Female alcoholics. IV. Marital situation and husbands. Little research on the husbands of alcoholic women has been reported. A few studies have shown that they often are alcoholics or are suffering from other psychiatric diseases. The present study describes 51 men, married to female alcoholics, as regards alcoholism, other psycho-social disturbances and mortality, and accounts for the marital situation after an observation period of 6-12 years. A comparison is made with a control group of married male alcoholics. About 50% of the husbands were shown to be alcoholics, 14% had been treated for psychiatric diseases and more than 10% were disabled due to somatic diseases. At the end of the observation period, one-third of both patient groups were still married, one half of the male and one-third of the female patients were divorced. Twenty per cent of the marriages among the male patients and 35% of those among the female patients had been terminated by death. Ten female alcoholics and 14 husbands died, which is a significant excess mortality for both sexes. Mortality among the husbands was higher than expected due to cirrhosis of the liver and diseases of the circulatory system.


Evidence that depression rating scales primarily measure a social undesirability response set. Many popular methods of measuring depression have not been adequately validated for discriminant validity from social desirability. In a study of 26 patients, 14 with secondary depression, and 12 nondepressives, it was shown that the commonly used Beck Depression Inventory and MMPI Depression scale and the Carroll self-administering version of the Hamilton scales correlate as highly with social undesirability as with each other. Social desirability ratings of item alternatives on the Beck and Hamilton scales by 12 normal students showed the depth of depression to be significantly related to social undesirability response scores. The difficulty of distinguishing depression and social undesirability response set was discussed and it was suggested that "low self-esteem" may be all that is measured by the rating scales used in this study.


Verbal tests and transsexualism.

Verbal tests and transsexualism. Gender discriminating vocabulary tests administered to a consecutive series of 53 male transsexuals show different results. The Slater Selective Vocabulary Test, Cohen's factors and the Terman-Miles Attitude Interest Analysis Test (M-F) show male transsexuals to have a higher degree of feminization than normal controls. The Wechsler-Bellevue Vocabulary Test and the Wechsler M-F Test are difficult to interpret, and do not show a clear trend of feminization in transsexual males. The investigation has shown that male transsexuals have a vocabulary which differs from that of normal males in the direction of greater feminization.


Experience of father and later relations to men. A systematic study of women's relations to their father, their partner and their son. Using data from a longitudinal, prospective study of 69 women, their partners and first-born children, the woman's description of her parents was compared with her report about her relationships to her partner and child. Information was independently collected from partner and child. The woman's way of relating both to her partner and to her son was more strongly connected with her report about her early paternal than with her report about her early maternal contact. The woman's experience of her father was related to her way of interacting with her child in the case of a son but not in the case of a daughter. Thus, the specific importance of a woman's image of her father for her way of relating to other significant males was emphasized.


Influence of deaf-mute parents on the character of their offspring. Hearing children raised by deaf-mute parents suffer severe communication problems with their environment from the very moment of their birth. Later on feelings of alienation may ensue. Such conditions may influence the personality of offspring of deaf-mute people. A detailed representative case report of a patient with borderline personality is reported. The patient was a daughter of a quite typical deaf-mute couple. An attempt to relate some of her main characteristics and mechanisms of adaptation to factors in her early childhood is described.


Increase in weight after treatment with depot neuroleptics. A trial has been performed investigating changes in weight in 99 female patients who have been treated with clopenthixol decanoate or perpehnazine enanthate after prior treatment with different oral neuroleptics. We found a significantly higher mean weight after the oral treatment period and a slight, but not statistically significant, further weight increase after the following depot period. In addition the rate of increase in weight was significantly lower during the depot treatment period. These increases might be due to achievement of a steady-state in weight during the first treatment period with oral intake. We found no difference between clopenthixol decanoate and perphenazine enanthate as regards change in weight or rate of change in weight.


Vitamin B12 concentrations in psychiatric patients. In an attempt to evaluate the possible relationship between vitamin B12 deficiency and mental disease, the blood content of vitamin B12 was investigated in 835 consecutive psychiatric patients. Low serum vitamin B12 values were found in approximately 10% of these patients, due to latent pernicious anaemia in one case, post-gastrectomy in seven cases and small intestinal resection in one case. In the remaining 72 cases vitamin B12 deficiency was probably caused by nutritional insufficiency. After correction of the dietary defect there was a spontaneous increase in serum vitamin B12 in 75% of these patients. No specific psychiatric syndrome was connected with hypovitaminosis B12, but a preponderance of arteriosclerotic dementia suggests that low serum vitamin B12 values are secondary to mental illness leading to apathy and loss of appetite. Most cases will recover without further vitamin B12 supplements. But some patients may need treatment because of severe mental and physical disabilities.


Psychiatric examination of all eight adult males with the karyotype 46,XX diagnosed in Denmark till 1976. Psychiatric examination has been made in all eight adult males with the karyotype 46,XX diagnosed in Denmark til 1976. Apart from emotional immaturity in most probands, no psychopathological traits were found, except in one who had neurotic symptoms. They were all of normal intelligence and socially well adjusted. All had male psychosexual orientation, but weak sexual libido and potency were found in the oldest probands. In several respects males with 46,XX differ from Klinefelter males with the karyotype 47,XXY, and the reasons for this are discussed.


Seasonal births in schizophrenia. A southern hemisphere study using matched pairs. Season of birth of schizophrenics was investigated by comparing 915 carefully selected schizophrenic patients with controls matched for age and sex. While the winter-spring excess of schizophrenic births was similar to Northern Hemisphere findings, further examination of data revealed a new feature: a striking excess of male schizophrenic births for the decade 1915--24. The hypothesis of differential resistance to infection is discussed as an explanation for these findings.


Effect of naloxone or levallorphan on serum prolactin concentrations and apomorphine-induced growth hormone secretion. Naloxone HCl (0.8 mg intravenously; n=9) or levallorphan tartrate (0.25 mg subcutaneously; n=5) had no effect on basal prolactin or growth hormone secretion in normal men. Neither narcotic antagonist inhibited the growth hormone secretory response to apomorphine HCl (0.75 mg subcutaneously). These findings suggest that narcotic antagonists do not block dopamine receptors in the hypothalamic-pituitary axis in man and that if these agents have antischizophrenic properties then these are not mediated by dopamine receptor blockade.


Psychiatric assessment of healthy children with various EEG patterns. A sample of 222 health children, 112 girls and 110 boys, aged 5--16 years, with different types of EEG pattern, were investigated by current child-psychiatric methods. The children were recruited from a large material of children selected in accordance with strict criteria of normality from the paediatric and neurological points of view (Petersén & Eeg-Olofsson (1970/71)). The aim of the child-psychiatric assessment was to find out whether any clinical correlation with the EEG patterns could be shown. First of all, 96 children with some form of EEG deviation were included. Besides these, 126 children with normal EEG were recruited at random from the material. In this selected material significant relations emerged between clinical variables and EEG patterns. Normal EEG showed negative correlations with child-psychiatric variables, while deviating EEG patterns were positively correlated. Many of the correlations disappeared in the oldest age group.


Depression and homicide. A psychiatric and forensic study of four cases. Four examples of homicide followed by attempted suicide are presented based on the psychiatric examinations prepared for the use of the courts. Three cases were suffering from unbearable states of endogenous depression and the fourth showed a serious chronic neurotic depression following an acute grief reaction before and during homicide. The relationship between depression and homicide is discussed from the standpoint of clinical psychopathology. Criminal responsibility of these cases is also discussed.


Elective mutism.

Elective mutism. Eleven children who had received a diagnosis of elective mutism upon admission to the children's psychiatric clinic, were followed up 8--18 years later. The average age upon admission was 9 1/2 years, and at the time of follow-up, 23 years. Nine of the children came from homes with a strong familial shyness and reservation, and eight lived in social isolation. Six were particularly overprotected. Six came from discordant family constellations. All were diagnosed neurotic, eight specified as compulsion-neurosis. All were of normal intelligence. Six children received extensive individual psychotherapy (four upon admission to the clinic, two by way of out-patient treatment). We were unable to offer similar treatment to the remaining five. During the course of treatment three of the admitted patients improved, the fourth and the two ambulatory patients remained unchanged after up to 4 years of therapy. The follow-up study showed the three unchanged patients and the five who had received treatment, now were cured of the symptom; improvement took place in connection with a change of environment. The five who had not received treatment were better adjusted than those who had been separated from home for several years, at a vulnerable age. The importance of early prophylactic intervention is emphasized.


Propranolol and newer antihypertensive drugs in the management of hypertension. Among the newer antihypertensive agents are the beta-blocking drugs, such as propranolol. These agents are useful as second-step drugs to be used if diuretic therapy alone is not effective. In mild to moderately severe hypertension, propranolol, in does of up to 480 mg/day in combination with a thiazide diuretic, has been found to be effective in over 80% of patients on long-term therapy. This degree of response is essentially similar to that noted with a combination of reserpine and a diuretic agent. Although some observers believe that propranolol produces many fewer side effects than the other step 2 drugs (reserpine and alpha-methyldopa), there are some patients who do experience restlessness, insomnia, and depression. Clonidine may be substituted for another step 2 drug, is of moderate potency, but may not be tolerated by a large number of patients because of the severe dry mouth and drowsiness that it produces. Prazosin appears to be a suitable substitute for hydralazine as an effective vasodialator if thiazides plus propranolol or thiazides plus reserpine or alpha-methyldopa are not effective. In some instances, it many be an acceptable second-step drug because of its alpha-adrenoreceptor-blocking properties. The angiotensin II competitive inhibitors or converting enzyme inhibitors may in the future have some place in the management of hypertension.


The risk of diagnostic cardiovascular catheterization. This report details a prospective study of the risk of diagnostic cardiac catheterization performed in a private, community hospital. Over the first 131 months of operation of our laboratory, 745 adult patients underwent diagnostic cardiac catheterization consisting of 2,676 various catheterization procedures. Six patients experienced seven major complications; two of these complications left a permanent deficit. There were no deaths during catheterization and none later which were attributable to it. The risk to the patient of having a major complication associated with a cardiac catheterization in our series was 0.8 per cent. The risk to the patient of having a major complication when a catheterization procedure was performed was 0.3 per cent. The risk of having a complication resulting in a permanent sequela was 0.07 per cent. We conclude that diagnostic cardiac catheterization can be accomplished with little risk to the patient, either of death or of other major complication.


Propranolol withdrawal in angina pectoris: a prospective study. In a prospective study, 100 consecutive patients (mean age 51.3 years) with angina pectoris had propranolol abruptly discontinued 24 to 144 hours (mean 39.0 hours) prior to elective coronary arteriography. The mean duration of therapy was 8.2 months and the mean daily propranolol dose was 216.1 mg. New York Heart Association Class II, III and IV symptoms were present in 30, 41, and 29 patients and one, two, or three coronary arteries were more than 50 per cent narrowed in 37, 29, and 34 cases, respectively. Three patients experienced minor increases in chest pain and two suffered non-transmural myocardial infarctions prior to the time of scheduled cessation of therapy. The same number of minor and major complications occurred in the post-withdrawal period. All four patients who developed non-transmural myocardial infarction in this study had pre-existing Class IV symptoms. The course of the remaining 90 patients was uneventful. These findings do not support the concept of a rebound propranolol withdrawal reaction.


Incidence of mitral valve prolapse in subjects with thoracic skeletal abnormalities--a prospective study. The incidence of mitral valve prolapse (MVP) in 80 patients with various thoracic skeletal abnormalities (TSA) was examined prospectively using compete history and physical examination, chest x-rays, electrocardiography, phonocardiography, and echocardiography. There were 76 males and four females, ranging in age from 18 to 80 years. Thirty-four patients had narrow anteroposterior diameter of the chest (asthenic habitus) (Group 1), 13 had straight back (Group 2), and 33 had pectus excavatum (Group 3). Twenty-five of the 80 patients (31 per cent) had evidence of MVP, 22 by echocardiographic criteria and three by phonocardiographic criteria. The incidence of MVP in this predominantly male population was substantially higher than that reported in the general adult population. Thoracic skeletal abnormality is an important nonauscultatory feature of mitral valve prolapse syndrome. The association between TSA and MVP may be a manifestation of a single connective tissue defect during embryonic development of the bony thoracic cage and the atrioventricular valves. All patients with TSA, even when asymptomatic, should be screened for MVP by noninvasive investigations. The recognition of MVP in patients with TSA may be of potential value in prevention of life-threatening endocarditis and cardiac arrhythmia.


Cross-sectional echocardiographic spectrum of papillary muscle dysfunction. Cross-sectional echocardiography identified two abnormal patterns of mitral valve closure in 14 patients with mitral regurgitation due to papillary muscle dysfunction: (1) in three patients with an akinetic inferior-posterior wall but normal cavity size, papillary muscle fibrosis was associated with late systolic mitral valve prolapse, and (2) in nine patients with ventricular dilatation or ventricular aneurysm, the point of mitral valve coaptation was displaced towards the apex of the left ventricle. In two of these patients both abnormalities were observed. In contrast, abnormal patterns were identified in only four of a group of 40 patients without angiographic evidence of mitral regurgitation (10, normal; 27, coronary artery disease; three, congestive cardiomyopathy). Thus, cross-sectional echocardiography can be useful to identify mitral regurgitation secondary to papillary muscle dysfunction.


Effect of isoproterenol on regional myocardial perfusion and tissue oxygenation in acute myocardial infarction. The effect of isoproterenol infusion on regional myocardial perfusion and tissue oxygenation during acute myocardial infarction was investigated in anesthetized dogs. Measurements of regional flow with radioactive microspheres and myocardial lactate and adenosine triphosphate from analysis of myocardial biopsies were compared in normal, marginal, and infarcted tissue in dogs with a ligated coronary artery. After 10 minutes of isoproterenol 0.15 microgram/Kg./minute, flow was unchanged in the marginal and infarcted regions, and, although rises occurred in most dogs, changes were inconsistent in the normal regions. In the marginal regions, tissue lactate rose by 5.6 mumoles/g (97 per cent) and adenosine triphosphate fell by 2.4 mumoles/g (46 per cent) after isoproterenol. No consistent changes occurred in the normal or infarcted regions of the dogs given isoproternol or in any regions of control dogs given saline. It is concluded that beta-adrenergic stimulation with isoproterenol increases tissue ischemia in experimental acute myocardial infarction.


Effect of isoproterenol on the "early repolarization" syndrome. A study has been carried out on a group of subjects with RS-T segment elevation, a normal variant of early repolarization. Following isoproterenol administration, the RS-T segment became isoelectric. In most cases this was accompanied by shorter QT and longer QTc intervals. The same effects were observed after physical exertion but not after atropine or amyl-nitrite. Propranolol administration exaggerated RS-T elevation. Considering the mechanism with which isoproterenol acts and some analogies with the electrocardiographic picture experimentally obtained by means of the unilateral stimulation of the stellate ganglions, the hypothesis is advanced that the normal variant of early repolarization is related to an enhanced activity of the right sympathetic nerves.


The effect of exercise on left ventricular ejection time in patients with hypertension or angina pectoris. Using the method and regression equation of Lewis and associates, the present study confirms their findings in normal men up to the age of 65 years. Despite the significantly higher myocardial oxygen consumption, as measured by the double product, the hypertensive patients responded in a similar fashion. The patients with angina pectoris, however, showed a significantly prolonged post-exercise ejection time.


The use of the diving reflex to terminate supraventricular tachycardia in a 2-week-old infant. The use of the diving reflex to terminate a case of paroxysmal supraventricular tachycardia (PST) is described in a 2-week-old infant who presented in severe congestive heart failure with supraventricular tachycardia at a rate of 300. The infant's face was placed in a basin of ice water at 5 degrees C. for 5 seconds with manual occlusion of the infant's nostrils to prevent aspiration. The PST converted to a sinus rhythm of 120 within 3 seconds of facial immersion. The physiology of the diving reflex is reviewed and the uses and hazards of this reflex in terminating attacks of PST in infants is discussed.


Right ventricular infarction. Clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction. Twelve patients with a clinical diagnosis of right ventricular infarction are described. All had acute inferior wall myocardial infarction associated with the bedside findings of jugular venous distension, clear lungs on auscultation, and arterial hypotension. Hemodynamically, there was elevation of right-sided filling pressures not explained by normal or minimally elevated pulmonary wedge pressures. Four patients had an incorrect diagnosis of acute cardiac tamponade. However, a review of the data showed that the hemodynamic features of right ventricular infarction more closely resemble those of pericardial constriction, a point that may be helpful in distinguishing right ventricular infarction from cardiac tamponade. Invasive and noninvasive techniques that exclude the presence of pericardial fluid and suggest enlargement and abnormal contractility of the right ventricle were helpful in establishing the diagnosis of right ventricular infarction in several patients.


Coronary hemodynamic and myocardial metabolic alterations accompanying coronary spasm. Arterial pressure, coronary sinus blood flow with the thermodilution technique and calculated coronary vascular resistance were measured and coronary arteriography performed at rest and after the administration of ergonovine in 14 patients with atypical chest pain (group 1) and 6 patients with variant angina (group II). Mild diffuse narrowing of the left coronary bed in group I was not accompanied by S-T segment shifts, and coronary vascular resistance did not change significantly. In contrast, severe focal spasm (greater than 90 percent narrowing) of the left anterior descending coronary artery in group II patients was accompanied by S-T elevation and a marked overall increase in coronary vascular resistance (from 0.65 +/- 0.07 to 1.14 +/- 0.10 mm Hg/ml per min) (P less than 0.005). In addition, the myocardial arteriovenous oxygen difference increased and net lactate extraction changed to lactate production in the two patients in group II in whom these measurements were made. Thus, thermodilution coronary sinus blood flow measurement may be a sensitive method for detecting primary increases in coronary vascular resistance due to a high grade focal spasm in the left anterior descending coronary artery.


M mode and two dimensional echocardiographic features of porcine valve dysfunction. The echocardiographic features are presented of degeneration of nine glutaraldehyde-fixed porcine xenograft valves implanted in eight patients. These features occurred 11 to 68 months after implantation and were correlated with surgical and necropsy findings. Acute bacterial endocarditis was present in two patients, and had been successfully treated medically in three other patients 47 to 52 months before valve degeneration was recognized. The valve was severely thickened in four patients and in two of the four the thickening was associated with a significant hemodynamic transvalve gradient. M mode echocardiography demonstrated increased thickness and loss of the cusp detail. In five patients severe regurgitation due to a tear in one or more cusps developed in the the valve in the mitral position. M mode echocardiography in all five patients revealed on the valve systolic or diastolic fluttering echoes, or both. The two dimensional echocardiogram demonstrated thickened cusps with systolic protrusion of the leaflets into the left atrium. Both modes of echocardiography were of valve in identifying degeneration of the porcine xenograft valve.


Precordial electrocardiographic mapping after exercise in the diagnosis of coronary artery disease. A technique is described for recording the precordial electrocardiographic body surface map before and after exercise. The technique provides an extra dimension to the conventional exercise electrocardiogram because a measurement can be made of the area and severity of S-T segment changes that are projected onto the front of the chest. Sixteen lead isopotential surface maps were recorded before and after exercise in 109 patients with angina who subsequently underwent coronary arteriography. In addition, exercise electrocardiograms were obtained in 53 of these patients using three orthogonal leads and in all patients using a single chest unipolar chest lead. Precordial surface mapping after exercise was found to have a greater sensitivity (95 percent) than electrocardiography using either the orthogonal leads (68 percent) or a single chest lead (64 percent) (P less than 0.01). The specificity of the three techniques did not differ significantly (P greater than 0.05). The technique of precordial surface mapping after exercise improves the ability to diagnose coronary artery disease and can easily be applied to clinical practice.


Two dimensional echocardiographic assessment of patients with bioprosthetic valves. The clinical utility of two dimensional echocardiography in assessing bioprosthetic and left ventricular function was studied in 40 consecutive patients 1 week to 60 months after valve replacement surgery. These patients were referred to obtain normal baseline studies as well as to evaluate complications:suspected endocarditis, embolic phenomena and congestive heart failure of unknown cause. Independent M mode echocardiograms were also obtained in each patient. Confirmation of ultrasonic studies was by cardiac catheterization with angiography, surgery and pathologic study in 10 patients; cardiac catheterization with angiography alone in 7 patients; surgery and pathologic study in 3 patients; autopsy in 3 patients; blood cultures to confirm or exclude endocarditis in 10 patients; and confirmation on clinical grounds in 7 patients. Technically adequate two dimensional studies were recorded in 39 of 40 subjects. Two dimensional echocardiography accurately assessed 15 of 16 patients with an abnormal bioprosthetic valve and a normal left ventricle (1 of 16 patients had a false positive two dimensional echocardiogram); 8 of 8 patients suspected to have prosthetic valve or left ventricular dysfunction but who were normal; 7 of 7 patients with a normal prosthesis and an abnormal left ventricle; the one patient with an abnormal valve and left ventricle; and 7 of 7 clinically normal patients who were referred for baseline studies. In summary, the two-dimensional echocardiogram demonstrated a 97 percent diagnostic accuracy rate which was significantly greater than the 67 percent (P less than 0.001) for M mode echocardiography in the same group of patients. It is concluded that two dimensional echocardiography has excellent diagnostic accuracy in assessing bioprosthetic and left ventricular function and is superior to M mode echocardiography in evaluating patients after such valve replacement.


Krypton-81m in the physiologic assessment of coronary arterial stenosis in man. Fifteen patients with frequent anginal chest pain underwent diagnostic cardiac catheterization. After coronary arteriography a specially designed cardiac catheter was seated in the aortic root, permitting the continuous infusion of krypton-81m into the right and left aortic sinuses. A gamma camera, areas of interest and a visual display unit were used to record images and the regional myocardial equilibrium of activity before, during and after a standarized atrial pacing test. The unique physical properties of krypton-81m allowed the continuous imaging and recording of moment to moment changes in regional myocardial perfusion. This investigation revealed that when the coronary arteriogram was normal or revealed lumonal stenosis of less than 50 percent, regional myocardial perfusion was uniform at rest and during stress. Two patients with a previous history of myocardial infarction had defects of regional perfusion at rest and during stress. Krypton scintigraphy demonstrated reversible regional defects in myocardial perfusion during stress in seven patients with greater than 70 percent stenosis of one or more coronary arteries. Alterations in regional myocardial perfusion occurred within 30 seconds of the start of atrial pacing in all the patients and preceded the onset of electrocardiographic signs of ischemia or chest pain.


Anatomy of coronary arteries in univentricular hearts and its surgical implications. The coronary arterial anatomy in 26 univentricular hearts, its relation to the morphologic characteristics of the ventricles and rudimentary chambers, and its surgical implications were analyzed. All of the hearts except two had been operated on; 18 had septation with or without an extracardiac conduit and 6 had had palliative procedures. Twenty-one univentricular hearts with a left ventricular type main chamber had an anterior outlet chamber (17 left-sided subaortic, 3 right-sided subaortic and 1 right-sided subpulmonary). Right and left delimiting arteries outlined the outlet chamber in 16 hearts (76 percent). In 20 of the 21 hearts, large delimiting parallel branches of the right coronary artery course over the anterior wall of the heart; 13 of these vessels had been injured surgically with resultant ischemic myocardial necrosis. Five univentricular hearts did not have an outlet chamber; two had a left ventricular type main chamber and three had a morphologically right ventricular main chamber. Three of the five hearts had rudimentary pouches, located anteriorly in one and posteriorly in two. The two rudimentary pouches lying posteriorly were not outlined by delimiting arteries. Two of the five univentricular hearts without an outlet chamber also had injured coronary arteries. Thus, the identification of outlet chambers and rudimentary pouches in univentricular hearts is facilitated by the determination of coronary anatomy. The presence of major delimiting parallel branches over the usually favored ventriculotomy sites renders them vulnerable to surgical injury; such mishaps occurred in 15 of the 24 hearts that had either corrective or palliative operations.


Hemodynamic effects of dobutamine in children. Dobutamine is useful for augmenting cardiovasuclar function in adults. However, no information is available on the action of dobutamine in children. To determine its hemodynamic effects in children, we infused dobutamine into 12 children with congenital heart disease during diagnostic cardiac catheterization. We administered dobutamine in two doses: first 2 and then 7.75 microgram/kg per min for 10 minutes each. We meaured heart rate, cardiac output, systemic and pulmonary arterial, right atrial and pulmonary capillary blood pressures before and during the infusion of dobutamine. Systemic and pulmonary vascular resistances, cardiac index and stroke index were calculated. Cardiac output, cardiac index, stroke volume, stroke index and systemic arterial phasic and mean blood pressures increased sugnificantly (P less than 0.05) and pulmonary capillary mean blood pressure decreased significantly (P less than 0.05) during the infusion of each dose of dobutamine compared with control values. Heart rate, pulmonary and right atrial mean blood pressure and systemic and pulmonary vascular resistance were unchanged with either dose of dobutamine. We noted no adverse effect from the drug.


Echocardiographic assessment of the effect of an antihypertensive regimen on left ventricular performance. A regimen consisting of chlorthalidone, hydralazine and propranolol would be useful in some hypertensive patients with coronary artery disease or aortic dissection if it could be shown that reflex cardiac stimulation induced by hydralazine is completely neutralized by propranolol. Nine hypertensive patients were treated with chlorthalidone during week 1, chlorthalidone and hydralazine during week 2 and a combination of chlorthalidone, hydralazine and propranolol during week 3. Blood pressure, heart rate, mean velocity of circumferential fiber shortening (VCF) measured echocardiographically and plasma renin activity were measured weekly. This potent three drug regimen reduced mean blood pressure from 142 to 102 mm Hg, and with the third drug, propranolol, heart rate, VCF and plasma renin activity returned to control levels from the greater elevated levels produced by the diuretic drug and hydralazine. In six additional patients VCF (an index of left ventricular contractility) was found to be proportionate to the rate of rise of aortic pressure (dP/dt) or aortic shearing force. This regimen appears safe for use in patients with ischemic heart disease and aortic dissection.


Individual titration of diazoxide dosage in the treatment of severe hypertension. Diazoxide, 300 mg as a single bolus injection, is widely used to treat severe hypertension. Although usually effective, this standard dosage may decrease the blood pressure too much, inducing hypotensive problems. In this study 32 patients with a diastolic blood pressure above 125 mm Hg were treated with smaller bolus injections, 105 or 150 mg, which were repeated every 5 minutes as needed to reduce the diastolic pressure to 110 mm Hg or less. Seven patients of the 32 patients needed only one injection of 150 mg; only one patient needed more than three injections. This individual titration with mini-bolus injections of diazoxide was effective and did not induce hypotension or other side effects.


His bundle electrocardiography in digitalis-induced "atrioventricular junctional" Wenckebach periods with irregular H-H intervals. His bundle electrograms were recorded during catheter insertion for prophylactic demand pacing in two patients with accelerated or nonaccelerated "atrioventricular (A-V) junctional" rhythms associated with A-V junctional Wenckebach periods. This appears to be the first published report of so-called A-V junctional Wenckebach periods in which the characteristic irregularities of the H-H intervals were recorded. Patient 1 had an additional area of "complete" anterograde A-V nodal (A-H) block. In Patient 2 the rate of impulse formation was consistent with nonparoxysmal A-V junctional tachycardia. The His bundle recordings were obtained in patients with digitalis toxicity and should be interpreted in the context. The integration of clinical and intracardiac findings with extrapolations from microelectrode and pharmacolic studies and with deductions from the clinical electrocardiograms suggests that the conduction disturbances probably occurred within the A-V node itself (in its AN region). This hypothesis implies that automaticity also originated in the A-V node because the site of impulse formation must have been proximal to the site of the Wenckebach periods. However, conclusive proof of of these postulates will require further studies with refined techniques.


Constrictive pericarditis: early and late complication of cardiac surgery. Constrictive pericarditis is not considered a complication of cardiac surgery. However, three cases are presented in which equalization of diastolic pressures and the ventricular pressure pattern of early diastolic dip-late diastolic plateau, characteristic of restrictive disease, appeared after cardiac surgery. In one patients cardiac constriction developed less than 2 weeks after surgery, and loculated clotted and unclotted viscous blood was removed from the pericardial space. In the other two patients the pericardial space was obliterated by dense adhesions. Thus constrictive pericarditis should be considered in postoperative patients who either do not recuperate satisfactorily after surgery or whose condition deteriorates after initial recovery.


Separation of conjoined thoracopagous twins joined at the right atrial. A case of conjoined thoracopagous twins with a shared atrial myocardium who were successfully surgically separated is described. Twin B had hypoplastic right heart syndrome and was dependent on Twin A for oxygenation of her blood. The twins were surgically separated by dilating Twin B's ductus arteriosus with an infusion of prostaglandin E1 and creating an aortopulmonary shunt to increase her pulmonary blood flow; both twins survived the operation. However, 1 week after surgery Twin B had hepatic and renal failure and died.


On the clinical significance of the plasma alpha-amino-n-butyric acid:leucine ratio. The ratio of plasma alpha-aminobutyric acid to plasma leucine that has been proposed as a specific biochemical marker of alcoholic liver injury, was measured in normal children an children with a variety of metablic disorders. The ratio was found to be lower in children that in adults. It was elevated in children with Reye's syndrome, tyrosinemia, homocystinuria, nonketotic hyperglycinemia, and ornithine transcarbamylase deficiency. The results indicate that an elevated ratio is not specific for adults with alcoholic liver injury and that the ratio may be high even without the presence of clinically apparent hepatic disease. An altered ratio may reflect the presence of an inherent metabolic defect.


The retention of calcium, iron, phosphorus, and magnesium during pregnancy: the adequacy of prenatal diets with and without supplementation. Vitamin and mineral supplementation is often prescribed by physicians to meet the additional nutrient requirements of pregnancy. In order to partially ascertain the effectiveness of these prenatal supplements, the retention of calcium and iron was determined in pregnant women consuming supplemented or unsupplemented self-selected diets. The retention of phosphorus and magnesium, minerals not included in the prenatal supplements, was also determined. Seven-day metabolic balance experiments spaced periodically throughout the pregnancy were conducted on 10 healthy pregnant white women. The retention of calcium by the supplemented group was comparable to that of the unsupplemented group, while the retention of iron was more dependent on the magnitude of the iron intake than on its source. Although no supplement contained phosphate, the intake of phosphorus met the recommended allowances for this mineral. Significantly related to the intake of dietary calcium, the adequate phosphorus intakes reflected diets providing adequate calcium. The mean magnesium intake was only 60% of the recently established recommended dietary allowance. Although the calcium and iron salts provided by the prenatal supplements were well utilized, the intakes of phosphorus and magnesium indicate that the reliance on the effectiveness of mineral supplements should not lessen the emphasis by the physician on the importance of a good prenatal diet.


Malabsorption of water miscible vitamin A in children with giardiasis and ascariasis. Vitamin A absorption was studied using a water-miscible oral preparation of vitamin A in 19 children ages 1 1/2 to 9 years old with giardiasis and/or ascariasis, both before and after their eradication with appropriate therapy, and in three children without parasites. Marked impairment of vitamin A absorption was noted when administered in a water miscible form in children with 1) combined infection with Giardia lamblia and Ascaris lumbricoides, 2) giardiasis alone, and 3) in a proportion of children with ascariasis alone. In children with both giardiasis and ascarasis eradication of the infections promptly lead to a significant improvement in vitamin A absorption and restored it to normal. Children with giardiasis alone also showed improved vitamin A absorption after therapy. In children with ascariasis alone successful therpay did not lead to a statistically significant improvement.


Plant fiber. Carbohydrate and lipid metabolism. Plant fibers are the portions of plant foods that are not digested in the human small intestine. During this century, remarkable advances have been made in defining the  characteristics and importance of most nutrients such as carbohydrate, proteins, fats, vitamins, and minerals. Plant fibers have largely been neglected because they considered to have no nutritive values. In the last decade, however, considerable attention has been focused on the various plant fibers because of their influence on gastrointestinal physiology. Evidence is emerging that plant fibers have profound influences on human nutrition because they alter the absorption and metabolism of many nutrients. We will review the evidence that plant fibers greatly influence the absorption and subsequent metabolism of carbohydrates and fats.


An hypothesis for the action of dietary fiber along the gastrointestinal tract. Dietary fiber consists of a sponge matrix with specific physicochemical properties. These properties are dependent on the structure and composition of the fiber components and determine the physiological effects of different food fibers in the upper and lower gastrointestinal tract.


Hospital malnutrition. A prospective evaluation of general medical patients during the course of hospitalization. Nutrition status was evaluated in 134 consecutive admissions to a general medical service and throughout hospitalization among patients hospitalized 2 weeks or longer. Likelihood of malnutrition was determined using eight nutrition-related parameters: serum folate and vitamin C, triceps skinfold, weight/height, arm muscle circumference, lymphocyte count, serum albumin, and hematocrit. On admission 48% of patients had a high likelihood of malnutrition, which correlated with a longer hospital stay (20 versus 12 days for patients with a low likelihood of malnutrition) and an increased mortality rate (13 versus 4%). Likelihood of malnutrition increased with hospitalization in 69% of patients with paired determinations. Compared to admission, at final follow-up a greater proportion of patients fell into the depleted range of values for folate, triceps skinfold, weight/height, arm muscle circumference, lymphocyte count, and hematocrit. These parameters worsened in over 75% of patients admitted with normal values. Hematocrit fell in all patients with normal admission levels. These findings demonstrate and association between nutrition status and hospital course and a worsening trend during hospitalization.


Polyethylene glycol as a quantitative fecal marker in human nutrition experiments. Data are summarized from five experiments in which polyethylene glycol (PEG) was fed to 51 subjects as a quantitative fecal marker. In three experiments PEG was fed continuously for 35 to 106 days. Preexperimental diet was assumed to have been completely excreted when the ratio of fecal PEG to fecal dry solids became constant. This took more than 7 days to occur in 50% of the subjects. Fecal recovery of PEG averaged only 93% of that consumed. PEG was a valid fecal marker for nitrogen, calcium, magnesium, iron, and zinc, but was less valid for sodium. In one experiment where PEG and chromic oxide (Cr2O3) were fed simultaneously, PEG was excreted faster on average than Cr2O3. In most subjects, small amounts of Cr2O3 were excreted sporadically for 42 days after Cr2O3 feeding had ceased. Inclusion of quantitative fecal markers permitted identification of the time when preexperimental diet had been completely eliminated, subjects who showed marked pooling of intestinal contents, and changes in the amount of fecal dry solids. However, an average fecal recovery of only 93% of the PEG or Cr2O3 consumed suggests that further work is needed before the recovery of either of these markers can be used with confidence for the correction of nutrient balance data.


Knowledge and belief in nutrition.

Knowledge and belief in nutrition. In a nutrition questionnaire, subjects have been given the options of answering questions with yes, no, or don't know. From these responses it has been possible to calculate the levels of their "correct knowledge," their "perceived knowledge" (that is the knowledge that each subject believed he had) and the "accuracy of knowledge". Questions about common nutritional problems were given to physicians, medical students, nurses, and theology students. All groups had a high level of "perceived knowledge," generally greater than 80% for the questions asked, but the accuracy of the knowledge was alarmingly low. The highest level was in physicians, in whom 79% of the perceived knowledge was accurate, but in theology students only 36% of the perceived knowledge was accurate. Two thirds of the "knowledge" of nutrition held by theology students was therefore false by current scientific standards. These findings have implications for future nutrition education.


Nutritional supplementation and the outcome of pregnancy. I. Birth weight. Colombian women at risk of malnutrition were enrolled in a health care program and randomly assigned to supplementation and control groups at the beginning of the third trimester of pregnancy. The net dietary intake increments resulting from supplementation amounted to 155 cal and 20 g of protein per day. Supplementation had a significant effect on the mean birth weight of male infants, but not that of female infants; the mechanisms responsible for the sex differences remain to be elucidated. The randomized trial design of the experiment and the documented similarity between the experimental and control groups at the onset permit the conclusion that the observed differences were caused by the food supplementation program. The effect of supplementation on maternal weight gain and the association of the latter with birth weight strongly suggest that improved maternal nutrition mediated the effect on birth weight.


Nutritional supplementation and the outcome of pregnancy. II. Visual habituation at 15 days. Colombian women at risk of mild-to-moderate malnutrition were enrolled in a health care program and randomly assigned into nutritional supplementation and control groups at the beginning of the third trimester of preganancy. One hundred unsupplemented and 144 supplemented infants were tested at 15 days of age: a 2X2 checkerboard was presented eight times followed by a single presentation of a 6X6 checkerboard. Unsupplemented infants showed less initial attention followed by slower habituation and higher levels of movement than the supplemented infants. The observed effect of maternal nutritional supplementation during the last trimester of pregnancy on new-born attention was interpreted to be maturational in nature.


Self-perceptions of the stigma of overweight in relationship to weight-losing patterns. Preliminary, exploratory studies examine self-perceptions of the stigma of overweight in relatiopship to weight-losing patterns of female and male children of different ages. It is suggested that the concept of stigma may be a viable analytical tool in studying overweight as: an exclusive focus in interaction, related to a negative body image, overwhelming others with mixed emotions, clashing with other attributes of the person, an equivocal predictor of activities, and related to one's sense of responsibility for one's overweight. Female adolescents in the Slimnastics class in a high school and children and adolescents in an obesity clinic in a hospital were studied. Male children and female adolescents had more trouble losing weight than did female children and male adolescents. Youth who viewed overweight as both one's responsibility and as an illness that required the joint efforts of oneself and others, especially professional experts, were more successful in losing weight than those youth who believed that overweight was solely their responsibility or not at all their responsibility. Intensive focusing on one's overweight and one one's negative body image seemed to inhibit or deter weight losing for some youth.


Genetic and biological variability in human nutrient requirements. Multiple factors, associated with the host and environment, as well as the chemical form of the nutrient, its availability, chemical and metabolic interactions among nutrients, result in a variability in nutrient requirements that is probably well beyond that observed in controlled laboratory studies of small groups of "normal" healthy subjects. Although many factors are recognized as contributing to the variation in human nutrient requirements, current knowledge is largely of qualitative significance: Garn (40) state that this level of knowledge and investigation "has a long past but no foreseeable future." It is sad commentary that neither do we know adequately the quantitative extent of biological variation in requirements among individuals for any of the essential nutrients nor the quantitative importance of most of the factors which affect requirements in population groups. We believe that the potential contributions of nutrition toward solving problems of human disease and for maintaining health in populations depend as much on a better definition of the quantitative aspects of human nutrient requirements as on improved understanding of the utilization, function and metabolism of nutrients at the cellular, organ, and whole body level.


Work-induced muscle hypertrophy in vitamin D-deficient rats. To determine if vitamin D deficiency would retard the ability of muscle to hypertrophy in response to mechanical stress, we severed the gastrocnemius tendon on one leg of rats in each of three groups, the treatment of which differed only in the amount of vitamin D in the diet. After 1 week the increased size of the soleus and plantaris in the leg in which the gastrocnemius was severed relative to that of the sham operated leg, was determined for each rat. Despite differences in body weight and serum calcium among the groups, we found no difference in the percent of muscle hypertrophy. We conclude that muscle hypertrophy can occur in response to local mechanical forces despite a deficient hormonal environment that otherwise retards growth.


Steady-state turnover and body pool of ascorbic acid in man. The time course of radioactivity in plasma and urine after oral administration of a single dose of (1-14C)ascorbic acid has been followed in healthy nonsmoking male volunteers. The investigation was carried out under steady state conditions with regard to ascorbic acid intake (30 to 180 mg/day). Using pharmacokinetic principles, turnover, pool size, and rates of metabolism and excretion could be calculated. It was found that the half-life of ascorbic acid was inversely related to the dosage and that the pool could be increased to about 20 mg/kg bodyweight by increasing the dosage. It was concluded that on a daily intake of about 100 mg ascorbic acid this pool size would be reached in 95% of the population.


The effect of iron and protein deficiency on the development of acquired resistance to reinfection with Nippostrongylus brasiliensis in rats. Iron and protein deficiency delays the immunological rejection of Nippostrongylus brasiliensis from the small intestine of rats undergoing a primary infection with the parasite. In the present study, iron and protein deficiency significantly reduced acquired resistance to reinfection with N. brasiliensis. Repletion of deficient animals with iron and protein restored their capacity to mount an effective immune response to a secondary infection with the parasite. These results suggest that chemotherapy of helminthiasis should be integrated with nutritional supplementation.


Bone status and fracture rates in two regions of Yugoslavia. Bone status and fracture rates were evaluated in two Yugoslav populations with very different dietary habits. In district A (Podravina) the daily calcium intake was about twice that in district B (Istra). There were similar but smaller differences in the intakes of other nutrients. In district B metacarpal cortical width was reduced in all age groups of both sexes but the difference tended to decrease with age. The proximal femur fracture rate was higher in district B than district A but there was no difference between the forearm fracture rates in the two districts. Our results confirm that bone mass at any age is clearly the result of age and sex and most probably other genetically determined factors but also show that this expression is nutrition related. The data suggest that nutrition (in particular the calcium intake) is an important determinant of bone mass in young adults but seems to have little effect on age-related bone loss in either males or females. The main determinant of cortical bone mass in the elderly seems to be the cortical bone mass in middle life. The proximal femur fractures of old people reflect declining cortical bone mass but the distal forearm fractures of middle-aged women are unrelated to cortical bone mass or nutritional status.


Zinc metabolism in humans after oral and intravenous administration of Zn-69m. Seventeen patients were studied after separate oral and intravenous administration of 50 muCi Zn-69m to determine if Zn-69m is suitable for studying zinc metabolism in humans and to determine if the route of administration affects kinetics. Patients stayed on a metabolic ward for each study. Activity was measured in the total body, urine, feces, blood, plasma, red blood cells, and by detectors over liver and thigh. Five day urine to fecal ratios were 0.44 (intravenous), 0.018 (oral). Most activity went rapidly to liver, then followed two component exponential loss patterns in both cases. Thigh area doubling time was 5.7 days whether the zinc was given orally or intravenously. Plasma activity decreased to less than 2% of that injected by 24 hr after intravenous administration and decreased from a maximum of 1.2% of that ingested, 3 hr after oral administration to 0.7% by 24 hr. Red blood cell activity increased through the 5-day study period to maximum values of 6.4% of that injected after intravenous administration and 2.4% of that ingested after oral administration. Similar metabolic patterns were observed regardless of whether Zn-69m was administered intravenously or orally, suggesting that these patterns were not affected by the mode of administration for the cases studied.


Content of zinc in serum, urine, hair, and toenails of New Zealand adults. The content of zinc in samples of serum, hair, and toenails and in a 24 hr urine from groups of the New Zealand population was investigated. The 110 normal healthy adults were mainly male and female students; the female students had a higher serum zinc and hair zinc concentration but a lower urinary zinc excretion than did the male students. The range in values within the normal groups was wide. No strong relationship was found with linear regression analysis or with multiple regression analysis of the data for the male or the female students. Other groups studied were oyster openers with a higher dietary intake of zinc from oysters, industrial workers exposed to zinc in their occupations, and hospital patients with leg ulcers or various dermatoses and with a potentially low zinc status. Only external exposure to zinc from an industrial source (galvanizing) or from the use of zinc-based creams increased the zinc concentration in the samples measured, and then only in hair and toenails. The hospital patients did not appear to have a lower zinc status comparable with adults from other countries. It was concluded that the measurement of zinc in serum, urine, hair, and toenails did not provide a sensitive indication of zinc status.


Effects of some cereal brans and textured vegetable protein on plasma lipids. The hypothesis that dietary fiber lowers serum cholesterol was tested in 10 healthy men, 19 to 54 years old, who ate a mixed diet similar to the diets of many American adult males, that contained 16% of calories as protein (70% from animal), 40% as fat (P/S = 0.3), 44% as carbohydrate (9% of calories as sucrose) and 3 g of crude fiber. The energy intake ranged from 2700 to 3500 kcal adjusted to their height and weight. Weight and fitness were held constant. After 30 days of equilibration on the basal diet, they ate 26 g of either soft white wheat bran, corn bran (CB), soybean hulls (SH), textured vegetable protein, or hard red spring wheat bran (HRS) for periods of 28 to 30 days each in no particular sequence. Each fiber was fed to four to six subjects. The dietary fiber contents of soft white wheat bran, CB, SH, and HRS were: 44, 92, 87, and 51%, respectively. Mean daily fecal weight increased (P less than or equal to 0.01) from 72.4 to 144, 68 to 128, and 81 to 151 g when CB, SH, and HRS were fed respectively. No effects were noted with soft white wheat bran or textured vegetable protein. Total plasma cholesterol decreased 12% with HRS (P less than or equal to 0.05) and 14.0% with SH (P less than or equal to 0.05). Low density lipoprotein cholesterol decreased 21% with HRS (P less than or equal to 0.05). High density lipoprotein cholesterol did not change with any of the dietary fiber sources nor did the ratio of high density lipoprotein cholesterol to total cholesterol. Some triglyceride lowering effect was seen with all sources of dietary fiber (P less than or equal to 0.01). There was a significant direct correlation between the area under the oral glucose tolerance curves and the levels of total cholesterol (r = 0.57, P less than or equal to 0.0001) and low density lipoprotein cholesterol (r = 0.49, P less than or equal to 0.0007), and between fasting plasma glucose and triglycerides (r = 0.32, P less than or equal to 0.03). Results were replicated when subjects were fed the same fiber source on two occasions at 2 to 4 month intervals.


Influence of whole or skim milk on cholesterol metabolism in rats. Male Wistar rats were fed commercial ration and given whole milk, skim milk, or water to drink. After 3 weeks the control group showed the greatest weight gain. Rats given whole milk had the smallest livers. Serum cholesterol levels were significantly lower in rats fed either whole or skim milk, but other serum lipids were unaffected. Liver triglyceride levels were lowest in the rats on skim milk. Activities of hepatic fatty acid synthetase, hydroxymethyl-glutaryl coenzyme A reductase and cholesterol 7alpha-hydroxylase were similar in the two milk-fed groups and considerably lower than in the controls.


Serum and liver concentrations of vitamin A in Thai fetuses as a function of gestational age. Serum and liver vitamin A values were determined in 26 male and 20 female Thai fetuses varying in gestational age from 13 weeks to term. In general pregnancies were of healthy young women from the Bangkok area. The median, mean and range of fetal serum retinol values (+/- SE) were 25.8, 30.7 +/- 3.0, and 1.9 to 109.6 microgram/100 ml, and of liver values were 16.4, 19.4 +/- 2.2, and 1.1 to 51.6 microgram retinol per gram of liver. Median and mean serum and liver values were about 10% higher in males than in females, but not significantly so. Serum retinol concentrations neither correlated with liver concentrations, except below 5 microgram/g, nor served as a valid indicator of total liver stores of vitamin A. Serum retinol values declined slowly with gestational age to term, whereas liver vitamin A concentrations tended to increase until the 28th week and then to fall until term. Whereas the liver to body weight ratio remained essentially constant (0.0425 +/- 0.003, P less than 0.0001) during the gestational period, vitamin A concentrations in both serum and liver showed marked variability.


Physical growth: National Center for Health Statistics percentiles. Anthropometry is an effective and frequently performed child health and nutrition screening procedure. The value of physical growth data depends on their accuracy and reliability, how they are recorded and interpreted, and what follow-up efforts are made after identification of growth abnormality. The new National Center for Health Statistics percentiles can be used to improve identification of potential health and nutritional problems and to facilitate the epidemological comparison of one group of children with others.


A review of body composition studies with emphasis on total body water and fat. Tritiated water meausres a volume 4 to 15% body weight larger than that by desiccation, and, at present, only 0.5 to 2.0% of the overestimation can be explained by the exchange of hydrogen of tritiated water with those of the proteins and carbohydrates of the body. The remainder of the error is unexplained. Water in the lumen of the gut is an appreciable percentage of total body water (TBW) in many mammalian species, with the pig and the human as possible exceptions, and it should be considered an integral part of TBW. Consequently, the exclusion or inclusion of this transcellular water as part of TBW significantly affects the final TBW volume. As tritiated water exchanges with water in the gut, a comparison of the data from the indirect method with the data from the direct method can only be made when water in the gut is included in the desiccation method. Conceptually, the amount of water in lean body mass is a reflection of the actively metabolizing cell mass of the body. However, water in the gut is outside this cell mass, and if included, it significantly overestimates the water associated with the lean body mass compartment. The percentage of water in fat-free wet weight for most mature animals is estimated at 73.2%, although the mean values in the literature range from 63% for the beagle to 80% for the mouse, with the mean for the majority of species between 70 and 76%. If the percentage of water in fat-free wet weight lies between 70 and 76% for most species, then the error in calculating fat using the figure 73.2% in the equation (% fat = 100 - % TBW/0.732) is significant. In the application of this equation, the largest potential error lies in the estimation of TBW with tritiated water.


The quantitative effect of infection on the use of food by young children in poor countries. A framework based on consistent and explicit set of assumptions is developed for evaluating the effect of infection on the intake and efficiency of use of food by children under 5 years old in poor countries. A variety of data is used to obtain quantitative estimates of catabolic losses, clinical and subclinical absorbtive losses, changes in food intake patterns, and losses due to high infant and childhood mortality. Although additional data are required before these estimates can be considered reliable, it appears that about 9% of the food available to a cohort of children under 5 years old in Bangladesh is not used for maintenance, growth, or activity of those children who survive to their 5th birthday. The amount of food that is not used effectively may be reduced to about 3% in a (hypothetical) situation where all sources of infection are eliminated but other conditions remain unchanged. The estimates suggest that the most important factors contributing to this inefficiency are reduced intake through food withdrawal and anorexia, and high mortality in young childhood. The potential nutritional effects of various public health programs are tentatively assessed.


Medical evaluation of the special supplemental food program for women, infants, and children. The special supplemental food program for women, infants, and children administered by the United States Department of Agriculture, was evaluated nationally. Participating infants, children under 4 years old, and pregnant and nursing women were investigated initially, and after receiving food supplements. The supplements were iron-fortified infant formula, iron-fortified infant cereals, and fruit juices for the infants, and milk, cheese, iron-fortified cereals, eggs, and fruit juices for the children and women. Initially, the average birth weight was lower and the infant mortality rate was higher than expected in a well nourished population. There was also evidence of slight growth retardation, a high anemia rate, and a high percentage of participants having saturation of transferrin values  less 15%. The program had no effect on the prevalence of unsatisfactory values for saturation of transferrin. There was an increase in weight gain during pregnancy, and increase in birth weight, an acceleration of growth, and a reduction in the anemia rate in all participant categories except women in the first and second trimesters of pregnancy.


Growth standards for poor urban children in nutrition studies. In order to estimate the importance of a variety of environmental and dietary factors as determinants of growth in a group of 123 poor Peruvian urban children between 2 and 19 years old, we found it necessary to express anthropometric measurements in units that were not age- or sex-dependent. Height quotient and weight quotient for each child were calculated from height and weight ages derived from the 50th percentile of the Boston reference data for the appropriate sex. Only 5% of the children had heights above the Boston 50th percentile (height quotient greater than 100) and 18% had weights above the 50th percentile (weight quotient greater than 100), but 88% had weights that were appropriate or excessive for height (weight/height quotient greater than or equal to 1.00). Some CATch-up" gains in relative height and weight were apparent in preschool children but more impressive gains in both linear and ponderal growth, relative to the Boston data, were evident between 8 and 13.5 years in girls and 10 and 17 years in boys. When the same quotients were calculated for a much larger sample from the same socioceonomic level it seemed likely that this last peak was due to earlier puberty and sexual maturation, and that quotients derived from the Boston data would have different meanings at different ages, making them inappropriate for further statistical analysis. New quotients for the study population, derived from the larger Peruvian group, did not have sex- or age-dependent trends. Racial and regional differences in patterns of growth must be taken into account in the interpretation of anthropometric and nutritional data.


Oriental diagnosis in stomach cancer patients. A new method of performing Oriental diagnosis using Meridian Imbalance Diagram which, consisting of 23 different ratios, has a highly discriminatory significance. Using this method, Oriental and Western diagnosis in the same patients were compared. To do this we compared the Meridian Imbalance Diagrams of 22 patients entering our hospital for surgical operations with those 19 in a healthy control group. Four significantly different ratios became evident. The postoperative reports showed that 10 of the patients were suffering from stomach cancer. The Oriental diagnosis data of this new group were then compared to the data of the control group. This time, 10 ratios were found to be significantly different. This shows the existence of a pattern of Oriental diagnosis corresponding to a specific Western diagnosis.


Hemostatic abnormalities in malignancy, a prospective study of one hundred eight patients. Part I. Coagulation studies. A prospective study of hemostatic abnormalities in 108 cancer patients was undertken at an oncology clinic in a university teaching hospital. Tests included Quick prothrombin time, activated partial thromboplastin time, thrombin time, platelet count, modified Ivy bleeding time, fibrinogen, fibrin degradation products (FDP), euglobulin lysis time, protamine sulfate test, and factor V, VII, VIII and X assays. Ninety-eight per cent of the patients had one or more abnormal coagulation tests. The commonest abnormalities were elevated fibrin degradation products and prolonged thrombin time. Thrombocytosis occurred in 57% of patients, hyperfibrinogenemia in 46%, thrombocytopenia in 11%, and non had hypofibrinogenmia. It is suggested that platelet count, fibrinogen concentration, and serum FDP assay are the most useful tests in assessing the hemostatic abnormalities in cancer patients, although thrombin time, factor V assay, and bleeding time may also be helpful. The peripheral blood smears of 53 patients were reviewed, and only one showed microangiopathic hemolytic anemia. The data illustrate that subclinical coagulopathy is relatively frequent in patients with malignancy.


Rapid detection of dengue viral antigens by counterimmunoelectrophoresis. Counterimmunoelectrophoresis (CIE) was applied to detect dengue viral antigen in an experimental system and in clinical situations. In the experimental system, all four types of dengue viruses (dengue 1 to 4) were detected when tested against rabbit hyperimmune sera. With homologous antibody, antigen could be detected when hemagglutinating titer was as low as 1:20. In clinical situations, 67% of the sera of patients with dengue hemorrhagic fever collected on day 4 after onset of fever were positive by CIE. Antigens could be detected most frequently from day 4 to day 7. In 11% of the cases, antigens were found to persist as long as 38 days. Validity of this detection was confirmed in some cases by immunologic methods. Virtues of CIE are its technical simplicity, rapidity, and economy.


Bone marrow granulomas in Q fever.

Bone marrow granulomas in Q fever. This report describes the case of a patient who had a fever of unknown origin and granulomatous hepatitis. Numerous granulomas were present in sections from a bone-marrow biopsy and bone-marrow clot obtained as a part of the diagnostic evaluation. Subsequent serologic studies proved the patient had Q fever. The authors re-emphasize that a distinctive form of granuloma occurs in the bone marrow with Q fever and that Q fever should always be a consideration in the differential diagnosis of bone-marrow granulomas.


Whole-blood clotting time, activated partial thromboplastin time, and whole-blood recalcification time as heparin monitoring tests. The authors performed whole-blood clotting time (WBCT), activated partial thromboplastin time (APTT), and whole-blood recalcification time (WBRCT) tests on normal blood or citrated plasma, each milliliter containing 0-0.5 unit heparin, and on samples from patients, of whom many were receiving heparin anticoagulation therapy. Six partial thromboplastin reagents were used. Linearity between clotting time and heparin concentration was observed with WBCT and APTT, determined with Hyland partial thromboplastin (kaolin-activated) and Dade ("Improved" Activated Cephaloplastin and Actin) reagents. With a General Diagnostics preparation (Platelin -plus, celite as the activator) and another Hyland partial thromboplastin reagent (silica-activated), the sensitivity to heparin decreased to beyond 0.3 unit/ml plasma. No correlation was observed with the old Dade Activated Cephaloplastin reagent, WBRCT was completely insensitive to heparin in concentrations as high as 0.24 unit/ml blood. With patient samples, correlations were observed between WBCT and Hyland (kaolin) APTT, and between Hyland and Dade Actin APTT. However, WBCT and WBRCT, and APTT and WBRCT, correlated poorly.


Activated partial thromboplastin time and minor coagulopathies. Five commercially available activated partial thromboplastin time (APTT) test systems were compared with the kaolin partial thromboplastin time (KPTT) method to determine sensitivity in detecting minor coagulation defects. All reagent systems detected severe factor VIII-, IX-, and XI-deficient hemophilia. Homozygous states of factor XII deficiency, Fletcher factor deficiency, and high-molecular-weight kininogen deficiency (Fitzgerald trait) also showed abnormally long APTTs by all systems. Of 19 samples from patients with deficiencies of factors XII, VIII, IX, XI, and II ranging from 2.5 to 52%, eight had deficiencies that were not detected by reagent A (ellagic acid); two, by reagent B (ellagic acid); two, by reagent C (kaolin); one, by reagent D (silica); one, by the KPTT method. All deficiencies were detected by reagent E (celite). Heparin effect on plasma was less well detected by reagent A (ellagic acid) than with the other test systems. APTT test systems can vary greatly in their abilities to detect minor coagulation abnormalities.


Hematologic findings in cases of mammary cancer metastatic to bone marrow. The hematologic findings in 22 cases of mammary cancer metastatic to bone marrow are presented. Cancer of the breast was the most frequent neoplasm metastatic in bone marrow in this study of 2,878 bone-marrow examinations. All 22 patients who had carcinoma of the breast metastatic to bone marrow had clinical, radiographic, or hematologic evidence of widespread metastatic disease. Peripheral blood was abnormal in 58% of the cases, and in most of these cases two or more abnormalities were present. Bone-marrow biopsies were superior to particle sections and aspirates in identifying tumor, but correlations among all modalities were necessary for proper interpretation. Although the morphologic features of tumor cells in sections and smears were quite characteristic for carcinoma of the breast, pitfalls in interpretation were numerous and should be recognized. The mean survival time of these patients was only 6.9 months after identification of bone-marrow metastases. The significant response to chemotherapy obtained with some individuals, however, should encourage aggressive therapy of this disorder.


Ultrastructural examination of urinary sediment. Value in renal amyloidosis. Examination of urinary sediment has been recommended as a useful diagnostic aid for renal amyloidosis. This procedure was evaluated in the cases of 57 patients, including 11 with proven renal amyloidosis and 13 considered very likely to have the disease. At least three types of urinary fibrillar material were observed: 10-12-nm-diameter fibrils similar to amyloid; 7-10-nm-diameter fibrils with characteristics of intracellular tonofibrils; and 15-30-nm-diameter fibrils suggestive of fibrin tendrils. Only four of 24 patients who had renal amyloidosis proven or suspected had amyloid-like fibrils in the urinary sediment, while four control patients, including three with diabetic nephropathy, had similar fibrils. Sixty-eight per cent of all urines contained material consistent with tonofibrils. Ultrastructural examination of urinary sediment as a diagnostic aid for renal amyloidosis lacks sensitivity and specificity and has very limited clinical value.


Unsuitability of electron microscopic examination of urinary sediment for the diagnosis of amyloidosis. Several recent reports suggest that amyloidosis can be diagnosed by ultrastructural identification of fibrillar proteins in the urinary sediment. However, the authors routinely identified similar fibrils in the urinary sediments of all patients with a wide variety of renal diseases who were producing urinary casts, as well as in those of stressed healthy individuals. They therefore conclude that electron microscopic examination of the urinary sediment alone has little value in the diagnosis of amyloidosis when unaccompanied by chemical or immunologic tests.


Ultrastructure of the agent of Legionnaires' disease in the human lung. This report confirms the gram-negative ultrastructural characteristics of the Legionnaires' disease organism by direct examination of pulmonary tissue from six confirmed cases--two from the original Philadelphia epidemic of 1976 and four from more recent sporadic cases. All microorganisms seen in all six lungs were identical ultrastructurally and were predominantely within intra-alveolar macrophages, as previously observed by light microscopy. They appeared as short, blunt rods that were clearly prokaryotic; i.e., they had diffuse electron-lucent nucleoid areas interspersed among areas of well-defined ribosomes, a pinching nonseptic division, and enclosure within a double envelope consisting of two three-layer "unit" membranes, each approximately 75 A wide. This structure, together with a pinching division, is typical of gram-negative bacteria. The Legionnaires' disease organism multiples both intracellularly and extracellularly in tissue and has no unique ultrastructural features that would aid in its specific identification. These findings are compared with recent reports describing the ultrastructure of what was considered to be the Legionnaires' disease organism in yolk sac and culture medium, and in one human lung.


Nephropathy in angioimmunoblastic lymphadenopathy. Two elderly men who had fulminating systemic illnesses typical of angioimmunoblastic lymphadenopathy died in acute oliguric renal failure. In both, glomerular lesions were present. In one patient mild diffuse proliferative glomerulonephritis associated with necrotizing arteritis was seen, and in the other, minimal change was observed by light microscopy. In both, immunoglobulin-containing dense deposits within glomeruli were observed by fluorescence and electron microscopy, suggesting that the renal disease was mediated, at least partly, by deposition of immunoglobulin.


Juxtanuclear lymphocytes in histocultures of mammary cancer. Juxtanuclear lymphocytes in histocultures of mammary cancer. Am J Clin Pathol 71: 64-71, 1979. This is the first report of a special orientation of autochthonous lymphocytes at a juxtanuclear zone of human mammary cancer cells in primary histocultures. The phenomenon, juxtanuclear orientation of lymphocytes, was observed in 99 histocultures from 16 of 45 (35%) successfully explanted cancers. A total of 686 instances of juxtanuclear orientation of lymphocytes was counted, versus 354 instances of random lymphocytic activities; juxtanuclear/random ratios ranged from 0.2 to 5.2. Ratio determinations may be potentially useful for assistance in evaluating prognosis; the preliminary findings are inconclusive but suggest that a ratio of one or more may indicate a more favorable clinical course. The immediate importance of juxtanuclear orientation of lymphocytes is that it offers a new measurement of pathologic lymphocytic activity that should have applications in basic and clinical studies of host responses in general.


A prospective evaluation of placental lactogen as a test for neonatal risk. This study evaluates the usefulness of maternal serum concentrations of human placental lactogen in the management of high-risk pregnancies. The study was performed in a community hospital over a year's time and involved 250 gestations. The test detected only 11.4% of the pregnancies defined as high-risk by clinical criteria and none of the pregnancies in which the newborn was compromised. Serum human placental lactogen is an insensitive test in predicting the outcome of pregnancies in an obstetric population unless historical information regarding maternal disease is unavailable.


Factors affecting stability of isozymes of creatine phosphokinase. Human brain-type (BB) creatine phosphokinase (CPK) and skeletal muscle (MM) CPK were purified from autopsy tissues. The stability of each isozyme with and without the reducing agent mercaptoethanol in human plasma, saline solution, and saline solution with bovine serum albumin was studied. Human BB CPK, at 37 C, without added mercaptoethanol, lost 50% of its activity in 15 minutes during incubation in plasma. It was much more stable at both room temperature and 4 C. BB CPK was also unstable in saline solution plus bovine serum albumin in the absence of mercaptoethanol but was much more stable in the presence of mercaptoethanol. Plasma factors with molecular weights less than 1,000 were potent inhibitors of CPK activity. Electrophoresis following incubation of BB CPK in plasma without mercaptoethanol revealed a new band with CPK activity with the electrophoretic mobility close to that of cardiac muscle (MB) CPK, but no band with the electrophoretic mobility of MM CPK was noted. A new band whose electrophoretic mobility was intermediate between that of MM CPK and that of MB CPK appeared after 21 hours of incubation of MM CPK in human plasma. Modifications of methods for handling blood samples in order to increase the possibility of preserving CPK isozymes in human plasma are proposed. Immunologic methods for determining CPK isozymes may provide more definitive answers as to the nature of the isozyme species present in human sera in various diseases.


The ratio of free to esterified cholesterol in serum. A new discriminant in correlating lipid metabolism with disease state. A normal range has been established for the ratio of free to esterified cholesterol in serum. It has been observed that whereas this ratio remains constant in clinically healthy subjects and is not influenced by sex or age, it is markedly altered in certain disease states. The present study is concerned with the correlation of the normal free:esterified cholesterol ratio with ratios determined for 148 patients hospitalized for various reasons. This study has allowed correlations to be made with respect to various groups of diseases, such as cardiac disease and cancer. Changes in the free:esterified cholesterol ratios offer a new and incisive discriminant in correlating the relationships between cholesterol and various diseases. The methods used were gas-liquid chromatography for determination of "free" and "total" cholesterol and the new enzymatic methods for "free" and "total" cholesterol.


Antibiotic-resistance transfer in Yersinia enterocolitica. Most clinical isolates of Yersinia enterocolitica have been reported to be inhibited by a wide variety of antimicrobial agents. This finding indicates that Y. enterocolitica infrequently acquires resistance by gene transfer from other bacteria in nature. In the present study the authors examined whether Y. enterocolitica has the potential for acquiring antibiotic resistance from another organism in vitro. Mixed cultures of multiple-antibiotic-resistant Escherichia coli and a sensitive Y. enterocolitica yielded resistant Y. enterocolitica. Resistance to at least four drugs was transferred at a frequency of approximately 10(-7) transconjugants per donor. The newly resistant Y. enterocolitica transferred resistance to a sensitive E. coli at a slightly higher frequency. Resistance to at least one antibiotic was transferred to all five strains of Y. enterocolitica tested.


Simplified method of feeding infants born with cleft palate with or without cleft lip. Most infants born with a cleft palate with or without cleft lip are undergrown and have histories of difficult feeding. For the past two years, all of the infants born with isolated cleft palate with or without cleft lip, referred to the Boston Floating Cleft Palate Clinic, were fed using a simplified method. A standard nipple that was cross cut and a standard glass baby bottle were used. The infants were fed in the sitting position and burped frequently. Data indicating that nutrition in these infants is adequate as judged by weight gain was provided.


Risk of nutritional rickets among vegetarian children. Records of the dietary intake of 52 preschool vegetarian children seen from 1974 to 1976 revealed that macrobiotic vegetarian diets provided amounts of vitamin D, calcium, and phosphorus that were marginal as well as less than the amounts provided by other vegetarian diets. Vitamin D supplements were rarely given. Two subjects had roentgenographic evidence of rickets. The medical histories of 32 children on macrobiotic diets who were examined in 1977 more frequently included prior physical and roentgenographic findings indicative of rickets, whereas those of 17 other vegetarian children did not. Children in the former group were more likely to have elevated levels of serum alkaline phosphatase. Two additional cases of rickets in children consuming a macrobiotic diet confirmed by roentgenograms were brought to our attention during the study.


The 'breech head' and its relevance.

The 'breech head' and its relevance. Eight infants had scaphocephaly with prominent occipital shelving. This abnormal head shape is identified as a postural deformation associated with breech intrauterine position, and it is noted to resolve during infancy with no apparent residual impairment in most cases. At the same time, the "breech head," as we have designated this unusual head form, may occur in the setting of a primary problem in fetal morphogenesis, and it may be itself a factor contributing to birth injury during vaginal delivery of the breech infant.


Assessment of intellectual development after surgery for craniofacial dysostosis. A 2-year-old girl with Crouzon's disease underwent three craniectomies. At age 4, she began a series of psychological tests to monitor her intellectual and academic functioning. Eight years after surgery, her intellectual functioning was comparable to that of her unaffected sister and far superior to that of her affected cousins, who were from similar home environments. Although the exact contributions of early identification and surgical intervention to the patient's intellectual and academic achievement could not be ascertained, these results suggest that some patients who receive early surgical treatment for Crouzon's disease may maintain a consistent rate of intellectual and academic development.


US cancer incidence and mortality in the first year of life. Based on the Third National Cancer Survey (1969 to 1971), the incidence of malignant neoplasms in the United States was 183.4 per million live births per year in infants younger than 1 year and 36.5 in newborns younger than 29 days. In both age groups, neuroblastoma was the most commonly diagnosed neoplasm. Overall, cancer incidence in infants younger than 1 year was almost 3.5 times greater than mortality determined from US death certificates from 1960 to 1969. For individual tumor types, the ratio between incidence and mortality varied between 159 for retinoblastoma and 1.5 for leukemia largely reflecting relative differences in survival due to treatment.


The effectiveness of pediatric nurse associates as clinical instructors of medical students. Pediatric nurse associates (PNAs) have provided health care services for children, taught physical diagnosis to first-year medical students, and acted as role models for students and residents. Their role as clinical instructors has not been measured objectively. This study evaluated the effect of PNA interaction with medical students in a pediatric clerkship. Students taught by PNAs had higher gains in factual knowledge and greater skills in physical examination as measured by a videotape of a patient encounter. The PNAs demonstrated that they can be effective instructors of medical students.


Asymptomatic transient uveitis in children with inflammatory bowel disease. Although acute anterior uveitis has been noted in children with inflammatory bowel disease, it has not been appreciated in the absence of ocular symptoms. To determine the presence of asymptomatic uveitis, slit-lamp examinations were performed in 19 children with granulomatous bowel disease and seven with ulcerative colitis. In the former group, six had uveitis, while no abnormalities were noted in those with ulcerative colitis. Abnormalities consisted of cells and flare in the anterior chamber. In the group with asymptomatic uveitis, all were male, three were black, and all had colonic involvement. No positive correlations were noted between the presence of uveitis and bowel symptoms, duration of illness, extraintestinal manifestations, or specific treatment regimens. None of the six children with uveitis had evidence of spondylitis, and five were HLA-B27-negative. Repeated eye examinations six to 12 months later disclosed no evidence of uveitis in four of five children and improvement in the remaining child. These data suggest that asymptomatic transient uveitis is common in children with granulomatous bowel disease, but progression to severe adult uveal disease remains unclear.


Congenital hypopituitarism in female infants. Its association with hypoglycemia and hypothyroidism. Congenital hypopituitarism was found in two female infants who had profound hypoglycemia and hypothyroidism. In both infants, death occurred despite recognition of the disorder and institution of appropriate therapy. Autopsy findings showed an absent pituitary gland and sella turcica, with hypoplastic adrenal and thyroid glands, and ovaries in one case, and pituitary gland aplasia with absent thyroid and right adrenal glands plus a hypoplastic left adrenal gland in the other case.


Hyperglycemic hyperosmolar coma in a 9-month-old child. Hyperglycemic hyperosmolar coma is a life-threatening emergency with a mortality much higher than that of other forms of hyperosmolarity such as hypernatremia or diabetic ketoacidosis. Despite the differences in the three conditions, present evidence suggests that correction of hyperosmolarity should proceed slowly to avoid the seizures that may occur in all three conditions. This report describes a 9-month-old diabetic child who initially had hyperglycemic hyperosmolar coma and who is one of the youngest survivors of this syndrome in the American literature. This case report points out the limited understanding of the pathophysiology of this syndrome and the consequent problems of therapy.


Staff evaluation.

Staff evaluation. The necessity for evaluating hospital pharmacy department personnel, and the recognized methods for performing such evaluations, including their advantages and deficiencies, are reviewed. Performance appraisal systems using ranking, person-to-person comparison, grading, graphic scales, checklists, forced-choice description, selection of critical incidents and management by objectives (MBO) are detailed, with emphasis upon their use in hospital pharmacy departments. All of these systems, with the exception of MBO, place inappropriate emphasis upon various subjective personality trails while failing to include objective results attained by personnel. Most of these methods (again excepting MBO) deny the evaluate-manager the opportunity to coach staff members in an attempt to improve results achievement. Staff evaluation, when carried out under an MBO system, is more likely to provide the hospital pharmacy department and its director with improved staff performance and development.


Screening and selecting candidates for a hospital pharmacy residency program. An applicant screening and selection procedure for a hospital pharmacy residency program which (1) efficiently processes a large number of applicants while minimizing the subjective nature of the review process and (2) ranks candidates for submission to the ASHP Residency Matching Program is described. A screening and selection committee consisting of five staff members of the hospital pharmacy department was created. Goals of the residency program and qualities of the optimal resident were defined prior to development of the screening and selection program. Two forms were used by staff in the screening process: a screening worksheet for the preinterview screen, and an evaluation chart for the interview phase. Each form outlined the criteria which serve as indicators of academic, professional and personal development in a format that allows easy extraction of data. By carefully defining program goals and identifying specific human qualities most compatible with those goals, the likelihood of successful applicant selection through use of a systematic screening process is increased.


Computer-based system for adverse drug reaction detection and prevention. An online computer-based system for monitoring patients for potential adverse drug reactions during their hospital stay is described. The adverse drug reaction monitoring system uses a Digital Equipment Corporation (DEC) PDP-11 computer which is programmed in MUMPS (Masschusetts General Hospital Utility Multi-programming System). Primary references from the medical and scientific literature are analyzed and evaluated before being included in the data base. The patient's adverse reaction history, obtained by nursing personnel during a patient interview, is entered into the computer by pharmacy staff. The computer screens new prescription orders for potential adverse reactions; any adverse reaction reports are sent to the patient's physician. Other special programs that are used in the patient monitoring system include medication profiles, drug-drug interaction screening and prescription discontinuation date entry. The computer system enable detection of potential adverse drug reaction and notification of the patient's physician prior to administration of the prescribed drug.


Audit of anticoagulant therapy of pulmonary embolus, deep vein thrombosis and thrombophlebitis. The use of heparin sodium and warfarin sodium in the treatment of pulmonary embolus (PE), deep vein thrombosis (DVT) and thrombophlebitis (TP) was studied by a hospital pharmacy department. During a four-month period, the charts of 26 patients were audited for anticoagulant dosages used; laboratory test monitoring of anticoagulant dosage used; laboratory test minitoring of anticoagulant therapy; complications of, contraindications to, and patient compliance with anticoagulant therapy. These variables were evaluated on the basis of compliance with a written anticoagulant protocol. Initial doses of heparin sodium and warfarin sodium were acceptable in 43% of patients. Maintenance dosing with heparin sodium was acceptable in 89% of patients. Activated partial thromboplastin times (APTT) were ordered correctly for 65% of patients. APTTs were within therapeutic ranges in 31% of patients. The duration of heparin-warfarin overlap was possibly to definitely acceptable in 71% of patients. Prothrombin times were properly monitored in 50% of patients. Complications of anticoagulant therapy were evident in only one patient. There were a number of potentially serious diversions from the protocol. The pharmacy department planned to issue bulletins designed to correct the problems.


Interdisciplinary inpatient warfarin education program. An educational program on warafarin counseling for inpatients of a 200--bed community hospital which uses both pharmacy and nursing personnel is described. Following a physician's request for the educational service, a registered nurse arranged for the patient to view a slide presentation of anticoagultants and provided a booklet designed to reinforce the learning objectives for the warfarin education program. After the patient viewed the film and read the booklet, a pharmacist or nurse made a follow-up visit to answer questions and reinforce the objectives. The checklist of learning objectives was completed by the pharmacist or nurse and remained in the patient's chart as a permanent record of medication counseling. Forty-five request for warfarin patient education were received during the program's first six months of operation. The pharmacist spent an average of 30 minutes with each patient; the nurse spent an average of 15 to 20 minutes with each patient. The average time required of nursing and pharmacy service to provide the program was one and two hours per week, respectively. The warfarin education program provides an important patient service with a reasonable expenditure of time by pharmacy and nursing personnel.


Patient package inserts and the pharmacist's responsibility. Patient package insert regulations by the Food and Drug Administration are discussed, emphasizing the pharmacist's responsibility. The possible criminal and civil liability problems the pharmacist may face under the regulations are considered. Legal implications of alternatives to using PPIs provided by the manufacturer are presented. The prudent pharmacist will examine the alternatives, weighing the administrative, clinical and legal implications of the various approaches.


Charging for hospital pharmaceutical services: product cost, per diem fees and fees for special clinical services. A method of charging for pharmaceutical services is described which includes the cost of drug products, dispensing fees for intravenous drug admixtures, per diem fees for basic dispensing and clinical services (according to patient type), and fees for special clinical services. The basic per diem charge covers drug purchasing and inventory control, department management, drug information services, dose preparation, drug order interpretation, drug therapy monitoring, and the availability of pharmacists to answer the questions of nurses and physicians. The clinical services for which special fees are charged are: hemogram drug report, drug liver function report, aminoglycoside dosing guidelines, heparin i.v. infusion, oral anticoagulation, patient drug history, operant conditioning, parenteral nutrition guidelines, and pharmacokinetic drug level interpretations and consultations. The reasons for changing to the system, the services provided and experiences with the system are discussed. Implementation of the system is discussed in relation to the calculation of fees; comparisons with alternate charging methods; approval of special clinical service charges; computer billing; information about pharmacy charges for patients; and third-party payers.


Charging for hospital pharmaceutical services: computerized system using a markup and a dose fee. The methods used to determine pharmacy charges for a pricing program in a 940-bed hospital using a computerized on-line pharmacy pricing and inventory control system are described. The program requires input of only four pieces of information: (1) patient number; (2) drug identification number; (3) dose factor; and (4) total number of doses dispensed. In the pricing formula, the charge to the patient is calculated by adding the product of the total cost of medication and the markup factor to the product of the dose fee and the total number of doses received. Advantages of the system are: (1) the patient or third-party payer can be given an itemized bill for all pharmaceutical charges; (2) the system accounts for all medication costs, whether they are charged to the patient or not; (3) the revenue for the department can be projected and adjusted accurately; (4) the charges are fair and equitable; (5) the patient is charged for medication administered only; and (6) the system produces accurate statistical reports for both the pharmacy and the financial services department. The disadvantages is the number of man-hours needed for the pricing function.