Women in alternative health care. Their influence on traditional medicine. Male domination of the traditional health care systems is well recognized. In contrast, it appears that women are a more important force in the alternative health care system, which is made up of neighborhood clinics and community health centers. A study of 17 such alternative health care centers in the San Diego area discloses that women account for almost half of the directors, all seven of the assistant directors, more than three-fourths of the clinic coordinators, and almost half (40%) of the membership of the boards of directors. Since many of the recent innovations in traditional health care derive from the alternative health care movement, the influence of women on the traditional systems may be more substantial than heretofore recognized.


Hypomagnesemia. Suppression of secondary hyperparathyroidism in chronic renal failure. Chronic renal failure is accompanied by secondary hyperparathyroidism. Inhibition of parathyroid hormone secretion has been reported to be induced by hypomagnesemia in conditions other than chronic renal failure, since severe hypomagnesemia is rare in chronic renal failure. In the case reported here, the patient had chronic renal failure and malabsorption-induced hypomagnesemia; she exhibited hypoparathyroidism while hypomagnesemic, and hyperparathyroidism after magnesium was replaced. Hypomagnesemia induced parathyroid hormone suppression in this patient with chronic renal failure, despite the presence of chronic hyperfunctioning parathyroid cells.


Cubital tunnel syndrome.

Cubital tunnel syndrome. The symptoms of cubital tunnel syndrome in 118 patients were mainly those of muscular atrophy, but they also included sensory disturbances in the ring and little fingers and pain in the ulnar side of the forearm. The syndrome occurs equally in men and women, with no particular age preference in adults. Seven tests are useful in diagnosing the condition. Treatment consists of excising the band, which constricts the ulnar nerve at the elbow. Sensory recovery is usually complete, but muscular atrophy may not recover in older patients. In my series of 561 nerve decompressions, ulnar nerve decompression was carried out eight times more often at the elbow than at the wrist.


Necrotizing fasciitis. Importance of roentgenographic studies for soft-tissue gas. Twenty-six patients with necrotizing fasciitis were treated during a nine-year period. Twenty-one (81%) had diabetes mellitus and 19 (73%) had gas in their soft tissues from nonclostridial infection. Although crepitation was found by physical examination in only five patients, roentgenographic examination of the involved site disclosed gas in every patient in whom it was subsequently found at surgery. Previous studies have not used roentgenography to search for soft-tissue gas. The 21 diabetic patients in our series had a mortality of 19%, the lowest yet reported. This suggested that roentgenographic study of cases with fasciitis permits earlier diagnosis and favorably affects outcome.


Lower-extremity arterial emboli from ulcerating atherosclerotic plaques. Ten cases of lower-extremity emboli originated from proximal, ulcerated atherosclerotic plaques. Two distinct clinical presentations were seen. Embolization of cholesterol-rich debris was usually widespread and lodged in terminal arteries, producing either focal digital ischemia or livedo reticularis of the extremity. By contrast, thrombi arising from mural erosions were larger and produced a picture indistinguishable from emboli of cardiac origin. Biplanar aortography was essential in making the correct diagnosis. Anticoagulation has not prevented recurrent embolization. Endarterectomy or graft replacement of the diseased arterial segment is the preferred method of treatment. Lumbar sympathectomy is a useful adjunct when persistent cutaneous ischemia is present.


Helping hemiparetics to help themselves. Sensory feedback therapy. Despite the presence of some voluntary movement, the loss of discrete control impairs functioning of the arm and hand in most hemiparetics. Seventy hemiparetic patients, aged 12 to 78 years, were treated and followed up for six months to three years. Electromyographic activity monitored from dysfunctional primary movers during attempted movement was displayed to the patients as a continuous oscilloscopic trace, reflecting generated muscle activity and allowing its quantification. Coupled with operant conditioning techniques, these displays were modified gradually by reinforcing the patient's effort with auditory feedback during successive approximations to a desired level. Such therapeutic use of electromyographic displays often resulted in a progressive improvement of voluntary movement. More than half the patients acquired and retained purposive movements that meaningfully improved their functional capabilities.


Postcholecystectomy diarrhea.

Postcholecystectomy diarrhea. Diarrhea developed in three patients following cholecystectomy. Fecal bile-acid excretion was elevated in the two patients for whom it was measured. All three patients' diarrhea resolved with cholestyramine resin therapy. This experience suggests that gallbladder removal may lead to a bile-acid-mediated diarrhea in some patients, and that this condition appears to respond to cholestyramine therapy.


Changes in physicians' attitudes toward telling the cancer patient. In answer to a questionnaire administered in 1961, 90% of responding physicians indicated a preference for not telling a cancer patient his diagnosis. To assess attitudinal changes, the same questionnaire was submitted to 699 university-hospital medical staff. Of 264 respondents, 97% indicated a preference for telling a cancer patient his diagnosis--a complete reversal of attitude. As in 1961, clinical experience was the major policy determinant, but the 1977 population emphasized the influence of medical school and hospital training. Our respondents indicated less likelihood that they would change their present policy or be swayed by research. Clinical experience was the determining factor in shaping two opposite policies. Physicians are still basing their policies on emotion-laden personal conviction rather than the outcome of properly designed scientific studies.


Trainees' retention of cardiopulmonary resuscitation. How quickly they forget. Lay persons trained in cardiopulmonary resuscitation (CPR) were evaluated six months after completion of a four-hour basic life support course to determine the degree to which CPR cognitive and psychomotor performance skills were retained. Evaluation criteria were based on the American Heart Association's recommended standards. The data disclosed a significant decrease in the resuscitators' retention of CPR knowledge and skills.


Alveolar hydatid disease in Minnesota. First human case acquired in the contiguous United States. A 56-year-old woman from southwestern Minnesota underwent an extended left hepatic lobectomy to remove a large multinodular mass with a necrotic central cavity. The clinical, serological, and pathological findings led to the diagnosis of alveolar hydatid disease, and specific identification of Echinococcus multilocularis was achieved by growing mature larvas in voles inoculated intraperitoneally with tissue from the hepatic lesions. The patient probably acquired her infection some years previously from pet cats or dogs that had become infected by ingesting infected rodents. In North America E multilocularis is enzootic in the northern tundra zone of Alaska and Canada. Since 1964 the cestode has been recognized with increasing frequency in several north-central states, including Minnesota. The parasite may extend its range farther south, since suitable animal hosts occur throughout the United States.


Glycohemoglobins and glucose tolerance.

Glycohemoglobins and glucose tolerance. Glycohemoglobin (GHb) levels were assayed after chromatography on weakly acidic acrylic cationite columns in 167 patients undergoing glucose tolerance test (GTT) and in 105 known diabetics. In 95% of patients with normal GTT levels, the GHb level was in the range of 6.8% to 9.8%. The GHb level was normal in patients with latent diabetes. Glycohemoglobin levels were elevated in patients with poorly controlled diabetes. Even in patients with normal GTT results, GHb levels correlated positively with fasting plasma glucose and glucose tolerance values. In patients with abnormal GTT results or diabetes but not receiving insulin therapy, the correlation between GHb levels and fasting plasma glucose values was significant. The GHb level that distinguished between latent and overt diabetes correlated strongly with the values of fasting plasma glucose and glucose tolerance and reflected changes in the control of diabetes.


Food and water restriction in the wrestler. The present practice in wrestling of "making weight" is hazardous to the health of growing young men, primarily because competitors lose too high a percentage of body fat. The Tcheng-Tipton-Clarke method should be used to control food restriction, while observation of specific gravity of urine should be used to control fluid restriction and hydration.


Thyroglobulin in benign and malignant thyroid disease. Thyroglobulin (TG) is a 19S glycoprotein produced by normal thyroids and almost all nonmedullary thyroid cancers. Radioimmunoassays measure serum levels of TG, and these levels are abnormally elevated in patients with metastatic thyroid cancer. Data from our study show that TG measurement is not effective in screening high-risk populations for thyroid cancer. Nevertheless, serum TG determinations are useful for assessing the presence and possibly the extent of residual or recurrent nonmedullary thyroid cancer in patients who have undergone total thyroidectomy.


The multiple roentgen manifestations of sclerosing mediastinitis. Sclerosing mediastinitis is excessive production of fibrous tissue in the mediastinum. Its most common manifestations, widening of the mediastinum and superior vena caval obstruction, are the only roentgenographic findings generally recognized to be associated with this disease. Analysis of 29 cases of sclerosing mediastinitis and review of the literature reveal that compression of mediastinal organs by constricting bands of collagen may cause various roentgen manifestations including bronchial or tracheal obstruction leading to atelectasis or obstructive pneumonitis, pulmonary venous obstruction, pulmonary artery obstruction, esophageal obstruction and nerve entrapment. The most common abnormality seen on the chest roentgenogram, mediastinal widening, is usually superior and especially right paratracheal in location. Superior vena caval compression is smooth and tapered rather than irregular as in malignant disease. Pulmonary venous and arterial obstruction may cause cor pulmonale and death, although the other manifestations are usually not life-threatening. The most common causes of sclerosing mediastinitis are generally considered to be granulomatous diseases, especially histoplasmosis, although many other causes have also been suggested. The disease may be regarded as an inappropriate response to one of several stimuli.


[Properties of hypoxanthineguanine-phosphoribosyltransferase (HGPRTase) in a gout patient with partial deficiency of this enzyme (author's transl)]. Some physicochemical properties of HGPRTase were studied in hemolysates and fibroblasts of a gout patient with partial deficiency of this enzyme. In comparison to normal HGPRTase the mutant enzyme from erythrocytes was found to have an elevated apparent Km-value for hypoxanthine and guanine and a lower Km-value for PRPP. The patient's enzyme from erythrocytes is more stable at +4 degrees C and +80 degrees C, the enzyme from fibroblasts more labile than that of controls. The inhibition of the mutant enzyme by some purine nucleosides and -nucleotides differed from that found in controls. No evidence was shown for an inhibitor of the patient's HGPRTase from erythrocytes. Ultracentrifugation of hemolysate in a saccharose gradient revealed no difference in the sedimentation coefficient.


Etiopathology and classification of acquired coagulation disorders in the newborn infant. In the newborn period low vitamin K dependent coagulation factors are frequently found in connection with normal global tests. To investigate this peculiar coagulation status studies were performed in 54 newborns who were divided into three groups according to their clinical course and the existence of bleeding. The results are compared to coagulation tests used for the diagnosis of disseminated intravascular coagulation (DIC). An early sign of an increased turnover of coagulation factors is a difference in the fibrinogen concentration determined by an immunological technique and a coagulation test which is sensible to fibrin(ogen)-degradation-products (FDP'S). At this stage factor II, V and VII levels are still within the normal range suggesting an increased production. In a more severe disturbance of the clotting system the increased turnover is no longer compensated by an increased production, and platelets and later on factor II and VII levels are lowered. At this early stage of DIC the vitamin K dependent factors are correlated to the factors I and V. Finally factors I and V drop as well. This stage in most infants is accompanied by the clinical symptom of bleeding. The clotting tests results are well correlated to the severity of the disease.


[Phase coordination between maternal and fetal heart rhythm during pregnancy (author's transl)]. In pregnant women during 8th and 9th month of pregnancy simultaneous registrations of the maternal and the fetal electrocardiograms were carried out, generally by systematic long-term studies during night rest. It could be proofed by examinations of the frequency distribution of the maternal R-peaks within the fetal cardiac cycle as well as of the frequency distribution of the fetal R-peaks within the maternal cardiac cycle that around a whole number frequency relationship of both of the heart rhythms a phase coordination between maternal and fetal heart actions occurs, leading to a preference of a defined phase relationship. According to the detected phase relationship it can be presumed, that the fetal rhythm is triggered by the guiding maternal pulse wave rhythm within a small range.


Comparison of phenytoin determinations in plasma, plasma dialysate and saliva for control of antiepileptic therapy in children. Phenytoin was determined in plasma or serum, dialysate from plasma or serum and saliva in 45 children and 7 adults by gas chromatography. 200 microliter of plasma were necessary for dialysis. Close correlations were found between phenytoin concentrations in the different media (r greater than or equal to 0.95). Since in some cases the levels in saliva were extremely high in comparison to plasma and dialysate, precautions are advisable when using phenytoin determinations in saliva for therapeutic decisions. Clinical data from 15 children with high phenytoin levels suggest that there is no advantage in determining the unbound fraction of the drug in plasma for the control of antiepileptic therapy.


[Effect of Co-trimoxazole on renal creatinine excretion in man (author's transl)]. Clinical observations have shown, that administration of Co-trimoxazole (Trimethoprim-Sulfamethoxazole) may result in an elevation of the serum-creatinine level. In 27 subjects the endogenous creatinine- and inulinclearance were measured before and during oral or parenteral application of Co-trimoxazole. The inulinclearance showed no significant differences (p greater than 0,05). But the endogenous creatinine clearance showed a reduction of 18% during the oral and of 13% during the parenteral treatment (p less than or equal to 0,05). These observations indicate a functional inhibition of the tubular creatinine secretion by Co-trimoxazole.


Morphologic changes in arterial grafts in rabbit ears. The morphology of auto- and allografted segments of rabbit central ear arteries was studied at various times after grafting. Autografts showed thrombosis only in the immediate postoperative period. Autografts developed intimal thickenings whose cellular elements at all stages were almost exclusively myointimal in type. Their medial smooth muscle cells were viable at all stages. Allografts frequently thrombosed within 8 weeks of grafting. Intimal thickenings that developed in the first 6 weeks in allografts mainly contained infiltrating hematogenous cells with few myointimal cells. Immune cells infiltrated all of the layers of allograft walls, and the smooth muscle cells of their medias showed increasingly severe degeneration and by 8 weeks had completely disappeared. In long established allografts, the intima was extremely thick and contained myointimal cells and fibrous tissue. Their medias were fibrosed. In long standing allografts, immune cell infiltration was no longer present. The thrombosis of allografted arteries that occurred within 8 weeks of grafting was related to immunologic events observed within the vessel grafts. Differences between myointimal cells and smooth muscle cells with regard to their morphology and orientation were identified. A possible origin of myointimal cells from endothelial cells is suggested.


Regeneration of cerebral microvessels: a morphologic and histochemical study after local freeze-injury. The sequential changes that occur during regeneration of cerebral microvessels was studied in young mice after a local freeze-injury. The immediate breakdown in the blood-brain barrier to horseradish peroxidase was followed by dissolution of cells in the vessel wall although the basal lamina was preserved. This residual basal lamina formed the pathway for the orderly regeneration of microvessels. Three days after injury, reactive endothelial cells with prominent pinocytosis and patent interendothelial channels were present at the edge of the lesion. By 5 days, endothelialization of necrotic vessels was in progress with patent vascular channels and tight junction formation. Establishment of astrocytic contacts or perivascular fibrosis by 7 days was generally followed by reconstitution of normal vascular morphology and integrity at 15 to 35 days after injury.


Stability of messenger ribonucleic acid of free and membrane-bound polyribosomes of the livers of rats treated with ethionine. Administration of ethionine to female rats results in disaggregation of free and membrane-bound polyribosomes and inhibition of protein synthesis in the liver. The administration of adenine and methionine to ethionine-treated rats reverses these effects, even after actinomycin D treatment which inhibits new RNA synthesis. The membrane-bound polyribosomes show greater recovery of the state of aggregation and of in vitro protein synthesis than do the free polyribosomes of rat liver. The messenger RNA (mRNA) in the recovering membrane-bound polyribosomes appears to come from endoplasmic reticulum membranes and is not related to increased nucleocytoplasmic translocation of existing mRNA. Initiation factors-dependent stimulation of polyphenylalanine synthesis by ribosomes and by initiation factors of membrane-bound polyribosomes is increased more than the synthesis by ribosomes and by initiation factors of free polyribosomes in the livers of ethionine-treated rats receiving actinomycin D and adenine plus methionine. Our results suggest that stable mRNA associated with membranes remains in the rat liver after injury by ethionine, and during recovery induced by adenine and methionine, the mRNA is utilized to reform membrane-bound polyribosomes.


Management of thoracic outlet syndrome.

Management of thoracic outlet syndrome. Twelve hundred patients with thoracic outlet syndrome have been managed between 1973 and 1978. Diagnosis was based on a careful history and detailed physical examination designed to establish the presence of brachial plexus irritation. The cervical spine was evaluated and nerve conduction studies were obtained. All patients were initially treated with a comprehensive physical therapy program. One hundred thirteen patients had transaxillary first rib resections. Eighty percent of surgical patients had complete relief of symptoms and 13 percent were improved. Seven percent were unimproved and none was made worse by operation. There were no operative deaths. Complications occurred in 3 percent, and there were no recurrences requiring operation. This management plan reduced the number of patients requiring operation to 9.4 percent while maintaining satisfactory surgical results.


Surgical management of straddling atrioventricular valve. Corrective operations were attempted in 10 patients with straddling atrioventricular valve (SAVV), and successful palliative operations were performed in another nine patients. SAVV occurred as a part of five different cardiac complexes, and three anatomic types were encountered. The SAVV was a tricuspid valve in eight patients, right atrioventricular valve (in univentricular hearts) in five, and mitral valve in six. Four types of corrective procedures were used: (1) the Rastelli operation, (2) isolated closure of the universally present ventricular septal defect by a patch deviating around the straddling portion of the SAVV, (3) replacement of the SAVV with or without insertion of an extracardiac conduit, and (4) closure of the SAVV plus right atrium-pulmonary artery anastomosis (modified Fontan procedure). All three hospital deaths occurred in patients managed by replacement of SAVV and extracardiac conduit insertion (technique 3). This experience allows preliminary speculation about preferred methods of surgical management.


The spectrum of Ebstein's anomaly of the tricuspid valve. The structure of the tricuspid valve in 14 cases of Ebstein's malformation is described and compared with that in the normal heart. The anomalous hearts showed a spectrum of malformation, varying from minimal displacement of the adjacent parts of the septal and inferior leaflets of the tricuspid valve to presence of an imperforate membrane or muscle shelf between the inlet and trabecular zones of the right ventricle. In "typical" Ebstein's anomaly the anterosuperior leaflet was abnormally attached so as to partially obstruct the route from right atrium to distal right ventricle, the communication between these chambers being between the abnormally attached leaflet and its malformed neighbors. In two hearts, a muscular shelf produced stenosis between inlet and trabecular portions, but a competent valve was produced at this site, the atrialized part of the right ventricle being of normal thickness. The significance of these findings is considered with regard to possible methods of repair. Description of the anomaly is facilitated by considering the right ventricle as possessing inlet, trabecular, and outlet portions. The essence of the anomaly is displacement of the tricuspid orifice to the junction of the inlet and trabecular ventricular zones.


Pneumonectomy for intractable left bronchial compression in d-transposition of the great arteries. In infants with transposition of the great arteries (TGA) tracheobronchial obstruction may occur as a result of compression by a dilated posterior pulmonary artery, especially if there is a large interventricular septal defect with its attendant large pulmonary blood flow and high pressure. Banding of the pulmonary artery may give temporary relief. A patient with TGA had collapse of the left lung at 2 months of age, following atrial septectomy. Bronchoscopy and bronchography revealed extrinsic compression of the left main bronchus. Banding of the pulmonary artery at 6 months of age relieved the respiratory distress. At 8 years of age atelectasis of the left lung recurred following a Mustard procedure. Two additional procedures were attempted to decrease the pressure of the pulmonary artery on the bronchus but these were unsuccessful. At age 9 years, pneumonectomy, her sixth thoracotomy, was performed as a final attempt to relieve the respiratory problem caused by persistent atelectasis. She is now 17 years of age and has remained asymptomatic during the last 8 years.


Surgical treatment for a complicated congenital aortic stenosis. The association of a three-level obstruction of the left ventricular outflow tract with mitral incompetence, coarctation of the aorta, and the Wolff-Parkinson-White syndrome. We report a case of complex congenital aortic stenosis with obstruction at all three levels of the left ventricular outflow tract (subaortic, aortic, and supravalvular aortic stenoses) associated with a mitral malformation, coarctation of the aorta, and the Wolff-Parkinson-White syndrome. The subaortic stenosis was corrected by excision and myotomy, and the supravalvular stenosis by a widening prosthetic operation with a Dacron patch extending as far as the aortic ring, at which level a Björk-Shiley No. 17 aortic prosthesis was inserted. The mitral valve was replaced by a Lillehei-Kaster prosthesis. The coarctation of the aorta was not significant and was left alone. Permanent pacing was needed because of peroperative surgical section of the bundle of His. Reviews of the literature and the various techniques used to widen the left ventricular outflow tract are included.


Role of surgery in the management of pulmonary sporotrichosis. Management of four patients with sporotrichosis is summarized; one was treated medically and three were treated surgically. Thirty-seven cases from the literature are reviewed. The role of surgery in the management of pulmonary sporotrichosis is outlined as follows: (1) diagnosis of pulmonary infiltrates and/or pulmonary cavities of undetermined origin, (2) surgical intervention in patients with persistent infiltrates with cavitary lesions resulting from sporotrichosis, following failed medical treatment, and (3) resection of associated pulmonary cavitary lesions in patients in spite of adequte medical control of sporotrichosis. Surgical principles that must be observed in the management of pulmonary sporotrichosis follows:(1) Resection is the procedure of choice. The magnitude ranges from segmental resection to pneumonectomy. Clean resection is necessary. (2) Antifungal drug therapy--preferably with amphotericin B--is advisable preoperatively and postoperatively, since the major cause of late death is progression of the disease when clean resection has not been feasible. (3) Resection combined with drug therapy can be curative without increased risk in physiologically operable and anatomically resectable disease. (4) Thoracoplasty can be a lifesaving procedure for bilateral cavitary lesions with severe hemoptysis in patients with impaired pulmonary functions.


Fogarty catheter extraction of foreign bodies from tracheobronchial trees of small children. The inhalation of a foreign body into the tracheobronchial tree tree presents a life-threatening situation. A satisfactory outcome requires the timely and atraumatic removal of the offending agent. The morbidity associated with present methods of dealing with this problem is well documented. Four cases are described to illustrate the efficacy and simplicity of a new technique of endoscopic extraction with the aid of a Fogarty embolectomy catheter. The actual technique and anesthetic management are described.


Implantation of an endocardial tined lead to prevent early dislodgment. Early electrode dislodgment from the ventricular apex is a major complication associated with transvenous cardiac pacing. A new lead with flexible tines proximal to the tip electrode has been developed to minimize acute dislodgment incidence. The bipolar tined lead was implanted in 79 patients. This experience was compared to 48 implants of a standard bipolar endocardial lead. Stimulation threshold, sensing, and resistance measurements from both leads were comparable. Although the cephalic vein was the preferred venous route, the jugular vein was needed more often for tined lead insertion than for standard lead insertion. The incidence of early dislodgment with the tined lead was 2.5 percent compared to 8 percent with the standard lead (no significant difference). This preliminary experience can only suggest that the addition of flexible tined leads may reduce early electrode dislodgment.


Lung transvascular fluid dynamics with extracorporeal membrane oxygenation in unanesthetized lambs. Extracorporeal membrane oxygenation (ECMO) is used for long-term support of patients with acute respiratory failure. We investigated the effect of partial venoarterial (VA) and venovenous (VV) bypass with filler-free silicone spiral-coil membrane lungs on steady-state lung transcapillary fluid filtration in six unanesthetized lambs for periods of 11 to 32 hours. Using three thoracotomies we prepared animals to collect lung lymph; lymph obtained in this way is representative of lung interstitial fluid. By studying lymph flow and composition we demonstrated that the permeability of the pulmonary capillaries does not change during prolonged partial VV or VA bypass with a membrane lung. There was no accumulation of lung water during bypass, and lung protein and fluid leak neither increased not decreased with bypass flows equivalent to those used clinically. Thus prolonged use of ECMO in unanesthetized lambs appears to be neither harmful nor beneficial to the steady-state dynamics of fluid exchange in the lung. Furthermore, total pulmonary blood flow is not a determinant of net fluid filtration across the lung microcirculation.


Use of athrombogenic tubing for perfusion rewarming following surface-induced deep hypothermia. A method of heparinless, oxygenatorless, left heart bypass perfusion rewarming following surface hypothermia, with the use of a closed circuit with 130 ml. prime volume including heat exchanger, has been devised. The use of polyurethane-polyvinyl-graphite (PPG)-coated tubing has previously been reported. In this text, the use of an athrombogenic coating with cetyl-pyridinium chloride (CPC) as a regional heparin carrier was studied in dogs, comparing groups with PPG tubing and total systemic heparinization or plain polyvinyl tubing without systemic heparinization. Heparin compounded in the CPC coating eluted into the blood and caused mild transient whole-body heparinization during rewarming from 20 degrees to 25 degrees C., as evidenced by prolongation of the thrombin time. Alterations of hematologic parameters in all three groups were similar to those during surface rewarming except for those affected by heparinization. The left heart bypass method was found useful for hypothermic open-heart surgery when utilized with an athrombogenic surface coating or total body heparinization. It was concluded that the CPC coating is superior to the PPG coating since no cracking surface develops, it is translucent, and it provides a more effective athrombogenic surface.


Effects of cardiac surgery on renal function in children. In order to determine whether cardiac surgery with cardiopulmonary bypass (CPB) affects renal function in children, glomerular filtration rate (GFR and renal plasma flow (RPF) were determined preoperatively and on the second postoperative day by a single-injection, urineless technique in a randomly selected group of 10 children. The GFR was 126.7 +/- 6.8 ml. per minute per 1.73 sq. M. (mean +/- S.E.M.) before the operation and 127.4 +/- 16.2 on the second postoperative day (p = 0.95). The RPF was 541.7 +/- 80.6 ml. per minute per 1.73 sq. M. preoperatively and 536.0 +/- 82.1 on the second postoperative day (p = 0.8 to 0.9). The results in this group of 10 children indicate that renal function is not markedly altered 2 days after cardiac surgery with CPB and deep hypothermia with circulatory arrest. The study also revealed a falsely decreased creatinine clearance. This was due to an increase in postoperative plasma creatinine values, probably related to an increase in plasma noncreatinine chromogens.


Experimental evaluation of aortic homograft valves mounted on flexible support frames and comparison with glutaraldehyde-treated porcine valves. The durability of the aortic homograft valve, when mounted in a rigid support frame, has been limited in some cases by aortic wall detachment from the frame in the commissure buttress area. To investigate the effects of frame flexibility, a stent was designed which was suitable for canine aortic valves of selected sizes. Of the two materials tested, acetal copolymer was found to be superior to polypropylene, as stents made from the latter material were permanently deformed as a result of polymer creep under the action of a cyclic load. Observations of a commercially available glutaraldehyde-treated heterograft mounted on a polypropylene frame indicated that stent flexibility was less important than had been suggested in earlier reports. It is considered that the glutaraldehyde preservation and the method of mounting this valve in the frame are major factors in prolonging the life of the implant.


Replacement of mitral, aortic, and pulmonary valves for rheumatic heart disease. Rheumatic disease of the pulmonary valve has been documented at autopsy. Most of the reported cases of calcified pulmonary valves are associated with congenital heart disease. A unique case of rheumatic aortic and mitral valve disease associated with calcific pulmonary stenosis is presented. Prosthetic replacement of all three involved valves was carried out successfully. This is believed to be the first reported triple valve replacement of its kind.


Increased mortality rate from coronary artery disease following operation for coarctation of the aorta at a late age. Sixty-six patients past 35 years of age at operation for coarctation of the aorta had significantly higher hospital (five of 66, 7.5 percent) and late cardiovascular (10 of 61, 16.4 percent) mortality rates than 137 patients aged 15 to 34 years (mean, 21.9 years). Three of the five hospital deaths, as well as four of the 10 late deaths, in the group greater than 35 years of age were due to myocardial infarction. Thus the total coronary mortality rate was 10.6 percent (seven of 66 patients), with all deaths occurring in men. It appears that coronary artery disease (CAD) is a significant complication in male patients who undergo operation for coarctation of the aorta at a late age.


Equipment for inducing cold cardioplegic arrest. A technique for the infusion of the cardioplegic solution used at St. Thomas' Hospital is described. A flanged aortic root needle is used for patients with competent aortic valves and hand-held metal cannulas for those with aortic regurgitation.


Diagnostic and therapeutic aspects of the surgical approach to Wegener's granulomatosis. Over a 16 year period, 47 patients with Wegener's granulomatosis were treated at the National Institutes of Health. Age at the onset of disease ranged from 15 to 75 years with a mean of 42.2 years. The group was evenly divided between male and female subjects. With seven exceptions, all patients had the classic form of Wegener's granulomatosis, with upper airway and pulmonary disease and glomerulitis. The most consistently abnormal laboratory test was an elevated erythrocyte sedimentation rate. Most of the patients were treated with cyclophosphamide alone or in combination with prednisone. In 37 patients the disease now is well controlled or in complete remission from 1 to 9 years after the onset of symptoms. Of the 10 patients who died, only two were considered treatment failures. Forty-one of the 47 patients had chest x-ray changes at some point in their clinical course. Nineteen had bilateral involvement and 22 unilateral disease. Three of 11 patients with nodular disease had cavitation, and four of 21 with less discrete infiltrative disease demonstrated cavitation. Four patients had an associated pleural effusion and another four had pleural thickening. As part of the diagnostic procedure, 24 patients underwent an open lung biopsy. Two patients had a lobectomy for presumed neoplastic disease. In one patient the diagnosis of Wegener's granulomatosis was made by endobronchial biopsy. In the remaining patients the diagnosis was made by biopsy of another site. Endobronchial involvement is being seen with the increasing patient survival. Three patients had subglottic tracheal stenosis necessitating tracheal dilatations. One of the three also had multiple areas of bronchial stenosis responding to cyclophosphamide therapy. A fourth patient had progressive left main-stem bronchial stenosis which necessitated a sleeve resection. Five patients had pericarditis secondary to Wegener's granulomatosis.


Intralesional BCG immunotherapy of pulmonary tumors. A new method of baccile Calmette Guérin (BCG) immunotherapy has been evaluated in 25 patients with lung cancer. This technique involves the direct intratumor injection of BCG in patients with pulmonary tumors. Four patients underwent transbronchoscopic injections of tumor, with significant resolution of tumor in three. Twenty-one patients underwent percutaneous injection with the aid of fluoroscopic imaging. Twenty of these 21 underwent pulmonary resection. Toxicity was limited to fever and malaise. The severity of this toxicity was closely related to the magnitude of reactivity to PPD. There were no intraoperative or postoperative complications occasioned by BCG injection. The histologic features were characterized by granulomatous inflammatory reactions in the tumors and the regional lymph nodes. These histologic findings are identical to those seen in animal tumor models in which potent systemic antitumor immunity is induced. BCG intratumor injection is technically feasible and safe, and it is appropriate to begin phase 2 and phase 3 clinical trials.


The coronary hemodynamics of left main and branch coronary stenoses. The effects of reduction in stenosis diameter, stenosis length, and number of stenoses. Although considerable investigation has been devoted to the concept of "critical" coronary stenosis, there is general lack of agreement on which coronary stenoses consistently decrease coronary blood flow (CBF). In 32 open-chest dogs we studied CBF and the aorta-distal coronary pressure gradient at rest and with reactive hyperemia (RH) as stenoses were created in the left coronary artery (LCA) or its major branches--anterior descending (LAD) or circumflex (LCx) arteries. The effects of stenosis location, reduction in stenosis diameter, stenosis length, and the number of stenoses were studied. Resting CBF and resting distal coronary pressure were decreased by short snare stenoses, which reduced the diameter of the LCA or either major branch more than 80%. Lengthening 50 to 60% LAD or LCx stenoses decreased CBF and increased the pressure gradient. There were small increases in pressure gradients but no change in CBF with multiple stenoses in either the LAD or LCx branch. During peak RH, CBF was decreased by a 60% LCA or branch snare stenosis. Peak RH CBF responses decreased further as length of an LAD or LCx stenosis increased. Multiple stenoses affected peak RH CBF responses significantly more than a single stenosis of the same total length. These data indicate that several anatomic variables of coronary stenosis affect the physiological responses of the coronary circulation. The variables are (1) reduction in lumen diameter, (2) length of stenosis, and (3) number of stenoses in one vessel.


Total occlusion of left coronary artery. Incidence and management. From July 1, 1972, to Jan. 1, 1978, 527 patients underwent coronary revascularization. In four (0.76%) of these patients arteriography demonstrated total occlusion of the left main coronary artery. The incidence of acquired occlusion of the left coronary artery encountered in the cardiac catheterization laboratory during the same period was 0.17% in patients undergoing coronary arteriography. Literature review reveals 13 patients with total occlusion of the left coronary artery, and only seven of these were treated operatively, some with suboptimal results. With an average of three grafts per patient, all four of our patients are in Class I of the New York Association an average of 23 months postoperatively. These patients were dramatically symptomatic preoperatively, and their clinical management in terms of pharmacologic or mechanical intraoperative support was no different from that of patients with critical stenosis of the left main coronary artery. This report documents the incidence of left coronary artery occlusion encountered in clinical practice. This incidence should not be as rare as the literature review suggests.


Distribution of oxygenated blood by transseptal left atrial cannulation during lung support in the open-chest model. The hemodynamic characteristics and anatomic configuration of the aortic root determine the extent of coronary bed filling by the desaturated blood ejected by the left ventricle during conventional lung support with extracorporeal membrane oxygenation (ECMO), unless turbulence is created close to the coronary ostia by high-flow bypass ratios (greater than 80% of cardiac output) or ascending aorta cannulation. Using a total right heart bypass preparation, we studied the effect of returning blood transseptally into the left atrium upstream to the coronary arteries by means of a specially designed double-lumen cannula inserted via the jugular vein. Desaturated blood was used in six dogs ventilated with 100% oxygen (Group A), and oxygenated blood was used in 10 hypoxic dogs (Group B). We observed homogeneous mixing of oxygenated and desaturated blood at wide ranges of bypass flow ratios (20 to 80%) as determined downstream to the left atrium, i.e., left ventricle, coronary artery branch, root of the aorta, and descending thoracic aorta. Adequate coronary oxygenation (PO2 greater than or equal to 60 mm. Hg) was obtained with 40% of cardiac output oxygenation, a flow that could be met with a single superior vena cava (SVC) cannula through the major lumen of such a cannula. Total avoidance of high-pressure arterial cannulation and homogeneous distribution of oxygenated blood, regardless of the bypass flow ratio, by this technique are obvious advantages not available with conventional ECMO cannulations.


Cardiac rhythm following exclusion of the sinoatrial node and most of the right atrium from the remainder of the heart. In this study two surgical interventions on the right atrium were followed by long-term observation of their effect on the cardiac rhythm. In the first, the sinoatrial (SA) node and a small area of surrounding atrium were excluded from the heart by a circumferential incision. This was followed immediately by an unstable junctional rhythm accompanied by periods of pacemaker arrest. After 14 days a rhythm, indistinguishable from sinus rhythm, became permanently established. On atrial mapping the area of earliest epicardial breakthrough was the low right atrium, indicating that the pacemaker was in this area. In the second procedure, most of the right atrium including the SA node was excluded by an incision from the remainder of the heart, but left in continuity were the left atrium, right atrium in the area about the coronary sinus and inferior vena caval ostium and the atrial septum (areas where the low atrial pacemakers are known to occur), and the ventricles. A permanent junctional rhythm associated with periods of pacemaker arrest was produced. In two dogs permanent atrial fibrillation eventually developed. The area of earliest breakthrough found on epicardial mapping was to the right of the right inferior pulmonary vein, close to the atrial septum. One of the differences between the two interventions was the amount of right atrium remaining between the potential low atrial pacemakers and the atrioventricular (AV) node. It is suggested that summation, a factor needed for the atrial excitation wave to penetrate the AV node, was inadequate in the more extensive intervention. This may explain the failure of a potential low atrial pacemaker to become dominant in the second intervention. The clinical implications of these findings are discussed.


Right atrial-right ventricular anastomosis for correction of tricuspid atresia. Previously reported methods for the correction of tricuspid atresia involve the use of conduits and/or valves. Since many of the younger patients will outgrow their conduits and the long-term durability of the valve prostheses is open to question, we have devised an operation in which the right atrial (RA) appendage is anastomosed to the right ventricle (RV) with the aid of a pericardial patch. The RV, if not too hypoplastic, is used as a pumping chamber and the pulmonary valve is in its normal position. Three patients, 8, 9, and 12 years of age, were operated on with good clinical and hemodynamic results. Postoperatively, all three were acyanotic and had improved physical capacity compared with their preoperative status. The RA pressure in the first two patients 1 year after operation was 12 mm. Hg and at angiocardiography the RA-RV anastomosis was widely patent. In one of the patients, the RV was too hypoplastic to function. It should be possible to perform this operation even in younger patients and it may eliminate the need for palliative procedures and reoperations.


Lymphoid neoplasia following connective tissue disease. A retrospective review was undertaken to ascertain whether there are distinctive histopathologic features of the lymphoid neoplasms that occur in patients with previous connective tissue disease. Of 29 patients studied, 12 had malignant lymphoma with diffuse large-cell cytomorphology. Only 1 of these 12 had an immunoblastic cell type. The remaining 17 patients had neoplasia of a widely diverse nature. Six had lymphocytic lymphoma (one nodular poorly differentiated, three diffuse poorly differentiated, and three diffuse well differentiated), two had Hodgkin's disease, three had plasma cell myeloma, and six had chronic lymphocytic leukemia. Data fail to confirm a relationship between lymphoid proliferations with immunoblastic morphology and connective tissue diseases.


Transmural eosinophilic gastroenteritis with ascites. An atopic patient with recurrent abdominal pain, diarrhea, and ascites was shown to have eosinophilic gastroenteritis. Transmural involvement was inferred from the findings of dense eosinophilic infiltrates in the jejunal mucosa and eosinophilia in the ascitic fluid. An impressive response to steroid treatment occurred. The reported cases of eosinophilic gastroenteritis with ascites are reviewed.


Chronic active liver disease with common variable hypogammaglobulinemia. Progressive liver injury in chronic active liver disease is usually associated with elevation of serum immunoglobulin levels. However, the role of immunoglobulins in the pathogenesis of this disease is still obscure. We report here the case of a 41-year-old man with hypogammaglobulinemia since at least 1964 in whom chronic active liver disease later developed. From 1954 he had had frequent respiratory tract infections, and these continued, along with diarrhea, despite regular gamma-globulin therapy. Studies in 1969 showed absent serum IgA and IgM and an abnormally low level of IgG. In 1974, liver enzyme abnormalities were recorded and a diagnosis of chronic active liver disease was made. A liver biopsy showed cirrhosis with active hepatitis. Lymphocyte function studies revealed that the T cells suppressed B-cell maturation and production of immunoglobulins. He was treated with azathioprine and prednisone, and this therapy has been associated with a decrease in both the elevation in liver enzymes and the frequency of infections. This case suggests that liver cell injury in chronic active liver disease is independent of the elevation of immunoglobulins and that immunosuppressive therapy may be well tolerated by patients with hypogammaglobulinemia.


Treatment of recurrent ventricular tachycardia by patient-activated radiofrequency ventricular stimulation. A new pacing technique may benefit selected patients with drug-resistant, chronic, recurrent ventricular tachycardia. This report describes two patients treated effectively with permanently implanted, patient-activated, radiofrequency ventricular stimulators. Both used the device successfully for repeated termination of episodic, sustained ventricular tachycardias. Optimal utilization of this technique requires extensive prior electrophysiologic assessment and drug trials, does not supplant continued drug therapy, and is not without potential hazard.


Pseudoepileptic seizures in children and adolescents. Eighteen patients ranging in age from 4 to 20 years who were seen at the Mayo Clinic from 1970 through 1976 for suspected epilepsy were studied. Seventeen of these patients had previously been treated with anticonvulsant medication, and the majority had been subjected to multiple diagnostic procedures. After careful analysis of their histories, clinical examinations, and appropriate laboratory studies, their seizures appeared to be nonepileptic in nature. Various psychogenic and other nonorganic causes were identified. These cases are presented to alert the physician to the not infrequent occurrence of pseudoepileptic seizures in children and adolescents who do not have epilepsy.


Unilateral essential hematuria.

Unilateral essential hematuria. At the Mayo Clinic between 1961 and 1975, 54 patients presenting with gross hematuria had "essential hematuria" of unilateral origin diagnosed. Criteria for this diagnosis included normal findings on excretory urogram, unilateral bleeding demonstrated at cystoscopic examination, the absence of infection, and a negative history for bleeding diathesis, analgesic abuse, renal surgery, or trauma. Of these patients, 52 responded to follow-up inquiry; 2 died of unrelated causes. Ancillary studies such as renal arteriography, renal biopsy, and repeated excretory urography and cystoscopic examinations were not helpful in establishing a cause, and no explanation for the hematuria was ever found in any of these patients. Although contributing no information as to the cause of unilateral essential hematuria, the study suggests that the patient who fulfills the above criteria need not undergo an extensive workup beyong excretory urography and cystoscopy and that repeated examinations are unnecessary and unrewarding. Most patients continue to do well despite intermittent or persistent hematuria. Essential unilateral hematuria probably is a benign condition that seldom requires surgical intervention.


Horseshoe kidney associated with surgery of the abdominal aorta. Of 53 patients with horseshoe kidney (9 in the present series), 45 underwent operation for an abdominal aortic aneurysm: 40 electively and 5 on an emergency basis. The remaining eight patients underwent revascularization for arteriosclerosis obliterans. Of the 53 patients, 35 (66%) had renal artery anomalies. The anomalous arteries prevented aortic repair in 6 patients (17%), were left undisturbed in 9 (26%), were revascularized in 7 (20%), and were ligated in 13 (37%). Partial nephrectomy was required in 2 of the 13 patients undergoing arterial ligation. Symphysiotomy was performed in 16 (30%) of the 53 patients. The following approach to management of horseshoe kidney associated with disease of the abdominal aorta is suggested. 1. Whenever a horshoe kidney is suspected, excretory urography, aortography, and, if necessary, selective renal arteriography should be obtained preoperatively. 2. Anomalous renal arteries arising from resected segments of the aorta should be revascularized whenever technically possible, usually by reimplantation of the renal artery into the aortic graft. 3. If an anomalous renal artery is ligated, the kidney should be inspected for signs of ischemia, and partial nephrectomy should be performed if ischemia occurs. 4. Symphysiotomy should be avoided. If division is necessary, symphysiectomy is preferable to symphysiotomy. In either circumstance, care need be taken lest there be fusion of the urinary collecting system and the renal parenchyma. In most patients with horseshoe kidney, aortic surgery has been accomplished without complication and with only minor alteration in surgical technique, even when the renal anomaly is first detected at surgical exploration.


Patterns of ambulatory health care in five different delivery systems. Few empirical investigations permit systematic comparison of the impact of widely-varying delivery systems within a single population sample. This study provides such a comparison, describing patterns of ambulatory care among patients using five different systems in Washington, D.C. as a regular source of health care: solo practice, fee-for-service group practice, prepaid group practice, public clinics, and hospital outpatient departments or emergency rooms. Comparisons are adjusted statistically to account for major patient group variations, and the results reveal substantial differences among the five systems. Sources used primarily by the poor--hospital outpatient departments, emergency rooms, and public clinics--contained important structural and financial barriers, and had the lowest rates of patient-initiated use. The prepaid system, in contrast, maximized patient's access to both preventive care and symptomatic care, and did not seem to inhibit physician-controlled follow-up care. The results suggest some perverse effects of fee-for-service payment: patients, especially poor patients, appeared to be deterred from seeking preventive and symptomatic care, while physicians were encouraged to expand follow-up services. Moreover, services in fee-for-service systems were distributed less equitably relative to both income and medical need than in the prepaid system. These findings have direct implications for policy decisions concerning organizational and financial arrangements for the delivery of ambulatory care.


Consumer participation and community organization practice: implications of national health legislation. This paper reviews ten federal health laws from the perspective of the extent to which consumer participation had been incorporated as an integral aspect of health program, identifies some issues and dilemmas of implementing consumer participation activities, and offers suggestions for the involvement of consumer advocates. The review of the laws showed uncertainty of outcomes, conflicting philosophies, conflicting purposes, conflicting strategies, and conflicts relating to representativeness, legitimacy and consumer role. Despite the inconsistent record of Congress to legislate consumer participation, two recent health laws, P.L. 93-641 and Title III of P.L. 94-63, appear to offer major opportunities in promoting consumer involvement in planning and policy development activities. However, because these laws continue to delegate the responsibility for implementing consumer involvement programs to providers, established institutions and state agencies, consumer advocates are urged to increase their knowledge of the laws and to assist consumers to realize their right of self-determination. The cause is worthy and represents a desirable goal for public health--and in the final analysis, for the survival of our democratic society.


Institutional outpatient clinics: a case study in unmet needs. An outpatient clinic of a charity hospital, managed by a medical school of a large Latin American country, was studied to assess the characteristics of the patients and the management of their conditions. All medical records of registered patients of the clinic were abstracted for identification, demographic and clinical data, for two periods of one month each, yielding 2,153 patient observations. The study period represented 18 per cent of the total days of operation of the clinic in 1975. A 20 per cent stratified sample of all cases was studied in depth to characterize the management of patients. Up to 40 per cent of all patients were rejected by the clinic, a result of the system of selection and handling of the patients. Only 36 per cent of all patients received minimally satisfactory care when treated. These results are analyzed within the framework of the conflict between professional and academic values of the medical profession and the medical and social needs of the patients.


Active patient orientation and outcomes in hypertensive treatment: application of a socio-organizational perspective. In the area of chronic ambulatory illness, it is well recognized that poor participation by patients in the treatment process greatly limits the potential benefits of effective medical technology. Patients' contributions to treatment outcomes might be enhanced if medical care was oriented to consider patients as active participants in the treatment process, rather than as passive-obedient recipients of care. A systematic attempt is needed to define and measure services along a specific dimension of "Active Patient Orientation" and to relate these measurements directly to treatment outcomes. Applying a socio-organizational perspective, the study reported here examined the link between an active patient orientation and treatment outcomes. Hypertensive patients were asked to characterize their care along the dimension of Active Patient Orientation (APO). Findings indicate that patients who are afforded a high degree of APO are significantly more likely to have their blood pressures under control and to exhibit more positive cognitive and behavioral responses to illness-management. Further, the data suggest that level of APO can be significantly increased through incremental changes in systems of routine clinic care.


The relationship of an overt commitment to the frequency and speed of compliance with symptom reporting. This study investigates the effect of an overt verbal commitment on compliance with returning symptom report cards. Patients in two flu inoculation clinics were placed in an experimental condition. Patients in two other comparable flu inoculation clinics were placed in the control condition. After receiving their inoculations, all patients were asked to mail back a postcard after 48 hours that indicated the occurance of any symptoms. Patients in the experimental condition were asked if they would comply with the request. Patients in the control condition were not asked for a commitment. Patients in the experimental condition returned significantly more cards and significantly sooner than those in the control condition. This technique has both clinical and research applications.


Predicting blood pressure control in hypertensive patients: an approach to quality-of-care assessment. In assessing the quality of medical care, techniques were needed which can predict which patients are likely to have good or poor health outcomes. This study describes one way of identifying a subgroup of hypertensive patients whose diastolic blood pressures (DBP) are at high risk of remaining uncontrolled while under treatment. Medical care and patient variables were measured for 123 hypertensive medical clinic patients. Stepwise discriminant analysis identified a set of six variables which best distinguished between patients with well-controlled and uncontrolled DBP. When measurements of these variables were divided into high and low risk responses for uncontrolled DBP, the number of high risk variables was directly related to the proportion of patients with uncontrolled DBP. The variables also predicted DBP control among 63 patients in an entirely different medical care setting.


Forecasting bed needs and recommending facilities plans for community hospitals: a review of past performance. A university-based hospital consulting group reviewed six studies of Michigan hospitals retrospectively in 1975. The studies represented all those done between 1967 and 1971 requiring forecasts of acute bed supply and service needs. The original studies developed forecasts using empirical studies of patient origin and rigorously prepared authoritative forecasts of county populations. The 1975 review compared forecasts of population, service population, and bed need against current values and also interviewed clients to assess retrospective satisfaction with the recommendations. Although the consultants strove steadily to minimize the bed supply and base population forecasts were accurate, the studies overestimated bed needs. Further, the clients were often dissatisfied with the original recommendations, and frequently acted to exceed them. Comparing the 1975 actual with what would now be recommended by the consultant indicates that the "error" cost the communities about $50 per person per year.


Detection of cervical and breast cancer: a community-based pilot study. Pilot screening clinics were conducted in two Los Angeles County health districts where cervical cancer incidence and mortality rates were high. Results are of interest because they provide information on planning and operating community-based clinics in low-income areas where there are women who are unlikely to seek or are ineligible for available health services.


[Comparison of the results of incus interposition and artificial columella in tympanoplasty (author's transl)]. The average postoperative air-bone gap after interposition of an incus between tympanic membrane and stapes footplate is too high in case of missing crura of the stapes, it is 27 dB. The interposition of an artificial prosthesis, according to Shea and beeing made of "Platipore", leads to a statistically based lower air-bone gap with a mean of 20 dB. Concerning the change of bone conduction, there is no difference between these two methods of operation. The rate of artificial prosthesis which are perforating the tympanic membrane, increases after seven months up to 15%, but only 4% of the incuses invade the plane of the tympanic membrane after 22 months.


[Problems of autologic incus interposition in cholesteatoma operations (author's transl)]. Our clinical study proves whether or not the warning is justified not to reimplantate autologic ossicula in cholesteatoma operations in order to avoid recidives. After interposition of the autologic incus in 18 patients we found cholesteatome recidives--originating from the incus--in two cases. According to histological studies, even the most careful preparation cannot avoid that some cells of the epithelium remain on the ossicula, from which a cholesteatoma recidive may develop. Clinical studies show rather low rates of recidives compared with the histological findings. Possibly remaining squamous epithelium cells in autologic ossicles need not always cause recidives. Clinical and histological studies lead to the demand that because of the possibility of cholesteatoma recidives autologic ossicula should not be reimplated in cholesteatoma operations.


[The complex tympanic membrane impedance in various middle ear disturbances (author's transl)]. Clinical experience with two-component registration (Susceptance and Conductance) of the tympanic membrane impedance at two frequencies (220 and 660 Hz) is reported. More than 1000 results of the last 6 years have been evaluated. The normal tympanometric shape is confirmed by computer simulation. More information about mass and elasticity relations of the middle ear is obtained by the complex registration at 660 Hz. Clinical examples are presented to demonstrate the influence of scars on the ear drum and of a disruption of the ossicular chain. In 77 cases of otosclerosis with stapes fixation, as confirmed by operation, the shape of the pressure-dependent admittance is significantly narrower than in normal hearing ears. For a glomus tumor a pulsation of the oto-admittance following the electro-cardiogram can be shown. In a classification of the tympanometric types the different shapes correspond well to the set of functional finding (normal) ears, otosclerosis, Eustachian tube malfunction, processes of the middle ear cavity, post operation state). The extreme sensitivity of the method, however, produces a small group of unpredictable results for each type. So differential diagnosis is to be done by usual audiometric methods or microscopy of the ear drum.


[Critical review of the SISI-test (author's transl)]. For the last twenty years since the first publication the SISI-test (Jerger et al. 1959) is used as a standard test in audiometry, although the clinical utility has been doubted by many audiologists. The aim of this study is to show essential test-theoretical mistakes which exist--apart from the bad clinical results--in the SISI-test. The most important fault is, that the diagnosis of clinical groups is established by means of the comparison of different test-stimuli (different main intensities).


[Brainstem auditory evoked response (BER) in paedaudiological diagnosis (author's transl)]. Intention of paedaudiology is to detect and to evaluate hearing loss in children. In new born and small infants, in children with behavioral disorders and multiple disabilities, the clinical techniques of audiometry are often not useful. The brainstem audiometry is a reliable alternative and not so cost intensive and time consuming as it is often assumed. Encouraging is this technique in regard of hearing aids: prevention of attaching unnecessary hearing aids, ruling out not appropriate fitted hearing aids and proper habilitation of unilateral hearing loss.


[Tracheotomy superior, media and inferior? (author's transl)]. The traditional classification of tracheotomy in superior, media and inferior is not important. It only is important that the tracheotomy tube is in a tensionless position and does neither irritate the larynx nor the thyreoid gland. This can be obtained by strict conservation of at least the first tracheal ring and by dissection of the isthmus of the thyreoid gland.


[How to prevent the various neuralgic complaints after operation of maxillary sinus? (author's transl)]. In order to avoid multiple neuralgic complaints after operations of maxillary sinus the following advice for cautions operative procedures is as follows: 1. A vertical incision in the mucosa of the fossa canine behind the eye-tooth instead of the usual horizontal section. 2. A small dorsolateral fenestration in a part of less nervous ramification in the facial bone layer of the antrum of High-more. 3. The limitation of resection of the mucous membrane in pathological areas of the sinus. 450 operations of the maxillary sinus were done in this way, which resulted in a lower rate of postoperative neuralgic complaints. Another advantage was the minimized intraoperative bleeding and the absence of postoperative swelling and haematoma formation of the cheek.


[Monomorphous tubular salivary gland adenoma of the middle ear (author's transl)]. A case of monomorphous tubular salivary gland adenoma of the middle ear is presented. Ectopical tissue of salivary gland is conceived as a morphogenetic disturbance and is closely related to the n. facial. Case-taking, therapy, topogenesis and morphology are discussed.


[Extreme case of open laryngeal trauma (author's transl)]. Description of a very rare case of open laryngeal trauma, caused by a high-pressure 'cutting' waterjet. Immediate wound-toilet, healing without any complication within few days.


[Pathohistology of necrotizing sialometaplasia in parotid glands (author's transl)]. Under the descriptive term necrotizing sialometaplasia a lesion (infarct) is described in the minor salivary glands of the mouth, mucous glands in the nose and in the maxillary sinus. Identical changes are seen in the parotid gland after surgical treatment. In the German literature there is no report on necrotizing sialometaplasia or infarction of salivary gland. In this paper 6 infarcts of the parotid gland are reported. The pathohistologic picture is described, the proposed etiopathogenic factors are discussed. The diagnostic problems between the infarct of salivary glands and squamous carcinoma and low grade mucoepidermoid tumours were pointed out.


[About the estimation of human parotid gland amylase in fractionated secretions (author's transl)]. The amylases are the main proteins in parotid secretions. In 30 probands the amylase secretion is observed under rest and gustatoric and parasympathicomimetic stimulation. A stimulation specific behaviour of amylase secretion is found. Under parasympathicomimetic stimulation by subcutaneous injection of Pilocarpin a high increase of amylase concentration is observed, in comparison to gustatoric stimulation where the concentration doesn't change. Different enzymatic activities of amylase under rest- and stimulation-conditions couldn't be found.


[Hereditary combination of branchial fistulas and middle ear malformations (author's transl)]. Four cases with hereditary combinations of branchial fistulas and middle ear malformations in three generations of one family are reported. We found preauricular fistulas and lateral cervical fistulas combined with different types of middle ear dysplasias. In one case a preauricular fistula running through the middle ear and ending in the dura could be exstirpated. Such rare varieties must be considered, when preauricular fistulas are found together with congenital middle ear deafness.


[Chronic pancreatitis: diagnostic value of endoscopic retrograde pancreaticography, of pancreatic sonography, and of secretin-pancreozymin test corrected for volume losses (author's transl)]. Endoscopic retrograde pancreaticography (ERP) and secretin-pancreozymin test corrected for losses (SP test) were performed in 153 patients suspected to have pancreatic disorders in order to evaluate diagnostic significance of these procedures. Pancreatic sonography was done in addition in 110 of these patients. If pancreatic excretion was normal, ERP results turned out to be normal in the same patients as well. SP test involves rather extensive laboratory work-up, but it does yield the most precise results as far as diagnosis of chronic pancreatitis is concerned. For this reason, and because of the possible complications caused by ERP, ERP should be applied only, when surgery is considered. Results of SP test and sonography coincided rather well. Therefore, sonography, not doing any harm to the patient, does have its place in the diagnosis of chronic pancreatitis.


[Chronic atrophic gastritis: histological studies of stomachs removed by surgery (author's transl)]. Partial gastrectomy was performed in 23 patients for different reasons, and the specimens recovered were investigated histologically. Localization and size of inflammatory and atrophic changes were looked for especially. Inflammatory lesions of the fundus area are distributed primarily as spots and do not spread continuously; they extend from the aboral gastric region to the upper parts of the stomach. These alterations start as small and spot-like lesions, increase in size and join neighbouring lesions to form larger inflammatory areas. Atrophic alterations of the mucosa generally develop in the same way as inflammatory lesions occurring most frequently in the antral zone and in the adjacent areas of the fundus as well; however patterns of distribution of inflammatory and atrophic changes do not seem to correlate well in the individual case.


[Cimetidin treatment of duodenal ulcer resistant to antacid therapy (author's transl)]. A selected group of 21 patients having received antacids (neutralizing capacity less than 50 meq HCl/d) as treatment for duodenal ulcers showed no improvement of the disease as demonstrated by endoscopic control after 8-16 weeks. Subsequent treatment of this group with 1 g Cimetidin/d for periods of 4-8 weeks was successful as far as healing of the ulcers is concerned in 85% of the cases, however symptoms of duodenitis persisted. In a control group of 39 patients which did not improve after 8 weeks of treatment with antacids the same therapy was continued for another 8 weeks; during this second period ulcers disappeared in 12 patients = 30% of the group. Improvement of symptoms resulted on the average after 6 days of therapy with cimetidine. One third of the patients treated with cimetidine relapsed with ulcers after approximately 4 months as demonstrated by endoscopy. Patients with duodenal ulcers resistant to therapy with antacids do represent a selected group suited to test the potency of new therapeutic methods as for instance treatment with cimetidine.


[Immunoglobulin producing immunoblastoma of the duodenum (author's transl)]. A case report is given of a 32 year old patient harboring an immunoblastoma of the duodenum. Immunoglobulins could be demonstrated histologically in the tumor cells for the first time by a special technique. Clinical and morphological findings are discussed.


[Relapsing lipomatosis of the ileocolic junction after surgery (author's transl)]. A 58 year old women had massive hemorrhage from ulcers originating from lipomatosis of the ileocecal valve. The tumor and part of the intestine were removed by ample surgical resection and ileo-ascendostomy was performed. The patient relapsed 11 months later with hemorrhage and lipomatosis adjacent to the anastomosis established surgically 11 months before. This case report demonstrates that lipomatosis does not only occur at the ileocecal valve but as well at junctions established artificially between ileum and colon. The reasons for this latter event are unknown.


[Surgical management of incontinence in rectal constipation (author's transl)]. In rectal constipation chronic filling of the rectum with feces will cause continuous rectal dilatation, a permanent stimulus for defecation and finally rectal incontinence. Reduction of rectal volume and perfect continence may be achieved in these cases by surgical removal of part of the elongated colon; thus surgery may have its place as an alternative to medical treatment of this disease. Patients with rectal constipation do not have an aganglionic segment of the colon, as is the case in Hirschsprung's disease; the dilated part of the colon is characterized on the contrary by hypertrophic intestinal wall.


[Operational control of the effectiveness of assisted blood circulation]. Introduction into the clinical practice of methods providing for mechanic support to the heart demands equipping the apparatus of assisted circulation with appliances, helping to operatively assess the effect of applying some or other procedures helping the heart performance. The existing criteria do not allow the degree of restoring the contractility of the myocardium under the effect of assisted circulation to be appraised. Criteria may be of help in comparing the energy balance of the myocardium with application of assisted circulation and the energy balance of an unloaded myocardium are proposed.


[Possibility of using DST-30 thermoelastoplast in blood transfusion systems]. Investigating possible application of the DCT-30 thermoelastoplastic shows advantages of some physico-technical properties of this product based on natural caoutchouc and latex by comparison with base-rubber onene. It justifies recommending the former for making injection tubes in the blood transfusion systems.


[Technology of preparing gauges for calibration of medical syringe cylinders]. Thermal treatment substantially influences the resistance of calibres used in mollification (vacuum calibrating) of glass cylinders for medical syringes, the highest resistance of calibres made of the XH32T alloy and the 12X18H10T steel being achieved through their preliminary annealing in the argon atmosphere. The quality of manufactured syringes is affected also by wrong calibres shape and, formostly, by their out-of-roundness, whose degree in individual cases reaches 2--3 micrometer.


[Method of determining the aggregational properties of the formed elements in blood]. A theoretical analysis of the filtration dynamics showed that the hydrodynamic resistance of the filter and the time of the blood flow proportional to it is determined by the degree of aggregation and adhesion of the constituents. The design of the device and the sequence of operations for investigating the influence of the pharmacological agents on the aggregation of cells are described. A micromethod with the use of Panchenkov's device has been devised, which enables the aggregation of cells in the blood drawn through a puncture of the finger to be investigated.


[Evaluation of the functional and clinical qualities of the new GSG-2 dual-sensor gamma-topograph]. A double-sensor gamma-topograph model GSG-2 has been constructed to realize colour shade lining and black-and-white photographic registration of images reflecting spatial distribution of radioactive isotopes introduced to patients for diagnostic purposes. On the ground of trial tests the valuation of functional and clinical qualities of the device is given.


[Operating characteristics of EK1T "Malysh" electrocardiographs]. In terms of features specific for the operation of the single-channel transister electrocardiograph EK1T "Malysh" a number of recommendations aimed at improving the quality and accuracy of reproducing electrocardiograms are proposed.


Maternal serum metabolites during prolonged starvation in pregnant pigs. Pregnancies in pigs were sustained during periods of prolonged starvation in spite of maternal body weight losses exceeding 40 kg. Maternal stores of protein were made available for feto-placental development during starvation of the dam. Concentrations of maternal serum proteins, urea nitrogen, electrolytes, and iron were determined in sequential blood samples of healthy Yorkshire pigs during a prolonged period of 40 days inanition (water only) in either the middle third (days 30-70) or last third (days 70-110). Serum protein levels remained similar to full-diet controls throughout these two periods, whereas serum concentrations of albumin and urea N increased primarily during the last third of gestation in starved dams. Serum Na+ levels declined during prolonged inanition while Ca2+ increased and K+ remained unchanged. It was only near term that Fe2+ levels decreased in those dams starved during a period of 40 days in the last third of pregnancy. These results indicated that maternal serum components were sustained at adequate levels to maintain normal development of conceptuses during prolonged starvation in either the middle third or last third of pregnancy in the pig.


The response to intravenous glucose of patients on maintenance hemodialysis: effects of dialysis. To learn whether a single dialysis can acutely improve the intravenous glucose tolerance (i.v.GTT) of chronically dialyzed patients, a standard i.v.GTT was performed on 10 nonobese uremic subjects on maintenance hemodialysis for 27 +/- 9 (mean +/- SEM) mo, and on a control group of 13 normal subjects. The uremic patients were tested first 0.2-17 (range) hr, and then 65-109 hr, from last dialysis. In the uremic sera, plasma glucose was analyzed by 4 methods; 2 reducing (neocopurine and ferricyanide) and 2 enzymatic (hexokinase and glucose oxidase). The reducing methods markedly overestimated plasma glucose concentration because of the presence of nonglucose reducing substances (notably, creatinine). This inteference was significantly cut down by dialysis. A single dialysis, on the other hand, failed to improve the glucose fractional decay rate (KG) computed from the glucose oxidase data (1.69 +/- 0.2%/min before and 1.35 +/- 0.1 after dialysis, versus 1.47 +/- 0.1 of the normal subjects). The same conclusion was derived from the data measured by the other 3 methods of glucose assay. Fasting plasma insulin concentrations were, on average, above normal (5.5 +/- 0.6 muU/ml) both before (12.3 +/- 2.7, p less than 0.05) and after (17.2 +/- 3.5, p less than 0.01) a single dialysis. Likewise, the area under the glucose-induced plasma insulin curve was significantly greater than normal (1.46 +/- 0.21 mU/ml . min) both before (2.26 +/- 0.34, p less than 0.05), and after (2.86 +/- 0.43, p less than 0.01) dialysis. A single dialysis had little effect on either basal or glucose-stimulated insulin release, and no significant difference in the insulinogenic index (insulin area/glucose area) was found between the control and the uremic group in either test. Insulin response was not correlated with KG, whereas it was significantly associated with higher triglyceride levels. Creatinine, urea or methylguanidine did not appear to have any influence on KG, but lower serum potassium levels were significantly associated with poorer i.v.GTT's. Plasma calcium bore a reciprocal relation to the insulinogenic index. Chronically dialyzed subjects show some degree of tissue insulin resistance, which a single dialysis fails to correct. Electrolyte disturbances may play a role in this metabolic derangement.


Factors altering platelet monoamine oxidase. The influence of oral glucose intake. The specific activity of human platelet monoamine oxidase from control subjects undergoing glucose tolerance tests is reduced drastically. Three hours after intake of 100 g of glucose only 25%-30% of the MAO-baseline activity was measured with tryptamine. beta-phenylethylamine and p-tyramine as substrates. At about 5 hr, platelet MAO activity has increased again. Inhibition was not due to small molecular weight inhibitors or other diffusible factors. Studies of other platelet enzymes, including succinate dehydrogenase and isocitrate dehydrogenase (NADP+ dependent) showed no parallel reductions; hGH, insulin, blood glucose and platelet glycogen concentrations did not correlate with platelet MAO activity. The changes of MAO activity in respect with p-tyramine and tryptamine as substrates 24 hr after glucose ingestion suggest changes of the lipid microenvironment of this enzyme of the outer mitochondrial membrane.


Sterol and bile acid metabolism during development. 3. Occurrence of neonatal hypercholesterolemia in guinea pig and its possible relation to bile acid pool. The relationship of the changes in plasma cholesterol to bile acid pool was studied in the newborn guinea pig. Plasma cholesterol reached the maximum on the fifth day and gradually declined to adult levels. The cholesterol concentration in the high density lipoproteins (HDL) was higher in the newborn guinea pig than in the adult. Plasma triglycerides peaked on the third day and decreased markedly. The bile acid pool increased progressively after birth with a 13-fold increase at 5 days of age. While the hepatic triglycerides decreased sharply in the newborn guinea pig, hepatic cholesterol increased in the first 5 days and then decreased to adult levels. This study has described the occurrence of "neonatal hypercholesterolemia" in the guinea pig and its possible relationship to the low level of bile acid synthesis.


Triiodothyronine turnover studies in euthyroid patients with autonomous thyroid nodules. Triiodothyronine (T3) kinetic studies were carried out using 126I-T3 and the single injection technique in eight clinically euthyroid patients with autonomous thyroid nodules and the metabolic results were compared to those obtained in a group of 12 healthy control subjects. Plasma labeled T3 concentration was measured by a chromatographic method based on the extraction of the hormone on Sephadex G-25 columns, followed by its elution with a specific anti-T3 antiserum. The analysis of the experimental plasma disappearance curves of the labeled hormone was performed using the noncompartmental method. The results obtained showed a significantly increased metabolic clearance rate of T3 in the patients with autonomous thyroid nodules, as compared to the control group. On the average, the T3 production rates were increased more significantly than the corresponding circulating levels of the hormone, therefore, suggesting that the significant TSH inhibition observed in the euthyroid patients with autonomous thyroid nodules could be related with an increased peripheral utilization of triiodothyronine.


Purification and characterization of a troponin C-like phosphodiesterase activator from bovine thyroid. A troponin C-like phosphodiesterase activator from bovine thyroid has been purified to homogeneity. The overall purification was about 9,800-fold with a yield of 8%. Bovine thyroid activator protein is identical in biologic properties to that isolated from bovine brain. They have the same specific activity regarding stimulation of bovine brain cyclic nucleotide phosphodiesterase. Both proteins form a Ca2+-dependent complex with heart muscle troponin I which is stable in 6M urea-polyacrylamide gel and which is similar, but not identical, to the troponin C-troponin I complex. The physiochemical properties of bovine thyroid activator protein are identical with those of bovine brain and other phosphodiesterase activator proteins and are similar to heart muscle and skeletal muscle troponin C as follows: (A) they bind 3-4 exchangeable calcium ions/mol with dissociation constants between 10(-5) and 10(-6) M, (B) they are highly acidic with a high content of aspartic and glutamic acids and isoelectric points of approximately 4.1, (C) these proteins have an unusual ultraviolet absorption spectrum with six discrete maxima between 250 and 284 nm which are characteristic of phenylalanine and tyrosine, and (D) these proteins have a low content of cysteine, histidine, tyrosine and proline. The tryptic peptide maps of bovine thyroid and brain activator protein are very similar. However, despite a very similar amino acid composition, the peptide map of bovine heart muscle troponin C is significantly different from that of the other two proteins. The molecular weight of thyroid and brain activator protein is 16,500, while that of heart troponin C is 18,500. Thyroid and brain activator protein, as well as heart troponin C, appear to undergo significant Ca2+-dependent conformational changes, as measured by the difference in the circular dichroism spectrum and electrophoretic mobility observed in the presence and absence of calcium ion.


Carbohydrate metabolism in lean and obese Zucker rats. Carbohydrate metabolism was evaluated in lean and obese Zucker rats. Plasma glucose concentration, renal and hepatic gluconeogenesis, and hepatic glycogen content and rates of synthesis were investigated in 2-mo and 8-mo-old animals. Mild hyperglycemia was observed in obese Zucker rats compared to lean rats and was more pronounced in males than in females. Rates of glucose disappearance were normal in both female and male rats, although there was a trend toward decreased clearance in the male. Total organ hepatic and kidney PEPCK activity and kidney glucose production were elevated in obese compared to lean rats. Total organ hepatic glycogen levels and rates of glycogen synthesis were increased significantly in obese compared to lean, the increase being greater in males than females. The mild hyperglycemia present in obese Zucker rats is not associated with delayed disappearance of intravenously administered glucose, but may be due to the increased production of glucose by whole kidney and liver.


Effect of glycerol on triglyceride metabolism in the rat. Lipid metabolic studies were carried out on the male Wistar rats fed on glycerol-rich diet in order to elucidate the mechanism of glycerol-induced hypertriglyceridemia. No difference was found between the glycerol fed rats and the control rats in the rate of triglyceride secretion from the liver measured by the Triton WR-1339 method as well as in the rate of incorporation of labeled glycerol into liver triglyceride. The facts that the half-life of the intravenously injected Intralipid in the blood was significantly delayed in the glycerol fed rats and that the lipoprotein lipase activity released from epididymal adipose tissue of the glycerol fed rats was markedly decreased to 19% of that of the control rats seem to account for the serum triglyceride elevation induced by the glycerol feeding.


The peritoneal absorption of insulin in diabetic man: a potential site for a mechanical insulin delivery system. The potential of the peritoneum as a site for an "artificial beta cell" was studied. Three 14-hr studies were performed in an insulin-dependent diabetic male maintained on chronic peritoneal dialysis. All studies were performed between dialyses and throughout three standard American Diabetes Association (ADA) 600 calorie meals. The degree of insulin absorption from the peritoneal space was assessed by measuring the changes in plasma-free insulin concentration during these studies. The results of this study demonstrate that normalization of plasma insulin profiles may be observed with the administration of insulin into the peritoneal space. This absorbed insulin exerts hypoglycemic activity that suppresses the meal-induced rise in plasma glucose concentration. Thus, the peritoneal space may be a feasible route into which insulin may be delivered by an artificial beta cell.


Glucose metabolism in man: responses to intravenous glucose infusion. We have determined the effect of unlabeled glucose infusions, with and without added insulin, on glucose metabolism in normal male volunteers by means of the simultaneous primed-constant infusion of 6-3H and U-13C-glucose. Glucose kinetics were measured after 90 min of infusion. When steady state had been reached, endogenous glucose production (2.53 +/- .058 mg/kg . min, X +/- SEM) was suppressed at all rates of exogenous glucose tested (1, 2, and 4 mg/kg . min). The absolute degree of suppression was most marked (75%) at the highest rate of infusion, but the greatest degree of suppression, relative to infusion rate, was at the lowest infusion rate. The control of plasma glucose concentration during the glucose infusion was achieved primarily through regulation of endogenous Ra. The rate of uptake of glucose only increased during the 4 mg/kg . min infusion, even though there were significant elevations in the plasma glucose and insulin concentrations during the 2 mg/kg . min infusion as well. The glucose clearance rate increased only when sufficient insulin was infused with the 4 mg/kg . min glucose infusion to control the hyperglycemia that developed if no insulin was administered. Approximately 43% of the infused glucose was directly oxidized when the infusion rate was 1 or 2 mg/kg . min. That value fell to 32% when the infusion rate was increased to 4 mg/kg . min, regardless of whether insulin was infused or not.


Differential effect of isoproterenol on acute glucagon and insulin release in man. In man, the infusion of arginine or isoproterenol elevates immunoreactive glucagon and insulin levels. Since arginine administered as a pulse stimulates the acute secretion of both hormones, and an insulin rise is observed after the bolus injection of isoproterenol, these findings probably represent a direct effect of arginine and isoproterenol on islet cells. To determine if there is an acute alpha-cell response to isoproterenol, we have administered this beta-adrenergic agonist as a bolus to healthy volunteers. Arginine administered as a pulse elicited both insulin and glucagon responses whereas pulses of isoproterenol, at half maximal and maximal insulin-stimulating doses, had little effect on glucagon levels. This relative insensitivity of the alpha cells to stimulation by isoproterenol suggests that endogenous beta-adrenergic tone may have a stronger influence on insulin than on glucagon secretion. Furthermore, these findings raise the possibility that beta-adrenergic regulation of plasma glucagon levels in vivo occurs by an indirect mechanism rather than a direct effect on the alpha cells.


Leucocytic movement and contractile protein. In a study on leucocytic movement, it was found that leucocytes showed periodical dynamic patterns with each motile function, and a possible organization in their motile system. It was also clarified that the motile form and function of leucocytes were co-ordinately controlled by the intracellular level of ATP and that the characteristic contraction wave observed in moving leucocytes was substantial as a morphological manifestation of the contractile element in moving leucocytes. Based on these findings, an attempt was made to extract contractile protein from leucocytes. It was shown that the protein consisted mainly of myosin and actin, which is similar to protein of muscle. Thus, it was concluded that development of the pseudopod, which is indispensable for cell movement, seemed to result from liquid substance in the granuloplasm being squeezed out through contraction of contractile protein located in the surface layer of the granuloplasm. In non-muscular cells, the same type of ordered structure as seen in muscle has not been found yet, but it seems likely that the protein is capable of converting chemical energy into movement.


The role of contractile proteins in wound healing and fibrocontractive diseases. During the healing of an open wound, the majority of granulation tissue fibroblasts (myofibroblasts) acquire morphological, biochemical, pharmacological, and immunological characteristics typical of contractile cells. The presence of contractile proteins and the appearance of gap junctions between several myofibroblasts make them similar to cultivated fibroblasts; these have been proven to develop in vitro a contractile force similar to that exerted by granulation tissue during wound contraction. These observations suggest that myofibroblasts are responsible for granulation tissue contraction. Epidermal cells moving over an open wound also develop a contractile apparatus and many cellular connections in the form of gap junctions. These changes may be the morphological support for epithelial cell movements. The presence of gap junctions between myofibroblasts and healing epidermal cells shows that granulation tissue contraction and epithelial cell movement are probably synchronized rather than individual phenomena.


The beginning doctor: a problem-based course for first year medical and dental students. A problem-based course designated as 'Beginning Doctor' was given to 136 first year medical and dental students. The students were divided into small groups and under guidance of a tutor studied largely unfamiliar clinical problems presented to them as written résumés. They determined what further information they required, obtained the information on their own and described it to the oters in plenary sessions. The tutors acted as facilitators of student learning rather than as sources of information. Contrary to the widely held assumption that students in these parts of the world are passive learners, incapable of taking direct responsibility for their own learning, the staff was pleasantly surprised to see the enthusiasm and the competence with which the students tackled the problems and easily adopted the self-learning mode.


Attitudes of Ugandan medical students toward 'straight' and 'modified' ECT. In Third World countries, limited resources of anaesthetists and resuscitation facilities mean that electroconvulsive therapy (ECT) is usually given 'straight' (i.e. without anaesthetic and muscle relaxant). This study compared the attitudes of Ugandan medical students towards ECT given straight and ECT administered with muscle relaxant and general anaesthesia (i.e. 'modified' ECT). Results confirmed the clinical impression that students regarded straight ECT as an inhumane method of treatment. However, whilst this was a major factor influencing students' preference for modified ECT as a treatment for themselves or for a close friend, it was relatively unimportant in determining their choice of ECT technique for a patient. Convenience of administration was the main criterion applied by students when deciding whether they would prefer to administer straight or modified ECT to a patient. Implications for medical education and the development of professional attitudes are discussed.


The urgent need to train orthopaedic surgeons in Third World countries. The paper stresses the need to train orthopaedic surgeons for Third World countries. The urgent need for such a programme is emphasized. A suitable training scheme is outlined which could be followed in any developing country to train its own orthopaedic surgeons of the future. The importance of training in the local environment is emphasized.


A course on collaboration between social workers and general practitioners during their vocational training. The educational programme reported was an experiment in the vocational training scheme of the department of General Practice, Erasmus University, Rotterdam, Holland, and is now part of the course. The programme focused on the training in team function (co-operation) given to trainee GPs and social workers. It became clear that both groups during their professional training develop markedly different attitudes and views about patient (client) care. These differences form a fundamental handicap in any discussion about teamwork. During the programme the students were made aware of this divergence of viewpoint and were taught how to handle these resulting handicaps and, if possible, to eliminate them.


Some notes on the admission of graduate applicants to the medical schools. A survey of the admissions policy adopted by the medical schools towards older applicants, and in particular graduate applicants, has been carried out. Some 1000 graduates applied for places in 1976, of whom about one in six was successful (compared with one in four for all applicants). The academic requirements for this category of student are normally at least an upper second class degree, age maxima vary from 25 to around 30 years and, increasingly, schools require a financial guarantee from students not in receipt of a Local Education Authority grant. A minority of medical schools reserve a proportion of places for older applicants, but only a very small minority of schools will consider reducing the length of their course for graduate entrants. These factors are tabulated for each of thirty-one of the medical schools in the United Kingdom and the Irish Republic.