Metabolism and measurement of chloroprocaine, an ester-type local anesthetic. Blood levels of intact chloroprocaine were determined using a GLC procedure capable of detecting as little as 10 ng of chloroprocaine/ml of blood. It was necessary to detective plasma cholinesterases in collected samples by adding echothiophate iodide to blood sampling tubes. An extraction procedure, followed by a TLC separation and spectrodensitometric assay, was developed for measurement of the metabolite 2-chloro-4-aminobenzoic acid in plasma and urine. With these procedures, data were obtained showing that chloroprocaine is hydrolyzed rapidly by plasma cholinesterases. No unchanged drug could be detected in any blood samples obtained from volunteers who received chloroprocaine by intravenous infusion or from obstetric patients who had epidural anesthesia during labor and delivery. Blood levels of 2-chloro-4-amino-benzoic acid rose promptly with the administration of chloroprocaine and declined rapidly after drug administration. Most of the metabolite was recovered in urine.


Macromerine and normacromerine biosynthesis in Coryphantha macromeris var. runyonii. The biosynthetic conversion of epinephrine to normacromerine in Coryphantha macromeris (Engelm.) Br. and R. var. runyonii (Br. and R.) L. Benson (Cactacae) has been studied. Metanephrine, which has been isolated from this cactus and is a normal metabolite of epinephrine in mammalian systems, appeared to be the likely intermediate between epinephrine and normacromerine. Normacromerine turnover studies suggested a 16-day interval between metanephrine administration and harvest of the cacti. During this incubation period, the cacti specifically converted 4.77% of the administered DL-7-3H-metanephrine to normacromerine. Based on biochemical precedents, the postulated metabolic fate of normacromerine in the cactus was an enzymatic N-methylation to give macromerine. However, radiolabeled normacromerine was a very ineffecient precursor to macromerine.


Papaver bracteatum Lindl.: quantitative extraction and determination of thebaine. An interlaboratory procedure for the quantitative extraction and analysis of thebaine from different tissues of Papaver bracteatum Lindl. is presented. Each step was evalutated for the yield of thebaine by use of 1-3H-thebaine and GLC. The method of drying and milling of tissue and the size of resultant particles were important factors in the quantitative recovery of thebaine.


Spectrophotometric determination of theophylline formulations. Minophylline (theophylline ethanoate of piperazine) and aminophylline (theophylline ethylenediamine) were determined spectrophotometrically in dosage forms without interference from excipients and/or preservatives. A mixture of minophylline, in about 30-fold concentration, with phenobarbital was assayed for both components with good accuracy and high reproducibility.


Trace determination of acetaminophen in serum. A simple and accurate method for measuring acetaminophen in serum was developed using liquid chromatography with electrochemical detection. Acetaminophen can be quantitated in 100 microliter of serum over the range of 20 ng/ml--20 microgram/ml. The method is linear (r = 0.9997) and reproducible (RSD = 3.0% at 2 microgram/ml, RSD = 5.1% at 200 ng/ml, n = 6). An internal standard (N-propionyl-p-aminophenol) is used, and a single extraction is performed.


Extraction and TLC separation of food, drug, and cosmetic dyes from tablet-coating formulations. A rapid method for extraction of dyes from tablet-coating formulations is described. The dyes were released from their lakes by treatment with concentrated phosphoric acid and dissolved in methanol. After being made alkaline with ammonium hydroxide, the mixture was centrifuged to obtain a clear supernate for application to the TLC plate. With ethyl acetate--methanol--water--concentrated ammonium hydroxide (150:40:35:5) on silica gel, 20 dyes were separated sufficiently to confirm their presence in the coating formulation.


Collaborative study of a GLC method for vitamin E. The official GLC method of the Association of Official Analytical Chemists (AOAC) for determining vitamin E was modified and collaboratively studied for the National Formulary (NF). The internal standard hexadecyl hexadecanoate (cetyl palmitate) was substituted for the dotriacontane used in the AOAC method, and some other minor changes were made. Eleven samples, representing all types of NF formulations and NF bulk materials, were analyzed by 11 laboratories. The coefficients of variation of the reproducibility and repeatability were 4.5 and 2.4%, respectively, for all laboratories and samples. The values were 3.4 and 1.6%, respectively, when the one laboratory statistically determined to be an outlier was excluded. The coefficients of variation of reproducibility and repeatability for alpha-tocopheryl acid succinate were 2.1 and 1.5%, respectively. All of these values lie within the 5% limit required by the NF.


The epidemiology of tuberculosis in physicians. The incidence of tuberculosis in physicians was determined by mailed questionnaire. Since 1950 tuberculosis infection preceding entry into medical school has decreased by 73%; at the same time, infection after beginning recent graduates exceeded 1% per year, and age-specific infection rates among physicians were at least twice the US average. Tuberculosis developed in nearly one in ten physicians infected after medical school entry; in two thirds, disease preceded or coincided with recognized tuberculin positivity. No tuberculosis occurred in physicians who used isoniazid chemoprophylaxis, but two thirds of tuberculin-negative physicians did not have annual skin tests, 56% of known recent converters used no chemoprophylaxis, and 25% of those initiating isoniazid prophylaxis did not complete a 12-month course. The Bacillus Calmette-Guérin vaccine recipients had 80% less tuberculosis than unimmunized physicians infected after beginning medical school.


Prophylaxis for postoperative deep-vein thrombosis. Synergistic effect of heparin and dihydroergotamine. Randomized clinical trials in 300 patients undergoing major abdominal surgery or hip replacement arthroplasty were performed to investigate the efficacy of dihydroergotamine mesylate, heparin calcium, or a combination of dihydroergotamine with heparin in preventing postoperative deep-vein thrombosis (DVT). The diagnosis of DVT was established by an uptake test using fibrinogen labeled with iodine 125; in patients undergoing hip replacement, phlebography was also employed to confirm or refute the presence of isotopic thrombi. The data indicate that the combination of dihydroergotamine and heparin is more effective than heparin or dihydroergotamine alone in preventing DVT.


Family (parental) history and prevalence of hypertension. Results of a nationwide screening program. In a nationwide screening program, blood pressure measurements, family (parental) histories of hypertension, and self-evaluations of weight class were obtained for more than a half million people. Positive family history was associated with hypertension prevalence double that found in persons with negative history and was independent of weight. When overweight was also present, however, hypertension prevalence was three to four times as high. Hypertension was more likely to have been previously diagnosed in screenees if family history was positive. However, such screenees did not have a higher proportion receiving effective treatment than those with negative family history. When an index case of hypertension is found, other family members should be examined. For persons with positive family history, nutritional-hygienic recommendations to avoid overweight may be important in reducing the risk of becoming hypertensive.


Pseudofolliculitis barbae. No 'pseudoproblem'. Pseudofolliculitis barbae possibly affects 45% of all black servicemen and is a source of much misunderstanding and social unrest in the military. A recent study of 96 cases of pseudofolliculitis barbae has elucidated a successful shaving technique. It employs a 30-day period of beard regrowth to eliminate ingrown hairs, twice-daily use of a new polyester skin-cleansing pad, and use of solely electric hair clippers for facial hair removal. Ninety-six percent of those using this technique could thereafter conform to the Air Force grooming code.


Clinical performance and specialty choice of COTRANS students. The clinical performance and specialty choice of 33 Coordinated Transfer Application System (COTRANS) students accepted with advanced standing into the third year of an American medical school were compared with the performance and choice of students from other American medical schools. The undergraduate grade point average of the COTRANS group was considerably lower than that of the other students. The science Medical College Admission Test scores in science were comparable, and the performance on part I of the National Board of Medical Examiners was considerably higher. Clinical performance, choice of specialty, and affiliation of graduate program of the COTRANS students did not differ from those of students entering the curriculum in year 1. Carefully selected students completing the first two years of basic science in a foreign medical school can successfully compete with students already enrolled in the American medical curriculum.


Gentamicin-resistant Staphylococcus aureus. Emergence in an intensive care nursery. Gentamicin sulfate--resistant Staphylococcus aureus suddenly appeared in an intensive care nursery in December 1976 and became the dominant Staphylococcus; it accounted for 96% of the isolates by April 1977. All gentamicin-resistant strains were sensitive to amikacin sulfate, but 98% and 49% were resistant to kanamycin sulfate and tobramycin sulfate, respectively. All but one of the gentamicin-resistant strains were sensitive to methicillin sodium. The mechanism of gentamicin resistance appears to be plasmid mediated. Phage typing, used for epidemiologic purposes, also demonstrated that most gentamicin-resistant strains shared susceptibility to phages 29 and 52; however, 13% were completely different, indicating that gentamicin resistance is not solely related to a phage-susceptible factor.


Clinical importance of microhematuria.

Clinical importance of microhematuria. To evaluate the etiology of microhematuria, the cases of 200 consecutive patients with asymptomatic microhematuria who had undergone complete urologic examination and two-year follow-up were reviewed. Most patients were 50 to 59 years old. Highly significant urologic lesions were found in 20% of patients. Thirteen percent of these patients had a genitourinary malignant neoplasm. No urologic lesion could be identified in 19% of patients in this group. The results suggest that present diagnostic modalities have substantially refined and improved the urologist's diagnostic abilities. The urologic examination of patients with asymptomatic microhematuria, particularly in those older than 40 years, is justified.


Irreversible renal failure following vesicoureteral reflux. Antireflux surgery was performed in five patients with vesicoureteral reflux at a time when renal insufficiency was present. Notable proteinuria was present in four of the patients, and a kidney biopsy specimen showed glomerular lesions in one. Despite the eradication of reflux and of infection, all five patients continued to have progressive renal insufficiency culminating in renal failure. Vesicoureteral reflux nephropathy may include a glomerulopathy leading to progressive glomerular sclerosis. Antireflux surgery would not alter this ongoing process and therefore would not halt progressive renal failure.


Rates of pneumonia during influenza epidemics in Seattle, 1964 to 1975. Influenza A epidemics were associated with a doubling to tripling of pneumonia rates among adult members of a prepaid medical care group studied between 1963 and 1975. Rates of influenza A associated with pneumonia increased with age. Influenza B epidemics did not have a similar effect. Overall pneumonia rates were highest in children younger than 5 years, but in this age group, other respiratory viruses dominated as causative agents. Influenza A and B epidemics were not always synchronized with those reported for the United States, and rates of influenza A infection varied between urban and suburban areas in sequential epidemics. In 1974, a year practically free from influenza A, a prolonged Mycoplasma pneumoniae epidemic kept rates of pneumonia high, especially during the summer.


Subungual squamous cell carcinoma.

Subungual squamous cell carcinoma. Twelve patients with subungual squamous cell carcinoma were treated at Memorial Sloan-Kettering Cancer Center during a 27-year period. To our knowledge, only 58 cases are reported in the literature. Trauma and chronic infection were predisposing factors in some of the cases, and radiation therapy was a substantive predisposing factor in our series. Disarticulation of the distal phalanx proved effective in most patients.


An exercise testing program for large populations. A demonstration cardiovascular evaluation and exercise testing program was assessed for feasibility, cost, and accuracy. More than 1,800 people were examined in three years. The conditions of as many as 55 people per day were examined at a cost of $60 to $70 each. Abnormalities uncovered were similar to those observed in other studies. The program was considered successful in rendering services conveniently at low cost and with accuracy.


Deep infections from Petriellidium boydii treated with miconazole. Infections due to the fungus Petriellidium boydii, particularly deep infections, are being reported with increased frequency. The organism generally is resistant to antifungal agents. Three patients were treated with miconazole, a new drug demonstrated to be active in vitro against the fungus. Miconazole alone was effective in treating two patients. The third patient showed an excellent therapeutic result with concomitant surgery. This experience confirms the in vitro results and suggests the utility of this drug in petriellidiosis.


Athletic shoe dermatitis. Contact allergy to ethyl butyl thiourea. Ten patients with severe foot dermatitis were found to be highly allergic to innersole material prepared by Spenco Medical Corporation and used in Nike athletic shoes. Contact allergy testing showed sensitivity to ethyl butyl thiourea, a chemical accelerator in some neoprene (polychioroprene) rubber products.  The dermatitis was recalcitrant and in many cases persisted long after discontinuance of wearing Nike shoes, raising the concern that traces of ethyl butyl thiorea or cross-reacting chemicals may be present in other footwear.


Microsurgical treatment of transient cerebral ischemia. Preliminary results in 50 patients. Extracranial-intracranial arterial bypass is a microneurosurgical procedure recently introduced in the treatment of a variety of cerebrovascular ischemic states. Fifty patients with transient ischemic attacks (TIAs) localized to the distribution of the internal carotid artery underwent this procedure during a 48-month period. All have been followed up for at least 14 months after surgery. There were no operative deaths, and notable postoperative morbidity has been experienced in less than 8% of cases. Seventy-six percent of patients have been asymptomatic since surgery, 14% have continued to experience TIAs, and 6% have had completed strokes (2% occurring in the operative hemisphere).


Identifying the primary site in metastatic cancer of unknown origin. Inadequacy of roentgenographic procedures. Two hundred sixty-six patients with metastatic nonsquamous carcinoma of unknown origin underwent upper and lower gastrointestinal series, intravenous pyelograms, and chest roentgenograms (CR) for location of a primary cancer site. Of 129 identified cancer sites, only 22 were verified antemortem, whereas necropsy disclosed 25 cases with false-positive examination results. The CR patterns thought typical for lung cancer (eg, single mass lesion and hilar or mediastinal adenopathy) were often shown (43%) to represent metastatic lesions. Because contrast roentgenographic studies are costly, uncomfortable, of low yield, and often misleading, they should be limited to cases with specific organ dysfunction.


Exercise-related hematuria. Findings in a group of marathon runners. Sequential urine specimens were obtained from 50 marathon runners before, immediately after, and on three successive days following a marathon race. All prerace samples were normal, but nine (18%) of the 50 postrace urinalyses showed gross (one specimen) or microscopic (eight specimens) hematuria. No formed elements other than RBCs were seen, and all abnormalities cleared by 48 hours. Exercise-related hematuria appears to be a frequent, self-limited, and benign condition. Physicians should be aware of its occurrence and reserve extended testing for cases in which abnormalities persist beyond 48 to 72 hours.


Long-term prognosis in transient global amnesia. Transient global amnesia (TGA) is generally believed to be a transient ischemic attack affecting short-term memory centers. A recent three-year follow-up found a high incidence of subsequent dementia and stroke in patients with TGA. We studied the course (average, 46 months) of 32 patients with TGA and found a low rate of recurrence (12.5%), dementia (6%), or transient ischemic attacks (3%). Transient global amnesia would appear to carry a more benign prognosis than classical transient ischemic attacks.


Conduction system in two cases of sudden death two years after the Mustard procedure. This report describes a serial section examination of the conduction system in two children who died suddenly 2 years following the Mustard procedure for complete transposition. The first child manifested sinus rhythm alternating with junctional rhythm in the last year of life. The second child, 2 months before death, had first-degree atrioventricular (AV) block which progressed to second-degree block with 2:1 conduction alternating with a junctional rhythm with AV dissociation. Examination of the conduction system in both cases revealed the approaches to the sinoatrial (SA) and the AV nodes to be markedly fibrosed. In addition, in Case 1 the SA node was interrupted by sutures and in Case 2 the SA node was considerably fibrosed. The arrhythmias produced and the probable cause of sudden death in both cases may be related to surgical injury to the approaches to the SA and AV nodes. This study and the review of the literature emphasize the necessity of maintaining the integrity of the SA node, the approaches to the SA and AV nodes, and the superior preferential pathway while performing the Mustard procedure for complete transposition.


Aorta-pulmonary shunts in growing pigs. Functional and structural assessment of the changes in the pulmonary circulation. Aorta-pulmonary shunts were produced in growing pigs, 4 to 12 weeks of age, by anastomosing the thoracic descending aorta to the pulmonary trunk, and the animals were followed for periods of 1 to 3 months. Correlation between the hemodynamic findings and the lung structure, analyzed by quantitative methods, showed that the young group (operated upon at 4 weeks of age) developed more severe pulmonary hypertension with increased muscularization of arteries of all sizes and reduction in the size of those running with respiratory bronchioli and beyond. Since this response is similar to that seen in cases of left-to-right shunt associated with congenital heart defects and pulmonary hypertension early in life, it seems that the present experiments reproduce the early response of the growing lung to such hemodynamic disturbance.


Left ventricular mechanics of counterpulsation and left heart bypass, individually and in combination. Counterpulsation and left heart bypass devices have been successfully used to salvage patients with severe left ventricular power failure following cardiopulmonary bypass. Each of these techniques is believed to reduce or minimize myocardial work, yet the effects of these devices on the force of myocardial contraction have not been defined. In the present investigation the effects of counterpulsation produced by intravascular (intra-aortic balloon pumping) and extravascular (pulsatile assist device) balloon devices, partial left atrial-aortic bypass, and total bypass on left ventricular mechanics were examined. The devices were studied individually and in combination in 10 anesthetized open-chest dogs. Left ventricular wall stress, external work, and contractility indices were calculated by computer using a changing volume spherical model of the left ventricle. Results indicate that although all currently available circulatory assist devices reduced peak left ventricular wall stress, a spectrum of relative effectiveness progressed from intra-aortic balloon pumping or pulsatile assist device alone through the combination intra-aortic balloon pumping plus the pulsatile assist device. Partial left heart bypass was more effective than intra-aortic balloon pumping plus the pulsatile assist device in reducing peak wall stress, but the difference was small. Total left heart bypass was vastly superior to any of the other modalities tested in its effects on peak wall stress as well as external work. The addition of counterpulsation to partial or total left heart bypass produced minimal changes in left ventricular systolic mechanics.


The role of surgery in primary osteomyelitis of the chest wall. Seven patients with primary osteomyelitis of the chest wall are described. All patients presented with pain at the site of infection, and four patients had a tumor-like mass that could easily be confused with a neoplastic process. All were heroin addicted and pseudomonas was the most common organism cultured. Conservative management with antibiotics for a minimum of 4 weeks is recommended with operation assuming a secondary role, namely, to assist in the initial diagnosis or in the form of limited resection of residual sinuses. Primary wide resection is discouraged.


Natural history of saccular aneurysms of the left ventricle. We have studied the natural history of left ventricular aneurysms (LVA) in 40 patients not treated surgically who were followed for a mean period of 5 years, 8 months. These patients have been divided into two groups according to the presence (Group B) or absence (Group A) of significant symptomatology. The causes of death are dominated by arrhythmias and congestive heart failure (CHF). The survival rate at 10 years is 66.7% for the entire group. In asymptomatic patients the 10 year survival rate is 90%, but it is only 46.3% in those who were symptomatic at the time of the initial diagnosis. In general, the clinical course of survivors is stable in Group A but has deteriorated steadily in Group B. Nonfatal complications include arrhythmias (observed in 34% of all patients), thromboembolic phenomena (29%), CHF (29%), and recurrent myocardial infarction (22.5%). Factors influencing prognosis are the extent of the aneurysm, the association of asynergic segments, the ejection fraction of the residual ventricle, the left ventricular end-diastolic pressure (LVEDP), and the presence of ventricular extrasystoles at the time of diagnosis. The mere presence of aneurysm is not, in itself, an indication for operation. Incapacitating angina and refractory CHF are the most valuable indications for surgical resection. The question is raised as to the value of operation in patients with little or no symptoms, in those with isolated life-threatening arrhythmias, and in those in whom a mural thrombus is the only distressing feature.


Evaluation of the mediastinum by gallium-67 scintigraphy in lung cancer. Delineation of the metastatic spread of lung cancer has been attempted by a variety of means. Controversy as to the indications for organ surveys, mediastinoscopy, scintillation scanning, and biopsy techniques still exists. Since definition of the micrometastatic state is yet unachieved, the staging of disease for therapy continues to be predicted on documented spread beyond the site of the origin. The records of 75 patients in whom the presence or absence of mediastinal metastases was known were retrospectively reviewed to establish the sensitivity, specificity, predictive values, and accuracy of 67Ga scintigrams. Comparisons were made with chest roentgenograms, mediastinal tomograms, and endoscopic findings. Five patients had 67Ga-negative studies. In the 70 patients having 67Ga-positive lung lesions, mediastinal 67Ga uptake had a sensitivity of 88%, a specificity of 86%, predictive values of 93% for a positive test and 76% for a negative test, and a test accuracy of 87%. These studies, plus those of others, permit selectivity of choosing candidates for mediastinoscopy. If the primary is 67Ga positive, a negative mediastinal scan obviates mediastinoscopy. If the mediastinum is 67Ga positive, mediastinal exploration is indicated. The level of involvement dictates whether resection is undertaken in suitable surgical candidates. This approach, employed since 1976, has lowered the costs of staging, and 67Ga has become our scintigram of choice.


Lung cancer involving the superior vena cava: pneumonectomy with concomitant partial resection of superior vena cava. We report two cases in which partial resection and reconstruction of the superior vena cava (SVC) were performed with the use of a temporary SVC-right atrial internal bypass for complete resection of carcinoma of the right lung. In the first case, the SVC was invaded by the primary tumor itself, arising in the anterior segment of the right upper lobe. In the second case a metastasized tracheobronchial lymph node had invaded the SVC. In both cases, partial resection of SVC was performed safely with the internal bypass technique.


Regional cardiac dilatation after acute myocardial infarction: recognition by two-dimensional echocardiography. To assess the early topographic changes after acute transmural myocardial infarction, we studied 28 patients during the first two weeks after infarction by serial two-dimensional echocardiography. Regional end-diastolic segment lengths and wall thicknesses for anterior and posterior left ventricular walls were calculated. Eight patients showed infarct expansion, with disproportionate dilatation and transmural thinning in the infarcted zone, that was significantly different (P less than 0.005) from changes in non-infarcted regions. This regional expansion led to an overall left ventricular dilatation in these eight patients of 25 per cent compared to 5 per cent in the 20 patients without infarct expansion. Although the eight patients with regional expansion did not have significantly higher peak creatine kinase or Killip classification, they had a significantly greater eight-week mortality (four of eight versus none of 20, P less than 0.004). Thus, regional cardiac dilatation may be an early, lethal consequence of transmural infarcts, and appears to be an important mechanism of acute cardiac dilatation after myocardial infarction.


Duodenal-ulcer disease associated with elevated serum pepsinogen I: an inherited autosomal dominant disorder. To delineate genetic factors involved in the pathogenesis of duodenal ulcer, serum pepsinogen I levels were determined by radioimmunoassay in two large kindreds with multiple members affected with duodenal ulcer. An elevated serum immunoreactive pepsinogen I concentration (greater than 100 ng per milliliter) segregated as an autosomal dominant trait in these families. Furthermore, 10 of 11 patients with clinical ulcer disease in these families had hyperpepsinogenemia. An elevated serum pepsinogen I concentration appears to be a subclinical marker of the ulcer diathesis in families with this autosomal dominant form of peptic-ulcer disease.


A rationale for continued federal support of medical education. Changing circumstances and shifting public attitudes are forcing policy makers and educators to reconsider the rationale for a continuing federal role in support of medical education. Federal institutional support programs are criticized as being inappropriate to current and future needs, socially inequitable and subject to abuse by a coercive governmental apparatus. A rationale for federal support can be advanced, but such support must be designed to avoid unwarranted subsidies and to encourage maximum reliance upon private-sector resources, and should be confined to functions for which the federal government in uniquely suited. The appropriate federal role is conceived as being the ultimate guarantor of financial access to the medical-education system by otherwise qualified students, perfecting the market for human-capital investment.


Viral hepatitis, type B. Studies on natural history and prevention re-examined. Frozen serial serum specimens obtained from past studies on the natural history and prevention of Type B hepatitis in children were retested by radioimmunoassay for the following markers of hepatitis B infection: hepatitis B surface antigen (HBsAg) and antibody (anti-HBs), hepatitis B e antigen (HBeAg) and antibody (anti-HBe), and antibody to hepatitis B core antigen (anti-HBc). The interval between exposure and evidence of viremia (HBsAg) was as short as six days. HBsAg and HBeAg persisted for two to five months and occasionally for more than one year after recovery. After the disappearance of their respective antigens, anti-HBc and anti-HBs persisted for more than seven years and anti-HBe for one to two years. Treatment with hepatitis B immune globulin after exposure induced complete or partial protection or prolongation of the incubation period. Administration of heat-inactivated hepatitis B virus, MS-2 strain, to 29 children induced an inapparent infection in three, characterized by a transient appearance of HBsAg and HBeAg, and the persistence of anti-HBc, anti-HBe and anti-HBs for more than two years.


Autoradiographic enhancement of mammograms. Investigation of a new dose reduction technique. Autoradiographic image enhancement using thiourea labeled with 35S was investigated as a means of reducing dose in mammography. It was found that mammograms underexposed as much as tenfold can be autoradiographically intensified so that the enhanced image is comparable with a normal exposure. Limitations to routine use include cost, processing time, and disposal of radioactive solutions.


Single-view mammography screening. Three-year follow-up of interval cancer cases. In 1974, screening trials indicated that both the sensitivity and specificity of single-view mammography are high. During the subsequent three years, 11 cases of breast carcinoma have been detected in the study population of 6,845 women aged 40 or older. The average incidence was three cases per year, compared to the expected rate of 8.9. The age-adjusted incidence rate in 1975, the year after screening, was 55.4 per 100,000, which is 40% of the expected rate of 140. In 1976 it was 75.9, or 54% of the expected rate of 141. These results support the view that single-view mammography is an efficient screening method, at least in the subject population described.


Trisomy 9p, a chromosome aberration with distinct radiologic findings. Radiographic analysis of 33 cases of trisomy 9p (21 familial, 12 nonfamilial) disclosed consistent abnormalities in the hands, feet, and pelvic bones, with one exception (subsequently considered a misdiagnosis). Most of the abnormalities were present only during the period of epiphyseal growth and occurred with similar frequency in both familial and nonfamilial cases. There was no correlation between the severity of osseous involvement and the amount of trisomic chromosomal material. The pattern of radiographic findings in trisomy 9p appears to be unique, at least among chromosome aberrations, and may help in establishing a specific diagnosis in nonfamilial cases.


Radiologic findings in persistent thyroglossal tract fistulas. Recurrent cysts and persistent fistulas are frequent complications of thyroglossal cystectomy if the excision is not extended through the hyoid bone to the foramen cecum. In 3 cases of persistent thyroglossal tracts, fistulography was performed and found to be valuable in demonstrating the extent of the tract. Surgical excision was completed and specimens were examined histologically. The retained upper portion of the thyroglossal tract was the established cause of the recurrent symptoms; removal of the entire tract up to the foramen cecum was confirmed as the recommended procedure.


Computed tomography in oculocraniosomatic disease (Kearns-Sayre syndrome). Computed tomography (CT) in patients with oculocraniosomatic disease (OCSD) or Kearns-Sayre syndrome has not been previously reported to the authors' knowledge. CT scans were performed in 6 children and 3 adults with OCSD. Abnormalities in children included: intracranial calcifications (4 patients); white matter disease (3 patients); cerebellar hypoplasia (1 patient); and scattered areas of decreased density in the cerebellar hemispheres, mesencephalon, and thalamus (1 patient). CT scans were normal in all adults. OCSD should be considered in the differential diagnosis in patients with intracranial calcification and white matter disease.


Computed body tomography in chronic pancreatitis. CT of the pancrease permitted correct positive diagnosis in 28/50 or 56% of patients with chronic pancreatitis proved by laparotomy or retrograde ductography. Diagnoses were based on CT identification of one or more specific hallmarks of chronic pancreatitis including calcifications (18/50 or 36%), parenchymal atrophy (7/50 or 14%) and pancreatic duct dilatation (2/50 or 4%), as well as the principal surgical complications, pseudocyst and abscess (15/50 or 30%). In 9 patients, CT disclosed pancreatic calcifications not visible on conventional radiographs. In 32 patients, ultrasound was less informative than CT giving a correct diagnosis in 8 pseudocycts (25%). In the patient with unexplained upper abdominal complaints, a positive CT diagnosis of chronic pancreatitis permits more confident patient management than a negative, or "no tumor" diagnosis rendered by other noninvasive examinations.


Computed tomography in the evaluation of post-nephrectomy patients. Twenty-one CT examinations were performed in 19 patients who had undergone previous nephrectomy for renal carcinoma or retroperitoneal malignancy. Nine patients were free of disease and 10 had recurrence. Findings of recurrent disease included masses in the vacant renal fossa, inability to visualize the inferior vena cava or aorta, and ipsilateral psoas muscle thickening. Possible pitfalls in diagnosis are discussed.


The effect of the distended urinary bladder on placental position and its importance in amniocentesis. Ultrasonography was performed using the full-bladder technique in 58 patients with intrauterine gestations. Postvoiding scans were then obtained to assess changes in placental position and determine the optimal window for amniocentesis. Twenty-two of the 41 patients with gestations between 13 and 21 weeks and 4 of the 17 with gestations between 24 and 34 weeks had changes in placental position after voiding, presumably due to the effect of the distended bladder on uterine position. These findings should be considered when using ultrasound to locate a suitable window for amniocentesis.


The heterogeneous liver scan: ultrasound correlation. Fifty-five heterogeneous technetium-99m sulfur colloid liver scans of 48 patients with suspected metastatic disease were compared with gray scale ultrasound results. Of the 52 ultrasound scans corresponding to the nuclear scans with mild to moderate heterogeneity, 35 (67%) were normal, 11 (21%) were consistent with hepatocellular disease, 3 were incomplete because of abdominal gas, and 2 were false positive studies interpreted as suspicious for tumor. Ultrasound is not recommended for searching for space-occupying lesions when the nuclear scan is mild to moderately heterogeneous; it did detect the presence of tumor in 1 of 3 patients with severely "mottled" nuclear scans.


Radionuclide sinography: diagnosis of lateral sinus thrombosis by dynamic and static brain imaging. Four patients with lateral sinus thrombosis were studied by radionuclide (RN) dynamic studies and RN static brain scans. Findings included: (a) abrupt termination of RN activity in the midportion of a lateral sinus ("stump sign"); (b) nonvisualization on dynamic, increased visualization on static images ipsilateral to a prominent sinus groove on a plain skull radiograph; and (c) increased activity on static images with nonfilling on angiography. RN demonstration of the "stump sign" is pathognomonic of lateral sinus occlusion; the latter two patterns require radiographic demonstration of an ipsilateral sinus groove or angiography for significance.


Radiologic aspects of hepatic echinococcosis. Value of the intravenous viscerogram and computed tomography. Over five years, 105 patients with hepatic echinococcosis were studied. Plain radiographs of the hepatic area yielded the correct diagnosis in 35% of patients. Intravenous viscerograms were diagnostic in all but 14 of the patients (an accuracy of 83%). Computed tomography was performed in 19 cases and proved the most efficient of the techniques--it was diagnostic in all 19 cases. The radiological signs of this entity are discussed.


Parathyroid lesions localized by radionuclide subtraction and ultrasound. Radionuclide subtraction technique and gray-scale echography were used to localize parathyroid lesions in 6 patients with primary hyperparathyroidism. In 3 cases, surgery verified the scintigraphic findings. All lesions weighed less than 1 g, with the smallest weighing 350 mg. These procedures provide complementary information in preoperative localization of hyperfunctioning parathyroid tissue.


Fluorescent thyroid imaging: clinical evaluation of an alternative instrument. Fluorescent imaging of the thyroid was performed successfully in 43 patients with incident low-energy photons generated by an x-ray tube. The images were comparable in quality and information content to those obtained with 123l or 99mTc pertechnetate. The estimated absorbed radiation dose to the gland is approximately 40 mrads. Fluorescent imaging is a clinically useful means of evaluating the thyroid.


Late effects on the eye of conformation radiotherapy for carcinoma of the paranasal sinuses and nasal cavity. Sixty patients with carcinoma of the paranasal sinuses and nasal cavity were treated with conformation radiotherapy technique (an improved moving-field technique). Only 28 were suitable for long-term follow-up with regard to eye complications. All patients receiving more than 5,800 rads in 6 weeks (1,700 reu in cumulative-radiation-effect dose) had strong panophthalmia with corneal ulceration within 2 years of radiotherapy. Of 21 eyes receiving 800--1,700 reu (2,800--5,400 rads in 6 weeks), 18 experienced visual disturbance from radiation cataracts and 3 equivocal changes at postirradiation intervals of 5 years. No patient receiving less than 800 reu (2,800 rads in 6 weeks) showed such complications.


Lymphocyte cytotoxicity in X-irradiation induced rat small bowel adenocarcinoma. IV. Activation of cellular immunity by X irradiation. Exposure of only the ileum and jejunum of Holtzman male rats to 100--2000 R resulted in almost immediate and dose-dependent activation of anti-tumor cellular immune mechanisms, as measured in vitro by the cytotoxicity of the animals' peripheral blood lymphoid cells to allogeneic cultured cells from an x-irradiation induced Holtzman rat small bowel adenocarcinoma. These cytotoxic responses were somewhat specific; the lymphoid cells did not kill prostatic adenocarcinoma target cells and cytotoxicity could not be induced by x-irradiation of some tissues other than the small bowel. Results suggest that exposure of an organ to ionizing radiation results in changes which sensitize the lymphoid cells in the animal to recognize and kill cancer cells of the particular tissue. Immunologic suppression by ionizing radiation presumably did not occur because only a small portion of the body was exposed.


Pharmacologic enhancement of gallium-67 tumor-to-blood ratios for EMT-6 sarcoma (BALB/c mice). At various intervals after intravenous injection of carrier-free 67Ga-citrate, iron dextrane or deferoxamine mesylate was injected into EMT-6 tumor-bearing BALB/c mice. After treatment, rapid clearance of 67Ga from soft tissues was observed. Tumor uptake was not greatly affected, and so increased tumor-to-blood ratios were observed. The authors conclude that these drugs can enhance target-to-nontarget uptake ratios for tumors.


An improved method for localization of nonpalpable breast lesions. Insertion of a hooked stylet into the region of a mammographic abnormality is a simple method of localization prior to biopsy. The hook on the stylet does not permit movement of the localization device away from the lesion during the interval between placement and surgical excision. A xeroradiograph of the biopsy specimen determines whether the suspected region was obtained surgically.


Pyloric channel ulcers and the air-contrast examination. Three patients with pyloric channel ulcers presenting a diagnostic challenge on double-contrast gastrography are reported. These ulcers might have been overlooked had not films of the pyloric region been obtained when the ulcer was filled with barium. The air contrast examination of the distal stomach should be supplemented by the components of the conventional examination likely to show a pyloric channel ulcer as a barium-filled crater.


Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Isolated single coronary artery is a rare congenital anomaly occuring in approximately 0.024% of the population. This entity can be diagnosed during life only by coronary angiography. Ten patients with isolated single coronary artery are reported. Based on angiographic analysis, a new classification is proposed, according to the site of origin and anatomical distribution of the branches. Typical angina did not occur with single coronary artery in the absence of coexisting coronary artery disease or aortic stenosis. No correlation was apparent between the type of anomalous patterns and the symptoms of angina.


Intramural hematoma (incomplete perforation) of the esophagus associated with esophageal dilatation. Five cases of intramural hematoma of the esophagus complicating esophageal dilatation are presented along with a review of the literature. In all 5 patients, this complication developed during dilatation for benign stricture. The esophagram in each patient demonstrated double columns of contrast material separated by a radiolucent stripe, characteristic of incomplete tear of the esophagus. All 5 responded to conservative management without complication.


Gastric polyps in familial polyposis coli. Familial polyposis coli has been considered a disease in which polyps are confined to the colon and rectum. The authors recently saw 3 cases in which either adenomatous or hyperplastic polyps were also present in the stomach and duodenum. The polyps were detected only by endoscopy or air-contrast radiographic examination. These cases and other recent studies indicate that gastric and duodenal polyps are more common in familial polyposis coli than previously recognized and should be considered an integral part of the syndrome.


Fibrous ureteral polyps.

Fibrous ureteral polyps. Twelve cases of fibrous ureteral polyps are presented, illustrating their characteristic radiographic appearances. Two types--a long pedunculated mobile variety having a smooth surface, and a relatively shorter lesion covered with thin, finger-like projections--may be identified. Demonstration of the typical findings on excretory urography and/or retrograde ureterography establishes the diagnosis and permits surgical conservatism. Although no sex preponderance was noted, a wide sex-related age disparity was observed, the involved males being much younger than the females.


Cervical spine trauma: the common combined conditions. The two most common groups of combined traumatic conditions of the cervical spine are hyperextension and hyperflexion fracture-dislocations. In a series of 400 patients with fractures and/or dislocations of the cervical spine, 25% had hyperextension and 19% hyperflexion fracture-dislocations. A computer analysis of the cases revealed that there are five distinct types of hyperextension and four types of hyperflexion fracture-dislocations. Each of the types is considered as to incidence, causes, mechanism of injury, and roentgen and differential diagnosis.


Double-contrast arthrography of the elbow. Double-contrast arthrography using gravity provides more detail than single-contrast techniques. With gravity, air rises to the uppermost portion of the joint and the positive contrast material settles. The cartilagenous articular surfaces and the synovial lining of the elbow are coated with contrast material and highlighted by the intra-articular air. Cartilagenous intra-articular bodies can be identified and located and the size of cartilagenous encapsulated osseous bodies can be confirmed. This method is faster to perform and easier to interpret than single-contrast studies, exposes the patient less than a tomographic examination, and is helpful before surgical exploration.


Echolocation and pursuit of prey by bats. Echolocating bats use different information-gathering strategies for hunting prey in open, uncluttered environments, in relatively open environments with some obstacles, and in densely cluttered environments. These situations differ in the extent to which individual targets such as flying insects can be detected as isolated objects or must be separated perceptually from backgrounds. Echolocating bats also differ in whether they use high-resolution, multidimensional images of targets or concentrate specifically on one particular target dimension, such as movement, to detect prey.


Diphytanyl and dibiphytanyl glycerol ether lipids of methanogenic archaebacteria. The lipids of nine different methanogenic bacterial strains are comprised of diphytanyl glycerol diethers, previously known only in extremely halophilic bacterial, as well as dibiphytanyl diglycerol tetraethers, known formerly only in the extremely thermoacidophilic bacteria Thermoplasma and Sulfolobus. Of the methanogens examined from four representative taxonomic groups, Methanobacterium and Methanospirillum contained both types of isopranyl ethers in nearly equal proportions, whereas the coccal forms, Methanosarcina and Methanococcus, possessed diphytanyl glycerol diethers, but with only a trace of or no dibiphytanyl diglycerol tetraethers. The occurrence of both types of isopranyl glycerol ethers in methanogenic bacteria supports the proposal that they have a close genealogical relationship to the extremely halophilic and thermoacidophilic bacteria.


Ethanol ingestion: differences in blood acetaldehyde concentrations in relatives of alcoholics and controls. Blood acetaldehyde concentrations were significantly elevated after a moderate ethanol dose in 20 healthy young men with alcoholic parents or siblings compared to matched controls with no familial alcoholism.


Catechol-O-methyltransferase: thermolabile enzyme in erythrocytes of subjects homozygous for allele for low activity. Low catechol-O-methyltransferase (COMT) activity (less than 8 units per milliliter) in the human erythrocyte is inherited as an autosomal recessive trait (COMTL). The average half-life of COMT in erythrocyte lysates incubated at 48 degrees C was significantly shorter in lysates from three subjects with low enzyme activity than in lysates from three subjects with high enzyme activity (12.5 +/- 0.9 minutes compared with 21.2 +/- 1.4 minutes, P less than .01). When the ratios of COMT activities in lysates heated at 48 degrees C for 15 minutes to enzyme activities in unheated samples were used as a measure of enzyme thermostability in blood samples from 316 randomly selected subjects, the ratios were significantly less for subjects with low enzyme activity than for subjects with higher enzyme activity. The presense of thermolabile COMT in blood of individuals homozygous for COMTL raises the possibility that the locus COMT may represent the structural gene for the human enzyme.


Cholecystokinin in the brains of obese and nonobese mice. Extracts of the cerebral cortes of genetically obese (ob/ob) mice with hyperphagia contain 0.05 +/- 0.02 microgram (mean +/- standard error) of cholecystokinin octapeptide equivalent per gram of wet weight compared to 0.15 +/- 0.01 microgram per gram for their nonobese littermates and 0.20 +/- 0.01 microgram per gram for normal LAF1 mice. These findings are suggestive of a causal relation between the diminished brain immunoreactive cholecystokinin content and the unrestrained appetite of the obese mice.


Target range-sensitive neurons in the auditory cortex of the mustache bat. Echolocating bats determine distance to targets by the time delay between their emitted biosonar pulses and the returning echoes. By varying the delay between synthetic pulses and echoes in stimulus pairs at various repetition rates and durations, neurons have been found in the auditory cortex of the mustache bat (Pteronotus parnellii rubiginosus) which are sensitive to target range during the search, approach, and terminal phases of prey capture or landing. Two classes of range-sensitive neurons were found: (i) tracking neurons, whose best delay for response to an echo following the emitted pulse becomes shorter and narrower as the bat closes in on the target, and (ii) range-tuned neurons, whose best delay is constant, and which respond to the target only when it is within a certain narrow fixed range. Range-tuned neurons are specialized for processing echoes only during a particular period of the search, approach, or terminal phases of echolocation, and they provide support for a theory of ranging in bats that incorporates groups of neurons with a spectrum of preferred echo delays to detect target distance.


Reducing epileptic seizures through operant conditioning of central nervous system activity: procedural variables. Operant conditioning of the sensorimotor rhythm of the human electroencephalogram with time-outs contingent on epileptiform activity reduces epileptic seizure rates in patients whose seizures are not well controlled by medication. A comparison of this procedure with time-out training alone demonstrates that operant conditioning of the sensorimotor rhythm is neither necessary nor sufficient for seizure reduction.


Plasticity: the mirror of experience.

Plasticity: the mirror of experience. A simple avoidance training procedure during early development produces massive neural traces in visual and somatic cortices of kittens reared in a normal environment. A preponderance of cells in these areas had response preferences for the stimuli used during training. Furthermore, some of these cells exhibited properties never found in normal animals not receiving such training. It appears that, even in an environment in which many other stimuli are present, some early experiences powerfully affect brain development and the way in which other experiences exert their effect.


Tumor surveillance: how tumors may resist macrophage-mediated host defense. Both normal human serum and supernatant from explanted malignant tumors contained a heat-stable low-molecular-weight factor that inhibited monocyte activation in vitro. In contrast, serum from individuals with solid tumors enhanced monocyte activation. It is suggested that the systemic activation of monocytes that occurs in malignant disease may be an appropriate host response but that successful tumors may continue to grow because they subvert the normal physiological signal for inhibition of macrophage activation.


Raphe inhibition of sympathetic preganglionic neurons. Anatomical and electrophysiological studies suggest that the medullary raphe gives rise to a monosynaptic, inhibitory projection on sympathetic preganglionic neurons. Physiological and behavioral data indicate that this sympathoinhibitory pathway participates in the central control of cardiovascular function.


Cerebral glucose utilization: local changes during and after recovery from spreading cortical depression. Cerebral glucose utilization is markedly increased in most areas of the cerebral cortex and reduced in many subcortical structures during spreading cortical depression. During recovery, cortical glucose utilization is still elevated, but the increased metabolic activity is distributed in columns running perpendicularly through the cortex.


Postoperative evaluation of the exocrine function of the pancreas after pancreaticoduodenectomy. The exocrine function of the residual pancreas of eight patients who underwent pancreaticoduodenectomy was studied with the 131I-triolein absorption test and by 75Se-selenomethionine scintiscanning. In six patients, a pancreaticojejunostomy was performed, while in the other two patients, the pancreatic duct of the residual pancreas was ligated. The fecal 131I-triolein excretory rate in the duct ligation group was more than 50 per cent, while, in all but one patient in the duct anastomosis group, it was less than 10 per cent. Pancreatic scintiscanning in the duct ligation group was negative before and after operation. All of the patients with anastomosis of the duct had an image of the pancreas before operation. However, postoperatively, scintiscanning of the pancreas was negative in two patients and became negative late in the postoperative period in four others without any decline of fat absorption. The cause for this postoperative change in scintiscanning of the pancreas and the discrepancy of this finding with that obtained with the 131I-triolein absorption test remains to be studied.


Flexible sigmoidoscopy as a screening procedure for neoplasia of the colon. Two hundred asymptomatic United States veterans older than 40 years of age were evaluated with a flexible sigmoidoscope plus Hemoccult stool tests. Mean distance and time for the former were 56.4 centimeters and 7.4 minutes, respectively. There were no complications. Polyps greater than or equal to 0.5 centimeter in diameter were found in 11.9 per cent of those older than 50 years. No polyps of this size were found in patients younger than 50 year of age. Results of Hemoccult tests were negative in 83.3 per cent of those with polyps. A flexible sigmoidoscope is a safe, rapid and effective means of identifying that portion of the asymptomatic adult population having colonic polyps. For this purpose, it is vastly more sensitive than Hemoccult stool testing. Because of the relationship between colonic polyps and carcinoma, this technique may prove invaluable in the identification of those patients with an increased potential for the development of carcinoma of the colon.


Morbidity of a negative finding at laparotomy in abdominal trauma. Although it is undesirable to perform an unneeded laparotomy in patients with abdominal trauma, it is more serious to delay exploration and incur morbidity or mortality. Because a negative finding at laparotomy has a low incidence of complications, early exploration is justified in instances in which intra-abdominal injury is suspected. Although peritoneal lavage for blunt trauma and selective exploration for some stab wounds may reduce the incidence of unnecessary laparotomies, the high incidence of major injury associated with gunshot wounds precludes use of selective exploration as a reasonable policy.


Gracilis muscle flap for closure of the persistent perineal sinus. A persistent perineal sinus may develop in those patients undergoing proctocolectomy for inflammatory intestinal disease. Healing often resists the traditional methods of wound management. Wide excision, transposition of the vascularized gracilis muscle flap into the rigid cavity and closure have all allowed rapid primary healing to occur and the return of these patients to full function.


Cholelithiasis following subtotal gastric resection with truncal vagotomy. Subtotal gastrectomy with bilateral truncal vagotomy is a good operation for peptic ulcer disease. Recurrence rates are low, and diarrhea and dumping are usually tolerable. The development of gallstones following this procedure, however, has become more problematic in that further opeation becomes a real necessity. In two groups of patients having undergone a standardized subtotal gastrectomy, with and without truncal vagotomy, only 6 per cent of the patients with resection alone had biliary calculi develop. This is consistent with the incidence of gallstone formation in the normal population. However, in the group undergoing resection with bilateral vagotomy, 21 per cent had gallstones develop which were detected by ultrasonography or oral cholecystography and confirmed at operation. This suggests that cholelithiasis following truncal vagotomy is a long term complication which must be recognized and, unless otherwise indicated, requires an additional surgical procedure. Only when results of long term follow-up studies verify the therapeutic effectiveness of such operations as highly selective or parietal cell vagotomy without drainage will a more physiologically sound operation be within our grasp.


Lipase and colipase in canine pancreatic juice as etiologic factors in fat necrosis. Lipase and colipase have been purified to homogeneity from canine pancreatic juice. The purity of the lipase and colipase preparations was established by acrylamide gel electrophoresis. Either lipase or colipase alone did not produce fat necrosis when injected intraperitoneally into mice. Fat necrosis was seen only when both lipase and colipase were used together. Selective removal of lipase from fresh canine pancreatic juice by immunoprecipitation with an antilipase specific antiserum also eliminated its fat necrotizing activity. Together, these results identify the fat necrotizing factors to be pancreatic lipase and colipase. Their uncontrolled release during acute pancreatitis is believed to constitute the cause of fat necrosis. The absolute amount of lipolytic activity was not found to be the crucial factor in the induction of fat necrosis. It is suggested that the colipase molecule may have other functions besides enhancing the lipolytic activity of purified lipase in causing fat cell necrosis.


Chronic mesenteric ischemia masquerading as cancer. Mesenteric vascular insufficiency should be suspected in patients with a history of abdominal pain, marked weight loss and significant atherosclerosis. Selective mesenteric angiography is essential and should be used early in the work-up studies of such patients. To ensure clinical correlation, there should be significant occlusion demonstrated in two of the three major mesenteric arteries. Four patients studied extensively for an intra-abdominal neoplasm had occlusive disease of the mesenteric artery demonstrated by arteriography. Elective surgical revascularization of the intestine successfully corrected the problem.


An experimental study of the correction of gastroesophageal reflux by gastroplasty. The rationale and efficacy of gastroplasty in controlling gastroesophageal reflux were studied by manometry and cinefluorography in the dog. The pressure in a 7 by 3 centimeter gastric tube, constructed from the lesser curvature of the stomach and interposed between the esophagus and the stomach, was 3.6 +/- 1.0 centimeters higher than in the stomach. When abdominal compression was applied, the pressures were similar in the tube and the adjacent stomach, 19.0 +/- 4.0 and 19.4 +/- 4.0 centimeters, and free reflux was demonstrated between the two. When the gastric fundus was wrapped around the gastroplasty tube, its resting pressure was 13.1 +/- 0.5 centimeters higher than gastric pressure. During abdominal compression, the pressure in the gastric tube increased to 23.0 +/- 0.6 centimeters suggesting a flutter-valve arrangement that produced an effective antireflux barrier. These data suggest that gastroplasty can be an effective antireflux method only when combined with fundic wrap.


Lyophilization of crystalline hemoglobin solution and exchange transfusions with lyophilized, reconstituted hemoglobin. Crystalline hemoglobin solution was lyophilized following deoxygenation or addition of several compounds, or both, to establish protective conditions for obtaining freeze-dried hemoglobin chemically and functionally unaltered and clinically suitable as a blood substitute. Glucose and sucrose were most active in protecting the hemoglobin molecule from deterioration. The results of stability studies demonstrated that lyophilized hemoglobin maintained at 4 degrees C. did not show any significant alteration in structure and function for a period of nine months. Freeze-dried hemoglobin samples stored at room temperature were unchanged for six months, but after this time, a progressive increase in methemoglobin content and a decrease in P50 were observed. The effectiveness of lyophilized hemoglobin in vivo was investigated by transfusions in rats exchanged to blood replacements of 75 or 95 per cent, using lyophilized hemoglobin reconstituted soon after lyophilization or after seven months of storage at room temperature. The data show that lyophilized, reconstituted hemoglobin is effective in restoring or maintaining, or both, vital signs. In rats transfused to a 75 per cent blood replacement, several hematologic and physiologic parameters change soon after transfusion but return to normal pretransfusion levels within seven days after transfusion.


Prevention of hypocalcemia in children due to parathyroid infarction after thyroidectomy. A high incidence of hypercalcemia was found in children after subtotal thyroidectomy for thyrotoxicosis in 17 patients. The most common cause of post-thyroidectomy hypocalcemia was not glandular extirpation but, seemingly, infarction due to devascularization. This complication has been eliminated by a change in the operation technique.


Immediate and long term effects of instrumental dilation of the sphincter of Oddi. Large dilators passed through the sphincter of Oddi do not prevent retained or recurrent common bile duct stones. Large dilators are more likely to cause postoperative pancreatitis than are small ones. Pancreatitis resulting from maximal dilation is more likely to be severe, and the patients are more likely to die from it.


The extended single transverse neck incision for composite resections. An extended single transverse neck incision was used in an unselected group of 40 patients undergoing a composite resection for carcinoma of the head and neck. While 21 of the 40 patients had a fistula and wound infection develop, carotid artery exposure due to flap necrosis occurred in two patients while carotid artery rupture occurred in only two. The extended single transverse neck incision results in a viable flap because of its excellent blood supply. Despite being subjected to fistula formation and infection, it usually results in excellent carotid artery protection, adequate surgical exposure, minimal cosmetic deformity and does not interfere with primary or secondary reconstruction.


Assessment of peritoneojugular shunts by direct roentgenographic examination. The silicone rubber tubing of the LeVeen peritoneojugular shunt can be safely punctured with a 23 gauge needle. Radiopaque contrast material can be injected through the needle to delineate the cause of any obstruction to the venous tubing.


A method of aspirating thyroid cysts.

A method of aspirating thyroid cysts. This method is safe, efficient and dependable. Important points in the method are positioning of the patient and operator, localizing the cyst with one hand and controlling the needle with the other and aspirating material by way of a connection tube to a syringe with the aid of an assistant.


Civilian popliteal artery trauma: an eleven year experience with 83 injuries. Limb loss is the outcome in one third of previously reported popliteal artery injuries. This report summarizes 83 injuries with an amputation rate of 9.6%. Penetrating traumas accounted for 61 (73%) injuries and blunt traumas for 22 (27%). The incidence of amputation varied with injury type from none in seven stab wounds to three of 19 (15.8%) shotgun wounds. Distal ischemia or a pulse deficit highlights the presence of arterial trauma, and the external wound defines its site in most patients. Urgent operation is indicated by these findings. Equivocal findings suggest less compromised flow, and such patients are managed best by arteriographic confirmation before operation. Early systemic anticoagulation is indicated to decrease distal small-vessel thrombosis. The successful management of these injuries requires early and complete restoration of arterial and venous flow. This is accomplished most effectively by priority definitive reconstruction. Compulsive attention to complete restoration of arterial flow during the initial procedure is mandatory. Resection or bypass of all damaged arterial wall, liberal use of autogenous vein grafts, and repair of concomitant venous injuries enhance continued arterial patency. Routine distal catheter thrombectomy and frequent intraoperative arteriography promote and confirm complete reconstruction. Early performance of four quadrant fasciotomy is indicated if compartmental hypertension is suspected. Thorough debridement of injured and questionably viable soft tissue and adequate fracture stabilization are integral parts of successful revascularization.


Scalenectomy versus first rib resection for treatment of the thoracic outlet syndrome. Five years ago a follow-up study of first rib resections disclosed a recurrence rate of over 15%. Many patients were reexplored supraclavicularly, and in every case the anterior scalene muslce was found to be reattached to the bed of the first rib. Scalenectomy invariably was successful, which led to this study of scalenctomy as the first operation for all cases of persistent thoracic outlet syndrome (TOS). The study revealed that most patients with TOS gave a history of neck trauma and had symptoms not only of paraesthesias of the hands and weakness of the arms, but also of neck pains and headaches. The common physical findings were tenderness over the scalene muscles and duplication of symptoms with the arms raised. A scalene muslce block with a local anesthetic was the most useful diagnostic test. The good-to-excellent long-term results following 239 scalenctomies and 214 first rib resections were almost identical, 68% and 70%, respectively, with fair results in 20% and 13%, respectively. In patients with a history of neck trauma followed by headache, neck pain, arm weakness, and parasthesias in the hand, anterior and middle scalenectomy should be considered. On the other hand, first rib resection is recommended for patients with no history of neck trauma and symptoms limited to the arm and hand, particularly those patients with signs of arterial or venous insufficiency.


Obstruction of the superior vena cava.

Obstruction of the superior vena cava. A 10 year experience in 66 patients with obstruction of the superior vena cava (SVC) was reviewed. Pathogenesis was malignancy in all except two patients with granulomatous mediastinitis (3%). Venography was especially helpful in determining extent of SVC obstruction and collateral circulation. Only nine patients are still alive; 57 are dead (mean survival, 3.9 months). Patients with upper airway obstruction and/or cerebral edema only survived 1.4 months (P less than 0.001). The two patients with benign obstruction had a new operation to bypass the SVC using a spiral graft of saphlenous vein with complete relief of SVC syndrome up to 26 months. Lymphomas responded to radiation (63% improved), but response in the bronchogenic carcinoma group was variable (42% improved) and was not related to palliative radiation, chemotherapy, or both. Patients receiving full-course mediastinal radiation (more than 5,000 rads) had improved survival (9.9 months). Three patients with bronchogenic carcinoma and severe SVC syndrome (cerebral edema and upper airway obstruction)  had excellent palliation using spiral vein bypass graft and postoperative radiation. This experience suggests that treatment of patients with obstruction of SVC based on evaluation of signs, symptoms, and venography may provide extended palliation. If the syndrome is mild, full-course mediastinal radiation is given. If there is cerebral edema or upper airway obstruction, operation to bypass the SVC will relieve SVC syndrome immediately and will allow orderly radiation therapy.


Hemodynamic effects of aortic clamping and decompression with a temporary shunt for resection of the descending thoracic aorta. To assess the effects clamping of the proximal thoracic aorta and of subsequent decompression with a temporary shunt on cardiac function during resection of aneurysms of the descending thoracic aorta, mean arterial (MAP), central venous (CVP), mean pulmonary arterial (MPAP), and pulmonary capillary wedge pressures (PCWP), as well as cardiac index (CI), were measured in eight patients at baseline, 2 minutes after clamping the aorta beyond the left carotid or left subclavian artery, and 2 minutes after opening the shunt. Following clamping, MAP, CVP, and PCWP increased significantly (P less than 0.05), while CI decreased significantly, an average of 29%, and heart rate remained unchanged. After opening the shunt, all pressures returned to baseline levels. CI increased, but remained below the baseline level in seven of the eight patients (P less than 0.05). Our data indicate that significant deterioration of left ventricular performance results from clamping and that the deleterious effects can be reversed by use of a temporary shunt. They support the recommendation of proximal aortic decompression during thoracic aneurysmectomy.


Surgery in acute and chronic venous disease. This report describes a favorable experience with 140 cases of surgical intervention in deep venous disease of the lower extremity, divided between acute and chronic problems. Of these, 107 were treated for acute phlebitis and 33 for deep venous insufficiency. Seventy-seven cases of acute iliofemoral phlebitis underwent thrombectomy. Preoperative venography was done in all, and postoperative venography was done in 57 patients. Of these, 75% had patent iliofemoral segments after a modified surgical approach. A positive correlation has been found between the degree of adherence of the iliofemoral clot and the postoperative patency rate--and this usually can be predicted from the preoperative venographic findings. Clinical follow-up averages 4 years and extends to 11 years. Ligation and division of the superficial femoral vein was done as the sole procedure in 30 patients with acute deep venous thrombosis (DVT) and in five with deep vein insufficiency. Its indications were guided by preoperative venography. It has been successful as a means to control emboli in selected cases. Long-term ill-effects have been minimal. In chronic severe venous insufficiency, expanded applications for surgery are presented. Ligation of incompetent veins, reconstruction of valves, and anastomosis of major segments of the femoral system are presented with preoperative and postoperative studies. Postoperative thrombosis has not been a problem. Specific procedures are presented to remedy chronic problems of the deep venous system.


Revascularization of the poorly functioning kidney. The effect of renal vascularization on renal function in kidneys with poor preoperative excretory function is summarized in this report. Twenty-five patients with kidneys having preoperative creatinine clearance of less than 30 ml/min, as determined during split renal function studies (SRFS), which were revascularized for treatment of secondary renovascular hypertension and then were reevaluated by repeat SRFS form the basis of this report. There were 13 male and 12 female patients. The type of renal artery lesion was atherosclerotic in 21 patients and fibromuscular dysplastic in four patients. Eight individuals had total renal artery occlusion. Significant contralateral renal artery disease was present in 15 patients (60%). Preoperative creatinine clearances in the affected kidneys ranged from 0.27 ml/min (mean, 16 +/- 9 ml/min). after operation, creatinine clearances ranged from 0 to 72 ml/min (mean, 32 +/- 16 ml/mn). Fifteen of the 16 kidneys with preoperative creatinine clearances less than 20 ml/min had improvement in renal function following revascularization (P less than 0.01). Improvement (60%) or cure (36%) in hypertension followed revascularization in 24 of the 25 patients. The most dependable predictor of successful management of both hypertension and retrieval of renal function in these patients was the arteriographic demonstration of a patent distal vessel without evidence of severe intrarenal stenoses. These results support an aggressive attitude toward the use of revascularization in the operative treatment of such patients with renovascular hypertension, even when the residual excretory function is minimal or absent.


Noninvasive radionuclide assessment of cardiac function in patients with peripheral vascular disease. Disorders of the peripheral vascular system often are associated with heart disease which may increase operative risk. The purpose of this study was to investigate the clinical usefulness of radionuclide angiocardiography for evaluation of cardiac function in patients with vascular disorders. This simple procedure provides measurements of cardiac output, pulmonary blood volume, and left ventricular end-diastolic volume, stroke volume, and ejection fraction with no significant risk or discomfort to the patient. A total of 22 patients with vascular disorders were studied by this technique. Five patients had systemic arteriovenous malformations. The cardiac output, end-diastolic volume, and stroke volume were documented to be greater than normal in these patients before operation. In three patients studied following closure of the arteriovenous fistula, the cardiac output, left ventricular end-diastolic volume, and stroke volume decreased. Postoperative changes in left ventricular ejection fraction were variable. A group of 17 patients with atherosclerotic vascular disease underwent cardiac evaluation. In nine patients with no history of cardiac disease, the lowest ejection fraction of 0.45 occurred in a patient with a saccular thoracic aneurysm, the only patient of the 22 who died after operation. A wide variation in ejection fraction was observed in patients with a history of cardiac disease which ranged from 0.32 to 0.86. Objective documentation of cardiac function by radionuclide angiocardiography would appear to enhance the management of patients with peripheral vascular disorders.


Apperceptive signals demonstrating the dynamic disturbance of myocardial ischemia. Analog pressure signals (catheter-tip manometers) from the left atrium, left ventricle, and aorta and a flow signal from the arota were obtained in 25, open-chest, anesthetized dogs in which 115 episodes of ischemia were produced in an area of the left ventricle subtended by the distal left anterior descending coronary artery and its last major diagonal branch. The left ventricular pressure and its first derivative (dP/dt) were displayed as an X-Y loop. The character of this loop went through a unique series of dynamic changes in 110 of the 115 ischemic episodes, indicating that this is a useful tool for monitoring myocardial ischemia. Spectrum pairs of the above signals were analyzed with digital computational transfer functions in 14 ischemic episodes of three experiments and preliminary assessment reveals unique pole and zero changes in many pairs during each episode which also may prove to be a useful indicator of the hemodynamic disturbance incurred during myocardial ischemia.


Autogenous tissue reconstruction in the management of infected prosthetic grafts. Infection is the most dreaded complication associated with implantation of a prosthetic arterial graft. Although remote bypass followed by complete removal of the infected prosthesis has proven to be a satisfactory method of treatment, in certain instances remote bypass alone is not feasible and other modes of surgical treatment must be employed. This report describes the use of autogenous reconstructions within the infected field, including endarterectomy and replacement of the infected graft with arterial or venous autografts in 24 patients. The key approach in these patients was (1) accurate preoperative assessment of the extent of graft infection, (2) aggressive surgical efforts to remove all infected prosthetic material, and (3) autogenous reconstructions within the infected field to supply critical vascular beds. Three patients died, for a mortality rate of 13%. There were no strokes and only two amputations. Suture lines involving autogenous tissue healed, even when in an infected field. In the aortofemoral group, preservation of aortic continuity is very desirable, when possible. We believe that these techniques provide the maximal potential for salvage of life and limb in the management of this dreaded vascular complication.


Long-term results of 474 arterial reconstructions for severely ischemic limbs: a fourteen year follow-up. A retrospective study of 474 femoropopliteal and femorotibial bypasses performed for limb salvage with a follow-up of up to 14 years is presented. The overall operative mortality rate was 4.2%. Initial limb salvage rate for femoropopliteal was 82.8% and for femorotibial, 67.9%. Cumulative limb salvage rate, as calculated by the life-table method, at 1, 5, 10, and 14 years for femorpopliteal was 67.6%, 59.7%, 54.0%, and 31.5%; for femorotibial 53.9%, 46.9%, 42.2%, and 42.2%. Initial and long-term salvage of severely ischemic lower extremities can be achieved in a large number of patients by revascularization to the popliteal and more distal arterial tree. Therefore we conclude that arterial reconstruction for salvage of severely ischemic limbs should be considered in lieu of primary amputation in all patients with popliteal or tibial run-off.


[Retinoid-selective ultraviolet phototherapy (SUP) in psoriasis]. 27 patients with generalized psoriasis were treated with oral administration of Ro 10-9359 (50--75 mg/d) and daily radiations with a source emitting UVA and UVB light at 292.5--335 nm (so called selective UV-phototherapy, SUP). In 24 patients full remission was seen, partly with few remaining lesions at the predilection sites. The average number of sessions necessary for clearing was 21.6 in 5.3 weeks. The total energy required was 68 J/cm2. Only slight side effects, such as cheilitis and hair loss (4 cases) were seen. The clinical efficacy of this combined retinoid-UV-treatment is comparable to the therapeutic effect of systemic PUVA; however, its practicability seems to be higher, and its application on an out-patient basis better.


[Evaluation of disorders in spermatogenesis and male infertility as based on the study of spermatological results]. Spermatozoa count, motility, and morphology as semen volumen and fructose are the main spermatological parameters in the assessment of male fertility disturbances. The spermatological findings should be referred to the pattern of spermatozoa transport through the cervical mucus. More extended morphological analyses are necessary in the evaluation of the disturbances of spermatogenesis. The spermatological findings may reflect the clinico-pathological syndromes of the disorders of the germinal epithelium.


Effect of intravenous hydrocortisone administration on glucose homeostasis in small for gestational age infants. The effects of I.V. hydrocortisone (H) (10 mg/kg) on glucose homeostasis were evaluated at 25 to 85 hours of age in 14 infants who were small for gestational age (SGA) in comparison to 17 control SGA infants. Three hours after H administration, higher levels of plasma glucose than in controls were detected (mean +/- S.E.M.): 4.78 +/- 0.2 vs. 2.88 +/- 0.2 mmol/l (p less than 0.01), while lower levels were found for blood pyruvate (38 +/- 7 vs. 89 +/- 12 mumol/l--p less than 0.01), plasma insulin (6.4 +/- 0.5 vs. 12 +/- 0.8 muIU/ml--p less than 0.05) and plasma glucagon (62.25 +/- 6.6 vs. 81.6 +/- 6.6 pmol/l--p less than 0.05). Three hours after H administration, I.V. injection of L-alanine (150 mg/kg) produced a significant rise over baseline of plasma glucose concentration from 4.78 +/- 0.2 to 5.94 +/- 0.2 mmol/l at 50 min (p less than 0.05), whereas no significant change was observed in controls. There was no significant change in plasma glucagon and insulin concentrations after L-alanine injection in either group. These results show that in SGA infants primed with H, the rise of plasma glucose concentration after L-alanine administration is observed with low plasma insulin levels and without stimulation of glucagon secretion. They suggest that H induced a reduced peripheral utilization of glucose by lowering the plasma levels of insulin and a production of glucose from alanine through gluconeogenesis.


Sudden infant death in Copenhagen 1956--1971. II. Social factors and morbidity. 131 cases of the Sudden Infant Death Syndrome (SIDS) among infants born in the Municipality of Copenhagen during 1956--1971 were analysed on the basis of data collected prospectively by the infant health visitors and abstracted from police reports. Compared with controls, a significantly larger number of SIDS infants had been born out of wedlock, were living only with their mother, had parents in a less secure occupation, lived in more crowded, poor-quality dwellings and districts. The "home standard" was lower among the SIDS families, including a lower standard of infant care, a higher percentage of not keeping the appointments with the infant health visitors and a lower mental capacity in the mothers; there was no difference with respect to the mother's physical capacity. More congenital malformations and more cases of asphyxia were found among the SIDS infants, and a significantly larger number of the SIDS infants had been admitted to hospital, with a tendency to being kept there longer. It is concluded that a relationships exists between poor social conditions, increased morbidity, and SIDS. At the same time, it is pointed out that during recent years the differences between cases and controls as regards certain of the social parameters studied have decreased.


Sudden infant death in Copenhagen 1956--1971. III. Perinatal and perimortal factors. 139 cases of the Sudden Infant Death Syndrome (SIDS) among infants born in the Municipality of Copenhagen during the period 1956--1971 were analysed on the basis of data collected from police reports and (for 131 cases) from the infant health visitors' records. In the SIDS group there was a greater male preponderance than among others dying in the same age range. Compared with the living controls, the SIDS mothers had attended less prenatal examinations, more often delivered their babies at home; the SIDS parents were younger, and yet the SIDS infants were less often firstborns. There was no difference with respect to history of abortions, maternal state of health during pregnancy, or events at delivery. The age at death for the SIDS infants is of a distribution similar to that for fatal respiratory infections. Prematures died later than matures, but this difference is not statistically significant. It is concluded that perinatal factors and SIDS are correlated, but owing to changes in predisposing factors and decreasing differences between cases and controls in recent years as well as interdependence of the factors, it seems doubtful whether the incidence of SIDS can be reduced by alleviating the above-mentioned unfavourable factors.


A variant form of 2-methyl-3-hydroxybutyric and 2-methylacetoacetic aciduria. A new case of assumed beta-ketothiolase deficiency, excreting 2-methyl-3-hydroxybutyrate and tiglylglycine is described in a 15-year-old boy. The patient presented with episodes of metabolic acidosis following intercurrent infections in the early childhood. After the age of 7 years he has had periods of headache, but no acidotic episodes have occurred even during infections. Systematic dietary treatment has not been instituted, and the patient is physically and mentally normal. This indicates a mild variant of the beta-ketothiolase deficiency. Diagnosis of the condition may be obscured by large quantities of ordinary ketone bodies, and requires gas chromatographic and mass spectrometric techniques.


Immuno-deficiency in Schwartz-Jampel syndrome. Two sisters born in a consanguineous marriage and affected by Schwartz-Jampel syndrome had a complex immunodeficiency, involving not only the humoral but also the cellular immune response.


IgG subclass levels in infancy and childhood. The concentrations of IgG1, IgG2, IgG3 and IgG4 were determined by electroimmunoassay in 10 pairs of maternal and cord sera and in sera of 162 healthy children, aged 6 weeks to 15 years. Specific rabbit antisera against the IgG subclasses were used. The content of the normal serum pool WHO 67/97 was used as reference. The mean value, standard deviation and normal range of each IgG subclass were calculated for each age group and compared with the adult values. All IgG subclasses were present in cord serum except for IgG4 in those cases where also the maternal serum lacked demonstrable IgG4. The IgG subclasses followed the pattern of total IgG with a fall during the first 3--6 months and a subsequent gradual rise with age. The IgG1 and IgG3 levels rose faster with age than IgG2 and IgG4. Adult levels were not reached before puberty. No IgG4 was detectable in 12--21% of the children above 7 years of age.


Breast milk iron--a declining concentration during the course of lactation. The present investigation is the first longitudinal study of the concentration of iron in breast milk and is based on 229 milk samples obtained from 27 mothers during their period of lactation up to 9 months. The samples were collected at the beginning and at the end of each feed during a 24-h period to reflect as accurately as possible the actual concentration of iron. The median value declined during the course of lactation from 0.6 to 0.3 mg/l with a large range of values. The results indicate that the concentration is lower than is generally stated or is unusually low in Finnish mothers. As a consequence some infants may require iron supplementation during prolonged breast feeding although in general, the high bioavailability of breast milk iron prevents the development of iron deficiency.


The concentrations of copper and zinc in human milk. A longitudinal study. Twenty-seven healthy Finnish mothers were followed during the course of their entire lactation period. A total of 229 individual milk samples, collected in the beginning and at the end of each feed during a 24-h period, were obtained from the 2nd week to the 9th month of lactation. The copper and zinc concentrations were determined by atomic absorption spectrophotometry. The concentrations of the trace-elements investigated were dependent on the stage of lactation. The median copper and zinc concentrations decreased during the course of lactation from about 0.60 mg/l and 4.0 mg/l to 0.25 mg/l and 0.5 mg/l, respectively. The importance of considering the stage of lactation in the evaluation of the trace-element nutrition value of breast milk should be emphasized. The calculated means of the concentrations of these trace-elements in mature human milk presented in the literature seem to overestimate the actual levels in prolonged lactation.


Renal function in infants with hyperbilirubinemia. A total of 45 infants were studied on the fourth or fifth day of life: 13 term and 10 pre-term infants with serum bilirubin levels ranging between 257 and 390 mumol/l were compared with 12 term and 10 pre-term infants with serum bilirubin levels below 195 mumol/l. The groups did not differ with regard to mean gestational age or mean post-natal age. GFR and CPAH were determined with the single injection clearance method and ability to excrete Na+ was determined following an oral loading of sodium chloride. GFR was lower in infants with hyperbilirubinemia and correlated negatively to the highest recorded serum bilirubin value. CPAH was similar in hyperbilirubinemic infants and controls. The urinary sodium excretion was significantly higher in infants with hyperbilirubinemia.


Influence of general anaesthesia on ano-rectal manometry in healthy children. According to several investigations ano-rectal manometry is a valuable diagnostic test of Hirschsprung's disease. In order to yield accurate results it requires a quiet, calm child who cooperates. In the few instances when this is not possible, general anaesthesia may be desirable. Manometric recordings of the internal and sphincter activity were therefore performed in 15 healthy children when awake and during general anaesthesia. The tonic activity at rest was significantly reduced during anaesthesia. Relaxations of the internal sphincter in response to rectal distension were recorded in all children both when awake and during anaesthesia. They were, however, significantly less pronounced during anaesthesia. These findings strongly suggest that ano-rectal manometry in the diagnosis of Hirschsprung's disease may be performed with advantage during general anaesthesia if the child does not cooperate when awake.


Sleep and blood pressure: further observations. Twenty-seven healthy people with a wide range of casual blood pressure readings (120/70 to 230/120 mm. Hg) had their blood pressure recorded continuously over a 24-hour period. Arterial pressure fell during sleep and only rose appreciably after the patients had awakened and a further rise was associated with physical activity, once they were out of bed. This pattern was observed in 18 untreated patients and in nine currently receiving hypotensive treatment. This study suggests that arterial pressure is not specifically related to time and is chiefly governed by physical activity and sleep.


Coronary arteriography in acute transmural myocardial infarction. Coronary arteriography was performed 16 +/- 3 days (range 7 to 21 days) in 106 patients with acute transmural myocardial infarction (61 posterior infarct, 45 anterior infarct). Coronary arteriography was performed without serious complications. Only 44% of patients with anterior infarct had total occlusion of the left anterior descending artery while a significant stenosis of the vessel was observed in the others -27% had a single vessel disease, 49% had two lesions and 22% had three lesions; one patient had angiographically normal coronary arteries. Among the patients with posterior infarction, 21% had one vessel disease and double or triple lesions accounted for 39% of each. Sixty per cent of patients with anterior infarction and 45% with posterior infarction had no collateral vessels. In the others patients collateral circulation had a protective effect only in anterior infarction. Age has no effect on the distribution and number of lesions nor on the development of a collateral circulation. The location and severity of the lesions were not different in patients who presented with arrythmias and those who did not.


Comparative effect of counterpulsation and bypass on left ventricular myocardial oxygen consumption and dynamics before and after coronary occlusion. In this preparation counterpulsation effect was found equivalent to 42 +/- 7% of complete left ventricular bypass before, and 46 +/- 9% post-coronary occlusion. We conclude that counterpulsation is effective mainly by reducing a major determinant of myocardial oxygen consumption, i.e., afterload, whereas left ventricular bypass by reducing primarily preload results in secondary afterload reduction when peripheral resistance is unchanged. At the higher left ventricular bypass levels, reduction of myocardial oxygen consumption is far greater than during balloon counterpulsation. Acute functional loss of myocardium does not alter the effect of these assist methods regarding the reduction of myocardial oxygen consumption. Whether selection of either method for clinical application should be made only on the basis of its capability for reduction of myocardial oxygen consumption remains to be justified by conclusive demonstration of beneficial effect of reduction of myocardial oxygen consumption in the specific circulatory disorders.


Anomalous drainage of the right superior vena cava into the left atrium as an isolated anomaly. Rare case report. A case of cyanotic congenital heart disease with left ventricular hypertrophy is described. Cardiac catheterization showed a right superior vena cava draining into the left atrium without other cardiovascular abnormality. This is the fifth case of this rare congenital anomaly described in the literature and the first one reported in a male. The patient was 7-months-old when diagnosed. Despite the important right-to-left shunt, after a follow-up of 2 years, growth and development are normal.


Treatment of premature ventricular complexes with acebutolol. The effect of intravenous acebutolol versus saline solution on frequent premature ventricular complexes was evaluated in a double-blind, randomized study in 20 patients, including 3 with chronic obstructive pulmonary disease. Frequent premature ventricular complexes were abolished or reduced by 75% or more in none of 12 patients given saline solution but in 18 of 20 patients (90%) given acebutolol (P less than 0.001). This therapeutic effect of acebutolol persisted for at least 2.5 hours in 17 of 20 patients (85%), for at least 3.5 hours in 14 (70%) and for at least 4 hours in 8 (40%). Acebutolol was well tolerated by the three patients with chronic obstructive pulmonary disease. These data indicate that intravenous acebutolol is useful in the treatment of premature ventricular complexes.


Left superior vena cava to left atrial communication diagnosed with radionuclide angiocardiography and with differential right to left shunting. Anomalous left superior vena cava to left atrial communication, although rare, should be considered in the presence of a right to left shunt without right ventricular hypertrophy, especially when the cause of the shunt cannot be identified at cardiac catheterization. We present a case with a diagnosis based on two radionuclide techniques. Nuclear angiography, performed after the injection of technetium-99m pertechnetate into the left arm, demonstrated the anomaly. Total body scans performed after intravenous injections of labeled albumin microspheres indicated 65% right to left shunting of left arm venous return but only 9% shunting of right arm venous return, findings that are diagnostic of left superior vena cava to left atrial communication.


Postpartum acute myocardial infarction: a rare occurrence of uncertain etiology. Two women who had an acute myocardial infarction during the early postpartum period are described, and the findings in nine other women previously reported on are summarized. Attention is called to the atypical nature of ischemic heart disease and myocardial infarction in these patients when compared with myocardial infarction during pregnancy and with ischemic heart disease in men. Postpartum infarcts most often occur in women in their 20s during their first pregnancy, frequently a pregnancy complicated by the preeclampsia-eclampsia syndrome, and are associated with a high mortality rate. In one of our patients and one patient previously reported on, the results of coronary arteriography were normal, suggesting that coronary arterial thromboembolism or spasm was a cause of the infarction. Because postpartum myocardial infarction may be unrelated to atherosclerotic narrowing, detailed angiographic studies in such patients appear warranted. These cases indicate the variety and complexity of ischemic heart disease in women.


Accelerated ventricular rhythm in childhood. Four patients, aged 6 to 14 years, with accelerated ventricular rhythm were studied from June 1976 to June 1978. Three were asymptomatic and had no evidence of cardiac disease. One patient had equivocal evidence of myocarditis. All four patients are well without therapy. The benign nature of this rhythm and the importance of its differentiation from ventricular tachycardia is stressed.


Asynchronous ventricular relaxation: an angiographic temporal analysis of asynchronous left ventricular relaxation in man. Segmental "early relaxation" is a common angiographic finding. An attempt was made to elucidate the temporal characteristics of this event. Twenty subjects with and 20 without segmental early relaxation were studied. The left ventricular diastolic relaxation time was precisely determined angiographically, and the findings were as follows: 0.12 +/- 0.04 second (mean +/- standard deviation) in the normal patients, 0.14 +/- 0.03 second in the patients with coronary artery disease but no segmental early relaxation and 0.20 +/- 0.04 second in the patients with segmental early relaxation. These findings indicate that early relaxation is associated with a significantly prolonged ventricular relaxation time. The use of the term asynchronous ventricular relaxation is proposed to denote the disturbed diastolic properties of the ventricle with "early relaxation."


Differential accumulation of radiopaque contrast material in acute myocardial infarction. The differential accumulation of radiographic contrast materials in ischemically damaged and normal myocardium was assessed with direct measurement (fluorescent excitation analysis) of the iodine content of tissue samples from dogs with 48 hour old myocardial infarctions. Tissue samples were obtained 10, 30, 60 and 180 minutes after the intravenous administration of 2 ml/kg body weight of diatrizoate meglumine and sodium (Renografin-76). At all time intervals, the iodine concentration of infarcted tissue was at least threefold greater than that of normal myocardium. At 180 minutes the ratio between iodine concentration in infarcted myocardium and that in normal myocardium was 8.5 and between that in infarcted myocardium and that in blood was 2.6. The iodine concentration in the liver was similar to or greater than that in the infarcted area at time intervals after 10 minutes. These results suggest that the intravenous administration of contrast material may facilitate the identification of acutely infarcted myocardium with computerized X-ray transmission tomography.