Bacteremia and fungemia complicating neoplastic disease. A study of 364 cases. During a 14 month period there were 364 episodes of bacteremia and fungemia at Memorial Sloan-Kettering Cancer Center. The first nine months of the study were retrospective, and the next five prospective. In patients with leukemia or lymphoma (group 1), Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus were the most frequently isolated organisms. The mortality in this group was 40.5 per cent. In the patients with solid tumor (group 2), Esch. coli, Staph. aureus, Bacteroides sp. and Candida sp. were most frequent. Mortality was 27.8 per cent. The source of infection in both groups was often indeterminate. High mortality was associated with pulmonary and intraabdominal infection and with Ps. aeruginosa, K. pneumoniae or polymicrobic sepsis. Factors of prognostic significance were the causative microorganism, source of infection and shock. Although mortality was higher in patients with leukopenia than in those with normal leukocyte counts, the differences were not significant. The mortality in this series was low considering the severity of the underlying diseases and the immunosuppressed state of many of the patients. In a prospective, randomly controlled study, mortality was further diminished by infectious disease consultation at the time the positive blood culture was reported. Severe fungal superinfection, predominantly aspergillosis and candidiasis, was found in 52 per cent of the autopsy patients with leukemia or lymphoma (group 1), but in only 8 per cent of those with solid tumors (group 2).


Concurrent hypercortisolism and hypermineralocorticoidism. Hypertension and hypokalemia occur in patients with Cushing's syndrome whereas aldosterone production is normal and plasma renin activity is usually normal or increased. A normal aldosterone level in the face of suppressed plasma renin activity is unusual and suggests excess mineralocorticoid hormone activity. Our patient, who had Cushing's syndrome due to adrenocortical adenoma, can be classified as having low renin hypertension (suppressed renin and normal aldosterone levels). The mineralocorticoid hormone in excess was deoxycorticosterone which suppressed renin. The aldosterone production was normal and was produced solely by the adenoma. Contralateral adrenal gland suppression of both the zona glomerulosa by deoxycorticosterone via renin, and of the fasciculata by cortisol via ACTH was demonstrated after removal of the adenoma. Normal adrenal function was gradually restored.


A comparative study of CLEP scores between MT and MLT students. CLEP subject examinations for the areas of clinical chemistry, microbiology, hematology and immunohematology were administered to medical technology (MT) and medical laboratory technician (MLT) students. Test scores were analyzed and showed that MT students scored from 25% to 48% higher than MLT students. Mean percentile ranks were compared with college courses completed; these indicated that additional upper division academic courses raised the mean percentile rank. Results indicate that the Microbiology Category Examination evaluates general microbiology rather than clinical microbiology. Data in this study support the use of the CLEP examinations to measure cognitive knowledge of MLTs for upward mobility, thereby eliminating duplication of course content.


Sensitivity of cold hemagglutination testing as a function of red cell age. It has been suggested that freshly obtained red cells fail to agglutinate in the presence of antibody, and that the same cells left for several days at 4C in anticoagulant will usually be agglutinated by the same antibody, erythrocyte stabilization being responsible for this differential effectiveness of agglutination. Since supportive documentation for this assumption is not available, and since the concept of differential effectiveness of agglutination as a function of red cell age may be of great significance to the sensitivity of laboratory procedures which take advantage of antigen/antibody reactions, the above hypothesis was investigated using a cold agglutination procedure as a test system. Cold hemagglutination was chosen for reasons of expediency. Results of that investigation, possible explanations for the original hypothesis, and suggestions for further testing are presented here.


A comparison of diagnostic and certifying examinations. Testing and measurement represent a critical component of an educational system since they provide the essential information for making fundamental educational decisions. The type of information required in a particular situation determines how one should conceive, develop, and evaluate the measurement device. This paper compares certifying exams used to determine a person's overall level of competence, and diagnostic exams used to determine a profile of a person's strengths and weaknesses in a particular area. These two types of exams are discussed in terms of their associated educational problem, types of decisions required, optimal test development procedures, and appropriate forms of reliability and validity.


The association of maternal and neonatal thrombocytopenia in high-risk pregnancies. In this study of 136 women with pre-eclampsia, eclampsia, placenta previa, or abruptio placentae, 21 mothers were noted to have thrombocytopenia. Seventeen of the 21 were in the pre-eclampsia group. Of the 21 thrombocytopenic mothers, nine were associated with thrombocytopenia in the children, seven children had normal platelet counts, and five had no counts performed. Eight of the nine thrombocytopenic neonates were associated with pre-eclampsia in the mother, and five of these were not believed to have disseminated intravascular coagulation as the etiology of the platelet defect. The results suggest that thrombocytopenia is common in high-risk pregnancies in both the mother and the baby. However, the etiology of the platelet defect cannot be easily explained on the basis of a hypercoagulable state.


Ultrasound as an aid in intrauterine transfusion. Although the number of patients with Rh isoimmunization in pregnancy has been decreasing in recent years, intrauterine transfusion is still an important form of therapy for those patients whose infants have erythroblastosis. We have used both gray-scale and real-time ultrasonography for the last ten cases in which intrauterine transfusion was necessary. These techniques were used in preference to fluoroscopy and x-ray control to identify the placental site and fetal abdomen and to direct the insertion and placement of the transfusion needle. We were able to visualize the needle when it entered the amniotic cavity and the fetal abdomen. The technique afforded continuous visualization and a cross-sectional image of the fetus, steps which increase the efficiency and safety of the procedure and decrease radiation to the fetus.


The effect of progesterone on estrogen-induced uterine blood flow. The effect of progesterone on estrogen-induced uterine blood flow was investigated in repeated experiments in seven nonpregnant, oophorectomized ewes with chronically implanted electromagnetic flow probes and catheters inserted into branches of the uterine arteries. Administered alone, progesterone has no effect on base-line uterine blood flow. Following intramuscular injection of progesterone (3 to 5 mg-per kilogram of body weight), peak uterine blood flow responses to 1 microng of estradiol-17beta were suppressed by 25 per cent compared to those of control animals. Direct intra-arterial infusion of progesterone, at concentrations sufficient to reproduce uterine venous levels observed in late pregnancy in the sheep, inhibited estrogen-induced uterine blood flow by 20 per cent. The findings support the hypothesis that progesterone modulates the estrogen-induced flow responses in both the pregnant and nonpregnant uterine vascular bed.


Erythrocytic microcytosis: clinical implications in 100 patients. Hematology results from 3800 blood samples were examined for the presence of erythrocytic microcytosis. One hundred patients with electronically measured mean corpuscular volumes of 75 cubic microns or less were reviewed to determine the cause of microcytosis and evaluate recently described simplified techniques for separating thalassemia trait from other causes of microcytosis. The discriminant function formula of England and Fraser [MCV - RBC - (5 x Hgb) - 3.4] was found to be useful in uncomplicated patients with the Mediterranean type of thalassemia trait (betadegree) but less useful in the African type (beta+) of heterozygous beta-thalassemia. Anemias of chronic disorders were found to be a major cause of microcytosis. Microcytosis of no apparent cause was found in some children. Improved techniques in hemoglobin A2 quantification remain the best approach for detecting beta-thalassemia heterozygotes.


The relationship of mammary temperature to parturition in human subjects. Four hundred and seventy thermography studies were performed on 210 women to measure mammary temperature prior to, during, and immediately following pregnancy. Mean mammary temperature of 33.3 +/- 0.1 degrees C. (S.E.M.) obtained in 14 nonpregnant patients increased to 34.2 +/- 0.1 C. (S.E.M.) by nine weeks of gestation (p less than 0.01). The difference between mammary and sternal temperature was negative in the nonpregnant state and became positive after 18 weeks of pregnancy. Mammary temperature remained significantly higher in the pregnant group than in the nonpregnant group (p less than 0.001) up to term. In six postpartum patients, a further increase from prepartum values to 35.4 +/- 0.6 degrees C. (S.E.M.) occurred. The results suggest that relatively large changes in mammary blood flow and/or metabolic rate take place in human subjects in early pregnancy and on the day following parturition.


Subspecialization in obstetrics and gynecology. The formal development of subspecialities with obstetrics and gynecology has focused attention on problems of physician supply and demand. The need for subspecalized practitioners appears to be 750 in maternal-fetal medicine and 350 each in reproductive endocrinology and gynecologic oncology. Taken together, this number represents about 10 per cent of presently certified specialists. As supply is now developing, the demand in gynecologic oncology should soon be saturated, but there will be a longer term demand in maternal-fetal medicine and in reproductive endocrinology. However, the expectation of 30 per cent of present residents that they will enter subspecialities is far in excess of available fellowships or ultimate need. Fellowships leading to subspecialty certification should be approved by the Residency Review Committee, and numbers should be limited to best estimate of need.


The relationship between bone marrow sideroblasts and iron deficiency in chronically hemodialyzed uremic subjects. Bone marrow sideroblast counts were found to be persistently depressed to between 0 and 30 per cent in 24 uremic patients with residual renal tissue undergoing chronic dialysis therapy. Marrow sideroblastopenia notwithstanding, sideroblast counts in these subjects correlated well with iron balance, being respectively 6.6 +/- 0.8 (S.E.M.) per cent in iron depleted, and 18.2 +/- 1.7 per cent in iron-repleted individuals (p less than 0.0005). Following bilateral nephrectomy a persistent relative marrow sideroblastosis developed, counts reaching values of 46.5 +/- 3.1 per cent on average. It is suggested that this sideroblastosis is a response to reduced heme synthesis and reflects the iron removal function of ferritin granules within erythroid cells.


The prognostic significance of carcinoembryonic antigen in the plasma and tumors of patients with endometrial adenocarcinoma. Carcinoembryonic antigen (CEA) levels in plasma and the immunocytochemical detection of tumor CEA were studied in patients with endometrial adenocarcinoma treated at the University of Kentucky Medical Center from 1973 to 1976. The incidence of CEA elevation in a group of 60 patients varied directly with uterine size, histologic differentiation, and stage of disease. Immunoperoxidase staining for CEA was performed on 42 specimens, and four were positive, indicating a tissue concentration of CEA of at least 5 microng per gram. Following operation, CEA levels returned to normal within eight weeks in all but two patients, both of whom were later shown to have persistent or recurrent cancer. These data suggest that serial plasma CEA determinations may be useful in predicting occult recurrence of endometrial cancer in patients in whom the plasma or tumor initially contains elevated concentrations of this antigen.


Prognostic factors in Staphylococcus aureus endocarditis and results of therapy with a penicillin and gentamicin. Data on 40 patients with Staphylococcus aureus endocarditis treated with appropriate antibiotics in adequate dosage at the University of Cincinnati Medical Center hospitals between January 1961 and June 1975 were analyzed. The overall mortality was 40 per cent. The mortality was 11.1 per cent in patients under 50 years old and 63.6 per cent in patients over 50 years old (p less than 0.01). Seven patients were narcotic addicts who had no underlying disease and were under 50 years old; all survived. For patients without underlying diseases, the mortality was 0 per cent in those under 50 years old and 75 per cent in those over 50 years old. Patients who died had a greater number of major underlying diseases (pre-existing cardiac disease, diabetes mellitus, alcoholism and/or cirrhosis) than the survivors. Patients over 50 years old had significantly more major underlying diseases than patients under 50 years old (p less than 0.001). Among patients over 50 years old, those who died had more complications than the survivors while the number of underlying diseases were comparable. A group of patients treated with gentamicin during the first two to three weeks of therapy in addition to a penicillin was compared to a similar group treated with a single antibiotic. The mortality of both groups was 40 per cent.


Aspirin therapy in microangiopathic hemolytic anemia and renal failure. An 18-year-old man presented initially with findings compatible with disseminated intravascular coagulation. Following a brief partial response to intravenous heparin therapy rapid deterioration of renal function was associated with evidence of a hypercoagulable state characterized primarily by excessive platelet aggregation and sequestration. Initiation of aspirin therapy led to a prompt rise in the platelet count and permanent improvement in renal function.


Antidiuretic action of chlorpropamide in diabetes insipidus patients and in normal subjects. The antidiuretic action of chlorpropamide was studied in 10 diabetes insipidus patients sensitive to vasopressin and 15 normal subjects. After an oral load of water followed by sustained hydration through water ingestion in a volume equivalent to the urinary flow, chlorpropamide (4 mg/kg body weight) was intravenously administered as a single dose, either alone (34 experiments) or simultaneously with pitressin infusion (6 experiments). During the experiments, creatinine clearance as well as osmolal and plasma and urine electrolyte concentrations were measured. Several urine collection periods were made before and after the administration of chlorpropamide. In thes experimental conditions, chlorpropamide promoted a marked antidiuresis (p less than 0.01) in patients with diabetes insipidus and presented no antidiuretic effect (p greater than 0.01) in normal subjects, even with a double dose. However, if previously to the experiment, the normal individuals were dehydrated (mean weight loss of 4.8 per cent) or the diabetes insipidus patients were hydrated (mean weight gain of 6.4 per cent) a reverse behavior was observed: that is, the normal subjects did present (p less than 0.01) and the diabetes insipidus patients did not present (p greater than 0.01) antidiuresis to chlorpropamide. The results suggest that the state of hydration modulates the action of chlorpropamide in a way apparently independent of the antiduretic hormone.


Non-contact and Mackay-Marg tonometry: comparison in patients ages 7 to 85 years. In a sample of 212 eyes of patients referred to an ocular pathology clinic, measures of intraocular pressure (IOP) using the non-contact tonometer (NCT) and the Mackay-Marg tonometer were highly correlated (+0.91), the NCT MEASURES BEING LOWER BY AN AVERAGE OF 6.5 MM Hg. In a general optometry clinic, the mean IOP as measured with the NCT on 987 eyes of patients, ages 7 to 85 years, was 15.7 mm Hg (S.D.=3.5 mm Hg). Stability of IOP was age, found for this sample, is unexpected if IOP is proportional to systemic blood pressure which rises with age. Several hypotheses propose to explain the apparent inconsistency.


An examination of Ball's desaturation of intermittent monochromatic light in two patients with retinitis pigmentosa. In 1971, Walters hypothesized that Bartley's brightness enhancement, the Broca-Sülzer phenomenon, and the desaturation of intermittent trains of short-wavelength monochromatic light (the Ball effect) were all the result of scotopic involvement at photopic levels. In support of this hypothesis, ERG data were presented showing the presence of a scotopic B-wave under conditions which normally did not produce them. In the present paper, data are presente from two patients with retinitis pigmentosa that seem to contradict Walters' hypothesis and to suggest the possibility of a more complex mechanism.


Direct readout of spectral sensitivity for clinical and research purposes. The application of spectral sensitivity measurements to clinical problems has been limited by the complexity of calculating the corrections for nonlinearity and non-neutrality of the neutral wedge and for the quantum intensity of the test beam. Asimple electronic system is described which performs all these calculations automatically, as the subject makes the sensitivity setting, and records the sensitivity on an XY plotter. A range of 5 log units is covered with an accuracy of 0.05 log units.


The topology of hair streams and whorls in man, with an observation on their relationship to epidermal ridge patterns. Hair slope, whorl, cross and field formation is expressible in a topological form. The mathematical description required suggests an origin for the patterns in a growth process occurring in the upper dermis which determines the patterns of the hair slope. The formulae proposed by Euler, Poincaré and Ludwig are adopted as a descriptive method for the analysis of hair patterning resulting from hair slope. A unitary theory for hair streams and fingerprint patterns is suggested by the discovery, on one remarkable human foetus, of sites where epidermal ridges and convergent hair whorls were combined. Placement of the parietal scalp whorl in man is linked to hominid brain and skull development, and its associated hair field is noted to be bipartite, as revealed through patterns of differential hair loss.


Genes and people in the Caspian Littoral: a population genetic study in Northern Iran. Data for the distribution of alleles controlling two blood group systems and secretor status, for hemoglobin types, five serum protein groups and 15 red cell enzyme systems has been obtained. Eleven of the systems showed polymorphic variation and these systems have been used to calculate genetic distances using Morton's Kinship measure. No systematic relationship between genetic distance and geographic location of linguistic affiliation is apparent. There is, however, an apparent cline of decreasing frequency of PGDc from east to west and also significant differences in the frequency of G6PD deficiency corresponding to variation in the ecology of the region. Genetic distance comparisons with other selected populations reveal that the Turkic and Turkoman speaking peoples in the Caspian area cluster with the Kurds, Greeks and Iranis. The Persian speakers are genetically remote from these populations; they are, however, close to the Parsis who migrated from Iran to India at the end of the Seventh Century A.D. Several unusual genetic variants were detected, including a novel MDH phenotype, a superoxide dismutase phenotype identical with the Scandinavian type, and rare forms of LDH, PGM locus 2, ceruloplasmin, diaphorase, peptidases and PHI.


Successful rehabilitation following amputation of dominant versus nondominant extremities. In a study of 154 lower extremity amputees who received prostheses, those patients who lost a left lower extremity tended to make better progress in rehabilitation than those who required a prosthesis for the right leg. Eighty-three percent of the amputations were performed for vascular disease with no right-left difference. Heart disease played a greater role as a factor in limiting rehabilitation in those with left limb loss. Goals set and attained for loss of the left leg were higher than those for loss of the right leg. Left leg amputees can navigate more frequently without aids than can the right leg amputees. The use of a cane made both groups equal in rehabilitation time. Patients with a loss of the left leg attained maximum benefits of rehabilitation sooner than their colleagues with a loss of the right leg. Differences were nearly 2.3 weeks when the median was 22 weeks.


Defective enamel histology of prehistoric teeth from Illinois. Histological enamel defects have been used as indicators of childhood morbidity and nutritional inadequacy. However, the usefulness of these defects has been hampered by a lack of clear criteria for differentiating normal and defective enamel. This report demonstrates that the criteria of abnormal prism structure can accurately differentiate defective enamel (i.e., pathological bands) from normal enamel. In addition, pathological bands can be divided into three distinct subtypes: distorted structure bands, black spot pathological bands, and structureless pathological bands. It has been assumed that the patterning of pathological bands and enamel hypoplasia is the same for all populations. Comparisons between populations show that each population has its own unique pattern. It has also been assumed that striae of Retzius, pathological bands, and enamel hypoplasias represent three grades of severity of the same phenomenon. Correlations between these three features demonstrate instead that this patterning is possibly influenced by the morphology of the teeth.


Masticatory function and post-Pleistocene evolution in Nubia. The present research focuses on craniofacial variation in Nubia over approximately 10,000 years. Samples were grouped according to their temporal location and subsistence pattern, and represent a transition from a hunting-gathering adaptation (Mesolithic) to a transitional hunting-gathering-agricultural adaptation (A-C Group) and finally to a fully agricultural adaptation (Meroitic/X-Group/Christian). The purposes were: (1) to compare the Mesolithic sample with the later Nubian populations; and (2) to evaluate further the hypothesis that change in Nubian craniofacial morphology was due to changing functional demands associated with the progressive change in subsistence adaptation and associated behavior. The results tend to support recent views that the Nubian Mesolithic population is probably ancestral to later Nubian groups, and that the masticatory-functional hypothesis can best account for craniofacial change among the Nubians since 12,000 B.P. According to this hypothesis systematic reduction in functional demand placed on the masticatory complex from the Mesolithic led, secondarily, to an alteration of the growth of the maxillomandibular complex such that the face became progressively less robust and more inferoposteriorly located relative to the cranial vault. Both the increase in the height of the vault relative to its length, producing a more "globular" appearance, and the reduction in dental size were tertiary, compensatory responses to altered facial size and position.


A low-cost signal averager and data-acquisition device. A low-cost data-acquisition device, which can be used as a signal averager or temporary data buffer, is described. It consists of 1) an input stage built with a multiplexer, sample-and-hold amplifier, and an analog-to-digital converter; 2) a memory section made of static shift registers with recirculate capability; 3) an output stage built with a demultiplexer and a digital-to-analog converter and, 4) a control module which provides the logic signals to operate the machine. Basic diagrams are presented and several applications are described.


Biliary transport of cholephilic dyes: evidence for two different pathways. The hepatobiliary transport of three structurally related phthaleins was compared in the rat, and found to differ to a large extent in three experimental conditions: 1) after a 72-h fast; 2) after a 4-day phenobarbital treatment; and 3) during infusion of bile salts: sodium dehydrocholate or taurocholate. In the fasting group, bile flow and bile salt excretion (on a whole liver basis) decreased by 49 and 41%, respectively; bromsulphthalein sodium (BSP) and dibromsulphthalein sodium (DBSP) transport maximum (Tm) were reduced by 59 and 50%; however, rose bengal (RB) Tm remained normal. Phenobarbital pretreatment yielded a 44 and 29% increase in BSP and DBSP Tm, respectively, whereas RB Tm remained unchanged. Dehydrocholate infusion caused a 27 and 49% increase in BSP and DBSP Tm, whereas RB Tm increased by 12%. On the contrary, equimolar taurocholate infusion yielded a more important increase in RB Tm (56%) than in BSP and DBSP (31 and 22% respectively). It is suggested that RB does not share the same liver-to-bile excretory pathway as that of the former molecules. Our results emphasize the difficulties in predicting the biliary excretion of foreign compounds, even when their structure is closely similar.


A prosthetic appliance for a patient with a brachial plexus injury and forearm amputation: a case report. Among the prosthetic and orthotic appliances available, neither a conventional mechanical prosthesis nor the myoelectric control system provided optimal results for a 19-year-old patient with a traumatic, irreversible paralysis of the brachial plexus and below-elbow amputation. A new device was therefore constructed that combined the mechanical pull of the first system and the electric hand of the second. Its functions, the training program, and the end result are reported.


Fetal metabolic response to maternal fasting in the rat. To determine the fetal response to altered maternal fuel supply, the effects of prolonged maternal fasting, begun 24-96 h before term, were examined and compared with values from normally fed term animals. Fetal weight decreased only after 48 h of maternal fasting. Prolonged maternal fasting was associated with low blood glucose, high blood ketone bodies, and decreased gluconeogenic substrate in the fetus. Plasma insulin was decreased, whereas plasma glucagon was increased in the fetus of fasted mothers. Infusion of [2-3H]glucose into the mother to constant specific activity gave a ratio of maternal to fetal glucose activity of 1.0 in fed and 1.56 in fasted mothers. Fetal liver from fasted mothers showed both increase in activity of key gluconeogenic enzymes (glucose-6-phosphatase and phosphoenolpyruvate carboxykinase) and increased conversion in vitro of lactate, alanine, serine, and glycerol in glucose by liver slices. It is inferred that maternal fasting induces fetal substrate alterations and hormonal changes appropriate to premature appearance of hepatic gluconeogenesis. The priority for endogenous fuel provision in this state leads to impaired fetal growth.


Compartment analysis of metabolism of chromium(III) in rats of various ages. The metabolism of chromium(III) was studied in groups of female Wistar rats of various ages (35, 60, and 120 days) after a single intravenous injection of 51CrCl3 in trace amounts. In all the animals, the plasma disappearance curve could be adequately described by a sum of three exponential terms between 0 and 265 h postinjection. A three-compartment mammillary model is proposed that permits the description of Cr(III) metabolism in quantitative terms. The model defines compartment volumes, clearances by exchange, and clearances by excretion. The total excretory clearance is the sum of three components: urinary clearance (fu), fecal clearance (fd), and a residual clearance (fs), corresponding to an apparently irreversible deposition of chromium into long term body reservoirs. The parameters of the model are reported for each age group; when their values are expressed per 100 g of body wt, all the components of the excretory clearance decrease with age. In all cases elimination takes place primarily via the urine and fs accounts for 31-41% of the total excretory clearance. Consistent with the model, 51Cr was found to accumulate with time in several organs such as bone, kidney, spleen, and liver after a single intravenous injection of 51CrCl3.


Unidirectional influx of glutamine and other neutral amino acids into liver of fed and fasted rat in vivo. The fractional extraction of unidirectional influx of several neutral amino acids (glutamine, leucine, alanine, tryptophan, and cycloleucine) into rat liver in vivo is studied with a tissue-sampling, single-injection technique. Liver uptake of 14C-amino acid is expressed as an index relative to the hepatic clearance of a 3H-labeled water (3HOH) internal reference. The maximal fractional extraction of 3HOH influx into liver, 0.85, and the rate constant of 3HOH exodus back to blood, 0.87 min-1, provide an estimate of portal blood flow, 0.93 ml min-1 g-1, in the barbiturate-anesthetized, laparotomized rat. Given the extraction data for the 3HOH reference, liver uptake indices for the five amino acids studied are converted into maximal fractional extractions of amino acid influx into liver: glutamine, 0.72 +/- 0.03; leucine, 0.56 +/- 0.02; alanine, 0.43 +/- 0.04; tryptophan, 0.40 +/- 0.03; cycloleucine, 0.25 +/- 0.01; and sucrose, 0.09 +/- 0.02. The influx of glutamine and cycloleucine is shown to be increased (35%) with 48 h of fasting. These data indicate that glutamine penetrates the liver cell membrane faster than any of the 19 amino acids studied thus far. The rate of unidirectional influx of glutamine and other amino acids into liver is estimated and reveals that the capacity of liver cells to transport amino acids is severalfold greater than that of other organs such as brain or muscle.


Development in calves and heifers after hypophysial stalk transection or hypophysectomy. Growth was inhibited markedly in prepuberal bull and heifer calves after either hypophysial stalk transection or hypophysectomy as compared with that found in sham-operated calves or in unoperated calves. Male mounting behavior and evidence of puberal estrous behavior were lost or undetected after hypophysial stalk transection or hypophysectomy. Testes regressed, contained few spermatogonia and interstitial cells, and lacked spermatogenesis. Epithelial cells of seminal vesicles, bulbourethral glands, and prostate were cuboidal, indicating inadequate testicular androgen. Atresia of numerous ovarian follicles and reduced ovarian weight occurred in hypophysectomized heifer calves. Graafian follicles regressed after hypophysial stalk transection of sexually mature heifers, but ovaries responded to pregnant mare serum and human chorionic gonadotropin by follicular development, ovulation, and formation of multiple corpora lutea. Thyroid and adrenal gland weights decreased and adrenal cortices atrophied after hypophysectomy, but not after stalk transection. Thyroid glands contained colloid-filled follicles with flattened epithelial cells; atrophy was more extensive after hypophysectomy. Hypophysial stalk transection or hypophysectomy severely depresses growth and arrests sexual development in young calves, but in mature animals exongenous gonadotropins can sustain gonadal function.


Vagotomy impairs pentagastrin-induced relaxation of canine gastric fundus. In eight dogs, a separated, vagally innervated pouch was made from the gastric fundus. Electrodes were implanted on the pouch, and an antral gastric fistula was created through which gastric juice was drained externally during all tests. After recovery, the fasted, conscious dogs received intravenous infusions of 154 mM NaCl to which randomly selected doses of pentagastrin were intermittently added while intraluminal pressure and electric activity of the distended pouch were recorded. Transthoracic vagotomy was then performed, and the dogs were restudied. Before vagotomy, pentagastrin decreased the amplitude of the phasic changes in intraluminal pressure and of the bursts of spiking potentials of the pouch. The D50 for inhibition of mean intrapouch pressure was 4.2 ng/kg per min. After vagotomy, pentagastrin still decreased intrapouch pressure and inhibited fundal spikes, but larger doses were required to produce equivalent decreases in pressure. The D50 was 41.4 ng/kg per min after vagotomy. Our conclusion is that pentagastrin-induced relaxation of the canine gastric fundus is impaired, but not abolished, by vagotomy.


Brain serotonin turnover in chronically uremic rats. Brain serotonin turnover was investigated in chronically uremic and sham-operated pair-fed control rats. Animals were injected ip with 100 mg/kg body wt of pargyline HCl, a nonreversible monoamine oxidase inhibitor, and decapitated 0, 30 and 60 min later. The level of total tryptophan in plasma was decreased, and that of free tryptophan was increased in the uremic group. Uremic and control rats had similar concentrations of tryptophan and serotonin at 0 and 30 min after pargyline administration. However, the brain serotonin concentration was elevated in the uremic group 60 min after pargyline treatment. The brain serotonin turnover rate was higher and serotonin turnover time was lower in the uremic group. These results indicate that uremic stress, in addition to altering plasma tryptophan levels, also affects brain serotonin turnover.


Migrating action potential complex of cholera: a possible prostaglandin-induced response. Distal ileal loops of New Zealand white rabbits exposed to cholera toxin demonstrated the presence of a highly organized myoelectric pattern defined as the migrating action potential complex (MAPC). We investigated the mechanism by which cholera enterotoxin stimulates MAPC activity. Certain anti-inflammatory drugs have altered the secretory component of cholera diarrhea. We investigated effects of these anti-inflammatory drugs on the MAPC. Indomethacin, 5.0 mg/kg iv, abolished all MAPC activity. Indomethacin, 1.5 mg/kg iv, or acetylsalicylic acid, 150 mg/kg given intragastrically, altered propagation velocity and at times its direction of propagation, but did not abolish the MAPC. An infusion of prostaglandin F2alpha, 2 microng/kg per min intraluminally, induced MAPC activity similar to that of the cholera complex. Indomethacin, 5.0 mg/kg iv, produced no significant changes in number of complexes or propagation velocity. These observations suggested that inhibition of the cholera complex by indomethacin may result from the alteration of prostaglandin synthesis and that prostaglandins may initiate the motility component of cholera diarrhea.


Lost mass and excretion as stimuli to parabiotic compensatory renal hypertrophy. To help determine the roles of lost renal mass and lost excretory ability in producing renoprival hypertrophy, observations were made in otherwise normal rats cross-circulated for 24 h with rats prepared in one of the following ways: bilateral nephrectomy, bilateral ureteral ligation, or bilateral nephrectomy with 24 h of uremia. Bilateral nephrectomy produced parabiotic increases in renal mass and in the average cellular concentration of RNA: bilateral ureteral ligation did not. Uremia did not potentiate the effects of bilateral nephrectomy. Lost mass is the determinant of compensatory renal hypertrophy.


Effects of alpha-adrenergic blockade on renal function in hemorrhagic shock. This study was undertaken to determine whether alpha-adrenergic blockade would reverse the altered kidney function in hemorrhagic shock. Urinary excretion of Na+, K+, and total solute were studied in 10 anesthetized dogs before and after administration of phenoxybenzamine (PBZ) in shock. Five of the 10 dogs were used to evaluate the effect of shock on renal hemodynamics. Another group of five dogs was used as controls. Normovolemic shock caused a reduction in renal blood flow (RBF) from 9.0 +/- 1 to 6.0 +/- 0.6 ml/min per kg, and an increase in renal vascular resistance (RVR) (P less than .05). When compared to the untreated shock animals, phenoxybenzamine caused an 83% increase in RBF and a 53% decrease in RVR. Treatment of control animals with phenoxybenzamine resulted in a 10-fold increase in urinary [Na+], while urinary [K+] remained unchanged. Neither urinary [K+] nor urinary [Na+] was affected significantly by PBZ in the shock group. Although the excretion rate for Na+ was increased severalfold in the untreated shocked animals when compared to controls (14.0 +/- 3 vs. 1.7 microneq/min) the excretion rates for K+ (P less than .05) and total osmotically active substances (P less than .01) diminished. Phenoxybenzamine caused significant increases in the excretion rates for Na+ and K+ in both the control and shocked dogs. The observed changes in excretion rates when PBZ was given most likely reflect drug-induced changes in renal hemodynamics.


Movement of p-aminohippurate between lumen and cells of renal tubule. This study explores the role of brush border (luminal) membranes in p-aminohippurate (PAH) transport by the rabbit kidney. Under control conditions PAH appears in urine at the same rate as simultaneously injected inulin; no evidence for a secretory delay was found. After suppression of secretion by limiting concentrations of Benemid (probenecid), urinary PAH is largely derived from glomerular filtrate: its tubular transit time exceeds that of inulin. Excess Benemid abolishes this delay. Filtered PAH on its way to excretion appears to be permitted by a mechanism sensitive to high concentrations of Benemid to pass through an extraluminal volume equivalent to that of the proximal tubule cells. These results strengthen the previously suggested model for tubular PAH transport, and provide justification for use of glomerulus-to-ureter transit times in localizing tubular transport mechanisms.


Renin-angiotensin system and aldosterone secretion during aortic constriction in the rat. Suprarenal aortic constriction sufficient to reduce renal perfusion pressure by approximately 50% increased aldosterone secretion in anesthetized rats pretreated with dexamethasone. Bilateral nephrectomy under the same experimental conditions blocked the aldosterone response. Additionally, [1-sarcosine, 8-alanine]angiotensin II blocked the response in aldosterone secretion to aortic constriction in dexamethasone-treated rats. Finally, in rats hypophysectomized to exclude the influence of ACTH, the aldosterone response to aortic constriction was blocked by [1-sarcosine, 8-alanine]angiotensin II. The results indicate that angiotensin II increased aldosterone secretion during aortic constriction in the rat. These observations, along with those reported previously in sodium-depleted rats, point to an important overall role for the renin-angiotensin system in the control of aldosterone secretion in the rat.


Effect of furosemide on renal handling of glucose in the rat. Clearance and intratubular microinjection studies were performed in rats during extracellular volume expansion before and after furosemide administration to evaluate renal tubular transport of glucose. Three groups of animals were studied: group I, intact rats; group II, acutely thyroparathyroidectomized rats; and group III, thyroparathyroidectomized rats receiving parathyroid extract after a control period. In all groups furosemide caused a significant increase in the urinary flow rate and sodium excretion. There was no significant change in filtered glucose and glucose excretion. After early distal tubular injections of [14C]glucose, recovery was complete both before and after furosemide infusion. Furosemide had no effect on [14C]glucose recovery after the late proximal injection. These results indicate that furosemide has no effect on the renal handling of glucose in normoglycemic rats. There is no evidence for glucose reabsorption in the nephronal segments distal to the early distal tubular segment in this experimental state. Our data suggest, but do not prove, that no glucose is transported by the rat nephron beyond the pars recta during normoglycemia.


Sugar interaction with the antiluminal surface of the proximal tubule in dog kidney. The pulse-injection multiple-indicator-dilution technique in vivo has been used to investigate bidirectional sugar interaction with the antiluminal surface of the nephron in dog kidney. Simultaneous renal vein and urine outflow curves were obtained for radiolabeled sugars known to interact with the antiluminal surface. The following sugars were tested relative to T-1824 albumin (plasma reference) and creatinine (extracellular reference) under conditions of high-dose phlorizin preloading (75-225 mg/kg): D-glucose, D-xylose, D-fucose, D-mannose, D-galactose, L-arabinose, myoinositol, and D-fructose. The results indicate that as the plasma concentration of phlorizin increases there is, first, a partial inhibition of sugar interaction at the antiluminal membrane so that only unidirectional uptake of sugar from blood to tubular cell is observed, followed by complete inhibition of sugar interaction at the peritubular face of the antiluminal membrane, resulting in superposition of sugar and creatinine curves in the renal vein effluent. Two possible interpretations exist. i) Phlorizin exerts its inhibitory action successively at the cytoplasmic and then at the peritubular face of the antiluminal membrane. Moreover, since all of the sugar substrates are inhibited by phlorizin, the data suggest that the sugar-membrane interaction takes place at a common site at the level of the proximal tubule. ii) Alternatively, the action of phlorizin could result from a metabolic inhibitory effect affecting multiple sugar transport systems at the antiluminal membrane.


Autonomic afferents at T1 in elicitation of volume-induced tachycardia in the dog. Intravenous infusion of blood elicited tachycardia in anesthetized dogs with beta-receptor blockade (dogs with vagal efferents intact but cardiac sympathetic efferents blocked) and bradycardia in dogs with combined beta-receptor blockade and rhizotomy at T1 (dogs with vagal efferents intact but cardiac sympathetic efferents plus autonomic afferents at T1 blocked). This suggests that tachycardia elicited by volume in infusion may be partly due to a reflex with its afferent pathway at the T1 segment of the spinal cord and its efferent pathway in the vagi. Moreover, infusion evoked bradycardia in dogs with right-sided rhizotomy at T1, which was not significantly different from the response elicited in dogs with bilateral rhizotomy at T1. Additionally, the tachycardia response induced in dogs with ventral or dorsal rhizotomy at T1 was significantly different from the bradycardia response elicited in dogs with both dorsal and ventral rhizotomy at T1. These results suggest that the afferent pathway predominates on the right side, and its entry at T1 may be via both dorsal and ventral roots.


Responses of the canine myocardium to stimulation of thoracic cardiac nerves. The thoracic cardiac nerves were stimulated in each of 21 dogs anesthetized with alpha chloralose. Recordings were made of heart rate, blood pressure, and contractile force from all four cardiac chambers. Walton-Brodie strain-gauge arches were sutured to both atria, and to three locations of each ventricle, representing both anterior and posterior surfaces. The functional autonomic components of each nerve were summarized and classified into four basic types. Types I and II were both located medial to the thoracic vagi. These were shown to contain both sympathetic and parasympathetic components traveling to all four chambers of the heart. The sympathetic componnent of the type II nerves produced reflex changes in force of contraction and systemic blood pressure. Nerves classified as types III and IV produced no parasympathetic effect on the heart. These were all located lateral to the thoracic vagi. While the type III nerves carried sympathetic efferent fibers to all four chambers, the type IV nerve carried sympathetic fibers predominantly to the right atrium.


Cerebral blood flow and behavior during brain stimulation in the goat. Cerebral blood flow, heart rate, arterial blood pressure, and behavior were studied in conscious goats during electrical stimulation of the diencephalon and mesencephalon. Stimulation of the subthalamic area produced a considerable increase in ipsilateral cerebral blood flow and heart rate, accompanied by either a small or a large increase in systemic arterial blood pressure. Cardiovascular effects were associated with changes in alertness. The increase in cerebral blood flow was partially abolished by previous administration of atropine directly into the internal maxillary artery. Stimulation of the mesencephalic reticular formation caused a marked increase in blood pressure with no change or with some decrease in cerebral blood flow. After administration of phentolamine into the internal maxillary artery, stimulation produced increase in cerebral blood flow. The behavioral response consisted of restlessness and attempted flight. These results suggest the existence of cholinergic vasodilator and adrenergic vasoconstrictor pathways to cerebral blood vessels that may be stimulated electrically.


Effects of renal denervation on renin release in response to tilting and furosemide. In anesthetized cats head-up tilting for 30 min and infusion of furosemide at 0.75 mg/kg in 30 min significantly raised renin release from the innervated kidney (increments of 90.7 +/- 21.4 ng/min on tilting and 105.4 +/- 26.4 ng/min after furosemide); a small and inconstant increase from the contralateral denervated kidney (increments of 16.8 +/- 16.0 and 16.3 +/- 17.7 ng/min, respectively) was abolished by acute bilateral adrenalectomy. Larger doses of furosemide (6.0 mg/kg) could release renin from the denervated kidney also, but the response was still more marked on the innervated side especially in the early period of infusion (increments of 132.7 +/- 23.8 and 33.7 +/- 23.8 ng/min of innervated and denervated sides at 10 min). The response of the denervated kidney to 6.0 mg furosemide/kg was not affected by adrenalectomy. Stimulation of juxtaglomerular cells by tilting is entirely due to sympathoadrenergic activation; stimulation by furosemide is also entirely neural when the diuretic drug is given in moderate doses, but is partly independent of innervation when larger doses are administered.


Carotid body chemoreceptor reflexes and their interactions in the seal. In the anesthetized spontaneously breathing harbor seal Phoca vitulina stimulation of the carotid body chemoreceptors by intracarotid injections of sodium cyanide or by hypoxic hypercapnic blood causes an increase in tidal volume, respiratory frequency, and respiratory minute volume. The heart rate invariably decreased. Experimental dives caused apnea and bradycardia. When the carotid bodies are stimulated within 10 s of the commencement of a dive, the chemoreceptor-respiratory response is abolished, but the chemoreceptor-cardioinhibitory response is considerably enhanced. Electrical stimulation of the central cut end of a superior laryngeal nerve also causes apnea and bradycardia; stimulation of the carotid body now fails to produce a respiratory response but the cardioinhibitory effect is enhanced. These results indicate that the carotid bodies cause reflexly hyperventilation and bradycardia, and that these responses are considerably modified by other inputs to the central nervous system.


Control of extracellular sodium concentration by antidiuretic hormone-thirst feedback mechanism. The effectiveness of the antidiuretic hormone (ADH)-thirst feedback mechanism to control extracellular sodium concentration was studied in dogs. The design consisted of increasing daily sodium intake from 10 to 200 meq in a group of dogs, first in the normal condition and second with a continuous 24 h/day infusion of an amount of ADH sufficient to maintain urine osmolarity at a maximal level and with fixed water intake. We were therefore able to compare the effectiveness of sodium concentration control in the same dogs with and without feedback control of the ADH-thirst mechanism, the difference in effectiveness being a quantitative measure of the control capability of the system. In the normal condition the increase in sodium intake resulted in a steady-state 2.3% elevation in sodium concentration. With the feedback control of ADH secretion and water intake blocked, the same sodium forcing produced an 11.9% increase in extracellular sodium concentration. The minimum feedback gain for the system calculated from the data is -4.2. We conclude that control of sodium concentration in the intact state is accomplished mainly by the ADH-thirst feedback mechanism.


Effect of volume expansion and veratrine on salt gland secretion in the goose. The influence of acute intravascular volume expansion on salt gland secretion of conscious, adult geese was investigated. The intravenous administration of 5% dextran in Krebs-bicarbonate-Ringer solution in an amount equivalent to 30% of the estimated blood volume caused a transient but highly significant increase in salt gland secretion independent of changes in plasma osmolality or sodium concentration. Intravenous veratrine (60 microng) caused a similar increase in salt gland secretion only when administered after the volume load. Intravenous 5% NaCl always caused a prolonged and significant increase in salt gland secretion which was not potentiated by veratrine. Volume expansion and hypertonic saline caused a significant tachycardia while veratrine caused a significant bradycardia. It is concluded that a volume component may contribute to the initiation of salt gland secretion in the goose and that the peripheral receptor involved is most likely vascular in origin.


Brainstem control of shivering in the cat. I. Inhibition. Regions containing heat gain tonic inhibitory areas in mesencephalon and upper pons were studied using topical microinjection of a local anesthetic. This inhibition was compared in the mesencephalic decerebrated and intact animals. In mesencephalic animals that failed to shiver, bilateral injections of procaine into the ventromedial pontine tegmental areas released some heat gain responses and in intact anesthetized cats injections in the same regions increased intensity of shivering. These effects on inhibitory areas are reversible and can be repeated in the same preparation several times. Permanent effects were obtained by electrolytic lesions or by the local microinjections of 1% osmic acid. In summary, it is shown, by means of microinjection of local anesthetic, that a tonic inhibitory area located in the ventromedial pontine reticular formation completely inhibits shivering in the mesencephalic decerebrate preparation and partially inhibits shivering in the intact anesthetized preparation.


CNS regulation of body temperature in euthermic and hibernating marmots (Marmota flaviventris). Hypothalamic thermosensitivity of marmots was characterized during euthermia and hibernation. Hypothalamic temperature (Thy) was manipulated with chronically implanted, water-perfused thermodes while the animal's rate of oxygen consumption was continuously measured. The threshold Thy for eliciting an increase in metabolic heat production (MHP) and the proportionality constant (alphaMHP) relating rate of MHP to Thy were determined. In four euthermic marmots alphaMHP averaged -1.1 W-kg-1-degrees C-1. During the entrance into hibernation, as body temperature (Tb) declined from 36 to 8 degrees C, the threshold Thy for the MHP response progressively declined and was demonstrable at all times. The Thy of marmots in deep hibernation at an ambient temperature (Ta) of 5 degrees C plateaued near 7.5 degrees C, but threshold Thy for MHP showed a continuous slow decline of 0.2-0.4 degrees C a day, until one day prior to arousal. Proportional regulation of Tb was demonstrable at all times during deep hibernation. The average proportionality constant for the MHP response to hypothalamic cooling during deep hibernation in three marmots was -0.08 W-kg-1-degrees C-1. These results demonstrate that the hypothalamic regulator of Tb is active throughout hibernation and that there are progressive changes in its thermosensitivity.


Dependence of the driving force of the sodium pump on rate of transport. The driving force for active transport of Na+ in the isolated toad bladder, ENa, was measured as the reciprocal slope of the change in conductance with change in short-circuit current after stimulation with antidiuretic hormone. The base-line short-circuit current was altered by change in ambient Na+ concentration or addition of amiloride, maneuvers which alter availability of Na+ at the site of active transport. In the absence of a chemical gradient for Na+ across the bladder, ENa was found to be inversely related to the rate of Na+ transport, a finding incompatible with the simple electrical analogue that has been proposed for the system. The results provide additional support for the view that ENa measured in this way has both energetic and kinetic components.


Scalar perceptions of distance in simple binocular configurations. Under reduced viewing, a single visual object tends to appear about 2 m away. Gogel (1972) found that the far point in a binocular configuration of two points of light also tended to appear about 2 m away, while the near point was displaced toward the observer. Attempts to replicate this latter result with points of light, as well as with a large rectangle for the nearer object, proved generally successful. Under some conditions, however, the far point was perceived to be closer to the observer when seen with the near point than when seen alone or with the rectangle. This unexpected result suggests caution in assuming that the far object in such a configuration will always remain at a stable perceived distance.


An independence of induced amnesia and emotional response. A photograph of a nude was interpolated midway through a 30-item list. Recognition memory of items at various serial positions was measured by presenting 12 old and 12 new pictures on a test trial. Palmar conductance was also measured. Significantly decreased recognition memory and increased palmar conductance accompanied presentation of the picture of the nude. When the two measures were compared for individual subjects, however, no correlation was found. These data suggest that both responses are likely to occur to the presentation of the critical item but that the responses are independent.


The role of number and familiarity of stimuli in the perception of brief temporal intervals. The influence of stimulus number and familiarity on judged duration were investigated. The stimuli were slides with different numbers of stimulus elements of a familiar or unfamiliar nature. The task was to reproduce the durations of the slides, each shown for four intervals: 5, 9, 13, and 17 sec. The results show that the number of stimulus elements presented within a given interval affected its perceived duration, although the familiarity of those elements (as defined herein) did not. Finally, the shorter intervals sampled here were overestimated and the longer intervals were underestimated, thereby supporting Vierordt's law.


Short tube decompressive jejunostomy.

Short tube decompressive jejunostomy. Experience with short tube decompressive jejunostomy in twenty-nine patients with small bowel obstruction is presented. Many advantages are gained by operative decompression of obstructed, dilated small bowel. The favorable results with its use make short tube decompressive jejunostomy a safe, acceptable method of decompressing dilated small bowel.


Percutaneous transhepatic cholangiography in diagnostic evaluation of 160 jaundiced patients. Results of an improved technic. Percutaneous transhepatic cholangiography (PTC) was carried out in 160 patients with jaundice in whom the diagnosis could not be established by means of conventional methods of investigation. In PTC, selective catheterization of the common bile duct was employed and cholangiograms of high quality were obtained. In patients with obstruction of the biliary passages, the catheter was left indwelling centrally in the biliary passages for external bile drainage. The investigation, thus, did not necessitate immediate operation in these patients. PTC was successful in 113 of the 115 patients with obstructive jaundice. In forty-five patients the suspicion of obstruction could be discharged. Normal biliary passages were demonstrated in twenty-six patients. In nineteen patients it was impossible to cannulate the biliary tree and this was tantamount to nonobstructive jaundice. Complications occurred in six patients, but were not exclusively due to PTC. PTC provides a possibility for differentiation between obstructive and nonobstructive jaundice and thereby laparotomy can frequently be avoided. The incidence of complications may be maintained at an acceptable, low level provided the technic is meticulously observed.


The value of psychiatric team screening of candidates for jejunoileal bypass surgery. The relationship between successful outcome of jejunoileal bypass surgery and the results of evaluation by a psychiatric team is reported on. In a surgical group of sixty-one patients, the recommendations of the team were found to be significantly related to the outcome of surgery and correctly identified the emotional hazards so common in this procedure.


Complications in surgical patients. A comparison of methods for identifying occurrence. Because reporting of complications by physicians is not reliable, monitoring of the hospital course of surgical patients by nurses can improve effectiveness of identifying complications. Monitoring the course of only those patients who remain in the hospital more than four postoperative days will disclose 90 per cent of complications expected in all patients undergoing operation. Twenty hours per week of a nurse's time is sufficient to monitor 1,300 such patients annually. Identification of patients with large hospital bills will include most patients with complicated hospital courses but does not discriminate them from the large number of uncomplicated courses which also generate large hospital charges.


A literary review on ice therapy in injuries. There is good evidence that cold application can be useful in certain situations as a therapeutic modality. In particular, it seems ideally suited to the acute injury where the reduction in local factors such as hemorrhage and edema can hasten recovery. Although cold has established physiologic effects which can be useful, there are specific contraindications to its use which must be recognized. Although the method of application is not critical, new products such as moldable frozen gel packs make on-the-field use simple. The important concept in the use of cold for treating the acute injury seems to be early prolonged application.


An appraisal of radical pancreatoduodenectomy based on insulin secretion. The effect of pancreatoduodenectomy on insulin secretion was determined in seven patients with periampullary malignant tumors. As a uniform stimulus for secreting insulin, 100 gm of glucose was administered orally to all patients and glucose tolerance tests were carried out. Glucose intolerance and poor insulin secretion were obvious both pre- and postoperatively. Indexes of an initial insulin response, of a maximum insulin increment, and of total secretion of insulin responding to the stimulus of glucose were significantly lower in these patients before and after pancreatoduodenal resection, as compared with normal subjects. It was also observed that these three indexes, which express the ability of the pancreas to secrete insulin, decreased without exception after pancreatoduodenectomy. In light of these data it is postulated that radical pancreatoduodenectomy further diminishes the already insufficient secretion of insulin indicated by the oral glucose tolerance test in patients with periampullary malignant tumors.


Interstitial pressure measurements in the anterior and posterior compartments in athletes with shin splints. We found no basis for increased intercompartmental pressure in either the anterior or posterior compartments as the cause of shin splints. The pain in all 14 of the patients studied was localized to the posterior medial border of the tibia at the origin of the posterior tibial muscle, and evidence of periostitis in this area was seen in two of our patients, suggesting the possible tearing away of the posterior tibial muscle from its origin. Shin splints is a lay term which has assumed medical diagnostic significance and should be removed from common usage by more accurately localizing the focus of pain.


Parotid fistula and tympanic neurectomy. Parotid fistula is most commonly a posttraumatic situation. In posttraumatic cases, spontaneous closure of the fistula is the general rule. Conservative approaches to the occurrence of a parotid fistula are eliminating oral intake by the patient and applying a pressure dressing while maintaining nutrition by the intravenous route. Anticholinergic drugs decrease the production of saliva and thus would appear to be beneficial. When a parotid fistula does not heal under these conditions, then more aggressive treatment is indicated. Treatment should be based on whether the fistula is ductal or glandular in origin. Several methods of treatment have been advocated in the past. Low dose radiotherapy has been mentioned by some authorities as the treatment of choice for parotid fistula. This was used in one of our patients without response. Excision of the fistulous tract with ligation of the parotid duct has been advocated by some authorities. Tympanic neurectomy appears to be a satisfactory method of dealing with selected parotid duct fistulas, and glandular fistulas are best treated by tympanic neurectomy. Suppression of parasympathetic activity by the use of tympanic neurectomy has been said on some occasions to be transient (for example, Frey's syndrome). In dealing with parotid fistulas it would not appear to matter whether the effects are transient or permanent. The suppression of activity by tympanic neurectomy lasts long enough to allow for healing of the fistulous tract and relief of symptoms.


Studies of the growth and infiltration of experimental tumor of the pancreas in rabbits. An experimentally transplanted pancreatic cancer was induced by means of an intraductal injection of Vx2 carcinoma supernatant into the pancreatic duct of rabbits. The presence of ductal obstruction appeared to assist the nidation and growth of injected cancer cells in the pancreas. Tumors induced in the head of the pancreas grew by extension to the body and tail where they also produced interspersed, nodular tumor masses. Tumors induced in the body and tail region, on the other hand, grew by direct expansion towards the head, but this did not produce the interspersed nodular tumors in the head portion. These observations indicate that cancer of the head of the pancreas associated with the stenosis or obstruction of the pancreatic duct resulted in ductal dissemination and extensive lymphatic infiltration in the body and tail, a wider cancer invasion than recognizable at the gross cancer border. This extension was noncontinuous and interspersed, so that radical curative surgery for such cancer of the head of the pancreas would indicate total pancreatectomy.


Use of an in vivo oxygen electrode to determine the effect of hemorrhagic shock on liver oxygen tension. Measurement of arterial and liver tissue oxygen tension (PO2) in animals subjected to hemorrhagic shock demonstrates a significant (p less than 0.001) decrease in tissue PO2 while PaO2 remains essentially unchanged. In fact, marked increase in PaO2 fail to increase tissue PO2 to control levels, demonstrating that the act of increasing FIO2 and/or PaO2 is inadequate treatment of decreased tissue oxygenation in marginal or low flow states. Measurement of tissue PO2 in a variety of clinical situations seems warranted to allow alterations of therapy to improve flow when indicated by inadequate tissue oxygenation. The application of this simple but extremely useful technic should result in improved survival rates in critically ill patients.


The effects of operative stress on the coagulation profile. There is a tendency toward hypercoagulability in the postoperative period. This is manifested by changes in a number of coagulation parameters, and if not offset by some protective mechanism, thrombosis may occur. This protection appears to be mediated more through the fibrinolytic mechanism than through the action of antithrombin 3 (AT-3) because AT-3 activity diminishes in the early postoperative period. The introduction of variables such as invasion of the vascular system, intraoperative heparin administration, administration of whole blood, and insertion of a Dacron prosthesis does not appreciably affect the response of the coagulation profile to operative stress.


Sump tube drainage as a source of bacterial contamination. There is well documented evidence indicating in-appropriately high basal gastrins in patients with duodenal ulcer disease. After stimulation by protein meals, calcium infusion, and insulin-induced hypoglycemia there appears to be an exaggerated release of gastrin in patients with duodenal ulcers compared to control subjects. Vagotomy in general tends to increase serum gastrin by decreasing acid secretion and allowing less inhibition for antral gastrin release. This increase appears less with selective vagotomy and parietal cell vagotomy compared to truncal vagotomy, suggesting vagal inhibition of gastrin release outside the antrum. Antrectomy may decrease serum gastrins by removing a major source of the hormone. However, extra antral gastrin sources, if stimulated properly, may result in little postoperative change.


Peripheral ischemia due to retroperitoneal fibrosis. Two patients with retroperitoneal fibrosis demonstrated symptoms of peripheral vascular ischemia. Arteriolysis to free the distal aorta and iliac vessels was successful in both patients. Aortography in the posteroanterior view was equivocal, but the accompanying urologic abnormalities and a history of methysergide ingestion helped establish the etiology of the ischemia. The most direct approach to the treatment of the vascular obstruction caused by retroperitoneal fibrosis is complete arteriolysis. Most previous reports indicate that it is relatively easy to establish a dissection plane between the fibrotic plaque and the vessel wall. We found that the fibrotic process invaded the vessel wall. Accordingly, the surgeon must anticipate a difficult, tedious dissection when performing arteriolysis for the treatment of vascular compression secondary to retroperitoneal fibrosis.


Yet another technic for exposing the circumflex coronary artery. A cheap, commercially available elastic net designed to hold dressings on limbs or other tubular parts of the anatomy can most conveniently be adapted to the dislocation of the heart necessary for the exposure of the circumflex coronary and its branches; trauma to the heart is minimized and assistants' hands are not in the way.


The Cardiff Aldavac anaesthetic-scavenging system. The Cardiff Aldavac system consists of a reservoir, adsorption canister, flow restrictor and the necessary pipe connections. It enables theatre pollution control without structural alteration or special installation. It utilizes the hospital piped medical vacuum system but protects the system from excessive flows or contamination by volatile anaesthetics and still allows the vacuum to be used for other purposes.


Pneumotachography in intubated infants.

Pneumotachography in intubated infants. A new flat-bodied pneumotachograph head is described which can be readily interposed between a commercially available endotracheal tube connector on one side and a suitable low dead space attachment on the other. The head was designed to enable the respiratory flow of infants and neonates to be measured both easily and accurately, and without adding appreciably to the work of breathing. The method used to heat the head, and to heat and humidify the inspired gases are also detailed. The underlying aim has been to record inspiratory and expiratory flow as accurately as is possible within the bounds of practical clinical measurement.


Naso--tracheal jet ventilation for micro-laryngeal procedures. Adequate pulmonary ventilation during general anaesthesia in completely relaxed patients during laryngoscopy has been provided with the aid of a readily available suction catheter and a manual oxygen valve. Operating conditions for the surgeon are excellent, clear photography through the operating microscope is facilitated and the exposure is a considerable improvement on other methods of anaesthesia.


The value of topical lignocaine for bronchoscopy under general anaesthesia. Patients for bronchoscopy were randomly allocated to two groups, one receiving 4 ml 4% lignocaine spray and a control group which was not sprayed. There were no significant differences in the incidence of cough and spasm on recovery between the groups. The findings of a double-blind study comparing patients sprayed with 0-9% saline or lignocaine showed a significantly higher incidence of spasm in the saline group.


Gastro--oesophageal reflux in late pregnancy. Lower oesophageal sphincter pressure and fasting plasma gastrin and progesterone were measured in 31 women in the last trimester of pregnancy and in 10 healthy female control subjects. Eighteen of the pregnant women suffered from heartburn but 13 did not. All of the control subjects and 10 women from each of the two pregnant groups were tested for gastro--oesophageal reflux by direct measurement of intraluminal pH. The mean barrier pressure of the lower oesophageal sphincter was lower in both groups of pregnant women than in the controls (P less than 0-05) and the mean barrier pressure of the women with heartburn was lower than that of the pregnant women without heartburn, though this difference did not reach statistical significance. Eight of 10 of the pregnant women with heartburn had moderate or severe reflux, and3 of 10 of the pregnant women without heartburn also had moderate or severe reflux. Most women who reflux have heartburn, nevertheless, some asymptomatic women also reflux, and therefore all pregnant women must be considerered at risk from Mendelson's syndrome if subjected to a general anaesthetic for an emergency obstetric procedure.


[Doxapram-induced changes in circulation and myocardial efficiency (author's transl)]. The effects of Doxapram 2.0 mg/kg intravenously on circulation and myocardial oxygen supply were studied in 9 anaesthetized closed chest dogs. Immediately after Doxapram increases in heart rate (maximum+40.5%, 1st min), mean aortic pressure (+49%, 3rd min), cardiac index (+18%, 3rd min), total peripheral resistance (+32%, 3rd min), pulmonary arterial pressure (+48%, 1st min), left ventricular end-diastolic pressure (+79%, 1st min), myocardial blood flow (+38%, 3rd min), myocardial oxygen consumption (+74%, 1st min) and left ventricular work (+76%, 1st min) were observed. The changes in heart rate, mean aortic pressure, myocardial blood flow, myocardial oxygen consumption and heart work were persistent up to 20 min after Doxapram 2.0 mg/kg intravenously. Max dp/dt, coronary vascular resistance and the myocardial efficiency were not influenced after Doxapram.


[Apgar status, blood gases and acid base balance of neonates after caesarean sections, using either thiopentone or ketamine for induction of anaesthesia (author's transl)]. Apgar status and acid base balance of 206 neonates, delivered by caesarean section under general anaesthesia, were investigated in order to compare the possible effects of either thiopentone- or ketamine-induction on the postpartum adaption. Several other criteria were recorded also, for instance, a possible neonatal asphyxia, the induction-delivery-interval, the maternal age, the administration of other than anaesthetic drugs etc. There were not correlations between the Apgar status and the induction-delivery interval in either groups. The number of neonates within the 3 Apgar-classes, and the asphyxiated neonates, were equally distributed in the thiopentone- and ketamine-groups. There was no correlation between maternal ages and either the thiopentone- or ketamin-babies, but a marked correlation with the number of depressed newborns. Those neonates, who were suspected to be hypoxic before anaesthesia showed a more depressed post-partum respiration after thiopentone- than after ketamine-induction. On the other hand it seems to be that neonatal respiration and total Apgar status was more depressed if the "ketamin mothers" were treated with sedatives, hypnotics and/or analgesics before caesarean section. The blood gas values and the acid base parameters did not show a statistically significant difference between the pH of the thiopentone- and the ketamine-neonates. These differences can be explained as the combination of the nonsignificant changes in PCO2 and standard-bicarbonate values. As far as can be judged from the above mentioned criteria it may be deduced that ketamine or thiopentone can equally well be used for inducation of anaesthesia for caesarean section.


[Results of monitoring intracranial pressure in patients with severe head injury]. Intracranial pressure (ICP) was monitored in 100 patients with severe head injury. In comparison to intraventricular pressure epidural measurement gives reliable values with less risk for the patients. There are no firm values for the onset and development of post traumatic brain oedema. In most cases clinical findings allowed no conclusions as to the height of ICP. On the other hand the effects of diuretic agents varied so much that exact oedema therapy is only possible after observation of the values of ICP monitoring. Combined use of ICP monitoring and high doses of dexamethasone reduced mortality significantly.


[Modifikation of the stylet for tracheal tubes (author's transl)]. The modified stylet (Rüschelit plastic) is longer than the common one. By pushing forward as far as necessary the stylet alone can be used to enter the larynx in cases of difficult intubation. The stylet is long enough to allow a loop to be formed at its proximal end to ensure stability between the tube and the stylet.


Inhibition of adrenal medullary catecholamine secretion by enflurane: I. Investigations in vivo. The effects of enflurane anesthesia on adrenal medullary catecholamine secretion and on the pressor effect of splanchnic-nerve stimulation were studied in cats given pentobarbital for basal anesthesia. Inhalation of enflurane, 1.2 and 2.2 per cent, caused dose-related inhibition of both spontaneous catecholamine release and secretion evoked by splanchnic-nerve stimulation. During inhalation of 2.2 per cent enflurane spontaneous release of epinephrine was decreased to 19 and 25 per cent, respectively, of the initial values, and the stimulated release was decreased to 30 and 15 per cent, respectively. Enflurane also inhibited the pressor effect of splanchnic-nerve stimulation, whereas that of norepinephrine was not changed significantly. These results are similar to those previously obtained with halothane and methoxyflurane. It is concluded that the decrease in catecholamine secretion caused by enflurane is in part due to a direct effect on the chromaffin cell, namely to an inhibition of the secretion-stimulating effect of acetylcholine released from splanchnic nerves.


Inhibition of adrenal medullary catecholamine secretion by enflurane: II. Investigations in isolated bovine adrenals--site and mechanism of action. To determine the site and mechanism of action underlying the inhibition of adrenal medullary catecholamine release by enflurane, the authors measured the effects of enflurane on catecholamine secretion evoked by various secretagogues in isolated bovine adrenals perfused with Locke's solution. Catecholamine concentrations in the perfusate were measured spectrofluorometrically. Enflurane caused concentration-dependent inhibition of catecholamine release in response to activation of the nicotinic receptors in the chromaffin cells with acetylcholine or dimethylphenylpiperazinium (DMPP). An enflurane concentration of 0.88 mM caused 50 per cent inhibition of the DMPP-induced secretion. The inhibition induced by enflurane was shown to be noncompetitive. The catecholamine release evoked by activation of the muscarinic receptors with pilocarpine was only slightly decreased by 3.74 mM enflurane. At this concentration the release in response to KCl, 56 mM, was partially inhibited, whereas the output in response to tyramine (from glands perfused with calcium-free Locke's solution) was unaffected. It is concluded that the site of action of enflurane is the cell membrane. At concentrations above 1 mM, enflurane may impair calcium ion influx, but at lower concentrations it probably interacts with hydrophobic regions of the nicotinic receptor.


Use of the smooth Teflon clip to prevent pulmonary embolism in the postoperative period. This report details experience with 50 patients who had vena caval interruption with a smooth Teflon (Moretz) clip placed at the time of surgery for other conditions in a high-risk patient population. No fatal pulmonary emboli were encountered; one patient developed bilateral iliofemoral venous thrombosis during the immediate postoperative period (Table 9). Another patient developed iliofemoral venous thrombosis and a nonfatal embolus two years after the vena caval interruption. Two patients developed postoperative edema, but no incapacitating edema and no ulcers were noted. Many of our patients were subjected to further risk of venous thrombosis and pulmonary embolism when hospitalization for medical care or operative procedures was required subsequent to the initial procedure. Vena caval interruption with a smooth Teflon clip can be recommended to prevent pulmonary embolism in high-risk patients who require surgery and to provide continuing protection during subsequent illness; however, extremity sequelae are minimal.


Longitudinal ureteral split for retroperitoneal fibrosis with ureteral involvement. Idiopathic retroperitoneal fibrosis may rarely invade the ureteral wall, thereby rendering the attempt to perform classical ureterolysis futile. Possibilities for surgical correction include resection with end-to-end anastomosis, utilization of a spiral strip of ureter, small bowel substitution, iatrogenic nephroptosis or longitudinal incision of the involved ureter down to the mucosa. Two patients treated using the latter technique have been followed for 7 months and 132 months without recurrence of the obstructive process. The surgeon, when treating idiopathic retroperitoneal fibrosis, must be prepared to treat intrinsic ureteral involvement using the most appropriate surgical technique.


The Pyrah technique for ileal loop diversion: experience with 100 cases. One hundred patients underwent ileal loop diversion using the Pyrah technique between 1959 and 1975. Sixty-seven were performed because of benign urinary tract lesions and 33 were performed as part of planned treatment of various malignant conditions. Neurogenic bladder dysfunction accounted for 56 of these diversions. There were 67 early and 69 late complications. Patients having preoperative irradiation therapy had a much higher incidence of complications. An alarming 19 per cent demonstrated progressive deterioration of the upper tracts following diversion. It is noteworthy that this rate of upper tract deterioration compares favorably with that reported in several other series. Early mortality was 6 per cent, and death occurred four times more often in patients with malignant conditions.


[Determination of the relative iodine concentration in the lumens of thyroid follicles of normal and neotenic Triturus helveticus, and evaluation of the halogen content of the thyroid colloid. Electron microprobe study (author's transl)]. The stable, bound iodine in the thyroid colloid of Triturus helveticus has been studied with the electron microprobe. Some animals show a normal development. Others are accidentally neotenic due to certain ecological conditions. The values of punctate iodine concentrations (CPI) have been computed and expressed in relative units (counts/s). The mean CPI per lumen is very variable from one follicle to another in the same thyroid section. During normal development, the mean CPI per animal is generally higher in metamorphosing individuals than in larvae. During development with neoteny, the mean CPI per animal attains high values if the larval state is maintained in its totality; the CPI decreases in partially metamorphosed animals, but increases again after metamorphosis. The amount of halogen contained in the thyroid colloid has been computed in relative units (colloid iodine pool). Throughout normal development, the pool remains small if the animals have not attained the adult state. In increases considerably in entirely larval neotenic newts, decreases during metamorphosis but increases afterwards. In totally neotenic newts, the thyroid gland receives only a low hypophyseal stimulation and reacts as the thyroid gland of various hypophysectomized Urodeles. Our results pose the problem as to whether TSH regulates the transepithelial iodine flows, which permit the expansion of the colloid iodine pool, when this hormone is secreted at a very low levels.


Relationship of maternal, fetal, and amniotic fluid prolactin levels. Serum prolactin (PRL) was measured by radioimmunoassay in 80 women in serum and amniotic fluid during various stages of normal pregnancy and at delivery. In addition, prolactin levels were measured in cord sera at 60 newborns. PRL levels in maternal serum progressively increased during pregnancy, and they were lower than the corresponding levels in amniotic fluid. A relative decline in the amniotic fluid prolactin between the 39th and the 40th week of gestation was observed. The mean concentration of PRL in umbilical blood was significant lower than that in maternal blood at delivery. The lack of correlation between the PRL in amniotic fluid and the levels found in maternal and newborns serum suggests an independient source of PRL in each of the three compartments.


[Optical rotatory dispersion of levorin and isolevorin]. Optical rotation dispersion of levorin A2 and isolevorin A2, macrocyclic heptaen antibiotics in the region of 260--320 nm due to the presence of ketogroups in the molecules of these antibiotics was studied. On the basis of the study of the optical rotation dispersion, diffusion properties and molecular models of the antibiotics it was supposed that levorin and isolevorin differed in the space configuration of the macrocycli lactone ring.


[Action of rifampicin on the ultrastructure of Staphylococcus cells]. The ultrastructure of Staphylococcus after its contact with rifampicin was studied by the method of electron microscopy. Changes in the submicroscopic structure of the cells depending on the antibiotic dose and incubation time with the drug were shown on solid and liquid media. After removal of the antibiotic from the medium at the stage of demaging the Staphylococcus ultrastructure growth of the cells with normal ultrastructure was observed.


[Distribution of polyene antibiotics in the cells of a tissue culture of puppy kidney]. The results of the studies on interacellular distribution of amphotericin AM-2, a wate soluble derivative of amphotericin in the cells of the puppy kidney tissue culture exposed to the antibiotic in a concentration of 50 gamma per 1 ml medium for 17 hours are presented. It was found that the antibiotic was firmly bound with the kidney cells: 15.4 per cent of the initial amount of the antibiotic was detected in the washed cells. Analysis of the antibiotic distribution in separate subcellular components showed that sorption of amphotericin AM-2 by the plasmic membranes, nuclei and cytoplasm was respectively 18.3, 35.6 and 9.7 per cent of the amount absorbed by the cells. Binding of a significant amount of the antibiotic absorbed by the plasmic membranes and nuclei with the above fractions was reversible. The results of the study provided a supposition that amphotericin AM-2 penetrated into the cells of the kidney tissue which adds some new findings to the studies on the mechanism of action of polyenic antibiotics in cells.


[Characteristics of the action of antibiotics in an experimental process caused by Cl. histolyticum]. The cells of Cl. histolyticum isolated from the muscular tissue of albino mice infected with the microbe and treated with oxyglucocycline or cephaloridin were similar to each other and the cells of the initial strain with respect to their morphological features, growth character on liquid and solid media and saccharolytic activity. The strains isolated from the animals treated with oxyglucocycline were characterized by lower gelatinolytic, hemolytic, caseinolytic and (to a less extent) collogenolytic activity. The strains isolated from the animals treated with cephaloridin slightly differed from the initial strain by their cultural properties. The lethal effect of the total toxin of both variants of the strains studied were similar, only the time of the animal's death being different. The data of the study may serve as one of the explanations of various effects of the antibiotics differing in their modes of action on the microbial cell in cases of infection caused by Cl. histolyticum.


[Effect of mineral phosphorus on mycoheptin biosynthesis]. The effect of mineral phosphorus in doses of 22.8 to 684 gamma/ml in a synthetic medium on biosynthesis of mycoheptin, an antifungal antibiotic was studied. It was found that the maximum productivity of the mycelium was at the phosphorus concentration in the medium equal to 22.8--45.6 gamma/ml and the concentration of 91.2 gamma/ml was optimal for the growth of the antibiotic-prodicing organism. The phosphorus optimal concentrations for the growth and antibiotic synthesis phases did not coincide that provided consideration of phosphorus as a limiting factor useful in control of the antibiotic biosynthesis. The content of pphosphorus in the medium 6 times higher than the optimal concentration did not inhibit the biomass accumulation and had no significant effect on the colony morphology.


Respiratory function after repair of congenital diaphragmatic hernia. Respiratory function studies were carried out in 22 infants who had successful repair of diaphragmatic herniae of the Bochdalek type. Thoracic gas volume was initially reduced in only 3 of these, but subsequent studies showed that improvement occurred. There were no consistent abnormalities in either dynamic compliance or mean pulmonary conductance. This is evidence that there is rapid adaptation which compensates for any alteration in the parenchymatous tissue in the lungs or abnormalities in the bronchial tree in infants soon after the repair of congenital diaphragmetic herniae. Further studies are necessary to determine the changes in these lungs with growth.


Pharmacokinetic observations of phenytoin disposition in the newborn and young infant. The pharmacokinetic profile of phenytoin (DPH) was studied in 30 infants aged 2 days to 96 weeks. The plasma DPH half-life during the first week of life in term infants was prolonged and very variable (20-7 +/- 11-6 h, mean +/-SD). Thereafter the plasma half-life was much shorter (7-6 +/- 3-5 h). In preterm infants the half-life was much longer (75-4 +/- 64-5 h) and more variable. The mean apparent volume of distribution was similar in these groups of infants: preterm newborn 0-80 +/- 0-22 l/kg, term infants during the first week of life 0-80 +/- 0-26 l/kg, and term infants greater than 2 weeks of age 0-73 +/- 0-18 l/kg. Predictions of steady-state plasma DPH concentrations, based on these kinetic parameters, were confirmed. Very low "trough" plasma DPH concentrations were observed after the 14th postnatal day in 19 infants receiving 8 mg/kg per 24 h orally. On the other hand, infants of less than one week of age receiving the same dose, especially if preterm, frequently showed drug accumulation to toxic plasma DPH concentrations. The impaired binding of DPH to newborn plasma protein was confirmed but "normal adult values" were approached by the age of 3 months. An intravenous loading dose of 8 mg/kg (sodium phenytoin) can be expected to generate a mean plasma DPH concentration of 10 mg/l (40 micronmol/l) in the newborn. Loading doses of up to 12 mg/kg were given without untoward effects. During the first week or so of life plasma Dph half-life is so variable that no fixed dosage regimen can be derived from the available data. Beyond the second week of life, however, a dose of 8 mg/kg per 24 h is probably inadequate for most infants.


The stomach in malnutrition.

The stomach in malnutrition. Basal gastric acid output was reduced in 9 out of 14 infants and young children with malnutrition compared with 21 age-matched controls. In all the patients the response of the gastric mucosa to stimulation by pentagastrin was impaired, and gastritis of variable severity was present in 8 out of the 9 patients in who biopsies were performed. Impaired gastric acid secretion probably contributes towards bacterial overgrowth and diarrhoeal diseases in malnourished children.


Conservative treatment of a BCG osteomyelitis of the femur. A 3-year-old boy presented with an osteolytic lesion and periosteal reaction in the distal metaphysis of the right femur which failed to respond to immobilization and intensive antibiotic treatment. Since the infection seemed to be of low virulence and fewer than 4 years had elapsed since BCG vaccination BCG osteomyelitis was suspected. Tuberculostatic treatment led to rapid recovery and surgical measures were unnecessary.


Gastrointestinal adaptation following small bowel bypass for obesity. Small intestinal morphologic and biochemical changes were studied following jejuno-ileal bypass for obesity after body weight stabilization had occurred. Four patients underwent biopsy of in-continuity and bypassed jejunal and ileal segments of the small intestine 11 to 22 months after the bypass operation. Microscopically, marked mucosal villus hypertrophy of the in-continuity bowel was observed, especially in the ileum. Bypassed jejunal mucosa underwent atrophy compared with pre-bypass jejunum, whereas bypassed ileum appeared similar microscopically to pre-bypass ileum. The specific activities of mucosal disaccharidase enzymes (maltase, sucrase, lactase and trehalase) in units per mg protein remained similar to pre-bypass levels in segments of the in-continuity jejunum and the bypassed jejunum and ileum. On the other hand, elevated mucosal disaccharidase levels were measured in biopsy specimens of the in-continuity ileum. Total enzyme activity per unit length of intestine, however, was estimated to be elevated in both in-continuity jejunum and ileum secondary to mucosal villus hypertrophy. These data indicate that following small bowel bypass: (1) the in-continuity ileum undergoes greater biochemical and morphologic adaptation than the jejunum; and (2) intraluminal nutrients and chyme appear to be essential to maximal intestinal adaptation.


Nissen fundoplication for reflux peptic esophagitis. One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a group of 104 patients reported five years ago, the incidence of persistent or recurrent esophagitis remains approximately the same (10% versus 8%). This is consistent with the assumption that the Nissen procedure when initially successful tends to remain so and that late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the "gas-bloat syndrome" was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Late follow-up, however, averaging four years indicates a marked reduction in this disorder with either absence or clinical insignificance in 87% of patients. Nonetheless, moderate symptoms persist in 11% and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a three-fold increase in resting pressure following Nissen fundoplication (p less than .001). It is hoped that manometric study will provide a more reliable prognostic measure of sphincter restoration than the measurement of pH across the gastroesophageal junction.


Elastic tissue dysplasia of the internal carotid artery. Elongation with kinking of the internal carotid artery is not an uncommon finding. Cerebral vascular insufficiency has been reported secondary to this abnormality. Although arteriosclerosis is a frequent cause in adults, the etiology in children has never been explained. Three children with significant kinking of the internal carotid artery are reported here. Each underwent surgical correction by excision and reconstruction. Histological review showed the elastic tissue to be disrupted, diminished in amount, and unevenly distributed. Retrospective examination of this elastic tissue dysplasia showed it to be localized, there being normal morphology both proximally and distal to the involved area. There was recurrence of elongation and kinking in one patient due to incomplete excision. Correction was accomplished after re-excision of the involved tissue with a vein graft interposition. From this study, it can be concluded that elongation and kinking of the internal carotid artery in children is secondary to elastic tissue dysplasia. It is imperative that the entire involved area be removed in order to prevent recurrence. The excised specimen should be studied histologically with elastic tissue stains. Such stains cannot be performed as frozen section. Should permanent studies show the margins of resection not to be beyond the dysplastic tissue, careful followup of these children is essential to recognize recurrence.


Clinical experience with the Kim-Ray Greenfield vena caval filter. Over a four year period in two institutions, 85 Kim-Ray Greenfield vena caval filters were inserted in 76 patients who have been followed for a minimum of 6 to 53 months. The most frequent indication for placement was pulmonary embolism during anticoagulant therapy. Both femoral and jugular routes were used for transvenous insertion, and fewer complications were associated with the jugular approach. Surgical mortality within two weeks of operation occurred in three patients (4%), none from recurrent embolism. Late complications included recurrent thrombophlebitis in 7% and persistent extremity edema in 12% of patients. Two patients developed recurrent embolism (2.6%) which also was seen in 2 patients after clips were placed on the vena cava above the filter after misplacement. Venacavagrams in 31 patients an average of 11 months postoperative showed patency in 30 (97%) and lysis of trapped thrombi in four patients. No episodes of migration have occurred and the filter offers the advantages of sustained patency and effective filtration without vena caval occlusion.


Surgical management of chronic pulmonary embolism. The clinical course of most patients with pulmonary embolism is one of gradual resolution with re-establishment of flow in the pulmonary arteries. In a small but definite group of patients, the emboli do not resolve and a state of chronic pulmonary embolism ensues. The primary thrombotic process in the systemic venous system may persist, and in some instances may be unrecognized. Such patients experience recurrent showers of emboli which may ultimately occlude a large part of the pulmonary arterial circulation with development of severe respiratory insufficiency. Six patients with this syndrome are described, and in each there was a history of dyspnea, cyanoiss, and exercise intolerance associated with a low arterial PO2, right ventricular hypertrophy, and pulmonary hypertension. Pulmonary scans and arteriograms demonstrated that more than half of the major pulmonary arteries were occluded and, in addition, smaller vessels were also obstructed. Pulmonary embolectomy was performed in each patient. Five of the 6 obtained a highly gratifying response, including relief of the dyspnea and cyanosis, an increase in arterial PO2, and a decrease in pulmonary arterial pressure. In each of the five in whom improvement occurred, the back-bleeding from the pulmonary artery at the time of embolectomy was quite good. In the sixth patient, the back-bleeding was very poor, and despite embolectomy, the vessel thrombosed postoperatively with no improvement in the patient's clinical course. Follow-up studies in these patients range up to 8 years with demonstration of continued patency of the pulmonary arteries as well as continued improvement in clinical symptoms and in the arterial PO2.


Seven year experience with mounted porcine valves. From March, 1969, through June 1976, 108 porcine aortic xenograft valves were used for mitral or aortic valve replacement in 95 patients. This experience provides one of the longest follow-ups available for evaluation of the porcine bioprosthesis. The first fifteen valves were locally mounted on Cutter stents and preserved in buffered formalin. Subsequent valves were prepared by the Edwards and Hancock Companies with glutaraldehyde preservation. Oral anticoagulation was routinely used for the first 6 weeks following surgery. Hospital mortality was unrelated to the valve type. All but four of the surviving patients with formalin preserved valves have required reoperation because of valve failure. There have been two valve failures in the patients who received gluteraldehyde valves, but there have been no embolic or thrombotic complications. Late cardiac catheterization has shown hemodynamic results equal to or better than prosthetic valves. The continuing long-term results indicate that the porcine xenograft is the valve of choice for cardiac valve replacement.