to report an early (10 to 30 min) 6 to 7 mm Hg increase in IOP above predrug levels following topical norepinephrine (NE) (5mumol) administration in conscious normal rabbits. This early elevation in IOP was significantly more pronounced in bilateral superior cervical ganglionectomized (BG) rabbits. The time course for peak IOP elevation slightly preceded the accompanying peak mydriatic effect in all groups. IOP returned to baseline levels in about 60 min in the BG rabbits, but the mydriasis persisted. Pretreatment with topical indomethacin significantly reversed the early hypertonic NE effect on IOP in the BG animals implying the involvement of prostaglandin synthesis. The IOP continued to fall significantly after 60 min in the BG group with indomethacin pretreatment. This latter result suggests a predominant long-lasting NE effect. The indomethacin pretreatment had no effect on pupil size of any group, but phenoxybenzamine (PBA) reduced the mydriatic effect, implying a direct or a predominant role of NE on iris muscle.


A bioavailability comparison in rabbits of two steroids formulated as high-viscosity gels and reference aqueous preparations. In order to assess the bioavailability of steroids from a high-viscosity gel, rabbit cornea and aqueous humor levels were measured over 12 hr following topical instillation of a gel and reference preparation. Concentrations associated with a 1% tritiated prednisolone acetate gel were found to be approximately four times larger than those of the reference preparation. A graphical comparison of the 1% tritiated prednisolone sodium phosphate data showed the area under corneal and aqueous time curves to be five and 10 times greater, respectively, with the gel than data associated with the reference preparation. The gel vehicle is well retained in the rabbit eye and is responsible for the large increases in bioavailability.


Biochemical characterization of procollagen-collagen synthesized by rabbit corneal endothelial cells in culture. Collagen synthesis was studied in monolayer cultures of rabbit corneal endothelial cells by following [14C]proline and [3H]glucosamine or [3H]fucose incorporation into a fraction enriched for collagen and its precursor molecules. Sodium dodecyl sulfate gel electrophoresis of this fraction showed that it consisted of a high-molecular-weight (greater than 300,000 daltons) polypeptide. This component was collagenase sensitive and, in the presence of dithiothreitol, gave rise to two polypeptides of the apparent molecular weights of 200,000 and 160,000 daltons. Pepsin digestion of this material destroyed all the high-molecular-weight material and gave rise to a single collagenase-sensitive component of an apparent molecular weight of 115,000 daltons. This 115,000 dalton material is similar to previously observed basement membrane collagens, and the 160,000 and 200,000 dalton components are probably precursor chains of basement membrane collagen. The very-high-molecular-weight material (greater than 300,000 daltons) may represent a disulfide-linked complex of these precursor chains. DEAE-cellulose column chromatography confirmed the presence of a single procollagen species distinct from the collagen fraction. Amino acid analysis of collagen and procollagen fractions showed a decreased hydroxyproline value as compared with previously reported basement membrane collagens or collagen precursors.


Ocular surface epithelium and corneal vascularization in rabbits. I. The role of wounding. A new model for rabbit corneal vascularization, created by making a penetrating wound in corneas with epithelium of conjunctival origin, is described. Obligate resurfacing of the cornea from conjunctival epithelium usually leads to a small, but consistent peripheral superficial corneal vascularization. Subsequent penetrating wounds elicit, in 75% of cases, a marked vascular ingrowth. Normal eyes and eyes resurfaced by peripheral corneal epithelial cells do not vascularize after such wounds. The vessels are located in the anterior corneal stroma, and the regenerated epithelium has a conjunctival appearance. Although increased hydration plays a role in this vascularization, the extent of vascularization was much greater in the presence of regenerated epithelium of conjunctival origin than in the presence of regenerated epithelium of corneal origin.


Oxygen levels beneath the closed eyelid. The level of oxygen at the anterior corneal surface beneath the closed eyelid is shown to be equivalent to an atmosphere of 7.7% oxygen. This finding is in good agreement with assumptions which have been based on the oxygen level at the palpebral conjunctiva. However, in some instances a significant amount of oxygen is derived not only from the palpebral conjunctiva but also from the atmosphere as a result of an imperfect palpebral aperture seal.


Rhodopsin determinations in C57BL/6J-pallid strain mice. The influence of light environment on rhodopsin concentration per eye was determined in littermate pigmented and nonpigmented C57BL/6J-pallid gene mice reared under cyclic light or continuous dark environments. Attempts to exacerbate a congenital manganese deficiency in pallid strain mice included dietary deprivation and supplementation with manganese and exposure to intense light followed by the determination of rhodopsin recovery rates in darkness. Homozygous pallid mice (pa/pa) reared in cyclic light had rhodopsin levels which were significantly lower than heterozygous (+/pa) or homozygous (+/+) black control mice. Dark-rearing resulted in a significant increase in rhodopsin per eye in pallid strain mice and equivalent levels in adult mice, but young pallid strain mice did not achieve the same rhodopsin concentration as young +/+ mice. Although dietary manganese deprivation or supplementation did not significantly alter rhodopsin levels among pallid mice, the deficient diet resulted in lower rhodopsin per eye in the young +/+ control animals. The recovery of rhodopsin in darkness following intense light exposure was equal and complete within 24 hr for most genotypes. However, recovery by pallid mice after 24 hr was significantly lower than by pigmented or albino genotypes.


[Hypacusis in acquired hypothyroidism (author's transl)]. We examined 56 patients with latent or clinical hypothyroidism and a control group of 18 patients with acute hypothyroidism. We were especially interested in the localization and extent of hearing abnormalities. 45% of the patients with chronic hypothyroidism showed a hearing loss. 2 of these patients had a pure conductive loss, 7 a combined hearing loss and 16 a sensorineural hearing loss. We demonstrated hair cell damage in 13 of the patients with chronic hypothyroidism. This loss was mild to moderate in over 90% of the cases. Although several patients had basilar-cochlear hearing losses, no characteristic audiograms could be found. 50% of the patients showed a small improvement in hearing after thyroid substitution therapy. The results of our examinations are discussed in detail.


[The prognostic value in tympanoplasty surgery of eustachian tube function tests (author's transl)]. A study was undertaken to test the validity of preoperative Eustachian tube ventilation measurements in 107 patients with conductive deafness and chronic middle ear disease. By standard static aspiration and deflation tests and with the Valsalva probe correlations were found in some patients between tubal function and the extent of middle ear damage as shown by the air-bone gap on audiometry and the findings at operation. However no prognostic information was evident with these measures since no relationship existed between tubal function and operative success as judged by closure of the air-bone gap or by healing of the tympanic membrane defect.


[Angio-immunoblastic lymphadenopathy (author's transl)]. The general clinical and pathological findings of angio-immunoblastic lymphadenopathy are reviewed and illustrated by a case-report with involvement of the tonsils. Our patient showed all the characteristic signs of this disease, including fever, pruritus, rash, generalized lymphadenopathy and hepatosplenomegaly. Histologically the wellknown triad of arborizing postcapillary vessels, proliferation of immunoblasts and plasma-cells, as well as deposition of PAS-positive interstitial material was found. Laboratory findings included a polyclonal hyperglobulinemia and a hemolytic anemia. Treatment consisted of corticosteroids and supportive medications. The prognosis is generally poor, with a median survival of 13 months. At present, the cause is unknown.


[The results of hearing aid usage in a group of patients older than 65 years (author's transl)]. Two groups of 50 patients were randomized from patients who came to have their hearing aid fitting controlled. One group (A) had a mean age of 27.6 years with a standard deviation of +/- 12.8 years. The second group (B) had a mean age of 75.06 years with a standard deviation of 5.7 years. Our statistical analysis of these patients showed that results of hearing aid instrumentation were comparable in both groups. The investigation has revealed that hearing aid fitting should not be contraindicated because of older age.


[Dominantly inherited bilateral ear anomalies (author's transl)]. A family, in which 12 patients through 5 generations had bilateral symmetrical anomalies of the external ears is reported. Assessment of the pedigree shows an autosomal dominant inheritance.


[Results of heterologous tracheal transplants in animal experiments (author's transl)]. In the present study, 7 x 15 mm Cialit-preserved human tracheal segments were grafted to the tracheas of five 3-month old piglets. 72-120 days later, the animals were sacrificed and the grafts with proximal and distal control areas were removed. Tissues were then examined macroscopically and by light and scanning electron microscopy. We found that: (1) all grafts had taken well; (2) no animal suffered from clinical signs of respiratory obstruction or inflammation; (3) although luminal diameters of the tracheas increased from 8 mm to 22 mm, the size of the grafts remained unchanged but the resulting tracheal stenosis did not cause respiratory obstruction; (4) the graftet areas showed re-epithelialization. The nature of the re-epithelialization as well as the fate of the submucosa and tracheal cartilage will be reported in a subsequent publication.


Acetabular development after reduction in congenital dislocation of the hip. A study of acetabular development in 148 patients with 185 congenitally dislocated hips treated by closed reduction from 1940 to 1968 showed that eight years after reduction the acetabular index was normal (less than 20 degrees) in 49.2 per cent, satisfactory (from 20 to 24 degrees) in 34 per cent, and poor (more than 24 degrees) in 16.7 per cent. Early treatment led to the best acetabular development. Significant and continuing improvement of the acetabular index was observed between two and eight years after reduction when the femoral head remained concentrically reduced. Failure to maintain proper reduction and necrosis of the femoral head led to poor results.


Congenital dislocation of the hip.

Congenital dislocation of the hip. From January 1970 to December 1976, seventeen patients with twenty-two congenital hip dislocations were treated by open reduction through a medial approach. The average follow-up was 42.2 months. The patients were evaluated for acetabular development, aseptic necrosis, and intraoperative findings. The incidence of aseptic necrosis was 10 per cent. The acetabular index improved rapidly during the first year after reduction. After the first year the rate of development was decreased, but the acetabular index continued to improve throughout the period of study. The medial approach provides a safe, effective way to reduce a dislocated hip in infancy. This procedure is advocated when closed reduction cannot be obtained by gentle manipulation or maintained by positioning once reduction is done.


Growth and development of congenitally dislocated hips reduced in early infancy. We determined the acetabular angles, center-edge angles, comprehensive quotients, and Shenton's lines from sequential roentgenograms of thirty-seven children with congenitally dislocated hips treated by closed non-manipulative reduction in early infancy. The values were compared with those obtained from roentgenograms of 164 normal children who ranged in age from three months to five years and of forty-three adolescents and adults. The hip recovering from congenital dislocation developed similarly to the normal hip but differed in that it showed a greater rate of decrease of the acetabular angle and an increase in the center-edge angle. Significant development after the age of five years still was manifested in the reduced hips.


Treatment of unreduced traumatic posterior dislocations of the hip. A study was made of thirty-nine traumatic posterior dislocations of the hip that had remained unreduced for from three days to nine years. The purpose of the review was to compare the results of closed and open reduction with those of primary reconstructive surgery. Three of the twenty hips that had closed or open reduction had good results as compared with ten of the thirteen hips that had primary reconstructive surgery. Six hips that were left dislocated had uniformly poor results.


Ischemia of the lower extremity after total hip replacement. Following total hip replacement, three patients had early and one had late ischemia of the ipsilateral extremity. Three required vascular surgery and one, a lumbar sympathectomy for relief of pain at rest. In each instance there had been multiple previous procedures on the same hip resulting in extensive scarring, shortening, flexion contracture, or fusion. The ischemia after total hip replacement was probably the result of interruption of critical collateral circulation about the hip or of traction on the femoral vessels tethered by scar when the short limb was lengthened or when the hip contracture was corrected. Evaluation by Doppler pressures and arteriography was helpful. Careful preoperative evaluation, early recognition of signs of ischemia, and prompt institution of appropriate management are essential to prevent this complication and to treat it adequately once it occurs.


Mechanical failures in total hip replacement requiring reoperation. During the years 1971 through mid-1977, approximately 3,000 total hip replacements were performed at The Hospital for Special Surgery using metal-to-plastic prostheses. During that period of time, thirty-five operations were done for mechanical failure in the absence of infection. The mechanical failures were distributed as follows: Fourteen patients had dislocations of the prostheses and seven patients had loosening of the femoral component, mostly with varus positioning of the femoral stem. Six patients, most of them heavy, active men, had fractures of the femoral stem. Three patients had loosening of the acetabular component. (In two of three there was insufficient bone stock over the acetabulum.) Four patients had proximal migration of the greater trochanter and one had a fracture-dislocation of the acetabulum. In all cases a technical or anatomical problem could be identified as the reason for mechanical failure necessitating reoperation. By careful preoperative planning, proper selection of procedures and positioning of prostheses, bone-grafting when necessary, and stricter attention to the technique of using cement, we could conceivably have avoided two-thirds of these failures.


Sciatic paralysis. A complication of bleeding following hip surgery. Of five patients in who sciatic paresis developed as the result of hemorrhage and hematoma following hip surgery, four were receiving prophylactic or therapeutic anticoagulants. The patient who was managed expectantly still had disabling motor and sensory deficity at follow-up. Three patients who had early operative decompression showed more complete return of nerve function. The fifth patient died three weeks after onset with the neuropathy still present. Severe low-back and buttock pain, ecchymosis over these regions, marked swelling in the thigh, sciatic-nerve tenderness, and a distal sciatic neural deficit in the ipsilateral lower limb of a patient who has had hip surgery are evidence of hemorrhage in the vicinity of the sciatic nerve. Early recognition and prompt surgical decompression can prevent irreversible nerve damage.


Posterior iliopsoas muscle transfer in myelodysplasia. A Sharrard posterior iliopsoas muscle-transfer procedure was done in forty-two hips of twenty-four children with myelodysplasia. Folow-up ranged from twenty-nine months to approximately ten years. An over-all success rate of 50 per cent was achieved which included all hips operated on for potential and existing instability. The success rate for surgery in hips with an existing instability was 29.6 per cent. Factors predisposing to a poor result were: age more than five years old, dysplastic acetabulum (index more than 30 degrees), prior hip surgery, and inequality of limb length. This operation is recommended primarily for hips not previously operated on in children less than five years old who have a normal acetabular index. If the child is more than five years old or if acetabular dysplasia exists, reconstruction of the acetabulum should precede or accompany the tendon transfer for best results. Iliopsoas muscle transfer is unlikely to be successful if used as a salvage procedure.


Contracture of the hip secondary to fibrosis of the gluteus maximus muscle. Twenty-eight children were treated who had limited flexion of the hips and various degrees of contracture of the abductor and external rotator muscles because of fibrosis of the gluteus maximus muscle. Although the lesions could be classified as those associated with poliomyelitis, infection of the gluteus maximus muscle, and fibrosis of unknown etiology, all forty-five hips had a typical restriction of motion such that an affected hip could not be flexed in the usual sagittal plane, but had to be flexed in abduction. Poliomyelitis may have been adjunctive to the causative factor of the lesion in some cases but the probable primary etiology was multiple intramuscular injections. Excellent correction of the hip contracture was achieved in all patients by division of the fibrotic bands.


The supporting structures and layers on the medial side of the knee: an anatomical analysis. The goal of this study was to delineate the consistent anatomical structures in the medial side of the knee and to determine their relationship to one another. One hundred and fifty-four fresh human knee joints were dissected. A three-layered pattern was found in which ligaments could be consistently placed. We have made suggestions regarding the nomenclature of these structures. The limits of of the so-called capsule and its significance as a stabilizer of the knee joint were examined. Only minor variations in the over-all anatomical pattern were found.


Biomechanical study of the elbow following excision of the radial head. The extent of proximal migration of the radius in thirteen patients who had had the radial head excised for fracture was 1.9 millimeters. After an average of twenty years there was minimum loss of motion of the elbow and forearm but strength was moderately decreased. The patients often had degenerative arthritis at the elbow that generally was not severe but correlated with the amount of pain. It correlated poorly with the severity of arthritis, loss of strength, motion, or pain. Over-all, the patients did well following resection of the radial head and there was no deterioration of results with time. An instrumented method for functional evaluation provided an objective and sensitive quantitative means to assess the need for and effectiveness of reconstructive procedure.


Synovectomy or total replacement of the knee in hemophilia. Eighteen major operations on the knee joint were performed in sixteen patients with hemophilia, eight operations being synovectomy and ten being total knee replacement. Synovectomy was performed for recurrent bleeding associated with synovitis. The average age at operation for patients who underwent synovectomy was 16.4 years, and the average follow-up was thirty-one months. No patient had a recurrent hemorrhage following synovectomy. The patients who had total knee arthroplasty for disabling pain had an average age at surgery of 35.7 years and an average follow-up of twenty-three months. The pain was markedly reduced in all eight patients and all achieved full unprotected weight-bearing. Loss of some motion was observed in twelve patients, but the functional gain outweighed the loss of knee mobility. Seven major complications occurred in the sixteen patients, but none of them affected the outcome.


Irreducible traumatic dislocations of the hip. Little attention has been paid to the various causes preventing or blocking a concentric reduction following traumatic dislocation of the hip without apparent fracture. In a review of fifty-four dislocations, nine required open reduction after either a failed attempt at closed reduction or a non-concentric reduction. The factors preventing closed reduction included the femoral head buttonholed through the capsule and the piriformis muscle displaced across the acetabulum. A concentric anatomical reduction was prevented because of an inverted lumbus or an osteocartilaginous loose body in the acetabulum. Guidelines for diagnosis and treatment are discussed.


Replacement of the trapezium for arthritis of the basal articulations: a new technique with stabilization by tenodesis. Forty-six patients (fifty hands) had replacement of the trapezium by a silicone implant that incorporated a local tendon strip to stabilize the device. The patients had intractable pain due to degenerative changes of multiple facets of the trapezium. The over-all rate of subluxation and dislocation was 10 per cent. In all hands, pain-free improved movement resulted. The pinch strength approximated the normal, averaging six kilograms for women and eight kilograms for men.


Distal radial epiphyseal displacement after impaired distal ulnar growth. Impairment of growth of the distal end of the ulna was produced in rabbits by excision of the distal epiphyseal plate. This caused a sequence of changes in the distal radial epiphysis consisting of combined increased chondrogenesis and decreased osteogenesis of the radial two-thirds of the distal epiphysis, and decreased chondrogenesis and increased osteogenesis on the ulnar side. At six to nine days postoperatively, cracks appeared concomitant with tilting of the plate and epiphysis, in the epiphyseal plate or at its metaphyseal junction. An incomplete radial epiphyseal separation occurred, a step-like deformity developed in the metaphysis, and an ulnar deviation developed.


The surgical treatment of the carpal-tunnel syndrome correlated with preoperative nerve-conduction studies. The diagnosis of carpal-tunnel syndrome was made clinically in 124 cases (101 patients) and in each instance it was confirmed by nerve-conduction studies. Surgery was carried out with a uniform technique. Retrospective analysis of the series suggests that nerve-conduction studies can be used as a prognostic factor. Those patients with motor abnormalities appeared to have a more favorable result than those with only sensory abnormalities. Neurolysis was found to be a valuable adjunct to the release of the volar carpal ligament. Preoperative duration of symptoms did not appear to significantly influence the results of the operation.


Projections of a telencephalic auditory nucleus-field L-in the canary. Anterograde projections of a telencephalic auditory area - field L of the neostriatum - were traced in canaries, Serinus canarius. Field L was defined as the neostriatal projection of nucleus ovoidalis of the thalamus. Using amino acid autoradiography, two efferent projections of field L and adjacent neostriatum were observed: (1) a projection to the medial and ventral borders of nucleus hyperstriatum ventrale, pars caudale (HVc) and (2) a smaller projection to medial paleostriatum augmentatum (PA). When autoradiographic injection sites included neostriatum postero-ventral to field L, a projection to archistriatum outlining the anterior and ventral borders of the nucleus robustus archistriatalis (RA) resulted. Injection sites that included neostriatum antero-lateral to "L" gave rise to projections to the interior of HVc proper. Above background numbers of silver grains were consistently observed over caudal dorso-lateral portions of nucleus ovoidalis. Following lesion of field L and adjacent neostriatum, argyrophilic degeneration was traced to medial PA and to a shelf of neostriatum underlying HVc. All observed anterograde projections were ipsilateral. Two of the nuclei outlined by neostriatal projections in this study, HVc and RA, have important roles in the motor control of canary song (Nottebohm et al., '76). The development of song is dependent on auditory information. Auditory-vocal neural connections described here may be involved in song learning.


Ascending projections to the inferior colliculus. Cells that send ascending projections to the inferior colliculus were identified following injections of horseradish peroxidase into the colliculus. Labelled cells were found in all subcollicular auditory nuclei. Virtually all cells of the ipsilateral ventral nucleus of the lateral lemniscus and medial superior olive appear to project to the colliculus. Very few cells in these nuclei were labelled on the contralateral side. Heavy labelling on the contralateral side was found in the dorsal nucleus of the lateral lemniscus and cochlear nucleus, with less labelling being found ipsilaterally in these nuclei. The lateral superior olive was approximately evenly labelled on the two sides, with about half the cells from each side projecting to each colliculus. Cells in all periolivary cell groups were labelled, with most being found adjacent to the medial superior olive. An effort was made to identify individual cell types that were labelled and some 24 cell types were identified. In the cochlear nucleus there were marked differences between cell types in the extent of their labelling. Topographic projections matched previously described tonotopic organization of the colliculus and all major subcollicular nuclei except the ventral nucleus of the lateral lemniscus. A description of the cells in the nucleus is provided.


Proliferative and migratory activity of glial cells in the partially deafferented hippocampus. The proliferative response of the glial cell population of the adult rat hippocampus deafferented by unilateral lesion of the entorhinal cortex was studied using 3H-thymidine autoradiography. Two experimental paradigms were used, involving: (1) intraventricular 3H-thymidine injection at a number of post-lesion intervals with sacrifice six hours later and (2) intraventricular injection at 30 hours post-lesion with sacrifice at 6, 96, or 192 hours later. The first increase in the number of labeled glial cells was obtained at 20 hours post-lesion and was confined to areas of degenerating axons. By 30 hours a large and uniformly dense proliferative response was observed throughout the ipsilateral, and medial aspects of the contralateral, hippocampus encompassing both deafferented and intact regions. Cell division continued through 50 and 65 hours post-lesion particularly in directly deafferented regions, but diminished to control levels by 80 hours. Although oligodendroglia and astrocyte-like cells were sometimes found to have incorporated the label the most common proliferative element within the hippocampus corresponded to previous light microscopic descriptions of "microglial" cells. The experiments using thymidine injection given at the peak proliferative period followed by survival periods of varying lengths indicated that a progressive redistribution of labeled nuclei occurred resulting in an accumulation of labeled cells in the zones of deafferentation. Multiple division of cells within these areas as well as the migration of nuclei from non-deafferented regions was found to contribute to this effect. The possible involvement of glial proliferation with other morphological effects of deafferentation, including the sprouting response of intact afferents, is discussed.


The parasagittal zonation within the olivocerebellar projection. II. Climbing fiber distribution in the intermediate and hemispheric parts of cat cerebellum. Olivocerebellar fibers from different subnuclei of the rostral inferior olive decussate in the brain stem and terminate as climbing fibers in one or two narrow, longitudinally arranged zones of the cerebellar cortex. These fibers issue collaterals to the central cerebellar nucleus that receives its afferents from the same cortical zone in which the parent fibers terminate. The rostral medial accessory olive projects to zone C2 and sends collaterals to the posterior interposed nucleus. A differentiation can be made between the rostral pole of this subnucleus which projects primarily to the paraflocculus and the ansiform lobule. More caudal areas connect with zone C2 in the anterior lobe and the paramedian lobule. The dorsomedial cell column projects to a lateral zone (zone A2) of lobule IX and more rostrolateral portions of the medial accessory olive supply a still more lateral zone of this lobule. The rostral half of the dorsal accessory olive sends fibers to zones C1 and C3. These fibers issue collaterals to the anterior interposed nucleus. A distinction can be made between the ventrolateral dorsal accessory olive, projecting to lobules II-IV and the ventral folia of the paramedian lobule and the dorsomedial portion of the rostral dorsal accessory olive that connects with lobules V, VI and the dorsal folia of the paramedian lobule. The most rostral part of the dorsal accessory olive provides more fibers into zone C3, more caudally located cells distribute primarily to zone C1. The rostral principal olive is connected with zone D and collateral terminations are found in the lateral cerebellar nucleus. In the paraflocculus the D zone can be divided into subzones D1 and D2. This study further substantiates the similarity in the organization of corticonuclear and olivocerebellar connections. The results are in general agreement with other recent investigations on the olivocerebellar system (Armstrong et al., '74; Brodal et al., '75; Brodal, '76; Hoddevik et al., '76; Brodal and Walberg, '77a,b; Oscarsson, '73, '76; Oscarsson and Sjölund, '77a,b).


Patterns of cell proliferation in the retina of the clawed frog during development. Quantitative assays of the spatial pattern of cell production in the developing retina of Xenopus have been made using 3H-thymidine labelling and colcemid blockade of mitosis. Reconstructions were made from serial sections showing the position of every mitotic figure in the retina. After stage 54 the number of mitotic figures decreases at the dorsal margin of the retina and increases at the ventral margin. The ventral:dorsal ratio of mitoses reaches 10:1 by metamorphosis. Density of mitotic figures is maximum at the point of entry of the ophthalmic vessels at the ventral margin. In spite of asymmetrical production of retinal cells the cell density remains constant throughout the retina, probably as a result of displacement of retinal cells dorsally to compensate for the relatively greater proliferation ventrally. It is also proposed that the asymmetrical retinal growth serves to maintain the relationship between each point in visual space and corresponding points in the two retinae as the eyes are displaced dorsally on the head during metamorphosis.


Influences of thyroxine on cell proliferation in the retina of the clawed frog at different ages. The change in spatial pattern of retinal cell production that occurs after midlarvae stages in Xenopus is shown to occur because of a greater proliferative response to thyroxine in the ventral than in the dorsal margin of the retina. The asymmetry of retinal cell production is not caused by a dorsoventral difference in the duration of the mitotic cycle. It is concluded that the asymmetry is due to differences in the number of proliferative cells in different parts of the retinal margin.


Patterns of cell proliferation in the developing retina of the clawed frog in relation to blood supply and position of the choroidal fissure. The pattern of retinal vasculative is described and the position at which cell proliferation at the ventral retinal margin is maximal was shown to be at the point of entry of the ventral blood vessels. To test whether there is a causal relation between retinal blood supply and retinal cell production, surgical inversion of the eye, transplantations and excisions of retina were done to change the pattern of retinal vasculature. The growth pattern of inverted eyes was normal with respect to the internal axes of the eyes. After excision of part of the retina or after fusion of retinal fragments to form compound eyes, the pattern of retinal cell proliferation was not correlated with the distribution of retinal blood vessels, but was correlated with the position(s) of the choroidal fissure(s).


The time of origin of the mesencephalic trigeminal neurons in Xenopus. Time of origin of the mesencephalic trigeminal cells (MTC) in Xenopus 'has been studied with 3H-thymidine autoradiography. The first MTC's were formed at stage 20, and they continued to arise up to stage 58. The mitotic rate of MTC's was found to be ten per cent at any time from stages 20--50, with a slow decrease thereafter. MTC's in the tectum were distributed in a spatio-temporal manner. Cells generated earliest were located in the rostral pole of the tectum and were followed in caudomedial sequence by cells formed later. The generation times of MTC and the neurons of the sensory trigeminal ganglion (TGC) were strikingly dissimilar, indicating that they probably do not represent a common cell lineage, that is, the former may not arise from the mesencephalic neural crest. It is proposed that the majority of MTC's generated from stage 30 onward, derive through proliferative activity of precursor cells in the di-mesencephalic junction and in the tectal neuroepithelium.


Afferent influences on the development of the brain stem auditory nuclei of the chicken: otocyst ablation. The effects of embryonic deafferentation on the morphological development of the avian cochlear nuclei, n. angularis (NA) and n. magnocellularis (NM), were investigated. The right otocyst was surgically removed from chick embryos at 55 to 60 hours of incubation and the subsequent development of total volume, neuron number, and neuron cross-sectional area were studied with quantitative methods in animals sacrificed at 2-day intervals between embryonic days 9 and 19 and at 28 days posthatching. The development of NA and NM is severely affected by otocyst ablation. Between embryonic days 9 and 19, a large group of NA neurons in the medioventral portion of the nucleus on the operated side moves to an ectopic ventromedial position, while the remainder of this nucleus stays in its normal dorsolateral position. Beginning about day 13 of incubation, the normal increase in the volume of NA and the size of its neurons becomes progressively retarded and 40% of its neurons are lost. The growth of NM is also retarded after day 11 of incubation and the growth of mean neuron size is retarded after day 15. There is a 30% loss of neurons in NM which begins after embryonic day 11. The results indicate the primary cochlear fibers make a critical contribution to the growth and maintenance of their target neurons. The absence of this facilitative influence following otocyst ablation becomes apparent just at the time synapses would normally be formed between the the primary auditory afferents and the brain stem auditory neurons. The abnormal movement of neurons in nucleus angularis to an ectopic position after otocyst ablation suggests that primary auditory afferents may serve to stabilize the position of their target cells within the developing brain.


Electron microscopic evidence of a ventronasal to dorsotemporal variation in fiber size in pigeon optic nerve. Using a uniform sampling method, electron-microscopic examination of pigeon optic nerve revealed a dorsotemporal to ventronasal gradient in mean fiber size. In the dorsotemporal region small, myelinated axons (mean diameter = 0.87 micrometer, S.D. = 0.27) were predominant. Also unique to this region were scattered clusters of fine, unmyelinated fibers. A wider, bimodal spectrum in fiber size (mean diameter = 1.50 micrometer, S.D. = 0.66) was found in the ventronasal region of the nerve. Axons located in the area between these regions possessed a mean diameter of 1.15 micrometer, S.D. = 0.43. This gradient, constant throughout the length of the nerve, resulted from a nasal-to-temporal diminution in size and frequency of large fibers superimposed upon a relatively uniform small fiber base. The total number of fibers within the nerve, excluding those comprising the unmyelinated clusters, was calculated to be approximately 2.3 x 10(6). The overall distribution in fiber size appeared to be unimodal with the peak at 0.75 micrometer and mean diameter = 1.04 micrometer, S.D. = 0.44. Although previous investigators have reported that cross-sectional analysis of pigeon optic nerve revealed a homogeneous distribution in fiber size, the findings of the present study may be more compatable with anatomical and physiological features of pigeon retinotectal organization. These features include visual field acuity gradients, ganglion cell population pattern, and density fields of tectal afferent terminations.


Desmoplastic malignant melanoma: study of a case by light and electron microscopy. This article is a study by light and electron microscopy of a case of desmoplastic malignant melanoma that attempts to resolve the conflict in views regarding the nature of the cells responsible for the desmoplasia associated with this clinico-pathologic entity. On the basis of evidence presented, it is concluded that the cells are dedifferentiated cells of the malignant melanoma with fibroblastic features and probably fibroblastic functions rather than host-engendered fibrolbasts in response to invasive melanoma. The evidence consists of the finding of macular desmosomes between those cells, a feature previously noted in amelanotic and melanotic melanomas, the finding of others by electron microscopy of fibroblast-like cells in spindle-cell squamous carcinomas, and the finding by light microscopy of features of vascular invasion of the malignancy. That the diagnosis of this variant of malignant melanoma by pattern can be made by light microscopy is reaffirmed.


A surgical technique for cosmetic blepharoplasty. A method of blepharoplasty for cosmetic purposes to eliminate superfluous skin and fat from aging eyelids is described in detail. A technique for correct placement of incisions, a method of locating and excising orbital fat, control of bleeding and a safe method of approximating skin flaps are discussed and illustrated.


Understanding the relationship between lateral spread of freeze and depth of freeze. The predictable relationship between lateral spread of freeze and depth of freeze is a keystone concept in the clinical evaluation of "depth dose" of cryosurgical procedures. This relationship can be readily determined and understood by carrying out simple experiments using potato models and checked directly by measurements on patients. When using specialized treatment methods such as the "cone-spray" technique with liquid nitrogen, it is necessary to limit the technique to properly selected cases and to spray the treated surfaces evenly if the predictable ratio of depth of freeze to lateral spread of freeze is to be used.


The combined use of cryosurgery and intralesional injections of suspensions of fluorinated adrenocorticosteroids for reducing keloids and hypertrophic scars. Freezing with liquid nitrogen in the conventional manner of cryosurgery followed immediately by injection of a suspension of a fluorinated adrenocorticosteroid is an effective way of treating keloids and hypertrophic scars. Details of the method are given.


Trichilemmoma.

Trichilemmoma. Trichilemmoma is an uncommon cutaneous neoplasm that originates in the outer hair sheath. We are reporting two cases, one of lobular pattern, the other a massing of cells of the follicular infundibulum. In each case, the clinical appearance was nonspecific and the mistaken clinical diagnosis was basal-cell carcinoma.


A comparison of the asthmatic response to methacholine and exercise. The airway responses to methacholine and to exercise challenges were compared in 45 young adults with asthma. The spirometric response to five minutes of treadmill exercise was first documented. On a separate day methacholine dose-response relationships were determined. All asthmatics had an abnormal response to methacholine, and 36 had an abnormal response to exercise. Methacholine sensitivity and exercise-induced asthma were significantly related (r = 0.69, p less than 0.001), but the relationship was nonlinear; the increased response to exercise related to the logarithm of the methacholine response. Between asthmatics with generally unreactive airways, small variation in methacholine sensitivity was associated with large variations in the severity of exercise-induced asthma; between more responsive asthmatics, there was a smaller effect. It is suggested that exercise-induced asthma is dependent on two factors: a stimulus generated during exercise and a response from abnormal bronchi. The bronchial response may be a limiting factor in asthmatics with less responsive airways.


Basophil chemotaxis under agarose: variability among guinea pig donors and response to sera of different species. Guinea pig basophils were tested against chemotactic factor(s) generated from homologous and heterologous sera. An "under agarose" method of quantitating leukocyte chemotaxis was adapted to measure serum-derived basophil chemotactic factor(s) (BCF). The method was found to be simple, reproducible, and sparing of time and reagents and it provided simultaneous controls. Because of the economy of reagents compared with the Boyden chamber technique, basophils from individual guinea pigs could be studied and were found to be variable in responsiveness. A definite difference in the response of guinea pig basophils to zymosan-activated sera of various other species was demonstrated. Guinea pig basophils responded to zymosan-activated serum from guinea pig and rat but failed to respond to zymosan-activated serum from human, hamster, rabbit, or cow. Optimal conditions were determined for cell numbers, serum activation and dilution, and migration times for studies of guinea pig BCF. The under agarose technique provides a practical alternative to chamber methods for the study of basophil chemotaxis. Although guinea pig basophils do not respond to human serum-derived BCF, the economy of reagents with this technique gives promise toward adaptation of the method to studies of human basophil chemotaxis.


Optimization of parameters in protein nitrogen unit precipitation procedure for allergenic extracts. This work establishes the optimum conditions for the protein nitrogen unit (PNU) phosphotungstic acid (PTA) precipitation procedure for allergenic extracts. The volume of extract analyzed, the dilution of the extract prior to precipitation, the percent PTA in the precipitating solution, the washing of the precipitate, and the volume of concentrated HCl initially added to the extract were optimized, as they were found to be the factors which affected the amount of PTA precipitate obtained. Varying the digestion time, the digestion temperature, and the percent HCl in the 15% PTA precipitating solution did not cause detectable differences in the PNU values of the extracts studied.


Papain-induced asthma--physiological and immunological features. Increasing reports of respiratory disease associated with exposure to papain prompted clinical, physiological, and immunological studies of the supervisor of a meat tenderizer factory who developed asthma after long-term contact with papain dust. His symptoms were worse at work and better on weekends and vacations. Bronchial inhalation challenges produced both immediate and late asthma to papain but not to the other ingredients in the food product. Immunological studies revealed the presence of specific IgE antibodies by direct and passive transfer skin tests and the radioallergosorbent test, and specific precipitating antibodies by immunodiffusion tests. These findings are indicative of a dual type I and III hypersensitivity. Papain acting as an allergen in an occupational setting is a risk factor for eliciting asthma even in a nontropic individual.


Preservation of sexual potency in prostatic cancer patients after 125I implantation. Sexual histories were obtained in 51 men with prostatic cancer and their spouses, before and after pelvic lymphadenectomy and retropubic 125I implantation. The average age of the patients was 64.7 years. Sexual activity was retained in 40 of the 41 patients who were sexually active before operation. Ten patients had been sexually inactive before operation--4 with diminished potency and 6 with complete erectile impotence. Sexual dysfunction was most often pyschogenic. At six months after the operation, 5 of these patients had resumed satisfactory sexual intercourse as a result of reassurance, encouragement and education of the remaining sexual potential. No patient was rendered completely impotent as a result of the procedure. Preservation of sexual potency represents a significant advantage of 125I implantation over other therapeutic modalities in the treatment of localized prostatic carcinoma.


Reduced serum albumin concentration in the elderly: a report from the Boston Collaborative Drug Surveillance Program. The relation of serum albumin concentration to age was assessed in a series of hospitalized medical patients. Those with disease states (e.g., dysproteinemia, renal insufficiency, hepatic dysfunction, malnutrition) potentially associated with abnormal serum albumin levels were excluded, leaving a study population of 11,090 patients. The mean serum albumin concentration fell progressively with each decade of age, from 3.97 gm/100 ml in subjects aged less than 40, to 3.58 gm/100 ml in those aged 80 or older (F greater than 50.0, P less than .001). The percentage of patients with a normal serum albumin level (4.0 gm/100 ml or higher) also decreased progressively with age, whereas the frequency of a low serum albumin level increased with age. Sex, primary diagnosis, blood urea nitrogen concentration, duration of hospitalization, and geographic location of the hospital did not influence the findings. The reduced serum albumin concentration in the elderly could contribute to age-dependent changes in the clinical effects of certain albumin-bound drugs, since pharmacologic activity can be influenced by the extent of albumin binding, in turn related to albumin concentration.


Depression in the elderly.

Depression in the elderly. Depression in the elderly is difficult to classify and may be more of a symptom than a disease entity. The core problem with the elderly is inability to handle multiple losses. Feelings of helplessness and reduced self-esteem are significant. The resultant depression often appears mild but the risk of suicide cannot be ignored. The family physician is the key person in the diagnosis of depression. The close relationship between physical factors and depression may make differentiation difficult. Treatment involves a sympathetic but firm approach, particularly when dealing with the hypochondriacal patient. Regression in the elderly is a serious problem that requires staff teamwork. Reactivation techniques which combat feelings of helplessness and hopelessness are of particular importance. When the patient no longer responds well to appropriate drugs, electroconvulsive treatment may be of value. Family and marital therapy should not be overlooked. The nihilist has no place in geriatric medicine.


Amantadine in senile dementia: electroencephalographic and clinical effects. Nineteen patients with senile brain disease (including 2 with parkinsonian symptoms) were treated with amantadine in an oral dosage of 200--300 mg daily. Seven showed definite clinical benefits such as increased alertness and decreased agitation, and 2 others showed slight benefits. However, in only one instance was the benefit maintained without complications. Toxic effects such as overactivity, anxiety and visual hallucinations were observed in 8 patients. Withdrawal effects (e.g., lethargy and staggering) occurred when amantadine was discontinued. The electroencephalograms (EEGs) of all 19 patients showed a frequency increase, chiefly of occipital alpha activity, and sometimes a return to normal, irrespective of clinical changes. Toxic side effects were associated with particularly prominent EEG acceleration. In 10 of the 19 patients, the clinical changes were further validated by by additional psychologic assessments. Although the value of amantadine is limited when given in this way to patients with senile brain disease, it seems important to observe its effects in drug combinations aimed at correction of neurotransmitter imbalances.


Religious motivation in middle age: correlates and implications. The purpose of this study was to determine the relative relationship of self-rated health, age, sex, race, three measures of self-concept (actual, appearance, and ideal), education, occupation, and locus of control to religious motivation in middle age. The subjects were 301 men and women between the ages of 45 and 65 years from 22 randomly selected United Methodist churches. The results of the study show that factors reflective of the process of acculturation such as sex, ideal self-concept, and locus of control maintain the strongest relationship with religious motivation. Women, persons who have high idealized self-concepts, and adults who believe that what happens to them is under their personal control are less likely than others to be extrinsically motivated or to show a "self-centered" dependence upon religion. Consequently, the findings suggest that an important relationship may exist between the "comfort" or "challenge" functions of religion and spiritual well-being in later life for middle-aged groups.


Social interaction and life satisfaction: an empirical assessment of late-life patterns. Problems of social and psychological adjustment in later life have been examined by numerous investigators. Some have found positive relationships between social interaction and personal adjustment, while others have found interaction and adjustment to be unrelated. The purpose of the research reported here was to examine how different ways of measuring interaction may affect its relationship with personal adjustment. Data were obtained in interviews with 218 noninstitutionalized persons aged 70 and older. Findings indicate that both the number of persons interacted with, and the frequency of this interaction, are of little importance for the adjustment of older people. We suggest that the quality, rather than quantity, of social interaction is crucial to understanding adaptations to old age.


Age-related changes in reproductive hormones and in Leydig cell responsivity in the male Fischer 344 rat. Age-related changes in testicular responsiveness to pituitary hormone stimulation were measured in Fischer rats. Suspensions of dispersed Leydig cells were prepared from the testes of groups which were 5, 12 and 29 months old. The suspended cells were challenged with 250, 750 and 2000ng Monkey-LH (LER 1909-2) for two hours and the medium subsequently assayed for testosterone. Concentrations of the hormone were determined per million cells in suspension. Besides measurement of testosterone production by each age group, pituitary and plasma LH, FSH and prolactin, and plasma testosterone were also assayed by radioimmuno-technique. Total testis weight increased in the oldest animals as the result of a high incidence of gonadal pathology. If tumorous tissue was excluded, however, testis weight fell for this group. Also, significant decreases in Leydig cell number were apparent in 12 and 29-month-old rats. Basal testosterone production, on a per million cell basis, however, was not significantly differnet in young and middle-aged rats, nor was the change in the amount of steroid produced by LH stimulation of the isolated Leydig cells. Seminal vesicle weight, prostate weight and serum testosterone decreased with age. Similarly, pituitary LH and FSH concentration decreased, but pituitary prolactin increased. Histological changes and pituitary hypertrophy reflected this increase in prolactin concentration. It is proposed that decreased testicular function in old age may not totally be the result of a decrement in Leydig cell steroid producing capacity, but that it may also occur due to Leydig cell loss, possibly as the result of age associated changes in the brain and pituitary.


Patterns of change in selected serum chemical parameters of middle and later years. Six serum constituents known to vary with renal function were analyzed in a probability sample of 500 persons 55 years and over, and their sex trends compared to other ages. Creatinine, BUN and alkaline phosphatase are elevated in this group whereas calcium is low and phosphorus strikingly so, especially in males. A possible explanation lies in age-related renal parenchymal changes which influence both glomerular filtration and tubular functions in ways that differ from true renal disease. These results have directed implications for geriatric diagnosis and therapy.


Geriatric evaluation unit of a medical service: role of a geropsychiatrist. Psychiatric evaluation as a part of the complete geriatric workup was done on 143 consecutive patients transferred to a Medical Geriatric Evaluation Unit. The patients' age ranged from 48 to 94 years. The findings were: free of psychiatric problems--19.1%; organic brain syndrome--58.8%; dysphoria-depression--36.8%; paranoid--3.7%; alcohol abuse--8.1%; marital maladjustment 18.3% (of marrieds). The Geropsychiatrist diagnoses, participates in psychiatric management, consults, and supervises psychiatric evaluation by other team members. He is an esential member of the Geriatric team since proper recognition and treatment of psychiatric problems is necessary to complete treatment and to make optimum disposition.


Perception of age in the elderly.

Perception of age in the elderly. One hundred-fifty persons age 65 and over who identified themselves as feeling younger, or as old or older than their age, were studied in terms of seven dependent variables describing psychological functioning. Younger age perceptions were associated with better psychological functioning in Blacks and whites as well as in males and females. This was true even when social class, disability, and impairment were controlled. The variable which discriminated best between perceived age groups was locus of control, with more internality being associated with younger age perceptions.


Adult age and the rate of an internal clock. Two experiments were conducted to determine whether young and old adults differ in the rate of a hypothetical internal clock. Clock rate was measured as the slope of the function relating actual duration to perceived duration. No age differences were apparent when subjects were asked to judge the duration of a flash of light in Exp. I, or to judge the duration of a dark interval between two light flashes in Exp. II. It was concluded that there is no evidence to support the hypothesis that perceptual and motor speed differences associated with increased age can be attributable to a slower rate of internal time.


Adult age differences in false recognitions. Adult age differences in the depth of processing in recognition memory were examined for the three groups with mean ages of 19, 45, and 70 years. Subjects were tested for phonological and semantic false recognitions with a continuous recognition memory procedure using both moderate (4 sec) and slow (8 sec) presentation rates. Both middle-aged and elderly subjects displayed a greater false recognition effect for both rhymes (phonological) and synonyms (semantic) of previously presented items than did young adults. Thus, there appeared to be little, if any, age-related deficit in depth of processing as defined on a sensory-semantic dimension. On the other hand, middle-aged and elderly subjects correctly recognized fewer of the previously presented (i.e., old) items than did the young adults. Age-level differences in retention of old item information were viewed as reflecting differences in the extent of elaboration within a processing domain. Rate of presentation did not affect either processing depth as measured by false recognitions, or memory per se as measured by the recognition of old items.


Memory loss and response bias in senescence. Recognition memory was studied in young and elderly women by assessing memory strength and response bias using Signal Detection Theory methodology. Young women (mean age 21 years; n = 8) had better recognition memory (d' and d'e) than did elderly women (mean age 71 years; n = 16) but the groups did not differ significantly on correct recognitions (hit rate) or incorrect recognitions (false affirmative rate). Evaluation of response bias indicated that the elderly women adopted a lax response strategy which resulted in an inflated correct recognition rate. The data indicate that, in aging research, evaluation of memory in terms of correct and incorrect recognitions can lead to erroneous interpretations, due to uncontrolled bias effects. Age does adversely influence recognition memory strength suggesting that acquisition and/or storage processes are not invariant with age.


Decreased discrimination of food odors in the elderly. Sixteen young students, aged 19-25, and 16 healthy elderly subjects, aged 72-78, rated the odor similarity for all 91 combinations of pairs of 14 commercial food flavors. Hedonic ratings were also obtained. Two multidimensional scaling procedures, INDSCAL (Carroll & Chang, 1970) and SSAI-MINISSA (Guttman, 1968; Lingoes, 1965), were applied to the similarity data, yielding flavor spaces or maps which  were similar to one another. INDSCAL, an individual difference model, provided weights for each subject on each of the dimensions of a multidimensional space common to all subjects; the weights indicated that the young subjects, but not the elderly ones, were well represented by the common multidimensional arrangement with some idiosyncratic stretching along the axes. The weights and individual subject spaces suggested that the ability of subjects to judge qualitative odor differences between food flavors may decrease with age. Elderly subjects were best at discriminating fruits from the rest of the stimuli.


Dimensions of adult self-concept.

Dimensions of adult self-concept. A 70-item adjective checklist was administered to four groups of adults as part of a longitudinal study of psychosocial change during four normative transitions. Data gathered at two times with a five-year interval were cluster analyzed separately. Six clusters were extracted from the first set of data, 7 from the second, with minor changes in dimensionality: all 6 original clusters had counterparts in the second analysis, but some dimensional change was seen in all but one cluster. The argument is made that although such dimensional change is often treated as error or completely ignored in longitudinal research, this inattention can lead to serious problems in the interpretation of results.


A causal model of life satisfaction among the elderly. A path analysis model of life satisfaction is proposed and applied to data from interviews with 141 persons aged 60 years and over. Predictor variables examined are self-reported health, income, education and an activity index. The analysis was conducted separately for the two sexes. Health and activityemerge as strong predictors of life satisfaction while income influences life satisfaction indirectly via activity. The importance of investigating direct and indirect effects of variables via path analysis is discussed.


Longevity and age exaggeration in Vilcabamba,  Ecuador. Systematic age exaggeration was found after age 70 in an Equadorian population noted for extreme longevity. Extreme ages (over 100 years) were either incorrect or unsubstantiated. There was no evidence of increased longevity in the Vilcabamba population.


Recall and reliability of interview data from older women. Retrospective fertility histories were collected from a purposive sample of 211 white, ever-married women, residing in four metropolitan areas of the USA and belonging to the birth cohorts of 1901-1910. At the time of interview, these women were aged 66 to 76. A random sample of 50 of the original respondents was reinterviewed by telephone on selected topics from the questionnaire. Responses to questions on dates and numbers of marriages, as well as births and other fertility events were coded to show whether the responses were exact, estimated by the respondent, or calculated by the editors. Respondents provided exact answers to an average of 90% of the questions they were asked. Reliability ratios, which were calculated for the above variables as well as ever-use of contraceptive methods, were comparable with those observed in previous studies of women in the childbearing years.


Blood vessel transplantation to bone.

Blood vessel transplantation to bone. In dogs an artery, a vein, and a vascular bundle were transplanted into intact bone, isolated bone segments, necrotized bone, and homografts of bone. Active proliferation of new blood vessels and formation of new bone occurred in all instances where the vascular bundle was used, when the vein was implanted into the intact bone and isolated bone, and only when the artery was implanted into intact bone. As a result of these experiments, vascular bundle transplantation has been performed in patients with Kienboeck's disease, and avascular necrosis of the scaphoid, the femoral head, the talus, and other conditions.


The intrinsic vascularization of human peripheral nerves: structural and functional aspects. A combination of microangiographic and histological methods was used to analyse the intrinsic microvascular system of human peripheral nerves of freshly amputated arms. Special attention was paid to perineurial and intrafascicular vascular systems. The human nerves present a microvascular system analogous to the intraneural system of experimental animals. The fascicles are vascularized segmentally by epineurial vessels, and each fascicle presents a well-defined fascicular vascular organization composed of endoneurial and perineurial microvascular systems in combination. The possible effects of intraneural dissection on intrafascicular blood flow are discussed. It is suggested that intraneural dissection produces considerable trauma to the nerve and an inflammatory reaction in extrafascicular layers, but that due to the barrier function of the perineurium the effects on intrafascicular tissues can be limited.


Median nerve entrapment syndrome in the proximal forearm. Median nerve compression in the proximal forearm is relatively uncommon. This study reviews 71 cases over a 20 year period. Of the 71 in this series, 51 were treated surgically. The time of onset to definitive treatment ranged from 6 months to 5 years, with an average of 9 months. The ages of patients varied from 15 to 56 years and there were 13 males and 58 females. Past criteria for making the diagnosis are reviewed and an added series of clinical observations is made, including three definitive stress tests. In all cases surgically treated compression of the median nerve has been found at one of three levels, in the following order of frequency: the pronator teres, the flexor superficialis arch, and the lacertus fibrosus. Follow-up has been from 6 months to 19 years and four cases in the series were considered to be failures.


The radial tunnel syndrome.

The radial tunnel syndrome. Twenty patients with symptoms present for an average of 21.1 months and who in most cases had been treated by several conservative techniques for chronic tennis elbow were diagnosed as having radial tunnel syndrome, as originally described by Roles and Maudsley. Release of the tunnel was followed by eventual relief in 19 instances (95%).


Digital clubbing: a unique case and a new hypothesis. A study of a unique case of unilateral digital clubbing secondary to a true posttmaumatic aneurysm of the ulnar artery in the palm is presented. The clubbing of the digits resolved following resection of the aneurysm. Detailed evaluation of the patient included Doppler flow studies, differential pulse pressure recordings, measurement of reactive hyperemia, angiography, and differential capillary blood gas determinations. The contralateral hand of this otherwise healthy young patient was employed as a control. Findings of increased blood flow, decreased peripheral resistance, and increased oxygenation then were evaluated in light of the findings of other investigators. This study and the information gathered from an extensive review of the literature strongly suggest that a neurocirculatory reflex is the common denominator of the various conditions associated with clubbing. The afferent and efferent limbs of this reflex are proposed.


Open complex metacarpophalangeal joint dislocation. Two cases: index finger and long finger. Two patients with open complex dislocation of a metacarpophalangeal joint were treated by cleansing of the wound, open reduction, primary wound closure, and early motion. One dislocation occurred in the index finger, the other in the long finger which is only the second such case to be described. Antibiotics were given before and continued for 5 days after operation. There were no infections, and both patients regained an excellent range of motion without pain.


Anomalous tendon slips from the flexor pollicis longus to the flexor digitorum profundus. Anomalous tendon slips from the flexor pollicis longus to the flexor digitorum profundus are described. Clinical examination of 194 patients suggests that the anomaly is present in at least one extremity of 31% of individuals and in both extremities in 14%. Dissection of 43 cadavers demonstrated the anomaly in at least one extremity of 25% and in both extremities of 6%. Four cases are described in which the anomaly probably was responsible for chronic tenosynovitis. The anomaly was excised surgically in all cases.


The dorsal ganglion with anomalous muscles. Either an anomalous extensor indicis proprius muscle or an extensor digitorum brevis manus may coexist with a dorsal wrist ganglion. To assure relief of symptoms, treatment must include division of the fourth dorsal extensor compartment in the case of the former muscle, and excision in the case of the latter.


Restoration of elbow extension power in the tetraplegic patient using the Moberg technique. In tetroplegic patients extensor power can be restored to the elbow by transferring the posterior deltoid muscle to the triceps aponeurosis. Thirteen patients representing 14 posterior deltoid muscle transfers were evaluated 13.8 months later. Using a 0 to 5 muscle grading system, the average preoperative muscle grade for elbow extension power was 0.5. After operation the average had increased to 3.6. All patients were satisfied with their results and noted a significant improvement in the activities of daily living. In no case was there a loss of preoperative functional capacity.


Herpetic whitlow: herpetic infections of the digits. Ten cases of herpes simplex infections of a digit were observed during a 3 year period. The diagnosis was confirmed in seven cases by culture or tests of serum antibodies. In three cases the clinical characteristics were sufficient to suggest the diagnosis. Medical and dental personnel are particularly prone to develop this affliction; their occupations are a frequent clue to the diagnosis. Nonsurgical treatment of this self-limited entity is recommended.


Visualizing the marrow granulocyte reserve. The MGR, the pool of band and segmented neutrophils from which sudden demands for extra blood neutrophils are met, has been studied by measuring blood neutrophil increments following administration of endotoxin, corticosteroids, or etiocholanolone. Alternatively its size may be estimated from marrow differential counts with or without estimates of marrow mass. In 34 studies of 31 patients with diverse causes of neutropenia, measurements were made of the MGR comparing endotoxin response and differential counts of marrow aspirates coupled with estimates of absolute marrow mass derived from EIT rate. Responses to endotoxin were normal in 10 studies and subnormal in 24. The factor which best predicted endotoxin response was the percent of marrow neutrophils and neutrophil precursors which were band and segmented forms. All responders to endotoxin had greater than 25% marrow neutrophils and neutrophil precursors that were band and segmented; 20 to 21 subjects with less than a normal response to endotoxin had  less than 25%. These studies suggest that no further information is gained by measuring endotoxin response in neutropenic patients who have a reduced percent of band forms and segmented neutrophils in marrow aspirates.


The dilute whole blood clot lysis assay: a screening method for identifying postoperative patients with a high incidence of deep venous thrombosis. A dilute whole blood clot lysis assay was used to identify patients with a high incidence of DVT. Of 191 orthopedic and urologic patients who underwent surgery, the over-all incidence of DVT as determined by 125I-fibrinogen leg scan was 35% in the 92 individuals with abnormal assays and 1% in the 99 patients with normal assays. The likelihood that an individual patient might have developed DVT increased progressively with the number of abnormal assays (p less than 0.001). The incidence of DVT increased from 28% in patients who had one abnormal assay, to 35% in patients with two abnormal assays, to 56% in patients with three abnormal assays. These studies establish the clot lysis assay as a simple means to screen for patients with a high incidence of DVT. A normal assay can eliminate patients from consideration for more extensive studies (venography, fibrinogen scan, impedance plethysmography), whereas those patients with one or more abnormal assays should be seriously considered for these additional studies.


Shape-changing agents produce abnormally large platelets in a hereditary "giant platelets syndrome (MPS)". Geometries of platelets in citrated PRP obtained from normal donors (17) and donors (5) with a hereditary dominant giant platelet syndrome, herein referred to as "Montreal platelet syndrome" (MPS), are compared. The measured geometric axial ratio (rp = thickness/diameter) is used to classify platelet morphologies into three groups: discocytes (rp less than 0.5), disco-echinocytes (rp = 0.5 to 0.9), sphero-echinocytes (rp greater than 0.9). MPS discocytes are normal sized; however, MPS sphero-echinocytes and disco-echinocytes have mean volumes approximately two times larger than normal. It is demonstrated that these larger-than-normal sized MPS platelets can be produced directly from MPS discocytes by treatment with agents known to induce platelet shape change (adenosine diphosphate, thrombin, and incubation at 4 degrees C). Treatment of platelets obtained from normal donors which have been resuspended in MPS PPP and ADP or incubation at 4 degrees C causes the formation of normal-sized disco-echinocytes and sphero-echinocytes. The diameters of MPS disco-echinocytes are identical to the diameters of MPS platelets observed on peripheral blood smear, whereas those of MPS sphero-echinocytes are approximately 20% lower. It is suggested that the appearance of abnormally large platelets in MPS is related to a defect in the mechanism which regulates platelet size and shape during shape change.


Biochemical quantitation of the chemotactic factor inactivator activity in human serum. CFI of whole human serum was measured by a new assay that utilizes chemotactic factor-induced release of a lysosomal enzyme (N-acetyl glucosaminidase) from cytochalasin B-exposed neutrophils as an index of chemotactic activity. The effectiveness of serum as an inactivator of chemotactic factor-induced enzyme release closely correlated with the serum CFI as determined by assay of neutrophil chemotaxis in Boyden chambers. In comparison to serum from healthy persons, there was elevated CFI in the serum from patients with sarcoidosis and Hodgkin's disease by both assay systems. The results indicate that measurement of serum inhibition of chemotactic factor-induced lysosomal enzyme release from neutrophils provides a rapid, reliable, and reproducible assay of serum CFI. (J Lab Clin Med 93:17, 1979.)


Serum isoamylase measurements in pancreatitis complicating chronic renal failure. This investigation was designed to determine whether serum isoamylase measurements can aid in establishing the diagnosis of acute pancreatitis in renal failure patients. Twenty-two hemodialysis patients were studied, four of whom had documented acute pancreatitis. Total serum amylase and pancreatic isoamylase concentrations were significantly higher (p less than 0.02) in the pancreatitis patients than in the 18 patients without pancreatitis, but there was appreciable overlap between these two groups. In each of the four patients with pancreatitis, the percentage of serum amylase derived from the pancreas (range, 80% to 90%) was well above the highest value (67%) observed in the patients without pancreatitis. These results suggest that determination of the percentage of serum amylase represented by pancreatic isoamylase is of assistance in establishing the diagnosis of acute pancreatitis in renal failure patients.


The effect of prostaglandin-synthesis stimulation and blockade on sodium excretion at a fixed renal perfusion pressure. PGE synthesis was increased by an infusion of AA and decreased with indomethacin or carpofen. Intrarenal infusions of arachidonate increased RBF from 222 +/- 37 to 275 +/- 51 ml/min (p less than 0.05) and UNaV from 85 +/- 23 to 121 +/- 32 muEq/min (p less than 0.05), with renal vein PGE increasing from 0.41 +/- 0.08 to 1.81 +/- 0.69 ng/ml (p less than 0.05). However, when renal perfusion pressure was reduced and maintained constant at 82 +/- 4 mm Hg during the AA infusion, RBF, and UNaV did not change, 185 +/- 26 vs. 178 +/- 21 ml/min and 10 +/- 3 vs 8 +/- 3 muEq/min, respectively, although renal vein PGE increased from 0.8 +/- 0.2 to 1.95 +/- 0.52 ng/ml (p less than 0.05. During Pl with indomethacin, 2 mg/kg, RBF fell from 210 +/- 27 to 120 +/- 16 ml/min (p less than 0.05), and UNaV diminished from 39 +/- 6 to 22 +/- 10 muEq/min (p less than 0.05), as renal vein PGE decreased from 0.37 +/- 0.04 to 0.19 +/- 0.03 ng/ml (p less than 0.05). When renal perfusion pressure was reduced and maintained constant at 90 +/- 2 mm Hg, renal vein PGE fell from 0.72 +/- 0.29 to 0.20 +/- 0.08 ng/ml (p less than 0.05), whereas RBF and UNaV were unchanged during Pl, 172 +/- 20 vs. 166 +/- 30 and 33 +/- 15 vs. 28 +/- 11, respectively. The results indicate that the change in sodium excretion with variation in prostaglandin synthesis is best explained by concomitant changes in RBF.


Case mix in a primary care teaching practice for two clerkship schedules. Student-physicians saw patients from assigned families at primary care training sites either one or two half-days a week. These practice conditions caused a skewing of diagnoses away from seeing acute conditions. Students who saw patients two half-days a week made 21 percent fewer acute care diagnoses than were made in the practice. Those students at the clinical site one half-day a week saw 28 percent fewer acute disease diagnoses. Accordingly, there was an increase in the percentage of chronic disease and health supervision diagnoses in the case mix of these student-physicians. This part-time scheduling of students at the training sites was related to a disruption in continuity of care for the patient. While a little less than half of acute illness care was performed by student-physicians, over two thirds of chronic disease diagnoses were made by these once-or-twice-a-week trainees. Almost nine tenths of health care supervision was accomplished within the trainees' twice-a-week schedule.


The after-hours call: a survey of United States family practice residency programs. This article reports the results of a 1977 survey of 245 family practice residency programs providing after-hours care. The objectives of the study were: (1) to clarify the involvement of family practice residents in this aspect of medical care; (2) to investigate the organization of after-hours care in the family practice centers as a possible training model for future family physicians; and (3) to establish whether or not specific educational activity was based on after-hours calls. All the responding operational programs provided after-hours care to patients, using all levels of residents as providers. Most of the programs used an answering service. Only 67 percent documented all patient encounters in writing. Regular educational feedback to residents was undertaken by 71 percent of the residency programs.


Diagnostic vocabulary for primary care.

Diagnostic vocabulary for primary care. The diagnostic vocabulary of a clinician appears to be specific and measurable for each clinical discipline. The diagnostic vocabulary of 11 primary care physicians over four-years' work has been analyzed. For every 1,000 patients cared for, each physician made, on average, 2,691 diagnoses every year, representing a diagnostic vocabulary of 475 different clinical entities. This vocabulary has been analyzed according to frequency of usage and clinical decision making. The clinical, teaching, and administrative implications of this analysis are discussed.