Recurrent Reye's syndrome.

Recurrent Reye's syndrome. The clinical diagnosis of recurrent Reye's syndrome can be made only after a systemic exclusion of other diagnostic possibilities. We report such a case, providing guidelines for a complete clinical and biochenical evaluation of this entity. If a comprehensive study of patients experiencing recurrent Reye's syndrome is to be made, each patient must be subjected to thorough examination.


Dominant inheritance of Scheuermann's juvenile kyphosis. Familial occurrence of Scheuermann's juvenile kyphosis is well known, but no specific mode of inheritance has been recognized. We describe five families in which the disease seems to follow and autosomal dominant pattern of inheritance.


Problem acuteness and medical record utility. We studied the usefulness of having the patient's medical record available to the pediatrician at the time of the patient's visit. For most acute problems, the medical record had no effect on the management of the patient, whereas the record frequently affected the handling of chronic or recurrent problems. These results suggest a means of improving the effectiveness of pediatric emergency room management and also a means for defining empirically criteria for evaluation of care by record audit.


Basilar skull fractures in children. The incidence of CNS infection and the use of antibiotics. Forty-six cases of basilar skull fractures in children were reviewed to determine the incidence of CNS infection following injury and the possible value of antimicrobial chemoprophylaxis. The clinical course of the children who were treated with antibiotics was compared with that of patients who received no antimicrobial therapy. Included in the study were patients with hemotympanum alone or with hemotympanum plus additional clinical or roentgenographic signs of basilar skull fracture; patients with tympanic membrane perforation without otorrhea but with blood in the auditory canal; and children with either otorrhea or rhinorrhea. Acute, delayed, or recurrent infection of the CNS did not develop in any of the patients. This study is the first of its kind presented in children. It would seem on the basis of the present series that the systematic use of antibiotic prophylaxis in children with hemotympanum following basilar skull fractures is unwarranted and that children with other signs of basilar skull fractures may have an equally small risk of meningitis following injury.


Infant tracheostomy. A new look with a solution to the difficult cannulation problem. Although most infant airway and ventilatory problems will be best solved by the use of endotracheal tubes, clear-cut indications for tracheostomy exist. Past reticence to use tracheostomy for infants has been due mainly to the fear of decannulation problems. Recognition of obstructive airway lesions, particularly the lumen-narrowing tracheal stomal granuloma, has been facilitated by the routine use of the newer infant bronchoscopes with optical telescopes. Successful decannulation begins with proper tracheostomy technique, and continues through tracheostomy management and a well-conceived decannulation program. Decannulation should include evaluation of the structure and function of the airway endoscopically and it may include translaryngeal endoscopic resection or formal surgical removal of any obstructing lesions. Experienced nursing personnel are essential to the entire program.


Xeroradiography in the evaluation of acquired airway abnormalities in children. Xeroradiography of the neck was performed on 36 children with suggested or known acquired tracheal abnormalities. The information obtained from the lateral projection xeroradiograph was superior in selected cases to the conventional soft tissue roentgenogram. In these cases, the information obtained justified the increased (12-fold) radiation exposure and obviated the need for positive contrast examination. This procedure should be considered in any case in which a fluoroscopic contrast examination is indicated.


Staphylococcal scalded skin syndrome. A complication of circumcision. Numerous complications have been reported as a result of neonatal circumcision. We describe here three cases of staphylococcal scalded skin syndrome that were thought to be due to infected circumcisions. A review of the literature failed to disclose descriptions of staphylococcal scalded skin syndrome as such a complication. In spite of recent American Academy of Pediatrics recommendations against routine circumcision, it will continue to be a common procedure. Careful preoperative and postoperative screening and guidance are urged to prevent staphylococcal scalded skin syndrome and other complications.


Fournier's syndrome. Report of three cases and review of the literature. Three children, aged 9 days, 3 weeks, and 9 1/2 months, were treated for Fournier's syndrome. The portals of entry for a miscellaneous group of pathogens included a circumcision in the first, a circumcision and a diaper rash in the second, and a hot water burn in the third. The development of the condition after a circumcision is noteworthy because it is an extremely common surgical procedure. Medical and minor surgical treatment of the gangrenous areas during the period of rapid healing was successful. This approach contrasts with those researchers who recommend grafts. All three children survived, although one died three years later of complications from the original burn, and in another, one testicle could not be palpated after healing.


Oculoglandular disease of parinaud. A manifestation of cat-scratch disease. Among patients with cat-scratch disease, the oculoglandular form is the most common unusual manifestation. This condition, seen in 14 of 585 patients with the infection encountered in a private pediatric practice over a span of 23 years, belongs in the syndrome of the oculoglandular disease of Parinaud. Most of the 14 patients described were only mildly ill and had but little discomfort. All patients recovered without residuals. Diagnosis is based on four criteria: exposure to a cat, usually an immature one; the presence of a localized granuloma of the eye; the presence of preauricular lymphadenopathy; and a positive skin test to cat-scratch antigen of known potency. Several unusual features, never before described, of oculoglandular disease due to cat-scratch disease are submitted.


Partial exchange transfusion in sickle cell anemia. Use in children with serious complications. Seventeen children with sickle cell anemia received 40 partial exchange transfusions for serious complications of sickle cell anemia, and preoperatively to reduce the risk of anesthesia. Each patient received two partial exchange transfusions at 24-hour intervals and all patients tolerated the exchange transfusions well. The mean hematocrit level rose from 22.9% before the exchange transfusion to 40.6% at the end of the second exchange. The mean sickle hemoglobin level decreased from 93.8% before the exchange to 28.0% after the second exchange. Patients with acute lung syndrome had remarkable improvement in clinical symptoms and PaO2 levels, and those with acute liver crisis had substantial reduction in serum bilirubin levels. All the other patients showed marked clinical improvement following the exchange transfusions.


Familial Mediterranean fever. A case report. A case of familial Mediterranean fever in a young girl presented typical diagnostic dilemmas. Although intermittent proteinuria was noted, a rectal biopsy specimen failed to demonstrate the presence of amyloidosis. Treatment consisted of supportive therapy and colchicine, to which she responded. In a cosmopolitan population, familial Mediterranean fever should be considered in the differential diagnosis of fever of unknown origin.


Resistant ascites in alcoholic liver cirrhosis: course and prognosis. A group of 29 patients with decompensated cirrhosis of the liver who retained a large amount of ascites under a hospital regimen during two months or longer was identified. The prognosis for this selected group of patients, while grave [during continuous hospitalization 11 out of 29 patients (= 38%) died], is not without hope: 18 patients (62%) improved and could be discharged from the hospital. Their further course was influenced by resumption of alcohol usage. Five of 11 (45.4%) who resumed drinking died due to hepatic causes within 10 months. Of the remaining six only one lost his ascites. Those who abstained (7 patients) remained alive for an average follow-up of 33 months and all lost their ascites. Alcohol resumption significantly decreased both survival (P less than 0.05) and ascites resorption (P less than 0.0015). Continued abstinence from alcohol may thus obviate the need for surgical measures to relieve ascites in these patients.


Pigment gallstone composition in cirrhotic and noncirrhotic subjects. The composition of pigment gallstones from patients with and without cirrhosis was compared. Carbonate-containing pigment stones were distinguished from noncarbonate stones by infrared spectroscopy. Calcium was the major cation of each stone group. The major anion in noncarbonate pigment stones was bilirubinate or phosphate, but was carbonate in carbonate stones. The composition of pigment stones from cirrhotic and noncirrhotic patients was similar except that significantly less carbonate was present in carbonate stones, and less pigment (bilirubinate) was present in noncarbonate stones from noncirrhotics. These data suggest that irrespective of the presence of cirrhosis, the formation of noncarbonate pigment stones involves the selective precipitation of calcium bilirubinate and phosphate, whereas carbonate stone formation involves the selective precipitation of calcium carbonate.


Malignant lymphoproliferative disorders in chronic liver disease. Report of four cases and review of the literature. Four patients who manifested an association between chronic liver disease and lymphoma are reported. Three of them had nonalcoholic cirrhosis and one had chronic cholangitis. Non-Hodgkin's lymphoma developed long after the presence of liver disease had been established in three of the patients. The fourth patient died of hepatic coma and Hodgkin's disease was discovered incidentally at autopsy. Drugs could not be incriminated in the development of either cirrhosis or lymphoma in any of the patients. A review of the literature is presented, and the view that the association between chronic liver disease and lymphoma is not coincidental is supported.


Hemostatic alterations in inflammatory bowel disease: response to therapy. Twelve patients with acute, untreated inflammatory bowel disease (IBD) were followed prospectively for coagulation and platelet function. With no symptomatic coagulopathy, abnormalities were found in all patients. With acute diseases, elevations of fibrinogen (9/12), factor V (8/12), and factor VIII (6/12) were common. Depressions of antithrombin III levels were also observed acutely (8/12). Abnormalities of platelets were both quantitative and qualitative. Thrombocytosis was present (11/12), and abnormalities in the rate and percent platelet aggregation were seen (9/10). During therapy, factors V and VIII, antithrombin III levels, and the quantitative and qualitative platelet abnormalities returned towards normal in direct correlation with sedimentation rate and clinical disease activity.


Effect of phenolphthalein on the function and structure of rodent and human intestine. Phenolphthalein (PHE) is the active ingredient in at least 12 over-the-counter laxative preparations. It is alleged to have a minor effect in the small intestine compared with the colon where it is supposed to alter motor activity or water absorption or both. We measured water absorption from segments of rat intestine in vivo, and from the nearly intact small intestines of patients with established ileostomies. In rats, each intestinal segment served as its own control so that water absorption in a test period (PHE, 1--15 mg/100 ml) could be expressed as a percentage of the control period when buffer was infused. PHE inhibited water absorption, and the degree of inhibition was related linearly to log10 PHE concentration. The similarity of slopes of the regression lines suggested that all segments of the rat intestine were equally sensitive to PHE. In six patients, PHE, 100 mg four times a day, increased weight of ileostomy output by 30%, and Na+ output by 39%. These facts indicate that some of the laxative effects of PHE result from inhibition of water absorption in both large and small intestines.


Relation between serum pancreatic isoamylase concentration and pancreatic exocrine function. Serum pancreatic isoamylase concentrations were compared to secretory and clinical evidence of pancreatic insufficiency in 19 consecutive alcoholic patients undergoing pancreatic stimulation testing for suspected pancreatic insufficiency. In patients with normal total serum amylase levels, there was a good correlation (r = 0.83) between serum pancreatic isoamylase activity and stimulated pancreatic secretion of amylase and the 8 patients with a low pancreatic isoamylase concentration had markedly diminished pancreatic secretion of amylase, lipase, and bicarbonate. However, patients with elevated total serum amylase activity frequently had extremely poor pancreatic exocrine function despite normal or elevated levels of pancreatic serum isoamylase. Thus, the finding of a subnormal serum concentration of pancreatic isoamylase provides strong evidence for pancreatic exocrine insufficiency; however, a normal or elevated serum pancreatic isoamylase activity cannot be used as evidence for normal pancreatic exocrine function.


Changes in plasma motilin concentration and gastrointestinal contractile activity in conscious dogs. Simultaneous measurement of plasma motilin concentration and gastrointestinal contractile activity was make in 12 healthy dogs. Plasma motilin concentration was measured by radioimmunoassay and gastrointestinal contractile activity was monitored by means of chronically implanted force transducers. During the interdigestive state, it was found that the plasma motilin concentration increased in complete accordance with the cyclical interdigestive contractions of the stomach. Furthermore, plasma motilin concentration was lowered by the ingestion of food, and it reamined low as long as the gastric motor activity was in the digestive pattern. Since, as reported previously the interdigestive contractions can be induced by tthe exogenous administration of motilin, we concluded that (1) motilin is released at constant intervals during the interdigestive state, and this release is suppressed by the ingestion of food; (2) motilin induces the interdigestive contractions of the stomach and duodenum; and (3) motilin is an interdigestive hormone and is the only known polypeptide hormone of the gut whose release is not induced by a meal.


Prevalence of Giardiasis: a study at upper-gastrointestinal endoscopy. The prevalence of giardiasis was assessed in 1000 consecutive adult patients undergoing upper-gastrointestinal endoscopy for the usually accepted indications. Patients with upper-gastrointestinal bleeding were excluded. The diagnosis was established by examination of duodenal aspirate and duodenal mucosal impression smears. In 21 patients (2.1%) trophozoites were detected both in the duodenal juice and stained mucosal impression smears. All were treated with metronidazole or tinidazole. In 14 of 16 patients who had subsequent duodenal intubation, eradication of the parasite was confirmed. In five patients previously existent abdominal pain disappeared with clearing of the parasite, and no other cause for their abdominal pain was discovered. A search for Giardia lamblia infestation may be a worthwhile additional procedure at the time of endoscopy when no other cause for abdominal pain is found.


Vitamin D dependence and aboral gradient of in vivo intestinal calcium transport in the rat. Rates of small-and large-intestinal calcium transport and their dependence on low doses of vitamin D were compared. Young rats were depleted of vitamin D by feeding a rachito-genic diet for 8--9 weeks; 48 and 24 hr prior to study, half were repleted with 200 IU vitamin D2. Duodenum and ileum, or cecum and colon, were perfused separately in situ with 1.6 mM calcium and tracer 45Ca in saline. There was an aboral gradient for net calcium transport and lumen-to-plasma flux with higher values in proximal than distal segments. Vitamin D repletion increased net calcium flux and lumen-to-plasma flux in duodenum and ileum, but not cecum and colon. Plasma-to-lumen flux (calculated as the difference between lumen-to-plasma flux and net flux) tended to be higher in colon than other segments and was not altered by vitamin D repletion.


Basophilic leukemia presenting as gastroduodenal ulceration: effect of H-2-receptor blockade. A patient with multiple gastroduodenal ulcers and gastric hypersecretion due to histamine excess associated with basophilic leukemia is described. Treatment with the histamine H-2-receptor blocker, cimetidine, was able to abolish the gastric hypersecretion and gastrointestinal blood loss. A literature review produced four other cases of multiple gastroduodenal ulceration with this disease, suggesting that it is more common than previously recognized. The availability of a potent H-2-receptor antagonist offers effective and specifically tailored therapy to counteract the gastrointestinal effects of hyperhistaminemia in basophilic leukemia and other "histamine excess" diseases.


The effect of hyperthyroidism on gastric emptying rates and pancreatic exocrine and biliary secretion in man. Malabsorption and diarrhea in hyperthyroidism has been attributed in part to an increased rate of gastrointestinal transit as measured with barium sulfate suspension. Data are unavailable on the effect of hyperthyroidism on gastric emptying rates of normal food and pancreatic enzyme secretion. These functions have been studied in 4 hyperthyroid patients and compared to results obtained when treatment achieved euthyroidism. Pancreatic trypsin secretion was half the euthyroid level in the hyperthyroid state. No significant change in bile salts occurred, although there was a tendency for a greater proportion of dihydroxy bile salts while hyperthyroid. Gastric emptying rates of a mixed fat, protein, and carbohydrate liquid meal were normal. Similarly the gastric emptying rate of a beef stew plus chicken liver meal was normal. We conclude that in hyperthyroidism gastric emptying rates of "physiologically active" food is normal. Pancreatic enzyme secretion is depressed in hyperthyroidism and may contribute to maldigestion.


Effects of caloric restriction on the kinetics of indocyanine green in patients with liver diseases and in the rat. The effect of caloric restriction on the hepatic uptake and excretion of indocyanine green (ICG) was studied in man as well as in rats. It was demonstrated that following a 72-hr caloric restriction in man, the plasma clearance rate for ICG was increased significantly at the low dose of 0.5 mg/kg, and transport maximum was increased without a significant change of storage capacity. In rats, the maximal biliary excretion was significantly increased after 48-hr fast, but neither maximal hepatic uptake (Vmax) nor hepatic ICG content was altered. The evidence is consistent with the view that fasting increases the ICG plasma clearance at low doses by enhancement of excretory steps at the bile canalicular membrane.


Diagnostic value of combined transhepatic venography and inferior vena cavography in chronic Budd-Chiari syndrome. In a series of 19 patients with Budd-Chiari syndrome, transhepatic venography and inferior vena cavography were used to localize the site of hepatic outflow obstruction. Classification into two types was made on the basis of the site of obstruction. Four cases were grouped as type I, in which obstruction was localized in the hepatic vein alone, and the inferior vena cava (IVC) was patent. Fifteen cases were of type II, in which there was a well-defined obstruction in the intrahepatic portion of the IVC or ostium of a hepatic vein. This study highlights the frequent occurrence of IVC obstruction as a cause of chronic Budd-Chiari syndrome in northern India and the utility of transhepatic venography in its diagnosis.


Achalasia in father and son.

Achalasia in father and son. Achalasia has not been previously reported in father and son. A man, age 38, and his father, age 66, presented two years apart with symptoms of dysphagia and aspiration. The diagnosis of achalasia was made on the basis of x-ray and endoscopic findings and on esophageal motility studies performed on the father. Both responded well to pneumatic dilatation and have been asymptomatic for 24 months and 6 months, respectively. These cases again suggest a genetic basis for achalasia.


Effect of topical acid on duodenal pepsinogen secretion in the rat. The effect of topical acid on duodenal pepsinogen secretion was studied in the anesthetized rat. Perfusion of a 5-cm segment of the proximal duodenum with normal saline or buffered saline (pH 7.2 or 6.0) elicited no detectable pepsinogen response. Perfusion with 10, 25, and 100 mN HCl resulted in a graded increase in pepsinogen output. Acetylcholine bromide, 500 microgram/ml, in buffered saline, pH 7.2, also stimulated pepsinogen secretion. The pepsinogen response to 100 mN HCl and to acetylcholine was completely abolished by atropine. Secretin, 2 units/kg, did not alter pepsinogen output during perfusion with buffered saline or acid, while secretin, 75 units/kg, increased pepsinogen output. These observations suggest that topical acid stimulates duodenal pepsinogen secretion through a cholinergic reflex and that secretin is not a significant stimulant of duodenal pepsinogen secretion in the rat within the dose range employed (1--2 units/kg).


Gastric retention in peptic ulcer disease. A reappraisal. The saline load test is a popular method to demonstrate gastric retention. This technique, however, does not permit evaluation of volumes contributed by gastric secretion. We have studied 11 normal subjects and 7 patients with pyloric outlet obstruction using a dyedilution technique. We measured simultaneously rates of water secretion, fractional emptying rates, total intragastric volumes, and the fractions of gastric volume contributed by gastric secretion both during fasting and following a 250-ml water load. Total intragastric volume was significantly increased in patients with outlet obstruction compared to normal subjects both during fasting and following the water load (P less than 0.01). This increase resulted from significantly increased water secretion (P less than 0.01) combined with significantly decreased gastric emptying (P less than 0.01). Thus, gastric retention produced in patients with outlet obstruction by delayed emptying appears to be magnified by gastric hypersecretion of water. These data in no way invalidate the use of the saline load test in the diagnosis of gastric retention states, but help define the role of gastric secretion in the residual volumes measured following the load.


Hypergastrinemia of antral origin in duodenal ulcer. A case of recurrent duodenal ulcer, basal gastric hypersection, and hypergastrinemia of antral origin is presented. The diagnosis was suggested preoperatively by stimulation tests with secretin and food. Billroth II antrectomy led to normalization of serum gastrin within half an hour. The gastrin content of the antral mucosa was not increased, neither was antral G-cell hyperplasia demonstrable. Postoperatively the basal gastric acid output and fasting serum gastrin levels were normal, without a postprandial increase in serum gastrin concentrations. The case does not support the existence of a specific disease called antral G-cell hyperplasia.


Watery diarrhea syndrome with elevated levels of vasoactive intestinal polypeptide associated with pancreatitis and pancreatic pseudocyst. A 32-year old patient presented with recurrent pancreatitis, severe watery diarrhea and elevated serum levels of vasoactive intestinal polypeptide. His diarrhea appeared to respond to intramuscular propantheline. Initially he improved but had another attack of pancreatitis while hospitalized. Evaluation by ultrasound revealed the presence of a pseudocyst and endoscopic retrograde pancreatography demonstrated complete occlusion of the main pancreatic duct. Exploratory laparotomy was performed with drainage of a pseudocyst. Analysis of the pseudocyst fluid revealed an elevated amylase, lipase and vasoactive intestinal polypeptide level. It is believed that this patient's severe diarrhea was related to his pancreatitis and pancreatic pseudocyst with elevated levels of vasoactive intestinal polypeptide.


Superior mesenteric artery compression syndrome. An attempt was made to search the medical records of the University Hospital and five affiliated hospitals at Rochester, NY for the last 10 years. Seventeen patients with superior mesenteric artery compression syndrome were found. The prevalence of this disease in a chronic-care hospital (0.965/1,000 admisssions) is significantly higher than that in acute general hospitals (0.0108-0.0520/1,000 admissions) by Chi square statistic (P less than 0.001). This syndrome should be suspected in patients with chronic wasting diseases who are bedridden and have lost weight after which they develop frequent vomiting or aspirations. On reviewing 146 cases from the literature after 1963, duodenojejunostomy was considered to be the best procedure for severe cases. The same good results were not achieved after gastrojejunostomy and lysis of the ligament of Treitz. Gastrojejunostomy provided adequate decompression of the stomach but was inadequate for releasing duodenal obstruction. Some patients after division of the ligament of Treitz had difficulty in downward displacement of the duodenum and the symptoms of obstruction persisted necessitating duodenojejunostomy. This paper demonstrates that in two patients gastrojejunostomy failed to relieve the obstruction. One of them had to be reoperated on and a duodenojejunostomy was performed with relief of obstructive symptoms.


The parotid and the pancreas.

The parotid and the pancreas. Parallel studies in parotid and pancreatic function and histology were carried out in Thomas fistula dogs with irradiation-induced chronic pancreatitis. After completion of base line studies of parotid and pancreatic secretion, four dogs were subjected to 2,400 rads tumor dose over two weeks (with a nominal single dose of 1,175 rets); two additional dogs served as control. Sequential studies were performed on pancreatic secretion in response to secretin and on parotid secretion in response to urecholine. After a short-lived period of hypersecretion. There was a progressive reduction in pancreatic secretory rate, bicarbonate and enzyme outputs (greater than 90% after three months). Parotid secretion increased over this period but subsequently decreased, so that at eight months there was a marked reduction both in pancreatic and parotid function. Whereas pancreatic histology showed diffuse interstitial fibrosis and reduction of acinar tissue, no histologic changes were noted in the parotid glands. Although the mechanisms are unclear, alterations in parotid secretion may be of value in the diagnosis of chronic pancreatitis, in the evaluation of its severity, and may yield information on the duration of the disease.


Association of pancreatitis and variant ductal anatomy: dominant drainage of the duct of Santorini. Four patients with acute relapsing pancreatitis were found to have drainage of the main pancreatic duct through the duct of Santorini and accessory papilla by endoscopic retrograde pancreatography. No other cause of pancreatitis was identified. These cases and the possible significance of this association are discussed.


Hepatic injury due to oxacillin administration. Hepatotoxicity, in association with intravenous oxacillin therapy, is described and documented for the first time by liver biopsy in an illicit drug user suffering from acute staphylococcal endocarditis. Mild gastrointestinal symptomatology, fever, eosinophilia and abnormal liver enzyme abnormalities were noted. Liver biopsy showed features consistent with a drug-induced hepatic injury. Cessation of therpy led to rapid reversal of clinical and biochemical changes and on further observation no evidence of chronic hepatic dysfunction was noted. A brief review of oxacillin hepatic injury is presented.


Ectopic gallstone as a cause of gastric outlet obstruction. Gallstone ileus is, of course, a well known cause of small bowel obstruction. A gallstone, however, is a very rare cause of gastric outlet obstruction. Three cases illustrating this phenomenon are exhibited. Radiographs were diagnostic in two of the studies. All three patients did well postoperatively.


Adrenergic and cholinergic innervation of the supraduodenal common bile duct. The in-built intrinsic adrenergic and cholinergic nervous apparatus of the supraduodenal common bile duct of the cat and the dog was studied using modern selective specific neurohistochemical technics. A rich distribution of fluorescing varicose adrenergic axons and small nerve fascicles was observed within all layers of the duct. The cholinergic innervation was even more richly developed, including large nerve fascicles and nerve trunks as well as cholinergic nerve cells and small ganglia. The present observations corroborate the theory that the common bile duct actively participates, under dual neural control, in biliary dynamics and is not merely a passive conducting tube.


Sigmoid stricture: an unusual presentation of perforated appendicitis with abscess formation. Appendicitis is the most common acute surgical condition affecting the abdomen. The manner of onset and location of pain depend, to a great extent, upon the different anatomical positions of the appendix and its proximity to the parietal peritoneum which senses the location of the inflammatory process. When perforation occurs, abscess formation or diffuse peritonitis may develop. We wish to report an unusually rare case of perforated appendicitis with abscess formation presenting clinically and radiologically as a sigmoid stricture.


Effects of enteric microbial overgrowth on small intestinal ultrastructure in the rat. The ultrastructural effects of bacterial proliferation in the upper gastrointestinal tract induced by intraperitoneal injections of mecamylamine HCl were investigated in rats. We found increased populations of nonspecific enteric bacteria in the lumen of the upper small intestine and ultrastructural abnormalities in the absorptive epithelial cells, including increased numbers of lysosomal vacular structures, fused microvilli and dilated endoplasmic reticulum. The bacteria did not penetrate into the damaged mucosal cells and so actual cytoplasmic infiltration is apparently not required in order to cause these ultrastructural changes. The alterations were not merely due to the pharmacologic agent we used, mecamylamine, since rats with subnormal numbers of enteric bacteria in the upper small intestine, whether subjected to the course of the drug or not, did not display the ultrastructural changes noted above. Concomitant with increased numbers of enteric bacteria in the small intestine, there were increased concentrations of deconjugated bile salts and decreased absorption of glucose. These findings are compatible with the following hypothetical sequence of pathogenesis: mecamylamine leads to intestinal stasis leads to bacterial overgrowth leads to deconjugation of the bile salts leads to ultrastructural alterations.


Studies of the kinetics of purified conjugated bilirubin-3H in the rat. Radio-labeled conjugated bilirubin was purified from rat bile by affinity chromatography. Following the intravenous injection of tracer doses of this material, the initial fractional plasma disappearance rate of conjugated bilirubin-3H in the normal Sprague-Dawley rat was found to be approximately 50% faster than that for unconjugated bilirubin-3H (0.51 +/- 0.94 [SE] vs. 0.35 +/- 0.02 min.-1; P less than .001). Hepatic recovery studies in the rat indicated that, over the first four minutes after injection, disappearance of cholephilic anions from plasma is accounted for almost entirely by hepatic uptake. Hence, these studies demonstrate that hepatic uptake of conjugated bilirubin is substantially faster than that of unconjugated bilirubin. Net hepatic clearance of conjugated bilirubin in normal rats was three-fold greater than that of unconjugated bilirubin (0.94 +/- 0.16 vs. 0.30 +/- 0.03 ml./min./100 gm. body weight; P less than .001), presumably reflecting both the more rapid hepatic uptake and the ability of the former pigment to by-pass the conjugation step. Hepatic uptake of conjugated bilirubin was shown to be inhibited by unconjugated bilirubin, sulfobromophthalein and indocyanine green but not by glycocholate. These observations cannot be explained by simple diffusion and suggest that the hepatic uptake mechanism for conjugated bilirubin is the same as that for the unconjugated pigment.


Percutaneous transhepatic cholangiography with a thin needle. Experience with 25 cases. Percutaneous transhepatic cholangiography with a thin needle was successfully employed in 23 of 25 patients with jaundice. A 100% success rate was seen with dilated bile ducts. Not a single complication was observed in our series. With our limited series, it can be assumed that proximal obstruction is more likely to mean neoplasm of either the gallbladder or bile duct, whereas distal obstruction with visualization of dilated cystic duct means either neoplasm of the head of pancreas or metastatic carcinoma.


Long-term treatment with histamine H2-receptor antagonists in Zollinger-Ellison syndrome. Continuous treatment of three Zollinger-Ellison patients with histamine H2-receptor antagonists for 14, 26 and 31 months resulted in effective relief of complaints and marked reduction in gastric acid secretion. In one of the patients the dose of cimetidine had to be doubled after 15 months of treatment because of a rise in basal gastric acid secretion accompanied by recurrent diarrhea. Fasting and secretin-stimulated serum gastrin levels were not affected by long-term treatment with histamine H2-receptor antagonists. No side-effects were observed in the three patients on long-term treatment.


Primary aortoduodenal fistula. Case presentation and review of literature. One hundred and twelve cases of primary aortoduodenal fistulas were reviewed. The most common etiological agent was an atherosclerotic infrarenal abdominal aortic aneurysm. There was a male to female predominance of 9:2 with an average age of 62 years. Most fistulas occurred between an infrarenal aneurysm and the third portion of the duodenum because of the relatively fixed position of the duodenum and its direct anatomical relationship posteriorly with the aorta. Patient symptoms may vary from abdominal or back pain with gastro-intestinal bleeding to just hematemesis or melena. Twenty per cent gave a history of abdominal aneurysm while up to 70% may have an abdominal mass on physical examination at the time of admission. Tentative diagnosis is established by history and physical examination with duodenoscopy, barium duodenogram and angiography available only if temporally feasible. Surgical exploration is the only treatment with resection of the aneurysm, synthetic graft placement and duodenal suturing as the procedure of choice.


Chronic idiopathic pseudo-obstructive bowel disease. An illness characterized by recurrent episodes of small bowel obstruction is described. The patient, a 79-year old gentleman has been followed for 20 years. During this time he has hospitalized 19 times. Extensive investigation, including three exploratory laparotomies, have failed to show a cause of the bowel dysfunction. The clinical findings have been similar on each admission. Cramping abdominal pain, vomiting, obstipation often followed by diarrhea, tender distended abdomen, high pitched bowel sounds and abdominal x-rays revealed dilatation of small and large intestine and delayed gastric emptying on various admissions. The failure to demonstrate a recognized etiology for the repeated bowel obstruction over a long period of time warrants a clinical diagnosis of chronic idiopathic intestinal pseudo-obstruction (C.I.I.P.). The age of the patient at the onset of symptoms and the duration of the dysfunction prompted a review of the literature. Twenty-seven reported cases allowed a comparison of this case with the clinical features previously described. Symptomatic therapy, consisting of small bowel decompression by intestinal intubation during the acute episode, was followed by the use of elemental diets given slowly and continuously during the convalescing period. The patient continues to be comfortable and able to maintain his body weight between episodes which, however, seem to be increasing in frequency.


Hodgkin disease: an analysis of 128 cases. An analysis of 128 cases of Hodgkin disease seen at the Department of Pathology, All India Institute of Medical Sciences, New Delhi, during the period 1968--1974 is presented with reference to histopathological and clinical findings. A male preponderance is noted in all age groups, and this is most noticeable in children under 15 years of age. There is a predominance of cases with the histologic subtypes associated with a poor prognosis (mixed cellularity and lymphocyte depleted). Only nine cases of nodular sclerosis type were seen.


In vitro functional capabilities of canine polymorphonuclear neutrophils collected simultaneously by continuous-flow centrifugation and continuous-flow filtration leukopheresis. Polymorphonuclear neutrophils were simultaneously collected from dogs by continuous-flow centrifugation and continuous-flow filtration leukapheresis. In vitro studies were performed on cells obtained by the two methods as well as on control cells. Studies consisted of assessment of phagocytic capacity, degranulation, chemotaxis, hexose monophosphate (HMP) shunt activity, and bacterial killing. The cells obtained from the filter were metabolically more active than those harvested by centrifugation, as evidenced by increase in resting HMP shunt activity and dimunition in total available lysozyme-secreting activity compared to centrifuged cells. Despite their impaired phagocytic capacities, the filtered cells were able to kill Staphylococcus aureus as efficiently as the centrifuged cells. Both cell populations responded to chemotactic gradients equally.


Studies on red-cell aplasia: IX. Ferrokinetics during remission of the disease. Ferrokinetic studies and external organ measurements of radioiron were performed on five patients with pure red-cell aplasia (PRCA) in remission. One patient with PRCA in relapse was also studied. Of those in remission, one patient had erythroid hyperplasia and ineffective erythropoiesis after the remission occurred. This was indicated by a very short 59Fe clearance rate and reduced red-cell 59Fe incorporation, a marked increase of the erythron iron turnover over the fixed red-cell iron turnover, and a prolonged marrow transit time. These indices were normal three years later. Four patients had normal effective erythropoiesis while in remission. Two patients had an extended marrow distribution. These studies indicate that some cases of PRCA evolve into a state of ineffective erythropoiesis with erythroid hyperplasia. It is possible that in some patients, primary refractory anemia with ineffective erythropoiesis may be related to PRCA because of the evolution from one state into the other. Alternatively, a second pathologic process may have been acquired between the PRCA and normal hematopoiesis.


Accumulation modes of alkylating agents on normal peripheral blood lymphocytes. The in vitro uptake by normal peripheral blood lymphocytes of 14C-labeled cyclophosphamide and nitrogen mustard has been measured in a manner which parallels cell exposure to drugs used in the nitrogen mustard-oncovin-procabazine-prednisone (MOPP) and cyclophosphamide-oncovin-procarbazine-prednisone (COPP) clinical protocols. Accumulation of these alkylating agents occurs in two recognizable patterns. The first exhibits a saturation phenomenon, since radioactivity can be partially blocked by an equal concentration of unlabelled drug, reflects stereospecificity, and represents a minor fraction of total deposition. The second form, proportionately larger than the first, is dependent on drug concentration in the suspending medium, with radioactivity increasing in an apparently limitless linear fashion, uninfluenced by competitive inhibition. This part also is less tenaciously held by the lymphocyte. While the mere presence of drug on the lymphocytes does not necessarily imply injury or lethality, the fact that these peripheral lymphocytes are able to accumulate cytotoxic agents and are partially interchangeable with an analogous fixed lymphoid cell mass suggests that clinical immunosuppression and lymphocytopenia may be related, in part, to cell drug deposition.


Corticosteroid-induced lymphocytopenia in man: absence of splenic influence and effect of recipient serum. Pharmacologic doses of corticosteroids produce a profound, transient lymphocytopenia in man. We have studied the role of the spleen and possible induction of cytolytic factors in the generation of this effect. A 200 mg IV dose of hydrocortisone-21-hemisuccinate was administered to five normal subjects and five subjects whose spleens had been removed as a result of trauma. Sequential peripheral blood lymphocyte counts and subpopulations were then determined, and the effect of serum (obtained from the recipients at several time points after steroid administration) on autologous lymphocyte viability was assessed in vitro. The asplenic subjects experienced the same marked lymphocytopenia as normal individuals, and post-steroid serum was not cytotoxic to autologous lymphocytes. The in vitro results support the view that corticosteroid-induced lymphocytopenia is not the result of lymphocytolysis in man. If lymphocyte redistribution is the cause, as has been suggested, our in vivo results directly demonstrate that the spleen does not play a major role.


Association of 5q- and refractory anemia. The association of refractory anemia with partial deletion of the long arm of one No. 5 chromosome (5q-) has been reported in six patients within the last two years. We wish to report an additional patient with refractory anemia and an acquired chromosomal deletion, del(5)(q15), in a direct bone-moarrow preparation. The specificity of this deletion for refractory anemia is discussed. It remains to be seen whether patients with refractory anemia and 5q- tend to develop acute leukemia, as has been recently suggested.


Parasinusoidal location of megakaryocytes in marrow: a determinant of platelet release. Megakaryocytopoiesis occurs in the hematopoietic (extravascular) compartment of marrow. Thus, platelets must traverse the wall of the vascular sinuses of marrow to enter the circulation. We have examined mouse and rat marrow, fixed by rapid immersion so as to maintain anatomical relationships as close to the natural state as possible. Quantitative transmission electron microscopy (TEM) of random transections of femurs established that megakaryocytes reside less than 1 mu from a marrow sinus wall with a probability unlikely to be the result of chance (P less than 0.001). An intimate relationship exists between the megakaryocyte periphery and the abluminal surface of the endothelial lining cell. At the time of platelet release megakaryocyte cytoplasm invaginates and penetrates the endothelial lining cell. The penetrating cytoplasm is detached and enters the marrow circulation. From their dimensions in comparison to circulating platelets, the released cytoplasm represents a packet of platelets that undergoes further fragmentation in the circulation. The parasinusoidal location of megakaryocytes and the process of sinus-wall penetration and platelet delivery was observed by TEM and scanning electron microscopy. These studies provided quantitative support for a specific anatomical arrangement of megakaryocytes in marrow. Moreover, the process of platelet release appears to be a physiological form of metastasis with invasion of vascular walls and vascular spread of cells, that are in this case amitotic.


Platelet satellitism and phagocytosis by neutrophils: association with antiplatelet antibodies and lymphoma. Satellitism and phagocytosis of platelets by neutrophils in EDTA anticoagulated blood have been considered in vitro phenomena without clinical significance. We observed these in a patient with acute, severe thrombocytopenic purpura who subsequently proved to have malignant lymphoma. Wide oscillations in the platelet count were noted and recurrent, severe gastrointestinal bleeding occurred even when the platelet count was normal. Platelet function was abnormal as shown by decreased platelet adhesion to glass beads, absence of a secondary wave of aggregation in response to ADP and eqinephrine, and no aggregation with collagen. Suspension of control platelets in the patient's plasma induced similar aggregation defects in the control platelets. Combination chemotherapy resulted in regression of lymphadenopathy, but platelet abnormalities and bleeding persisted. Platelet satellitism and phagocytosis by neutrophils seen on peripheral blood films may be associated with true thrombocytopenia, abnormal platelet function and bleeding with an underlying systemic disease.


Hemopoietic support capacity of the adult mouse liver: II. Studies in acetylphenylhydrazine-treated mice. We investigated the hemopoietic support capacity of the liver in intact and splenectomized adult mice treated with three daily injections of acetylphenyl-hydrazine (APH). Packed red cell volumes, liver and spleen weights, numbers of pluripotent hemopoietic stem cells (CFU-S) in blood and liver, and liver histology were evaluated 4,8,12,16, and 20 days after the first injection. We found that 1) splenectomized, APH-treated mice had a greater and more sustained increase in the weights of their livers than the increase found in livers of intact APH-treated mice; 2) APH treatment elicited a much greater increase in the blood and liver CFU-S of splenectomized mice (47 and 42 times normal, respectively) than it elicited in the blood and liver CFU-S of intact mice (4--5 and 4 times normal, respectively); and 3) APH treatment induced numerous foci of hemopoietic tissue in the livers of splenectomized mice. The results of the CFU-S studies can be explained by, and to some extent support, the thesis that the adult mouse liver does not support proliferation of normal CFU-S, but can trap large numbers of circulating CFU-S. In addition, these studies suggest that the livers of adult mice are able to support only limited proliferation of differentiated hemopoietic elements.


Prognostic value of nucleoli and cell size in chronic lymphocytic leukemia. In an effort to improve prediction of duration of survival in chronic lymphocytic leukemia, correlations between blood-cell morphology and survival were investigated. Blood films made on 108 patients at the time of diagnosis of chronic lymphocytic leukemia were reviewed by a single hematologist. Lymphocyte diameter and the fraction of lymphocytes containing nucleoli were both found to have an inverse correlation with survival. Bone-marrow aspirate films were available for 64 patients. Differential leukocyte counts showed that the median for marrow lymphocytes was 64%. Those patients with a greater than median proportion of lymphocytes on marrow aspirate had a shorter survival time than those with less than median.


Guidelines for protocol studies in chronic lymphocytic leukemia. The treatment of any malignant disease requires appropriate criteria for diagnosis of the disease, appropriate methods for study, and techniques for evaluating response to treatment. In the past five years, there have been a number of proposed guidelines for studies in chronic lymphocytic leukemia (CLL). These submitted guidelines represent a further re-evaluation of concepts in CLL, and are currently in use by Cancer and Leukemia Group B for protocol studies. It is clear that revisions will continue to be make as new knowledge accumulates. In the meantime, these are submitted for publication for use by other investigators.


Hemoglobin A1C separation by isoelectric focusing. A modified type of isolectric focusing has been applied successfully to the separation of hemoglobin A1C (HbA1C) from HbA in normal and diabetic cell lysates. It consists of transforming a linear pH gradient into a nonlinear one, by the addition of an amphoteric substance ("separator" or "pH gradient modifier") with an isoelectric point (pI) close to the pI's of the two hemoglobins. Among the "modifiers" tested, histidine, proline, threonine, beta-alanine, 6-amino caproic acid, and 5-amino valeric acid are not useful in the hemoglobin pI range (pH 6.9--7.0). The dipeptide histidyl-glycine (pI = 6.8; pI-pK1 = 1) is very efficient in flattening the pH gradient, in the hemoglobin region. even when added in low concentrations (10--100 mM), thus affording full resolution of the two hemoglobin species.


Studies on a new variant of the Hermansky-Pudlak syndrome: qualitative, ultrastructural, and functional abnormalities of the platelet-dense bodies associated with a phospholipase A defect. The structure and functions of platelets from a patient in whom albinism and hemorrhagic diathesis were associated have been investigated. Electron microscope studies showed a large reduction in the number of dense bodies and this was confirmed by an examination of fluorescent platelets loaded with mepacrine. The rare dense bodies were much bigger than normally observed; their density was diminished and was localized in a peripheral ring. Other platelet constituents were found to be normal. Platelet peroxidase activity was normal in the canaliculi of the dense tubular system; catalase-positive granules were also present. Serotonin uptake by the patient's platelets was much decreased and reserpine, a potent inhibitor of serotonin accumulation by normal human platelets, did not further decrease this incorporation. The uptake of free 14 C-arachidonic acid by the platelets was greatly diminished, as was its thrombin-induced liberation from phosphatidyl-choline and phosphatidyl inositol. Moreover, platelet phospholipase A1 activity was much reduced and phospholipase A2 activity was undetectable.


Circulating inhibitors of blood coagulation associated with procainamide-induced lupus erythematosus. We studied a patient being treated with procainamide in whom we observed a high antinuclear antibody titer and prolonged activated partial thromboplastin (PTT), prothrombin (PT), and Stypven times (ST). Serum antibody concentrations against single-stranded DNA were elevated while those aginst native DNA were not elevated, suggesting the procainamide-induced lupus syndrome. Dilution of the patient's plasma with normal plasma failed to correct the PTT and PT, indicating the presence of an inhibitor(s) to blood coagulation. The anticoagulant activity was associated with the IgG fraction of the patient's serum. Addition of purified or partially purified human factors IX, X, VIII, VII, XIa, prekallikrein, high molecular weight kininogen, or phospholipids to the patient's plasma failed to correct the PTT, PT, or ST; however, purified human factor XII and prothrombin corrected the PTT and ST, respectively. These results indicate that production of antibodies directed against antigenic determinants on coagulation proteins can be a manifestation of procainamide-induced lupus erythematosus.


Average heterozygosity revisited.

Average heterozygosity revisited. The estimate of heterozygosity and proportion of polymorphic loci for 33 red blood cell loci has been updated by the elimination of some loci of questionable status and the addition of data on 33 loci. The new figures for heterozygosity and proportion of polymorphic loci, .105 and .283, respectively, are based on 60 red blood cell loci of European origin populations. These values are less than those calculated by Lewontin in 1967, and furthermore they do not appear to be reaching an asymptote. At the present time, the red blood cell data and allozyme data for European populations have similar estimates of heterozygosity and proportion of polymorphic loci.


Regulation of growth and gene activity in euploid hybrids between human neonatal fibroblasts and epithelioid amniotic fluid cells. Pure populations of proliferating synkaryons were obtained from polyethylene glycol-mediated crosses between diploid human foreskin fibroblasts and epithelioid amniotic fluid cells. These hybrids proved to be chromosomally stable tetraploids. They continuously produced heteropolymeric G6PD and showed strictly additive patterns of silver staining of both parental sets of nucleolar organizing chromosomes. Collagenous proteins characteristic of the fibroblast parent were synthesized, while fibronectin production appeared to be directed by the epithelioid portion of the genome. Even though these heterotypic hybrids proliferated at a reduced rate and achieved fewer population doublings relative to homotypic (fibroblast X fibroblast) crosses, they survived passage by trypsinization better than pure populations of epithelioid cells. These observations suggest a concerted action of both parental genomes with respect to proteins responsible for "household" functions, but complementation and possibly modulation of gene action with respect to "luxury" protein synthesis and cell growth.


Hereditary retinoblastoma: delayed mutation or host resistance? Evidence is presented from the literature that there is little need to postulate delayed mutation for the retinoblastoma locus. Both penetrance and expressivity in the gene carrier can be defined as a variable determined by genetic and environmental factors, not by a Poisson distribution of tumors formed. Of individuals who received a new mutation from a healthy parent, approximately 13% do not manifest retinoblastoma, and the heritability of the host resistance is estimated at about 90%. The nonhereditary form of retinoblastoma may occur in the most susceptible group of the population.


Savings achieved through cephalosporin surveillance. The process by which a 427-bed, acute-care teaching hospital reduced the cost of cephalosporin therapy is described. During a nine-month surveillance period, cefazolin prescribing patterns were monitored. Of the 674 patients who received cefazolin, 640 (92%) received dosages greater than those recommended in the literature. Attempts were made to alter inappropriate prescribing through pharmacist-physician consultation and through contact with the medical service representative of the company which supplied cefazolin. Because these efforts failed, the pharmacy and therapeutics committee decided to delete cefazolin from the formulary. Cephalothin and cephapirin were found to be clinically similar; therefore, the committee recommended that the less expensive cephapirin be dispensed whenever a parenteral cephalosporin was ordered. Prior to the switch to cephapirin, cefazolin accounted for 49% of all parenteral cephalosporin use and 62% of the cephalosporin cost. Cephalothin and cefazolin were 30% and 88%, respectively, more expensive than cephapirin. In the first year after the switch, the hospital saved $33,196 (28.8% of the previous year's total expenditures for cephalosporins).


Audit of the de Haen Drugs-In-Use Drug Information System. An audit of 100 abstracts from the de Haen Drugs-In-Use Drug Information System was conducted to determine the reliability of this drug information source. The original article was reviewed and compared with the information contained on the corresponding de Haen card. The card was audited for accuracy, completeness and judgment of abstraction. Forty-six cards contained at least one error. A total of 66 errors were observed: 47 involved errors of accuracy, 15 involved errors of completeness and 4 involved errors in judgment. The subscriber is urged to use the de Haen abstracts as a means of literature access only, and not as a primary source of drug information.


Right atrial indwelling catheter for patients requiring long-term intravenous therapy. The use of a central venous catheter for long-term intravenous therapy is described. The catheter's history, physical description, and uses are discussed. Also reviewed are complications from use of the catheter, the pharmacist's role in patient teaching, and the procedure for administering medications through the catheter. A listing of drugs administered through the catheter, incompatibility data and patient teaching instructions are also included.


Duplicate prescription system to facilitate communication between a hospital pharmacy and community pharmacies. A duplicate prescription system which enables a university hospital pharmacist to fill a copy of the prescription and return the original prescription to the patient for obtaining continuing supplies in his local community is described. The system is based on a prescription form and carbon duplicate with designated space for notations, and clarifications by the pharmacist. Instructions for use of the form and a statement that the prescription copy cannot be filled legally at any other pharmacy assures that the system will not be misused. The system helps assure that an initial quantity of medication is obtained by the patient before he leaves the hospital. Time spent by patients and prescribers in establishing initial and continuing supplies of medication is decreased under the system. The system is of substantial benefit to patients and health care providers.


Successful treatment of acrodermatitis enteropathica with zinc sulfate. A case of a 22-month-old child with acrodermatitis enteropathica (AE) is reported. At five months of age, the patient experienced generalized oral and cutaneous candidiasis for which she was treated with nystatin and iodochlorhydroxyquin-hydrocortisone. She then had to be treated for secondary infection of the lesions. After three months, the cycle repeated, and the patient was treated with topical clotrimazole, Mycolog (nystatin, gramicidin, neomycin sulfate, triamcinolone acetonide) and oral nystatin. After a worsening of her condition, she was admitted to a hospital where she was treated initially with procaine penicillin G, then methicillin sodium and gentamicin sulfate. Treatment with zinc sulfate, 50 mg t.i.d., was initiated when laboratory studies showed a serum zinc level of 60 microgram/dl. Skin lesions were 99% resolved and serum zinc increased to 118 microgram/dl after 17 days of zinc sulfate therapy. Previous case reports and studies of the clinical features, treatment and pathogenesis of AE are reviewed.


Unilateral chronic pyelonephritis and hypertension: coincidental or causal relationship? Three patients with well documented unilateral chronic pyelonephritis (UCP) of bacterial origin, one hypertensive and two normo-tensive, were presented. Removal of the contracted kidney in the hypertensive patient did not eradicate the hypertension. An attempt was made to define UCP as closely as possible. The clinical, roentgenologic, bacteriologic, functional and pathologic criteria of UCP was described. But, as other conditions may mimic the roentgenologic, functional and pathologic picture of UCP, a history of recurrent urinary tract infection accompanied by a documented unilateral renal bacteriuria is the basic requirement for a sustained diagnosis of UCP. In view of these more exacting criteria in the diagnosis of UCP, and its water and salt-losing functional pattern, UCP is a rare cause of hypertension, in the majority of cases the association of UCP with hypertension is merely coincidental.


Myocardial infarction immediately following cardiovascular stress testing. A 45 year old man with recent onset of atypical chest pain, who sustained an acute myocardial infarction within 15 minutes after a negative treadmill exercise test, is described. The clinical course was complicated by persistence of chest pain despite afterload reduction and electrocardiographic evidence of inferoapical myocardial infarction. Coronary arteriography three and a half months later revealed minimal obstructive disease.


Laboratory ordering: a system which eliminates paperwork. A traditional ordering system can be replaced by a time- and paper-saving traveling requisition system. The increased speed of ordering which results can decrease lead time for receiving frequently used supplies.


Criterion-referenced testing in medical technology education: Professional Performance Situation Model. In applying the Professional Performance Situation Model to the medical technology profession, situations describing actual laboratory performance are used as a basis for defining competence. As these definitions of competence are derived, appropriate criterion-referenced (domain-referenced) assessments are designed to measure the achievement of competence. This paper describes the process by which situations representing clinical practice are derived, the extrapolation of skill and knowledge statements reflecting expected performance, the generation of domains of competence, the design of criterion-referenced assessments, and some examples of prototype instruments used to assess attainment of the competence. The techniques include multiple choice items, checklists for use in the clinical component of the educational experience, and the adaptation of the written simulation for instruction and evaluation in medical laboratory sciences education. Validity of this approach is discussed, as well as possible implications for its use in developing assessments to measure continued competence in the profession beyond the baccalaureate education.


Comparison of dewpoint and freezing point osmometry. Osmolality was measured on 32 clear serum samples and on 23 urines, with dewpoint and with freezing point osmometers. The observed regression equation was dewpoint = 0.96 freezing point +7.6, with a correlation mean for 32 clear sera analyzed by both methods was not significantly different. However, when 14 lipemic sera were analyzed, the dewpoint measurements were higher: X dewpoint = 291.6; X freezing point = 284.1. The between-run standard deviation observed for a normal serum pool yielded a coefficient of variation of 1.04 with the freezing point and 2.38 with the dewpoint instrument. Results indicate that the dewpoint device should be used with caution for lipemic serum samples.


A nontraditional approach to medical laboratory technology education. The nontraditional program in medical laboratory technology for adult students was initiated at Corning Community College in 1975. The overall design of the model permits adults who have gained knowledge and skills as a result of their work experience to have opportunities for the assessment of these learnings and for flexible, modular instruction to increase their level of competency in medical technology. The central goal of this model is to increase the educational alternatives available to the adult population, specifically, the working adult in the medical laboratory. This approach enables individuals who are currently employed to attain an Associate in Applied Science (AAS) degree and eligibility for certification as a medical (clinical) laboratory technician.


Analysis of motor disorder in retarded infants and young children. A prospective longitudinal study of 53 retarded infants and young children without evidence of a frank physical disability suggests that their delayed motor development was related to a subtle but specific disturbance in the evolution of infantile reflex behavior. The aberration was characterized by a delay in the appearance of postural adjustment reactions, specifically, of propping and equilibrium responses that, under normal circumstances, precede the accomplishment of successive gross-motor milestones. Motor development in this selected group of retarded children was delayed for their chronological age but was consistent with the maturational level of postural adjustment reactions.


Effects of repeated assessment on standardized test performance by infants. Infant-intervention programs that evaluate their effectiveness by repeatedly testing infants with standardized tests may confound intervention effects with repeated-testing effects. Further, maternal participation in testing may increase infants' test scores, either directly by giving infants practice with test-like items at home between test administrations or indirectly by helping infants adapt to the test setting. Thirty-five infants were tested at 3-month intervals between 4 and 28 months of age with the Bayley Scales of Infant Development and at 31 months of age with the Stanford-Binet; 25 infants were tested with the Bayley at 4 months and the Stanford-Binet at 31 months. Mothers of some infants in each group participated in the testing process. Between-subjects analysis on the Stanford-Binet revealed no effects for repeated testing or maternal participation. Within-subjects analyses for repeatedly tested groups demonstrated that maternal presence during testing, but not repeated testing, was associated with significantly higher Bayley scores. It was concluded that maternal presence is a potent influence on Bayley performance, that repeated experience with the Bayley biased neither performance on another standardized test of development nor subsequent Bayley performance, and that infant intervention programs are not likely to confound their evaluation designs by testing infants repeatedly.


Placement from community-based mental retardation programs: how well do clients do? Mentally retarded clients (N = 131) placed during a 2-year period from either an independent living or competitive employment training program were evaluated as to placement success. Thirteen percent returned to the training program. Successful independent living placement was related to intelligence and demonstrated skills in symbolic operations, personal maintenance, clothing care and use, socially appropriate behavior, and functional academics. Successful employment was related to sensorimotor, visual-auditory processing, language, and symbolic-operations skills. Major reasons for returning from a job to the competitive employment training program included inappropriate behavior or need for more training; returning from community living placement was related to money management, apartment cleanliness, social behavior, and meal preparation.


Use of active sorting and retrieval strategies as a facilitator of recall, clustering, and sorting by EMR and nonretarded children. The ability of 60 EMR and 60 nonretarded children to acquire and retain a sorting and retrieval strategy designed to be facilitative of recall and clustering was examined. All subjects were given a baseline task and, based on their performance, were assigned to one of three groups: experimental, practice, and control. The experimental group received a multi-session training procedure that consisted of instructing the subjects to arrange the stimuli in conceptual arrays, to name individual stimuli and the superordinates to which the stimuli belong, and to count the number of stimuli in each superordinate. The practice group was presented with the same stimuli but received no training. The control group received only the baseline and criterion measures. Analyses of data showed superior performance by the experimental group on measures of short- and long-term recall, clustering, and sorting.


Performance of MA-matched nonretarded and retarded children on discrimination learning and transfer-shift tasks. The effects of the nature of the relevant dimension, response mode, imagery, and age on discrimination learning and shift performance was examined. Three age groups were used, CA 8 years-MA 8 years, CA 5 years-MA 5 years. CA 8 years-MA 5 years. The latter group learned both intradimensional and extradimensional shifts slower than did the former two groups. Subsequent analyses suggested that the reason for the slower learning in the retarded group was their greater frequency of control by dominant dimensions and/or the initial control by novel stimuli. A second finding was related to the particular procedure employed. Children were required to either press a button to indicate which of two stimuli was correct or pick up the correct stimulus. Form-relevant but not color-relevant problems were facilitated by the pick-up procedure. These findings suggest that dimensional dominance may be a consequence of the procedures employed in previous reports where children were or were not permitted to manipulate the stimuli.


Systematic correction procedures in vocational-skill training of severely retarded individuals. Seventy severely retarded adults were taught a vocational assembly-skill task involving a difficult visual--motor discrimination. Comparisons of relative effects on trials-to-criterion were made among two types of verbal-correction procedures (general: "try another way" and specific: "flat side in") and three types of systematic physical-correction procedures (gesture, physical prompt, and repeated practice). Reliable differences in effects occurred only between the three systematic physical-correction procedures, with repeated practice the most effective, physical prompts next, and gestures the least effective. The results were interpreted as demonstrating the efficacy of trainer-related training procedures in relation to stimulus-related strategies, as well as relative efficacy among trainer-related correction procedures.


Verification of property statements by retarded and nonretarded adolescents. Educable mentally retarded and nonretarded adolescents verified true and false statements about the properties of common objects. For the true sentences, one-half contained properties rated as highly salient to the given object, and half contained less salient properties. Further, at each level of salience, one-half of the properties were static (physical) properties, e.g., "Carrots are orange," and half were action properties, e.g., "Rabbits can hop." True verification times were more rapid for all subjects when sentences contained highly salient properties. In addition, sentences containing action properties were verified faster than those containing static properties, but only by the retarded subjects (whose response times were slower overall). Additional analyses indicated that the retarded subjects responded particularly rapidly to action properties that designate "what can be done to an object" (extrinsic-action properties) as opposed to "what an object can do" (intrinsic-action properties). These findings were discussed in relation to the organization of semantic knowledge and the apparent group differences in the weighting of semantic features.


Small-group training as an alternative to individual programs for profoundly retarded persons. A comparison of group and individualized training methods was made by teaching 12 profoundly retarded men a series of imitative tasks under one of three program conditions. Each of the conditions was allotted 20 hours of training time from staff. The four members of the intact-group program received their 20 hours of instruction on a group basis. The four individual-program members had the training time divided between them and were taught separately. In a third program, the add-in group had the entry times of its membership staggered so that special attention could be given to each new member. The results indicated that the group programs were as effective as individual treatment for increasing imitative skills when staff time was held constant. Advantages of group programming were discussed in terms of increased activity and socialization for clients.


Attitudes of caretakers toward the sexual behavior of mentally retarded persons. A multidimensional questionnaire was administered to staff members at three residential facilities for retarded persons to determine their attitudes toward the actual and potential sexual behavior of retarded persons. The questionnaire covered the areas of masturbation and heterosexual and homosexual behavior. Dimensions were scaled to reflect progressively more intimate behavior so that acceptability of each response along the dimensions could be assessed. A mean of 31.2 percent of those questioned felt that no sexual behavior, not even simple physical contact, was acceptable for retarded persons. This indicates that sex-education programs for retarded persons may be met with resistance by a substantial percentage of staff. Among those staff members who found it acceptable for retarded people to engage in sexual behavior, peak acceptability occurred for heterosexual behavior. Sexual behavior in public, especially public masturbation, was considered a significant problem. More specific effects were identified, and the implications of these results for educational programs and the development of intervention procedures were discussed.


Effects of within-stimulus and extra-stimulus prompting of letter discrimination by mentally retarded persons. Two different prompting procedures for teaching letter discrimination to mentally retarded persons were compared. Each of 24 severely retarded subjects received training on six alphabet letters, three by extra-stimulus prompting (adding to topographically different cue, a pointing finger) and three by within-stimulus prompting (accentuating critical features of the stimuli themselves). Letter discrimination was tested prior to, immediately following, and 2 weeks after training. A significantly greater proportion of letters trained by within-stimulus prompting was learned (p less than .001), thereby replicating past research with autistic children. Since mentally retarded persons are overselective and attend to few cues in a stimulus array, within-stimulus prompting may be more effective than between-stimulus prompting.


Use of a relational focus strategy in oddity performance of EMR adolescents. A series of 5-item oddity tasks was administered to 44 EMR adolescents to determine whether a consistent strategy was used to achieve problem solutions. Such a strategy requires establishing a relational hypothesis for two items in a set and retaining that hypothesis in memory while testing subsequent items against it. Evidence for use of a consistent strategy would be found in a particular pattern of response latencies and errors dependent upon the position of the odd stimulus in each 5-item set. Analysis of variance of the mean latency scores and errors for the five positions in which the odd item occurred suggested that a consistent strategy was being applied.


Effect of imposed vs. self-generated imagery and sentence mediation on the free recall of retarded adolescents. The effectiveness of verbal and imaginal elaborations on the free recall of institutionalized EMR adolescents was investigated. Fifty subjects were assigned to one of five conditions: experimenter-imposed verbalization, experimenter-imposed imagery, subject-generated verbalization, subject-generated imagery, and control. The subjects saw 15 pictures, presented in sets of 3, for five trial bloks, and were asked to recall the 15 pictures after each trial block. Over all trials combined, it was found that recall in the experimenter-imposed verbalization and the experimenter-imposed imagery conditions was reliably superior to recall in the control and subject-generated verbalization conditions. Although retarded adolescents were capable of producing verbal or imaginal elaborations, as evidenced by post-experimental inquiry, elaborations facilitated recall only when they were supplied by the experimenter.


Pregnancy hypertension, parity, and the renin-angiotensin system. Factors which influence levels of plasma AII in late pregnancy have been studied in 50 primigravidas and 53 multigravidas. A highly significant relationship has been shown between diastolic blood pressure and plasma AII (r = 0.4190 p less than 0.005) in primigravidas but not in multigravidas (r = 0.205; p less than 0.3). Multiple regression analysis and analysis of covariance have been applied to a series of independent variables with plasma AII as the dependent variable. The single most important variable related to AII levels in primigravidas was diastolic blood pressure whereas in multigravidas it was proteinuria. Rhesus blood group was shown to have a significant effect in both parity groups, Rh-negative primigravid women exhibiting higher values of AII.


Late follow-up in women with nephrosclerosis diagnosed at pregnancy. Thirteen nephrosclerotic women were followed for 2 to 7 years from the time a diagnosis was made following a pregnancy complicated by hypertension. Ten patients developed sustained hypertension. Twelve women who were examined responded with a hypertensive pattern to acute salt load. Of the 10 patients who were examined, seven had a reduced renal plasma flow (RPF) demonstrated by the phenolsulfonphthalein (PSP) excretion test. The present observations support the view that the vascular lesion in the kidneys precedes and persists independently of pregnancy. The pregnant state brings the hypertensive disease to clinical expression.


Pregnancy in familial dysautonomia.

Pregnancy in familial dysautonomia. This report describes the first two known instances of viable pregnancies in two patients with familial dysautonomia (Riley-Day syndrome). The offspring were apparently normal. Several conditions, specifically related to autonomic and sensory dysfunction in pregnancy, are discussed.


Surge of fetal plasma triiodothyronine before birth in sheep. Plasma thyroid hormone and cortisol concentrations were measured from early third trimester to delivery in seven pregnant ewes and their fetuses. A surge in fetal plasma triiodothyronine was found during the six days prior to delivery, the mean values rising from less than 30 to 125 ng. per deciliter. During this period the fetal plasma cortisol also increased from less than 1 to 8.1 microgram per deciliter. During this period there was no significant change in fetal plasma thyroxine (T4) or reverse T3 concentrations and no change in maternal plasma concentrations of any of these hormones. The abrupt increase in fetal plasma T3 concentrations with no rise in plasma T4 suggests that there was an alteration in extrathyroidal conversion of T4 to T3 rather than an increase in thyroid secretion, since the latter would be expected to cause an increase in both plasma T4 and plasma T3. The changes in plasma T3 and cortisol concentrations in a fetus that died in utero eight to 10 days before term resembled those occurring prior to normal parturition.


The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. The relationships among maternal anxiety, selected stress-related biochemical factors, and progress in three defined phases of labor were determined for 32 married, normal, primigravid women, 20 to 32 years of age. Comparisons of plasma epinephrine, norepinephrine, and cortisol in third-trimester pregnancy, during labor, and after delivery are provided. At the onset of Phase 2 of labor (3 cm. of cervical dilatation), self-reported anxiety and endogenous plasma epinephrine are significantly correlated. With the deletion of subjects to control for the effect of medications, higher epinephrine levels are significantly associated with lower uterine contractile activity at the onset of Phase 2 and with longer labor in Phase 2 (3 to 10 cm. of cervical dilatation). The relationship between epinephrine and progress in labor is explained by an adrenoreceptor theory.


Effect of cholestyramine and phenobarbital on pruritus and serum bile acid levels in cholestasis of pregnancy. Serum bile acid concentrations were followed in 29 patients with cholestasis of pregnancy treated for pruritus with either phenobarbital or cholestyramine. The response of serum cholic and chenodeoxycholic acid levels to phenobarbital administered to 10 patients in a 100 to 150 mg. daily dose was variable: some decrease was found in four and some increase in three of the patients, but no clear effect on itching could be seen in any of them. In five of the other 10 patients treated with cholestyramine, 4 Gm. two or three times a day, serum cholic and chenodeoxycholic acid levels fell within 1 week of treatment, in one of these near to normal with complete relief from pruritus. It seems that patients with initially high serum bile acid levels do not respond to cholestyramine treatment. In these cases the biliary excretion and enterohepatic circulation of bile acids may be diminished to such an extent that the anion-binding resin is unable to augment fecal elimination of bile salts sufficiently to lower their serum levels.


Vaginal and cervical squamous cell dysplasia in women exposed to diethylstilbestrol in utero. Two hundred and fifty patients were examined because of a history of in utero exposure to diethylstilbestrol (DES) or because of the presence of physical findings suggesting such exposure. One thousand biopsies were examined for the presence of neoplasia and then compared to the colposcopic findings. There were no cases of glandular or squamous cell carcinoma. Fifteen (6 per cent) of the patients had squamous cell dysplasia. The degree of dysplasia was mild in 11 and moderate in only 4 (1.6 per cent) of the women. The majority of the cases of dysplasia involved the cervix, whereas the vagina was involved in only four cases, with simultaneous cervical dysplasia in three of these. Patients with cervical mosaic and white epithelium had dysplasia on biopsy much more frequently as compared with patients with similar colposcopic appearances in the vagina. Our results suggest a low incidence of significant squamous precancerous change in the DES-exposed population and provide evidence that colposcopic data concerning dysplasia pertinent to the cervix cannot be applied without modification to the evaluation of dysplasia in vaginal adenosis.


Chemotherapy for squamous carcinoma of the cervix: doxorubicin--methyl CCNU. Treatment was initiated for metastatic or recurrent squamous carcinoma of the cervix with a combination of doxorubicin and methyl CCNU in 37 patients. Results after at least one full course of chemotherapy were fully evaluated in 31 of these patients. The objective response rate of 45.1 per cent obtained with this therapy compared favorably with those obtained by other authors using single or multiple agents. This chemotherapy regimen may need to be modified to improve patients' tolerance. The improved survival rate and high number of complete remissions demonstrated in this pilot study show promise for this type of chemotherapy in the future.


Synthetic progestins: in vitro potency on human endometrium and specific binding to cytosol receptor. The relative potency of six commonly used synthetic progestins has been evaluated in an organ culture system for human endometrium. The affinities of these progestins for endometrial progesterone receptor were also evaluated after removing the CBG-like protein by spheroidal hydroxylapatite chromatography. All six progestins induced an increase in tissue glycogen during culture at lower concentrations than did progesterone; only one (medroxyprogesterone acetate) had a relative affinity greater than progesterone. The relative potencies and affinities of the synthetic progestins were found to have the same relative order but to differ in relative magnitude.


Toxicity manifestations following intravenous Corynebacterium parvum administration to patients with ovarian and cervical carcinoma. Manifestations of clinical toxicity were evaluated following 341 courses of intravenous Corynebacterium parvum adjuvant immunotherapy in patients with ovarian and cervical carcinoma. Most patients exhibited symptoms of minor toxicity, which decreased in intensity as subsequent courses of therapy were administered. Temperature elevations to 38.5 degrees C. were the most objectively measured signs of toxicity but temperature elevations greater than 38.5 degrees C. occurred following only 20.5 per cent of the infusions. Blood pressure alterations were not a serious problem and no serious central nervous system or renal toxicity was noted. The minor side effects should not preclude the use of C. parvum as an immunopotentiating agent if it is shown to be beneficial in the treatment of human malignant disease.


Amniotic fluid cortisol in normal and diabetic pregnant women and its relation to respiratory disease in the neonate. One hundred and thirty samples of amniotic fluid from normal and diabetic pregnant women were analyzed for cortisol concentration. In normal pregnancies, cortisol was present in low concentrations until 35 weeks' gestation, followed by a sharp rise at 36 weeks and a continued upward trend to 39 weeks. The rise after 35 weeks was delayed or absent in many patients with diabetes. In the combined population, the incidence of respiratory disease with a lecithin/sphingomyelin ratio greater than or equal to 2 was 26 per cent if the amniotic fluid cortisol was less than 4.3 microgram per 100 ml. and 2.9 per cent if the cortisol concentration was greater than or equal to 4.3 microgram per 100 ml.


Use of computers in the labor and delivery suite: an overview. Some simple computers for fetal monitoring are already commercially available. These systems are designed to alarm when abnormalities reflected by the fetal heart are detected during labor. Unfortunately, the problems of fetal heart rate/intrauterine pressure data analysis have been oversimplified. An "ideal" obstetric computer-based data management system would begin, as the clinician should, with the assessment of risk from the patient's past history, pregnancy course, and labor progress as a basis for analyzing the condition of the fetus during labor. Systems available now are of limited scope, expensive, and of unproved clinical value. Premature attempts at clinical computerization will accomplish little, except to give computers a bad name. Let the buyer beware!


Severe edema-proteinuria-hypertension gestosis. Severe edema-proteinuria-hypertension (EPH) gestosis (pre-eclampsia) appears in at least two forms (A and B). The A type is mostly complicated by fits, while the B type is characterized by multiple organ failure. The perinatal mortality rate is especially high in the B group. All gravid women with severe EPH gestosis benefit from blood volume expansion therapy.


Early vulvar carcinoma.

Early vulvar carcinoma. Fifty-eight cases of early vulvar neoplasia were reviewed from the Tumor Registry at Magee-Womens Hospital, between 1947 and 1976. Twenty-three cases were carcinoma in situ; 16 were microinvasive, and 19 were occult carcinoma. All of the cases were treated surgically. The modality of surgical treatment varied from local excision to radical vulvectomy with inguinal lymph node dissection. Regardless of the surgical therapy, none of the patients died of the vulvar malignancy. It is recommended, as part of routine gynecologic surveillance, that more critical attention be given to examination for early epithelial neoplastic lesions of the vulva. This can be accomplished by simple inspection and the use of special diagnostic aids. Biopsy specimens should be reviewed histologically for depth of invasion and the treatment individualized to the patient with considerations for conservatism, especially in younger women.


Adolescent sexual activity: contraception and abortion. One hundred twenty-five pregnant adolescents 16 years of age or younger and their parents were studied prior to abortion and were compared with 72 nulligravid control subjects. The control group reported less incidence of sexual intercourse and more causal heterosexual relationships of shorter durations. A significantly larger percentage of the abortion group approved of premarital sexual intercourse "when the couple is going steady." Sixty-eight per cent of the adolescents who were seeking abortions had never used a contraceptive. Abortion "on demand" was favored by the majority of the abortion group, whereas the control group favored "abortion under special circumstances." Neither were the pregnant teenagers' parents aware of nor had they discussed their daughter's sexual activities, much less contraception. Prevention of unwanted pregnancies in early adolescence should encompass an educational effort on the part of the health professions, involving both the adolescents and their parents.


Studies on the duration of egg transport by the human oviduct. II. Ovum location at various intervals following luteinizing hormone peak. The location of ova in the genital tract between 24 and 144 hours following the LH peak was determined in 23 normal women. Nineteen eggs were found in the Fallopian tubes between 24 and 96 hours and five eggs were recovered from the endometrial cavity between 96 and 144 hours following the LH peak. According to the present data and considering that ovulation occurs in the human subject nearly 17 hours after the LH peak, it is concluded that the transport of unfertilized ova in women is characterized by a period of retention in the ampulla, which lasts approximately 72 hours, followed by rapid transit through the isthmus and appearance of the ovum in the endometrial cavity around 80 hours after ovulation.


Gonorrhea in pregnancy.

Gonorrhea in pregnancy. Pregnancy complicated by gonorrhea was studied in 178 patients delivered of their infants over an eight-year period. There was an increased incidence of chorioamnionitis (p less than 0.05) and intrauterine growth retardation (p less than 0.05) in these patients when compared with matched controls. In 19 patients with positive gonorrheal cultures at delivery, there was a significant increase in the incidence of premature rupture of membranes (p less than 0.05), chorioamnionitis (p less than 0.05), and prematurity (p less than 0.05). Recurrence or persistence of positive cultures was found in 18 per cent of the patients with pregnancy gonorrhea. Two required hospitalization for intensive parenteral treatment when repeated attempts at outpatient management were unsuccessful.


Induction of labor with oral prostaglandin E2 in normal and high-risk pregnancies. There were 153 oral prostaglandin (PG) E2 inductions attempted in 149 patients. For various reasons nine cases were dropped from the study. Of the remaining 144 induction attempts, 96 were judged successful, with a success rate of 67 per cent. Details of these inductions are presented, including summaries of three patients with uterine hypertonus and three with uterine hyperstimulation. As a rule, the labor pattern established with oral PGE2 was effective and indistinguishable from normal spontaneous labor. After review of the data we feel that induction of labor with oral PGE2 is no more hazardous to mother or infant than with other oxytocic agents. In our opinion oral PGE2 offers the obstetrician an additional means for induction of labor in normal and high-risk pregnancies. The need for close observation of the progress of labor during PGE2 inductions is emphasized.


Polyamines in amniotic fluid, plasma, and urine during normal pregnancy. Polyamines have been implicated as markers of cell kinetic parameters. Putrescine and spermine were elevated in the urine of women with normal pregnancies. Particularly striking was the over 75-fold increase in spermine excretion. Putrescine was more than twofold that found for normal women. In several patients followed serially during pregnancy to assess the temporal pattern of the urinary excretion of polyamines, it was found that the highest levels of all three polyamines occurred at 12 weeks of gestation. In amniotic fluid, putrescine was higher prior to 30 weeks of gestation whereas spermidine was significantly higher at or beyond 30 weeks of gestation. Spermine was relatively high in both groups. Studies are ongoing to assess whether alterations from these normally elevated patterns will occur in the fluids of pregnant women at high risk for abnormal fetal development.


Transfer of estradiol to human milk.

Transfer of estradiol to human milk. A radioimmunoassay for the measurement of estradiol in human milk is evaluated. The detection limit was found to be 25 pg. of estradiol per milliliter of milk. In milk samples collected from four lactating women during three to four months and from one pregnant and lactating woman, the concentration of estradiol was found to be below the detection limit of the assay. When six lactating women were given vaginal suppositories containing 50 or 100 mg. of estradiol, it was possible to estimate the estradiol concentration in milk. A ratio of transfer of estradiol from plasma to milk during physiologic conditions is calculated to be less than 100:10.


Neonatal neurobehavioral tests following cesarean section under general and spinal anesthesia. The Scanlon Group of Early Neonatal Neurobehavioral Tests (E.N.N.S.) was administered to 150 babies delivered by elective cesarean section. Fifty of the mothers were induced into general anesthesia with thiopental, 4 mg. per kilogram, and 50 with ketamine, 1 mg. per kilogram. Fifty mothers received spinal anesthesia with 6 to 8 mg. of tetracaine. All mothers receiving spinal anesthesia were given 100 per cent oxygen by a transparent face mask and all undergoing general anesthesia received N2O-O2 (6L:6L) until delivery of the baby. All mothers were healthy and all babies weighed 2,500 grams or more, were apparently normal, and had Apgar scores of 7 or more at one minute to 10 at five minutes. Spinal anesthesia was associated with the greatest percentage of high scores on both the first and second day for overall assessment, pinprick response, tone, rooting, sucking. Moro response, placing, alertness, and total decrement (habituation) scores. There was a statistically significant difference between all the scores for spinal compared to the other two groups. The scores were lowest following a thiopental induction and intermediate with ketamine although the difference did not reach statistical significance.


Distribution of the bulk of the normal placenta. Review and classification of 800 cases by ultrasonography. A series of 800 ultrasonographic placentographies is reviewed and categorized by the location of the main bulk of the placenta. It represents, to our knowledge, the first such study of the undisturbed placenta and demonstrates a remarkably even distribution with frequent overlapping of more than one uterine sector. A simple form of categorization is presented and the clinical implications and value of ultrasonography are underscored.


Early detection of human chorionic gonadotropin in urine by simple immunoassays. Data are presented to show that human chorionic gonadotropin (hCG) in urine can be detected early in pregnancy by simple immunoassays performed prior to or around the time of the expected but missed menstrual period. Differences between the use of simple immunoassays with urine and radioimmunoassays and radioreceptor assays with serum are discussed.


Resident training goals in obstetrics and gynecology for the 1980's. Presidential address. Residency training goals and manpower needs in the 1980's and beyond should bear a consistent relationship. Projections for supply and demand for obstetrics and gynecology and for those medical specialties with overlapping responsibilities, though fraught with uncertainties, suggest that currently approved training programs in obstetrics and gynecology will meet clinical manpower needs for 1990. The role of the obstetrician-gynecologist in the primary care of women will be increasingly shared with others and the trend in urban areas for task delegation seems likely to increase. The popular and pervasive emphasis on primary care carries with it the serious risk that the present shortage of qualified investigators may not be corrected in the next decade. This could seriously hamper our efforts to recruit new faculty and maintain quality in our training programs.


The effect of estrogens on hypothalamic structure and function. Data accumulated from studies of several species indicate that sex steroids are metabolized by neuroendocrine tissues in a manner analogous to that of other target tissues. Evidence that androgens or their estrogenic metabolites affect the morphology and function of the nervous system in fetal, newborn, developing, and adult rats is presented. The destruction of neural processes subsequent to the administration of large doses of estrogen to intact rats can now be added to the previously known effects on synaptogenesis, cell morphology, and function. We believe this destruction to be a form of chemical deafferentation and that it may underlie age-related hypothalamic failure and the development of multifollicular ovaries in the rat. Implications for other species are not clear at present.


Intrauterine ethanol-induced termination of pregnancy in cynomolgus monkeys (Macaca fascicularis). The effectiveness of locally applied ethanol in terminating early pregnancy in cynomolgus monkeys was studied. In a randomized trial ethanol (70 per cent, 1 ml.) or saline (0.9 per cent, 1 ml.) was injected extra-amniotically through a sterile blunt-end needdle inserted through the cervix into the uterine cavity. Six of seven monkeys receiving ethanol showed vaginal bleeding beginning one or two days after treatment. With the one failure, alcohol leakage occurred from the Luer-lock needle joint at the time of injection and the amount entering the uterus was unknown. No animal receiving saline showed any vaginal bleeding. The six monkeys showing vaginal bleeding were found to have nonenlarged or subnormally enlarged uteri one month after treatment. All monkeys subsequently resumed menstrual cycles within one year. Three monkeys became pregnant and were delivered at term of healthy offspring. Histologic evaluation of uteri from ethanol-treated monkeys revealed necrosis of decidua and, to a lesser degree, of the placenta one day after injection. The high efficacy of 70 per cent ethanol in inducing endometrial sloughing and the documentation of normal subsequent pregnancies in 50 per cent of treated monkeys make this technique worthy of consideration as a menstrual induction agent in women.