Increased insulin sensitivity and cellular insulin binding in obese diabetics following treatment with glibenclamide. The aim of the present study was to examine the effect of glibenclamide on the insulin receptors, the insulin sensitivity and the insulin secretion in obese non-ketotic diabetics. Two groups of 9 obese diabetics were studied before and after 10 days' treatment with a 1200 kcal's diet and a 1200 kcal's diet + 10 mg/day of glibenclamide, respectively. In the group treated with diet alone we found no significant alteration of the insulin secretion pattern (P greater than 0.1). However, the insulin sensitivity increased 37% (P less than 0.01). Furthermore, the insulin binding to monocytes increased (P less than 0.01) due to a 36% rise of the binding affinity. In the group treated with glibenclamide and diet the insulin secretory pattern was unchanged, too (p greater than 0.1). The insulin sensitivity, however, increased 83% (P less than 0.01). Moreover, the insulin binding was raised (P less than 0.01) as a result of a 80% rise of the number of insulin receptors. In 4 patients who were treated with diet (1200 kcal/day) plus glibenclamide and in 5 patients who were treated with diet alone (1200 kcal/day) the insulin binding to monocytes was studied during treatment for 1 year. After 1 year we found a significantly (P less than 0.005) higher cellular insulin binding in the glibenclamide treated patients compared to the patients who got diet alone. We conclude that 1) the augmentation of the insulin sensitivity is of great importance for the normalization of the diabetic state in obese, 2) the increase in insulin binding may be of importance for the increase in insulin sensitivity, 3) glibenclamide appears to enhance the insulin sensitivity through an increase in the number of insulin receptors.


Demonstration of the intermediate cells of Billingham and Medawar in the epidermis of Macaca mulatta and rhesus monkey. The digest of the pure epidermis preparation from Macaca mulatta demonstrated three types of dendritic cells i.e. (1) dopa-positive melanocytes, (2) dopa-negative Langerhans' cells and (3) weakly dopa-positive intermediate cells of Billingham and Medawar. The last type of cell was found to have characteristics being intermediate between those of the melanocytes and of the Langerhans' cell. A similar digest prepared from the epidermis of the rhesus monkey demonstrated isomorphous dendritic cells which were all dopa-negative. Here also the intermediate cells of Billingham and Medawar with characteristics intermediate between those of the melanocytes and of the Langerhans' cells were identified.


Studies on periodontal conditions in asthmatic children. The effect of extrinsic asthma on periodontal conditions was studied in a group of 30 asthmatic children. Clinical examination revealed that asthmatic children had more gingivitis than their healthy controls. The asthmatic children who received an inhaled corticosteroid as treatment had more severe gingivitis compared with asthmatic children on disodium cromoglycate treatment. The amount of plaque was not altered. The peroxidase activity was assessed from whole saliva. The results revealed that this defense mechanism was not altered in asthma. An enzyme group which is involved in inflammation, the arginine aminopeptidases, was found to be slightly elevated in the gingival fluid of asthmatic children. The results indicate that gingival inflammation is increased in asthma.


Interferon therapy in multiple myeloma.

Interferon therapy in multiple myeloma. A woman with multiple myeloma relapsed after 6 years of satisfactory tumor control with melphalan therapy. When progression then occurred, she was given exogenous human leukocyte interferon, 3 x 10(6) reference units twice daily i.m., as the sole therapy. Side-effects of the interferon therapy consisted of fever reactions and thrombocytopenia. One month after the initiation of interferon therapy there was 1) improvement of general health with less pain and tiredness, 2) reduction of the M-component, IgG-lambda, in the serum, and 3) a reduced plasma cell concentration in the bone marrow. After 5 months of interferon therapy tumor progression occurred despite continuous interferon treatment. At the same time, the tumor cells were less sensitive to interferon in in vitro tests than prior to interferon therapy. It is suggested that interferon therapy should be given as initial treatment to a few patients with multiple myeloma in a phase I trial.


Paraplegia in myelomatosis--a study of 20 cases. A retrospective study of 20 cases of multiple myelomatosis and paraparesis treated during 1966-77 is presented. All patients but one had been submitted to decompressive laminectomy. A close correlation between duration of paraparesis before operation and prognosis was found, eight patients with a duration of paraparesis of several days remaining paraplegic. No particular paraparesisprone patient group with respect to duration of myelomatous disease, Ig class or various laboratory findings could be identified. In several instances radionuclide scan was effective in localizing vertebral lesion. In most patients radicular type back pain signalled vertebral damage and subsequent paraparesis. In many cases long survival after operation and excellent to good functional results made surgery a worthwhile procedure. The importance of postoperative radiotherapy and adequate chemotherapy is stressed.


Balanced intraintestinal nutrition: digestion, absorption and biological value of selected preparations of milk proteins. The absorption of an enzymatic hydrolysate of whey proteins, hydrolysates of milk proteins and casein, 7% hydrolysate of bovine blood produced by Polfa under the trade name "Aminokwasy", and a standard mixture of amino acids from isolated small intestine loop of dogs and rats was compared. The composition of amino acids of the initial proteins and hydrolysates obtained from these proteins was determined. The biological value of selected proteins and hydrolysates was assessed determining the mean weight gain, nitrogen content of the body, urinary excretion of urea and creatinine, blood urea level and NPU. No significant differences were found in the absorption of nitrogen from the hydrolysate of milk and whey proteins. The nutritional value of whey protein hydrolysate was, however, slightly higher than that of an analogous hydrolysate of milk proteins. It seems that of all tested proteins whey hydrolysate (free of lactose) is the most suitable source for obtaining preparations for no-residue intraintestinal feeding.


Development of biclonal gammopathy in a patient with von Recklinghausen's neurofibromatosis. A well established case of von Recklinghausen's neurofibromatosis, in which a biclonal gammopathy developed, has been studied. One of the paraproteins was characterized as IgG kappa, the other as IgG lambda. This combination of anomalies has not been described previously in the literature.


Balanced intraintestinal nutrition: comparison of absorption degree of selected fats and emulsions of fats. The absorption of emulsion of  soybean oil, soybean oil and molted butter was compared with that of the Intralipid preparation manufactured by Vitrum. The experiments were carried out on a dog and rats using the method of isolated intestinal fistulae. It was found that the emulsion of soybean oil prepared by the authors was absorbed in a degree similar to that of Intralipid fat emulsion and that it could be used as a component of a preparation intended for balanced non-residual intraintestinal nutrition.


The prognosis of insulin dependent diabetes mellitus and the importance of supervision. 1451 patients with IDDM, onset before 1953 and before the age of 30 were followed until death or until 1976. Survival with diabetes, relative survival and the influence of supervision on survival were examined. It is shown that only 50% of the patients survived more than 30 diabetes years. The patients had an overmortality of more than 600% in relation to age and sex matched non-diabetics. Frequent supervisions in the out-patient clinic reduced as well the overmortality as the prevalence of severe complications significantly.


Balanced intraintestinal nutrition. A preparation for intraintestinal no-residue nutrition. The investigations were carried out on dogs and male Wistar rats using the method of isolated intestinal loops. The absorption of nitrogen from a preparation was studied. The protein component of the preparation was an enzymatic hydrolysate of whey proteins, milk proteins, casein and a 7% bovine blood hydrolysate manufactured by Polfa. Comparative investigations were carried out on the effect of the protein component on the absorption of fat from the tested preparation. No significant differences were found in nitrogen absorption from the hydrolysates of milk proteins administered in the form of a protein-fat-carbohydrate emulsion or in fat absorption depending on the protein component. On the basis of theoretical assumptions and experiments on laboratory animals the composition of a preparation for balanced no-residue intraintestinal nutrition was elaborated in which the protein component was a hydrolysate of whey proteins without lactose and the fat component was soybean oil.


The role of catecholamines in clinical medicine. The sympathetic nervous system is of major importance for the regulation of several physiological functions. Drugs which inhibit the actions of catecholamines and adrenergic drugs are used in the treatment of many clinical disorders. The potential role of catecholamines in a number of human diseases has, however, until recent years been studied to a limited extent only due to lack of methods for quantitation of sympathetic nervous activity. After the development of enzymatic isotope-derivative assays, reliable measurements of noradrenaline and adrenaline in plasma became available. Studies in man have shown that plasma noradrenaline is an index of sympathetic nervous activity. The present survey deals with sympathetic nervous activity and plasma adrenaline in a number of clinical disorders viz. arterial hypertension, duodenal ulcer, thyrotoxicosis, diabetes mellitus and ketotic hypoglycemia.


Diagnostic radiology: geography of a high technology. A survey was made of the manpower employed, facilities available and utilization of radiology in countries in tropical Africa and Southeast Asia. The data obtained are compared with those from industralized societies in temperate climates. The level of use of radiographic services varied by a factor as high as 40. The differences between the level of radiology manpower available could be over a hundredfold and for x-ray technologists, many hundred times. The concentration of services in capital cities is characteristic of many tropical societies. Measures to improve radiologic health care in tropical countries, with particular emphasis on rural areas, are discussed. The main need is for availability of radiodiagnosis close to the primary care level in rural areas to deal with the important clinical problems of trauma, chest infections, and obstetrics. Simplification of equipment and employment of technicians with short training can help relieve maldistribution of services.


Performance of evaluation of computed tomography scanners using a phantom model. A phantom was designed to test computed tomography (CT) scanner performance relative to spatial resolution, contrast resolution, field uniformity, spatial linearity, artifact resistance, and radiation dose. Translate/rotate, stationary detector with rotating x-ray tube, and rotate-only scanners were tested under conditions that produced the best possible results for each machine within the dose ranges used in clinical practice. Machines can be ranked according to results for each parameters tested. The range of performance exhibited on machines tested was unrelated to class of scanner. Further, machine dedication to a particular body region did not necessarily secure superior results for that region. Spatial resolution at low contrast levels (poor on most machines) seems to be the most sensitive test of performance.


CT resolution and diagnostic accuracy.

CT resolution and diagnostic accuracy. To justify CT purchases and document certificates of need, the clinical effectiveness of CT scanners with different cost and resolution must be compared. The diagnostic accuracy and anatomic detail in three scanners with different resolution were studied. Seventeen patients were studied with both a first or a second generation CT scanner and a third-generation scanner. Appearance of normal and pathologic structures was compared. Cerebral sulci, corticomedullary discrimination, basal cistern vessels, and some pathologic lesions were seen in third generation images that were not seen in the others. Higher resolution scans provide significantly better anatomic detail and accuracy in detecting pathologic processes.


High dose preoperative irradiation of the lower neck and supraclavicular fossae. Preoperative irradiation of 5,000 rad in 5 weeks before total laryngectomy with radical neck dissection was compared for two groups of patients: (1) those treated to a smaller volume through lateral opposed fields (37 patients) and (2) those treated to a larger volume by adding a third field directed to the lower neck and supraclavicular fossae (46 patients). There were no significant differences in tolerance to irradiation or in postoperative complications. However, locoregional tumor control improved significantly from 63% to 90% (P less than 0.02) with the three-field technique, and all four stomal recurrences were in the two-field group. Deaths from intercurrent disease and from distant metastases without local recurrence account for the failure to improve the overall survival rate.


Sequential CT observations of irradiated intracranial germinomas. Computed tomography (CT) has improved the accuracy of preoperative diagnosis of intracranial tumors. CT findings of germinoma are a mass of isodensity or of slightly increased density with significant, homogeneous enhancement after intravenous contrast injection. These findings are characteristic but not pathognomonic, and differential diagnosis from other solid tumors is not easy. Cerebrospinal fluid cytology and response to irradiation aid in this differential diagnosis. The nine cases of germinoma reported showed rapid response to irradiation even at small doses (600 rad), and complete disappearance of the mass on CT at 1,600--3,300 rad. Other radiosensitive masses to be differentiated in the pineal region are pinealocytoma or pinealoblastoma.


CT metrizamide myelography for intraspinal and paraspinal neoplasms in infants and children. Computed tomography (CT) metrizamide myelography is an accurate and satisfactory method for examining the spinal cord in infants and children with suspected intraspinal neoplasms. It was performed in 13 infants and children and in one adult with intra- and paraspinal neoplasms. CT metrizamide myelography in paraspinal masses provides the total geography of the mass; that is, possible intraspinal extension, as well as the paraspinal portion itself. As such, it is superior to conventional myelography.


Radiographic changes of the skull in sickle cell anemia. Skull radiographs of 194 patients from 4 months to 55 years old with sickle cell anemia revealed porous decreased bone density in 25%, widening of diploë associated with a relative decrease in the width of the outer table in 22%, and vertical "hair-on-end" striations in 5%. The youngest patient with vertical striations was 5 years old and the oldest was 39. Serial examinations in 60 patients revealed no decrease of the skull width nor disappearance of the striations with age.


Radiography of glycogen storage diseases. Sixty-three patients with glycogen storage disease were evaluated. Findings on plain film examinations, excretory urography, barium gastrointestinal studies, ultrasonography, and angiography were categorized by type of glycogen storage disease. In type I findings include hepatomegaly with hepatic dysfunction, renomegaly with an increased incidence of renal calculi, and osteopenia with various associated osseous abnormalities. These changes were less pronounced in types III, IV, and VI. Type II displayed either cardiac or skeletal muscle glycogen deposition. Correlation with postmortem examination in 14 individuals is given.


Radiology of the pterygoid plates and pterygopalatine fossa. The pterygopalatine fossa is a major distribution center for the parasympathetic innervation and vascular supply of deep facial structures. Through eight bony canals or foramina, this fossa communicates with the nasal and oral cavities, infra-temporal fossa, orbit, pharynx, and middle cranial fossa. Therefore this important structure provides a natural pathway for dissemination or spread of disease processes to contiguous structures. The normal gross and radiographic anatomy of the pterygopalatine fossa and the adjacent pterygoid plates are considered in detail. Variation in these structures as well as their alterations in a variety of pathologic entities are described.


Ultrasonic recognition of parenchymal gas. Abdominal sonography in six febrile patients was suspicious for parenchymal gas. In five, immediate radiographic confirmation was obtained. Four patients had gas-containing abscesses, one had gas sequestered in a hepatic hematoma, and in the other subcapsular hepatic gas probably originated by mesenteric dissection from pneumatosis cystoides intestinals.


Ultrasound diagnosis of masses elevating the inferior vena cava. The inferior vena cava is frequently involved in diseases of the abdomen and retroperitoneum. Critical evaluation of this vessel's course can greatly help in determining the origin of an adjacent mass. Ultrasound was used to divide the inferior vena cava into three parts. A vector type principle was applied to masses anteriorly displacing the vena cava, and the location of the mass was compared to the particular portion of the cava most affected. With this approach, it was often possible to determine what structures a mass may have originated from.


Ultrasonic assessment of renal transitional cell carcinoma: preliminary report. The value of ultrasound in determining the etiology of nonopaque filling defects seen in the renal pelvis at intravenous urography is under study. The ultrasound findings in three patients with proven transitional cell carcinoma of the kidney were similar and consisted of separation of the central renal echo complex by a region of low-intensity echoes. This pattern is distinct from characteristically echogenic nonopaque renal calculi and anechoic hydronephrosis. Renal collecting system blood clots may have an echo pattern similar to collecting system tumors, but can usually be distinguished by their mobility and transitory nature. Further investigation into the specificity and sensitivity of the ultrasonic diagnosis of renal collecting system masses is underway.


Medial deviation of the pelvic ureters after abdominoperineal resection of the rectum. Pre- and postoperative urograms of 47 patients undergoing abdominoperineal resection were reviewed for ureteral deviation and obstruction. Postoperative medial deviation occurred in 11 patients (23.4%). Both ureters were involved in six of these patients. Ureteral deviation was identified as early as 3 days after surgery. Obstruction of the ureters occurred in four patients and was due to tumor in three of these.


Ureteral obstruction resulting from vascular prosthetic graft surgery. Four cases of ureteral obstruction are described which were primarily due to compression from an overlying vascular graft and retroperitoneal fibrosis. Infection may also be causal. Excretory urography should be performed routinely after vascular prosthetic surgery to permit early diagnosis of this complication. Ultrasonography may also be helpful in certain cases.


Metastatic transitional cell carcinoma from the bladder: radiographic manifestions. Metastases from transitional cell carcinoma of the bladder are not widely appreciated radiographically, although they are commonly found at autopsy. Radiographic evidence of metastatic disease was reviewed in 51 patients. Sites included lung, 28; bone, 24; mediastinum, eight; liver, eight; brain, three; urethra, one; abdominal nodes, one; and extradural space, two. The patterns of lung metastases consisted of solitary nodules, multiple nodules, sigmental infiltrates, pulmonary edema, and a Pancoast tumor. A sarcoidlike pattern with hilar and interstitial disease was also seen. One patient had a malignant pleural effusion. Mediastinal lymph node enlargement was isolated or associated with lung involvement. Bone metastases demonstrated either an osteoblastic or a mixed osteolytic-osteoblastic pattern in 47% of the instances. Ivory vertebrae were identified in three patients. Because of the significance of identifying metastatic disease before any extensive curative bladder surgery, we recommend at least a preoperative chest radiograph, a bone scan, and a liver scan.


Risk factors and occult breast cancer in young women. The National Cancer Institute guidelines for mammography in women 35--49 years old are challenged. Forty-nine occult breast cancer patients under 50 years of age were analyzed regarding risk factors and compared with an age-matched control group. Of the cancers, 86% would have been missed had NCI recommendations been followed. Results refuted the NCI guidelines and showed that late parity (over 28 years) and history of breast cancer in the extended family are statistically significant risk factors. Negative mode low-dose xeromammographic examinations permitted detection of 49 occult breast cancers, usually without axillary node metastases. Patients were screened because of risk factors enumerated in the article.


Influence of contrast material on renal venous renin activity. The influence of contrast material on renal venous renin activity was evaluated in a prospective study of 20 hypertensive patients. It is concluded that the absolute values of renal venous renin activity are either unchanged or unpredictably changed after injection of contrast material. The renal venous renin activity ratios seem to be less valid than the absolute values in predicting the significance of renal vascular or parenchymal disease.


Minimum blood vessel diameter measured by magnification angiography. Visibility of small blood vessels was improved by magnification angiography of biologic specimens. Blood vessel diameter was determined for increasing magnifications by various screen-film combination. Significantly smaller vessels were recognized with the magnification technique in all screen combinations. Noisy screen-film combinations with better square wave transfer functions did not allow visualization of blood vessels as small as those screen-film combinations with poorer square wave transfer functions but less noise.


Presacral space revisited.

Presacral space revisited. Increase in the width of presacral space measurements is considered indicative of disease of the rectum and/or other structures in the pelvis. The traditionally accepted normal width of presacral space is not more than 15 mm. In some normal patients older than 45 years, the presacral space is wider than 15 mm and may even exceed 20 mm.


Foley catheter method of esophageal foreign body removal: extension of applications. The fluoroscopically controlled Foley catheter technique can be used to remove nonopaque esophageal foreign bodies that are smooth or soft and foreign bodies in patients with esophageal strictures or after esophageal atresia repair. These situations have previously been felt to be contraindications for this procedure. Successful treatment was accomplished in 21 of 25 patients.


Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy. Technetium-99m dimethyl acetanilide iminodiacetic acid (HIDA) cholescintigraphy was performed on 90 patients with suspected acute cholecystitis. Visualization of the gallbladder established patency of the cystic duct and excluded the diagnosis of acute cholecystitis in 50 of 52 patients. Nonvisualization of the gallbladder with visualization of the common bile duct was diagnostic of acute cholecystitis in 38 patients, all subsequently proven at surgery. The observed accuracy of this procedure is 98% and specificity is 100%. The false negative rate is 5% and false positive rate is zero. Technetium-99m-HIDA has many advantages which make it the procedure of choice in evaluating a patient for suspected acute cholecystitis. It is a rapid, simple, safe examination which provides functional as well as anatomic information about the hepatobiliary system in individuals with a serum bilirubin level up to 8 mg/100 ml.


Computed tomography and 67Ga citrate radionuclide imaging for evaluating suspected abdominal abscess. A retrospective analysis of the results of 67Ga citrate radionuclide imaging and computed tomography (CT) in 45 patients with suspected abdominal abscess was conducted to determine the mertis of each method. Both techniques were highly sensitive in detecting abdominal abscesses, and often provided complementary and supplementary diagnostic information; their combined use many times offset the limitations of each method used alone. Guidelines are suggested that permit rapid evaluation, while limiting diagnostic errors, when using 67Ga citrate radionuclide imaging and CT in the presence or absence of localizing symptoms and signs.


Computed tomography in the evaluation of osteosarcoma: experience with 25 cases. Experience with computed tomography (CT) in 25 patients with histologically proven osteosarcoma is presented. CT was as accurate as conventional radiographic methods in determining the presence of a lesion, but it was definitely superior in defining the extent of disease, particularly intramedullary extension and soft tissue extraosseous tumor component. CT was capable of demonstrating skip metastases in one patient. CT plays a key role in the preoperative evaluation of osteosarcoma patients, particularly when less than radical surgery is planned as primary treatment and when postoperative recurrence is suspected. CT is also useful in assessing the response to therapy in nonsurgical cases. The technique involved in the performance of this examination is discussed.


Familial hyperphosphatasemia: diagnosis in early infancy and response to human thyrocalcitonin therapy. Familial hyperphosphatasemia is an uncommon hereditary disorder of membranous bone with concurrent overproduction and overdestruction of bone and bone collagen by osteocytes. This process does not allow normal maturation into compact lamellar bone. Two cases of severely affected children are presented which demonstrate that the condition can be diagnosed in early infancy by abnormalities in the long bones. At this stage the skull may appear normal and the characteristic thickening of the calvarium appears later. The disease is treatable with human thyrocalcitonin; these and previously reported cases have responded favorably.


Technique of percutaneous transluminal angioplasty with the Grüntzig ballon catheter. Recanalization of superficial femoral artery occlusions and of stenoses in the superficial femoral and pelvic arteries using the Grüntzig balloon catheter are described. Among patients successfully treated, 2 year patency rates of 72% and 87% for superficial femoral and iliac artery lesions, respectively, were achieved by this method. The catheter is now commercially available in the United States and Europe.


Aneurysm rupture secondary to transcatheter embolization. False aneurysms of the pancreatic and peripancreatic arteries are a well recognized complication of chronic pancreatitis due to proteolytic enzymatic digestion of the arterial wall. These false aneurysms can be a source of life-threatening hemorrhage. Three cases are reported in which attempted embolizations of these bleeding aneurysms resulted in rupture into the gastrointestinal tract. Special precautions should be taken in such a procedure because of the inherent weakness of the aneurysmal wall.


Portal vein aneurysm.

Portal vein aneurysm. While there have been a few references to portal vein aneurysm in the world literature, this is the first report in United States radiologic literature. During a routine evaluation for fever in one patient, an ultrasound examination suggested this unusual entity at the junction of the splenic and superior mesenteric vein. It was later confirmed by angiography. Two other patients were being investigated angiographically for gastrointestinal bleeding when portal vein aneurysms were discovered. In contrast to the central location of the first patient's aneurysm, the latter two were more distal in the portal tree. The literature is reviewed and different etiologic hypothesis discussed.


Circumaortic venous ring: incidence and significance. A left circumaortic renal vein was found in 11% of 74 left renal venograms, an incidence similar to that at autopsy. Cavography proved to be an unsatisfactory method of demonstrating the renal veins. Prior knowledge of a venous ring is important when blood samples from the adrenal or renal veins are to be collected. When caval interruption is planned, a circumaortic venous ring may provide a fully developed collateral pathway immediately after surgery if the procedure is planned without awareness of its presence.


Esophagitis induced by combined radiation and adriamycin. With the increasing use of combined chemotherapy and radiotherapy in the treatment of certain types of malignancy, a clinically distinct type of esophagitis has been recognized as an undesirable side effect. It occurs with low doses (less than 2,000 rad) of mediastinal radiation in patients who simultaneously or sequentially receive either adriamycin or actinomycin D. Characteristic of this entity is "recall": recurrent episodes of esophagitis with each course of chemotherapy. The radiographic findings are nonspecific, ranging from subtle alterations in motility to severe damage with irreversible stricture formation. The primary differential diagnostic considerations are infectious processes. The radiographic spectrum, clinical aspects, and differential diagnoses in five patients are discussed.


Gallbladder: common cause of antral pad sign. An impression on the posteroinferior aspect of the gastric antrum is often caused by a mass lesion in the pancreas. However, the gallbladder more commonly causes such as indentation. In any case of this "antral pad sign", a gallbladder impression should first be excluded.


Radiographic features of eosinophilic gastroenteritis (allergic gastroenteropathy) of childhood. The child with eosinophilic gastroenteritis has failure to thrive, a history of allergy or asthma, iron deficiency anemia, and peripheral eosinophilia. This type of eosinophilic gastroenteritis has earned the designation "allergic gastroenteropathy." Pathologic change in the gastric antrum of six children with this disease correlated with an abnormal air-contrast examination of the antrum. The affected children had an irregular, lacy, antral surface rather than the smooth, bald surface seen in normal children. The small bowel in allergic gastroenteropathy is usually abnormal but nonspecific as to etiology. Much more specific is the combination of small bowel and gastric antral abnormalities. Findings encourage air-contrast radiography of the antrum in children with suspected allergic gastroenteropathy.


Ultrasound of gallbladder wall thickening and its relation to cholecystitis. A prospective ultrasound study of gallbladder wall thickness in patients with suspected gallbladder disease was performed over a 9 month period. Gallbladder walls thicker than 3 mm in fasting patients whose gallbladders were wider than 2 cm were considered abnormal. Gallstones were documented by ultrasound in 62 patients, a thickened gallbladder wall was demonstrated in 12 of these. Five patients without cholelithiasis had thick-walled gallbladders and were diagnosed as acalculous cholecystitis.


Erect scanning of pancreas using a gastric window. A technique that can offer improved ultrasonic visualization of the pancreas is reported and evaluated. One hundred subjects were scanned in an erect sitting position with fluid-filled stomachs ("erect gastric window" technique). Conventional supine scans were initially performed in all cases; oblique, semierect, decubitus, prone, and standing positions with and without fluid-filled stomach were also evaluated. Compared with supine scans, the "erect gastric window" technique, occasionally supplemented by semierect, oblique, or decubitus views, provided significantly improved visualization of the pancreas in 93% of subjects. The nonvisualization rate was reduced from 19% to 1%.


Ultrasound of epigastric injuries after blunt trauma. Blunt trauma to the epigastrum may result in a retroperitoneal hematoma involving the head of the pancreas and descending duodenum. Secondary effects include obstruction of the gastric outlet, obstruction of the biliary tree, and extrinsic compression of the inferior vena cava. Four patients with epigastric trauma were reviewed who had been examined by ultrasound of the abdomen. Ultrasound showed the extent of the retroperitoneal hematoma, its effect on contiguous organs, and was helpful in clinical management.


Dural and direct cavernous sinus fistulas. Fistulas between the cavernous sinus and the carotid artery occur either after trauma or spontaneously. Unilateral exophthalmos is invariably the most conspicuous symptom. Until recently, treatment consisted of some method of occluding the carotid artery involved. Interventional catheter techniques have since been developed that use either Gelfoam embolization or released balloons. The results seem very promising, but long-term results of these new techniques are not yet available. Carotid-cavernous sinus fistulas may be dural or direct, each requiring a different interventional technique. Theredore, it is essential to determine the type involved by selective internal and external carotid angiography. This paper discusses 19 patients with carotid-cavernous fistulas, four of whom were successfully treated by catheter techniques. Gelfoam embolization was used in one case, and in three cases the fistula was closed with the aid of a balloon.


CT detection of intracranial aneurysms in subarachnoid hemorrhage. Contrast enhanced computed tomography (CT) scans of 59 patients with subarachnoid hemorrhage were evaluated for intracranial aneurysms. After prospective study, the CT results were compared with angiography. Depending on the location, the CT detection rate varied from a low of 36% for the internal carotid artery complex to a high of 76% for anterior and middle cerebral artery aneurysms. It was concluded that angiography may be deferred if the causative aneurysm is demonstrated by CT.


Lateral decubitus pneumoencephalography-angiography for localizing atrial and paraatrial vascular lesions. In two cases where computed tomography (CT) and cerebral angiography failed to determine whether an arteriovenous malformation was within or directly adjacent to the atrium of a lateral ventricle, lateral decubitus pneumoencephalography combined with cerebral angiography successfully localized the lesions. This procedure may be necessary in the workup of angiographically vascular lesions in the atrial-paraatrial region if on CT the ventricular surface is poorly defined or surgical clips from a previous operation obscure the lesion or the adjacent ventricle. Interpretation of this study involves triangulation of the vascular lesions relative to the ventricle or observation of the movement of the lesion relative to the movement of the ventricle on differently angulated frontal projections. Since the surgical approach is influenced by the radiographic differentiation of an intraventricular from a paraventricular mass, this procedure is crucial in evaluating these vascular abnormalities.


Cranial CT findings in patients with meningomyelocele. The association between meningomyelocele and various cranial abnormalities, particularly Chiari II malformation is well established. Cranial CT scans in 47 patients with meningomyelocele proved to be a safe and effective method of elucidating the type and extent of anatomic abnormalities associated with this disorder, and evaluating and following the degree of hydrocephalus seen in these patients. Of the 47 patients, 43 (92%) showed CT findings indicative of an abnormally low fourth ventricle, the hallmark finding in Chiari II malformation. In 67% the fourth ventricle was not visualized, and in 25% it was directly visualized in an abnormally caudal position. Other findings included hydrocephalus (85%), a striking and possibly unique heart-shaped psuedomass in the posterior fossa (58%), and abnormal configuration of the lateral ventricles ("vampire bat" configuration). Calvarial abnormalities, in particular lacunar skull, were also noted at CT.


Intraventricular hemorrhage and hydrocephalus in premature newborns: a prospective study with CT. In a prospective study, 100 premature infants were studied with computed tomography (CT) brain scans within the first week of life. In 44 of these,hemorrhages originated from the subependymal germinal matrix, and ranged in severity from isolated germinal matrix hemorrhages to blood-filled, dilated ventricles with extension of hemorrhage into the brain parenchyma. A system of grading the severity of hemorrhage was developed. Grades I and II hemorrhages resolved spontaneously and grades III and IV were associated with progressive hydrocephalus. Asymptomatic hemorrhages that would not have been diagnosed on clinical grounds were detected by CT. This study offers a clearer understanding of the true incidence and natural history of cerebroventricular hemorrhage and associated hydrocephalus in premature neonates and may clarify etiologic factors and identify children at risk for subsequent neurologic abnormalities.


Preliminary report of the M. D. Anderson Hospital/Texas A & M variable energy cyclotron fast-neutron therapy pilot study. The records of 248 patients treated with fast neutrons and of 102 comparable but nonrandomized control patients treated conventionally with photons, surgery, or combined surgery and photon irradiation were reviewed. Fast neutron therapy included treatment with neutrons alone, a neutron boost after photon therapy, or a schedule of alternating neutron and photon treatments (mixed beam). The results with mixed beam irradiation were superior to those obtained with the other neutron therapy techniques, and compared favorably with the results of standard treatment methods. However, the lack of a conclusive advantage for neutron therapy in this pilot study illustrates the need for on-going randomized clinical trials.


Esophageal diverticula.

Esophageal diverticula. Congenital, neuromuscular and motor abnormalities of the pharynx, esophagus and diaphragm, coupled with intra- and extraluminal factors, play roles in the pathogenesis of esophageal diverticula. Principal presenting symptoms are regurgitation, obstruction, aspiration, pneumonitis and esophagitis. Cineradiography and manometry are useful methods of evaluation. Treatment, which may be simple excision or myotomy, does not correct the basic motor abnormality that is often associated with the diverticulum.


Evaluation of a gonococcal serologic test. The fluorescent gonorrhea test--heated (FGT-H), an indirect immunofluorescent method for detecting the presence of antigonococcal antibodies in serum, was evaluated in 1,000 women referred to a private clinic for the termination of pregnancy, 202 women treated at a municipal venereal disease clinic, and six women hospitalized with gonococcal bacteremia. The test was positive for 17.7% of private outpatients, even though gonococci were cultured from only 1.1% of these women, and another 5.1% had histories of gonococcal infection. Positive test results were found for 68.3% of the women in the venereal disease clinic population, in which the prevalence of gonococcal infection was 36.1% and an additional 25.2% had had gonorrhea previously. The test was positive for all six patients with gonococcemia. The sensitivity of the test in the low-risk population was 72.7%, which was not significantly different from the sensitivity of 84% in the high-risk population. Specificity of the test was 83% in low-risk patients, but only 41% in high-risk patients. These findings indicate that a negative test is a highly reliable means for excluding gonorrhea in populations of low-risk women. The predictive value of a positive test is low, ranging from 4.5% in the low-risk group to 45% in the high-risk group.


Nonuniform distribution of occult blood in feces. Inhibition of anti-Rh29 by erythrocytic stroma in feces was devised as a specific test for fecal occult blood. The sensitivity of this test was equivalent to that of a standard Hemoccult test, namely, 10(8) erythrocytes/g feces. Comparison of results of this test with results of Hemoccult tests of random stool specimens and of stools following ingestion of autologous blood revealed nonuniform distribution of occult blood in feces. The extent of nonuniformity was determined by testing samples of stool specimens following ingestion of 51Cr-labeled autologous blood. This allowed comparison of Hemoccult, inhibition of anti-Rh, and radioactivity, and showed that the three labels could separate in the feces and that some single small samples of feces could be relatively free of blood while blood was readily demonstrable in other portions. The variability of standard Hemoccult test was somewhat reduced by dispersing the feces in distilled water before performing the test.


Raised intracranial pressure: its management in Neisseria meningitidis meningoencephalitis. Further reduction in morbidity and mortality from bacterial meningitis is unlikely to stem from innovations in antibiotic management. Emphasis must therefore be directed toward prevention, more rapid diagnosis, and improved therapy for maintaining the integrity of the CNS. Raised intracranial pressure is frequently associated with bacterial meningitis. In selected patients with bacterial meningitis and clinical evidence of elevated intracranial pressure, monitoring and aggressive treatment of this pressure could be crucial to survival.


Systemic group D streptococcal infection in newborn infants. Thirteen cases of group D streptococcal neonatal sepsis and/or meningitis were identified at the Cincinnati Children's Hospital from 1970 to 1976. Ages at onset of disease ranged from 1 to 25 days. The most frequent symptoms were fever (five cases), lethargy (five cases), and respiratory difficulty (four cases). Blood cultures for seven infants were positive; CSF cultures for five infants were positive; and CSF and blood cultures for one infant were both positive. In 12 patients, parenteral antibiotic therapy consisted of a penicillin and an aminoglycoside. One infant with a severe meningomyelocele died. The other 12 infants showed a rapid clinical response with seven patients improving within 48 hours of the start of therapy. Infection with group D streptococcus results in a low-grade systemic disease in both full-term and premature infants that responds favorably to appropriate therapy.


Iduronate sulfatase analysis of hair roots for identification of Hunter syndrome heterozygotes. Iduronate sulfatase, the enzyme deficient in Hunter syndrome, can be readily measured in individual hair roots. Samples from Hunter syndrome hemizygotes had activities at or near the limits of detection. Samples from two mothers of Hunter syndrome patients, one an obligate heterozygote, had lower average iduronate sulfatase activity than the normal mean, and a significant number of hair roots had activity in the pathognomic range. A third mother showed a normal distribution of enzyme activity, and no hair roots were in the range of those from an affected individual. These results are similar to studies on the distribution of other X-linked enzymes in individual hair root samples from heterozygotes. This suggests that hair root iduronate sulfatase assessment is useful in the detection of Hunter syndrome carrier status, but further refinement of the test system is necessary.


Pericarditis due to Mycobacterium tuberculosis and Mycobacterium fortuitum: a case report. In this case study, pericarditis results from Mycobacterium tuberculosis and Mycobacterium fortuitum. Both organisms were isolated from three different clinical specimens: a pericardial fluid, pericardium, and a thoracentesis fluid. A mixed mycobacterial culture was initially suspected upon examining Ziehl-Neelsen stained smears prepared from the primary cultures following seven to ten days of incubation. Dilutions and subcultures were subsequently performed, confirming the presence of two different organisms.


C-reactive protein--a review.

C-reactive protein--a review. C-reactive protein (CRP) is an acute-phase protein present in normal serum which increases significantly with tissue necrosis of inflammation. Presented in this review is a history of investigations of the protein, and its physical, immunological, and functional characteristics, as well as the various methods used for its detection and quantitation. The relationship of CRP to other acute-phase reactants is summarized with respect to its value in clinical diagnosis. The clinical application of CRP in detecting and monitoring post-surgical complications and in helping detect various disease states is also discussed.


An in vitro model for the study of enzymatically mediated biomechanical changes in the chorioamniotic membranes. The effects of different incubation media on the biomechanical properties of nine chorioamniotic membranes were studied. Significant alterations in strain/rupture, work/rupture, and rupture/tension values have been demonstrated after a 24 hour incubation period in pseudoamniotic fluid (PAF). These changes can be arrested if enzyme inhibitors are added to the incubation media. This study suggests that biomechanical alterations in the chorioamniotic membranes may be biomechanical, namely, enzymatically mediated.


Betamethasone and the rhesus fetus: multisystemic effects. In this controlled study of betamethasone administration to pregnant rhesus monkeys, using dosages per gram of fetal body weight similar to those reported in several human clinical studies, the most significant fetal pulmonary changes observed were increases in maximum lung volumes. The fact that comparable increases in peak volumes were demonstrated on saline filling supports our contention that these changes are related primarily to lung structural alterations rather than surfactant effects. Additional findings in the treated animals included reduced fetal head circumference, thymus weight, adrenal weight, placental weight, and maternal postoperative weight and increased fetal hepatic weight. Any of these glucocorticoid-induced changes could portend serious side effects. Further studies are needed to delineate the risk:benefit ratio of such treatment.


The Chediak-Higashi syndrome: quantitation of a deficiency in maximal bactericidal capacity. The maximum bactericidal capacity of neutrophils from a patient with the Chediak-Higashi syndrome (CHS) was measured by a quantitative assay in which the neutrophils were challenged with increasing multiples of Staphylococcus aureus, 502A. At various bacterial challenges from 0.5 to 65 bacteria per neutrophil, the CHS cells killed normal numbers of bacteria in 60 minutes. However, at higher ratios with a mean of 118 bacteria per neutrophil, the percentage of bacteria killed in 60 minutes by CHS neutrophils (8.1 +/- 2.3%) was significantly less (P < 0.001) than that killed by normal neutrophils (44 +/- 2.3%). The CHS neutrophils lagged in their ability to kill low challenges of bacteria (0.5 or 1.2 bacteria per neutrophil) only at 20 minutes. A hydrogen-peroxide-producing strain of Streptococcus faecalis was killed normally by the CHS neutrophils at 60 minutes, with all ratios of challenge up to 114 to 1. Electron microscopic examination of 60-minute specimens from high ratios of challenge that were stained for myeloperoxidase activity revealed a failure of many bacteria-laden phagosomes to display this marker of degranulation. The results of this study indicate that the maximal bactericidal capacity of CHS neutrophils is saturated by a significantly lower challenge of bacteria than is required to saturate normal cells. This appears to be the result of sequestration of a significant portion of these cells' bactericidal resources in the giant granules that do not participate appreciably in degranulation.


The treatment of Paget's bone disease with sodium ethidronate. Of 58 patients with Paget's disease treated with disodium ethane-1-hydroxy-1,1-diphosphonate (EHDP) in doses of 20 and 10 mg/kg/day, a group of 20 patients with the oligostotic form of the disease showed a significantly greater incidence of complications, such as worsening of bone pains, when compared with a group of 38 patients with the polyostotic disease (P less than 0.05). The group of 32 patients that received 20 mg/kg/day showed a greater although not significant incidence of clinical complications than the group of 26 patients treated with 10 mg/kg/day. Bone biopsies performed in one polyostotic and three oligostotic cases who suffered episodes of bone pain worsening during treatment with 20 mg/kg/day disclosed a severe osteomalacia. Both groups treated with 20 and 10 mg/kg showed a highly significant decrease of urinary hydroxyproline (THP) excretion and of serum alkaline phosphatase (P less than 0.01) after two and six months of treatment although the trend comparison between doses was not significant. It is suggested that the dose of EHDP should be related to the extent of the disease.


In vitro and in vivo production of chemotactic inhibitors by tumor cells. The ascites fluid or peritoneal washings of DBA/2 mice bearing the P815 mastocytoma have been found to contain a chemotactic factor inactivator (CFI) which inactivates the bacterial chemotactic factor as well as the chemotactic activity associated with the C3 and C5 fragments when assayed on rabbit neutrophils. The amount of CFI is proportional to the number of tumor cells in the peritoneal exudate. The inactivator is also found in tumor cell hemogenates as well as in culture fluid from tumor cells growing in vitro. The activity is heat-labile but is not affected by protease inhibitors. Its molecular weight is greater than 50,000 daltons, based on Sephadex chromatography and sucrose density gradient ultracentrifugation studies. In C57BL/6 mice, which reject the mastocytoma, CFI levels decrease in proportion to the decreasing numbers of tumor cells.


Thyroid hormone-aldosterone interaction on Na+ transport in toad bladder. Repeated administration of thyroxine (T4) in vivo (2 microgram/100 g body wt for 6 days) lowered by 2.3 times (P less than 0.025, df = 18) the basal rate of Na+ transport measured by the short-circuit current (SCC) in vitro in the urinary bladder of the toad (Bufo marinus). This difference was not accounted for by a change in the plasma aldosterone concentration. Moreover the response of the SCC to aldosterone in vitro was markedly inhibited in bladders from T4-treated animals (P less than 0.001, df = 18). These findings raised the possibility of a direct interaction between thyroid hormone and aldosterone in the target cell. The effects of L-triiodothyronine (T3) and aldosterone were examined in vitro. T3 alone (60 nM) had no significant effect on the base-line SCC (deltamuA = -14 +/- 11 (SE) muA per hemibladder; P greater than 0.3, n = 10). By contrast, T3 (60 nM) inhibited the response of the SCC to aldosterone from 6 to 8 h after its addition (deltamuA = -98 +/- 19 muA per hemibladder; P less than 0.001, n = 10). The inhibition by T3 was present at 6 nM (P less than 0.01, n = 10) and became not significant at 0.6 nM. T3 had no significant effect on base-line or aldosterone-stimulated H+ transport. Thyroid hormone might therefore regulate the late response of the SCC to aldosterone at the level of its target cell.


Circadian control of thermoregulation in the squirrel monkey, Saimiri sciureus. The characteristics and control of the circadian rhythms of core body temperature (colonic) and skin temperature (tail) were studied in chair-acclimatized squirrel monkeys (Saimiri sciureus). When animals were entrained to a light-dark cycle (12 h 600 lx; 12 h less than 1 lx) these two temperatures displayed prominent, reproducible, tightly coupled circadian rhythms. In contsant light of 600 lx, where no other effective circadian time cues were present, both temperature rhythms persisted with free-running periods. Within each animal, however, these rhythms were not as tightly coupled to one another as in LD. On occasion colonic and tail temperature rhythms free-ran with different circadian periods and some animals demonstrated "splitting" of the colonic temperature rhythm, with the colonic temperature rhythm displaying a bimodal pattern. These results suggest that the circadian rhythm of body temperature in primates is under the control of more than one potentially independent circadian oscillator.


Adult mental health services in a health maintenance organization. The authors describe an adult mental health service within a health maintenance organization and present information on the department's setting, staffing patterns, programs, and philosophy. They believe that the emphasis on brief focal psychotherapy, the staff of mental health care providers who are committed to this type of setting, and the thorough integration of the program into the larger HMO system all contribute to the provision of high-quality services at a reasonable cost.


A behavioral program for the treatment of chronic patients. The authors report the development of a short-term behavioral therapy program for chronically hospitalized schizophrenic patients who had responded only minimally in a therapeutic community. The basic program was a token economy, which concentrated on personal care activities, productive activities, and leisure activities, combined with drug treatment. During the first 9 months of the program 105 patients were admitted and 79 were discharged--24 to nursing or group homes and 47 to their own home or family. At 1-year follow-up 62 patients were still in the community without any readmissions. The findings that a token economy can be effective with chronic patients at comparatively little additional expense has broad implications for custodial care facilities with limited resources.


Evaluation of the results of external choledochoduodenostomy for retained, recurrent, or primary common duct stones. Twenty-five patients were treated for retained, recurrent, or primary common duct stones by permanent drainage of the biliary tract with external choledochoduodenostomy. Twenty-one patients had common duct stones which became evident two to fifty years after the initial biliary tract procedure and which may represent stones formed in the common duct. Three recent patients had a clinical history of primary common duct stones, had stones which were soluble in chloroform-methanol solution, and had hepatic bile which was lithogenic as determined by evaluating the molar percentage of cholesterol, phospholipid, and bile salt in bile samples obtained at the time of choledochoduodenostomy. These data suggest that further stone formation is possible and that permanent bypass of the sphincter of Oddi is indicated to prevent recurrent bile duct obstruction. Long-term evaluation of the results of external choledochoduodenostomy indicates that the procedure is safe and effective in the prevention of recurrent biliary tract calculi.


The conservative management of anorectal cancer by radiotherapy. Thirteen patients with an anal or rectal carcinoma were given curative radiotherapy. Four had medically inoperable tumors, one had a surgically inoperable tumor and eight refused abdominoperineal resection. Six patients received external radiotherapy only. Seven patients received external radiotherapy and an interstitial implant. Nine of thirteen patients (60 per cent) are alive without evidence of disease from fifteen to fifty-five months (average, 30 months). Six of seven patients who received external radiotherapy combined with an interstitial implant were controlled locally, whereas three of six patients who received external radiotherapy only were controlled. Patients who underwent total excision and/or fulguration prior to irradiation had better local control than those who underwent either biopsy only or a subtotal excision. This treatment method may be offered as an alternative to abdominoperineal resection in patients who are medically unfit or who refuse surgery.


[Aqueous-and serum levels of cephalexin and penicillin V after oral application in man (author's transl)]. This clinical study implies orally administered cephalexin and penicillin V as agents with effective aqueous homor penetration in noninfected human eyes. Aqueous humor concentration of cephalexin increases up to 15% of the serum level 2 h after application. Administration of 1 g or 2 g cephalexin revealed no significant difference in aqueous humor concentration.  So penetration of blood-aqueous-humor barrier can be regarded as a saturation process. Individual results of 92 cephalexin determinations are variant and not related to body weight or age of the patients.


Linear arrays of intramembrane particles on microvilli in primate large intestine. Distinctive linear arrays of intramembrane particles were present in microvillar membranes of approximately 5% of surface columnar cells observed in freeze-fracture replicas of monkey colon and human rectum. On these cells, longitudinally-oriented rows of P face particles and corresponding E face grooves appeared on all exposed microvilli. The constituent particles varied from round (8-9 nm in diameter) to rod-shaped (18 nm long). Microvilli of the great majority of columnar cells displayed randomly distributed P face particles similar to those previously observed in small and large intestine of birds and small mammals. The significance of the linear arrays is not known. It is postulated that they may represent protein assemblies which are specific to a functionally-distinct subpopulation of primate intestinal columnar cells.


Oral cromoglycate: its value in the treatment of adverse reactions to foods. Thirty-two patients who reacted adversely to foods were given oral cromoglycate and placebo separately for two periods of seven days each. Adverse reactions were prevented by cromoglycate alone in 24. The symptoms responding to cromoglycate affected not only the gastrointestinal tract but also the skeletal, vascular and nervous systems.


Treatment of perennial rhinitis with flunisolide corticosteroid spray. Flunisolide nasal spray was compared to its propylene and polyethylene glycol vehicle in a randomized double-blind study of 20 adult patients with perennial rhinitis. After a two-week baseline period patients received either active flunisolide 50 microgram q.i.d. or placebo for four weeks. Laboratory studies included serum 8 a.m. cortisols, nasal air-flow measurements and nasal smears for eosinophils and fungi. Patients kept daily symptom diaries. There was no difference between active and placebo groups for sneezing, runny nose or nose blowing. Although post-nasal drip showed the greatest improvement in the active group, there was a trend for improvement in both groups. By the second week the percentage of eosinophils on nasal smear significantly decreased in both groups. Nasal air-flow measurements also showed improvement in both active and placebo groups. There was no change in serum cortisol levels compared to baseline. Side effects were similar in both active and placebo groups. Although no positive fungal cultures were obtained during the double-blind study. Candida was cultured during the long-term program in one patient.


[Therapeutic guides in hypertonic dehydration (author's transl)]. Physiopathology of hypertonic dehydration is revised. The bases of treatment are discussed; they are based on: 1. Basal requirements of fluids. 2. Slow correction of deficit. 3. Replacement of maintaining losses. Total fluids support will carry to rehydration in 2 or 3 days. In the most severe cases peritoneal dialysis is associated. The indications, technique and realization of peritoneal dialysis during hypertonic dehydration are discussed.


Thyroid function studies in the nephrotic syndrome. Total serum and urinary thyroxine (T4), triiodothyronine (T3), and thyroxine-binding globulin (TBG) as well as serum free T4, thyroid-stimulating hormone (TSH), and T3 resin uptake (T3RU) were measured in seven patients with the nephrotic syndrome. The nephrotic syndrome was defined by proteinuria exceeding 3 g/24 h. All patients were clinically euthyroid. Most values for total serum T4, free T4, T3, T3RU, TBG, and TSH were within normal limits. However, the mean serum T3 and TBG values were significantly lower in patients compared with the control group. The values (mean +/- 2 SD) for urinary T4 were 24.3 +/- 20.3 in the patient group and 1.5 +/- 0.7 microgram/24 h in the control group. Urinary T3 values for patients and the control group were 2100 +/- 856 and 848 +/- 253 ng/24 h respectively. Urinary TBG was 2.1 +/- 1.8 mg/24 h in the patients and undetectable in the control group. There was no correlation between daily urinary T3 and T4 and urinary TBG. There was a weak correlation between daily urinary protein excretion and urinary T4 (r = 0.5).


Morphological and cytochemical study of Chlamydia with EDTA regressive technique and Gautier staining in ultrathin frozen sections of infected cell cultures: a comparison with embedded material. The cryo-ultramicrotomy technique was applied to study the ultrastructure of Chlamydia using two strains: one of C. psittaci and one of C. trachomatis. It clearly appeared that in both strains reticulate bodies show a high degree of plasticity, contrasting with the rigid spherical appearance of elementary bodies. Ultrastructural cytochemical study shows DNA fibrils dispersed throughout the cytoplasm in reticulate bodies whereas DNA is condensed in a nucleoid in elementary and intermediate bodies. The EDTA regressive technique reveals ribonucleoproteins in reticulate and elementary bodies of both studied strains.


Ultrastructure and development of an exosporium-like outer spore envelope in Bacillus subtilis. An exosporium-like outermost envelope is occasionally observed in thin sections of Bacillus subtilis spores. Treatment of the mature spores with urea and mercaptoethanol (sometimes completed by sodium dodecyl sulfate) or with NaOH, disorganizes and partially solubilizes the outer spore coat. This treatment permits a clear visualization of the exosporium in all spores of several B. subtilis strains. Exosporium appears either as a single sheet, 8-9 nm thick, or with a triple-layered unit membrane-like profile. Frequently it exhibits a crystal-like periodic pattern. The exosporium primordium appears first at stage IV, and its development is apparently independent of the formation of the cortex and of the spore coats. No morphological relationship was found between the outer forespore membrane and the exosporium.


Ultrastructural effects of chemical agents and moist heat on Bacillus subtilis. I--Effects on vegetative cells. The ultrastructural alterations induced by treatment of vegetative Bacillus subtilis cells with organic solvents, trichloroacetic acid (TCA) and moist heat were examined by electron microscopy. Organic solvents disorganize the membrane and change the asymmetric unit membrane profile to a symmetric profile. They also lead to partial solubilization of the membrane and produce small or extensive gaps. Membrane damaging activity increases in the following order: xylene = toluene less than octanol less than choroform. TCA coagulates the cytoplasm which shows large, electron-dense, pronase-sensitive blocks. Moist heat alters both the membrane and the cytoplasm.


Ultrastructural effects of the chemical agents and moist heat on bacillus subtilis. II.--Effects on sporulating cells. When sporulating cells are treated with the organic solvents (xylene, toluene, octanol and chloroform), with TCA or with moist heat (10 min at 80 degree C), the sporangial cells exhibit the same ultrastructural changes as do the vegetative cells. The forespores undergo similar changes after early but not after late treatment. Resistance toward the killing effect and toward ultrastructural alterations appear in the same order. One could correlate the appearance of resistances with precise ultrastructural events as follows:--xylene resistance: cortex formation (stage IV);--resistance to toluene, octanol and chloroform: coat development and cortex maturation (respectively early, middle and late stage V);--TCA and heat resistance: spore maturation (stage VI). The possible mechanisms of the chemical resistances are discussed.


Immunochemical studies on a Yersinia enterocolitica O:9 lipopolysaccharide cross-reacting with Brucella abortus and Vibrio cholerae extracts. The presence of two distinct lipopolysaccharides in Yersinia enterocolitica O:9 is described: one isolated from the aqueous phase and one from the phenol phase (Westphal system). The sugar moiety of the phenol phase lipopolysaccharide has been identified as being responsible for the serologic cross-reaction of Y. enterocolitica O:9, Brucella abortus and Vibrio cholerae. The phenol phase antigen consists of glucose, galactose, glucosamine, 2-keto-3-deoxyoctonic acid, heptose, lipid A and a protein moiety. Haemagglutination experiments revealed two different structures: one that readily coats erythrocytes and another that requires alkali treatment. The former may be separated by repeated adsorptions on erythrocytes. Serologically, the two structures behave like a single antigen. The action of normal rabbit serum on the erythrocyte-containg capacity of the two structures was studied.


Isolation and properties of bovine colostral trypsin inhibitor. The trypsin inhibitor of bovine colostrum was isolated by affinity chromatography, and impurities removed by trichloroacetic acid precipitation. The inhibitor showed electrophoretic microheterogeneity which was not due to sialic acid content. It inhibited bovine and rat trypsin, showed weak inhibition of bovine chymotrypsin and was inactive against rat chymotrypsin and bovine renin, kallikrein, thrombin and trypsinogen. The dynamics of secretion of the inhibitor in the first 8 milkings post-partum were very similar to those of colostral immunoglobulins.


A study of the macro and micro immunoglobulins to Brucella abortus and their transfer from cow to calf via the colostrum. Samples of adult bovine serum, colostrum, the serum of unsuckled and suckled calves were subjected to gel filtration through Sephadex G 200. All samples (except those of unsuckled calves) contained antibodies to Brucella abortus. Four phases were recorded in normal adult serum corresponding to IgM, IgG, Albumin and a fourth phase of smaller nitrogen-containing molecules. In colostrum phase 2 was relatively large and phase 3 was absent indicating absence of albumin. In the serum of the unsuckled calves phase 2 was absent, indicating a virtual absence of IgG. Agglutinins and Complement fixing antibodies were found in the fractions of both phase 1 and phase 2. Incomplete antibodies occurred only in phase 2, which suggested that they occurred only as 7S molecules. By immunising pregnant heifers shortly before calving with formalin Killed Strain 19 vaccine, it was found that serum IgM may be secreted in colostrum and in this manner transferred to the calf on suckling. It is considered that the immunoglobulins of importance in protecting the young calf from Br. abortus, and also in neutralising Strain 19 vaccination, are of the IgG incomplete (7S) class. These antibodies appear to be less heat-labile than 7S agglutinins.


Dilation of the eustachian tube by electrical stimulation of the mandibular nerve. The recent studies of the anatomy of the eustachian tube and related structures in the Rhesus monkey (Macaca mulatta) have shown that the monkey tubal system is similar to the human. This investigation in Rhesus monkeys was an attempt to verify previous studies in other animals that the tensor veli palatini muscle was the only dilator of the eustachian tube. Two unipolar stimulating electrodes were introduced into the foramen ovale, and the mandibular branch of the trigeminal nerve was electrically stimulated. Simultaneously, pressure-flow recordings through the eustachian tube were monitored. Stimulus-response relationships were obtained for five Rhesus monkeys. The degree of tubal dilation by the tensor veli palatini muscle contraction was shown to be a function of stimulating current levels. Artifically induced dilations were quite similar to the physiological dilations during swallowing when these animals were tested alert. Following complete transection of the tensor muscle, regardless of the stimulus level, no tubal dilations were observed. Stimulation of the nerve to the internal pterygoid and stimulation of the levator veli palatini muscle induced only constrictions of the tube. The tensor veli palatini muscle is the only paratubal muscle responsible for active dilation of the eustachian tube in the Rhesus monkey, and its motor innervation is the mandibular division of the trigeminal nerve.


Monocular nystagmic responses to caloric stimulation. Twenty-five normal subjects and 173 clinical patients received standard bithermal caloric testing. Vestibular nystagmus was evaluated for cumulative slow phase velocity from the summated horizontal eye recording and independent recording of the left and right eye. These data revealed that cold water stimulation produced more intense activation of the ipsilateral eye. Simultaneous closed-circuit video and D.C. electro-oculographic recordings from eight normal rhesus monkeys in response to cold water irrigations confirmed the fact that this stimulus leads to differential activation of the extraocular muscles. A possible explanation for this finding is discussed.


Further studies on the circulating M antigen in human and experimental Schistosoma mansoni infections. Circulating M antigen, previously described in urine from patients infected by Schistosoma mansoni, was shown in serum from infected patients, using human anti-M immune serum with immunodiffusion and immunoelectrophoretic analyses. This antigen was also shown to be present in the serum and urine from infected hamsters, in the urine from infected rabbits and in the serum from infected mice. Generally, it appeared on day 20 after infection. M antigen was specific for the genus Schistosoma and for the immature and adult worm stage. Its electrophoretic migration was cathodic. The molecular weight of urinary M antigen was around 45,000 daltons. The M antigen was thermostable, soluble in trichloroacetic acid, and contained no lipid component. It was hydrolyzed by protease, ribonuclease, amylase or neuraminidase, but was destroyed by sodium metaperiodate. All these properties betoken the polysaccharidic nature of M antigen.


[Antibiotic resistance study of clinical strains of Pseudomonas aeruginosa]. The study of 40 clinical strains of Ps. aeruginosa isolated from the wound surfaces of the patients showed that all the isolates were resistant to one or several antibiotics. The number of the strains resistant to 5, 4, 3, 2 or 1 drug was 5, 22.5, 25. 30 or 17.5 per cent respectively. Fifteen strains carried resistance plasmids capable of conjugative transfer. Eleven out of 21 plasmids controlled resistance to chloramphenicol, 7 plasmids controlled resistance to streptomycin and sulfanylamides, 1 plasmid controlled resistance to streptomycin and chloramphenicol. The presence of two types of the plasmids controlling resistance to chloramphenicol and streptomycin + sulfanylamides respectively was found. All the plasmids proved to be capable of conjugative transfer between the strains of Ps. aeruginosa ML (PAO). The frequency of the plasmid conjugative transfer in such crosses ranged from 10(-6) to 10(-3). Most of the plasmids belonged to the incompatibility groups P-2 and P-7. One plasmid belonged to the incompatibility group P-5. It should be noted that about a half of the plasmids (11 out of 21) belonged to the incompatibility group P-7 which up to the present time was conditional, since was represented by a single plasmid Rms 148.


Interpretive criteria for cefamandole and cephalothin disk diffusion susceptibility tests. A multi-center study of 1,838 clinical isolates established the accuracy of diffusion susceptibility tests with 30-mug cephalothin disks and 30-mug cefamandole disks. The same interpretive zone standards can be applied to tests with either disk but the two drugs cannot be tested interchangeably.


Effects of carbon sources on antibiotic resistance in Pseudomonas aeruginosa. The metabolism of branched-chain amino acids, branched-chain acyl derivatives, d-glucose, l-glutamate, and Mueller-Hinton medium was investigated to determine their effects on the growth, lipid composition, and antibiotic susceptibility of Pseudomonas aeruginosa. The unsaturated fatty acid content of the readily extractable lipids was altered by growth on selected branched-chain amino acids and their acyl derivatives. Bacteria grown on branched-chain acyl derivatives became more susceptible to polymyxin B and colistin. The effect acyl derivatives had on increasing susceptibility was also manifest in mixed media which contained both an acyl derivative and a carbon source which did not increase susceptibility. Growth on branched-chain amino acids gave mixed results which were dependent on a number of factors, including unique manifestations of individual amino acids, growth conditions, and availability of other carbon sources. The cultural conditions which altered susceptibility to polymyxin antibiotics did not correlate with similar effects on susceptibility to carbenicillin and gentamicin. An adaptive resistance to polymyxin B was observed when the sole carbon source was d-glucose or l-glutamate.


Hospital isolates of Serratia marcescens transferring ampicillin, carbenicillin, and gentamicin resistance to other gram-negative bacteria including Pseudomonas aeruginosa. Thirteen independent isolates of Serratia marcescens associated with nosocomial urinary tract infections were obtained from the clinical microbiology laboratory at Hines Veterans Administration Hospital. The isolates were resistant to at least ampicillin, carbenicillin, gentamicin, and tobramycin. They could be divided into two groups on the basis of their antibiotypes. Group I (9 strains) showed resistance to 13 antibiotics, including 3 beta-lactams, 6 aminoglycosides, tetracycline, sulfonamide, trimethoprim, and polymyxin B. Group II (4 strains) was resistant to 11 antibiotics, including 3 beta-lactams, 5 aminoglycosides, sulfonamide, trimethoprim, and polymyxin B. Donors from both groups transferred resistance traits to Escherichia coli. Transconjugants from matings with group II donors all acquired resistance to nine antibiotics, including the three beta-lactams, five aminoglycosides, and sulfonamide. Transconjugants from matings with group I donors were of varied antibiotypes, inheriting resistance to up to 11 of the 13 antibiotics. Resistances to trimethoprim and polymyxin B were never observed to transfer. E. coli transconjugants of each group were capable of transferring multiple-antibiotic resistance to several other members of the family Enterobacteriaceae. All group II S. marcescens and E. coli donors and all group I S. marcescens donors transferred carbenicillin, streptomycin, kanamycin, gentamicin, tobramycin, and sisomicin resistance to Pseudomonas aeruginosa. The results suggest that these S. marcescens strains harbor R factors of a broader host range than previously reported.


Outer-membrane penetration barriers as components of intrinsic resistance to beta-lactam and other antibiotics in Escherichia coli K-12. A new technique has been devised to investigate the penetration of antibiotics through the gram-negative outer membrane; the application here was to study intrinsic resistance of Escherichia coli K-12. Exponential cells in broth were briefly treated with 2.5 mM ethylenediaminetetraacetic acid at 5 degrees C to disrupt the outer membrane penetration barrier, and the response of treated and untreated cells to antibiotics was compared by turbidimetry. A barrier index was derived to describe the ability of 7 beta-lactam and 10 other antibiotics to penetrate the outer membrane of strain Y10. There was correlation between the molecular weight and log(10) barrier index (r = 0.59, P congruent with 0.01). The envelope mutant D22 (envA) had low barrier indexes for erythromycin, rifampin, ampicillin, and cloxacillin. For the beta-lactams, outer membrane penetration and affinity for inner membrane target site(s) triggering cell lysis were measured as independent components of the overall activity; although penetration and overall activity varied greatly, the affinities of most were within a narrow range.


Effect of cephapirin on formation of D-alanine carboxypeptidase in growing Bacillus subtilis cells. Cephapirin was utilized to examine the interaction of beta-lactam antibiotics with growing Bacillus subtilis cells and the biological effects simultaneously produced. Saturation binding and quantitative cell death were observed at the cephapirin concentration of 0.1 mug/ml. Cephapirin bound to all penicillin-binding proteins except the d-alanine carboxypeptidase. A specific [(14)C]benzylpenicillin-binding assay was developed for the d-alanine carboxypeptidase. At the lowest saturating concentration of antibiotic (0.1 mug/ml), cephapirin inhibited formation of the d-alanine carboxypeptidase. Upon incubation with cephapirin, 18% of the membranous d-alanine carboxypeptidase was released into the media. The data suggest that beta-lactam antibiotics may affect the formation of bacterial cytoplasmic membranes in addition to their effect on cell wall synthesis.


Purification by affinity chromatography and properties of a beta-lactamase isolated from Neisseria gonorrhoeae. beta-Lactamase activity was detected in cell-free preparations obtained from ultrasonic treatment of Neisseria gonorrhoeae after growth in liquid medium. Crude preparations of beta-lactamase were subjected to affinity chromatography, using several beta-lactam antibiotics as ligands bound to agarose supports. Affinity gels produced by coupling 7-aminocephalosporanic acid or 6-aminopenicillanic acid by their amino groups to carboxyl-terminal agarose via a five- to eight-carbon spacer arm proved to be effective chromatography media. beta-Lactamase preparations subjected to chromatography using these gels were purified 200-fold, with approximately 80% recovery of active material. Purified preparations were judged homogeneous by their behavior during electrophoresis on polyacrylamide in both the presence and absence of sodium dodecyl sulfate. Characterization of the purified enzyme established a molecular weight of approximately 25,000 and an isoelectric point of 5.4. Analyses of substrate specificity, effect of inhibitors, pH, and kinetic parameters were performed. The evidence suggests that the beta-lactamase produced in N. gonorrhoeae closely resembles the character of class IIIa (TEM-type) beta-lactamases.


In vitro activity of rosamicin, josamycin, erythromycin, and clindamycin against beta-lactamase-nagative and beta-lactamase-positive strains of Neisseria gonorrhoeae. Randomly selected strains of beta-lactamase-negative and beta-lactamase-positive Neisseria gonorrhoeae were tested by an agar dilution method for susceptibility to rosamicin, josamycin, erythromycin, clindamycin, and penicillin G. Rosamicin was more active than erythromycin, which was more active than josamycin or clindamycin; the latter two were similar in their activity. The susceptibility to the macrolide antibiotics and clindamycin was independent of beta-lactamase production, but the penicillin minimal inhibitory concentrations were higher in the beta-lactamase-positive group because of the enzyme.


Resistance of African green monkey kidney cell lines to actinomycin D: drug uptake in 37 RC cells after persistent inhibition of transcription. 37 RC cells, a cultured line derived from African green monkey kidneys, survived long treatments with actinomycin D (AMD; 0.1 to 0.5 mug/ml) under strong inhibition of ribonucleic acid synthesis and blocking of cell division. One aspect of the complex cellular response to this treatment was a progressive lowering of the influx rate of AMD and, consequently, of its endocellular concentration, leading to a late resurgence of transcription. Overall protein synthesis decreased in AMD-treated cells, but more of the residual protein was exported to the cell surface, a fact associated with the development of numerous strands of endoplasmic reticulum and Golgi bodies in the cytoplasm. The lowering of AMD influx during the treatment was not simply due to the decay of protein synthesis, and there was no evidence for a carrier-mediated transport of the drug. It was paralleled by, but seemingly not related to, modifications in cellular microtubules and microfilaments. The rate of AMD influx was restored to levels comparable to those of untreated cells by short exposure to ethylenediaminetetraacetic acid and trypsin. It is concluded that the changes in plasma membrane of 37 RC cells, creating an obstacle to the influx of AMD after long treatment with this drug, probably consist of an accumulation and/or a different distribution of glycoproteins or other surface components on the cell surface.


Changes in lung ultrastructure following heterologous and homologous serum albumin infusion in the treatment of hemorrhagic shock. The object of this study was to compare the ultrastructure pulmonary effects of the infusion of homologous and heterologous serum albumin solution in the treatment of hemorrhagic shock in baboons. Adult baboons subjected to hemorrhagic shock were resuscitated with either baboon serum albumin, human serum albumin, or Ringer's lactate solution. The lungs were fixed in vivo with potassium pyroantimony, a solution which produces electron dense interstitial precipitation of sodium. The lungs from animals resuscitated with baboon serum albumin showed evidence of interstitial edema, including dispersion of collagen fibers, interstitial smudging and increased interstital sodium concentrations. Similar changes were seen following human serum albumin infusions. Lung tissue from animals treated with Ringer's lactate solution showed minimal changes from normal. These results suggest that interstitial pulmonary edema develops after either homologous or heterologous serum albumin infusion in the treatment of hemorrhagic shock in baboons.


DL-ethionine treatment of adult pancreatic donors. Amelioration of diabetes in multiple recipients withe tissue from a single donor. Transplantation of adult rat pancreatic islet tissue as a free graft requires the separation of islet from exocrine tissue to avoid host injury or graft destruction by digestive enzymes. The poor yield from islet isolation techniques currently necessitates the use of multiple donors to ameliorate diabetes in a single recipient. DL-ethionine (DLE) is an agent selectively toxic to the exocrine pancreas. We examined the effect of DLE administration on pancreatic digestive enzyme content and islet mass in adult Lewis rats and the ability of such pancreatic tissue dispersed by collagenase digestion without specific islet isolation to ameliorate diabetes when transplanted to the portal vein of syngeneic rats with streptozotocin induced diabetes. Rats fed normal chow supplemented with 0.5% DLE for 14-20 days showed a logarithmic loss of pancreatic mass. Total pancreatic amylase content declined to 0.3 + 0.1 mg, less than 3% of control values (14.3 +/- 1.0 mg). Total insulin content in DLE treated rats was 87 +/- 8 microg, not significantly different from control rats (101 +/- 7 microg). Histological examination confirmed the selective atrophy of exocrine tissue in DLE treated rats. Fresh pancreatic tissue prepared from a single DLE treated donor ameliorated diabetes 75% of the time when transplanted to one or two recipients and 65% of the time when divided between three of four recipients. Tissue prepared from a single DLE treated donor and stored for 24-48 hours ameliorated diabetes 91% of the time when divided between one or two recipients. Only four of 31 diabetic rats transplanted with fresh pancreatic tissue from untreated adult donors became normoglycemic. Pretreatment of adult rats with DLE induces selective exocrine atrophy, permits dispersed pancreatic tissue from a single donor to ameliorate experimental diabetes in up to four recipients, and allows tissue to be preserved by culture for up to 48 hours without specific islet isolation.


Antigenicity of venous allografts.

Antigenicity of venous allografts. With isolated exceptions, the clinical use of venous allografts has been disappointing. Considerable evidence indicates that allograft antigenicity plays a major role in the failure of venous allografts when used as arterial replacements. Recent reports suggest that DMSO-cryopreservation of venous allografts may reduce allograft antigenicity while preserving allograft viability. The present study examines the effect of modifications of vein allografts on subsequent allograft antigenicity. Skin grafts were transplanted from ACI to Lewis inbred strains of male rats. Primary skin graft rejection occurred in 9.0 +/- 1.0 days. Subcutaneous implantation of fresh inferior vena cava from ACI rate into Lewis rats resulted in subsequent skin graft rejection in 5.0 +/- 1.0 days, confirming the antigenicity of venous tissue. Cryopreservation of ACI inferior vena cava for seven days prior to implantation, with or without 15% DMSO, resulted in subsequent skin graft rejection in 5.0 +/- 1.0 days. Treatment of ACI inferior vena cava with 0.30% gluteraldehyde for 20 minutes prior to implantation in Lewis rats resulted in skin graft rejection in 9.0 +/- 1.0 days, the same time as a first set rejection. This study indicates that unmodified veins are normally antigenic and that this antigenicity is not eliminated by cryopreservation with or without DMSO. Gluteraldehyde treatment appears to reduce allograft antigenicity, but results in a nonviable graft. At the present time, there is no known way to reduce the antigenicity of viable venous allografts.


Liver failure with steatonecrosis after jejunoileal bypass: recovery with parenteral nutriton and reanastomosis. Two women, aged 41 and 51 years, developed jaundice, encephalopathy, and hypoprothrombinemia during rapid weight loss four and 12 months after jejunoileal bypass for refractory obesity. Both were treated for liver failure and received a prolonged course of nutrition parenterally and orally. Serial liver biopsy specimens demonstrated extensive alcoholic-like hepatitis and cirrhosis that improved with nutritional repletion and reanastomosis. Postoperative biopsy specimens later demonstrated minimal portal fibrosis in one patient and inactive mild cirrhosis in the other. Although previous reports indicate that patients usually die when they develop liver failure of this severity after jejunoileal bypass, prolonged intensive nutritional repletion was associated with sufficient clinical and histologic improvement in these two patients so that intestinal reanastomosis could be performed safely.


The spectrum of Bacillus bacteremias in heroin addicts. Bacillus bacteremias occurred in two heroin addicts. The first patient had one day of fever and chills after intravenous heroin use. Persistent cereus bacteremia consistent with endocarditis was documented and responded to four weeks of antibiotic therapy. The second patient had non-cereus Bacillus species isolated from blood cultures three times over eight days, each time after renewed heroin use. The patient remained well, and the bacteremias cleared spontaneously. Because Bacillus species frequently contaminate heroin injection materials and because the Bacillus bacteremias were temporally associated with intravenous heroin use, Bacillus bacteremias in both patients probably eventuated from heroin abuse. These cases, in conjunction with two previously reported cases of Bacillus endocarditis in heroin addicts, suggest that heroin addicts are at risk for developing Bacillus bacteremias, which may vary in severity from endocarditis to benign transient bacteremias.


[2 or 3 level blocks in the Tawara node during atrial tachycardia]. In atrial flutter (or paroxysmal atrial tachycardia), the ventricular response is dependant on the passage through 3 superposed zones of conduction in the Tawara node, the zone of decremential conduction being the central zone N. When the ventricular response is between half and a quarter of the atrial rate there are two possible explanations: type B alternate Wenckebach period (mobitz I block in the central zone N, 2/1 block at the nodo-ventricular junction) or type A alternate Wenckebach period (Mobitz I block in the central zone N and 2/1 block at the atrio-nodal junction). These two responses may alternate in the same patient depending on the drug therapy or vagal activity due to a phenomenon similar to the "GAP" phenomenon. Inexactitudes in the working out of the arithmetic formulae may easily be explained by a certain degree of concealed conduction of blocked activation in one zone or more rarely by hisian extrasystoles. Type A alternate Wenckebach periods are always easier to construct than type B. Perfect 3/1 atrial flutter can only be explained by a type B alternate Wenckebach period with a 3/2 period with a 3/2 period in the N zone and a 2/1 block in the NH zone. When the ventricular rhythm is permanently very slow or when the RR intervals are greater than four times the atrial cycle, 3 zones of block are usually at issue (the third being located in the inferior part of the node or superior part of the bundle of His). Examples of 5/1, 6/1 flutter are thereby analysed. Rapid atrial pacing after termination of the atrial arrhythmia allows a better analysis of its mechanism and the successive reproduction of conduction defects in each zone of block.


[Comparison of 24 hours ambulatory electrocardiography and endocavitary recording in the diagnosis of heart rate disorders]. Ninety symptomatic patients aged between 16 and 90 years were investigated by ambulatory continuous 24 hour electrocardiography. 75 of these patients underwent endocavitary exploration of atrioventricular conduction and sinus node function within 48 hour of ambulatory electrocardiography. Symptoms occurred during the recording in 30% patients, enabling the mechanism of the malaise to be determined. Every time that abnormalities in the zone surrounding the Tawara node were demonstrated by endocavitary recordings, the 24 hour electrocardiogramme showed the symptoms to be due to other causes than complete heart block. In 70% patients no symptoms were experienced but 58% of them had cardiac arrhythmias and particularly sinus node dysfunction (24 out of 37 patients) on the 24 hour electrocardiogramme. Comparing the results of these two methods of investigation, continuous electrocardiography appears to be a better technique for the diagnosis of sinus node dysfunction but endocavitary study of sinus node function would seem more suited to determine its severity. Endocavitary recordings seem more reliable in the investigation of paroxysmal atrioventricular blocks. These results demonstrate the complementary nature of these two methods in determining the causes of syncope and dizziness.


[Comparison of echocardiography and phonomecanography in adult aortic valve stenosis. 55 cases]. The results of echocardiography and phonomecanography were compared in 55 cases of adult valvular aortic stenosis. Although the most reliable echocardiographic sign of the severity of stenosis is the systolic separation of the aortic valve echos, it should be amphasised that: -- this cannot be measured in 25 % cases; --in 10 % cases the values obtained vary with the angle of the transducer. In these cases, the finding of a left ventricular posterior wall thickness greater than or equal to 15 mm is specific for severe aortic stenosis. On the other hand, the left atrial, left ventricular and aortic internal dimensions and the morphology of the mitral leaflets do not help in the estimation of the severity of adult aortic stenosis. The best correlations between echo and phonocardiography are the values of aortic valve opening and : --hemi-ascension time (r = 0.67); --left ventricular ejectiontime (r = 0.93) when patients in cardiac failure are excluded. The complementary nature of these two investigations is notable, and should, in pure aortic stenosis without angina, spare patients who are often elderly and fragile from heamodynamic investigation.


[Pathological data of 92 rheumatic mitral valve after surgical ablation : comparison with pre-operative echocardiography results]. The echocardiographic information obtained pre-operatively with an electronic linear scanning system (Multiscan) was compared with the results of pathological examination of the excised mitral valve in 92 patients, and showed a close correlation. The way in which the pathological changes influence the various parameters usually used to distinguish this type of rheumatic valvular disease is demonstrated. Two-dimensional imagery provides precise information : this is shown by comparison of the still frames of the videoscopic recording and the photographs of the corresponding pathological specimens. Valve thickness, length and thickness of the chordae, calcification, mitral valve surface and commissural separation are well shown, especially at the anterior leaflet. Study of transverse incidences seems the most reliable method of estimating mitral valve area. Systolic separation of mitral valve echos, according to the usual criteria, is a good sign of associated mitral incompetence and was found in 83% of cases of mixed mitral valve disease. The mean values of anterior mitral leaflet excursion, diastolic slope and opening speeds were compared in three groups of mitral stanosis with preferential antatomical features and a control group of pure mitral stenosis with supple valves. No individual parameter was found to be specific for a particular antatomical feature, showing multiple correlations to be indispensable. The difficulty of diagnosis by isolated traditional echocardiography is confirmed and the association of two dimensional imagery would seem essential not only in making the diagnosis but also in the pre operative work up.


[Indices of left venticular performance and evaluation myocardial quality in mitral valve insufficiency, chronic aortic valve insufficiency and stenosis]. 132 patients with pure mono-valvular cardiopathies (mitral incompetence, aortic stenosis and aortic incompetence) were classified into two groups according to the values of the systolic work index/myocardial mass ratio (SWI/MLV). Normal values of the ejection function (EF) and mean velocity of circumferential fibre shortening (VCF) for each cardiopathy were so obtained. Only patients with aortic stenosis of group I (SWI/MLV greater than or equal to 0.75 gm . g-1) had normal EF. All the other patients had EF and VCF values below normal although this did not always imply impaired myocardial function. Therefore the myocardial mass should also be considered in the evaluation of myocardial function and it would seem desirable to take this parameter into account in the management of these patients.


[Ejection as index of left ventricle function]. Quantative left ventricular cineangiography performed 1 year post operatively in 24 patients with prosthetic aortic valves demonstrated significant reductions in the end diastolic volume and myocardial mass. Cardiac work was only slightly reduced. When cardiac work was compared to the end diastolic volume or myocardial mass results suggestive of myocardial hypercontractility were obtained. However when cardiac work was normalised simultaneously with the end diastolic volume and myocardial mass, the index so obtained was lowered pre operatively but did not differ significantly from normal values after operation. This index with seems to reflect the clinical evolution appears to be of greater value than the other indices used for determining left ventricular function. The reducted function of the hypertrophied myocardium was shown to be reversible during the 1 year post operative period.


[Surgically treated chronic aortic valve insufficiency. Long term results. Surgical indications]. The timing of surgery in chronic aortic regurgitation depends to a large extent on the operative results that may be expected in this type of valve disease. In 88 cases of chronic aortic regurgitation submitted to surgery there were 6 operative deaths (6.8%). Five years after operation the actuarial survival was 58% for the whole of the group and 68% for cases of rheumatic aortic regurgitation. Analysis of the causes of failures, late deaths, persistence or recurrence of severe impairment of activity, and of serious disturbances of ventricular rhythm, showed that the most important cause was myocardial dysfunction, which was responsible for two thirds of the bad results. Analysis of the late prognosis as a function of the various pre-operative parameters revealed the bad influence of cardiomegaly as measured by radiological examination (cardio-thoracic ratio and cineangiography) and of disturbances in left ventricular function. The actuarial survival curves showed very significant differences according to whether the cardiothoracic ratio was greater or smaller than 58%, and according to the amount of heart failure pre-operatively.  Similarly, an end-diastolic volume index of 240 ml/m2 and an ejection fraction less than. 40 seemed to be serious findings. These facts, taken in conjunction with the natural history of this valve lesion, suggest that the indications for surgery should not only be symptomatic aortic regurgitation but also well tolerated regurgitation in which cardiomegaly, end-diastolic volume and/or the ejection fraction have reached a certain level.