Haemoglobin concentration and peripheral blood cell counts in women. The population study of women in Göteborg 1968-1969. Hb concentration, PCV, erythrocyte and leucocyte counts in the peripheral blood, MCV, MCH and MCHC in a population sample of 1462 women in ages between 38 and 60 years are presented. In addition, a description is given of thrombocyte counts in 38-year-old women. Significant differences with age were found for Hb concentration and PCV and for leucocyte counts. High correlations were found between Hb and PCV in the various age groups studied, while lower correlations were found between erythrocyte counts on one hand and Hb or PCV on the other. There was an overrepresentation of smokers among women with high Hb values and among those with high leucocyte counts. The higher leucocyte counts in the youngest age groups could be explained by the larger number of smokers in these ages. Thrombocyte counts were lower in smoking than in non-smoking women.


Intracellular localization of 55Fe after serum-mediated uptake by human erythropoietic cells. Marrow cells of 3 patients with normoblastic erythropoiesis and 1 with sideroblastic erythropoiesis were incubated with serum-bound 55Fe Cl3 and studied by the technique of electron microscope autoradiography. In the 3 normoblastic marrows, both the mean grain counts and the percentages of grains situated over the cytoplasm (excluding the mitochondria) were higher in the early erythroblasts than in the intermediate and late erythroblasts. The percentages of autoradiographic grains situated over the mitochondria of early intermediate and late erythroblasts were 11.9-27.4, 56.5-61.1 and 65.3-65.9, respectively. Although the mean grain counts over these three cell classes in the sideroblastic marrow were similar to those in the normoblastic marrows, the proportions of grains over the mitochondria were higher, particularly in the early erythroblasts. In all 4 cases (1) some grains were situated at the junction between heterochromatin and euchromatin and (2) a few of the 55Fe-labelled immature-looking cells did not display the ultrastructural features usually attributed to pronormoblasts.


'Available oxygen', a realistic expression of the ability of the blood to supply oxygen to tissues. An expression of clinical applicability is sought for quantitating the availability of oxygen to the tissue from the blood. An 'available oxygen' is defined as the arteriovenous oxygen content difference when the mixed venous oxygen tension is assumed to be 20 mmHg. The acceptance of this latter assumption is argued on mathematical and functional grounds.


Haemolysis in athletes due to hereditary spherocytosis. Three athletes, one cross-country skier and two middle distance runners, experiencing poor response to intensified training and decline in performance during prolonged periods of frequent competitions, associated with a tendency to develop anaemia, were found to have spherocytosis, and increased osmotic fragility of the red blood cells. All had family members with the same blood abnormality, but without symptoms. The observations suggest that the frequency of hereditary spherocytosis is higher than indicated by overtly affected cases and that mild cases are easily overlooked. Hereditary spherocytosis should be looked for in athletes with a tendency to decline in blood haemoglobin concentration during periods of intensive training and competition.


Effect of calcium and factor D depletion on C3 conversion by rat intestinal glycoprotein. These studies demonstrate that a rat intestinal glycoprotein fraction may activate C3 in normal human serum by the alternative complement pathway alone and by the classical pathway alone. Conversion of C3 by the rat intestinal glycoprotein fraction amounted to 55% when both the classical and the alternative pathways were intact, to 21% when the classical pathway was blocked by ethyleneglycol-bis-(beta-aminoethyl ether)N,N'-tetraacetic acid, and to 21% in Factor-D-depleted serum. Comparable figures for zymosan were 58%, 44%, and 12%, and for sheep erythrocytes sensitized with anti-sheep haemolysin, 27%, less than 1% and 21%, respectively.


Characterization of amyloid of ageing obese-hyperglycaemic mice and their lean littermates. Amyloid fibrils, isolated from 18-month-old obese-hyperglycaemic mice and their lean littermates, were characterized immunologically and chemically. The main amyloid fibril subunit protein was protein AA, which cross-reacted completely with an antiserum against amyloid from mice with experimentally induced amyloidosis and had an amino acid composition and N-terminal amino acid sequence identical to that protein. These results indicate that the spontaneously occurring amyloidosis in obese-hyperglycaemic mice and their lean littermates corresponds to human, secondary amyloidosis and may serve as a model for that disease.


Whole-body autoradiography and allied tracer techniques in distribution and elimination studies of some organic solvents: benzene, toluene, xylene, styrene, methylene chloride, chloroform, carbon tetrachloride and trichloroethylene. Whole-body autoradiography has been used to study the distribution and fate of 14C-labeled benzene, toluene, xylene, styrene, methylene chloride, chloroform, carbon tetrachloride and trichloroethylene in mice after inhalational exposure. Total radioactivity, including the volatile part of the solvents were registered by autoradiography of dried, evaporated tape-fastened sections. In addition, dried, evaporated tape-fastened sections were extracted with water, trichloroacetic acid and a series of organic solvents and autoradiographed to register organs where metabolites were firmly bound. In another facet of the study, the quantitative elimination of the solvents and their metabolites via various routes was investigated. The expiration of unchanged solvents was subject to mathematical and computerized compartmental pharmacokinetic analysis. All solvents were rapidly taken up in fatty and nervous tissues where they were retained for different periods of time largely dependent on their fat solubility. Unexpectedly long retention times were noted for the chlorinated solvents, particularly for chloroforn, which showed a specific long-term retention in the cerebellum, meninges and spinal nerves, indicating interactions with specific nervous tissue receptors. Solvent metabolites appeared rapidly in several organs, mainly the liver and kidney, and were excreted both via urine and bile. Toluene and xylene metabolites were completely extractable whereas firmly bound metabolites were registered after inhalation of benzene, styrene and all chlorinated solvents, notably in the liver and kidney but also in the bronchi of the lung. Three-compartment pharmacokinetics were observed for the majority of the solvents selected for study although a two-compartment model was found to fit the elimination rate curves for styrene, methylene chloride and chloroform in the exhaled air. The fat solubility of the solvents was found to influence their pharmacokinetics since lower rate constants were generally obtained for the expiration of more fat soluble solvents.


[Cardiological indications for anticoagulant therapy]. The present status of short-term and long-term anticoagulant therapy and prophylaxis in cardiac disease is reviewed, with a view to providing new guidelines for treatment and prevention of thromboembolic complications in acquired heart disease.


[Ambulatory management of chronic alcoholism]. Alcoholism frequently goes undiagnosed in day-to-day medical practice because the possibility of successfully treating alcoholics on an out-patient basis is too little known. Concepts of how alcoholism arises usually relate to an isolated individual and, therefore, do not cover the whole reality of this multifactorial disease. Treatment in a "social network" presupposes that the patient's problems are understood as disturbed interactions with his environment. With this concept in mind it is possible to approach the essential conditions of the disease. 484 patients have been treated according to this program. 352 (72.7%) were followed up for an average of 8.3 years (range 2--19 years). 37.4% were in complete remission, 33.7 had markedly improved and 28.9% were unchanged or worse.


[Action mechanism and clinical indications for thrombocyte aggregation inhibitors]. The mechanisms of action of three most commonly used antiplatelet agents (aspirin, sulfinpyrazone, dipyridamole) are briefly discussed. Aspirin inhibits the prostaglandin synthetase of platelets irreversibly and thereby blocks the production of prostaglandin endoperoxides and thromboxane A2, which stimulate platelet aggregation. A daily aspirin dose of 200--300 mg is sufficient to achieve this effect. Sulfinpyrazone appears to interfere with the adhesion of platelets to subendothelial structures and atherosclerotic plaques. Dipyridamole increases cyclic AMP in platelets and thus reduces platelet response to aggregating agents. A few of the satisfactorily performed studies on the clinical effectiveness of antiplatelet agents are mentioned. Sulfinpyrazone treatment of patients with myocardial infarction (Killip--classification I and II), starting 25--35 days after the acute myocardial infarction, reduces cardiac mortality and incidence of sudden death for a period of two years. The efficacy of aspirin treatment in coronary artery disease is not yet definitely established. In patients with transient ischemic attacks, particularly males with appropriate carotid lesions, aspirin therapy reduces the frequency of transient ischemic attacks and possibly the incidence of stroke and death. Sulfinpyrazone is ineffective in these patients. Sulfinpyrazone and aspirin are of value in the prevention of thrombosis in straight arterio-venous shunts. Aspirin reduces the frequency of deep venous thrombosis after total hip replacement in males but not in females. In patients with recurrent venous thrombosis, sulfinpyrazone treatment is effective in preventing thrombosis.


[Drug interactions].

[Drug interactions]. Beneficial and adverse interactions between drugs may occur in any process that influences the pharmacokinetic and pharmacodynamic behaviour of a given drug and thus affects its therapeutic or toxic effects. Many additional "patient factors" and "drug factors" influence clinical occurrence and severity of adverse drug interactions. In dealing with drug interactions and their consequences, a uniform mode of classifying and reporting drug interactions based on clinical relevance appears to be the prime necessity. A number of adverse drug interactions commonly occurring during cardiovascular therapy are discussed.


[Non-Hodgkin lymphomas: classification, staging and therapy]. In recent years considerable advances have been made in the treatment of non-Hodgkin lymphomas, yet the results are not so impressive as the progress in treating patients with Hodgkin's disease. This may be partly explained by the lack of standardized histological classification and staging procedures, which are responsible for our incomplete knowledge of the pathogenesis and clinical course of the different lymphoma types. The most important histological classifications and procedures for adequate staging are presented. To the extent of present knowledge the initial manifestations and pathways of dissemination are discussed. So far established data makes it possible to lay down therapeutic principles which differ according to stage and histology. Loco-regional stages should be treated by radiotherapy alone. In advanced phases combined cytotoxic chemotherapy is for the most part the accepted form of treatment. While in prognostically favorable histological types a mild regimen may suffice, aggressive cytotoxic regimens should be preferred in treating unfavorable histological types. Treatment modalities combining radiotherapy and chemotherapy are still experimental. Hodgkin's lymphomas and diffuse histiocytic lymphomas in stages III and IV are potentially curable by chemotherapy.


[Cholestyramine and digoxin intoxication: therapeutic efficacy?]. Plasma levels of digoxin were measured in a patient after massive intoxication. Pharmacokinetic analysis of the data as compared with other cases of digoxin intoxication reveals that in these situations oral administration of cholestyramine may be of benefit to the patient.


[Paraganglioma of the glomus caroticum]. Extra-adrenal paraganglioma (chemodectoma) is a rare tumor; the tumor of the carotid body is the most frequently observed chemodectoma. Histochemical analysis of the glomus cell shows catecholamine in all cases, but functional activity of those tumors is an exception. The diagnosis of carotid body tumor can be confirmed by carotid arteriography. Surgery is the treatment of choice. Malignant degeneration of chemodectoma has been observed in a few cases.


[Therapeutic recommendations in idiopathic spontaneous pneumothorax]. The treatment of spontaneous pneumothorax is still controversial. To evaluate pleural drainage with a chest tube the therapeutic results in 73 patients with benign pneumothorax were reviewed. Benign spontaneous pneumothorax treated with a thick chest tube size Charrière 18-22 disappeared within an average of only 6.6 days. On the other hand, the high recurrence rate of 24% after the initial pneumothorax and 37% after the first recurrence is comparable with the results of conservative management in other pneumothorax series in the literature. Small pneumothorax without severe symptoms should therefore be supervised conservatively on an outpatient basis. The more extended forms of pneumothorax should be treated with thick chest tubes. Failure of therapeutic effect, second ipsilateral relapse or the first contralateral pneumothorax are indications for parietal pleurectomy.


[Course and quantitative evaluation of the lung involvement in cystic fibrosis]. On the basis of clinical observations the course of pulmonary involvement in cystic fibrosis is studied, and an attempt at classification into three severity groups is made. Clinical and radiological findings, quantified by special scores, are presented and correlations between scores and lung function data are demonstrated. Although respiratory function tests - in particular the ratio of residual volume to total lung capacity (RV/TLC) - correlate with the clinical and chest radiographic scores, division into three severity degrees is only reliable for groups of patients. In the individual patient the clinical, radiological and lung function findings must be taken into account together. Assessment according to a scoring system may be helpful.


[Female genital bilharziasis. 1 case].

[Female genital bilharziasis. 1 case]. In a Swiss woman who had travelled in Africa ovarian and tubal bilharziasis (Schistosoma haematobium) was found by chance during laparotomy. In both sexes genital bilharziasis is nearly always caused by Sch. haematobium and is a complication of bilharziasis of the bladder and intestine. Genital bilharziasis in woman is found principally in the cervix and in the vagina, less commonly on the vulva and in the fallopian tubes and ovaries, and rarely in the body of the uterus.


[Diagnosis and therapy in daily practice]. Diagnosis and treatment are two essential elements of medical practice. For obvious reasons, it is often impossible to make a definite diagnosis during the initial work-up. This raises the problem of how extensive diagnostic procedures should be to initiate adequate treatment. It is evident that the professional experience of a physician exerts a great influence on therapeutic measures instituted in the private office or in the hospital. Consequently, in certain instances, treatment may be started without a definite diagnosis. Nevertheless, the axiom "no treatment without prior diagnosis" remains a basic principle of medicine.


[The value of echocardiography in the diagnosis of cardiac diseases]. Single beam echocardiography is now an established diagnostic tool in non-invasive cardiology. The principle indications are valvular diseases, pericardial effusion, aneurysm of the ascending aorta, and congenital heart disease. In the absence of regional contraction disorders, left ventricular function can be assessed by the extent of systolic shortening of the left ventricular diameter. More recently, two-dimensional echocardiography has made a very significant contribution to anatomical and functional evaluation of the heart and the great vessels, since the cardiac structures can be visualized in various cross-sections. This technique is especially helpful for the assessment of left ventricular regional contraction disturbances, the diagnosis of dysfunction of artificial valves and bioprotheses, the detection of dissecting aneurysm, and the estimation of mitral valve area in mitral stenosis. Since various left ventricular axes can be determined, the quantitation of left heart volumes appears to be within the capability of the two-dimensional technique.


[Current chemotherapy of pulmonary tuberculosis]. Tuberculosis has today lost much of its dread for mankind: in 1976, 1823 persons contracted tuberculosis and 182 died of pulmonary tuberculosis in Switzerland. In contrast, 1375 died of pneumonia, 1309 of non-specific airway disease and 2202 of bronchial cancer in the same year. The present data on morbidity and mortality in Switzerland resemble those of the other industrial European countries or the USA. The decrease in morbidity and mortality of pulmonary tuberculosis was caused-among other factors-by chemotherapy. Chemotherapy not only profoundly changed the infectivity of tuberculous patients and made ambulatory, domiciliary treatment possible, but cured pulmonary tuberculosis. The introduction of the bactericidal rifampicin led to the latest major landmark in the chemotherapy of tuberculosis in the past 20 years: namely, short-course chemotherapy. Together with the other first-line drugs (isoniazid, streptomycin, ethambutol), rifampicin shortened the duration of chemotherapy from 18--24 to 9--12 months. Short-course chemotherapy is today the therapy of choice for most patients with pulmonary tuberculosis.


Methylation of mouse liver DNA studied by means of the restriction enzymes msp I and hpa II. The restriction enzymes Hpa II and Msp I both recognize the sequence 5'-CCGG (C, cytosine; G, guanine). However, Hpa II cuts mouse liver DNA to fragments four times larger than does Msp I. The size of DNA cut by Msp I is close to that predicted from base composition and nearest neighbor analysis. The most probable explanation of these results is that in mouse the site 5'-CCGG is highly methylated.


Radiation from tritiated thymidine perturbs the cell cycle progression of stimulated lymphocytes. Tritiated thymidine was found to affect the cell cycle progression of phytohemagglutinin-stimulated human lymphocytes. By means of flow cytometry a statistically significant increase in the G2 and M phases of the cell cycle was observed in cultures with low concentrations of tritiated thymidine added 18 hours before the cultures were harvested.


Retinoblastoma with 13q- chromosomal deletion associated with maternal paracentric inversion of 13q. A girl with sporadic unilateral retinoblastoma and mental retardation has an interstitial deletion in the long arm of chromosome 13. Her mother has a paracentric inversion of one chromosome 13; the deleted chromosome 13 in the daughter is derived from the mother's normal chromosome 13.


On the nature of human interlimb coordination. Movement time varies as a function of amplitude and requirements for precision, according to Fitts' law, but when subjects perform two-handed movements to targets of widely disparate difficulty they do so simultaneously. The hand moving to an "easy" target moves more slowly to accommodate its "difficult" counterpart, yet both hands reach peak velocity and acceleration synchronously. This result suggests that the brain produces simultaneity of action not by controlling each limb independently, but by organizing functional groupings of muscles that are constrained to act as a single unit.


Defects of bile acid synthesis in Zellweger's syndrome. Abnormal mitochondrial structure and function have been documented in patients with Zellweger's syndrome (cerebrohepatorenal syndrome). In vitro studies have suggested that the formation of C24 bile acids (chenodeoxycholic acid and cholic acid) from C27 cholesterol requires mitochondrial oxidative clevage of the terminal three carbons of the side chain. Therefore, three patients with Zellweger's syndrome were examined for the presence of mitochondrial defects in bile acid synthesis. All three excreted excessive amounts of 3 alpha, 7 alpha-dihydroxy-5 beta-cholestan-26-oicacid, 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-cholestan-26-oic acid, and 3 alpha, 7 alpha, 12 alpha, 24 xi-tetrahydroxy-5 beta-cholestan-26-oic acid (varanic acid), precursors of chenodeoxycholic acid and cholic acid that have undergone only partial side chain oxidation. These findings give added support to the role of mitochondrial oxidative side chain cleavage in the overall scheme of bile acid synthesis.


Cone inputs to ganglion cells in hereditary retinal degeneration. The photoreceptor layer degenerated, but cone nuclei apparently devoid of outer segments were retained in retinas of aged rats of the Royal College of Surgeons strain from which optic tract activity was recorded. Measures of sensitivity showed these single axons of retinal ganglion cells to have photopic spectral responses. Cone remnants containing a cone pigment may be the photoreceptive elements in these retinas.


DNA repair and longevity assurance in Paramecium tetraurelia. At given doses and clonal ages, ultraviolet irradiation-induced DNA damage reduced clonal life-span, but when followed by photoreactivation, extension of clonal life-span was observed. If photoreactivation preceded the ultraviolet treatment, no significant beneficial effect was detected. Because studies of others have shown that photoreactivation repair monomerizes the ultraviolet-induced cyclobutane dimers in DNA, but does not affect the other photoproducts, these results indicate that DNA damage can influence the duration of clonal life-span unless that damage is repaired. Repeated treatment with ultraviolet and photoreactivation resulted in significant mean and maximal clonal life-span extension when compared with untreated controls, and it is assumed that the rejuvenation effect was due to the correction or prevention of some age damage.


Hybrid myelomas producing antibodies against a human neuroblastoma antigen present on fetal brain. Spleen cells from mice immunized with a cultured human neuroblastoma were hybridized with the mouse plasmacytoma P3X63Ag8. Hybrid myelomas were screened for production of antibodies that reacted with human neuroblastomas but not with cells from other tissues. One of these hybridoma antibodies reacted with an antigen present on the six human neuroblastomas tested, one of two retinoblastomas, a glioblastoma, and fetal brain, but did not react with other tumors or tissues including adult human brain.


Multiple sclerosis: presence of lymphatic capillaries and lymphoid tissue in the brain and spinal cord. Thin-walled channels resembling lymphatic capillaries and containing lymphocytes were observed in perivascular spaces throughout the central nervous system of patients with various neurological disorders. This suggests that immunological surveillance in the central nervous system may normally involve lymphocyte circulation through the perivascular compartment. In some old multiple sclerosis plaques, perivascular lymphoid tissue was found which was organized in a manner similar to the antibody-producing medullary region of lymph nodes. This may indicate continuous processing of the putative multiple sclerosis antigen in such lesions.


Semliki forest virus: cause of a fatal case of human encephalitis. A fatal case of human encephalitis has been observed for which our results indicate that Semliki Forest virus (SFV) was the etiologic agent. This is surprising in view of the fact that this virus, which has been widely studied, was believed to be one of the arboviruses nonpathogenic for man. Described are the clinical course, the virological examinations performed, and the histopathological findings in the central nervous system.


Opioid peptides modulate luteinizing hormone secretion during sexual maturation. Subcutaneous injections of naloxone, an opiate antagonist, lead to an increase in serum luteinizing hormone concentrations in female but not in male rats before they reach puberty. In addition, estradiol benzoate specifically blocks the luteinizing hormone response to naloxone in prepubertal female rats, suggesting that the opioid peptides have a physiological role in the endocrine events leading to sexual maturation.


A test of some models of hemispheric speech organization in the left- and right-handed. A new method generates specific predictions concerning the expected frequencies of aphasia after unilateral injury to the brain in the left- and right-handed. These predictions are then compared with the observed data for all known studies between 1935 and 1973 to derive the best-fitting model of hemispheric speech lateralization in the left- and right-handed.


Sudden infant death.

Sudden infant death. In "Uranium mill tailings: Congress addresses a long-neglected problem" by Luther J. Carter (News and Comment, 13 Oct. 1978, p. 191), the chemical designation for yellowcake was given as (308)U, instead of the correct formula, U(3)O(8).


L Amino acids and D-glucose bind stereospecifically to a colloidal clay. L-Leucine, L-aspartate, and D-glucose bind in a stereospecific manner to a colloidal clay, bentonite. This binding has high-affinity, saturable characteristics. The biologically uncommon enantiomers, D-leucine, D-asparatate, and L-glucose, do not exhibit any selective absorption on bentonite. It is suggested that this difference between stereoisomers could account for the evolution of life forms possessing a great preponderance of L amino acids and D-glucose.


Circadian rhythm of serotonin N-acetyltransferase activity in organ culture of chicken pineal gland. When chicken pineal glands were organ-cultured in darkness, serotonin N-acetyltransferase activity was low during daytime, increased at midnight, and decreased on the next morning. The autonomous increase of N-acetyltransferase activity was suppressed by illumination of the glands. When pineal glands were cultured under a light-dark cycle (LD 12:12), the change of N-acetyltransferase activity continued to oscillate in phase with the light-dark cycle for 3 days.


Mitochondrial DNA analyses and the origin and relative age of parthenogenetic lizards (genus Cnemidophorus). Morphological, karyological, and allozyme analyses indicate that the parthenogenetic lizards Cnemidophorus neomexicanus and diploid C. tesselatus are hybrids formed, respectively, by crosses involving the bisexual species C. tigris and C. inornatus, and C. tigris and C. septemvittatus. Mitochondrial DNA, which is inherited maternally, was obtained from each of these species. Analyses of the mitochondrial DNA's and their restriction endonuclease digestion products by electron microscopy and agarose gel electrophoresis support the hybridization hypothesis by indicating that C. tigris (specifically the subspecies marmoratus) was the maternal parent species for both C. neomexicanus and C. tesselatus. Furthermore, these data imply that these two parthenogenetic species are younger than some races of C. tigris.


Premature senescence in cultured skin fibroblasts from subjects with cystic fibrosis. Cultured skin fibroblasts from subjects with cystic fibrosis exhibited normal population doubling times in early passages. After about 13 cumulative population doublings, cystic fibrosis lines doubled more slowly than controls and ceased doubling after about 19 weekly passages. Control lines continued doubling for 27 passages. The premature senescence noted in cells from subjects with cystic fibrosis reconciles controversial observations of cell doubling reported in the literature. Data presented here demonstrate that experiments with cystic fibrosis cells in late passage may generate misleading results since differences from control lines may be ascribed to generalized senile changes rather than to specific results of the cystic fibrosis genotype.


Narcotic analgesia: fentanyl reduces the intensity but not the unpleasantness of painful tooth pulp sensations. Forty subjects rated the magnitude of painful electrical stimulation of tooth pulp before and after the intravenous administration of either fentanyl, a short-acting narcotic, or a saline placebo. The responses were choices of verbal descriptors from randomized lists of either sensory intensity (that is, weak, mild, intense) or unpleasantness (annoying, unpleasant, distressing) descriptors. The fentanyl significantly reduced the sensory intensity without reducing the unpleasantness of the tooth pulp stimuli, indicating that the mechanisms of narcotic analgesia may include a significant attenuation in pain sensation in addition to effects on pain reaction. These results stress the importance of using multiple measures of pain.


Distribution of transmembrane polypeptides in freeze fracture. Human erythrocytes have been freeze-fractured, and the polypeptides associated with the separate halves of the membrane bilayer have been analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis. The transmembrane proteins were differentially separated by the fracture process. Although sialoglycoproteins associated with the outer half of the membrane, the anion transport protein (band 3) mainly remained with the inner half of the membrane. Well-defined fragments of the sialoglycoproteins were produced by the freeze-fracture procedure, indicating that selected covalent bonds of these transmembrane proteins were broken.


Sodium-selective liquid ion-exchanger microelectrodes for intracellular measurements. The sodium-selective ligand 1,1,1-tris[1(1)-(2(1)-oxa-4(1)-oxo-5(1)-aza-5(1)-methyl)dodecanyl]propane dissolved in 3-nitro-o-xylene containing a small amount of the lipophilic anion tetrachlorophenyl borate was used as a liquid ion-exchanger in sodium-selective microelectrodes. The microelectrodes gave rapid, stable responses that were linear functions of the logarithm of sodium activity. They were tested under conditions approximating those to be expected in the cell interior, and the results indicated that they can be used to measure intracellular sodium activity without significant interference from intracellular potassium.


Membrane surface potential changes may alter drug interactions: an example, acetylcholine and curare. Curare is known to be less effective as an acetycholine antagonist when the divalent cation concentration of the extracellular solution is increased. This observation can be accounted for by the negative surface potential on the end plate; an increase in divalent cation concentration decreases the negativity of the surface potential and thereby lowers the concentrations of cations at the membrane-solution interface. The concentration of divalent cations, such as curare, will be reduced more than the concentration of univalent cations, such as acetylcholine. The observations can be accounted for by a surface potential of about -50 millivolts. The same principle can explain the reported actions of divalent cations on the affinity of receptors for acetylcholine. The effects of surface potential on concentrations at active sites may play an important role in drug interactions.


Lateral geniculate nucleus in dark-reared cats: loss of Y cells without changes in cell size. In cats reared in the dark from birth until 4 months of age, the dorsal lateral geniculate nucleus contained few normal Y cells in either the binocular or monocular segments. Although most of the neurons appeared to be normal X cells unaffected by light deprivation, many cells with abnormal receptive field and response charcteristics were encountered. These effects were permanent, since 1 to 2 years of normal visual experience following initial light deprivation did not lead to any functional recovery. The sizes of cell bodies in cats reared in the dark were similar to those of normal animals, an indication that changes in geniculate cell physiology need not be related to changes in cell size.


Microwave radiation and chlordiazepoxide: synergistic effects on fixed-interval behavior. In the presence of low-intensity pulsed microwave radiation, at an average power density of 1 milliwatt per square centimeter, the response-rate-increasing effects of chlordiazepoxide were potentiated in rats. The behavioral effects of a drug can be modified by brief exposure to a low-level microwave field even when the radiation level alone has no apparent effects on the behavior.


A brain event related to the making of a sensory discrimination. Event-related potentials associated with detected targets in a vigilance task were analyzed in two ways: (i) by sorting the potentials in terms of sequential reaction time bins of 50 milliseconds and (ii) by examining the single trial waveforms. A negative component (N2) covaried in latency with reaction time. These results support the hypothesis that N2 reflects a decision process which controls behavioral responses in sensory discrimination tasks.


Smooth pursuit eye movements: is perceived motion necessary? It has recently been shown that perceived motion, in the absence of any appropriate retinal motion, is a sufficient stimulus to generate smooth pursuit eye motions. This raises the question of whether perceived motion is necessary for pursuit. In three experiments we obtained a negative answer to this question: retinal motion always governed pursuit.


Fungal arthritis. II. Coccidioidal synovitis: clinical, diagnostic, therapeutic, and prognostic considerations. This is the second phase of a review of fungal arthritis that will be presented in three parts. Coccidioidal synovitis will be discussed in this issue. Part I was a review of Candida arthritis; part III will be a review of cryptococcal, sporotrichal, histoplasmal, and blastomycotic arthritis.


Multiple imaging modalities for the study of pancreatic disease. Gray scale ultrasonography (US) and computed tomography (CT) have enhanced the role of various imaging modalities in the evaluation of patients with suspected pancreatic disease. When these anatomical studies are normal or equivocal, a functional, radionuclide pancreas scan may be useful. Pancreatic imaging can be achieved using ultrasound, transmission CT, single photon radionuclide imaging, and positron emission CT. A diagnostic imaging decision chart for the evaluation of patients with possible pancreatic disease is useful in choosing the correct imaging modality in a specific situation. Such a chart and its theoretic basis are described in this review. The need to optimize the pancreatic work-up with respect to cost-benefit decisions and diagnostic accuracy, sensitivity, and specificity are of particular concern to the physician. Of all the potential areas for disease, the pancreas has been and remains a particularly difficult diagnostic problem.


The roles of Gallium-67 scintigraphy, ultrasonography, and computed tomography in the detection of abdominal abscesses. The evaluation of patients with suspected abdominal abscesses begins with a history and careful physical examination. Gallium-67 (67Ga) scintigraphy, ultrasonography (US), and computed tomography (CT) are utilized only after other routine investigations have failed to localize the abscess. All three modalities are reliable for the detection of abdominal abscesses. The decision regarding which of these three diagnostic tests to use in a particular patient rests upon clinical considerations. If the patient has acute localizing signs and symptoms, 67Ga should not be used initially. In this type of patient, rapid diagnosis is best provided by either US or CT. Further radiologic investigation may be terminated if the CT or US findings are characteristic of an abscess. A 67Ga scan should be performed in a patient with acute localizing signs and symptoms if the initial CT or US is negative. In a patient with nonlocalizing signs and symptoms, 67Ga imaging should be employed as the first procedure since the entire body is easily surveyed. If the 67Ga images are abnormal, then CT or US should be utilized for further lesion characterization. This diagnostic approach will optimize the rapidity of patient evaluation and will minimize diagnostic errors.


Anatomic correlations in radiogallium imaging of the peritoneum and retroperitoneum. Radiogallium (67Ga) imaging of the abdomen and pelvis has been useful not only in detecting inflammations in these regions, but in pointing out their precise anatomic localization. Once the anatomic site is determined, it is often possible to infer the source of origin of the problem (such as ruptured viscus or pancreatitis). Interpretation of the images depends on recognition of patterns that define known anatomic boundaries such as the transverse mesocolon, root of the small mesentery, perirenal space, and pararenal space, or else show diffuse peritoneal uptake. The anatomic patterns may have continued usefulness in future studies, such as when radiolabeled leukocytes are employed to localize inflammations.


The relationship of computed tomography, gray-scale ultrasonography and radionuclide imaging in the evaluation of hepatic masses. Hepatic scintigraphy, gray-scale ultrasonography, and computed tomography have proven to be useful in the initial detection and evaluation of hepatic masses. These studies appear to be complimentary since each provides information not available from the others. Hepatic scintigraphy is currently the method of choice for the initial evaluation of the liver for mass lesions as it is easily performed, relatively inexpensive, and affords detectability of intrahepatic mass lesions at least as great as that of ultrasonography or computed tomography. When a definite or suspected abnormality is seen by hepatic scintigraphy, computed tomography or ultrasonography may be helpful in providing better anatomic definition or clarification of the nature of the abnormality. The choice between these latter two modalities depends on the type of scanning equipment available and the observer's experience with each method.


Transduction at electroreceptors: origins of sensitivity. Electroreceptors of four different classes were analyzed in terms of adaptations leading to high sensitivity. The large receptor of mormyrids is a sensitive phasic receptor. Voltage amplification is provided by an impulse-generating mechanism in the receptor cells. The cells are specialized in that their threshold is very close to the resting potential. Inward current may be mediated by Ca channels, which show little inactivation. Transmission to the afferent nerve is electrotonic and is apparently not otherwise specialized. Other phasic receptors appear to use regenerative responsiveness more for active filtering than for voltage gain. Tonic electroreceptors of freshwater fishes lack regenerative responses in their receptor cells. Stimuli act directly on the presynaptic membrane to alter Ca permeability and modulate the release of transmitter. The absence of regeneration is ascribable to shunting by fixed conductances. The relation between transmitter release and depolarization is much steeper than the corresponding relation at the squid giant synapse. Indirect arguments suggest that the great voltage sensitivity does not reside in any properties of the Ca channels, but in subsequent processes leading to transmitter release. The ampulla of Lorenzini is the most sensitive electroreceptor. Its sensitivity apparently resides in the regenerative oscillatory activity of the receptor cells. The receptor is kept in its operating range by accommodative processes, probably involving Ca-activated outward current. A number of mechanisms of electroreception appear relevant to mechanosensitive acoustico-lateralis receptors. The specialized accommodative processes and the adaptations increasing sensitivity are likely to be relevant to many other systems as well.


Aseptic (avascular) necrosis of the femoral head in psoriasis. Aseptic (avascular) necrosis of the femoral head associated with psoriasis is reported. The clinical histories of nine patients with avascular necrosis of the femoral head and one patient with bilateral humeral head osteonecrosis are summarized. Psoriasis was the only associated condition found in three of the patients. Only two patients had received systemic corticosteroids in significant amounts (greater than 1 gm of prednisone). Four patients had received methotrexate therapy for psoriasis. Other possible contributing factors including serum uric acid levels are discussed. Psoriasis should be added to the list of systemic diseases associated with aseptic (avascular) necrosis. Avascular necrosis of the femoral head should be considered in any patient with psoriasis and pain in the hip or thigh.


Conjunctival biopsy in the diagnosis of sarcoidosis. The diagnosis of sarcoidosis with ocular involvement is often difficult and accompanied by a certain measure of uncertainty due to a paucity of additional physical signs. In the ophthalmic literature, it is controversial as to whether biopsy of a clinically normal conjuctiva should be done if sarcoidosis is suspected. Many authors advocate biopsy only in the presence of conjunctival follicles or nodules. However, a positive biopsy from a clinically normal-appearing conjunctiva has been reported. Recently, we saw a patient with bilateral uveitis, evanescent cranial nerve palsies, and other clinical manifestations suggesting central nervous system and ocular sarcoidosis. Random biopsy of a normal-appearing conjunctiva revealed a noncaseating granuloma consistent with sarcoidosis. Since conjunctival biopsy is a simple office procedure with minimal morbidity, this diagnostic tool should be considered for patients with clinically suspected sarcoidosis, even in the absence of conjunctival follicles or nodules.


Cancer associated with collagen-vascular disease. Two cases of cancer, each associated with a different collagen-vascular disease, are reported. The first patient, a 71-year-old white man, had a history of acute dermatomyositis and malignancy for a few weeks only. Death was associated with adenocarcinoma of the lesser curvature of the stomach with metastases to the liver and beyond. The second patient, a 69-year-old white man, had had symptoms associated with Raynaud's phenomenon for more than a decade and difficulty in swallowing, attributed to progressive systemic sclerosis for more than two years. He died with an epidermoid carcinoma of the esophagus with extension to the lung and metastases to the liver and lungs.


Typhoid fever in children: a forgotten disease? All indexed cases of typhoid fever occurring in children over a ten-year period in Jacksonville, Fla, were studied retrospectively. This review revealed that anorexia was the most common gastrointestinal complaint and that neurologic symptoms and signs were nearly as common as gastrointestinal signs. There was a significant delay in diagnosis in most cases because typhoid fever was not included in the differential diagnosis upon admission. This is probably due to the decline in the incidence of typhoid fever in the United States and the resultant lowering of the index of suspicion for the disease on the part of physicians in general. Representative cases are presented in detail.


Influenza 1978.

Influenza 1978. During January and February 1978, an outbreak of respiratory infection occurred at Fort Sam Houston, Texas. Both influenza A/Texas and A/USSR were isolated in the hospitalized patients. Two different strains of influenza A have not previously been documented during a single outbreak. This raises the possibility of recombination with emergence of a new antigenic strain.


Transport of the neonate.

Transport of the neonate. A regionalization program, initiated in 1973 at Vanderbilt University Medical Center, has included community hospital site visits, formal nursing courses, and neonatal transport. The neonatal transport program was designed not only to give initial medical care to the sick newborn, but also to develop the educational aspects of the regionalization program. Analysis of data from the first two years (614 transports) revealed significant educational interactions occurring during transport. Improved perinatal care the second year was reflected in decreased regional neonatal mortality and improved neonatal management.


Congenital tuberculosis and associated hypoadrenocorticism. Two cases of probable congenital tuberculosis occurring in the ten-year period from 1966 to 1976 are reported. One infant with confirmed congenital tuberculosis also had symptomatic hypoadrenocorticism. Tuberculosis should be considered in the differential diagnosis of the seriously ill infant.


Granulomatous interstitial nephritis: a complication of heroin abuse. A 27-year-old man, a known heroin addict with previously diagnosed nephrotic syndrome, had a percutaneous renal biopsy for recurrent proteinuria. The biopsy revealed a glomerular lesion compatible with focal sclerosing hephropathy. The renal interstitium also demonstrated numerous active granulomas characterized by the presence of both multilamellated basophilic material and areas of unstained fibrillar material. These findings represent a previously undescribed complication of parenteral heroin abuse--renal granuloma formation.


Proximal femoral focal deficiency: a clinical appraisal. In patients with unilateral proximal femoral focal deficiency, the leg length inequality is almost always greater than five inches at skeletal maturity. Consequently, prosthetic management should be planned before the patient walks. A standard plan of treatment of the patient with unilateral PFFD is not possible at this time, primarily because of the varying percentage of femur missing and the controversy of management of the hip in patients with type A or B deformity. However, we found that ankle disarticulation with Syme flap closure combined with arthrodesis of the knee is a reasonable plan in many patients with unilateral PFFD. This allows correction of the knee and hip flexion contractures and gives the patient a functional, cosmetic stump. By the time he begins school, he is functioning as an above-knee amputee. This is not an undesirable goal, as one of us (E.G.R.) recently examined an above-knee amputee, a Captain in the United States Army, who continued his hobby of sky diving.


Basic pediatrics: a new American physician in an African village hospital. This communication presents a picture of medical practice, with an emphasis on pediatrics, in a rural hospital in the Transkei Republic of Southern Africa. The manner in which this setting appeared to and confronted a new graduate and his attempts to practice medicine are reported. An evaluation of the experience in terms of an education and suggestions for interested students and physicians are described.


Detection of fetal anencephaly using real-time ultrasound. Anencephaly can be diagnosed using real-time ultrasonography. This enables visualization of the fetal movements and facilitates identification of the fetal parts, making certain the exact orientation of the fetus. Thus, the negative finding of the lack of fetal calvarium, as well as the positive finding of insufficient space for a calvarium to exist between the fetal thorax and the uterine wall, can be confidently ascertained. One can then be certain that a fetal head is not being missed by the ultrasound beam, as is possible with a rapidly moving fetus using B-mode ultrasound.


Telltale mouth flora: a clue to the diagnosis of factitious recurrent thigh abscesses. A 27-year-old man had recurrent abscesses of the thigh caused by organisms typical of mouth flora. The unusual identity of these organisms from a thigh abscess led to the recognition that the illness was induced by self-injection with saliva, and that the patient had many of the characteristics of Münchausen's syndrome.


Osteosclerosis (punctate form) in multiple myeloma. Generalized punctate and nodular osteosclerosis associated with multiple myeloma is reported with review of the literature and differential diagnoses. This patient differs from some others reported earlier in the absence of any recognized osteolytic lesions either during life or at autopsy.


Giant renal calculus with metastatic carcinoma. A case of a massive renal calculus is described. The radiographic appearance is discussed, and attention is drawn to the more subtle radiographic finding of a metastatic tumor which proved fatal. No autopsy was done.


Adult respiratory distress syndrome secondary to diffuse pulmonary blastomycosis. We have described diffuse pulmonary blastomycosis in a previously healthy 19-year-old man, which resulted in the adult respiratory distress syndrome (ARDS). Physicians must have a high index of suspicion for treatable causes of ARDS, and the use of open lung biopsy for early diagnosis is stressed.


Congenital retroperitoneal hemangioendothelioma with Kasabach-Merritt syndrome. This is the first documented congenital retroperitoneal hemangioendothelioma. The patient presented at birth with a retroperitoneal mass and thrombocytopenia. Postmortem examination revealed the tumor to be a hemangioendothelioma, arising from the posterior abdominal wall. The association of an angiomatous tumor will thrombocytopenia represents the Kasabach-Merritt syndrome.


Inadvertent intracranial placement of a nasogastric tube through a basal skull fracture. Inadvertent intracranial placement of nasogastric tubes may occur during intubation of patients with severe maxillofacial trauma and basal skull fractures. Oral intubation, nasogastric intubation under fluoroscopy, or nasogastric intubation under direct vision will eliminate the possibility of this complication.


Advanced digoxin toxicity in renal failure: treatment with charcoal hemoperfusion. Glycoside toxicity, a common and potentially fatal complication among patients taking digoxin, is treated basically by managing cardiac arrythmias until the patient can excrete enough drug to decrease the intoxication. Patients with renal failure, however, are particularly difficult to manage. We describe a case of advanced digoxin toxicity in an elderly man with severe renal failure, treated with a charcoal hemoperfusion device.


Computerized tomography in selected intracranial vascular abnormalities. Computerized axial tomography (CAT) is a reliable technic for examining patients with a variety of intracranial abnormalities. In acute lesions where there is extravasated blood, the CAT scan shows areas of increased density on the precontrast study which measures 70 to 90 Hounsfield units. In lesions with increased flow or blood volume, the postcontrast study reveals areas of increased density due to greater pooling of contrast medium. In areas of nonhemorrhagic ischemia the CAT scan shows persisting low density.


Transient global amnesia.

Transient global amnesia. Transient global amnesia is a clinical syndrome characterized by sudden onset of short-term memory loss followed by retrograde amnesia in an otherwise healthy subject. During the attack, the patient remains alert and retains much of his personal identity. The patient usually becomes upset and concerned about his memory loss. This condition may be diagnosed incorrectly as hysteria, psychosis, or temporal lobe seizure, despite its unique clinical features.


"Empty" sella: review of 76 cases.

"Empty" sella: review of 76 cases. We reviewed 76 cases of the empty sella syndrome. Headache was the chief complaint in 47 cases (62%), and 45 patients (60%) presented with signs and symptoms related to increased intracranial pressure and/or pituitary dysfunction. The CSF pressure was elevated in 35 of the 62 patients who had lumbar puncture, suggesting that increased intracranial pressure may play an important role in the pathogenesis of "empty" sella.


Traumatic rupture of the thoracic aorta. Our experience with 36 cases of traumatic rupture of the aorta has prompted an aggressive investigative and surgical approach. Age range, mechanism of injury, and associated injuries are quite variable. Aortogram is essential for diagnosis and should be done with any evidence of mediastinal abnormality following a deceleration injury. The preferred method of repair is graft interposition for the transected aorta, using femoral vein to femoral artery bypass with an oxygenator in the system. The salvage rate is good if an aggressive surgical approach is used.


Rehabilitation of patients with cardiac disease and associated cerebrovascular accident. The physician is faced with multiple rehabilitation problems when a patient with cardiac disease develops a cerebrovascular accident. This presentation outlines the recommended rehabilitation procedure used for such patients referred to the Physical Medicine and Rehabilitation Service of St. Luke's Episcopal Hospital. The implementation of combined cardiac and stroke rehabilitation is described. Controlled levels of energy expenditure are ordered and increased within the patient's improving cardiac work tolerance. The type of level of exercise prescribed will depend upon the existing neurologic deficits and degree of cardiac impairment.


Sodium pyruvate treatment for hyperkeratotic disorders. We have successfully used 5% sodium pyruvate in Eucerin for the treatment of congenital disorders with hyperkeratosis. It was most effective in those disorders with the most hyperkeratosis, and it was nonirritating even after extensive use. The efficacy of pyruvate may be due to the relatively low pKa of pyruvic acid.


Methotrexate-induced diffuse interstitial pulmonary fibrosis. Three patients received respectively 190 mg, 175 mg, and 196 mg of methotrexate and developed bilateral pulmonary infiltrates without evidence of peripheral blood eosinophilia. Sputum in the three cases failed to reveal acid-fast bacilli, pathogenic fungi, or opportunistic organisms by cultures and appropriate stains. Despite discontinuance of the drug and/or institution of corticosteroid therapy, progressive respiratory failure led to death. In all three cases, autopsy revealed gross and microscopic features indistinguishable from those seen in the Hamman-Rich syndrome, and methotrexate hepatotoxicity was present in one. Pulmonary eosinophilia or granulomas, classically seen in previously reported cases of methotrexate pneumonitis, were not observed. It is suggested therefore that methotrexate be added to the list of agents capable of inducing diffuse interstitial pulmonary fibrosis. Conversely, diffuse interstitial pulmonary fibrosis should be considered in the differential diagnosis of patients receiving methotrexate who develop bilateral pulmonary infiltrates seen on chest roentgenograms.


Rheumatic fever and gonococcal pharyngitis in an adult. The arthritis of rheumatic fever in adults may mimic acute gonococcal arthritis. To further characterize this clinical picture the features of six patients presenting with the migratory polyarthritis of acute rheumatic fever have been analyzed. There were two men and four women, ranging in age from 18 to 43; in five the initial clinical impression was gonococcal arthritis. In all patients, however, the diagnosis of acute rheumatic fever was subsequently established. Characteristics of acute rheumatic fever not commonly described included tenosynovitis in all six and an erythematous rash in three. In three patients synovial fluid WBC exceeded 28,000/cu mm, with greater than 90% neutrophils. In five of the six, gonococcal arthritis was ruled out by appropriate studies and by failure to respond to antibiotics in all patients. The one patient with serum antigonococcal antibodies had gonococcal pharyngitis and acute rheumatic fever.


Long-term follow-up of patients with Austin Moore Prostheses. A retrospective study of the long-term follow-up of patients with Austin Moore prostheses is presented. Sufficient data were present to evaluate 78 hips postoperatively at six months, and 1, 5, 10, and 15 years when applicable. The average age of patients at the time of operation was 56.1 years. Most preoperative diagnoses resulted from previous operative procedures which had failed (there were only six fresh fractures). The operative technic is discussed. Postoperatively, cessation of pain is relatively early and the return of function increases linearly but at a slower rate. The importance of partial weight-bearing for four to six months postoperatively as well as daily physical therapy is emphasized. The mean amount of settling of the prostheses (total in the femur and acetabulum) was 1.63 cm in all patients. We believe that certain postoperative principles are applicable to all types of reconstructive surgery of the hip.


Malacoplakia of the vagina.

Malacoplakia of the vagina. Malacoplakia of the vagina was incidentally discovered in a 47-year-old white woman with a history of chronic active hepatitis and steroid hormone therapy. The relation between malacoplakia, liver disease, and steroid therapy is discussed.


Cecal volvulus.

Cecal volvulus. A recent experience with cecal volvulus of acute and chronic types is presented. The four cases were treated surgically by both reconstructive and extirpative means with equally good results. Early diagnosis and vigorous treatment are emphasized to avoid a high mortality rate in this condition.


Rapid treatment of psychosis with haloperidol. Rapid parenteral treatment of agitated psychotics is now possible with haloperidol. A review of its pharmacology and clinical trials is presented, and protocols are derived which will rapidly effect and maintain a substantial remission in a majority of cases.


Status of the physician-patient privilege. While in most states information physicians obtain from the about patients is confidential and cannot be disclosed without the patient's permission, a recent California Supreme Court decision affirms that when the doctor reasonably believes his patient can cause violent harm to third persons, he had an overriding duty to warn the third parties and appropriate authorities. Such possible violent harm may be direct, such as physical assult, or indirect, such as an automobile accident resulting from driving while taking certain drugs. The duty to break the privilege of confidentiality does not apply when the injury is likely to be self-inflicted or involve only property damage.


Ventilation-perfusion lung imaging in diaphragmatic paralysis. We have described a patient with paralysis of the diaphragm, in whom dyspnea, hypoxemia, and hypercapnia increased when he changed from the upright to the supine position. Ventilation (V) and perfusion (P) images of the right lung appeared to be normal and remained nearly the same in the upright and supine positions. In contrast, V and P images of the left lung were smaller than those of the right lung in the upright position and decreased further in the supine position. In addition, the ventilation image of the left lung was much smaller than the perfusion image in both positions.


Malignant transformation of polyostotic fibrous dysplasia. We have described an unusual case of polyostotic fibrous dysplasia in a 25-year-old white woman who had malignant transformation into a mesenchymal tumor with widespread metastases and features of rhabdomyosarcoma. Masculinization also occurred with high plasma testosterone levels. A mechanism for the development of masculinizing features is discussed.


Postpartum thrombophlebitis of the ovarian vein. Puerperal pelvic thrombophlebitis is most commonly found in the ovarian veins. It may be diagnosed by laparotomy, but it should be suspected clinically when symptoms develop two to five days after delivery. If medical treatment with antibiotics, anticoagulants, and bed rest is unsuccessful, surgical intervention with ligation or removal of ovarian veins may be necessary.


Tetracycline-induced aplastic anemia.

Tetracycline-induced aplastic anemia. A 54-year-old man developed mild renal insufficiency after treatment with gentamicin and cephalothin. He then received tetracycline for eight days, 500 mg orally four times daily, for a total dose of 15 gm. Twelve days after discontinuation of the drug, a severe but reversible aplastic anemia developed. We propose that bone-marrow-toxic concentrations of tetracycline resulted from the preexisting renal insufficiency. Because of the temporal relationship between tetracycline administration and aplastic anemia, and the lack of any other explanation, we conclude that this case illustrates a rare but potentially fatal complication of this drug.


Bilateral renal cell carcinoma in von Hippel-Lindau disease: treatment with staged bilateral nephrectomy and hemodialysis. The second reported case of bilateral renal cell carcinoma associated with von Hippel-Lindau disease and treated successfully with staged bilateral nephrectomy and hemodialysis is presented, accompanied by a brief review of the literature.


Cryptogenic cirrhosis associated with methyldopa. A 55-year-old woman developed cirrhosis with portal hypertension while taking methyldopa. No other cause for the cirrhosis was evident. In view of the known hepatotoxic effects of methyldopa, a causal relationship is implied. Possible mechanisms of drug toxicity include both immunologic reactions and direct hepatocellular damage by the drug or its metabolites.


Severe diarrhea secondary to propranolol. We have described two patients with propranolol-induced severe diarrhea, confirmed by rechallenge with the drug. In both cases the diarrhea was readily reversible with discontinuation of the drug.


Cavitary pulmonary metastases from vulvar carcinoma. A patient with vulvar carcinoma and multiple cavitary pulmonary metastases was diagnosed by transbronchial lung biopsy. The patient had no pulmonary symptoms, and the lesions regressed radiographically with combination chemotherapy. Although unusual, vulvar carcinoma can metastasize to distant organs.


Sarcoidosis presenting as a unilateral hilar mass. Sarcoidosis has been characterized by a variety of clinical presentations ranging from complete lack of symptoms to incapacitating multisystem disease. Bilateral thoracic lymph node enlargement with or without pulmonary disease is the most common presentation. An elderly woman with eye pain, visual disturbance, nonproductive cough, and weight loss was found to have unilateral hilar enlargement on roentgenographic examination of the chest. An aggressive search for a neoplastic process disclosed only noncaseating granulomas consistent with sarcoidosis. The patient completely recovered on corticosteroid therapy alone.


Adrenal calcification present at birth.

Adrenal calcification present at birth. Presented in a case in which calcification of the adrenal gland was roentgenographically evident on the first day of life. The earliest previously reported case of adrenal calcification was at 8 days of age and was attributed to an intrapartum hemorrhage. It is proposed that an intrauterine third trimester insult was responsible for prepartal hemorrhage which resulted in adrenal calcification present at birth.


Gentamicin failure in staphylococcal bacteremia. Gentamicin has been relied upon in some antibiotic combinations against Staphylococcus aureus, should it be present. Reported is a case of Staphylococcus aureus bacteremia treated inadvertently by gentamicin, and the gentamicin failed.


Hepatitis B presenting with tenosynovitis. A 31-year-old nurse's aide developed fever, malaise, migratory arthralgias, arthritis, and severe tenosynovitis six weeks after pricking her finger with a needle contaminated by blood from a patient having type B viral hepatitis. Although disseminated Neisseria gonorrhoeae infection was the initial diagnosis, her symptoms worsened on treatment with ampicillin. While the patient was on aspirin therapy, her symptoms improved dramatically and eventually resolved as she showed evidence, through laboratory findings, of an anicteric hepatitis B infection. Evidently tenosynovitis can be part of the hepatitis B prodrome.


Vasectomy as an outpatient procedure.

Vasectomy as an outpatient procedure. The technique of vasectomy performed at Groote Schuur Hospital on 250 men under local anesthesia is detailed. The importance and extent of adequate counselling are outlined. The procedure is acceptable, effective and safe, and complications have been minor and transient.


Complementary roles of radionuclide scintigraphy and transmission computed tomography in the diagnosis of intracranial disease. Transmission computed tomography (TCT) is a very useful technique for detection of intracranial disease, but radionuclide (RN) scintigraphy also has a place and is cheaper. The best results are however obtained by using both diagnostic techniques in a complementary manner. It may be possible one day to combine the two techniques and produce an in vivo autoradiograph.


The effect of paraquat on the aerobic metabolism of rabbit alveolar macrophages and lung fibroblasts. In this study the effects of paraquat on the aerobic metabolism and viability of isolated rabbit alveolar macrophages and lung fibroblasts were investigated, and compared with the effects of other known metabolic inhibitors, i.e. sodium fluoride (NaF) and potassium cyanide (KCN). The manometrically and polarographically determined endogenous oxygen consumption of lavaged alveolar macrophages compared very well (180,9 +/- 35,8 and 169,3 +/- 26,8 nmol per 10(6) viable cells per hour respectively). Exogenous glucose (10 mM) and autologous serum (1:3 v/v) added to the medium had no significant effect on the basal respiration rate. The mean cell protein content, determined by the micro-Kjeldahl and Lowry techniques, amounted to 242,6 +/- 37,6 microgram/10(6) macrophages. Paraquat (2 mM), like NaF (20mM) and KCN (5 mM), decreased the viability of the macrophages far less than it did the oxygen utilization of the viable cells, and resulted in an 80% inhibition of oxygen uptake. In contrast, paraquat (1 mM) induced a marked stimulation (230%) of the cyanide-insensitive respiration of alveolar macrophages. The concentrations of paraquat (nmol/10(3) cells) which reduce macrophage metabolism to almost zero were virtually non-toxic to fibroblasts, as measured by their oxygen consumption.


The arts of percussion and auscultation of the chest re-examined. Clinical teaching of percussion and auscultation is examined critically, and it is suggested that there is confusion on the subject both in textbooks and in the minds of clinicians and students. Percussion should be viewed more in terms of 'feel' than 'sound', and thus a classification of 'hard', 'intermediate' and 'soft' dullness is introduced. As regards auscultation, a plea is made for differentiation between obstructed and non-obstructed consolidation of lobes, a point recognized by some clinicians, but not enunciated with clarity by teachers. The differences between the clinical findings in obstructive consolidation of the upper and lower lobes are discussed. The importance of distinguishing between tracheal and bronchial breathing is emphasized.


Duodenal ulceration in Indians and Blacks in Durban. Duodenal ulceration among Black and Indian patients admitted to King Edward VIII Hospital, Durban, over a 26-year period (1950-1976) was studied. Analysis was made over a series of time intervals within this period, and expressed as the number of admissions for duodenal ulcer per 1,000 total admissions (excluding obstetric and gynaecological patients). Admissions for duodenal ulceration increased 2,4-fold among the Indians and 11,9-fold among the Blacks from 1950 to 1976. The disease appears to have become commoner among women in both race groups. The peak age for Indian men is the 3rd decade, but for Indian women the peak age incidence has changed from the 4th to the 6th decade. There is now a peak in the 3rd decade for Black men, compared with the 4th decade, as reported 20 years ago. The pattern is similar in Black women. The clinical presentation is similar in the two groups, although it is significant that haemorrhage occurs more frequently among the Black patients.


An ultrastructural study of a juvenile melanoma. An unusual variant of juvenile melanoma, namely a sclerosing juvenile melanoma occurring on the buttock, has been studied by light and electron microscopy. The diagnosis of a pigment tumour was confirmed by the presence of structures common to these lesions, i.e. melanosomes, intracytoplasmic fibrils and microvilli on the cell surface. The tumour consisted of two cell configurations, namely a multinucleated giant cell and a second cell made up of two separate cells lying in close apposition, the cytoplasm of one cell being dark and the other light. This tumour can be differentiated from a benign naevus by the bizarre histological appearance on light microscopy. On electron microscopy the distinction is made by the presence of the very large multinucleated giant cells, the apposition of the light and dark cells, the scanty melanosomes and the presence of intracytoplasmic lumina. The value of electron microscopy in the determination of the nature of unusual skin tumours is discussed.


The accelerated diagnosis of jaundice with ultrasonography and narrow-needle cholangiography. The accuracy of ultrasonography in the diagnosis of jaundice in 70 patients has been compared with that of transhepatic cholangiography and the results of surgery and liver biopsy. A simplified system of grouping the ultrasonic data is presented. The results indicate that ultrasonography is capable of differentiating obstructive from non-obstructive jaundice in 94% of cases and of defining the correct anatomical level in 85% of cases. The accuracy of narrow-needle cholangiography was 100% for obstructive jaundice and 66% normal duct entry rate for non-obstructive jaundice.


The effect of allantoin on cellular multiplication in degenerating and regenerating nerves. Injury to a peripheral nerve is, among other things, followed by degeneration of axons and myelin, as well as by a sharp increase in the number of cells (especially Schwann cells) in the part distal to the injury. The effect of allantoin--a cell proliferant--was tested on the above-mentioned reactions in the sciatic nerve of rats. The nerves were crushed and re-exposed 7, 14, 21, 35 and 90 days after the injury, and removed for histological examination. The results obtained in a group of rats treated with allantoin were compared with those obtained in a control group of rats. The results showed that allantoin had a statistically significant effect on the cellular multiplication seen in the nerve 7 and 14 days after the injury. Myelin degeneration was also found to be more advanced in the allantoin-treated nerve preparations examined 14 and 21 days postoperatively than in the control nerve preparations.


Giant haemangiomas of the scalp. A report of 2 cases. Two cases of giant scalp haemangiomas are presented. In both patients a coagulation defect similar to that described by Kassabach and Merrit resulted, although not as severe. The possible mechanisms involved are discussed and a regimen for treatment is suggested.


Fetal malformation due to phenobarbitone. A case report. A child with facial and digital anomalies and mental retardation after exposure to phenobarbitone during gestation is presented. The teratogenicity of anticonvulsants, including phenobarbitone, is discussed, and guidelines for anticonvulsant therapy during pregnancy are suggested.


Leprostigma in hanseniasis.

Leprostigma in hanseniasis. Ignorance, fear and superstition surround the problems of hanseniasis. In almost all cultures the predominant attitude is marked by emotion, disgust and rejection towards persons suffering from this disease. All efforts aimed at the control of hanseniasis are doomed to failure unless the significance of stigma and associated social and economic factors are given adequate consideration. A programme of destigmatization is outlined.


Patterns of hepatic injury induced by methyldopa. Twelve patients with liver disease related to methyldopa were seen between 1967 and 1977. Illness occurred within 1--9 weeks of commencement of therapy in 9 patients, the remaining 3 patients having received the drug for 13 months, 15 months and 7 years before experiencing symptoms. Jaundice with tender hepatomegaly, usually preceded by symptoms of malaise, anorexia, nausea and vomiting, and associated with upper abdominal pain, was an invariable finding in all patients. Biochemical liver function tests indicated hepatocellular necrosis and correlated with histopathological evidence of hepatic injury, the spectrum of which ranged from fatty change and focal hepatocellular necrosis to massive hepatic necrosis. Most patients showed moderate to severe acute hepatitis or chronic active hepatitis with associated cholestasis. The drug was withdrawn on presentation to hospital in 11 patients, with rapid clinical improvement in 9. One patient died, having presented in hepatic failure, and another, who had been taking methyldopa for 7 years, showed slower clinical and biochemical resolution over a period of several months. The remaining patient in the series developed fulminant hepatitis when the drug was accidentally recommenced 1 year after a prior episode of methyldopa-induced hepatitis. In this latter patient, and in 2 others, the causal relationship between methyldopa and hepatic dysfunction was proved with the recurrence of hepatitis within 2 weeks of re-exposure to the drug.


Asthma, high-dose corticosteroids and Klebsiella meningitis. A side-effect of high-dose corticosteroid therapy, namely the development of Kebsiella meningitis, in an asthmatic patient is reported. The possible mechanisms involved are discussed.


Traumatic diaphragmatic hernia presenting pregnancy. A case report. A right-sided traumatic diaphragmatic hernia was present in a woman who was 24 weeks pregnant, 8 years after a motor vehicle injury. The hernia had not been diagnosed previously. Correction of severe anaemia and surgical repair of the diaphragmatic defect were successful.


Lesser curve necrosis following proximal cell vagotomy for gastric ulcer. A case report. A case of avascular necrosis of the lesser curve of the stomach following a highly selective vagotomy (HSV) for a gastric ulcer is reported. It is fortunately rare, but is a frightening complication. The necrosis, which is presumably ischaemic in origin, is caused by total devascularization of the lesser curvature of the stomach. The complication is usually diagnosed late and has a considerable mortality.


The pathophysiology of gastric surgery.

The pathophysiology of gastric surgery. Gastric surgery may be followed by mechanical postoperative problems, usually due to impaired gastric emptying or the afferent loop syndrome, recurrent dyspepsia, the early or late dumping syndrome, diarrhoea, or nutritional disturbances. The pathophysiological basis of these disorders is discussed and their clinical features are briefly considered.


Female sterilization.

Female sterilization. Sterilization of the female is emerging as a popular method for the permanent regulation of family size in developed countries, and as one of the more effective methods of population management in developing countries. As women move from poor rural cultures to more affluent urban ones, cultural and religious objections to permanent family planning disappear under the pressures of greater child survival and more hope for self- (and child) improvement. Postpartum sterilization remains the most appropriate and attractive method in terms of timing and technique, but interval sterilization (done in the absence of pregnancy) has stimulated interest in minilaparotomy, laparoscopy, and particular concern as to reversibility of sterilization. The techniques of sterilization will be reviewed as to their relative appropriateness in different cultures and different practices, as well as the problems of reversibility.


A possible role of prolactin in preventing heartburn during pregnancy. Although heartburn, thought to indicate reflux of gastric contents into the oesophagus, occurs frequently in pregnant women during the last trimester, its aetiology is not clear. Prolactin blood concentrations rise progressively during pregnancy and heartburn is known to disappear spontaneously during the last weeks of pregnancy. In view of this and other factors, motility studies and estimation of serum prolactin levels were carried out on 20 pregnant Black women. Results show that patients with prolactin levels over 3,000 microunits/ml had significantly higher mean barrier presures (sphincter pressure-gastric pressure) than the patients with hormone levels of less than 3,000 microunits/ml (P less than 0,02). No direct correlation could, however, be demonstrated between barrier pressures and prolactin levels (r = 0,3494). It is concluded that further studies would seem to be indicated on an animal model to establish the importance of prolactin in the regulation of the lower oesophageal sphincter tone.


Incidence of aerobic and anaerobic infection in patients with incomplete abortion. The incidence of infection in 100 cases of abortion was studied. Intra-uterine swabs and products of conception were cultured both aerobically and anaerobically. Significant potentially-pathogenic organisms were cultured from 94 of 100 intra-uterine swabs and from all 100 samples of the products of conception. Anaerobes were cultured from 70 intra-uterine swabs and from 56 products of conception. The spectrum and relative proportion of organisms isolated resemble those found in the normal vagina and cervical os. In addition, positive blood cultures were obtained from 24 patients, 8 on admission and 17 after evacuation. With this high incidence of infection, routine antimicrobial therapy for aerobic and anaerobic organisms should be given to all patients with abortion.


Headaches--fact or fantasy?

Headaches--fact or fantasy? Headaches are among the commonest symptoms encountered in active general practice. Much appears in the medical literature on this subject, most of it not applicable to everyday practice. A simple classification, a pattern of easy recognition, and a treatment plan for these chronic headaches are presented.


[The role of public relations in medical practice. With special reference to medical research]. Because medical practice and especially medical research depend on the goodwill of others, increased emphasis should be placed on the role of public relations, especially in the complex area of communication between medical scientists and the man in the street. The nature of these communication problems is described, and suggestions are made as to how public relations, if properly managed, can give substance to an otherwise ill-defined concept. Opportunities and problems in the marketing of medical research are briefly described.


The diagnosis and treatment of conduct disorders in young people. Conduct disorders are among the most prevalent psychiatric disorders currently encountered in young people. The condition 'conduct disorder' is, however, an 'umbrella concept' which affects divergent personality subtypes. Treatment in the past, based on such an 'umbrella concept', has often proved itself prognostically dubious. This article stresses the need for the direction of management towards differential diagnosis and treatment of the various conduct disorder subtypes.


A possible causal relationship between defective fibrinolysis and pulmonary hypertension. Pulmonary hypertension may be associated with multiple thrombi in the pulmonary arteries or with diffuse microembolization from a cryptic source. A 27-year-old man without any of the recognized clinical risk factors for venous thrombo-embolic disease presented with repeated attacks of chest pain and dyspnoea. Haemodynamic studies were compatible with the diagnosis of primary pulmonary hypertension. Despite intensive study there was no evidence of peripheral venous thrombosis. A survey of the plasma fibrinolytic profile showed unequivocal evidence of low spontaneous plasma fibrinolytic activity. The plasminogen activator activity of the venous wall was also markedly reduced. From these findings it would seem that a defective fibrinolytic defence mechanism may be an important predisposing factor in the pathogenesis of 'primary' pulmonary hypertension.


The third dimension in renal diagnosis. Scanning electron microscopy of normal and abnormal kidney. Scanning electron microscopy, a relatively young discipline, has been used mainly for research purposes and very seldom as a diagnostic procedure. A study was made of normal and abnormal kidneys by light, transmission and scanning electron microscopes. Normal human and rat kidneys were examined under the scanning electron microscope but cellular detail was not clearly defined. Tissue was then cryofractured, critical-point dried, sputter-coated and examined again. Scanning electron microscopy then revealed greater cellular detail. Rats were injected with a solution of 0,6% uranyl nitrate in normal saline, and cryofractured sections were examined. Pathological changes were seen in the glomerulus as well as in the tubules. Scanning electron microscopy, while not replacing conventional modes of examination, can provide a rapid third dimension in the diagnosis of renal lesions.


Agranulocytosis in an arthritic patient treated with levamisole. A case report. A case of agranulocytosis in a man with nonspecific seronegative polyarthritis treated with levamisole in the form of a proprietary veterinary anthelmintic is described. At the time of presentation he had a relative monocytosis. Recovery was uneventful and was heralded and paralleled by an increase in monocytes, serum vitamin B12 and total vitamin B12 binding capacity. Levamisole induced agranulocytosis and the significance of monocytosis and serum vitamin B12 binding proteins in neutropenia are briefly reviewed.


Amoebic liver abscess in patients presenting with jaundice. A report of 5 cases. Five patients with severe jaundice resulting from amoebic liver abscess are described. All had features of hepatic parenchymal damage and cholestasis, and 1 patient developed hepatic coma. In addition, acute tubular necrosis and renal failure occurred in 3 patients. Four patients in the series survived. The importance of early recognition and treatment of amoebic liver abscess in patients presenting with jaundice is emphasized, so that the serious and often fatal complications of hepatic and renal failure can be prevented.


Vascular malformations of the spinal cord (angiodysgenetic myelomalacia): a critique on its pathogenesis. Two cases of angiodysgenetic myelomalacia are presented. Both patients had progressive weakness and sensory deficits in the lower extremities and vascular malformations of their spinal cords. The lesions were located on the dorsum of the spinal cord and the dorso-spinal roots. We believe the symptoms that developed later in life were due to spinal cord ischemia resulting from late degenerative changes in the vessels of the malformation and an ever increasing spinal "steal".


Surgical treatment of chronic subdural hematomas in infants. Subdural hematomas in infants are associated with a high risk of recurrence. In an effort to combat this risk, a surgical procedure consisting of excision of the subdural membranes, a reduction of the craniocerebral disproportion and a restoration of the normal angle of junction of the cerebral bridging veins and the superior sagittal sinus is proposed.


Massive epistaxis from aneurysm of the carotid artery. The syndrome of massive and sometimes fatal epistaxis from an aneurysm of the internal carotid artery is reviewed. Two cases are reported in which exsanguination occurred with anterior and posterior gauze packing in place. The use of standard methods for controlling severe epistaxis in this syndrome was a futile exercise. This distressing and frustrating experience prompted the development of an emergency method to prevent exsanguination pending definitive surgical treatment. A description of this technique is presented and a proposal made for its use.


Hypervolemic hypotension in surgical treatment of intracranial aneurysm. Fifty cases of intracranial aneurysms were operated upon under hypervolemic hypotension. The cerebral metabolism was maintained within normal range. The dissection and clipping of the aneurysm were considerably easier, and a premature rupture of the aneurysm could be handled without difficulty. The advantages and the surgical results are discussed.


Aneurysm developing on the infundibular widening of the posterior communicating artery. A patient had a subarachnoid hemorrhage in 1969. Four-vessel angiography demonstrated an infundibular widening of the posterior communicating artery alone. In 1978, nine years later, angiography demonstrated that the infundibular widening had enlarged and developed into an aneurysm, though unruptured. Another aneurysm of the anterior communicating artery was also found. Both were confirmed at operation and clipped. Review of the pertinent literature emphasizes that the infundibular widening may be preaneurysmal.


Removal of giant clival chordoma by an anterior cervical approach. Chordoma, a primary malignant neoplasm of the cerebro-spinal axis, is difficult to diagnose and impossible to cure. The only effective treatment is early radical surgical removal, regardless of its size or location. A giant, 65gm tumor arising from the clivus, C1 and C2 vertebrae was successfully removed with low morbidity. The surgical technique is described and compared to other operations with their advantages and disadvantages. A plea is made for surgical removal as the initial treatment for these lesions to prevent fatal intracranial metastasis.


Traumatic epidural hematoma in shunt dependent patients: a report of two cases. Two patients are reported with congenital aqueductal stenosis and hydrocephalus, with functioning ventriculoperitoneal shunts, who developed posttraumatic epidural hematomas. Relative paucity of neurological signs in spite of large size of hematomas is discussed.


Carotid-choroidal aneurysms: remarks on surgical treatment and outcome. Seven patients with ruptured carotid-choroidal aneurysms were operated on in a three-year period. The anterior choroidal artery was thought to have been left intact in all cases at the operation. However, postoperative angiography revealed impairment of the choroidal circulation in two cases. These were the only patients who developed postoperative morbidity. Preservation of the anterior choroidal artery seems to be of paramount importance in dealing with carotid-choroidal aneurysms.


Injury to the spinal cord produced by acupuncture needle. An unusual case of injury to the upper cervical spinal cord is reported. A 62-year-old woman had been treated with acupuncture for stiffness of the muscles of her neck four to five years before she developed gradually progressive hypalgesia and hypothermesthesia over the right half of her body. Radiological examination and CT scan revealed the broken tip of an acupuncture needle between the first and second cervical vertebrae. The needle was removed. There was a moderate recovery of sensation.


Jugular foramen neurinomas.

Jugular foramen neurinomas. Three patients with neurinomas of the jugular foramen are described. One of them had a small tumor confined within the jugular foramen and each of the other two had a tumor originating from the glossopharyngeal nerve. The common feature in all these patients was the presence of marked enlargement of the jugular foramen. Polytomography, jugular venography and bilateral retrograde vertebral arteriography were used to make the diagnosis. Total removal of their tumors was successfully accomplished using microsurgical technique. Forty-two other cases in the world literature are reviewed and analyzed.


Delayed response to brain tumor chemotherapy. Five cases of recurrent malignant gliomas are reported. They showed unequivocal and long-lasting improvement of the clinical status and brain scintigram after progressive clinical and scintigraphic deterioration occurred during the initial courses of chemotherapy. The differential diagnosis of tumor regrowth and this unusual delayed response are discussed. Swelling of dead tumor cells and a secondary inflammatory reaction could explain the initial clinical deterioration. The delayed response may be consistent with the slow removal of dead cells from the brain. This has been observed experimentally. Evaluation of the response of a malignant glioma to chemotherapy should be made by serial observations during a sufficiently long period of time.


Lattice degeneration of the retina.

Lattice degeneration of the retina. Lattice degeneration of the retina is the most important of all clinically distinct entities that effect the peripheral fundus and are related to retinal detachment. The purpose of this review is to survey the extensive literature, to evaluate the many diverse opinions on this subject, and to correlate and summarize all the known facts regarding this disease entity. The disease is fully defined and described, both clinically and histologically. Some aspects of the disease are still poorly understood, and some remain controversial, especially in the area of management. For this reason, the indications for treatment are discussed under eight subsections, with a view toward providing practical guidelines for recommendations in management.


Myocardial infarction following carotid endarterectomy: a review of 683 operations. In a series of 683 consecutive carotid endarterectomies, there were 16 postoperative myocardial infarctions which resulted in five deaths. Of 399 operations on patients with no previous history of heart disease, there were only two myocardial infarctions (0.5%). Two hundred and eighty-four operations were performed on patients with heart disease, and vasopressors were administered in 135 of these procedures. For these patients the risk of myocardial infarction increased from 2.0% to 8.1% with the use of vasopressors (P less than 0.001). The management of the patient with stable heart disease undergoing carotid endarterectomy is discussed.


Preoperative saphenous venography in arterial reconstructive surgery of the lower extremity. Preoperative saphenous venography was performed in 100 extremities in 60 patients to evaluate the saphenous vein for use as an arterial bypass graft. In 18 of the patients (30%), venography demonstrated vein abnormality, disease, or small size, which significantly influenced the management of the patient or the conduct of the operation. Good correlation was observed between venographically determined saphenous vein anatomy and diameter and those observed at operation in 52 patients. The average diameter of the saphenous veins on preoperative venograms was 3.4 mm (range, 1.0 to 6.0 mm). These veins dilated to an average diameter 73 +/- 5% greater than that observed venographically, so that the average diameter of harvested, dilated saphenous veins was 5.5 mm (range, 3.0 to 10.0 mm). All veins measuring 2.0 mm or more on the venograms dilated to 4.0 mm or more at operation and were suitable for femoropopliteal or small vessel bypass grafts. Four saphenous veins measuring 1.0 mm or more on the venograms dilated to 3.0 mm or more at operation and were suitable for small vessel bypasses. Thus preoperative saphenous venography can be of value in lower extremity arterial reconstructions. The procedure allows detection of anomalies and disease processes that would prevent the use of one or both saphenous veins as arterial bypass grafts and identifies the best available venous segment thereby obviating unnecessary incisions and minimizing operating time.


Giant cell (temporal) arteritis. The differential diagnosis. A patient was referred to the neuro-ophthalmology unit with a diagnosis of Foster-Kennedy syndrome; "papilledema" had been noted in the right eye and optic atrophy in the left. Results of radiographic examinations and lumbar puncture had been normal. The considerations and procedures leading to a correct diagnosis of giant cell arteritis are discussed.


Seat belt aorta: acute dissection and thrombosis of the abdominal aorta. Aortic trauma mainly involves the thoracic aorta (95%), while the abdominal aorta is infrequently involved (5%). Of growing interest is the role of seat belts in abdominal aortic injuries. Although seat belts are known to cause injuries to the abdominal viscera, they rarely produce aortic trauma. We report here an acute dissection with thrombosis of the abdominal aorta leading to complete peripheral occlusion as a result of lap-type seat belt injury. The two previously reported cases of similar injuries which resulted in incomplete occlusion are reviewed. A hypothesis for the causal mechanism of these injuries is described. The authors also stress careful follow-up of all patients with seat belt injuries since other intra-abdominal vascular injuries may be present.


Visual system involvement in giant cell (temporal) arteritis. A case of giant cell arteritis is reported. The presenting complaint was referable to the vertebral-basilar system. Visual symptoms and signs of vertebral-basilar, carotid, posterior ciliary, and branch central retinal arterial involvement are described. Blindness occurred on steroid therapy. Death resulted from steroid complications. The wide clinical spectrum and management of this condition are discussed.


Direct measurement of arteriovenous anastomotic blood flow in the septic canine hindlimb. Absolute blood flow through hindlimb capillaries and arteriovenous anastomoses (AVA) was determined by the radioactive microsphere technique of relative shunt measurement combined with direct (electromagnetic) measurement of femoral artery blood flow. Studies were performed before and 72 hours after infection was created in six dogs by implanting fecal-contaminated wicks in one hindlimb. Three control dogs had sterile wicks implanted. Septic dogs demonstrated decreased arterial pressure and increased core temperature with no change in mean cardiac index. Infected legs had increased total femoral blood flow, decreased peripheral resistance, decreased arteriovenous (A-V) O2 difference, but unchanged oxygen consumption, Paw temperature increased in both infected and normal contralateral limbs. Muscle blood flow (MBF) (Xe133 clearance) increased only in infected legs. A-V shunting increased five-fold and AVA flow increased seven-fold in infected hindlimbs, significantly more than that in contralateral or control limbs. Increased A-V shunting correlated highly (r=0.95) with increased total femoral blood flow in infected legs, but increased MBF was not correlated (r=0.05). Despite increased MBF, increased AVA flow occurs in septic canine hindlimbs and contributes to the low-resistance, high-flow, but unchanged oxygen consumption described in this model.


A pilot program of multiple cadaver organ and tissue retrieval. A one year pilot project conducted at a 2,000 bed medical center involved a unique approach to the retrieval from cadavers of multiple viable organs and tissues. Aspects of the program included a special unit for sterile evaluation and storage of tissue, a computerized registry of potential donors, a nurse to coordinate and expedite retrieval, and a retrospective chart review to define the incidence and location of potential cadaver donors. There were requests for 121 tissues by 39 investigators. Eleven different tissues were needed within 4 hours of death. Forty-two percent of individuals contacted directly enlisted in the donor registry, three of whom were identified on the computer at the time of death. A five-fold increase in cadaver donor evaluation referrals occurred, and one third of referrals resulted in viable tissue retrieval. A review of 728 deaths indicated that 45% could have been potential eye donors, 27% pancreas donors and 2.5% kidney donors. A coordinated program to retrieve multiple viable organs and tissues for transplantation and research appeared to be effective in this initial pilot study.


Gastric histology and function in patients with intrathoracic stomach replacement after esophagectomy. The histological changes and gastric function alterations in 19 patients who had intrathoracic stomach replacement following esophagectomy were studied. Atrophic gastritis was noted in 13 of the 19 patients. The mechanical response of the stomach to distention by food was largely retained. The basal and maximal acid output was reduced markedly, and the serum gastrin was elevated. An association between the degree of gastritis, the percentage of gastric motility at rest, and acid secretion is demonstrated. These changes are consistent with patients with duodenal ulcer following vagotomy and dyloroplasty. Postprandial elevation in serum gastrin was noted in patients with or without vagotomy. The lack of significant difference in integrated gastrin response suggests that the vagus may not be important in the control of postprandial gastrin release.


Effects of hemorrhagic shock on nuclear DNA. Rats, with their liver DNA labeled with 3H-thymidine, were subjected to hemorrhagic shock. In nine rats reversible hemorrhagic shock with a blood pressure of 40 mm Hg for 30 minutes resulted in no breaks in the DNA. Twenty-seven animals were subjected to severe hemorrhagic shock. Blood pressures of 40 mm Hg were maintained in the 27 animals until 50% of the shed blood was infused in 11 animals and until 70% of the shed blood was reinfused in 16 animals. This degree of hemorrhage resulted in the DNA being broken, so that 45.1% and 52.1% of the DNA was of a small molecular weight species, as compared with 9.5% and 10.8% in the preshocked animals (P less than 0.001). The injured DNA was not repaired 1.5 hours after the animals were resuscitated in the animals subjected to severe hemorrhagic shock.


General surgeons and their surgical practices. The work characteristics of general surgeons were studied as part of a national study of surgeon manpower. General surgeons were found to work long hours relative to other surgical specialists. Although general surgeons' operative workloads ranked fourth among the 10 surgical specialties, they were only modest in comparison with the surgeons with the highest operative loads (thoracic surgeons). The major conclusion is that the supply of general surgeons is more than adequate to meet the need for general surgeon consultants.