Clinical significance of fetal heart rate patterns during labor. V. Variable decelerations. Among a large series of high-risk patients who had direct electronic monitoring, 330 fetuses presented "variable" decelerations and 598 had no decelerations. Among those with variable decelerations, there were 18 who presented such associated fetal heart rate (FHR) alterations as tachycardia, fixed baseline, and slow recovery ("hypoxic components"). The fetal outcome, as well as the characteristics of FHR patterns, were compared among the three groups. Baseline changes were significantly higher among pure variable decelerations and still higher among those having variable decelerations with hypoxic components. Likewise, one- and five-minute Apgar scores were significantly lower in that order. Only 4 per cent with no decelerations had clinical fetal distress while 23 per cent with variable decelerations and 78 per cent of those with variable and hypoxic components had distress. Neonatal death was higher among groups with variable decelerations. Premature rupture of membranes seemed to be the only clearly different (and probably influencing) clinical condition, being higher among the group with variable decelerations. Variable decelerations ("cord patterns") are associated with a relatively high rate of depressed infants. This problem is much worse when elements characteristic of hypoxia are identified in FHR tracings. The degree of drop in FHR frequency is not among those elements so identified. It is thus possible to prevent significant fetal deterioration by meticulous analysis of FHR tracings and active management when "late" components are identified on variable decelerations.


Evolution of thinking in fetal respiratory physiology. An outstanding characteristic of intrauterine life is the low oxygen pressure (Po2) of fetal blood. It seemed at one time that in order to tolerate the Po2 of the uterine environment the fetus must have a relatively slow rate of oxidative metabolism or depend upon anaerobic pathways of substrate utilization. Subsequent studies have shown that the fetus has a high rate of oxygen consumption and that lactic acid is a substrate rather than a net product of normal fetal metabolism. The circulatory response of the fetus to acute hypoxia is centered on the requirement of maintaining the arterial oxygen flow to the heart and central nervous system without increasing cardiac output. The arterial oxygen flow concept helps in understanding the physiologic meaning of the high oxygen affinity of fetal blood and the boundary conditions of the fetal defense against hypoxia.


The role of cilia in fertility: an evaluation by selective microsurgical modification of the rabbit oviduct. Fertility, ovum transport, and ciliary activity were examined in 35 rabbits after either unilateral microsurgical reversal or double transection (surgical controls) of 1 cm. segments of distal, middle, or proximal ampulla. Fertility was also examined following similar segmental reversal at the level of the distal and proximal isthmus in eight additional rabbits. Reversal of 1 cm. segments of distal, middle, or proximal ampulla effectively prevented pregnancy. In contrast, control animals that underwent double transection without reversal experienced unaltered fertility. Reversal of 1 cm. segments of distal or proximal isthmus was also consistent with normal fertility. Ova placed on the fimbrial surface of oviducts that had undergone ampullary segmental reversal were arrested at the distal anastomosis of the reversed segment. When mechanically displaced into the reversed segment, such ova were transported toward the ovary and were again arrested at the distal anastomosis. Transampullary transport of ova was normal in doubly transected controls. Ova were transported across both anastomosis sites to the ampullary isthmic junction. Studies of ciliary activity confirmed that cilia within reversed segments of ampulla beat in the ovarian direction, counter to that in the rest of the oviduct. Direction of ciliary beat remained unaltered in surgical controls. These experiments demonstrate a critical role of tubal cilia in ovum transport through the rabbit ampulla. In contrast, other mechanisms control ovum transport into and through the tubal isthmus.


The corneal endothelium and the spectrum of essential iris atrophy. We found that the spectrum of essential iris atrophy (progressive essential iris atrophy, Chandler's syndrome, and the Cogan-Reese syndrome) began as a corneal endothelial degeneration, which, with ectopic endothelial membrane overgrowth over an open angle, followed by contraction of this membrane and further growth onto the iris, accounted for all aspects of the syndrome.  The contractile membrane caused the synechiae, the glaucoma, the corectopia, the ectropion uveae, the occasional iris nodules, and the iris atrophy. Thus we found this disease to be primarily of the cornea, and only secondarily of the iris. The results of this study led us to propose a new designation for this spectrum: primary proliferative endothelial degeneration.


The prevalence of HLA-B7 in presumed ocular histoplasmosis in patients with peripheral atrophic scars. Patients identified in the Walkersville, Maryland, epidemiologic study of presumed ocular histoplasmosis as having only peripheral atrophic scars showed no increase in frequency of HLA-B7 over a control population. Because this antigen is increased in patients with a history of active macular or peripapillary lesions, these findings indicate an inherent predisposition in some patients to develop posterior pole lesions after an ocular infection with Histoplasma capsulatum. The precise mechanisms by which the histocompatibility complex participates in the pathogenesis of these lesions is unknown, but our data are compatible with previous suggestions that alterations in the immune response of these individuals are in some way important in the development of disciform scarring in the posterior pole.


Effects of panretinal photocoagulation on rubeosis iridis, angle neovascularization, and neovascular glaucoma. Ninety-three patients received ruby laser panretinal photocoagulation in one eye for diabetic retinopathy and we examined them at an average time of 7.1 years later. In 14 patients, the untreated eye developed rubeosis iridis and the contralateral treated eye did not. In seven patients, the untreated eye developed angle neovascularization and the contralateral eye did not. The untreated eye developed neovascular glaucoma and the contralateral treated eye did not in four patients. Our findings suggest that eyes with proliferative retinopathy that received panretinal photocoagulation are less likely to develop rubeosis iridis, angle neovascularization, and probably neovascular glaucoma, than those eyes not receiving panretinal photocoagulation.


Long-term treatment of glaucoma with systemic propranolol. In 17 patients with glaucoma and in two with ocular hypertension, all of whom had not responded satisfactorily to any conventional therapy, treatment was extended to include propranolol systemically. In periods up to 3.5 years, this therapy has kept the intraocular pressure at levels below 23 mm Hg in seven patients. Propranolol was withdrawn in five patients whose visual field continually deteriorated. No correlation between worsening of visual field defects and decrease in systemic blood pressure was noted. In the other patients propranolol was withdrawn because of increasing intraocular pressure or side effects.


Leaking filtering blebs.

Leaking filtering blebs. Histologic examination of ten leaking filtering blebs revealed an epithelial tract running from the surface of the bleb down to the episclera in eight cases. These epithelial tracts were considered the real cause of the persistent leakage.


Vitreous findings in fellow eyes of aphakic retinal detachment. One hundred patients had bilateral aphakia, primary rhegmatogenous retinal detachment, and adequate visualization of the retinal and vitreous in the fellow eye. Of 43 patients with posterior vitreous separation and no retinal tear in the fellow eye, only one (2%) subsequently developed retinal detachment. Of 40 patients without posterior vitreous separation in the fellow eye, eight (20%) later developed retinal detachment following posterior vitreous separation. The remaining 17 patients had posterior vitreous separation and retinal tear or detachment at the time of initial examination. Thus, if posterior vitreous separation occurs without forming retinal tear, the risk of developing retinal detachment is significantly lowered.


Retinal holes.

Retinal holes. Holes of the peripheral retina, defined as full-thickness breaks of trophic origin with no associated flap or free operculum, were found in 136 (2.4%) eyes from 2,800 autopsied subjects. Primary retinal holes (those with no indication of a proximal causative lesion and with no lattice degeneration in either eye) occurred in only eight of the 5,600 eyes studied; all were unilateral, single, less than 0.25 disk diameter in size, within the basal zone, and in eyes from elderly subjects. Secondary holes were found in 128 (2.3%) of eyes and of these, lattice degeneration was the most common cause (103). Other lesions complicated by hole formation included zonular traction tufts (10), chorioretinitis (9), meridional folds (3), and pavingstone degeneration (2). Retinal holes in surgically aphakic eyes did not differ qualitatively or quantitatively from those in age-matched phakic eyes.


Choroidal osteoma.

Choroidal osteoma. A 15-year-old white girl had a presumed choroidal hemangioma in the posterior pole of the right eye. The lesion appeared to grow, and we performed a phosphorous uptake test, which was positive. Subsequent studies demonstrated that the tumor was a choroidal osteoma.


Rhegmatogenous retinal detachment following chorioretinal inflammatory disease. Preexisting ocular inflammatory disease was responsible for 44 cases (1.7%) of rhegmatogenous retinal detachment in a large series of consecutive retinal detachments. Characteristics of retinal detachments following ocular inflammatory disease include a longer duration of the detachment, fewer observable retinal breaks, a higher incidence of visible vitreous membranes and preoperative macular puckers, a younger age distribution, and a higher incidence of phakic patients. In comparing the group of postinflammatory rhegmatogenous retinal detachments with detachments not associated with inflammation, the following characteristics did not show any statistically significant difference: sex, the eye involved, the status of the ciliary epithelium, the presence or types of retinal folds, the rate of operative complications, or the rate of reattachment at six months.


Choroidal folds.

Choroidal folds. We documented the presence of choroidal folds in a series of 59 eyes. Fifteen separate conditions were established as causes of the choroidal folds. Hyperopia was the most common cuase, although no definite etiology could be established in ten cases.


Immune complexes in retinoblastoma.

Immune complexes in retinoblastoma. Thirteen patients with retinoblastoma were tested for circulating immune complexes using the Raji cell radioimmunoassay. Eight of 13 patients had statistically significantly increased levels of immune complexes.


An unusual case of metastatic carcinoma to the eyelid. A 46-year-old woman developed a painless nodular lesion of her right lower eyelid four years after having a right radical mastectomy for breast carcinoma. The lesion slowly increased in size over one year to involve full thickness eyelid tissue that included the margin and inferior punctum and was associated with localized loss of cilia. The clinical appearance of the lesion and its course of development suggested a primary eyelid neoplasm. Incisional biopsy revealed metastatic mammary carcinoma.


Conjunctiva in asymptomatic contact lens wearers. Biopsy specimens of the upper tarsal conjunctiva from 11 asymptomatic, biomicroscopically normal contact lens wearers (five hard and six soft) were studied by scanning electron microscopy. The conjunctiva in lens wearers showed areas of normal epithelial cell surfaces interspersed among areas of altered cells. The altered cell surfaces were characterized by centralized clumped microvilli and baring of that portion of plasma membrane around the cell periphery. The degree of centralization of microvilli varied widely, from a mild tendency to centralize accompanied by slight reduction in cell diameter, to an exteme centralization and dramatic diameter reduction. In some cells, the centralized microvillar structure had a unique mucuslike covering. Numerous altered cells were present in all 11 specimens from asymptomatic contact lens wearers. The number of these cells found by conjunctival biopsy of the hard contact lens wearers and the number in the soft contact lens wearers apparently did not differ. The upper tarsal conjunctiva in these asymptomatic contact lens wearers has an altered epithelial surface, different from that observed in normal subjects without contact lens-wearing experience and from subjects with contact lens-associated giant papillary conjunctivitis.


An unusual case of ophthalmoplegic migraine. A 33-year-old man complaining of headache and diplopia lasting one hour or less and occurring weekly was found to have ophthalmoplegic migraine. He was treated unsuccessfully with propranolol HCl, ergotamine tartrate, and methysergide maleate.


Evaluation of dexamethasone acetate as a topical ophthalmic formulation. Penetration of an ophthalmic suspension of 0.1% dexamethasone acetate into the rabbit cornea and aqueous humor was unaffected by the status of the corneal epithelium or by the presence or absence of intraocular inflammation. However, the total quantity of this corticosteroid that could be measured in the cornea or aqueous humor was significantly less than that produced by either dexamethason alcohol or dexamethasone sodium phosphate. Despite this, dexamethasone acetate was the most effective of the three dexamethasone derivatives in suppressing inflammation in the cornea, which indicates that following topical administration to the eye it is the most potent of the dexamethasone derivatives studied. This greater therapeutic effect does not seem to be accompanied by a greater propensity to increase intraocular pressure. Comparison of the intraocular pressureincreasing effect in known corticosteroid responders of dexamethasone acetate with that of dexamethasone sodium phosphate, the least effective of the dexamethasone products studied, demonstrated no difference between the two drugs. These data support the conclusion that dexamethasone acetate is superior to the commercially available dexamethasone derivatives for use as a topical ocular anti-inflammatory agent.


Acute posterior multifocal placoid pigment epitheliopathy. A 21-year-old man developed blurred vision and retinal pigment epithelium changes similar to those in acute posterior multifocal placoid pigment epitheliopathy following vaccination for swine flu. The patient's medical examination revealed no infectious agents. A hypersensitivity to the attenuated virus of the swine flu vaccine appears to have produced his initial flu-like symptoms and retinal pigment epithelium changes.


An insertion sleeve for pars plana infusion ports. To facilitate placing pars plana infusion ports, we modified the shaft of a piece of 10-gauge tubing or of a hypodermic needle by removing the beveled tip and Luer hub, passing the tubing through the inserter sleeve, and then reattaching the tubing to the Luer hub.


Removal of blood from the retinal surface in pars plana vitrectomy. The technique of removal of blood from the retinal surface in pars plana vitrectomy using a blunt-tipped needle open to the atmosphere has two disadvantages: uncontrolled suction force at the tip of the needle, and a drop in intraocular pressure to zero when the needle is vented to the atmosphere. Modification of the procedure can eliminate these problems. By connecting the blunt-tipped needle to a bag of intravenous fluid, the suction force of the needle can be controlled; and by elevating both the bag connected to the infusion line and that connected to the suction needle, the intraocular pressure can be increased and the problem of intraocular bleeding minimized or eliminated.


Localizer for retinal detachment surgery. A new mechanical localizer for retinal detachment surgery has two modes of action. The localizer is positioned under visualization in the undepressed state to avoid engaging or marking sclera until the surgeon elects to depress the marking pick after optimum localization.


Topical retinoic acid in the treatment of corneal xerophthalmia. Eight children with corneal xerophthalmia (x2 or x3A) received standard high-protein diets and massive systemic vitamin A therapy. Retinoic acid, 0.1% in oil, was applied daily to one eye, and oil alone to the other. Topical retinoic acid proved safe and effective in speeding corneal healing, especially during the first critical days.


Congenital varicella cataract.

Congenital varicella cataract. A 16-month-old boy with 1:16 and 1:8 serum titers to varicella zoster fluorescent membrane antigen had had unilateral cataract and microphthalmos since birth. The mother had suffered varicella during the fourth month of pregnancy. Cataract aspiration in the child was uncomplicated.


Massive spontaneous subretinal hemorrhage. We studied eight cases of massive, spontaneous subretinal hemorrhage which was characterized by the sudden appearance of one or more large, dark, elevated hematomas under the retina. The initial location of the hemorrhage may have been in the choroid or under the pigment epithelium, or both, but further extravasation of the blood anteriorly frequently resulted in hemorrhage under the neurosensory retina and in the vitreous. Although the lesion can initially be mistaken for a melanoma, the diagnosis is confirmed by the formation of a typical, elevated scar in the involved area. Frequent fundus examinations are essential, and ultrasound, radioactive phosphorus uptake testing, and bilateral patching are helpful in establishing the diagnosis. The hemorrhage is usually the result of a ruptured vessel from a subretinal neovascular network or arterioclerotic degeneration and may be precipitated by the use of anticoagulants.


A variable focus telescopic instrument for indirect ophthalmoscopy with increased magnification and stereopsis. We devised a new binocular indirect ophthalmoscope and a complimentary examination technique that provide enhanced fundus magnification and optimum stereopsis through a wide range of patient pupillary apertures. The lightweight, mechanically simple instrument uses a variable focus Galilean telescopic observation system to enlarge the condensing lens image of the fundus seen by the examiner. The present device is capable of about X 1.5 fundus magnification with negligible stereopsis through a 20-mm patient pupil, continuously increasing to X 8.5 with greatly enhanced stereopsis through an 8-mm pupil. A zoom focusing capability considerably extends the magnification, stereopsis, and small pupip penetrating characteristics of a given condensing lens by allowing the examiner to binocularly observe the telescopically magnified fundus image throughout the 30-cm to 60-cm focusing range of the ophthalmoscope.


A new fundus lens ophthalmodynamometer.

A new fundus lens ophthalmodynamometer. I devised a new ophthalmodynamometer by means of which a measured force is applied to a fundus lens, while the disk vessels are viewed at the slit-lamp microscope. In my hands, the new device was superior to the Bailliart ophthalmodynamometer when tested in normal volunteers. With the fundus lens ophthalmodynamometer, the diastolic end point differed between the two eyes by a mean of 2.3%, compared to 6.4% with the Bailliart. The new device showed a better correlation with systemic diastolic blood pressure than did the Bailliart instrument. The effect of intraocular pressure on the reading with the fundus lens device was significant, although variable.


Intracranial sarcoidosis with optic tract and temporal lobe involvement. Intracranial sarcoidosis was diagnosed in a 23-year-old man when he developed a markedly incongruous right homonymous hemianopic visual field defect. The diagnosis was substantiated by radiologic evidence of bilateral hilar and paratracheal adenopathy, typical of pulmonary sarcoidosis. Subsequently, computed axial tomography indicated a large intracranial lesion in the suprasellar cistern with extension into the left temporal lobe along the optic tract. A mediastinal biopsy of the lymph nodes was positive for sarcoid. Intensive corticosteroid therapy resulted in restoration of vision, marked improvement of the visual field defect, decrease in the pulmonary hilar adenopathy, and almost complete resolution of the left temporal lobe lesion.


Meningeal carcinomatosis with blindness. A 53-year-old man had bilateral blindness secondary to meningeal carcinomatosis from pulmonary adenocarcinoma. Histopathologic examination of the visual system showed extensive infiltration of the arachnoid of the proximal optic nerves and chiasm, with minimal invasion of the optic nerves themselves. The visual pathways within the cerebral cortex were not affected.


Supranuclear oculomotor palsy and exotropia after tetanus. An 11-year-old boy developed generalized tetanus complicated by a supranuclear gaze palsy and exotropia. This case led us to include supranuclear palsy in an expanded definition of cephalic-tetanus.


Amaurosis and blood loss.

Amaurosis and blood loss. A 57-year-old alcoholic man sustained permanent bilateral blindness and optic atrophy as a complication of hemorrhage from peptic ulcer disease. Post-hemorrhagic visual loss occurs in middle-aged, debilitated persons a short time after repeated episodes of hemorrhage from any site.


Melanocytic tumor of the anterior uvea.

Melanocytic tumor of the anterior uvea. A patient with spindle melanoma involving the iris and ciliary body refused enucleation at the time of diagnosis in 1933. The eye developed painful glaucoma 13 years later and was enucleated. Histopathologic examination indicated spread of the tumor intrasclerally and subconjunctivally. The patient is still alive without evidence of metastases, 32 years after enucleation and 45 years after initial diagnosis.


Astrocytic hamartoma of the retina not associated with tuberous sclerosis. A 6-year-old boy had a peripapillary lesion diagnosed as retinal astrocytic hamartoma, which was not associated with tuberous sclerosis, neurofibromatosis, or intraocular extension of a glioma. The patient was observed for nine years, during which time the lesion grew significantly. Because of this growth and the evidence of proximal optic nerve involvement on computed tomography, radiation therapy was administered with a resultant marked reduction in visual acuity. The eye was subsequently enucleated. The enucleated eye was studied by both light and transmission electron microscopy. The specimen had a retinal astrocytic hamartoma with sparse vascularization and only superficial optic nerve involvement. Additionally, it revealed optic nerve drusen in varying stages of development, significant accumulations of subretinal macrophages, and an almost total loss of retinal outer segments with the preservation of the retinal pigment epithelium.


Sebaceous gland carcinoma of the eyelid. We diagnosed sebaceous gland carcinoma of the right lower eyelid in an 82-year-old man. Computed tomography showed the lesion extending from the eyelids anteriorly to the optic foramen posteriorly. With this orbital neoplasm, was an occlusion of the central retinal artery in his right eye. The right orbit was removed surgically and biopsy of the optic foramen region indicated malignant cells. Localized radiation to the right orbit was then initiated postoperatively.


Microsurgical removal of a primary intraorbital meningioma. A 48-year-old woman with a primary intraorbital meningioma associated with the optic nerve sheath underwent a microsurgical removal of the tumor through a lateral orbitotomy. Visual recovery was essentially complete.


Development of the granulomatous response in murine toxocariasis. Initial events. The cellular evolution of the persisting, muscle-associated granuloma in murine toxocariasis (visceral larva migrans) was chronicled for 11 weeks by light and electron microscopy. The initial granuloma consisted primarily of eosinophils and appeared to develop from the acute inflammatory infiltrate. During the ensuing 48 hours, most of the eosinophils appeared to loose their granules and disintegrate. The resulting cellular debris was then taken up by newly arrived macrophages which become the predominant mononuclear cell in the lesion by 28 days of infection. By 11 weeks, the granuloma had become a fibrotically encapsulated epithelioid granuloma surrounding the inciting larva. This histologic reaction is compared with the liver granulomatous response to Toxocara and to the well-characterized schistosome egg granuloma. A possible delayed hypersensitive etiology for the Toxocara granuloma is suggested.


Effects of insulin on experimental catecholamine cardiomyopathy. We have recently shown that insulin attenuates norepinephrine (NE) dose-response curves in both isolated cardiac muscle and intact heart preparations. Accordingly, an intact rabbit model was used to determine if insulin would reduce the extent of myocardial damage following a standard NE infusion. Each animal was given pentobarbital, 30 mg/kg, and heart rate, arterial pressure, glucose, blood gases, and pH were measured. NE (2 microgram/min/kg) was given intravenously for 90 minutes. After 48 hours the rabbits were killed and the hearts were examined microscopically and assigned a histologic score. Florid lesions were present in 17 of 24 sections (71%) from 12 animals. They were characterized by myofiber necrosis and an intense cellular reaction. However, only 5 of 40 sections (12.5%) from 20 rabbits given insulin (10 units/kg) 30 minutes before the NE infusion showed advanced lesions (P less than 0.001). The mean histologic score was reduced from 1.7 to 1.0 (P less than 0.001). The frequency of advanced lesions increased to 86% in animals given a higher dose of NE (3 microgram/kg/min) and was reduced to 53% by pretreatment with insulin. A dosage of 5 units/kg was as effective as 10 units/kg, but rabbits given 1 unit/kg manifested cardiomyopathic changes identical to those in rabbits not pretreated with insulin. No differences in heart rate, arterial pressure, PO2, or pH were evident between the groups. It is concluded that large doses of insulin reduce myocardial damage produced by NE in this model. This may be linked with the phenomenon of insulin inhibition of the inotropic action of NE.


Pulmonary arteries and veins in experimental hypoxia. An ultrastructural study. Pulmonary vessels of rats were studied electron microscopically after 4 days to 4 weeks of hypoxia and were compared with those of control rats and of "regression" rats that, after a period of hypoxia, were allowed to survive in normal air for up to 4 weeks. Both the hypoxic and the regression rats had medial hypertrophy, not only of arteries and arterioles but also of veins and venules. In contrast to the control and the regression rats, many of the hypertrophic vessels of all types in the hypoxic rats showed signs of constriction, ie, crenation of the wall, indentations of medial smooth muscle cell nuclei, and excrescences of smooth muscle cell cytoplasm, often protruding deeply into the endothelium. These observations permit the following conclusions: a) Vasoconstriction due to hypoxia is not confined to pulmonary arteries and arterioles, as generally assumed, but also occurs in veins and venules. b) Medial hypertrophy may be found in the absence of vasoconstriction; this is especially evident during recovery from hypoxia.


Role of ions and extracellular protein in leukocyte motility and membrane ruffling. Ruffling and motility, either directed or random, of polymorphonuclear leukocytes (PMNL) were shown to require a monovalent cation (MC). Na+ and Li+ are most effective. These MC-dependent activities are modulated by nonspecific proteins and peptides and are inhibited by cytochalasin B and by alkylating agents such as TPCK (L-[tosylamide-2-phenyl]ethylchloromethyl ketone) but not by ouabain or colchicine. The modulation by protein, but not the inhibition by TPCK or cytochalasin, is competitively inhibited by hydrophobic chemotactic peptides such as f.met-phe and f.phe-met. These hydrophobic peptides, which activate MC influx, promote motility at low concentrations of Na+ (0.1 mM); however, at higher concentrations of Na+ (1.0 mM) the same concentrations of peptides inhibit motility. This inhibition is the result of excessive Na+ and water influx with resultant cellular swelling. The chemotactic peptides, when present as a concentration gradient, function in chemotaxis by competing with the protein at the leading edge of the cell, with resultant local ion influx and swelling. Hydrolysis of the peptide is not required since protease inhibitors have no specific effect on peptide directed migration, although they do inhibit migration. Since local influx of MC and H2O with resultant hydrolysis of ATP is absolutely required for all motility in these cells, it is likely that local swelling and depolymerization of the actin cytoskeletal system are the primary reversible events in PMNL motility. This local swelling or ruffling apparently results in the pushing of cellular contents into the relaxed swollen submembrane areas of the cell by continued contraction of unswollen areas of the cell.


An actin-binding protein in human platelets. Interactions with alpha-actinin on gelatin of actin and the influence of cytochalasin B. A protein (molecular weight, approximately 250,000) with actin-binding properties has been isolated from human platelets. Addition of the actin-binding protein (ABP) to semiviscous solutions of purified actin containing troponin-tropomyosin (TM-TP) complex resulted in formation of viscous gels consisting of randomly associated actin TM-TP filaments. alpha-Actinin (alphaA), a muscle protein recently detected in platelets, also induced random cross-linking of dissociated actin into gels. Sequential addition of ABP and alphaA resulted in gels consisting of parallel associated actin TM-TP filaments in bundles, suggesting a cooperative interaction. Cytochalasin B (CB) had no apparent effect on the cross-linking of randomly associated actin TM-TP filaments induced by either protein alone but prevented development of bundles of parallel filaments when ABP and alphaA were added sequentially. In addition, CB disrupted the bundles of parallel associated actin TM-TP filaments when added to gels already formed by the dual action of ABP and alphaA and caused simultaneous release of alphaA from the complexes to the supernatant. The findings suggest that platelet ABP and alphaA may induce actin filaments to form the parallel associations observed in platelet pseudopods.


Tumor immunity. An overview.

Tumor immunity. An overview. The frequent failure of the host's immunologic responses to impose restraints on tumor growth and dissemination has led to the realization that a number of factors, both immunologic and nonimmunologic, may act in concert to affect tumorigenesis. Immunologic mechanisms involved in tumor cell destruction are predicated principally on in vitro procedures, but the relevancy of these experimental observations to the actual events in vivo remains unclear and unresolved. The macrophage has been shown to be an integral segment of the immune response and to constitute an important element of the host defense against tumors. In this connection, interferon may be implicated in tumor cell destruction through macrophage activation to cytotoxicity. Studies of age-related susceptibility of New Zealand Black mice to three different carcinogens, ie, 3-methylcholanthrene, x-irradiation, and murine leukemia virus, have further emphasized the multifactorial determinants which may be operational in oncogenesis. Advances in our knowledge of tumor immunology have suggested a number of possible modalities for preventing tumors from escaping immunologic destruction and should continue to contribute to further elucidation of neoplastic mechanisms.


Circulation and migration of small blood lymphocytes in the rat. I. Kinetics of lymphocyte circulation in the lymphoid organs. Seventy male Wistar rats were the recipients of labeled small lymphocytes (1.5 X 10(7) each) collected from the peripheral blood of syngeneic donors. The migrating labeled lymphocytes were traced in the various organs 1 to 60 minutes following their transfusion. Lymphoid organs and liver were processed for extraction of labeled nucleotides and for radioactivity assay. The purpose of this work was to study the dynamics of the circulation of the small lymphocytes between blood and lymphoid system. This study was done before equilibrium between these two compartments was reached. The result of this work showed that the small blood lymphocytes recirculate continuously between peripheral blood and the lymph node with duration less than 3 minutes per cycle. In a lymph node, this circulation is 80 times more efficient than the circulation via the thoracic duct lymph.


Thyroid capsule changes during the development of thyroid hyperplasia in the rat. Young adult male Fischer rats were fed 0.25% thouracil in a low-iodine diet to produce hyperplasia of the thyroid gland. The capsule of the thyroid gland increased in thickness from approximately one cell in controls to a substantial multilayered structure. Increase in capsule thickness was noted by 3 days. The cell population of the capsule was largely fibroblasts, but during a period within the interval from 14 to 28 days, the capsule tended to be exceptionally thick and contained many mononuclear leukocytes. At later times the capsule was not quite as thick and the leukocytes largely disapproved. Capillaries developed in the capsule probably by sprouting. The capsule growth was so extensive that certain neighboring tissues were often incorporated into the capsule, including arteries, veins, nerves, striated muscle, and lymph nodes. There was some regional specificity in the development of capsular hyperplasia. Connective tissue increased around the thyroid and parathyroid glands but not between them. Connective tissue in partitions with the thyroid gland also increased in thickness, although the extent of accumulation of cells and intercellular matrix was much less than in the capsule.


The thymus in hemochromatosis.

The thymus in hemochromatosis. Although iron in cases of hemochromatosis has been described in virtually every organ, its presence in the thymus has only been rarely observed. While investigating all cases of hemochromatosis autopsied at The Johns Hopkins Hospital over the past decade, 4 adult cases in which the thymus was available for histologic study were examined in light of recent documentation of this organ's role in lymphopoiesis and secretory activity. Iron-containing moieties were found within both lymphocytes and epithelial cells of these involuted thymic glands. The thymic iron suggests either an uptake of iron moieties from the vascular pool or their synthesis within the cell itself. While the former mechanism provides evidence against the existence of an impermeable blood-thymus barrier, the latter supports the existence of a metabolically active gland with complex function.


Desensitization of the neutrophil aggregation response to chemotactic factors. In the presence of Ca2+ and Mg2+, the chemotactic fragment of C5, the synthetic chemotactic oligopeptide formyl-methionyl-leucyl-phenyl-alanine, and the ionophore A23187 aggregated human neutrophils. Aggregation induced by the two chemotactic factors was transient and reversed within 2 to 4 minutes after exposure; aggregation induced by A23187 was sustained and continued to increase over 15 minutes. In the absence of the bivalent cations, none of these three agents aggregated the cells. If bivalent cations were added after cell contact with a chemotactic factor, aggregation was detected after, but not before, addition of the cations. Under these conditions, the magnitude of the aggregation response was sharply reduced: cells preincubated with a chemotactic factor for longer than 2 to 4 minutes aggregated minimally after addition of bivalent cations. Moreover, cells preincubated with a chemotactic factor for 4 minutes, exposed to bivalent cations, and then rechallenged with the same chemotactic factor also showed a minimal aggregation response, ie, the cells were "desensitized" to the original stimulus. However, cells desensitized to one of the chemotactic factors still aggregated prominently when exposed to the other chemotactic factor or to A23187. Cells could not be desensitized to the ionophore A23187. Desensitization of the neutrophil aggregation response closely resembles desensitization of mast cell and leukocyte degranulation. Degranulation and aggregation appear to be closely related cellular responses to immunologic stimuli. Both responses may reflect alterations in surface membrane permeability to bivalent cations and/or changes in surface membrane adhesiveness to other biologic membranes.


Ultrastructural cytochemistry of iron absorption. Conventional ultrastructural autoradiographic and morphologic studies of the duodenal mucosal cell have generally corroborated physiologic observations of iron absorption, but such methods have limited resolution and fail to distinguish ferric and ferrous iron. This study describes the application of the Prussian blue reaction as an electron microscopic cytochemical stain to the investigation of inorganic iron absorption in iron-deficient, normal, and iron-loaded rats. Ferrous iron is converted to ferric iron at the microvillus membrane. Subsequently intraepithelial ferric iron appears bound to a non-heme acceptor substance in microvilli and later appears as small non-membrane-bound stain deposits which are concentrated in the apical cytoplasm. The appearance of larger stain deposits in the lateral intercellular spaces, in the basal extracellular spaces, and along the intraluminal and extraluminal outer plasmalemma of adjacent endothelial cells of the lamina propria suggests passage of iron from epithelial cells through the lamina propria to blood vessels. The extreme sensitivity of the method compared with simultaneous ultrastructural autoradiographic techniques is demonstrated and suggests usefulness of the method in further studies of iron metabolism.


Estimation of parenchymal cell content of human parathyroid glands using the image analyzing computer technique. By means of the image analyzing computer technique, a complete determination of the parenchymal tissue distribution in serially sectioned parathyroid glands were accomplished. The technique had good reproducibility. Taking into account the shrinkage of the different tissue components during histotechnical procedures and the tissue densities, it was possible to calculate the parenchymal cell mass of unfixed glands. The cell distribution varied considerably, and in most glands as many as 10 sections at different levels had to be examined to get a reliable ratio between the parenchymal and fat cell tissue. The results seriously question the validity of histopathologic examination of one or a few sections of parathyroid glands in evaluation of the parenchymal cell mass, as well as diagnoses based on examination of partial glandular biopsy specimens.


The Aymara of Western Bolivia. II. Maxillofacial and dental arch variation. Maxillofacial and dental arch dimensions of the Bolivian Aymara population are age and sex dependent. Interpopulational comparisons reveal these dimensions to differ from those seen in Aleuts, Australian aborigines, and Swedes, but to be similar to those of the indigenous Taiwanese. Finally, these dimensions are not the same in Aymara of unmixed ancestry, and Mestizos residing in the same villages.


Digital dermatoglyphic patterns in a sample of the Nigerian population. Eight hundred Nigerians (400 males and 400 females) were screened for the analysis of digital dermatoglyphic patterns. The frequency distribution of the patterns are 52.09%, 27.67%, 19.20% and 1.13% for ulnar loops, whorls, arches and radial loops respectively. Except for arches, the males have more of the patterns than females. The pattern intensity indices for males and females are 11.2 and 9.9 respectively. Bilateral symmetry is similar in both sexes and the percent distribution is as high as 81.5% and 84% on digit V in males and females respectively.


A longitudinal and cross-sectional analysis of the growth of the postnatal cranial base angle. Radiographs of 32 children, 16 girls and 16 boys, taken at 1 month, 3 months, 9 months, and once a year until 5 years 9 months were selected from the Denver Series. The cranial base deflection was measured by five sets of angles. A cross-sectional evaluation revealed a significant decrease in angle size by all methods of measurement by 9 months of age. Little change was noted after 1 year, 9 months, indicating that studies beginning after 2 years would not find this decrease. All individuals followed a pattern of reduction between 1 month and 9 months with variable changes at 3 months. Choice of landmark affected the degree and timing of the observed change but not the overall pattern. Differences in measuring techniques evaluated the mean degree of deflection to range from -6.9 degrees to -13.8 degrees.


A genetic survey in the Bhil tribe of Madhya Pradesh, Central India. Examination of blood groups, plasma proteins and red cell enzyme types (23 loci), in a sample of 145 Bhils, a tribal group of Madhya Pradesh, Central India, demonstrates their genetic uniqueness. They differ in a number of systems from the nearby nontribal groups both of Hindus and Muslims. The results suggest that the Bhil frequencies include vestiges of the ancestral genepool of a more widespread aboriginal population whose influence is detectable in the gene frequencies of some other populations in India.


A family study of two skeletal variants: atlas bridging and clinoid bridging. The frequency of two non-metric skeletal traits, atlas bridging and clinoid bridging, were examined serially in a randomly chosen sample of 147 families who participated in the Burlington Growth Study. The sample is representative of an Ontario white Anglo-Saxon population. Partial and complete atlas briging occurred in 29.2% of the sample, partial and complete clinoid bridging in 15.2%. Atlas bridging appears at an average age of 10.7 years, clinoid bridging at seven years, demonstrating that these characters are not simply expressions of soft tissue sclerosis in old age. Both traits show no strong associations with bone robusticity although atlas bridging is slightly more frequent in males. Both traits are more frequent in relatives of affected individuals than in the sample as a whole. Correlations between parents and offspring and between sibs are highly significant for atlas bridging, less so far clinoid bridging. These traits should fit either a single gene or quasi-continuous, polygenic model of inheritance. Several tests for polygenic inheritance such as the correlation between first and second born sibs' trait condition, the relationship between trait expression in offspring and total trait incidence in affected parents, and the correlation between trait frequency and expressivity on an intergroup basis were all positive for atlas bridging. The evidence for polygenic inheritance of clinoid bridging is weaker but suggestive. The results obtained in this study for atlas bridging are comparable to data from one earlier family study. The evidence suggests that these two traits should prove useful as genetic markers in skeletal population studies although there is still need for careful control over trait observation and description. Future research should attempt to measure non-metric traits continuously when their underlying distributions are known to be graded.


Canadian Eskimo permanent tooth emergence timing. To identify the times of emergence of the permanent teeth of Canadian Eskimos (Inuit), 368 children and adolescents were examined. The presence or absence of all permanent teeth except the third molars was recorded and these data subjected to probit analysis. Female emergence times were advanced over males. Generally, the Inuit of both sexes showed statistically significant earlier emergence times than Montreal children, except for the incisors. The present results do not support hypotheses indicating that premature extraction of the deciduous teeth advances the emergence of their succedaneous counterparts. There is some indication the controls of deciduous tooth emergence continue to play some part in emergence of the permanent dentition, especially the first permanent teeth that emerge.


Communality of surnames: a measures of biological interrelationships among thirty-one settlements in upper Val Varaita in the Italian alps. The upper part of the Alpine valley of the Varaita (population about 1,596) has three communities situated in a triangle about 6 km on a side but divided into frazioni (clusters of houses) that form a "Y" along the road and river in the valley floor. The coefficient of relationship (Ri) based on the communality of surnames between pairs of frazioni and between pairs of the communities shows very high levels of interrelationship (up to 0.26 compared with 0.5 for brothers). It tends to be higher between frazioni of the same community than between communities. It is highest among five pairs of contiguous frazioni within 1 km of each other. It tends to be highest between frazioni of the community least influenced by tourism and migration. It is not dmonstrably affected by the division of one community into two parishes. It is about twice as high between contiguous communities as between the two communities with an intervening one. The high values represent the long history of the same surnames in the valley and the accumulation of relationship through high levels of valley endogamy.


The genetic hypothesis for the transmission of Australia antigen (HBsAg). Exceptions have been cited which rule against the simple autosomal recessive hypothesis for the transmission of susceptibility to infection with Australia antigen (HBsAg). An attempt is made here to present a genetic model for a complex segregation analysis of a new and unique set of data to test this hypothesis. Regression techniques were used to estimate in four populations, age and sex-specific penetrance levels and the frequency of the gene whose product is hypothesized to be HBsAg. While the genetic hypothesis was not in general supported, observed deviations and their possible causes are discussed.


Analysis of hair samples of mummies from Semma South (Sudanese Nubia). Hair samples from 76 burials at Semna South (Sudanese Nubia) were examined using a variety of techniques. Electrophoresis and fluorescence microscopy indicated some oxidation of the cuticule and keratin protein had taken place. However, the cuticular structure and the lack of fluorescence of the cortex indicate that the low humidity and non-alkaline conditions preserved the physical and chemical properties of the hair well. Pigmentation, even allowing for oxidation of melanin, showed a higher proportion of lighter samples than is currently associated with the Nubian area. Hair form analysis showed medium diameter and scale count; the curling variables were intermediate between European and African samples. There was a high ratio of maximum to minimum curvature (a measure of irregularity), approached only by Melanesian samples. Meroitic and X-group burial types were not statistically significantly different (largely due to sample sizes), but the X-group, especially males, showed more African elements than the Meroitic in the curling variables. Principal components analysis showed the Semna sample to be significantly different from seven populations examined earlier.


Genetic counseling for psychiatric patients and their families. The author presents an overview of genetic counseling for psychiatric patients and their families, including a brief summary of contemporary research into the evidence of genetic factors, the familial risks, and the possible modes of inheritance for major psychiatric disorders. The purpose is to review and condense the available literature pertaining to psychiatric genetic counseling for the benefit or psychiatrists and counselors in their day-to-day practice and for the general "consumer." It is hoped that giving the general public access to such information will help to reduce the suffering commonly brought about by the stigmatization of mental disorders.


The incidence of psychosurgery in the United States, 1971--1973. As part of the work of the APA Task Force on Psychosurgery, the author surveyed 1,901 neurosurgeons on how many psychosurgical procedures they performed in 1971, 1972 and 1973. A total of 1.481 questionnaires were returned: 195 neurosurgeons indicated they had performed a total of 476 procedures for intractable pain and 1.039 procedures for psychiatric conditions. Excluding the procedures reported by 4 neurosurgeons who performed more than 20 psychosurgical operations in any one of the three years, the number of psychosurgical operations in 575 for the three years, which the author suggests should allay fears about the abuse of psychosurgery.


First-rank symptoms in the postacute schizophrenic: a follow-up study. Schneider's diagnostic system of first-rank symptoms (FRS) is acknowledged by psychiatrists throughout the world as a decisive basis for the diagnosis of schizophrenia. Recently, the author's and others' works have challenged this view. This report examines the relationship between FRS, psychotic symptoms, prognosis, and outcome at the postacute stage. The assessment of FRS was made from an interview schedule (a modification of the Wing Present State Examination) developed for the systematic assessment of psychotic symptoms. The results question the utility of FRS as a primary diagnostic approach to schizophrenia, suggesting that Schneider's system may not be superior to other diagnostic approaches.


Hyperkinetic/aggressive boys in treatment: predictors of clinical response to methylphenidate. Data on 84 nonretarded boys aged 6--12 with the hyperkinetic/MBD syndrome were drawn from a comprehensive, longitudinal investigation in the interest of identifying factors that contribute significantly to variation in clinically rated improvement during treatment with methylphenidate. The size of the multiple correlation (R = .50) indicates that 25% of the variation in the children's response to methylphenidate is jointly predictable from age at referral, degree of perinatal complications, and score on the hyperactivity factor. The authors discuss stepwise multiple regression analysis as the method of choice in drug response prediction studies and the possible effects on the results of such studies of differing definitions of improvements.


The group psychotherapy dropout phenomenon revisited. In this two-year study, patients referred for group therapy were extensively screened and carefully prepared for the therapy. In spite of this effort there was a 29% dorpout rate after group therapy began. All of the therapists reported that they disliked the patients who dropped out, and many of these patients were seen as hostile toward the therapists. The author suggests that for many groups the dropout phenomenom may be basic to the establishment of group cohesiveness and that instead of trying to prevent or reduce the dropout phenomenon, efforts should be directed toward reconceptualizing the more positive aspects of it.


Families and hospitals: collusion or cooperation? The author describes the therapeutic problems that can arise on a family-oriented psychiatric inpatient service. The stress emerging from the therapeutic demands on and changes in the internal structure of the family may cause the family to seek to reestablish its internal equilibrium by changing the hospital staff and structure at the ward level, department level, and the hospital administration level. These transactions between the hospital and families, which are complex, are extremely important to recognize because they can undermine the therapeutic process.


Hysteria split asunder.

Hysteria split asunder. The authors present the proposed DSM-III classification of the traditional hysterical disorders, i.e., disorders that suggest physical illness but in which psychological factors are judged to be of importance. The use of the DSM-III inclusion and exclusion criteria--physical mechanism explains the symptoms, symptoms are linked to psychological factors, symptom initiation is under voluntary control, and there is an obvious recognizable environmental goal--are discussed in the differential diagnosis of somatoform disorder, factitious disorder, malingering, psychological factors affecting physical condition, and undiagnosed physical illness.


Group therapy training in psychiatric residency programs: a national survey. The authors used a questionnaire sent to the directors of the 256 approved American psychiatric residency programs to examine the availability, content, and orientations of group therapy training. They found that 78% of the responding programs offered group therapy training, a substantial increase from earlier estimates; that an approach incorporating didactic courses, observation and leadership of groups, supervision, and participation in an experiential group was gaining increased acceptance; that most of the programs provided a variety of arrangements for supervision of group training; that the theoretical orientations mirrored the field of group therapy itself; and, finally, that associated disciplines were gaining increasing acceptance.


Consultation-liaison versus other psychiatry clerkships: a comparison of learning outcomes and student reactions. The authors present the results of a one-year study showing equivalent mastery of basic psychiatric knowledge and skills and equally favorable student reactions after psychiatry clerkships on a consultation-liaison service and on other more traditional psychiatry services. They recommend further research highlighting the unique contributions of consultation-liaison clerkship training to knowledge, skills, and attitudes for holistic primary care.


The transition to practice seminar.

The transition to practice seminar. The author discusses the lack of organized faculty attempts to facilitate psychiatric residents' transition to professional practice. Interviewed residents suggested that faculty discontinue their "benign neglect" of the transition and provide information and discussion regarding the realities of different types of practice. He describes the six-session seminar he developed at Massachusetts General Hospital, which focuses on the process of transition from residency to practice, emphasizes the role of faculty as decision facilitators, and explores the costs and benefits of different types of psychiatric practice.


Training psychiatrists of working with blacks in basic residency programs. The author summarizes recommendations on how specific training for working black and other minority patients can be integrated into the existing relatively traditional residency programs. He also discusses psychotherapeutic issues and problems encountered in biracial and/or transcultural therapy that must be resolved if the training is to succeed.


Psychiatric education and training of Asian and Asian-American psychiatrists. The Asian and Asian-American physician in a standard psychiatric residency is faced with discrimination at several levels, as well as special problems of professional role confusion and personal  identity, all of which can create barriers to professional development and productivity. Further, most standard psychiatric residencies do not include teaching or supervision specific to treating Asian patients. The author proposes the establishment of a specialized program, focusing on ethnic minority groups, within a general psychiatric residency; he discusses specific features of such a program. This approach may help to alleviate the problem of inadequate resources for handling the mental health problems of Asian-Americans and underutilization of mental health resources by this group.


An alternative view of the neurobiology of dreaming. The author critiques the recently proposed activation-synthesis hypothesis about the origin and formation of dreams. Many findings do not support the new hypothesis that specific pontine physiological processes, rather than mental processes, instigate dreams and produce their distortion. First, dreaming often occurs in the absence of the pontine processes. Second, forebrain activity (which can have mental correlates) is crucial to the instigation and maintenance of dreaming sleep. Finally, activity of the proposed pontine dream generator, which is claimed to cause dream distortion, is not reliably accompanied by dream distortion.


The activation-synthesis hypothesis of dreams: a theoretical note. The author examines Hobson and McCarley's activation-synthesis hypothesis of dreams from the point of view of theory construction and the logic of science. After reviewing pertinent literature, he concludes that modern sciences has not yet established a well-defined mind-body isomorphism. Therefore, conclusions about the psychological meaning and motive of dreams cannot validly be drawn from neurobiological data.


Comparison of the incidence and severity of extrapyramidal side effects with fluphenazine enanthate and fluphenazine decanoate. Forty-nine schizophrenic outpatients stabilized on oral antipsychotic medication and procyclidine received 12.5 mg or 18.75 mg of fluphenazine enanthate or fluphenazine decanoate and were examined for extrapyramidal side effects one and two weeks later. Extrapyramidal side effects were present in 30 patients (61%) but were clinically significant in only 11 (22%). Fluphenazine enanthate produced more clinically significant extrapyramidal symptoms, particularly akathisia, than did fluphenazine decanoate.


Severe depersonalization treated by behavior therapy. The author reports the use of behavior therapy in the treatment of two cases of severe intractable depersonalization. Outcome criteria included full psychiatric assessment, patients' self-ratings, and psychometric test scores. Treatment by flooding was highly effective in one case, and associated obsessive symptoms and anticipatory anxiety were substantially decreased in the other. Behavioral techniques may prove especially helpful in cases in which anticipatory anxiety, phobic avoidance, and obsessive perseveration are exacerbating features.


Neurobiological vulnerability to low-dose amphetamine psychosis. The authors present a case to illustrate a model of drug-induced psychosis wherein the drug acts as if it fits with some neurobiological predisposition in the patient. Patients with a good interpersonal developmental history but extreme sensitivity to a psychotomimetic drug may provide a model for neurobiological vulnerability to psychosis.


Enuresis treatment with imipramine hydrochloride: a 10-year follow-up study. The authors followed 29 young adults who had been treated for enuresis with imipramine hydrochloride 10 years earlier. To test beliefs that enuresis is symptomatic of severe psychopathology or of urological conditions, they studied whether the treatment had been followed by psychological decompensation; an inhibition of learning; a predisposition to drug abuse; negative effects on health, growth, weight, and development; or continued urinary symptoms. None of these negative effects was present; in general the subjects were active, well-motivated, and sociable and showed no significant psychiatric symptoms. One patient still wetted but only occasionally.


Sexual function and affect in parkinsonian men treated with L-dopa. Using psychiatric interviews, sexual and affect rating scales, hormonal studies, and neurologic assessment, the authors assessed the effect of L-dopa treatment on men with Parkinson's disease. Patients demonstrated variable affect changes. Approximately one-half of the patients reported an increased sexual interest that was not related to improvement in locomotor function. Hormonal factors appeared to be involved. The findings suggest that male parkinsonian patients who possess an intact hypothalamic-pituitary-gonadal axis experience increased sexual function related to L-dopa treatment.


Environmental health and safety concerns and energy conservation practices in academic institutions and hospitals. Although there are many energy conservation practices which are now being applied in hospitals and academic institutions, there well be additional pressures for even further reductions in such energy use in the near future. In many instances, these reductions in energy use can be done within existing standards and do not endanger the health of persons who reside within these institutions. However, this paper highlights the fact that over-eager attempts at energy reduction may result in adverse effects on patients, students, staff, research programs, or the general public. For this reason, it is important for persons making decisions regarding energy conservation practices to be aware of these potential adverse effects and design energy conservation programs accordingly.


Driver education and fatal crash involvement of teenaged drivers. Fatal crash involvement of teenagers per licensed driver and per population in 27 states was related to the proportions of teenagers who received high school driver education. Among 16--17 year olds, driver education was associated with a great increase in the number of licensed drivers, without a decrease in the fatal crash involvement per 10,000 licensed drivers- About 80 per cent of the 16--17 year olds who took high school driver education obtained licenses that they would not otherwise have obtained until age 18 or thereafter. The net effect is much higher death involvement rates per 10,000 population, on average, in states with greater proportions of 16-17 year olds receiving high school driver education. The data suggest that most teenagers would obtain licenses when they are 18--19 years old, irrespective of high school driver education, and indicate that differences among the states in fatal crash involvement rates per 10,000 licensed 18--19 year old drivers were not significantly related to either high school driver education or delayed licensure.


The effect of a reduction in leading causes of death: potential gains in life expectancy. The potential gains in total expectation of life and in the working life ages among the United States population are examined when the three leading causes of death are totally or partially eliminated. The impressive gains theoretically achieved by total elimination do not hold up under the more realistic assumption of partial elimination or reduction. The number of years gained by a new-born child, with a 30 per cent reduction in major cardiovascular diseases would be 1.98 years, for malignant neoplasms 0.71 years, and for motor vehicle accidents 0.21 years. Application of the same reduction to the working ages, 15 to 70 years, results in a gain of 0.43, 0.26, and 0.14 years, respectively for the three leading causes of death. Even with a scientific break-through in combating these causes of death, it appears that future gains in life expectancies for the working ages will not be spectacular. The implication of the results in relation to the current debate on the national health care policy is noted.


The rural nurse practitioner: a challenge and a response. From a cohort of 525 employed nurse practitioners (NPs) who graduated between May 1975 and June 1976, 85 (16 per cent) reported practicing in rural areas. While 91 per cent of the rural NPs chose the short-term certificate programs rather than the master's degree for their NP preparation, 47 per cent had already earned a baccalaureate or master's degree prior to NP training. Family NPs comprised the most frequent specialty area chosen, followed by pediatric and adult specialties. Of the 85, 99 per cent were actually providing a broad array of primary care services to clients over a wide age range. Physicians were periodically available on site in about 80 per cent of the practices, by telephone in 97 per cent of the practices, and in 60 per cent of the practices provided additional consulation by record review. Major motivations of the NPs for entering rural practice were to participate in a creative approach to health care delivery (50 per cent of the practice setting were less than five years old), and for the opportunity for role autonomy. Over 95 per cent of these NPs and employers were satisfied with the NP role.


Family nurse practitioners in primary care: a study of practice and patients. In this nationwide study 8,905 patients were seen by 356 family nurse practitioners (FNPs) during February through April 1977. The ratio of white to black and white to "other" patients was six to one. Racial minorities were seen significantly more often than were whites in public clinics supported predominantly by public tax monies. The smallest number of patients seen was in the "elderly" age group, 65 and over. Elderly patients were located to a greater extent in the South and they used both private and public clinics. The number of infants and children seen was greater in the Western region and in semi-urban areas. The predominant patient problems seen by FNPs were Prevention/Health Supervision and Respiratory. Although there were similarities between top ranking primary care problems seen by FNPs in this study compared with primary care physicians in other studies, proportionately more FNP patient contacts were for Prevention/Health Supervision and the patients tended to be in the younger age group.


The financial viability of rural primary health care centers. Primary health care centers have been proposed to meet the health care needs of rural America. Some centers become financially "self-sufficient", receiving their entire budgets from direct patient or third-party payments; others shut down when external funding is withdrawn. An explanation for this difference is important, because funding agencies may not wish to subsidize centers whose financial futures appear bleak. This study identifies the correlates of financial self-sufficiency. A survey conducted in late 1976 or 164 rural clinics provided 101 usable responses. Multiple regression analysis of the data shows that the longer a center has been in operation, the more self-sufficient it will become. Hospital control of the center and provision of laboratory tests increase self-sufficiency; outreach services and nonprofit status reduce it. Two variables related to financial self-sufficiency are separately examined. Clinics with a faster growth rate of patient visits are more self-sufficient, and smaller clinics tend to grow faster. More self-sufficient clinics experience less difficulty in keeping professional staff. The presence of a state Area Health Education Center (AHEC) program also eases the problem of staff retention.


Family allowance and family planning in Chile. Family allowances designed to promote maternal and child health and welfare could be self-defeating if they stimulated otherwise unwanted births, as often assumed. That assumption, with its public health and demographic implications, needs testing. An attempt to test it was made in Chile in 1969--1970 through interviews with 945 wives receiving an allowance and 690 non-recipients. Recipients practiced contraception significantly more than did non-recipients. This was not explained by wives' educational attainment or employment, the couples' earnings, or number of living children, but was associated with a 50 per cent greater utilization of professional prenatal care by recipients during the most recent pregnancy; women with such care (regardless of allowance status) were 75 per cent more likely than others to control their fertility. Prenatal care was probably sought more by recipients in part because an additional stipend was provided as soon as pregnancy was confirmed, usually at clinics with integrated family planning. Greater family income, attributable to the allowance, probably also contributed to the recipients' better prenatal attention and to contraceptive practice. Noteworthy, too, was the finding that with the number of living children controlled, contraceptive practice was significantly greater amoung couples who had never lost a child.


Children's views of health: a developmental study. Two hundred and sixty-four first, fourth, and seventh grade children were asked to define health, state what it felt like to be healthy and not healthy, and to give criteria they would use to judge another person's health status. A chi square analysis was done to compare differences for age, sex, intelligence, and socioeconomic status. Results indicated that children saw health as a positive attribute which enabled them to participate in desired activities, that a person was healthy if he could do what he wanted to do, and that health and illness were two different cncepts rather than on a continuum as is often cited in the literature. Mental health was not considered as part of being healthy except by a few of the oldest children. There were both qualitative and quantitative changes with age which were consistent with theories of concept development. It is recommended that future studies be conducted with both adults and health workers. (There is some evidence that consumers and health professionals do not have the same ideas about health.)


Informed consent by children and participation in an influenza vaccine trial. Two hundred thirteen school children, ages six to nine, were presented the opportunity to participate in an experimental trial of swine influenza vaccine. In non-directive question and answer sessions, all groups of children except one composed only of six year olds elicited all relevant information on the details of the trial and the associated risks and benefits. Forty-six per cent of the subjects declined to participate. Letters requiring informed consent of the parents were sent to the homes of the others. Almost 15 per cent of these parents agreed to their children's participation. In this setting, children initiate their own visits to the school nurse practitioner. A significant association was found between volunteering for the study and higher use of services (but not for medical reasons). Younger children and boys, regardless of their patterns of use, were less inclined to volunteer for the experiment.


Sexual knowledge, attitudes, and practice of Israeli adolescents. A study of 4,976 high-school students in Israel, representative of this age group for the entire country except for 13 percent who attend religious schools, revealed that about one-third of the boys aged 14-15 and almost one-half of those in the 16-17 age category have had sexual intercourse. The respective figures for girls are 6 percent and 16 percent. Age at onset of sexual activity was found to be higher and the level of knowledge about the same as in reports from the Western world. Students of Oriental origin, as well as those considering themselves religious or traditional tended to be less active sexually, more conservative in their attitudes, and less knowledgeable. In contrast, students of both sexes residing in kibbutzim were found to be more active sexually and more knowledgeable. A double standard for girls was accepted, especially among the female respondents, except in the kibbutzim. A subgroup of girls highly sexually active, in contrast to their own attitudes, has been identified, and possible reasons for this discordance discussed. As sexual activity among teenagers is becoming more prevalent, comprehensive and early sex education school programs should be encouraged.


A comparative study of physicians' and nurses' conceptions of the role of the nurse practitioner. Attempts to define the role of the nurse practitioner as a new health care provider raise questions about the traditional health care division of labor. In order to determine nurses' and physicians' conceptions of the NP's role, parallel surveys were conducted among registered nurses and primary care physicians in southeastern Pennsylvania (including Philadelphia). Respondents (679 nurses and 597 physicians) indicated their opinions on the issue of autonomy for NPs and on the issue of specific tasks appropriate to the NP's role. There were significant differences between nurses and physicians with respect to both of the issues under consideration, but there were also important differences within each of these groups. Nurses were more likely to assert that an NP might practice independently, and also had a higher conception of the NP's capabilities. Physicians who were interested in employing a nurse practitioner had opinions which were closest to those of nurses. These findings suggest that conflict between nurses and physicians might be minimal as long as the nurse practitioner movement remains relatively small, but that there may be latent conflict inherent in any large scale attempt to change the health care division of labor at the present time.


Overcoming barriers to the employment and utilization of the nurse practitioner. A national longitudinal cohort study of nurse practitioners and their employers conducted during 1973--1976 provided data on barriers to the development of the nurse practitioner role in primary care. Nearly 90 per cent of the 500 primary care nurse practitioners responding and 75 per cent of the 407 employers responding reported encountering one or more barriers to the role development of the nurse practitioner in their practice setting. Nurse practitioners identified an average of 2.2 barriers and employers identified an average of 1.6 barriers each. Specific barriers identified by 20 per cent or more of the nurse practitioners and employers were legal restrictions, limitations of space and facilities, and resistance from other providers. The data and other evidence suggest that these barriers are not insurmountable and that progress is being made in overcoming these obstacles.


Physician behavior as a determinant of utilization patterns: the case of abortion. Health services utilization may be influenced by the structure of the health system and the behavior of health professionals as well as by the actions of individual patients. This research examines the responses of obstetricians toward women seeking abortion. The population for this study includes all obstetrician-gynecologists with any private practice in Maryland during 1975 (473). Each responding physician (443) was presented with a case history vignette describing, in a telephone interview, a woman who is pregnant and considering an abortion. The sociodemographic characteristics of the woman were systematically varied to determine effects of patient attributes on physicians' patient management decisions. Decisions to refer the patient or to participate personally in her care were found to be associated most strongly with the patients' financial resources. Three hundred and twelve obstetricians returned a mail questionnaire, probing their own attitudes and characteristics. Physicians' liberal or conservative attitudes toward expansion of reproductive health care services and their level of disturbance by the abortion procedure were also influential in these patient management decisions. Simultaneous examination of both patient and physician characteristics indicated that the former had the greater weight in accounting for referral decisions.


Prevalence of sickle cell trait and HbC-trait in Blacks from low socioeconomic conditions. In the present investigation we did not observe age or sex differentials in the prevalence of sickle cell or HbC-traits in Black males or females of low socioeconomic status. When our data were compared to those of others, we found no evidence for a socioeconomic differential in the prevalence of these traits.


Acute bacterial meningitis in Cairo, Arab Republic of Egypt, 1 January 1971 through 31 December 1975. Between 1 January 1971 and 31 December 1975, 1,333 patients with acute bacterial meningitis were admitted to the meningitis ward of the Abbassia Fever Hospital. These cases are tabulated by distribution of diagnosis, seasonal distribution,  age and sex distribution, and age-specific case fatality ratio. Results are compared with those of other large series of cases reported from other parts of the world. The annual incidence of acute bacterial meningitis in Egypt varies widely. Recent data show this to be due to variations in the incidence of group A meningococcal meningitis. The study includes the declining phase of an epidemic of that disease and confirms a previously reported finding that the case fatality ratio in group A meningococcal meningitis varies inversely with the annual number of cases.


Studies on hepatitis B surface antigen and antibody in Nauru. I. Distribution amongst Nauruans. The age specific prevalence of hepatitis B surface antigen and antibody was studied among a random sample of Nauruans over the age of 10 years. Overall, 79% of subjects showed evidence of past infection with hepatitis B virus with the highest prevalence among young people. While there was no difference in the infection rate between males and females, the carrier rate in males was 50% higher. In both sexes the carrier rate declined with increasing age. Significant differences in carrier rates were detected among people living in different parts of the island.


Hepatitis B antigenaemia on Wuvulu Island. A survey of the population of Wuvulu Island was undertaken to determine the prevalence of hepatitis B antigenaemia (HBsAg). Seventy-five percent of the population were tested, and 17.7% of those tested were positive for HBsAg. The percentage of positive sera increased with age but declined in the 5th decade of life. There was a marked difference in positivity between the two villages on the island (25.9% and 9.9%) which cannot be explained by several existing hypotheses for HBsAg transmission.


Natural transmission of Keystone virus to sentinel rabbits on the Delmarva Peninsula. Domestic rabbits were exposed in the Pocomoke Cypress Swamp from early May through October 1973, to act as sentinel indicators of Keystone (KEY) virus transmission on the Delaware-Maryland-Virginia (DelMarVa) Peninsula. Rabbits were bled weekly and their sera were tested for the presence of neutralizing antibody to both KEY and James-town Canyon (JC) viruses. Adult mosquito activity was monitored concurrently by CDC miniature light traps with Dry Ice. Of 100 rabbits exposed, 20 rabbits acquired neutralizing antibody to KEY virus as a result of their exposure; none acquired antibody to JC virus. Eighty-three percent of susceptible rabbits exposed converted immediately after the emergence of Aedes atlanticus adult mosquitoes in early September. Rabbit seroconversions were not limited to any particular habitat within the swamp. The conversion of a large proportion of sentinel rabbits immediately following emergence of A. atlanticus, and the previous demonstration of transovarial transmission of KEY virus by A. atlanticus, suggest that vertically infected individuals are capable of viral transmission at their initial engorgement. Such transmission provides the initial step in a vertebrate amplification cycle.


Johnston Atoll virus (Quaranfil group) from Ornithodoros capensis (Ixodoidea: Argasidae) infesting a gannet colony in New Zealand. Ten strains of Johnston Atoll (JA) virus were isolated from Ornithodoros capensis collected in a Gannet (Sula bassana serrator) colony in New Zealand. Its sensitivity to ether and sodium deoxycholate were confirmed and it was shown to have an RNA genome. It multiplied in day-old chicks but, unlike the prototype virus, it was not pathogenic for them. Transmission experiments and the high incidence of birds with neutralizing antibody indicate that the virus is maintained in the colony by a cycle involving ticks and Gannets. This is the first recorded tickborne arbovirus in New Zealand and extends the known range of JA virus from the tropics into the temperate zone.


Relative hyperelectrolytemia in northern Nigerians. A number of studies among the peoples of tropical Africa have shown exceptionally low electrolyte levels. This paper reports a study of more than 200 healthy northern Nigerian subjects which yielded precisely the opposite picture--exceptionally high levels of both sodium and chloride. The relatively high protein and urea values in the same individuals suggest that the high electrolyte levels seen are due to dehydration. The implications of these findings are discussed.


Changes in coagulation effects by venoms of Crotalus atrox as snakes age. Venom samples separately collected at monthly intervals from three Crotalus atrox specimens as they aged from 2 to 22 months showed many quantitative changes of biological activities. But more important were qualitative changes of coagulation activity. Up to 8 months the venoms clotted fibrinogen solutions directly. At 9 to 10 months, plasma was clotted but not fibrinogen. Subsequently the venoms no longer clotted plasma. Qualitative venom changes with growth of snakes could explain some of the conflicting reports both on clinical aspects of snake bite in man and on experimental venom work. The findings emphasize the importance for clinicians dealing with snake bite to monitor the clot-quality of their patient's blood--a simple bedside test for defibrinogenation, no-clot indicating zero fibrinogen and speck-clot representing fibrinogen concentrations under 50 mg/100 ml. With strongly defibrinating venoms, non-clotting blood is a very sensitive sign of systemic envenoming. In contrast, the relatively feeble defibrinating activity of juvenile C. atrox venom suggests that, if the blood is non-clotting in C. atrox bites, this indicates the victim has received a potentially lethal or near-lethal dose of venom urgently requiring effective antivenom therapy.


Growth of Babesia bovis in bovine erythrocyte cultures. Babesia bovis was cultured in a suspension of bovine erythrocytes incubated at 37 degrees C in Medium 199 with 50% bovine serum. The cells in culture were kept in suspension by slow stirring in spinner flasks and the medium was replaced at 24-hour intervals. Persistent multiplication of the parasite in a short series of subcultures suggests the feasibility of this approach for continuous culture.


Proliferative glomerulonephritis, hypocomplementemia, and nucleic acid antibodies in rats infected with Trypanosoma rhodesiense. Host immunologic responses were studied in Sprague-Dawley rats infected with a human isolate of Trypanosoma rhodesiense. Retro-orbital sinus bleedings were obtained on days 0 and 14 and at 21 or 28 days. Infected and control rats were sacrificed on day 21 or 28 of the infection. Mild glomerulitis, as assessed by increased cellcularity and/or widening of the mesangial region, was apparent in 6 of 7 infected animals. Finely granular deposits of IgM and IgGl were found in most glomeruli with less prominent deposits of IgGa and IgA. Focal cortical mononuclear interstitial infiltrates were present in 2 of 7 rats. Subepithelial or mesangial electron dense deposits were present in the glomeruli of infected rats. Hypocomplementemia was present by day 21 and involved both the classical and alternative pathways of complement activation. Antibodies to native DNA and single-stranded RNA were present by day 21. These studies indicate the feasibility of studying trypanosomal glomerulonephritis in rats and will provide a convenient model for detailed immunologic and morphologic investigation of host immune responses in African trypanosomiasis.


Epidemiological and clinical features of Brugia timori in a newly established village. Karakuak, West Flores, Indonesia. The epidemiological and clinical features of Brugia timori filariasis in a newly established village, Karakuak, West Flores, is described. The microfilarial rate by finger stick and Nuclepore filtration was 24% and 30%, respectively, and the disease rate 64%. Infected persons were found in every family and household with no predominant age or sex preference. Development of elephantiasis in the population was associated with residence in the new village of Karakuak, where extensive rice field cultivation was initiated soon after arrival. The irrigated fields provided excellent breeding sites for the vector, Anopheles barbirostris. People with no previous exposure to the parasite developed elephantiasis earlier and more frequently than those originating from other endemic areas.


Schistosomiasis in Saudi Arabian recruits. A morbidity study based on quantitative egg excretion. We surveyed stool and urine specimens from 245 Saudi Arabian trainees for parasites. Schistosoma mansoni eggs were found in the stool in 66 (26.9%) and S. haematobium eggs were recovered from the urine in 1 (0.4%). Additional parasites were recovered in 167 (68.2%) of the survey group and were not more common in those with schistosomiasis (P greater than .10). Schistosome egg counts ranged from 0--6,320 eggs/g feces (mean 447.9). When patients with high egg counts (over 400 eggs/g) were compared with uninfected controls, abdominal complaints and fatigue were found to be more frequent (P less than .05) in the infected group, as was eosinophilia (P less than .001). Other laboratory and physical examination findings were equally present in both groups. This study reaffirms the value of quantitative examination of stool specimens for schistosome eggs.


Schistosoma haematobium in the Wabi Shebelle Valley of Ethiopia. A survey of the lower Wabi Shebelle Valley of southeastern Ethiopia was made to assess the presence of schistosomiasis haematobia in the modernized plantation of Gode and adjacent areas. The disease is present in Kellafo, Mustahil, and in the Burukur flood plain 100 km downstream from Gode, and absent further north. This is related to the ecology of the different areas.


Schistosoma mansoni and S. haematobium infections in Egypt. IV. Hepatic lesions. We performed 400 consecutive autopsies in Cairo, Egypt. The intensity of schistosome infection in these cases was measured by counting adult worms recovered by perfusion and dissection and by counting eggs in the tissues of infected cases. Symmers' clay pipestem fibrosis of the liver was clearly related to the presence and intensity of Schistosoma mansoni, but not S. haematobium, infection. Morphologic findings in cases with Symmers' fibrosis were comparable to those in Brazilian cases, and the intensity of S. mansoni infection associated with Symmers' fibrosis was similar in Brazil and Egypt. The fine bilharzial periportal fibrosis described by Hashem was not identified in our material, and Symmers' fibrosis was present in all cases of portal hypertension caused by schistosomiasis. Schistosome eggs were found concentrated in areas of portal fibrosis of cases with Symmers' fibrosis. In the absence of Symmers' fibrosis, eggs did not concentrate in large portal areas regardless of the intensity of infection or the presence of lesser degrees of portal fibrosis. We thus feel it unlikely that Symmers' fibrosis is formed by the fusion of fibrotic granulomas around the schistosome eggs.


Resistance of mice to secondary infection with Schistosoma mansoni. I. Comparison of bisexual and unisexual initial infections. Mice receiving a unisexual primary infection with either sex of Schistosoma mansoni did not develop detectable resistance to reinfection. In contrast, mice receiving a bisexual primary infection developed a high degree of resistance. The number of adult worms developing from the challenge infection was reduced, relative to controls, by 72--100% at challenge times of 6 weeks or greater.


Resistance of mice to secondary infection with Schistosoma mansoni. II. Evidence for a correlation between egg deposition and work elimination. Mice reinfected with Schistosoma mansoni 6--8 weeks after a primary infection largely or completely eliminated the second infection prior to the 7-week adult worm stage. In contrast, challenge worm counts were not lower than controls at the 6-day lung schistosomulum stage. At reinfection intervals of 12 or more weeks, worm counts were reduced at both stages. The reduction in lung schistosomulum count was proportional to the number of schistosome eggs present in the lungs, with no significant reduction being detected at any challenge time in mice free of lung eggs. Isolated schistosome eggs injected intravenously into the lungs of normal mice induced moderate to high levels of resistance to infection, while eggs injected subcutaneously or imtraperitoneally did not. It is concluded that the deposition of schistosome eggs in sites encountered by migrating schistosomula may be essential for mice to become resistant to reinfection with S. mansoni.


Intrasellar cysticercosis presenting as a pituitary tumor: successful transsphenoidal cystectomy with preservation of pituitary function. A 42-year-old woman from El Salvador presented with arthralgias and headache. She was found to have an enlarged sella with an intrasellar mass. Transsphenoidal exploration of the sella revealed a cysticercus. The cyst was removed and normal pituitary function was retained. Review of the literature showed three previously reported confirmed or suspected cases of intrasellar cysticercosis: in two, the diagnosis was made at autopsy; in the third, a patient with hypopituitarism, intrasellar cysticercosis was suspected in life but never confirmed histologically. Transsphenoidal cystectomy successfully treated our patient without compromise of pituitary function and is recommended for similar cases.


Reversal reactions in lepromatous leprosy following transfer factor therapy. Five patients with active leprosy, four with polar lepromatous (LL) and one with borderline lepromatous (BL) disease, were each treated with transfer factor (TF) from approximately 7.4 x 10(9) lymphocytes given in 36 divided doses over a 12-week period. The TF was prepared from blood donated by normal, healthy, lepromin skin test-positive individuals. During treatment all four of the LL patients, but not the BL patient, developed clinical reversal reactions. Histopathologically, skin biopsies in these four LL patients showed evidence of transformation of collections of multibacillary macrophages into paucibacillary epithelioid cells and giant cells. To our knowledge, this is the first histopahtologic documentation of reversal reactions occurring in polar LL. To the extent that reversal reactions are evidence of effective cell-mediated immunity of Mycobacterium leprae, these results indicate that TF is capable of at least partial correction of the immunologic deficit of lepromatous leprosy.


Major vascular injuries secondary to pelvic fractures: an unsolved clinical problem. Twelve patients sustained sixteen pelvic fracture-related iliac and femoral arterial (5) and venous (11) injuries. Death was due in large part to delays in recognition and direct operative control of the major vascular disruption. Prompt operative exploration of all pedestrians admitted in hemorrhagic shock will open pelvic fractures characterized by a double break in the pelvic ring should reduce the 83 per cent mortality currently associated with this combination of injuries.


Penetrating injuries to the iliac arteries. Despite advances in the management of traumatic truncal and peripheral vascular injuries, penetrating trauma to the iliac arteries carries a high mortality. Among more than 600 patients with arterial trauma seen at the Ben Taub General Hospital between January 1958 and December 1977, eighty-three had penetrating injury to the iliac arteries. Thirty-two patients (39 per cent) died within thirty days of injury, none of these dying within 48 hours of injury. Injuries were managed by resection and end-to-end anastomosis (36 per cent), lateral arteriorrhaphy (27 per cent), ligation (20 per cent), and prosthetic interposition (10 per cent). Three perigraft infections occurred with ultimate removal of the graft and ligation of the common iliac artery. Among patients with penetrating injuries who arrive alive at a hospital, iliac artery wounds result in massive intraperitoneal blood loss, in contrast to aortic injuries which frequently have a protective tamponade for a period of time. Delay in surgery, irreversible shock, dilutional bleeding diathesis, and respiratory insufficiency result in a high mortality. A high index of suspicion and prompt aggressive surgery are necessary to improve changes of survival of patients with this highly lethal injury.


Cimetidine inhibits burn edema formation. Large doses of cimetidine significantly inhibit edema formation in thermally injured rat skeletal muscle. Tissue sodium influx and potassium efflux is also sharply restricted. These effects were obtained even if the administration of cimetidine was delayed for up to 4 hours after injury, but no beneficial effect occurred if drug administration was delayed for 14 hours, when most of the edema had already accumulated. The minimal effective dose is between 0.1 to 0.2 mg/gm.


Intestinal disruption due to blunt abdominal trauma. Twenty-three patients with thirty-one disruptions of the intestines due to blunt abdominal trauma are reviewed. The bowel disruptions occurred in the stomach (2 perforations), duodenum (9), proximal jejunum (18), and sigmoid colon (2). The causes of injury, diagnostic difficulties, delays in treatment, associated trauma, surgical correction, and results are analyzed. Deaths (4) and complications (6) are presented in detail. Intestinal disruptions can be due to a variety of types of blunt trauma, with the automobile being the most common etiologic agent. The bowel can perforate anywhere in its course. Intestinal perforations are often associated with severe injuries which will probably be the determining factors in survival. Persistence, particularly repeated physical examination, is required for the diagnosis of bowel injury. Routine diagnostic tests for duodenal injury are not reliable. Retroperitoneal hematomas around the duodenum must be explored. The injuries themselves are easy to repair, and repair is secure when performed at the primary operation. Prophylactic antibiotics are recommended.


Diagnostic peritoneal lavage: fourteen years and 2,586 patients later. During a fourteen year period, diagnostic peritoneal lavage was 98.5 per cent accurate in determining the presence or absence of blunt intraabdominal injuries among 2,586 patients. Of these, 69.4 per cent had a negative lavage and 29.2 per cent a positive lavage. Six patients (0.2 per cent) had a false-positive lavage. Thirty-two patients (1.2 per cent) had a false-negative lavage; however, all but one of these patients underwent exploratory laparotomy on the basis of clinical acumen or other diagnostic tests.


Abdominal aortic aneurysms. A comparative analysis of surgical treatment of symptomatic and asymptomatic patients. This retrospective study of 120 patients identified three separate variables that influence operative mortality in patients with abdominal aortic aneurysms. These are age, presence or absence of symptoms, and presence of three preoperative risk factors or more. Based on this study and the fact that any aneurysm may rupture without warning, we conclude that observation of good risk asymptomatic patients until symptoms occur is unjustified. Asymptomatic patients less than seventy years old can undergo abdominal aortic aneurysmectomy with minimal mortality. Carefully selected asymptomatic patients more than seventy years old can also under surgical intervention with acceptable results.


Discussion and management of late failures in reconstructive procedures involving the abdominal aorta. Review of fifty-eight late failures of 326 procedures performed for revascularization of the abdominal aorta over the past six years showed a low overall operative mortality of 9 per cent. Secondary vascular procedures directed at the aorta itself or at its graft substitute proved more effective in relieving symptoms and restoring flow than did secondary procedures directed at more distal problems in the lower extremities. The aortofemoral graft in conjunction with profundaplasty proved to be the most effective means of restoring flow to the lower extermity after graft occlusion in a previous aortoiliac or aortofemoral graft.


Acute hemodynamic effects of lumbar sympathectomy. Lumbar sympathectomy increases total limb blood flow after aortofemoral bypass in a high percentage of cases. This was true in eleven of fourteen extremities (78.6 per cent) in our series even though no specific selection criteria for entry into the study, other than the need for aortofemoral bypass, were used: that is, patients were entered into the study irrespective of preoperative ankle/arm pressure indexes or results of hyperemia testing. Overall, flow rates after sympathectomy was added to aortofemoral bypass were 1.55 times greater than after aortofemoral bypass alone. This degree of augmentation of flow may be important, particularly in cases of limited outflow.


Results of breast biopsies for mammographic findings. The results of breast biopsies for mammographic findings have been presented, in which 314 biopsies were done on 274 patients. From this number of biopsies, the diagnosis of cancer was established in fifty-seven cases (18 per cent of the biopsies). More than 50 per cent of the lesions were infiltrating duct cell carcinomas. The number of breast biopsies required increased markedly after the national publicity in 1974. As more biopsies were done, the incidence of carcinoma increased, and a significant number of these were found in women less than fifty years old. We believe this justifies the continued judicious use of mammography, even in the younger patient, if clinically indicated.