Coronary collateral circulation as an important factor to modify the ischemic injury of the myocardium in coronary ligated dogs. Effect of coronary ligation on epicardial and intramyocardial ST-segment voltage was investigated in 121 dogs. After ligation of the anterior descending coronary artery, marked  ST-elevation, more than 2 mV, was detected in 102 dogs (Group-I) in epicardial lead of the area which was nourished by the ligated coronary artery. In 7 dogs (Group-II), coronary ligation produced negligible changes in ST-segment voltage in epicardial lead, while significant ST-elevation was observed in the leads of middle and inner layers of the myocardium. Systemic hemo-dynamic parameters showed no statistically significant difference between the 2 groups. Coronary collateral indices, however, revealed the significant difference between them. Systolic peripheral coronary pressure was 29.3 +/- 3.1 mmHg in Group-I and 59.2 +/- 10.6 mmHg in Group-II (P less than 0.05). Retrograde flow was also greater in Group-II (14.8 +/- 4.4 ml/min) than in Group-I (1.3 +/- 0.5 ml/min) (p less than 0.01). Diversion of retrograde flow produced a marked ST-elevation in Group-II. Restoration of retrograde flow to the myocardium immediately decreased the ST-segment voltage. These results suggest that spontaneously developed collaterals have an important function for the prevention of the occurrence of ischemic injury after coronary ligation in dogs.


Inhomogeneous spread of excitation in canine Purkinje fibers. Spread of excitation in isolated canine bundle branches was examined by microelectrode technique in order to investigate the possibility of dissociated impulse transmission in normal Purkinje fibers. In all experiments, local excitation of the preparation evoked either by fine bipolar extracellular electrodes or an intracellular microelectrode proceeded much faster along the longitudinal axis of the fibers than along the transverse axis. As a result, the spread of excitation in the vicinity of stimulating site showed significantly inhomogeneous character. The inhomogeneity of excitation spread became more manifest with more eccentric location of the stimulating site in a given preparation. Larger preparation showed greater degree of inhomogeneity. Nevertheless, the inhomogeneous spread of excitation alone appeared unlikely to provide multiply pathways which were functionally dissociated with each other. When premature stimulation was applied, however, different conductivity among fibers within a single false tendon was oberved, suggesting that each conducting element became more independent.


Electrophysiologic effects of pindolol on atrioventricular conduction in canine heart. The effects of intravenous pindolol on the electrophysiologic properties of the atrioventricular conduction system was studied in intact dog, using His bundle electrogram and the extrastimulus method. Pindolol was administered intravenously in a dose range of 4 to 40 micrograms/Kg. The latter dosage of pindolol is above those used clinically. Significant effects of intravenous pindolol were observed on sinus cycle length, the A-V nodal conduction time, the ERP of the atrium, the ERP and FRP of the A-V node, and the ERP of the ventricle. Sinus cycle length was prolonged during sinus rhythm. Intraatrial conduction time was not altered by pindolol, while the ERP of the atrium was slightly increased. The A-H interval was generally prolonged by pindolol without Wenckebach type A-V block, but the H-V interval was unchanged. Both ERP and FRP of the A-V node was prolonged. The ERP and RRP of the His-Purkinje system were not statistically evaluated, because no block within the His-Purkinje system were not statistically evaluated, because no block with the His-Purkinje system or prolongation of H-V interval was produced and only a few QRS complexes by extrastimulus showed aberrant configration in the intact canine heart. In addition, pindolol prolonged the ERP of the ventricle.


Electrophysiological studies in two patients with dystrophia myotonica and atrioventricular conduction block. Two patients with dystrophia myotonica showed high-grade atrio-ventricular block. Both underwent electrophysiological studies which revealed sinus and A-V nodal disease with normal intraventricular conduction in 1 case and His-Purkinje conduction disease in the other. Dystrophia myotonica may, therfore, involve all parts of the cardiac conduction system and may affect the generation of cardiac impulses. Pacemaker implantation may be necessary especially if drugs such as procainamide, which in addition to controlling myotonic symptoms may aggravate conduction disorders, are to be used.


Immunochemical studies of lipids. V. Effect of modified hydrophobic moiety on immunogenicity and immunologic reactivity of Forssman glycolipid. The role of hydrophobic moiety in determining the immunologic properties of glycolipid haptens was studied with the derivatives of Forssman glycolipid modified by ozonolytic cleavage of double bonds in hydrocarbon chains. The immunogenicity was not affected by this modification; comparable antibody responses were elicited in rabbits immunized with intact or modified Forssman glycolipid, regardless of its different hydrophobicity, in complete Freunds adjuvant. Modified hydrophobic portions did not affect the class and specificity of antibodies produced. On the other hand, immunologic reactivity was strongly influenced by hydrophobic moiety; the ability to form immune precipitates with antibodies decreased as the hydrophobicity of glycolipid decreased. The reactivity in complement fixation and hemolysis inhibition tests also showed parallel decreases, though the addition of auxiliary lipids greatly reduced these differences in reactivity.  The results indicate the different influences of hydrophobic moiety of glycolipids on their immunogenicity and immunologic reactivity in vitro.


Experimental Pseudomonas infection in mice: effect of single cyclophosphamide administration on Pseudomonas infection. The kinetic effect of cyclophosphamide (CY) was investigated using the immune response to sheep red blood cells (SRBC), activation of the mononuclear macrophage system and altered susceptibity to pseudomonas infection. The level of delayed type hypersensitivity (DTH) was enhanced with suppressed antibody formation, when antigenic stimulation was given about 3 days after CY administration. In contrast, antibody formation increased markedly when challenged with antigen about 10 days after CY administration. Activity of macrophage system as measured by rate of carbon clearance and spreading of peritoneal macrophage was decreased within 6 days after CY, therefore increased to a peak at the 13th day of CY administration. CY increased a susceptibility to pseudomonas infection at the early time of its administration such as the 3rd day, whereas more increased resistance was observed at the later time such as the 13th day. These results indicated that B-lymphocyte depletion included by administration of sublethal dose of CY (200mg/kg) was followed by vigorous hyperplasia of B-lymphocyte.


Studies on the physicochemical properties of house dust mite (Dermatophagoides pteronyssinus) allergens involved in reaginic reaction. The physicochemical nature of the allergenic component of Dermatophagoides pteronyssinus extract was studied by gel filtration, ion exchange chromatography, isoelectrofocusing, and polyacrylamide gel electrophoresis. Fractions were assayed for allergenic activity by the direct radioallergosorbent test (RAST) (dilution method), RAST inhibition (50% inhibition method) and human skin testing. Fractions were further studied by preparative polyacrylamide gel electrophoresis and the band showing a flow rate value of 0.35 was the most potent in allergenic activity. Fractionation by isoelectrofocusing yielded three factions with allergenic activity of pI = 4.8, PI = 7.4 and pI = 10.0 Sephadex G-100 gel filtration revealed that allergenic activity was present in fractions with molecular weight ranging from 17,000-45,000 and discrete ion exchange chromatography evidenced three fractions with very high allergenic activity. In the present study we propose that the allergenic material of D.P is composed of 3 physicochemically different substances whose molecular weight lie in the 17,000 to 45,000 range.


Establishment and characterization of a human neuroblastoma cell line in tissue culture. A new continuous cell line, GOTO, has been established in tissue culture from a human neuroblastoma arising from the adrenal and maintained for 5 years. The cells are small and fibroblast-like, and grow in dense layer. Population doubling time was approximately 48 hr. The modal chromosome number was near-diploid. Neither marker  chromosomes nor double-minute chromosomes were abserved. Inoculum of 10(7) cells produced tumors in ATS-treated hamsters and athymic nude mice, and the histological appearance of tumors was consistent with undifferentiated neuroblastoma. Neural features of the cells were also confirmed by ultrastructural examination. Biochemical analysis showed this cell line to be cholinergic. Morphological differentiation leading to neurite formation was induced by cultivation in serum-free medium.


[An investigation of the environment in a certain vanadium refinery (author's transl)]. An investigation of the environment of the working place was made as part of the investigation of damages to health that had broken out in a certain vanadium refinery; and the following conclusions were obtained: When the atmospheric dust volume and V2O5 concentration by unit working step were measured with a high volume air sampler, V2O5 exceeded the threshold limit value given by ACGIH in the P.O. flake production step, while the measurement of V2O5 concentration during one-shift working hours with a low volume air sampler gave 64.3 micrograms/m3 even in the grinding step where the maximum concentration was found, and values under 10 micrograms/m3 in all the other steps. Such concentrations may be considered to have been derived from the fact that P.O. casting in accomplished in a short time, and that the fume and dust that are transiently produced at high concentrations are dispersed outdoors by spontaneous ventilation. Damages to health such as a high prevalence of green tongue appeared to have resulted from failure in exercising elementary sanitary care such as imperfect facilities for safety and sanitation, and failure to thoroughly enforce wearing of masks.


[Results of the special physical examination of workers in a vanadium plant (author's transl)]. Special physical examinations were made in order to find out the actual status of damages to health that had broken out in a factory collecting V2O5 from iron sand; and the following results were found: 1. Pharyngitis and bronchitis were found in 25% of the workers exposed to vanadium, but neither pneumonia nor hepatitis was observed. 2. Among the subjective and objective symptoms, respiratory irritation and discoloration of the tongue were frequent. 3. Black spot-like pigmentations gathering in a zonal form 1-2 mm wide in the transitional part and oral mucosa of the upper lip were found. Prevalence rate of this sign was 14.3% in the workers exposed to vanadium. 4. The mean valus of total serum protein and the serum cholesterol in the exposed workers were lower than those in the controls. The difference in the values between both groups is statistically significant. 5. Both the mean values of vanadium concentrations in vurine and its creatinine ratios in the exposed workers were twice to three times those in the controls; however, these parameters decreased to about one third in two months by improving the health and environmental control-measures. 6. Draft items to be checked in special physical examinations of workers handling vanadium have been proposed.


[Testicular atrophy of mice induced by ethylene glycol mono alkyl ethers (author's transl)]. Toxicities of ethylene glycol (EG) and 6 ethylene glycol mono alkyl ethers administered orally were studied. Mice were given various doses (62.5, 125, 250, 500, 1,000, 2,000 and 4,000 mg/kg body weight) of the compounds daily for 5 days/week, for 5 weeks. High doses of ethylene glycol mono methyl ether (EGM), ethylene glycol mono methyl ether acetate (EGMA), ethylene glycol mono ethyl ether (EGE) and ethylene glycol mono ethyl acetate (EGEA) produced marked testicular atrophy and leucopenia. Dose-responce relation was found in these effects. EGM was more effective than EGE, while ethylene glycol mono butyl ether and ethylene glycol mono phenyl ether had but slight effect and EG had no detectable action on testis and leucocytes. Toxic doses being expressed as mg/kg body weight, esterification seemed to weaken the atrophic action of EGM and EGE, but when expressed as mol/kg, significant difference was found neither between EGM and EGMA nor between EGE and EGEA. The mechanism of testicular atrophy induced by low ethylene glycol mono alkyl ethers is likely to be an inhibitory action on cell division.


[Combustion gas toxicity of textiles (author's transl)]. Textiles are used so widely as interior materials of many buildings, houses, and transportation facilities, that the combustion gas has a chance of intoxication of a fire accident. Therefore this investigation was undertaken to clarify the toxicity of the gas and to obtain an index for safety standards in such cases. The combustion gases of cotton, polypropylene, acrylic, flame retardant (F.R.) cotton and F.R. acrylic fabrics were analyzed by a gas chromatograph and a GC-Mass spectorograph, and also tested with experimental animals to determine the lethal factors including blood gas analyzing technique. The gas exposuring test based on gas analysis data showed that the toxicity of these combustion products increased in the following orders: cotton, polypropylene, F.R. cotton, F.R. acrylic and acrylic. Comparative indices of the toxicity showed that acrylic increased 7.26-fold as compared with that of cotton. It was recognized that the lethal factors in the mice was due to carbon monoxide and/or hydrogen cyanide during the exposure one hour, and that sequelae due to acrolein during the seven day observation period after the exposure. Flame retardant treatment increased twice the toxicity of cotton. On the contrary, that of acrylic was reduced by 0.8 time compared with the original fabric, so that the treatment could be recommended only in case of acrylic from the safety standpoint. From the above results, it can be stressed that vigorous smoke exhaust procedure should be executed in the case of fire accidents for saving human lives.


[ALAD activity of red cells of different ages. (1st report) (author's transl)]. Rabbit erythrocytes were fractionated into populations of young cells (top layer) and old ones (bottom layer) by centrifugation, based on the fact that the specific gravity of young erythrocytes was lower than that of old ones. Then, reticurocyte count and osmotic resistance of red cells were compared between both populations. As a result, it has been obtained that many reticurocytes were found in the top layer, while none of those was found in the bottom layer. Furthermore, cells of the top layer were more resistant to hemolysis in the hypotonic media than those of the bottom layer. These findings suggested that the cell population of the top layer was young and that of the bottom layer was old. In comparison between both populations, the mean value of ALAD activity of young cells was 2.6 times higher than that of old ones. The rate of decrease of ALAD activity after intravenous administration of lead was similar in both populations while the amount of decrease of ALAD activity in the young cells was 2 to 3 times higher than that of the old ones.


[Evaluation of toluene toxicity using Sidman avoidance behavior by lever pressing in rats (author's transl)]. Effects of single exposure to toluene on the operant behavior in rats were studied. The animals, in which the behavioral base line had been established, were exposed to 0, 1,000 and 3,000 ppm of toluene vapor for four hours, and the effects on the behavioral pattern of lever pressing were investigated for one hour after the end of exposure using Sidman avoidance test. 1) Exposure to 0 or 1,000 ppm of toluene did not affect the established operant behavior of the rats. 2) Exposure to 3,000 ppm produced increased responses, shortening of the inter-response-time, and no change in shock counts at the early stage of Sidman avoidance test when compared with those before exposure. 3) The behavioral change indicated here appears to be caused by a temporary breakdown of the established timing of lever pressing. 4) The effect of toluene on the operant behavior was strongest immediately after the aviodance test begun and the behavior recovered in about an hour. From the results of our experiment it can be said that the experimental methods used in this study is useful to evaluate the toxicity of toluene to the central nervous system of the animals.


Immunotherapeutic trials of murine and guinea-pig solid tumors by oral administration of BCG. Efficacy of oral administration of BCG on the growth of various tumors in mice and guinea pigs was studied. The growth-inhibitory effect varied depending on the tumor systems and the experimental conditions. Weekly oral administrations with 5-mg doses of BCG to mice or 80-mg doses of BCG to guinea pigs were ineffective on syngeneic mouse melanoma B16 or syngeneic guinea pig hepatocarcinoma line-10 but effective on syngeneic mouse carcinoma IMC and syngeneic guinea-pig fibrosarcoma H9A. Oral BCG seemed effective also on allogeneic mouse carcinoma Ehrlich, developed with a relatively small size of tumor cell inoculum, and on guinea-pig syngeneic liposarcoma H10. On Ehrlich tumors, oral BCG given once a week seemed to have better effects than did oral BCG given twice a week or subcutaneously once or repeatedly; heat-killed BCG given orally showed no effect. However, it seems premature to draw a definite conclusion on the efficacy of oral BCG on Ehrlich and H10 tumors, because some of these tumors regressed spontaneously even in nontreated control animals. The host responses to oral BCG were studied with the following results. Weekly oral administration with 80-mg doses of BCG to guinea pigs elicited positive skin reactions to 25 TU PPD in about 65 days after the first BCG, while a single sc injection of 8 mg of BCG did so within 10 days. Orally administered BCG organisms were recovered largely from Peyer's patches, a little from the mesenteric lymph nodes, and very little from the liver and the spleen. The BCG distributive pattern was in reverse order when BCG was given subcutaneously. Histologic examinations of Peyer's patches indicated enlargement of germinal centers, in which primitive reticular cells proliferated prominently and the macrophages with tingible bodies scattered frequently.


Application of the parallel line bioassay method to quantitative determination of the HBs antigen in radioimmunoassay. Precise and reproducible quantitative determination of hepatitis B surface antigen by applying the parallel line bioassay method was proposed. In this method, the value of any given sample can be expressed in terms of a relative value to a fixed standard or reference preparation. Decrease in antigenic reactivity due to the lowered protein content could be prevented by using 0.02% human albumin in physiological saline solution as the diluent. The use of such stabilizer(s) should be considered in the dilution or storage of samples containing HBs antigen.


Evaluation of gastrectomy combined with the resection of other organs in the treatment of gastric cancer. We evaluated the prognostic significance of gastrectomy combined with resection of adjacent organs in 154 cases. Patients who had undergone gastrectomy with or without combined splenectomy showed similar results and cases with combined colectomy showed a poor survival rate. However, relatively favorable results were obtained in gastrectomy cases in which combined pancreas or liver resection was performed due to direct cancer infiltration.


Specific immunotherapy for non-curatively resected gastric cancer. The prognosis of patients with advanced gastric cancer treated with non-curative resection is very poor. In order to improve patient prognosis, we have tried specific immunotherapy as an adjunct to surgery since January 1968. Sixty-two patients with gastric cancer underwent non-curative resection during the period of this study. Twenty-eight of these patients were treated with specific immunotherapy after surgery, and 34 patients received no additional therapy. The five year survival rate was 35 per cent in the former group, and zero in the latter. No significant difference in the degree of tumor extension and invasion was noted between the two patient groups. We concluded that specific immunotherapy as an adjunct to non-curative resection for advanced cancer is worthy of further study.


Clinical value of immunochemotherapy with OK-432 or PS-K for stomach cancer patients. A prospective clinical trial was undertaken in 121 patients with stomach cancer to compare immunochemotherapy with 5-fluorouracil and FT-207 combined with OK-432 or PS-K, immunostimulators, and plain chemotherapy with 5-fluororacil and FT-207. Of the 121 patients who received immunochemotherapy, 67 patients (group A) had undergone curative removal of the tumor. The other 54 patients had undergone noncurative tumor removal or had recurrence after non-curative tumor removal and they were divided into two groups (groups B and C) on the basis of lymphocyte reactivity induced with PHA. Although group A exhibited a significant increase in PHA-induced lymphocyte transformation and a trifling increase in lymphocyte counts, its survival rate within a 36 month period did not differ from that of the peer controls. Group B, composed of 21 patients showing improvement of PHA-induced lymphocyte transformation, significantly prolonged its survival compared to the peer controls. The survival of group C, composed of 33 patients showing a gradual drop in PHA-induced lymphocyte transformation, was not prolonged compared to the peer control patients; and they showed significant decreases in lymphocyte counts. The overall survival of group B and group C was not superior to that of the 48 peer controls.


Pathological changes of anastomotic false aneurysms. Anastomotic parts of polyester vascular prostheses implanted in thoracic aortae of 270 dogs were examined. Anastomotic false aneurysms were seen with 3 cases (1.2%), in which disruption did not occur, however, the grafts which have no aneurysm showed the following features, i.e., suture migration, degenerative changes of the host arterial wall sustaining a suture and dissection between the host arterial wall and a prosthesis. From the results of an analysis of the arrangement pattern of smooth muscle cells in neointima, it was clarified that a suture had been subjected to continuous tensile stress. So that, the host arterial wall sustaining a suture is clinched and pulled toward prosthesis by the suture at every pulsation during implantation. These results indicate that the features mentioned above are phenomena of the developing into anastomotic false aneurysms.


Long-term prognosis for reconstruction of arterial lesions due to arteriosclerosis. Out of 769 patients with arterial diseases, reconstructive surgery was performed on 100 limbs of 79 patients for arteriosclerosis. The overall patency rate was 59 per cent over a period of 3 to 8 years. Long-term patency was influenced by the condition of the run-off arteries, the site of the operation, and the method of surgery. No relation was found between patency rate and hypertension, cardiac insufficiency, total serum cholesterol, diabetes mellitus, or age. The survival rate was 62 per cent at 5 years and 48 per cent at 7 years. These rates were significantly poor (p less than 0.001), compared with those in the normal population. Mortality was related to the degree of hypertension, with cardiac and renal failure being responsible for 72 per cent of deaths. Aggressive reconstruction may be indicated in cases with hypertension of stage 2 or below based on the WHO classification. However, especially in patients with associated diabetes mellitus close long-term observation of the cardiovascular system is necessary.


A manometric assessment of anorectal pressures and its significance in the diagnosis of Hirschsprung's disease and idiopathic megacolon. Anorectal manometric studies were performed on nine patients with Hirschsprung's disease and ten patients with idiopathic megacolon for the purpose of differentiation, comparing with those of the normal subjects. The anorectal reflex was absent in all nine of the patients with Hirschsprung's disease while in all of ten patients with idiopathic megacolon rectal distension produced a relaxation in the anal canal like that of the normal subjects. Manometric studies proved to be a reliable and non-invasive technique for the diagnosis of Hirschsprung's disease and were of particular value as simple screening tests in patients with a clinical suggestion of this disease. The manometric studies of the patients with Hirschsprung's disease or idiopathic megacolon in the present series also demonstrated that the pronounced internal sphincter contraction combined with a total absence of reflex relaxation or an inadequate response of the sphincter to rectal distension might be responsible for the obstructive symptoms in these diseases.


A case of double pylorus.

A case of double pylorus. Doubling of the pyloric channel is one of the rare anomalies of the intestinal tract. There have been 23 cases of double pylorus that we have been able to find in the literature. As the etiologic aspects of double pylorus the majorities of the cases were thought to be acquired lesions from ulcer disease except three cases. We present a case of double pylorus which seems to be acquired lesion, with a review of the literature.


Congenital pyloric atresia--a report of two cases. Two cases of the membranous type of pyloric atresia are described and a review of 99 cases reported in the literature is presented. Excision and incision of diaphragm with pyloroplasty was performed on both cases. The first patient was alive following the second operation of gastroduodenostomy for postoperative stenosis. The second premature patient died of sepsis on the 58th postoperative day. The treatment should be surgical and the operative procedure should be chosen depending on the type of atresia. Excision or incision of the diaphragm with pyloroplasty and gastroduodenostomy are the procedures of choice. Gastrojejunostomy should be avoided because of its high mortality rate.


The recognition of infective endocarditis. Patients with infective endocarditis are frequently first evaluated in an emergency department at a time when clinical data are insufficient for a conclusive diagnosis. The records of 22 patients with proven bacterial endocarditis first seen in our emergency department were reviewed. The most common feature of the initial history was the presence of fever in 11 (50%). The most common physical finding was a heart murmur in 18 (82%). All patients had positive blood cultures. The most frequently isolated organism was Staphylococcus aureus. Pertinent clinical and laboratory data available on admission that enabled the emergency physician to suspect infective endocarditis were systemic manifestations of fever, malaise and arthralgias together with anemia, leukocytosis and hematuria.


Anxiety in ambulatory emergency patients. The anxiety level of ambulatory emergency department patients without a diagnosis of a physical illness was studied. These patients were compared to a group with a diagnosis of nontraumatic surgical disease. Both the study group and the comparison group were found to have elevated anxiety levels. In addition, those with nonphysical illness had elevated levels of covert anxiety when compared to their overt levels (p less than .03) and when contrasted with the comparison group's covert levels ( p less than .03). In the treatment of all a patient's problems the psychosomatic illnesses evidenced by raised covert anxiety levels may require intensive treatment both within and without the emergency department.


Socioeconomic aspects of stab and gunshot wounds. Records of 294 patients with gunshot, stab, or shotgun wounds admitted to Charlotte Memorial Hospital and Medical Center between July 1, 1976 and June 30, 1977 were reviewed. Data were gathered on 24 clinical, social, and economic aspects to discover any patterns in these areas. Eighty-three percent of the patients were male; 71%, black; 70%, unmarried; and 56%, between 16 and 30 years of age. Fifty-five percent came to the hospital between 10 pm and 3 am; 57% on Friday, Saturday, or Sunday; 31% came in June, July, or August. Sixty-four percent were gunshot wounds, 80% of which were by small caliber weapons. Ninety-four percent of all patients survived. The patients "consumed" 3,260 hosptial days, 526 intensive care unit days, 533 units of blood, and 261 operations, totaling 595 hours of operating room time. Hospital charges totaled $668,000, of which 1.1% was paid from private funds and nearly 65% from the taxpayers and other private paying patients.


Physician and patient acceptance of emergency nurse practitioners. Patient and physician attitudes toward emergency nurse practitioners (ENP) were surveyed in our emergency medical service. The responses to the questionnaires indicated a high degree of satisfaction with the ENP similar to that reported in a survey of patient reaction to physician assistants (PA) in the emergency department. In our emergency medical service, physicians expressed a concern over the practitioner's care of the emergent patient. Their confidence in the practitioner's clinical judgment was greater in their care of nonurgent and urgent patients.


Esophageal perforation secondary to alkaline battery ingestion. A 16-month-old infant ingested an alkaline battery, 22 mm x 5 mm, which became entrapped in her esophagus. She was brought to the emergency department with a four-day history of vomiting. After tube thoracostomy, the battery was removed by esophagoscopy. However, she experienced cardiac arrest in the intensive care unit. Post mortem examination revealed exsanguination by perforation of the posterior aspect of the aortic arch as the cause of death. Microscopic examination showed liquefaction necrosis through the mucosa and submucosa of the esophagus into the upper mediastinum and right pleural space. The possible role of the alkaline center of the battery causing perforation is presented.


Central retinal artery occlusion.

Central retinal artery occlusion. Central retinal artery occlusion is characterized by sudden, painless visual loss due to blockage of retinal blood flow. It has been reported in all age groups including children but is most frequent in the sixth decade. Both thrombosis and embolism have been suggested as possible mechanisms. The emergency treatment includes intravenous acetazolamide, digital ocular massage, and inhalation of 5% carbon dioxide -- 95% oxygen for ten minutes. Following emergency treatment, immediate ophthalmologic referral and consultation is required. Comprehensive medical evaluation should be initiated to exclude systemic vascular disease.


Hiccups: an unusual manifestation of an abdominal aortic aneurysm. A patient with hiccups was found to have an abdominal aortic aneurysm that subsequently ruptured. We believe that a leaking abdominal aortic aneurysm led to an ileus-induced distention of the splenic flexure of the colon with consequent diaphragmatic irritation and phrenic nerve stimulation. This led to persistent hiccups as a result of repetitive stimulation of the reflex arc mediating hiccups. Persistent hiccups require investigation for an underlying organic etiology, and a leaking abdominal aortic aneurysm should be included in the differential diagnosis.


Clear view of the index sesamoid: a sign of irreducible metacarpophalangeal joint dislocation. If the index sesamoid bone is clearly seen in the joint following significant injury to the index metacarpophalangeal joint on radiographic examination, there is the probability of incarceration of the volar plate. In almost all cases, an open reduction will be necessary to re-establish the normal relationship between the second metacarpal and the proximal phalanx. In a case of irreducible dislocation of the index metacarpophalangeal joint, attempted reduction caused the injury to appear as a subluxation.


Preliminary report: the role of short-leg, tone-reducing casts as an adjunct to physical therapy of patients with cerebral palsy. In the past two years, we have used specially constructed, short-leg casts as an adjunct to the therapy program for 99 patients with cerebral palsy. The casts provide tone reduction and increased stability, while allowing mobility, and have been useful in initiating weight-bearing activities and improvement of gait pattern.


Atlanto-occipital instability as a result of pituitary adenoma: case report with successful management by cervico-occipital fusion. A 48-year-old woman with an extensive pituitary adenoma developed atlanto-occipital instability secondary to erosion of the base of the skull by the tumor. The pathophysiology, diagnosis and surgical treatment are described.


Skeletal changes during prolonged external irradiation: alterations in marrow, growth plate and osteoclast populations. This report describes hematologic and skeletal changes in young mice subjected to continuous external whole body irradiation (45 rads/day) for 4 days to 12 weeks. Irradiation caused a rapid depletion of hematopoietic stem cells, marrow aplasia and pancytopenia, all of which persisted during the period of irradiation but resolved afterward. In spite of suppressed cellular proliferation and disarray of cartilage cell columns in metaphyseal plates, linear bone growth appeared to continue at physiologic rates. Histologic and morphometric studies provided no evidence of impaired osteoblast function, but the presence of thickended trabeculae beneath the growth plate and of cartilagenous islands within cortical shafts of long bones indicated that bone remodeling was deficient. Direct osteoclast counts demonstrated that marrow aplasia was followed by a progressive decline that could not be reversed by parathormone injections or infusions with mature macrophages and lymphocytes but that resolved once the bone marrow recovered following cessation of irradiation. Therefore, the altered bone remodeling probably resulted from radiation injury to osteoclast precursors in the hematopoietic compartment.


An assistive equipment controller for quadriplegics. A joystick is traditionally used to manipulate electrically powered wheelchairs and radio-controlled model aeroplanes. Extensive modifications of the joystick have resulted in the development of an inconspicuous chin-operated control; the latter enables quadriplegics with high-level spinal cord injuries to operate not only electric wheelchairs but also a complete range of other assistive devices, including robotic arm and environmental control systems currently under development. Through the use of the chin-operated control such quadriplegics can manipulate any of these devices or systems without the help of an attendant and without interfering with the use of a mouthstick.


Extremity fractures in children with neuromuscular disease. This report discusses the occurrence and management of fractures seen in 30 children with neuromuscular disorders. Twenty fractures were seen in 17 ambulatory patients, ages 5 to 16. Twelve of the patients in this group had Duchenne muscular dystrophy (DMD), 3 had spinal muscular atrophy (SMA) and 2 had Charcot--Marie--Tooth (CMT) disease. Treatment consists of reduction of the fractures followed by immobilization of the extremities; however, continuation of everyday activities, including ambulation, should be emphasized. In fact, five patients ceased walking as a direct result of immobilization following fracture. Sixteen fractures were seen in 13 non-ambulatory patients, ages 4 to 19. These fractures were generally caused by very small forces; the fractures were rarely displaced. Eight of the fractures in osteoporotic and contracted knee joints occurred in either the distal femur or proximal tibia. Functional loss can be minimized by splinting until the patient no longer complains of pain. Splinting should be followed by rapid return to full activity.


Iatrogenic compression of the thoracic outlet. Arterial injury and brachial plexus nerve compression have been reported in association with surgical procedures in the area of the thoracic outlet. An initial report of iatrogenic injury was related to the operative correction of Sprengel's deformity, which required lowering of the scapula in a child. Compression of the neurovascular bundle between the clavicle and the first rib occurred during this surgical migration. The developmental anatomy of the costo-clavicular area and the descent of the upper limb from its initial cervical position are reviewed. This relationship between the clavicle and the first rib may also be altered by surgical procedures carried out on adults. Two cases of the iatrogenic injury to the brachial plexus are reported in association with operations performed in the area of the clavicle. Correction of these injuries resulted when the costoclavicular space was re-established.


The surgical approach to refractory trochanteric bursitis. This article identifies and describes a small group of patients with trochanteric bursitis for whom all modes of conservative therapy have failed. They are treated surgically by release of the ileotibial band, removal of trochanteric osteophytes and debridement of the gluteus maximus bursae. In this series all of the patients had satisfactory results and returned to near-normal function without significant complications.


[Method of cardiac stimulation in sick sinus syndrome]. The condition of the conducting system of the heart and the sinus node recovery time were studied in 27 patients with the cardiac rhythm pathology under consideration. On the grounds of the resultant data the question concerning the implantation of this or that type of pacemaker (operating in a fixed regimen or "on demand") and-the positioning of the fixing electrode in the atria or ventricle was resolved. The advantages and shortcomings of each of the suggested methods for surgical treatment of sick sinus node are discussed.


[Myocardial scintigraphy in the diagnosis of infarct in patients with disorders of intraventricular conduction]. Myocardial scintigraphy with pyrophosphate-99mTc-Sn was used as a diagnostic test in 23 patients with different disorders of rhythm and intracardia conduction who were admitted to the department of emergency cardiology of the All-Union Cardiological Scientific Center, Academy of Medical Sciences of the USSR with suspected acute myocardial infarction. Scintigrams were positive in 11 of 12 patients with acute myocardial infarction who were examined in periods of 6 hours of 10 days. One patient examined on the 13th day of the disease had negative scintigrams. In 6 of 11 patients with myocardial infarction not confirmed, the scintigrams were also negative, in 3 other patients positive scintigrams were due to a postinfarction aneurysm. The authors conclude that myocardial scintigraphy with pyrophosphate-99mTc-Sn is an adequate test in the diagnosis of acute myocardial infarction, especially in the examination of patients with disorders of intracardiac conduction.


[Lidocaine pharmacokinetics and substantiation of the new method of its administration in myocardial infarct]. Lidocain pharmacokinetics was studied in 12 patients with acute myocardial infarction (males and females from 40 to 90 years of age with obvious disorders of hepatic and kidney function or severe hemodynamic disorders). In ten of them the main pharmacokinetic parameters were determined; the average value of lidocain clearance was 0.45 1/min. The optimum rate of continuous drip infusion was calculated (1.35 mg/min). It is shown that the existing method of lidocain administration by the "initial dose + infusion" schedule is unsatisfactory from the pharmacokinetic standpoint. Recommendations are given for the choice of the optimum concentrations of lidocain solution used in different rates of continuous infusion.


[Effect of digoxin on central hemodynamics in myocardial infarct]. The effect of digoxin on the cardiac index and diastolic pressure in the pulmonary artery was studied in 17 patients with acute myocardial infarction on the 1st-3rd day of the disease by the method of thermodilution. Twelve of these patients had clinical manifestations of congestive circulatory insufficiency. Digoxin was infused intravenously in a dose of 0.5 mg. Its infusion led to reduction of diastolic pressure in the pulmonary artery from 19.0 to 16.7 mm Hg and rise of cardiac index from 2.26 to 2.4 1/min/m2 (statistically untrustworhty difference). In all cases digoxin concentration in blood serum examined by the radioimmune method was therapeutical (1.64 ng/ml, on the average). The positive hemodynamic effect of digoxin infused in a dose producing its therapeutic concentration in blood is negligible.


[Role of changes in rheological properties of blood in the pathogenesis of disorders of cardiac rhythm and conductivity]. Changes were induced in the rheological blood properties and hemostasis in 40 albino rats by intracardiac injection of high-molecular dextran, arvin, and ethanol. Ten rats received dipyridamole. Changes caused by these agents in erythrocyte deformability were determined by the rheoscopical method. Their effect on the threshold of ventricular fibrillation induced by electric current was also determined. Dextran and arvin reduced erythrocyte deformability and the threshold of ventricular fibrillation to half the initial values. An increase in the ventricular fibrillation threshold due to the effect of dipyridamole was attended by improvement in erythrocyte deformability. Ethanol reduced the threshold of ventricular fibrillation and caused disorders of cardiac atrioventricular conduction. Intravenous infusion of high-molecular dextran and arvin caused various disorders of cardiac rhythm and atrioventricular conduction in 11 out of 12 rabbits. Preliminary administration of rheopolyglucin in 3 rabbits prevented the development of cardiac arrhythmias on injection of dextran and arvin. The authors believe that deterioration of the blood rheological properties is one of the pathogenetic mechanisms in the development of disorders of cardiac rhythm and conduction.


[Competitive rhythm as a complication of asynchronous electric cardiac stimulation]. The article analyses arrhythmias recorded in the hospital period in patients with various disorders of atrioventricular conduction in continous asynchronous stimulation of the heart. The frequency with which the competitive rhythm occurred in implantation of 134 asynchronous cardiostimulants was 11.9%. Mortality from its development was 18.8%. The authors believe unjustified widening of the scope of indications for asynchronous stimulation of the heart to be one of the main causes of parasystole. Strict adherence to these indications in conducive to marked decrease in the incidence of this complication but does not rule it out completely. Implantation of biocontrolled cardiostimulants, in cases with corresponding indications, is the optimum method for the prevention of competitive rhythm.


[Recording the bundle of His potential from the chest surface]. An attempt was made to record the bundle of His potential from the chest surface in 38 persons by means of definite filtration, intensification, and averaging of the ECG. Three electrode leads were used for each person examined: transthoracic, horizontal, and on the longitudinal heart axis. In 34 persons (89%) the potential was recorded in the P--Q interval, its width and distance from the QRS complex corresponded to the parameters of the bundle of His potential. The potential was recorded most frequently in the transthoracic lead (50%).


[Direct recording of electrical activity of human sinoatrial node]. The authors developed a method for recording the electrical activity directly from the human sinus node through the right subclavian vein. Electrical activity of the sinoatrial node (SA) was studied in 179 patients with CHD (angina pectoris, myocardial infarction). The sick-sinus syndrome (SSS) was revealed in 86 patients. The duration of slow deflection Sd, Ss -- P interval (from the onset of Ss to the onset of P wave), P -- A1 interval (from the onset of P wave to the first atrial spike) was prolonged in cases with SSS. The duration of Sd, Ss -- P and P -- A1 decreased after nitroglycerine and atropine administration but increased after benzodixin administration. The data on direct pacing of the SA node and the changes in the duration of phase Sd and Ss after the administration of drugs confirm that slow deflection Sd and rapid preatrial deflection Ss reflect the electrical activity of the SA node.


[Treatment of acute left-ventricular insufficiency complicated by tachyarrhythmia under conditions of cardiological emergency service]. The article analyses 188 cases treated for acute left ventricular insufficiency (ALVI) in different forms of tachyarrhythmia. It was established that in patients with supraventricular paroxysmal tachycardia ALVI develops when the rate of cardiac contractions is 180 +/- 3/min on the average, whereas in patients with cardiac fibrillation it develops when the rate of contractions is 163 +/- 4/min. For successful treatment of ALVI of a tachyarrhythmic character it is necessary to restore the sinus rhythm or slow down the rhythm of cardiac contractions in patients with supraventricular paroxysmal tachycardia to 113 +/- 5/min on the average and in patients with cardiac fibrillation to 118 +/- 2/min. Isoptin and obsidan produce the highest decelerating effect. In half of the patients with tachyarrhythmia. ALVI was relieved by means of antiarrhythmic agents among which obsidan and isoptin proved most effective.


[Syndrome of premature ventricular repolarization]. ECG abnormalities are described in 71 persons with the syndrome of premature repolarization of the ventricles. The syndrome of premature ventricular repolarization is considered a benign, most probably congenital, change of the electro-physiological state of the heart which due to its morphological peculiarities, however, leads to hyperdiagnosis of ischemic heart disease. In the discussion of the pathogenesis of this syndrome, the main attention is focused on the increased effect of the vagus nerve and the possible existence of anomalous additional pathways of atrioventricular conduction.


[Effect of emotional stress on the contractile function of human heart (according to the echocardiographic data)]. Cardiac function was studied by echocardiography in 12 healthy sixth-year students at mid-semester, immediately before taking an exam and 30 minutes after it. It was found that the emotional stress experienced prior to the exam is attended with an increase in cardiac output by one and a half times and external work by two. This increase of the pump cardiac function is ensured without any essential increase in the diastolic dimensions of the left cardiac ventricle at the expense of fuller blood ejection from the left ventricle and decrease of its residual systolic volume. Since the students had taken more than 50 exams in the past and were adapted to the pre-examination situation, the circulatory changes revealed may be regarded as adaptive providing for the rich flow of blood to the brain.


[Antiaccelerative and antiarrhythmic effect of veratramin on myocardial cells in culture]. It is shown that veratramin (2.5 X 10(-5)M) inhibits, partially or completely, the accelerative effect of adrenalin (5.5 X 10(-7) M), isoproterenol (10(-7) M), prostaglandin E2 (5 X 10(-5) M), and glucagon (10(-5) M) in experiments on cultures of newborn rat cardiac cells and the effect of histamine on 3--4-week embryo cultures. Veratramin (1.25--25 X 10(-5) M) arrests digitoxin-induced (1.25 X10(-5) M--5 X 10(-5) M) fibrillation of individual cells and of cell groups. Veratramin alone and in combination with adrenalin does not change the inotropic parameters of individual cells. Bearing in mind that veratramin (2.5 X 10(-5) M) inhibits the accelerative effect of substances which activate and those which do not activate adenylatecyclse, as well as the fact that it has no effect on the content of cAMP in cultures and does not correct the increase in the cAMP content induced by adrenalin (5.5 X 10(-7) M), the authors conclude that the chronotropic effect of veratramin is not associated with the cell receptor mechanisms but is due to its effect on the transport of ions through the cell membrane, which is a responsible process in the generation of impulses.


Adenylate cyclase in human gastric mucosa: its activation by histamine in morphologically different biopsy specimens. In morphologically different biopsy specimens from fundic, antral and duodenal mucosa of 134 persons, basal and histamine stimulated adenylate cyclase activity was studied: Basal and stimulated adenylate cyclase activities were log-normally distributed. Only in the fundic but not in the antral and duodenal mucosa adenylate cyclase was sensitive to histamine. The mean basal activity in the fundic gastric mucosa was 148, in response to 10(-5) mol/l histamine 292 pmol cAMP/mg protein/20 min. In human fundic biopsy specimens histologically identified as normal gastric mucosa, the stimulatory effect of histamine on adenylate cyclase decreased with the individual's age. In bioptic material from patients suffering from histologically proven chronic gastritis the histamine effect decreased with the degree of atrophy. A similar loss of histamine sensitivity was found in gastric mucosal biopsies of antrectomized individuals operated at least 5 years before by the Billroth I or II method, whereas in the mucosa of patients with gastric or duodenal ulcer no loss occurred. In contrast, the most pronounced stimulatory action of histamine was found in this latter group. Since a histamine sensitive adenylate cyclase is localized only in the glandular area of the fundic mucosa and the histamine sensitivity depends on a morphological intact structure of the mucosa, it can be concluded, that the effects of histamine on adenylate cyclase and on hydrochloric acid acid secretion have to be considered as a mechanism linked together.


[Acute combined alpha- and beta-adrenergic blockade in essential hypertension: effects on blood pressure, renal function, renin, and aldosterone]. In seven patients with uncomplicated essential hypertension the effects of an acute alpha-adrenergic blockade, alone and combined with a chronic beta-adrenergic blockade, on blood pressure, renal function as measured by standard clearance methods, plasma renin activity, and plasma aldosterone were evaluated. Acute alpha-adrenergic blockade with phentolamine (20 mg by intravenous infusion) significantly enhanced the antihypertensive effect of chronic beta-adrenergic blockade with slow-oxprenolol (160 mg/ day X 14 days) (- 14.5% verus - 7.4% for pulse pressure, - 12.4% versus - 6.0% for diastolic pressure, 2 alpha less than 0.05). Under combined adrenergic blockade renal plasma flow increased, glomerular filtration rate and filtration fraction decreased (2 alpha less than 0.05 each), whereas the fractional clearances of sodium, potassium, free water, and solute load remained unchanged. The activation of the renin-angiotensin-axis, elicited by alpha-adrenergic blockade alone, was suppressed by the preceding beta-adrenergic blockade. These findings demonstrate a favourable antihypertensive action of a combined blockade of alpha- und beta-adrenergic receptor sites without untoward side effects on renal function or the renin-angiotensin-axis.


[Unusually long survival times in patients with advanced Hodgkin's disease (author's transl)]. Of 18 patients with advanced Hodgkin's disease who obtained a complete remission with a modified De Vita treatment protocol 15 maintained their complete remission for an average of 76 months till the end of the observation time.


The nexus in serial cross-sections of myocardium from cats subjected to hypovolemic shock. A three-dimensional interpretation. Right ventricular papillary muscles from control cats and from cats subjected to hypovolemic shock were studied in cross-section, including serial sections, by electron microscopy. Loops of nexus and a redundant right angle nexus were followed through serial cross-sections in papillary muscles from the shock cats. These unusual nexus configurations were interpreted as a possible means of connecting perpendicular sheets of nexus, of interdigitating adjacent cells, and of providing slack to be taken up during the radial swelling of myocardial contraction. The flexibility of the intercalated disc which is implicit in this interpretation may explain the ability of cardiac myocytes to recover from the severe distortions adjacent to the intercalated disc which occur in myocardial zonal lesions, and perhaps, if they are reversible, in other lesions which occur in proximity to the intercalated disc.


The effect of a liver protein synthesis inhibitor on plasma SAA levels in a model of accelerated amyloid deposition. Animals treated with AgNO3 and amyloid-enhancing factor deposit large quantities of splenic amyloid in 48 hours. The kinetics of SAA production was examined in such a model in the presence and absence of an inhibitor of liver protein synthesis (ethionine). Ethionine had little effect on splenic protein synthesis but inhibited both the production of SAA and liver protein synthesis. When experiments were performed with fed mice, ethionine induced an inhibition of liver protein synthesis lasting 16 hours. Thereafter, liver protein synthesis began to recover, accompanied by a rise in plasma SAA levels. These results are consistent with hepatic but not splenic synthesis of SAA.


Myointimal plaques in pulmonary vascular sclerosis associated with interstitial lung fibrosis. In interstitial fibrosis of the lung, pulmonary vessels show priminent sclerotic changes. We have studied arteries in lung biopsies from patients with lung fibrosis of varied etiology using light and electron microscopy. It was found that the sclerotic change is essentially confined to arteries within fibrotic areas, areas of "nonfibrotic" lung having vessels with no intimal thickening. The changes are most striking in arteries with an external diameter of 500 micrometer. or greater (p less than 0.001), although smaller sized vessels also show significant changes. Ultrastructurally, the plaques are composed of typical smooth muscle cells with basement lamina, pinocytotic vesicles, dense bodies, and cytoplasmic microfilaments. These arterial changes could result from damage to the blood vessel which accompanies the mechanism producing lung fibrosis. Alternatively, the myointimal change could conceivably be part of an adaptive response following the establishment of fibrosis. In either instance, the narrowing would decrease blood flow to physiologically disadvantaged areas of the lung, and the muscle fibers might play an active role in reducing the blood flow.


Cognitive structure and behavioral regulation in alcoholics. Compared with nonalcoholics, alcoholics were less able to focus on relevant cues (i.e., they had weaker cognitive control) and less able to recall pertinent ideas or events and possible consequences (i.e., their internal scanning was narrower).


Identifying drinking problems in V.A. hospital patients. Of 147 patients studied, clinicians identified 28 as problem drinkers; the patients' responses to interview items indicated as normal drinkers or abstainers, 9 indicated by interview responses that they were problem drinkers.


College students' expectations of the results of drinking. Social drinkers, when drinking, are expected to feel better and to be kinder, more fun to be with and more energetic and active than they would be if they were not drinking; inebriated alcoholics are expected to be meaner, less fun to be with and more lethargic than they would be if they were not inebriated.


Age and BAC when arrested for drunken driving and public drunkenness. Blood alcohol concentrations of young people arrested for driving while intoxicated and public drunkenness over a 4-year period in Randolph County, Arkansas, tended to be lower than those of older arrestees.


Women A.A. members and nonalcoholics; scores on the Holmes and MacAndrew Scales of the MMPI. Three groups of women-members of Alcoholics Anonymous, psychiatric inpatients and normal subjects--showed no significant differences in scores on the Holmes and MacAndrew Scales of the MMPI.


Men and women's responses to the Michigan Alcoholism Screening Test. Men alcoholics scored significantly higher than women alcoholics on 7 of 24 items of the Michigan Alcoholism Screening Test; over-all, however, the test appears to be equally effective for both sexes.


Attitudes of paraprofessionals toward alcoholism; setting effects. Paraprofessionals working in a residential alcoholism treatment program had significantly more "custodial" attitudes and attitudes of "humanism" toward alcoholics and beliefs concerning a psychological etiology of alcoholism than did paraprofessionals at a sobering-up station.


Ten years' experience with the Björk-Shiley tilting disc valve. More than 10 years of clinical experience with 1,800 consecutive valve replacements with the Björk-Shiley tilting disc valve were focused on improving its durability, flow dynamics, thromboresistance, and in vivo functional control. Although the original Delrin disc functions excellently after 10 years in the human circulation, the durability of the prosthetic valve was further prolonged by the introduction of pyrolytic carbon as disc material. The opening mechanism was also reinforced by integrating the bearing struts with the valve ring. No other presently available heart valve prosthesis shows such a low resistance to flow for a given tissue diameter. The disc was equipped with a ring-shaped radiopaque marker that permitted noninvasive functional control. The 5 year survival rates were 82% after aortic, 66% after mitral, and 66% after mitral and aortic valve replacements, including the operative mortality rates. The incidence of systemic emboli was 0.7% per year after aortic, 4.2% per year after mitral, and 2.2% per year after mitral and aortic valve replacements with anticoagulation treatment. The incidence of obstruction by thrombosis was 0.3% per year for aortic, 1.3% per year for mitral, and 2.3% per year tricuspid prostheses. The new convex-concave model decreases the stagnation zone behind the disc, decreases emboli from 4.2% to 1.2% per year after mitral valve replacement, and has a lower gradient.


Late failure of porcine valve heterografts in children. Heterograft porcine valves have gained wide acceptance in replacement of diseased cardiac valves, and their clinical performance in adults has been very satisfactory over follow-up periods of up to 8 years. Valve replacement in children is relatively infrequent and experience with porcine xenografts is necessarily small. Our combined experience at three university hospitals has been with 25 children, 17 months to 16 years of age, who have been followed for 10 to 54 months (mean follow-up 33 months). Porcine valves were used to replace the aortic valve in nine, the mitral valve in seven, both valves in two, the tricuspid valve in two, and the pulmonary valve in five patients. Severe bioprosthetic valve dysfunction has occurred in five (20%) of these patients so far and necessitated replacement because of severe stenosis in mitral (two) or aortic (three) valve prostheses at 18 to 45 months after implantation; one postoperative death occurred among the five reoperations. Pathological examination showed extensive fragmentation of collagen with focal heavy calcification and degeneration. In addition we have encountered deterioration and calcification of two porcine valves in 23 valved conduits followed for 12 to 70 months (mean 43 months), requiring removal and replacement of the valves 65 and 67 months after implantation. This experience indicates a disquietingly high incidence of relatively early failure of porcine xenograft valves in children. This is significantly higher than the failure rate observed in adult patients. The failure rate is not consistently related to the small size of an implanted valve which becomes relatively narrow with the growth of the patient, leading to excessive turbulence and trauma to the prosthesis. Other factors, including increased turnover of calcium and accelerated rejection in growing children, may contribute to these failures and should be examined in order to improve long-term results. A satisfactory performance would make heterografts the ideal valvular prosthesis in children, since anticoagulation is avoided.


Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period. An unselected, consecutive cohort of 125 patients underwent operative repair of acute and chronic aortic dissections with tubular graft interposition over a 16 year span. The absence of remote geographical referral biases and the unselected nature of this series provided a patient population that was representative of the disease process (as assessed heretofore only from autopsy series). Furthermore, this enabled high-risk subsets to be defined by retrospective analysis. Patients were classified according to whether the ascending aorta was involved (type A with involvement, type B without), irrespective of the site of intimal tear, and according to age of the dissection: Fifty-three patients had acute type A (Ac-A), 29 had chronic type A (Ch-A), 20 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissections. Fourteen percent (17/125) of the dissections had ruptured. Concomitant aortic valve replacement (AVR) was performed in 11% (6/53) for Ac-A cases and 38% (11/29) of the Ch-A cases. A total of 391 patient-years of follow-up was analyzed; follow-up averaged 4.5 years and extended to 13.7 years. Over-all operative mortality rate was 34% (18/53) for Ac-A, 14% (4/29) for Ch-A, 45% (9/20) for Ac-B, and 22% (5/23) for Ch-B; during the most recent 5 year interval these figures were lower: 27%, 8%, 20%, and 20%, respectively, N = 50. Multiple preoperative variables were found to correlate significantly with both operative death and long-term survival. Operative survivors generally experienced satisfactory functional benefit. Late attrition averaged 8% per year; 61% of all late deaths were related to cardiac or cerebral causes. Over-all actuarial survival (+/- SEM) for the entire cohort was 54% +/- 5% at 5 years and 26% +/- 7% at 10 years; for the 89 patients surviving operation, these figures were 76% +/- 5% and 37% +/- 10%, respectively. No significant differences in long-term survival were evident between the different subgroups. Whether the primary intimal tear had been resected or concomitant AVR had been performed had no statistically significant bearing on operative mortality, functional result, necessity for late reoperation, or late attrition. The long-term "natural" history of surgically treated patients with aortic dissections, as defined in this study, should facilitate comparison with other treatment modalities. Results of the present analysis support immediate operative intervention for patients with Ac-A dissections and probably for those with Ac-B dissections. Additionally, surgical treatment of patients with symptomatic or enlarging Ch-A and Ch-B dissections provides satisfactory rehabilitation and long-term survival. Finally, we re-emphasize our recommendation for simplified classification of aortic dissections, based solely upon the presence or absence of ascending aortic involvement. Pathophysiology and expected biologic behavior pivot on this feature, and appropriate clinical strategy can thereby be defined.


Treatment of aneurysm of transverse aortic arch. Although aneurysms involving the aortic arch are usually well localized and amenable to reconstructive operation, the reported results of this form of therapy at this level are not as good as in other portions of the aorta. The difference is due to cerebral and bleeding disturbances associated with cerebral protection techniques. This report describes 30 patients and emphasizes the variability of extent of these lesions and the results of methods employed for cerebral protection, which varied according to extent of disease. The aneurysm involved all but the proximal ascending aorta in one patient and was replaced with a permanent ascending aorta-innominate and left common carotid artery bypass graft. Eight aneurysms were limited to the transverse arch; one was removed with the aid of temporary bypass and seven with cardiopulmonary bypass and separate brachiocephalic normothermic perfusion. Temporary and permanent bypass grafts were used in four patients with lesser involvement. None of these techniques was used in 17 patients who had distal arch involvement. Of the 30 patients, 26 survived and 18 are still alive despite the treatment being spread over a 22 year period. Cerebral complications occurred in 3 patients, two of whom died. These problems were avoided in five patients treated more recently by using lows flows under low pressures. Coagulopathies did not occur. Although the technique of cardiopulmonary bypass, profound hypothermia, and circulatory arrest provides a more convenient and technically simpler method of operation, the disadvantages of coagulopathies with excessive bleeding, pulmonary problems, and lack of consistent cerebral protection argue against its routine use at this time.


Patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement. Experimental study. The experimental results of patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement are reported. The operative technique of this new surgical method is described and the indications are discussed.


Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. This communication describes a new surgical procedure of enlarging the narrow aortic valve ring by extending the aortic incision through the fibrous origin of the aortic leaflet of the mitral valve into this leaflet. A fusiform patch is sutured to the V-shaped defect in the aortic leaflet of the mitral valve and in the aortic anulus. This procedure permits the replacement of the aortic valve by a suitable prosthesis. Between June of 1976 and February of 1978, eight patients underwent this surgical procedure. At the time of operation the patients were between 8 and 50 years old. The estimated enlargement of the aortic root ranged from 10 to 25 mm. The operative technique is described, peculiarities of this method are discussed, and the results are reported. Six to 27 months following operation, the clinical condition of six patients is good. Four patients show no impairment of mitral valve function. In one case, preoperatively diagnosed mitral incompetence persists. In another patient the pericardial patch broke from the aortic leaflet of the mitral valve, so that the valve had to be replaced on the fourth postoperative day. One patient died of myocardial necrosis because of insufficient myocardial protection during operation. One child with acute aortic insufficiency caused by staphylococcal endocarditis and congestive heart failure died of septicemia 3 months postoperatively. Mitral incompetence was not detectable in this child.


Anterior approach for tumor of the superior sulcus. A new approach for the resection of tumors of the superior sulcus is described. The exposure is gained through a proximal median sternotomy extended into the anterior fourth intercostal space as well as to the base of the neck on the appropriate side. This approach guarantees excellent exposure of the tumor, subclavian artery, and brachial plexus as well as access to the ribs posteriorly and the border of the vertebral bodies. Hilar dissection is readily accomplished without change of the patient's position. Disadvantages relate to depth of exposure, especially in large individuals, and the complicated wound closure.


Surgical treatment of Ebstein's anomaly. Early and late results in twenty patients subjected to valve replacement. Twenty patients with Ebstein's anomaly underwent corrective operations between 1965 and 1978. Sixteen were in Functional Class III or IV (N.Y.H.A.) and four were in Class II but were having episodes of anoxia, syncope, or a rapid increase in cardiac size. In the first 10 cases (1965 to 1972) the tricuspid valve was replaced with a Starr-Edwards prosthesis, and in the second group (1972 to 1978) a dura mater valve was used. Five patients also underwent plication of a very large atrialized right ventricular segment. The atrial septal defect was closed totally in four cases, partially in eleven cases, and left open in five cases; one patient also underwent closure of the ventricular septal defect. Four patients died in the immediate postoperative period, three of whom were in the first group. There were three late postoperative deaths in the remaining 16 patients, all of them in the first group. All 13 of the surviving patients are in Functional Class I, except for one patient who is in Class II.


Septation of the univentricular heart. Transatrial approach. The technique of septation of the univentricular heart via a transatrial approach is described in detail. Clinical details of four patients having Type A-III univentricular heart document the feasibility of working through the right-sided atrioventricular valve to place a cloth prosthesis into the ventricle to divide it into approximately equal chambers. Improved hemodynamics were observed in the postoperative period, which probably were related to retaining the integrity of the ventricular wall. This approach seems best suited to the ventricular chamber estimated to be large by echocardiography without severe pulmonary outflow tract obstruction. Techniques for enlargement of the pulmonary outflow tract are also described.


Mustard's operation modified to avoid dysrhythmias and pulmonary and systemic venous obstruction. Between, May of 1973 and May of 1978, 130 patients underwent correction of complete transposition of the great arteries by a modification of the Mustard operation specifically designed to avoid dysrhythmias and to minimize systemic and pulmonary venous obstruction. Of the 102 surviving patients who underwent this operation, 99 still exhibited sinus rhythm on the latest standard electrocardiographic (ECG) recording. On 24 hour ECG recording between 2 weeks and 4 years postoperatively, nine (15.5%) of 58 patients having the Mustard operation for simple and complex transposition showed dysrhythmias. There were no cases of pulmonary venous or inferior vena caval obstruction in this series. Six cases of superior vena caval obstruction were encountered. Our operative and autopsy findings point to the importance of avoiding the area of the sinus and atrioventricular nodes, since by doing so, we have reduced postoperative dysrhythmias. Operative technique, in particular, wide excision of the septum secundum and baffle design as suggested by Brom, have reduced the incidence of superior and inferior caval obstruction and pulmonary venous obstruction. The modifications we have applied in our series suggest that Mustard's operation should not be discarded prematurely.


Growth of the pulmonary anulus and pulmonary arteries after the Waterston anastomosis. Twenty-six patients with tetralogy of Fallot underwent angiocardiography before a Waterston shunt and again several years later, prior to complete repair (mean interval 40 +/- 15.6 [SD] months). The ratio between the diameter of the pulmonary valve anulus (PVA) and that of the descending thoracic aorta (Ao) increased by 0.32 +/- 0.233, significantly more than is reported to occur after a Blalock-Taussig anastomosis (p = 0.0001). This increase had some relation to the interval between the two angiographic studies (r = 0.34, p = 0.08) and to the mean pressure in the main pulmonary artery (MPA) at the time of the second study (r = 0.35, p = 0.08). The ratio of diameter of the right (RPA) and left pulmonary arteries (LPA) and that of the Ao also increased by 0.24 +/- 0.226 and 0.20 +/- 0.201, respectively. These data suggest that an initial large aortopulmonary shunt may result in less need for transannular patching at complete repair.


Treatment of early postinfarction ventricular aneurysm by intra-aortic balloon pumping and surgery. In nine patients with medically refractory left ventricular failure and/or ventricular arrhythmias, secondary to acute formation of a ventricular aneurysm, intra-aortic balloon pumping (IABP) was instituted 24 to 36 hours before diagnostic angiographic studies. Ventricular irritability was reduced and heart failure was controlled in all patients. Eight patients underwent operation, four within 3 weeks of an acute myocardial infarction and four within 3 months. All had resection of the recent infarction and two had myocardial revascularization as well. Two of the eight patients died in the early postoperative period from intractable ventricular fibrillation. All six patients who survived the operation (mean follow-up 12 months) had excellent clinical results. Ventricular irritability was suppressed and only one patient had residual heart failure. However, there was one late death 7 months after operation. The results suggest that surgical therapy may be effective in the management of medically unresponsive arrhythmias and/or congestive heart failure in the acute or intermediate postinfarction phase. IABP assistance was helpful in supporting the circulation and reducing ventricular irritability during the preoperative and postoperative periods.


Total joint arthroplasty. The hip.

Total joint arthroplasty. The hip. Total hip arthroplasty, one of the most successful orthopedic procedures of this century, can provide relief of pain and improved function in a wide variety of hip conditions. Long-term follow-up has shown, however, that problems can occur, especially with the femoral prosthesis. As a result of this, surface-replacement total hip arthroplasty was developed, and at present it appears to be a very useful procedure for younger patients with concentric hip disease. Both procedures are discussed along with restrictions and complications inherent in their use.


Total joint arthroplasty. The knee.

Total joint arthroplasty. The knee. Total knee replacement has become an established form of treatment for gonarthrosis and usually results in excellent relief of pain and approximately 90 degrees of joint motion with satisfactory joint stability. The anatomic stability that cannot be restored at surgery must be provided for by additional prosthetic stability. Fixation of prosthetic devices, particularly in the tibia, is marginal and results in an increased incidence of loosening when the quality of bone is weak, as in osteoporosis, or when shear stress is increased because of malalignment or prosthetic constraint. Resurfacing techniques provide the greatest options if surgical revision is necessary. Surgical goals should be realistically assessed so as to maintain the best potential for future treatment options.


Total joint arthroplasty. The ankle.

Total joint arthroplasty. The ankle. When conservative measures fail to relieve significant disability due to ankle joint disease, the only surgical method of treatment has been arthrodesis. Because of less than ideal results and other long-term problems with ankle arthrodesis, and after numerous investigation to characterize the ankle mechanically, we developed a prosthetic ankle joint replacement. The Mayo total ankle replacement is a metal-on-polyethylene, congruent, constrained prosthesis. Analysis of 94 patients (102 ankle prostheses) revealed good clinical results in patients with rheumatoid arthritis and in older persons with posttraumatic degenerative disease. Younger, more active patients in the latter category had more disappointing results. Further design development is under way to improve range-of-motion characteristics, decrease constraint forces, and improve bone fixation of the prosthetic components.


Total joint arthroplasty. The foot.

Total joint arthroplasty. The foot. A prosthesis has been designed with which to resurface the painful, degenerated first metatarsophalangeal joint. Clinical evaluation thus far has indicated satisfactory results in 16 of 18 instances. This procedure will probably give the best results in the older patient with hallux rigidus, but the length of follow-up is as yet too short to allow firm opinions to be formed.


Total joint arthroplasty. Applications in children and adolescents. Sixty total hip arthroplasties were performed in 47 severely disabled children and adolescents. Follow-up was from 1 to 5 years. The complication rate was 22%. Loss of the prosthesis occurred in only one patient, who had had multiple operations. Eighty-five percent of these patients had good to excellent results.


Total joint arthroplasty. Applications in the management of bone tumors. Limb-saving resection has become a valid alternative to amputation in carefully selected patients with bone tumors. As interest grows in this technique, efforts continue to improve our methods of bone and joint reconstruction to restore a functional extremity. Previously there was little interest in this form of treatment despite a limb-saving potential, because of inadequate methods of skeletal reconstruction. The purpose of this paper is to review these previous methods and to outline our present approach to the problem.


Total joint arthroplasty. The role of biomechanics. The role of biomechanics is intricately involved in total joint replacement from its inception to its clinical use. By integrating knowledge of joint function and material properties, the artificial joint is designed and tested. After clinical use, the joint function is again studied and failure modes are defined. Biomechanics is the single most important discipline that can be employed to study the cause of failure in order to improve design and technique. This will increase the reliability of, and decrease the incidence of failure associated with, total joint replacement.


Total joint arthroplasty: principles and guidelines for postoperative physiatric management. Postoperative physiatric treatment is an integral part of the replacement of hips, knees, ankles, shoulders, elbows, wrists, and digital joints. Neuromuscular substitution patterns and incoordination usually prevail after joint replacement because of the usual long-term expectation and experience of pain, limitation of motion, fatigue, weakness, and the unavoidable operative trauma. The goals of postoperative physiatric treatment, in line with those of joint replacement surgery, are relief of pain and reestablishment of comfortable, normal neuromuscular functions and their reasonable, safe application in appropriate activities of daily living and of locomotion. By close collaboration between the Department of Orthopedic Surgery and that of Physical Medicine and Rehabilitation, certain principles and detailed protocols of postoperative management have been developed over the last 10 years. These are described in some detail for each of the joint replacements. Optimal results can be achieved only through meticulous attention to physical and psychosocial details, with close cooperation and communication among the involved services and persons.


Chronic gouty nephropathy treated by long-term hemodialysis and allopurinol. A patient with intractable tophaceous gout and advanced renal failure responded favorably to treatment by long-term hemodialysis and administration of allopurinol. Plasma uric acid levels returned to normal, tophi decreased in size, and the frequency of attacks of gout decreased markedly and permitted the patient to return to full-time employment.


Conservation of ribosomal fidelity during ageing. The function of ribosomes prepared from the liver of young (2--5 months old) and senescent (15--26 months old) mice were compared in vitro. The conclusions that can be drawn from the liver of senescent mice is 10 to 40% lower than that of young mice; (2) the fidelity of translation does not change grossly with age; (3) the thermosensitivity of translational activity of ribosomes and the activity of ribosome-associated ribonuclease do not change with age; (4) there is an age-dependent accumulation of free 40S ribosomal subunits in the cytoplasm of mouse liver. The relation of age-dependent changes in the structure and function of ribosomes is discussed.


Fine structure of IMR-90 cells in culture as examined by scanning and transmission electron microscopy. Cells from the new strain IMR-90 were examined by scanning (SEM) and transmission (TEM) electron microscopy at early, middle, and late population doubling levels. The cells are characteristically flattened and elongated and arranged in clusters from 1 to several cells thick. Long thin processes extend from the poles and sides of the cells. The number of blebs and microvilli on the cell surface varies. In later population doubling level (PDL) cultures, a larger number of cells have greater quantities of microvilli on their surface. It is suggested that the increased number of microvilli might represent an increased level of differentiation. By TEM the cells typically have elongated to oval shaped nuclei which are sometimes deeply invaginated. The cytoplasm contains a well developed Golgi region, elongated mitochondria, microtubules, filaments, a variety of vesicles, vacuoles and dense bodies and large amounts of RNA in the form of granular endoplasmic reticulum and ribosomes. Cytoplasmic appearance, particularly the number of dense bodies, varies widely at all PDL. With increasing PDL, cells tend to have nuclei with more condensed chromatin, and a cytoplasm containing less mitochondria and granular endoplasmic reticulum and more dense bodies. Also at later PDL there is a higher frequency of cells containing long, thin dense mitochondria as well as bizarre shaped mitochondria. In older populations there are many cells in a state of filamentous degeneration. Cells with large numbbers of surface projections (microvilli) tend to be correlated with an osmiophilic cytoplasm containing many filaments and numerous dense bodies.


The synthesis of glycosaminoglycans in aging rat liver. A brief note. The synthesis of glycosaminoglycans (GAG) was studied in liver slices from postnatal (9 days), young (140 days), adult (490 days) and senescent (940 days) rats. It was found that the rate of synthesis was highest in postnatal rat liver and decreased to about half in young rats with no further reduction in adult and senescent age groups. The specific radioactivity of the precursors of GAG synthesis did not change with age. The synthesis pattern of specific types of GAG in postnatal liver was characterized by a significant higher percentage of chondroitin sulfate and hyaluronic acid. In the following age classes the profile of specific GAG synthesis did not change significantly (heparin sulfate: chondroitin sulfate" hyaluronic acid: "keratin sulfate" = 84%:8.3%:1.5%:1.6%).


Prediction of neonatal death or need for interhospital transfer by prenatal risk characteristics of mother. A closed-circuit television system is implemented between neonatal specialists at a large neonatal care hospital and nurses caring for infants in the newborn nursery in a small community hospital located in an inner city, predominantly black, economically deprived area. Data are systematically collected relating prenatal risk characteristics of mothers to outcome measures, including selected intrapartum maternal complications, neonatal morbidity and mortality, neonatal therapeutic interventions, and transfer of neonates from the small hospital to the larger hospital. To our knowledge, study of factors predicting transfer has received little attention in the literature. A log linear model is used to identify specific groups of prenatal risk characteristics capable of predicting maternal and neonatal outcomes.


Assessing functional status among elderly patients: a comparison of questionnaire and service provider ratings. This paper describes a comparative analysis of questionnaire-based measures of functional status and clinical ratings of disability made by general practitioners and health visitors. Both approaches to functional assessment were used in rating 92 elderly primary care patients in terms of their performance of 13 mobility and self-help activities. Simple dichotomous and more complex trichotomous measures of performance were used to summarize functional ability in both the questionnaire and the provider's evaluation. Agreement between questionnaire-based and rater assessments was greatest for less complex mobility and self-help functions in comparisons using both dichotomous and trichotomous scales.


Emergency medical service: delays, response time and survival. A major concern in emergency medical services (EMS) planning has been the need to minimize ambulance response time, only one of several delays in reaching definitive care. Other important delays include patient delay in seeking medical care and dispatch delay. In this study, the importance of response time in light of other delays is discussed, and response time as one determinant of patient survival is analyzed, using Seattle's EMS system as a case study. The major conclusion is that paramedic response times influence short-term patient survival.


Implications of alternative sampling strategies for emergency medical service evaluation. Evaluations of emergency medical service (EMS) programs have been ambiguous, due in part, to problems of sample definition. Four different sampling strategies were studied: 1) all patients in cardiac arrest; 2) patients with a final diagnosis of myocardial infarction (MI); 3) patients with an emergency room diagnosis of "rule out MI"; and 4) patients identified by the ambulance team as a possible MI. Using a regional data base of all ambulance runs, we created study samples based on each of these strategies and measured the error that may be introduced as a result of sample selection. Bias was measured along three parameters of EMS system performance: 1) observed incidence of MI in the ambulance system; 2) condition recognition--the ability of the ambulance team to correctly identify acute cardiac patients; and 3) emergency room and hospital mortality rates. The emergency room diagnosis strategy systematically excludes all false-positives, while samples based on the ambulance team's assessment omit all false-negatives. The final diagnosis strategy yields significant underestimates of cardiac mortality. Samples restricted to cardiac arrests result in biased estimates of both the incidence of MI and the number of deaths.


Public challenge of physician authority. A sample survey of the public in a midwestern state substantiates the existence of widespread challenges to the authority of physicians, a phenomenon previously reported only impressionistically in the media. Attitudes tending to reject physicians' right to direct their interaction with patients characterized more than half the sample and were related to younger age, higher educational level, and greater health knowledge, with a consumerist and anti-authority stance also explanatory. Actual challenging behavior occurred at least once for about half the group, but in this instance was related less to age and knowledge than to more extensive experience with the health care system, as well as a lack of trust in people in general and doctors' competence in particular. However, explained variance was modest, arguing that other variables, not identified in this study, are at work. Surprisingly, respondents' health status, race, sex, and pattern of insurance coverage had little impact on either attitude or behavior, while both knowledge and a general tendency to reject authority were influential factors. Implications for physician-patient relations in the future are discussed in light of a number of social changes, including the rising educational level of the American public.


[Clinical course and recurrences of the nephrotic syndrome due to minimal histologic lesions. Review of 73 cases (author's transl)]. The clinical course of 73 patients with nephrotic syndrome due to minimal histologic lesions was studied. A renal biopsy was performed in all of the cases; 23 biopsies were studied by immunofluorescence and two renal biopsies were carried out in eight cases. The follow-up period varied from 6 months to 10 years. The following treatment were used: 23 patients received prednisone alone, 48 were given prednisone plus chlorambucil, and 2 were treated only with chlorambucil. Sixty-five patients achieved a complete remission; a total of 39 recurrences occurred in 23 of them. The relapses took place 16 months on the average following complete remission. Twenty-three patients (32.4 percent) cured with only prednisone. Forty-eight required the association with chlorambucil, 8 percent of whom experienced recurrences before being completed cured. Two individuals were treated with chlorambucil alone and ach;eved a complete and stable remission. Eight patients (10.95 percent) could not be cured. Five of them showed a glomerular focal hyalinosis in the second renal biopsy. Six patients had hematuria at the onset: two of them achieved complete remission with recurrences; four did not. Three of the latter had glomerular focal hyalinosis. There were small foci of immunoglobulin deposits in 13 cases; 11 of them obtained complete remission with relapses and 2 achieved partial remission.


[Comparative functional study of 25 patients with intrathoracic sarcoidosis (author's transl)]. Pulmonary function in 25 patients with intrathoracic sarcoidosis was studied by three different methods: clinical, as related to the presence or absence of dispnea; response to corticoid treatment, and roentgenologic stage. A total of 60 examination were made on the 25 patients. Each examination included: pulmonary volume (vital capacity and RV/CT coefficient), ventilatory mechanics (elastance, resistance, critical flow, and specific conductance), and gas exchange (DCO/VA and (A-a) O2). The following results were obtained from statistical evaluation of the mean values compared with normal values: 1) patients with dyspnea showed a greater pulmonary elastance and (A-a) O2 than normal; 2) treatment with corticoids only produces an improvement in the diffusion capacity in respect to the total volume (DCO/VT); 3) examinations corresponding to the three different roentgenologic stages varied only in pulmonary volume and only when stage III was compared with stages I and II; 4) the terminal stage of the disease is physiologically similar to the typical pattern of emphysema.


[Urinary excretion of hydroxyproline in patients with chronic respiratory insufficiency (author's transl)]. The level of urinary excretion of hydroxyproline is considered as an index of the metabolic activity of the collagen. It increases in situations which include an increase in the osteoblastic activity or in the bone resorption. In respiratory insufficiency a series of conditions occur which are theoretically capable of modyfing this parameter. Twelve patients (9 males and 3 women) with chronic respiratory disease in a situation of respiratory insufficiency (hypoxemia and/or hypercapnia at rest) were studied. The urinary excretion of hydroxyproline in these patients was 15.30 +/- 8.16 mg/day/m2, significantly greater than that of a control group with similar characteristics which was 9.97 +/- 3.07 mg/day/m2 (p less than 0.05; Student's t test). The existence of a significant correlation between the urinary excretion of hydroxyproline and the degree of hypoxemia (r = 0.66; p less than 0.01) was likewise verified; in the same way, although to a lesser degree with the hypercapnia (r = 0.62; p less than 0.05). The different factors capable of influencing the bone metabolism in respiratory insufficiency are discussed, as well as the effects of the medications used by these patients. It is possible, on the other hand, that the increase of the urinary excretion of hydroxyproline does not depend only on alterations in the metabolic condition of the bone, but also on a reduction in the hepatic metabolism of the amino acid in relation with gasometric modifications.


[Practical considerations in dealing with cerebral ischemia (author's transl)]. The handling of patients with cerebral ischemia is reviewed, taking into consideration recent concepts regarding etiopathogenesis along with new diagnostic and therapeutic methods. A particularly important new diagnostic method is computerized axial tomography. The subject is divided into four sections in order to present a practical outline. The first section deals with the arterial circulatory system. Evaluation of patients with arteriosclerosis of the vessels in the neck and/or intracranial are reviewed in some detail, according to whether the clinical manifestation was transitory ischemia, progressive cerebral infarction, or complete cerebral infarction. Emphasis is placed on the proper selection of diagnostic tests and application of therapy in each case. The second part is a discussion of the changes in arterial blood pressure in the etipathogenesis of stroke. Arterial hypertension is an important factor in production of small infarctions. In the third section a review is made of the role of the heart in transitory ischemia and as a cause of cerebral infarctions. Lastly, the hematologic factors which might contribute to the development of cerebral ischemia, along with the other causes, are mentioned.


[Transitory ischemic accidents. A retrospective study of 150 cases of ischemic infarction in the region of the median cerebral artery (author's transl)]. Transitory ischemic accident is an episode that commences abruptly with subjective or objective neurological disturbances, persists for a brief time, and returns to normal within 24 hours of onset with complete recuperation of neurological function. Using this as a basic definition, the authors specify the characteristic symptoms of different types of transitory ischemic accident and review in retrospect 150 cases of ischemic infarction in the region of the median cerebral artery. Thirty-eight percent of the patients suffered transitory ischemic accidents prior to stroke. The symptoms included the following, in order of frequency: motor nerve disorder, sensory nerve disorders, speech disturbances, and visual defects. Most of these patients presented a definite stroke within less than one month's time following the last transitory ischemic accident. The similarity of the symptoms in both conditions was noticeable. The authors study the angiographic images, the pharmacologic and toxic previous histories, and other associated diseases in each patient. They point out, lastly, that transitory ischemic accident should be considered the first manifestation of a cerebrovascular disease and not just as an isolate, reversible episode of little importance.


[Clinical protocol for study and treatment of bronchogenic carcinoma (author's transl)]. Bronchogenic carcinoma constitutes one of the primary causes of death in our population. The only means of controlling the disease in a significant way is by surgery, which about a third of the patients undergo. This fact, together with the age at which the pathology appears, its frequent association with chronic pulmonary disease, and the rapidity of its metastatic spread, make it necessary to establish a protocol for the study, diagnosis, and treatment of bronchogenic carcinoma. These norms should be applicable in prospective epidemiologic studies and for evaluating methods of diagnosis and treatment. The Interhospital Bronchogenic Carcinoma Co-operative Group has established a protocol, which includes the criteria of operability, resectability, preoperative examinations, indications of mediastinoscopy, etc. The authors mention the histopathologic classification, the TNM criteria, and the characteristics of localized or advanced disease.


[Pulmonary infarction as a cause of pneumothorax: report of two cases (author's transl)]. Pulmonary infarction is a very uncommon cause of pneumothorax. The authors report two patients with pneumothorax arising as a complication of pulmonary infarction. One was a 72-year-old man who had hemoptysis, pleural effusion, and alveolar condensation. Four days later he developed a hydropneumothorax and pulmonary cavitation. He died of heart failure. The pulmonary infarction was not septic in this case. The other patient was a 12-year-old boy who suffered a septic embolism with cavitation as a result of an infected wound. He later developed a tension pneumothorax and died in a state of shock. The authors have found only 16 cases of pneumothorax as a complication of pulmonary infarction in the literature. It is surprising that, even though all infarctions are in contact with the pleural surface, the incidence of pneumothorax is not higher. The infarctions may or may not be septic. Cavitation is not necessarily present, though infarctions are usually cavitated before pneumothorax develops. Tension pneumothorax occurs in some cases.