[Cerebral bioelectric activity disorders in acute intoxication with hypoglycemic agents]. The authors present 10 acute suicidal poisonings with hypoglycaemic agents with particular reference to the course of disturbances of brain bioelectric activity. In most patients diffuse changes prevailed during the coma in the form of irregular, usually high-voltage slow activity. Normalization of EEG tracings was very slow, often it took several months, although the duration of hypoglycaemia was usually short (1--5 days). In patients with prolonged toxic coma profound structural lesions of the central nervous system developed with appearance of decortication (apallic syndrome). The authors think that the particular severity of central nervous system lesions in these intoxication and the persistence of changes point to the necessity of seeking more efficient measures of treating neuroglycopenia.


[Blood serotonin level in sciatica and the serotonin theory of migraine pathogenesis]. The blood serotonin level was determined by the fluorescent method of Ashcroft in 13 patients with sciatic pains during the pains and after the disappearance. The serotonin level was usually higher at the time of pains. In the discussion the author reminds that serotonin level falls during a migrainous attack and points out that the results of the present study confirm the specificity of sertonin level fall in migraine.


[Biochemical and electrophysiological studies in subjects with occupational exposure to lead poisoning]. In 36 men working in occupations with lead exposure the conduction velocity was measured in the motor fibres of the median, ulnar and peroneal nerves, and determinations were carried out of blood lead level, 24-hour urinary excretion of lead and delta-aminolaevulinic acid, and activity of delta-aminolaevulinic acid dehydratase in the erythrocytes. The comparison of the results of electrophysiological and biochemical investigations shows that lesions of the peripheral nervous system are not always correlated with the biochemical indices of lead poisoning and that peripheral nervous system damage, mainly subclinical, may develop in early period of exposure.


[Role of computerized tomography in the diagnosis of arteriovenous anomalies of the brain]. The authors describe typical and atypical patterns of cerebral arteriovenous anomalies demonstrated by means of computerized tomography performed in 12 patients in whom these anomalies were found during subsequent operations. The authors compare the advantages and disadvantages of computerized tomography and angiography in the diagnosis of these anomalies.


[Primary malignant lymphoma of the central and peripheral nervous systems]. The authors present a case of malignant lymphoma in a man aged 64 years. Neoplastic infiltrations mainly in the form of perivascular accumulations were limited to the central nervous system (both central and peripheral). In the histological examinations of internal organs including lymph nodes and spleen no neoplastic tissue was found.


[Lesions of the insula and operculum: a syndrome]. A case of a clinical syndrome with transient hemiparesis, hemihypaesthesia, lancinating pains of a hand and "thalamic" position of this hand in a 60-year-old women. The clinical diagnosis was that of Dejérine-Roussy syndrome. Histological examination disclosed lesion of the lower part of the cortex of the insula, temporal aperculum- ventral part of the claustrum, capsula extrema and externa and also the uncinate and fronto-occipital fascicles.


[Pre-sacral epidermoid cyst communicating with spinal CSF cavity (author's transl)]. A 6-year-old girl was transfered to our hospital because of continuing pleocytosis, and detection of the squamous cells and cholesterin crystals in the CSF. Neurological examination on admission revealed no remarkable disorders, except for weakness of anal sphincter. X-ray examination of the spine showed a deformity of the sacral vertebra. Myelography revealed a pre-sacral cystic tumor, which was connected with spinal CSF cavity at cul-de-sac of the spinal canal by a narrow fistula. The tumor was totally removed and no meningitic sign appeared in postoperative course. Histological examination diagnosed it as a typical epidermoid tumor. Attention should be payed to the location, size, structure and clinical course in this particular case.


[Three cases of brain injury due to windshield impact (author's transl)]. Three cases of brain injury due to windshield impact (tempered windshield) were reported. In the case of brain injury, multitude of small cracks injured the frontal lobe through the orbital roof with facial injuries due to windshield impact. Though we are apt to misdiagnose because of very small wounds, the diagnosis can be made easily from the plain film. The craniotomy, with complete removal of glass fragments and dural plasty, must be performed for the purpose of preventing infection and cerebrospinal fluid rhinorrhea. We believe that the use of seat belt and H.P.R. type laminated windshield is the best precaution against the windshield impact.


[Case of intracranial chondroma].

[Case of intracranial chondroma]. The authors present a case of intaracranial chondrome originating from the pia mater and discuss the development of intracranial chondromas and role of cranial trauma in it.


Traumatic anterior atlanto-occipital dislocation. The five cases of atlanto-occipital  dislocation reported in the world literature are reviewed, and four additional cases are presented, including two survivors. The pathological anatomy of this potentially catastrophic injury and its management are briefly discussed. Because immediate recognition of the atlanto-occipital dislocation is critical to proper treatment and because the neurological findings are extremely varied, a new radiographic criterion for its identification has been developed.


Autogenous skull cranioplasty: fresh and preserved (frozen), with consideration of the cellular response. Every craniotomy requires immediate replacement of a fresh autograft of skull or, in the presence of cerebral swelling, delayed reimplantation of preserved autogenous skull. Resumption of osteogenesis, the index of viability, determines the effectiveness of these segments of calvaria in protecting the brain and restoring skull conformity. The cellular response in skull replaced either at the end of craniotomy or after frozen preservation was studied by light and fluorescence microscopy, skull roentgenograms, and radionuclide scintigraphy. In 5 patients eventual total remodeling of skull was found at the time of a second craniotomy performed from 1 to 19 years after the first. In 12 patients skull sections removed aseptically at craniotomy were frozen and stored for 1 to 35 months at -20 degrees C in bacitracin. This cytotoxic preservative method fixed the tissue, which appeared unchanged on light microscopy and was sterile on bacteriological and fungal cultures. In 53 patients who underwent autogenous cranioplasty with skull stored frozen for 3 weeks to 19 months, 48 operations were totally successful. Complications included infections in 2 patients, resorption in 2 infants, and incomplete restoration in 1 adult. In 10 patients the sequential dynamics of skull revitalization were found to be: revascularization, resorption, and accretion. The repair of membranous skull is similar to that of endochondral bone of the skeleton. Skull is metabolically intensely active after reimplantation and is the ideal material for cranioplasty.


A reticulothalamic system mediating proprioceptive attention and tremor in man. This report descirbes the electrophysiological characteristics of thalamic and subthalamic targets used to control tremor. In these targets exploratory electrodes recorded one or more of the following events. Electrical stimulation produced enhancement of tremor or other complex motor responses. Somatic evoked potentials (SEPs) induced by proprioceptive stimulation showed only late components, the amplitudes of which changed in various attentive situations. Multiunit activity showed spontaneous 3- to 6-Hz rhythmic bursts. And a lesion produced neglect of contralateral extremities and an ipsilateral decrease of scalp-recorded SEP late components. In contrast, in the areas located immediately posterior and dorsal, electrical stimulation produced contralateral paresthesias. Early components of SEPs could be recorded, as were rhythmic bursts of multiunit activity after the occurrence of peripheral tremor. Lesions produced sensory deficits in the contralateral extremities and ipsilateral blocking of all components of scalp SEPs. The latter areas are identified as the lemniscal system, but the former seem to be extralemniscal. Their electrophysiological characteristics suggest that they are probably involved in the process of selective attention and motor control.


Cerebral arterial spasm: part 9. In vitro effects of nifedipine on serotonin-, phenylephrine-, and potassium-induced contractions of canine basilar and femoral arteries. We performed in vitro experiments with a small volume chamber to determine the inhibitory effect of nifedipine on serotonin-, phenylephrine-, and potassium-induced contractions of canine basilar and  femoral arteries. Nifedipine, an inhibitor of the influx of extracellular calcium into smooth muscle cells, was found to be a sensitive inhibitor of contractions of the basilar artery induced by all three agents. In contrast, nifedipine did not significantly inhibit the serotonin- and phenylephrine-induced contractions of the femoral artery but did inhibit potassium-induced contractions of the femoral artery. Calcium-induced contractions of the  basilar artery were also inhibited by nifedipine. These experiments demonstrate a relatively selective effect of nifedipine on the basilar artery, and a mechanism to explain this selective effect is postulated.


Cerebral arterial spasm: part 10. Reversal of acute and chronic spasm in dogs with orally administered nifedipine. In vivo experiments in dogs demonstrated angiographically that the subarachnoid injection of blood produced cerebral arterial apasm both immediately after the injection of blood and 2 days later. The sublingual adminstration of nifedipine reversed both the acute and the delayed cerebral arterial spasm. In addition, sublingual administration of nifedipine 20 minutes before the subarachnoid injection of blood prevented the acute spasm.


Effect of furosemide on experimental traumatic cerebral edema. The present study was designed to test the effectiveness of furosemide in reducing cerebral edema due to closed head trauma. A Remington Humane Stunner was used to deliver blows to the heads of anesthetized cats. Impacted animals were divided into three groups: (a) trauma, no drug, and ad lib. fluid intake after head injury; (b) trauma, no drug, and standardized fluid intake (0.9% NaCl; 10 ml/lb/day); and (c) trauma, furosemide (3 mg/lb/day), and standardized fluid intake. For the treated cats, we began furosemide therapy 1 hour after head injury and used three intramuscular injections/day. The animals were killed 48 hours after head trauma. From animals with unilateral contusion, we took bilateral white matter samples from five points along the centrum semiovale and tested for edema using density determinations with an organic density gradient. Serum electrolytes, blood urea nitrogen, and weight were determined before the cats were impacted and before they were killed. All impacted animals demonstrated weight loss. Density data showed a normal water content for white matter in the uncontused hemispheres of all impacted cats. Contused hemispheres showed a significant decrease in density (increase in brain water content) for both treated and untreated cats. In the furosemide-treated animals, however, the brain edema was significantly less than that found in the untreated groups. Analysis of data from individual brain sections of furosemide-treated animals suggested a reduction in the spread of edema fluid 48 hours after head injury.


Influence of arterial blood pressure upon central hemorrhagic necrosis after severe spinal cord injury. To determine the influence of systemic arterial blood pressure upon the pathogenesis of spinal cord injury, we eliminated the increase in systemic blood pressure normally observed after trauma to the spinal cord with the ganglionic blocker chlorisondamine. Blockade of the pressure response did not influence the development of hemorrhagic necrosis in the spinal cord. We conclude that the transient pressure response accompanying spinal cord injury is probably not a major factor in the pathogenesis of hemorrhagic necrosis at the site of the spinal cord injury.


Chronic extradural hematoma: case report. A recent experience with a chronic extradural hematoma found unexpectedly during an evaluation for an enlarged sella turcica is reported. This case, as well as pertinent literature, demonstrates the variability of the classical signs in the chronic lesion. Our experience suggests that the diagnosis of patients with persistent symptoms after head injury may be clarified by computerized tomographic scanning, which in the present case revealed chronic extradural hematoma.


Influence of nitroprusside on cerebral pressure autoregulation. The authors studied 10 cats to assess the question of abolition of cerebral autoregulation attendant on the use of nitroprusside for hypotensive anesthesia. After the establishment of stable base line parameters, a continuous infusion of sodium nitroprusside was begun in a dose sufficient to maintain a mean systemic arterial pressure of 65 mm Hg. Infusion was continued for incremental periods of 30 seconds to 10 minutes, increasing the time of infusion by 30 seconds after each subsequent trial. At 10 seconds after the cessation of nitroprusside administration, intravenous dopamine was infused to raise the systemic arterial pressure to a mean of 100 mm Hg, and the subsequent response in intracranial pressure was recorded in each instance. In no animal was a loss of cerebral autoregulation noted when the nitroprusside infusion was maintained for 3 minute or less. When the infusion was maintained for 4 minutes or longer, cerebral autoregulation was lost in each animal, and the length of time to return of cerebral autoregulation correlated with the duration of nitroprusside infusion. Sodium nitroprusside disturbs the integrity of cerebral pressure autoregulation, and the onset and extent of this disturbance is a dose-dependent phenomenon.


Trans-sphenoidal removal of a Rathke's cleft cyst. Symptomatic Rathke's cleft cysts are uncommon. We present a case with suprasellar extension manifested by hypopituitarism and visual disturbances. The treatment was trans-sphenoidal evacuation and partial removal of the capsule. We suggest that the trans-sphenoidal approach to these lesions is usually adequate and that radical removal of the capsule is not necessary.


Neurogenic tumors of the brachial plexus: report of two cases. Two cases of solitary neurogenic tumors of the brachial plexus unassociated with von Recklinghausen's disease are presented. One patient had a malignant schwannoma. The lesion of the other patient was benign and was diagnosed pathologically as a plexiform neurofibroma. These uncommon neurogenic tumors of the brachial plexus unassociated with von Recklinghausen's disease pose diagnostic and surgical problems. The initial clinical presentation is usually that of a painless supraclavicular mass. At the time of surgical exploration, the exact site or nerve of origin cannot always be identified. If motor loss is caused by such a tumor of the brachial plexus, it usually indicates a malignant lesion and a poor prognosis. Although wide radical excision of a malignant neurogenic tumor is indicated surgically, one of our patients had an early malignant recurrence that necessitated immediate amputation.


Accessory light for the surgical microscope. This report describes a new accessory fiberoptic light for the most widely used surgical microscope. The advantages of this light are that it permits easy sterile draping of the microscope, does not require a special lens cover, can be adjusted to vary the size and location of the field of illumination, and produces minimal interference with the passage of microinstruments into the operative exposure.


Cerebellar infarction.

Cerebellar infarction. Cerebellar infarction has been inadequately recognized by clinicians. A review of 75 cases showed that in 55 of them the infarct acted as an expanding mass lesion and compressed the brain stem. Once this occurred, the mortality without operation was very high. With surgical treatment, the mortality was reduced considerably. The computerized tomographic scan is the diagnostic test of choice.


Prognosis of patients with severe head injury. The relationship between clinical features of brain dysfunction in the first week after severe head injury and outcome 6 months later has been analyzed for 1000 patients. Depth of coma, pupil reaction, eye movements, and motor response pattern, and patient age prove to be the most reliable predictors. The degree of brain dysfunction changes markedly soon after injury, and more reliable predictions of outcome result when assessment is based on the best level of functioning recorded in each early epoch. Predictions based on very early assessment are, therefore, often unduly pessimistic. Individual predictions of outcome, based on a large data bank, provide a powerful tool for assessing the relative efficacy of alternative treatments.


Enhancement of experimental cerebral edema after decompressive craniectomy: implications for the management of severe head injuries. Decompressive craniectomy has been advocated as a treatment for the cerebral edema associated with massive head injury. Although craniectomy has been successful in lowering intracranial pressure after head injury, a comparison of computerized tomographic scans of comparable patients with traumatic brain edema treated by medical means or decompressive craniectomy showed that bony decompression resulted in apparent exacerbation of edema. To investigate the possibility of enhancement of brain edema by craniectomy, we produced standardized cold lesions in the brains of 10 dogs. Five animals served as controls. In the other 5 animals we performed large decompressive craniectomies after lesioning. Physiological parameters were comparable in both groups. The dogs were killed 8 hours after lesioning. After fixation, their brains were cut into 1-mm-thick slices. We used an image analysis facility built around a PDP 11/105 computer to measure the volume of edema as outlined by Evans blue staining. The mean volume of the brain edema in the control animals was 0.27 +/- 0.19 ml. Mean edema volume was over 7 times greater in craniectomized animals (1.96 +/- 1.89 ml). This difference is statistically significant (p less than 0.05). The driving force for the formation of edema fluid is the difference between intravascular and interstitial presssure. Decompression of the brain by bone removal probably results in a reduction of interstitial fluid pressure and edema enhancement. The clinical literature contains no evidence that craniectomy decreases the morbidity or mortality of human head injury. In view of our experimental findings, this is not surprising. Indeed, pathological evidence indicates that severe edema (such as that accentuated by craniectomy) may produce permanent changes in the neuropil.


Ultrasonic B-scan echoarteriographic imaging of experimentally induced thrombi in dogs. Ultrasonic echoarteriography is a noninvasive method of visualizing extracranial arteries in health and disease. The real-time echoscanning device developed at the University of Cincinnatti utilizes a 5-MHz (center frequency) pulse-echoimaging system. B-mode pictures of the tissues studied are obtained and displayed on a video screen, real-time operation being provided by the scanning mechanism operating at 30 frames per second. In our experiments internal arterial damage produced by surgically scraping the intima induced experimental thrombosis in nine carotid in nine carotid and three femoral arteries in dogs. Where pathologically demonstrated, the thrombi were demonstrated by ultrasonic echoarteriography in every instance. Echoarteriography seemed more sensitive than contrast arteriography in the detection of a partially occlusive thrombus.


Heterotransplantation of human craniopharyngiomas in athymic "nude" mice. Surgical biopsies from 2 human craniopharyngiomas were transplanted subcutaneously into 6 athymic "nude" mice. Morphologically characteristic craniopharyngiomas grew in 5 of these animals. In 4 animals growth was sufficient to allow transplantation into a second generation of animals. In all, 11 craniopharyngiomas were present at autopsy in the 14 animals into which the tumors had been transplanted. The tumors that grew in the animals had the same adamantinomatous architecture, epithelial nests, and keratinized nodules that were present in the original surgical sample and that are characteristic of human craniopharyngiomas. It may be possible to study growth characteristics and therapeutic sensitivities of human craniopharygniomas growing in "nude" mice.


Resection of multiple nocardial brain abscesses: diagnostic role of computerized tomography. We present a case of multiple brain lesions in which the preoperative computerized tomographic (CT) scan suggested the presence of brain abscesses rather than metastatic tumors. The patient presented with symptoms of left frontal and right cerebellar mass lesions, confirmed by carotid and vertebral arteriography and a radionuclide brain scan. A CT scan revealed multiple contiguous ring-enhancing lesions of various sizes at both sites. With the exception of a prior mild pulmonary infection, no findings suggested underlying malignancy, immunosuppression, or medical illness. We based our decision to administer antibiotics preoperatively on the presumed presence of abscess. We found and totally removed two multiloculated abscesses during one operation and initiated sulfa drug therapy (sulfisoxazole) immediately after identification of the Nocardia organism. The patient experienced no postoperative complications and at 6-months follow-up is clinically free of disease.


Recurrent intracerebral blastomycotic granuloma: diagnosis and treatment. We present a patient with a recurrent intracerebral blastomycotic granuloma. The computerized tomographic scan appearance of this lesion is illustrated. Of the 81 reported cases of intracranial blastomycosis, only 35 have represented solid intracerebral lesions; the other patients have had spinal lesions or meningitis. This patient represents the first reported recurrence of an intracerebral blastomycotic granuloma. The treatment utilized, surgical resection combined with intravenous and intraventricular amphotericin B, represents a unique approach to this problem. The diagnosis and currently advocated treatment of intracranial blastomycosis is reviewed, particularly in regard to the potential for recurrence of blastomycosis.


Xanthogranulomas of the third ventricle. Two patients with xanthogranuloma of the 3rd ventricle are described. In each instance the tumor obstructed the interventricular foramina and caused dilatation of the lateral ventricles and signs of increased intracranial pressure; computerized tomography demonstrated the dense, nonenhancing lesion in the anterior 3rd ventricle. The pathogenesis of these rare tumors is discussed. These cases affirm the need to consider xanthogranuloma in the differential diagnosis of anterior 3rd ventricle tumors in adults.


Extracranial-intracranial arterial bypass to a single branch of the middle cerebral artery in the management of a traumatic aneurysm. This case required the clipping of a single branch of the middle cerebral artery for the treatment of a traumatic aneurysm. To ensure an adequate blood supply distal to the occlusion, we anastomosed the superficial temporal artery to that branch of the middle cerebral artery (MCA) distal to the aneurysm. Despite the low flow required to irrigate only one branch of the MCA, the anastomosis remained patient. This case demonstrates the feasibility of performing small vessel anastomoses in spite of low flow demand.


Scanning electron microscopy in the evaluation of neurosurgical neoplasms: a review of new approaches. Present and potential applications of scanning electron microscopy (SEM) to the study of solid neoplasms, the lining of cysts, exfoliated cells, mineral deposits, and supporting tissues of the central nervous system (CNS) are discussed. Special features of the SEM image include a large field of view and depth of focus, high resolution, and a three-dimensional impression of surface topography. These features have contributed a clearer understanding of similarities between colloid cyst and olfactory epithelium. They demonstrated differences between glial and nonglial fibrils of selected CNS neoplasms. These features may ultimately enhance decisions, diagnosis, and study of neoplastic origins and spread within the CNS and cerebrospinal fluid. Special features of tissue examination by SEM  include processing without the need of thin sections and elemental analysis by X-ray spectroscopy. These features have been applied to studies of calcium and thorium associated with meningiomas and a schwannoma.


Computed tomography of the human skeletal muscular system. A description of different levels of the normal adult human skeletal muscular system is given as derived by computed tomography (CT). A standard program is presented by which a maximum number of muscles which are affected by neuromuscular diseases can be examined with a minimum of radiation. Twenty-four patients of different ages, 12 males and 12 females, were examined. Descriptions of different levels of the skeletal muscular system, with measurements of cross-section and density of a number of important marker muscles are presented. Variations of these parameters with age, sex, and cerebral dominance are discussed. It is concluded that CT scans can greatly enhance our insight into the effects of neuromusclar diseases on normal and abnormal skeletal muscles.


Angiography and computed tomography in the evaluation of cerebral venous malformations. The information obtained by computed tomography (CT) and cerebral angiography is compared in eight cases of cerebral venous malformation. Angiography was found to be more reliable for detecting the presence and specific nature of these malformations. Pathological and radiographic differential features between the various forms of cerebral vascular malformations are discussed.


Meningioma of the paranasal sinuses.

Meningioma of the paranasal sinuses. Meningiomas originating in the paranasal sinuses are rare. These tumors are thought to arise from embryonal arachnoid nests which were pinched off and left behind during embryonic development. We have described various radiographic findings of two patients with meningioma arising in the paranasal sinuses (frontal sinus origin in a 65-year-old female, and sphenoid sinus origin in a 26-year-old female). The paranasal origin of meningioma was accurately determined on the basis of CT and arteriography. A review of the 11 cases previously reported and our cases indicates that there are no specific clinical or radiographic findings of meningiomas of the paranasal sinuses.


The superficial recurrent ophthalmic artery: meningeal supply to petrous ridge meningiomas. The superficial recurrent ophthalmic artery arising from the second portion of the ophthalmic artery is rarely visible angiographically. Described herein is a patient having a recurrent ophthalmic artery which had hypertrophied to a degree sufficient to supply a highly vascularized meningioma of the petrous ridge. Coexistence of marginal tentorial branches, namely the superficial recurrent ophthalmic artery and the meningohypophyseal trunk, is an embryological dilemma. Furthermore, this case demonstrates the capacity of the ophthalmic artery to supply posteriorly situated neoplasms.


The rotational component in the dynamics of the C2-3 spinal segment. The technique of the PA axial projection of the arches of the upper cervical vertebrae into the occipital foramen and the normal findings, are described. The influence of maximum forced anteflexion at the craniocervical junction and rotation of the head on the relations of atlas and axis is demonstrated. It seems that in this position rotation at atlas-axis level is restricted and partly transmitted to the C2-3 segment. Thus, selective clinical examination of the rotational component of the dynamics at C2-3 can be achieved and the pathological restrictions of movement can be assessed.


Cervical double contrast myelocisternography by the lateral approach (technical note). A simple method for the combined examination of the cervical spinal canal with Amipaque, and of the craniocervical junction with air, by one and the same puncture without changing the patient's position during the examination, is described.


Passage of Amipaque (metrizamide) through the arachnoid granulations. 125I labelled Amipaque (metrizamide) was introduced by cisternal puncture into six rabbits and perfused at various pressures. The torcular was exposed, frozen rapidly, and excised intact. Sections of arachnoid proliferations were made from the frozen specimen and either freeze dried or sandwiched directly for autoradiography. Some specimens were freeze dried en bloc prior to sectioning and sandwiching. All sections were exposed for 2-3 weeks at -80 degrees C prior to development of the autoradiographs. On microscopic examinations of the autoradiographs most of the activity was in the tubules or between cells suggesting intercellular passage. Some label was also present within the brain. The significance of this is discussed.


Evaluation of the internal auditory meatus with acoustic neuromas using computed tomography. Forty-seven patients with 48 unoperated acoustic neuromas have been studied by computed tomography (CT) with respect to bone changes. CT and conventional X-ray examination of the skull were compared. The importance of using a small collimator, proper selection of the plane of the CT section and changing of the window level is stressed. CT detects porus changes as accurately as conventional X-ray methods.


The contracting cord sign of multiple sclerosis. A new sign of multiple sclerosis, the contracting cord sign, is described. The myelographic demonstration of a large cord that subsequently decreases in size may suggest multiple sclerosis. Multiple sclerosis must be considered in the differential diagnosis of an enlarged spinal cord. Distinguishing between the collapsing cord and the contracting cord is discussed.


Radiolucent intracranial dermoid Cyst. Report of an unusual case. An intracranial dermoid cyst presenting as a radiolucent mass on the plain radiographs of the skull is described.


Spontaneous rupture of a pineal teratoma. A case of a spontaneously ruptured pineal teratoma is presented. This was diagnosed by computed tomography (CT) and was confirmed later at operation.


Unusual metastases from a medulloblastoma: case report. Calvarial and extracranial metastases by hematogenous spread of primary intracranial neoplasms have been considered a rare occurrence. This report deals with the clinicopathological and radiological findings of a child with metastatic medulloblastoma. Correlation of serial postoperative computed tomography (CT) scans and the autopsy examination indicated hematogenous calvarial and intracranial spread of the primary lesion.


Computed tomography of intracerebral toruloma. The CT features of intracerebral toruloma are described and the clinicopathological features briefly reviewed. The diagnosis of intracerebral toruloma should be considered when pulmonary opacities are associated with multiple intracerebral enhancing masses.


Ruptured aneurysm of an azygos anterior cerebral artery. A ruptured saccular aneurysm of the azygos pericallosal artery was found and clipped successfully in a woman of 47 years. Aneurysm of an azygos pericallosal artery is extremely rare.


[Therapeutic value of the cell separator. Review and case reports]. The advent of continuous-s, semicontinuous-flow centrifugation and filtration leukapheresis systems permits the procurement of large quantities of granulocytes and platelets from single donors and the removal of abnormal excessive blood components (plateletpheresis, lymphapheresis, eosinapheresis, plasma exchange). This paper describes therapeutic applications of CFC, SCFC, FL in various disease processes; the results are discussed. Our data agree with those reported by the litterature.


[Specific hyposensitizing therapy. Considerations on its effectiveness and validity]. The Authors reported on the effects of the specific desensitizing therapy performed by them on 684 patients suffering from different allergies (rhinitis, asthma from pollens and other inaled agents) who were put under observation from 1-1-1970 to 13-12-1972 and treated for several years. The survey ends with comparisons between the results of similar studies effected by other Authors.


[Mondor's disease. Considerations on 5 cases]. The clinical, anatomical, topographical and pathological features of Mondor's disease are described, and five personal cases are presented. Their aetiopathogenetic characteristics reflect the doubts expressed in the literature. Stress is laid on the benign nature of the disease, the possibility of treating it at the out-patient level, and the complete remission of both subjective and objective symptoms obtainable in the space of a few weeks.


[Prognostic factors in thromboembolectomy with the Fogarty catheter for acute ischemia of the limbs]. The Authors describe the results obtained in 181 patients treated with thromboembolectomy by Fogarty catheter for acute limb ischaemia. Data were analyzed with the help of a set of computer programs for statistical computations, and some highly significant prognostic factors were determined: ischaemia duration and severity cause a substantial increase of both death and amputation probability; associate diseases or thrombosis are significant factors for amputation; occlusion level for death. The patients whose limb was saved without the pulse being present were characterized by ASO or thrombosis.


[Non-invasive method of control of myocardial function in post-infarction patients treated with digitalis glycosides. Polygraphic and echocardiographic methods]. Following the guide of the publications written by Weissler, Thomas, Ahmed, Perry, Buyukoztur, Rahimotola, the Authors have executed on 25 patients with results of the myocardic infarction a polygraphic examination, comparing the variations of the intervals of the systolic time (STI) with the modifications of the fraction of the ejection (Fe) and of the velocity of the circular fibres (Vcf), calculated with echocardiographic method. From the results obtained the Authors have concluded that there is a perfect correspondence among the alterated values of the isovolumetric contraction time (TCIV), preejection period (PEP), LVET/PEP, and the variations of the Fe and Vcf, and furthermore the amelioration obtained with the digitalis therapy are controlled justly with both the methods. In conclusion both the polygraphic examination and the echocardiographic examination consent a perfect control of the patients with results of the miocardic infarction if they are subject to a digitalis treatment or not, and furthermore they permit a functional valutation of the patient.


[The cholecysto-coronary syndrome observed with polygraphic and echocardiographic examinations]. The cholecysto-coronary syndrome already many times observed by various Authors at the standard electrocardiogram and after effort with not much significative results, has been studied by our group with a polygraphic and echocardiographic method. 55 subjects aged between 30 and 55 years have been examined, to each of them besides a standard electrocardiogram and after effort a polygraphic examination including a tracing of electrocardiogram, a phonocardiogram, and a carotid pulse has been made, after the STEM, TEVS, TC, TCIV, PPE and the TEVS/PPE have been calculated. The parameters obtained have been compared with the ideal values of the subject in examination, calculated according to the formula of Diamond and Killip. Moreover an echocardiographic examination has been performed in 10 of the 55 patients, both to exclude valvular anomalies and ventricle enlargements, and to calculate the velocity of the contraction of the circumferential fibres (Vcf). The examination performed pointed out an increase of the TCIV and PPE with decrease of the ratio TEVS-PPE at the polygraphic examination and moreover a decrease of the Vcf at the echocardiogram. From the whole of the results obtained we can conclude that the cholecysto-coronary reflex determines a decrease of the contribution of the O2 to the myocardium, of a limited entity, so much that it doesn't give clear signs in the standard ECG, but sufficient to establish a suffering of the sarcomer that manifests itself with an alteration of its contraction velocity.


[Cases of paroxysmal atrial fibrillation]. By examining carefully 516 cases of atrial fibrillation and in particular of 144 paroxysmal atrial fibrillation, the Author draws considerations on pathogenesis of paroxysmal atrial fibrillation, on the most important clinical notes, on prognosis and treatment. He also suggests to define the typical paroxysmal forms which to his opinion are different from those he prefers to call "unstable fibrillation".


[A case of splenic torsion in a child].

[A case of splenic torsion in a child]. A case of torsion of the spleen complicated by bowel occlusion occurred in a 3 1/2-yr-old boy is reviewed. Pathogenesis, symptoms and diagnostics are discussed. The rarity of the lesion in childhood is underlined together with the utility, in diagnostics, of plain films of the abdomen taken some hours one from the others.


[A catamnestic study of recovered alcoholics]. Fifty-one alcoholics, previously admitted to the hospital for medical care and treated with disulfiram, were re-examinated after 1-3 years. In thirty of them (58%) total abstinence was found; eighteen patients (35%) behaved so in spite of disulfiram withhold during the first year of self-administration. No side-effects were reported. General behaviour, mood, work, interest and familiar relationships improved. The treatment generally failed in the cases of secondary alcoholism as in marked neurosis or psychosis. The research proved the main role of family and environment in the successful cases. The treatment with disulfiram is useful but incomplete.


[Selective bronchial arteriography in broncho-pulmonary pathology]. 104 selective bronchial arteriographies were performed in 25 patients with bronchopulmonary neoplasia, 11 with mediastinal tumours, 15 with bronchopulmonary inflammation, and 53 with haemoptysis. An assessment is made of the diagnostic value of the information obtained. It is felt that this form of examination is particularly useful in detecting the site of bleeding cases of haemoptysis, and in the provision of treatment by means of embolisation.


[Diagnostic value of urography in the study of arterial hypertension]. In spite of the widespread use of intravenous urography and its extensive employment in the study of hypertension, there is still no unanimity of views as to its application in such pathology. 147 urographies belonging to 330 hypertense patients admitted to the Bari Medical Pathology Department between 1-1-1975 and 30-9-1977 have therefore been examined so as to assess its diagnostic value. Thereafter, the percentage of abnormalities found with urography were evaluated and compared with those in the population at large. Results stress on the one hand the higher incidence of renal ptosis and poly-cystic kidneys in the hypertense, and also highlight the possibility of revealing clinically silent diseases with this technique; on the other hand, many urographies (more than 50%) were useless and it is not always possible to diagnose certainly the presence of stenosis of the renal artery owing to the presence of false positives and negatives.


["Resistent" obesity. Clinical and metabolic aspects, cellularity of the adipose tissue and personality factors]. A study was made of 20 patients with "resistant" obesity selected from a series of about 4000 observed between 1970 and 1976 in an assessment of the possible existence of features distinguishing such patients from those who respond to treatment and display a satisfactory decrease in weight. The group was marked by a higher incidence of familial obesity, earlier onset of overweight, and certain personality features (evaluated by psychometric tests). Their blood sugar and insulin curves, blood cholesterol and uric acid, adipose tissue cellularity, and blood pressure (LHAP) were similar to those in the general series. Whereas their blood triglyceride values were normal, however, those in the general series were up by 21%. It is therefore felt that the clinical tests used at present do not enable the "resistant" obese subject to be distinguished. "Resistant" obesity may well constitute a distinct nosological entity, but one that is only identifiable via the patient's response to treatment.


[Changes in acid-base equilibrium and water-electrolyte balance in hepatic cirrhosis]. The acid-base and hydroelectrolyte balance were evaluated in 116 patients with cirrhosis of the liver divided (a posteriori) into subjects without ascites, those with tractable ascites, and those with intractable ascites. Alterations were much earlier and more frequent in the pre-ascitic stage. A fall in arterial blood O2 tension also proved a poor prognostic factor. The water load test and 24-hr determination of natriuria best reflected the clinical picture and should thus act as pointers to the correct planning of treatment.


[Levodopa treatment of a case of torsion spasm with athetosis]. The result about Levodopa treatment in torsion dystonia and athetosis are quite contradictory. We report an interesting case, significant for the results that we obtained in a long treatment period. A girl was suffering from age of 8 years of torsion dystonia associated with athetosis. We made our first clinical examination when 12 years old: she was not able to stand-up and to walking, neither was she able to be sitting in a chair without arms. In two months of treatment with Levodopa 3.000 mg. by day, the symptoms completely disappeared. During the first two years of treatment, at every effort to decrease the therapy we observed an important increase of symptoms. Successively it was possible to decrease the therapy and now, after 8 years of treatment, with a minimal dose, the girl doesn't show any symptoms, so that she can manage a normal relative life. Probably these good results depend on the fact that was a sporadic recessive form of torsion dystonia case.


[Changes in basal gastric acid secretion in humans after intravenous administration of glucose]. We have inquired into the variation of the secretion acid gastric in a man after a rapid infusion of an hipertonic solution of glucose (g 0,33/Kg of weight), comparing it with that induced by the caffeinic stimulant. From this comparison we have noticed a sharp secretory answer in the first 30' whether out of the HCl free or the total acidity that tends to become exhausted progressively. We want to put forward the hypothesis of a probable interference in a stimulating manner of the high glycemia over the production of entero-hormones.


[History and socio-political motivations of acupuncture in China and in Europe]. In this paper is described the story of acupuncture in China and in Europe. Besides storical points of view, are discussed the social-political reasons that raised acupuncture to a high level in people Republic of China, and the practical reasons of this therapy. Besides are discussed summarily the indications and scientific bases of this methodology.


[Acupuncture in the treatment of pain in psychiatry and in psychosomatic medicine]. The Authors examine the possibility of using acupuncture in psicogenic pain. Particular attention is given to different problems: 1) a correct use of acupuncture; 2) establish a relation doctor-patient not impersonal or objectival; 3) understanding of the meaning of the simptoms and of the psychological reasons.


[Acupuncture in ischemic pain of the extremities]. In this paper is put in evidence the efficacy of reflexotherapy (acupuncture) in the treatment of ischemic pain. The vasodilatation obtained brings back to a normal aerobic glicolisis in the ischemic tissues, especially in the muscles and consequentially a total or partial analgesic effect.


[Acupuncture analgesia in instrumental examinations of the uterus]. The Authors put in choise the acupunctural-analgesia in front of general anaesthesia in uterus's critical instrumental inspections. Following the biomolecular data and the obtained results without any anaesthesiologic risk, the Author presents the used methods and, also if the number of patients is low, the Author advises the acupunctural method in above-mentioned disease.


[Circulatory disorders and acupuncture]. The present study was designed to examine whether acupuncture is useful in the treatment of some disorders of the vascular system as the thromboangiitis obliterans of the extremities, the Raynaud's disease and in the therapy of ulcers by venous stasis. From the data presented it appears that acupuncture is effective in releasing the arterial spasm and especially in increasing the circulation in collateral vessels. In order to prove the efficiency of acupuncture in the above disorders, the response to acupuncture was compared with that obtained by a pharmacological treatment with lumbar paravertebral block.


Vaginal adenosis in stillborns and neonates exposed to diethylstilbestrol and steroidal estrogens and progestins. A histologic study was conducted of sagittal sections of the genital tracts of 281 autopsied female stillborns and neonates. The prevalence of vaginal adenosis among 43 offspring exposed in utero to diethylstilbestrol (DES) was 70%, a frequency 18 times greater than the 4% prevalence among 159 unexposed offspring. The relationship of the prevalence of vaginal adenosis to the gestational age at initial exposure was highly significant: 81% of those first exposed during the period of vaginogenesis had adenosis, whereas none exposed after 21 weeks' gestation had adenosis (P1 = 1 X 10(-4)). The relationship of the prevalence of vaginal adenosis to the total dose of DES prior to 22 weeks' gestation also was significant (P1 = 0.02), and this relationship was independent of gestational age at first exposure (P1 =0.01). In contrast, the prevalence of adenosis among 23 offspring exposed to steroidal estrogens and progestins was about the same as that among the unexposed offspring. Vaginal adenosis was unrelated to the complications of pregnancy for which the hormones were given, the calendar year of birth, and the gestational age at delivery.


Evaluation of colposcopic accuracy without endocervical curettage. A study was undertaken to evaluate the accuracy of colposcopic examination when performed without the use of endocervical curettage. It included 763 cases of suspected cervical-vaginal pathology. An additional evaluation of colposcopic accuracy was made for special-case categories of 1) stromal invasion, 2) pregnancy, 3) menopause, and 4) diethylstilbestrol (DES) exposure. Colposcopic accuracy was determined by cytologic and histologic material obtained either at the initial colposcopic evaluation or during follow-up surgery. With the literature as a standard for accuracy, it was concluded that the omission of endocervical curettage from the colposcopic examination did not reduce accuracy. In addition, the diagnostic conization rate was lower than in most reported series. Finally, the rate of missed invasive lesions was not increased by the omission of endocervical curettage.


Intentional ureteral ligation in advanced pelvic malignant disease. It is now widely accepted that debulking operative resections can provide effective palliation for some patients with advanced pelvic malignancy, particularly with those malignancies originating in the ovary. Some of these radical operations require the resection of long segments of the ureter and portions of the bladder. Although there is a variety of techniques that can be used in this situation to restore the continuity of the urinary tract, in some instances a simple ureteral ligation may represent the best method of managing the "short ureter." In our experience with 23 patients who underwent intentional ureteral ligation, the procedure was found to be safe, expeditious, and beneficial in managing some of the complex problems associated with advanced pelvic malignant disease.


Smooth muscle tumors of the vagina.

Smooth muscle tumors of the vagina. The clinical and pathologic features of 60 smooth muscle tumors of the vagina were studied to determine the pathologic characteristics which best relate to clinical behavior and to define criteria for the diagnosis of leiomyosarcoma. Cellular atypism, mitotic activity, and tumor size and contour were examined, and their relationship to recurrence was evaluated. Only 5 neoplasms recurred, and these were all greater than or equal to 3 cm, with greater than or equal to 5 mitotic figures per 10 high-power fields (HPF) and various degrees of atypia. The only patient whose tumor had an infiltrating margin died with metastatic tumor in the lungs. With the exception of this 1 neoplasm, all other smooth muscle tumors of the vagina were either benign or only locally aggressive. Local excision is the treatment of choice when the tumor is well circumscribed. A neoplasm with moderate to marked atypism and greater than or equal to 5 mitotic figures per 10 HPF merits the designation of leiomyosarcoma.


The value of sonography in suspected ectopic pregnancy. Of 356 women undergoing sonography to diagnose or rule out an ectopic gestation, data sufficient to assign a final diagnosis were available on 260 of them. Ectopic gestation was diagnosed in 25 cases in this group and intrauterine pregnancy in 99, while the remaining 136 patients were found not to be pregnant. During sonography, ectopic gestations were suspected or diagnosed in 27 instances: In 17 cases this was in agreement with the final diagnosis, but neither an intrauterine nor an extrauterine gestation existed in 10 cases, although neoplastic or inflammatory masses were present. Of the 25 patients with the final diagnosis "ectopic pregnancy," this was not detected with sonography in 8 instances. Intrauterine pregnancies were diagnosed by sonar in 94 of the 99 cases. Although reliable sonar identification of ectopic gestation is not always possible, sonography is helpful in diagnosing intrauterine pregnancy so that surgical intervention can be avoided.


Conservative surgery for tubal pregnancy. Twenty-four conservative surgical procedures for unruptured tubal pregnancies were performed on 23 patients with poor past obstetric performance. All cases were diagnosed preoperatively by laparoscopy. Salpingotomy was performed in 20 cases and fimbrial expression of the ectopic pregnancy was performed in 4 cases. In the group of conservatively treated patients there were 15 live births in 11 women and 28 intrauterine pregnancies in 14 women. No ectopic pregnancies occurred in the operated tube. Early diagnosis and conservative surgical treatment of unruptured tubal pregnancy is appropriate for patients with poor reproductive histories.


External cephalic version in breech presentation under tocolysis. A prospective trial is presented of the benefits and risks of external cephalic version in breech presentation. From January through October 1977, attempts at external version were performed in 53 cases with a success rate of 70%. The version technique is described. Mode of delivery after the maneuver in mothers with breech presentation who for different reasons were not included in the series is reported as well. Both the incidence of breech presentation and the incidence of cesarean section in breech presentation were reduced during the period of study. No serious complications in association with attempts at external version were observed.


Fetal heart rate patterns and fetal distress in fetuses with congenital anomalies. Over a 3-year period at the Long Beach Women's Hospital, where electronic FHR (fetal heart rate) monitoring was routine, there were 8622 live births, including 41 infants born with major congenital malformations. The neonatal death rate in these malformed infants was 44%; 17 were delivered by cesarean section, 11 of which were performed because of fetal distress. There were no characteristic FHR patterns that would specifically identify major congenital malformations. There was a significantly increased incidence of prematurity, breech presentation, and cesarean section delivery in the congenital malformation group as compared to the overall population delivering at the Women's Hospital. The clinical implications of these observations are discussed.


Morbidity and mortality of advanced gestational age: post-term or postmature. A 6-year retrospective review of 53 post-term infants admitted to a neonatal intensive care unit (NICU) was undertaken to determine whether morbidity and mortality related to uteroplacental insufficiency were confined to infants with the postmaturity syndrome. Objective identification of infants with significant intrauterine growth retardation (IUGR) was done using the ponderal index (PI). All neonatal deaths occurred in large, appropriately grown infants and were associated with anoxic encephalopathy. Morbidity was equally distributed between normally grown and malnourished infants. Developmental outcome was similar in the 2 groups of infants. Neonatal complications and sequelae occurred in the absence of recognizable fetal malnutrition. Therefore, the post-term infant should be considered at risk, even if normally grown.


Antenatal versus neonatal transport to a regional perinatal center: a comparison between matched pairs. Fifty randomly selected newborn infants of maternal transports admitted to the neonatal intensive care unit (NICU) at Long Beach Memorial Hospital in 1976 and 1977 were matched by birth weight, gestational age, and outcome with 50 transported neonates. The factors compared included type of delivery, 5-minute Apgar score, length of hospital stay, distance of transport, admitting diagnosis, need for assisted ventilation, and length of time on assisted ventilation. Only 2 factors were found to be statistically different between the 2 groups. There was an increased cesarean section rate in transport mothers but a lower morbidity among preterm neonates born to maternal transports.


The changing perinatal and maternal outcome in chorioamnionitis. Chorioamnionitis is difficult to detect clinically, but its recognition in those at risk is essential. A retrospective study of 140 patients from among 26,129 deliveries was conducted over a 2-year period. The findings suggest that in modern obstetric practice, both perinatal and maternal complications associated with chorioamnionitis (particularly sepsis) are infrequent problems. Four neonatal deaths occurred but no infants died of sepsis. There were no maternal deaths, but 38 patients developed postpartum infections. Cesarean section did not appear to improve either perinatal or maternal outcome. With the use of appropriate modern antibiotics, extraperitoneal cesarean section and cesarean hysterectomy are probably no longer indicated. Not all neonates born out of a microbiologically contaminated intrauterine environment required antibiotic therapy, however, and individualization is recommended.


The value of the Partogramme in the management of labor. The Partogramme was evaluated at the University Center for Health Science or Centre Universitaire des Sciences de la Santé (CUSS) in Yaounde, Cameroon, Africa. A retrospective study of 686 patients and a prospective study of 1045 patients were conducted. With the institution of this program, the perinatal mortality decreased by 10 deaths/1000 births. The use of the "alert" and "action" lines offered accurate and reliable guidelines for early detection of abnormal labor. Two-thirds of the morbidity and mortality and 72% of deliveries with medical or surgical interference occurred in the clinical group where the labor curve crossed the action line. Regional values for functional divisions of labor are provided. The advantages of the Partogramme are discussed.


The physiologic hyperparathyroidism of pregnancy. Is it primary or secondary? Controversy exists over whether the increase in maternal serum parathyroid hormone levels observed during the second half of pregnancy is due to autonomous parathyroid function or is secondary to changes in maternal serum ionized calcium levels. In order to study this problem further, 9 subjects were followed serially throughout normal pregnancy. Total serum calcium, ionized calcium, parathyroid hormone (PTH), calcitonin, and albumin levels were measured monthly. Six of these subjects had the studies repeated 6 weeks postpartum. Serum ionized calcium levels were found to decrease from 3.81 +/- 0.12 mg/dl to 3.63 +/- 0.18 mg/dl between 21 and 25 weeks' gestation. This decrease was significant at P less than 0.01. The ionized calcium remained in this lower range until term. A significant return to 3.77 +/- 0.1 mg/dl was observed 6 weeks postpartum. Serum PTH levels showed a significant rise after 21 weeks' gestation (P less than 0.05). No serial change in serum calcitonin was observed during pregnancy, although the mean level of the group was significantly higher than in nonpregnant controls (P less than 0.01). The increase in maternal serum PTH observed during pregnancy appears to be due in part to a decrease in maternal serum ionized calcium.


Maternal hypoxemia and fetal breathing movements. Fetal breathing movements (FBM) were observed daily using a real-time B-mode ultrasound method in a patient with sickle cell anemia in crisis. Observations were made on 2 occasions in the presence of maternal hypoxemia (PO2 less than or equal to 40 mmHg), and FBM were noted to be absent. Conversely, when maternal PO2 was 60 mmHg or greater, FBM were present 23--80% of the time. The FBM were reduced or absent within 90 minutes of maternal Demerol injection. These observations suggest that the human fetal response to hypoxemia may be similar to that observed under expermental conditions in the animal fetus.


Diffuse vaginal adenosis associated with imperforate hymen. A case of imperforate hymen associated with adenosis of the proximal surface of the obstructing membrane and of the vaginal wall is reported. The histogenesis of vaginal adenosis coexisting with congenital obstructive lesions is discussed, and the importance of careful follow-up of the patients with this type of anomaly is emphasized.


Clomiphene citrate therapy and associated ovarian endometrial cysts. Four cases are presented of ovarian endometrial cyst formation associated with the use of clomiphene citrate therapy for oligo-ovulation and infertility. All required surgical intervention. Clomiphene citrate should be used with caution in patients with pelvic endometriosis and ovulatory dysfunction.


Experience with teenage pregnancy.

Experience with teenage pregnancy. A retrospective study of 4224 deliveries to women age 19 or younger was conducted. The purpose of the study was to evaluate the characteristics of teenage pregnancy in an urban, predominantly nonwhite, socioeconomically depressed population. A total of 10,011 infants were delivered during the study period, with 42% (4224) of the infants born to teenagers. It is concluded that teenage pregnancy among the urban, nonwhite poor is characterized by poor outcome, primarily as a reflection of the high-risk obstetric population from which it derives, and only secondarily due to any risk inherent to maternal age. In addition, a striking characteristic of pregnancy in this age group is its tendency to repeat itself. Teenage pregnancy is a sociologic problem with medical consequences, and medical programs as they presently exist are incapable of bringing about the ultimate solution--prevention.


Women's attitudes toward gynecologic practices. Seventy-five female students and faculty members at a community college completed a questionnaire exploring their attitudes toward gynecologic procedures, their physicians, and the discussion of sexual concerns. Eighty-five percent reported negative feelings toward the pelvic examination (anxiety, vulnerability-humiliation, and dehumanization). Forty-one percent expressed negative feelings toward their physician's behavior, while 43% reported positive feelings. Seventy-two percent would not discuss sexual concerns with their physicians. A large percentage of recommendations (87%) addressed themselves to the doctor-patient relationship rather than to procedural matters (29%). These findings recommend serious self-scrutiny and behavior change on the part of physicians. Specific recommendations to alleviate the current situation are provided by the authors, and suggestions are made for incorporating the findings into educational environments.


A dynamic graph for documentation of gestational age. A graphic format is presented for the display and storage of data relating to gestational age. The graph permits rapid retrieval and synthesis of often confusion information and is thereby useful in the management of complicated pregnancies.


Midtrimester placenta previa: normal or pathologic finding. During the years 1974-1977 ultrasonic placentography demonstrated midtrimester placenta previa (MTPP) in 123 women. The procedure was performed because of vaginal bleeding in 65 cases and prior to amniocentesis in 58 asymptomatic cases. Eighty-eight patients were found to have grade I placenta previa (PP), 12 to have grade II, 14 to have grade III, and 9 patients to have grade IV PP. These different variants of PP were correlated with the ultimate outcome of these pregnancies: Bleeding due to PP or PP at term were reasons for cesarean section in 4 cases of grade I PP, in 2 cases of grade II, in 7 cases of grade III, and in 7 out of 9 cases of grade IV PP. Among those patients who had grades III and IV PP, 13 out of 23 had premature or immature deliveries. These results suggest that finding of MTPP, especially symptomatic MTPP, should alert the physician to the clinical significance of PP later in pregnancy.


Carcinoma of the vulva arising in condylomata acuminata. A case of carcinoma of the vulva arising in condylomata acuminata is presented. The patient was much younger than is classically reported for carcinoma of the vulva. The vulvar growth was first noted during pregnancy, and it continued to grow and enlarge following delivery. Malignancy appeared to develop after a relatively short time. It is sometimes difficult to distinguish vulvar condylomata acuminata from carcinoma from clinical evidence alone. It is, therefore, mandatory in doubtful cases to take multiple biopsies from the lesion before treatment is instituted.


A maternal death associated with prostaglandin E2. A maternal death following prostaglandin E2 (PGE2) administration is reported. It is suggested that prostaglandin may not be safer than other methods of uterine evacuation for late abortion and fetal death.


Congenital atresia of the cervix.

Congenital atresia of the cervix. A case of rare müllerian anomaly, congenital atresia of the cervix in a functional bicornuate uterus, is presented together with a review of the literature in English. The patient in this case took an active role in the decision regarding the nature of the surgical treatment she was to undergo. It is suggested that total hystrectomy with preservation of the ovaries is the treatment of choice.


Ultrasonic detection of "hourglass membranes" with funic presentation. Two cases of prolapse of the amniotic sac through a partially dilated cervix, the so-called "hourglass membranes," are presented. In both cases, ultrasonography revealed the umbilical cord in the prolapsed sac. Both fetuses were grossly immature, and efforts were made to delay labor. In neither patient did rupture of the membranes occur. Fetal distress developed in 1 case, necessitating an emergency cesarean section shortly after the initiation of tocolytic therapy. A 27-week, 800-g infant was delivered who subsequently died. The second case resulted in a 3-week delay in the delivery of a viable fetus who did well. It is concluded that when confronted with a very immature fetus, aggressive measures to delay delivery are justified.


Routine fetal heart rate monitoring in the antepartum period. A total of 4517 successful antepartum nonstress tests (NST) was performed on 2003 high- (28%) and low- (72%) risk obstetric patients. Most patients were monitored from 32 to 34 weeks' gestation onward. A reactive NST was defined as 2 accelerations in 10 minutes--15 beats/min minimum amplitude; 15 seconds minimum duration. The test was repeated at the next visit in low-risk patients with reactive NST or in 1 week in high-risk patients with this response. Nonreactive tests were followed immediately by a stress test in high-risk patients, but only after repeat nonreactive NST within 24 hours in low-risk patients. About 88% of low-risk and 86% of high-risk patients demonstrated ractive NST only. Late decelerations during subsequent stress testing or labor, low Apgar scores, and perinatal deaths were more common in low-risk pregnancies than in high-risk pregnancies and more common in those with nonreactive NST than in those with reactive NST. High-risk/reactive NST babies, however, fared better than low-risk/nonreactive NST babies. Of the 16 perinatal deaths 6 died antepartum, 2 died in labor, and 8 died as neonates. Presumed asphyxia accounted for 6 deaths while significant anomaly accounted for 5; sepsis and trauma accounted for 2 each. In only 2 instances was a reactive NST followed by a death from apparent asphyxia. Routine NST testing appears to improve the resolution of maternal risk classification and may contribute to better perinatal outcome.


An epidemiologic study of eclampsia.

An epidemiologic study of eclampsia. The epidemiologic characteristics of 298 cases of eclampsia treated from 1967 to 1974 in the Siriraj Hospital, Bangkok, Thailand, are described. The incidence of eclampsia was 0.2% of all deliveries, and the nulliparas had a higher incidence than the multiparas in all age groups. About 90% of patients had inadequate or no antenatal care, and 43% of patients suffered their first convulsion after admission to the hospital. Although the patient's own neglect was the major causative factor, physician error played some role in the development of eclampsia. The maternal mortality rate was 4.7%, and factors influencing maternal and perinatal death rates are discussed. The rate of cesarean section for eclamptics was 7%, as compared to a 3% rate for the general obstetric population. The findings suggest that more frequent use of properly timed cesarean section can improve the outlook for both the fetus and mother. An active program aimed at reducing the incidence of eclampsia and its maternal and perinatal mortality is emphasized.


The efficacy of intraamniotic steroids for induction of labor. Labor induction in humans by the injection of 18 mg of betamethasone (Celestone) into the amniotic sac was investigated in a group of 19 pregnant women. Eight of the  cases were high-risk pregnancies of 36-39 weeks' gestation, and 11 were normal pregnancies of 40-42 weeks' gestation. A group of 19 women at similar stages of pregnancy served as a control group. The criterion for the efficacy of the technique was the onset of labor or rupture of the membranes within 72 hours of the injection. Contrary to other reports, it was concluded that the technique is ineffective since no significant difference was found between the experimental and control groups.


Comparison of glucocorticoid conjugates with other indexes of fetal maturation. Controversy exists as to whether cortisol acts physiologically to accelerate human fetal lung maturation. Recent data from this laboratory showed that cortisol and corticosterone conjugates (GCS) rise fivefold in anmiotic fluid late in pregnancy and correlate well with the palmitic/stearic (P/S) ratio (r = 0.79). In this study GCS was compared with various tests of fetal maturation. In a series of 38 cases compared with the lecithin/sphingomyelin (L/S) ratio, the GCS and palmitic acid had the highest concurrence (84% agreement), followed by the "shake" test (82%), cortisol (74%), cytology (64%), gestational age determined by ultrasound (63%), and creatinine (47%). The GCS correlate better than cortisol itself, probably because cortisol in amniotic fluid is derived from the chorionic membrane as well as from fetal urine. These observations provide convincing evidence of a physiologic link between fetal lung maturation and alteration in fetal steroid production.


The radioreceptor assay for hCG in ectopic pregnancy. The Biocept-G test (Wampole) is a commercial modification of the radioreceptor assay for human chorionic gonadotropin (hCG) which takes 1 hours to process and has a sensitivity of 200 mIU/ml for hCG. Over a 9 1/2-month period, 70 consecutive patients with proven ectopic pregnancy were evaluated by the Biocept-G test, 2-minute urine slide test, and culdocentesis. Of 67 of these patients, 94% had a positive Biocept-G test, 82% had a positive culdocentesis, and 69% had a positive urine slide test. Sixty-nine (97%) of the 70 patients had either a positive Biocept-G and/or a positive culdocentesis, while only 1.7% had both a negative culdocentesis and a negative Biocept-G. Thirty-two patients underwent laparoscopy or laparotomy during this time period to rule out ectopic pregnancy but were not found to have this condition. The Biocept-G had a 94% accuracy rate in determining the presence or absence of intrauterine pregnancy in this group, compared to an 82% accuracy rate for the urine slide test. The Biocept-G has the highest true-positive rate for ectopic pregnancy published to date for a rapidly performed, commercially available pregnancy test.


A prospective study of the oxytocin challenge test and newborn neurobehavioral outcome. In a prospective study, infants of high-risk mothers delivered over a 1-year period were evaluated by clinical, biochemical, and behavioral methods. Of 67 newborns whose mothers had oxytocin challenge tests (OCTs), 54 were delivered after negative tests, and 13 after positive tests. Infants with positive OCTs had poor state organization and reflexive performance when compared with negative-OCT babies. These infants also showed evidence of intrauterine malnutrition, but did not have any greater asphyxiation than the negative OCT group. These results are consistent with the hypothesis that a positive OCT implies pathological placental respiratory insufficiency, which may be superimposed, in many instances, on impairment in utero of the placenta's nutritional function. The clinical manifestation of such dysfunction is the alteration in subtle neonatal neurobehavior.


Transverse vaginal septum.

Transverse vaginal septum. Transverse vaginal septum, perhaps the most common congenital anomaly of the vagina, is nonetheless an unusual finding. A case report and its management and theories concerning the embryology of the vagina are presented. The varying presentations of imperforate versus perforate transverse septa are reviewed, as well as diagnostic tools and treatment modalities. Surgical excision of the septum is advocated.


A prospective trail comparing hysterectomy, hysterectomy plus vaginal radium, and uterine radium plus hysterectomy in stage I endometrial carcinoma. From 1958 to 1967, a prospective randomized trial was conducted in 189 women with stage I, group I endometrial adenocarcinoma, comparing treatment by hysterectomy alone, preoperative uterine radium followed by hysterectomy, and hysterectomy and postoperative vaginal radium. All women have been followed for a minimum of 10 years. The actual survival rate at 5 years for all patients was 94.5% and at 10 years, 92.6%, with no statistical significance among the 3 treatment groups. Ther was also no statistical significance in survival rate in relation to size of uterine or myometrial invasion. There was a statistically significant difference in survival between grade I and grade III lesions (P less than 0.01) and between grade II and grade III lesions (P less than 0.05).


Brenner tumors of the ovary.

Brenner tumors of the ovary. The clinicopathologic findings in 24 cases of Brenner tumors of the ovary, seen at the University of Michigan Medical Center between 1941 and 1975, are reported. Abnormal uterine bleeding was the most common presenting symptom. Associated endometrial changes ranging from glandular hyperplasia to invasive adenocarcinoma were found in 5 cases. No consistent relationship was found between the thecomatous appearance of the stoma of the tumor and endometrial changes suggestive of estrogen stimulation. Seven patients had other types of ovarian neoplasms. Four patients had bilateral brenner tumors. Three Brenner tumors were histologically and clinically malignant. This study suggests that the presumed potential steroidogenesis of the Brenner tumors of the ovary may not always be a product of the thecalike cells of the stroma. The need for further biosynthetic studies is reemphasized. Furthermore, when conservative therapy of a benign tumor is attempted, the contralateral ovary should be carefully examined and a wedge resection considered. The optimal therapy of malignant Brenner tumors has not been established; adequate surgery and careful staging followed by individualized adjuvant therapy is recommended.


Serum lysozyme levels in patients with solid tumors. Serum lysozyme has been demonstrated to be an indicator for macrophage activity in the tumor-bearing host. Therefore, we investigated lysozyme levels in the sera of 336 untreated tumor patients (121 malignant melanoma, 61 lung cancers, 70 cervical cancers, 49 breast cancers and 35 benign breast tumors, and 36 healthy controls). Patients with malignant melanoma and lung cancer had significantly higher lysozyme levels than the healthy controls. Within the clinical stages in melanoma, there was a decrease of lysozyme in stages II and III in comparison to stage I, but still above that of the control values. Patients with benign breast tumors had normal levels, whereas in breast cancer patients of stages I and II there was a significant reduction in the lysozyme levels. In stages III and IV no differences to the control group could be detected. In patients with cervical cancer (FIGO II and III) serum lysozyme levels were found to be within the normal range. From this study it can not be concluded that serum lysozyme reflects the immunological reactivity of the tumor bearer. Nevertheless, the reduced levels in stages I and II of breast cancer might point to an immunological defect.


C cell adenoma of the human thyroid gland. A case of C cell thyroid adenoma in a 47-year-old female patient is described. The nodule showed progression over 34 years. The adenoma cells showed histochemical and ultrastructural properties characteristic for C cells. Histologic examination revealed no atypical features of nodule cells nor infiltration of capsule by neoplastic cells. In the period of 8 years following the excision there was neither recurrence nor metastases.


Indication and clinical evaluation of radical and semiradical neck dissection on the basis of 271 operations. Between the period of 1956 and 1973, 271 radical and semiradical neck dissections were performed. The 'en bloc' method was used in 75 patients with cancer of the larynx and in 47 thyroid cancer patients. Analysis of the patient material revealed the operative mortality of 1.5%. 5-year survival was observed in 34.8% of the patients. The incidence of local recurrence amounted to 21%.


Effect of 1(4-amino-2-methyl-5-pyrimidinyl) methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) on Sato lung carcinoma (SLC). Preliminary result of immunochemotherapy for SLC by combination of ACNU and Propionibacterium acnes. ACNU was highly effective for Sato lung carcinoma transplanted intravenously or intramuscularly by using a large single dose, and the cytotoxic action of ACNU for SLC showed clear dependence upon tumor size. Nonspecific activation of host-defence mechanism by Propionibacterium acnes contributed to the suppression for the regrowth of solid SLC treated by ACNU.


Prosthetic replacement of the patellofemoral joint. We are just beginning to fully appreciate the significant role of the patellofemoral joint in total knee replacement surgery. Most of the new generation prostheses have a flanged femoral component. The tendency is to make the flange more anatomic in shape as more attention is paid to patellar tracking. Most systems have an optional polyethylene button to resurface the patellar side of the patellofemoral joint, and indications for its use are increasing. Although pain relief with patellar buttons seems uniform, the potential complications of stress fracture, loosening, and wear must temper our enthusiasm for their use until there is longer follow-up. Vitallium hemiarthroplasty of the patella is available in prostheses with and without the requirement for cement fixation. Most investigators have good results in chondromalacia (as a secondary procedure), but the experience in the literature is small. Results have been poor when the femoral side of the joint has been involved. Metal to plastic isolated patellofemoral prostheses have been designed to treat disease on both sides of the patellofemoral joint or to salvage unflanged total knee replacements with residual patellofemoral symptoms. Short term experience has been promising.


The synovial fluid.

The synovial fluid. The synovial fluid is readily available for study in all cases of effusion. Whenever a question of diagnosis arises, the fluid should be removed for study. Removal of large effusions gives temporary relief of pain. The fluid removed should be smeared on a slide, stained with hematoxylin and eosin, and plated for bacterial, viral, and fungal cultures. The solid constituents of the fluid can easily be studied in the simplest of laboratories. Most of the constituents of plasma are present in synovial fluids. Quantitation of glucose, protein, and cells and an attempt to identify crystals, cartilage fragments, or even foreign bodies are crucial to therapy and the evolution of the disease.


Synovectomy of the knee joint.

Synovectomy of the knee joint. Patients with active rheumatoid arthritis of the knee should be considered for synovectomy to arrest the disease and to preserve joint function. Careful selection of patients on the basis of the weight bearing roentgenogram is important. Surgery should not be delayed if there is evidence of progression of the disease on serial roentgenograms, or if the original films reveal early joint disease. Preservation of the suprapatellar pouch to prevent adhesions of the quadriceps mechanism greatly improves the postoperative range of motion. Long term follow-up over 10 years has demonstrated the value of synovectomy in rheumatoid arthritis of the knee.


Diagnosis of osteoarthritis: the value of laboratory tests. Osteoarthritis by definition involves a progressive degeneration in one or many synovial joints and has a multifaceted etiology. The limitation of pathologic responses to an initial insult minimizes the value of microscopic examination of the tissues long after the original injury. The cornerstone of diagnosis has been the plane film x-ray examination, which allows the study and comparison of macroscopic changes that are common to osteoarthritis and aids in diagnosing other causes of arthritis. Synovial fluid analysis in doubtful diagnoses is useful in ruling out specific arthritides such as infection or crystal induced arthritis, or in pinpointing inflammation as a factor in the individual case. Synovial fluid studies are especially important in allowing recognition of conditions in which appropriate treatment can prevent secondary osteoarthritis, e.g., sepsis. This technique may also be necessary to rule out sepsis before implant joint reconstitution.


Laboratory diagnosis  of postoperative sepsis of the musculoskeletal system. The diagnosis of acute sepsis after musculoskeletal surgery is based on the results of the clinical examination. Microbiologic evaluation of clinical specimens permits identification of the causal organism(s) and of the susceptibility studies. In the subacute stage of postoperative sepsis, roentgenographic examination, a peripheral leukocyte count, erythrocyte sedimentation rate, hemoglobin level, and nuclear scans can be helpful to the clinician. Frozen section histologic examination of tissues and Gram staining of fluids obtained at surgery have resolved the choice in differential diagnosis between aseptic and septic loosening of painful prosthetic components. Laboratory evaluation, including tissue biopsy, identifies the chronic complications of amyloidosis and malignant change in patients with long term sepsis of the musculoskeletal system.


Anemia in the orthopedic patient: a diagnostic approach. Anemia is the most common hematologic abnormality in the orthopedic patient. The diagnostic work-up is relatively simple if a systematic routine for ordering laboratory test is employed. The approach presented here includes a series of alogarithms incorporating pertinent laboratory tests that allow for a presumptive diagnosis and subsequent confirmation of a particular disease process. Whether all or none of the confirmatory tests is carried out depends on the severity of the anemia as well as the clinical setting. Failure to confirm a diagnosis means that other pathways should be followed or that additional diagnostic possibilities should be considered. There has been no attempt to cover all diagnostic possibilities should be considered. There has been no attempt to cover all diagnostic possibilities but rather to demonstrate a general approach to laboratory utilization.


The Dens-Arch synchondrosis versus the Hangman's fracture. The synchondrosis between the dens and arch of C2 is a normal structure in infants and children. It is not visible on lateral views of the cervical spine, but is routinely visible on oblique views. In such cases it has a distinct tendency to mimic a C2-arch fracture. The varying appearance of this synchondrosis and its differentiation from a true fracture of C2 are the subjects of this report.


CT whole-body scanning and scintigraphy in children with malignant tumours. A comparative retrospective study. A restrospective comparison between CT and scintigraphy with 99mTechnetium-phosphate (Tc-P) and 67-Gallium-citrate (GA) has been performed in 8 children with malignant extracranial tumours and in 9 children during concurrent control after treatment. CT was superior to scintigraphy in the primary tumour evaluation with regard size, type and invasiveness of the tumour. In the same way, regression, progression or local recurrence after treatment was better visualized by CT than by Ga and Tc-P scanning. In the detection of secondary spread of the tumour, CT is most sensitive of the modalities in the examination of the lungs, whereas Tc-P schintigraphy still is the method of choice to study metastases in the skeleton.


Shunt metastases of pineal tumors presenting as a pelvic mass. Three children with pineal area tumors and ventriculoperitoneal shunts developed pelvic masses. In two, the solid masses reflected tumor cells seeded to the Pouch of Douglas while the third developed a loculation of fluid and tumor cells at the shunt tip.


Intestinal perforation in newborn following intrauterine meconium peritonitis. A newborn infant, who had suffered intrauterine perforation and had developed peritoneal calcification, showed no sign of pneumoperitoneum on the first radiograph taken 3 hours after delivery. At that time air was present in the stomach only. Subsequently pneumoperitoneum developed as air passed down the gut to the point of perforation. Thus, the absence of pneumoperitoneum on a radiograph taken very early in life does not exclude an intestinal perforation.


Radiological features in trisomy 8.

Radiological features in trisomy 8. Radiological study may prompt the correct diagnosis of Trisomy 8 mosaicism when the clinical features are mild and could be overlook. Skeletal features characteristic of Trisomy 8 are found in the skull, elbows, spine, pelvis, hands and feet.


Subglottic mucocele in an infant.

Subglottic mucocele in an infant. A subglottic mucocele caused partial obstruction of the upper airways. The radiologic findings were asymmetrical narrowing of the subglottic area with a mass arising from its posterior wall simulating a subglottic hemangioma. Surgical treatment was successfull.


Venous angioma of the neck in a child.

Venous angioma of the neck in a child. Venous vascular masses in the neck are rare entities in the pediatric population. Aneurysmal dilatation or ectasia of the superficial cervical vein, the so-called "venous angioma" is a very uncommon condition. A 12-year old female with venous angioma involving the right neck is described. The preoperative diagnosis was confirmed by angiography.


Radiological aspects of the small bowel after extensive resection in children. The authors present radiological aspects of small bowel after extensive resection. They describe the main phenomena related to compensatory hypertrophy: dilatation of the loops, mucosal fold-thickening and motor disturbances. The main complications demonstrated by the radiological examination are presented; gallstones, non-functioning anastomosis, bacterial overgrowth.


Trichuriasis. Roentgenographic features and differential diagnosis with lymphoid hyperplasia. Twenty patients with massive trichuriasis were studied with double contrast barium enema. The following changes were observed: 1) Impregnation defects of the colonic wall probably due to abundant mucous secretions. 2) Granular features. 3) Pear-shaped caecum. 4) Radiolucid ringlike images with some contrast material in its center, similar to those seen in lymphoid hyperplasia. On closer observation it was seen that the radiolucid ring was not complete and was continued by a prolongation which corresponds to the whipworm. This feature is central to the differential diagnosis.


Acroosteolysis. Problems of diagnosis--report of four cases. Four cases of idiopathic acroosteolysis are reported. The first is a common phalangeal type, the second, the Hozay variety. The third case was diagnosed after a mumps infection, and marked regress of the changes was noted in the following years. The fourth case shows skin changes, periostitis, mild osteosclerosis, and skull changes as well as acroosteolysis.


The wide spectrum of the asphyxiating thoracic dysplasia. Seven cases of A. T. D. are presented. Radiological findings were extraordinarily diverse. The prognosis of the disease is difficult for each individual case, because of the frequent pulmonary complications and cystic renal lesions are not always directly related to the severity of the bone changes. The authors believe that the term "thoracic-pelvic-phalangeal dysplasia" proposed by Langer, is the most adequate, since it points to the key factors in the diagnosis of the disease.


Neonatal hyperviscosity: I. Incidence.

Neonatal hyperviscosity: I. Incidence. Capillary hematocrits were performed on 790 infants during the first four hours after birth. These infants were delivered between August 8 and December 7, 1974, at the University of Colorado Medical Center, which is at an altitude of 1,061 m above sea level. When the capillary hematocrit was 7% or greater, venous hematocrit and blood viscosity were determined. Capillary hematocrits obtained from warmed heels in the first hour after birth were spuriously high and not consistently related to venous hematocrit. Venous polycythemia, defined as a hematocrit of 65% or greater, occurred in 4% of the newborn population. Hyperviscosity (greater than 2 SD above the mean for newborns) occurred in 5% of the newborn infants. At a venous hematocrit of 65% or greater, hyperviscosity was predictable, but some infants with venous hematocrits between 60% and 64% also had hyperviscosity of the blood. The incidence of polycythemia and hyperviscosity was further related to birth weight and gestational age. The infants who were small for gestational age were at highest risk of polycythemia and hyperviscosity, followed by infants who were large for gestational age. However, the greatest number of infants with hyperviscosity were term appropriate for gestational age. Preterm infants with gestational ages of less than 34 weeks were not affected.


Obstructive sleep apnea and near miss for SIDS: I. Report of an infant with sudden death. An infant girl followed up from birth to death at the University Medical Center had ""congenital stridor'' and a ""near miss for SIDS'' event at 3 months of age. As part of an ongoing SIDS research project, she underwent 24-hour polygraphic monitoring at 21 weeks of age. Sudden infant death occurred within 30 hours after the polygraphic study. Polygraphic data obtained from this infant are compared with those from control infants and other infants with near miss for SIDS who were of similar ages. The number of mixed and obstructive respiratory events during sleep was abnormally high on the infant's recording. Histologic findings, involving particularly the midline structures of the brain stem, are discussed.


The effects of stimulant medication on the growth of hyperkinetic children. This article reviews the literature on possible growth-suppressing effects of stimulant medications in the long-term treatment of children with the hyperkinetic behavior syndrome. The evidence clearly indicates a temporary retardation in the rate of growth in weight and suggests a temporary slowing of growth in stature, but no effect on adult stature or weight. This temporary effect on growth is present during the first few years of treatment and seems related to drug dosage and to the presence or absence of drug holidays. These conclusions related specifically to treatment during the prepubertal period; little is known of the growth-related effects of treatment extending through pubescence.


Manometry and histochemistry in the diagnosis of Hirschsprung's disease. Acetylcholine esterase histochemistry and rectal manometry have been used sequentially to evaluate constipated children and to make the diagnosis of Hirschsprung's disease. When applied together, these modalities give a reliable diagnosis of Hirschsprung's disease, restricting the use of deep rectal biopsy to those patients in whom symptoms are most suggestive of Hirschsprung's disease. Acetylcholine esterase histochemistry may be more reliable than rectal manometry in the newborn and premature periods. It is hoped that the combined use of these techniques may make deep rectal biopsy obsolete except in patients with hypoganglionosis.


Malignant paraganglioma (pheochromocytoma) of the urinary bladder: report of a case and review of the literature. A rare case of malignant paraganglioma of the urinary bladder with metastasis to a lymph node in a 12-year-old girl is reported, and eight other previously recorded cases are reviewed. Headache, fainting, and hypertension initiated by voiding were the most prominent clinical symptoms. Hematuria was present in three cases and aided in prompt diagnosis. Cystography, pelvic angiography, and cystoscopy were most diagnostic. Segmental cystectomy when feasible, was the preferred surgical treatment. The prognosis was slightly better than for other forms of extraadrenal pheochromocytomas.


Renal anomalies in fetal alcohol syndrome. Six patients with fetal alcohol syndrome were found to have developmental abnormalities of the kidney. In only one patient was investigation for renal pathology made in the absence of clinical indication. Two had palpable masses in the left upper quadrant, one had pyelonephritis, one had painless hematuria, and the fifth patient had symptomatology suggestive of renal failure. Although the renal pathology was not of the same type in all cases, it is of interest that four patients had either unilateral or bilateral renal hypoplasia.


Conotruncal malformation complex: examples of possible monogenic inheritance. Two families are described in which there is possible monogenic inheritance of congenital cardiac defects within the spectrum of faulty conotruncal septation (CTS). Evidence for a genetic control of conotruncal septation arises from genetic and embryologic studies of similar defects in the Keeshond dog model, the excess of sibship pairs with conotruncal septation defects in sibship pairs with congenital heart diseases, and previously reported pedigrees of families with multiple affected individuals with conotruncal septation defects. It is suggested that in the small number of cases of congenital cardiac defects in which there is a strong family history for CTS defects, a higher recurrence risk should be considered rather than the usual polygenic recurrence risk of 3% that is usually given in such situations.


IQ measurement in children with skeletal dysplasia. We have reviewed the IQ studies on 68 children with skeletal dysplasia. These data should provide useful information for the counseling of parents with newborn affected children. Previous studies have documented retardation and hydrocephalus in association with achondroplasia. Some parents report that they were given a poor prognosis for their child's mental development early in his or her life. This study shows that the 34 children with achondroplasia and 34 with other skeletal dysplasia performed intellectually in the same range as other children.


The role of the pediatrician in the delivery of mental health services to children. Nine pediatricians reported on all patients seen during a four-week period in January and February 1976 in Monroe County, N.Y., to determine the prevalence and nature of mental health problems seen in their practices, the characteristics of the affected children, and the treatment provided to them. Of the 3,742 patients seen, 187, or 5.0%,were reported to have an emotional, behavioral, or school problem. The prevalence rate ranged from 1.4% to 7.8% by pediatrician, with five reporting rates within +/- 1.2% of the mean. High rates were associated with children in the 7 to 14 year age group (9.9%), those on Medicaid (8.6%), those who were not living with a father (10.9%), those whose presenting complaint was a chronic physical condition (11.7%), and children with a disease of the digestive system (16.7%) or with ""symptoms, signs and ill-defined conditions'' (14.3%). Functional impairment was reported to be moderate or severe in 40% of the 187 children with mental health problems. The most frequently reported problems (primary or otherwise) were adaptation reaction (22.5%), specific learning disorder (19.3%), hyperkinetic disorder (19.3%), psychosomatic disorder (12.8%), and conduct disorder (12.8%). The most frequent form of treatment provided was supportive therapy or counseling (85.6%) and suggestions regarding environmental changes (43.3%). Drugs were prescribed for 16.0% of the affected children, with 6.4% receiving methylphenidate or amphetamines. Referral for psychological care or consultation was made for 36.9%. The frequency of mental health problems observed by the pediatricians was about five times the annual rate of Monroe County children contacting a psychiatric inpatient or outpatient setting.


Difficulties in providing intensive care. The results of a pilot project investigating the feelings, attitudes, and behavior of physicians working in a pediatric intensive care unit are presented. With recent technologic advances in out capacity to help patients suffering from catastrophic illness, various segments of American society have become concerned about the unrestricted use of medical science. Questions have arisen about the economic costs, long-term medical outcome, emotional costs to patients and families, legal problems, and ethical implications of "heroic" therapy. By contrast, we have asked relatively few questions about the social processes involved in providing intensive care. We know little about the emotional and functional responses of the physicians in critical care facilities, and their decision making processes remain obscure. This investigation evolved from the conviction that environments comprised of sophisticated medical technology and extensive life support systems pose pressing problems for those working and learning in them.


The influence of funding on the future of pediatric nurse practitioner programs. Current funding sources threaten the future position of PNPs as providers of primary care. Most nurse practitioner programs of all disciplines including pediatrics rely for funds on the Division of Nursing, Bureau of Health Manpower, Department of Health, Education and Welfare. These funds are sufficient only for about half of currently operational programs and other sources of financing are not adequate to support the remainder. Another factor affecting the future of such programs is the trend to modify the preparation of the nurse practitioner from the clinically centered continuing education format to that based in schools of nursing and directed toward the MS degree. This is against the fundamental philosophy of the training of the PNP and will lead to diminishing participation of pediatricians in training programs. Unless there is evidence to show that the shift to graduate type education is fundamental to the competence of the nurse practitioner, the enthusiastic nurse who chooses to extend her professional skills should be allowed to do so without limiting this activity only to those who seek advanced academic degrees.