[Pacemaker failure due to postcardiotomy syndrome--case report]. A failure of the sensing function of a pacemaker with a sutureless myocardial lead caused by postcardiotomy syndrome, is reported. The pacemaker failure appeared on the sixth postoperative day and disappeared after healing of the syndrome. Attention is called to the possibility of a postcardiotomy syndrome causing a pacemaker failure.


[Diurnal variations of human serum amino acid concentration]. In 5 healthy persons, as well as in 9 hospitalized patients with Parkinsonism and without metabolic disorders, diurnal variations of the concentrations of amino acids are determined in blood serum. It has been found that in addition to the peaks due to the digestion after meals, another peak in concentrations appeared. This peak was found between 2 and 4 a.m. and did not appear simultaneously for all amino acids. During this time, the urinary excretion of amino acids was also high.


Vascularization of the conducting system in the human heart. On 200 randomized specimens of the human heart, of either sex, from 20 to 80 years of age, we investigated the vascularization of the conducting system of the heart in relation to the type of coronary ramification, by the dissection, injection-corrosive, radiographic and coronarographic method. The symmetrical type of arterial vascularization was established in 24%, the right type in 63% and the left type in 13% of the cases investigated. The sinoatrial node is vascularized in 60% by the right and in 40% of the cases by the left coronary artery. The atrioventricular node and the stem of the atrioventricular bundle are vascularized by the right coronary artery in 85% of the cases investigated, in 13% by the left and in 2% by both arteries. The right fasciculus of the atrioventricular bundle is vascularized by the left artery, the left fasciculus by both arteries. The vascularization of the posterior strand in both ventricles is conformable to the type of arterial vascularization of the heart.


Functional implications of felid forelimb anatomy. The elbow and wrist anatomy of 17 felid species were studied and compared with that of other representative mammaliam carnivores. Based on the shape and position of the olecranon fossa, it was determined that for felids the  forelimb cannot travel in a "pendulum-like" motion during locomotion, but must travel through an arch away from the parasagittal plane of the body. For the anterior limb, the degree of deviation from the parasagittal plane was correlated with habitat preference. In this regard, those felids that are exclusive forest dwellers (found exclusively in high, densely structured habitats) had the greatest angle of inclination of the olecranon fossa. In addition, these, species had a large lateral olecranon tuberosity for the attachment of the lateral head of the triceps muscle. For those felids that inhabit more open terrain (low-structured habitat), the olecranon fossa was less inclined, the medical olecranon tuberosity relatively large, and the medial head of the triceps was significantly heavier than those of the forest felids. Both the wrist and elbow joints exhibited a large degree of mobility which was reflective of the claw-equipped forelimb being used as a hunting weapon.


Electron-microscopic study of the maturing rat red nucleus. I. The large-neuron population. The maturing large neurons of the rat red nucleus in animals ranging in age from 1 to 21 days of postnatal life were studied ultrastructurally. Days 1--6 were characterized by rapid morphologic maturation occurring concomitantly with the onset of synaptogenesis. Morphogenesis was confined to the soma, while the first synaptic contacts were also formed in relationship to the soma. Days 6--9 demonstrated continued somal morphogenesis exemplified by cytoplasmic expansion and by the conspicuous presence of perisomatic and growth cone processes. Proximal dendritic morphogenesis was initiated, and synaptogenesis became complex with synaptic sites occurring in relation to the neuronal soma, the perisomatic processes and proximal dendrites. Days 9--15 were characterized by the completion of somal and proximal dendritic morphogenesis and by a massive degree of synaptogenic activity. During this interval, the soma lost perisomatic and growth cone processes, while somatic spines appeared. By the end of this period the neuronal soma and the proximal dendrites appeared mature in terms of both morphology and synaptic input. Complete neuronal maturation was ultimately attained by day 21 of postnatal life.


The effect of dynamic loading on the growth of epiphyseal cartilage in the rat. The Hueter-Volkmann law of epiphyseal pressures describes an inverse relationship between static compressive forces parallel to the axis of epiphyseal growth and the rate of growth of that cartilage. Studies of histological sections of the epiphyseal plate of the fourth metatarsals of (a) control, (b) bipedal and (c) bipedal rats with amputation of the fifth metatarsal show that dynamic compressive forces can stimulate epiphyseal cartilage growth. Within certain parameters, both the relief and increase of dynamic compression accelerate epiphyseal growth. It is the amount and kind of loading that are important factors to accelerate epiphyseal growth.


[Form and attachment of the human sinus tarsi and canalis tarsi ligaments]. In addition to loose connective tissue, fat and blood vessels, the sinus and canalis tarsi also contain the capsules for the intertarsal joints as well as several varyingly stable tracts of fibers which present themselves in varying planes and directions but are nevertheless in a discernible arrangement to one another. This arrangement of fibers was studied on the feet of 40 adults whereby five distinct and clearly definable bundles could be regularly dissected. Starting from the lateral side and going medialis of the retinaculum mm. extensorum inferius, also a lig. talocalcaneum obliquum and a lig. canalis tarsi. Microscopically, fibrocartilage is evidenced in the ligaments and retinacula near their points of attachment to the bone. The ligaments lying lateral to the axis of movements for the talocalcaneal joint restrain the inversion while the medially lying lig. canalis tarsi prevents the eversion.


Innervation of the rabbit cornea. A histochemical and electron-microscopic study. The innervation of the rabbit cornea was investigated histochemically and electron-microscopically with special reference to the autonomic nerves. Both formaldehyde- and glyoxylic-acid-induced fluorescence methods revealed adrenergic nerves in the stroma; a few fibres were also observed between the basal epithelial cells near the limbus. Acetylcholinesterase- (AChE-) positive nerves were found both in the stroma and in the epithelium, whereas nonspecific cholinesterase (NsChE) activity appeared only in the stromal nerves. Under the electron microscope, both AChE and NsChE activities were observed to be located in the axon membranes. A weak NsChE reaction also appeared in the Schwann cells. When the specimens fixed with KMnO4 were examined under the electron microscope, most nerve fibres did not contain any special axoplasmic structures, although several axons contained mitochondria. Moreover, two vesicle-containing axon types were found in the stromal nerves; axons with small granular vesicles and axons containing small agranular vesicles. In the epithelium, two types of fibres were observed; one type containing only mitochondria while the other showed both agranular vesicles and mitochondria.


Muscle weights and succinic dehydrogenase distribution in the hind limb musculature of two rodents (Thryonomys gregorianus and Pedetes capensis) with different locomotory habits. The hind limb muscles of the spring hare (Pedetes capensis) were found to be relatively heavier than the hind limb muscles of the cane rat (Thryonomys gregorianus). The distribution of succine dehydrogenase activity was investigated in four of these muscles (m. gluteus superficialis, m.semimembranosus, m. biceps femoris and m.rectus femoris) from both animals. It was found that the spring hare had a higher proportion of low-activity fibres in all four muscles than the cane rat. All muscle fibre types were also smaller in diameter in the spring hare than the cane rat. These results are discussed in relation to the different locomotry habits of the two animals.


Quantitative histomorphological studies on the spinal ganglia of the Indian buffalo (Bubalus bubalis). Spinal ganglia of C3, C7, T5, T12, L2 and L5 spinal dorsal roots were studied. These ganglia vary in their size. Their greatest cross-sectional area was at C7 (2.12 cm2) in the cervical region and at L5 (1.39 cm2) in the lumbar region. The neurons were either spherical or oval in contour. The smallest neurons (mean size 68.50 X 55.64 micrometer) were located in the T5 ganglion, while some of the largest neurons (mean size 79.17 X 63.34 micrometer) were noticed in the C3 ganglion. As for their cross-sectional area, the ganglionic neurons at the L5 level were the largest (3,713.16 micrometer2), while the least value (2,994.60 micrometer2) was noted in T5 ganglionic cells. The amphicytes (satellite cells) were clearly defined. The neuronal cytoplasm revealed finely granular Nissl material. The neurons exhibit a pale-staining, centrally located vesicular nucleus with a prominent nucleolus. Few multipolar cells with eccentric nuclei were noted in the L5 ganglion.


[Reaction of peripheral vestibular ganglion cells on experimental stimulation in guinea pigs]. The effects of adequate stimuli upon the ganglion cells of the ganglion vestibulare and ganglion geniculi n. facialis were studied in the guinea pig labyrinth. During experimental examination, swelling up to 112% as well as shrinkage up to 35% were noticed. These volume changes do not coincide with the changes occurring in the corresponding sensory nuclei during the same stimulus. As the ganglion cells receive their impulses from various sensularies, they are responsible for several types of movement. A periodical increase and decrease of the nuclear volume are assumed to be an expression of the general total activity. The cells of the ganglion geniculi respond very strongly to these movement stimuli, which are not regarded to be adequate. Consequently it was proved that strong inadequate excitations can also influence the neighboring ganglion cells. In the cytoplasm, strong excitations lead to variations in the Nissl content. An intensive material exchange between the cytoplasm and the karyoplasm is assumed to be a cause for the changes of the nuclei volumes. But only the relation between the cell nuclei and the cell somata is altered. The volume of the whole cell remains approximately constant.


Neuronal-vascular relationship in experimental ischaemic anoxia. The concept of temporal and spatial relationship between neuronal and vascular changes in the central nervous system following different kinds of anoxia still remains debatable, in that it is uncertain if anoxia-ischaemia primarily produces vascular changes in the brain or it initially damages the cerebral neurons. The present investigation has been undertaken to denote the sequential relationship between neuronal and vascular changes following experimental cerebral ischaemic anoxia. Adult healthy albino rats were subjected to ischaemic anoxia by bilateral clamping of their common carotid arteries for varying intervals of 5, 10 and 15 min. The animals of each group were subsequently sacrificed on days 1, 3, 5, 7 and 10 after the clamping procedure, for light-microscopic study of their brains. Our findings are characterized by initial vascular changes, which appear to have resulted in 'no-reflow' leading subsequently to neuronal damage. The latter, in turn, secondarily caused damage to the microvasculature.


Sharpey fiber bone development in surgically implanted dog mandible. A scanning electron-microscopic study. Ticonium metal implant placed surgically in the previously edentulatized adult dog mandible induced the formation of an extensive Sharpey fiber system. Sharpey's fibers extended from the peri-implant area, deep into alveolar bone. The frequency of Sharpey's fibers and the degree of their mineralization varied from scattered location and unmineralized state to heavy clustering and full mineralization. This study suggests that the formation of Sharpey's fibers and the degree of their mineralization are determined by biophysical forces of pressure received at a given site.


Number, diameter and distribution of the rat optic nerve fibers. Light- and electron-microscopic methods for nerve fiber counting and diameter measuring are described. These methods were applied to the rat optic nerve. Differences between light- and electron-microscopic results are shown. Coincidences and divergences with the current literature data are discussed.


A quantitative assessment of post-natal development in CF rats. The post-natal development in CF rats from 5 litters was followed anthropometrically from the day of delivery to day 75. Weight, CR length, tail length and patello-calcaneal length of individual rats were measured every day and the rate of gain per day was calculated for each parameter. During this period, the rate of gain in weight showed two peaks (from days 26 to 30 and 56 to 60). The CR length and tail length had only one such peak (from days 16 to 20 and 21 to 25, respectively). The patello-calcaneal length rather exhibited an initial fall in the rate of growth up to day 45 followed by a slight increase till day 50 after which it became steady. Robustness as judged by: formula: see text was found to be maximum in the first few days after birth. Body weight or: formula: see text showed better correlations with other parameters than the gross age. The growth curves appeared as straight lines having breaks, indicating that though the growth was exponential it had sudden changes in its rate.


Effects of ovariectomy and estradiol injection on nuclear structures of endometrial epithelial cells. The changes of the rate of RNA synthesis produced by castration and estradiol injection on the surface endometrial cells of the rat are profited to study the variations in the number and size of nuclear ribonucleoprotein structures and in the disposition of chromatin. Two-dimensional measurements on sections contrasted with preferential procedures were employed to estimate the fraction of nuclear volume occupied by each element. Young adult rats in estrus are used as controls. 3 weeks after ovariectomy, the area fraction occupied by the nucleolus is reduced almost to a third of the control value, while the number of perichromatin granules per unit area of nucleus has significantly increased. A single injection of 20 microgram of estradiol produces a rapid decrease of the number of perichromatin granules to a fourth of the value of castrate animals, in 15-30 min, followed by a slow increase. Nucleolar area fraction begins to increase 2 h after estrogen administration and at 24 h it is higher than in controls. It is concluded that the changes of the nucleolar volume are due to the effects of estradiol on the synthesis of nucleolar RNA, while the variations of perichromatin granules are produced by the combination of the effect on extranucleolar RNA synthesis and on its processing and/or transporting to the cytoplasm. Both effects are independent and undergo different temporal courses.


The presence of alkaline phosphatase in the coronal suture of rat. The purpose of the present study was to determine the presence of alkaline phosphatase within the coronal suture, the dura mater and the pericranium. The histologic sections reveal that no alkaline phosphatase activity could be observed within the coronal suture as well as the dura mater, while the pericranium did contain this enzyme. These findings are brought in relation with the occurrence of synostoses, which can be induced under experimental conditions.


Microbodies of the pig liver. A morphologic and morphometric study. The ultrastructure of hepatic microbodies of pigs was studied in liver samples fixed in phosphate-buffered 2% glutaraldehyde (pH 7.4) and postfixed in 2% osmium tetroxide. The microbodies were rounded or ovoid in shape and contained a granular matrix enclosed with a single limiting membrane. The matrix, in many of the organelles, contained an amorphous or an organized (crystalloid) area. The crystalloids were organized as fine, alternating electron-opaque and electron-lucent lines, or as groups of tubules arranged in more than one plane. Profiles of smooth endoplasmic reticulum were usually found near the microbodies. 34 microbodies were approximately 0.67 +/- 0.02 micrometer (mean +/- standard error) in length and were approximately 0.56 micrometer (+/- 0.02 micrometer) wide. The marginal plates consisted of strata which exhibited a periodicity. The average length and width of 17 plates was approximately 0.34 +/- 0.03 micrometer and 0.002 micrometer, respectively. This study clearly establishes the occurrence of marginal plates in microbodies of porcine liver.


[Experimental investigation of thoracic aorta myocytes in mice. Contribution to the problem of the cause of arteriosclerosis]. The reactivity of myocytes has been ultrastructurally investigated. Pieces of aorta thoracic from mice were organ-cultured on the chorioallantoic membrane of chicken eggs incubated for 14 days. The outstanding finding were individual myocytes of the media--probably in a particular cytoenergetic stage--undergoing necrosis. They were enclosed from almost unaffected myocytes. Transferred to in vivo conditions, these findings may serve as a model for a participation of myocytes in the devleopment of disseminated multifocal arteriosclerotic plaques. The reactivity of the myocytes as to their ability of proteoglycan and lipid synthesis was opposed to Benditt's hypothesis of the genesis of an arteriosclerotic plaque caused by a monoclonal cell line originating from a mutated myocyte of the artery wall near the site of the plaque. The hypothesis of Kaunitz has been discussed, according to which the high serum cholesterin level with severe arteriosclerosis may be rather a consequence of cholesterin synthesis by the 'reparative' tissue of the arteriosclerotic lesion than its reason.


[Absence of signs of deconnection in four cases of partial anterior and median callosal lesions of vascular and neurosurgical origin (author's transl)]. Three cases of partial anterior and median callosal vascular lesions and one surgical case are presented. Some months later a neuropsychological examination did not show any signs of deconnection. Two interpretations are equally plausible: either the limited extension of the lesions as well as their location explain the absence of signs of deconnection, or these signs had existed but were regressive.


Supracondylar fracture of the humerus in children. A long-term follow-up study of 107 cases. A total of 107 cases of supracondylar fracture of the humerus in children were examined after a follow-up period of 8 to 18 years. No serious complications were found. Conservative treatment gave good results, and open reduction was seldom indicated. Rotational displacement and displacement in the frontal or sagittal plane remodelled by the end of the growth period, whereas tilting of the distal fragment into varus or valgus remained. The position of reduction should be checked roentgenologically until bony consolidation occurs, by measuring Baumann's angle or the carrying angle, and rereductions should be performed within 2 weeks.


[Tick-bite meningoradiculitis (author's transl)]. Meningoradiculitis due to tick-bite is rare and poorly documented. Its etiology remains hypothetical, but is thought to be caused by a viral infection carried by the tick. It is characterized by a striking clinical picture, especially symptoms of a subjective nature. The involved area extends asymmetrically from the site of the bite with variable latency. The CSF is characteristic, showing definite lymphocytosis and a moderate protein reaction. The prognosis is excellent although recovery may take several months. In the event of facial paralysis, there is a risk of postparalytic spasms. Treatment is symptomatic; no drug has proved effective.


Humeral shaft fractures. Treatment with a simple hand sling. Complications of operative treatment of closed fractures of the shaft of the humerus occur in about 12 per cent of cases. Fixation of the arm in some form of cast gives better results but the complication rate is still 5.5 per cent and there is a risk of shoulder-hand-finger syndrome. In order to minimize these complications the author treated patients with humeral shaft fractures by supporting the hand only, in a simple sling. The method is described and its advantages discussed. All the fractures, including transverse ones, united in 3 to 6 weeks without any serious complications.


Proliferation of bone marrow and thymus cells and increased osteoclasia after antigenic challenge in rats. Injection of a single dose of an antigenic substance (sheep red blood corpuscles) in young rats results in a significant rise in the number of mitoses in bone marrow (and in thymus) and in addition a significant rise in the number of osteoclasts in the metaphyses of the ribs. This increased osteoclasia appears 1 day after the peak values of the bone marrow and thymus mitoses. This and earlier investigations make it probable that there is a causal relationship between bone marrow stimulation and increased osteoclasia.


[Computerized axial tomography and epileptic entities (author's transl)]. On the basis of a personal classification, the authors attempt to establish a correlation between the CAT scan and various forms of epilepsy. Although some results are entirely consistent, the authors find that in a fair number of apparently lesional forms of epilepsy the CAT detects approximately the same percentage of abnormalities in cases with a history of clear pathological antecedents as in those without such antecedents. In the light of this finding, the relation between the CAT record and the true cause of epilepsy is reconsidered.


[Pure bilateral agraphia, right astereognosia and arithmetic defects associated with a left parietal tumor (author's transl)]. A case of bilateral agraphia produced by a left parietal glioma is described in a 49 year-old right-handed woman. Hypothesis of a pure agraphia, etiology and non-frontal localisation of tumor are discussed. This agraphia is associated to a right astereognosia; neither functional nor behavioral relationships are found between these two defects, and it appears that their are probably associated according to the parietal locus of lesions.


Bone growth alterations resulting from application of CO2 laser beam to the epiphyseal growth plates. An experimental study in rabbits. The CO2 laser beam was used to create defects 3 mm in depth in the distal growth plate of one femur in a group of 59 rabbits. In most of the 32 rabbits in which the defect was created on the lateral aspect of the epiphyseal plate the procedure resulted in the subsequent development of valgus deformity and shortening of the femur. In most of the 27 rabbits in which defects were produced both medially and laterally to the epiphyseal plate there was a subsequent marked shortening of the bones. Histological studies revealed that the laser-induced defects of the growth cartilage led to epiphysiodesis and premature disappearance of the epiphyseal growth plates.


Early complications of primary shoulder dislocations. A prospective study of the complications of primary shoulder dislocation was carried out for the 3-year period 1973-1976. The clinical examination was made initially in the Casualty Department and the patient was re-examined in the Department of Physical Medicine. In the evaluation special attention was given to the condition of the rotator cuff, the blood vessels and the motor and sensory function of the affected extremity. Sixty-three out of 238 patients (26 per cent) presented with the following complications: 29 lesions of the brachial plexus, 21 of the axillary nerve and 28 ruptures of the rotator cuff tendon. Complications occurred more frequently in the age group over 50 years (P less than 0.001) and in manual labourers compared with office workers (P less than 0.05). If the humerus remained unreduced for more than 12 hours, the frequency of complications increased (P less than 0.01).


[Electroencephalogram and CAT scan in 393 cases of epilepsy. Consistency between focal EEG changes and focal CAT changes (author's transl)]. A simultaneous study of EEG recordings and CAT scans in 393 epileptics led to the following findings:--in our population, the EEG pattern is normal in 6.8% of the cases and the CAT normal in 64.6%;--focal EEG changes give focal CAT changes in 38.6% and diffuse changes in 4.1% of the cases;--diffuse EEG changes give focal CAT changes in 18% and diffuse changes in 8.8% of the cases;--focal CAT changes give focal EEG changes in 68% and diffuse changes in 28% of the cases;--diffuse CAT changes give focal EEG changes in 27.5% and diffuse changes in 51.8% of the cases;--out of the 393 epileptics, 72 presented distinctly focal changes on simultaneous EEG and CAT records. The changes were on the same side in 80.5% of the cases. The reasons for the lack of consistency in 19.5% of the cases are discussed.


Fixation of pelvic fractures and dislocations. An experimental study on the loading of pelvic fractures and sacro-iliac dislocations after external compression fixation. A trapezoid external compression fixation frame, assembled with the Hoffman instruments, was used for stabilizing experimental injuries to the pelvic skeleton of ten cadaver specimens. The resistance to loading in a position corresponding to upright standing was tested in 17 experiments and related to the calculated load in vivo. The results indicated that ipsilateral injuries, either presenting as dislocations of the sacro-iliac joint and symphysis or as unilateral fractures of the sacrum or ilium in combination with fractures of the pubic rami could be stabilized by the external compression frame well enough to permit weight-bearing in the upright standing position. Bilateral injuries to the pelvic skeleton, vertical or oblique, could not, however, be stabilized enough to resist more than a fraction of the normal load in the upright standing position.


Erythrocyte sedimentation rate in infected and non-infected total-hip arthroplasties. The postoperative course of the erythrocyte sedimentation rate (ESR) following total hip replacement was studied in 18 patients with delayed infections and compared with the course in 75 uncomplicated cases. Normally, the ESR returned to the preoperative level in 3--6 months, but in delayed infections it was significantly increased already during the first postoperative months, and never returned to normal levels. There was also a small but significant difference between the preoperative values in the two groups, which in women may be explained by a pre-existing infection in the hip.


Lateral dislocation of the patella following Marmor and Guepar arthroplasty of the knee. The follow-up of 50 knees treated with the modular Marmor prosthesis and 50 with the Guepar hinge joint included tangential radiography of the femoro-patellar joint. After Marmor arthroplasty lateral patellar dislocation was found in seven knees, in six causing pain. After Guepar arthroplasty lateral patellar dislocation was found in 32 knees, but pain was present in only three. There was only a questionable correlation between pre-existing valgus deformity and postoperative lateral patellar dislocation, and an external rotation deformity of the lower leg was found in only five cases after Guepar arthroplasty. Thus, neither phenomenon could explain the high incidence of lateral patellar dislocation in the Guepar series. These dislocations must be assumed to be due to the unphysiological strain on the extensor apparatus inherent in this type of prosthesis.


Radiological diagnosis of lateral ligament lesion of the ankle. A comparison between talar tilt and anterior drawer sign. In a prospective study of 244 patients with ankle lesions a comparison between the talar tilt and the anterior drawer sign was made, leading to the following conclusions: Ligament lesions which are not disclosed by the talar tilt examination may be diagnosed by the anterior drawer sign. The anterior drawer sign cannot replace the talar tilt examination, or vice versa. The two methods are complementary. It is not possible to differentiate between an isolated lesion of the anterior talofibular ligament and a combined lesion of the anterior talofibular and the calcaneofibular ligaments by the two methods.


Lateral instability of the ankle treated by a modified Evans procedure. A technically simple tenodesis of the peroneus brevis tendon has been applied in the treatment of 42 patients with lateral instability of the ankle; 33 patients have been examined 2-10 years after the operation and 91 per cent showed excellent or good results. It is concluded that this procedure gives good stability in the varus as well as the antero-posterior direction and is therefore comparable to the technically more difficult Watson-Jones procedure.


Centripetal compression triple arthrodesis. Forty-nine compression triple arthrodeses were performed in 45 patients whose average age was 16 years. An external compression device was applied to secure rigid fixation of the tarsal bones. The device consisted of two large rings, six compression screws and six small transfixion rings. Union of the tarsal joints was obtained within 6 weeks in 93.7 per cent of cases, and within 8 weeks in the remaining 6.3 per cent. Non-union was completely avoided and the period until fusion reduced to almost half that expected after conventional operations. The compression also ensured maintenance of the correction of deformity initially obtained.


Calcaneal cysts. A radiological and anatomico-pathological study. A radiological and anatomico-pathological study of 17 cases of calcaneal cysts in young patients without other known affections is documented. There are two essential histological characteristics of the fibrous wall lining the cysts: (1) hemosiderin deposits together with cholesterol and an associated giant cell reaction, which can be attributed to previous hemorrhages; (2) newly formed bone--similar to that observed in solitary cysts of the humerus and femur--applied to preexisting trabeculae which forms a bony wall explaining the typical radiological picture. These uncommon cysts may be the evolution of purely local hemorrhages in the trigonum calcis.


Degenerative changes in the first metatarso-phalangeal joint of ballet dancers. In 20 female performers of classical ballet the range of dorsiflexion of the big toe was found to be significantly decreased. However, in only one case was the decrease sufficiently great to interfere with the dancer's ability to perform. In spite of the severe stress put on the first metatarso-phalangeal joint in dancers the resulting degenerative changes were found to be minor and in most instances without clinical consequences. The results indicate that professional ballet, contrary to what is believed, rarely has harmful effects on the first metatarso-phalangeal joint.


Scanning electron microscopy of the ischaemic kidney--changes in the surface microstructure of glomerular epithelial cells. Domestic rabbits were used to study the changes that occur during ischaemic conditions in the kidney. With a scanning electron microscope, the microcellular changes at the surface of gomerular epithelial cells were observed regularly from the onset of ischaemia until five hours later. After one hour of ischaemia, the surface of the glomerular epithelial cells showed mild swelling and some change in its smooth appearance. One part had taken on a sponge-like appearance. After 2.5 hours of ischaemia, the epithelial cells had atrophied and the entire cell surface was clearly sponge-like. It was no longer possible to distinguish the small pore-like structures that had been seen on the cell surface in the normal. Moreover, 2.5 hours of ischaemia was the time when, biochemically, cell metabolism had completely ceased and the permeability of the cell membrane had altered. The cell was considered to have undergone irreversible change by this stage. After 5 hours of ischaemia, cells were markedly atrophied and the appearance of the surface had become even more sponge-like.


Light and electronmicroscopic observations on hepatic hematopoiesis of human fetuses. I. Granulocytopoiesis in the hepatic mesenchymal tissue. Focusing on hematopoiesis, especially granulocytopoiesis, livers from ten human fetuses between 7 to 13 weeks of gestation were observed with light and electron microscope. In the hepatic mesenchymal tissue variable number of granulocytes in varying stage of maturation were found from 10 to 13 weeks of gestation. The granules of neutrophils in human fetal livers were classified into three distinct types. The first granules appeared in myeloblasts. The second granules, possibly formed in Golgi complex, were more larger and observed after the promyelocytic stage. The third granules, predominant in mature neutrophils, were pleomorphic. Other than granulocytic, erythrocytic and stromal cells, unclassifiable cells were occasionally encountered. The role of mesenchymal tissues in the granulocytopoiesis, the development of fetal neutrophils and the problem of hematopoietic stem cells were discussed.


Histopathological study of congenital cystic kidneys with special reference to the multicystic, dysplastic type. Ten autopsy cases of congenital cystic kidneys were studied by histopathological examination. Eight cases with dysplastic type revealed immature mesoderm, cartilage, localized tight fibrous tissue, hemangiomatous lesion consisting of arterio-capillary-venous elements, extramedullary hematopoiesis, primitive lymph nodes, adipose tissue, and abundant neural tissue in the kidney as well as cystic lesions. These findings strongly suggest that congenital cystic kidneys of dysplastic type are derived from hamartoma or hamartomatous changes chiefly consisting of mesodermal tissue, most of which corresponds to tissue anomaly and is very close to the aberrant form of Wilms' tumor. The presence of focal fibrosis and lymphoid cell infiltration forming focal renal tissue destruction suggest local disturbance of tissue differentiation due to some casual elements. As common feature of this type, it is revealed that the babies show lower weight for their fetal ages and die shortly after birth or are delivered as still birth due to hypoplasia and atelectasis of the pulmonary tissue.


Growth and cytogenetic characteristics of nickel sulphide-induced rhabdomyosarcomas in rats. Rhabdomyosarcomas induced by single intramuscular injections of nickel sulphide (Ni3S2) in Fischer and Hooded rats were cultured in vivo and in vitro to study their growth characteristics and chromosomal constitution. The tumor cell suspensions cultured in vitro exhibited more myogenic differentiation on the coverslips than those cells grown in vivo in diffusion chambers. A characteristic feature of in vivo cultures was the appearance of microclusters which resembled the primary tumors. Chromosome analyses of primary tumors revealed that a majority of these had a modal number in the diploid or near diploid range. Fischer rat primary tumor cells exhibited abnormal configurations including rings, dicentrics and triradials. A comparison of the chromosome make-up of the primary tumors and their metastases was performed on four sets of tumors. Three out of four metastases examined showed the diploid chromosome make-up characteristic of the primary tumors suggesting that the tumors with the diploid or near diploid chromosome constitution are more likely to produce metastases.


Fetal case of xeroderma pigmentosum--first report of an autopsy case. Fetal autopsy case of xeroderma pigmentosum was reported. This male fetus of 24 gestational weeks was prenatally diagnosed as xeroderma pigmentosum by detecting the DNA-repair defect of the amniotic fluid cells. Autopsy revealed not only maldevelopment of the fetus (stillbirth) in general for the standard, but also showed slight developmental retardation of various organs including kidneys and lungs, which could be examined by microscopic analysis. It was suggested that abnormality of the somatic organs began to appear at the fetal stage in this case of xeroderma pigmentosum.


Pneumatosis cystoides intestinalis. Autopsy study of two fatal cases in adults. Two cases of pneumatosis cystoides intestinalis (PCI), apparently of different etiologies, were found at autopsy in cancer patients. One case was associated with chronic obstructive lung disease and with emphysema of soft tissues of the mediastinum, retroperitoneum, and mesentery, whereas the other showed pseudomembranous enteritis with bacterial and fungal overgrowths. The latter case supports the role of gas-forming bacteria, while the former provides an anatomical evidence of pulmonary disease as a cause of PCL. Obstruction of the upper gastrointestinal tract may contribute to the occurrence of PCI by a complication of aspiration pneumonitis or disturbance of the normal bacterial flora of the intestine as well as an increase of the intraluminal pressure. In addition to the etiologic considerations, the importance of clinical diagnosis of PCI has been emphasized since both cases in the present report were more or less related to the cause of death.


Unusual primary malignant reticulosis of the bone marrow. An unusual case of primary reticulosis of the bone marrow in a 67-year-old female has been described. Pathological-anatomical characteristics of the present case are as follows; 1) Primary non-destructive proliferation of neoplastic reticulum cells or their variants, confined to the systemic bone marrow. Metastatic foci were noted in several areas where extramedullary hematopoiesis occurred. 2) Cytologically, neoplastic cells resemble atypical plasmacytic cells. No active phagocytosis was noted in neoplastic cells. 3) Histologically a significant increase in reticulin fibers was observed closely associated with proliferating cells. 4) Electron-microscopically these cells showed developed endoplasmic reticula but were distinguishable from myeloma cells by their irregular cytoplasmic border, which became frequently obscure, and by the presence of a desmosome-like structure. 5) These cells showed a negative immunofluorescent reaction to all types of human immunoglobulin classes. The morphological characteristics of these cells distinguished the disorder from poorly differentiated myelomatosis.


[Clandestine places: illegal sale of alcohol for urban worker populations]. The authors have studied the illegal commerce of alcohol in popular urban communities. This sale is done in so called clandestine places. The study was approached from a cultural-anthropological point of view and its objective is a descriptive-exploratory study based on observation and interview techniques. A definition and a tipology of these places was attempted, emphasizing group dynamics and interpersonal relations between the owner of the place and the customer; among the customers; among the place itself and the rest of the community organizations, formal and informal ones. A primary analysis was done, according to which these clandestine places appear legitimized by nets of interpersonal relations, critical economic situations and places that satisfy recreational needs of the inhabitants. In order to eliminate the former, adecuate substitutes for recreation and social interaction ought to be considered.


[Effects of late overstimulation in children with early maternal deprivation]. The reactions of ten minorities of a Social Protection Institution for forsaken children were studied, through the stimulation's impact of a travel to Disneyworld during 3 days. The methodology was based on semistructured interviews before the travel, by returning and 2 months after it. The results show that the stimulation, that the travel represented for 8 minorities, was an event beyond the ego's capacity of assimilation. The 2 children with better adapting capacity were those, in which foregoing histories, the affective lack had been less intensive than in the another minorities.


[On the Erlebnis of death].

[On the Erlebnis of death]. The living experience of death is examined in this paper in his philogenetic and linguistic contexts showing how in every cases it has a central meaning of separation and vanishing of the scene of life. In respect to the living experience itself, there are three distinguishable modalities relationed with the time and a similar distinction can be pointed out in respect to its links with the Other's binding. With regard to this last subject, other problems appear as the problem on bereavement, mourning and anaclisis or the transfiguration of the lost object by means of the apprehension of its sense.


Quantitation of the gain in mortality in life-time after pacemaker treatment. A total of 140 patients given permanent pacemaker 1963--73 were followed during three years with regard to survival. Indication of pacemaker implantation was AV block in 82% and disturbed consciousness in 84%. The first half of the series had a survival equal to that of the second half. The survival was 86, 73 and 64% and the excess mortality, which is above normal, was 9, 16 and 20% after one, two and three years, respectively. Concepts of fractional life-time and death-time were developed. These express the proportion of the total observation time that is life and death, respectively. The fractional life-time was 0.80 and the fractional death-time 0.20. The excess death-time was 0.12 (12%) of the total observation time. Mortality, survival, life-time and death-time were compared in three studies, the present one and two from Denmark. The great similarities were obvious. An estimation of the unpaced survival during three years, based on studies of AV block before the pacemaker era, indicated the great benefit of pacemaker treatment.


Hypergonadotropic hypogonadism in oligophrenia. Eight patients representing five different, probably hereditary neurological syndromes with oligophrenia and hypogonadism as the common features have been examined clinically and endocrinologically. Two sisters suffered from polyneuropathy, one male from ataxia, one male from spastic tetraplegia, two sisters and a brother from myopathy and one male patient from epilepsy and polyneuropathy. The latter patient was diagnosed as having an acute intermittent porphyria. All the patients had degenerative neurological disorders. The karyotypes were normal. The patients all had signs of hypogonadism. Four male patients had marked testicular atrophy but otherwise normal external genitalia. The testosterone levels in the blood were normal or slightly decreased. Three of the females had their menarche at a normal age but a very early menopause. The fourth female has never menstruated. The four females had normal breasts and body hair. All patients had high basal luteinizing hormone (LH) and follicle-stimulating hormone levels and the response to i.v. LH-releasing hormone was exaggerated. The prolactin values were normal. None of the examined patients had any signs of thyroid or adrenal insufficiency and the sella turcica was normal. A possible etiology to their hypergonadotropic hypogonadism is discussed.


Idiopathic acquired panmyelopathy in pregnancy. A case report. A case of idopathic acquired panmyelopathy (aplastic anaemia) in pregnancy in a 32-year-old woman is presented. The outcome for mother and child was favourable. Special attention is paid to the management of the delivery. Another aspect of interest is the haematologic status of the child. In panmyelopathy an immunologic mechanism may operate as indicated by the finding of platelet membrane associated immunoglobulins, which were also present in our patient. If the bone marrow lesions in this disease are indeed due to immunological injury, they are mediated by immune complexes or by a cellular mechanism, for it is well know that IgG antibodies may pass through the placenta and induce lysis of circulating blood cells in the newborn. There was no evidence of bone marrow damage in the infant. This is in accordance with the cases mentioned in the literature.


Intracutaneous herniation of fat in connection with microangiopathia diabetica. Three women with diabetes mellitus presented an unusual change in the skin on the distal and acral parts of the extremities, most distinctly on the upper surface of the hands. The surface was raised in small cushions but had the colour of intact skin. The skin felt doughy and swolen on palpation but there was no oedematous pitting. It had been suspected earlier that these skin changes indicated myxoedema or heart disease and the patients had been treated with diuretics. In all three cases, however, histological examinations revealed a more or less reduced, atrophic dermis with here and there an appreciable dislocation of the subcutaneous layer of fat, which with the sweat glands formed an intracutaneous herniation up against the epidermis. These histological changes explained the clinical picture of cushions in the skin. As these patients had diabetes mellitus and the histological picture also included vascular changes of the type associated with a diabetic microangiopathy, it is considered that this form of intradermal herniation of fat is yet another skin change which may be elicited by diabetes mellitis.


Thyrotoxicosis in a patient treated with lithium carbonate for mental disease. In recent years a few cases of hyperthyroidism and several of hypothyroidism which developed during lithium therapy have been described. We give an account of a case of hyperthyroidism, due to painless thyroiditis in a patient on long-term lithium therapy.


The relationship between QT interval and ventricular arrhythmias in acute myocardial infarction. Out of a total of 947 patients admitted to the CCU at Serafimerlasarettet during 2 years, all those with AMI and vintricular fibrillation (VF) or ventricular tachycardia (VT) during the CCU stay were selected. The QT interval could be measured in 15 patients with VF and 12 with VT before the event. The QT interval was also measured in two control groups; one consisted of 27 consecutively admitted patients with AMI without ventricular arrhythmias (VA), the other of 27 non-AMI patients treated in the CCU. Most patients in the group with VA showed pathologically prolonged QT intervals and there were statistically significant differences between this group and the control groups regarding corrected mean QT intervals. If these findings are confirmed, QT measurements might be of value in the prediction of malignant VA in AMI.


Alpha-methyldopa and drug fever. A study of the metabolism of alpha-methyldopa in patients and normal subjects. The metabolism of alpha-methyldopa was studied in 5 patients with febrile reactions to the drug, and compared with the metabolism in 5 patients without such reactions and in 4 normal subjects. A depression of the drug metabolism was found in drug fever patients, which may affect either the intestinal mucosal conjugation of the drug or the hepatic transformation. The decreased metabolism is assumed to be a possible causative mechanism of the adverse reaction.


Massive doses of procainamide for ventricular tachyarrhythmias due to myocardial infarction. Three patients are described in whom malignant ventricular arrhythmias appeared in connection with a reinfarction some days after hospitalization for an acute myocardial infarction and in whom massive doses of procainamide, up to 7.5 g/day i.v., were necessary to prevent these arrhythmias. The serum concentration of procainamide was 2--4 times higher than the recommended upper level, but no side-effects were observed. With the dose given, one would have expected still higher serum concentrations. Several reasons for this finding are discussed, including the effects of renal function, intestinal leakage, storage of the drug in tissues and hitherto unknown metabolic pathways of procainamide in patients, who are slow acetylators.


The effect of propranolol on serum levels of T4, T3 and reverse-T3 in hyperthyroidism. The effect of propranolol (40 mg t.d.s.) on the peripheral levels of T4, T3 and reverse-T3 was studied in 26 patients with hyperthyroidism. The compounds were measured by specific radioimmunoassay techniques. The levels were followed for five weeks and compared with the levels before treatment. The results show that propranolol had no significant effect on the peripheral levels of T4 despite a rapid amelioration of clinical symptoms. A significant reduction of T3 levels was obtained during the first to fourth week of treatment. No significant decrease was obtained after the fourth week. A significant elevation in reverse-T3 levels was obtained during the second to fourth week of treatment. No significant change was obtained either during the first week or after the fourth week. Inconsistent fluctuations in hormone levels, both before and during treatment, could be seen in individual cases. The results suggest that the reduction of clinical symptoms must be caused by an extrathyroidal action of propranolol which does not seem to involve the pituitary gland.


Non-invasive assessment of cardiac function in poisoning with drugs. Systolic time intervals (STI) have been used in evaluating cardiac function in 21 patients who had taken an overdose of drugs. Registrations were made in all patients on arrival at the hospital and on the third day. On arrival STI was abnormal in 16 patients (76%). At the second registration it was still abnormal in ten (48%). Prolongations of total electromechanical systole (QS2) and preejection period (PEP) were the most frequent findings. The patients with abnormal STI at the first registration showed a significant improvement in QS2 (p less than 0.01) and PEP (p less than 0.05) from the first to the third day. Two of the four patients who had taken amitriptyline in a slow release form showed a prolongation of PEP and an increase in PEP/LVET from the first to the third day, and on patient has a further prolongation of the fifth day. The findings may be explained by a reduction of cardiac contractility caused by the membrane-stabilizing effect of the drugs.


Effect of alcohol on chemotaxis, adherence and phagocytosis of human polymorphonuclear leucocytes. In view of the presumed increased susceptibility of chronic alcoholics to infectious diseases, the influence of alcohol in vitro on leucocyte adherence, neutrophil chemotaxis, phagocytosis and intracellular killing was investigated with highly standardized methods. A significant inhibitory influence on these leucocyte functions was found only at alcohol concentrations in excess of those obtained clinically. An interesting observation not reported before was increased adherence, phagocytosis and chemotaxis at low to moderate concentrations of alcohol.


Abnormal microheterogeneity of transferrin in serum and cerebrospinal fluid in alcoholism. The serum and CSF proteins were analyzed by isoelectric focusing in 16 male alcoholics after alcohol intoxication and after 10--14 days of alcohol abstinence. An abnormally marked protein band with pI 5.7 was found in serum in 15 patients and in CSF in 12 at the first examination. On crossed immunoelectrofocusing it appeared as an increased, cathodal, microheterogeneous molecular form of transferrin. The abnormality was reversible and decreased or normalized in serum in all cases after abstinence. In 6 patients with clinical signs of cerebellar degeneration, an abnormal microheterogeneous pattern of CSF transferrin of partly different appearance to that in serum remained after abstinence. Disturbed liver synthesis of transferrin is a probable origin of the serum finding, which may be specifically related to alcohol abuse. Substitution or loss of acidic amino acids and/or decreased iron binding ability are possible structural explanations.


Obstructic characteristics of Björk-Shiley, Hancock, and Lillehei-Kaster prosthetic mitral valves in the immediate postoperative period. The flow obstruction in mitral valve implants was studied in the immediate postoperative period in 19 patients with Björk-Shiley, Hancock, or Lillehi-Kaster prosthetic mitral valves. The effective valve area (Ae) was used as a measure of the flow obstruction. The blood velocity in the implants was estimated with a non-invasive ultrasound Doppler system. The cardiac output was determined with an indwelling thermodilution catheter. The collected data allowed the determination of Ae. Multiple determinations of Ae, at various cardiac outputs and pulse rate were generally performed in each patient during the first 2--3 postoperative days. The investigation demonstrated that the method employed was useful for the study of mitral implant performance. The obtained values of Ae demonstrated that the flow obstruction in presthetic mitral valve implants is frequently considerable.


Does a disturbed insulin release promote hypoglycemia in alcoholics? Peroral glucose tolerance tests, i.v. tolbutamide tests and postfasting alcohol tests were performed in three alcoholics, who had been admitted to hospital with hypoglycemic symptoms. In one one case the findings indicated extreme insulin sensitivity and in two cases there was evidence of a distrubed insulin release. These two factors might have a bearing on the occurrence of hypoglycemic symptoms in alcoholics.


Exercise performance and body dimensions in anorexia nervosa before and after rehabilitation. The boys and five girls (mean age 15.0 y.) with anorexia nervosa (AN) were studied before and after a treatment which restored their body weight to normal. Before treatment the patients' average weight loss was 25% of their premorbid weight. The function and dimensions of the oxygen transport system were determined with heart (HV) and blood (BV) volumes, lean body mass (LBM) and exercise tests on a bicycle ergometer with determination of maximal aerobic power (VO2 max). Before treatment, the patients had bradycardia and hypotension. HV and BV decreased in proportion to the loss of body weight. During maximal exercise, attainable oxygen uptake and heart rate were low. VO2 max decreased out of proportion to the circulatory and body dimensions. After treatment, HV and BV increased in proportion to the rise in body weight. LBM increased significantly in all patients. Heart rates at rest and during exercise were within the range of normal and VO2 max increased. It is concluded that the circulatory system is highly adaptive to the low caloric intake in AN and is totally normalized after weight gain.


Taste dysfunction and changes in zinc and copper metabolism during penicillamine therapy for generalized scleroderma. The taste function and the zinc and copper levels in serum and urine were followed for up tp 16 weeks in ten patients who were started on penicillamine therapy for generalized scleroderma (9 patients) and rheumatoid arthritis (one patient). During therapy the serum zinc concentration remained unchanged, whereas the serum copper concentration increased significantly during the first 4--5 weeks and then tended to decrease. Urinary copper rose significantly and remained considerably above the upper normal limit throughout the study. Six of the patients complained after about 4--5 weeks of a decreased taste function, which was gradually restored whether the medication was stopped or continued. The alterations in the taste acuity for sweet, salt, sour, and bitter significantly paralleled the variations in urinary copper before as well as during therapy. Thus, the patients who showed the most pronounced loss of taste, had a lower urinary copper output than those whose taste acuity was less disturbed.


Vitamin B12 body stores during oral and parenteral treatment of pernicious anaemia. Oral treatment of pernicious anaemia patients with 1 mg cyanocobalamin daily has been shown before to be as effective as conventional injection therapy. The result of this study indicates that oral treatment also keeps the vitamin B12 body stores adequately filled, a confirmation of earlier results obtained in another way.


Short-term effects of 1-alpha-hydroxy-vitamin D3 in patients on corticosteroid treatment and in patients with senile osteoporosis. Six patients with bronchial asthma undergoing long-term corticosteroid treatment and six patients with senile osteoporosis were given the same oral dose of 1-alpha-hydroxy-vitamin D3 (1alpha-OH-D3) and calcium. The immediate effect on blood and urine chemistry and on the intestinal calcium absorption rate were studied. Hypercalcaemia occurred frequently among the patients treated with corticosteroids but not among those with senile osteoporosis. We conclude that corticosteroids do not counteract the effects of 1alpha-OH-D3. No correlation was found between the calcium absorption rate and the degree of osteoporosis, nor did the serum PTH levels show any differences that could be attributed to the treatment.


A tetracycline-based histomorphometric evaluation of bone resorption and bone turnover in hyperthyroidism and hyperparathyroidism. Increased bone, resorption previously found in hyperthyroidism might be caused by a direct stimulating effect of thyroid hormone(s) on bone cells or by an increased sensitivity to circulating parathyroid hormone. In order to disclose qualitative differences in the response of bone resorbing cells to excess parathyroid hormone and excess thyroid hormone(s), histomorphometric analysis of iliac crest biopsies was performed in 25 hyperparathyroid and 40 hyperthyroid patients after tetracycline double-labelling. The main target cells for parathyroid and thyroid hormones were different. Parathyroid hormone stimulated osteocytic osteolysis and increased osteoclastic resorption surfaces equally in trabecular and cortical bone. The osteoclastic resorption was inactive. Thyroid hormone(s) had no effect on osteocytes but increased the osteoclastic resorption surfaces in trabecular and cortical bone, with a pronounced preponderance in cortical bone. The osteoclastic resorption was active and followed by a significant loss of both cortical and trabecular bone. The findings support the assumption that increased bone resorption in hyperthyroidism is caused by a direct stimulating effect of thyroid hormone(s).


Brain energy metabolism in global brain oedema. Different degrees of severity in global brain oedema were induced by varying amounts of water intoxication (50, 100, 150, and 200 ml Aqua dest./kg b.wt. intravenously) in groups of six cats, which were functionally nephrectomized. Animals loaded with physiological saline and sham-operated served as controls. Two hours following the water load, the tissue concentrations of CrP, ATP, ADP, AMP, pyruvate, glucose, and lactate were determined by optical enzymatic analysis. The results show disturbances in brain energy metabolism dependent on the severity of the brain oedema. The high energy compounds and in consequence the ATP/ADP-ratio, and respectively the energy charge potential, fall in direct relationship to the severity of the brain oedema. Lactate and lactate-pyruvate ratio increase. The energy source of the cell, glucose as well as pyruvate, significantly falls in the group with severe brain oedema. The results of the brain energy metabolism were compared with our previous study concerning the brain water content, rCBF and CPP in global brain oedema (Meinig et al. 1973). The results show that the disturbances of energy metabolism are directly related to the rCBF and are not dependent on CPP over a wide range.


Diagnosis of intracranial space-occupying lesions with DTPA-Sn-99mTc. DTPA-Sn-99 mTc is an excellent radionuclide for brain scintigraphy procedures with a rapid blood clearance through glomerular filatration. No previous preparation of the patient is necessary. We have studied forty nine patients with primary or metastatic brain tumours as well as calvarium metastases. There have been five false negatives. We have found three types of scintigraphic patterns depending on whether the lesion is better visualized in early or late images, or does not change throughout the study. The sequential brain study, obtaining views at five minutes, and at one and two hours post-injection allows for an adequate morphological characterization of the lesion and occasionally, a histological diagnosis.


The reliability of computerized axial tomography in the diagnosis of infratentorial mass lesions. A neurosurgical appraisal. The accuracy of CAT in the diagnosis of infratentorial expanding lesions is analysed on the basis of 224 personal cases. The posterior fossa lesions are classified in four groups according to the reliability of CAT as the only pre-operative examination. The present indications for conventional neuroadiological procedures are also outlined. Particular emphasis is laid on the information supplied by CAT in postoperative follow up to detect both immediate and delayed complications.


The pericranium flap operation. A new operation for the treatment of progressive infantile hydrocephalus. A preliminary report of 20 cases. A new operation is described for the treatment of progressive infantile hydrocephalus. A pericranial flap with intact blood supply is introduced into the right lateral ventricle and fixed in place by suture to the dura or the skull. Twenty cases were subjected to the new operation with four deaths. The operation was successful in causing the arrest of the hydrocephalus and changing the mental state of early and mild cases.


Contribution to the surgical treatment of acute supratentorial subdural haematomas. Acute traumatic subdural haematoma suspected of extending over an entire hemisphere must be treated with all speed. To obviate unnecessary skin incisions and subsequent craniectomies and craniotomies during the operation, we think it advantageous to plan a series of burrholes at set points in order to; a) begin to clear the haematoma; b) assess its extent and possible origin; c) decide whether a hemicranial or smaller craniotomy is called for.


Azotaemia in severe head injury--central dysregulation or renal failure? We have investigated serum urea, uric acid, and creatinin crealinine levels in 39 patients with craniocerebral trauma. The most impressive observation was a change in serum urea, which was found significantly increased up to 237 mg% on the seventh day (mean value) after severe injury, and turned out to be of great prognostic value. Patients with a serum urea above 100 mg% did not survive the acute stage. Uric acid and creatinine were only significantly increased in patients with lethal outcomes, the first being elevated by about 300% in the first week, the second remaining normal for four days increasing thereafter. It is concluded from these first data that a hypercatabolic state due to shock, central dysregulation, or both, is responsible for the dissociated behaviour of urea, uric acid and creatinine during the first four days, after which renal failure as a secondary change is shown by the rise in serum creatinine.


Delayed consequences of endothelial removal from rabbit aortae. One year after de-endothelialization of rabbit aorta by a balloon catheter, the damaged areas show arteriosclerotic thickening. In the study described here, aortae from six rabbits were examined 2 years after the single injury. Three had advanced atherosclerotic lesions. All the animals had been fed standard rabbit chow, and the five tested did not have hypercholesterolemia when they were sacrificed. Apparently vascular injury alone is sufficient basis for development of atherosclerotic disease in the rabbit.


The role of platelets in transient ischemic attacks and cerebral vascular accidents. In a 5 1/2-year study in 585 patients, aspirin, 1200 mg/day, reduced 50% the risk of stroke or death in men who had experienced at least one episode of neurological disability in carotid or vertebral-basilar territory. Adding sulfinpyrazone to aspirin did not improve the results, and sulfinpyrazone alone was no better than placebo. Women did not experience the same benefit; aspirin did not reduce their risk of stroke or death.


Influence of antiplatelet drugs on platelet-surface interactions. Platelet aggregates are important in the thromboembolic complications of prosthetic devices, and drugs that alter platelet function have shown promise in clinical trials. Results with these drugs have increased insight into the interaction of platelets with artificial materials, particularly when the clinical experience has been correlated with the results of in vitro models. In a bead column/surface contact model, the characteristic interactions of platelets with artificial surfaces resemble effects of adding thrombin ADP to platelet-rich plasma. Anti-inflammatory agents and other antiplatelet drugs inhibit these reactions. Results in an in vivo model, survival of 51 Cr-labeled platelets in sheep bearing arteriovenous shunts of test materials, correlate systems indicate that the initial events upon contact of a surface with plasma proteins persistently influence the long-term behavior of that surface toward blood. A review of clinical studies discusses the effect of antiplatelet drugs on platelet survival and also on thrombotic complications of heart valve replacement and other conditions employing prosthetic devices.


Effects of various S-adenosylmethionine preparations on histamine methylation in vitro and in vivo. To test possible enhancement of in vivo methylation of histamine, mice were injected with S-adenosylmethionine (SAM) of approximately 96% purity. Instead of the expected enhancement, very strong inhibition of methylation was observed. Tests indicated that S-adenosylhomocysteine (SAH) probably was not the inhibitor. Pure SAM, from another source, showed no inhibition of methylation in rats and guinea pigs, and only slight inhibition in mice. Pure SAM was much more effective than the 96% SAM for histamine methylation in vitro. It seems either that injected SAM cannot enter cells containing the histamine methylating enzyme (HME), or that the endogenous supply of SAM is optimal. The inhibitor may be structurally related to SAM, possibly a by-product of SAM synthesis. As it is very effective even in the presence of large amounts of SAM, in pure form it would probably be the most potent inhibitor of histamine methylation available.


Histamine content and mast cells in human gastric and duodenal mucosa. A high histamine content was found in all areas of human gastric and duodenal mucosa. In single subjects there was no general preference of histamine being located predominantly in fundus and corpus. In biopsy specimens of human corpus mucosa many histamine-containing O-PD reactive cells could be identified. In the sections treated previously with O-PD also many toluidine blue staining cells (mast cells) could be visualized. As shown by a transcription technique their place and number was the same as those of O-PD reacting cells. It is concluded that histamine in human corpus mucosa is localized exclusively in mast cells which seem to participate in acid secretion and in duodenal ulcer disease in man.


When a child dies.

When a child dies. The family physician can be of great help to the parents after a child dies. Practical points to keep in mind are: in acute mourning, denial of death is a common response; parental emotional "detachment" from the dead child takes six to 12 months; parents may be motivated to "replace" the child too quickly; parental relationships with the surviving children can be impaired by overprotectiveness, and the physician should be aware of his limitations in this situation.


Echocardiography in the cardiac work-up. Increasingly popular, echocardiography is now widely available. It poses no risk, causes no discomfort and reveals a great deal of information. Interpretation requires expertise. A simple algorithm provides decision points leading to use of this technique for diagnosis and follow-up and for avoiding overutilization. Clinical correlation and (when indicated) correlation with other cardiac tests are essential.


Complement consumption and IgE binding by house dust allergen in the serum of atopic patients. The reactivity of complement (C) with housedust allergen has been investigated in separate groups of sera from atopic patients with seasonal hay fever, bronchial asthma, atopic dermatitis, animal dander allergy or asthmatic bronchitis as compared to controls. Complement consumption was more pronounced on average in the allergy groups, with the exception of atopic dermatitis. Total IgE levels were elevated in all groups, especially in atopic dermatitis. There was no correlation between C-sensitivity and IgE data (RAST and RIST). The mean levels of C1-inhibitor, 1-antitrypsin and 2-marcroglobulin in the atopic group were found normal. A significant correlation was found between the extent of C-consumption by house dust allergen and the level of C4 in sera. It is concluded that both C and IgE differ from normal in atopic patients, but that neither one is suited for the routine diagnosis of atopy in individual serum samples.


Hand infections.

Hand infections. Superficial infections include paronychia, cellulitis and lymphangitis. Grave infections include felon, purulent tenosynovitis, thenar infections, septic arthritis and human bites. Treatment by incision and drainage, moist heat, elevation, splinting and specific antibiotics or other agents applies to most hand infections. When pus is found, adequate drainage usually gives good results. Without drainage, pressure necrosis and gangrene often follow. Rest for the infected part and for the patient is as important as any other facet of treatment.


The detection of asymptomatic colorectal cancer. The classic symptoms and signs of colorectal cancer (change in bowel habits, weight loss, melena or a palpable abdominal mass) signify advanced disease. Improvements in survival rates have not occurred in the last 15 years because the majority of patients have metastases at the time of surgery. Asymptomatic patients are detected by routinely screening stools for occult blood. If practiced routinely, this technique will improve survival statistics by identifying patients and instituting treatment at an earlier stage of disease.


Management of the rape victim.

Management of the rape victim. If a rape crisis center and specialized personnel are not available, the family physician can adequately examine and treat the rape victim as well as collect and properly handle all the required medical evidence. The detailed history has several facets. Laboratory confirmation can be obtained for prior consensual intercourse, sodomy and other special aspects. Treatment is indicated for the prevention of venereal disease and pregnancy. Psychologic support is essential. The physician's examination and testimony can play an important legal role.


Atrial flutter. Electrocardiographic, vectorcardiographic and echocardiographic correlation. The duration, contour, and amplitude of atrial flutter wave (f) was studied by electrocardiogram (ECG) and vectorcardiogram (VCG) in 32 patients and was related to the size of the left atrium (LA) measured by the echocardiogram (E). The following ECG parameters were analyzed: (1) the duration of left atrial depolarization, i.e., LA wave; (2) the amplitude of LA wave; (3) the surface area of LA wave; (4) maximum amplitude (A) of f in Leads 2 and V1. There was good correlation between LA size and the duration of depolarization and surface area (p less than 0.01), but the maximum amplitude of the f wave in Leads 2 and V1 failed to predict LA size. The post-conversion sinus P wave showed abnormal LA depolarization time (P greater than 0.12 sec.) in 62 per cent of patients with enlarged left atrium (ELA) and in 43 per cent of patients with normal size LA (NLA). The VCG of the flutter wave revealed two patterns, (1) an eliptical smooth fsE loop in 63 per cent of patients with NLA, and (2) distorted fsE loop in 67 per cent of patients with ELA. Both VCG patterns were subdivided in two subgroups according to the number and location of conduction delays. The VCG of post-conversion P wave confirmed conduction delays in both groups. We conclude that both the size of the left atrium and conduction delays play a basic role in the duration and contour of left atrial wave.


Study of the temporal effects on conduction and refractoriness of the His-Purkinje system in man. Temporal effects on refractoriness within the His-Purkinje system (HPS) were studied in 14 patients in whom effective refractory period (ERP) of HPS could be determined, using His bundle electrograms, incremental atrial pacing, and atrial extrastimulus method. His-Purkinje conduction times (H-V interval) and relative (R), effective (E), and functional (F) refractory periods (RP) of HPS were measured during the control period and repeat measurements were made after a 30 minute interval. H-V intervals were unchanged from control in all patients. Although changes of the magnitude of 5 to 25 msec. in either direction from control values commonly occurred, on the average, no statistically significant changes were seen in RRP, ERP, or FRP of HPS. The results of the present study confirm the stability of refractoriness of HPS over a 30 minute period and provide baseline data for future investigations of cardiovascular drugs which act primarily on the distal part of the A-V conduction system.


Effects of rapid digitalization on total and regional myocardial performance in patients with coronary artery disease. In order to evaluate the effects of rapid digitalization on LV volumes, ejection fraction, and asynergy, 21 patients without heart failure were studied with a combination of hemodynamic and angiographic techniques before and after administration of intravenous ouabain (0.007 mg./Kg.). Seven patients had no CAD and served as normal (control) subjects (Group I), while 14 patients had extensive coronary disease (Group II). All pre-ouabain parameters were within the normal limits in Group I. After ouabain infusion, all indices of LV contractility: dP/dt, VCF, and ejection fraction rose significantly in the normal group, while LV filling pressure and end-diastolic volume remained unchanged. The baseline hemodynamic and volumetric values for Group II patients corresponded closely to their normal (Group I) counterparts, and exhibited similar changes after ouabain administration. Eight patients in Group II also had regional disorders of LV contractility, delineated by 23 abnormal hemiaxes of shortening. After ouabain, 15 out of 23 asynergic segments (65 per cent) improved, seven remained unchanged, and one worsened. It is therefore concluded that rapid digitalization not only enhances LV performance in normal subjects and in patients with CAD, but can also markedly reduce the extent of LV asynergy.


Comparative influence of ouabain, norepinephrine and heart rate on myocardial oxygen consumption and inotropic state in dogs. The purpose of this study was to compare the myocardial oxygen cost of augmented inotropic state produced by ouabain, norepinephrine, or increased heart rate. This problem was examined in dogs using an isovolumically contracting left ventricular preparation. Inotropic state was measured as the maximum observed contractile element velocity at the lowest common level of wall stress (MAX V). Peak left ventricular wall stress was maintained constant in each dog so that it would not influence changes in myocardial oxygen consumption (MVO2). Ouabain (4 X 10(-2) mumoles/Kg.) and norepinephrine (2 X 10(-3) mumoles/Kg./minute) always augmented inotropic state (MAX V) and increased MVO2. The positive slopes of the regression of MVO2 on MAX V for ouabain (45.4 +/- 12.5 microliter/beat/100 Gm./muscle length/sec; mean +/- SEM) and norepinephrine (34.5 +/- 5.6 microliter/beat/100 Gm./muscle length/sec; mean +/- SEM) were not significantly different, indicating that for an equal augmentation of inotropic state, ouabain increases myocardial oxygen demands to the same extent as does norepinephrine. When the results with ouabain or norepinephrine were compared to results obtained by altering heart rate, it was found that increasing inotropic state by these pharmacologic agents is more costly in terms of myocardial energy demands than when inotropic state is enhanced by increasing heart rate.


Complications due to cloth wear in cloth-covered Starr-Edwards aortic and mitral valve prostheses--and their management. Five cases of complications due to cloth wear in cloth-covered composite-seat Starr-Edwards aortic and mitral valvular prostheses are described. The complications of cloth wear were recurrent systemic emboli in three patients, two with aortic and one with mitral prosthesis, and severe hemolytic anemia in two patients with aortic prosthesis. The over-all incidence of clinically significant complications due to cloth wear in aortic and mitral valve prosthesis was 2.5 per cent. The diagnosis of cloth wear is impossible before reoperation and it was made by exclusion of other causes of recurrent transient cerebral ischemic attacks or systemic emboli and by exclusion of other causes of hemolytic anemia. Clinical and laboratory findings suggestive of cloth wear are described. Aggressive management of complications of cloth wear by reoperation is likely to prevent disabling or lethal consequences. Porcine xenograft aortic and mitral bioprostheses were used in these patients to replace the cloth-covered valvular prostheses. The symptoms due to cloth wear were abolished in all patients by reoperation, and all patients are off anticoagulants postoperatively. The operative mortality rate for reoperation in this small group of patients was zero.


Sampling and analytical methods for phosphine--a review. An overview of sampling and analysis of phospine with an emphasis on industrial hygiene is presented. Recent advances in solid sorbents behavior allow these devices to be used followed by gas chromatographic analysis. Sampling with filter paper--AgNO3 and colorimetric analysis remains a reliable technique. A comparison of the strengths and weaknesses of analytical (gas chromatography, chromogenic, colorimetric and electrochemical) and sampling (impregnated papers, solid sorbents, bubblers and evacuated cylinder) techniques is made.


A new polycarbonate fast neutron personnel dosimeter. Registration of fast-neutron-induced recoil and (n,alpha) tracks directly in sensitive polymers especially polycarbonate foils when etched by the electrochemical etching (ECE) method provides a simple, sensitive, and inexpensive means of fast neutron dosimetry. The wide dose range and a dose equivalent response, negligible fading rate, and insensitivity to X, beta, and gamma radiations make such a method feasible for many neutron dosimetry applications, especially personnel dosimetry. Due to very large size of the tracks, even the unaided eye can be used as a reading device.


Radioactive pollutant determinations using gamma-ray spectroscopy. Qualitative and quantitative determination of radionuclide contamination in environmental samples is often complicated by the presence of uranium- and thorium-series radioelements as well as 40K. High resolution gamma-ray spectroscopy with lithium-drifted germanium detectors provides a method for the determination of man-made radio-nuclide contaminants in many matrices with a minimum of chemical separation. Methods have been studied for increasing the efficiency of such determinations by using large samples in reentrant beakers ("Merinelli beakers") and small samples inside the well of a recently developed Ge(Li) well detector. Specific examples for the determination of 129I(16 m.y. half-life) in the well detector and recent fall-out in grass samples are presented.


Characterization of potential indoor sources of ozone. Ozone emission factors were developed for domestic electrostatic air cleaners and photocopying machines. The air cleaners had emission rates from 0-546 microgram/min. These rates will ordinarily not produce air concentrations which are greater than 60 microgram/m3 (0.030 ppm) above background. The emission rate for photocopying machines varied from 48-158 microgram/copy. In small, poorly ventilated rooms these emission rates were sufficient to produce incremental steady state ozone concentrations up to 396 microgram/m3 (0.202 ppm). Recent copying machine maintenance was found to reduce ozone production to less than the detectable level, 4 microgram/m3 (0.002 ppm).


Enhancement of air filtration using electric fields. Although polarized electrostatic air filters are efficient air filtrating devices, their main disadvantages are difficulty in collecting conductive particles or in operating at relative humidities above 70%. We describe here a new filter design that eliminates these problems. A nonconductive media, normally a glass fiber mat, is placed between two insulated conductive screens. As the voltage across the screens is increased, the penetration of particles decreases exponentially. Increasing the electric field from 0 to 10 kV/cm will decrease the mass penetration from 60% to less than 10% of a polydispersed 0.8 micrometer ammd(sigma g = 2.0) sodium chloride aerosol. The experimental effects of face velocity, particle charge and size, packing density, fiber size, and screen insulation mirror the theoretical effects of these variables on particle penetration.


Analysis of total arsenic in urine and blood by high speed anodic stripping voltammetry. A method for the measurement of parts per billion levels of total arsenic in urine and blood is described. Samples are wet ashed with a mixture of HNO3, HCIO4, and H2SO4 acids. Ashed materials are subjected to a reductillationTM procedure to reduce As (V) to As (III) and to separate arsenic from the sample matrix. Collected arsenic is then quantitated by anodic stripping voltammetry (ASV) at a gold film electrode. ASV analysis time is only 2 minutes. By simultaneous reductillation of 4 samples, ppb arsenic determinations can be accomplished at a rate of about 12 per hour. The method is as accurate, precise and reliable at the nanogram level as the more universally accepted colorimetric techniques are at the microgram and milligram levels. For replicate analysis of real samples, method precision ranged from +/- 1.4 ppb at the 5 ppb level to +/- 0.96 ppb at the 25 ppb level. Accuracy is estimated at +/- 6% over the range 5 to 500 ppb arsenic.


Abbreviated guidelines for heat stress exposure. A wide array of recommendations, rules and research results have been arregated into a simplified set of decision criteria for estimating threshold levels of heat stress. The WBGT is used as a basis, with appropriate modification for metabolic heat generated during work, velocity of air movement, state of acclimatization, amount of clothing (e.g., shorts, jackets, coats, enclosed suits), age, obesity, and sex. When WBGT levels for the person-task-environment combination are exceeded, initiation of appropriate engineering and work practices are indicated.


Regional redistribution of myocardial blood flow after coronary occlusion and reperfusion in the conscious dog. Early and late changes in regional myocardial blood flow distribution within the left circumflex coronary arterial bed after occlusion and after occlusion and reperfusion were compared with the extent of myocardial tissue necrosis. Radiolabeled microspheres, 15 micrometer, were used to study regional myocardial blood flow in conscious dogs at 5 minutes, 2 and 6 hours and 1 month after coronary occlusion. Blood flow was measured in conscious dogs whose hearts were reperfused for 72 hours after 2,6 and 24 hours of occlusion. Blood flow was measured in four distinct transmural myocardial zones delineated by dye injections and gross infarct features of the occluded left  circumflex coronary bed. After occlusion, myocardial flow was redistributed from deep layers to outer layers, and within 6 hours after occlusion collateral flow was increased to the outer zones in excess of redistributed flow. After reperfusion, blood flow greately increased to regions containing predominantly normal tissue, and flow was redistributed away from the necrotic zones. The indigenous collateral circulation was a major determinant of infarct size in the occluded and reperfused myocardium. The concept of a migrating and narrowing marginal zone is discussed.


Combined nitroprusside-dopamine therapy in severe chronic congestive heart failure. Dose-related hemodynamic advantages over single drug infusions. To assess the circulatory effects of afterload reduction and inotropism individually and in combination as rational therapy for refractory heart failure, nitroprusside and dopamine were administered to 13 patients with severe cardiac decompensation. Dopamine at average doses of 3 and 7 microgram/kg per min produced increases in cardiac output and reductions in peripheral resistance. At doses of 15 microgram/kg per min, dopamine increased heart rate, peripheral arterial pressure and side effects. Nitroprusside alone decreased left-sided filling pressures and increased cardiac output. When the agents were administered together, the increases in cardiac output were significantly greater than with either agent alone and there was physiologic improvement in overall circulatory function. The relations among changes in afterload (systemic impedence), preload (filling pressures) and cardiac index help to explain the salutary effects of combined therapy in patients with refractory heart failure.


Human Electropharmacology of Tocainide, a lidocaine congener. The electropharmacology of tocainide, an orally active congener of lidocaine, was evaluated in 10 patients with coronary artery disease. Electrophysiologic measurements including sinus nodal recovery time, sinoatrial conduction time, intraatrial conduction time, atrial, atrioventricular (A-V) nodal and ventricular refractory periods and intraventricular conduction time were obtained before and after intravenous infusion of tocainide. At blood levels shown to be effective against ventricular arrhythmias, tocainide produced no statistically significant changes in the electrophysiologic measurements, although occasional marked individual effects were observed. No side effects were observed during these studies. No adverse effects on A-V conduction were observed in patients with an intraventricular conduction disturbance or a prolonged control H-V interval. Thus, plasma tocainide concentrations effective in the therapy of ventricular arrhythmias exert no adverse effects on cardiac electrophysiologic properties in patients with coronary artery disease.


Recurrent cardiac tamponade and large pericardial effusions: management with an indwelling pericardial catheter. A new technique, using an atraumatic indwelling catheter, has been developed for short-term management of large or rapidly reaccumulating pericardial effusions. This technique (1) permits continuous pericardial fluid drainage, obviating repeated aspirations; (2) provides a convenient route for intrapericardial instillation of chemotherapeutic agents; and (3) enables one to await the results of diagnostic studies without subjecting a patient to thoracotomy. Experience in three patients suggests that in some cases the use of this catheter may eliminate the need for surgery; in others, it may serve as a valuable temporary measure to achieve stabilization of the patient's condition.


Diagnosis of dissecting aortic aneurysm with suprasternal echocardiography. A 33 year old woman with Marfan's syndrome and aortic root dissection was studied with precordial and suprasternal echocardiography. The precordial approach revealed some typical features of aortic root dissection. With suprasternal echocardiography it was possible to visualize the characteristic diagnostic feature of this disease: within the aortic lumen an m-shaped pattern--the aortic intimal flap--moving downward to the posterior aortic wall during systole. The diagnosis was confirmed with aortic cineangiography and intraoperative findings. Thus, suprasternal echocardiography can be a useful method of detecting aortic root dissection, especially in patients with aortic arch dissection alone.


Systemic hypertension complicating tetralogy of Fallot: effects of antihypertensive therapy. A 20 year old woman with tetralogy of Fallot and an associated atrial septal defect presented with severe hypertension and congestive heart failure. She had been acyanotic for several years. An acute trial of antihypertensive therapy during cardiac catheterization resulted in severe systemic oxygen desaturation and loss of consciousness. Since surgical correction, antihypertensive therapy has been well tolerated. This case demonstrates the hemodynamic importance of systemic vascular resistance in tetralogy of Fallot and the need for extreme caution if aggressive antihypertensive therapy is attempted before surgical correction.


Effect of propranolol on fetal tachycardia in diabetic pregnancy. Propranolol was administered during the last 20 days of pregnancy to a diabetic woman because of fetal tachycardia (heart rate approximately 200 beats/min). With a daily dose of 160 mg of propranolol, a fetal heart rat of 120 to 160 beats/min could be achieved. Blood concentration of propranolol was measured in the mother and infant after birth. The level in the neonatal blood was 20 percent of the maternal sample, which is definitely higher than expected from animal experiments. No undersirable effect of propranolol treatment was detected. Postpartum, the infant demonstrated paroxysmal supraventricular tachycardia, and propranolol was again essential in maintaining a normal rate.


Myocardial imaging with thallium-201: a multicenter study in patients with angina pectoris or acute myocardial infarction. A multicenter study of rest and exercise thallium-201 myocardial imaging in 190 patients from five centers was performed. Exercise images were obtained after graded treadmill or bicycle stress with use of five different gamma camera models and were interpreted by the originating investigator without knowledge of other clinical data. Of 42 patients with less than 50 percent coronary stenosis, 4 (10 percent) had a resting image defect, 1 (2 percent) a new exercise defect and 5 (12 percent) either a resting or an exercise image defect, or both. Of 148 patients with coronary stenosis of 50 percent or greater, 64, (45 percent) had an image defect in the study at rest, 90 (61 percent) had new or increased defects after exercise, and 115 (78 percent) had resting or exercise defects, or both. New exercise image defects were more common than exercise S-T depression (90 of 148 [61 percent] versus 62 of 148[42 percent]; P less than 0.01). In a second group of 111 patients with acute myocardial infarction studied at three centers, 90 patients (81 percent) had image defects compared with 71 (64 percent) two had new electrocardiographic Q waves (P less than 0.01). Smaller infractions, as assessed with serum enzyme values, and diaphragmatic infarctions were less commonly detected than larger or anterior infarctions. These findings suggest that myocardial imaging complements the electrocardiographic identification of acute myocardial infarction of exericse-induced myocardial ischemia.


Exercise-induced left ventricular dysfunction in symptomatic and asymptomatic patients with aortic regurgitation: assessment with radionuclide cineangiography. In patients with aortic regurgitation,, left ventricular dysfunction at rest, which is associated with a poor long-term prognosis, often develops before severe symptoms. To determine whether evidence of left ventricular dysfunction could be detected before it appeared at rest, 43 patients with severe aortic regurgitation were studied using radionuclide cineangiography during exercise. In 30 normal subjects, left ventricular ejection fraction increased during exercise (57 +/- 1 percent [mean +/- standard error] at rest, 71 +/- 2 percent during exercise, P less than 0.001). In contrast, among 21 symptomatic patients, ejection fraction was normal at rest in 14 patients (average 47 +/- 2 percent) but normal during exercise in only one patient (average 38 +/- 2 percent, P less than 0.001). Ejection fraction was normal at rest in 21 of 22 asymptomatic patients (average 62 +/- 2 percent) but was normal during exercise in only 13 (average 57 +/- 3 percent, P less than 0.001). Thus, exericse-induced left ventricular dysfunction can precede symptoms and dysfunction at rest. Radionuclide assessment of left ventricular function during exercise may prove valuable in sequentially following the state of left ventricular function in patients before the onset of symptoms or of irreversible left ventricular failure.


Exercise training and plasma catecholamines in patients with ischemic heart disease. A 3 month program of exercise training was carried out in 10 patients with ischemic heart disease to assess the contribution of catecholamines to the training effect of improved exercise capacity and enhanced myocardial oxygen delivery. Training resulted in a significant increase in maximal treadmill exercise time (mean +/- standard error the mean 374 +/- 28 versus 567 +/- 33 seconds, P less than 0.0001). The heart rate-arterial pressure product, an index of myocardial oxygen consumption,  was decreased at rest and at all levels of exercise after training. After training, the mean plasma norepinephrine level during supine rest was reduced (320 +/- 23 to 191 +/- 20 pg/ml, P less than 0.01) and plasma epinephrine values were unchanged. When these previously sedentary patients exercised on a treadmill to the maximal level attained before exercise training, the mean plasma norepinephrne and plasma epinephrine concentrations were  significantly reduced. These data suggest that the beneficial adaptations of the cardiovascular system to exercise training are at least partially mediated by changes in the catecholamine response to exercise.


Slow filling period/rapid filling period ratio in the apexcardiogram: relation to the diagnosis of coronary artery disease. Apexcardiograms were performed in 68 consecutive patients who had either normal findings or coronary artery disease on cardiac catheterization. The height of the a wave in relation to the total apexcardiographic deflection (a/H) and the duration of both the rapid (RFW) and the slow (SFW) filling periods were determined in each case. The patients were classified into three gorups: I, no evidence of heart disease on catheterization; II, significant coronary artery disease with elevated left ventricular end-diastolic pressure; and III, coronary artery disease with normal filling pressure. There was a significant difference (P less than 0.001) between the SFW/RFW values (mean +/- 1 standard deviation) in control subject (group I, 2.3 +/- 0.5) and in subjects with coronary artery disease (group II, 4.7 +/- 1.6 and group III, 4 +/- 1.7). Setting the upper limit of normal for SFW/RFW at 2.8 (mean + 1 standard deviation) identified 94 percent of patients, in group II, 71 percent of patients in group III and 86 percent of all patients with coronary disease (group II plus group III). This sensitivity appeared greater than that of the a/H ratio. Only 2 of 17 patients (12 percent) without coronary atherosclerosis had an SFW/RFW ratio greater than 2.8. It is concluded that (1) the slow/rapid filling period ratio is a useful noninvasive measurement for identifying subjects with ischemic heart disease; (2) the increased values for slow/rapid filling period ratio associated with obstructive coronary lesions may be caused by impairment of early left ventricular distensibility; and (3) this ratio should be determined in patients with other forms of heart disease to determine its specificity.


Echocardiography: pericardial thickening and constrictive pericarditis. A total of 167 patients with pericardial thickening noted on M node echocardiography were studied retrospectively. After the echocardiogram, 72 patients underwent cardiac surgery, cardiac catheterization or autopsy for various heart diseases; 96 patients had none of these procedures. In 49 patients the pericardium was directly visualized at surgery or autopsy; 76 percent of these had pericardial thickening or adhesions. In another 8 percent, pericardial adhesions were absent, but no comment had been made about the appearance of the pericardium itself. In the remaining 16 percent, no comment had been made about the pericardium or percardial space. Cardiac catheterization in 64 patients revealed 24 with hemodynamic findings of constrictive pericarditis or effusive constrictive disease. Seven echocardiographic patterns consistent with pericardial adhesions or pericardial thickening are described and related when possible to the subsequent findings at heart surgery or autopsy. The clinical diagnoses of 167 patients with pericardial thickening are presented. The hemodynamic diagnosis of constrictive pericardial disease was associated with the echocardiographic finding of pericardial thickening, but there were no consistent echocardiographic patterns of pericardial thickening diagnostic of constriction. However, certain other echocardiographic abnormalities of left ventricular posterior wall motion and interventricular septal motion and a high E-Fo slope were suggestive of constriction.