Faecal flora of South Indian infants and young children in health and with acute gastroenteritis. The faecal flora of 29 healthy infants and young children was compared with that of 49 children of similar age and socio-ecomonic status with acute gastroenteritis. In the healthy children the most common organisms in the faeces were bifidobacteria, veillonellae, enterobacteria and enterodocci with anaerobes outnumbering aerobes. Most members of the noraml faecal flora were present in the diarrhoeal stools, but anaerobes were signigicantly reduced in number and enterobacteria were significantly increased, thereby altering the ratio of anaerobes to aerobes. The alterations in the flora were not related to the nature of the aetiological agent or to the severity of the diarrhoea. The changes appeared to be a direct result of the altered colonic environment produced by the diarrhoeal state. In 13 of the 28 patients from whom bacterial pathogens were isolated, the pathogens were the predominant faecal organsims.


Gas-lipuid chromatographic analysis of metabolic products in the identification of bacteroidaceae of clinical interest. The acid end-products of 185 isolates from the family Bacteroidaceae were separated and analysed by gas-liquid chromatography on broth cultures. Different media were evaluated and definitive studies were performed in a fully supplemented complex medium. The limitations of this approach to the identification of a wide range of strains from various clinical sources were determined and the results were compared with those of a series of morphological, biochemical, tolerance and antibiotic-resistance tests. All test strains were identified to generic level by simple microscopic and colonial observations and GLC analysis; additional tests were required to allow species or subspecies identification of most strains. Population differences were detected between some species or subspecies isolated from different clinical sites by quantitative analyses of fatty acids, but individual strains could not always be separated because of overlapping ranges of distribution of acids that were common products of more than one species or subspecies. Small differences in minor products between different species or subspecies were variable and are not considered adequate for discrimination at these taxonomic levels without support from other observations. The potential application of the GLC technique to the rapid and accurate identification of these organisms in hospital laboratories is considered.


Membranous dysmenorrhea in the chimpanzee (Pan troglodytes). A report of four cases. A macroscopic and histologic description of membranous dysmenorrhea in chimpanzees is given. The similarity of these cases to those in women make the chimpanzee an interesting model for studies on the presently unknown etiology of membranous dysmenorrhea.


Reproduction of the greater bushbaby (Galago crassicaudatus panganiensis) under laboratory conditions. A breeding colony of Galago crassicaudatus panganiensis was maintained under laboratory conditions for four years, August 1971 to July 1975. The estrous cycle and the gestation period averaged 39 and 132 days in length, respectively. Twinning occurred in 14.5% of the pregnancies. No postpartum estrus was observed, although 1.2 conceptions per female per year were recorded. Breeding occurred throughout the year. Puberty occurred between ten and 18 months of age, the first conception occurred between 15 and 18 months of age, and reproductive capability decreased rapidly between ten and 12 years of age.


Transport of organic anions through the erythrocyte membrane as K+-valinomycin complexes. K+, Rb+, or Cs+ complexes of valinomycin form ion pair complexes with picric acid and trinitrobenzenesulfonate (TNBS). The formation of a picrate-K+-valinomycin complex is supported by spectral evidence. These complexes have zero net charge and readily permeate the intact erythrocyte membrane. The K+-valinomycin complex has been used to convert the nonpenetrating TNBS into a penetrating covalent probe, making it as useful vectorial probe to measure accessible amino groups of proteins and phospholipids on both sites of the erythrocyte membrane. The enhanced transport of TNBS into the cell by valinomycin is dependent on external K+ in the medium. The entry of TNBS into the cell is manifested by an increased labeling of hemoglobin and membrane phosphatidylethanolamine (PE). Stilbeneisothiocyanatedisulfonate (SITS) and anilinonaphthalenesulfonate (ANS) inhibit both the basal and K+-valinomycin stimulated labeling of PE and hemoglobin by TNBS. The data suggest two independent effects of ANS and SITS, one mediated by an inhibition of the anion transport protein and another by the incorporation of these hydrobic anions into the cell membrane with an increase in negative charge on the membrane which leads to an inhibition of TNBS permeation into the cell by electrostatic repulsion.


Ion transport by rabbit colon: II. Unidirectional sodium influx and the effects of amphotericin B and amiloride. The unidirectional influx of Na from the mucosal solution into the epithelium of in vitro descending rabbit colon (JName) determined under short-circuit conditions, is comprised of two components: one represents entry of Na into transporting epithelial cells and is abolished by amiloride which also abolishes Na absorption (JNanet). The other represents diffusional Na entry into paracellular pathways traversing the epithelium. In all instances, exposure of the mucosal surface to amphotericin B increased tissue conductance and JName and elicited K secretion. Tissues showing a spontaneous Isc of approximately 4 microneq/cm2hr did not respond to amphotericin B with increased Isc and JNanet. However, in tissues characterized by a lower Isc under control conditions, amphotericin B increased Isc and JNanet to approximately 4 microneq/cm2 hr. These findings suggest that amphotericin increases JNanet and elicits K secretion by disrupting the normal perm-selectivity of the mucosal membrane. Under these conditions the extrusion of Na from cell-to-serosal solution becomes the rate limiting step in transepithelial Na transport. Finally, a close correlation between JName and JNanet was was observed when the rate of Na absorption varied either spontaneously or experimentally with amiloride, suggesting that the backflux of Na from cell-to-mucosal solution is undetectably small.


Similarity in effects of Na+ gradients and membrane potentials on D-glucose transport by, and phlorizin binding to, vesicles derived from brush borders of rattit intestinal mucosal cells. Both the presence of sodium and of an electrical potential difference across the membrane have been found to be necessary in order to achieve optimal D-glucose-protectable phlorizin binding to brush border membranes from rabbit small intestine. The effect of delta approximately muNa on phlorizin binding shows a close similarity to that on D-glucose transport, confirming that phlorizin is indeed bound to the D-glucose transporting protein. Possible modulations of binding by a transmembrane potential are discussed on the basis of some models.


Are extreme halophiles actually "bacteria"? Comparative cataloging of the 16SrRNA of Halobacterium halobium indicates that the organism did not arise, as a halophilic adaptation, from some typical bacterium. Rather, H. halobium is a member of the Archaebacteria, an ancient group of organisms that are no more related to typical bacteria than they are to eucaryotes.


Goodman et al.'s method for augmenting the number of nucleotide substitutions. Statistical properties of Goodman et al.'s (1974) method of compensating for undetected nucleotide substitutions in evolution are investigated by using computer simulation. It is found that the method tends to overcompensate when the stochastic error of the number of nucleotide substitutions is large. Furthermore, the estimate of the number of nucleotide substitutions obtained by this method has a large variance. However, in order to see whether this method gives overcompensation when applied together with the maximum parsimony method, a much larger scale of simulation seems to be necessary.


On investigating the statistical properties of the populous path algorithm by computer simulation. Counterconclusions to those of Tateno and Nei. Goodman et al.'s (1974) populous path algorithm for estimating hidden mutational change in protein evolution is designed to be used as an adjunct to the maximum parsimony method. When the algorithm is so used, the augmented maximum parsimony distances, far from being overestimates, are underestimates of the actual number of nucleotide substitutions which occur in Tateno and Nei's (1978) computer simulation by the Poisson process model, even when the simulation is carried out at two and a half times the sequence density. Although underestimates, our evidence shows that they are nevertheless more accurate than estimates obtained by a Poisson correction. In the maximum parsimony reconstruction, there is a bias towards overrepresenting the number of shared nucleotide identities between adjacent ancestral and descendant nodal sequences with the bias being stronger in those portions of the evolutionary tree sparser in sequence data. Because of this particular property of maximum parsimony reconstructed sequences, the conclusions of Tateno and Nei concerning the statistical properties of the populous path algorithm are invalid. We conclude that estimates of protein evolutionary rates by the maximum parsimony--populous path approach will become more accurate rather than less as larger numbers of closely related species are included in the analysis.


Missile emboli.

Missile emboli. Missile emboli remain unusual and challenging problems. Failure to recognize and adequately manage these uncommon lesions can result in loss of limb and/or life. No one individual or medical center has an extensive experience with missile emboli. An analysis of approximately 7,500 Vietnam casualties with known vascular trauma revealed an incidence of about 0.3%: 22 patients with missile emboli. The majority were associated with fragments from explosive devices and involved the arterial system. The missile emboli were removed in all but three patients. Only one patient had a vascular complication. There was no mortality or amputation in this series.


Delayed hypersensitivity and neutrophil chemotaxis: effect of trauma. To investigate alterations in host defense produced by trauma, skin testing with five standard recall antigens was done on admission and weekly on 53 patients with blunt trauma and seven with penetrating missile injuries, who then were classified as normal (N), 2 or more positive responses; relatively anergic (RA), one positive response; or anergic (A), no response. Neutrophil chemotaxis was tested 145 times in 32 patients. Degree of injury was assessed by assigning one point to pelvic fracture, long-bone fracture, head, chest, or abdominal injury, to a maximum of five. The A and RA patients had greater trauma, 3 vs. 1.6 for N, and a significantly increased rate of sepsis (p less than 0.005) and mortality (p less than 0.05). Incidence of anergy depended upon age and extent of trauma. Neutrophil chemotaxis in A and RA patients was significantly (p less than 0.001) worse at 96.7 +/- 2.4 mu and 99.8 +/- 1.7 mu compared to N, 113.2 +/- 1.7 mu, and controls 121 +/- 4 mu. With recovery, chemotaxis returned to normal. It is concluded that failure of delayed hypersensitivity responses follows trauma, is related to the severity of injury and age of patient, and is associated with an abnormality of neutrophil chemotaxis and increased rate of sepsis.


Hyperglucagonemia and hepatic ketogenesis in burned swine. A porcine burn model demonstrates hypoglycemia in spite of hyperglucagonemia. The ketone response to free fatty acids is defined for the normal and burned pig. Ketogenesis is augmented beyond that expected from free fatty acids during the postburn period. These metabolic changes may be related to the hyperglucagonemia and/or the relative hypoinsulinemia observed in the burned pig.


Behavioral contracting in a burn care facility: a strategy for patient participation. Behavioral contracting is a valuable tool for resolving persistent behavioral problems interfering with the treatment and recovery of severely burned patients. Coercive bidding of the patients for more control occurs in an environment where they experience extreme forms of loss of control and associated enforced regression. The ensuing conflicts between patient and staff often lead to breakdown in mutual cooperation, with deleterious effects on patient-staff morale. Staff experience highly ambivalent feelings toward a problem patient and may wish to withdraw from him, feeling threatened in their image of themselves as competent professionals. Beyond reducing disruptive conflicts on the ward, behavioral contracting aims to mobilize patient and staff around common and explicit goals, and to maximize patient cooperation and productive control in the recovery process. Contracts are valuable because: 1) they facilitate productive communication about issues which underlie patient-staff conflict; 2) they facilitate solutions to problem interactions between patients and staff; 3) they afford both patients and staff a sense or self-control. We provide a rationale for behavioral contracting and discuss the indications for initiating contracts with hospitalized burn patients, and describe methods for developing, implementing, and managing behavioral contracts in order to improve communication and effectiveness in patient-staff interactions.


Left ventricular pump failure associated with diffuse coagulation in experimental intraoperative autotransfusion. Autotransfusion of blood from the peritoneal cavity of pigs under a regimen of acid citrate dextrose solution 1:10 v/v for reservoir anticoagulation or systemic heparinization with 300 Iu/kg did not affect cardiac performance. Rapid deterioration of left ventricular pump performance was observed when low dose systemic heparin 100 Iu/kg was used. Evidence suggests that this is related to diffuse coagulation.


Ketamine anesthesia for tangenital excision of burn eschar: a burn unit procedure. The burn eschar is the major source of infection in the severely burned patient, and it hampers healing and prevents skin grafting. Tangenital excision has been shown to be safe for rapid removal of the eschar. For the last 14 months we have used this method beginning about 7 days postinjury. Our burn unit is composed of a four-bed, horizontal, laminar airflow isolation system, and transfer out of the sterile environment to the operating room would expose the patient to airborne contamination. Intramuscular ketamine anesthesia was used to allow major debridement to be carried out in the unit itself. Forty-five patients aged 18 months to 71 years have undergone 150 excisions in the burn unit under anesthesia with no complications. The burns ranged from 20 to 75% of body surface (mean, 40%). Because ketamine is a cardiorespiratory stimulant, ventilation and vital signs were well maintained. Psychological side effects of ketamine were minimal, particularly in the younger age group.


A simple radiologic aid in the diagnosis of small avulsion fractures of the knee. The diagnosis of knee injuries roentgenographically can present difficulties. Two illustrative cases demonstrate that simple medial and lateral oblique projections with standard radiographic techniques can contribute to increased detection of small avulsion fractures which can be missed on the standard radiographic projections.


Fracture of the distal radius with ulnar nerve palsy. A patient with immediate palsy of the ulnar nerve secondary to a distal fracture of the radius and possibly a dislocation of the distal radio-ulnar joint (Galeazzi's fracture) is described. Surgery demonstrated a serious contusion of the nerve, scarring around the nerve, and thrombosis of the ulnar artery. Symptoms rapidly disappeared after neurolysis.


Toxic agents resulting from the oxidative metabolism of steroid hormones and drugs. The oxidative metabolism of some exogenous compounds, and possibly some endogenous compounds as well, can lead to the formation of reactive metabolites. These intermediates react as electrophiles, and they lead in some instances to cell death or cell transformation. Three routes (other routes are also known) of toxicity are discussed. These are the epoxide/dihydrodiol pathway, the catechol/o-quinone pathway, and the alkylation pathway. The possible formation of electrophiles from diethylstilbestrol, from natural estrogens, and from ethynylestradiol is discussed in terms of protein binding. Protein binding is presumptive evidence of electrophile formation, but it does not necessarily indicate that the parent compound is highly cytotoxic, mutagenic, or carcinogenic. Mutagenic and carcinogenic activity is presumed to require reaction of an electrophile with nuclear material. There is evidence for protein binding for these estrogens (diethylstilbestrol, natural estrogens, ethnylestradiol) as a consequence of oxidative metabolism.


Bilateral diaphragmatic rupture due to blunt trauma--a rare injury. A young male patient with bilateral rupture of the diaphragm due to blunt trauma is presented. A separate tear occurred in each hemidiaphragm but recognition and repair of the right side was delayed. After healing of other injuries successful operation was performed 55 days postinjury by a transthoracic approach.


Replacement of serum in cell culture by hormones: a study of hormonal regulation of cell growth and specific gene expression. The hypothesis that the growth of mammalian cells is regulated by hormones is now supported by considerable evidence. Two rat pituitary cell lines, GH3 and GC, a mouse melanoma, M2R (B16), and a human cervical carcinoma cell, HeLa S-3, have been grown indefinitely in serum-free (SF) hormone-supplemented medium. No visible changes of growth characteristics were observed in the cells grown continuously in the SF condition. However, changes in the activity of a plasma membrane enzyme, alkaline phosphatase, and in the relative intensity of surface proteins that are labeled by the [125I] lactoperoxidase technique were found in HeLa cells grown in the SF condition. To study the role of hormones required in the regulation of cell growth, HeLa cells were grown in the absence of one of the required hormones. The following results were obtained. Epidermal growth factor is probably involved in the regulation of the synthesis of macromolecules such as RNA and of the protein content per cell. Transferrin, the accessory factor in the SF condition, supplies iron for cells. The two basic peptides in this SF system, fibroblast growth factor and insulin, are probably involved in the balance of nutrients and energy inside the cell. The replacement of F12 medium with a better-balanced medium, MCDB 105, can mimic the requirements for these two peptides. The steroid hydrocortisone (HC) is probably involved in alteration of the cell surface. This is indicated by the effects of HC on cell morphology, rate of detachment from the dish, and the pattern of [125I] lactoperoxidase labeling of surface proteins. In addition, it is necessary to change the medium more frequently to maintain the culture in the medium without HC. This observation suggests that HC may be involved in the control of homeostatic properties of the cell surface. The production of rat prolactin by GH3 cells was also studied. GH3 cells in the SF condition produce 1.6 microgram prolactin per 10(5) cells in 24 h, while 2.4 microgram is produced in the presence of serum. Prolactin production in the SF condition is enhanced by the presence of thyrotropin-releasing hormone and inhibited by triiodothyronine (T3). T3 is the major growth factor for these cells. Without it cell growth is severely limited, while prolactin production is elevated. This result suggests that the GH3 cell line in the SF condition may be an ideal system for the study of hormonal regulation of cell growth and specific gene expression.


Traumatic false aneurysm of the hand in hemophilia. An unusual case of traumatic false aneurysm following a puncture wound in the hand of a hemophiliac, despite Factor VIII replacement, demonstrates the necessity for careful evaluation of such patients when there is profuse and continued bleeding. Following surgical repair of the false aneurysm and the ulnar proper digital nerve of the thumb 17 days postinjury the patient had an uncomplicated recovery. Partial arterial laceration, the underlying pathology of this lesion, may be demonstrated by arteriography or surgical exploration.


Post-traumatic meralgia paresthetica--an unusual presentation. A case of meralgia paresthetica with severe skin reaction following trauma to the anterolateral aspect of the thigh is presented. Relief of the patients' symptoms was achieved by neurolysis of the lateral femoral cutaneous nerve.


Traumatic dislocation of the radial head in a 5-year-old boy: case report. A case report of anterior traumatic dislocation of the radial head in a 5-year-old boy without evident injury of the ulna is presented. Reduction and immobilization in flexion and supination in a plaster cast for 2 weeks were carried out. After 2 years the final result is satisfactory and there is no difference between the injured and normal forearms.


The pathophysiology of the anterior tibial compartment syndrome: an experimental investigation. In an experimental study in dogs of the anterior tibial compartment syndrome, three measurements were taken before, during, and following raising pressure in the compartment: blood flow, muscle function, and peroneal nerve conduction. If fasciotomy was performed within 4 hours, peroneal nerve conduction velocity always returned to normal regardless of amount of pressure or length of time pressure was applied; if performed after 12 hours peroneal nerve conduction velocity did not return to normal at any pressure or time condition, suggesting that irreversible damage to the nerve had occurred. Blood flow, as measured by rate of clearance of Xe133, always returned to normal within 2 hours of fasciotomy regardless of the time postinjury or amount of pressure applied. Muscle function (CPK and LDH) did not always return to baseline with fasciotomy and in some instances the absolute values were higher after fasciotomy. Further clinical studies using these measurements are recommended.


Prehospital advanced emergency care: a potential pitfall. Effective prehospital treatment of the severely injured and acutely ill by an Advanced Emergency Care system may change symptoms and signs by the time patients arrive at the hospital. To provide optimal care, physicians must appreciate the capabilities and limitations of the EMT-paramedic. The EMT-paramedic must report verbally and via written record the course of prehospital events. Cardiac rhythms must be documented for review. It should be the responsibility of the medical directors of such Advanced Emergency Care systems to provide supervision, refresher training, critiques, and evaluation, to establish medical responsibility and credibility.


Computerized drug dosing in renal failure: a real problem and a practical solution. In the presence of impaired renal function a number of pharmacologic agents require dose adjustments to avoid toxicity. Physician dose variations of a wide range of pharmaceuticals, 237 orders for 30 drugs for 107 patients, were compared to doses recommended by a computer program which considers renal function in calculating its dose. Disagreement in dose regimens was evaluated by comparison of physician-dose to computer-dose for three classes of drugs: wide range, narrow range, and 80% renally excreted. With true renal impairment (serum creatinine greater than or equal to 1.2 mg/100 ml and creatinine clearance less than 80 ml/m) significant overdosing occurred for narrow range and 80% renally-excreted agents, 83 and 77% respectively. There is a great potential hazard observed to be avoided. It is recommended that dose adjustments for nephrotoxic or renally-excreted agents be implemented using creatinine clearance (estimated or measured) with, at the very least, manufacturer's recommendations.


Resistant Enterobacter cloacae in a burn center: the ineffectiveness of silver sulfadiazine. Enterobacter cloacae sepsis was found in 15 burn center patients in 1976, of whom 13 died. Nine of the deaths occurred in the first 60 days. The Burn Center isolates were resistant to silver sulfadiazine (AgSD) in agar cup-plate tests and confirmed by tube dilution tests. Hospital, non-burn isolates of E. cloacae were sensitive to AgSD. All E. cloacae isolates were sensitive to mafenide acetate (MA) in the agar cup-plate tests, but this was not confirmed by the tube dilution tests. The agar cup-plate susceptibility test is a simple, rapid and effective technique for determining resistant and sensitive isolates of E. cloacae. Patients who were changed from AgSD to MA because of resistant E. cloacae infection did not have improved survival. An animal study showed that AgSD was ineffective against this strain of E. cloacae and that MA was more effective than AgSD when applied 24 hr postburn but neither were effective at 48 hr postburn. MA was bacteriostatic but not bactericidal with this E. cloacae strain.


Arterial trauma involving the lower limb. Experience with 105 lower limb arterial injuries in 103 patients in a general hospital is described. The pathology is discussed: it is noted that spasm per se could not be incriminated as a cause of ischemia. Management of the injuries and associated fractures is outlined. A plea is made for use of external fixation in compound injuries. An aggressive approach to the degloved limb, open three-compartment fasiotomy for severe vascular injury with signs of ischemia, and delayed primary closure for wounds with septic complications are recommended. Associated soft-tissue injury requires arterial reconstruction even in the presence of muscle rigor and anesthesia.


Missed, maluniting, and malunited fractures of the lateral humeral condyle in children. Five cases of fracture of the lateral humeral condyle in children are described to illustrate the importance of recognition and proper management of this injury. The cases represent different degrees of severity of this injury. Failure of recognition of this fracture leads to serious late complications. Management of missed and maluniting fractures is discussed. It is our practice to internally fix these injuries.


Effects of 1alpha-hydroxycholecalciferol on osteoporotic changes induced by calcium deficiency in bone fractures in adult rats. Adult male rats maintained on a low calcium intake during 6 weeks prefracture developed osteoporotic changes of the tibia fracture during a healing period of another 6 weeks. Treatment based on combined use of daily peroral doses of 1alpha- hydroxycholecalciferol and an optimal calcium intake reversed the osteoporotic changes in the fractured tibia after only 2 weeks, and the act of reversion became still more pronounced after 4-6 weeks. 1alpha-hydroxycholecalciferol treatment is recorded, when supported by an optimal calcium intake, to positively influence the levels of serum calcium, dry weight, and total ash content as specific weight and cortical thickness of the fractured tibia, following experimental fractures.


Autotransfusion of contaminated intraperitoneal blood: an experimental study. Contamination of blood by bowel contents has been generally assumed as an absolute contraindication to autotransfusion. Since abdominal trauma is frequently accompanied by bowel injury and massive blood loss, a potential major use for autotransfusion has thus been precluded. To test this presumption, autologous blood grossly contaminated with feces was incubated in the peritoneal cavity and then autotransfused in dogs. The animals were hemorrhaged 20, 30, or 40% of their estimated blood volume, producing mild to severe hypovolemic shock. Reinfusion of contaminated blood had little effect on survival with 20 or 30% hemorrhage, but contamination markedly decreased survival with 40% hemorrhage:90% survived without contamination while only 30% survived with contamination. The use of antibiotics in a similar group of dogs subjected to 40% hemorrhage essentially eliminated the risk of autotransfusion: 90% of these dogs survived autotransfusion of contaminated blood.


Fatal peritonitis after massive blood transfusion: case report. A case is presented in which successful repair of a superior vena cava gunshot wound was followed by death due to peritonitis. A mild case of endometritis progressed to generalized peritonitis after the patient's immune defenses were compromised by massive transfusion of banked blood. Clinicopathologic correlation is provided.


Brachial artery disruption following closed elbow dislocation. Although elbow dislocation occurs frequently, associated brachial artery injury is rare. Adequate treatment of this injury includes prompt arteriography, reduction of the dislocation, vascular repair, and transarticular fixation of the reduction. A case report and review of the literature are presented.


Retrosternal dislocation of the clavicle producing thoracic outlet syndrome. Following traumatic retrosternal dislocation of the clavicle, the patient presented with thoracic outlet syndrome 6 months postinjury with swelling and cyanosis of the right upper extremity, and cramps of the right arm and forearm after heavy manual work. When open reduction of the dislocated clavicle failed, the medial half of the clavicle was resected. Four years postoperation, the patient is doing well, and is asymptomatic. A review of the literature, anatomy, mode of injury, mechanism of injury, pathology, clinical picture, diagnosis and treatment are discussed.


Disruption of a normal aortic valve as a result of blunt chest trauma. Many cardiac lesions may result from nonpenetrating chest trauma. Myocardial contusions and lacerations are most common. Isolated valvular lesions are rare. The most common of these, in surviving patients, is aortic valve disruption (12). The course and management of a patient with a torn aortic valve as a result of nonpenetrating trauma are presented. Surgical replacement (porcine) of the valve and stabilization of the fractured sternum were followed by full recovery at 7 months postinjury.


Oxygen consumption from fresh versus 21-day-old ACD whole blood. The oxygen delivery capacity of fresh whole blood was compared with that of 21-day-old blood in an isolated, perfused canine hindlimb preparation. At the outset, 21-day-old blood was found to have depressed levels of 2,3 DPG and higher p50's relative to those of freshly procured blood, implying an increased oxygen affinity of the former product. Despite this, oxygen consumption from 21-day-old blood was not demonstrated to be significantly different than that from fresh blood. It is concluded that significant improvement in oxygen delivery capacity alone should not be construed as justification for the choice of fresh over older blood clinical replacement therapy.


Intravenous pyelography in abdominal trauma. The present report is a retrospective review of 23 patients admitted to the University of Kentucky Medical Center during 1975 and 1976, selected because they had sustained renal trauma as ascertained by hematuria, intravenous pyelography (IVP), or operative intervention. The value of IVP was determined by the patients' eventual hospital course. Of five patients with penetrating injuries, all had hematuria and an intravenous pyelogram on admission. One of these patients did not require an operation. Among the 18 patients with blunt abdominal trauma, six of the 14 patients who had hematuria and an IVP on admission were spared operation. Four patients did not have hematuria, but all four had a renal lesion. Two of these patients required an operation: one for inspection of a traumatic left nephrectomy; the other for bilateral renal artery occlusion, successfully repaired after 16 hours. Whenever feasible all patients sustaining abdominal trauma should have an IVP regardless of whether or not hematuria is present.


Surgical restraint in the management of hepatic injury: a review of Charity Hospital Experience. We have reviewed 546 cases of hepatic trauma treated from 1964 through 1976: 76 patients with blunt injury, 308 with gunshot wounds, and 162 with stab wounds. Hypovolemic shock was present in 22%. The overall mortality was 10%. Stab wounds had a negligible mortality of 0.6%, whereas 12% of patients with gunshots and 28% of patients with blunt trauma died. Management followed the general principles of control of hemorrhage and conservative debridement with avoidance of major procedures. Eighty-four per cent of patients required only drainage or suture and drainage. Only 8% had extensive debridement. An additional 5% (31 patients) underwent hepatic lobectomy. Hepatic artery ligation, as an isolated procedure, was not employed. Common bile duct cannulation was employed only six times. Mortality among patients treated by suture or drainage was 5.4%. When resection was required, a 52% mortality resulted. We conclude that the principles of conservative surgical treatment can give a satisfactory survival rate in most hepatic trauma.


Factors associated with deaths of burned patients in a community hospital. In a study of 310 burned patients, 27 of whom died, treated during a recent 3-year period, we have found that the following factors contributed to mortality: severity of the burn injury, advanced age of patients, race of the patients, cause of the burns, pre-existing medical problems, inadequate or inappropriate early resuscitative measures, and possible errors or oversights in the management of a few patients. Whether the patients were treated by general or plastic surgeons and whether the patients were "staff" or "private" appeared to have no significant bearing on survival or mortality. Death rates for the sexes were approximately equal. Deaths of patients who survived the immediate postburn period resulted mainly from pulmonary failure, renal failure, sepsis, and cardiac failure or from various combinations of these factors.


Portal venous system injuries.

Portal venous system injuries. Traumatic injuries of the portal venous circulation occur infrequently but often pose management problems. During the past 13 years, 94 patients have been treated at the Ben Taub General Hospital for traumatic injury to the portal venous system, including 37 portal, 45 superior mesenteric, seven splenic, and nine inferior mesenteric venous injuries. Injury resulted from penetrating wounds in all but 17 patients. Associated vascular injuries were present in 80 patients. Twenty-six patients died from failure to control hemorrhage. Six deaths resulted from postoperative complications. Operative approach necessitated lateral venorrhaphy in 66 patients, ligation in 23, end-to-end anastomosis in one, saphenous vein mesocaval shunt in two, end-to-side portacaval shunt in one, and clamping and packing in five. In spite of numerous associated vascular and visceral injuries, portal venous injuries can be successfully managed utilizing generally available vascular reconstructive techniques.


The use of microscopy as a guide to primary excision of high-tension electrical burns. High-tension electrical burns sustained by 44 patients were of two types: one is caused by the intense heat of contact with an electric arc, and in the other flow of current against resistance of the deep tissues between arc wounds of entrance and exit produces deep thermal destruction. Microscopic studies in nine patients support the conclusions that such high-tension burns are thermal injuries, that the tissue destruction is not uniform, and that the slow evolution of unexcised wound reflects the admixture of areas of varying tissue viability which may become infected. An aggressive surgical approach designed to minimize tissue loss, avoid infection, and close wounds as early as possible was guided by intraoperative and later microscopic determinations of tissue viability. Despite a high amputation rate in our patients, it was avoided in the upper extremity in three patients, and maximal length of extremities was preserved in seven others. The use of microscopic analysis is recommended to determine the viability of tissues in thermal burns.


Disseminated intravascular multiple systems activation (DIMSA) following thermal injury. Seventy-seven major thermal injury victims were studied with a number of hematologic and immunologic tests initially and sequentially during the first postburn month. The patients were grouped by initial prognostic index as well as by ultimate survival. Pairs were grouped by initial prognostic index as well as by ultimate survival. Pairs of test data from subjects studied at successive time intervals were compared with prognostic index and ultimate survival. Statistically significant changes in coagulation, fibrinolytic, complement, and kinin tests all occurred within these groups. These findings strongly suggest that intravascular contamination occurs following thermal injury in proportion to the extent of the burn, because of the occurrence and persistence of statistically significant multiple system changes. Regrouping all of the blood data according to ultimate death or survival reinforced the concept of intravascular contamination and provided the basis by which one can compute laboratory prognostic indices. The combination of plasminogen, C'3 complement, C'H50, one-minute kinin, and TEG index discriminated between death and survival with 91% accuracy by the end of the first postburn week. These data offer the potential for select blood measurements in refining current prognostic indicators. This may provide an objective data base for the analysis of new treatment programs in thermal injury victims.


The effects of cortisone on liver blood flow in experimental hemorrhagic shock: using a new simplified radioisotope clearance method to measure liver blood flow. Liver blood flow was measured in the dog under control and hemorrhagic shock conditions by the 133Xe clearance method. 133Xe was administered first into the portal vein and its clearance from the liver recorded, and then directly into the liver tissue and another clearance curve was obtained. The resuts were compared. We have also investigated the effects of corticosteroids, given in pharmacologic doses, on liver blood flow in hemorrhagic shock. We have shown that the difference between the results of tissue injection and those of portal injection of 133Xe was not significant (p greater than 1.10). Hemodynamic studies indicated that the liver blood flow is decreased, the liver venous resistance and portal venous pressures are increased in dogs in hemorrhagic shock, and that hydrocortisone, with the blood pressure and the bleedout volume held constant in the experimental model, lowers the liver venous resistance and raises the liver blood flow significantly (p less than 0.05) at various stages of hemorrhagic shock.


Myocardial conducting system dysfunctions from thoracic impact. An analysis of electrocardiograms (ECG lead II) obtained following blunt thoracic impacts conducted on 12 anesthetized pigs indicated that all animals developed some degree of trauma to the heart conducting system: sino-atrial nodal disturbances, atrio-ventricular junctional dysfunction, intraventricular conduction defects (e.g., bundle branch blocks), or ventricular fibrillation. The induced ventricular fibrillation proceeded rapidly to the demise of four animals in this study. A comparison of the occurrence of ventricular fibrillation with measured biomechanical response parameters indicated a significant correlation of ventricular dysfunction with high levels of sternal acceleration (930 g) and impact velocity (10.7 m/s). The initiation of ventricular fibrillation did not correlate with typical biomechanical thoracic injury "indicators" (i.i., level of normalized thoracic deflection, cumulative AIS, peak spinal acceleration, or applied force). An injury severity classification (MCD) was subsequently developed for the evaluation of myocardial conducting system dysfunctions.


Evaluation of technetium scanning for myocardial contusion. Myocardial contusion is a serious problem not easily diagnosed. Laboratory and clinical studies carried out on myocardial infarction suggested that Technetium scanning might clarify this diagnostic dilemma. Radionuclide imaging with Technetium was carried out in 29 patients suspected of having myocardial contusion. Of 13 patients in whom contusion was confirmed electrocardiographically, scan was positive in only two. Use of the technique in diagnosis of myocardial contusion is not recommended.


The "swallowed bullet" syndrome.

The "swallowed bullet" syndrome. A unique case is reported in which a bullet, after entering the maxillary antrum, penetrated the hard palate, was deflected into the esophagus where it struck the cervical spine, and then passed uneventfully through the gastrointestinal tract.


Post-traumatic radio-ulnar synostosis.

Post-traumatic radio-ulnar synostosis. Five years after an untreated ulnar fracture, a young man seen with no active or passive forearm rotation was found to have a radio-ulnar synostosis, which was surgically excised with interposition of a silicone membrane and soft tissue to decrease any tendency for new formation of the synostosis.


Avulsion injury to the renal pedicle: successful autotransplantation after "bench surgery". Avulsion injury to the renal pedicle from blunt trauma is a common injury in children. We report a patient who survived this injury with successful reimplantation of the kidney after bench surgery to trim the vessels and the ureter. The function of this kidney is somewhat impaired and shows posttraumatic scarring 19 months post-surgery. This appears to be the first report of such a patient in the literature.


Superior mesenteric artery injury following blunt abdominal trauma: case report with successful primary repair. A case of blunt abdominal trauma causing injury to the superior mesenteric artery with successful management is presented. The role of aortography in diagnosis is discussed. The patient, with multiple chest injuries sustained in an automobile accident, has recovered following surgical repair of a laceration of the SMA, treatment for respiratory distress, and spontaneous cessation of rectal diverticular bleeding.


Some clinical characteristics of children with paralytic poliomyelitis referred for physiotherapy. One hundred and fifty-two case records of poliomyelitis children were studied to examine the clinical characteristics of the patients. They were the random first 152 cases referred and hence constituted a representative study. The results showed that there was a preponderance of males in the data. The highest incidence was among children in the 13-24 month age group. Eighty-eight per cent of the children suffered from paralysis of the lower limb while 11.3 per cent suffered from involvement of the upper limb. Twenty-nine per cent of the patients demonstrated flexion/abduction deformity of the hip while 52.6 per cent showed foot drop resulting from tibialis anterior paralysis. Of the children studied 3.9 per cent came from the upper social class while 96.1 per cent came from the lower social class.


African histoplasmosis of the jejunum. Report of a case. A case of histoplasmosis of the jejunum is presented. This is apparently the first reported case of African histoplasmosis primarily affecting the jejunum. Grossly, there was stricture formation together with tubercles scattered over the surface of the bowel and adjoining mesentery. Also the mesenteric lymphnodes were enlarged. It is therefore difficult to distinguish jejunal histoplasmosis from tuberculosis, carcinoma and lymphoma of the jejunum and diagnosis can only be based on the demonstration of the characteristic yeast cells from the specimen.


Observation on haematological patterns in pulmonary tuberculosis in Nigerians. Twenty-one cases of pulmonary tuberculosis seen in the last two years in the chest clinic of the University College Hospital, Ibadan were studied for their haematological patterns at diagnosis and three months after. One group was put on anti-tuberculosis drugs only while the other group was put on anti-tuberculosis drugs and oral iron. The haematological results after 3 months show a significant rise in packed cell volume (PCV) less than 0.01 in the group given oral suppliments. Megaloblastic bone marrow changes occurred in 20 per cent of the patients after 3 months. Seventy-five per cent of the patients had myeloid hyperplasia of the bone marrow at diagnosis and only one of the patients had hypoplastic marrow. It is suggested that oral iron and folate be added to anti-tuberculosis therapy in these patients as part of their management.


Study of otitis media and malaria among pyrexic attender of an under-fives clinic. All 138 children attending two under-five clinics with a rectal temperature of 100 degrees F or over had their ears examined and a blood film taken for malaria parasites. Twenty-eight per cent were found to have otitis media and 37 per cent to have malaria. No symptom was found to be sufficiently discriminating for a diagnosis to be made on history alone in either condition.


Reversible portal hypertension in amoebic liver abscess: a case report. A fifty eight year old male patient, with an amoebic liver abscess showed reversal of portal hypertension demonstrated by radiological and endoscopic evidence of oesophageal varices, on successful treatment of abscess. This appears to be the first report of reversible oesophageal varices in amoebic liver abscess. The relevant features have been discussed with reference to available literature on the subject.


Unusual presentation of primary amoebic meningoencephalitis--a serious diagnostic and therapeutic problem. A fatal case of meningo-encephalitis due to Amoeba naegleria is discussed. It was a problem for diagnosis because of its unusual presentation. The patient, a young pregnant female presented with pyrexia, severe headache, and photophobia. Anti-biotic therapy was started after a provisional diagnosis of acute pyogenic meningitis had been made. There was no response to antibiotic therapy. Facial nerve palsy and abnormal activity in the left centro-temporal region in the EEG was observed and suspicion of an intra-cranial space occupying lesion was entertained. Carotid angiography and ventriculography, however, showed no abnormality. Repeat cerebrospinal fluid examination revealed motile amoebae. The patient, however, died shortly afterwards. This case is documented for its atypical clinical presentation and therapeutic problems.


Prevalence of coronary heart disease in Pakistani patients suffering from maturity onset diabetes mellitus. In a group of 500 ambulant Pakistani patients suffering from diabetes mellitus, electrocardiographic evidence of coronary heart disease was present in 45 (9%). The frequency was higher in the males (12.1%) as compared to females (7.2%). The male diabetics with coronary heart disease had significantly high mean serum cholesterol values as compared to those without it. A positive family history of ischaemic heart disease, and the presence of small vessel disease as well as hypertension were more frequently associated with coronary heart disease. The overall frequency of hypertension was 21.2 per cent in this group of diabetics.


UV-induced mutation in bacteriophage T4. Two late gene am mutants of bacteriophage T4 that can be induced to revert by UV were crossed to a temperature-sensitive ligase mutant. In the double mutants, UV-induced reversion was eliminated at a semirestrictive temperature. When the single am mutants were irradiated and then allowed a single passage in a permissive host, the UV-induced reversion frequency was increased by 15- to 25-fold. This increased mutagenesis was also abolished by the presence of the ligase allele. When the UV-irradiated single am mutants multiply infected a permissive host, allowing multiplicity reactivation to occur, the induced reversion frequency was reduced similarly to the reduction in lethality. The mutagenesis that remained was again abolished by the presence of the ligase allele. It is concluded that UV induces mutations in phage T4 through the action of a pathway that includes polynucleotide ligase. The increase in mutation frequency after growth in a permissive host implies that mutagenesis can occur at more than one stage of the infection rather than only in an early stage before expression of the mutant genome. The process of multiplicity reactivation appears to be error-free since it overcomes lethal lesions without inducing new mutations.


Temperature-sensitive mutant of adenovirus type 2 blocked in virion assembly: accumulation of light intermediate particles. A temperature-sensitive mutant of human adenovirus type 2, ts112, was isolated and characterized, ts112 was blocked in a late function required for virus maturation. At restrictive temperature, it accumulated light precursor particles that were able to mature into infectious virions upon temperature shift-down. Use of a mild extraction procedure and a reversible fixation by a cleavable diimido ester permitted the isolation and analysis of these labile intermediates in the adenovirus assembly. These accumulated particles had a sedimentation coefficient of about 600S and a buoyant density of 1.315 g/cm3 in CsCl. They contained a DNA fragment of 7--11S and two nonvirion proteins having molecular weights of 50,000 (50K) and 39.000 (39K), respectively. They resembled in composition and morphology the light intermediate particles found in wild-type adenovirus 2, which were identified as precursors of heavy intermediates, preceding the young virions. The ts112 lesion was apparently located at the exit of either the 50K and/or 39K proteins and at the entry of viral DNA.


Adenovirus type 2 assembly analyzed by reversible cross-linking of labile intermediates. Dimethyl-4,4'-dithiobisbutyrimidate dihydrochloride was used as a cleavable cross-linking reagent to maintain the structure of labile intermediates in adenovirus type 2 assembly. Analysis on sucrose gradients of nuclear adenovirus particles revealed two size classes, with sedimentation rates of 750 and 600S. After reversible fixation with diimido ester, the different classes were further separated on CsCl gradients and characterized with regard to their buoyant density, DNA content, and polypeptide composition. The 750S particles banded at 1.345 g/cm3 in CsCl, contained a DNA with a sedimentation coefficient of 34S in alkaline sucrose gradients, and had a polypeptide composition similar to that of young virions. The 600S population consisted of two types of particles with buoyant densities of 1.315 and 1.37 g/cm3. The 1.315-g/cm3 particles contained a DNA fragment of 7--11S and lacked the core proteins V and VII. In their place were found precursors P VI and P VIII and two nonvirion proteins with molecular weights of 50,000 (50K) and 39,000 (39K). 34S DNA was present in the 1.37-g/cm3 particles, which also lacked core proteins V and VII, as well as the 50K and 39K. Pulse-chase labeling kinetics suggested that the 1.315-g/cm3 particles were anterior to the 1.37-g/cm3 particles, themselves preceding the 1.345-g/cm3 young virions, and that the release of both 50K and 39K, possible scaffolding proteins, was required for entry of viral DNA.


Head maturation pathway of bacteriophages T4 and T2. IV. In vitro transformation of T4 head-related particles produced by mutants in gene 17 to capsid-like structures. T4 mutants in gene 17 accumulate particles which contain the main head protein in the cleaved form (gp23*) arranged in an unexpanded lattice (empty small particles), together with other expanded capsids (empty large particles). The isolated empty small particles can be transformed in vitro, by lowering the ionic strength, to capsid-like structures. This structural transformaton is not coupled to chemical modification of the structural proteins of the empty small particles. In contrast to unexpanded particles that are easily dissociated, the transformed structures are as resistant to dissociation as other T-even head-related particles with expanded lattice. Furthermore, the transformed particles are able to bind in vitro hoc and soc proteins, rendering capsids indistinguishable from the normal T4 capsids both morphologically and by their stability against denaturing agents. Our results indicate that the in vitro transformation of the empty small particles might mimic important and characteristic aspects of the in vivo maturation of T4 heads, thus suggesting a possible role of the "cleaved but unexpanded" particle in the maturation pathway of the T4 shell.


Purification of the influenza hemagglutinin glycoprotein and characterization of its carbohydrate components. Hemagglutinin from influenza A/PR8 virus was purified after treatment of the virus with sodium deoxycholate followed by extraction with tri-n-butyl phosphate. This fully disrupted the virus while preserving hemagglutinating activity. The hemagglutinin was obtained in the form of small aggregates that could be separated from other viral components. Purified hemagglutinin was hydrolyzed to determine carbohydrate composition and digested with Pronase to analyze oligosaccharide structures. Sugars present in the hemagglutinin were galactose, mannose, fucose, and glucosamine in molar rates of about 6:11:2:5, and these comprised 16% of the hemagglutinin glycoprotein. Oligosaccharides obtained from virus included a major component of a molecular weight of 2,800, composed of glucosamine, galactose, mannose, and fucose, and a minor heterogenous component of a molecular weight of 1,500 to 2,000, containing predominantly mannose. The 2,800-molecular-weight oligosaccharide was a constituent of the hemagglutinin, and treatment of this large oligosaccharide with specific exo-glycosidases demonstrated the presence of terminal galactose and fucose and allowed the deduction of a general structure for this component.


Size analysis and relationship of murine leukemia virus-specific mRNA's: evidence for transposition of sequences during synthesis and processing of subgenomic mRNA. Virus-specific mRNA from purified polyribosomes of mouse cells infected with Moloney murine leukemia virus (M-MuLV) was analyzed by electrophoresis in agarose gels, followed by hybridization of gel slices with M-MuLV-specific complementary DNA (cDNA). The size resolution of the gels was better than that of sucrose gradients used in previous analyses, and two virus-specific mRNA's of 38S and 24S were detected. The 24S virus-specific mRNA is predominantly derived from the 3' half of the M-MuLV genome, since cDNAgag(pol) (complementary to the 5' half of the M-MuLV genome) could not efficiently anneal with this mRNA. However, sequences complementary to cDNA synthesized from the extreme 5' end of M-MuLV 38S RNA (cDNA 5') are present in the 24S virus-specific mRNA, since cDNA 5' (130 nucleotides) efficiently annealed with this mRNA. The annealing of cDNA 5' was not due to repetition of 5' terminal nucleotide sequences at the 3' end of M-MuLV 38S RNA, since smaller cDNA 5' molecules (60 to 70 nucleotides), which likely lack the terminal repetition, also efficiently annealed with the 24S mRNA. The sequences in 24S virus-specific mRNA recognized by cDNA 5' are not present in 3' fragments of virion RNA that are the same length. Therefore, it appears that RNA sequences from the extreme 5' end of the M-MuLV genome may be transposed to sequences from the 3' half of the M-MuLV 38S RNA during synthesis and processing of the 24S virus-specific mRNA. These results may indicate a phenomenon similar to the RNA splicing processes that occur during synthesis of adenovirus and papovavirus mRNA's.


Virion RNA species of the arenaviruses Pichinde, Tacaribe, and Tamiami. The principal RNA species isolated from labeled preparations of the arenavirus Pichinde usually include a large viral RNA species L (apparent molecular weight = 3.2 X 10(6)), and a smaller viral RNA species S (apparent molecular weight = 1.6 X 10(6)). In addition, either little or considerable quantities of 28S rRNA as well as 18S rRNA can also be obtained in virus extracts, depending on the virus stock and growth conditions used to generate virus preparations. Similar RNA species have been identified in RNA extracted from Tacaribe and Tamiami arenavirus preparations. Oligonucleotide fingerprint analyses have confirmed the host ribosomal origin of the 28S and 18S species. Such analyses have also indicated that the Pichinde viral L and S RNA species each contain unique nucleotide sequences. Viral RNA preparations isolated by conventional phenol-sodium dodecyl sulfate extraction often have much of their L and S RNA species in the form of aggregates as visualized by either electron microscopy or oligonucleotide fingerprinting of material recovered from the top of gels (run by using undenatured RNA preparations). Circular and linear RNA forms have also been seen in electron micrographs of undenatured RNA preparations, although denatured viral RNA preparations have yielded mostly linear RNA species with few RNA aggregates or circular forms.


Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature. Manifestations of xanthogranulomatous pyelonephritis in 26 patients closely mimicked those of neoplastic and other inflammatory renal parenchymal diseases. Middle-aged or older women were affected most often. Most patients presented with anemia, chronic febrile illness, a painful tender flank mass and recurrent urosepsis. Some features of nephrogenic hepatic dysfunction were present in 13 patients. Bacterial cultures of renal tissue were almost always positive but the spectrum differed considerably from that of the bladder urine. Urographically, a renal mass lesion was encountered in 62% of the patients, nephrolithiasis in 38% and a functionless kidney in 27%. Angiographically, none of the 4 mass lesions studied was distinguished from hypernephroma. Indeed, a correct preoperative diagnosis was made in only 1 instance. There were 3 stages of xanthogranulomatous pyelonephritis recognized. Treatment consisted of nephrectomy for diffuse or advanced stage disease or both (21 patients), excision of the diseased renal segment for localized and low stage disease (2 patients) and renal biopsy (3 patients). Xanthogranulomatous pyelonephritis did not recur but in some patients bacteriuria continued or hypertension developed.


Transitional cell carcinoma of the kidney 25-year experience. Seventy patients with transitional cell carcinoma of the kidney operated upon at Barnes Hospital during the last 25 years are reviewed. The relationship of the pathologic stage, grade, findings on excretory urography and survival is studied. The stage and survival rates were predicted fairly accurately on the basis of the excretory urogram alone. Survival of patients was determined occasionally by the status of the associated bladder tumors more than by the renal cancer. Because of tumor multiplicity we recommend total nephroureterectomy as the treatment of choice. The role of radiation therapy is considered.


A preliminary study of chemotherapeutic treatment for bladder tumors. Our objective was to develop new methods of chemotherapeutic treatment for bladder tumors. Once or twice a week under cystoscopy 10 to 20 mg, doxorubicin hydrochloride were administered directly into the tumors. This procedure was repeated until the size of the tumors was reduced or had disappeared completely under cystoscopic study. A new type of flexible needle was fabricated for this purpose. In 9 patients studied the total success rate was 78%. No significant side effects were seen in any of the patients.


Perineal-abdominal cystourethrectomy with pelvic node dissection: a new 2-stage procedure for selected cases. An ileal conduit diversion followed 7 to 14 days later by cystourethrectomy with pelvic node dissection was done on 20 patients with carcinoma of the bladder. Two types of patients were selected for this operation: 1) those with an advanced stage of carcinoma involving the bladder neck, prostatic urethra or prostate, primarily cases suspected of having focal metastatic disease in the urethra, and 2) patients who had had a previous pelvic operation with resultant dense adhesions and scarring. The cystourethrectomy with pelvic node dissection is begun perineally. After the specimen, consisting of the urethra, part of the urogenital diaphragm, seminal vesicles, prostate and bladder is dissected, mobilized and, finally, pushed into the pelvis the perineum is closed and the operation is completed abdominanlly through a Pfannenstiel incision.


Selection of an operation in the management of 155 cases of urethral strictures in male subjects. A method is described for the selection of an appropriate operation in the repair of 155 male urethral strictures. A brief outline of the important aspects of the operation is presented. The patients have been followed 2 to 4 years postoperatively.


The management of priapism in sickle cell anemia. After assessing the data currently available on the multiple modalities used to manage priapism secondary to sickle cell disease we adopted a specific therapeutic regimen for the treatment of this problem. Early non-surgical measures, including hydration, alkalization and analgesics, rapid red cell infusion to double the hematocrit and late shunting procedures in conjunction with exchange transfusion, offer the soundest approach on pathophysiological grounds. There is currently no evidence to support early surgical intervention as the best approach to conserve potency in this problem.


Differences in pathological characteristics and prognosis of clinical A2 prostatic cancer from A1 and B disease. A retrospective study was done of 53 cases of clinical stages A1 to B2 prostatic carcinomas staged by pelvic lymphadenectomy. The study compared the histologic differentiation, degree of lymphocytic infiltration, incidence of lymph node metastases and type of cellular response of clinical stage A2 to stages A1 and B disease. The available data pertaining to the incidence and survival of patients with stage A2 prostatic carcinoma were analyzed. Our study indicates that 1 of every 3 unsuspected carcinomas is of clinical stage A2. The stage A2 tumors are diffused, with a higher degree of undifferentiation and a higher incidence of lymph node metastases than tumors classified clinically as stages A1 and B1. Also the survival of patients with clinical stage A2 tumors is lower than the survival of patients with clinical stage B1 disease. Clinical stage A2 tumors are more advanced biologically than clinical stage B1 tumors.


Sandwich therapy in testis tumor: current experience. Sandwich therapy, a regimen of lymphadenectomy combined with preoperative and postoperative cobalt teletherapy, yielded a survival rate of 84% in 13 patients with stages A and B non-seminomatous testis tumor. This statistic is consistent with the previously reported survival rate of 83% achieved among 35 patients treated with this regimen from 1958 to 1970 at our institution. Bone marrow depression, retroperitoneal fibrosis and possible induction of a second malignancy were important side effects of radiation therapy. The superior survival rates with fewer severe side effects of treatment obtained by other investigators using either lymphadenectomy alone or lymphadenectomy combined with chemotherapy have prompted us to discontinue sandwich therapy as standard treatment for non-seminomatous testis tumors at our institution.


The phenotypic expression of selective disorders of male sexual differentiation. Normal male sexual differentiation is the result of a series of individual steps that occur in an orderly fashion: testicular differentiation, müllerian regression, wolffian duct development, differentiation of the urogenital sinus and external genitalia, phallic growth and descent of the testes. Herein we present the pathophysiological mechanism by which selective disorders disrupt these normal events and produce specific phenotypes.


Diethylaminoethanol-cellulose in the treatment of absorptive hyperoxaluria. There were 22 patients in whom oxalate stones formed and who had absorptive hyperoxaluria treated with diethylaminoethanol-cellulose. In more than 2 years this form of treatment did not seem to have any serious side effects. It achieved a decrease of urinary oxalate values in all patients in whom oxalate hyperabsorption had been found. Diethylaminoethanol-cellulose is an anionic exchanger capable of retaining oxalate in vitro and in vivo.


The influence of retrograde contrast medium on urinary cytodiagnosis: a preliminary report. It has been recommended that before retrograde brushing of upper urinary tract lesions to diagnose malignancy the contrast medium should be washed away with saline because of possible cellular distortion. There were 21 paired specimens from 19 patients submitted for urinary cytodiagnosis. One specimen was a contrast medium wash, similar in pH and osmolality to urine, and the other a saline wash. Cellular detail was adequate for cytodiagnosis in 20 of the 21 contrast medium specimens. Of 7 specimens from patients with malignancy 3 were diagnosed correctly as malignant, 1 was classified as suspicious and 3 were falsely negative in the contrast wash group. Of the 3 falsely negative diagnoses 2 were changed to malignant when the paired saline wash specimens were examined. Urologists should not discard the contrast medium specimen prior to retrograde brushing but should send it along with a saline wash specimen for cytodiagnosis because the discarded contrast material and irrigant may have diagnostic cells.


Detrusor hyperreflexia: the effect of posture and pelvic floor activity. Detrusor hyperreflexia is described in patients with neurological disorders, bladder outflow obstruction, persistent enuresis and in female incontinent patients with obvious neurological or urological disease. Postural changes were present in 60% of the patients and in 45% of the patients examined reflex relaxation of the pelvic floor occurred with the uninhibited detrusor contractions.


Use of the iced cystogram to differentiate bladder neck and external sphincter obstruction. An iced cystogram was done on 31 patients with neurogenic bladder and voiding dysfunction. We observed 5 distinguishable patterns upon which therapeutic measures to improve balance could be based. We found the iced cystogram to be a simple, inexpensive yet reliable technique to assess detrusor sphincter imbalance. With the information obtained from this study the therapeutic options were delineated more clearly and the results of the treatment were made more predictable.


Hydronephrosis secondary to ureteropelvic obstruction in children: a review of 14 years of experience. The clinical presentation and surgical management of 88 children and infants with hydronephrosis secondary to ureteropelvic obstruction are reported. The importance of recognizing associated anomalies of the genitourinary tract is stressed and the advantages of an anterior transperitoneal surgical approach are discussed. The operative technique and drainage procedure varied according to the nature and severity of the abnormality but the dismembered pyeloplasty with extrarenal drainage is favored.


The clinical significant of cystitis cystica in girls: results of a prospective study. Twenty-two girls with recurrent urinary tract infection and endoscopically proved cystitis cystica were studied prospectively to determine control of infection with long-term, continuous nitrofurantoin or sulfisoxazole (6 to 12 months), effect on the bladder changes and rate of recurrence of infection after discontinuation of medication. Infection was controlled equally with both drugs but, despite adequate control, 24% had evidence of cystic changes upon completion of the treatment period. An additional 44% became reinfected during the 1-year followup with no drugs. Only one-third of those presenting with urinary frequency, urgency and urge incontinence had improvement of these symptoms with control of infection alone. It appears that childhood cystitis cystica is the response of the bladder to long-term, inadequately treated bacterial lower urinary tract infection. Many months to years of continuous medication are required for healing. Toilet retraining, in addition to anticholinergics, also may be necessary to achieve urinary control.


Long-term followup after exstrophy closure: late improvement and good quality of life. Now that we have observed the growth and development of 17 of our anatomically reconstructed exstrophy patients through 20 or more years of followup, we are convinced that reconstruction should be the preferred primary treatment. Most of these patients are healthy, attractive, well educated adults and have achieved emotional maturity and stability, despite their many problems. Anatomical reconstruction also has considerable advantages over other current treatments for exstrophy that were not apparent initially.


Response of micropenis to topical testosterone and gonadotropin. Five patients were treated with gonadotropin and topical testosterone for micropenis associated with hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonadotropin weekly for 3 weeks, with a 6-week interval followed by 10% topical testosterone cream twice daily for 3 weeks. Serum testosterone levels were measured and remained equivalent for both modes of therapy. Average penile growth response with gonadotropin was 14.3% increase in length and 5.0% increase of girth. Topical testosterone produced an average increase of 60% in penile length and 52.9% in girth. The greatest growth response occurred in prepubertal male subjects with a minimal response in postpubertal male subjects. This study suggests that 10% topical testosterone cream twice daily will produce effective penile growth. The response appears to be greater in younger children, which is consistent with previously published studies of age-related 5 reductase activity.


Glomerulocystic kidney: proposed etiology and pathogenesis. Glomerulocystic kidney, an unusual lesion seen only in infancy or early childhood, involves cystic dilatation of Bowman's space without evidence of urinary obstruction. This disease may result from intrarenal medullary obstruction in the third trimester of pregnancy because 1) it is similar to the cystic kidney lesion produced by urethral obstruction, 2) patients with glomerulocystic kidney have no evidence of extrarenal urinary tract obstruction and 3) most patients with glomerulocystic kidney have evidence of inflammation and fibrosis in the renal medulla. A prenatal drug history of prolonged maternal ingestion of phenacetin in an infant with glomerulocystic kidney prompted us to submit a possible etiologic source for the hypothesis of intrarenal obstruction.


Obstructive renal cysts.

Obstructive renal cysts. Renal cysts usually are asymptomatic, produce no harm to the kidney and require no treatment once diagnosed. However, an occasional expanding cyst causes progressive obstruction to caliceal or pelvic outflow. Herein is reported observations on 4 patients in whom cysts produced significant obstruction to the pelvic or major caliceal outflow. In 3 cases treatment was by decompression, with resolution of the obstruction. Two requirements must be met for a cyst to obstruct: 1) it must lie at or near the hilus and 2) it must have turgor sufficient to overcome the pressure of the intrapelvic urine. In contrast to most renal cysts those producing significant obstruction require operation.


Symptomatic renal angiomyolipoma: report of 8 cases, 2 with spontaneous rupture. Of the 97 patients with symptomatic renal angiomyolipoma not associated with tuberous sclerosis reported in the literature 13 have presented with a clinical picture of shock because of spontaneous rupture and massive retroperitoneal hemorrhage. Eight new patients with symptomatic renal angiomyolipomas are described, 2 of whom presented with an acute abdomen. Renal angiomyolipomas are essentially benign tumors. Several angiographic and pyelographic characteristics have been described but none appears to be unequivocally diagnostic. Because of the inability to make a precise preoperative diagnosis and the possibility of massive hemorrhage, nephrectomy is indicated in patients with such unilateral solid tumors in the absence of the tuberous sclerosis complex.


Prostaglandin-mediated hypercalcemia in transitional cell carcinoma of the bladder. A patient with known transitional cell carcinoma of the bladder and hypercalcemia was evaluated for urinary prostaglandin levels when no bone metastases or elevated parathormone levels could be demonstrated. Urinary levels of prostaglandin E metabolite were assessed in relation to serum and urinary calcium levels during treatment. The serum calcium levels decreased from the 13.0 mg. per cent range whenever the rpimary tumor was manipulated (transurethral resection) or when other treatments directed at the tumor were used (radiation therapy and chemotherapy). Serum and urinary calcium levels, and urinary prostaglandin E metabolite decreased when 3 gm. aspirin were given daily. These data suggest that the somewhat unusual hypercalcemia in our patient was caused by a prostaglandin-secreting transitional cell carcinoma. Prostaglandin-secreting tumors are reviewed herein.


A new surgical approach to traumatic rectourethral fistulas. To solve the dual problem of recurring stenosis of the posterior urethra and difficult closure of the fistulous tract in traumatic rectourethral fistulas the Johanson urethroplasty has been used in 4 cases of lower fistulas and the direct urethra-bladder neck anastomosis has been used in 4 cases of upper fistulas. The good results obtained seem to confirm the value of these methods. Direct urethra-bladder neck anastomosis also has been used successfully to treat posterior urethral strictures.


Posterior urethral valves managed by cutaneous ureterostomy with subsequent ureteral reconstruction. Six boys, 2 weeks to 5 years old, underwent cutaneous ureterostomy for massively dilated upper urinary tracts secondary to obstruction by posterior urethral valves. Cutaneous ureterostomies had been performed elsewhere in 2 patients. Two patients underwent transurethral fulguration of the valves initially with no improvement. Blood urea nitrogen, creatinine and serum electrolyte values continued to increase and, therefore, cutaneous ureterostomies were performed with dramatic improvement. Two patients presented with sepsis, one of whom had a positive blood culture. Both children had severe pyonephrosis and after the conditions improved with medical treatment cutaneous ureterostomies were done. The total number of surgical procedures required for all patients was 59, including renal biopsies, nephrostomies and cystoscopies. No kidneys, except for the severely dysplastic ones, were lost and all patients resumed normal growth rates and have had no urinary tract infections. All laboratory values are within normal limits.


Pull-through intraurethral bladder flap. A new surgical technique for post-prostatectomy incontinence is described. A simple surgical procedure was developed using a tube from a bladder flap and was applied successfully to 4 patients. Of the 4 patients 3 with total incontinence as a result of different surgical procedures on the prostate were cured and 1 was improved.


Renal cell carcinoma: natural history and results of treatment. We reviewed 166 cases of renal cell carcinoma. The presenting symptoms varied from vague backache to hypovolemic shock. The most common symptoms were pain, hematuria, a palpable mass and hypertension. Most cases involved were clear cell carcinoma (83 per cent) and survival was no better than in cases of granular cell carcinoma. The tumors metastasized to almost every organ of the body. Bilateral simultaneous primary renal cell carcinoma is described in 1 patient, who has survived for more than 5 years. The over-all 5-year survival rates of simple and radical nephrectomy were 32 and 66.6 per cent, respectively. Radiation therapy does not improve survival irrespective of stage. The 5-year survival rate with renal vein involvement was 32 per cent. Nephrectomy in patients with distant metastasis did not alter survival. Among the patients with metastasis 74 per cent were dead before 1 year and 96 per cent before 3 years.


Coagulation factors in renal adenocarcinoma. Coagulation factors, including plasma fibrinogen, serum fibrinogen-fibrin degradation products, platelet counts and prothrombin times, were studied in patients with renal adenocarcinoma. Plasma fibrinogen levels were elevated and correlated with tumor stage, disease activity and therapy. Fibrinogen-fibrin degradation product levels also were elevated, although such elevations did not correlate with other parameters. Platelet count and prothrombin times were normal. Fibrinogen may be a valuable marker of disease activity in patients with renal carcinoma. In addition, since significant intratumoral fibrin deposits have been demonstrated anticoagulants or fibrinolytic agents may enhance cytotoxic therapy and should be considered in adjunctive chemotherapeutic protocols.


New technique of antireflux ureteroileal anastomosis and its clinical experiences. Free ileoureteral reflux in patients with an ileal conduit has been indicated as the etiology of late renal complications. A new technique for ureteroileal anastomosis was devised in an attempt to prevent reflux without causing obstruction. This anastomosis has been done on 20 ureters from 11 patients with pelvic malignancies. Satisfactory results have been obtained in patients with normal as well as dilated ureters, with no serious operative complications, no episodes of pyelonephritis and no renal deterioration. The ureteroileal junction created with this technique has been demonstrated radiographically and histologically.


Urologic aspects of vesicoenteric fistulas. The classic symptoms of pneumaturia and fecaluria were not present in many of 100 patients (male to female ratio of 2.4) with vesicoenteric fistulas who presented with fever, abdominal mass or cystitis. There was a urinary tract infection in 95 per cent of the patients studied but only 29 per cent had a mixed infection. Roentgenographic studies suggested a fistula in 18 to 35 per cent of those studied but cystoscopy was singularly the most successful diagnostic technique (79 per cent). Inflammatory bowel disease in 63 per cent and colorectal adenocarcinoma in 16 per cent were the most common etiologic factors. Bladder carcinoma was the cause in only 5 per cent. Treatment consisted of single or multistage surgical repair of fecal diversion in 95 operable patients, with gratifying results, and of expectant management in the 5 inoperable patients.


Cellular immunity in bladder cancer patients. The leukocyte adherence inhibition test was used to evaluate the cellular immune status of 16 patients with a histological diagnosis of transitional cell carcinoma of the bladder. The reactivity of the leukocytes was measured against extracts of transitional cell carcinoma as well as renal cell carcinoma. The leukocytes of age and sex-matched control subjects, as well as patients with urinary tract infection, also were studied. The leukocytes of patients with transitional cell carcinoma were more reactive to extracts of transitional cell carcinoma. These results suggest that a response to tumor-associated antigens is present in transitional cell carcinoma patients.


Microphallus: clinical and endocrinological characteristics. The clinical and endocrinological features of 15 male subjects with small but normally formed external genitalia are reviewed. Nine of these patients had a simple microphallus alone, while the other 6 patients exhibited associated central nervous system defects. The endocrine data obtained from both groups were the same and were consistent with defective hypothalamic function. Parenteral testosterone seems to be the present treatment of choice but we believe it should be started early in life to take advantage of the greater hyperplastic response of the young.


Why retroperitoneal lymphadenectomy for testicular tumors? Most patients with seminoma can be managed successfully with irradiation after a high inguinal orchiectomy. Since anaplastic seminoma has a high predilection for dissemination adjuvant chemotherapy with an alkylating agent, such as L-phenylalanine mustard, is advised. There is much more controversy regarding the management of patients with non-seminomatous tumors. Because lymphangiography has an accuracy of about 90 per cent the justification of a retroperitoneal lymphadenectomy for staging purposes is no longer valid. Irradiation of the retroperitoneal and pelvic lymph nodes in a good survival rate for patients with clinical stages I and II diseases. It is anticipated that with limited resection in selected stage IIB patients and with the judicious use of elective or adjuvant chemotherapy the results in these patients may be improved further. The morbidity associated with retroperitoneal lymphadenectomy is no longer justified since equally effective alternative approaches with lower morbidity rate are available.


Biochemical markers of cultured human prostatic epithelium. Medium from primary cultures of human prostatic cells was examined for polyamines and carcinoembryonic antigen. Spermine was elevated in medium from 5 of 17 epithelial cell cultures but was not found to be a specific marker for cultured human prostatic epithelial cells. Carcinoembryonic antigen was elevated in all 27 prostate epithelial-cell culture fluids tested, 24 of which had more than 20 ng. carcinoembryonic antigen per milliliter. Medium from other cultured human cells (prostate fibroblasts, genitourinary tumor and non-tumor cells), as well as control medium, contained less than 1 ng. carcinoembryonic antigen per milliliter. Carcinoembryonic antigen, as measured in this study, is a way to demonstrate the presence of human prostatic epithelial cells in culture.


Bone marrow acid phosphatase in staging of prostatic cancer: how reliable is it? To evaluate the reliability of bone marrow acid phosphatase in the staging of prostatic carcinoma we analyzed 50 bone marrow samples collected at random from the hematology service at this hospital. The samples were assayed for acid phosphatase content by a colorimetric method using sodium thymolphthalein monophosphate as a substrate and by 2 immunochemical assays developed at our laboratory (counter immunoelectrophoresis and radioimmunoassay). We found a high percentage (61 per cent) of falsely positive results in patients with various hematological diseases without evidence of prostatic carcinoma by the colorimetric evaluation. All of these patients except 1 had negative immunochemical assay. Until a specific assay for prostatic acid phosphatase is developed for clinical use we caution the use of a single elevation of bone marrow acid phosphatase as a parameter of metastatic disease.


The importance of the urine flow rate in semi-quantitative assessment of the standard renogram. Renograms were recorded at different rate of urine flow in 30 healthy Nigerian children to establish semi-quantitative criteria to assess the standard renogram. The results indicate that knowledge of the urine flow rate during renography is necessary for meaningful interpretation of the study. They further showed that for semi-quantitative assessment of the renogram the time to peak and time to peak half values are easily identified indexes that can be measured accurately with negligible observer variation. Regression equations for the relationship between urine flow rate on the one hand, and time to peak and time to peak half values on the other have been obtained and used to compute nomograms, which should be useful for future work in this area.


Surgical treatment of renovascular hypertension in the pediatric patient. Of 27 children who underwent surgical treatment for renovascular hypertension 16 (59 per cent) were cured, 5 (19 per cent) were improved and 6 (22 per cent) were failures. Improved results were obtained in patients with unilateral renal artery stenosis. Several reconstructive vascular procedures were used, and their relative efficacy and indications are discussed. Renovascular hypertension in children is a curable disease and revascularization with preservation of renal parenchyma should be the aim of surgical therapy in most cases.


Ectopic ureteroceles in children.

Ectopic ureteroceles in children. An ectopic ureterocele may be defined as a cystic dilatation of the distal submucosal or intravesical portion of a ureter that is associated with the ectopic moiety of a completely duplicated system or, in the absence of duplication, associated with a ureter draining into an ectopic position. Using this definition, we reviewed our experience with 22 children treated during a 7-year period. More than 50 per cent were less than 3 years old at the time of presentation. The female preponderance was 3 to 1. Urinary infection was the most frequent mode of presentation. The diagnosis is made most easily when there is a high index of suspicion. Although treatment must be tailored to the situation, in general total heminephroureterectomy and excision of the ureterocele are the preferred choice. Eighty-seven per cent of the patients so treated has a satisfactory result.


The non-obstructive ectopic ureterocele. We have seen 5 children with a non-obstructive ectopic ureterocele associated with an undilated upper pole collecting system. Thus the telltale signs of renal duplication found with obstruction of the upper pole were absent. Cystoscopy confirmed the diagnosis when retrograde injection of the ureterocele outlined a narrow ureter and small dysplastic kidney. Because reflux usually was present in the ipsilateral lower pole ureter (86 per cent) surgical treatment consisted of excision of the ureterocele and common sheath ureteral reimplantation. Removal of the small non-functioning upper renal segment was not necessary in most instances. The embryology of this anomaly is discussed.


Management of vesicoureteral reflux.

Management of vesicoureteral reflux. The retrospective analysis of 210 patients between 1 month and 17 years old with 314 primary vesicoureteral units with reflux was reviewed. Our results show that there was a direct correlation between the grade of reflux and the per cent of abnormal ureteral orifices. Medical management of low grade reflux produced successful results in 60 per cent of the cases. Operation was highly successful in grade I, II, and III reflux as opposed to grade IV. The distal tunnel (Glenn-Anderson) and Politano-Leadbetter procedures were equally effective in curing reflux. Postoperative urinary infection occurred equally in all grades and usually was confined to the bladder.


Is there bacteremia after suprapubic aspiration in children with urinary tract infections? It has been shown that bacteremia may occur after bladder puncture in animals. Whether this also happens in man is not known. Thirty-three patients who were suspected to have urinary tract infection were examined for bacteremia after suprapubic bladder puncture. Of these children 19 had infection. There was no positive blood culture in any of these cases after suprapubic bladder puncture.


Influenza virus immunization. Antibody response and adverse effects in children with renal disease. Before and four weeks after immunization with a single 0.5-ml dose of influenza virus vaccine, sera from 36 children with renal diseases were tested for serum hemagglutinating-inhibiting antibody (HAI) titers to A/New Jersey/76, A/Victoria/75, and A/Port Chalmers/73. Before immunization, 1:40 HI antibodies to A/New Jersey were noted in one child only, to A/Victoria in ten children (27%), and to A/Port Chalmers in 25/34 children (68%). Serum HAI titers increased fourfold or more (P less than .01) in 31/36 children (86%) after immunization. Neither the type of the renal disease nor therapy with prednisone had any effect on the rise of serum HAI titers (P less than .05). Of the seven children with preimmunization proteinuria, four had a transient rise in protein levels following immunization. None required an increased prednisone dose for exacerbation of nephrotic syndrome. Children with chronic renal problems should be protected against influenza.


Influenza immunization in patients with chronic renal disease. Patients receiving long-term hemodialysis (23) and patients with moderate to severe renal impairment and without hemodialysis (14) were immunized with inactivated influenza A/New Jersey/76 whole virus vaccine. Fourfold or greater increases in hemagglutinating-inhibiting antibody (HAI) titers occurred in 94% of controls, 93% of nondialyzed patients with chronic renal disease, and 87% of patients with continual hemodialysis. Postimmunization geometric mean titers in both groups of patients were equivalent to those of controls. The proportion of patients responding to vaccine was independent of levels of creatinine clearance, and the presence of preimmunization HAI titers also had no effect on frequency of seroconversion. Though some element of immunologic suppression is associated with chronic renal disease, it is not reflected in the humoral antibody response to influenza A/New Jersey/76 vaccine.


Myocardial reinfarction after anesthesia and surgery. During the years 1974 and 1975 at our institution, 587 patients who had suffered previous myocardial infarctions underwent anesthesia and surgery. Thirty-six (6.1%) had a reinfarction and 25 (69%) died. Patients operated on within three months of the previous infarction had a 27% reinfarction rate. This decreased to 11% if the infarct had occurred three to six months previously and stabilized at 4% to 5% if the interval was more than six months. Risk factors associated with significantly increased reinfarction rates included preoperative hypertension, intraoperative hypotensive episodes, and noncardiac thoracic or upper abdominal operations of more than three hours' duration. Time under anesthesia was strikingly correlated with reinfarction rates in the entire group. Postoperative intensive care unit admission did not significantly affect the reinfarction rate, nor did diabetes, angina, patient age or sex, or site of the previous myocardial infarction.


Incidence of hemorrhagic complications in patients with cancer. The incidence and type of hemorrhage were studied in 718 patients with solid tumors. All patients were receiving myelosuppressive chemotherapeutic agents. Seventy-five patients (10.4%) experienced one or more episodes of hemorrhage. Bleeding was due to tumor invasion in 25 patients (33.3%), was due to disseminated intravascular coagulation in seven patients (9.3%), and was unrelated to malignant neoplasms or drug treatment in six patients (8%). Thirty-seven patients (49.3%) had hemorrhages associated with drug-induced thrombocytopenia. There was a quantitative relationship between the incidence of hemorrhage and the platelet count for both the thrombocytopenic group and the total group of patients with hemorrhages from all causes. The incidence of hemorrhage was low until the platelet count decreased below 10,000/cu mm.


Racket sports. An ocular hazard.

Racket sports. An ocular hazard. Eighty-two injuries secondary to the racket sports were studied during a 15-month period. Ordinary glasses provided considerable protection in the play of tennis and badminton, but not in the play of squash and racquet ball. Plastic safety lenses (USA Standard Practice for Occupational and Educational Eye ,nd Face Protection, approved Sept 18, 1968 by the USA Standards Institute [ANSI Z87.1-1968]) mounted in a sturdy frame (industrial or athletic) or an eye protector are necessary for squash and racquet ball. Contact lenses provide no ocular protection. Males suffered more serious injuries than females, but injuries were not related to the age or experience of the players. Eye protection is recommended for the racket sports.


Extreme but asymptomatic carboxyhemoglobinemia and chronic lung disease. Carboxyhemoglobinemia is a well-known consequence of carbon monoxide exposure from smoking. However, only moderately elevated levels have been reported. We report the case of an asymptomatic man with severe chronic obstructive lung disease and carboxyhemoglobin levels repeatedly in excess of 30% (maximum, 38.0%) due to smoking. The mechanism by which such high levels were attained was primrily a combination of arterial hypoxia and a high carbon monoxide yield from tobacco. For a given level of carbon monoxide exposure, the hypoxic person will attain a higher carboxyhemoglobin level than will a person without hypoxia.


How and when to use the digitalis serum levels. The indications for measuring serum digoxin levels are suspicion of digitalis intoxication and the need to know the status of digitalization. Pitfalls of interpretation include time of serum sample relative to time of last digitalis dose, age of patient, atrial arrhythmia, electrolyte disturbances, disease state of the patient, recent radioisotopes "on board," abnormal absorption or metabolism, and laboratory error. The serum digoxin level is a useful clinical tool but only when employed with good judgment. Not every patient receiving digitalis requires the measurement of a blood level.


Skeletal manifestations of polymyalgia rheumatica. In a review of 39 patients with polymyalgia rheumatica (PMR), sternoclavicular and acromioclavicular arthropathy was noted in 15% and 10% of the patients, respectively. Diffuse clavicular swelling preceded the onset of PMR in one patient. Carpal tunnel syndrome was seen in four patients (10%).


Noninvasive verification of fetal respiratory movements in normal pregnancy. A newly developed high-speed ultrasound imaging system enabled accurate observations to be made of fetal respiratory movements in utero. Visual monitoring of data acquisition eliminated artifactual recording.


Liquid protein diets and torsade de pointes. Three women, aged 27, 33, and 35 years, experienced recurrent syncope five months after losing 36 to 41 kg using liquid protein diets. No abnormalities were noted during physical examination except in one who was hypothyroid. Serum potassium levels varied between 2.9 and 3.9 mEq/liter. The ECGs demonstrated prominent U waves, QUc prolongation, and ST and T wave abnormalities, with left axis deviation in two patients. Syncopal episodes were due to ventricular tachycardia and fibrillation, which were not responsive to conventional antiarrhythmic agents used in two patients. Patients using liquid protein diets may thus experience reversible QUc prolongation giving rise to serious arrhythmias that are probably best treated with drugs that shorten the QTc interval. Caution should be exercised in the use of liquid protein diets for weight reduction in obesity.


Cardiac complications of protein-sparing modified fasting. Cardiovascular abnormalities developed in a patient during a protein-sparing modified fasting diet. Syncope was the complaint at the time of examination. Hypotension, persistent QTc interval prolongation, and a low QRS voltage were observed before the development of refractory ventricular tachycardia. At autopsy, antemortem thrombi were attached to the left ventricular endocardium and a fenestrated aortic valvule. Strick protein-sparing modified fasting is not without risk of sudden death even with close medical supervision.


Deoxycorticosterone and 17-ketosteroids. Elevated levels in adult hypertensive patients. Plasma 11-deoxycorticosterone levels were manyfold elevated in three adult patients with hypertension and elevated urinary excretion levels of 17-ketosteroids but without Cushing's syndrome. Dexamethasone therapy resulted in suppression of these steroids and in improvement of blood pressure in two of the patients. A partial adrenal 11beta-hydroxylase deficiency appears to best explain these findings.


Hepatitis in undertakers.

Hepatitis in undertakers. Six of 106 undertakers (5.6%) gave a past history of hepatitis during their professional careers; this was no different from the frequency in a control group of 3,162 accountants (5.1%) who had no direct contact with blood. None of the undertakers or 210 blood donors matched for age, sex, and ethnic background had serum positive for hepatitis B surface antigen. Five undertakers (4.7%) had blood that was positive for antibody to hepatitis B surface antigen, compared with six of 210 (2.9%) in the control group; this difference was not statistically significant (P greater than .25). Thus, undertakers appear to be in a low-risk occupation with reference to acquisition of hepatitis B. Although the numbers are too small for statistical analysis, there appeared to be an increased exposure to hepatitis B in undertakers who take no preventive precautions. We recommend that the minimal precautions for undertakers be the wearing of gloves.


High fiber diet in hyperlipemia. Comparison with cholestyramine treatment in type IIA hyperlipoproteinemia. Fourteen patients with type IIa hyperlipoproteinemia were treated with a high fiber intake (powdered cellulose or soy hulls or both) for six months. Eight of the patients were treated with 16 g of cholestyramine resin daily without the high fiber intake for an additional six months. The cholesterol intake was comparable in both treatment programs. The mean serum cholesterol levels decreased during both, but the decrease occurred and was more pronounced in all patients treated with cholestyramine. Responsiveness to the high fiber diet was not related to an increased responsiveness to cholestyramine treatment. In most patients the serum triglyceride levels increased, and the fasting plasma glucose level did not change substantially during either treatment program. Both regimens were free of adverse side effects.


Leukemic reticuloendotheliosis. Loss of platelet defect after splenectomy. A 59-year-old woman with leukemic reticuloendotheliosis had pancytopenia and hypersplenism. Before splenectomy, she had an abnormal bleeding time and a severe defect of secondary-wave platelet aggregation. After splenectomy, the platelet count returned to normal, and the aggregation defect was no longer present. This response suggests that the spleen may contribute to the platelet dysfunction.