Fish hypersensitivity. II: Clinical relevance of altered fish allergenicity caused by various preparation methods. In double-blind, placebo-controlled, oral food challenges with fish, a 12-fold higher false-negative rate was found compared with other food antigens. In an effort to elucidate this discrepancy, cooked lyophilized fish extracts (used in double-blind, placebo-controlled, oral food challenges) were compared with cooked, nonlyophilized fish extracts (used in open challenges) by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, immunoblot, and ELISA-inhibition assays. Altered fish allergenicity as a result of food processing was examined with canned tuna and salmon. Forty-five children and young adults with food allergies, including 18 patients with IgE-mediated hypersensitivity to fish, were challenged with canned tuna. All 45 challenges with canned tuna were negative. Two of these patients are allergic to salmon and also have negative reactions to challenges with canned salmon. In vitro investigation by sodium dodecyl sulfate-polyacrylamide gel electrophoresis of tuna and salmon extracts revealed a striking loss of definable protein fractions in the canned fish extract when compared with raw and cooked fish extracts, and immunoblot analyses demonstrated minimal IgE-specific binding to the canned fish extracts. In addition, decreased allergenicity of the canned tuna and salmon was demonstrated by ELISA-inhibition assay and by negative oral challenges with canned salmon in two patients allergic to salmon. Collectively, these findings suggest that some of the major allergens responsible for IgE-mediated food allergy to fish are more labile than previously recognized.


Safety and efficacy of fire ant venom in the diagnosis of fire ant allergy. Thirty-three adult patients who had had systemic allergic reactions to fire ant stings and 33 insect-nonallergic control subjects were skin tested with single lots of Solenopsis invicta (Sol i) fire ant venom (IFAV) and two commercially available imported fire ant whole body extracts (IFA WBEs). All three extracts were analyzed for protein concentration. Sol i II and Sol i III concentrations were each assayed by means of two ELISAs with complementary monoclonal antibodies, one species specific and one cross-reactive. Radioallergosorbent test (RAST) to IFAV and both IFA WBEs was performed on sera from all study subjects. Both IFA WBEs contained high concentrations of fire ant body proteins. Sol i II and III concentrations each varied twofold between the two IFA WBE preparations. Patients were generally more reactive to IFAV than IFA WBE by skin testing and RAST. IFAV RAST appeared to be a more sensitive assay than IFA WBE RAST. No adverse reactions occurred to skin testing with IFAV, but intradermal testing with higher concentrations of IFA WBE caused delayed large local reactions in 16 of 30 (53%) control subjects. These reactions were attributed to the large amounts of extraneous body proteins in IFA WBE. These results (1) demonstrate that skin testing with IFAV is safe, (2) indicate that IFAV is more potent than IFA WBE, and (3) suggest that IFAV may be the superior reagent for diagnosis of fire ant allergy.


Olfactory loss and allergic rhinitis.

Olfactory loss and allergic rhinitis. Olfactory loss is of importance for allergists to investigate in their patients, because if it is due to either allergic rhinitis or nonallergic rhinitis, it is potentially reversible. One should be sure to consider nasal polyposis and inflammation from chronic sinusitis, especially of the ethmoidal sinuses. Simple screening in the office can be achieved with an odor identification test of widely available substances as described above. Should there be no response to treatment or if the patient has a history of chronic sinusitis, recalcitrant nasal polyposis, or previous otolaryngologic procedures, further evaluation including rhinoscopy may be required. Recent olfactory loss in the absence of nasal symptoms and in the absence of abnormalities in the nasal cavity should suggest further investigation to look for a more central process. Morphologic investigation with electron microscopy of the olfactory epithelium and the superior nasal cavity is just beginning. The impact of inflammation in this area awaits investigation.


Mediators of allergic rhinitis.

Mediators of allergic rhinitis. Although histamine is the principal mediator of the immediate allergic reaction, other inflammatory mediators as well as neuropeptides also contribute to rhinorrhea and nasal congestion. Within minutes of exposure to allergen, mast cells produce histamine, leukotriene C4, and prostaglandin D2. A concomitant increase occurs in neuropeptides and bradykinin. In vitro mast cell activation also leads to the release of tumor necrosis factor--alpha, several interleukins, and granulocyte-macrophage colony--stimulating factor. Because all these various mediators and neuropeptides may play a role in producing rhinorrhea and congestion, antihistamines alone cannot control all of the symptoms of allergic rhinitis. However, the combination of antihistamines with topical corticosteroids can inhibit the generation, release, and activity of most if not all of the mediators potentially involved in the allergic response.


Inhibition of mediator release during the early reaction to antigen. A nasal lavage model and a new filter paper disk model have been used to measure biologic and physiologic responses to antigen challenge in patients with allergic rhinitis. Pretreatment of subjects with cetirizine reduced the number of sneezes induced by antigen challenge but did not significantly reduce levels of histamine or prostaglandin D2 in a double-blind, placebo-controlled trial with the lavage model. Pretreatment with 60 or 300 mg of terfenadine did significantly reduce levels of histamine, kinin, albumin, and TAME-esterase activity in a double-blind, placebo-controlled study with this model. Again with the nasal lavage model, a double-blind, placebo-controlled comparison of pretreatment with 60 mg of terfenadine or 10 mg of loratadine showed that both agents significantly reduced sneezing. Both drugs also lowered levels of antigen-induced histamine and TAME-esterase, but only terfenadine did so significantly. In a double-blind, placebo-controlled study, the new disk method showed that terfenadine reduced sneezing but not nasal congestion in eight patients with allergic rhinitis. Terfenadine significantly reduced the weight of nasal secretions on both sides of the nose and significantly reduced histamine on the ipsilateral side.


Functional roles of today's public health nutritionist. This study found that functional roles of public health nutritionists in eight southeastern states differed significantly on the basis of education, dietetic registration status, years of experience, and type and level of service. Subjects (n = 992) were mailed a 95-item questionnaire with three parts: demographic, professional practice, and grant-writing experience. Results based on a 59% response rate indicated that most of the 14 functional roles studied were practiced in accordance with guidelines presented in Personnel in Public Health Nutrition for the 1980's. Only two roles, counselor and educator, were performed somewhat inconsistently. Personnel with bachelor's degrees did have more counseling responsibilities than those with more advanced degrees. However, nonregistered dietitians also had more counseling responsibilities than did registered dietitians. Direct care providers had fewer educator responsibilities than did personnel with administration/management job responsibilities. All personnel reported research responsibilities that increased with advanced education, training, years of experience, and type and level of service. We found that beyond-entry-level personnel had more administrative and policy-setting responsibilities, which is consistent with The American Dietetic Association's Role Delineation for Registered Dietitians and Entry-Level Dietetic Technicians (1990). We conclude that, with the exceptions of the counselor and educator roles, public health nutrition practice is consistent with personnel guidelines.


Development of financial management competencies for entry-level and advanced-level dietitians. The major purposes in this study were to develop a list of financial management competencies for entry- and advanced-level dietitians, determine hospital foodservice directors'/chief dietitians' (practitioners) perceived importance of these competencies at both levels of practice, and determine educators' perceived importance of these competencies at the entry level. Drawing from the literature and the judgment of eight experts, we developed a list of 50 financial management competencies. Written questionnaires that included importance scales for the competencies were mailed to (a) practitioners in a random sample of 1,500 member hospitals of the American Hospital Association and (b) directors of Plan IV/V, Approved Preprofessional Practice, and Dietetic Internship programs. Response rates were 34% for the practitioners and 47% for the educators. Practitioners rated 8 competencies as important or very important for entry-level dietitians and 26 as important or very important for advanced-level dietitians. Practitioners rated all competencies higher for advanced-level dietitians than for those at the entry level, and educators rated all competencies higher than did practitioners. Content areas, identified by factor analysis, were similar for both levels of practice. Our findings indicate that emphasis in undergraduate and practice programs should be given to the eight competencies identified by practitioners and educators as most important. Our results also may be used for development and evaluation of graduate and continuing education programs and for specialty certification in foodservice management.


More effective nutrition label formats are not necessarily preferred. An experimental design was used to compare performance and preference for five nutrition label formats. Four performance measures--accuracy and false-positives in identifying nutrient differences, time required, and correctness in judging which product was more nutritious--were derived from a product-comparison task. A sample of 1,460 food shoppers over 18 years old was recruited by a shopping mall-intercept method. Results of the study demonstrated that preferences and performance do not necessarily agree. The Control format, which had no nutrition profile information, performed the best but was liked the least. The Adjectival format, which provided nutrition profile information in the form of descriptive adjectives, was the most preferred. Results also showed that listing Daily Reference Values or nutrition profile aids increased preference but either did not affect performance or decreased it, depending on the specific aid and performance measure. Formats that some subjects liked for having adequate information others disliked for being hard to use. Formats that some subjects liked for being easy to use others disliked for having inadequate information. Age, education, and race were related to all of the performance measures except judgment of relative nutrition. Only gender was related to preference. Results of the study are useful as guidance for the development of consumer education materials.


Parental and professional perceptions of problems associated with long-term pediatric home tube feeding. We surveyed 24 caregivers of children fed by gastrostomy tube to identify day-to-day problems encountered in home enteral nutrition. In a second survey, 21 respondents cross-validated the problem list by rating how often they experienced each problem and how difficult each problem was to manage. Problems related to social functioning, recreational activities, and family functioning were rated by caregivers as the most frequent and difficult. We asked 11 pediatric feeding specialists to rate the same problems based on their perceptions of the frequency and severity of problems experienced by caregivers. Moderate agreement was found between professional and caregiver ratings, although professionals generally rated problems as more common and difficult than did the caregivers. Additionally, positive relationships were found between caregiver ratings of common gastrostomy-tube problems and general levels of stress in the home. Data suggest that problems identified by caregivers as most common and difficult are often in the social rather than the medical realm. A broadly based family assessment that focuses on medical and social aspects of home enteral nutrition may maximize nutritional benefits for the patient as well as improve general family functioning and reduce stress in the home.


Nutrition labeling of raw fruit, vegetables, and fish. In response to certain requirements of the Nutrition Labeling and Education Act of 1990 (the 1990 amendments), the Food and Drug Administration (FDA) developed a voluntary nutrition labeling program for the 20 most frequently consumed raw fruit, vegetables, and fish in the United States. FDA used data on retail sales and food consumption to identify which foods to include in the program and developed guidelines for retailers to use in setting up the labeling program in their stores. FDA provided interim nutrition labeling data for retail use. These data are to be revised and updated at least every 2 years. A representative sample of 2,000 grocery stores will be used to assess compliance of retailers with the nutrition labeling guidelines. Substantial compliance with the guidelines is defined as compliance by 60% of the 2,000 stores.


Feeding the ultraendurance athlete: practical tips and a case study. With the rising popularity of ultradistance sports events lasting from 6 to 24 hours or multiple days, athletes are consulting registered dietitians for specialized dietary advice. Many dietitians, however, lack experience with these types of events. This article provides basic guidelines ffor fueling the ultradistance athlete. The goals are to maintain normal hydration and blood glucose levels, which can be done by enforcing programmed drinking (approximately 250 to 500 mL/15 minutes, depending on the athlete's sweat rate and environmental temperature) and programmed eating (1 to 1.5 + g of carbohydrate per kilogram of body weight per hour, depending on the athlete's acceptance of and tolerance to solid and/or liquid foods during exercise). Athletes who compete longer than 6 to 8 hours should consume adequate electrolytes, particularly sodium (approximately 1 g/hour) through either sports drinks or foods. These guidelines are applied to a case study of the 1991 women's winner of the Race Across America, a 2,930-mile biking event.


Mammography and Papanicolaou smear use by elderly poor black women. The Harlem Study Team. To describe factors related to the use of mammography and Papanicolaou smears in low-income women aged 65 or more years to guide development of future interventions. A cross-sectional survey. Elderly Black women attending a public hospital medical clinic. Information obtained in a face-to-face interview of a random sample of patients. Four-hundred and forty-five women (94%) consented to be interviewed; 74% reported a mammogram, and 85% reported a Papanicolaou smear in the past, although these early-detection tests were not obtained with any regularity after age 65. Concordance between self-reported screening use and blind chart review was more than 90%. The major reasons for non-use of both screening tests were that a physician hadn't recommended them or that the women didn't know they needed them. Levels of knowledge about breast and cervix cancer were low; 68% believed bumping or bruising the breast caused cancer, and only 25% knew that cancer risk increased with advancing age. In logistic regression models, health status, provider type, perceived benefit, life satisfaction, and knowledge of test intervals were each significantly associated with mammogram use. Age, health status, education, perceived susceptibility and benefit, life satisfaction, and knowledge of test intervals were independently related to Pap use (P < .05). This study illustrates that elderly, poor, minority women who are regular health-care users do use mammography and Pap smear screening services. Incorporating screening into routine primary care and physician and patient education could enhance the use of early cancer detection procedures in this age group.


Screening for depression in hospitalized elderly medical patients: taking a closer look. To re-examine the test characteristics of the Geriatric Depression Scale (GDS) and the Brief Carroll Depression Rating Scale (BCDRS) in elderly medical inpatients, simulating the procedure followed by clinicians when using screening instruments. Masked comparison of GDS and BCDRS with psychiatric interview. Durham VA Medical Center. 109 consecutively admitted persons aged 70 or over. Screening by a social worker using GDS and BCDRS on day one, followed the next day by an investigator's structured psychiatric interview to determine the presence of major depressive disorder (MDD). By this method, the sensitivity and specificity of the GDS (cutoff 11) were 82% and 76%, respectively; for the BCDRS (cutoff 6), they were 73% and 79%. Among those with a negative test, the likelihood of MDD dropped from an a priori probability of 10% to an a posteriori probability of 3% with the GDS and 4% with the BCDRS. Among those with a positive test, the likelihood of MDD was 27% for the GDS and 28% for the BCDRS. Excluding patients with cognitive impairment (MMSE < or = 25) only slightly improved test characteristics. These estimates are considerably below those reported in earlier studies where concordant screening, two-stage screening, or other methods have been utilized and may impact the decision whether or not to screen for depression using these instruments.


The relationship between low vision and performance of activities of daily living in nursing home residents. To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents. Survey. A non-profit geriatric long-term care facility. 21 males, 82 females, aged 66-98. Survey of 103 nursing home residents. ADL functioning assessed via Maryland Appraisal of Patient Progress (MAPP); medical data collected through chart review; ophthalmological data obtained through dilated eye examination by an ophthalmologist. In comparison with residents having good vision (n = 52), a significantly greater proportion of residents with low vision (n = 51) were dependent on caregivers for performing ADLs (eg, toileting, transferring, washing). Residents with low vision had significantly more eye pathology (eg, cataracts, age-related macular degeneration) than did residents with good vision. There were no significant differences between groups with regard to presence of musculoskeletal problems (eg, arthritis) or number of medical conditions (eg, cardiovascular disorder, cerebrovascular accident). There is a strong link between low vision and ADL disability in nursing home residents. Moreover, ADL dependency is significantly related to the presence of eye disorders.


Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. To assess whether we could export a successful multifaceted influenza vaccination program from an academic medical center to a community setting. Pre/post study using concurrent control groups. Clinics in a staff model Health Maintenance Organization (HMO). One urban and one suburban clinic were chosen as intervention clinics, while two similar clinics were selected as control clinics. All patients aged 65 and over enrolled in the four clinics. An informational mailing to patients, a standing-order policy allowing nurses to administer vaccine, a vaccination reminder on daily appointment lists, and availability of walk-in visits for vaccination. Patients in the control clinics received usual care. Vaccination rates were determined using a validated postcard survey of 150 randomly selected patients at each clinic both at baseline (1988-89) and after the intervention (1989-90). The baseline vaccination rates ranged from 51.4% to 74.6%, with nearly all vaccinations taking place at the HMO. In one intervention clinic, the vaccination rate improved from 56.4% to 72.3%, P = 0.01. In the other, the baseline rate was 74.6% and did not change significantly after the intervention. There was no change in the vaccination rate in the control clinics after the intervention period. An influenza vaccination program that combines several organizational interventions may be successfully exported from an academic to a community setting and may serve as a useful model for others.


Public-private partnerships: the Connecticut model for financing long-term care. Responses to the growing crisis in long-term care financing have included efforts to negotiate partnerships between the private and public sectors for the purpose of developing innovative models for long-term care insurance. One such set of models has been encouraged by support from the Robert Wood Johnson Foundation's "Long Term Care Insurance Program" grants. The Connecticut Partnership for Long Term Care uses a cooperative approach to encourage the development of private sector long-term care insurance products that are integrated with Medicaid eligibility determinations. The Connecticut model is described, accompanied by a history of its development, and a comparison is made with other models currently under consideration by national policy analysts.


Morbidity, disability, and health status of black American elderly: a new look at the oldest-old. There are over 2.5 million black Americans aged 65 and over living in the United States today, including some 258,000 persons aged 85 years and over. The post-World War II baby boom within the US black population should ensure that the numbers of persons aged 65 and over will increase into the 21st Century. If present trends continue, it is projected that the current population of black elders will also age. This means that the numbers of black persons aged 85 and over will also increase. Data from both national surveys and population-based community studies concerning the health and well-being of black elders are now becoming available. This report presents information concerning self-reported health status, chronic disease prevalence, disease-risk-factor prevalence, measures of physical functioning, and nursing home utilization rates for age groups within the black population aged 65 years and over. The availability of such data should lead to the development of targeted interventions designed to lessen impairment and prolong independent living.


Geriatric care approaches in health maintenance organizations. The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.


Depression in the elderly: effect on patient attitudes toward life-sustaining therapy. To determine the effect of depression on preferences for life-sustaining therapy in older persons. A survey comparing depressed, older veterans and a similar, but non-depressed, control group. A 490-bed Veterans Affairs teaching hospital. Medical inpatients over 65 years of age were potential subjects. Patients who were in intensive care, cognitively impaired, unable to communicate, abusing alcohol or drugs, or unable to return for outpatient care were excluded. Ninety-five eligible subjects (29%) refused to participate. Depressed subjects scored >14 on the Geriatric Depression Scale (GDS) and were diagnosed as depressed by a psychiatrist who was blind to the GDS results. Complete data were collected on 50 depressed and 50 control subjects. A self-administered questionnaire quantified patients' preferences regarding life-saving interventions in their current state of health and in four hypothetical scenarios of serious illness. Depressed subjects desired fewer interventions than control subjects in their current health and in hypothetical scenarios with a good prognosis (P < or = 0.05). There were no differences between groups in poor prognosis scenarios. However, depression did not explain more than 5% of the variance in decision-making in any situation. In good prognosis scenarios, subjects' assessment of quality of life was the most powerful predictor of desire for life-saving interventions, accounting for 9%-17% of the variance (P <0.01). These results suggest that depression is associated with treatment refusal in situations with a good medical prognosis. Depression, however, is only a weak predictor of treatment refusal. Further research is needed to define which patients would accept medical treatment if effectively treated for depression.


The effect of geriatric evaluation and management on Medicare reimbursement in a large public hospital: a randomized clinical trial. To study the effect of a geriatric evaluation and management program on health care charges and Medicare reimbursement. Prospective randomized controlled trial during a 1-year study period. Large medical school-affiliated public hospital in an urban community. Patients at least 70 years old admitted to the medicine service were screened and randomized into two groups of 100 patients each. Patients randomized to the experimental group underwent initial comprehensive geriatric evaluation and once discharged from the hospital were enrolled in a geriatric care management and treatment program. The control group received usual care only. The major intervention of this study was in outpatient long-term care. Total charges for services billed to Medicare Part A and Part B and total Medicare reimbursement. The Medicare charge and reimbursement data were obtained by use of the Medicare Automated Data Retrieval System, a linked Medicare Part A and Part B utilization file. Total charges and reimbursement were greater for the control group but not significantly so. Subset analysis revealed significantly greater inpatient charges (P < 0.03) and Medicare reimbursement (P < 0.005) for the control patients and a greater likelihood of utilization of home health care services in the experimental group (P < 0.01). A geriatric evaluation and management program appeared to shift utilization and Medicare expenditures from inpatient services to home health care services. There was no evidence that the experimental program resulted in increased expenditures for Medicare. In selected populations, geriatric evaluation and management programs may contribute to cost containment.


Community-acquired bacteremia in the elderly: a prospective study of 121 cases. To describe community-acquired bacteremia in the elderly and correlate clinical and laboratory findings with outcome. Prospective study of consecutive cases. Large community-based teaching hospital. One hundred and twenty-one elderly patients aged 65 to 89 years, seen between February 1, 1986 and January 31, 1988. Bacteriological cultures, symptoms and signs, laboratory findings, and mortality. Gram-negative organisms accounted for 65 (54%) cases and Gram-positive organisms for 47 (39%) cases, while nine (7%) cases were polymicrobial. E. coli (39%), Klebsiella sp. (8%), S. pneumoniae (14%), and S. aureus (12%) were the most commonly isolated organisms. The overall mortality was 38%. A poor prognosis was associated with confusion as a presenting symptom (P < 0.0003), hypotension (P < 0.0003), and inappropriate or delayed treatment (P < 0.02). A good prognosis was associated with E. coli as the pathogen (P < 0.0003) and prompt, appropriate antibiotic therapy. Community-acquired bacteremia in the elderly has a high mortality rate. Early recognition and prompt, appropriate treatment are critical in reducing the mortality.


Shoe sole thickness and hardness influence balance in older men. To test the hypothesis that shoes with thick, soft midsoles, such as modern running shoes, provide better stability in older individuals than those with thin-hard midsoles. In addition, we examined the relation between footwear comfort and stability and stability when barefoot. Randomized-order, cross-over, controlled comparison. Subjects were drawn from an internal medicine practice. A random sample of 25 healthy men, minimum age 60 years. Additional selection criteria were absence of disabilities influencing ability to walk and lack of history of frequent falls. Balance failure frequency, which was defined as falls from the beam per 100 meters of beam walking when 10 passes were made down a 9 M long balance beam. Comfort rating was based on an ordinal scale. Contrary to the hypothesis: (1) midsole softness was associated with poor stability (F(2,48) = 17.9, P < 0.0001); (2) thick midsoles also provided poor stability (F(1,24) = 7.36, P < 0.01). When barefoot, subjects showed 19% higher balance failure frequency than with the poorest shoe and 171% greater than the best shoe (t = 5.33, P < 0.0001). Higher comfort was generally found in shoe types associated with higher balance failure frequency. For optimal stability, shoes with thin, hard soles are preferable for older individuals. Health professionals should exercise caution when recommending shoes with thick, yielding midsoles, such as running shoes, to unstable elderly individuals. Older men and women with a history of falls or who are obviously unstable, should avoid barefoot locomotion.


Development of scoring criteria for the clock drawing task in Alzheimer's disease. To investigate the reliability and validity of free-hand clock drawings, a frequently used measure of constructional apraxia, in patients with Alzheimer's disease. Survey for the purpose of testing reliability and validity of a new scale. Memory Disorder Clinic at a university-affiliated hospital in the Upper Midwest. Forty-six patients were diagnosed with clinically probable dementia of the Alzheimer type after a dementia evaluation, and 26 normal elderly controls were research volunteers without a history of cognitive dysfunction. Neuropsychological tests, dementia-related scales, and clock drawings rated by a new 20-item Clock Drawing Interpretation Scale. Reliability measures, correlations, and clustering of items in the CDIS. The CDIS had inter-rater reliability (r = .94), internal consistence (rtt = .95), and reproducibility over a 6-month interval. CDIS scores were significantly correlated with two dementia-related scales and all neuropsychological tests and had the highest correlations with other measures of constructional apraxia. All but four Alzheimer patients (91%) and none of the controls had CDIS scores of 18 or less. Clinicians may reliably screen patients with Alzheimer's disease with the clock-drawing task, a measure sensitive to deficits in constructional apraxia.


Characteristics of diabetic ketoacidosis in older versus younger adults. To describe how diabetic ketoacidosis in those aged 65 or over differs from that in younger adults. Retrospective chart review of all adult patients with a primary or secondary discharge diagnosis of diabetic ketoacidosis (n = 338). Three urban teaching hospitals in Milwaukee, WI from January 1, 1987 to May 31, 1990. Two hundred twenty cases in 150 patients met our criteria for severity of illness to be included in the study. Twenty-seven cases were in patients > or = age 65; 193 cases were in patients < age 65. The older patients were less likely to have been using insulin before hospitalization (55.6% vs 80.2%, P = 0.004) and less likely to have had a prior episode of diabetic ketoacidosis (8.0% vs 51.4%, P = 0.001). The presenting laboratory data were not significantly different between older and younger subjects. There was a trend toward a higher mean insulin dosage to bring the patient's blood glucose to < or = 300 mg/dL for those age 65 or older; 69.1 units vs 44.9 units (P = 0.06). The time required to obtain a glucose < 300 mg/dL was greater in older patients (10.5 vs 7.7 hours, P = 0.01). The average length of stay for those age 65 or older was 12.4 days vs 6.7 days (P = 0.001). Thirdly, of those age 65 or older, 7% vs 29% of younger subjects had a blood glucose or Accucheck < or = 49 mg/dL at some time during their hospital course. The hypoglycemic episodes were more likely to be asymptomatic in older patients (P = 0.03). The mortality rate was 22% for those age 65 or older vs 2% for younger subjects (P = 0.001). The mortality rate for those in age groups 60-69 years, 70-79 years, and > or = 80 years was 8%, 27%, and 33%, respectively. In patients > or = 65, mortality was confined to those with coexisting renal disease or infection. Older patients with diabetic ketoacidosis are less likely to have been using insulin before hospitalization. They tend to receive more insulin therapy during their acute management, have a longer average length of hospital stay, and have a higher mortality rate.


A pilot study of anabolic steroids in elderly patients with hip fractures. To determine the safety and efficacy of the anabolic steroid nandrolone in elderly patients with hip fractures. A randomized double-blind placebo-controlled trial. The orthopedic ward of a university teaching hospital. 29 frail elderly females with hip fractures. Subjects received nandrolone 2 mg/kg (n = 15) or placebo (n = 14) by weekly injection for 4 weeks or until discharge. Baseline functional status was assessed by the Lawton-Brody ADL and IADL. Hemoglobin, transferrin, thyroid-binding prealbumin, albumin, liver function tests, creatinine, weight, MAMC, bioelectric impedance, standard anthropometrics and grip strength were measured at baseline and weekly intervals. Rehabilitation parameters and length of stay were recorded. The placebo and nandrolone groups were similar in age, although the control group had slightly higher baseline ADL scores. There was no difference between groups in biochemical parameters, anthropometrics, body composition, grip strength, rehabilitation end points or length of stay. One subject in the nandrolone group had a doubling of AST and was withdrawn from the study. Nandrolone can be given safely to frail elderly subjects with hip fractures but is likely to be of minimal benefit at the doses we employed.


Driving in Alzheimer's disease.

Driving in Alzheimer's disease. To determine if the impaired mental skills in Alzheimer's Disease (AD) may adversely affect driving ability. Retrospective survey. The Alzheimer's Clinic of the University of Kansas Medical Center. We interviewed 67 AD patients and their families and compared them with 100 elderly, non-spousal controls. The questionnaire was designed to obtain information on their driving habits, with emphasis placed on whether they were still driving, and the number of accidents per year for the past 10 years. Forty-six of the AD subjects had stopped driving because of safety concerns expressed by the subjects, their families, or health care providers, and two had stopped for other reasons. Only two of the normal controls had stopped driving (P < 0.0001, Chi-square test). Over the past 3 years, the 19 AD subjects who were still driving had 263.2 motor vehicle accidents per million vehicle miles of travel compared with 14.3 for the controls (P < 0.002, Mann-Whitney U test) and 5.7 for the general driving population age > or = 55 years (P < 0.05, Students one group, two-tailed t test). This study suggests that a significant traffic safety problem exists in subjects with AD who continue to drive. Efforts should be directed to detect patients with AD whose driving presents a traffic safety problem.


Inadequate treatment of depressed nursing home elderly. To determine the prevalence of antidepressant drug treatment among nursing home elderly with major depression. Survey early and late in nursing home stay. Sixty Medicaid/Medicare-certified skilled nursing homes. Admission cohort of 5,752 residents age 65 or older in 1976 through 1983. Chart review by nurse-abstractors of physicians' diagnoses, drug used, and alertness rating. Diagnosis of depression equivalent to DSM-III-R major depression. Of 868 persons with a diagnosis of depression in the medical record, only 10% were treated with antidepressant drugs. More received neuroleptics and benzodiazepines than received antidepressants, but most (52%) received no psychoactive drug at all. A subset of 258 depressed persons had positive notations in their records supporting a mental status rating of "alert and oriented." Of that subset, only 15% received antidepressants. When followed from admission to discharge or end of study the prevalence rate of antidepressant drug treatment increased by 4%. In the late 1970's and early 1980's, even when the primary care physician made and recorded a diagnosis of depression, most such nursing home residents remained untreated, incorrectly treated, or inadequately treated.


Recurrent unexplained syncope in the elderly: the use of head-upright tilt table testing in evaluation and management. To investigate the usefulness of head-upright tilt table testing for vasovagal episodes in the evaluation and management of elderly patients with recurrent idiopathic syncope. Prospective survey. Electrophysiology laboratory of a university hospital. Twenty-five patients (11 male, 14 female; mean age 73 +/- 6 years) with recurrent unexplained syncope and seven control subjects with other causes of syncope (4 male, 3 female; mean age 70 +/- 4 years). Each patient underwent head-upright tilt table testing for 30 minutes with or without an infusion of isoproterenol (1-3 micrograms/min given intravenously) in an attempt to provoke bradycardia, hypotension, or both. Syncope occurred in nine patients (36%) during the baseline tilt and in seven patients (28%) during isoproterenol infusion (total positives 64%). None of the controls had syncope during the test. All of the patients who had positive test results eventually became tilt table negative with therapy, and over a mean follow-up period of 24 months, no further syncopal episodes have occurred. Head-upright tilt table testing combined with isoproterenol infusion may be a useful tool in the diagnosis of vasovagal syncope in the elderly and in the evaluation of preventive therapy.


Instrumental activities of daily living as a screening tool for cognitive impairment and dementia in elderly community dwellers. To identify which Instrumental Activities of Daily Living (IADL) are related to cognitive impairment, independent of age, sex, and education; to assess the performance of an IADL score using these items in screening for cognitive impairment and dementia in elderly community dwellers. Survey based on the baseline interview of the PAQUID study on functional and cerebral aging. Community survey in 37 randomly selected parishes in Gironde, France. Random sample of 2,792 community dwellers aged 65 and over (participation rate: 69%). Two-phase screening: (1) functional assessment, Mini-Mental State Examination (MMSE) and DSM-III criteria for dementia; (2) in DSM-III-positive patients, NINCDS-ADRDA criteria applied by a neurologist. Functional assessment: IADL scale of Lawton and Brody. Criterion standards: cognitive impairment: MMSE score lower than 24; dementia: DSM-III and NINCDS-ADRDA criteria. Four IADL items are correlated with cognitive impairment independent of age, sex, and education: telephone use, use of means of transportation, responsibility for medication intake, and handling finances. A score adding the number of IADL dependencies has a sensitivity of 0.62 and a specificity of 0.80 at the lowest cut-off point (score > 0) for the diagnosis of cognitive impairment. The same score at the same cut-off has a sensitivity of 0.94 and a specificity of 0.71 for the diagnosis of dementia. The prevalence of dementia (2.4%) is reduced by a factor of 12 in subjects independent for the four IADL. The four IADL score could be incorporated into the screening procedure for dementia in elderly community dwellers.


The effect of aging on intact PTH and bone density in women. To determine whether age-related bone loss is negatively associated with serum intact parathyroid hormone (PTH). Survey. University hospital outpatient department. 100 community-dwelling women, age 18 to 80, recruited as a convenience sample. Dependent variables--bone density at the spine and femoral neck by dual-energy X-ray absorptiometry. Independent variables--age, menopausal status (binary) and intact serum PTH by Allegro immunometric assay. Post-menopausal women had higher serum PTH and lower bone density of spine and femoral neck than premenopausal women. Bone density at the spine decreased with age, but this effect was accounted for by menopausal state. Bone density at the femoral neck decreased with age even after adjusting for menopause. Log PTH was negatively associated with bone density at the femoral neck but not significantly at the spine. Multiple regression analysis adjusting for age and menopause showed no significant association between intact PTH and bone density at the spine or the femoral neck. Although this study confirmed the rise in intact PTH with age, there is no evidence that this is the mediator of age-related bone loss.


The Mini-Mental State Examination: identifying the most efficient variables for detecting cognitive impairment in the elderly. To study how well the scoring on each item of the MMSE relates to the sum-score when the purpose is to identify persons with cognitive impairment, and to identify an equally effective subset of MMSE items for predicting cognitive impairment. Retrospective survey of MMSE data for 850 elderly. A variety of clinical settings. Mean age 82 years (range 54 to 99), 74% women. The subjects were of three different categories: geriatric in-patients, patients living under supervision, and elderly people living independently at home. Five of the binomial ("State," "Town," "Name a pencil," "Name a watch," "Read and obey") and one of the polychotomous MMSE variables ("Learn three words and repeat immediately") had low sensitivity and gave high percentages of misclassifications versus the sumscore dichotomized at the cut-point 23/24. Univariate logistic regression indicated that the three remaining polychotomous variables ("Spell backwards," "Recall three words," and "Three-stage command") can be scored binomially. Two factors were identified on factor analysis. Logistic regression analysis showed that 12 of the original 20 items predicted the sumscore dichotomized at 23/24 with only 3% misclassifications. Validation against the psychogeriatrician's diagnosis showed that this 12-items MMSE derivative performs as well as the full MMSE. Six of the 20 MMSE variables perform poorly regarding sensitivity and misclassifications versus the sumscore at cut-point 23/24. Two additional items did not contribute to the prediction of a low/high sumscore. The remaining 12 MMSE items can all be scored binomially and produce a sumscore which is equally as effective as the sumscore of the full MMSE when the purpose is to identify elderly patients with cognitive impairment.


The demented elderly in the city of Helsinki: functional capacity and placement. To study prevalence, functional capacity, and placement of demented patients in a randomly selected population. Survey. Random sample from population registry of the City of Helsinki. Nine hundred subjects aged 75 years, 80 years and 85-years, 300 in each group. For each participant, we completed a questionnaire for the subject and an informant and a functional-capacity scale and Mini-Mental Status Examination by a community nurse, including the Clinical Dementia Rating (CDR) scale. Subjects with CDR of 0.5 or greater were examined by a neurologist who diagnosed the presence or absence of dementia according to DSM-III-R. Ninety-three subjects of the 656 whose CDR was known were found to have dementia. Three-quarters of them lived in institutions, and they comprised 33%, 60%, and 68% of all institutionalized patients in the above-mentioned age groups, respectively. Community residents suffering from dementia often lived with a caring relative and needed many services. A considerable part of the need was not met. In the older age groups, the need for institutional placement due to dementia is great. According to our study, it seems unlikely that these patients could be cared for in any other way, at least not on a large scale. The need for services for home-dwelling patients is also great, and the relatives carry a heavy load in taking care of demented patients.


Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital. A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring. Survey. Compliance monitors were provided to eligible patients at discharge from the hospital to measure drug intake behavior prospectively for a period of 3 weeks. Ambulant patient care after discharge from a geriatric hospital, Krankenhaus Bethanien, which is affiliated with the University Clinic, Heidelberg. A consecutive convenience sample of 18 independently living elderly patients (median age 76 years) completed the study. The patients were on maintenance therapy with cardiac glycosides and/or potassium-sparing diuretics prescribed to be taken once daily. The monitoring method provides information about patients' real timing of drug use by continuously recording date and time of openings and closings of the medication containers (monitors). In addition to a standard measure, the percentage of prescribed doses taken, information about regularity of drug use is obtained. Compliance, percentage of prescribed doses taken, was remarkably variable; it ranged from 24% to 100%, 95% CI: 62%-84%. Mean compliance declined from the first to the third week after discharge, 85% vs 69%, 95% CI: 74%-95% and 56%-81%, respectively (P < 0.05). Omissions of doses, the predominant pattern of non-compliance, were observed in 17 of 18 patients. Regularity of dose timing, as defined by the number of interdose intervals within 24 h +/- 15%, varied from 10% to 100%, 95% CI: 46%-76%. Continuous electronic monitoring revealed highly variable compliance in patients prescribed maintenance therapy. Even with a once-daily regimen, persistent and high compliance cannot be assumed. The monitoring technique may be of great value to research and, possibly, to practical therapeutic management.


Advances in management of hypertension in older persons. Recent studies have now demonstrated that it is more important to focus on the SBP level than the DBP level in older persons. In addition, recent studies indicate that persons over age 80 still derive substantial benefit from treating ISH or DH. Also, studies now show that low-dose diuretics have a more favorable impact on subsequent coronary heart disease rates than was previously demonstrated. Finally, although caution is urged, it is unlikely the J-shaped relationship between treated DBP or SBP and subsequent mortality is due to overly aggressive treatment of high blood pressure. Table 4 provides the authors' guidelines for treating older persons with high blood pressure.


Psychoanalytic ecumenism and varieties of psychoanalytic experience. Using the metaphor of ecumenism, the current status of psychoanalysis and the American Psychoanalytic Association is examined. The dialectical tendencies to oppose and to unify are noted in psychoanalytic theory, technique, and practice, as well as in the administrative and political life of our organization. Fostering tolerance for new hypotheses without sacrificing empirical discrimination, and promoting broad participation without lowering standards confront us as major tasks demanding continuing vigilance and effort.


Gender differences in physician stress.

Gender differences in physician stress. Differences in perceived stressors in medical practice were identified in this study of 72 male and female physicians. Although both men and women physicians felt pressured by the amount of time demanded by their profession, women had the additional pressure of family obligations. Male physicians were most distressed by relationships with patients, the inability to cure, and the threat of malpractice. Female physicians, on the other hand, were more likely to be concerned about the responsibility inherent in the doctor's role. Although physicians have many similar attitudes and behaviors because of their professional socialization, their reactions to the pressures of medical practice are also influenced by sex-role socialization. Norms and traits appropriate to each gender affect the way in which male and female physicians experience objective conditions in the work environment.


Followup in psychoanalysis: what happens to treatment gains? A recent panel (1989) discussed the feasibility and the desirability of systematic post-treatment followup study of psychoanalytic patients. In this paper, I compare the data bearing on these issues from the Menninger Foundation Psychotherapy Research Project, headed by me, and the Boston Institute Project, headed by Kantrowitz, and I indicate why their data are neither comparable nor adequate enough to warrant the conclusion that their apparent discrepant findings--that in the Menninger project outcome at termination tended to be predictive of the subsequent followup course, while in the Boston project this was not so--are more than chance events. I then present detailed case descriptions of two patients from the Menninger project who were quite similar in character and in illness structure, had seemingly comparable analytic courses, and similar good therapeutic results, but had quite different followup courses, one with further consolidation, and the other with regression. I present some of the determinants of this difference.


Women in academic medicine: perceived obstacles to advancement. To investigate perceived obstacles to the advancement of women in academic medicine, we sent a questionnaire assessing perceptions of the fairness and supportiveness of the academic environment to the 229 female teaching and research faculty of the School of Physicians & Surgeons at Columbia University. The overall response rate was 85%. Forty-six percent believed that they had not had the same professional opportunities as their male colleagues, 52% believed that salaries were not equivalent for men and women in similar positions, and 50% believed that promotions were awarded in a biased manner. Thirty percent reported that sexist behavior was common and that sexual harassment occurred in the workplace. Eighty-one percent experienced conflicts between their professional and personal lives and most believed that the institution failed to adequately address the needs of women with children. This survey indicates that there are significant perceived obstacles to the advancement of women in academic medicine that must be addressed.


The differential effect of psychotherapy and psychoanalysis with anaclitic and introjective patients: the Menninger Psychotherapy Research Project revisited. Analyses of the data from the Menninger Psychotherapy Research Project (MPRP) have consistently indicated little difference in the therapeutic outcome between patients seen in psychoanalysis and those seen in psychotherapy. Reanalysis of the data from the MPRP, utilizing a distinction between two broad configurations of psychopathology (Blatt, 1974, 1990a; Blatt and Shichman, 1983), however, indicates that patients whose pathology focuses primarily on disruptions of interpersonal relatedness and who use primarily avoidant defenses (anaclitic patients), and patients whose pathology focuses primarily on issues of self-definition, autonomy, and selfworth and who use primarily counteractive defenses (introjective patients) differ in their responsiveness to psychotherapy and psycho-analysis. Based on recently developed procedures for systematically evaluating the quality of object representation on the Rorschach, reanalysis of the Menninger data reveals that anaclitic patients have significantly greater positive change in psychotherapy, while introjective patients have significantly greater positive change in psychoanalysis. These statistically significant patient-by-treatment interactions are discussed in terms of their clinical implications as well as the importance of differentiating among types of patients in studies of therapeutic outcome and of therapeutic process.


Language and the psychoanalytic process: psychoanalysis and Vygotskian psychology. II. This paper follows our previous one, where we described a psychoanalytic conception of language, thought, and internalization that is informed by the thinking of Lev Vygotsky. Here, several aspects of the analytic process which allow for the understanding of ineffable experiences in the analysand's history and the analytic situation are investigated: specifically, primal repression, metaphor, and the role of speech in free association. It is suggested that Freud's notion of primal repression be revived and redefined as one aspect of the descriptive unconscious. Some implications of primal repression for transference and resistance are explored. The metaphoric in its broad sense is examined as one example of how early dynamic experiences embedded in the process of language acquisition can be reached within the clinical situation. It is proposed that an understanding of free association is enhanced by awareness of distinctions between inner, egocentric, and social speech. The basic rule can be interpreted as an invitation for the analysand to use inner speech in collaboration with the analyst as best he or she can. Further, the aliveness and degree of superficiality of the analysis can be seen as a function of the analyst's ability to appreciate the properties of inner speech and foster the conditions in the analysis that allow for its unfolding.


G. C. Lichtenberg: dreams, jokes, and the unconscious in eighteenth-century Germany. The German physicist and writer Lichtenberg (1742-1799) was well known during the nineteenth century as a humorist, thinker, and psychologist. He was also a favorite author of Freud, who read him beginning in his teens, quoted him frequently, and called him a "remarkable psychologist." Despite this, he has been ignored by psychoanalysts and historians of psychiatry alike, and most of his writing is still unavailable in English. An introduction to Lichtenberg as a psychologist is provided, stressing material dealing with dream analysis, association theory, and drives. Relevant excerpts are translated into English. Lichtenberg is shown to have insisted upon the need for a systematic and rationalistic study of dreams, to have analyzed individual dreams (describing them as dramatized representations of thoughts, associations, and even conflicts from his own waking life), and to have emphasized the functional link between dreams and daydreams. His remarks on drives and commentary on eighteenth-century association theory represent a significant practical application, and thus refinement, of Enlightenment rationalistic psychology. These achievements are assessed in light of Freud's early fascination with him; it is argued that Lichtenberg is an example of the relevance of the historical and cultural background of psychoanalysis to clinical practice.


Location and peptide content of pelvic neurons supplying the muscle and lamina propria of the rat vas deferens. Retrograde tracing and immunohistochemistry have identified the location within the rat pelvic plexus of neurons which project to the vas deferens, and their neurochemical properties. The fluorescent tracers, Fast Blue and FluoroGold, were injected into the wall of the vas deferens and labelled neurons located within the ventral part of the major pelvic ganglion (MPG) and the adjacent accessory ganglia (AG). Most neurons were located in ganglia ipsilateral to the injection site. Noradrenergic neurons were defined as those containing immunoreactivity for tyrosine hydroxylase (TH). Five groups of dye-labelled neurons could be identified immunohistochemically, noradrenergic neurons containing neuropeptide Y (NPY) (60-70%), and four types of non-noradrenergic neurons, NPY-only neurons (5-10%), NPY neurons containing vasoactive intestinal peptide (VIP) (3-5%), neurons containing only VIP (15-25%) and neurons containing galanin (GAL) (2-5%). Noradrenergic axons, and axons containing NPY or GAL were primarily located within the muscle, whereas most VIP axons were found as a dense plexus within the lamina propria. Very few peptide-containing varicose nerve terminals surrounded dye-labelled (vas deferens-projecting) pelvic neurons. Thus, no peptide marker was found for most of the preganglionic inputs supplying postganglionic neurons which project to the vas deferens. These studies have shown that pelvic neurons supplying the vas deferens have a discrete location within the rat pelvic ganglia and that they comprise at least five neurochemical groups, providing innervation to the muscle and lamina propria. The preganglionic connections with these noradrenergic and non-noradrenergic (possible cholinergic) pathways, and further examination of the role of mucosal innervation remain to be determined.


Spectral analysis of sympathetic discharge, R-R interval and systolic arterial pressure in decerebrate cats. In 19 decerebrate and artificially ventilated cats, we analyzed, with a power spectral methodology, the variability simultaneously present in R-R interval and in thoracic preganglionic sympathetic outflow. R-R interval was characterized, as already described in humans and other experimental preparations, by two rhythmic components occurring at a frequency of about 0.1 Hz (low-frequency, LF) and at one corresponding to respiratory rate (high-frequency, HF) which, in these experiments, was set at 0.32 Hz. Two similar rhythmic components were also present in the sympathetic discharge. Arterial pressure changes were produced by aorta or vena cava flow obstruction in order to produce reflex responses in sympathetic activity. Reflex sympathetic excitations induced an increase in the LF component of both R-R interval and sympathetic discharge variabilities, while the HF components were simultaneously reduced. In contrast, reflex sympathetic inhibitions were accompanied by a decrease in LF components of both variability signals, while the HF components were simultaneously increased. A significant and positive correlation was found between changes in impulse activity and the amplitude of LF component of either R-R interval or sympathetic discharge variabilities. These data support the hypothesis that the low-frequency component of R-R variability can be used as a marker of sympathetic modulation.


Cardiovascular effects of central clonidine in conscious rats after hypothalamic lesions. The central injection of clonidine (an alpha 2-adrenoceptor agonist) in conscious normotensive rats produces hypertensive responses and bradycardia. The present study was performed to investigate the effect of electrolytic lesions in the anteroventral third ventricle (AV3V) region or in the lateral hypothalamus (LH) on the pressor and bradycardic responses induced by central clonidine in rats. Mean arterial pressure and heart rate were recorded in sham or AV3V-lesioned rats with cerebral stainless steel cannulae implanted into the lateral cerebral ventricle (ICV) or LH, and in sham or bilateral LH-lesioned rats with cannulae-implanted ICV. The injection of clonidine (40 nmol) ICV or into the LH of sham rats produced a pressor response (37 +/- 2-48 +/- 3 mmHg) and bradycardia (-45 +/- 10- -93 +/- 6 bpm). After AV3V-lesion (3 and 12 days) or LH-lesion (3 days) the pressor response was abolished and a small hypotensive response was induced by the injection of clonidine (-1 +/- 3- -16 +/- 3 mmHg). The bradycardia (-27 +/- 6- -57 +/- 11 bpm) was reduced, but not abolished by the lesions. These results show that the AV3V region and LH are important cerebral structures that participate in the excitatory pathways involved in the pressor response to central clonidine in rats. They also suggest that, in the absence of these pressor pathways, the hypotensive responses to central clonidine may appear in conscious rats.


Three-dimensional analysis of systolic blood pressure and R-R interval: proposal of self-sounding spiral theory. Having noted the findings that the frequency spectrum of fluctuation in blood pressure resembles that in R-R interval on ECG, and that both fluctuations are continuous time-related changes, we attempted three-dimensional analysis of blood pressure, R-R interval and time. The serial values in systolic arterial pressure and R-R interval which were simultaneously taken in 17 healthy volunteers (24.8 +/- 3.5 years old) were later analyzed using a personal computer. When dots of systolic pressure and R-R interval were plotted in order in a three-dimensional manner, they depicted spiral movements around an imaginary axis. The magnitude and angle of dot movement was then expressed quantitatively, by assuming the movements as a group of vectors. The vectors were uniformly distributed in four quadrants. The directions of the vector's connections were clockwise in about 75%, while their angles showed no particular tendency. Based on these three-dimensional morphological features of fluctuations in blood pressure and R-R interval, we propose a hypothesis called 'self-sounding spiral theory' for a mechanism preserving the cardiovascular homeostasis.


TCDD (2,3,7,8-tetrachlorodibenzo-P-dioxin) causes reduction in glucose uptake through glucose transporters on the plasma membrane of the guinea pig adipocyte. A single dose of 2,3,7,8-TCDD (1 micrograms/kg, i.p. injection) resulted in a significant decrease in cellular 3-O-methyl-[3H]-glucose uptake by guinea pig adipose tissue and pancreas after 24 hours. An in situ tissue culture study in which pieces of adipose tissue were incubated with 10(-8)M TCDD showed a time-dependent decrease in glucose uptake. Reconstitution of adipocyte plasma membrane from tested or control animals into artificial liposomes also resulted in this difference in glucose uptake. Binding of [3H]-cytochalasin B, a specific inhibitor of glucose transporter proteins, was significantly lower in acetone-ether powder preparations of TCDD-treated adipose tissue than from controls, suggesting that the total titer of these proteins is decreased by TCDD. Finally, the relevance of these results to glucose or lipid metabolism was tested. Lipoprotein lipase (LPL) activity of guinea pig adipose tissue was decreased after 8 hours of in situ incubation with TCDD indicating that glucose uptake was depressed at an earlier time point. These findings may contribute to a better understanding of dioxin-induced "wasting syndrome".


An immunoassay for metolachlor detection in river water and soil. An indirect enzyme-linked immunosorbent assay (EIA) for metolachlor (2-chloro-N-(2-ethyl-6-methylphenyl)-N-(2-methoxy-1-methylethyl)acetamid e) detection in river water and soil was developed using serum obtained from rabbits immunized against the acid of metalaxyl ((N-(2,6-dimethylphenyl)-N-(methoxy-acetyl)-DL-alanine methyl ester) conjugated to bovine serum albumin. The assay had a linear working range from 1 to 50 ng/ml with a mean I50 value of 13.6 ng/ml and a lower detection limit of 2.0 ng/ml. Both the mean interwell and interassay coefficients of variation were less than 4% over the range of the standard curves for samples which had been prepared in phosphate buffered saline (PBS), river water, or soil extract. Assay cross-reactivity to the following four structurally related chloro-acetanilide pesticides were: propachlor (0%), metazachlor (0%), alachlor (23%), and metalaxyl (5,000%). Mean recoveries of metolachlor in spiked (2.0 to 32.0 ng/ml range) PBS, river water, and soil extract were 102%, 103%, and 110%, respectively. Soil samples were taken over a 56-d period from field plots treated with metolachlor and analyzed by GC and EIA. The correlation coefficient for comparison of the two methods was 0.96 with the slope of the linear regression line being 0.78. Furthermore, no statistical difference (P less than 0.05) was found between the dissipation curves of metolachlor derived from GC data versus EIA data.


Microbial degradation of propoxur in turfgrass soil. This study was conducted to determine the degradation rates in turfgrass soil over a 12-month period after a single field application of propoxur and to isolate microorganisms from the soil capable of degrading the insecticide. Soil samples were collected from a turfgrass experimental site near Fort Lauderdale, FL one week before the field application of propoxur, and over a 12-month period after the field application. Mineralization rates in surface (0-15 cm depth) and subsurface (15-30 cm depth) soil samples collected before the field application were low. Mineralization in surface and subsurface samples collected 1, 6 and 8 months after the field application was much higher than for corresponding samples collected before the field application. Mineralization in the subsurface samples collected 12 months after the field application had reverted back to the similar rate for the corresponding sample collected before field application. Half-life values (t1/2) for propoxur showed similar trends to the results of mineralization. After a single application of propoxur, degradation in turfgrass soil was enhanced. Such enhancement lasted less than 12 months for the subsurface, but more than 12 months for the surface. A strain of Arthrobacter sp. capable of degrading propoxur was isolated from the soil.


Brain myelination in rats treated with ionizing radiation in utero. Effects of ionizing radiation on brain myelination and some physical development parameters were studied in laboratory rats (Fisher F-344 inbred strain). Rats were treated with three different doses of radiation (150 rad, 15 rad, and 6.8 rad) delivered on the 20th day of prenatal life. Exposure to 150 rad reduced body, brain, ovary, kidney, heart and spleen weights. Prenatal exposure to 150 rad of radiation reduced the cerebral cortex weight by 22 percent at 30 days of age, and 20 percent at 52 days of age which caused a reduction in cerebral cortex myelin content by 20 and 23 percent at the ages of 30 and 52 days respectively. This dose did not affect the myelin content of the cerebellum or the brain stem, or the myelin concentration (mg myelin/g brain tissue) of the cerebral cortex, cerebellum, and the brain stem. The cerebral cortex weight of the 15 rad treated rats was reduced at the age of 30 days. Exposure to 15 rad, and 6.8 rad did not affect either the myelin content or the myelin concentration of these brain areas.


Correction of overlapping second toe deformity: long-term results including a 7-year follow-up. An alternative to joint destructive procedures for the treatment of overlapping second toe deformity is presented. This manuscript examines a modification of the cartilaginous articulation preservation procedure previously described. A total of seven patients, eight feet were evaluated. The follow-up period ranged from 6 months to 7 1/2 years, with the average of 3 years. Subjective results were very satisfactory. Objectively there were complications, but overall, patient improvement was noted postoperatively. This study indicates that the procedure should be part of the surgeon's armentarium.


Hallux fractures: diagnosis and treatment. The authors present a review of the literature, mechanisms of injury, and radiographic presentations of hallux fractures. Sixty cases (64 injuries) were reviewed. Recommendations for treating each type of injury are also presented.


Verrucous carcinoma: epithelioma cuniculatum plantare. Verrucous carcinoma is a well-differentiated form of squamous cell carcinoma. This tumor has been shown to mimic a variety of other skin lesions with its insidious onset and apparently benign course. Early detection and a thorough histologic examination of this growth aid in proper diagnosis, treatment, and reduction in morbidity. An interesting case history and literature survey are presented to facilitate diagnosis and treatment of this rare pedal neoplasm.


First metatarsophalangeal joint arthrodesis with the Truncated Cone Reamer System. This manuscript introduces to the podiatric community the Truncated Cone Reamer (TCR) System for precise fashioning of the first metatarsal and proximal phalanx for a first metatarsophalangeal joint peg-in-hole type arthrodesis. As the name of the system suggests, the device reams out a truncated male cone at the metatarsal head and a corresponding female cone at the phalangeal base in the desired position. There is congruous cancellous bony contact at all apposing surfaces of the truncated cone for bony consolidation. The peg-in-hole intrinsically confers the arthrodesis stability. The authors present a step-by-step use of the TCR system, and a 1 year follow-up case study in which the TCR system was used as a template.


Histological study of the phalangeal articular side following Keller procedure for hallux valgus. Through a histological study, the authors have examined the coating tissue at the base of the proximal phalanx of the hallux. This study concerns five females who have undergone an operation according to Keller technique, and necessitated a reoperation for unsatisfactory results at the first operation. The study proves that resection of the phalanx leads, in time, to the formation of a coating fibrous cartilage. Such layer tends to reproduce a structure that is similar to an articulation, even though missing a hyaline cartilage. This microscopical structure supports well the load that is directed along the perpendicular axis of the phalanx, preserving, in time, a sufficient gliding capacity between the two surfaces, with optimal limitation of the natural wear-out process.


The modified Scarf bunionectomy.

The modified Scarf bunionectomy. The Scarf bunionectomy offers the surgeon the ability to correct a mild to moderate intermetatarsal angle with the stability inherent to this procedure. When an increased proximal articular set angle is encountered, this procedure could previously only address either the increased intermetatarsal angle or the increased proximal articular set angle. The authors' modifications will incorporate the best attributes of the Scarf, Reverdin, and McBride bunionectomies to allow for concomitant correction of the osseous and soft tissue components of the hallux abducto valgus deformity. The authors' experience with 27 of these procedures performed on 15 different patients from 1987 to 1991 is presented.


Fibular regeneration.

Fibular regeneration. Total regeneration of an osteotomized fibula is rarely reported in the literature. An extensive literature review failed to identify a publication addressing this specific topic. The following manuscript describes such an event where the fibula was used as a source of autogenous bone graft. A case report with long-term follow-up is also presented.


Podiatric considerations of angioleiomyoma. Angioleiomyoma is a benign soft tissue tumor that originates from the smooth muscle of blood vessels. Such lesions must be differentiated from fibroma, lipoma, ganglionic cyst, glomus tumor, neurofibroma, leiomyosarcoma, and phlebitis. These masses appear as encapsulated, glistening nodules that ordinarily respond well to surgical excision. It will be the intent of the present study to review the clinical and histological characteristics of angioleiomyomas as they may appear in podiatric practice.


Ultrastructural study on experimentally induced ovarian tumors in the rat. Ovarian tumors induced by intrasplenic ovarian grafting were studied ultrastructurally to obtain the details with particular references to cytoplasmic organelles associated with steroid synthesis. The grafted cells were transformed ultrastructurally at around 7 months following intrasplenic ovarian grafting, in fact, intermediate type of cells were also seen in the grafts at this period. The grafted cells before the transformation showed fine structural evidence of steroid hormone secretions, as indicated by the presence of abundant smooth endoplasmic reticulum, lipid droplets and mitochondria with tubular or vesicular criste. After transformation, the cells, however, had no fine structural features associated with the production of steroid hormones.


Preclinical hypogonadism in genetic hemochromatosis in the early stage of the disease: evidence of hypothalamic dysfunction. We studied endocrine functions at baseline and after TRH and LHRH stimulation in a group of 7 young male patients with genetic hemochromatosis (HE) without liver damage (i.e. fibrosis and cirrhosis). In five patients endocrine re-evaluations after complete iron depletion was also performed. Mean basal testosterone (T), FSH, LH and PRL were significantly lower than in controls. Serum T increased normally after HCG stimulation. The normal or high increments of LH after LHRH stimulation suggest that secretion capacity of LH was intact and that hypothalamic dysfunction could be responsible for the preclinical gonadal deficiency found in our patients. The response of PRL to TRH indicates that secretion capacity of lactotrophs although present, was decreased and did not improve after phlebotomy therapy. After iron depletion the two patients with the lowest basal T levels showed the highest increments indicating that in the early stages of hypothalamic-pituitary damage gonadal dysfunction is still reversible in HE patients.


Intraosseous lipoma of the calcaneus.

Intraosseous lipoma of the calcaneus. Intraosseous lipomas of the calcaneus are an extremely rare entity and appear radiographically very similar to many other lesions affecting the foot. A case report followed by a brief discussion of the etiology, clinical, pathologic, and radiologic findings is presented. The authors emphasize the importance of magnetic resonance studies as a definitive noninvasive diagnostic modality.


Secretion of growth hormone releasing hormone in obese children. We have evaluated baseline and l-dopa-stimulated peripheral growth hormone releasing hormone (pGHRH) secretion in 6 obese pre-pubertal children and in 7 age-matched controls. Baseline pGHRH levels were no different between obese (36.6 +/- 9.8 pg/ml, mean +/- SE) and control children (40.6 +/- 10.1 pg/ml). Administration of l-dopa (500 mg po) caused a significant increase of pGHRH levels in both the obese (65.3 +/- 19.8 pg/ml, p less than 0.05) and the control children (84.1 +/- 10.0 pg/ml, p less than 0.003). Mean peak pGHRH levels after l-dopa were not significantly different between the two groups, whereas mean peak GH levels were significantly lower (p less than 0.05) in the obese (7.9 +/- 1.9 ng/ml) than in the control children (20.5 +/- 4.9 ng/ml). We conclude that despite reduced GH secretion, obese children have normal baseline and l-dopa stimulated pGHRH levels.


Plantar fibromatosis: literature review and a unique case report. Plantar fibromatosis represents a relatively uncommon benign lesion of soft tissue. It is most often found to invest the central and medial portions of the plantar fascia and commonly occurs in conjunction with other fibrous proliferate disorders. The authors present a detailed review of the literature concerning this usually unencapsulated fibrous growth. A unique case involving a relatively large encapsulated mass found to undergo dorsal extension into the plantar musculature is also presented.


Evidence for cortisol as the mineralocorticoid in the syndrome of apparent mineralocorticoid excess. The hypothesis that cortisol is the functioning mineralocorticoid in the syndrome of apparent mineralocorticoid excess was tested by suppressing its secretion with dexamethasone. The subjects were two siblings with the type 2 form of this syndrome in which the defect in the peripheral metabolism of cortisol lies predominantly in ring A reduction but not in 11 beta-hydroxy dehydrogenation of cortisol to cortisone. Low dosage dexamethasone improved the hypokalemia within several days and hypertension was corrected after 3 weeks of treatment. Mineralocorticoid manifestations remained in remission during 10 yr of therapy with the synthetic glucocorticoid during which normal growth and development were restored. The effectiveness of dexamethasone supports the hypothesis that cortisol is the functioning mineralocorticoid in the AME syndrome.


Giant cell tumor of the foot.

Giant cell tumor of the foot. The author discusses giant cell tumor, often a monostotic bone tumor, as it affects the lower extremity. The lesion is most common at the ends of long tubular bones, and may transform into malignant pathology. Surgical resection with or without bone grafting is an accepted technique for treatment. Recurrent abnormality is possible, and close follow-up of these patients is recommended.


Nursing home elderly. Social-environmental factors. 1. Independence, cohesion, and functional health are related to well-being in elderly nursing home residents. 2. Nursing home residents may not criticize staff due to fear of a withdrawal of support. 3. Social support provided by visitors outside the nursing home may decrease the need for social support from sources inside the nursing home.


Recurrent tarsal tunnel syndrome.

Recurrent tarsal tunnel syndrome. The authors review two cases of recurrent tarsal tunnel syndrome. The patients had prior surgical tarsal tunnel releases with complete resolution of symptoms before ankle injuries resulting in recurrent tarsal tunnel syndrome. Tarsal tunnel is reviewed.


Osteotomies of the great toe.

Osteotomies of the great toe. Patients are operated on for forefoot problems at an increasingly younger age, according to the author's experience. This has resulted in extra articular osteotomies of the first phalanx of the great toe, usually associated with other forefoot procedures. There exist several indications for these osteotomies. Among them are hallux valgus, hallux rigidus, and other forefoot disorders, such as rheumatoid diseases. Since 1984, the author has performed 2850 great toe osteotomies, allowing him to specify indications, to elaborate osteotomy procedures (varisation, derotation, shortening) and to devise appropriate implants, including specific staples and compression screws. A great toe osteotomy system has resulted in facilitating the execution of this very useful procedure.


Perception of knowledge what administrators and assistants know. 1. Nurse administrators are responsible for the delivery of health care in long-term care settings, and it is nursing assistants who provide the majority of care meeting the basic needs of elderly in these settings. 2. A difference in knowledge perception exists between nurse assistants and nurse administrators on information needed by nurse assistants in the home care and nursing home settings. 3. Nurse assistants would benefit from expanded nurse assistant training programs that would include not only the physical, but also the psychological and legal needs of the elderly. 4. Improving the knowledge base and the competencies of nurse assistants would improve quality of care in long-term care settings.


[Medical and ethical problems posed by the prenatal diagnosis of distal absence of a limb]. Eight cases of distal amputation of limb are reported. The diagnosis were made by ultrasound scans at 18-25 weeks of amenorrhea. In all cases, according to the French law, our team of fetal medicine refused the therapeutic terminations of pregnancy requested by the parents. The therapeutic terminations of pregnancy were achieved by another unit of fetal medicine in France, or in another country. These reported cases address many questions about the aim of fetal medicine (therapeutic terminations of pregnancy or treatment of infants), the place of the parents request in the decision, the different decision arguments, and the variations in the decision between different fetal medicine crew facing to similar prenatal diagnosis.


[Limited lumpectomy combined with peroperative curietherapy for conservative treatment of breast cancer]. Lumpectomy together with axillary clearance and radiotherapy is a good alternative to Patey's operation for treating early cancers of the breast. In any case it has not been definitely worked out how much should be removed. In certain patients not much needs to be removed, in other larger areas of tissue need to be excised. We present our technique for carrying out limited lumpectomy which is carried out at the same time as radiation therapy making it possible to perform a less radical clearance. The results in the first 17 patients we have followed up with a mean of 4.5 years are very encouraging. There was only one local recurrence; this was some distance away from the area of the lumpectomy. The limits for the method are determined by the examination that is carried out on the margins that have been removed and on the availability of a team comprising surgeon, histopathologist and radiotherapist.


[Bilateral breast tuberculosis: a case report. Review of the literature]. We report a case of bilateral tuberculosis of the breast that presented as masses and where the diagnosis could only be made from the histology. The outcome was good following antibiotics and antituberculous treatment. Tuberculosis of the breast is a very rare infection. The incidence of the disease is 0.025% of all disease of the breast treated surgically. The basis of treatment at the present time is antituberculous antibiotic treatment and surgery for any residual masses.


[Ovulation induction by endogenous LH released by the administration of an LHRH agonist after follicular stimulation for in vitro fertilization]. Sixty-seven patients whose ovulation was stimulated following a protocol of Clomiphene Citrate/HMG in order to carry out in vitro fertilisation were divided randomly in to two groups. In the first group ovulation was provoked by giving 10,000 IU HCG IM, but in the other group ovulation was provoked by releasing endogenous LH after the administration of Triptoreline in a dose of 0.1 mg in a dose subcutaneously three times in one day at 8 hour intervals. The number of oocytes recovered, cleavage and embryo transfer were compared between the two groups over 48 cycles. The number of conceptions was statistically significantly higher in the group that had triptoreline (28%) as compared with 17.4% pregnancies in the other group (p less than 0.01). These figures confirm that the endogenous LH surge provoked by giving an LHRH agonist can cause adequate final oocyte maturation. This property which is associated with a very low risk of hyperstimulation, should make it possible to stimulate ovulation when it is not used for IVF and so replace the usual injection of chorionic gonadotrophins.


[The use of Fogarty's catheter for salpingoplasties in laparoscopic surgery]. Nowadays new techniques of laparoscopic surgery make it possible to carry out fimbrioplasties and salpingostomies with results as good as those obtained by microsurgery. We describe a new use for the Fogarty catheter as a means of traction and for demonstrating the ampulla and the fimbrial end of the tube. The pneumatic balloon of the end of the catheter is blown up in the tubal ampulla. This makes it possible to bring the tube close to the laparoscope which makes it possible to carry out precise precise maneuvers with such degrees of enlargement as make it like a form of microsurgery. This kind of procedure helps in these delicate and difficult operations.


[Vulvar sebaceous epithelioma].

[Vulvar sebaceous epithelioma]. A-77-years old woman had a solitary ulcerated tumor on her vulva present for one year. It proved, on histologic examination, to be a sebaceous epithelioma of 1.5 cm wide because of a peripheral area with less differentiated cells, excess of mitoses and slight invasiveness. To the authors' knowledge this is the first sebaceous epithelioma documented in this region. Previously have been described one sebaceous hyperplasia and two sebaceous carcinomas, one of them eight years after hemicolectomy for adenocarcinoma of the colon (Torre-Muir syndrome).


[Pelvic echinococcosis in women. Two case reports]. The purpose of this report of two cases of pelvic hydatid disease is to recall the aetiology and pathogenesis of this endemic condition in Morocco. We point out that because it gives rise to many different clinical signs it is difficult to diagnose accurately but if the appropriate blood tests are carried out in every case with a pelvic mass the diagnosis could not be missed. It is important to treat effectively this condition which can compromise both the gynaecological and obstetrical future of the patient and that can have serious repercussions extending to the upper urinary tract. The authors, too, show how important it is to follow up these cases after operation in order to spot recurrences.


[Laparoscopic surgery versus laparotomy. Comparative analysis of stress markers]. The place of laparoscopic surgery continues to increase in the field of surgery in our specialty. Although the advantages would seem to be obvious, it seemed to us interesting to quantify, if possible, the parameters of operative stress and compare laparoscopic surgery with conventional surgery. Markers studied are Prolactin, Cortisol, Adrenaline, Nor-Adrenaline, Dopamine and the Beta-Endorphins. The only marker that shows any difference in the two procedures in our study is Beta-Endorphin which is significantly less raised in laparoscopic surgery directly after the operation (p less than 0.01). This was very specific for pain, which is one of the benefits of this technique and shown in this parameter which confirms the clinical impression. The curves of the changes in the different markers have been analysed and discussed.


[Are there still indications for an abdominal hysterectomy? 340 cases]. This retrospective study of 340 hysterectomies carried out abdominally concern cases only where the pathology was benign and strictly limited to the body of the uterus. This has made it possible to review the 240 cases carried out for fibroids (70.6%), 63 for simple endometrial hyperplasia (18.5%), 28 for adenomyosis (8.2%) and 9 for atrophy of the endometrium (2.6%). We looked for lesions that could have been treated laparoscopically among these pathologies: submucous fibroids with a diameter of less than 4 cms and where the uterus was less than 10 cms in height and weighted less than 200 g, simple endometrial hyperplasia (the height of the uterus less than 10 cms and the weight less than 200 g, adenomyosis (uterus less than 10 cms in height and less than 200 g weight), this last criteria still "debatable", We found that 110 lesions were selected because they could have been treated conservatively. This means that 32.5% where there seemed to have been indications for hysterectomy out of 340 cases, could have been treated otherwise. These can be divided aetiologically in to: 54 cases of simple hyperplasia of the endometrium (15.9%), 34 cases with submucous fibroids (10.6%), 26 cases of adenomyosis (5.9%). If the cases of adenomyosis are excluded 90 out of 340 hysterectomies carried out abdominally (about a quarter) could have been treated conservatively.(ABSTRACT TRUNCATED AT 250 WORDS)


[Ureteral and bladder lesions after gynecologic surgery. Value of early diagnosis]. Ureteric and bladder injuries are recognized complications of gynaecologic surgery. Efficiency of conservative treatments is directly related to early diagnosis. Urinary vaginal fistulas are easily diagnosed in view of post-operative continuous leakage. Ureteral or bladder obstructions can be quite asymptomatic and result in renal destruction or bladder impairment. Reviewing 17 cases, we emphasize abnormal post-operative pain and biological changes which must aware of urologic complications and lead to radiographic studies. Double-J stenting or bladder drainage associated with filling of fistula with fibrin sealant gives a chance of complete recovery to urogenital fistulas. Percutaneous nephrostomy or clean intermittent catheterisation preserves renal or bladder function until adequate treatment of obstruction has been defined.


[Colposcopy in gynecologic cancers. Retrospective study of 192 examinations]. One hundred and ninety two colposcopic examinations carried out on 183 patients of whom 140 had carcinoma of the cervix, 26 carcinoma of the endometrium and 17 carcinoma of the ovaries were analysed in order to assess the value of colposcopy in patients with gynaecological cancer. The mean distance from the edge of the anus that was looked at was 45 cms--the range being from--130. Out of all the systematic examinations that were carried out before any treatment was started, 103 were for cervical cancer and among these invasion of the rectal mucosa was found in two cases (1.9%). Twelve cases of external pressure on the rectum and 9 cases of recto-colic polyadenomata (8.7%) of which one was malignant. Out of the 14 colposcopies that were carried out for carcinoma of the endometrium one case of rectal invasion was found and one case of external compression. In the 12 cases of cancer of the ovary 2 were found to have recto-colic spread, 1 external compression and 1 malignant polyadenoma. All these cases of spread to the rectum and colon were diagnosed in advanced cases (stage III or IV). In the 63 examinations carried out on follow-up the most common warning sign was a rectal discharge and the most commonly found lesion in the rectum was actinomycotic inflammation of the rectum. The 5 cases of recurrence in the rectum expressed themselves most often by the rectal syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)


[Treatment of the pelvis after total pelvic exenteration. Experience of the Regional Paul Strauss Cancer Center of Strasbourg]. Intestinal morbidity after total pelvic exenteration presents usually as fistulae. These appear particularly if irradiation has been carried out in the pelvis or the abdomen before surgery, and particularly as a result of the types of surgery carried out in the emptied pelvis. An analysis of 92 exenterations of the pelvis of which 52 were total exenterations led us to look at how treatments in the pelvis have evolved technically and to analyse the contribution they have made to reducing the number of fistulae and obstructions found as a result of this major surgery. Making a "sac" by packing the pelvis as suggested by the pioneer of this exceptionally extensive pelvic surgery gradually has been replaced by the use of endogenous material such as the omentum and more recently by the use of absorbable synthetic materials (vicryl) which give rise to progressive reperitonealisation. The authors approve of this last way of dealing with the emptied pelvic cavity because the synthetic material is very well tolerated clinically and the polyglactine 910 mesh is not predisposed to infection when it is used to make a hammock to prevent chronic radiation enteritis by holding the small intestines out of the pelvis.


[Lipid evolution during normal pregnancy]. We analyzed the relationship between the evolution of pregnancy and the amplitude of the lipid disorders in order to evaluate their chronologic transformations. This research concerned 83 pregnancies aged between 19-40 years during the 3 periods of gestation and 31 healthy control women in the same range of age. Our results showed an increased triglyceride in the 2nd period and an earlier decrease of both, cholesterol, phospholipid and apolipoproteins. These parameters showed a progressive increase of their blood concentrations during the 2nd and the 3rd period of pregnancy, in an other hand we evidenced a good correlation between gestational aged and these variations i.e.: triglyceride and mother's weight; this phenomenon could suggest an eventual role of the nutrition and the hygienic habitude in the lipid metabolism. The correlation between our observed lipid disorders and the mother's age or the parity were not significant.


[The risks of pyrimethamine-sulfadoxine combination in the prenatal treatment of toxoplasmosis]. Some of the alternative treatments to avoid termination of pregnancy in cases where the fetus is affected by toxoplasmosis is to treat it as soon as the diagnosis has been made. The authors who already have experience of using pyrimethamine with sulfadoxoine (Fansidar) in the post-natal treatment of congenital infection, thought after reviewing the literature that this association of drugs would be harmless if applied during pregnancy. The principal risk that arises in the fetus is the teratogenicity of each of the components of pyrimethamine and sulfadoxine and also their associations. In animals pyrimethamine can increase the frequency of cleft palates probably because of its antifolinic action but there is no formal proof that it is teratogenic in human beings. Furthermore, the theoretical risk of karnicerus in the new born using the Sulfonamide has not been demonstrated. In the mother the main but rare risk (1 in 75,000) seems to be for the production of severe skin lesions such as Lyell and Stevens-Johnson which could be brought about by sulfonamides, but not particularly sulfadoxine.


[Quadruplet pregnancies: management and obstetric and pediatric outcome]. Multi-fetal gestations are associated with increased frequency of maternal, fetal and neonatal complications. Data on the prognosis of multi-fetal pregnancies are of particular importance when the option of selective termination is considered. The present study details the obstetric management, neonatal outcome, and follow-up of seven quadruplet pregnancies in a french university center. The perinatal mortality was 250/1000. The neonatal mortality was 214/1000. The incidence of respiratory distress syndrome was 38%, bronchopulmonary dysplasia 19% and intraventricular hemorrhage 9.5%. Follow-up from one to 16 years shows that no child is handicapped. Our specific management for higher order multi-fetal pregnancies include early diagnosis, meticulous follow-up, early decrease of maternal activity, midwives at home, psychological care, delivery by cesarean section and a neonatalogist for each baby at the time of delivery.


[Pregnancy and obesity. A case control study of 140 cases]. A retrospective study of 70 fat women and 70 women of normal weight was carried out to compare their obstetric performance. The patients were assessed before pregnancy for corpulence by estimating the body mass index (IMC). Obesity was defined by having an index of 30 or above. The mean weight of the obese patients at delivery was 142 kgs and of the controls 65.4 kgs. The main risk in obese patients is a raised blood pressure (34%); and in spite of this no child showed intrauterine growth retardation. The mean weight of the newborn infants was 3.7 kgs against a mean weight of 3.2 kgs in the control group. Eighteen infants born to obese mothers were very heavy (25%). The increase in fetal weight explains why the caesarean section rate was three times as high in the obese patients as in the control due to disproportion (25%). These differences are statistically significant. Neonatal morbidity was similar in the two groups. It is debatable whether a slimming diet was worthwhile. All the same calorie intake reduced slightly to about 1.800 calories a day together with vitamin supplements is advisable. It does not have any ill effect on the fetus.


[Monitoring cervical dilatation by impedance]. Several different physics procedures have been tried to mechanize the recording of partograms. Can a measure of impedance of tissue Z using potential difference V, according to Ohm's law V = Z1, and 1 is a constant, be correlated with a measure of cervical dilatation using vaginal examination? This was our hypothesis. The tissue impedance meter was made to our design and applied according to a bipolar procedure. Our work was carried out on 28 patients. 10 patients were registered before labour started in order to test the apparatus and to record the impedance variations without labour taking place, and 18 patients were registered in labour to see whether there was any correlation. The level of impedance in the cervix without labour was 302.7 Ohms with a deviation of 8.2. Using student's t tests it was found that there was a significant correlation (p less than 0.001) in four measurements between the impedance measure and measures obtained by extrapolating the degrees of dilatation calculated from vaginal examination. This is a preliminary study in which we have defined the conditions that are necessary to confirm these first results and to further develop the method.