Reproducibility of a consensus panel in the interpretation of coronary angiograms. This report describes the consistency of coronary angiogram evaluation by a four man panel of experts rendering "consensus opinion." The panel evaluated films from 38 patients at two grading sessions separated by an interval of seven months. Fourteen patients' films were selected at random for duplicate evaluation. These contained 186 lesion sites. The panel was 95% consistent in designating significant stenosis (greater than or equal to 70%). "Consensus" panel reading appears more consistent than "group opinion" panel reading. The over-all standard deviation of the difference in panel reading was 14%. The panel was most consistent in evaluating the right coronary artery, proximal LAD, and proximal circumflex. In the left main segment two of fourteen duplicate evaluations showed major discrepancy.


Coronary artery fistulas emptying into left heart chambers. We present three cases of coronary artery fistulas entering into the left heart chambers. Coronary arteriography in one showed aneurysmal dilatation of the main left coronary artery and a fistulous communication with a large left atrium. Exploration during repair revealed an anomalous branch of the left circumflex emptying into the left atrium. In the second case the proximal left circumflex gave rise to a branch supplying a hemangioma which emptied into the left atrium. Coronary arteriograms of the third patient showed an enlarged left anterior descending artery with an anomalous branch emptying into the left ventricle. Shunt flow was estimated with hydrogen as a tracer in the last two cases and was two thirds and one third of the left coronary inflow, respectively. Review of the literature shows 32 previously reported cases of a fistula draining into the left side of the heart.


Echocardiographic evaluation of porcine heterograft valves in the mitral and aortic positions. We evaluated 15 porcine heterograft valves in the mitral position and seven in the aortic position by echocardiography. Combining our quantitative description of valve stent and leaflet motion with 31 previously reported cases, we suggest echocardiographic criteria for the range of normal porcine heterograft valve motion in the mitral position. Quantitative evaluation of valve leaflet and stent motion for valves in the aortic position is described for the first time. Correlative hemodynamic and echocardiographic data is provided for three patients who underwent postoperative catheterization. The use of echocardiography in following the function of porcine heterograft valves is discussed.


The predictive value of anginal chest pain as an indicator of coronary disease during exercise testing. To determine the significance of anginal chest pain during exercise testing, a series of 302 patients undergoing coronary arteriography with exercise testing was reviewed. Of the 302 patients, 85 had ischemic ECG changes and chest pain (Group I); 87 patients had ischemic ECG changes but no chest pain (Group II); 25 patients had chest pain but no ischemic ECG changes (Group III); 105 patients had neither chest pain nor ischemic ECG changes (Group IV). Coronary artery disease was present in 95% of Group I, 75% of Group II, 72% of Group III, and 28% of Group IV. Of those patients with coronary disease, multiple vessels were involved in 94% of Group I, 51% of Group II, 67% of Group III, and 21% of Group IV. The predictive value for presence and extent of coronary disease showed Group I greater than Groups II and III greater than Group IV (p less than 0.025). We conclude that (1) anginal chest pain during exercise testing predicts the presence and extent of coronary disease more accurately than its absence; (2) the presence of chest pain even without an ischemic ECG response during exercise testing appears to be as predictive of coronary disease as an ischemic ECG response alone; and (3) the combination of anginal chest pain during exercise testing and an ischemic ECG response is highly predictive of multivessel coronary artery disease.


An evaluation of range gated pulsed Doppler echocardiography for detecting pulmonary outflow tract obstruction in d-transposition of the great vessels. The aim of this study was to determine the accuracy of range gated pulsed Doppler (RGPD) echocardiography for detecting obstruction to the pulmonary outflow tract in children with d-transposition of the great vessels (d-TGV). Twenty-one children were randomly selected for those available with d-TGV and were studied by precordial and suprasternal RGPD echocardiography. Three were excluded, leaving a population of 18 subjects. The exclusive criterion used to judge the RGPD results was the output of the time interval histogram (TIH). Coherence of the TIH was considered to represent laminar flow. Dispersion of the TIH was considered evidence of flow disturbance and obstruction to the outflow tract. With the range gating feature, the first site of disturbance could be localized. Information was handled by a technique that decreased bias. RGPD results were then compared to diagnoses of the outflow tract established at cardiac catheterization or operation. Comparison of these results indicated that all seven children with obstruction were correctly identified by RGPD study, and the level of the first obstruction was correctly identified. With one exception, all children without pulmonary obstruction were correctly identified by the examination.


Blood pressure levels in acute myocardial infarction. Serial blood pressure recordings were taken for 72 hours in 112 patients with acute myocardial infarction and in 96 patients with cardiac ischemia, admitted to hospital no more than 6 hours after the onset of chest pain. During the first hour of admission 66 (31.7%) had a blood pressure recorded 160/100 or greater. By the sixth hour, without specific antihypertensive therapy, this number had fallen to 13 (6.3%). This fall was subsequently maintained with very similar trends for both acute myocardial infarction and cardiac ischemia. Such an early blood pressure fall in acute myocardial infarction may indicate that this is too labile a measurement to determine the need for, or efficacy of, antihypertensive therapy aimed at the preservation of myocardium. The hospital course and mortality rate of patients with acute myocardial infarction and early hypertension, as defined, did not differ significantly from the non-hypertensive group.


The effect of aging on ventricular contractile performance. The effects of aging on mechanical performance of isolated canine right ventricular trabeculae were studied in two age groups. The first group was comprised of nine dogs, about 9 months of age. The second group was composed of seven dogs over 8 years of age. Aging had no significant effect on developed force. Extent of shortening tended to decrease. There was a significant decrease in both the rate of rise of tension and the velocity of shortening (20%). THis reduction was primarily due to an increased duration of contraction. Twitch duration increased by as much as 40% during aging but most of this prolongation was due to a profound slowing of relaxation. Aging caused a significant increase in passive stiffness since equivalent changes in muscle length brought about twice as much increase in resting tension in the aged muscle as in the young muscle. On the other hand, aging caused a significant shift of Lo to the right. Taken collectively, these results indicate that aging is associated with increased passive stiffness and decreased speed of contraction without changes in strength.


Origin of the basal systolic murmurs in mitral stenosis. A study with intracardiac phonocardiography. In order to study the origin of the basal systolic murmurs in mitral stenosis, left and right heart catheterization was performed in 18 patients with mitral stenosis using intracardiac phonocardiography. Our data revealed that the basal systolic murmurs originated in the aorta, the pulmonary artery, and the outflow tract of the right ventricle. In 14 cases, we noted the maximal ejection systolic murmur in the aorta near the aortic valve. However, in two cases, there was a loud systolic murmur in the pulmonary artery. These murmurs occurred in early to mild-systole and were crescendo-decrescendo in configuration. The pitch of the murmur ranged from low to medium frequency in the majority of cases. They are produced by the turbulence of blood flow in the aorta and the pulmonary artery. A late systolic murmur was also recorded in the outflow tract of the right ventricle in two patients. This is thought to occur due to functional or relative infundibular stenosis of the right ventricle. It differs in location and timing from those in the aorta and the pulmonary artery. The outflow tract of the right ventricle is regarded as the third origin of the basal systolic murmur in mitral stenosis.


Noninvasive diagnosis of ischemic cardiomyopathy by fluoroscopic detection of coronary artery calcification. Twenty-four patients with severe congestive heart failure and cardiomegaly in whom the presence or absence of significant coronary disease could not be ascertained clinically underwent fluoroscopy for coronary artery calcification prior to cardiac catheterization. Ten of the patients were found to have significant coronary artery disease, and 14 had normal coronary arteriograms. Coronary artery calcification was found in all ten patients with significant coronary disease, and was absent in all of those patients with normal coronary arteriograms. We conclude that fluoroscopy for coronary artery calcification provides a reliable noninvasive method for differentiating ischemic from nonischemic cardiomyopathy.


Ventricular pre-excitation and prolonged Q-T interval syndromes in a patient with mitral valve prolapse. A 34-year-old woman with mitral valve prolapse, frequent ventricular dysrhythmias, and chest pain was studied. Surface electrocardiograms demonstrated short PR and prolonged Q-T intervals. A-V nodal conduction times during atrial pacing were characteristic of A-V nodal bypass tract function. The case is thus interpreted to be one of overlap between three syndromes known to predispose to cardiac dysrhythmias, i.e., mitral valve prolapse, Lown-Ganong-Levine syndrome, and prolonged Q-T interval syndrome.


Saint Augustine's College training program in industrial hygiene and safety. The Occupational Safety and Health Program at St. Augustine's College leads to a Bachelor of Science degree in Industrial Hygiene. This program enables the students to enter careers in practice and research in industry and government or to pursue graduate studies. The curriculum in industrial hygiene provides a broad academic foundation during the first two years of college, after which, students proceed with advanced studies in industrial hygiene and supporting courses in the natural and behavioral sciences. St. Augustine's College industrial hygiene and safety curriculum course descriptions are presented and other aspects of the program are discussed.


Dermal penetration of three topical insect repellents in dogs and rabbits. Three (14)C-labeled candidate insect repellents, cyclohexamethylene carbamide, n-butylsufonimidocyclohexamethylene and 2-hydroxyethylcyclohexane carboxylate were evaluated for skin penetration in dogs and rabbits. Absorption of the repellents was determined by monitoring excreted urine daily for seven days following topical application. Significant percutaneous absorption of all three repellents occurred within 24 hours. (14)C-cyclohexamethylene carbamide showed the greatest absorption. Measurable amounts of radioactivity persisted at the application site for both species after seven days.


Safety limits for a firefighter proximity suit. A standard one-piece firefighter proximity suit (jumpsuit style) was tested for heat accumulation and hood compartment ventilation. Large increases in temperature of the skin and hood compartmental air were recorded. Oxygen and carbon dioxide were monitored and hypoxic conditions found. Using the O2 and CO2 data, mathematical regression analyses were performed to predict the time exposures allowed for firemen entering various ambient atmospheric conditions. The short permissible exposure periods predicted for the proximity suit suggests limited usefulness and the need for immediate improvements in the design of the suit.


Labeling of monodisperse polystyrene microspheres with tightly bound 51Cr. Monodisperse radioactive polystyrene latex microspheres have been prepared by attachment of chromium-51 to latex spheres. Labeling was by emulsion polymerization of chromium acetylacetonate dissolved in styrene monomer using commercially available microspheres. This was accomplished with two successive polymerization steps: radiation excitation and radical polymerization initiated with potassium persulfate. After attachment of the label the particle suspension was purified by repeated centrifugation wash cycles to remove labile radioactivity. Results indicate a radioactive binding yield of greater than 80% to the particles. The stability of the label was tested in in vivo and in vitro leaching studies. In these tests, the activity leaching rate was estimated to be less than 0.2% per day.


Solid sorbent sampler for white phosphorus in air. A solid sorbent sampling tube packed with Tenax-GC is used with a personal sampling pump to collect samples of white (yellow) phosphorus vapor from air. The phosphorus is leached from the exposed sorbent into xylene and quantitated by gas chromatographic analysis. The capacity of the sorbents is in the range 10 to 20 microgramP4per100 mg of sorbent, which allows for up to 4 hrs of sampling at the OSHA Standard, 0.1 mg/m3. No interferences from red phosphorus, phosphine, water vapor, or other common gases are significant. The effects on the method of variations in temperature, pressure, humidity, sample storage and shipping conditions, and chromatographic parameters were determined.


A solid sorbent personal sampling method for the determination of acrolein in air. A personal air sampling method, using activated carbon with subsequent analysis by gas chromatography, has been developed for acrolein in the 0.05 to 5 ppm (parts per million) range for a five liter air sample. The sensitivity is 0.25 microgram (microgram) of acrolein. This first known viable method for acrolein using a solid adsorbent was made possible by the discovery that acrolein can be adsorbed on, and recovered from, hydroquinone-treated carbon with efficiencies as high as 90 percent. Samples must be analyzed the same day or frozen and analyzed within five days. Airborne contaminants possibly present in the acrolein production area do not interfere with the analysis.


Industrial hygiene engineering in the petrochemical industry. Industrial hygiene engineering can be utilized most effectively when it is employed in the design or construction phases of new or modified chemical manufacturing processes. Minimization of leaks, spills, fugitive emissions and other releases is the goal. Some chemical and physical agents can still be released during normal or non-normal operations and during plant turnaround procedures and these require continuous industrial hygiene surveillance. It follows that industrial hygiene principles must continue to be applied in all phases of the petrochemical industry from the beginning of the design and throughout the life of the unit.


Irrigated precipitator for sampling soluble aerosols. The design and performance of a simple parallel plate, irrigated, precipitator for use in  the sampling of soluble aerosols is described. Unifrom surface coverage of 0.044 +/- 0.003 mL/cm2 by the gravity fed collection fluid is provided with a fiberglass mat (Gelman type A/E filter), while a surface washout of approximately 45% occurs in fluid residence time tf = V/q for a collector surface inclination of 40 degrees relative to horizontal. Efficiency tests using laboratory generated DOP aerosols and field tests of sulfate-bearing particles indicate good correlation with the Deutsch equation. Values of V/Q, proportional to the instrument sampling time, representing the ration of collection fluid volume to air flow rate for the present design compare favorably with other available instrumentation.


Thermal oxidative degradation studies of phosphate esters. Five phosphate esters - tri-p-tolyl phosphate, tributyl phosphate, tris(1,3-dichloro-2-propyl)phosphate, tris(2,3-dibromopropyl)phosphate, and  tris(2-chloroethyl)phosphate- were subjected to thermal oxidative degradation in air at 370 degrees C. Degradation mechanisms were postulated and the toxic hazards assessed based on the volatiles produced. Tri-p-tolyl phosphate was found to undergo only minimal degradation; the other compounds were decomposed extensively. Butene was the main product formed on tributyl phosphate decomposition; hydrogen halides and halogenated C2- and C3- species were the main products formed by the halogenated phosphate ester. In the case of tris(1,3-dichloro-2-propyl)phosphate acrolein, not hydrogen chloride, presented the major toxic hazard.


Sampling of tangential flow streams.

Sampling of tangential flow streams. The causes and characteristics of tangential flow in industrial stacks are described. Errors induced by tangential flow in the determination of volumetric flow rate and particulate concentration are analyzed. Experiments were conducted at the outlet of a cyclone collector in order to investigate the effect of tangential flow on the determination of emission rates. Straightening vanes were found to be useful in the reduction of error in flow rate measurements.


Field tests of a permeation-type personal monitor for vinyl chloride. A passive dosimeter-type personal monitor for vinyl chloride has undergone extensive field testing. Collaborative studies by a number of laboratories confirm the accuracy, reliability, convenience and general acceptability of personal monitors utilizing gas permeation for sample collection and quantification. Data are generated as timeweighted averages and response is linear from 5 ppb to 50 ppm. The monitors which weigh only 35 g are unaffected by variations in environmental conditions.


Measurement of chromium VI and chromium III in stainless steel welding fumes with electrom spectroscopy for chemical analysis and neutron activation analysis. Electron Spectroscopy for Chemical Analysis (ESCA) was explored as a means of studying the oxidation state of chromium in SMAC (coated electrode) stainless steel welding fume collected on Nucleopore filters in the laboratory. Chromuim VI and III (as a percent of the total chromium) obtained from ESCA analysis was applied to results from Neutron Activation Analysis (NAA) to yield an average of 69 microgram chromium VI per sample. Diphenylcarbazide/atomic absorption (DPC/AA) results are reported for samples submitted to an industrial laboratory. Possible chemical species and solubility of chromium VI in stainless steel fumes is discussed in light of analogy between the SMAC process and the manufacturing process for chromates.


Prediction of metabolic rates for manual materials handling jobs. A mew approach for estimating metabolic rates for manual materials handling jobs is presented. This approach was applied to 48 different jobs. The model validation showed a correlation coefficient of 0.95 between the measured and predicted metabolic rates. The coefficient of variation (standard error/sample mean) was 10.2 percent.


Detection of critical coronary lesions with treadmill exercise testing: fact or fiction? This study was designed to determine whether treadmill exercise testing could identify patients with critical coronary lesions. Critical lesions were defined as obstruction of the left main coronary artery or concomitant narrowing of the left anterior descending and circumflex coronary arteries proximal to any major branches. The time of onset and degree of S-T segment depression were evaluated in 25 patients with critical lesions and in 50 patients with other types of lesions. S-T segment depression of 2 mm or more was present in 82 percent of patients with left main coronary disease and in 71 percent of patients with left main coronary equivalent lesions (both P less than 0.02 when compared with 36 percent of patients with other lesions). However, half of the 37 patients with this degree of S-T segment depression had noncritical lesions. Ischemic changes appearing in the first 3 minutes of exercise were seen in 63 percent of patients with left coronary disease and 35 percent of the patients with left main coronary disease equivalent lesions (P less than 0.001 and P less than 0.002, respectively, when compared with only 6 percent of patients with other lesions). The incidence of triple vessel disease was significantly greater in patients with critical lesions (55 percent in patients with left main coronary disease and 71 percent in those with the left main coronary equivalent lesions versus 10 percent in those with other lesions) (P less than 0.01). S-T segment depression of 2 mm or more is not a good indicator of critical coronary lesions because it has a low level of specificity. Consideration of the time of onset of ischemic changes adds to its usefulness, but it does not permit a definitive diagnosis in individual patients.


Significance of left axis deviation in patients with chronic left bundle branch block. Forty-nine patients with chronic left bundle branch block and a normal frontal axis were compared with 53 patients with left bundle branch block and left axis deviation. The following clinical variables were more frequent (P less than 0.05) in patients with left axis deviation: greater age, exertional angina, congestive heart failure, cardiomegaly, cardiac functional class II to IV, coronary artery disease and presence of organic heart disease. Absence of organic heart disease (primary conduction disease) was seen only in patients with a normal axis. Patients with left axis deviation had longer (P less than 0.05) mean P-R, A-H and H-V intervals and atrial and atrioventricular (A-V) nodal effective refractory periods. All patients were prospectifely followed up for 30 to 2,271 days with a mean +/- standard error of the mean follo-up period of 538 +/- 72 for the group with a normal axis and 604 +/- 72 days for the group with left axis deviation (difference not significant). A-V block developed in three patients (6 percent) with left axis deviation and in none of those with a normal axis. The cumulative 4 year mortality rate for the entire group approached 75 percent. The patients with left axis deviation had greater cardiovascular mortality (P less than 0.05). In conclusion, among patients with left bundle branch block, those with left axis deviation have a greater incidence of myocardial dysfunction, more advanced conduction desease and greater cardiovascular mortality than those with a normal axis.


Cardiac biopsy evidence for a cardiomyopathy associated with symptomatic mitral valve prolapse. Right ventricular endomyocardial biopsy was performed in 14 patients with mitral valve prolapse to determine the existence of an associated cardiomyopathic process. All 14 patients had echocardiographic, angiographic or auscultatory evidence of mitral valve prolapse, and all were symptomatic. The group had a high incidence rate of conduction system abnormalities (50 percent) and arrhythmias (64 percent), but only one patient had a significant hemodynamic abnormality. Light microscopy revealed an increase in endocardial and interstitial fibrosis in eight patients (57 percent). Electron microscopy, performed in 11 patients, showed mitochondrial degenerative changes in all 11. Nuclear chromatin clumping, intracell edema and myocyte degeneration were frequently present. It is concluded that endomyocardial and myocardial abnormalities exist in some symptomatic patients with idiopathic mitral valve prolapse.


Effects of digitalis on atrial vulnerability. The effects of digitalis on vulnerability to atrial fibrillation and flutter were assessed in man, using the model of repetitive atrial firing initiated by post-drive atrial extrastimulation. Nine patients without heart failure or significant mitral valve disease were tested before and 30 minutes after the administration of 0.01 mg/kg ouabain. When repetitive firing was manifested by flutter, neither the flutter cycle length nor the interval from the initiating beat to the first flutter beat was consistently altered by ouabain. Repetitive firing was found at the atrial site with the shortest functional refractory period. The vulnerable zone bordered this refractory period. The functional refractory period was lengthened after ouabain, from 231 +/- 13 to 246 +/- 15 msec (mean +/- standard error of the mean) (P less than 0.025). Partly because of prolonged refractoriness, the vulnerable zone was curtailed by ouabain, from 32.2 +/- 5.7 to 9.4 +/- 4.6 msec (P less than 0.001). This result suggests a protective effect of digitalis against atrial fibrillation and flutter independent of its hemodynamic actions.


Type A personality and extent of coronary atherosclerosis. The relation between type A personality and the extent of coronary artery disease was studied in 109 patients who underwent selective coronary angiography. Type A personality as measured with the Jenkins Activity Survey was not correlated with the extent of coronary artery disease as assessed from the number of vessels with 50 percent or greater narrowing of diameter.


Effect of lidocaine on conduction in the ischemic His-Purkinje system of dogs. The effect of lidocaine on His-Purkinje conduction in dogs with ischemic damage to the His bundle was compared with the effect of lidocaine in normal dogs. The anterior septal artery was ligated in 14 dogs, and 30 minutes later atrial pacing was performed to increase residual ischemic damage. Four to 6 days later, His bundle recordings were obtained during sinus rhythm and atrial pacing before and after the administration of lidocaine in a dose of 2 mg/kg and a total dose of 4 mg/kg. His bundle recordings were also obtained in nine control animals beofre and after the administration of lidocaine. Lidocaine significantly increased the H-V time in the animals with ischemic damage during sinus rhythm and at all packing rates. It also resulted in advanced His-Purkinje conduction defects including His bundle block and right bundle branch block in these animals. In contrast, the effect of lidocaine in the normal animals was negligible. It is concluded that lidocaine significantly depresses His-Purkinje conduction in the setting of preexisting ischemic damage. These results suggest that lidocaine may be used as a diagnostic tool to unmask latent His-Purkinje conduction defects due to ischemia.


Maximal exercise capacity of children with heart defects. Maximal treadmill tests following the Bruce protocol were performed by 830 children with heart defects and the endurance times compared with normal values from 327 children seen in the same clinic because of normal murmurs and from 388 normal children randomly selected and tested in the schools. When values in the normal clinic children were used as the reference, only 21 percent of the patients with heart defects had endurance times below the 10th percentile line. This line was 14 percent higher in the normal school children, and 47 percent of the patient group had values below the 10th percentile when values in the school children were used as the reference. Maximal heart rate in children with heart defects was almost always in the normal range (180 to 210 beats/min) except in patients with cyanosis or severe valve disease and, when encouraged to continue exercising, even these children had a mean maximal heart rate of 175 beats/min. When comparing the exercise capacity of children with heart defects with that of normal children, the source of the normal children is important; body build needs to be considered, as well as physical activity habits. Clinic patients without heart defects probably serve as a better normal control group than children obtained from the school system. Maximal exercise tests do not necessarily distinguish between children with mild or severe heart disease. Only children with lesions causing cyanosis or children with obviously severe disease have consistent reductions in exercise capacity.


The criss-cross and superoinferior ventricular heart: an angiocardiographic study. The angiocardiographic features of 11 patients with superoinferior and criss-cross type of atrioventricular (A-V) connections are presented. These unusual ventricular relations are thought to result from postseptation disturbances of ventricular looping. The angiocardiographic appearance of criss-cross is really an illusion, and the A-V connections among these patients are either concordant, discordant or straddling. The often small right A-V valve inflow and sinus portion of the ventricle, combind with the ventricular rotational anomaly, combine to give the angiocardiographic perception of criss-cross. A review of the 11 patients from this institution and those previously reported on suggests that most patients have a transposition of malposition of the great arteries; many have a small right ventricle, and about half have pulmonary outflow tract obstruction. In addition to the obvious embryologic, morphologic and clinical implications of these distorted ventricular loops, the criss-cross A-V hearts raise questions about the various segmental nomenclatures applied to these types of congenital heart disease.


Congenital heart disease in a cohort of 19,502 births with long-term follow-up. The Child Health and Development Studies are longitudinal studies of pregnancy and the normal and abnormal development of the offspring. Women who were membres of the Kaiser Foundation Health Plan entered the study in early pregnancy, and their children were examined frequently until the youngest child in the study was 5 years old. This is a more intensive follow-up than hitherto reported. Of the 19,044 live-born children, 163 had definite and another 31 had possible congenital heart disease; the crude incidence rates per 1,000 live births were 8.8 for definite congenital heart disease and 10.4 for definite plus possible congenital heart disease. The incidence rate of congenital heart disease was 7.9 percent among all stillborn fetuses subjected to autopsy and 10.2 percent among those in this group with autopsies evaluated as being detailed enough to detect heart disease. Among the live-born children with congenital heart disease, 21 died in the neonatal period and 22 died in later infancy and childhood; about half the deaths were judged to have been due to heart disease. About 30 percent of the children with congenital heart disease had associated severe anomalies of other systems. In the whole cohort, 50 children had diagnosed chromosomal abnormalities (2.63/1,000 live births) and about 30 percent of them had congenital heart disease. Among the group of 163 children with definite congenital heart disease, the diagnosis was made in 46 percent by age 1 week, in 88.3 percent by age 1 year and 98.8 percent by age 4 years.


Survival of patients with nontransmural myocardial infarction: a population-based study. A population-based study was conducted in metropolitan Baltimore in which the short- and long-term prognosis of 283 patients with nontransmural myocardial infarction was compared with that of 953 patients with transmural infraction. After simultaneous adjustment for several variables, the in-hospital case fatality rate was greater for patients with transmural (30.1 percent) than with nontransmural (18.3 percent) infarction (P less than 0.01). However, for patients discharged alive from the hospital and followed up for as long as 10 years, no significant differences in survival were found between the groups with transmural and nontransmural infarction. A multiple adjustment procedure yield 3 year case fatality rates of 27.1 percent and 28.3 percent, respectively, for patients with transmural and nontransmural myocardial infarction surviving the acute phase. These results suggest that the long-term prognosis of patients with nontransmural infarction is as guarded as that of patients with transmural infarction and that attempts to prevent subsequent mortality should be diligently pursued in both groups of patients.


Relation of lipids, weight and physical activity to incidence of coronary heart disease: the Puerto Rico heart study. The 2 1/2 year incidence of coronary heart disease was examined in relation to antecedent serum cholesterol and fasting triglyceride levels, physical activity status and relative weight in a cohort of 8,171 urban and rural men 45 to 64 years old participating in the Puerto Rico Heart Program. In this population with a low incidence rate of coronary heart disease, risk of coronary disease was related to serum cholesterol in both urban and rural groups, but this trend was statistically significant only in the urban population. Neither the urban nor the rural population showed a substantial or statistically significant association of serum triglyceride levels with incidence of coronary heart disease. Correlations among relative weight and serum triglyceride and serum cholesterol levels were noted. Despite small differences in incidence of coronary heart disease between urban and rural groups, values for serum cholesterol, triglycerides and relative weight were all significantly higher in the urban men. Only physical activity levels were higher in the rural men. Multivariate analysis, performed to sort out the net effects of these interrelated variables, revealed that serum cholesterol is related to the risk of coronary heart disease even when all variables are taken into account. Low levels of physical activity were significantly associated with a greater incidence of coronary heart disease only in urban men (P less than 0.05). Overweight, which was associated with higher lipid values and less physical activity, was not related to the development of coronary heart disease in either the urban or the rural cohort.


Thallium-201 myocardial imaging in anomalous left coronary artery arising from the pulmonary artery. Applications before and after medical and surgical treatment. Thallium-201 myocardial imaging was performed on six patients with an anomalous left coronary artery arising from the pulmonary artery. Initial images in three children (aged 4 months, 12 months and 2 1/2 years, respectively) demonstrated anterolateral perfusion defects in agreement with the electrocardiographic localization of infarction. Repeat imaging in two patients 2 to 3 months later, after clinical improvement with anticongestive therapy, demonstrated a reduction in the perfusion defect. In 3 other patients (aged 16, 16 and 20 years, respectively) thallium-201 scans performed during exercise stress demonstrated normal myocardial perfusion 7 to 15 years after operation (ligation of anomalous left coronary in two, ligation plus bypass graft in one). Thallium-201 imaging appears to be helpful in monitoring changes in myocardial perfusion before and after medical or surgical treatment of an anomalous left coronary artery, and may shed light on the pathophysiology of the defect. A possible practical limitation of thallium-201 imaging in this condition is the difficulty of imaging subendocardial infarction.


Adenocarcinoma complicating columnar epithelium-lined (Barrett's) esophagus. Prolonged reflux esophagitis leads to replacement of the esophageal squamous epithelium by columnar epithelium in some patients. This columnar epithelium resembles gastric or intestinal mucosa and has been implicated as a precursor of esophageal adenocarcinoma. A review of 14 cases of primary esophageal adenocarcinoma disclosed that 12 (86%) arose in a columnar epithelium-lined (Barrett's) esophagus. Ten of the 12 patients had a hiatal hernia or symptoms of reflux esophagitis or both. In ten patients the columnar epithelium adjacent to and remote from the invasive adenocarcinoma showed a spectrum of abnormalities ranging from mild dysplasia to carcinoma in situ. These data support the concept that esophageal adenocarcinoma is one complication of a columnar epithelium-lined esophagus, and suggest that the invasive carcinoma evolves through a sequence of epithelial dysplasia and carcinoma in situ in most cases. Esophageal biopsy and cytology can detect this dysplasia, and should provide an effective means for monitoring patients with Barrett's esophagus for impending malignancy.


Granulomatous mediastinitis due to rhizopus species. Phycomycosis is seen most frequently in association with states of immunologic disturbance or hormonal imbalance. Several characteristic sites of infection with Phycomycetes are recognized, but mediastinal involvement has not been previously reported. A case of mediastinal granuloma due to Rhizopus species is described, and comparisons are made with other infections of similar histologic appearance.


Myocardial abscesses.

Myocardial abscesses. A review of postmortem materials from two teaching hospitals, accumulated in a 14-year period (1962--1975), disclosed 63 patients with myocardial abscesses among 12,359 autopsies, an incidence of 0.5%. All 63 patients had multi-focal myocardial abscesses; the lesions were grossly discernible in six patients. Coexisting infective endocarditis was present in approximately 20% (12) of the 63 patients with myocardial abscesses. Candida and Staphylococcus aureus were most common organisms responsible for the abscesses. Candida was identified in 23 patients (37%) by histologic examination of the heart sections, and 11 of these also had antemortem blood cultures positive for Candida. Staphylococcus aureus was cultured from the antemortem blood of 22 patients, two of whom also showed candidal organisms in the heart at necropsy. Eighty-one per cent (51) of 63 patients had abscesses in one or more extracardiac organs. It appeared that most of the myocardial abscesses had resulted from disseminated sepsis. Surgical conditions, malignancy and alcoholic hepatic disease were the most frequent primary conditions in patients with myocardial abscesses.


Pneumothorax in a large autopsy population. A study of 77 cases. Postmortem chest roentgenograms in approximately 3,500 cases of a random autopsy population were reviewed. Pneumothorax was found in 77 cases (2.2%). Simple pneumothorax was present in 38 cases, and tension pneumothorax or combined simple and tension pneumothorax was present in 39 cases. Only 40 of the 77 patients had been clinically diagnosed as having pneumothorax. Pulmonary conditions most often present in cadavers with pneumothorax were bacterial pneumonia, pulmonary emphysema, and pulmonary embolism, with or without infarcts and infarct abscesses. Procedures most frequently associated with pneumothorax were mechanical ventilation and attempts at cardiorespiratory resuscitation. Rib fractures (iatrogenic and noniatrogenic) were found in 23 of the 77 cases.


Rapid diagnosis of actinomycosis by thin-needle aspiration biopsy. Actinomycosis was diagnosed in three cases by the use of thin-needle aspiration biopsy technic. Aspiration was utilized for morphologic studies and collection of material for microbiologic isolation. The critical histologic features of sulfur granules remain intact with aspiration technic. Thin-needle aspiration biopsy is a safe, simple, and rapid technic employed in the diagnosis of neoplastic disease. The use of this technic in the diagnosis of actinomycosis is demonstrated in this report.


Clinical significance of citrobacter isolates. Little is know about the clinical significance of isolating Citrobacter in the clinical laboratory. During a one-year period, 116 Citrobacter isolates were obtained from 77 patients with 83 suspected infectious episodes. The majority of the suspected infectious episodes involved the urinary tract (45%) or respiratory tract (41%). Citrobacter diversus was associated with 42% of the episodes, Citrobacter freundii with 29%, and Citrobacter species with 29%. In 42% of the suspected infectious episodes, the presence of Citrobacter was considered clinically significant; in the others, the significance of the Citrobacter isolates was indeterminate or considered to be commensal. Two thirds of the significant infections were hospital-acquired. Most patients (73%) from whom Citrobacter was cultured had underlying diseases or factors predisposing to infection. These data suggest that Citrobacter is a cause of significant opportunistic nosocomial infection in the hospital.


Rapid amylase and lipase determinations by nephelometry. The Coleman 91 nephelometer provides rapid, simple amylase and lipase assays, which are particularly suited to emergency requests. Linearity of amylase compares favorably with that of the Phadebas assay, and comparable precision was obtainable with serum and urine. Normal ranges for serum amylase are slightly higher than those based on the amyloclastic end-point assay. The serum lipase assay shows improved linearity over titrimetric procedures, although kinetics remain variably non-linear. Occasional sera show discordantly elevated nephelometric lipase and normal titrimetric lipase. Precision of the nephelometric lipase assay is somewhat lower than that of amylase; normal ranges are considerably higher than those based on titrimetry. Extremely lactescent sera may yield falsely low nephelometric amylase and lipase activities: these sera must be serially diluted to achieve actual values.


Transiently elevated apparent lipase by nephelometry. Occasional patient sera showing normal or minimally elevated lipase activity in the 6-hour titrimetric assay and discordantly high lipase activity in the 6-minute nephelometric assay were encountered. Most of these sera had normal amylase activity. They represented about 1% of outpatient sera subjected to amylase assay. A few sera with discordant lipase activities showed elevated amylase activities and were from patients with the diagnosis of pancreatic dysfunction. Nephelometric lipase assay in these sera showed pronounced nonlinear kinetics; in the most discordant cases a gradual decay of initially high activity to zero occurred. Elevated nephelometric lipase activity was lost inordinately in serial dilution of serum or on serial reduction of undiluted assay volume. In tracer experiments, two of these sera liberated no significant amount of free fatty acids after extensive "de-emulsification" of the nephelometric substrate mixture. This nonlipolytic "deemulsifying" activity was found to be relatively heat-stable in one serum. The nature of this activity remains obscure. A simple and effective protocol is suggested to detect and identify these aberrant nephelometric lipases in the routine laboratory.


A comparison of five manually operated coagulation instruments. The results of activated partial thromboplastin time (APTT) and prothrombin time (PT) determinations on the single-channel Coag-a-Mate, Coagulyzer Jr., Clotek, Electra 650, and Fibrometer instruments were compared with regard to precision, day-to-day reproducibility of results, and accuracy. There was no significant difference among the machines when PT was analyzed. In the APTT study, the single-channel Coag-a-Mate had the best overall precision (coefficient of variation 2 to 4%), while the Coag-a-Mate and the Electra 650 had the best day-to-day reproducibility (coefficient of variation 2 to 5%). The comparison study indicated good correlation (r greater than or equal to 0.95) between the reference instrument (Bio/Data CA-15) and the single-channel Coag-a-Mate, Electra 650, and Clotek. The correlation for the Coagulyzer Jr. was also quite good (r = 0.95), but it could not detect some of the clots detected by the other machines. The Fibrometer showed significantly poorer correlation (r = 0.87) when compared with the other instruments.


A semiautomated turbidimetric method for determination of plasma fibrinogen. A semiautomated turbidimetric technic for determination of the concentration of fibrinogen in plasma was compared with chemical analysis of the fibrin formed by addition of thrombin to plasma. The overall coefficient of correlation between the two methods was 0.98, although the turbidimetric technic was somewhat more accurate in hypofibrinogenemic plasma, and the chemical method, in normal plasma.


Evaluation of a packaged kit assay of serum ferritin and application to clinical diagnosis of selected anemias. The reliability of a radioimmunometric assay of serum ferritin concentration by a packaged kit was evaluated. In addition, application of the serum ferritin assay to the clinical evaluation of selected anemias was assessed. When appropriate serum dilutions were utilized, this method was sufficiently reproducible and reliable for application to the clinical laboratory. Serum ferritin was found to be a valuable tool in the differential diagnosis of anemia accompanied by hypoferremia, although iron depletion coexisting with either the anemia of chronic disease or active hepatocellular disease may not be clearly appreciated. The primary advantage of the determination was to help characterize the iron status of the patient with a hypochromic microcytic anemia or hypoferremia who would ordinarly require a bone-marrow examination for iron stores.


A simple test for detection of sickle hemoglobin in the neonatal period. The ease of denaturation by shaking of a solution of oxyhemoglobin S (oxy-Hb S) forms the basis for a simple and reliable test for confirmation or rapid detection of Hb S in children and adults. Comparison of results of this test with those from agar gel electrophoresis in capillary blood samples from 187 black neonates at 2 to 7 days of life showed no overlap of the amounts of hemoglobin precipitated between the group of neonates with Hb S (5.7--12.0%) and that without Hb S (0--4.7%). These results indicate that the shaking test, by virtue of being simple, reliable and inexpensive, may be used to detect and confirm Hb S in large numbers of neonates before their discharge from the nursery.


Specimen photocopying for surgical pathology reports. A method of direct photocopying of surgical pathology specimens is described. The copy thus obtained can be included as a part of the surgical pathology report, to visually indicate locations of lesions, margins, measurements, and sites of sections taken for microscopic examination.


Tubular carcinoma of the breast. A study of frequency. Tubular carcinoma of the breast is a recognizable histologic type of invasive mammary carcinoma, characterized by infrequent axillary lymph nodal metastases and an excellent prognosis. Of all carcinomas of the breast diagnosed in 1974 in the Louisville area, 42, or 10.3% were of the tubular variety. This is in contrast to the previously expressed opinion that tubular carcinoma is rare. Three histologic types of tubular carcinoma are described. Strict criteria for diagnosis of the mixed type are recommended.


Rhabdomyosarcomas of the uterus.

Rhabdomyosarcomas of the uterus. The authors report the clinicopathologic findings in four cases of adult women with rhabdomyosarcomas that originated in the endometrium or cervix, or both. All tumors were pure sarcomas and not components of carcinosarcomas or malignant mixed mesodermal tumors. In two patients, the tumors were typical botryoid embryonal rhabdomyosarcomas. Both patients were alive and well following combined treatments with surgery and chemotherapy or irradiation 3.0 and 2.7 years after operation, respectively, although one had a solitary pulmonary metastasis resected. The other two women had pleomorphic rhabdomyosarcomas, and both died rapidly of widespread tumor. Combination therapy rather than surgery alone probably should be used initially for patients with rhabdomyosarcomas of the uterus.


Splenic hamartoma.

Splenic hamartoma. This paper describes five cases of splenic hamartoma, a benign lesion, usually found incidentally in the spleen at autopsy. The current practice of laparotomy for staging of malignant lymphomas, especially Hodgkin's disease, has increased the numbers of surgically removed spleens. Because splenic hamartomas may be confused histologically with Hodgkin's disease involving the spleen, the authors have reviewed this entity, stressing the importance of recognizing and distinguishing it from a malignant process.


False-positive rubella hemagglutination-inhibition (HAI) titers in neonates and children with conjugated hyperbilirubinemia. Two neonates, one with extrahepatic biliary atresia and one with cystic fibrosis, and a 9-year-old child with atresia of the common bile duct had conjugated hyperbilirubinemia and elevated rubella HAI titers when kaolin pretreatment of serum was used. A beta-lipoprotein fraction of the serum that is frequently found in association with biliary obstruction was shown to be the probable source of the rubella HAI inhibitor. This beta-lipoprotein was not removed by standard kaolin treatment of serum, but was removed almost completely by dextran sulfate--calcium chloride treatment. In the presence of conjugated hyperbilirubinemia, routine kaolin pretreatment of serum is an inadequate measure for the removal of interfering substances, as false-positive rubella HAI results are obtained consistently.


Serum enzyme tests in diseases of the liver and biliary tree. Eight serum enzyme tests were performed over a three-year period in 1,147 cases of patients with suspected hepatobiliary disease, of whom 580 had identifiable primary disease of the liver or biliary system. Individually, aminotransferase assays did not provide good discrimination among the various categories of hepatobiliary disease, but when expressed as a ratio a useful degree of discrimination was obtained. Isocitrate dehydrogenase, guanase and glutamate dehydrogenase alone were poor discriminants of the various disease categories studied; combination of the latter enzyme with the aminotransferases in various ratios did not achieve worthwhile improvement. Adenosine deaminase was normal in most patients with extrahepatic obstruction and abnormal in most patients with parenchymal hepatic disease, and is potentially a useful test additional to the aminotransferases in routine diagnosis. 5'-Nucleotidase was more sensitive and specific than alkaline phosphatase in diagnosing hepatobiliary disorders. Abnormalities of all these enzymes were encountered in patients who did not have hepatobiliary disease, most frequently among subjects with cancer, diabetes mellitus, and diseases of the respiratory and cardiovascular systems.


Laboratory studies of erythrocytic pyruvate kinase deficiency. Pathogenesis of the hemolysis. Genetic polymorphism exists in erythrocytic pyruvate kinase (PK)-deficient hemolytic anemia, as briefly described. Destruction of erythrocytes varied in extent, but its mechanisms in different PK-deficient polymorphic persons investigated were similar. A paradoxical post-splenectomy reticulocytosis regularly occurred. Qualitative enzymatic differences, the biochemistry, and measurements of erythrocytic destruction were made in several PK variants. 51Cr autologous and cross-transfusions of PK-deficient erythrocytes into volunteers showed multimodel regression lines of several erythrocytic cohorts. 59Felabeled PK-deficient reticulocytes donated by PK-deficient splenectomized subjects were transfused 20 hours before splenectomy into two PK-deficient infants with hemolysis, and into two adult volunteers with autoimmune thrombocytopenia. The highest reticulocyte concentration in any organ initially was within the spleen. Radioiron-labeled erythrocytes and cytologic data showed large splenic reticulocyte pools. Splenic macrophages ingesting reticulocytes and erythrocytes were seen by both light and electron microscopy of the splenic pulp. After cyanide additives inhibiting reticulocyte oxidative phosphorylation, a bizarre erythrocytic cytologic configuration was found by scanning electron microscopy. These studies of PK-mutant subjects with PK-deficient erythrocytic hemolysis showed age dependent destruction of erythrocytes. Bimodal Cr survival data suggested reticuloendothelial removal of short-lived erythrocytes and reticulocytes. The transfusions of radioironlabeled PK reticulocytes and the data obtained by scanning electron microscopy suggested that the spleen was the initial hostile organ destroying a cohort of susceptible erythrocytes, prinicpally reticulocytes.


The 125I-fibrinogen euglobulin clot-lysis test. A new method for determination of the rate of plasma fibrinolytic activity is presented. The method is based on the euglobulin clot-lysis test, modified by the addition in vitro of a small amount of normal I-labeled fibrinogen to the patient's eublobulin fraction. The rate of fibrinolysis is determined by the release of radioactivity from the clotted euglobulin fraction as a function of time. The rate is expressed as the fibrinolysis constant, which is the mathematical value for the fibrinolysis curve. Mean normal value for the fibrinolysis constant for 17 normal adult volunteers was 0.14 +/- 0.09 (2 SD). The major advantages of this technic are that it is not necessary to rely on complete dissolution of the clot for the end point, the majority of the euglobulin clot is the individual's own fibrin(ogen), and a quantitative and kinetic index of overall fibrinolytic activity can be obtained.


Rapid assay for measurement of serum ferritin. The authors present a rapid modification of the tube immunoradiometric assay for serum ferritin quantitation. The method involves gentle rotatory mixing of the tube contents at ambient temperature and can be performed in a few hours. Variables affecting different stages of the assay were systematically investigated. The performance characteristics of the shortened assay in terms of reproducibility, sensitivity and recovery were then validated. Results with this method correlate well with those obtained by the conventional assay.


Standardization of the one-stage assay for factor VIII (antihemophilic factor). Although considerable progress has been made in perfecting the one-stage assay for factor VIII (antihemophilic factor), there remain variables that influence test results within laboratories as well as reproducibility between laboratories which have not been adequately evaluated. The purpose of this paper is to elucidate certain aspects of this assay that have not received adequate consideration and to describe the authors' assay method in order to provide a basis for comparison with results from other laboratories. It appears that variability results from: (1) differences in coagulability of different batches of substrate plasma obtained at different times from the same individual; (2) instability of some batches of stored substrate or standard plasmas; (3) variation in coagulability among vials of stored substrate or standard plasma from the same batch; (4) variation due to non-plasma reagents and instrumentation used to execute the test.


Phencyclidine identification by thin-layer chromatography. A rapid screening procedure for emergency toxicology. The clinical manifestations of phencyclidine abuse may include bizarre neuropsychiatric symptoms, which may mimic the untoward reactions of a variety of illicit drugs. Specific diagnosis and therapy depend, primarily, upon consideration of this drug followed by its prompt and accurate identification. A rapid modified thin-layer chromatographic technic for the detection and differentiation of phencyclindine from other alkaloids and neutral drugs with similar Rf values in this system is presented.


Implementation of a pneumatic-tube system for transport of blood specimens. Whole-blood specimens were transported through an installed 485-meter pneumatic-tube system dedicated to blood transport. The system featured constant-speed, low-carrier-velocity travel (3.6 m/sec) with controlled deceleration prior to arrival at its destination. Inserts were designed with ample use of padding to minimize agitation during transport and landing. Serum potassium, hemoglobin, and lactate dehydrogenase activity and whole-blood pH, PCO2, and PO2 were not altered in freshly drawn blood transported in this system. Partial filling or heparinization of the specimen containers did not alter the results. When specimens were allowed to clot prior to pneumatic-tube transport, significantly higher levels of serum lactate dehydrogenase were obtained. This study demonstrates that transport of whole-blood specimens by pneumatic tube without damage to blood components is feasible.


Chronic granulomatous disease with leukocytic glucose-6-phosphate dehydrogenase deficiency in a 28-month-old girl. A 28-month-old girl, whose parents are first cousins, was hospitalized following a series of severe infections. Results of functional granulocytic tests permitted the diagnosis of chronic granulomatous disease (lack of nitroblue tetrazolium dye reduction, impaired bactericidal activity for Staphylococcus aureus but normal activity for Streptococcus foecalis). Random migration was also impaired, and leukocytic glucose-6-phosphate dehydrogenase (G6PD) activity was decreased (37% of the normal mean). In contrast, erythrocytic G6PD activity was normal. Similar leukocytic studies of both parents revealed a moderate decrease of the mother's leukocytic G6PD activity (62% of the normal mean). This case represents an additional argument in favor of the recessive autosomal transmission of chronic granulomatous disease in females.


Anaplastic thyroid carcinoma following low-dose irradiation. Low-dose irradiation of the neck in childhood is associated with a markedly increased incidence of thyroid cancer. Such carcinomas have almost all been well differentiated, papillary or follicular types. This paper describes the development of metastatic anaplastic thyroid carcinoma in cervical lymph nodes a year after subtotal thyroidectomy for well-differentiated papillary carcinoma in a 32-year-old man who had had low-dose cervical irradiation at the age of 7 years. It appears that irradiation-related thyroid carcinomas, in at least a very small number of people, may be associated with aggressive carcinoma.


Self-help groups viewed by mental health professionals: a survey and comments. This paper presents a summary of a national survey of the utilization and evaluation of self-help groups by outpatient mental health facilities making and receiving referrals from self-help groups. Evaluations of self-help groups' effectiveness tended to be favorable, and respondents generally believed that they could play an important role in a mental health delivery system. Only 30.7%, however, believed that the probability was high that their agencies would be interested in exploring how their activities might be integrated with those of self-help groups.


Crisis intervention with families of servicemen missing in action. This study investigated reactions and processes in a crisis situation as well as experiences of those who engaged in crisis intervention activities. Thirty-two volunteers, who worked with 55 families of servicemen missing in action during the October 1973 Mideast war, described the families' reactions to the given situation as well as their own involvement. Reactions to crisis and expectations from the volunteers are described and discussed. Special scrutiny was directed at the volunteering phenomenon, and at the volunteers' motivations, needs, reactions, and conflicts.


Community influences on mental health program evaluation. Research in community psychology has demonstrated that community environments can play a key role in defining the operations of human service institutions. This study questioned whether significant community groups might indirectly influence the program evaluation record-keeping of mental health outpatient programs to reflect contact with problem areas considered important by those groups. An inventory of program evaluation materials was conducted in three types of mental health programs. The ranked frequencies of record completion for 10 designated problem areas were correlated with staff rankings of importance for agency work with problems identified by key community groups. Results indicate that the more important the community demand is to the staff, the more systematically complete will be data sources which document agency performance for that demand. Given the general lack of comprehensive development of program evaluation in many mental health programs, the results suggest that community interest groups may play a major role in determining what types of information on mental health problems are made available to the public. The resultant lack of balance and scope in these data inevitably limit the range of community responses for program improvement.


An assessment of a community's mental health needs. In this study social indicators and survey measures were used to predict 3-years of service utilization by the residents of 26 census tracts served by a community mental health center. Ten social indicators were selected from available census tract statistics, and seven survey measures were taken from an epidemiological survey of the catchment area of the mental health center. These data were analyzed first with univariate analyses of variance and then with stepwise regression to test their independent and combined relationship with utilization rates. The results showed that mental health utilization rates can be predicted with considerable accuracy by social indicators and survey measures. Combining survey measures and social indicators provided the greatest accuracy; implying that both social and psychological forces need to be considered. Social indicators alone were shown to be more powerful predictors than survey measures alone. Survey measures may be particularly valuable in identifying the special problems of members of different neighborhoods, while social indicators provide clues about the location of high-risk neighborhoods.


Increased clinic awareness and attitudes of independence through client advisory board membership. In order to determine the effect of client advisory board membership on clients' awareness of a clinic, and on client attitudes of independence, the responses of 13 board members were compared with those of 13 matched controls on two self-report measures (Clinic Recognition Test, Client Independence Questionnaire) before and after 3-month periods. Analysis of the results indicated that, whereas the responses of controls did not significantly change on the Client Independence Questionnaire, the responses of board members indicated a significant increase in attitudes of independence. And, even though both board members and control clients significantly increased their awareness of clinic and staff over 3 months, the awareness of the broad members was significantly greater than that of the control clients.


The psychologist in the community mental health center: an analysis of activities and training needs. Professional activities and expressed needs for additional training were examined in the case of 211 psychologists employed in 51 community mental health centers in western United States. Two-thirds of the work week is taken up directly or indirectly with traditional clinical services, 19% with community mental health activities; and the balance in program development, administration, research, and program evaluation. In contrast to the common assertion linking psychologists and research activity, the current results indicate that psychologists in community mental health centers devote very little time to research or program evaluation. Expressed training needs parallel reported activity patterns - highest for clinical functions and moderately high for community mental health functions. The significant impact of the community mental health movement is seen in both the distribution of professional activities and in expressed needs for additional competence.


Outcome evaluation of a referral system for juvenile offenders. Referral systems, among the most recent delinquency prevention programs, have not been evaluated on outcome measures. This paper describes the effectiveness of a referral system for young offenders. The subjects were 239 referred and nonreferred juveniles who were apprehended by the police. Program effectiveness was measured in two areas: diverting youths from court and preventing youths from having further police contact (preventing recidivism). Results indicated that the program served multiple offenders more frequently than it did first offenders, and first offenders who received the greatest amount of service had a higher incidence of recidivism than did low-service clients. Suggestions are made for more effective development and evaluation of referral systems.


A comparison of three survey methods to obtain data for community mental health program planning. A perennial problem for mental health planners is assessing community needs and existing services. The three most common methods used to obtain this data are the telephone survey, the mail-out questionnaire, and the face-to-face interview. However, there are advantages and disadvantages associated with each approach in terms of sampling, response rates, and economic costs. The present study utilized all three methods to survey the same community population in order to determine the comparability of obtained data and relative efficacy of the methods. A standard 21-item questionnaire was developed to obtain demographic and epidemiological data. This included nine Likert-type items to obtain opionions on a typical question such as "To what extent would you have confidence in recommending the Mental Health Center to members of your immediate family?" In the first method, survey teams made door-to-door interviews to complete 449 questionnaires on a random sample. In the second method, 1,000 questionnaires were mailed to a random sample with returns requested. In the third method, 224 people were randomly selected from the telephone directory and asked to respond to the questionnaire over the phone. Precautions were taken in all methods to ensure confidentiality of responses. All respondents were classified according to a two-factor index based on occupation and education. The data were analyed to determine whether comparable data were obtained through divergent methods. Results are discussed and implications are given for community mental health planners.


Attitudes toward seeking pastoral help in the event of the death of a close friend or relative. This study examined correlates of seeking help from clergymen in the event of the death of a close friend or relative. Demographic factors and attitudes toward seeking pastoral help in the event of the death of a close friend or relative were examined in 116 subjects. Half the subjects were undergraduates and half were from local congregations. Age, sex, socioeconomic status, religious affiliation, marital status, and intensity of religious belief were related to favorableness of help-seeking attitudes. Findings concerning sex of the subject were consistent with those in more general studies on help seeking. The remainder of the findings were in the opposite direction from comparable studies where the source of help was a mental health professional and the circumstances for seeking help are unspecified.


Alcohol and illicit drug use: follow-up study of treatment admissions to DARP during 1969-1971. The present study was based on follow-up data on 1409 persons interviewed 4 to 6 years after admission to drug treatment in the Drug Abuse Reporting Program (DARP). The admissions to DARP occurred in 1969-1971, and for most persons the follow-up data included 3 or more years after termination of DARP treatment. The study focused on variations in alcohol consumption associated with post-DARP drug use and treatment status. The results indicated that use of alcohol and non-opioid drugs (particularly marijuana) tended to be correlated, but that this was not true of opioid drugs. For a small segment of the sample, evidence suggested that substitution of use may have occurred between alcohol and opioid drugs. Also, persons with post-DARP drug treatment tended to use less alcohol than persons without treatment. Interpretations and implications of these findings are discussed.


Illicit drug use and return to treatment: follow-up study of treatment admissions to DARP during 1969-1971. The present study was based on follow-up data on 1,409 persons interviewed 4 to 6 years after admission to drug treatments in the Drug Abuse Reporting Program (DARP). The admissions to DARP occurred in 1969-1971, and for most persons the follow-up data included 3 or more years after termination of DARP treatment. The focus of this study was on illicit drug use of former DARP clients, taking into account if and when they reentered drug treatment after termination of DARP treatment. The results showed that a significant drop in opioid and nonopioid (but not marijuana) drug use generally occurred upon entry into other, post-DARP treatments, and that these beneficial effects of treatment tended to continue beyond the end of treatment. Overall, 42% of the sample had no further drug treatment during the first 3 years after DARP, and almost half (42%) of this group used no opioid or nonopioid drugs at all during this time. Comparisons between DARP treatment groups also indicated that therapeutic community clients had the lowest rate of return to post-DARP treatments.


Street heroin potency and deaths from overdose in San Antonio. Disagreement over the mechanism of death in so-called heroin overdose has been noted in the medical literature for more than a decade. We studied the relationship between the potency of street heroin and the frequency of heroin overdose deaths in San Antonio in order to test the "pharmacologic overdose" hypothesis. We found a small, nonsignificant correlation (r=+.13) between monthly mean heroin dose and monthly number of heroin overdose deaths over a 5-year period. This low correlation contradicts findings of previous studies in Washington, D.C. and Atlanta, conducted over shorter periods of time, in which high positive correlations were found. The low correlation does not support the pharmacologic overdose hypothesis. Since there were confounding variables, the data do not refute the hypothesis. These variables include the use of alcohol and other depressants, hidden suicide, and reduced opioid drug tolerance due to institutional treatment.


Methadone and criminality: a suburban perspective. In a suburban methadone program, using official police records, a study was made of patients' arrest records before and after methadone treatment. Eighty patients were willing to allow the researchers to secure their arrest records. These 80 patients were similar to the total clinic population of 226 in terms of demographic variables, arrest records, and addiction history. For these 80 patients both the rate of arrest and the number of patients arrested declined in association with entering methadone maintenance treatment. The decline was statistically significant for drug-related offenses but not for nondrug-related offenses. Overall, the decline in both rate of arrest and number of patients arrested was significant, but this was due to the decrease in drug-related arrests. Drug-related arrests play a dominant role in the criminality of the suburban patients in this study. Because of this, the reduction in drug-related arrests is more significant for this group of patients than it would have been for an inner-city patient population.


Chemical dependency education within medical schools: supervised clinical experience. Physicians can play a significant role in chemical dependency, including early identification and intervention, referral to treatment resources, patient and community education, and responsible prescribing practices. Some medical schools have begun to provide instruction in the psychology, pharmacology, and physical pathology of chemical dependency; yet surveys indicate that few offer supervised clinical experience with chemically dependent patients. At the University of Minnesota Medical School, chemical dependency treatment centers are used to provide supervised clinical tutorials for all second year students as part of a coordinated chemical dependency curriculum. The authors describe the development, goals, organization, instructional approaches, and assessment of these tutorials. It is argued that chemical dependency treatment centers are a valuable resource in the education of medical students, as well as other professionls, if used with a view to their assets and limitations.


Coca leaf as a therapeutic agent.

Coca leaf as a therapeutic agent. South American Indians have used coca leaf as a remedy for thousands of years. Coca might be useful as a treatment for gastrointestinal ailments and motion sickness, as a fast-acting antidepressant medication, as a substitute stimulant for coffee in certain cases, and as an adjunct in programs of weight reduction and physical fitness. In leaf form, coca does not produce toxicity or dependence. Its effects are distinct from those of cocaine, which is but one of a number of active compounds in the leaf. Coca can be administered as a chewing gum containing a whole extract of the leaf, including alkaloids, natural flavors, and several nutrients. Legal mechanisms exist for importing, distributing, and dispensing coca, and experimentation with it by interested physicians would be valuable.


Personality and sexual behavior of the adolescent smoker. The adolescent smoker (aged 14 to 17 years) shows little difference from the non-smoker in terms of scores on the Cattell 16 personality factor inventory. In particular, there is no evidence of tension, extroversion, or reversal of sexually-biased personality characteristics. The sexual promiscuity of the adolescent smoker is probably related more to liberal attitudes and a propensity for risk-taking behavior than to uncertainty regarding sexuality. In this age group the decision to start smoking regularly may depend more on the influence of parents and friends than on an inherent personality structure.


Impact of sex on length of time spent in treatment and treatment success. This paper examines the null hypothesis that there is no difference between male and female drug abuse clients in length of time spent in treatment and successful outcome of that treatment. The hypothesis is tested by means of multiple classification analysis on a random sample of 20,264 clients who were discharged from federally-funded drug abuse programs in 1975. Upon controlling for the effects of demographic client characteristics, treatment history, and drug usage, the authors conclude that the null hypothesis is sustained. Small differences are apparent, especially with respect to the length of time spent by clients in drug-free modality and day-care environment and in detoxification modality and hospital environment, and with respect to treatment success for clients in drug-free environment and hospital environment. However, these differences are not sufficient to warrant a rejection of the null hypothesis.


Efficient manometric technic for accurate regional measurement of esophageal body motor activity. We have developed a single station, manometric recording technic that allows quick and accurate measurement of motor activity occurring in all regions of the esophageal body. The manometric instrumentation features a catheter recording assembly with eight recording orifices spaced at uniform 3 cm. intervals. Each recording lumen is infused with water by a minimally compliant hydraulic-capillary system which achieves accurate recording of peristaltic and nonperistaltic motor activity in the esophageal body at an infusion rate of 0.5 ml./min. Because the recording sites of the manometric assembly span a distance of 21 cm., a distance which approximates the length of the esophageal body in humans, a detailed map of motor activity over the entire length of the esophageal body is achieved by securing the manometric assembly at one suitable portion. Because frequent repositioning of the manometric assembly is eliminated, the method described takes only a few minutes for comprehensive assessment of esophageal body motor activity.


Prostaglandin E1 inhibition of acid but not gastrin. Prostaglandin E1, while inhibiting gastric fistula and Heidenhain pouch acid output in the dog, did not inhibit gastrin released by acetylcholine irrigation of an isolated antral pouch independent of pH effect. Some increase in gastrin was noted to PGE1 against a background of calcium infusion and following a meal. This increase is presumably due to acid inhibition and to an increase in intraluminal pH.


Complications of vagotomy.

Complications of vagotomy. Most operations performed for peptic ulcer disease in the United States include vagotomy as part of the surgical procedure. This paper reviews the complications associated specifically with or increased in frequency and severity by this procedure. Included in this review are technical complications, gastric retention, recurrent ulceration, postvagotomy diarrhea, postvagotomy dysphagia and achalasia, postvagotomy biliary disease and nutritional problems. The frequency of these complications, their pathophysiology and therapeutic modalities available are reviewed. The main emphasis is on postvagotomy syndrome that can be treated medically and on the various treatment forms that have been suggested.


Clinical value of liver scans.

Clinical value of liver scans. The contribution of technetium sulfacolloid liver scans on patient care was evaluated in 200 consecutive patients; 100 in a public (Grady) and 100 in a private (Emory University) hospital. The problem oriented record clearly described the effect of liver scan on: 1. assessment of the patient's problem(s) and 2. plans made for its diagnosis or management. For the diagnosis and treatment of 30 patients with intrinsic hepatobiliary diseases, the scan was useful in five but was misleading in four. Specific diagnosis was obtained by other methods which made the liver scan an unnecessary overutilization of a diagnostic procedure in the evaluation of patients with primary liver or biliary diseases. The scan was useful in 95 of 123 patients with extrahepatic malignancy. This was mostly due to chemotherapy protocols requiring the scans. Only 18% of positive scans had no other clinical evidence for hepatic malignancy. Definite diagnosis was not made in any of the 123 patients by liver scan. In 47 miscellaneous conditions the scan was useless in 37 (79%). In three of these the scan was misleading and impaired patient care.


First 24 hours of acute pancreatitis. A biochemical and endocrine evaluation of initial versus repeated attacks. Differences in metabolic homeostasis in 12 patients with initial vs. eight patients with repeated attacks of acute pancreatitis have been compared during the acute phase of the disease. As a group, subjects with a previous history of pancreatitis had significantly lower glucagon concentrations (P less than 0.002) for the over all 24-hour study period. Conversely, the serum concentrations of blood sugar, insulin, growth hormone, gastrin, cortisol, nonesterified fatty acids, triglycerides and cholesterol failed to distinguish between the two patient groups. Likewise, immunoreactive plasma parathyroid hormone and calcitonin levels were comparable in both patient populations. Of the measurements considered, it would appear therefore that plasma immunoreactive glucagon is the best indicator of previous pancreatic inflammation. Evaluation of parenchymal integrity during an episode of acute pancreatitis would be of prognostic and therapeutic value in this disease.


Achalasia of the esophagus. Pneumatic dilatation in a four-year old boy. A four-year old boy with achalasia of the esophagus was successfully treated with pneumatic dilatation, using the standard Browne-McHardy dilator, without incident. His subsequent course over 10 months has been uneventful.


Gastrointestinal tuberculosis mimicking cancer--a reminder. Tuberculous involvement of the gastrointestinal tract may be suspected in the presence of active pulmonary tuberculosis. This case demonstrates that tuberculous enteritis may develop in the absence of obvious pulmonary involvement. The diagnosis in such instances is established by a combination of roentgenographic studies and surgical exploration.


Gastric bezoars--spontaneous resolution. Six cases of gastric phytobezoars were seen on fiberoptic gastroscopy over a period of four years during which time 1,400 gastroscopies were done. Four of these cases showed complete resolution of bezoars on repeat endoscopy during a follow-up period ranging from two weeks to one year. Our experience shows that, in the absence of gastric outlet obstruction, small bowel obstruction or other serious problems due to bezoars, they may not need surgical or aggressive medical treatment.


Pseudotumor in the Mallory-Weiss syndrome. A Mallory-Weiss laceration with endoscopic and radiologic features of a submucosal tumor is described. Repeat examination showed complete resolution of the lesion.


Pancreatic internal fistula to the left pleural cavity. A case of recurrent pancreaticopleural effusion is presented. The pleural effusion with high enzyme and protein contents resulted from a pancreatic internal fistula to the left pleural cavity. A sinus tract passing through esophageal hiatus was demonstrated by the endoscopic retrograde pancreatography (ERP). Surgical intervention afforded complete relief of abdominal pain and elimination of the pleural effusion.


Effect of acute and chronic administration of 5-FU on pancreatic secretion. The administration of various dose schedules of 5-FU did not result in any alteration of pancreatic secretion. The findings would not support the thesis that the gastrointestinal side-effects of this potent cancer chemotherapeutic agent are the result of a toxic pancreatic insufficiency.


Training staff pharmacists for clinical positions. A five-phase education and training program for establishing and maintaining the clinical competency of pharmacists in a 940-bed private, nonprofit hospital is described. In Phase 1 of the program, pharmacists are given selected textbook and journal materials in 15 study sections, each requiring 20--30 hours of the pharmacist's own time to complete. Phase 2 consists of two months of instruction in the daily clinical routine with emphasis on applying knowledge by investigating clinical problems through case presentation and by answering questions of health professionals. During Phase 3, the pharmacist is assigned to a patient-care area for two months to perform the duties of a clinical pharmacist. The pharmacist is assigned to the drug information center for two months during Phase 4. Phase 5, the year-round continuing education component of the program, consists of regularly scheduled clinical rounds, meetings and conferences. Upon completion of Phases 1--4, pharmacists selected for clinical positions provide clinical services for eight to 10 months and rotate to the pharmacy distribution area during the remaining two to four months per year. The education and training program described is important to the development and expansion of clinical services in this hospital.


Clinical segment of a pharmacy residency in a community hospital. A 13-week, advanced clinical project segment of a one-year, nonacademic pharmacy residency program in a community hospital is described. The primary responsibility of the residents is to provide clinical services, which involve close monitoring of the patient's drug therapy and understanding the patient's condition and the goals of therapy. In addition, residents are involved in teaching activities, which encompass a class on drugs for diabetic patients, a patient self-medication program for open-heart-surgery patients, a class on TPN and the emergency drug tray for a new nurse orientation program and presentations on drug topics to various nursing departments. A seminar/case study on some aspect of patient monitoring, preparation of a drug information bulletin, and a trip to either a national pharmacy meeting or well-known institutional pharmacy department round out the program. Behavioral objectives for the clinical segment of the residency are listed.


Impact of drug information services on patient care. The use of information provided by the Drug Information Service of the University of Connecticut Health Center and its effect on patient care were investigated. All drug information requests received during the period from May 1 to August 15, 1977, were reviewed and followed up to determine (1) the usefulness of the information provided, (2) specific outcome(s) of applying the information to a patient-specific problem and (3) the ultimate effect of these outcomes on the patient. A total of 491 requests were received and 443 (90%) of these were followed up. Of those followed up, 421 (95%) were related to patient care. Of the 421 requests related to patient care, 350 (83%) were patient-specific. Of the 350 patient-specific requests, 329 (94%) were judged by the requestors to have provided useful information. Of these 329 requests, 202 (58%) resulted in provision of information that affected patients' outcomes, of which 157 (78%) had positive effects on patients. It is concluded that (1) the drug information center is providing useful information to health professionals, (2) the information is being applied to patient-specific problems and (3) use of the information is having a positive impact on patient care.


Physician use and evaluation of a hospital-based drug information center. The use of a hospital-based information center by physicians was investigated. A questionnaire was used to gather information from physicians using the services of the center. The study was conducted over a six-month period. Of the 126 questionnaires distributed, 115 (91.1%) were completed and returned. The number of physicians studied was 100. The five categories of drug information most frequently requested involved adverse reactions, dosage, therapeutic use, availability and toxicity. Physicians used information most frequently for purposes of direct patient care. Evaluations of the quality, accuracy and quantity of information provided by the center were high. Physicians using information for purposes of direct patient care felt the information was clinically significant. Although certain inadequacies were identified, it was concluded that the center serves as a reliable source of comprehensive and accurate drug information for physicians.


Measuring pharmacist time use: a note on the use of fixed-interval work sampling. Pharmacist time use was studied to examine whether fixed-interval work sampling would provide results comparable to those obtained when random-interval observations were used. The study was conducted over a three-month period using pharmacists in a single community pharmacy as subjects; similar study methods have been used in hospital settings. Four separate measures of pharmacist time use were designated: tasks, duties, competencies and productivity. In every case the fixed-interval method gave an estimate that was not significantly different from the random-interval procedure (alpha greater than 0.05, difference of proportions test). The findings suggest that pharmacist work patterns are not sufficiently cyclical to introduce a bias in work sampling by fixed intervals. Fixed-interval work sampling yields results comparable to those using the standard work sampling methods that rely upon random time periods between observations.


Cross-reactivity between aspirin and ibuprofen in an asthmatic--a case report. A case of an adverse reaction occurring in a 53-year-old, aspirin-sensitive asthmatic male with nasal polyps following administration of a 400-mg ibuprofen tablet is reported. Symptoms of the adverse reaction included an urticarial rash, labored breathing, laryngeal edema and tightness of the chest. Treatment consisted of isoproterenol inhalant (self-administered), subcutaneous epinephrine 0.25 mg, intramuscular diphenhydramine hydrochloride 50 mg and intravenous hydrocortisone 250 mg. The pathogenesis of the patient's adverse reaction and the possible fole of aspirin, of other analgesics and of tartrazine in its development are discussed. The adverse reaction was not mediated immunologically but rather resulted from the prostaglandin synthetase (PGS)-inhibitor activity shared by aspirin, ibuprofen and other analgesics. Selection of an analgesic for an aspirin-sensitive patient should be based on the analgesic's PGS-inhibitor activity.


Effect of theophylline on allergen skin tests. The effect of theophylline on allergen-induced wheal and flare responses of 15 adults with atopy was studied in a double-blind, crossover study. After intradermal skin tests to determine baseline wheal and flare responses, subjects were assigned randomly to consecutive seven-day courses of theophylline 16 mg/kg/day (as Aminophylline USP) then of placebo, or the reverse. Subjects were tested with mixed weeds and mixed grasses allergens and with histamine diphosphate, codeine phosphate and a buffered saline control. Skin tests were repeated two hours after the last dose of theophylline or placebo in each treatment course, and serum theophylline concentrations were measured. The surface areas of the wheal and flare responses were measured by planimetry. No statistically significant difference (p greater than 0.05) was found between theophylline and placebo in the suppression of the allergen-induced wheal and flare response. Serum concentrations of theophylline were within the accepted therapeutic range. In therapeutic steady-state serum concentrations, theophylline does not significantly suppress allergen-induced wheal and flare response of atopic patients, and withdrawal of the drug before skin testing is unnecessary.


Distributing estrogen patient package inserts to institutional patients. A procedure for the distribution of patient package inserts (PPIs) for estrogens to outpatients (ambulatory and home health care) and inpatients (acute and long-term) was developed. The pharmacist dispenses the PPI to outpatients along with the prescribed drug. The name of the drug, the date, the pharmacist's initials and the fact that the PPI was issued are recorded in the patient's profile. The pharmacist then orally reinforces the information in the PPI. For inpatients, a preprinted double-tab label is adhered to the PPI which is distributed with the medication upon new estrogen orders. The portion adhered to the PPI lists instructions to the physician. The unadhered portion contains an area for recording the name of the drug product, the patient's name, the physician's signature and the date; this tab is affixed to the order sheet by the physician after he has provided and explained the PPI to the patient. Estrogens are not administered until physicians comply with the PPI procedure. While compliance with the PPI procedure has been satisfactory, this may be the result of a substantial decrease in the number of physicians ordering estrogens, along with a corresponding reduction in the number of estrogen products they now prescribe.


Teaching interviewing skills to pharmacy residents. An instructional program for first-year pharmacy residents in the use of interviewing techniques when assessing the drug therapy of patients is described. The objectives of this project were to (1) teach the appropriate use of interviewing skills and (2) observe the performance of pharmacy residents in assessing the drug therapy of ambulatory patients. Instructional methods included a written self-instructional packet, videotaped lecture and demonstration skits, group discussion, and role playing. Following these, during a four-week period, the residents interviewed patients in the outpatient pharmacy and reviewed their performance on videotape with the instructor. Two simulated patient case situations using a resident posing as a patient who provided predetermined information were used to measure student performance in interviewing patients. An improvement in the ability of the residents to employ the interview techniques and to assess the therapy of patients was noted.


Use of a programmable calculator to determine steady-state levels of drugs eliminated by parallel first-order and Michaelis-Menten kinetics. A programmable calculator procedure for the determination of steady-state levels of drugs eliminated by one or more apparent first-order plus one or two Michaelis-Menten processes in parallel is described. The differential expression for this pharmacokinetic system was converted to a reduced cubic equation suitable for calculators with trigonometric functions. A detailed program description and user instructions are presented. Steady-state levels of salicylic acid as a function of dosing rate were calculated to illustrate use of the program in clinical pharmacokinetics. The calculator program provides a facile and rapid means of determining the effect of changes in dosing rate, bioavailability and elimination constants on steady-state levels of salicylic acid and certain other drugs with nonlinear elimination characteristics.


Prediction of gentamicin serum levels using a one-compartment open linear pharmacokinetic model. The accuracy of predicting serum gentamicin levels based on a one-compartment open linear pharmacokinetic model was studied. Twenty-two patients accounted for 59 serum gentamicin levels which were measured by microbiologic assay and compared with predicted serum levels determined by pharmacokinetic calculation. Seventeen serum levels were collected at peak times, 15 at trough time and 27 at times between peak and trough. Forty-nine of the levels were obtained from patients with impaired renal function. Predicated gentamicin levels correlated well with measured serum levels (r = 0.85, p less than 0.001). Of the measured levels, 56% were within +/- 1 microgram/ml of the predicted levels. Of 49 levels collected from patients with impaired renal function, 59% were within +/- 1 microgram/ml of the predicted level. In 13 patients from whom multiple serum gentamicin levels were collected and predictions based on half-life or elimination rate obtained by fitting the first level, 83% of the measured levels were within +/- 1 microgram/ml of the predicted level. The one-compartment open linear pharmacokinetic calculations can be used to adequately predict serum gentamicin levels. In patients with changing or diminished renal function, pharmacokinetic predictions may not be accurate, and actual serum level determinations may be needed to monitor gentamicin therapy.


Chronic hypervitaminosis A.

Chronic hypervitaminosis A. A case of chronic hypervitaminosis A in a 51-year-old female is discussed. The patient was ingesting 27,500--35,000 international units of vitamin A daily for 30 years. The patient displayed the classic symptoms of the disease, including skin and hair changes, esophageal varices and extensive liver disease. Vitamin A products were discontinued and the patient's dietary intake of the vitamin was minimized. Previous reports and studies of hypervitaminosis A are reviewed. Social factors causing increased consumption of vitamin A and regulations governing the sale of vitamin A are discussed. By being aware of the factors influencing vitamin A consumption, hypervitaminosis A can be detected and prevented more readily.


Relative effectiveness and efficiency of group vs. individual training of severely retarded persons. Two groups of severely retarded individuals were trained on a work-recognition task: One group was trained individually, i.e., in one-to-one training sessions; the four members of the other group were taught simultaneously by one teacher. The group-teaching strategy resulted in rates of acquisition that were similar to those found with individual instruction. Further, group training proved to be far more efficient in terms of teacher time; i.e., subjects trained as a group acquired significantly more skills in less teacher time than did individually trained subjects. The results indicate that group training is a viable and, at least in some situations, a preferable method for teaching severely retarded persons.


Category structure and semantic priming in retarded adolescents. This study was designed to investigate the internal structure of semantic categories in mentally retarded adolescents as reflected in naming times to pictures of common objects. Pictures were presented in pairs that consisted of either categorically related or unrelated items. For related pairs, both the primes (first pictures) and targets (second pictures) varied in rated "typicality" (Rosch, 1975), being either typical or relatively atypical members of their primary superordinate category. An analysis of naming times to targets revealed a semantic-priming effect; targets in related pairs were named faster than those in unrelated pairs. Of major importance was the finding that naming times varied as a function of both prime typicality and target typicality. The data suggest that the semantic categories of retarded persons have an internal structure generally similar to that of the nonretarded persons from whom the typicality ratings were obtained and that even relatively atypical exemplars are functional category members for retarded persons.


Training visual-spatial ability in EMR children. Educable mentally retarded children were randomly assigned to either a visual-spatial training condition or a control group. The children who received training showed a gain from pretest to posttest on the Children's Embedded Figures Test that corresponds to approximately 4 years of maturation in nonretarded children. The performance of the children in the control group on the posttest was not significantly different from their performance on the pretest. Correlations between measures of visual-spatial ability and the employment adjustment of retarded persons obtained by other investigators suggest the potential importance of developing the visual-spatial skills of this population.