[Use of semipermeable membranes in several histochemical reactions]. A method for using semi-impermeable membranes in histochemical reactions is described by the example of studying the activity of acid phosphatase in white mouse kidneys. The advantage of this method over the classical histochemical methods of detection of the acid phosphatase activity in the kidney is that it does not require fixation of the material to be examined, permits a long-term storage of the preparations necessary for repeated histoenzymatic-chemical studies and is highly accurate in the determination of the enzyme activity because the losses of its activity unavoidable with the use of a liquid incubation medium are absent in this method.


[Debatable and unclear questions concerning the morphogenesis of cancer of the large intestine and rectum]. The analysis of the pertinent literature shows that there is no reliable evidence on the essential importance of intestinal adenomatous polyps in carcinogenesis. The villous and glandular-villous tumours very often are considered to be highly malignant. However the growth pattern as well as histological, iltrastructural, histochemical, immunological, and other characteristics of villous tumours are close to those of adenocarcinomas. Therefore, villous tumours without invasion can be referred to as either carcinoma in situ of superficial cancer. The combination of experimental investigations and studies on human material indicates that colonic cancer prodeminantly develops de novo, that is, without preceeding morphological changes.


[Ultrastructure of activation of connective and lymphoid tissue cells during experimental infectious-allergic carditis]. As a result of multiple and long-term antigenic stimulation with streptococcal products in experimental infectious-allergic carditis (EIAC) in rabbits there occurs functional activation of young connective-tissue cells of the cardiac valve, endothelial and perithelial cells of myocardium vessels and cells of the lymphoid tissue. Enhanced secretion of tropocollagen is common for mesenchymal heart cells in EIAC. At that, the most marked fibrillogenesis is observed in the cardiac valve in which tropocollagen is aggregated into mature fibrillae. Fibrillogenesis is less marked around myocardial pericytes, and formation of thinner, incompletely formed pre-collagen (FLS) fibrillae is predominant. In EIAC, in lymphoid organs plasmatization of B-lymphocytes and increased immunoglobulin formation in plasma cells are observed which is most marked in cisterns of a rough ergastoplasmic reticulum of immature cells.


[Granulomatous lesions in the lungs of experimental animals]. Granulomatous lesions of the lungs and regional bronchopulmonary lymph nodes in laboratory animals which developed spontaneously but were of epidemic nature are described. Stages of the development of pulmonary lymphoepithelioid granulomas and giant cells, the appearance of caseose-like necrosis, and the development of sclerosis of the nodules are observed. The features of sclerosing of the nodules, localization of histiocytes, macrophages, and collagen fibers are similar to those in a silicotic process in the lungs developing upon administration of Si. Micelium of Aspergilli fungus detected in a number of cases is likely to be the cause of the lesion. The nodular process in its early phases can be differentiated from tuberculosis, pseudotuberculosis, sarcoidosis, and in late stages from nodular silicosis and other granulomatous reactions of hypersensitivity of the delayed type.


[Structuro-functional coniophage transformation as a response to fibrogenic dust and the possibility of its medicinal correction]. Electron microscopic and cytochemical studies indicate that structural and functional changes in coniophage occur under the influence of fibrogenous dust. These changes consiste in fragmentation of single phagolysosomes containing dust particles with the release of the contents into the cytoplasm, disorders in the structure of mitochondria, granular endoplasmic reticulum, and plate apparatus. These changes lead to a decline in the bioenergetics and biosynthetic function of coniophage. At a late stage, a damage of phagolysosomal apparatus as a whole causes autolysis of the cell. A principal possibility of directed effect on the membrane structures of coniophage for the purpose of influencing the initial mechanisms of silicosis development is demonstrated.


[Pathogenesis and classification of ischemic heart disease]. Modern clinicians encounter considerable difficulties in the diagnosis and treatment of ischemic heart disease which is first of all due to insufficient knowledge of the main mechanisms of the development of coronary insufficiency, myocardial dystrophy, myocardial necrosis, and cardiosclerosis. From the point of view of molecular cardiology, myocardial hypoxia cannot be considered as the foundation for ischemic disease. Metabolic insufficiency of the heart both of coronary and non-coronary origin should also be taken into account. Apart from ischemic (coronary) disease, ischemia of the myocardium alongside with metabolic disorders occurs in most diverse conditions and diseases. Therefore, in future this diagnosis will be reconsidered towards a more accurate determination of the causes of these disorders. Examples from clinical practice are presented for the discussion os such causes and mechanisms. A classification of the causes of metabolic heart deficiency and its outcomes is proposed.


[Pathologic anatomy of experimental pneumoconiosis induced by coal dust in different stages of metamorphism]. The paper presents the results of investigations of experimental pneumoconiosis caused by inhalational administration of coal dust of the III and IV stages of metamorphism, of the similar petrographic composition without quartz admixtures. Coal dust of the IV stage of metamorphism was found to have more marked fibrogenic properties. Within 6-9 months, fibro-dust foci, destructive bronchites and pulmonary emphysema developed. Coal dust of the III stage of metamorphism within the same period causes only the development of cellular-dust foci, catarrhal bronchitis, and slightly manifest emphysema.


[Morphofunctional state of the cellular elements of a tuberculous granuloma]. In the process of histogenesis of tuberculosis granuloma in which the leading role belongs to cells of the bone-marrow origin their initial ultrastructure is rearranged and forms characterized by a high functional activity emerge. Mononuclear cells are transformed both into macrophages and epithelioid cells. Ultrastructural and functional differences in epithelioid cells were found. Some of them synthesize mainly hydrolytic enzymes, others protein, still others apparently produce glycosaminoglycans. The former have functions of macrophages, in the others no signs of phagocytosis are observed. Complexes of contacting epithelioid cells are one of the sources of multinuclear giant cells.


[Histologic and ultrastructural features of human parathyroid cancer]. Histological and electron microscopic examinations of cancer of the human parathyroid gland showed different histological variants of cancer from dark chief cells to be characterized by polymorphism of the size and shape of the cells, atypical nuclei, a decreased number of organelles, increase of their polymorphism, appearance of centrioles with satellites typical of rapidly proliferating cells. Acidophilic cells of a solid variant of cancer were characterized by polymorphism of the size and shape, and the presence of a large number of mitochondria with osmiophilic or clear matrix and polymorphic cristae. All histological variants of cancer of the parathyroid gland have foci of necrosis, invasion of tumor cells into the gland capsule, and into the blood and lymph vessels.


[Morphologic criteria for the initial forms of stage Ia invasive cancer of the cervix uteri]. Morphological study was carried out on biopsy and operation materials from 107 patients with initial forms of cervical cancer. The initial forms of cancer include lesions suspect for infiltrative cancer, and infiltrative cancer with the depth of invasion not more than 3 mm. The condition of the stroma in initial invasion which is considered to be a defence reaction is described in detail. In 85% of the patients the infiltrative cancer developed against the background of carcinoma in situ, in 15% against the background of dysplasia. The authors believe that the morphological features of the initial invasive forms are sufficient for distinguishing them as a separate stage Ia.


[Stimulating effect of fetal serum on the regeneration of several tissues]. Experiments in 164 animals carried out by morphological, histochemical, morpho-functional and clinical methods established the fact of stimulation of the recovery processes in post-operational wounds of the stomach, urinary bladder, and radius upon parenteral inoculation of the fetal serum. The process of healing of these wounds was found to be shortened by 10-25%. The main effect of the fetal serum is directed on activation of the proliferative processes of a young connective tissue in the reparation zone. A hypothesis of the stimulating role of embryospecific proteins (alpha-fetoprotein) is suggested.


[Malignant carcinoid that developed against a background of chronic gastric ulcer]. A description of malignant carcinoid of alveolartrabecular structure developing in the edge of chronic progressive gastric ulcer is presented. Granules detectable by argirophilic method of Grimelius, toluidine blue after acid hydrolysis, and lead hemotoxylin were found in the cytoplasm of tumor cells. Changes in the epithelium of the type of cancer in situ as well as marked hyperplasia of argirophilic cells were observed in gastric mucosa in the edges of the ulcer. Although this observation may be interpreted as a peculiar variant of Zollinger-Ellison syndrome, it is more likely that this is a malignized chronic ulcer with carcinoid differentiation of the tumor tissue.


[Recurrences of ovarian granulosa cell tumors]. Investigations of two cases of relapses of granulocellular tumors of the ovaries established their characteristics: cyst formation in nodes of the tumor growing on the peritoneum, formation of Call-Exner strucutres characteristic of the ovary tissue in tumors, and growth of the tumor on serous integument without ingrowing into the parenchyma of the abdominal cavity organs. The similarity of the observed characteristics of peritoneal tumor with typical signs of the ovary tumors suggests that mesothelium retains some properties common to those of the ovary tissue and acquired in embryogenesis.


[Ultrastructural changes in the epithelial cells of the small-intestinal mucosa in liver cirrhosis]. Electron microscopic study of epithelial cells of cryptae and villi of the mucous membrane of the small intestine was carried out in 11 patients with portal cirrhosis of the liver in the active phase. Changes including a decrease in the number of ribosomes, impaired structure of mitochondria, microvilli, terminal reticulum, and glycocalix were found. Epithelial cells of the villi were affected more than the epithelium of cryptae. These changes were identical in the duodenum and in the proximal part of the jujunum.


[Changes in the ultrastructure of parietal cells of gastric glands in chronic gastritis]. The studies of the ultrastructure of parietal cells in chronic gastritis revealed changes in mitochondria manifested by clearing of the matrix, reduction in the number and length of christae and partial or complite vacuolation of the cytoplasm. Changes of intracellular microtubules and endoplasmic reticulum were also found. The described disorders in the ultrastructure of parietal cells in chronic gastritis are the morphological substrate of disoredrs in hydrochloric acid secretion in this disease.


[Pathological aspects of acute suppurative infections of different etiology and localization]. In the past decade the rate of purulent infectious complications caused by staphylococci and gram-negative bacteria of the genera Pseudomonas and Enterobacteriaceae which are highly resistant to antibiotics has increased. In therapeutic institutions these microbes cause group contageous diseases which are called "hospital infection". They are characterized by the development of fibrinopurulent, purulent, or purulent-necrotic inflammation. The amount of necrotic changes, the depth of extention of the inflammatory process, and the severity of general toxicity in progressive infection depend considerably on the features of toxins, enzymes, and other biologically active substances of the causative agents. Differences in the pathogenesis, clinical and morphological manifestations, and specific antibacterial means for therapy of purulent infections require that individual forms are distinguished among them by etiology.


[Morphology of the liver in peptic ulcer and postgastrectomy complications (electron-microscopic study)]. Electron microscopic examinations of 13 liver biopsies obtained from 4 patients with duodenal ulcer, 4 with peptic ulcer of gastroenteroanastomosis and 3 with the dumping syndrome showed these diseases to be accompanied by nonspecific ultrastructural changes in hepatocytes, intercellular connections, the system of bile tubules and microcirculatory bed which are more marked in postgastroresection complications and not always correspond to the histological condition of the organ, particularly when changes in its histological structure are not very marked. From the fact that the range of ultrastructural changes in the livers of patients of these groups are more extensive and variable than histological ones, it may be assumed that the intact histostructure of the organ does not exclude the occurrence of pathological processes in it.


[Plasmocytic granuloma of the lungs].

[Plasmocytic granuloma of the lungs]. Research Institute of Tuberculosis of the RSFSR Ministry of Public Health, Moscow Summary-Five observations of plasmocytic granuloma from the resected lungs are described. Polymorphism of the cell composition of these formations and the stages of their development reporter in literature are based on proliferation of the cells of mononuclear phagocytic system. Therefore the authors consider plasmocytic granuloma to be a local manifestation of incompetence of compensatory reactions of this system.


Hematologic observations made in patients with acute respiratory distress syndrome in the cooperative ECMO project. In a recently completed three-year multicenter trial, 90 individuals with adult acute respiratory distress syndrome (ARDS) were randomly allocated to conventional therapy with or without long-term extracorporeal membrane oxygenation (ECMO). This study conclusively demonstrated that ARDS is associated with frequent major bleeding and thrombotic episodes and that the bleeding correlates best with the degree of thrombocytopenia and is enhanced by the machine. Neither heparin's therapeutic efficacy nor its ability to increase bleeding could be proven. ARDS is associated with a complex coagulation disturbance. Besides thrombocytopenia, there were lowered circulating levels of factors VII and XII which may be related to changes in the pulmonary endothelium. ECMO was associated with relative leukopenia and a marked shift to immature circulating leukocytes. Further studies are needed to better define the clinical importance of thrombosis and bleeding in the lung, the role for heparin in treatment, and the meaning of reductions in coagulation factors in defining the course, prognosis and response to therapy of patients with ARDS.


Uremic neuropathy: evidence of middle molecule toxicity. Ten dialysis patients were followed in a prospective study to determine the neurotoxicity of metabolites in the middle molecule (MM) molecular weight (mol wt) range of 500-200 daltons/molecule. In the absence of readily available direct serum measurements of MM concentrations, a theoretically calculated dialysis index, D1(MM), which included the combined effects of dialysis and residual glomerular filtration rate (GFR) on MM removal was used to estimate changes in their predialysis concentrations. The ten patients were dialyzed on protocols which yielded a D1(MM) less than 1.0. Evidence of uremic neuropathy developed in six of these ten patients, and five of these six also developed a progression in their anemia. Two additional patients with no signs of neuropathy developed a progression in their anemia. One patient developed pericarditis with tamponade. A total of eight patients developed complications. One additional patient developed increased weakness, tiredness and general malaise without change in objective findings. When the dialysis therapy to reduce MM concentrations by increasing the D1(MM) above 1.0 was instituted, the complications were reversed. Our data support the findings of others, namely, that there are toxic substances in the MM mol wt range of 500-2000 daltons/molecule. However, a synergism between elevated concentrations of small molecules and MM cannot be ruled out.


Human thoracic anatomy relevant to implantable artificial hearts. The objective of this study is to define the human thorax in a quantitative statistical manner such that the information will be useful to the designers of cardiac prostheses, both total replacement and assist devices. This paper pertains specifically to anatomical parameters relevant to the total artificial heart. Methods were developed for generating an integrated, statistical model of the anatomical structures within the human thorax. These methods involve definition of the anatomy in four areas: chest wall, pericardium, vascular connection locations, and great vessels. Results are presented in three dimensional scale views of the human thorax showing the main features pertinent to cardiac prosthesis implantation. Statistical variability of this data is also included. Measurements were obtained from a number of sources and represent both normal and diseased patients. The ERDA total artificial heart was shown to successfully fit the fiftieth percentile adult male human.


[Principles of growth in the acetabulum. Consequences for the shelf operations (author's transl)]. Not unlike a Mercedesstar the arms of the Y-growthzone divide the cup of the acetabulum into three equal segments. The three branches of the Y-zone are spheroid. So the socket can expand evenly and conform to the head by feed back. Otherwise the socket would fill up. For the cartilage of the concave acetabulum proliferates by apposition to its uppermost layers, exactly as the hyaline cartilage does in the convex condyles. The trend of the socket during growth goes outwards, forwards and downwards. It moves away from a metal mark, set into the ileum flush with the shelf. It is precisely this increasing distance, that happens to a surgical shelf in a child. Failure will be inevitable. 614 shelf operations checked.


[Subchondral cysts of the iliac acetabulum (author's transl)]. Subchondral solitary bone cysts occur, as well as in numerous other places in the skeletal system, also in the roof of the acetabulum. These cysts differ from typical arthrosis growelcysts in form, position and X-ray appearances. They can be found in hips otherwise normal on X-ray examination (Group I), or in the presence of prearthrosis or arthrosis (Group II). The clinical features and the pathological anatomy of this form of bone cysts are discussed, as well as its aetiology. The pain precipitated by these cysts is very favorably affected by operative filling of the cyst with autologous spongiosa, as shown by follow up of the 19 operations done by the authors. These operations were done on an average 7 years previously. The result was good or satisfactory in 17 out of these 19 cases. The 2 treatment failures were due to wrong indication for operation--the simultaneous arthrosis was already too advanced. The authors prefer for this operation the Watson-Jones approach and recommend, if a large acetabulum-roof-cyst is present, immediate filling of the cyst also if an intertrochanteric osteotomy is done at the same time because of prearthrosis or arthrosis.


[The relevance of histological results for the evaluation of materials for bone replacement (author's transl)]. Different groups have observed and reported deviating tissue reactions for the same material for bone replacement: for the "bioinert" Al2O3-ceramic close bone contact is mentioned, others report about a soft tissue layer adjacent to the implant; for the "bioactive" glass ceramic interfaces capable to transmit considerable shear forces are described, others found no interface bonding.--The analysis of the results of animal experiments and the evaluation of clinical follow-up studies show that these discrepancies had been caused by the differences of the biomechanical situations in the examined interfaces. It is pointed out that the negligence or not mentioning of the load pattern at the site of examination can lead to misinterpretations about the possibilities and limits of applicability of biomaterials.


[Myotendinitis crepitans of the abd. poll. long. and the ext. poll. brevis muscles with a reactive cheralgia paraesthetica (author's transl)]. 15 patients--among them 10 bricklayers--were observed with a peracute painful swelling of the long abductor and the short extensor of the thumb following a short strain of the hand. This swelling could reach the size of an egg and was accompanied by crepitation which could be heard and felt. A concomitant neuralgic pain deriving from the superficial branch of the radial nerve was observed in 5 cases. The author discusses pathogenesis and therapy of this syndrome.


[Desmoid fibromas of the extremities (author's transl)]. Two cases of rare desmoid fibromas are being reported, localised in the extremities. After a literature review of these tumors, the clinical characteristics are pointed out and difficulties in therapy discussed. The tumors occasionally appear on the forearm or the thigh of juvenile patients and show a similar development. In the first case, 7 operations with resection of the n. medianus and n. ulnaris were necessary to prevent a recurrence. In the second case, we saw a solitary and rapidly growing tumor, surrounding the sciatic nerve with a great tendency to recur.


[The biomechanical significance of the vastus medialis and lateralis muscles (author's transl)]. Anatomic considerations and electromyographic investigations show that the Mm. vasti medialis and lateralis both have a synergistic function with regard to the extension of the knee and an antagonistic function in stabilizing the rotation of the femur against the tibia. The rotational stabilisation for the femur by the Mm. vasti is very important in preventing knee injuries, especially ligamentous ruptures. On the other hand, extreme reflectoric muscle contractions, caused by a rotational trauma can cause chondromalacic lesions in the femoro-patellar joint, broadening the syndrome of the "unhappy triad" to an "unhappy tetrad".


[The influence of low-frequency DC (system Kraus-Lechner) on bone growth (author's transl)]. Osteons of Beagle-ulnae were calculated in growth. Controlled osteons were compared with osteons after "therapy". Stimulation was made with electro-nails system Kraus-Lechner. The mean-values of osteons after "therapy" surpass control. The fundamental question, whether induction of bone growth occurs with low frequency electromagnetism will in all probability be have to answered in the affirmative.


[On the morphology of the hyalin cartilage under immobilization and remobilization (author's transl)]. Structural degenerative changes in the hyaline cartilage of joints induced by immobilization are well known. To find out whether these changes are reversible, the right knee-joint from rabbits was immobilized by extra-articular fixation for 2 or 4 weeks, respectively. In 8 animals the joints were then remobilized for 6 months. Cartilage of the joints was investigated by light microscopy, scanning- and transmission electron microscopy. Already after 2 weeks of immobilization changes in the superficial layer of the cartilage were obvious; after 4 weeks all components of the cartilage tissue were involved in a degenerative process. These changes progressed in the 6-month period in which the joint was remobilized. At the end of the experiment the morphology of the cartilage tissue was comparable to the structural aspect of a typical arthrosis. It is concluded that an external immobilization of a joint which comprises also a pressure on the surface of the cartilage cannot be considered as a harmless procedure. It is recommended to be very cautious with the indication of a therapeutical immobilization of a joint and, if necessary, to use it as short as possible.


Muscle fiber atrophy after cast immobilization in the rat. The purpose of this study was to evaluate the effect of 6 weeks of bilateral cast immobilization on the adult Wistar rat plantarflexors. Knee and ankle joints were fixed in the neutral position, under sodium pentobarbital anesthesia. Controls (n = 7) and cast-immobilized (n = 7) rats were sacrificed at 6 weeks after the onset of the experimental period. The muscles were evaluated for muscle weight, protein content, and fiber histochemistry. There was equal weight loss in the gastrocnemius, soleus, and plantaris muscles, and greater loss of myofibrillar protein than of sarcoplasmic protein concentrations. Fiber atrophy of types I and II was equal in the soleus, and that of type II was greater than the type I atrophy in both regions of the plantaris. All soleus and 2 plantaris muscles demonstrated fiber damage. The results of this experiment suggest that the degree of fiber atrophy is specific to the fiber type and to its location in different muscles or muscle regions.


Paraplegia: succinylcholine-induced hyperkalemia and cardiac arrest. The rapid development of hyperkalemia leading to cardiac arrest can occur in patients with spinal cord injuries and other conditions when succinylcholine is used during the induction of anesthesia. Three patients with thoracolumbar spinal cord injuries resulting in lower motor neuron lesions or lesions above the lower extremity motor units developed hyperkalemia followed by cardiac arrest after succinylcholine administration. The mechanism by which succinylcholine leads to hyperkalemia from denervated muscle is described and precautions to be taken are mentioned. Physicians caring for patients with denervated muscle due to spinal cord injuries should be aware of this danger and nondepolarizing muscle relaxants should be used instead of succinylcholine.


Peripheral nerve involvement in spinal cord injury: an electromyographic study. This electromyographic study was undertaken to assess the peripheral nervous system in patients with various types of paraplegia. Twelve patients were studied. In 8 patients the paraplegia was of the spastic type while 4 had flaccid paraplegia. Electromyographic abnormalities consisting of denervation potentials, slowed conduction and inexcitability of nerve were demonstrated in the lower limbs of all patients. These findings suggest a diffuse neuropathy of unknown cause, although local pressure palsies may have occurred in some patients. Because this involvement was more apparent in the flaccid group of paraplegic patients as compared with the spastic one, it is concluded that the peripheral nervous system plays an important role in determining the type of paraplegia that develops following complete spinal cord lesions.


Idiopathic scoliosis: an electromyographic study. Thirty-one patients from 12 to 19 years of age having idiopathic scoliosis underwent electromyography of the paraspinal musculature using a Teflon-coated monopolar electrode. The studies conducted with the patients both prone and standing revealed no abnormalities on electrode insertion suggestive of a neuropathic process. In the prone position 29 patients had electrical silence on both the concave and convex side of the curvature. In the standing position most of the patients had asymmetrical activity with a preponderance of activity on the convex side. However, 33% of the patients in whom the spinal musculature was silent in the standing position had balanced curves. This observed correlation between a balanced curve and electrical silence warrants further study.


Spirometry in convalescent hemiplegic patients. The forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) were determined in 20 patients with convalescent hemiplegia. The FVC and FEV1 were reduced and the PEFR was within normal range. These results indicate a restrictive ventilatory defect with an FEV% that approached the vital capacity. The physical ability of each patient was assessed on the basis of the time it took to walk a distance of 18.5 meters as quickly as possible. Although it appears from the results that physical ability did not bear any relationship to the degree of restrictive ventilatory defect, other parameters of spirometry may be needed to confirm this. The results suggest that the restrictive ventilatory defect will be of more clinical importance in exercise tolerance for strenuous exercise than in ordinary daily activities.


Epidurography in reduction of lumbar disc prolapse by traction. As epidurography uses a water-soluble contrast medium in the diagnosis of disc lesions, this procedure can be repeated, unlike conventional myelography which uses an oily contrast medium. Successful employment of epidurography before and after traction in 14 cases of adult prolapsed intervertebral disc syndrome is described.


Language impairment evaluation in aphasic patients: developing more efficient measures. Two short forms of the Porch Index of Communicative Ability (PICA) were derived using data from 50 adult aphasic patients. Subtest, modality and overall intercorrelations, internal consistency reliability estimates, means and standard deviations were computed for both forms and full-length test. Results indicate that the short forms are equivalent. Further, they seem to be measuring the same traits as the long form, have only slightly lower reliability, and have practically identical means and standard deviations across all subtest, modality and overall scores.


Program evaluation of a physical medicine and rehabilitation unit: a new approach. Rehabilitation units must meet the increasing demand for empirical documentation of the quality of care patients receive. Hospitals wanting to do program evaluations will find few published materials providing norms by which to judge the adequacy of the functional outcomes achieved by their rehabilitation patients. The purpose of this research was to develop an approach to program evaluation that would serve the accreditation needs and would be relatively inexpensive to implement. Sixty-nine consecutive admissions for cerebral vascular accidents (CVA) were assessed on activities of daily living (ADL) and cognition using a behaviorally defined procedure called the "Level of Rehabilitation Scale" that was developed for program evaluation purposes. Nurses and spouses of patients were interviewed to obtain the observations that were rated. Further ratings on ADL and cognition were made at discharge. Those at home 6 weeks and 4 1/2 months after discharge were assessed on the same scales and on home-relevant activities. Experience with the instrument showed that ratings of function can be made in a reliable and valid fashion. The research provides the beginning of the accumulation of improvement norms for CVA inpatients and documents maintenance of improvement 4 1/2 months after discharge. Hospitals and rehabilitation units can utilize these norms and this method of program evaluation economically using nonclinically trained staff.


Communications options for patients with brain stem lesions. The communication treatment programs of five individuals with brain stem lesions were reviewed. The sequence of treatment included the following stages: early establishment of communication, establishment of a flexible nonvocal communication system, development of functional verbal communication, and maximizing intelligibility of speech.


Dumbbell neurilemoma simulating lumbar disk disease. The beneficial response to a nonsurgical program for lumbar disk disease in a 56-year-old woman seemed to obviate invasive procedures. Fourteen months later, the previous symptoms and findings recurred. A myelogram showed a block at T12-L1 and a small herniated disk at L4-L5. A neurilemoma was removed. The patient is well 4 years later.


Secondary spinal lesions in spinal cord injury patients. On hospital admission, 6 spinal cord injured patients were noted to have second noncontiguous levels of spinal injury that were previously unrecognized. These secondary levels of spinal injury were diagnosed as a result of routine admission total spine radiographic examinations. Two cases are described in detail, one with the secondary spinal lesion above and the other below the primary spinal cord injury. Careful total spine radiographic studies are recommended to prevent complications, in the event that such lesions are initially unrecognized.


Inverted spinal traction.

Inverted spinal traction. The effect of inverted positioning on spinal length and electromyographic (emg) activity of superficial lumbar area musculature was investigated in 20 healthy men. Spinal length tape measurements were taken with subjects first sitting erect and after 1 minute in the inverted position. An integrated bioelectric monitoring system was used to quantify emg activity. Initially, a stable emg baseline was identified for each subject resting supine on a motorized tilt table. The randomly selected control group subjects remained supine for an additional 245 seconds. Experimental group subjects were inverted for half this duration and returned to the resting position for the remainder. Data were recorded for 10-second accumulation periods of emg activity 16 times from each subject. The 1-tailed paired t-test was applied to all data. The difference between the means of the spinal length measurements taken sitting and during inversion was highly significant (p less than 0.005). The difference between the mean emg activity of the inversion period and the baseline mean was also statistically relevant (p less than 0.03). This study concluded that inverted positioning for short periods significantly increased spinal length and reduced emg activity of the superficial lumbar area musculature of normal males. These findings complemented the clinical observations of several authors.


Muscle state: reaction and movement time in elbow extension. Eleven subjects reacted to a randomly timed auditory stimulus by extending their right elbows as rapidly as possible under agonist muscle normal state, pretensed and relaxed conditions. Integrated electromyography (emg) was used to validate and quantify muscle state. Total reaction time was divided into premotor reaction time and motor reaction time components, and elbow movement time was measured under all conditions. Significant differences were observed in the integrated emg between the pretensed and relaxed experimental conditions. Differences were observed in total reaction time and premotor time, but not in motor reaction time or movement time.


Pulsating shortwave diathermy: value in treatment of recent ankle and foot sprains. The effects of 2 pulsating shortwave diathermy treatments (Diapulse and Curapuls) were compared with placebo treatment in recent ligamentous injuries of ankle and foot in 300 outpatients. The areas of comparison were reduction in swelling, recovery of strength and range of motion of the injured ankle, improvement of walking ability, and duration of disability. There were only slight differences between Diapulse and Curapuls treatment groups. No statistically significant differences could be observed in the recovery of strength and range of motion or in the duration of disability among the 3 groups, although walking ability in the Diapulse group recovered better than in the placebos (p less than 0.01) and reduction of swelling was significantly better for Curapuls (p less than 0.001 than for placebos.


Oral health services for adult rehabilitation patients: three illustrative cases. Recent research has shown that the actual capability of physical medicine and rehabilitation units to provide oral health services is less than the need as perceived by rehabilitation administrators. Three cases have been selected to illustrate the nature and diversity of health benefits that can be provided by a complete oral health service which focuses on rehabilitation patients. The advantages of offering a comprehensive oral health service include not only improvement of the oral health of the patient but also often directly aids the patients' achievement of overall rehabilitation goals. Furthermore, by synergistic interaction with the other rehabilitation disciplines, an oral health service can appreciably enhance the quality and the scope of the rehabilitation program itself. Additionally, a new adaptive device for oral grasping, designed for use by patients who lack the use of their upper extremities, is illustrated. The device is intended to provide the patient with a range of functions including recreational participation in board games as well as vocational activities which require the lifting or grasping of objects.


Pentazocine fibrous myopathy: report of two cases and literature review. Two patients are described in whom the analgesic, pentazocine (Talwin), injected intramuscularly over long periods of time, resulted in a fibrous myopathy of the injected muscles. Although early testing of pentazocine indicated a low abuse potential and no skin or muscle complications, reports of such abuse and complications have since appeared in the literature, a review of which is included.


Neurophysiologic syndromes in stroke as predictors of outcome. Outcomes in self-care following rehabilitation in 226 patients were correlated with 11 stroke syndromes, reflecting several pathophysiologic disturbances subsequent to either infarction or hemorrhage in cerebral or vertebro-basilar vessels. Self-care was scored on a 20-point scale for bed movements, transfers, feeding, dressing, personal hygiene, and bathing. Interjudge error among therapists did not exceed 2.5%. Mean score in left cerebral infarction without aphasia was used as a referent value. Scores in left cerebral infarction with aphasia and right parietal lobe syndrome with and without spatial agnosia were similar to the referent. Brain stem dysfunction with spasticity and right cerebral infarction with paresis and spatial agnosia fell below the referent value (Pless than 0.05). Higher levels were achieved in the syndromes of left and right anterior cerebral artery territories, brain stem dysfunction with ataxia, and left parietal lobe syndrome with comprehension aphasia, although t-values were not significant. Length of stay among the 11 groups was fairly uniform except for the  group with brain stem dysfunction with spasticity and the group with left hemiplegia with spatial agnosia. These groups indicated rather severe disabilities. Aside from neurologic dysfunction the range of scores was influenced by associated cardiopulmonary involvement.


Independent living rehabilitation needs of postdischarge stroke persons: a pilot study. The responses of 73 poststroke persons to a rehabilitation needs scale were analyzed. Forty-two of the respondents were married, and their spouses were interviewed separately. Four null hypothesis were tested: (1) Postdischarge stroke persons would not perceive themselves as still having rehabilitation needs. (2) The more frequent need statements would not be psychosocial in nature. (3) The frequency of need statements made by married stroke persons would not be different from single stroke persons. (4) Married stroke persons and their spouses would not be different in need statements made. Null hypotheses 1 through 3 were rejected at the P less than 0.01 level, but hypothesis 4 was not rejected. The sample stroke population perceived themselves as still having rehabilitation needs, and stroke patients or their spouses could be used as informants about rehabilitation needs. Single and married stroke persons emphasized different needs, particularly in the area of vocational rehabilitation. This statistically significant different (P less than 0.001) may stem from a dramatic discrepancy in income levels. The average income monthly for single stroke persons was $369, while the average income monthly of married stroke persons was $1120.


Cancer rehabilitation: assessment of need, development, and evaluation of a model of care. A sample of 805 cancer patients, comparable to but not identical with a national study, was screened to identify: rehabilitation problems encountered at different cancer sites; the need for rehabilitation services; and gaps in the delivery of rehabilitation care. Significant numbers of rehabilitation problems were found that could be improved by rehabilitation care. Psychologic  problems were commonly encountered and seemed more severe in patients with physical disabilities; these patients have to make adjustments to both life-threatening disease and to a disabling condition. The findings suggest a need for psychosocial support services on any oncology service; where cancer is associated with significant physical disability, a comprehensive rehabilitation team with psychologic management capability is often needed. Primary barriers to optimal delivery of rehabilitation care are the lack of identification of patient problems and/or lack of appropriate referral by physicians unfamiliar with the concept of rehabilitation. Health care financial support for the patients in the sample came primarily from private insurance, Medicare and Medicaid; financial support from the patient's family held up well even in the advanced stages of the disease. A model of rehabilitation care delivery was established and implemented, with the result being that gaps and barriers to rehabilitation service delivery disappeared rapidly.


Imprisonment of patients in the course of rehabilitation. The patient carries the major responsibility and plays the most significant role in the rehabilitation process. It is appropriate to continuously examine rehabilitation management techniques to determine the degree to which they facilitate or inhibit patient participation. Of 213 consecutive inpatients on the rehabilitation service of an urban municipal hospital serving a black community, 53 requested discharge before the team considered it advisable. Thus, one patient in four differed with the staff on the decisive issues of functional ability within the environment and readiness for discharge. These "imprisoned patients" were confined against their wills. Improved communication between patients and staff, patient education and mutual goal-setting would yield greater patient participation on the decision-making process.


Rehabilitation of patients with multiple sclerosis. There are inherent difficulites in the rehabilitation of patients with multiple sclerosis (MS). The clinical manifestations of the disease vary tremendously, as does its natural course. The many theories on the etiology, pathogenesis and treatment of MS are presented. However, at the current time, the patient with MS may be treated with the realistic goal of minimizing the effects of the disease. This is accomplished best in a rehabilitation setting. Diagnosis, prognosis, and factors associated with precipitaiton or exaggeration of symptoms, are discussed. Specific techniques of rehabilitation of decreased motor power, spasticity, ataxia and intention tremor, speech and optic defects, and impaired sensation are presented. Decubiti and ulcerations, bladder and bowel problems, and sexual dysfunction are recognized as common problems and attention must be directed to these. The importance and wide array of emotional difficulties in patients with MS is emphasized, and those patients who may benefit from psychotherapy are discussed.


Custon handles of dental acrylic to promote self-sufficiency of handicapped patients. Dental materials lend themselves to a multitude of applications outside the dental profession. The inherent physical properties of dental acrylic (autopolymerizing methyl methacrylate) provide the potential for practical adaptation to a variety of functional problems. A technique using dental acrylic is described, which is easily adapted to a variety of circumstances, enabling digitally handicapped patients to perform independent functions. Specific stepwise instructions are provided for the fabrication of an easily customized acrylic-handled toothbrush and an efficient one-handed knife. The combination of dental acrylic and this flexible technique provides a useful tool in the alteration of appliances for handicapped persons.


Relationship between somatic and psychopathometric variables in disorders of consciousness. Function psychosis is the most frequently observed response of the brain to disturbances in general practice and in hospital. A complete test system is presented for measuring grades of severity of function psychoses. It is possible to trace the course of the function psychosis in a curve similar to pulse and temperature curves.


The structure of vigilance.

The structure of vigilance. Vigilance is understood as a primarily behavioral category. Identical stimuli tend to evoke more or less differentiated behavioral responses dependent on a low or high state of vigilance. The rise of vigilance from coma to full attention moves along with increasing differentiation of evoked behavioral responses. With heterogeneous physical, figurative, and verbal stimuli, responses are elicited which can be arranged on an additive (Guttman) scale. Thus, vigilance is suggested to represent a one-dimensional function of the brain.


Evaluation of speech and language in neuropsychiatric disorders. Changes of language and speech in neuropsychiatric patients are described by use of a quantifying procedure. In the transcript of a standardized interview the following variables are evaluated (by estimation of indices): rate of speech, pauses, indistinct and incomprehensible articulations, aphasic disturbances, subordinate: principal clause ratio,  stuttering, neologisms, grammatical mistakes, thought disconnections, perseverations/verbigerations, vague utterances, disturbances of orientation, utterances with unusual though content, euphoric utterances, dysphoric utterances, and change of the affective state. Reliability of these indices is tested by inter-rater comparison. The course of speech-language reorganization during therapy is followed. The present method does not intend to give a detailed psycholinguistic analysis, but it yields an objective measure of clinical impressions on abnormalities of language and speech in neuropsychiatric disorders.


The measurement of change in sleep during depression and remission. Sleep disturbances, which are a prominent symptom of depressive illness, were analyzed in endogenously depressed patients during depression and during full remission. These disturbances may be described at the level of sleep stages, at the level of the sleep profile, and at the level of consecutive sleep records. The scoring of sleep stages in sleep records of depressive patients provides difficulties, because the temporal coherence of different electrophysiological descriptors of sleep is weakened during depression. The sleep profile of depressed patients is characterized by alterations in the normal sequence of sleep stages and frequent stage changes. The disturbances in the sleep profile are unstable in that they show marked day to day fluctuations. It could be shown in some patients that there is a correlation between parameters of the first REM sleep and urinary free cortisol excretion in corresponding nights.


From measurement to interpretation of change in psychopathology. The experimental literature on changes in verbal self-report, psychophyiological reactions and overt motor behavior under stress or therapy is reviewed. The concordance of changes across the systems is generally low, their order difficult to predict. The correlation of changes is interpreted to depend--besides crucial methodological issues--on the preparedness of the subject to test and to modify his propositions defining in which situations he might experience certain somato-visceral reactions and emit certain overt motor acts successfully.


[Psychological aspects of sleep deprivation. A controlled study on depressives and normals (author's transl)]. A study of total sleep deprivation for one night was performed on 12 patients with endogenic depression and 10 with neurotic depression, as well as a control group of 10 normals. The study was designed to answer the following questions: 1. Are the correlations between self-ratings and clinical assessments of sleep deprivation effects satisfactory? 2. Are sleep deprivation effects modified by the personality dimensions extraversion and neuroticism? 3. What effects do the interactions of rater and patient and their expectations have on therapeutic results? The findings confirmed the therapeutic effects of sleep deprivation in depressives. The correlations between self-ratings and clinical assessments were satisfactory. The therapeutic  effects were not significantly influenced by psychiatrist-patient interactions or their expectations. The relevance of these results to explanations of sleep deprivation effects is discussed.


[The symptom of EEG-flattening accompanying psychomotor attacks, their frequency, duration, form and significance. A video-band analysis of 78 patients with 187 attacks (author's transl)]. A total of 187 psychomotor attacks in 78 epileptic patients were recorded on video band; 48 patients (61.5%) and 100 attacks (55.5%) showed signs of EEG flattening. This flattening became manifest before the clinical onset of the fit in 11.88% of patients, simultaneously with the fit in 30.5%, during the fit in 17.1%, and at the end of the attack in 4.8%. In 10.7% of the attacks, the flattening was considered as a cardinal EEG symptom of the fit, since it lasted longer than two-thirds of attack duration. Side differences in flattening occurred only in 6.4% of all attacks. The constancy of flattening varied in patients who had several attacks. Only few cases showed consistent flattening. In 50% of attacks with a remembered aura, the flattening occurred before the clinical signs of the fit. Since EEG flattening is explained by an arousal activation of the ascending reticular formation, it is assumed that the epileptic discharge of the psychomotor attack is initiated by activation of the nonspecific ascending reticular and limbic systems. This results in EEG flattening and clinically in an unconsciousness reaction.


[Changes in lactate dehydrogenase levels in acute articular rheumatism, chorea minor and the Schönlein-Henoch syndrome in childhood]. Changes in serum LDH in AAR, Sydenham's chorea and purpura rheumatica and their significance were investigated in 103 cases observed at the 1st Paediatrics Clinic, University of Turin. A search was made for relation between such changes and the laboratory parameters in rheumatism. The data showed that blood LDH can be profitably determined in the diseases considered.


[Carcinomas of the small intestine].

[Carcinomas of the small intestine]. Two cases of carcinoma of the small intestine are described. In spite of its large epithelial surface, this organ is rarely a cancer site. For these reason, an account is given of cases observed over the previous year. In addition, mention is made of the pathological anatomy, symptomatology, preoperative investigation, and treatment of this form.


[Non-endocarditic mitral insufficiency]. A case of non endocarditic mitral insufficiency in a 76 years old woman is described. After an extensive pathogenetical introduction, a comparison is made between clinical features of this case an its pathogenetical possibilities. The conclusion is drawn that there are most probabilities for an atherosclerosis of the antero-medial limbus of the mitral valve, arising from a coexisting atherosclerotic mild stenosis of the aortic valves.


[Narcosis, platelet aggregation and arousing drugs]. During pentobarbital (25 mg/kg i.v. in 2 min), pentothal (15 mg/kg i.v. in 2 min) and ketamine (10 mg/kg i.v. in 2 min) narcosis, rabbits showed reduced platelet reactivity ot the direct aggregating effect of ADP (2 X 10(-5) M) and the indirect effect of thrombin (0.1 U/ml). Certain arousal drugs, specifically those of metabolic type such as SAMe (20 mg/kg i.v. in 2 min) and Thiola (166 mg/kg i.v. in 2 min) and of haemodynamic type such as nicergoline (6.66 mg/kg i.v. in 2 min) and hexobendine (5 mg/kg i.v. in 2 min) administered 31 min after narcosis induction, impede the depression brought on by narcosis on on platelet reactivity.


[Incidence of coronary, cerebral and lower-limb atherosclerosis in diabetics]. The literature data regarding the incidence of coronary, cerebral and lower extremity atherosclerosis in diabetes are reviewed. A retrospective assessment of data relating to in-patients of the Umberto I Hospital Medical Division during 1972-1975 showed that atherosclerosis occurs more often and earlier in diabetics. It is more frequent in women over 50, especially in the case of coronary forms. A similar high incidence of vascular lesions is also noted in subclinical forms. This is particularly true of coronary sites in females and lower extremity sites in males. It is clear that screening for glucose intolerance in all vasculopathic subjects, coupled with careful genetic and familial investigation, are essential acids to preventive and social medicine in this particular sector.


Intestinal obstruction due to phytobezoars. Observations in two patients with hypothyroidism and previous gastric surgery. Two patients had small-bowel obstruction due to phytobezoars. Both patients were hypothyroid. One patient had undergone a previous pyloroplasty for pyloric stenosis and the other a truncal vagotomy and a pyloroplasty for a duodenal ulcer. Similarities and differences between the two cases and the possible predisposing factors in the formation of the phytobezoars are discussed. The recognition of high-risk patients, and their education to prevent phytobezoars are emphasized.


Left-sided colectomy with retroileal colorectal anastomosis. Following resection of the sigmoid and descending colon for cancer or extensive diverticular disease, it may be impossible to make a colorectal anastomosis due to inadequate length of the residual transverse colon. To correct this problem, the remaining transverse colon may be pulled into the pelvis by making a "window" in the terminal part of the ileal mesentery. From January 1966 to January 1975, 302 resections of the descending colon with colorectal anastomoses were performed by one of the authors (R.B.T.) for upper sigmoid cancer and extensive diverticulitis at the Cleveland Clinic. Eleven patients (4%) had retroileal colorectal anastomoses. The retroileal apprach is a technical aid when performing an extensive left-sided colectomy and/or when there is insufficient length of residual transverse colon to make a tension-free colorectal anastomosis.


[Changes in the incidence of coronary vasculopathy in the Cosentina hospital population in the 3-year periods of 1950-52, 1956-58, 1963-65, 1966-68, 1969-71]. The incidence of admissions for coronary disease in relation to age, sex, diet, occupation and place of origin was examined for five 3-yr periods ('50-'52, '56-'58, '63-'65, '66-'68, and '69-'71). There was a marked increase in admissions and a greater incidence among middle-aged subjects and males. The percent frequency differences between urban and montane districts noted in the fifties were less apparent later in the last three-year period.


Transposed basilic vein-brachial arteriovenous fistula. A reliable secondary-access procedure. Over a two-year period, 25 transposed basilic vein-brachial arteriovenous fistulas were created as secondary vascular access procedures in patients undergoing chronic hemodialysis. The operative technique is described in detail. One-year patency rate by life-table analysis was 85%. There were two minor complications. The procedure is advocated as a reliable secondary-access procedure when a radial-cephalic arteriovenous fistula cannot be constructed or has failed.


[Alcoholism survey. Clinico-statistical study of 3009 patients in a General Medicine Division]. The alarming spread of alcoholism is noted and its aetiology is examined in the light of its many causes and influencing factors. Steps to stem the tide are discussed, along with the methods to be adopted and the persons by whom they should be put into effect. Drinkers are classed as large and small alcoholics and the incidene of alcoholism in 3009 male and female patients is examined in the light of the type of drink involved, occupation, age and reason for admission to hospital. Attention is drawn to the high number of male alcoholics. Screening for alcoholism in hospital is recommended as a means of preventing the syndrome.


[From the analysis of the inadequacies of a 200-bed zonal hospital to an alternative proposal of a single general hospital to be used by the whole territory]. The adequacy of the hospital to meet patients' needs was analysed on the basis of patients admitted to the Medicine Division over a 6 month period. Critical discussion of the numerous deficiencies encountered shows: 1) that the small zonal hospital of 200 beds is inadequate to perform the tasks and function of modern medicine; 2) that, more generally, the hierarchical distinction still ruling in regional, provincial and zonal hospitals is anachronistic. The proposal for a single General Hospital for acute patients (available for the whole territory) is put forward and the relations of this new unit with out-patient structures are defined.


Hemodynamic studies of the audiofrequency analysis of carotid bruits. The contribution of carotid audiofrequency analysis to the noninvasive diagnosis of carotid arterial lesions requires clarification. Carotid arterial stenoses were simulated in the dog and the following measurements were made: proximal and distal arterial pressure, blood flow, percent area reduction, and carotid audiofrequency analysis. A 40% area reduction produced a systolic bruit but no interference with flow or pressure. A 60% area reduction produced a pansystolic bruit and a reduction in peak systolic flow (precritical stenosis). A 70% area reduction produced a systolic bruit that extended into diastole, a reduction in mean blood flow, and an increased pressure gradient (critical stenosis). At total occlusion, there was no recordable heart sound or bruit. Carotid audiofrequency analysis can establish the hemodynamic importance of a carotid artery lesion and it is an essential component of any noninvasive examination.


Rational management of the asymptomatic carotid bruit. A noninvasive cerebrovascular evaluation has been devised that combines three separate but complimentary procedures: ocular pneumoplethysmography (OPPG), carotid audiofrequency analysis (CAA), and cerebral Doppler analysis. This evaluation has proven particularly useful in examination of the asymptomatic carotid bruit, and the management of such patients is aided by noninvasive testing. Patients with a poorly compensated stenosis (reduced OPPG) are all considered candidates for angiography and surgery. For patients with a well-compensated (normal OPPG) but surgically important stenosis (abnormal CAA or Doppler), angiography and surgery are recommended in selected patients. Angiography and/or surgery are believed safely withheld in all remaining patients. The reliability and effectiveness of this approach is evaluated in a series of 100 consecutive patients with an asymptomatic carotid bruit. There were no false-positive results and only known false-negative interpretation.


Doppler ankle systolic blood pressure. Prognostic value in vein bypass grafts of the lower extremity. The prognostic value of Doppler-derived ankle systolic pressure indices for predicting the patency of vein bypass grafts in the lower extremity was analyzed in 126 vein bypass grafts performed for limb salvage. Early or late graft failure was not found to correlate with the preoperative ankle systolic pressure index (ASPI). Intraoperative blood flow measurements did not correlate with the preoperative ASPI. An intraoperative graft flow of less than 0.7 at 24 to 48 hours, or an increase in ASPI of less than 0.4 were prognostic signs of early vein graft failure.


A simplified instrument for noninvasive vascular assessment. A simple, inexpensive pulse wave recording device was tested in large (25- to 40-kg) dogs. Femoral arterial flow, prestenotic and poststenotic arterial waveforms, and pressures were monitored as stenosis was induced with a constricting silk loop. The recording device tested was placed around the distal leg. The pulse wave recorder accurately reproduced the arterial pulse waveform. The amplitude of the device's waveform was linearly proportional to the arterial pulse pressure. The instrument was sensitive in detecing a flow-limiting stenosis. The cuff represents an advance in noninvasive vascular assessment because it is quite inexpensive, portable, and durable, as well as precise and sensitive.


Limb salvage by inverted Y vein grafts to below-knee arteries. Distal Y branches to other below-knee arteries were added to standard femorotibial bypass grafts to increase runoff, more effectively perfuse the ischemic limb, and improve limb salvage rate. Y grafts were performed in 16 lower limbs in 15 patients. Flow through the graft was increased significantly with each additional Y limb. Preoperative angiograms demonstrated filling of the distal vessels. Surgical indications were gangrenous toes or ischemic ulcers in 12 patients, and 13 limbs were saved. Three patients received bypass grafts for acute ischemic changes, limbs were salvaged in two of the three patients. Two Y grafts performed in 1971 and in 1974 remain patent. Between 1971 and 1977, forty standard femorotibial bypasses were done, with a long-term patency rate of 54%. During the past two years, 13 more Y grafts were performed, with an overall initial patency of 94%. Late results of the Y grafts have been surprisingly good, with no subsequent loss of grafts or limbs.


Preservation of erectile function after aortoiliac reconstruction. Men with aortoiliac atherosclerosis exhibit organic erectile dysfunction caused by inadequate blood flow and/or psychological factors. After aortoiliac reconstruction, organic erectile dysfunction may be due primarily to surgical interruption of autonomic nerve fibers. To avoid this, dissection principles preserving genital autonomic plexi were developed. The results of these dissections were compared with those of conventional bypasses. Thirty nondiabetic men (age range, 43 to 67 years) were studied. A history of erectile capacity was elicited preoperatively and evaluated postoperatively in follow-up interviews every six months. Normal postoperative erectile function was not affected by nerve-sparing dissections. Each of the 11 patients requiring conventional dissections was both preoperatively and postoperatively impotent. Four of the 19 patients who underwent nerve-sparing dissection were preoperatively and postoperatively impotent. Seven of these 19 patients maintained preoperative potency after nerve-sparing dissection. The potency of the remaining eight patients was either completely restored or improved after nerve-sparing dissection. This report emphasizes the importantance of a preoperative determination of a complex interplay of physical and psychological factors in erectile dysfunction.


Cardiac and pulmonary function in regional intestinal shock. After a two-hour period of regional intestinal shock (arterial inflow pressure 30 to 35 mm Hg; electrical stimulation of regional vasoconstrictor fibers at 6 Hz) a pronounced cardiovascular derangement is observed as reflected in a rapid fall in arterial blood pressure. In this study, central hemodynamics and lung function were investigated to elucidate if functional changes in the thoracic organs might explain the cardiovascular collapse. No alteration of pulmonary function was observed. A negative inotropic influence on the heart was, however, noted as judged by a decreased left ventricular stroke volume and left ventricular maximal pressure change in the face of an increased left ventricular end diastolic pressure. Based on earlier observations with the same shock model, it is proposed that the cardiac effects were caused by cardiotoxic material released from the hypoxic gut.


Splenectomy and the thymic involution of increasing age. Forty young female rats, aged about 3 months, were weighed on entry into the study; half were subjected to initial splenectomy. Animals were weighed at monthly intervals therafter. Ten animals from each group were killed at four months, and ten from each group at one year. Thymuses and spleens were dissected out and weighted. Because of progressive weight gain, all groups showed declining thymic index. Absolute thymus weight did not change signficiantly in splenectomized animals. Intact animals showed significantly reduced thymus weight at 4 months (P less than .001) and at 12 months (P less than .005). We conclude that the spleen may be a causative factor in the thymic involution of increasing age. The process is gradual and indolent compared to the rapid thymic weight depletion that occurs in the presence of growing tumor.


Potassium cardioplegia. An alternate method of intraoperative myocardial protection. Potassium-induced cardioplegia was studied in 38 mongrel dogs supported by normothermic cardiopulmonary bypass and subjected to 60 minutes of aortic cross clamping followed by 30 minutes of reperfusion. A study of preischemic and postischemic ventricular function and myocardial high-energy phosphate compounds, lactate, and glycogen showed substantial preservation of high-energy phosphates and ventricular performance when potassium cardioplegia was used. However, the substantial depression in contractility observed following ischemia nad reperfusion suggests that potassium cardioplegia alone does not provide adequate intraoperative protection of the myocardium.


Role of portal venous blood supply from the pancreas in maintaining hepatic functional reserve. Appraisal of Warren's shunt operation. Mitochondrial phosphorylative activity was measured in the livers of various shunted or pancreatectomized dogs. In simple portal vein branch-ligated dogs, the mitochondrial phosphorylative activity in the nonligated lobe, which was supplied with excess portal blood, increased to approximately 150% of control values. In splenocaval-shunted or totally pancreatectomized dogs, the mitochondrial phosphorylative activity did not increase even in the nonligated lobe. However, the mitochondrial phosphorylative activity in the nonligated lobe increased to 120% of control in 80%-pancreatectomized and 150% in 50%-pancreatectomized dogs. In distal splenorenal-shunted (Warren-shunted) dogs, the mitochondrial phosphorylative activity increased to 150% of control values. Thus, the Warren's shunt operation is considered to be the more reasonable procedure for treatment of liver cirrhosis with esophageal varices, from the point of view of hepatic functional reserve based on the energetic metabolism of the liver.


A treatment plan for rapid assessment of the patient with massive blood loss and pelvic fractures. Exsanguinating retroperitoneal hemorrhage secondary to pelvic fractures is a frequent cause of death in the injured pedestrian. Attempts at lowering the mortality from these injuries have led to a variety of suggested treatment modalities, including observation, arterial ligation, or direct suturing of the bleeding sites. Arteriographic embolization is perhaps the newest modality but requires implementation of a rapid and efficient triage and treatment plan. Each of the suggested modalities and the formulation of such a treatment plan are discussed and a case report showing the feasibility of immediate arteriographic embolization as the preferred mode of management is presented.


Adenocarcinoma of the small bowel associated with Crohn's disease. We treated a patient with adenocarcinoma complicating long-standing Crohn's disease; this brings the total number of reported cases to 38. Review of the previously published cases suggests that adenocarcinoma complicating chronic Crohn's disease is a separate pathologic entity, as compared with carcinoma de novo of the small bowel.


Cholecystocele. A congenital anomaly of the gallbladder. Complete excision of a cholecystocele is recommended unless the remaining biliary drainage of the liver would be jeopardized. Evidence suggests that the embryologic development of the gallbladder and cystic duct is probably a sequestration and differentiation process from the hepatic antrum and not an independent "budding" from the primitive hepatic diverticulum.


Mesenteric fibromatosis in Gardner's syndrome. Two patients with mesenteric fibromatosis in Gardner's syndrome were treated by us. These tumors are slow-growing and may remain quiescent for long periods. Review of similar cases in the literature discloses that less than half of these tumors have been removed, pointing to the difficulty of their resection. Dissection of the infraduodenal portion of superior mesenteric vessels may help define whether these tumors are resectable. Radiation therapy or treatment with antiestrogens may be helpful in the treatment of unresectable tumors.


Wound contraction and fibrocontractive disorders. A most important contribution to the understanding of wound healing has been the identification of the myofibroblast. These cells contract like smooth muscle cells and have been identified in a variety of chronic and open wounds. The myofibroblasts have been reported as the causative factor resulting in the wound contraction. This report demonstrates the presence of the myofibroblasts in breast capsule contraction, as well as in Peyronie's disease. The presence of the myofibroblast in Peyronie's disease and Dupuytren's contracture suggests that the myofibroblast may be the causal factor behind the association of these two disorders. The evidence suggests that a spectrum of fibrocontractive disorders exists that has the myofibroblast as the common denominator. Some evidence is presented that permits the speculation that the myofibroblast may be a transformation of the local fibroblast to a smooth muscle cell in response to forces applied to the tissue.


Frequency of bowel movements after colectomy with ileorectal anastomosis. Stool frequency was studied in 43 patients several years after they had undergone ileorectal anastomosis. Seven (16%) of the patients had high and potentially disabling frequency. The level of anastomosis above the anus, patient age, and length of ileum resected were not shown to be important factors. Resection in patients with neoplastic disease was generally better tolerated than in those with diverticulosis. From this study, it seems that potentially disabling stool frequency will be an inevitable consequence in about one sixth of the patients having the operation.


Management of familial breast cancer. I. Biostatistical-genetic aspects and their limitations as derived from a familial breast cancer resource. Practical guidelines are given to promote decision-making logic by the physician in managing patients seeking consultation (consultands) because they may be at high familial risk for breast cancer and associated malignant neoplasms. The protocol is designed to aid in the assessment of patients who may become candidates for intensified cancer surveillance and/or prophylactic surgery. A resource comprised of 90 extended breast cancer-prone pedigrees provides the basis for these specific recommendations. The resource shows marked tumor heterogeneity among pedigrees, an approximate 50% incidence of breast cancer and associated malignancies among offspring of affected parents, and threefold higher risk for development of mammary carcinoma in the opposite breast of familial patients with unilateral disease than in sporadic patients. In utilizing this protocol, it is crucial that family history be highly accurate from the standpoint of genealogic relationships and pathologic tumor verification so that management recommendations may reflect sound risk factor assessment. Interpretation of familial risk factors should ideally be made by an informed medical-geneticist. All members of the medical team should then be appraised of familial risk and collectively engage in decision making with the consultand. We believe that this approach can foster more effective control of familial breast cancer.


Management of familial breast cancer. II. Case reports, pedigrees, genetic counseling, and team concept. The lack of therapeutic progress, coupled with limitations in early breast cancer diagnostic surveillance, suggest the need for innovative control programs for this disease. We have provided certian practical criteria for prophylactic subcutaneous mastectomy based on family history, presence of precancerous diseases of the breast, and other breast cancer risk factors, and the attitudes, feelings, and emotional aspects of the patient, all of which temper decisions for the type of cancer surveillance program and/or prophylactic surgery.


Radiation-related thyroid carcinoma.

Radiation-related thyroid carcinoma. Of 1,825 subjects with a history of head or neck irradiation, 358 (19.6%) were found to have thyroid abnormalities. One hundred sixty-five (9%) had either single or multiple nodules 153 (8.4%) had diffuse thyromegaly, and 40 (2.2%) had had thyroid surgery. Surgery was performed on 113 subjects with nodules; carcinoma was found in 34 (30.1%). Clinical examination of the neck was the most valuable method of detecting abnormalities. Detection of nodules was not significantly enhanced by routine use of thyroid imaging studies. Measurements of levels of serum thyroid-stimulating hormone, thyroxine, triidothyronine resin uptake, and thyroid antibodies were not useful in screening for nodules or carcinoma.


Transcatheter thromboembolectomy of acute renal artery occlusion. Direct surgery of the renal artery has been performed for the relief of acute thrombotic or embolic occlusion of the renal artery to restore adequate renal perfusion and prevent irreversible renal failure. Occasionally, severe medical disease may increase surgical risk to a prohibitive level. An angiographic technique has been devised to provide an alternative approach and has been successfully used on five occluded renal arteries in four patients, with measurable benefit.


Penetration of clindamycin into the human appendix. Clindamycin penetrated extremely well into inflamed (19) and normal (one) appendices. Average levels in appendiceal tissue taken 26 to 300 minutes after a single intravenous dose were 154% of the simultaneous serum concentration.


Enhancement of tissue Po2 of strangulated bowel by topical application of sodium nitroprusside. The Po2 was measured in the tissue of the ileal wall of dogs before, during, and up to one hour after reversible occlusion of segmental arteries. The occlusion was then released and the reoxygenation of the bowel wall was observed. Sodium nitroprusside (50 mg in 100 ml of solution) applied topically to the ischemic segment enhanced reoxygenation as compared to control animals. Nitroprusside absorbed into the portal system did not cause hypotension, as is usual with systemic administration, because nitroprusside is inactivated by passage through the liver. Topically applied sodium nitroprusside alleviates intestinal ischemia by direct local vasodilatation and relaxation of smooth muscle spasm in the ischemic bowel wall. The intraperitoneal use of sodium nitroprusside should be clinically evaluated in situations where visceral perfusion is impaired.


Total colectomy and anal ileostomy in multiple polyposis coli. Two patients with familial polyposis coli were treated by total abdominal colectomy, endorectal mucosal stripping, and ileoanal anastomosis. About 24 months after operation, both patients had four to five soft-formed stools daily with good anal sphincter control. Because of its physical and emotional advantages and the fact that possible precancerous lesions are treated completely, we believe that this operation is superior to those generally used today.


Familial polyposis coli. Management by total colectomy with preservation of continence. Two cases of familial polyposis coli were managed by total colectomy and endorectal pull-through with excellent long-term results. The performance of a temporary loop ileostomy is advisable to prevent anastomotic complications. In addition, it avoids the excessive diarrhea and perianal excoriation that frequently occur in the early postoperative period until full continence is regained. This is the only method that allows the preservation of rectal function and prevents the occurrence of rectal cancer. It should be considered as a real alternative to either subtotal colectomy and ileorectal anastomosis or total colectomy with construction of an ileostomy.


Liver necrosis following hepatic artery transection due to trauma. Hepatic artery ligation for control of bleeding liver wounds has gained widespread acceptance. Hepatic necrosis is rarely seen after this procedure has been performed. Recently, a patient with multiple organ injuries secondary to a gunshot wound to the abdomen underwent hepatic artery ligation and hepatic necrosis developed even though the portal venous system was normal.


Metastatic axillary adenopathy. Use of estrogen receptor protein as an aid in diagnosis. In a patient with nonpalpable carcinoma of the breast, the diagnosis from a metastalic axillary node was made by measuring estrogen receptor protein (ERP). The specificity of the technique makes it useful as a diagnostic aid in a patient with mammogram negative for tumor.


Transmission of Northway and St. Louis encephalitis viruses by arctic mosquitoes. Transmission of a Canadian arctic isolate of Northway virus has been demonstrated after incubation of arctic Aedes communis mosquitoes at 13 degrees C for 27 days after intrathoracic injection of 300 plaque forming units of virus. Replication has also been demonstrated after intrathoracic injection of domestic A. aegypti mosquitoes of this virus. Virions of Northway virus, 84--92 nm diameter were morphologically typical of a bunyavirus after propagation in salivary glands of A. communis or in tissue cultures of baby hamster kidney (BHK-21) cells. An Ontario isolate of St. Louis encephalitis was transmitted by bites of A. communis after 27 days incubation at 13 degrees C after oral ingestion of 3 or 30 mouse LD50 virus. This mosquito species transmitted virus after 13 to 76 days incubation at 13 degrees C following intrathoracic injection of 3 mouse LD50 or higher virus doses.


Structural elements in adenovirus cores. Studies by means of freeze-fracturing and ultrathin sectioning. Rod-like elements have been observed in adenovirions after freeze-fracturing of purified, semi-purified and intra-cellular adenovirus type 5. Their rod-like shape was clearly demonstrated by means of stereomicrographs. Ultrathin sections prepared in parallel with the freeze-fracture replicas revealed linear structures such as ribbons, rings or rods in up to 30 per cent of the semi-purified or intracellular virus particles. These observations indicate that the main 'structural element' in the adenovirus interior is a linear structure either fragmented into 5 to 6 'rods' or folded 5 to 6 times to fit into the inner space of the virion.


Virulence and persistence of three prototype strains of mumps virus in newborn hamsters. Neuroadapted mumps virus (NMV) produces widespread central nervous system (CNS) disease and death after intracerebral (i.c.) inoculation of newborn hamsters. After intraperitoneal (i.p.) inoculation, NMV causes disseminated disease, moderate mortality and it persists in CNS tissues. Low tissue culture passage isolates of wild mumps virus do not establish CNS infection after i.p. inoculation; after i.c. inoculation they cause limited though persistent infection with little acute mortality. The biological behavior of a highly passaged vaccine strain of mumps virus (Jeryl-Lynn) is more similar to NMV than to the wild strain in its behavior in the newborn hamster.


[Effect of general vertical vibration and polychlorocamphene on the kidneys of inbred rats]. During two months, effects of general vertical vibration, polychlorcamphen and combination of these two factors were studied in the kidneys of 60 immature male rats of August and Wistar strains. Twenty animals were used as controls (10 per each strain). Under experimental conditions, decrease in body weight, in kidney weight, in their volume, linear dimensions and thickness of the cortical layer were noted. The changes were mostly pronounced under combined influence of vibration and polychlorcamphen. Interstrain differences demonstrating that renal changes, under experimental conditions, could depend on the genotype were also revealed.


[Ultrastructural features of gap junction type synapses in the motor nuclei of the frog spinal cord]. Ultrastructure of synapses in motor nuclei of the frog spinal cord has been studied electron microscopically. In the area examined, synapses with chemical and electrotonic means of transmission have been revealed. Synapses of a gap junction type formed by an intimate contact between plasmic membrane of neuronal processes or axonal terminals and dendrite (pericaryon) of motorneuron can serve as a morphological substrate for electrotonic transmission. Several types of electrotonic synapses have been determined: dendro-dendritic, dendro-somatic, axodendritic, axosomatic and axoaxonic.


[Adrenergic and cholinergic components of the innervation of the arteries of the base of the bird brain]. By means of Falck's and Koelle's methods adrenergic and cholinergic structures were studied in the arteries in the cerebral basis of blue rock pigeons and of hens, white leghorn stock. The number of nerve transmitters was estimated per 1 mm2 of the vessel surface. The arteries of the basis in pigeon brain are surrounded with developed adrenergic and cholinergic nerve plexuses, their density decreasing in the following order: nasal branch of the internal carotid artery, middle, nasal cerebral and basilar arteries. A little more cholinergic transmitters occur on the middle cerebral artery, while on the other vessels, concentration of cholinergic and adrenergic fibers is equal. In hens, the density in the arrangement of adrenergic nerve transmitters is higher in the nasal branch of the internal carotid and in the nasal cerebral arteries than in the basilar artery. At the same time, chromaffin cells forming numerous conglomerations in some places are found on the latter. In pigeons, the density of adrenergic fibers arrangement on the arteries of the cerebral basis is higher than in hens.


[Histoarchitectonics and capillary-glio-neurocytic relationships in the stellate ganglion of cats]. By means of injection into the microcirculatory network, section staining with hallocyanine chromic alumen, hematoxylin--eosin, silver impregnation after Bielschowsky--Gross, Baginsky, unequal intensity of microvascularization in cervical and thoracic portions have been stated, as well as different forms of interrelations between capillaries, neurocytes and gliocytes (capillaries are predominantly situated in parallel fashion to the surface of neurocytes, or else surround them). The distance between the capillary and neurocyte does not usually exceed 5--10 mkm. The contact area between neurocytes and capillaries increases with enlargement of neurocyte area. Glial and connective tissue elements are clearly differentiated after staining with acridine orange.


[Reparative regeneration of the steppe turtle thyroid gland]. In 100 mature tortoises (Testudo horsfieldi Gray) reparative peculiarities and dynamics of histogenesis of the thyroid gland were studied under the conditions of its partial resection. The most intensive reparative processes were observed on the injured surface of spring--summer group of animals. The source of the thyroid parenchymal proliferation in reptiles are thyrocytes in destroyed follicles, proliferates and intrafollicular islets from the adjacent parts of the organ. During winter season, revascularization and proliferation of epithelium is inhibited, thus resulting in delay of the organ's regeneration. In intact part of the thyroid gland, hypertrophy and hyperplasy of thyrocytes, increasing number of small follicles are observed. This demonstrates compensatory rearrangements of the remaining part of the organ.


[Time required for replenishment of synovial fluid under experimental conditions]. Experimental data to determine time for restoration of intraarticular fluid are presented. Mature healthy domestic goats served as experimental animals. From the carpal joints under sterile conditions, synovial fluid was sucked out as completely as possible. Every four hours during the first day and further in 2, 3, 4 days synovial fluid was taken from one of the joints. Cellular elements, their percentage, pH, viscosity (determined on the amount of hyaluronic acid), common proteins and their fractions were determined. It was demonstrated that the process of synovial fluid restoration, in case it was removed completely, took four days. At first the amount of synovial fluid is restored at the expense of its liquid part, percentage of common protein and its fractions increase, and viscosity of synovial fluid decreases. After two days, a gradual restoration of all physiological indices mentioned occurs. By the fourth day they are completely restored. Data of synoviogram demonstrate that at first blood cells appear in a great amount, while cells of tissue origin are very scanty, and by the fourth day percentage of cellular elements is equal to the original: cells of tissue origin--70-72%, blood cells--28--30%.


Cytogenetical and dermatoglyphic studies in patients affected by Steinert's myotonic dystrophy. Cytogenetic and dermatoglyphic studies were performed in 10 patients affected by Steinert's myotonic dystrophy. No anomalies were found in karyotype and dermatoglyphs in these patients, except for an occasional chromosomal translocation.


[Amyotrophy due to parietal lobe lesions]. A bibliographical revision about Silverstein's amyotrophy, with a historical sight analizing the physiopathogeny and its clinical manifestations is reported. The authors discussed the possible cause of the few references in the literature about the matter and relate three cases; they leave a blank in one of them with amyotrophy in the other side and the same side of the lesion, that got better with surgical treatment. This was not found in the bibliographical revision that has been looked for.


[Intra- and extradural surgical approach to meningoencephaloceles of the anterior floor]. Surgical treatment of ethmoidal encephalomeningoceles: intra and extra dural approach. The intra and extra dural approach for the treatment of ethmoidal encephalomeningoceles is described. A comparation with other surgical approaches is made and good results obtained in 5 cases are reported.


[Familial occurrence of basilar impression]. The authors studied nine members of the same family; two among them received surgical treatment for basilar impression and Arnold-Chiari malformation. In the other members of the family, several signs and symptoms of central nervous disease were observed. All patients had the apex of the odontoid apophysis above McGregor's line, 4 mm in the case 9, and 10 mm or more in the others.


[Interstitial hypertrophic neuritis. Study of 3 cases]. Three cases of hypertrophic interstitial neuropathy with severe decrease of motor nerve conduction velocity are reported; on sural nerve biopsy was found the typical onion bulb formation, with connective tissue proliferation. The pathogenesis of the onion bulb formation and the correlation with the decreased motor nerve conduction are discussed. The authors concluded that only one of the cases could be named Dejerin-Sottas disease, since the others probably are Charcot-Marie-Tooth disease cases.


[Multiple neuropaty caused by giant cell arteritis. Clinico-pathological report of a case]. The case of a 67 years old woman with giant cell arteritis and neuritis multiplex is reported. The diagnosis was based on the microscopic appearances of temporal artery biopsy specimens. The authors described the involvement of peripheral nerves in this disease and made differential diagnosis with polyarteritis nodosa. There was also hemorragic infarction of the brain without giant-cells in brain vessels. It is concluded that this diagnosis should be considered in any elderly patient with peripheral neuropathy.


Current status of hemofiltration.

Current status of hemofiltration. Hemofiltration is reviewed from the standpoint of the technical and clinical state of the art. It is a new technique and, at present, commercially available equipment is limited. Clinical experience suggests that hemofiltration results in easier attainment of salt and water balance and that control of hypertension is improved. The nomenclature used to describe convective solute and water removal alone and in conjunction with dialysis is outlined.


Inadequate clearance of small molecular weight solutes during hemofiltration using Cuprophan membranes. In a study of four patients treated with one hour of hemofiltration using Cuprophan membranes, followed by three hours of dialysis, it was found that patients will have reduced clearances of small molecular weight solutes. This may be prevented by increasing blood flow rates to compensate for the time spent in hemofiltration. Cuprophan membranes do not clear middle molecular weight solutes as well as other membranes, but fluid removal is comparable to that reported by other investigators using more porous membranes.


Assessment of hormone loss through hemofiltration. The concentrations of testosterone, cortisone, gastrin, insulin, gastric inhibitory polypeptide (GIP), somatomedin B, parathyroid hormone (PTH), human growth hormone (HGH) and thyroid stimulating hormone (TSH) have been determined in the plasma and the ultrafiltrate of five uremic patients undergoing intermittent hemofiltration treatment. There was a considerable loss of gastrin, insulin, GIP, somatomedin B and PTH by hemofiltration treatment. The plasma concentrations, however, did not decrease except for immunoreactive-PTH (IR-PTH) which returned from elevated to normal levels. Cortisone, HGH and TSH concentrations in the ultrafiltrate were below the measureable range. A significant elimination of 11-hydroxylated androstans by hemofiltration may have a positive effect on the disturbed steroid metabolism. Results indicate that hemofiltration does not cause a hormone deficiency syndrome. On the contrary, the loss of degradation products of hormones with disturbing biological activity may be a favorable effect of the hemofiltration treatment.


Reduced protein loss during hemofiltration using Cuprophan membranes. In a study of four patients treated with one hour of hemofiltration using Cuprophan membranes, followed by three hours of hemodialysis, it was found that protein loss during hemofiltration was minimal. Losses ranged from 0.013 mg/mg at a transmembrane pressure (TMP) of 300 mmHg to 0.012 mg/ml at a TMP of 600 mmHg. Protein loss was not dependent on TMP and varied from dialyzer to dialyzer. Protein levels in serum remained unchanged during the period of hemofiltration in these patients and no evidence of protein wastage was evident.


Rapid fluid extraction with the Gambro Ultradiffuser. Four patients were given fourteen treatments with the Gambro Ultradiffuser. One hour of ultrafiltration without dialysate and with negative pressure on the dialysate side was followed by four hours of dialysis with negligible transmembrane pressure (TMP). Mean fluid removal was 2678 ml per ultrafiltration period and the mean ultrafiltration rate was 37 ml/min. During the dialysis period, TMP was about +30 mmHg giving an ultrafiltration rate of 4 ml/min. Pulse rate was unchanged. Hematocrit increased 3%, plasma protein increased 21% and plasma albumin increased 25%. Plasma values of potassium, sodium, urea, creatinine and osmolality were unchanged. One patient experienced a reversible hearing loss during two ultrafiltration periods and two patients had severe, yet reversible, cardiac arrhythmias. One patient had hypertension during the ultrafiltration period. Rapid extraction of fluid up to 49 ml/min was possible. The mean mean arterial pressure was unchanged thought it exhibited great variation and three patients developed side effects.


Theoretical aspects of various ultrafiltration methods in artificial kidney therapy. A mathematical model including urea, creatinine and other osmotically important solutes (such as sodium, potassium and chloride) is applied to calculate volume shifts, caused by ultrafiltration, between the fluid compartments of the body. The volume shifts between the intracellular (ICV) and the extracellular (ECV) compartments are mainly caused by alteration of extracellular sodium concentration. Various methods of achieving ultrafiltration, including conventional dialysis, initial ultrafiltration using Cuprophan (without dialysis) or hemofiltration, produce different responses. In choosing a method, one must consider that both a rapid decrease of ECV and a fast shift of water from ICV to ECV should be avoided. In pure hemofiltration, ultrafiltrate is isotonic and water is removed from ECV only. Hemofiltration with dilution produces a very slow shift of water between ICV and ECV dependent on sodium concentration of plasma and diluting fluid. In initial ultrafiltration through Cuprophan, water is shifted from ICV to ECV. With ultrafiltration throughout the entire dialysis, there are pronounced shifts between ICV and ECV dependent on the difference of the sodium concentration between plasma and dialysate.


Clinical evaluation of a pre-set ultrafiltration rate controller available for single pass and hemodiafiltration systems. Introduction of high flux-type dialyzers, such as the RP-6, makes it necessary to devise an ultrafiltration rate controller for a single pass system. For this purpose, a new pre-set ultrafiltration rate controller has been developed and examined experimentally and clinically. The controller has twin chambers, each of which is divided into two symmetrical parts by a vertically-placed diaphragm. The diaphragm shifts repeatedly from right to left, aspirating in and driving out fresh or used dialysate alternately. If one removes a certain amount of used dialysate from a branch of the efferent line, negative pressure develops and aspirates an equal amount of water from the dialyzer. Therefore, extra dialysate obtained by a pump precisely reflects ultrafiltration rate. The controller has been used on five patients. The scheduled ultrafiltration rate was easily obtainable. The apparatus is also available for hemodiafiltration. Initial clinical trial has been promising.


The accurate control of ultrafiltration. An apparatus has been contructed to regulate ultrafiltration accurately during dialysis. The principle of the apparatus is that, per unit of time, exactly the same amount of dialysate is introduced into the dialyzer as is discharged from it. The apparatus consists of two isovolumetric pumps connected in line. The four compartments of the two pumps must change their functions at every pump stroke. This is a accomplished by a switching system. There is a continuously closed dialysate circuit. The fluid extracted from this circuit will be replenished from the blood compartment of the dialyzer. Ultrafiltration is regulated by a simple peristaltic pump, which sucks the fluid out of the closed dialysate circuit. The isovolumetric pumps and the switching system are driven by the elevated pressure of the dialysate (0.5--1.0 atm). The apparatus can be used in single pass dialysis. Dialysis in accordance with the Bergström principle can be simply performed. In over 5,000 dialyses with several types of dialyzers, ultrafiltration was always accurate within the measuring limits. Considerable improvement was noticed in the well-being of the patients; hypotension, nausea, vomiting and muscle cramps were not seen.


Clinical experience with continuously monitored fluid balance in automatic hemofiltration. Automatic fluid balancing, as obtained with the hemofiltration machines from Sartorius (Göttingen, West Germany) and Dialysetechnik (Karlsruhe, West Germany), is accurate enough to replace bed scales, which have been necessary in conventional hemodialysis for patients who are confined to beds. Side effects such as hypotension, nausea and muscle cramps during treatment may be reduced with these new machines, compared to conventional methods, provided that the rate of effective fluid withdrawal does not exceed 0.5 L/hr. In particular, the constant weight loss associated with automatic hemofiltration seems to be well tolerated by the patients with fewer side effects.


Hemodiafiltration: a new alternative to hemofiltration and conventional hemodialysis. A new dialysis method, termed hemodiafiltration, is proposed. The procedure consists of the combination of hemofiltration and conventional hemodialysis using high flux membranes with a transmembrane pressure (TMP) of 300--500 mmHg and a dialysate flow of 900 ml/min. Due to the combination of convective mass transfer and diffusion, the clearance values of both small and larger molecules are significantly higher than during hemofiltration or hemodialysis alone with the same membranes. The removal of excess water is better tolerated than during hemodialysis. With this new method, six patients have been successfully treated for six months (three times per week, three hours per treatment) without side effects. Thus hemodiafiltration appears to be the method of choice to shorten dialysis time.