The role of fiberoptic endoscopy in the diagnosis and management of duodenal neoplasms. This is a study of 11 cases of duodenal tumors encountered in 1200 consecutive duodenoscopic examinations over a 34-month period at The Johns Hopkins Hospital. Of these tumors, 4 were benign and 7 malignant. Endoscopic removal of 2 benign tumors was accomplished without morbidity and obviated the necessity for transabdominal surgery. The 2 other benign tumors were a probable lipoma and a benign polyp, and did not require surgical intervention. In 6 of the 7 patients with malignant lesions, the indication for performing duodenoscopy was an abnormal roentgenographic study. In each case, direct visualization of the abnormal area, together with biopsy and cytologic brushing, provided a definitive diagnosis of malignant disease and helped plan the therapeutic course. In the seventh patient, a primary adenocarcinoma at the duodenojejunal junction was found on endoscopic examination, after all other available diagnostic studies to find the cause of persistent gastrointestinal bleeding had been exhausted. Although duodenal tumors are not common, they were encountered in 1 of every 100 duodenoscopies at a referral center. With increasing use of fiberoptic endoscopy, such tumors will undoubtedly be seen with increasing frequency. In our experience, endoscopy has proved to be a safe and reliable method of distinguishing between benign and malignant duodenal neoplasms and of assistance in planning subsequent management.


Thymus-derived lymphocytes in type B acute viral hepatitis and healthy carriers of hepatitis B surface antigen (HBsAg). To assess thymus-derived (T) lymphocyte function in hepatitis B infection, lymphocytes from patients with type B acute viral hepatitis and healthy carriers of the hepatitis B surface antigen, were compared to normal controlss using phytohemagglutinin (PHA) -induced blast cell transformation and sheep-cell rosette formation. Overall cell (T lymphocyte) -mediated immune function was similar with these in vitro assays in all three groups, except for decreases in total T cells in isolated patients with acute disease. Consequently, if a defect in cellular immunity exists in normal controls with persistent hepatitis B infection, it is probably specific for the antigens of the hepatitis B virus and not related to a generalized impairment of T-lymphocyte function.


Syphilitic gastropathy.

Syphilitic gastropathy. A case study of a 22-year-old male with periumbilical, postprandial pain, partially relieved by antacids is presented. Abnormalities demonstrated on upper-gastrointestinal series and a positive FTA-ABS suggested gastric lues. This diagnosis was confirmed by demonstrating spirochetes in gastric mucosa, both by silver impregnation and fluorescent techniques specific for Treponema pallidum.


Particulate matter in reconstituted amphotericin B and assay of filtered solutions of amphotericin B. Amphotericin B colloidal solutions were prepared according to the manufacturer's directions and filtered with membrane filters of different porosity to test for particulate matter; and the concentration and in vitro microbiological activity of filtered and nonfiltered solutions were determined.  The amphotericin B solutions contained numerous particles.  Filtration through 0.85- and 0.45-mum filters did not reduce the in vitro antimicrobial activity, and filtration through 5-, 0.45-, and 0.22-mum filters did not alter the concentration of the drug when assayed spectrophotometrically.


Economic justification of pharmacist involement in patient medication consultation. The financial savings experienced by patients as a result of pharmacists' efforts in a discharge medication interview program were evaluated.  The study involved 1,000 patients discharged from the surgery service of a university hospital.  Pharmacists worked with physicians and patients in reducing the cost of medications by: (1) substituting less expensive drugs when possible, (2) relabeling bedside medication, (3) securing third party coverage for eligible patients, and (4) recommending purchase of non-prescription drugs over the counter.  Savings of nearly +1,700 were realized on 517 out of 1,832 prescriptions; this was equal to +9.13 of savings to the patient per hour of pharmacist consultation time.


Studies of human lymphocytes in the newborn and the aged. Proportions and absolute numbers of T and B lymphocytes were determined among 30 newborn infants and group of 77 elderly patients 60 to 95 years of age. Total lymphocytes in the cord blood of the newborn showed a distinct elevation in total numbers of T and B lymphocytes (p less than 0.005) as compared to that in blood from normal adult controls, reflecting the relative lymphocytosis of infancy. Proportions of cord blood T lymphocytes as reflected by the sheep cell rosette technic were considerable lower than those in lymphocytes from normal adult controls, however, proportions of cord blood T lymphocytes as determined by indirect immunofluorescence were not significantly different from those in controls. Old people showed a significant reduction in total numbers of lymphocytes (p less than 0.005) when compared with those in normal adult controls 18 to 51 years of age. Moreover, there was a significant increase in the relative proportions of peripheral blood B lymphocytes in the elderly although the absolute numbers of B lymphocytes in the elderly although the absolute numbers of B cells did not differ from those in younger controls. A significant decrease in total numbers of T cells as measured both by sheep cell rosettes and indirect immunofluorescence was recorded among older patients (p less than 0.001). In addition, there was a broad increment in the incidence of various autoantibodies (anti-nuclear, andi-IgG, antismooth muscle, antimitochondrial and antiparietal cell) among the old people studies. No direct correlation could be determined between relative B-cell percentage increase or T-cell decrease and the presence of various autoantibodies in individual patients. Diminution in total lymphocyte counts as well as absolute numbers of T cells in the elderly may provide the cellular basis for an increased susceptibility to neoplasia and infection.


Gonadal dysfunction in uremic men. A study of the hypothalamo-pituitary-testicular axis before and after renal transplantation. Evaluation of testicular function in 13 hemodialyzed patients revealed the following: plasma testosterone (ng/100 ml) was low (less than 300 ng/100 ml) in 6 and low normal in 7 patients; sperm counts ranged from 0 to 8 million/ml and motility from 0 to 8 per cent; testicular tissue from 2 patients showed an abnormal histologic picture ranging from hypospermatogenesis to germinal cell aplasia. Follicle-stimulating hormone (FSH, ng/ml) was normal in eight (10 to 217 ng/ml), and persistently eveated in five patients (265 to 760 ng/ml). Of the latter five patients, two were azzoospermic, one had germinal cell aplasia on postmortem examination, one had virtually no viable sperms, and the other was never able to furnish ejaculate for examination. Luteinizing hormone (LH, mg/ml) was high (more than 210 ng/ml) in five and normal in eight patients. Six patients when given clomiphene showed the normal response of increased FSH and LH release. Four of the 13 patients, when restudied 6 to 12 months later and while still on dialysis, showed further deterioration of plasma testosterone and sperm counts. Four of the patients subsequently underwent successful renal transplantation. All showed improvement in sperm counts (20 to 40 million/ml, motility 40 to 90 per cent) and plasma testosterone (440 to 850 ng/100 ml). These data suggest that both germinal cell and leydig cell functions were impaired among uremic men. These dysfunctions were not correctable by hemodialysis, but were completely reversed by renal transplantation. The high FSH among patients with azzospermia indicates a responsive pituitary. The positive response to clomiphene suggests that storage as well as release of both hypothalamic and pituitary hormones were normal. Attempts to localize a single defect at the testis failed to explain the post-transplant surge of FSH which invariably proceded improvement in spermatogenesis. It is therefore postulated that a defect in that portion of the hypothalamus involved in the receipt and/or interpretation of message might be at fault in uremia.


Infected subfural hematoma: three case reports involving gram-negative organisms. Three case reports of infected subdural hematoma are presented, two with Salmonellae and one with Escherichia. Infection of such hematomas most often occurs during bacteremia, and the area of infection is limited by the existing hematoma membrane. Clincally, fever, headache, nuchal rigidity, and focal neurological signs, especially in a patient with previous head trauma, suggest subdural infection. Treatment consists of drainage and systemic antibiotics. These case reports demonstrate the clinical features of this rarely reported entity, and especially illustrate the need for careful bacteriologic identification in suspected cases.


Calcitonin levels in thyroid-vein blood of man. Radioimmunoassay determinations of calcitonin from blood samples obtained by selective venous catheterization have demonstrated a large peripheral to thyroid vein gradient for this hormone in both normocalcemic and hypercalcemic persons. These fingings indicate that in fasting humans the thyroid gland maintains peripheral levels of calcitonin by actively secreting the hormone, and are consistent with the suggestion that the role of plasma calcitonin is of physiologic significance.


The prophylaxis of gonorrhea.

The prophylaxis of gonorrhea. The current level of the gonorrhea epidemic supports the need for additional measures for gonorrhea control. In the absence of evidence that prophylactic availability enhances promiscuity, a strong case can be made for venereal disease prophylaxis. This paper reviews the efficacy and acceptability of prophylactic techniques. In the military, acceptability and efficacy have been demonstrated for systemic antibiotics, and probably a postcoital prophylactic kit. These measures are either inappropriate or unavailable for general civilian use. The condom and vaginal spermicides offer promise of partial protection; further studies of efficacy and utilization are needed.


Comparison of results of microbiologic and radioisotopic assays for serum vitamin B12 during pregnancy. The serum vitamin B12 level falls progressively during pregnancy, when measured either by microbiologic assay or by a radioisotope dilution technique. The concentration of the vitamin assayed by radioisotope dilution was consistently higher than the value obtained by microbiologic assay. This discrepancy was greatest in early pregnancy and decreased as the duration of pregnancy increased. These results add further evidence to the hypothesis that changes in serum binders for vitamin B12 are of major significance in the pathogenesis of the observed fall in serum levels of the vitamin during pregnancy.


Urinary stress incontinence: differential diagnosis, pathophysiology, and management. It is appropriate to introduce this review of the subject of urinary stress incontinence with a discussion of  other disorders that may produce abdnormal urinary leakage,at times even stimulating true anatomic stress incontinence. It is obviously important to correctly identify patients with these other conditions and not perform surgical procedures unlikely to relieve their symptoms. Thereafter, the underlying pathophysiology of stress incontinence is considered in detail, since its fundamental understanding serves as the basis for both accurate diagnosis and proper selection and effective execution of the operations designed to correct true anatomic stress incontinence. A final section on patient management covers choice of the optimal surgical procedure for each individual patient, end results that should be achievable by proper selection and performance of the various operations, and a descriotion of some of the technical details that seem particularly helpful in carrying out the three principal types of surgical procedres currently in use.


Visual acuity improvement in eyes with corneal scars fitted with contact lenses. The vision of 190 eyes of 130 patients with corneal scars was tested with contact lenses, of which 166 eyes subsequently were fitted with contact lenses. Over 75% of all eyes with corneal scars showed a visual acuity improvement to 6/12 or better. All eyes with a nebular or macular corneal scar and an initial visual acuity of 6/60 or better improved to 6/12 or better. The visual acuity of 77% of the eyes fitted with contact lenses, compared to the visual acuity of 36% of the same eyes obtained with spectacle lenses, improved to 6/12 or better.


Baroreceptor mechanisms controlling sympathetic nervous rhythms of central origin. A study was made in the anesthetized cat of the slow wave of sympathetic nervous discharge (SND) locked in a 1:1 relation to the cardiac cycle (3 cycle/s periodicity). SND was recorded from the preganglionic splanchnic and postganglionic renal nerves. The data contradict the generally accepted view that the slow wave occurs as the direct result of a waxing and waning of baroreceptor nervous discharge. Although baroreceptor denervation unlocked the phase relations between SND and the cardiac cycle, the slow wave persisted and its duration was not changed. Furthermore, the slow wave was aborted by stimuli delivered to the baroreceptor nerves or paramedian reticular nucleus during a time span which accounted for less than 1 percent of the cardiac cycle. It is concluded that the 3 cycle/s periodicity of SND is representative of a vasomotor rhythm of central origin which is entrained to the cardiac cycle by the baroreceptor reflexes. The sympathoinhibitory effect leading to the entrainment of the slow wave is mediated in the brainstem. ta spinal component of baroreceptor-induced sympathoinhibition also was demonstrated.


Effects of vagotomy on urecholine-modified histamine dose responses in dogs. Histamine step-dose responses, 2-100 mug/kg-h in 6 successive 45-min steps, were studied in nine dogs with gastric cannula. In three of the dogs the gastric fundus was selectively vagally denervated and the dose responses were repeated. In both groups of dogs the dose responses were then studied against background intravenous infusions of urecholine (10, 20, 40, and 80 mug/kg-h). Vagotomy acted as a competitive inhibitor (Km doubled from 14 to 29 mug/kg-h, while Vmax was unchanged) and this effect could be reversed by smaller than 10 mug urecholine/kg-h. In both groups increasing backgrounds of urecholine increased Vmax from similar to 14 meq H+/30 min to similar to 23-24 meq/30 min and decreased histamine km from 14 mug/kg-h to about 1-2 mug/kg-h. Both changes were log linear. The effects of urecholine on histamine-stimulated H+ secretion thus showed synergism (decreased Km) and potentiation (increased Vmax), the former interpreted as a cholinergic effect on the parietal cell histamine receptors and the latter as the probable existence of spare cholinergic receptors not (normally) accessible to histamine. There were no intrinsic qualitative or quantitative differences in these responses between the vagotomized and the innervated stomachs.


Geometrical distribution of capillaries in mammalian striated muscle. Striated muscles of hindlimb, jaw, or tongue in dogs, cats, rabbits, rats, and guinea pigs were perfused under high pressure with Microfil (a silicone elastomer of viscosity 20 cP approx.) to outline the vascular bed. When the material had set, the muscles were fixed in formalin. Exmination of histological sections, strained by a modified Gomori trichrome method, showed capillaries containing Microfil as well as some, unperfused, filled with red cells. From well-perfused bundles the numbers of capillaries surrounding each fiber were counted; in all muscles these ranged from 0 to 9 with mean values betweeen 3.2 and 4.0. This was true of both red and white muscle. The mean number of fibers sharing one capillary ranged from 2.0 to 3.2, the lower value being found when four vessels surrounded a fiber and the higher value when there was only three. The results indicate a continuum of transitional models from a square array of fibers with each capillary between two adjacent fibers to a hexagonal array with capillaries at alternate vertices.


Protection of the ischemic liver by donor pretreatment before transplantation. Canine livers ischemically damaged for thirty minutes prior to auxiliary transplantation did not survive for long periods of time unless a combination of isoproterenol, allopurinol, and heparin was administered intravenously to the donor animal before the ischemic damage. These drugs had no protective effect when given individually. Ischemic livers treated with adenosine prior to transplantation also showed no improved recovery of function.


Lethal complications of bilateral nephrectomy and splenectomy in hemodialyzed patients. Routine bilateral nephrectomy and splenectomy (BNS) in uremic patients before transplantation are relatively safe procedures except when there is pre-existing sepsis, diabetes, or severe hypertension. A review of 421 patients undergoing routine pretransplantation BNS reveals that death before transplantation occurs in two definable groups of patients. In our series, the first group, those with juvenile onset diabetes, have a 15.4 per cent pretransplantation mortality (9.6 per cent operative and 5.8 per cent nonoperative) while being maintained on hemodialysis and awaiting transplantation. The second group, nondiabetic patients with other preoperatively definable risk factors such as severe hypertension and infected kidneys, had a 3.25 per cent pretransplantation mortality (1.9 per cent operative and 1.25 per cent nonoperative) while on hemodialysis. Paradoxically, these same factors are used as absolute criteria for pretransplantation nephrectomy at institutions where this operation is not a routine part of the pretransplantation regimen.


Gastroenteric anastomosis in Billroth II gastrectomy with maintenance of the physiologic diameter of the normal pylorus to prevent the dumping syndrome. Part II. Results in 1,300 cases. Clinical results of the use of a gastroenteric anastomosis with a diameter the size of the normal pylorus (1.9 cm) in 1,300 cases between 1954 and 1971 are presented mainly in terms of prevention of the dumping syndrome. We have had no patient with clinical manifestations of any degree of the dumping syndrome in the first two years after operation. These excellent results have led us to employ the method routinely. We recommend this method for its simplicity and, above all, its effectiveness in preventing the dumping syndrome.


Decreased function of a renal transplant after influenza virus infection. A sixteen year old female recipient of a renal transplant had decreased renal function one month after an influenza virus infection. An acute rejection episode induced by the viral infection was the probable cause. Renal function in transplant recipients should be carefully monitored for at least one month after viral infection.


Quantification of retinal lesions in diabetic retinopathy. A method of quantitative evaluation of the number of microaneurysms is described for clinical research in the therapy of early stages of diabetic retinopathy. In a double-blind study it can be demonstrated that the described method quantifies the progression of retinopathy statistically during only one year of observation in 32 resp. 40 patients. The difficulties of quantification are due to interpretation problems of the photographic documentation and the learning problem of the observer.


The influence of the route of administration on the clinical action of diazepam. The relative efficacy of diazepam 10 mg as a premedicant was assessed following its oral and intramuscular administration, using a "double-blind, double-dummy" technique, as well as its effect when given by both routes. Drugs were given to a standard patient population who were undergoing the same type of operation and receiving a standard anaesthetic. The most rapid onset of soporific action occurred when diazepam was given by mouth and this produced the best effect throughout the period of the study although its efficacy began to pass off after 60 minutes. It was superior in effect to the same dose injected into the thigh. The combined effect of oral and intramuscular diazepam was not notably greater than tht of the single oral dose. The injection of diazepam was followed by an unacceptably high incidence of pain, particularly when this was given into the thigh. There were no significant differences in either the course of anaesthesia or the incidence of post-operative nausea and vomiting. When the undesired effects are taken into consideration, the oral administration of diazepam should be the route of choice.


Plasma diazepam levels after single dose oral and intramuscular administration. Plasma diazepam levels were estimated by gas-liquid chromatography following a single 10 mg dose administered to a health adult female population by the oral and intramuscular routes. The highest levels were achieved following oral administration, reaching a peak at 60 minutes, although injection into the thigh resulted in a more rapid rise initially. Injection into this site produced higher levels than when the buttock was used. Injection by nurses into the latter site produced particularly low plasma levels over the 90-minute period of study. The plasma levels found at 90 minutes following the oral and thigh routes were found to be closely correlated with the weight of the patient.


Adrenocortical function related to Althesin anaesthesia and surgery in man. Althesin anaesthesia alone had no significant effect on plasma cortisol concentration. When Althesin induction was followed by maintenance with N2O and halothane there was a statistically insignificant fall, but with N2O, pancuronium and I.P.P.V there was a tendency for plasma cortisol concentrations to rise. This, too, was statistically not significant. A significant elevation in the mean plasma cortisol concentration was only found in patients during abdominal surgery.


Positive end-expiratory pressure. Effect on arterial oxygenation during respiratory failure in chronic obstructive airway disease. Changes induced in arterial oxygenation by positive end-expiratory pressure (PEEP) were analysed in twenty-nine instances in seven patients with chronic obstructive airway disease and acute respiratory failure, who were receiving IPPV. A significant decrease in mean PaO2 was found 4 hours after the removal of PEEP (P smaller than 0-01), but after its addition during the same period the PaO2 change was not significant. PaCO2 values were not modified by PEEP. The slight increase in mean PaO2 (20-9 mmHg) encountered during controlled ventilation with PEEP seems of doubtful clinical value. Alveolar-arterial oxygen gradient, while breathing oxygen 100%, was found to be elevated with a mean value of 276 mmHg. It appears from our results that PEEP is of little or no value in the routine ventilatory treatment of patients with chronic obstructive airway disease unless hypoxaemia is believed to be caused by a large intrapulmonary shunt.


Pneumopericardium associated with tracheal rupture. Management of a case complicated by the shock lung syndrome. A case history of a patient with unusual injuries following blunt thoracic trauma is presented. There was a pneumopericardium, bilateral tension pneumothoraces and rupture of the thoracic trachea, and the shock lung syndrome developed. Some points which arose in the management of the case are discussed, and it is pointed out that such injuries may be missed and must be considered in all patients with thoracic trauma especially those who do not improve with routine therapy.


The immediate care of head injuries.

The immediate care of head injuries. Anaesthetists have much to contribute as members of a team concerned with the management of a severe head injury. Many factors have been discussed but it must be remembered that their most important duty is to maintain a clear airway.


Chloroform at Christmas. An early reference from the Theatre-Royal, Edinburgh. James Young Simpson first administered chloroform to one of his obstetric patients on 5 November 1847. The speed with which the discovery caught the popular imagination is illustrated by a comic scene in a pantomime which formed part of an entertainment in Edinburgh presented on 27 December in the same year.


Acute opium poisoning: a report of two hundred cases in Iran. The diagnosis and management of 200 cases of self-poisoning due to orally ingested crude opium in Iran is reported and discussed. Gastric lavage supported when necessary by nalorphine was effective treatment in the majority of cases because of the slow absorption of opium. Mechanical ventilation was required in twelve cases (6%) only. There were three deaths; two of these were due to pulmonary oedema which was apparently not the result of hypoxia.


[Clinical investigations of the steroid anaesthetic agent CT-1341 (Althesin) (Cardiovascular and respiratory effects)]. The new steroid anaesthetic CT-1341 (Althesin) has been used as an induction agent in dose of 0.07 ml/kg body weight. Following injection, stage 1 anaesthesia is reached in an average of 30 sec with a clinical duration of between 12 and 20 min with total recovery, supported by a normal pre-anaesthetic EEG tracing, in 40 to 50 min. The respiratory depression following injection in characterized by a short period of apnea followed by an increased respiratory rate and a diminished tidal volume; there is a decrease of the pO2 of about 15%, but the pCO2 and pH values do not show significant variations. Concerning its action on the cardiovascular system, there was found an increase of heart rate (+14%), a decrease of both systolic (-19%) and diastolic pressures (minus decrease of both systolic (-19%) and diastolic pressure (-13.5%), central venous pressure and the peripheral vascular resistance (-14%) with hardly any change in the pulmonary artery pressure.


Radial artery cannulation.

Radial artery cannulation. The status of radial artery cannulation is reviewed. The technique of percutaneous puncture, equipment in use, and known complications are discussed. Recommendations are made for precautionary measures to reduce the complication rate. It is concluded that radial artery cannulation is a safe and useful procedure in certain anaesthetic and intensive care situations.


Management of tracheal rupture involving both bronchi. A patient with a rupture of the lower trachea and both bronchi is presented. A review of the significant clinical findings is presented, and the anaesthetic management is discussed. The necessity of early bronchoscopy in these patients and the ready availability of experienced medical staff in assessing all severe trauma is emphasized.


Evaluation of infant ventilators.

Evaluation of infant ventilators. A method of evaluating the performance of paediatric ventilators under simulated clinical conditions is described, together with the results of this evaluation of the prototypes of two ventilators designed specifically for use with infants and small children.


Teaching effectiveness: evaluation of computer-assisted instruction for cardiopulmonary resuscitation. Computer instruction for cardiopulmonary resuscitation (CPR), using a case-simulation program, was evaluated for its teaching effectiveness. First-month anesthesia residents, divided into two groups, A and B, underwent a cognitive evaluation on their 1st day of arrival and again on their 5th day. Both groups were provided with clear educational objectives and reading materials, a tutor was assigned to each student to answer specific questions. Students in group A, also given computer-assisted instruction (CAI), showed a significantly higher learning than those in group B, who served as controls. That CAI was a highly motivational form of learning was established by later voluntary participation in CAI of all group B students.


Psychomotor skills related to driving after intramuscular administration of diazepam and meperidine. Psychomotor skills related to driving and the ability to discriminate the fusion of flickering light were measured in a double-blind cross-over fashion in 11 healthy volunteers before, and 1, 3, 5, and 7 hours after, intramuscular injection of saline solution, 10 mg diazepam, or 75 mg meperidine. The late effects of meperidine were tested in five other subjects 12 and 24 hours after the injection. The effects of diazepam were the most harmful to coordinative and reactive skills, which were significantly impaired for as long as 5 hours. Meperidine impaired reactive skills for as long as 3 hours and flicker-fusion discrimination and coordinative skills for as long as 12 hours. It is concluded that patients should not drive or operate machinery for at least 7 hours after receiving 10 mg diazepam intramuscularly and for 24 hours after receiving 75 mg meperidine intramuscularly.


Sequential blood volume changes in patients undergoing total hip arthroplasty. Adequacy of transfusion based exclusively on clinical observations of hemodynamic changes and quantities of blood lost during total hip arthroplasty (THA) in 15 adults was tested by serial measurements of 51-Cr red-cell volume (RCV), 125-I RISA plasma volume (PV), and peripheral hematocrit (Hv) determined immediately before and 2 and 48 hours after operation. Blood transfusion and intravenous-fluid therapy were based on clinical observations and designed to restore blood volume (BV) to within 10 percent of its preoperative level prior to the isotopic determination 2 hours postoperatively. (When that determination showed a BV less than 90 percent, transfusions were given to restore it to between 90 and 100 percent). Isotopic data 2 hours after operation showed that the BV reduction--thought clinically to be less than 10 percent in every case--averaged 21.6 percent (range: 6 to 39 percent) and was shared by RCV and PV. Isotopic measurements 48 hours after operation showed that patients whose BV at 2 hours was within 10 percent of the preoperative BV were able to compensate for an average continuing RCV reduction of 23.9 percent by expansion of PV, resulting in an average BV reduction of 11.4 percent. Hv was a valuable guide for transfusion therapy at 48 hours, but not 2 hours after operation. In view of inadequacy of blood replacement based on clinical observations and the magnitude and variability of the 2 hour postoperative isotopically measured BV reductions in our patients, we recommend obtaining a derived BV by measuring PV and Hv preoperatively and 2 hours postoperatively as a further guide to transfusion therapy for each patient under-going THA. This is simpler and more practical than the two-isotope technique and is more sensitive than clinical observation alone. If clinical observation had been supplemented with a derived BV in our 15 cases, 80 percent instead of 30 percent would have had their BV restored to within 10 percent of the preoperative BV.


Hyaline membrane disease.

Hyaline membrane disease. In addition to confirmation of earlier epidemiologic observations, major advances have occurred in the past few years with respect to the diagnosis and treatment of hyaline membrane disease. Prenatal assessment of the risk for developing the disorder is now routinely possible by amniocentesis and analysis of the ratio of lecithin to sphingomyelin in amniotic fluid, or by surfactant titer ("shake test"). Such predictability and numerous other lines of evidence provide strong support for the hypothesis that hyaline membrane disease fundamentally reflects a deficiency of pulmonary surfactant. In accordance with the apparent primacy of surfactant deficiency, recent improvements in management are directed toward either increasing lung volume at end expiration by application of continuous distending airway pressure, or accelerating fetal lung maturation, with respect to the synthesis and secretion of surfactant, by prenatal administration of glucocorticoids.


The activity of chaulmoogra acids against Mycobacterium leprae. The activity of the crude sodium salts of the fatty acids of chaulmoogra oil and of hydnocarpic and chaulmoogric acids against Mycobacterium leprae was studied in mouse footpad infection. Multiplication of the organisms was inhibited when the salts were administered intraperitoneally and subcutaneously 3 times per week, and when chaulmoogric acid was administered intraperitoneally 5 times per week in half the equivalent dose. Dihydrochaulmoogric acid was also active, whereas palmitic acid was not. Hydnocarpic acid administered intraperitoneally once per week in a dose equivalent to half that of the sodium salts of the chaulmoogra fatty acids was not effective. The demonstration that chaulmoogra fatty acids possess activity against M. leprae lends weight to our earlier suggestion that a study of compounds analogous to these acids may yield effective antimicrobial agents with a unique mechanism of action.


Evaluation of mini-dose heparin administration as a prophylaxis against postoperative pulmonary embolism: a prospective double-blind study. A prospective double-blind study was instituted in a group of 150 general surgical patients to test the effectiveness of mini-dose heparinization in the pre- and postoperative periods. There was a 21 per cent reduction in the incidence of deep venous thrombosis in the heparin treated group. A radiopharmaceutical imaging technique with 99m-technetium macroaggregated albumin was used to evaluate the deep venous system. The procedure proved to be simple, safe, and painless; however, it was difficult to differentiate venous stasis from deep venous thrombosis. A negative study was good evidence that deep venous thrombosis did not exist. An additional benefit of this procedure was that a perfusion lung study could be obtained which provided additional information regarding pulmonary embolism without injecting additional radiopharmaceutical. Again, the negative perfusion lung study provided more information.


Dimethyl sulfoxide therapy in nonmongoloid infantile oligophrenia. We are herein submitting the results obtained with a group of 13 nonmongoloid, oligophrenic children after 180 days' treatment with DAT, and we have compared the results with those of a control group that received only conventional treatment. The children were examined before and after the treatment by means of the Binet-Simon tests, which have been standardized by Kuhlmann, and the Wise and Terman Merrill test. The control of organic lesion was determined by the Bender test. The variation mean of the control group was 0.08, and that of the DAT-treated group was 0.954; 0.874 was the mean difference, and 0.543 and 1.205 were the degrees of reliability. The difference between the results obtained from the DAT-treated group and the one that received conventional medication was significant (P equal 0.01). None of the 13 cases treated showed any signs of toxicity.


Pharmacologic and biochemical considerations of dimethyl sulfoxide. DMSO has multiple known pharmacological properties. In addition to those referred to include: cryoprotective action, radioprotective effect, influence on serum cholesterol in experimental hypercholesteremia, and platelet aggregation antagonism. How the multiple properties of this chemical affect therapy in clinical medicine must yet be explained. It is clear, however, that DMSO does affect biological systems, and that this influence has many clinical applications. Perhaps one of the most interesting and significant properties of DMSO is its ability to move other drugsthrough membranes. When mixed with DMSO, many drugs appear to be potentiated in their physiologic effect; thus smaller doses are required and less toxicity is demonstrated. In cancer chemotherapy, this value already has practical use. Some of the studies to be reported in this monograph will describe additional, almost unbelievable observations. Perhaps the mechanism of action of these clinical phenomena will be found in one or more of the pharmacological properties described. It would not be surprising, however, if we were to conclude with a resolution to search for new explantations of the mystery of DMSO, for it would appear that DMSO is really a new principle in medicine and cannot always be measured by existing standards.


Examination of lymphocyte membranes of athymic "nude" mice by scanning electron microscopy. Recent reports 1-3 have proposed that T-lymphocytes (thymus derived) could be distinguished from B-lymphocytes (thymus independent) by examining their features under the scanning electron microscope. T-cells were designated as having relatively smooth surfaced cells, whereas B-cells had "hairy" surfaces with many microvilli. We have examined this hypothesis in congenitally athymic "nude" mice, animals lacking T-cells,4 and have not been able to confirm these reports. We have found that lymphocytes from nude (nu/nu) mice are indistinguishable from lymphocytes obtained from normal littermates (NLM) and CBA/J mice. We have found that in all the murine lymphoid tissue examined, including nude, the complete gamut of cell surface types, ranging from smooth to "hairy" are present. Our studies indicate that the proposed T- and B-cell classification based upon human surface morphology under the scanning electron microscope is questionable in a mouse model. It is presently unclear whether the smooth lymphocytes seen in nude mice are immature B-cells, pre-T-cells, or another unidentified population of cells.


Antigenic and functional evidence for the in vitro inductive activity of thymopoietin (thymin) on thymocyte precursors. Thymopoietin, a polypeptide hormone isolated from bovine thymus, induced in vitro the differentiation of prothymocytes to cells with the antigenic and functional characteristics of intrathymic thymocytes. These changes included the acquisition of the differentiation antigens TL and Thy-1 (theta) and the ability to respond to the mitogen Con-A. Thymopoietin appears to be highly speicfic in inducing the prothymocyte to be highly specific in inducing the prothymocyte to thymocyte differentiation and does not affect the pluripotential stem cell measured by the colony forming assay (CFU-S), the erythropoietin-sensitive cell or B-cells. Experiments are in progress to determine whether additional hormonal inductive signals are required to complete the differentiation of an immunologically competent T-cell.


Involvement of T- and B-lymphocytes in the immune response to the protein exotoxin and the lipopolysaccharide antigens of Vibrio cholerae. The immune response at the level of individual immunocytes to the somatic lipopolysaccharide antigen derived from whole Vibrio cholerae and to the purified protein exotoxin from this organism were studied in terms of the role of T- and B-lymphocytes. By adoptive cell transfer studies with irradiated recipient mice, it was shown that normal spleen cells from normal syngeneic mice could readily transfer the capability of responding to both types of cholera antigens. However, when the spleen cells were depleted of T-cells with anti-theta serum and complement, antibody responsiveness to the LPS antigen, but not to exotoxin, could be achieved in recipients. Furthermore, by appropriate transfer of either bone marrow, thymus, or thymus-marrow cell mixtures to irradiated mice, it was shown that the response to the cholera somatic antigen was relatively independent of thymus cells, whereas the response to exotoxin required "helper" T-cells. The role of thymus and bone marrow cells in the intestinal tract in immune responses to the somatic and toxic antigens of cholera vibrios requires further investigation. Further studies should also provide additional information not only concerning the mechanism of the immune response to these antigens in terms of basic mechanisms of antibody formation, but also should provide valuable information in terms of anticholera immunity per se.


The absolute requirement for T-cells in the induction of IgM-secreting cells, in vitro. Anti-rabbit thymocyte antibody can totally inhibit the induction of IgM production that ordinarily is observed whem lymphoid cells are incubated, in virto, in the absence of added antigen. Univalent as well as bivalent antithymocyte antibody preparations were inhibitory when added to cells before the induction of immunoglobulin production had occurred but not afterwards. Spleen cells that had been treated with antithymocyte antibody and then cultured with thymocytes for 72 hours exhibited an enhanced inducttion of immunoglobulin production. Untreated spleen cells also showed this property, although both untreated lymph node cells and lymph node cells treated with antithymocyte antiboyd did not respond to thymocytes. The enhancement of the induction of immunoglobulin production by lipopolysaccharide was found to be T-cell dependent as judged from studies using antithymocyte antibody.


The nature and function of T-cell antigens. T-lymphocytes differ antigenically from B-lymphocytes. In the present study attempts were made to determine the role of surface antigens of T-cells, in their migration in vivo and in their response to mitogens. Exposure of thymus cells to anti-H2 sera inhibits migration to the lymph nodes (LN) to a greater extent than to the spleen. Fab fragments of H-2 antisera had only a slight effect on lymphocyte migration, inhibiting the LN-seeking stream only slightly more than the spleen-seeking stream. The interaction of Con-A with carbohydrates on the cell-surface of lymphocytes inhibits preferentially their localization in LN. Studies on the migration of lymphocytes that had localized either in the LN or spleens of primary host indicate that Con-A does not eliminate LN-seeking cells, but rather inhibits their active localization in LN. The subpopulation of lymphocytes, in both thymus and spleen that responds to Con-A was found to possess a higher H-2 antigenicity and a lower Ly and theta-antigenicity than the cells responding to PHA. Spleen cells responding to low concentrations of PHA had a relatively high H-2 antigenicity, whereas thos responding to high concentrations of PHA had a low H-2 antigenicity. Exposure of thymus cells to H-2 antiserum alone markedly inhibited their response to Con-A. Similar treatment of spleen cells had only a weak inhibitory effect.


Allergic contact dermatitis to underwear elastic. Chemically transformed by laundry bleach. Six subjects, allergic to the elastic in their undergarments, were patch test-negative to the rubber components and new elastic from the suppliers. However, washing the rubber with sodium hypochlorite gave the subjects allergic responses due to the effect of bleach on the rubber accelerator, zinc dibenzyldithiocarbamate (ZDC). To identify the allergen, ZDC was reacted with the sodium hypochlorite, and the resultant gum was extracted with diethyl ether. Eight compounds were identified in the reaction mixture by gas chromatography-mass spectrometry. The individual components were tested on volunteers after sensitization to the reaction mixture was produced in 14 of 25 volunteers. One component, N,N-dibenzylcarbamyl chloride produced an allergic response in each sensitized volunteer.


Miconazole therapy for endemic fungal disease. Miconazole nitrate (2.0%) cream was evaluated in the treatment of endemic dermatophytosis in an overcrowded prison. The active drug was compared in a random double-blind study with its control vehicle in the treatment of 99 inmates who had moderate to severe symptomatic disease. Tinea cruris and tinea pedis caused by Trichophyton rubrum predominated, although Trichophyton mentagrophytes and Candida albicans were also isolated and identified. Prompt clinical clearing occurred in 75.5% of those treated with miconazole versus 12.0% of those treated with the vehicle alone. Results of mycological examination closely paralleled and confirmed these clinical results.


Unilateral nevoid telangiectasia with gastric involvement. A 49-year-old man with liver disease developed a unilateral telangiectatic lesion over the left trigeminal and left C3, C4, C5, and T1 dermatomal areas. This case fulfills the criteria for unilateral nervoid telangiectatic syndrome (UNTS), and as such represents the 11th reported case of UNTS and the first case, to our knowledge, of visceral involvement associated with a similar vascular malformation. A hemorrhagic tendency is present in this syndrome when there is gastrointestinal involvement.


Monoparesis. Complication of constant positive airways pressure. Erb's palsy has been observed in 2 infants who had been treated with constant positive airways pressure for idiopathic respiratory distress syndrome. Both infants made complete neurological recovery from what was thought to be an acquired injury from the neck seal.


Arterial stenosis complicating renal allotransplantation in man: a study of 38 cases. Of 306 renal transplantations, stenosis of the artery supplying the grafted kidney was found in 38 patients three months to two years after they had undergone renal transplantation. The diagnosis was made by arteriography done because of refractory hypertension with or without impaired renal function in 36 patients and as a routine investigation in two normotensive patients. The stenosis was corrected surgically in 14 patients, with resultant lasting relief of hypertension in ten patients and improvement of renal function in five out of six patients with impaired renal function. Different types of stenosis were recognized: stenosis of the recipient artery, stenosis of the suture line, stenosis of the donor renal artery (segmental or diffuse) and multiple forms. The most frequent site of stenosis was the donor artery. There seems to be no single cause of stenosis: atheroma of the recipient vessels, faulty suture technique, hemodynamic disturbances, trauma to donor or recipient arteries account for some cases, whereas in other cases the evidence points to an immune mechanism. This complication of renal transplantation may be more frequent than is thought at present; therefore, routine renal arteriography should be performed at repeated intervals in all transplanted patients.


Spontaneous reversal of portal blood flow: the case for and against its occurrence in patients with cirrhosis of the liver. Because of its presumed serious clinical significance, we made an analysis of the evidence for and against the occurrence of spontaneous reversal of portal flow in cirrhosis of the liver. We examined the evidence obtained from manometric studies, radioactive tracer studies, radiologic studies, and actual measurements of magnitude and direction of portal blood flow. Concerning manometric studies, we introduced a physical analysis, based on first principles, which demonstrates that the occluded portal pressures cannot be used to construct a hydraulic gradient for portal flow. Similarly, we examined the weakness of the evidence derived from radioactive tracer and radiologic studies and, in the latter, the drastically opposite results reported by different investigators. Finally, we found that actual measurements of magnitude and direction of portal flow provide impressive evidence against the occurrence of spontaneous reversal of portal flow in cirrhosis. We conclude that unless new and convincing evidence is provided, it may not serve the best interests of medicine and of our patients to continue accepting spontaneous reversal of portal flow in cirrhosis as if it were a proven phenomenon.


Suppression of leukocyte chemotaxis in vitro by chemotherapeutic agents used in the management of thermal injuries. Polymorphonuclear leukocytes from burned patients exhibit suppressed chemotaxis possibly related to the susceptibility of such patients to opportunistic infection. This study assesses the effect of normal serum upon burn-suppressed leukocytes and the effects of three commonly used topical chemotherapeutic agents upon the chemotaxis exhibited by granulocytes from normal controls. In vitro incubation with normal serum restored chemotaxis to normal in the suppressed granulocytes from burned patients. The serum factor responsible for this restoration was heat labile. Serum albumin alone did not exhibit this effect. Both mafenide and silver sulfadiazine suppressed the chemotactic function of granulocytes obtained from normal controls, while silver nitrate exhibited no such activity. Studies of the chemotactic function of control granulocytes after incubation with sera from burned patients yielded similar results; only the sera from patients treated with silver nitrate failed to suppress normal leukotaxis. The chemotactic impairment found in leukocytes from burned patients, however, while related to burn size and predictive of prognosis, did not vary with the agent used for the topical therapy. These data suggest the presence of a reversible intrinsic defect in leukotaxis consequent to burn injury, related to some factor deficient in burn serum. In addition, extrinsic impairment of normal granulocyte leukotaxis by two commonly used chemotherapeutic agents is demonstrated.


Y-U advancement pyloroplasty.

Y-U advancement pyloroplasty. Heineke in 1886 and von Mikulicz in 1887 independently described the popular method of pyloroplasty by longitudinal incision and transverse closure. In some patients, particularly children, the Heineke-Mikulicz procedure has not always been satisfactory because of inadequate size and distortion of the muscular gastroduodenal funnel. In 1958, Moschel and co-workers reintroduced the concept of the Y-V advancement principle to enlarge the pylorus. This operation has not been widely adopted but has a number of attractive features, including simplicity, safety, and maximal channel size with minimal operating time. The standard Y-V principle has been modified in favor of a broadly based U-shaped pedicle constructed from the presenting surface of the gastric antrum which is advanced into an incision made in the anterior duodenum. This operation has been used in 33 patients, who range in age from 3 weeks to 17 years. They have been variously followed from 6 months to 10 years. The surgical need for pyloroplasty in this group of patients included hiatal hernia with delayed gastric emptying (19 patients); vagotomy for ulcer (7 patients); esophageal substitution (4 patients); vagotomy for reflux esophagitis (2 patients); and, in one instance, revision of an obstructed Heineke-Mikulicz pyloroplasty. Complications have been minimal; gastric drainage has been highly satisfactory. In long-term followup, no ill effect has been seen from the presence of antral mucosa in the proximal duodenum.


Use of radionuclide imaging in the early diagnosis and treatment of renal allograft rejection. Data are presented on the clinical application of radionuclide imaging to evaluate changes in cadaver transplant function in the immediate postoperative period. The method uses orthoiodohippuric acid (hippuran) administered IV, with scintillation imaging, and curve analysis by a digital computer. An initial study is always obtained 24 hours after transplantation. Serial studies are then obtained, as needed, to interpret the clinical course. Selected cases are presented which illustrate the use of this protocol in various clinical settings. In the oliguric patient serial studies have been of particular value. They have identified ATN so that over-enthusiastic treatment for rejection could be avoided. They have also identified acute rejection complicating ATN so that high dose steroid therapy could be administered appropriately. In the non-oliguric patient they have frequently contributed to the early diagnosis of acute rejection, and they have been useful in monitoring the effect and duration of treatment for severe rejection crisis. It is concluded that radionuclide imaging studies, when carefully applied and interpreted, are a valuable adjunct to the management of patients in this complex clinical setting.


Hypertension due to renal artery stenosis in transplanted kidneys. Hypertension appeared to be related to stenosis of the hypogastricrenal artery system in 5 patients among 153 recipients of renal allografts. Renin assay and arteriography were crucial in the comprehensive evaluation of patients whose hypertension was not clearly related to rejection or excessive sodium intake. Hypereninemia was persistent in 4 of the 5 patients. Stenoses of the transplant renal arteries in three patients were caused by extensive intimal plaque formation. In one patient, periarterial fibrosis caused reduction of flow; 180 degrees torsion of the anastomosis resulted in stenosis in the fifth patient. Surgical correction is difficult and may be facilitated by a transabdominal approach. Vein bypass is probably preferable to patch angioplasty for intimal lesions. Following operation, hypertension was ameliorated and function improved in all patients. Rejection, which has been suggested as one of the causes of intimal plaque formation, ultimately led to the loss of the transplant in one patient. Function is normal in two patients; two patients have evidence of chronic rejection. No effort should be spared to evaluate this special group of patients whose transplant function can predictably be prolonged by decisive surgical management.


Pulmonary responses of unilateral positive end expiratory pressure (PEEP) on experimental fat embolism. The role of positive end expiratory pressure (PEEP) was evaluated in preventing the deleterious mechanical respiratory effects of fatty acid pulmonary embolism. One group of animals had ventilation without PEEP, while the second group had PEEP of 10 cm H2O applied only to the right lung. In the right lung, PEEP slightly reduced the blood flow, increased the vascular resistance, but reduced intersititial edema and reduced the degree of shunting to almost normal. Hypoxemia was prevented in the right pulmonary venous system, but was prominent in the left. The hypoxemia and shunting in the left lung were comparable to the Group I animals without PEEP to either lung. These studies confirm the value of PEEP in the therapy of the pulmonary manifestations of fat embolism which are the lethal factors in the fatty embolism syndrome.


Fifty-two consecutive aortic valve replacements employing local deep hypothermia. From August, 1972, to May, 1974, 52 consecutive aortic valves were replaced with the Björk-Shiley tilting-disc prosthesis. The hospital mortality was zero. Patients ranged in age from 14 to 77 years, and 19 patients had simultaneous correction of associated cardiac lesions. Using techniques of low flow and local deep hypothermia, aortic valve replacement can be accomplished with little risk even in patients with associated coronary arteriosclerosis. Coronary artery perfusion is unnecessary and often hazardous. Follow-up periods vary from one to twenty-one months. Forty-nine patients are alive and substantially improved.


Outbreaks of Serratia marcescens infections in a cardiothoracic surgical intensive care unit. An outbreak of infections with pigmented Serratia marcescens involving 3 patients in a cardiothoracic surgical intensive care unit is reported. A respirator is thought to have been the source of pneumonia in 2 patients, and fomite spread from 1 of these is considered responsible for the induction of fatal endocarditis in the third patient. This outbreak demonstrates the rapid dissemination of a bacterial strain within the unit, several methods of dissemination, the wide variation in apparent virulence of the organism, the alterations of antibacterial host defense which made bacterial disease possible and which determined the site of infection, and the difficulties of adequate therapy. The third patient is the seventh reported with serratia infection of a prosthetic heart valve.


Comparative hemodynamic consequences of inflation hold, PEEP, and interrupted PEEP: an experimental study in normal dogs. Cardiac output and airway, intrathoracic, arterial, pulmonary artery, left atrial, and central venous pressures were studied in 8 mongrel dogs. They were anesthetized and ventilated with (1) inflation hold of various duration, (2) continuous positive end-expiratory pressure and one breath off). The results indicate a minimal decrease in cardiac output (of approximately 5 per cent) with inflation hold. Diminished cardiac output was noted with increasing levels of continuous PEEP. The severity of the decrease in cardiac output wasproportional to the airway pressure. The higher levels (20 cm H2O) OF PEEP were associated with profound decreases. Utilization of a technique of interrupted PEEP substantially reduced the adverse hemodynamic effects in the dog.


Straight suture plane to avoid periprosthetic leak in aortic valve replacement. A suture technique which avoids periprosthetic leakage during replacement of the aortic valve is described. Three types of stitch are inserted in a manner that causes all needle points to exit in a straight plane. The method was employed in 106 consecutive patients; of the 99 who survived operation, none have developed perivalvular leak.


Opportunistic endocarditis following open-heart surgery. The incidence of endocarditis following open-heart operations is declining, but the relative incidence of endocarditis by the opportunistic organisms, both bacterial and fungal, has increased. These "opportunists" require careful identification and sensitivity testing so that appropriate therapy can be planned. In cases of candida endocarditis, a positive precipitin test and elevated candida antibody titer may provide an earlier means of diagnosis than blood cultures. These patients should be treated promptly with adequate dosages of specific antimicrobial or antifungal agents. Reoperation should be considered early if there is evidence of valve dehiscence or embolic phenomena or if drug therapy fails to control the infection.


[Comparison of the antiangina pectoris action of 2 coronary vasodilators]. Twenty four patients were studied: 7 males and 17 females, with an average age of 56 plus and minus 6.93 years, with a main diagnosis of ischaemic heart disease and with an average of at least 7 angina attacks per week. The anti-angina effect of 2 drugs, dipridamol and pentaeritritol was compared using the random double blind technique on parallel groups which were comparable. Pentaertritol administered for 4 weeks reduced, with a statistical significance (P 0.01), the average number of angina attacks of the group, as well as with taking nitroglicerine tablets. The number of pain free days was increased from 1.5 per week to 5.5 in 7 days. The effort capacity of the patients increased (P 0.01), and also the degree of elevation of the ST segment during and post effort. The changes obtained in these same areas with dipiridamol had no statistical significance.


Cyclophosphamide therapy for rheumatoid arthritis. Cyclophosphamide in high doses was given for six months to 19 patients with rheumatoid arthritis. A second group of patients with rheumatoid arthritis whose conditions were stable on low-dose prednisone received in addition either cyclophosphamide or placebo for six months. Measurements of joint function and joint inflammation were used to estimate disease activity. Joint inflammation progressively decreased and joint function improved in the high-dose group. The low-dose cyclophosphamide-plus-prednisone group had a similar response that was different from the prednisone-plus-placebo group. Cyclophosphamide toxicity was common in the high-dose group and minimal in the low-dose-plus-prednisone group. Cyclophosphamide therapy improved the arthritis of these patients. The results were almost as good in the low-dose-plus-prednisone group, and the toxicity was much less.


Transient bacteremia associated with barium enema. A group of 175 patients had barium enema. Pour-plate blood cultures were obtained immediately before and after the procedure and 5, 10, 15, and 30 minutes later. Bacteremia was demonstrable in 20 (11.4%) patients. In some, blood cultures were positive for as long as 15 minutes after barium enema; all were negative at 30 minutes. Among the bacteria associated with the 20 episodes of bacteremia were Escherichia coli, Klebsiella, enterococci, Proteus morganii, Bacteroides, and Veillonella. The incidence of bacteremia among patients with ulcerative colitis, regional enteritis, rectal polyps, colonic or rectal carcinoma, nonspecific diarrhea, or other lower intestinal tract disorders was not much different from patients free of rectosigmoid disease. The results of this study suggest that a history of recent barium enema may be important in patients who have endocarditis.


Anticoagulants in cerebrovascular disease. A critical review of studies. Anticoagulant therapy in the treatment of cerebral thromboembolism remains controversial despite 20 years of statistical studies. Among the unresolved questions are (1) the relative value of aspirin vs coumarin derivatives for long-term therapy; (2) the relative benefits of long-term therapy vs short-term therapy; (3) the complications of anticoagulant therapy vs their therapeutic benefits; and (4) the optimal therapy of the various types of cerebral thromboembolic events, eg, transient ischemic attacks, strokes in evolution, and completed strokes. Much of this controversy derives from the same problems that have plagued the question of anticoagulation for acute myocardial infarction, namely that "the existing statistics were obtained without adequate attention to fundamental principles of clinical science". We have examined the available clinical studies bearing on this issue and are reporting our analysis of these studies.


Methylphenidate and haloperidol in children. Effects on attention, memory, and activity. Twenty-four hyperactive or unsocialized-aggressive children participated in an exploratory double-blind crossover study comparing the cognitive effects of methylphenidate hydrochloride (0.3 mg/kg), two doses (0.25 and 0.05 mg/kg) of haloperidol, and inert placebo. Each subject received each of four drug conditions, drug order being randomized by a Latin square design. At the end of each 18-day trial period, attention, immediate recognition memory, reaction times, and seat activity were tested. While drug effects were small, methylphenidate and, to a lesser extent, the low dose of haloperidol, facilitated performance, whereas there was some suggestion that the high dose of haloperidol may have caused a slight deterioration in performance. These results are contrasted with effects on social behavior where the latter improved behavior. No differences attributable to diagnosis were found.


Marihuana and setting.

Marihuana and setting. Marihuana or placebo cigarettes were smoked by 12 subjects in two environments, one "favorable" and one "neutral". The object was to determine the contribution of setting to the effects reported from the drug. Two quantifiable self-report measurements, the linear euphoriant scale and the card-sort version of the Addiction Research Center Inventory (marihuana and hallucinogen scales), were the major reporting criteria. Analyses of variance consistently demonstrated strong effects for subjects and drug but not for the environmental conditions. Reports of marihuana effects may be assumed to be highly colored by psychological differences in the mental set of subjects, or biological variations in their responses to the drug. The actual environment in which the drug is taken seems to play little, if any, role.


Etiology and treatment of homosexuality: a review. The major causal theories of and treatment approaches to male and female homosexuality are critically reviewed. Neither biological, psychoanalytic, nor learning and social-learning theories are found to provide convincing evidence for the etiology of homosexuality. All of these accounts, however, are viewed as providing mixed empirical support for their predictions, with social-learning research presenting the most consistent evidence. It is argued that both social-learning research findings and results from retrospective studies suggest that homosexuality may best be linked to the early qualitative learning and development of one's gender identity and gender role. Both psychoanalytic therapy and behavior therapy are found to have minimal successes and many failures. Most therapeutic successes seem to be with bisexuals rather than with exclusive homosexuals. The combined use of psychotherapy and specific behavioral techniques is seen to offer some promise for heterosexual adaptation with certain kinds of patients. However, it is argued that better prospects for intervention in homosexuality lie in its prevention through the early identification and treatment of the potential homosexual child.


The relationship between paranoid delusions and homosexuality. Freud predicted that paranoid delusions are motivated by unconscious homosexual impulses. The research conductedto test this hypothesis has been reviewed and it is concluded that the results do not support Freud's position. The results indicate anassociation between homosexual concerns and paranoid delusions but not in the manner that FREUD PREDICTED. For example, clinical studies indicate greater overt and conscious homosexual preoccupation in paranoid psychotics compared to nonparanoid psychotics, a finding not predicted by Freud. While psychological studies have tended to find more support for the Freudian position, several studies have failed to find supporting evidence and others are inconsistent in their results.


Rectovaginal separation operation after a "cutback" procedure for anorectal anomalies. The "cutback" procedure has been widely utilized over the 25 years for correction of mild forms of ectopic anus encountered in newborn females. As these children have become adolescents, some are troubled by the cosmetic appearance created by this procedure, recurrent urinary tract infections, and persistent vaginitis from continued fecal soiling. The rectovaginal separation procedure described (1) separates the rectum from the vagina by interposing adjacent tissues, (2) elongates the rectal canal, and (3) utilizes flaps of perineal skin to gain a normal degree of separation of the anus from the vagina. Five girls, ages 6 to 15 years, have undergone this procedure with a temporary loop colostomy to protect the perineum during healing. The long-term functional and cosmetic results three to seven years later have been excellent in four patients. The fifth girl has been observed only five months, but seems to have an excellent cosmetic result.


The solitary pulmonary nodule. Ten-year follow-up of veterans administration-armed forces cooperative study. Over a five-year span 1,134 patients with asymptomatic solitary pulmonary nodules were entered into a cooperative study. Of the 392 lesions found to be primary bronchogenic carcinoma, 67 patients were living and under observation ten years following operation. In the study, 32% of lesions were primary bronchogenic carcinoma, the incidence being 51% in patients above the age of 50 years. "Curative" resection was possible in 309 patients (78.9%) with a five-year observed survival of 38.5% and a ten-year observed survival of 20.1%. Factors that influenced long-term survival were size of lesion, age at operation, and interval between the last normal and the first abnormal x-ray film. Histologic cell type and extent of resection were not found to influence long-term survival.


Changes in functional residual capacity of the lung after operation. Functional residual capacity (FRC) of the lung was measured by the closed-circuit helium equilibration method before and for five days after upper abdominal operations in 28 patients (25 had cholecystectomies). Measurements in many were made with the patient both sitting in bed and sitting in a chair. Vital capacity (VC), residual volume (RV), and forced expiratory volume in one second (FEV1), as well as FRC, all decreased after operation, with the maximum decrease on days 1 and 2 and a gradual return toward preoperative values by day 5. Patients with 40% or less decrease in FRC after operation did not develop pulmonary complications. Change in position from bed to chair increased FRC 14.2% preoperatively and 17% postoperatively. The use of intermittent positive pressure breathing had no measurable effect on FRC. Similar changes in FEV1, VC, and RV also occurred, with maximum decreases on day 1.


Hemorrhage due to diffuse erosive gastritis. Of 796 patients admitted with upper gastrointestinal bleeding during a five-year period, 156 (20%) had erosive gastritis. Vigorous nonoperative treatment stopped bleeding in 117 (75%); emergency operation was required  in 39 (25%). In 24 of these 39 patients (group A), subtotal gastric resection with truncal vagotomy was performed. In the remaining 15 patients (group B), the operation was limited to pyloroplasty, truncal vagotomy, and multiple suture ligation. These patients were, on the average, 20 years older than the patients in group A, and 12 had life-threatening preoperative problems. (Only four of the group A patients had life-threatening preoperative problems.) The operative mortality in group A was 42%, with rebleeding occurring 33%. In group B, only 17% rebled and the operative mortality was 45%. Survival in the two groups was similar, even though those patients in group B were more critically ill. The less radical procedure may often be the best choice in the high-risk and elderly patients who bleed massively and in whom immediate salvage of life is the main issue.


Dissecting aneurysm of the descending aorta. Improved surgical results in 91 patients. Dissecting aneurysm of the descending thoraic aorta (type iii) is a specific disease process whose pathogenesis, pathologic description, surgical treatment, and prognosis is different from dissections of the ascending arota (types l and ll). From 1964 through 1974, 91 patients underwent surgical correction of type  iii dissection. The operative mortality was 21% and late mortality, up to ten years follow-up, was 13%. During the past four years, operative mortality has dropped to 6.5%. Mortality was determined by extent of the aneurysm and underlying cardiac disease. Antihypertensive and negative ionotropic drugs have not been used as definitive treatment but as adjuncts in perioperative support. Based on our present mortality of 6.5%, with no late mortality, we urge early surgical treatment of acute and chronic dissecting aneurysms of the descending thoracic aorta before extension, rupture, or massive enlargement of the aneurysm occurs.


The permanent gastrostomy. Use of the gastrointestinal anastomotic stapler. A permanent feeding gastrostomy was quickly and simply constructed in 29 patients with low operative risk using the gastrointestinal anastomotic stapler. The technique consisted of a simple application of this stapler on a carefully selected section of the stomach to form a Janeway type of gastrostomy. Activation of the device placed two double rows of staples and cut between them. This left the mucosa in approximation both in the tube and in the body of the stomach. A few additional Lembert sutures was all that was necessary. There were no suture line leaks nor other complications peculiar to the method.


[Quantitative estimation of the lymphatic bed density of film preparations (of organ membranes) using the luxometry (photometry) method]. The essence of the luxmetry technique is that we can make a conclusion of the density of lymph capillaries per a unit of the serous or other membrane on the basis of the difference in illumination of the microscope field with a cleared preparation without injection of lymph vessels and the preparation where the lymphatic network is injected with the Gerota's mass absorbing a part of light. With the help of the above method of luxmetry we can obtain new data about local and developmental changes in the density of lymph capillaries of the abdomen, epicardium, submucous basement of the sigmoid colon and skin as well as in some functional (pregnancy) and pathological states.


[Ultrastructure of the skin in systemic scleroderma]. Biopsy specimens of the skin of the back of the forearm and hand in 20 patients with systemic scleroderma were studied using histological and electron microscopy methods.  There were revealed evidences of intensified neofibrillogenesis, changes in collagen structures of the derma (destruction and defects of packing of collagenous fibrills, variability of their thickness in a fibre) and in the microcirculatory bed.  In 18 out of 20 cases the nuclei of the connective-tissue cells and cells of the basal layer of the epidermis contained the so-called nuclear bodies, which are considered by a number of authors as an indirect evidence of a viral infection.  The process of an intensified neoformation of collagen fibrils considerably predominated over destructive processes in collagen structures.


[Pathological anatomy of pneumonia in Mycoplasma pneumoniae infection in children]. A total of 43 section observations on acute respiratory viral diseases in children aged between 13 days to 13 years are described.  Using the direct and indirect fluorescent antibody test in 11 observations M. pneumoniae antigen was detected; in 4 observations this antigen was represented as monoantigen, and in 7 observations--in association with viruses of influenza, parainfluenza and adenovirus.  The characteristic features of mycoplasma pneumoniae were noted; very high blood filling of vessels of all calibres with the involvement of the system of microcirculation of the lungs, with phenomana of pronounced dilatation of the capillary net and with a tendency to thrombo-formation; diffuse lesions (dystrophic and inflammatory changes) of large and small bronchi and bronchioles; plasmocellular reaction in interstitia of the lungs, perbronchial follicles and bifurcated lymphatic nodes; the presence of M. pneumoniae antigen in histological sections of the lungs.  The author thinks it advisable to discard the term "M. pneumoniae-pneumonia" and replace it by "M. pneumoniae-infection" with predominent localization of the process in the lungs.


Expandable silicone implants for scleral buckling. IV. Experiments with an explant for macular breaks. A new expandable silicone rubber explant used to indent the sclera at the macula was tested experimentally in rabbits. The device consists of a Dacron-reinforced silicone rubber strip that has an expandable portion (or balloon) at its midpoint connected to a silicone filling tube. The explant was expanded with 0.03 to 0.06 ml of an antibiotic solution. Smooth, round buckles that exerted even indentation were produced. A decrease in height of 20% to 50% was observed ophthalmoscopically during six months of follow-up. The degree of buckling can be easily controlled during operation and may be modified postoperatively.


Malignant lymphoma of the paranasal sinuses. Sinus lymphoma is a rare but potentially radiocurable malignant neoplasm. The disease is isolated to the sinus and adjacent local tissues on initial presentation, and concurrent generalized lymphoma is unusual. With rare exception, the histologic pattern is that of a diffuse histiocytic non-Hodgkin lymphoma (reticulum cell sarcoma). Radiotherapy to the involved sinuses without prophylactic neck irradiation is the treatment of choice, and a survival rate of 50 percent to 70 percent can be expected.


Skin and homograft cartilage reconstruction. Conservative vertical hemilaryngectomy poses the problem of relating the need to remove the tumor completely to the aim of reconstructing an adequate airway lined with epithelium. An attempt has has been made in experimental animals to overcome this problem using pedicled skin and homograft cartilage. The findings suggest that this is a feasible technique, although somewhat hampered by problems unique to the animals concerned. The use of skin pedicles provides adequate cover without shrinkage, and although it is doubtful whether cartilage can survive intact in the long-term, it would seem that it may be adequate for the purposes intended.


Study of the adenovascular body of the posterior part of the nasal septum. The mucosa of the posterior part of the nasal septum is studied by in vivo observations in 40 seemingly healthy adults, vascular injection of two anatomical specimens rendered transparent, histological studies of serial sections of five anatomical specimens, and macroscopic and histological examination of specimens obtained from 20 cadavers. The presence of an "adenovascular" body was noted in the posterior part of the nasal septum; this body occupies about one fifth of the total area of this region. This study shows that this is a normal structure of the nose and suggests that its name be changed to adenovascular body of the posterior part of the nasal septum.


Blood flow measurements in skin flaps.

Blood flow measurements in skin flaps. For the last 50 years, the empirical approach of set length to width ratios for skin flaps has been held valid. Not until Milton's work in 1971 was this concept challenged. This report represents a method where precise, reproducible, and quantitative measurements of skin blood flow can be made using four radioactive nuclide microspheres and measures the blood flow changes in flaps of differing length to width ratios. Conclusions from our data suggest that the cutaneous blood flow in ventrally based, abdominal skin flaps in dogs is independent of base width as measured immediately after outlining and elevation.


Hearing loss during resuscitation.

Hearing loss during resuscitation. Tympanic injury secondary to positive pressure mask ventillation is rare. During resuscitative procedures, two patients developed partial deafness, one from disarticulation of the incudomalleal joint, the other from an oval window perilymph fistula. Excessive pressure transmitted rapidly through the eustachian tube is postulated to have caused both injuries.


Microorganism-like structures in Hodgkin disease. Electron microscopical demonstration. Ultrastructural examination of lymph nodes from patients with untreated Hodgkin disease showed unique spherical structures that were found extracellularly and within vacuoles of reticulum cells, macrophages, mononuclear cells, and occasional tumor cells. These spheroids varied in size and internal composition possibly in relation to developmental stages, and resembled mycoplasma morphologically and in cellular distribution. The spheroids were found predominantly in the neoplastic areas in lymph nodes of four out of nine patients with Hodgkin disease of the mixed cell variety, but were not seen in other types of Hodgkin disease or reticulum cell sarcoma. The structures were much more numerous in the lymph nodes from young children with Hodgkin disease. A lymph node of one child, disclosed numerous extracellular structures resembling viral type C particles in addition to mycoplasma-like spheroids. The results indicate that subclinical infections may occur in Hodgkin disease and contribute to the histopathologic manifestations of the disease.


Acute pulmonary alveolitis in narcotics abuse. Lungs of 17 narcotic abusers from medical-legal autopsies were studied to determine the pathological basis for regional alterations of ventilation and perfusion. Postmortem pulmonary angiographic and histological techniques demonstrated acute alveolar wall inflammation with exudation of fluid and cells into the alveoli in all eight abusers dying of narcotism and in six of nine dying of other causes. All abusers had extensive focal chronic intersititial inflammatory infiltrates. Vascular obstruction due to foreign material occurred only with intravenous use of oral pharmaceuticals, and then only in the microcirculation. Lungs of ten young adults dying suddenly with no history or evidence of narcotics abuse showed no acute alveolitis or intravascular foreign material. Intravenous narcotics injection produces transient acute alveolar inflammation that may account for respiratory manifestations and death. Permanent injury to the lung parenchyma or larger vessels with the usual forms of narcotic abuse is not common.


Extracellular glomerular microparticles in nephrotic syndrome of heroin users. Intracellular and extracellular glomerular microparticles (GMP) have been described in diverse human glomerulopathies. We have recently detected extracellular GMP in two heroin abusers with nephrotic syndrome. Most of the GMP were approximately 100 nm in diameter (range, 56 to 178 nm), and consisted ultrastructurally of an electron-dense central core surrounded by a concentric, lucent area and an electron-dense limiting membrane. Incomplete forms of GMP and residual laminated membranes without a central core were also present. The distribution of extracellular GMP was both intramembranous and subepithelial; they did not resemble virions morphologically. As these GMP have been observed in human glomerulopathies that are etiologically and morphologically varied, they probably represent nonspecific markers of glomerular injury. The prevalence of GMP in the nephrotic syndrome of heroin abusers awaits cumulative experience.


The case of The Case of the Midwife Toad. The facts concerning Kammerer's case are reviewed.  Koestler's view that Krammerer was unjustly accused is presented and shown to be incorrect.


Enzyme histochemical investigations of human malignant lymphomas. 26 cases of malignant lymphomas and 23 other lymphoreticular conditions were investigated enzyme histochemically. Each type of malignant lymphoma revealed a different enzyme histochemical pattern characteristic of its type. These features are not only applicable to differential diagnosis but also suggest clues to the understanding of histogenesis and nature of malignant lymphomas.


Gammacardiographic and ballistocardiographic comparison of indices of central haemodynamics and the myocardial contractile functional state in patients with coronary heart disease. A complex ballistocardiographic and gammacardiographic investigation was carried out in 62 patients with coronary heart disease; ballistocardiographic and gammacardiographic indices have been compared. We established pathologic ballistocardiographic changes, which indicate a disturbance of the myocardial contractile function. Considerable changes of central haemodynamics, studied by means of gammacardiography, were recorded. There is a relationship between ballistocardiographic indices of the myocardial contractile function and radiocardiographic indices of central haemodynamics.


Effect of ibuprofen dosage on patient response in rheumatoid arthritis. In a 4-week double-blind trial in 41 patients with rheumatoid arthritis, ibuprofen (Motrin) decreased the swollen joint count significantly at a dosage level of 2400 mg/day, but not at 1200 mg/day. Ibuprofen probably does have antiinflammatory effects in man, but only at higher dosages; antiarthritic activity at lower dosages reflects primarily analgesia and perhaps antipyretic effects. Complaints and clinical laboratory findings did not differ significantly between the dosage groups.


Effect of quinidine on maintaining sinus rhythm after conversion of atrial fibrillation or flutter. A multicentre study from Stockholm. In a controlled study comprising 176 patients, quinidine in the form of Kinidin Durules was found to reduced significantly the recurrence of the atrial fibrillation during a 1-year follow-up period after successful electric shock conversion. After one year, 51 per cent (52/101) of the patients in the quinidine group, and 28 per cent (21/75) in the control group remained in sinus rhythm (P smaller than 0.001). No less than 43 per cent of the patients converted to sinus rhythm during treatment with maintenance doses of quinidine sulphate before intended DC conversion. Gastrointestinal side-effects were not uncommon, and caused interruption of quinidine treatment in some cases.


Recent progress in the study of occupational lung diseases in Romania. This paper reviews studies of occupational lung diseases in Romania in the last two decades. Work concerned with the effects of exposure to textile fibres, irritant gases and fumes in the chemical industry, welding fumes, asbestos, cadmium oxide, and the relation between dust exposure, pneumoconiosis, and chronic bronchitis is briefly presented.


People and work: some contemporary issues. In advanced industrial societies social, economic, and technological changes are accompanied by changing values and attitudes to work, symptomatic of what some see as the transition to a post-industrial era. As a result existing job definitions and traditional forms of organization are being challenged and attempts made to restructure work so that it becomes meaningful and rewarding in the fullest sense, to the individual, to the enterprise, and to society. These range from programmes of job enlargement and job enrichment, within the framework of existing technologies, to experiments in the design of organizations as a whole in which fewer constraints are accepted as given. They entail and require a multidisciplinary approach as well as awareness of and commitment to the underlying values. The possibilities and benefits of restructuring work in these various ways have been demonstrated sufficiently to encourage interest at governmental level as well as by employers and trade unions. There are, however, no simple prescriptions or principles of universal application. Knowledge is still tentative and partial but there is consensus that the search for new ways of dealing with the organization of work and the allocation of resources is of fundamental importance.


Cataract surgery performed before 800 B.C. The general belief that the technique of cataract extraction in India in the Sushruta period (800 B.C.) was couching is no longer tenable. A study of the original text suggests that the method was more closely allied to the extracapsular extraction of recent times.


Chemical specificity of pyruvate kinase from yeast. Three analogs of phosphoenolpyruvic acid: (Z)-phosphoenol-3-fluoropyruvate, (Z)-phosphoenol-3-bromopyruvate and (Z)-phosphoenol-alpha-ketobutyrate were found to be substrates for yeast pyruvate kinase (ATP: pyruvate (Z)-O-phosphotransferase, EC 2.7.1.40)with maximal velocities much greater than those found for rabbit muscle pyruvate kinase. The analogs exhibited sigmoidal kinetics, which become hyperbolic upon addition of the allosteric effector, fructose 1,6-diphosphate. Moreover, the reaction of (Z)-phosphoenol-3-bromopyruvate with ADP to produce bromopyruvic acid and ATP irreversibly inhibited the enzyme with a half-life of 32 min.


Stimulatory effect of hydrostatic pressure on cell division in cultures of Escherichia coli. [14-C] Thymine incorporation into a trichloracetic acid-insoluble fraction of Escherichia coli HMS83 polA1 polB1 and cell division were observed as a function of time. The data presented show that hydrostatic pressures of about 600 x 10-5 N/m-2 stimulate that part of the division process which leads to the separation of cells. The kinetics of [14-C] thymine incorporation by this mutant suggest that completion of rounds of replication at high pressures is not dependent on DNA polymerases I or II or at least on high levels of these enzymes.


The effect of neomycin and streptomycin on the electrical polarisability of aqueous suspensions of Escherichia coli. Aqueous suspensions of bacteria scatter light strongly. In addition, the bacteria exhibit strong induced dipole moments in an electric field. In this note we report how, by measuring the intensity of the scattered light, the electric polarisability (alpha) of Escherichia coli could be monitored as small quantities of antibiotics were added to the suspensions. The effect of the presence of quite small quantities of antibiotic on the electrical polarisability, which gave rise to the induced dipole, was dramatic. From the hypothesis that alpha had its origins in the bacteria-solvent interface, a theory is presented which adequately accounts for both alpha and its changes in the presence of these antibiotics. The study is taken to suggest that the antibiotic molecules were adsorbed on to the bacterial surface thereby reducing the surface charge. This in turn reduces the number of counterions and the apparent induced dipole moment. Because the electric-field scattering method is both quick and sensitive to changes in alpha, it may prove a valuable method for the study of antibiotic action on  cell and microorganism surfaces.


Application of latex microspheres in the isolation of plasma membranes. Affinity density perturbation of erythrocyte membranes. Immunolatex spheres, originally developed as visual markers for scanning electron microscopy, were employed as membrane density perturbation reagents. Methacrylate spheres were bound to antibody molecules and used to label antigens on erythrocytes. Ghosts prepared from labeled cells were subjected to isopycnic centrifugation on continuous sucrose and dextran gradients. It was found that the labeled erythrocyte membranes had a substantially higher density than unlabeled membranes. The extent to which the membrane density was shifted on a given gradient depended on the number, size and density of the latex spheres and could be closely predicted by theory. These results suggest that the reagents and techniques described here have potential application for the isolation of plasma membranes from more complex cell types.


Energy requirements for the uptake of L-leucine by Saccharomyces cerevisiae. (1) Substrates capable of activating mitochondrial electron transfer and oxidative phosphorylation, namely, pyruvate, acetate, propionaldehyde and butanol, stimulated the concentrative uptake (transport and accumulation) of L-[14-C]leucine by Saccharomyces cerevisiae (wild type strain 207, starved cells). Under adequate experimental conditions, the L-[14-C]leucine uptake versus the oxygen uptake ratio was almost the same with either pyruvate, acetate or D-glucose as energy sources. Substrate oxidation also increased L-[14-C]leucine incorporation into the cell protein. (2) With S. cerevisiae D261 and D247-2 and propionaldehyde as an energy source, or with strain 207 and glucose as energy source, 2,4-dinitrophenol (50 muM) inhibited L-[14-C]leucine uptake, the inhibition being accompanied by stimulation of respiration. With S. cerevisiae 207 and propionaldehyde as energy source, 2,4-dinitrophenol inhibited both respiration and L-[14-C]leucine uptake, but with respiration being less affected than uptake. Displacement of accumulated L-[14-C]leucine was also inhibited by 2,4-dinitrophenol. (3) In the presence of glucose, and for relatively brief incubation periods, anaerobically grown cells of S. cerevisiae 207 and of a p-minus "petite" mutant of this strain incorporated L-[14-C]leucine with less efficiency than the original wild type strain 207, grown aerobically. With D-glucose as energy source, 2,4-dinitrophenol and iodoacetate inhibited alike L-[14-C]leucine uptake by the respiration competent cells. (4) It is postulated that in respiration-competent yeasts, the mitochondrion contributes to 6-[14-C]leucine uptake by supplying high-energy compounds required for amino acid transport and accumulation. Conversely, the promitochondrion in the anaerobically grown yeast, or the modified mitochondrion in the respiratory deficient mutant, competes for high energy compounds generated by glycolysis in the cytosol.


Demonstration of cells with igg receptor in human placenta. The presence of two types of cells with IgG surface receptors was demonstrated in mature and immature human placentas. One type corresponded morphologically to the Hofbauer cells and the second to the blood monocytes. Transitional forms between monocytes and Hofbauer cells were also observed.


Possible mechanism of E. coli messenger RNA degration: non-enzymatic degradation. The present paper points out lack of evidence to support the presently prevailing concept that E. coli mRNA turnover, in the gene expression process, cannot take place without mRNase(s). The present paper draws attention to possible physicochemical factors involved in the degradation, and advances a notion of non-enzymatic spontaneous degradation of E. coli mRNA in its expression process. This suggested hypothesis helps to explain hitherto reported findings on the mode of E. coli mRNA degradation.


[Quantitative behavior of immunoglobulins in Hodgkin patients following splenectomy]. The values of immunoglobulins in 14 patients with malignant lymphoma were determined before and 1 to 44 weeks following splenectomy. The IgM-fraction showed a significant decrease in all cases, whereas the IgG- and IgA-fraction showed no change in its concentrations. The reason for the IgM-decrease is probably due to the absence of IgM-producing cells in the spleen.


The radiological diagnosis of adrenal tumours. The radiological diagnosis of adrenal tumours is reviewed with special reference to the literature and the author's personal experience. The clinical presentation varies widely with the different pathology and radiological investigation is decided largely by clinical assessment. The various methods of investigation are related to the individual problems with special reference to arteriography and phlebography. Thirteen cases of Conn's tumour have been diagnosed by adrenal phlebography and 18 cases of phaeochromocytoma have been investigated by arteriography. These cases are reviewed in detail.


Continuous perfusion of human cadaveric kidneys for transplantation. 63 cadaveric kidneys have been preserved for up to 36 hours by continuous perfusion on a Gambro machine 52 kidneys were transplanted: 13 (25%) functioned immediately, 23 (44%) functioned after 2 to 28 days, and 16 (31%) failed to function. 11 kidneys with poor perfusion flow characteristics were discarded. Of 30 kidneys followed for more than 18 months, graft survival was 50%. Analysis of warm and cold ischaemia data, of perfusion flow rates and biochemical studies, and comparison of function of 18 pairs of kidneys only one of which was continuously perfused, suggests that this method of preservation effectively extends the preservation time to 36 hours, but does not improve the immediate function and non-function rates, and does not provide an accurate assessment of viability.


The technique and results of one-stages island patch urethroplasty. 27 one-stage island patch urethroplasties have been performed with the longest follow-up of 3 years. The method seems to have most of the advantages of standard 2-stages scrotal flap urethroplasty, and is suited to all but the most difficult and complicated strictures at any site in the urethra.


A controlled clinical trial of three different methods of perineal wound management following excision of the rectum. Three methods of perineal wound closure were studied in a randomized prospective clinical trial in 106 patients undergoing excision of the rectum for inflammatory or malignant disease. In method 2 the perineal wound was managed by open drainage. In both methods 2 and 3 the perineal wound was closed by primary suture, suprapubic suction drains being left down to the presacral space, but in method 2 the pelvic peritoneal floor was reconstituted, whilst in method 3 it was left unsutured. Topical and systemic antibiotics were administered to all patients submitted to primary closure of the perineal wound but not routinely to those whose perineal wound was left open. The overall operative mortality was 8-5 per cent but no deaths could be definitely attributed to perineal wound complications. The incidence of primary wound healing after methods 2 and 3 was 45-2 and 42-9 per cent respectively. Operative contamination of the perineal wound had an adverse effect on perineal wound healing. The incidence of persistent wound sinuses and unhealed wounds at 3 and 6 months after primary wound closure was rather less than that encountered after open drainage. It was concluded that primary closure of the perineal wound is the treatment of choice following excision of the rectum, except in cases in which contamination of the perineal wound has occurred during operation or the final state of haemostasis in the pelvis with diathermy and suture at the conclusion of the dissection was deemed to be unsatisfactory.


Povidone-iodine for the control of surgical wound infection: a controlled clinical trial against topical cephaloridine. One hundred and ninety-two operation wounds ina general surgical practice were randomly allocated to receive either topical cephaloridine or a providone-iodine spray, and the rate of wound sepsis was studied. In all types of operation cephaloridine proved superior to providone-iodine as a prophylactic, the difference reaching a significant level in potentially contaminated wounds.


Raised serum prolactin levels in amenorrhoea. Serum prolactin levels measured by specific radio-immunoassay were over 30 mug/l in seven out of 25 women with amenorrhoea and in eight women with the amenorrhoe-galactorrhoea syndrome. There was no apparent relationship between these levels and levels of follicle-stimulating hormone, luteinizing hormones, and thyroid-stimulating hormone. Bromocriptine caused a transient fall in the proclatin levels in six out of seven cases, and in three menstruation and ovulation were restored. Estimation of serum prolactin may become important in assessing the degree of hypothalamic-pituitary dysfunction in amenorrhoea, and it may help in identifying a subgroup of patients at risk of developing a pituitary tumour or patients who may respond to specific treatment.


Falciparum malaria semi-resistant to clindamycin. Clindamycin, a semi-synthetic antibiotic of the lincomycin family, at a dose of 450 mg eight-hourly for three days in adults cured five out of 10 patients moderately ill with chloroquine-resistant falciparum malaria. Combination therapy with full-dose quinine and clindamycin for three days cured all four patients so treated who were followed up, and with half dosage three out of five patients were cured. Both combinations, however, caused upper gastrointestinal toxicity and appeared to potentiate both toxicity and possibly antimalarial efficacy. Colitis due to clindamycin was not observed. Sequential therapy was not toxic and could be useful in patients who have relapsed after more conventional treatment.