Chronic active hepatitis in a patient presenting with clinical and serological evidence of SLE. A patient with clinical and serological manifestations of systemic lupus erythematosus (SLE) without renal or neurological manifestations was managed conservatively for 4 1/2 years. At this time she developed ascites and abnormal liver function tests, and was found to have severe chronic active hepatitis (CAH) with cirrhosis and portal hypertension. No clinical or biochemical evidence of liver disease was documented over the first 3 1/2 years of her illness, though no tests were performed in the 12 months before diagnosis. This case emphasizes the value of monitoring liver function tests over extended periods in such patients, since appropriate immunosuppressive therapy may benefit CAH, and as in this case, systemic manifestations of CAH may simulate SLE and precede clinical liver disease.


Systemic lupus erythematosus, partial lipodystrophy and hypocomplementemia. A patient with partial lipodystrophy, increased susceptibility to infection and a clinical picture compatible with systemic lupus erythematosus is described. This patient had persistently low serum C3 levels and a C3-cleaving factor similar to the C3 nephritic factor (C3NeF). During periods of disease inactivity, serum levels of the other components of the classical and alternative pathways of complement measured were normal; heat labile opsonic capacity was low, suggesting functional depletion of factors of the alternative pathway of complement activation.


Osteomalacia complicating a blind loop syndrome from congenital megaesophagus-megaduodenum. A young female with osteomalacia complicating a blind loop syndrome associated with congenital megaduodenum is described. In this case, the correction of vitamin D malabsorption by administration of antibiotics highlights the role of massive intraluminal bacterial overgrowth from destruction of vitamin D, or decreased unicellar solubilization due to deconjugation of biliary acids. The importance of cutaneous vitamin D synthesis in patients with osteomalacia of gastrointestinal origin is emphasized. The detection of megaduodenum and megaesophagus in the patient's father may be the first report of a familial association of these gastrointestinal abnormalities.


Osteomalacia and weakness complicating jejunoileal bypass. Five years following jejunoileal intestinal bypass surgery for obesity, a patient developed debilitating weakness and muscle pain. Osteomalacia was suspected clinically by radiographic and laboratory abnormalities and confirmed by bone biopsy. Malabsorption was documented as well as secondary hyperparathyroidism. Successful treatment of this syndrome with vitamin D and calcium identified a medically reversible disorder which obviated the need for surgical reanastomosis.


The development of membranous glomerulonephritis in a patient with rheumatoid arthritis and Sjögren's syndrome. A case of classical rheumatoid arthritis and Sjögren's syndrome complicated by the development of membranous glomerulopathy is presented. Circulating immune complexes were demonstrated. The possible relationship between glomerulitis and rheumatoid arthritis is discussed and the literature is reviewed. Chrysotherapy was instituted because of persistent synovitis. The patient responded and her proteinuria did not increase.


Electron microscopic study of depot corticosteroid crystals with clinical studies after intra-articular injection. Depot corticosteroid crystals and their in vivo handling after intra-articular injection have not been studied by electron microscope (EM). We therefore injected 20 mg of either prednisolone tebuate or triamcinolone hexacetonide into knee joints of 7 patients with osteoarthritis and painful effusions. Six patients had a rise in the synovial fluid leukocyte counts, but only 1 patient had clinical evidence of a post-injection flare. Scanning and transmission EM revealed intra- and extracellular crystals 24 hours and 1 week after the initial injection. These combined EM studies provide an adjunct to compensated polarized microscopy in differentiation of depot steroid from other crystals.


Vasculitis of the gallbladder in a 70-year-old man with giant cell (temporal) arteritis. A patient with giant cell (temporal) arteritis developed acute cholecystitis related to vasculitis. Histopathologically, the vasculitic lesions in the gallbladder resembled polyarteritis nodosa. In addition to demonstrating the rare occurrence of vasculitis of the gallbladder in a patient with giant cell arteritis, this case points out the inadequacies of currently used criteria to separate the various forms of arteritis.


Psycho-social adjustment of rheumatoid arthritis patients from two alternative treatment settings. Fifty rheumatoid arthritis (RA) patients are compared with a control sample of 72 non-patients on five attitude scales which measure psychol-social adjustment. Patients generally indicate more negative attitudes toward self, which are significantly related to variables such as severity of condition and socio-economic status. The adjustment of patients who are being treated by registered nurses (physician extenders) is not significantly different from that of patients who are being treated by physicians.


University center and community hospital: problems in integration. This study of health care in Chicago and its suburbs deals with a dilemma faced by many university hospitals located in our nation's metropolitan areas. Because of a massive displacement of population from the city to its suburban ring, some of the major medical centers in Chicago's inner zone have experienced a leveling-off of inpatient admissions. In contrast, outer zone and suburban community hospitals are in need of referral sources with specialized personnel and equipment to accommodate growing admissions. This imbalance would be corrected in a regional network based on an exchange of clients and services. A case study of the University of Chicago Medical Center highlights the tensions, strains, and resistances which inhibit the development of such a system and thus raises questions about the role of the research and teaching hospital in regional health care planning.


Hospitals and medical schools as factors in the selection of location of practice. A study analyzing the relationship between the state in which a physician practices and the location of residency training was conducted using as subjects 467 individuals who entered graduate medical training programs at the University of Texas Southwestern Medical School at Dallas. The study population included physicians who were graduated from medical schools between 1955 and 1969 and who entered a phase of graduate training (internship/residency) at one of Southwestern Medical School's affiliated teaching hospitals. Results of the study support the conclusions of an earlier report that stressed the influence of the location of residency training in retaining physicians in Texas. The statistical findings indicate that if all other factors are equal, additional residency positions filled by graduates of medical schools in the same state might aid in increasing the retention rate of medical practitioners there.


A teaching hospital medical clinic: secondary rather than primary care. Although medical clinics in teaching hospitals are said to dispense primary care, the assertion has not been established by formal descriptions of care in such clinics. In this paper the authors describe 287 patient visits to a medical polyclinic (where generalists and subspecialists of internal medicine practice together) over a one-year period. The prevalence of disease was much higher than in existing descriptions of office-based primary care. The majority of visits to subspecialists involved medical problems relevant to the subspecialty, but both subspecialists and generalists dealt with medical problems across subspecialty lines because most patients had multiple problems. Although the data indicate these patients' need for accessibility, comprehensiveness, coordination, and continuity is at least as great as that of patients receiving primary care, this clinic is most appropriately described as a secondary-care facility.


Histocompatibility antigens in paraplegic or quadriplegic patients with sacroiliac joint changes. HLA typing for the A and B loci and radiographic examination of the sacroiliac joints were performed in 54 randomly selected patients with paraplegia or quadriplegia of more than 3 years' duration. The sacroiliac joints were abnormal in 24 patients. No association was found between any of the HLA antigens of the A and B loci and the sacroiliac joint changes. There was, however, an increased incidnece of sacroiliac joint changes in quadriplegic as compared to paraplegic patients.


Inpatient performance of primary care residents: impact of reduction in time on the ward. The inpatient (ward/intensive-care-unit) performance of primary care medical residents was compared with that of their peers in the standard internal medicine residency program. The primary care residents spent half as much time on inpatient rotations as did their peers in the first two years of training. History-taking, physical examination, case presentation, record-keeping, patient management, and overall performance were assessed and scored by the attending physicians using the American Board of Internal Medicine's Clinical Performance Evaluation Form. The performances of the two groups were nearly identical, suggesting that substantial time in the first two years of residency can be devoted to ambulatory training without markedly compromising development of acute care skills.


The impact of a required preceptorship on senior medical students. The impact of a required preceptorship program was measured by comparing the perceptions of senior medical students who would have elected the preceptorship rotation had it not been required (the elective group) and those who participated only to fulfill the requirement (the required group). The main difference between the two groups before the preceptorship was the elective group's career preference for family medicine and the required group's preference for an internal medicine subspecialty. The preceptorship had no impact for either group on inclinations toward other specialties, preferred practice setting, or assessment of practice location determinants. Both groups, however, perceived an increase in knowledge of primary care practice and confidence in relevant clinical skills following the preceptorship. These results are used to support the value of a required preceptorship program.


Septic subcutaneous bursitis. Report of sixteen cases. Sixteen cases of bacterial infection of subcutaneous bursae were reviewed. Septic subcutaneous bursitis usually occurred following injury to the skin overlying the bursa. Two cases developed after bursal corticosteroid injection for treatment of aseptic bursitis. Bursal fluid culture yielded staphlococci in 14 cases and streptococci in 2. Blood cultures obtained in 8 patients were negative. No patient had clinical manifestations suggestive of bacteremia. Needle and/or incisional drainage of the bursa plus systemic antibiotics led to uneventful recovery in 14 patients. Two patients had chronic drainage. One resolved spontaneously and the other required bursectomy.


Teaching interviewing skills by encountering patients. First-year psychiatric residents were observed to lack many interviewing skills considered to be necessary for both physicians and psychiatrists. A method of teaching the skills in a group setting with live patients was constructed. The essential feature of the method is the total direction of attention to the process of interviewing as opposed to the content of the interview. Segments of videotaped interviews of the residents taken before and after the seminar series were rated by examiners who did not know the residents. In addition, participants reported a number of features about this seminar which helped them to improve their interviewing skills. The research results supported the self-report changes, demonstrating that each resident improved on the qualities measured as empathy, congruence, and level of regard.


Two types of amino acid substitutions in protein evolution. The frequency of amino acid substitutions, relative to the frequency expected by chance, decreases linearly with the increase in physico-chemical differences between amino acid pairs involved in a substitution. This correlation does not apply to abnormal human hemoglobins. Since abnormal hemoglobins mostly reflect the process of mutation rather than selection, the correlation manifest during protein evolution between substitution frequency and physico-chemical difference in amino acids can be attributed to natural selection. Outside of 'abnormal' proteins, the correlation also does not apply to certain regions of proteins characterized by rapid rates of substitution. In these cases again, except for the largest physico-chemical differences between amino acid pairs, the substitution frequencies seem to be independent of the physico-chemical parameters. The limination of the substituents involving the largest physico-chemical differences can once more be attributed to natural selection. For smaller physico-chemical differences, natural selection, if it is operating in the polypeptide regions, must be based on parameters other than those examined.


Prebiotic nucleotide oligomerization in a fluctuating environment: effects of kaolinite and cyanamide. The day kaolinite was tested for its ability to promote nucleotide oligomerization in model prebiotic systems. Heterogeneous mixtures of clay, water and nucleotide were repeatedly evaporated to dryness at 60 degrees C and redissolved in water in cyclic fashion in the presence or absence of cyanamide and/or ammonium chloride. With or without cycling, kaolinite alone did not promote the oligomerization of nucleotides at detectable levels. Cycling of clay in combination with cyanamide, however, promoted high levels of condensation to a mixture of oligonucleotides and dinucleotide pyrophosphate without requiring ammonium chloride. Although cycling with clay favored synthesis of dinucleotide pyrophosphate, cycling without clay enhanced formation of oligonucleotides. These results support the hypothesis that the presence of clays in fluctuating environments would have influenced the -ourse of prebiotic condensation reactions.


Countertransference as a factor in premature termination of apparently successful cases. In brief sex therapy rapid disappearance of symptoms may appear to signal success. However, superficial indications of success may be utilized by the sex therapist as an opportunity to escape from a therapeutic situation which evokes uncomfortable feelings. The need to terminate treatment abruptly may be conscious or unconscious. This presentation discusses a few of the multiple factors which may lead the therapist to initiate premature termination or to collude with the patient's problems rather than the patients' to alert clinicians to the adverse effects of countertransference.


Treating the marital crisis with the two-marriage equation. The technique the authors call"two-marriage therapy" (conjoint cotherapy by a married cotherapy team) has been developed to help the couple in a marital crisis confront the elusive nature of marriage, a being with self-images and unconscious deceptions, different from, but not separate from, the images and unconscious deceptions of the separate spouses. The key to the two-marriage analysis os discovering the limitations of cooperative relationships based on roles and expectations and the exploration of a mode of concern we term "coliberation". This paper attempts to show how the presence of a married cotherapy team facilitates this process and adds a significant salutary perspective on the marriage in conflict.


The weekend workshop for dysfunctional couples: assets and limitations. Two major new trends are emerging in the field of sexual counseling: the use of self-help programs and the increasing reliance on group therapy to overcome specific sexual complaints. The weekend sexual enhancement workshop represents a synthesis of both trends, but efficacy regarding outcome has not been well documented. In order to investigate specific changes in sexual and marital adjustment, two intensive weekend programs were conducted. Pre- and postmeasures were obtained for both groups. Based on the results of 15 couples who displayed a diversity of sexual dysfunctions, several conclusions can be drawn. The weekend workshop format appears effective in achieving three of its four major goals: (1) Couple communication improves via the stimulus of new information, group discussion, and permission to talk sexually. Marital satisfaction increases, particularly where the history of marital conflict is not chronic. (2) Attitude change occurs, and erroneous beliefs are relinquished in the face of new input. (3) The frequency of sexual interaction increases. (4) Long-standing sexual dysfunctions are not resolved as a result of group participation and information on self-help methods alone. Finally, the role of such weekend programs in sexual counseling in discussed.


Trace elements: an association with cardiovascular diseases and hypertension. Abnormalities associated with trace elements have not received much attention from clinicians in the past; however, in the past few years there has been a veritable explosion of knowledge about trace elements which are associated with abnormalities in experimental animals as well as in humans. The information explosion is rapidly reaching the stage where clinicians will be called upon more frequently to diagnose and treat trace element-related maladies.This article introduces to the clinician some pertinent relationships between several of the more common trace elements and their suspected relationship with cardiovascular diseases and hypertension.


Intramedullary tuberculoma of the spinal cord. In the differential diagnosis of intramedullary masses or tumors of the spinal cord, tuberculoma is an often overlooked possibility. Although rare, this entity should be considered in the differential gamut of spinal cord lesions even in the presence of a normal chest x-ray.


Outer space medicine and relevant ongoing biomedical research. An update of outer space medicine is given emphasizing main areas such as cardiopulmonary responses, vestibular functions, physiology, weightlessness, ecosystems, and radiation. A prospective view is also presented on the medical problems resulting from various hazards of outer space and planetary missions. Although an outgrowth of aviation and environmental medicine, this relatively new, special branch of medicine is currently undergoing an unprecedented rise as a vital modern specialty. The aims of the United States, Russia, and the nations of Europe in space research are shown to be in accord in learning how to live and work in space when confronted with the unique factors of zero gravity, cosmic radiation, and magnetic variations.


Respiratory effects of a single, moderately acute, smoke inhalation episode. Twenty-three hospital employees who suffered ill effects of smoke inhalation were pulmonary-function tested within 72 hours, after ten weeks, and again after 45 weeks of exposure. Four nonexposed control subjects were selected for comparison of data.Exposed persons commonly had restrictive lung disease which may have resulted from stimulation of irritant receptors in bronchi and/or interstitial edema of chemical injury at the level of the ventilation-perfusion unit. Airways obstruction was infrequent, despite the possibility of inhalation of di-isocyanates, an intermediary product of burning polyurethane foam that may cause chemical asthma. Eye and constitutional symptoms were also frequent.Clinical recovery was as a rule rapid and complete (within a week), but physiologic recovery was protracted (over 45 weeks in some cases). Most surprisingly, cigarette smoking and/or presence of cardiopulmonary disease did not contribute to morbidity.


Congenital stenosis of the cervical spine: diagnosis and management. An analysis of 11 cases of congenital stenosis of the cervical spine seen over the past three years is reported. The authors' experiences at an urban community hospital, as well as a large Veterans Administration Hospital, lead them to conclude that this disorder is a neurologically significant anomaly which is probably more common than published reports would imply. It can be clinically and radiographically distinguished from "pure" cervical spondylosis, to which it is related, and its treatment should be appropriately modified. It appears to have a predilection for young adult black males, and cervical myelopathy is the predominant clinical feature. Varying degrees of trauma, a disease endemic to the inner city, plays a major role in precipitating the neurological catastrophes associated with this potentially correctable disorder. Proper management of this entity demands a heightened awareness of its existence as well as a high standard of neurological and roentgenographic diagnosis, and operative performance. A flexible operative strategy which takes into account the specific biomechanical factors involved in this disorder as well as the patient's individual physiological and social status is imperative. Surgery offers a good opportunity for improving neurological function.


Endurance, strength, and coordination exercises without cardiovascular or respiratory stress. In an attempt to maintain physical health, the author studied various exercises and after six years of research has knowledge of a form of exercise which increases endurance, strength, and coordination without cardiovascular or respiratory strain. This paper introduces five exercises, outlines their physiology, and proposes some aspects of their mechanisms of action.


Perforated duodenal ulcer in a tropical African population. Duodenal ulcer is common in tropical African countries. In many cases, the patients are first seen as cases of gastric outlet obstruction because, in this environment, people present at the hospital in late stages of disease. Perforated duodenal ulcer in this environment, however, has received very little attention in the literature because previously it was rarely seen. It is not unlikely that some cases of severe gastric outlet obstruction from chronic duodenal ulcer are due to unrecognized perforated duodenal ulcers that have healed.Perforated duodenal ulcer is seen mainly in males, and many of these patients have never before been diagnosed as cases of peptic ulcer disease. The disease seems to be more common in people with blood groups O and AB. The majority of cases have a positive radiological examination.As the duration of presentation is relatively long, all patients in this series are treated with satisfactory results by simple closure and abdominal toileting.Gastric ulcer was not seen during this period of review.


Simplified double contrast examination of the esophagus. A modification of the "straw technic" of Amplatz(1) (used in examination of the stomach and duodenum) is employed as an inexpensive, rapid, and simple method for double contrast examination of the duodenum.


Role of radiotherapy in management of cancer pain. To a cancer patient, pain is a very distressing symptom and to the physician it heralds advanced nature of the disease. While the mechanisms of initiation of pain are simple, its perception is very complex. In cancer, the tumor growth which results in producing pressure, destruction of tissue, and obstruction is the main cause of pain production. Ionizing radiation, which checks tumor growth and shrinks the tumor most of the time, plays a major role in relieving pain in a cancer patient.


High output cardiac failure secondary to a Brescia-Cimino fistula. A patient with high output cardiac failure secondary to a Brescia-Cimino fistula is presented. The heart failure responded to a reduction in the fistula size. The literature on this complication is reviewed.


Pelvic endometriosis as demonstrated by gray scale ultrasound. Six cases of pelvic endometriosis are discussed and their ultrasonic appearances presented. The literature is reviewed concerning the ultrasonic appearance of pelvic endometriosis. The clinical significance of endometriosis in the differential diagnosis of females with pelvic pain is stressed. In this series endometriosis could not be differentiated from cystic lesions of the ovaries and from pelvic inflammatory disease ultrasonically. Other confirmatory measures or studies such as laparoscopy and biopsy were usually needed.


Spousal abuse.

Spousal abuse. Spouse abuse is being discussed and agonized over more frequently than in past years. Although interpousal and intrafamilial violence have been behaviors of note and considerable consequence, they have been attributable, almost exclusively, to the lower socioeconomic classes. Many hypotheses have been proposed concerning the etiology of violence. The author discusses some of the more general sociopolitical theories of violence and proposes three areas of significant moment to behaviorists.


Cancer incidence in the Western United States: ethnic differences. Incidence rates of selected cancer sites reported by the California Tumor Registry and the New Mexico Tumor Registry are analyzed to study ethnic differences in cancer in the United States. The white majority population shows high incidence of lung and breast cancers. Black males show the highest prostatic cancer rate. Data also confirm the unusually high incidence of nasopharyngeal cancer and low prostatic cancer rates among Chinese males. The Japanese have the highest stomach cancer incidence among all the ethnic groups analyzed. A comparison with the cancer incidence in the same ethnic groups in their native countries reveals the impact of environmental or cultural changes on lung, breast, and stomach cancers, and a possible genetic influence on the high incidence of nasopharyngeal cancer among the Chinese population in the United States.


Immunobiology of malaria.

Immunobiology of malaria. Malaria, the number one disease in the world, is caused by intracellular protozoans belonging to the Subphylum, Sporozoa; Suborder, Haemosphoridia; and Family, Plasmodiidae. The four classical organisms producing disease in man are Plasmodium vivax, P. falciparum, P. malariae, and P. ovale. Although malaria has been known to man for centuries, attempts are still being made to control and eliminate its devastating effects in tropical and subtropical areas of the world. Current active interest in malarial immunology and immunopathology derives from two main facts: (1) that human malaria is still one of the chief health problems in a broad tropical and subtropical zone in which lie most of the developing countries; and (2) most of the seminal leads in basic immunology are being applied to malarial immunology, either directly in human patients, or using laboratory animals as test objects.This paper addresses the nature of malarial immunity and target organs in malarial pathology.


Malignant melanoma of the foot in black patients: a case report and literature survey. Malignant melanoma in black patients is not the rare entity previously supposed if the numerous reported accounts are considered. In black patients, the tumor appears most commonly in the pedal region. The plantar surface appears to be most frequently involved. The literature on melanoma in blacks provides confusing statistics. Malignant melanoma in blacks represents a small, well-delineated subset of melanomas possibly with its own incidence and prognosis. A case report is presented, with a search of the Walter Reed Army Medical Center Tumor Registry and a review of pertinent current dermatological literature.


The right to health care: a brief review. The organization and delivery of health care in the United States is undergoing critical review. In recent years, the costs of medical services have skyrocketed to such an extent that many Americans have exhausted their scanty life savings for hospitalizations or other related medical expenditures. As a result, health care consumers have become disenchanted and are now demanding a change in the medical care system.In addition, there appears to be a conceptual change from good health being considered an individual responsibility, to one of social concern. Have we gained from Sweden's experience in health care or is this a moral issue?It is well known that health care system in the United States is in need of fundamental change, but we also know that change of this magnitude is usually quite slow and painful. One seriously ponders whether public dissatisfaction will surface to those heights which led to the massive revolt of the Great Depression. This is a moot question.


The need for psychoanalysis is alive and well in community psychiatry. While the author recognizes the positive impact community psychiatry has had on postpsychotic patients by the uses of medical management and environmental manipulation, he demonstrates that there is a deficiency in the treatment of lower socioeconomic patients with neurotic illnesses. Specifically, neurotic patients tend to be given supportive therapy and psychopharmacotherapy when a form of psychoanalytic psychotherapy would be more appropriate. The author supports these contentions by presenting three cases which have a diagnosis of hysterical neurosis and which clearly demonstrate the economic, topographical, structural, dynamic, and genetic components of the psychoanalytic theory. Finally, as psychoanalytic psychotherapy is too time-consuming, the author suggests that Freud's early psychoanalytic technique of symptom removal by memory recovery be used when appropriate.


Economic stress and mental health.

Economic stress and mental health. This paper correlates economic stress with minority status, resource allocations for mental health programs, and vulnerability to mental disability. Several hypotheses are advanced:1. A major and recurring psychological pattern of the American national character is prowhite, antiblack paranoia.2. Mental health fiscal allocations and programmatic determinations in ghetto, lower socioeconomic, minority-populated urban areas are predicated on political and racist considerations, the underlying motivation being to keep minorities at greater risk of mental disability.3. Economic privation and stress increase vulnerability to mental illness, especially in a minority population for whom health, mental health, educational, and social services are grossly inadequate.4. Poverty and economic stress combine with health systems that are unresponsive to the needs of blacks and other minorities, resulting in the perpetuation of disabilities and other conditions in blacks that are potentially preventable.5. Health and mental health resources should be increased rather than diminished during periods of economic stress, especially in the public sector.6. In order to provide each citizen with access to quality health and mental health care regardless of race and/or economic status, there must be enacted a national health insurance program based on tax-levy monies that will cover all aspects of health and mental health care.7. Racism and social status will continue to be powerful determinants of the quality of service that white professionals render to black patients and to poor white patients, unless our training institutions mount a massive campaign to train appropriately and to include significant numbers of minority candidates and trainees in the effort. To date this effort is virtually nonexistent.


Diagnostic value of creatine phosphokinase (CPK) isoenzymes in the absence of elevated total CPK. The value of creatine phosphokinase (CPK) isoenzymes, in the presence of normal total CPK, for assessing myocardial infarction is discussed. Forty-six patients in a coronary care unit were studied to ascertain the clinical usefulness of CPK isoenzymes for diagnosing myocardial infarction when the levels of total CPK were within normal range. The majority of patients studied had some cardiac abnormality on either ECG or x-ray examination. Approximately 50 percent of patients had chest pain, but only five of the 46 had a detectable CPK isoenzyme level on CPK electrophoresis. The results of this study suggest that CPK isoenzymes do not add anything of diagnostic value to the clinical picture if the total CPK is normal.


Lichen sclerosus et atrophicus in Nigerians. Lichen sclerosus et atrophicus has been considered very rare in the native African population. Only seven cases, all among the Bantu, have been described to date. Five cases are now reported and these cases are believed to be the first from West Africa.


Basal cell carcinoma of the ridge of the nose treated with Cobalt-60. A case is reported of an elderly woman treated for a basal cell carcinoma, located on the ridge of the nose. The malignancy had invaded the outer surface of the bone and nearby cartilage. It is well known that when carcinoma of the skin is located near to bony cartilage structures, those structures are prone to necrosis when treated with ionizing radiation. In this case, the authors treated the nose using telecobalt therapy and increased the effect of radiation therapy on the skin using a bolus. Results during the short follow-up after completion of treatment have been excellent.


Cultural consciousness and minority representation in health professions. It appears the problems inherent in the underrepresentation of minorities in the health professions, especially medicine, are likely to continue, at least in the near future. This being the case, it becomes important to maximize the effectiveness of those minorities already in the system.This paper describes a study conducted to verify certain assumptions which underlie programs aimed at increasing minority student enrollment in medical schools. It is assumed minority students are aware of the health problems unique to minority populations, that they plan to do something to address these problems, and that they will have some effect on the problem and the health of minority populations.


Deinstitutionalization.

Deinstitutionalization. This paper treats the issue of the treatment of the chronically mentally disabled. The author challenges the feasibility of plans for the treatment of the chronically disabled outside of mental institutions and questions whether in actuality there has been a sufficient commitment (moral, professional, and financial) to the local noninstitutional care of this population. The history of treatment of the mentally disabled over the past three centuries is reviewed. The failure of the community mental health center movement during the 1960s is described, and the reasons for that failure are presented. A note of extreme caution is sounded as behavioral scientists and mental health planners devise methods of caring for the chronic population, lest courses be embarked upon that have been given inadequate consideration and planning.


Long-term results of resection of the distal ulna for post-traumatic conditions. Sixty-two patients underwent resection of the distal ulna because of pain or limited motion after wrist trauma. The median length of resection was 23 mm. Injury to the distal radioulnar joint occurred primarily during fractures of the distal radius. Followup time averaged 87 months. The primary surgical indication was pain, but some procedures were performed in an effort to increase motion. All patients improved after surgery. Three patients had residual pain, 25 had mild pain, and 34 had no pain. Supination was greatly improved, with only modest improvement in other wrist motions. Four patients developed ulnar translation of the carpus (from 1 to 3 mm). Pseudoarticulation and ulnar regrowth of the carpus were noted, but neither pseudoarticulation nor regrowth was clinically symptomatic. Grip strength improved significantly after surgery, the average from 45.3 to 78.9% of the unaffected wrist. The presence or absence of radiocarpal arthritis preoperatively had no significant effect on the patients' estimates of results. Overall, 51 patients (82%) had satisfactory results. The primary gains were pain relief, increased supination, and increased strength.


The effect of thermal injury on hemodynamic, respiratory, and hematologic variables in relation to complement activation. The effects of thermal injury on circulation, respiration, and complement activity was studied in dogs. An aggregation of platelets in the blood and trapping in the lung were observed following burn injury. Leukopenia appeared first, then leukocytosis. Hemolysis of red cells corresponding to a destruction of about 30% of the erythrocytes was observed. A blood pressure decrease and a tracheal insufflation pressure increase followed thermal injury. Blood gas and lactate changes like those seen during a low perfusion state were recorded, but signs of impaired oxygenation of arterial blood were also observed. A possible mechanism by which denatured proteins might initiate some of the symptoms seen after thermal injury is suggested and its relation to complement activation is evaluated.


Arterial plasma amino acids during the first week following femoral shaft fracture. In ten patients with a femoral shaft fracture, arterial plasma amino acids and glucagon, blood glucose, and serum insulin were measured after an overnight fast on the third, fifth, and seventh days following injury. Ten normal subjects were controls. On all days, concentrations of the key glucogenic amino acid, alanine, were the same in both groups, but levels of another glucogenic amino acid, glycine, were significantly less in the fracture patients. Other amino acid changes following injury were maximal at 7 days, with significant elevations of phenylalanine, methionine, tyrosine, ornithine, lysine, arginine, valine, isoleucine, and leucine. Increased levels of insulin, glucose, valine, isoleucine, and leucine on the fifth and seventh days after injury implied insulin resistance. Plasma glucagon was elevated on the third (p less than 0.05) and seventh (p less than 0.01) days after injury, but the concentrations measured are insufficient to explain the impaired carbohydrate tolerance following a fracture.


Chronic traumatic aneurysms of the thoracic aorta: an analysis of 50 patients. The records of 50 patients having thoracic aortic aneurysms and a remote history of severe chest trauma were reviewed. Time intervals between thoracic trauma and operation varied from 3 months to 32 years (average, 11.9 years). In 25 patients (50%) this interval was greater than 10 years and in six (12%) greater than 20 years. Surgical correction was accomplished with low mortality and morbidity. Detection and diagnosis of chronic traumatic thoracic aortic injuries may not become clinically evident in some cases for many years. This diagnosis should be considered in all patients with a history of severe thoracic trauma, no matter how remote.


Operative treatment of pertrochanteric fractures of the femur: report of a three-year series. A series of 70 consecutive patients with pertrochanteric fractures of the femur treated by condylo-trochanteric (C-T) nailing is reported. Patients' ages ranged from 54 to 96 years, and they were followed up for 4 to 32 months. The mortality rate was 1.4%, and the overall complication rate among survivors 20.3%, but all complications were minor and transient. The fracture healed in every case, and the functional and anatomic results were good. The results are thought to be due to the superiority of indirect methods of fixation, which are in general technically easy and involve no major surgical intervention. This fact is highly favorable in this group of elderly and frail patients, among whom a major osteosynthesis would certainly carry a risk of high operative mortality.


Neurogenic gastroduodenal ulceration and bleeding associated with spinal cord injuries. Twenty-four of 576 consecutive patients with spinal cord injuries developed acute gastroduodenal ulceration and hemorrhage. Twenty-two were males and two were females: 88% were 12 to 25 years old. Seventeen patients sustained injuries to the spinal cord in sports and recreation related activities. Twenty-three patients had lesions of the spinal cord above the sympathetic outflow. Twenty patients developed gastroduodenal perforation or bleeding within 4 weeks following the injury. Ten patients developed perforation of gastric or duodenal ulcer and "shoulder tip" pain was a symptom of perforation in six patients. Six patients of seven who had gastroscopy and upper GI series were found at laparotomy to have ulcers. Gastric (nine) and duodenal (seven) ulcers were evenly distributed. There were no deaths due to gastroduodenal hemorrhage in the present series. A single cause for the pathogenesis of gastroduodenal ulceration and hemorrhage cannot be pinpointed. However, ischemia of gastric mucosa produced in various ways and altered equilibrium between the parasympathetic and sympathetic neural pathways following trauma to the spinal cord seem to be important in initiating the process.


Traumatic renal artery occlusion.

Traumatic renal artery occlusion. Six cases of complete occlusion of the main renal artery and one case of incomplete renal artery occlusion secondary to blunt abdominal trauma are reported, and the literature reviewed. The reported cases are analyzed as to clinical and radiographic findings, and mechanism of injury. Left renal artery occlusion occurs due to intimal fracture secondary to deceleration forces on the abdomen. Right renal artery occlusion results from direct epigastric trauma and compression of the artery against the vertebral column. An intravenous urogram with nonvisualization of the affected kidney should lead to immediate angiography. Arteriography is diagnostic, showing abrupt occlusion of the renal artery several centimeters beyond its origin, or before occlusion, an intimal flap.


Unsuspected atlas fracture and instability associated with oropharyngeal injury: case report. A case of oropharyngeal injury associated with an unsuspected direct atlas anterior arch fracture is presented. Instability at the occipito-atlanto-axial joints developed because of the coexistence of a rather common congenital defect of the posterior atlas arch. Awareness of the frequency of congenital atlas anomalies and the possibility of direct cervical spine injury with pharyngeal trauma will aid early recognition of this problem and allow early effective treatment.


Undiagnosed intrusion of a lateral incisor following trauma. The need to account for teeth missing after a traumatic episode, and the need for radiologic methods of investigation of the oral, perioral, and respiratory areas into which teeth may lodge are discussed. A patient with undiagnosed traumatic intrusion of a lateral incisor is presented in whose case routine radiographic investigation before restorative treatment planning revealed the tooth in the maxilla. If such teeth are not removed, respiratory distress or abscess, or delayed healing may complicate recovery.


Traumatic ulnar neuropathy from jet injection: case report. The usefulness and relative safety of the technique of jet injection, mainly used in mass immunization, have been well established. A patient who developed a traumatic ulnar neuroma at the site of jet injection of swine flu vaccine is reported. This unusual and previously unreported complication of this procedure is thought to have occurred because of the patient's extremely small size and small muscles.


Traumatic forequarter amputation: case report. Traumatic forequarter amputation is rare and extremely mutilating. A 21-year-old male factory worker who sustained a traumatic shoulder girdle amputation is described. The injury mechanism was traction from the machine's force combined with the compressive force on the sternoclavicular joint. The factors leading to survival from this injury include rapid transportation, prompt and effective resuscitation, including treatment of shock, and adequate surgical management. Recognition of the complications associated with retrosternoclavicular dislocation is emphasized.


Acute esophageal perforation in an adolescent burn patient. Acute esophageal perforation in a 15-year-old male who sustained 40% body burns in a gasoline explosion is reported. He experienced an acute esophageal perforation from gastric distention and esophageal reflux during initial transit to the Cincinnati Shriners Burns Institute on the second postburn day. Bilateral hydropneumothorax occurred and the patient soon expired without treatment. Prevention of this complication is best achieved by placement of a nasogastric tube and aggressive antacid therapy.


Posterior fracture-dislocation of the IV metacarpal hamate articulation: case report. Posterior fracture-dislocation of the metacarpal hamate articulation is rare. A single case managed with splint immobilization and early finger motion is reported. The early functional results utilizing this method are excellent.


[Etiopathogenesis of so-called congenital hydronephrosis]. Taking up again inquiries already known in the past, documents of pathological anatomy of his own person experience, and facts of embryology, the authors explain the etiology of the obstructive malformation of pyelo-ureteral function the etiology brings out two phenomena: --The insufficient hollowing of the cephalic end of the ureteral bud, which is initially grooved, when it detaches itself from the Wolffian canal, can transform itself into a full cellular cord which secondarily forms a groove after 23 mm stage.--The insufficient vascularization of the ureter just below the pelvis because of an abnormal anatomical disposition which causes displacement of the longitudinal uretero-pelvic arteries to a point clearly below the ureteropelvic junction. There an ischemia impedes the muscular development of the ureter just below the pelvic of which the wall becomes more sclerotic and fibrous than muscular. Thus a defect in the grooving of the ureteral bud and an arterial blood deficit results in a congenital ureteral stenosis. Pathological anatomical documents illustrate this theory from which flow two imperative technics; the necessity to eliminate the initial obstructive ureteral segment; care to protect the pelvic vessels which will have to vascularize the ureter which will be anastomosed to the cut edge of the pelvis.


[What is the value of segmental urethrectomy for urethral stenosis in males?]. The authors analyze the results obtained in a homogenous series of 49 patients with urethral stenosis treated by segmental resection of the urethra and end-to-end urethro-urethral suture, with the following conclusions:--Segmental urethrectomy is indicated only for short lengths of stenosis, which do not require the sacrifice of more than 4 cm.--Excellent results were obtained in 41 out of 49 cases (84%).--Good results remain stable, as they were still present in 33 of these 41 successful cases after periods varying from 14 months to 7 years (average: 3 years and 2 months).--Good results have a good chance of remaining as out of the 8 failures only 2 were due to secondary deterioration after a satisfactory initial result. Traumatic and congenital stenoses give the best results as suture of the two healthy sections of the urethra can be performed. Nine successful results were obtained in 10 cases of iatrogenic stenosis after in-dwelling urethral sounds or endoscopic procedures. Twelve cases were successful out of 16 traumatic stenoses of the membranous urethra following pelvic fractures. Two cases of traumatic stenosis of the perineal urethra were both treated with success, as were fourteen out of 15 so-called "congenital" urethral stenoses in which there was no history of trauma or infection. As far as the procedure used is concerned, a successful outcome depends upon the degree of mobilization of the urethral ends, which should be large in order to be able to suture without tension.--The factors causing failure include: absence of excision of post-traumatic callus, insufficient hemostasis, insufficiently prolonged modelling of the suture, favourable for the formation of synechia and, more particularly, a poor condition of the urethra: sclerosed inflammatory stenoses and untreated associated prostatitis.--Sexual impotence is found, temporarily, in all patients operated upon for urethral stenosis, but virility returns in all cases within variable periods of up to two years.


[Problems of cystic uretero-pyelitis (author's transl)]. The authors report on a series of 7 new cases of cystic uretero-pyelitis (C.U.P.). An historical and pathogenic review of this anatamo-radiologic entity is presented. The conditions for discovery were: renal colic in 4 instances, discovery during surgery in association with a pyeo-ureteral junction syndrome in one instance, and a hematuria in three instances (1 being accompanied by renal colic). Age varied from 22 to 78 years, with an average age of 61 years. The distribution between the sexes was equal: 4 women and 3 men. Urinary infection was observed in cases (colibacilluria), whereas it was absent in 3 cases. If hematuria is present, one should, as a rule, look for a possible association with an ureteral or vesical tumor (1 case). The final diagnosis can be established only through histological examination (this was the case in only 3 of our patients), but when there is a suggestive radiologic image and a reassuring clinical picture, one can recommend a simple medical treatment (1 recovery) and propose a steady radiologic surveillance. In case of doubt or hematuria, it is preferable to advocate surgical investigation: 2 patients out of the 3 showing a hematuria, were operated on, the third having refused. In one case, hematuria was due only to cystic uretero-pyelitis, while the second was known to have a vesical tumor with C.U.P. The real danger, in presuming a cystic uretero-pyelitis, is the failure to recognize a ureteral papillomatosis, hence the necessity of radiologic surveillance. The authors did not note any serious bilateral form. The only bilateral involvement seen in the 7 cases was not accompanied by reanl deficiency.


Evaluation of perihilar and central renal masses using the Chiba needle. The Chiba needle was used to puncture 14 central renal masses believed to be cysts. Of these masses 13 were cysts and 1 was a peripelvic liposarcoma. Arteriography was not done before puncture. No complications occurred when these central masses surrounded by parenchyma or adjacent to hilar structures were punctured. Renal cyst puncture and cystography using the Chiba needle are safe methods for optimal diagnosis of central and peripelvic systs.


Rheumatoid factor: correlation with recurrence in transitional cell carcinoma of the bladder. The serum rheumatoid factor was measured by the latex fixation test in different titrations in 100 cases of bladder tumors. The rheumatoid factor was found in transitional and squamous cell carcinoma of the bladder. The percentage of positive studies correlated well with the clinical staging of the tumors. The rheumatoid factor activity also correlated with the recurrence of transitional cell carcinoma. A high recurrence rate was found when the rheumatoid factor was present in contrast to a low recurrence rate when it was absent at the initial examination. The percentage of recurrences correlated with the titration of the rheumatoid factor. The mechanism of production of the rheumatoid factor and its correlation with tumor recurrence are discussed.


The possible role of the catecholamines of the corpora in penile erection. The etiology of impotence, which effects 50 per cent of the men with diabetes, is unknown. The neurotransmitter (norepinephrine) released from adrenergic neurons is thought to be the most direct regulator of vascular smooth muscle. We have measured the norepinephrine content of the erectile tissue of diabetic men. Our results indicate the presence of a dual neural regulator mechanism of the corpora that controls penile erection.


Management of advanced testicular seminoma. The treatment of seminoma (stages A, B1 and B2) with conventional x-ray therapy can be expected to give satisfactory cure rates. However, the cure rate for patients with advanced stages of B3 and C disease, treated with conventional radiation therapy, is unacceptable (22 per cent). It appears that with a pre-radiation/chemotherapeutic plan consisting of actinomycin D, vincristine and cyclophosphamide survival can be improved dramatically in these patients. After a rest period of 2 to 4 weeks radiation therapy is given to the retroperitoneal, mediastinal and supraclavicular lymph nodes as per standard therapy. If evidence of bulk disease persists or if positive alpha-fetoprotein or beta-human chorionic gonadotropin has been detected then retroperitoneal lymph-adenectomy should be done after completion of the radiation therapy. With adjuvant chemotherapy 5 of 5 patients survive free of disease 18 months to 5 years after therapy.


Cortisone acetate versus clomiphene citrate in per-germinal idiopathic oligospermia. Long-term, low dose clomiphene citrate (25 mg./day for 25-day cycles with 5-day rest periods) and long-term, low dose cortisone acetate (5 mg. twice daily) were compared in equivalent populations of men with idiopathic oligospermia. Clomiphene citrate seemed to be more effective than cortisone acetate in enhancing spermatozoal number and the likelihood of pregnancy. In addition, clomiphene citrate increased serum testosterone levels and provided an indicator of hypothalamic-pituitary-testicular axis responsiveness.


The varicocele and semen characteristics. Our results indicate that the physical presence of a varicicele is not always associated with an alteration in sperm cell concentration and that a reduction of semen characteristics is more likely in men with reduced sperm counts. Our study also indicates that a higher pregnancy rate after varicocele ligation occurred in wives of patients in the lower sperm count groups. Other forms of therapy also were found to be associated with pregnancy in wives of men with varicoceles. The post-surgical pregnancy rate was 25 per cent compared to 12 per cent in the non-surgical group.


Prostatic acid phosphatase by radioimmunoassay tumor marker in bone marrow. Bone marrow acid phosphatase was determined by radioimmunoassay and enzymatic analysis in 95 patients with benign prostatic hypertrophy, 50 patients with disseminated prostatic carcinoma and 36 patients with non-prostatic malignancy. The results indicate superior specificity of the radioimmunoassay. A brief review of the topic and the clinical implications are discussed.


Complications of 125iodine implantation and pelvic lymphadenectomy in the treatment of prostatic cancer. The operative, postoperative and late complications experienced by 300 consecutive patients who underwent 125iodine implantation and pelvic lymphadenectomy for localized prostatic cancer were analyzed. Of the patients reviewed 68 per cent had clinical stage B lesions, while 32 per cent had clinical stage C lesions. The incidence of intraoperative complications was 6 per cent. There were 2 postoperative deaths and 23 per cent of the patients had postoperative complications. Of 177 patients followed postoperatively for 6 months or more (mean 29.3 months) late morbidity was experienced by 49 (28 per cent). The incidence of impotence in 109 patients who were potent preoperatively and who were followed for a minimum of 15 months was 7 per cent.


Treatment of stage D hormone-resistant carcinoma of the prostate with estramustine phosphate. We report on 51 patients with hormone-resistant, stage D prostatic carcinoma who were treated with estramustine phosphate and followed for at least 6 months. Of the 51 patients 5 (10 per cent) had a partial objective response, 30 (59 per cent) remained stable and 16 (31 per cent) had progression of the disease. All of those patients who had a partial response or remained stable also experienced subjective improvement as judged by relief of pain and performance status. Approximately 8 per cent of the patients will be unable to take estramustine phosphate because of intolerable gastrointestinal side effects.


Urological injuries associated with pelvic trauma. We reviewed 100 consecutive cases of pelvic fractures at our hospital to establish the relationship between bone injuries and urological lesions. There were 11 major urological injuries found: 6 patients had bladder laceration, 4 had rupture of the membranous urethra and 1 had a ureteral injury. Emphasis is placed on the physiopathology of the urological injuries.


Bladder function in children with meningomyelocele: comparison of cine-fluoroscopy and urodynamics. We have assessed 60 children on an outpatient basis with cine-fluoroscopy combined with urodynamics. Bladder and rectal pressure together with sphincter electromyography were measured during bladder filling under fluoroscopy, which was followed by measurement of rectal pressure and sphincter electromyography during voiding under fluoroscopy. Comparison of the x-ray studies and urodynamics showed that the cystogram alone was not a reliable indicator of ray studies and urodynamics showed that the cystogram along was not a reliable indicator of detrusor function. The sphincter electromyogram during voiding must be interpreted in the face of intra-abdominal pressure changes owing to straining or Credé's maneuver. Residual urine estimations and the appearance of the bladder outflow on fluoroscopy were better parameters of outflow obstruction than sphincter electromyography.


External sphincterotomy at the 12 o'clock position. Transurethral resection of the external sphincter was done at the 12 o'clock position 61 times in 60 men. There was a 2.8 per cent incidence of postoperative impotence and a 75 per cent cure of vesicoureteral reflux but there was only a 65 per cent success rate of decreasing post-voiding residual urine after 6 months. The techniques and applications of the procedure are discussed.


Biofeedback in urology using urodynamics: preliminary observations. Biofeedback training aided by urodynamic instrumentation produced significant clinical improvement in 4 of 8 urological patients. The display of electromyographic activity of the periurethral striated muscles was facilitated by the use of a new intraurethral catheter with 5 surface mounted electrodes. This modality of treatment seems worth considering for selected patients with urinary retention or urinary incontinence.


Clean intermittent catheterization in children. The results of the application of clean intermittent catheterization to children are discussed. Of 34 patients only 7 maintained persistently sterile urine and 52 per cent had more than 1 positive culture in the followup period. Complications of the application of this technique are discussed. The major complication rate was 15 per cent and 6 per cent were considered failures of therapy. Only 1 of the 34 patients demonstrated progression of upper tract disease by excretory urography during the followup period. Intermittent catheterization was found to be effective in preserving renal function as well as helping to improve patient social acceptability.


The exstrophy support team: a new concept in the care of the exstrophy patient. The concept of the exstrophy support team is reported. It has extended the care of children with exstrophy into a lifelong continuum of effective assistence, not just by way of medical and surgical interaction but through knowledgeable and sympathetic coordination. There has been a spectacular improvement in over-all lifetime survival and much greater patient interest and appreciation with better followup and maintenance so that we can help quickly and effectively when problems arise. Now that we have achieved an increased longevity for these patients, we must be able to assure them the best possible quality of life.


Hypospadias: a familial study.

Hypospadias: a familial study. The families of 177 boys with varying degrees of hypospadias were evaluated prospectively to determine the occurrence of hypospadias and other congenital anomalies within this population. A significant number of male subjects in each family member category were affected, with first degree relatives (brothers and fathers) having a 14 and 9 per cent incidence, respectively. Siblings were at a greater risk for having this anomaly when the proband had a more severe degree of hypospadias and when the abnormality also was present in other relatives. A multifactorial mode of inheritance is suggested as the basis for transmission of this congenital defect.


Urolithiasis in children.

Urolithiasis in children. A 10-year review of stones in children at the St. Louis University Hospitals is presented. Stones related to infection were seen most often and urinary diversion secondary to congenital abnormalities of the urinary tract was the most frequent predisposing cause. The morbidity of stones in children is high.


Unusual aspects of urinary calculi in children. Urinary calculous disease is unusual in children in the United States. During the last 5 years (1972 to 1977) we have examined and treated 35 children with urinary calculi. The predisposing factors to calculus formation have been established in 20 children. Metabolic screening, although mandatory, has proved unrewarding in the evaluation of children with urinary calculi. Obstructive uropathy, immobilization, urinary stasis and infection, previously undiagnosed urologic anomalies, steroid therapy, milk-alkali syndrome, iatrogenic disease and endemic disease have contributed to stone formation. The management of children with urinary calculi generally parallels that of adults but reflects a need for caution when performing transurethral extraction of lower ureteral calculi. Reduction in dairy product intake, fluid diuresis and frequent changes in position may provide adequate prophylaxis against urinary calculi in children who must be immobilized.


Benign giant adrenal cyst and parathyroid adenoma: a case report. An unusual case of a benign adrenal cyst and a parathyroid adenoma occurring in a 59-year-old man with hypercalcemia is reported. Excretory urography, ultrasound, renal aortography, computerized axial tomography and selective thyroid venous sampling were used to establish a diagnosis. Left adrenalectomy was done because of a suspicion of malignancy, which was followed by excision of a retrolaryngeal parathyroid adenoma.


Apparent exceptions to the usual patterns in renal trauma. Selected cases of renal injuries illustrate the impression that clinical exceptions often may reflect errors in diagnostic interpretation and reaction rather than actual complications, rendering a policy incompetent or dangerously unreliable. These cases, as well as a comparison of debates regarding the management of renal trauma, are intended to offer further encouragement to a non-operative approach to injuries of intermediate degree.


Benign cholestatic jaundice after nephrectomy for pyonephrosis and sepsis. Severe benign postoperative intrahepatic cholestatic jaundice appeared immediately after nephrectomy in a patient with nephrolithiasis and septicemia. Convalescence was uneventful and no treatment was necessary. This diagnostic possibility should be considered whenever jaundice appears postoperatively for pyonephrosis and septicemia.


Quadruple renal neoplasia: bilateral renal tumors of dissimilar histogenesis. Four separate renal neoplasms were removed from a 64-year-old man during a period of 8 months. A lesion was first identified in the left kidney and the nephrectomy specimen had 2 separate adenocarcinomas. A third adenocarcinoma and a papillary urothelial pelvic carcinoma were found subsequently and segmentally resected from the right kidney. The patient died 9 years later with local recurrence of the urothelial neoplasm but no evidence of metastatic carcinoma.


Proliferative glomerulonephritis associated with reflex nephropathy. A case of unilateral reflux nephropathy treated by initial ureteral reimplantation and subsequent nephrectomy is reported. Pathologic examination of the resected kidney showed unsuspected proliferative glomerulonephritis. The relationship of chronic atrophic pyelonephritis, as seen in reflux nephropathy, and glomerulonephritis is discussed to emphasize that reflux nephropathy does not exclude the presence of other renal disease that may complicate the long-term care of the patient.


Renal failure owing to oxalate nephrosis after jejunoileal bypass. Oxalate nephrosis resulted in progressive renal failure in 4 patients after jejunoileal bypass for morbid obesity. In general, increased levels of oxalates in the blood and urine of such patients result from enhanced absorption of exogenous oxalates. Urinary calculous formation is determined further by concomitant deficiency of inhibitor substances, whereas oxalate nephrosis probably occurs as a result of oxalate deposition in renal interstitium via the blood stream. Clinical manifestations of oxalate nephrosis include pain, infection, hematuria and renal failure. Routine postoperative renal function studies and early renal biopsy in suspicious cases are urged to establish early diagnosis. Continued deterioration of renal function, despite therapy with oxalate restruction and oxalate binding agents, indicates a reversal of the bypass to preserve unaffected renal substance.


Coexistence of renal artery stenosis and uretheropelvic junction obstruction in hypertensive patients with elevated renin. Two hypertensive patients with elevated renin presenting with renal artery stenosis and ureteropelvic junction obstruction are reported. Nephrectomy was successful in 1 patient and the other patient was treated wiht renal autotransplantation and dismembered pyeloplasty. The diagnostic and therapeutic problems of coexistent renal lesions are discussed.


Retrocaval ureter: report of 8 cases and the surgical management. We present 8 cases of retrocaval ureter, one of which concerns a unique periureteral venous ring formed by the persistence of the right posterior cardinal vein along with a normal vena cava. Current radiographic concepts are reviewed and the importance of inferior venacavography in the preoperative evaluation for correction of the retrocaval ureter is emphasized.


Tandem transureteroureterostomy.

Tandem transureteroureterostomy. A case of bilateral hydronephrosis after transureteroureterostomy is reported. Management of such complications may be difficult and should include innovative ureteral salvage based upon fundamental principles of ureteral surgery.


Bladder perforations secondary to surgical drains. Three patients with complications secondary to pelvic surgical drains are described. The mechanism and management of complication as well as methods of prevention are discussed.


Fibroepithelial polyp of the verumontanum: a case report and review of the literature. A fibrous polyp of the verumontanum in a 10-year-old boy is described. The diagnosis, treatment and histology are discussed and the literature is reviewed. Perhaps this lesion will be noted more frequently with the availability of improved radiographic and cystoscopic techniques. The treatment has been greatly simplified with the advent of the pediatric resectoscope.


Penile lengthening after previous repair of epispadias. Unsatisfactory appearance and function of the penis are common after repair of complete epispadias. Reoperation can benefit the majority of these patients. The principles of repair in secondary cases as well as primary cases include wide mobilization of the corpora to gain length, resection of dorsal chordee to straighten the shaft, augmentation of urethral length with a graft, secure closure of the corpora over the urethra to avoid a fistula, wide mobilization of the mons to place hair-bearing skin in proper location and Z-plasty closure.


Scrotal cystocele.

Scrotal cystocele. Massive inguinoscrotal bladder herniation is a surgical rarity. A 2-stage voiding pattern is typically noted. Excretory urography and retrogradecystography are extremely helpful in verifying the diagnosis of bladder herniation. A case of scrotal cystocele is reported.


Sacral agenesis: diagnosis, treatment and followup of urological complications. Sacral agenesis is an uncommon congenital anomaly that usually is accompanied by other orthopedic anomalies but often occurs singularly. We report our experience in the treatment and long-term followup of 4 cases of pure sacral agenesis. We strongly stress the need for early diagnosis and long-term careful followup. In our group the diagnosis was often overlooked and followup was poor. Studies must be undertaken to determine the type and degree of neurogenic vesicopathy in each child since this may vary from one patient to the next. We urge the early and long-term use of intermittent catheterization.


Renal artery stenosis in hypertensive diabetics. The incidence of atherosclerotic renal artery stenosis was compared in consecutive renal angiography of 28 hypertensive diabetics and 104 hypertensive non-diabetics. Mean age and sex distribution were comparable. Angiographic evidence of atherosclerotic renal artery stenosis was present in 10 diabetics (36 per cent) and 50 non-diabetics (48 per cent). Stenosis was considered hemodynamically significant if the renal vein renin ratio of the involved to uninvolved side was 1.4:1.0 or more. A renal vein renin ratio equal to or more than 1.4 was observed in 4 of 7 diabetics (57 per cent) and 31 of 47 non-diabetics (67 per cent). Fibromuscular hyperplasia was not seen in diabetics but was present in 12 per cent of the non-diabetics. Hypertension was treated surgically and improved in 2 of 3 diabetics (67 per cent) and in 17 of 19 non-diabetics (89 per cent) with angiographic and hemodynamic evidence of renal artery stenosis. In this series the incidence of atherosclerotic renal artery stenosis of physiologic consequence was not significantly different in hypertensive diabetics when compared to hypertensive non-diabetics.


New technique for percutaneous nephrostomy under ultrasound guidance. The 8F cystocath has been used as a temporary percutaneous nephrostomy. B-mode ultrasonography was used to determine the depth and direction of trocar placement after initial confirmation with a spinal needle. No immediate complications were noted in 10 successful insertions and there was only 1 failure of entry.


Intraoperative localization of renal calculi using the Polarex 2 C-arm image intensifier. We present our experience with the C-arm image intensifier in the localization of renal calculi. We have found this technique to be exceptionally easy to use and extraordinarily efficient. However, unless the disk images are used primarily, rather than continuous fluoroscopy, the radiation exposure can be significant. This technique can be somewhat limiting in that exceptionally small stones or poorly opacified stones cannot be picked up easily.


Outpatient evaluation of patients with calcium urolithiasis. Eighty patients with proved calcium urolithiasis participated in an outpatient study designed to define the most likely metabolic problem related to the cause of the stone disease. Diagnostic categories included absorptive hypercalciuria (33 patients), renal leak hypercalciuria (20 patients), hypomagnesiumuria (27 patients), hyperuricemia and hyperuricuria (16 patients), hyperoxaluria (15 patients), normal stone-former (4 patients), renal tubular acidosis (2 patients) and suspicion of hyperparathyroidism (7 patients). Of the 80 patients 40 had more than 1 defect. Patients with a high suspicion of hyperparathyroidism were excluded from the study. Based on these criteria treatment plans incorporating medications, diet or both were instituted. Of 21 patients observed for greater than 2 years 90 per cent have shown no new stone disease.


Calcified renal cell carcinoma: a clinical, radiographic and pathologic study. A retrospective review from 1954 to 1977 revealed 17 patients with radiographically calcified renal cell carcinoma. Any calcified renal lesion, regardless of the characteristics of the calcification, must be regarded as suspicious for a malignant neoplasm. Calcified renal cell carcinoma appears to be a biologically distinct subgroup of renal parenchymal tumors. The angiographic diagnosis of these tumors often was difficult since most were either hypovascular or avascular. Most calcified renal parenchymal tumors were relatively large but tended to be localized and histologically well differentiated. These tumors were associated with a predicted 5-year survival rate of 77 per cent.


Controlled ureteral meatotomy.

Controlled ureteral meatotomy. An endourologic technique for a safe and adequate ureteral meatotomy has been devised. The ureter is catheterized anterograde through a percutaneous nephrostomy and a controlled ureteral meatotomy is done with a modified ureteral catheter. A silicone splint is then placed. The technique is safer than other techniques because repeated, more proximal incisions can be made and because the splint and proximal urinary division will prevent extravasation.


Surgical correction of ureteroceles.

Surgical correction of ureteroceles. A personal experience in the management of 73 ureterocele cases during the last 17 years and points of technical importance in the correction of this sometimes complex problem are described. Small adult-type ureteroceles are best resected, reimplanting the ureter, since simple unroofing can cause reflux. The infant-type ureterocele with a duplex collecting system requires individualization according to the status of the patient. In ectopic ureterocele cases the bladder outlet often requires repair. The spectrum of management for this group of problems is shown by representative cases.


Ureteral replacement using a new variation of the tailored ileal segment. Long-term complications of ureteral replacement by the small intestine are discussed. A new concept of tailoring the intestinal graft has proved successful in experimental animals. The first clinical application of this technique involves a 22-year-old women whose left kidney and right ureter were destroyed by tuberculosis. Excellent results were noted at the 3-year followup.


An evaluation of 170 diagnostic pressure flow studies of the upper urinary tract. An analysis of 170 pressure flow perfusion studies reveals that they can be valuable in patients of all ages, but particularly so in children, and in a variety of clinical conditions. The complication rate is low and there are few patients in whom these studies do not provide a clear-cut answer on the degree of obstruction. They can be recommended as useful and, at times, invaluable clinical tools.


Urethral compression procedure for the treatment of male urinary incontinence. We believe that there still is a place for passive compression of the bulbous urethra in the treatment of male urinary incontinence after prostatectomy or sphincterotomy. The procedure is simple to do and it is relatively free of complications. However, since it provides only passive resistance and cannot compensate for sudden increases in intravesical pressure, stress incontinence of minor degree is not uncommon. In our series of 184 cases 61 (33 per cent) became completely dry, required no protection and voided with a good stream and without residual urine. Another 51 patients had some stress incontinence but were pleased with the results so that 61 per cent derived definite benefit from the operation. There were 20 (11 per cent) major complications in this series. With recent modifications of the technique and the prosthesis the complication rate has been reduced to 7 per cent in the last 50 cases. The opportunity to adjust the compression postoperatively by injection provides advantages over other passive compression procedures.


A comparison of the Small-Carrion and Scott-Bradley penile prostheses. The Small-Carrion penile prosthesis has been implanted in 28 patients and the Scott-Bradley inflatable prosthesis has been implanted in 17. Almost all patients are satisfied with the results. There appeared to be no absolute correlation between the postoperative appearance of the penis and the sexual performance. Provided a reasonable cosmetic result is obtained the patient's attitude is the most important determinant of sexual function.


Extended pelvic lymphadenectomy for prostatic cancer. Thirty patients with clinically localized prostatic carcinoma underwent extended pelvic lymph-adenectomy, including the presacral and presciatic (lateral sacral) areas. The first echelon of pelvic nodes to be involved by metastases was the external iliac, obturator, presacral and presciatic. The deep presacral-presciatic nodes were involved almost as often as the more superficial external iliac-obturator group. Metastases limited only to the deep pelvic nodes were found in 14  per cent of the cases.


Preservation of sexual potency in prostatic cancer patients after pelvic lymphadenectomy and retropubic 125I implantation. Sexual histories were obtained from 51 patients (average age 67.7 years) with prostatic cancer and their spouses before and after pelvic lymphadenectomy and retropubic 125iodine implantation. Sexual potency was retained in 40 of the 41 patients who were sexually active preoperatively. Ten patients were sexually inactive preoperatively: 4 with diminished potency and 6 with complete erectile impotence. Sexual dysfunction was most often psychogenic in origin. At 6 months 5 of these patients had resumed satisfactory sexual intercourse as a result of reassurance, encouragement and education of remaining sexual potential. No patient suffered complete erectile impotence as a result of the procedure.


Applications of thin needle aspiration biopsy in urology. Percutaneous thin needle aspiration biopsy was done on 34 patients for better staging of malignant disease by study of opacified lymph nodes, on 12 patients to eliminate the possibility of a malignant etiology of ureteral obstruction and on 7 patients with potentially metastatic soft tissue or visceral lesions. Ideally, a positive biopsy should change subsequent patient management and may eliminate the need for an exploratory operation. A significant number of falsely negative results occur and, for this reason, a negative biopsy should not affect subsequent patient management.


Transcatheter arterial embolization in urological tumors: the use of isobutyl-2-cyanoacrylate. Transcatheter arterial embolization is a useful technique to manage urological tumors. Herein we describe a new embolic material (isobutyl-2-cyanoacrylate) in 5 cases of renal cancer embolization and in 1 case of bilateral hypogastric embolization for bladder cancer hemorrhage. Isobutyl-2-cyanoacrylate provides a complete, distal and irreversible embolization, making it suitable material in cancer embolization.


Urodynamic testing: alternatives to electronics. Electronic urodynamic testing, including bladder pressure, urethral pressure profile, voiding rate and velocity, and electromyography, is expensive in terms of equipment, operator and time. Clinical urodynamic testing, including voiding habits and timing, bladder capacity, residual urine volume, voiding cystography, cystometrography and neurologic evaluation, is readily done in the office. Analysis of common syndromes requiring urodynamic assay shows that clinical urodynamic testing may be more useful than electronic urodynamic testing for appropriate treatment.


Extravesical ureteroplasty.

Extravesical ureteroplasty. The results of extravesical ureteroplasty (Lich-Gregoir technique) for primary extravesical reflux in 62 children with 82 refluxing renal units are evaluated. Postoperative radiograms revealed persistent reflux in 5 (6.1 per cent) and obstruction in 1 (1.2 per cent) of the renal units. Of 7 patients in whom bilateral reflux had been noted previously but who had unilateral reflux at the time of operation, unilateral repair resulted in absence of reflux on the contralateral side in 6. The favorable success rate, low morbidity and median 5-day hospitalization support the use of extravesical ureteroplasty for uncomplicated reflux.


Ketamine as a detumescence agent during hypospadias repair. Ketamine hydrochloride was used successfully to produce detumescence in 7 children undergoing hypospadias repair. There have been no complications or side effects. We recommend ketamine hydrochloride as a useful adjunct in managing corporeal erections during urologic procedures.


Childhood urolithiasis.

Childhood urolithiasis. Between 1965 and 1976, 54 children with urolithiasis were evaluated and treated. Age, sex, race distribution, patient symptomatology, stone localization and type are outlined. The relationship of stone formation to urinary infection and/or genitourinary anomalies is reviewed, and treatment and recurrence patterns are studied.


Urinary kallikrein excretion in idiopathic nephrotic syndrome. The plasma kallikrein-kinin system, a potent vasodilator, has been implicated in causing the protein loss of the idiopathic nephrotic syndrome. However, the kidney possesses a kallikrein-kinin system separate from the plasma system. Thus, urinary kallikrein may reflect more accurately intrarenal events. Using a radiochemical esterolytic assay we measured the urinary kallikrein excretion in a patient with a minimal lesion nephrotic syndrome during relapse. Protein excretion was initially elevated (8.1 plus or minus 2.0 gm. per 24 hours) as was urinary kallikrein excretion (96.4 plus or minus 46.6 EU per 24 hours). After initiation of steroid therapy protein and kallikrein excretion decreased significantly (p less than 0.05). During the entire study kallikrein excretion was significantly correlated with protein excretion (r equals 0.89, p less than 0.01). It is tempting to speculate that activation of the intrarenal kallikrein-kinin system participates in the protein loss characteristic of the nephrotic syndrome.


Renal angiomyolipoma: diagnosis by combined ultrasound and computerized tomography. A case is presented of a 2 cm. renal angiomyolipoma. Computerized tomography demonstrated a region of low attenuation coefficient within this tumor, while B-mode ultrasound visualizes the tumor as a cluster of high amplitude echoes. The diagnosis of a renal angiomylipoma may be suspected preoperatively when this combination of findings is present with computerized tomography and ultrasound.


Renal cell carcinoma in a horseshoe kidney associated with von Hippel-Lindau disease. The first case of a renal cell carcinoma in a horseshoe kidney associated with von Hippel-Lindau disease is reported. Manifestations of the disease process as well as important points concerning the urological care of these patients are discussed.


Primary carcinoma in situ of the ureter and renal pelvis. Primary carcinoma in situ of the ureter or renal pelvis is rare. We describe 3 patients, each of whom had a different mode of presentation. When malignant cells in the urine from the upper urinary tract are associated with urographic evidence of an appropriate lesion, aggressive surgical therapy is indicated. In the absence of such a urographic abnormality patients with positive cytologic examinations should be followed closely because the exfoliated cells usually are from poorly differentiated neoplasms.


Severe mannitol-induced hyponatremia complicating transurethral prostatic resection. A case is presented in which the absorption of mannitol irrigation solution across prostatic veins resulted in severe hyponatremia in a patient undergoing transurethral prostatic resection. Since hyposmolality of the extracellular fluid was not seen because of the presence of mannitol the patient was asymptomatic despite a rapid decrease in the serum sodium concentration to 99 mEq./l. The importance of distinguishing dilutional hyponatremia from hyponatremia with normal or elevated osmolality is discussed.


The pneumococcal vaccine. Immunization at a crossroad. A new polyvalent pneumococcal vaccine (Pneumovax) was released in February 1978. In an effort to chronicle the dissemination of the vaccine to high-risk patients, we prospectively followed up a single clinic population and conducted a telephone survey of three neighborhood health centers, two private practices, and a university hematology clinic. Three months after notification of the vaccine arrival, physicians in the prospectively chronicled clinic had immunized six of 12 patients with sickle cell disease, five of 80 patients with chronic obstructive pulmonary disease, three of 225 patients with diabetes, and three of 45 patients older than 80 years. Immunization policy in the other clinics surveyed varied greatly. As an attempt to curb low-prevalence, high-severity illness in a small target population, the pneumococcal vaccine presents a new set of problems in the systematic implementation of an immunization.


Antibiotic control in a municipal hospital. The choice of an antibiotic for a patient is often a difficult decision. The clinician must contend with a bewildering variety of bacteria and use a number of expensive and toxic antimicrobial agents judiciously. To deal with the problems of excessive and inappropriate use, the medical staff of Coney Island Hospital established compulsory, prospective antibiotic control. Two years after initiation of this program, we analyzed changes in sensitivity patterns of hospital flora, physicians' prescribing habits and antibiotic use. A trend toward increasing resistance on the part of some Gram-negative isolates to certain beta-lactam antibiotics was noted. Antibiotic costs decreased an average of 38%, while prescribing skills improved.


Satellite streptococci. A major cause of "negative" blood cultures in bacterial endocarditis? In three of the 20 patients with bacterial endocarditis in our institution since 1975, satellite streptococci were recovered from the blood stream (15%). These organisms do not grow under usual laboratory conditions and may only be demonstrable after fortuitous contamination of the media. Clinicians and microbiologists must be alert to the possibility of satellite streptococci in patients with suspected bacterial endocarditis, and measures should be instituted to identify the organism.


Timolol in the treatment of open angle glaucoma. Timolol maleate is the first beta-adrenergic-blocking drug available in the United States for topical therapy in open angle glaucoma. It may be used alone for initial therapy in selected patients or with other antiglaucoma drugs in patients requiring additional control. It should be tried, before resorting to surgery, when traditional maximal medical therapy has failed or is not tolerated. Timolol has few local side effects, but since it is absorbed, it may produce systemic reactions similar to those induced by orally administered propranolol hydrochloride. Timolol appears to be an important advance in antiglaucoma therapy, although further experience is needed to determine whether its long-term usefulness will be limited by the development of tolerance or the appearance of unexpected side effects.


Gentamicin and ticarcillin serum levels. Ticarcillin disodium and gentamicin sulfate serum levels were measured one and five hours after intravenous administration. Patients receiving ticarcillin plus gentamicin had a significantly lower mean gentamicin level one and five hours after antibiotic administration than patients receiving cephalothin sodium plus gentamicin. The serum ticarcillin levels were significantly lower five hours after administration in patients receiving ticarcillin plus gentamicin than in those receiving ticarcillin plus cephalothin. Low antibiotic serum levels in patients with serious infections treated with these antibiotic combinations are of potential clinical significance; therefore, to ensure an optimal antimicrobial therapy, it is advisable to determine the drug serum concentrations (especially aminoglycoside) even in patients with normal renal function when treating with combinations of antimicrobials.


Adolescent suicide attempts.

Adolescent suicide attempts. The conditions of 40 adolescents in treatment following a suicide attempt were diagnosed according to the multiaxial classification of the American Psychiatric Association's proposed third edition of the diagnostic and statistical manual. All were psychiatrically ill before the suicide attempt. The most common diagnoses were those of depressive disorders and substance abuse disorders on the clinical psychiatric syndrome axis and borderline personality disorder on the personality and developmental disorder axis. The typical patient was a polydrug-abusing girl with a borderline personality disorder and a superimposed major depressive disorder. The most prominent personality characteristics associated with suicide attempts by these adolescents were a tendency to react severely to a loss, poorly controlled rage, and impulsivity. Suicide attempts by adolescents should be taken seriously by the physician and necessitate a thorough search for a possible underlying pathological condition.


Heparin-induced spinal fractures.

Heparin-induced spinal fractures. A 27-year-old woman received heparin sodium for 152 days because of antepartum iliofemoral thrombophlebitis. At the end of this time, spinal osteoporosis and multiple vertebral fractures became clinically evident and were attributed to the prolonged administration of heparin. Previously reported cases of "heparin osteoporosis" were reviewed. The significance of the daily dose of heparin and the duration of therapy are reemphasized. This therapeutic complication and the management of antepartum iliofemoral thrombophlebitis are discussed. Prolonged administration of heparin in daily doses exceeding 10,000 units is potentially hazardous.


Death caused by recreational cocaine use. Sixty-eight deaths associated with the recreational use of illicit cocaine were investigated by the Medical Examiner's Office of Dade County in Florida. Most fatalities occurred since 1975. Although 29 involved the use of other drugs (usually heroin), 24 persons died directly of the toxic effects of cocaine. Respiratory collapse and death occurred rapidly after the intravenous injection of cocaine. Oral or nasal ingestion resulted in a symptom-free interval lasting as long as an hour followed suddenly by generalized seizures and death. Toxicological analysis could not causally relate lidocaine hydrochloride or other adulterants to the untoward reactions. The data suggest that the rate of absorption, the peak blood concentration, and the prior use of cocaine all contribute to the possibility of a fatal reaction. Despite current belief, cocaine cannot be considered a safe recreational drug.


How ominous is an abnormal scan in bronchogenic carcinoma? Bone, brain, and liver radioisotope scans as prognostic indicators were studied in a series of 162 patients with primary bronchogenic carcinoma. One or more scans positive for metastasis reliably predicted death in less than six months. An abnormal bone scan was most significant (P less than .001). Reliability in predicting less than one year's survival in abnormal liver and brain scans was P less than .05 for both. Patients with two normal scans were found to have a 50% six-month survival expectation. Brain scans added little information, as they would have predicted a different prognosis for only three of 114 patients who received them.


Behavioral factors and urinary tract infection. Voiding and sexual habits of 84 female university students with a history of recurrent urinary infection were compared with those of a control group. There was one highly significant difference between the two groups: 61% of the patients but only 11% of the controls gave a history of regular voluntary deferral of micturition for periods of one hour to longer than six hours. Sexual practices among patients and controls were remarkably similar. A behavioral regimen stressing regular, complete bladder emptying was shown to be effective in preventing reinfection in the patient group. Voluntary urinary retention may play a pathogenic role in women with recurrent urinary tract infection, and its correction may play an important part in the management of urinary tract infection.


Therapeutic use of albumin.

Therapeutic use of albumin. Increasing use of normal human serum albumin may be contributing to the rising cost of medical care. To investigate whether albumin is extensively overused or abused, a study of the quality of albumin use was conducted in a Veterans Administration Hospital. Specific criteria for appropriate use were developed using guidelines defined at a national symposium. A review of use during a three-month period showed that surgery patients received 91% of the albumin administered during that period; of the total amount administered, 41% was used inappropriately; the decision to administer albumin to patients undergoing surgery appeared to be correct only 29% of the time; and an estimated $40,000 was spent on inappropriately used albumin at this hospital in 1977.


Monitoring tricyclic antidepressant plasma concentrations. Plasma concentrations of tricyclic antidepressants were monitored during treatment of 126 patients. Noncompliance in taking medication was suspected in 19 patients because of unusually low plasma concentrations in relation to the presumed dose. Determinations of plasma concentrations may also be useful for detecting inadequate treatment as judged by levels below the presumed therapeutic range. Attempts to correlate plasma concentrations with clinical response to amitriptyline hydrochloride and nortriptyline hydrochloride failed, probably because of the heterogeneity of depressive syndromes being treated. Plasma concentrations were correlated highly with dose in the case of amitriptyline, less so in the case of other drugs. Amitriptyline and imipramine hydrochloride generally produced plasma concentrations of the parent drug and metabolite higher in nanograms per milliliter than was the daily dose in milligrams; nortriptyline and desipramine hydrochloride did the opposite.


Patient behavior for blood pressure control. Guidelines for professionals. Behaviors critical to hypertensive patients' achieving therapeutic control and assuming active responsibility for their own care were defined by an interdisciplinary group brought together by the National High Blood Pressure Education Program. The report focused on the achievement and maintenance of long-term control through drug therapy and concentrated on the patient-physician interaction as a critical factor. The basic hypothesis that active participation by the patient favors successful management of hypertension identifies the physician, the prime diagnostician and initiator of the subsequent interaction, as a promotor of that important collaboration. The working group views the patient as the decision-maker and problemsolver, with the professional functioning as advisor and guide. This synthesis of available theory and practice in therapy adherence includes knowledge, attitudes, and skills defined under four major behaviors: making the decision for control, taking medication, monitoring progress, and problem solving.


Multiple cardiovascular injuries and motor vehicle accidents. A patient sustained blunt chest trauma in a motor vehicle accident. Cardiovascular trauma was initially obscured by more obvious orthopedic injuries. Thoracic aortic transection with false aneurysm formation was discovered incidentally during cardiac catheterization for traumatic tricuspid insufficiency. Successful repair of both lesions was subseqeuntly performed. This case demonstrates the difficulty in recognizing cardiovascular trauma in survivors of motor vehicle accidents and emphasizes the need for an aggressive diagnostic approach with consideration of coexisting injuries in patients who have sustained blunt chest trauma.


Erectile impotence treated with an implantable, inflatable prosthesis. Five years of clinical experience. Erectile impotence can now be treated with a device that mimics a natural erection. Between 1973 and 1977, we implanted an inflatable prosthesis in 245 men (235 with organic impotence and ten with psychogenic impotence). Of these, 234 are able to use the device to their satisfaction; no failures have occurred in the 152 cases treated in 1976 and 1977. The success of this treatment rests in part on the careful selection of patients by a team--a urologist, a sleep researcher, a psychologist, and a psychiatrist--each evaluating the patient independently. Our experience suggest that erectile impotence may be more common than generally believed and that impotence from organic causes may account for a greater percentage of cases than formerly thought.


Bronchodilator effects on gastric acid secretion. Nine patients with chronic obstructive pulmonary disease were given oral aminophylline, intravenous aminophylline, and various inhaled and oral adrenergic bronchodilators to determine the effect of these agents on gastric acid secretion and gastrin release. Inhaled epinephrine hydrochloride resulted in an increase in basal acid output of borderline significance (.05 less than P less than .10). Oral aminophylline caused a significant increase in basal acid output from 2.43 to 4.06 mEq (P less than .05). Intravenous aminophylline also caused a significant increase in basal acid output from 0.66 to 2.19 mEq (P less than .01). There were no statistically significant changes in serum gastrin levels after administration of any of the bronchodilators. Aminophylline should be used with caution, if at all, in patients with peptic ulcer disease. In these patients, a beta agonist should be used for initial therapy. If the addition of aminophylline is necessary, antacids should be given.


Acute adverse reactions to ibuprofen in systemic lupus erythematosus. Three young women with systemic lupus erythematosus who were given ibuprofen for arthritis voluntarily discontinued taking the drug. On reinstitution of therapy, profound hypotension, fever, and headaches developed within hours, without other identifiable cause. A possible relationship to salicylate intolerance was considered. Because of these apparent side effects, we stress caution in the use of ibuprofen in systemic lupus erythematosus, particularly if there is any history of salicylate intolerance.