Pancreatic excretion test and barrier hypothesis in progression of chronic pancreatitis. Simultaneous data of the pancreozymin-secretin test and the pancreatic excretion test with 5,5-dimethyl-2,4-oxazolidinedione DMO) were reported for 50 patients with chronic pancreatitis. The pancreozymin-secretin test was abnormal in 90% of the patients, while the pancreatic DMO excretion test showed abnormality in 100% of the patients. The dynamic process of pancreatic excretory dysfunction is discussed. Over 60% of patients with low to moderate grade chronic pancreatitis showed a discordant pattern of decreased DMO output with normal bicarbonate concentration or normal volume flow. Approximately 96% of patients with advanced grade chronic pancreatitis had a excretory pattern of decreased DMO output with low bicarbonate concentration and decreased volume flow. These findings may further develop a barrier hypothesis in chronic pancreatitis. In the early stage of chronic pancreatitis, when functional capacity of the duct is preserved fairly well, the extraductal barrier to the rapid DMO diffusion into the ducts (diffusion barrier) may be primarily responsible for impaired pancreatic DMO excretion. With progression of chronic pancreatitis, the intraductal barrier (outflow barrier) may become pronounced and precipitate pancreatic excretory dysfunction for DMO. The concept of pancreatic barriers may well serve to systematize major histologic alterations observed in chronic pancreatitis.


Inhibition of ethionine pancreatitis in the rabbit by DL-BETA-3 thienylalanine pretreatment. Beta-3 thienylalanine, an inhibitor of zymogen formation, was studied in the experimental model of ethionine pancreatitis in the rabbit. Beta-3TA pretreated and nonpretreated rabbits were given ethionine for six days and controls were given chow only. Animals were killed and serum amylase values determined. Pancreatic tissue was studied by light and electron microscopy. Beta-3TA pretreated rabbits on ethionine showed normal amylase values, while those receiving only ethionine showed high values. Microscopic examination showed severe pancreatitis in the nonpretreated group but only mild vacuolization of cells in the Beta-3TA pretreated animals. Electron microscopy demonstrated integrity of rough endoplasmic reticulum in pretreated animals and severe distortion of cytoplasmic organelles in nonpretreated animals.


Spontaneous umbilical hernia rupture: a report of three cases. Three cases of spontaneous umbilical hernia rupture in patients with alcoholic liver disease and ascites are reported. Eighteen cases have been previously reported in the literature. These 21 cases are reviewed in an attempt to determine precipitating events, prognostic factors, complications, and the results of therapy. All patients had significant ascites prior to umbilical rupture. Ulceration of the umbilicus prior to rupture was common (81%). The subsequent presence of peritonitis, hypotension, renal failure, gastrointestinal hemorrhage or hepatic coma was associated with significant mortality (80%). All patients with a serum albumin above 2.4 gm./dl. survived. There were no survivors in those patients who did not receive surgical treatment. Based upon the outcome of these 21 patients optimal treatment of this disorder would seem to be early surgical repair of the umbilical hernia, appropriate fluid and electrolyte replacement, antiobiotics and measures to reduce intraabdominal pressure.


Vagotogenic cholecystitis.

Vagotogenic cholecystitis. Truncal vagotomy provokes acute cholecystitis in the stone-containing gallbladder of dogs. An apparently similar sequence has been fortuitously observed in three patients. These circumstances suggest that where cholelithiasis is encountered in a clinical situation in which truncal vagotomy is performed, cholecystectomy or stone removal and cholecystostomy be done as a synchronous adjunctive procedure.


Incidence rates and risk factors of benign breast neoplasms. A case-control study of benign breast disease was conducted in Greater Boston in 1968-1969. Cases were nearly all women living in the reference population who were initially diagnosed as having fibrocystic disease, fibroadenoma or a "mixed" lesion during the study period. Controls were a random sample of the entire reference population. A mail questionnaire was completed for 678 cases and for 1807 controls. For fibrocystic disease the age-standardized incidence rate was 89.4 per 100,000 woman-years; for fibroadenoma it was 32.8. Fibrocystic disease rises in incidence to age 45 and then declines sharply. The incidence rate of fibroadenoma peaks during the 20's, while that of mixed tumors has a mode at 30 to 34. Among young women, the highest rates occur in married nulliparae, but this is not so at higher ages. Neither for fibroadenoma nor fibrocystic disease was there a consistent relationship of risk with parity or with age at first birth. Fibrocystic disease risk was strongly and directly related to age at natural menopause, directly but not strongly related to an index of socioeconomic status, and was increased among women who gave a history of arthritis. Both fibrocystic disease and fibroadenoma were much less frequent in more obese women. Neither fibrocystic disease nor fibroadenoma has an epidemiologic pattern which corresponds closely to that of breast cancer. Therefore, it seems reasonable to suggest that the apparent increased risk of breast cancer among women with benign breast disease is concentrated within a subset of these women.


Occurrence of cirrhosis and primary liver cancer in an Eskimo population hyperendemically infected with hepatitis B virus. Hepatitis type B is hyperendemic in Greenland with serologic evidence of infection in 54% of adults and a hepatitis B surface antigen (HBsAg) carrier rate of 7--25%. The impact of this infection rate on the occurrence of cirrhosis and primary liver cancer (PLC) was studied. Mortality rates for cirrhosis were obtained from official mortality statistics, 1951--1975. PLC was identified by a study of all biopsy and necropsy material taken in the study area during the same period. Neither cirrhosis nor PLC was found to be a more prevalent cause of death in this population than in Northern Europe where hepatitis B is at least 10-fold less prevalent. It is concluded that hepatitis B infection per se does not contribute significantly to the development of cirrhosis or to PLC, at least in the Eskimo population of Greenland.


Cohort study of venereal disease. I: the risk of gonorrhea transmission from infected women to men. Reliable data on the risk of transmission of N. gonorrhoeae would enhance our understanding of the importance of host defenses against gonorrhea and would aid in the evaluation of prophylactic measures. This paper examines the risk of transmission of gonorrhea from infected female to male and the role that variables such as race, prophylaxis and amount of exposure play in the development of gonococcal urethritis. Volunteer crew members of a large naval vessel were followed prospectively as a cohort to study their risk of acquiring gonococcal infection during a four-day liberty period in the Far East. At the same time the prevalence of N. gonorrhoeae was determined in a population of females to whom the sailors were exposed. The calculated risk of transmission per exposure with an infected partner was .19 for whites and .53 for blacks. A statistically significant relationship was noted between the risk of transmission of gonorrhea and both the number of partners and the frequency of sexual intercourse. Further, the increasing infection rate with increasing numbers of exposures in men who had a single sex partner suggests that the majority of men are in fact susceptible to gonorrhea if the quantity of exposure is sufficient.


Antitoxin responses in the elderly to tetanus-diphtheria (TD) immunization. A high per centage of reported cases of tetanus and diphtheria in the United States occurs in persons over 60 years old. The sera of 69 elderly persons, mean age 80 years, were tested for prevalence of tetanus and diphtheria antibodies, and only 51% and 59%, respectively, had protective levels (greater than or equal to .01 AU/ml). In a prospective study 27 elderly volunteers were given 0.5 ml tetanus-diphtheria (Td) toxoid twice, seven months apart. Before toxoid 26% and 59% of persons had protective antitoxin levels against tetanus and diphtheria. After one dose the per cent protected rose to 42 and 88. After the second dose all persons immunized had protective levels. No subjects had significant side effects after either dose. These data demonstrate that many elderly persons lack protection against tetanus and diphtheria and document that two doses of Td toxoid would confer immunity to virtually all such persons.


Botulism type B: epidemiologic aspects of an extensive outbreak. Between March 31 and April 6, 1977, 59 individuals developed type B botulism. All ill persons had eaten at the same Mexican restaurant and all had consumed a hot sauce made with improperly home-canned jalapeno peppers, either by adding it to their food, or by eating a nacho that had had hot sauce used in its preparation. There was a highly significant association between illness and consumption of hot sauce when a comparison was made between ill persons and well controls: 4% of all restaurant patrons eating at the restaurant during the outbreak period became ill with botulism; however, approximately two-thirds of those actually exposed to the toxic hot sauce became ill. Disease severity was statistically correlated with incubation periods. No differences in disease severity were found between persons of different age groups. The full clinical spectrum (mild symptomatology with neurologic findings through life-threatening ventilatory paralysis) of type B botulism was documented.


Physical activity as an index of heart attack risk in college alumni. Risk of first heart attack was found to be related inversely to energy expenditure reported by 16,936 Harvard male alumni, aged 35-74 years, of whom 572 experienced heart attacks in 117,680 person-years of followup. Stairs climbed, blocks walked, strenuous sports played, and a composite physical activity index all opposed risk. Men with index below 2000 kilocalories per week were at 64% higher risk than classmates with higher index. Adult exercise was independent of other influences on heart attack risk, and peak exertion as strenuous sports play enhanced the effect of total energy expenditure. Notably, alumni physical activity supplanted student athleticism assessed in college 16-50 years earlier. If it is postulated that varsity athlete status implies selective cardiovascular fitness, such selection alone is insufficient to explain lower heart attack risk in later adult years. Ex-varsity athletes retained lower risk only if they maintained a high physical activity index as alumni.


Follow-up of vasectomy using medical record linkage. The authors report the findings from an on-going of 1764 vasectomized men followed up by means of the Scottish medical record linkage system for a total of 4500 man-years after operation. The authors view the results so far as reassuring regarding the safety of vasectomy, although the mean length of follow-up (2.6 years) is still short. The study will continue. Some features of this method of follow-up are described and discussed.


Cardiorespiratory disease mortality among British and Norwegian migrants to the United States. Mortality rates for coronary heart disease (CHD), chronic non-specific lung disease (CNSLD), and lung cancer for ages 45-74 years were studied for British and Norwegian migrants to the U.S. and for sample of U.S. native-born. The observed order for CHD and lung cancer was as anticipated, with native-born experiencing the highest CHD rate, British migrants the highest lung cancer rate, and, in each instance, Norwegian migrants experiencing the lowest rates. For CNSLD, contrary to national comparisons, the British migrant rates were about equal to the U.S. native-born although Norwegian migrant rates were lowest, as expected. Migrants who were younger than 15 years of age at migration experienced the highest CHD mortality levels, but a decreasing gradient in mortality level with increasing age at migration did not materialize. Due to inherent limitations in the data, results for CNSLD and lung cancer mortality levels with respect to age at migration remain uncertain. Data on cigarette smoking status indicated substantial excess mortality for cigarette smokers compared to non-smokers and occasional smokers for all groups studied.


The relationship between alcohol, liver disease, and testicular pathology. Impotence, infertility and feminization have been frequently reported among male cirrhotic patients. Previous studies have suggested that liver disease was the basis of these effects. Recent clinical and laboratory experimental studies have suggested that alcohol consumption may have a direct effect on both testosterone metabolism and spermatogenesis. The effect may be mediated through the central nervous system or directly on the testes. The present study compared the pathology in the liver and testes and the estimated alcohol consumption among men who had died suddenly from a variety of causes. Of 137 men studied, 20(14%) had moderate to severe decrease in spermatogenesis. Only 9 of 19 with decreased spermatogenesis also had severe or very severe fatty infiltration of the liver. However, 17 of 19 were classified as heavy alcohol drinkers and 14 were estimated to consume at least 417 gm of alcohol per week. Finally, the alcohol history was reviewed in relation to liver and testicular pathology. Only a weak association between the liver and testes pathology was noted.


Assessment of surveillance and vital statistics data for monitoring abortion mortality, United States, 1972-1975. To assess the usefulness of vital statistics and surveillance for monitoring abortion mortality, the authors compared data from two systems of classification: 1) deaths classified according to the underlying cause by the National Center for Health Statistics (NCHS) under the International Classification of Disease, Adapted (ICDA) code numbers 640-645 (abortion) for 1972-1975; and 2) abortion-related deaths reported to the Center for Disease Control (CDC) through its epidemiologic surveillance of abortion mortality for the same years. Vital statistics classifications dealing with the underlying cause of death are based on criteria defined by ICDA guidelines applied to all available information listed on death certificates, and exclude some deaths classified as abortion-related by CDC. Surveillance classifications are based on broader criteria developed by CDC for expanded data gathered by individual case investigation. Results showed that the surveillance techniques had identified more deaths as abortion-related and had resolved more cases into the specific abortion categories of legal, illegal, and spontaneous than vital statistics tabulations based on death certificates. The authors estimate that the surveillance system alone reported 88% of all abortion-related deaths, the vital statistics system 52%, and the two systems combined a total of 94%. Inadequate physician documentation on the death certificate was the primary reason vital statistics data contained a smaller number of reported abortion deaths than surveillance data.


The role of nationwide nosocomial infection surveillance in detecting epidemic bacteremia due to contaminated intravenous fluids. Since January, 1970, the Center for Disease Control (CDC) has corridnated surveillance of nosocomial infections in a group of voluntarily cooperating hispitals in the United States. In 1970, this surveillance system failed to realize one of its major goals: detection of a nationwide epidemic of septicemia caused by contaminated intravenous products. However, retrospective review of infections reported to CDC revealed that the data received were sufficient for the outbreak to have been recognized. Beginning in July, 1970, one month after the contaminated products were first distributed and five months before the outbreak was actually detected. CDC data showed a persistent increase in the incidence of Enterobacter and Erwinia (presently designated Enterobacter agglomerans) bacteremia. Furthermore, monthly rates of cases of bacteremia caused by these organisms were higher in hospitals using the contaminated intravenous products than for hospitals not using them. Failure to detect this outbreak at the time of its occurrence was due to delays in data processing and insufficiently sophisticated data analysis. Based on this experience, CDC has modified the surveillance system to aid recognition of future outbreaks.


Estimating exposure-specific disease rates from case-control studies using Bayes' theorem. The methods used for selecting subjects yield three types of case-control studies: 1) incident cases are compared to non-cases chosen to be representative of the exposure distribution among the person-years which produced the cases. In this type of study the exposure-odds ratio equals the incidence density ratio; 2) incident cases are compared to residual non-cases at the end of the risk period (exposure-odds ratio = cumulative incidence-odds ratio); 3) prevalent cases are compared to non-cases (exposure-odds ratio = prevalence odds ratio). In study type 1 the equivalence of odds ratio to rate ratio requires no "rare disease assumption;" this permits estimation of exposure-specific illness rates when the overall rate is known. In study types 2 and 3 the exposure-odds ratio equals the corresponding rate ratios only when exposure-specific rates are low. Nonetheless, exposure-specific rates can be calculated without making any rare disease assumption using Bayes' theorem and information on the overall disease rate. A method for obtaining approximate confidence limits around the exposure-specific rates is presented.


Assuring "detached but passionate investigation and decision": the role of guardians ad litem in Saikewicz-type cases. The author focuses this Article upon the aspect of the Saikewicz decision which determines that the kind of "proxy consent" question involved in that case requires for its decision "the process of detached but passionate investigation and decision that forms the ideal on which the judicial branch of government was created." This aspect of the decision has drawn much criticism from the medical community on the ground that it embroils what doctors believe to be a medical question in the adversarial processes of the court system. The author criticizes the decision from an entirely opposite perspective, arguing that the court's opinion fails in not laying down guidelines that would assure a truly adversary process in Saikewicz-type cases. He agrees with the Saikewicz court that our democratic institutional structure and societal commitment to individual liberty require that persons not competent to consent for themselves to acts of euthanasia be protected by a process of "detached but passionate investigation and decision." However, he points out that this ideal of the court system was not realized in Saikewicz itself and is not likely to be realized in other cases without reform of some of the procedures currently being employed by the courts in "proxy consent" cases. Drawing on previous articles that he has written in related areas, he then proposes a set of guidelines that he believes not only will remove existing procedural deficiencies, but also may reform some aspects of the existing system that have drawn criticism from the medical community.


Park v. Chessin: the continuing judicial development of the theory of "wrongful life". Park v. Chessin, a recent New York case, marked the first step toward judicial acceptance of the theory of "wrongful life." Wrongful life suits involve a cause of action brought by an infant, against a physician, alleging that the physician's failure to inform the child's parents of the possibility of their bearing a severely defective child was the proximate cause of the infant's birth, and thus resulted in harm to the infant. This Note explores recent legal developments that give precedential support to the development of the theory of wrongful life. Furthermore, it demonstrates that the awarding of monetary damages is an appropriate remedy for the wrongful life plaintiff, and it examines possible methods for measuring those damages. The Note concludes with an analysis of the capability of courts to adjudicate wrongful life suits, and of the possible ramifications of judicial acceptance of the theory of wrongful life.


Reimbursement for clinical pharmaceutical services. Reimbursement for four clinical pharmaceutical services (growth hormone home instruction, patient consultation, patient visit and pharmacokinetic consultation), separate from other drug-related fees, is discussed. Included are descriptions of the clinical services, how they were provided, how charges were determined and documented, and how the proposal was submitted which initiated the charges. During a four-month observation period, from May to August 1977, 27 physicians requested a total of 71 clinical pharmaceutical services. Pharmacy charges generated by these requests totaled $4,492. Patients' and physicians' comments concerning the services have been positive, and pharmacy charges generated continue to average $1,100/month.


Appropriateness of the use of serum digoxin and digitoxin assays. The use of 145 digoxin and digitoxin assays was studied in a teaching hospital to determine if performance of assays was appropriate and therapeutically beneficial. Patient charts (121) were randomly selected from a list of all patients for whom digoxin or digitoxin assays were performed. Charts were compared with established criteria to determine whether the assay was indicated and performed correctly and whether dosage was adjusted correctly based on assay results. Of the assays reviewed, 49% were performed for irrational indications; 86% were performed appropriately under steady-state conditions; and 96% used serum samples appropriately drawn more than six hours after administration of the last digitalis glycoside dose. Of the assays performed at appropriate times in relation to dose and at steady-state plasma concentrations (120), 31 should have and 89 should not have resulted in a dosage change. Of the latter, 98% were evaluated correctly. Of the former, 36% were not evaluated correctly (i.e., indicated dosage adjustments were not made). Control of the use of digitalis glycoside assays is needed. Pharmacists should become involved in monitoring drug assays to assure appropriateness of assay request, interpretation and follow-up.


Bid purchasing of pharmaceuticals.

Bid purchasing of pharmaceuticals. The effects of bid purchasing of drug products by hospitals and the factors to consider in bid purchasing of pharmaceuticals are reviewed; further, the prices available with bid purchasing to a specific hospital in 1974 and 1977 are presented. Factors important for a successful bid purchasing system of pharmaceuticals are: (1) use of a formulary policy, (2) an effective procedure for handling bid purchasing and (3) criteria for evaluation of drug products. Significant differences were found between prices available with and without bid purchasing for 50 nonproprietary drug products in 1974 and for 19 products in 1977. Although monetary savings to hospitals do exist with bid purchasing of pharmaceuticals, the degree of savings is dependent upon the drug usage for that hospital.


Use of a pharmacy technologist to manage technicians' activities. The role of a pharmacy technologist, in comparison with that of a pharmacist and a pharmacy technician, is discussed as it was developed at one hospital. Training, staffing patterns, personnel functions, acceptance and salary of the technologist are described. The use of the technologist to manage technician-level personnel is suggested as a means of providing the pharmacist with more time for professional activities.


Gentamicin-cephalothin drug reaction.

Gentamicin-cephalothin drug reaction. A case report describing the occurrence of nephrotoxicity in a 26-year-old black male with sickle cell anemia after concurrent i.v. administration of gentamicin sulfate and cephalothin sodium is presented. Cephalothin 1 g.i.v. every six hours was given for three days for a Klebsiella infection demonstrated by urine and blood culture to be cephalosporin sensitive. Cephalothin was then discontinued and gentamicin, after an i.v. loading dose of 2.6 mg/kg, was given for 14 days in a dosage of 1.3 mg/kg every eight hours. After cultures of pus aspirated from the right thigh demonstrated Klebsiella, 2 g of cephalothin was administered i.v. every six hours and gentamicin sulfate was discontinued. Gentamicin therapy was reinstituted two days later, at a dosage of 5 mg/kg/day. The gentamicin-cephalothin therapy was continued for nine days. The gentamicin dosage interval was increased from every eight to every 16 hours when serum creatinine and gentamicin levels became elevated. Gentamicin was discontinued entirely two days later because serum gentamicin levels were not decreasing. Previous case reports and studies of nephrotoxicity associated with concurrent gentamicin-cephalothin therapy are reviewed. Pharmacists should be alert to the possible increased incidence of nephrotoxicity occurring with concurrent genticin-cephalothin therapy.


Campylobacteriosis in man: pathogenic mechanisms and review of 91 bloodstream infections. Five patients with Campylobacter fetus(previously called "Vibrio fetus") bacteremia are presented with enteric symptoms in four patients, a self-limited course in three, and with possible nosocomial infection in one patient who had disseminated malignancy. The clinical syndromes of 91 bacteremic patients with campylobacteriosis and C. fetus taxonomy and pathogenicity are reviewed. Studies of potential pathogenic mechanisms in enteric infections failed to reveal the production of either heat-stable or heat-labile, cholera-like enterotoxin, cytotoxicity or invasiveness. In comparison with different species of vibrio infections, C. fetus appears to produce disease by a different mechanism, one which involves a bloodstream infection, perhaps following penetration through the intestinal mucosa as has been demonstrated experimentally with salmonellae and yersinia. Such a pattern is consistent with the clinical pattern of C. fetus infections and the experimental studies reported herein.


Pathogenesis of hypercalcemia in lymphosarcoma cell leukemia. Role of an osteoclast activating factor-like substance and a mechanism of action for glucocorticoid therapy. The pathogenesis of hypercalcemia and mode of action of glucocorticoid therapy was examined in a patient with lymphosarcoma cell leukemia. Circulating neoplastic cells were cultured in vitro and secreted a bone-resorbing factor. The bone-resorbing factor was partially purified with the use of a bioassay for bone resorption, and was found to be chromatographically and pharmacologically similar to osteoclast activiating factor (OAF), which is produced by normal mitogen-activated peripheral blood lymphocytes. Other factors which stimulate bone resorption, such as parathyroid hormone, prostaglandins and the vitamin D metabolites, were excluded by criteria which included dose-response curves, radioimmunoassays, extraction in organic solvents and failure of glucocorticoids to inhibit bone-resorbing activity. The patient's hypercalcemia responded rapidly to prednisone therapy. The effects of the bone-resorbing factor secreted by the neoplastic cells on bone cultures to which cortisol was added were examined. Cortisol inhibited bone resorption directly at low doses (10(-8) M), which suggests that prednisone may have lowered the serum calcium in this patient by direct inhibition of bone resorption.


Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome. Antithrombin III levels were studied in relation to the occurrence of thromboembolism in 48 patients with various degrees of proteinuria. Nine of these patients had clinical signs of thrombosis, including four with renal vein thrombosis. In eight of these nine patients, antithrombin III concentrations were below 70 per cent. There was a significant negative correlation between the antithrombin III concentration and the urinary protein excreation (P less than 0.001). Antithrombin III was found in the urine of 32 of 42 patients. There was a significant correlation between the renal clearance and the degree of antithrombin III serum deficiency (P less that 0.001). The clearance and serum level of albumin closely paralleled these changes. We conclude that thrombosis in patients with severe proteinuria is associated with a deficiency of antithrombin III due to urinary excretion of this protein.


Hereditary osteodysplasia with acro-osteolysis. (The Hajdu-Cheney syndrome). A mother and son with acro-osteolysis (Hajdu-Cheney syndrome) are described. In addition to osteolysis of the distal phalanges, these patients have a generalized osseous dysplasia with osteoporosis, premature loss of teeth, short stature and a distinctive facial appearance. In one of the cases an enlarged sella turcica was associated with no abnormality of endocrine function. A biopsy specimen taken from an area of active osteolysis in a phalanx was studied by light and electron microscopy. There was active replacement of central medullary bone by a fibrous and angiomatous process characterized by the presence of small, thick-walled vessels and an unusual number of interspersed nerve fibers and mast cells. A neurovascular dysfunction with local release of osteolytic mediators may be involved in the pathogenesis of the disorder, but the nature of the osteolytic factor is unknown.


Asbestos exposure and related neoplasia. The 28 year experience of a major urban hospital. In a retrospective study of 49 cases of asbestosis, a steady increase in the frequency of diagnosis of asbestosis and asbestos-related neoplasia is documented from a major urban hospital since 1960. Although in the majority of cases the subjects were exposed to asbestos in a neighboring shipyard, in 20 per cent of the cases, asbestos exposure was in industries not related to shipbuilding, reflecting its widespread use. This selective population of patients with asbestosis more often than not had an associated neoplasm. The most likely accompanying tumor was pleural mesothelioma, and among cell types of lung cancer, adenocarcinoma was notably frequent.


Response to pyridoxine hydrochloride in refractory anemia due to myelofibrosis. Eleven of 14 patients with primary myelofibrosis were given a therapeutic trial with 250 mg of pyridoxine hydrochloride daily because of refractory anemia. The effect on the hemoglobin level and the hematocrit value was studied and compared to that in a group of untreated patients with the same degree of anemia. Six of 11 treated patients responded within three months with a rise in the hemoglobin level (at least 3 g/100 ml) and/or an increase in the hematocrit value (at least 10 per cent), and transfusions were no longer required. Deliberate discontinuation of pyridoxine treatment in one responding patient was followed by a relapse of the anemia; resumption of therapy once again induced an erythropoietic response. Spontaneous remissions of anemia were not observed in the untreated group. It is concluded that a trial with pyridoxine is warranted in patients with myelofibrosis and refractory anemia.


Diffuse interstitial pneumonitis. Clinicopathologic correlations in 20 patients treated with prednisone/azathioprine. Twenty patients with diffuse interstitial pulmonary disease diagnosed by open lung biopsy received combined prednisone/azathioprine therapy. Twelve patients demonstrated improvement with therapy. Each patient's clinical presentation, roentgenologic features and pathologic findings were correlated with their therapeutic response. Patients with an illness of one year's duration or less had a more favorable response to therapy than patients with a greater than two year duration of illness. Patients with associated extrathoracic abnormalities (anemia, glomerulitis, hepatopathy) exhibited a better therapeutic response that those with only pulmonary disease. The biopsy material from each patient was quantitatively graded on 20 morphologic variables. Statistical analysis using multiple linear regression revealed that a single variable, degree of interstitial fibrosis, was more that 90 per cent accurate in separating those responsive to therapy from those who failed to respond. Patients who respond to treatment had less interstitial fibrosis. Neither the amount of alveolar septal inflammation nor intra-alveolar cellular reaction was discriminatory in predicting response to therapy. A beneficial response to therapy was reflected in both improved lung volumes and gas exchange. Eight patients appeared to have a selective beneficial effect from azathioprine.


Lymphomatoid granulomatosis. Report of a case and review of the literature. A 24 year old man had a nonproductive cough and chest pain. Chest roentgenogram showed a diffuse infiltrate, and pulmonary function studies showed restrictive lung disease. Extremity weakness, deteriorating mental status and neuropathy progressed as pulmonary findings diminished on corticosteroid therapy. Lung biopsy showed lymphomatoid granulomatosis. The neurologic status deteriorated despite treatment with Cytoxan, intrathecal methotrexate and brain irradiation. Autopsy showed mass lesions of lymphomatoid granulomatosis in the brain and healed lesions in the lungs. A review of the neurologic and pulmonary findings in reported cases show that diminution of pulmonary disease with progression of neurologic disease manifest by mass lesion is unusual. Since the etiology, prognosis and prevalence of this disease remains undefined, all patients with this disease should be reported on.


A syndrome associating partial albinism and immunodeficiency. Two unrelated patients with partial albinism, frequent pyogenic infections and acute episodes of fever, neutropenia and thrombocytopenia are described. Their pigmentary dilution was characterized by large clumps of pigments in the hair shafts and an accumulation of melanosomes in melanocytes. Melanocytes had few short dendritic expansions, and keratinocytes were hypopigmented. No or few Langerhans' cells were detected in skin by electron microscopy and ATP-ase reactions. This pigmentary dilution, different from all other human albinisms, resembles the unique defect of the mutant dilute (d-d) mouse. Despite the presence of an adequate number of T and B lymphocytes, the patients were hypogammaglobulinemic, deficient in antibody production and incapable of manifesting delayed skin hypersensitivity or of rejecting skin grafts. Their leukocytes did not stimulate normal lymphocytes and could not generate cytotoxic cells during mixed leukocyte reaction. T lymphocytes of one patient were unable to exert a helper effect on the maturation of B lymphocytes into immunoglobulin-containing cells following in vitro stimulation with pokeweed mitogen. This suggests that the humoral deficiency might be secondary to a defect of helper T lymphocytes. Granulocytes did not show any morphologic abnormality, and their bactericidal activity was only moderately reduced. An increased number of polymorphonuclear leukocytes with polar distribution of Concanavaline A (Con A) receptors (capping) was found in one patient and her parents. The family histories suggest that this syndrome is transmitted as an autosomal recessive character.


Persistent bacteremia in staphylococcal endocarditis. We treated five patients with persistent Staphylococcus aureus bacteremia and endocarditis. Surgical intervention or a "second-line" antistaphylococcal agent was required for bacteriologic cure in each. Special bacteriologic evaluation failed to demonstrate methicillin resistance or antibiotic "tolerance" among the strains of Staphylococcus tested. Cephalosporin agents were noted to be more susceptible to inoculum effect than either methicillin or nafcillin. All patients survived; the explanation for their atypical course is obscure. We present an approach to patients with persistent Staph. aureus bacteremia and endocarditis.


Factitious and fraudulent fever.

Factitious and fraudulent fever. The task of elucidating the etiology of fever of undertermined origin remains a major undertaking. Factitious fever is uncommonly considered of major importance in the differential diagnosis of fever of undetermined origin although it is a readily identifiable, syndrome and one that is easily excluded one it has been considered. Early identification may reduce the necessity for prlonged, expensive and potentially hazardous hospitalizations for such patients. A retrospective study identified 2.2 per cent (11 of 506) of all patients whose fever on their charts was coded as fever of undetermined origin as having factitious fever. These patients either created factitious fever by manipulation of the thermometer or fraudulent fever by self-induced means. A review of the literature yielded an additional 70 cases in which fever was either the sole factitious sign or part of a larger, more complex factitious illness. Patients were typically young, female and often associated with the medical profession. Patients with factitious fever differ from those with the stereotyped Munchausen's syndrome and may be difficult to recognize. Signs leading to the recognition of this syndrome are emphasized. Since the nature of the psychiatric illness may vary from patient to patient, early discovery may facilitate psychiatric intervention as such patients may be more amenable to therapy.


Acute interstitial nephritis due to methicillin. Fourteen patients are described with a syndrome of methicillin-induced interstitial nephritis. In all patients severe renal dysfunction developed with an average peak serum creatinine of 8 mg/100 ml. An increased total peripheral eosinophil count was found in all patients. All patients had sterile pyuria and each of nine patients studied by Wright's stain of urine sediment had marked eosinophiluria. These findings are suggestive of methicillin-induced interstitial nephritis, although proteinura was a variable finding in our patients. Eight of 14 patients in our study received prednisone therapy for their interstitial nephritis, and the time lapse between maximal and final base line serum creatinine levels was statistically less in the prednisone-treated compared to the nontreated groups. Clinical manifestations of this syndrome are discussed, and the light and electron microscopic and immunofluorescent findings on renal biospy are described.


Pituitary function after pituitary apoplexy. Pituitary function was studied in nine patients who had recovered from pituitary apoplexy. All the patients recovered spontaneously; none required immediate surgery. Four of the patients had acromegaly, two had pituitary-dependent Cushing's syndrome, and a "functionless" pituitary adenoma was found in three. Low serum growth hormone concentrations were observed in three patients with acromegaly whereas the concentration remained increased in the fourth one. Of the two patients with Cushing's syndrome, a selective ACTH-deficiency developed in one and Nelson's syndrome appeared with excessive secretion of ACTH in the other. Transient or persistent hypofunction of the anterior pituitary occurred in al patients. Three patients underwent hypophysectomy after respective intervals of three, eight and 12 months after pituitary apoplex. The operation revealed a hemorrhage in one functionless adenoma and a large cyst in another one. In the third patient who had acromegaly, no signs of the pituitary apoplexy were observed at operation.


Contribuiton of M-mode echocardiography to cardiac diagnosis. An assessment in 1,000 successive patients. The contribution of M-mode echocardiography to cardiac diagnosis was evaluated in a series of 1,000 successive patients. Among subjects in whom a presumptive clinical diagnosis had been made, echocardiography demonstrated totally unexpected findings in 10 per cent, supported the clinical diagnosis in 50 per cent and was entirely within normal limits in 19 per cent. Among patients with evidence of heart disease but no firm clinical diagnosis, echocardiography established the diagnosis in 23 per cent, including 20 per cent of all patients referred for evaluation of chest pain or arrhythmia of unclear etiology. "Missed" clinical diagnosis frequently involved patients with mitral valve prolapse, congestive cardiomyopathy, pericardial disease or asymmetrical septal hypertrophy of the heart. This study quantifies the amount of independent information contributed by echocardiography to cardiac diagnosis and demonstrates that this technic provides data of important clinical relevance in a surprisingly large number of cardiac patients.


Generalized elastolysis (cutis laxa).

Generalized elastolysis (cutis laxa). Generalized elastolysis is a rare and unique systemic disorder of connective tissue in which the elastic fibers suddenly become fragmented, disorganized and fewer in number with the resultant production of such entities as cutis laxa, emphysema, aortic aneurysms and bowel diverticula appearing in the organ system involved, that is, skin, lung, vasculature or gastrointestinal tract. Presented here are three cases that, illustrate the typical features of this condition. In addition, 14 more cases were retrieved from the literature and the information reviewed. Various etiologic factors relating to the synthesis and degradation of elastic tissue are discussed in light of recent findings in the biochemistry of connective tissue.


Early anthracycline cardiotoxicity.

Early anthracycline cardiotoxicity. Eight patients in whom cardiac dysfunction developed within four weeks of receiving their first or second course of daunorubicin or doxorubicin are described. Four patients presented with pericarditis; three of these four had evidence of myocardial dysfunction. Histopathologic analysis of these patients was consistent with an acute myocyte damage and secondary inflammatory process. An additional group of four patients presented with symptoms and signs of heart failure. These patients were either elderly or had evidence of previous cardiac disease. One of these patients suffered a myocardial infarction 24 hours after receiving 60 mg/m2 of daunorubicin; earlier doses in the same course had been associated with evidence of myocardial ischemia. We conclude that anthracycline antibiotics may manifest clinically significant cardiotoxicity at total cumulative doses much less than have been associated with chronic cardiomyopathy.


Fatal pulmonary hypertension and resolving immune-complex glomerulonephritis in mixed connective tissue disease. A case report and review of the literature. Mixed connective tissue disease (MCTD) has been characterized as a benign rheumatic syndrome with a favorable response to immunosuppressive therapy. Serious renal and pulmonary involvement are reported to be rare in MCTD. We are describing a female adolescent with MCTD in whom fatal cor pulmonale developed due to recurrent thromboembolic primary pulmonary hypertension. Death occurred after two years of therapy with prednisone and azathioprine for an immune-complex glomerulonephritis. Paramesangial and intramembranous electron-dense deposits had been identified in several glomeruli at the start of treatment. Improved renal function and apparent histologic improvement were demonstrated four months after the institution of prednisone and azathioprine therapy, and stable renal function was maintained until death. The pulmonary hypertension was progressive and apparently not altered by either the prednisone or azathioprine. At necropsy, there was no evidence of a pulmonary arteritis or vascular immune-complex deposition to account for the recurrent thromboembolic lesions in the small pulmonary arteries and arterioles. This is a clinical course not previously described in patients with MCTD and may represent an extreme of the clinical spectrum of this syndrome.


Bacterial invasion of pulmonary vessels. Pseudomonas bacteremia mimicking pulmonary thromboembolism with infarction. Pseudomonas aeruginosa displays a curious propensity for invading blood vessels and causing vessel wall necrosis. This bacteremia-related "vasculitis" is often associated with hemorrhagic necrosis and infarction of surrounding organ parenchyma. With the exception of skin lesions, however, clinical manifestations of Ps. aeruginosa vasculitis seldom occur. In the patient we describe, fatal Ps. aeruginosa bacteremia was first manifested by a syndrome indistinguishable from pulmonary thromboembolism with infarction.


Evaluation of disc diffusion susceptibility testing performed from a four-hour subculture of positive blood culture bottles. Disc diffusion susceptibility tests were performed on standardized broth suspensions inoculated from a four-hour subculture of a positive blood culture bottle as well as from an agar plate subculture of the same positive blood culture bottle. The zone sizes and interpretative results of both methods were compared. Of 101 isolates tested, only one organism exhibited a very major difference between the two methods (one Staphylococcus epidermidis was interpreted as susceptible to methicillin by the four-hour subculture method and resistant by the agar plate subculture method). Thirteen other isolates showed minor changes from susceptible or resistant to intermediate or from intermediate to either susceptible or resistant with only one antibiotic each. The data indicates that disc diffusion susceptibilities may be performed easily and accurately from a four-hour subculture of positive blood culture bottles.


Development of a P.A.C.E.-approved continuing education program for the community hospital. A Professional Acknowledgment for Continuing Education (P.A.C.E.) approved continuing education program was developed for laboratory technologists at Sherman Hospital, Elgin, Illinois, on an in-service basis. The results of a needs analysis of staff technologists provided the basis for selection of program content. The program was presented as four one-hour monthly sessions and videotaped for showing at later dates. This methodology proved extremely effective in providing a maximum number of technologists with a P.A.C.E.-approved and documented continuing education program while keeping disruption of the work schedule in the laboratory to a minimum.


Utilizing program requirements to your advantage. A curriculum summary developed to assist program officials and faculty of this medical technology program in meeting the American Medical Association Committee on Allied Health Education and Accreditation requirements as enumerated in the Essentials of an Accredited Educational Program for the Medical Technologist is described. After developing this curriculum summary, the faculty and program officials reaped unanticipated benefits from this summary. The curriculum summary aided the faculty and program officials in assuring that there was agreement between cognitive, affective, and psychomotor terminal behavioral objectives with instructional activities and methods of student evaluation. The psychomotor terminal behavioral objectives were modified and utilized as the basis for criterion-referenced, pass/fail laboratory practicals. Finally, the curriculum summary provided a rapid means of review for the curriculum review committee.


The preservation of articular cartilage. Slivers of articular cartilage were stored in Ham's medium, plasma, polyvinyl pyrrolidone, and dimethyl sulphoxide at 0, -20, 4, and 38C. Survival was monitored by potassium determinations and autoradiography using S-35 and by matrix staining. Survival of 48 days was obtained in Ham's medium at 4C.


Interpersonal values and job satisfaction of medical technologists. The purpose of this study was to investigate the interpersonal value domain of certified medical technologists. By so doing, it was anticipated that a better understanding of what medical technologists consider important in their relationships with other people might be established. More specifically, this study examined the interpersonal values of medical technologists: 1) dichotomized by job satisfaction-dissatisfaction, and 2) at different job levels (bench level or supervisory level) in the clinical laboratory.


Continuing education for laboratory personnel. This study investigates the status of continuing education for laboratory personnel in West Virginia. From a total of 1,155 questionnaires mailed to 90 laboratories, 638 completed questionnaires were returned. Ninety-six and six-tenths percent of the survey population (616 responses) expressed a desire for continuing education programs, but only 416 persons (65.2 percent) indicated that they had attended at least one continuing education program in the past five years. Only 15.8 percent of the survey population (101 persons) indicated they had ever attended continuing education programs sponsored by West Virginia University. Based on the information obtained, a model program for continuing education is submitted.


Computerization of clinical laboratory procedure manuals. Current code requires federally licensed clinical laboratories to have standard operating procedure manuals describing all tests performed. A computerized system for generating, revising, and excerpting manuals, which produces hard copy and microfiche, has been developed and appears to meet the regulatory criteria. The salient aspects of pertinent federal regulations, the features of the computerized system, the format of the manual, the users' experience therewith are described.


Amperometric determination of chloride with a rotating platinum electrode. A titrimetric method for chloride analysis which uses a rotating platinum electrode for determining end points amperometrically was developed. It was found that sodium chloride solutions and both serum samples could be analyzed rapidly and accurately by this method. When a sodium chloride solution was added to a plasma sample, the recovery of the added chloride was 103 percent.


Adolescent pregnancy: the Jackson, Mississippi, experience. An adolescent pregnancy center combining the educational, medical, and social needs was operational in Jackson, Mississippi, from September, 1971, to July 1976. Administrative responsibilities were shared by the University of Mississippi and the Jackson Separate School District. From 1971 to 1975, 763 students were enrolled. The mean age was 16 and ages ranged from 11 to 18 years. Ninety-nine per cent were black and a majority were poor and from a single-parent home. There was a 78 per cent school retention rate, but the center did not reduce dependence upon welfare assistance. When center, noncenter, faculty, and unregistered patients were compared, no difference could be detected in the incidence of medical complications, low birth weight, hypertension, and hematocrit. When compared for age only hypertension and difficult deliveries appeared to be age related.


Immunologic and medical considerations in tuberculin-sensitized pregnant patients. One-hundred and seventy-two pregnant patients were identified as tuberculin sensitive in the first trimester. These patients were followed throughout pregnancy for any signs or symptoms of active tuberculosis which were discovered only in the index case. Post partum, patients were again re-evaluated for tuberculosis and prophylactically treated with isoniazid if they met established criteria. The tuberculous host also represented a model for the study of cell-mediated immunity, which presumably is altered in pregnancy. This investigation revealed a progressive depression of lymphocyte function to a specific antigen, purified protein derivative, obtaining significance at 36 weeks' gestation and continuing through delivery (p is less than 0.001). Nonspecific cell-mediated immunity, however, was not depressed when monitored throughout the gestation by the mitogen, phytohemagglutinin, which would stimulate all lymphocyte clones. This discrepancy in the alteration of specific clones of lymphocytes compared to all noncommitted lymphocytes may account for varying reports of the immune status of the pregnant woman.


Esophageal manometry in pregnant and nonpregnant women. Esophageal and gastric tone was recorded in six pregnant and six nonpregnant women by means of a new technique for intraluminal pressure recordings. The recordings were performed in supine and standing positions, at rest, and during swallowing of saliva or water. It was found that the pregnant women had lower intraesophageal pressures but higher intragastric pressures compared to the nonpregnant women. In one of the pregnant women a negative pressure situation was recorded between the stomach and lower esophagus. This patient also complained of severe heartburn when she was lying down. Gastroesophageal reflux seems to be aggravated in pregnant women since esophageal peristalsis in these patients has lower wave speed and lower amplitude compared to nonpregnant women.


Myotonia dystrophica: obstetric complications. We describe the course and outcome of 23 pregnancies in six women affected by myotonia dystrophica in a large Labrador family. A seventh patient had 14 pregnancies, so that the infertility commonly described in this disorder did not apply to this family. The rate of complications was high, particularly in respect of polyhydramnios, premature onset of labor, cesarean section, postpartum hemorrhage, and neonatal deaths. Polyhydramnios indicated that the fetus was abnormal. Direct observation of an atonic uterus at cesarean section supported other evidence that uterine muscle may be affected. We also report a newborn infant with the congenital form of myotonic dystrophy, a manifestation which has been attributed to the effect of a maternal intrauterine factor upon a fetus carrying the gene.


Fetal heart rate patterns and development in the first year of life. The development of 50 high-risk infants who were provided intrauterine monitoring during labor was prospectively evaluated. Twelve infants had normal fetal heart rate patterns, 16 moderate-severe variable patterns, and 22 severe variable or late deceleration patterns. The parity, socioeconomic status, race of the mothers, and sex of the infants were similar in each group. The infants were examined neurologically 48 to 72 hours after birth and at 2, 4, 6, 9, and 12 months of age. Denver Developmental Standard testing was performed at 2, 4, 6, 9, and 12 months of age. A statistically significant developmental bias was seen favoring those infants with normal fetal heart patterns. Fetal heart rate patterns predicted abnormal performance more accurately than did Apgar scores. Although this data is incomplete, the duration of ominous fetal heart rate patterns appears to adversely affect development.


Antepartum evaluation of the pre-ejection period of the fetal cardiac cycle. The pre-ejection period (PEP) of the cardiac cycle was studied in 65 antepartum fetuses by means of a noninvasive technique which used simultaneous recordings of abdominal fetal electrocardiogram (FECG) and ultrasound fetal Doppler cardiogram (FDCG). Although most of the fetuses were products of high-risk pregnancies, 45 fetuses had uneventful perinatal courses. The PEP's from these fetuses demonstrated a significant positive relationship with gestational age (p is less than 0.01). Uterine contractions induced for antepartum stress testing of the fetus were founnd to prolong the PEP by approximately 9.1 per cent in five cases (four fetuses). The average PEP of antepartum fetuses between 38 and 40 weeks was shorter than that of intrapartum fetuses by approximately 9.5 per cent. Comparison between clinical outcome and the PEP's of the fetuses who were born within a week after the last determination of PEP revealed a strong correlation between prolonged PEP duration and abnormalities in the perinatal course.


Clinical and neurobehavioral effects of repeated intrauterine exposure to oxytocin: a prospective study. A prospective investigation of 114 pregnant women compared 54 with consistently negative oxytocin challenge tests to 60 women who did not have oxytocin challenge tests but did have fetal monitoring during labor. Despite more high risk factors in the OCT group, there were no significant differences noted in the offspring. Specifically, extensive behavioral testing during the first 12 hours of life and at 3 days of age did not show any abnormalities. Furthermore, jaundice and respiratory distress were not seen more often after oxytocin exposure. These data argue that the OCT itself is without demonstrable adverse effects on the otherwise healthy fetus.


Oral contraceptives and platelet aggregation. There are conflicting data in the literature concerning the effects of oral contraceptives on platelet aggregation. We studied 26 healthy women who used oral contraceptives for at least three months. The control group consisted of 25 healthy women of childbearing age, who were receiving no medications. No differences in platelet aggregation in response to adenosine diphosphate, epinephrine, and collagen were found between the two groups.


Antiserotonin treatment of hyperprolactinemic amenorrhea: long-term follow-up with metergoline, methysergide, and cyproheptadine. Twenty patients affected by hyperprolactinemic amenorrhea-galactorrhea have been treated with one or more of the following serotonin antagonists: metergoline, methysergide, and cyproheptadine. Among the 11 patients without evidence of pituitary tumor resumption of menses was observed in five, two of whom had ovulatory cycles; one patient became pregnant; ovulations occurred only during treatment with metergoline. In the group of nine patients with enlarged sellae, three experienced isolated episodes of bleeding, while two had three and four menses each, respectively; all cycles were anovulatory. Plasma prolactin levels and galactorrhea were favorably affected by treatment only in a minority of amenorrhea-galactorrhea patients with and without tumors.


Inhibition of menstrual uterine motility during water diuresis. Induced water diuresis blocks the central release of antidiuretic hormone (ADH) which is, in turn, supposed to play a role in the high uterine activity recorded during human menstruation. In order to further explore this possibility, uterine and antidiuretic activities were studied during water diuresis in 27 normal menstruating women, prior to the insertion of an intrauterine device. Shortly after the initiation of the water overload, simultaneous inhibition of both uterine and antidiuretic activities was obtained. Furthermore, the administration of ADH by intravenous infusion re-established the uterine motility to normal values while the administration of oxytocin did not. It is suggested that ADH has a direct role in the control of uterine activity during human menstruation.


Maternal ethanol ingestion and the occurrence of human fetal breathing movements. The study of the development of fetal breathing movements in human gestation may provide an increased understanding of maturation of the functional central nervous system (CNS). In seven term pregnancies low maternal blood alcohol levels suppressed fetal breathing movements. No effects on fetal oxygenation or acid-base status were demonstrated at the low blood alcohol level. The suppression is therefore most consistent with a direct effect of alcohol on the fetal CNS. This investigation provides further support of the thesis that fetal breathing movements reflect some components of fetal CNS activity.


The transfer and metabolism of corticosteroids in the perfused human placenta. The transfer and metabolism of cortisol, prednisolone, betamethasone, and dexamethasone were investigated in vitro in the perfused human placenta. Maternal and fetal circuits were established but the steroid was added to the former only. The clearance expressed as a fraction of the antipyrine transfer rate varied from 0.27 to 0.50, but there were no significant differences among the four steroids. All the steroids were metabolized extensively to their respective 11-ketosteroids and again there were no material differences among the steroids. The metabolic conversions of dexamethasone and betamethasone were far greater in the perfused placenta than in minced placenta. From the standpoint of placental transfer and metabolism, as observed in the perfusion studies, none of the four corticosteroids offers a decisive advantage in the antepartum maturation of the fetal pulmonary surfactant system.


The effects of an antihistamine and/or a glucocorticoid on the prolactin response to surgical procedures. Prolactin (PRL) release in response to surgical stress has been demonstrated in a variety of species. Previous studies in rats indicate this response is blunted or blocked by pretreatment with either glucocorticoids or antihistamines. The present study was designed to investigate this phenomenon in man. Serum PRL levels before, during, and after major gynecologic surgery were measured in 20 women randomly assigned to one of four pretreatment regimens: (1) dexamethasone, (2) promethazine, (3) both agents, and (4) neither agent. Type of operation, preanesthetic medication, anesthetic agents, and estrogen status of patients were similar in all groups. Untreated controls exhibited the expected five- to tenfold increase in serum PRL concentration with surgery. Pretreatment with either dexamethasone or promethazine alone failed to suppress this response (in contrast to reported findings in the rat) and in fact promethazine appeared to cause an augmented response. However, patients given dexamethasone and promethazine together exhibited only a two- to threefold PRL increase, a significantly lesser response than that in any of the other groups. Thus, PRL release in response to general anesthesia and surgery is inhibited by the combination of an antihistamine (H-l) receptor antagonist and a glucocorticoid, whereas either agent alone has no suppressive effect.


The relationship of changes in mammary blood flow and plasma progesterone at the time of parturition in the ewe. Previous studies indicate that there is a fall in maternal plasma progesterone and a marked increase in mammary blood flow (MBF) at the time of parturition in ewes. In this experiment the role of progesterone as a cause of this increase in MBF was investigated. Progesterone was infused (9.9 mcg. per minute) into a branch of the mammary artery in five sheep during the induction of premature labor by fetal dexamethasone infusion (1 mg. per 24 hours) to prevent the normal fall in concentration of local mammary artery progesterone. Five ewes used as controls received a mammary artery infusion of cholesterol (9.9 mcg. per minute). In the cholesterol-infused group MBF increased significantly from baseline after 13 +/- 4 hours (mean +/- standard error) to a peak flow of 235 +/- 9 ml. per minute. In the group receiving the progesterone the increase in MBF was delayed to 35 +/- 7 hours, reaching only 161 +/- 22 ml. per minute. These results were significantly different from control group results (p less than 0.01). This study suggests that the fall in maternal plasma progesterone which occurs at the time of parturition may play a role in the increase in MBF that occurs prior to the onset of labor, delivery, and lactogenesis.


Vaginal blood flow during the menstrual cycle. Six nulliparous young women slept 16 to 27 consecutive nights in a clinical research center. Vaginal blood flow was estimated from rates of removal of heat from the vaginal wall by a cooled probe inserted by the women immediately upon awakening. Plasma levels of estradiol, progesterone, luteinizing hormone, and follicle-stimulating hormone were determined. Measured also were vaginal temperature and systolic and diastolic blood pressures. Systematic changes during the cycle were detected for all variables except systolic blood pressure. Rising levels of estradiol during late follicular phase were not correlated significantly with vaginal blood flow rates.


The relationship between blood flow and oxygen uptake in the uterine and umbilical circulations. Control measurements of uterine blood flow (N = 110) or umbilical blood flow (N = 84) and the oxygen content difference across the circulation in question were analyzed to assess the effect of flow rate, measured by the diffusion equilibrium technique, on the oxygen uptake of either the uteroplacental-fetal tissue mass or the fetus alone. Although the rate of uterine blood flow varied widely (110 to 418 ml. per kilogram per minute, the rate of uterine oxygen uptake did not change significantly at low or high rates of flow. Likewise, the rate of umbilical blood flow varied widely (154 to 444 ml. per kilogram per minute) without a significant change in fetal oxygen uptake at the extremes of flow. In both circulations this was due to the existence of a reciprocal relationship between flow rate and deltaO2.


Fetal blood velocity waveforms.

Fetal blood velocity waveforms. In this paper a method is described for obtaining and characterizing fetal blood velocity waveforms. The signals were recorded with a range-gated Doppler instrument and characterized after spectral analysis. Preliminary observations indicate differences in the waveforms obtained during normal pregnancies compared with some complicated pregnancies.


Effects of indomethacin on sheep uteroplacental circulations and sensitivity to angiotensin II. Indomethacin, a prostaglandin synthetase inhibitor, injected simultaneously into the abdominal aorta of the ewe and her fetus at 125 days' gestation causes vasoconstriction of both the uterine and umbilical circulations. There is no change in these hemodynamic effects of indomethacin in the presence of phenoxybenzamine, an alpha-adrenergic antagonist. When the indomethacin experiment is repeated seven to 10 days later, a uterine vasoconstriction 10 per cent greater than that found earlier occurs, but there is no change from control umbilical vascular resistance. The mean maternal arterial pressure response (20 mm. Hg) to angiotensin II with and without indomethacin also was examined at the same time in gestation. Indomethacin infusion to the ewe significantly reduces the pressor dose (nanograms per kilogram per minute) by 42 +/- 4 per cent. Thus, in pregnant sheep in the third trimester, endogenous prostaglandins appear to be: (1) partial determinants of basal blood flow in both the uterine and umbilical circulations and (2) modulators of the vasoconstrictive effects of angiotensin II in the ewe.


Circulatory responses to systemic infusions of estrone and estradiol-17alpha in nonpregnant, oophorectomized ewes. Uterine arterial blood flow dose-response curves to systemic infusions of either estrone (E1) or estradiol-17alpha (E2alpha) were determined in ten oophorectomized, nonpregnant ewes. Maximum uterine blood flow occurred with 5 microgram per kilogram of E1 and greater than or equal to 20 microgram per kilogram of E2alpha. Total uterine blood flow measured with isotope-labeled microspheres rose more than tenfold following 30 microgram per kilogram of either estrogen, as did blood flow to the myometrium, endometrium, and uterine caruncles (p less than 0.05). Distribution of uterine blood flow was unaltered. Cervical and vaginal blood flows increased ten-to twenty-fold with E1 and E2alpha, while mammary gland blood flow rose 54 and 77 per cent. Significant increases in adrenal and thyroid blood flows were documented. The only significant decrease in blood flow occurred in the pancreas (- 13 percent; p less than 0.05) following E2alpha infusion. At the dose studied, E1 and E2alpha are potent vasodilators of reproductive tissues, especially the cervix and vagina. As they appear to be the major estrogens during ovine pregnancy, it is likely they participate in the preparation of these tissues for parturition.


Distribution of cytoplasmic estrogen and progesterone receptors in human endometrium. Unoccupied estrogen receptors and progesterone receptors were measured in the cytoplasm of five sections along the length of endometrium obtained from noncancerous, premenopausal hysterectomy specimens. The concentrations of the two receptors were measured with tritiated estradiol or R5020 (a synthetic progestin), the latter two having been purified by high-pressure liquid chromatography, and were found to be highest in the fundus and lowest in the cervix. Progesterone receptor levels, ranging from 50 to 3,500 fmoles of R5020 bound per milligram of protein, were generally much higher in each section of the endometrium than estrogen receptor levels, which ranged from 0 to 500 fmoles of estradiol bound per milligram of protein. Near ovulation it seemed that the distribution profiles of both receptors became very steep, with more than a tenfold difference in the receptor levels being found between the fundus and the cervix. Receptor levels measured in endometrial samples obtained by curettage or aspiration should be interpreted with caution.


Studies with a pancreatic beta cell simulator in the third trimester of pregnancies complicated by diabetes. To determine the potential of an artificial pancreatic beta cell simulator as a therapeutic and research tool we have used the device for short-term monitoring and control of blood glucose concentrations in five pregnant patients with juvenile-onset diabetes (White's Class C) and three pregnant patients with maturity-onset diabetes (Class B). One patient with brittle juvenile-onset diabetes had successful control before, during, and after cesarean section. The other seven patients were studied during the third trimester of pregnancy and at least four weeks before delivery. Blood glucose control with Biostator regulation was excellent (mean, 96 mg. per deciliter; range, 85 to 107). The insulin requirements needed to achieve optimal glucose control with the Biostator were highly variable (range, 20 to 157 U. per 24 hours) but very similar to those previously calculated to provide optimal control by conventional means. Insulin requirements were unrelated to plasma growth hormone, placental lactogen, or glucagon concentrations. The greatest degree of insulin resistance was seen in obese patients with endogenous insulin-secretory capacity. This study indicates that a pancreatic beta cell simulator can normalize glucose concentrations and rapidly estimate daily insulin requirements in pregnant diabetic patients. In addition, the data suggest that exogenous insulin may indirectly suppress endogenous insulin secretion and thus contribute to the "insulin resistance" of obese patients with maturity-onset diabetes.


The effect of passive immunization against estradiol on the regulatory profile and character of labor in the rat. Treatment of pregnant rats with antiestradiol (A-E2) serum twice a day, starting at 2100 hours on day 19, sharply increased circulating total estradiol (E2) above control values and drastically reduced the biologically active E2 unbound (E2U) to A-E2 in plasma and uterine tissue. This A-E2-induced and--sustained E2U deficiency was not accompanied by similar changes in plasma and tissue progesterone (P), since P decreased similarly in the control and A-E2--treated rats in preparation for parturition. However, in the A-E2 rats the reduction in E2U was accompanied by a small, though significant, decrease in uterine vein prostaglandin F (PGF) during labor. This A-E2--provoked regulatory imbalance significantly altered normal parturition. In comparison with controls, labor in the A-E2 rats was delayed and prolonged by extended intervals between deliveries of individual fetuses of the same litter. The delay in the onset of labor significantly increased the birth weights of the newborn rats. Whether E2U deficiency is directly responsible for the asynchronic myometrial activity that delays and prolongs labor or whether it is mediated by reduced PGF release remains to be determined.


Neovasculogenic ability of prostaglandins, growth factors, and synthetic chemoattractants. Prostaglandins E1, E2, D2, A1, F1alpha, and F2alpha as well as synthetic chemoattractants and growth factors were tested for their ability to induce the proliferation of new blood vessels in the rabbit cornea. PGE1 showed the strongest neovasculogenic activity attracting new blood vessels in all of the cases. PGE2 was a weaker attractant than PGE1. PGF2alpha induced a less consistent reaction. All implants sequestering PGD2 or PGA1 were negative. Implants sequestering 1 microgram of fibroblast growth factor or epidermal growth factor variably stimulated the proliferation of keratocytes and epithelial cells in vivo. However, none of these demonstrated any vasculogenic activity. A small, but significant neovascularization was observed only in implants sequestering 10 microgram of growth factor per implant. Although active in vitro, nerve growth factor and formylated synthetic peptides were not stimulatory in vivo.


Subretinal neovascularization following rubella retinopathy. A 17-year-old girl and an 11-year-old girl with rubella retinopathy had decreased vision in one eye secondary to subretinal neovascularization and hemorrhage. In both cases a disciform scar with permanent decrease in central vision resulted.


A follow-up study by vitreous fluorophotometry of early retinal involvement in diabetes. A series of 25 diabetic patients who showed apparently normal fundi on ophthalmoscopy and fundus fluorescein angiography were observed by using vitreous fluorophotometry for 30 months. The results showed that the alteration of the blood-retinal barrier increased generally during the follow-up period, particularly in the diabetic patients who were under poor metabolic control. The degree of breakdown of the blood-retinal barrier was significantly associated with the duration of the diabetic disease.


Vitrectomy and Wagner's vitreoretinal degeneration. A 14-year-old boy, an 11-year-old girl, and a 3-year-old girl with Wagner's vitreoretinal degeneration had multiple retinal detachments. Surgical repair by means of conventional scleral buckling and encircling techniques was unsuccessful. However, after vitrectomy, their retinas remained flat.


Medicolegal hazards of intraocular lens implanting. If the result of cataract extraction is not good, patients with relatively good preoperative vision are more likely to sue than those with poor preoperative vision. One of the usual indications for use of a pseudophakos is good vision in one eye. At times the preoperative acuity in the operated eye is not bad. This creates an unfavorable risk:benefit ratio. Other factors that add to the risk of litigation are publicity in the lay press and problems with properly informing the patient to obtain consent.


The long-term effects of iridectomy for primary acute angle-closure glaucoma. Forty-nine eyes were treated with iridectomy for primary acute angle-closure glaucoma. Forty asymptomatic, normotensive fellow eyes were similarly treated. The duration of follow-up after surgery was 52.3 +/- 3.6 months. Thirty-seven (76%) of the eyes with acute attacks were cured by iridectomy alone and required no medical therapy. Twelve eyes (24%) developed increased intraocular pressure following iridectomy, but only one eye (2%) required filtering surgery. Eighty-eight percent of the asymptomatic, normotensive fellow eyes required no subsequent therapy, and none developed visual field defects. Visual acuity was unchanged in 22 of 49 (45%) of the acutely involved eyes and decreased more than six lines in 11 (22%) eyes. In the 40 fellow eyes, visual acuity was unchanged in 63% and decreased more than six lines in only one (2%) eye.


Toxicity of combined therapy with carbonic anhydrase inhibitors and aspirin. A 67-year-old woman and a 75-year-old woman taking carbonic anhydrase inhibitors for therapy of glaucoma and high doses of aspirin for therapy of arthritis developed severe acid-base imbalance and salicylate intoxication. Neither patient exhibited ill effects when taking high aspirin doses without carbonic anhydrase inhibitor. Carbonic anhydrose inhibitor-induced acidemia increases the risk of developing salicylate intoxication in patients receiving high aspirin doses.


Varix of the optic disk.

Varix of the optic disk. A 74-year-old woman had a saccular dilatation, presumably of the central retinal vein, on the optic nerve head. The lesion caused no symptoms, and over a four-month period showed (vidence of thrombosis and stagnation within it. The lesion caused no interference with either the arterial or venous circulation of the retina. We advised no treatment and continue to observe the patient.


Bilateral optic nerve hypoplasia with normal visual acuity. A 26-year-old man, a 19-year-old man, and a 55-year-old man had bilateral optic nerve hypoplasia. They all had normal vision, but considerable defects in the inferior segments of the visual fields.


Visual-evoked response differentiation of ischemic optic neuritis from the optic neuritis of multiple sclerosis. Fifteen patients with ischemic optic neuritis studied electrophysiologically had a characteristic change of marked reduction in the amplitude of the visual-evoked response even when loss of vision was moderate. The optic neuritis of multiple sclerosis rarely produced this change. Occasionally, small increases in the latent period of the visual-evoked response were recorded from the patients with ischemic optic neuritis. The optic neuritis of multiple sclerosis usually produced significant increases in the latent period. When the normal nerve was tested in patients with ischemic optic neuritis, the visual evoked response was normal. In patients with optic neuritis of multiple sclerosis, stimulation of the "normal" nerve usually produced an increase in the latent period similar to that seen when the involved nerve was stimulated.


Bilateral homonymous hemianopia.

Bilateral homonymous hemianopia. Bilateral homonymous hemianopia occurred in 15 patients seen during a four-year period. Persons with this visual deficit had similarly shaped visual field defects on corresponding sides of the vertical midline for each eye, equal visual acuity which is generally normal, and normal pupil and fundus examinations. The most common causes of the bilateral posterior cerebral artery insufficency were arteriosclerosis (40%), uncalherniation (20%), and migraine (13%).


Optic neuritis complicating measles, mumps, and rubella vaccination. A 6-year-old boy developed bilateral optic neuritis with decreasing visual acuity 18 days after administration of live attenuated trivalent measles, mumps, and rubella vaccine. The patient was treated with oral corticosteroids. The optic neuritis resolved within several weeks and normal vision returned. An afferent pupillary defect persistent in the more severely involved eye for 14 months following vaccination.


Retinitis secondary to acquired systemic toxoplasmosis with isolation of the parasite. A 43-year-old woman developed a heterophile-negative infectious mononucleosis syndrome for which no cause was apparent. During her illness she developed subjective changes in the central vision of her right eye and had focal retinal inflammation, which suggested the diagnosis of toxoplasmosis. The clinical course was accompanied by an increased titer to Toxoplasma gondii. Organisms were isolated from lymph node tissue and injected into the peritoneum of mice from which organisms were harvested.


Early diagnosis and evolution of dominant retinitis pigmentosa. A 5-month-old girl with retinitis pigmentosa was the healthy offspring of a family with progressive autosomal dominant retinitis pigmentosa. Serial evaluation by both electroretinograph and ophthalmoscopy over a four-year period confirmed the diagnosis and indicated that as early as 5 months of age, electroretinographic abnormalities were present in the patient. These consisted of a reduction in the dark-adapted b-wave amplitude, prominent X-wave, and no suppression of the second b-wave response to paired light stimuli at 75 msec. Progressive reduction in the scotopic electroretinography amplitude has occurred over the ensuing four years, although light-adapted (cone) function still appears normal. Clinical evidence of retinitis pigmentosa became apparent only late in the patient's third year when fine peripheral pigment clumping and vessel attentuation could be seen.


Reappraisal of Callender's spindle a type of malignant melanoma of choroid and ciliary body. A follow-up study and histologic reevaluation were made of 105 melanomas of the choroid and ciliary body that had originally been classified as Callender's spindle A type. There were 18 deaths attributable to tumor, with metastatic disease confirmed by autopsy or biopsy in eight cases. We were able to separate the 105 melanomas histopathologically into three groups. The first group consisted of 15 cases in which the spindle-shaped tumor cells were cytologically benign; no deaths were observed for this group. The 75 tumors in the second group were composed of spindle cells, but differed from those in the first group by their malignant features, namely, more atypicality of cells, mitotic activity, necrosis, invasion into sclera or through Bruch's membrane, larger size of the tumor, or any combination of the above. The prognosis for this group was good, comparable to that of spindle B melanomas. The 15 tumors in the third group contained epithelioid cells and had a poor prognosis, comparable to that of mixed-cell melanomas.


Intraosseous hemangioma of the orbital roof. A 63-year-old woman had an osseous hemangioma of the orbital rim. Diagnosis of this primary bone tumor was made by its distinctive radiographic appearance and confirmed by pathologic, examination. Although this is a benign lesion, it is expansile and can cause ocular signs. Surgical resection is the recommended treatment.


The mechanism of the Miochol lens opacity. We studied the reversible cataractogenic effect of Miochol on rabbits' lenses. The experiments demonstrated that the lens opacities developing after the intracameral injection of Miochol were caused by the hypertonicity of the solution and not by a biochemical effect of the acetylcholine.


Cystoid macular edema after cryotherapy. A 50-year-old man developed cystoid macular edema five weeks after cryotherapy of acute retinal tears. The cystoid edema cleared spontaneously, but ultimately the fovea developed wrinkling of the internal limiting membrane.


Violence toward children in the United States. This paper reports results of a survey of a representative sample of 2143 American families, designed to examine the incidence, modes, and patterns of parent-to-child violence. Findings suggest that violence, well beyond ordinary physical punishment, is an extensive and patterned phenomenon in parent-child relations. Implications are discussed, and directions for further research are indicated.


The medicalization and legalization of child abuse. Certain symptoms of family crisis and childhood injury are being "medicalized," "legalized," and called "child abuse"--to be processed and dealt with by a range of professionals who derive their social legitimacy and support in the process. Professional conflicts are considered, and the effects of the system on treatment interventions are discussed. Guidelines are offered to minimize the abuse of power of the professional definers.


Child abuse and neglect: the myth of classlessness. Increasingly, professional and public media are promulgating the belief that the problems of child abuse and neglect are broadly distributed throughout society, suggesting that their frequency and severity are unrelated to socioeconomic class. This paper argues that this belief is not supported by the evidence, and that its perpetuation serves to divert attention from the nature of the problems.


Imaginary figures of early childhood: santa claus, easter bunny, and the tooth fairy. The developmental progression of children's belief in three major figures of early childhood was examined through structure interviews with children and questionnaires for parents. Belief in Santa Claus, the Easter Bunny, and the Tooth Fairy varied with the child's age and the level of parental encouragement of belief. However, belief in these figures was unrelated to other indices of the child's fantasy involvement.


Periodic marital separation and physical illness. Repetitive, three-month separations and reunions are experienced by a group of United States Navy submariners and their wives. This study of the wives' contacts with medical facilities and personnel suggests that physical illnesses and complaints are related to the husbands' work cycle and are significantly more frequent during periods of separation.


Wilderness camping: an evaluation of a residential treatment program for emotionally disturbed children. A follow-up of 46 youthful clients discharged from a therapeutic camp between its inception in 1972 and September 1975 indicates an overall improvement in functioning, especially in the areas of school performance, interpersonal relationships, and household behavior. The one area in which no overall improvement was found was delinquency.


The parent-therapist program: alternate care for emotionally disturbed children. The development of an alternative to residential treatment centers is described. Healthy nuclear families are recruited and, in groups of five couples each, encouraged to function as extended families. Training in appropriate therapeutic techniques enables them to treat several disturbed children in their own homes. Evaluation of the program indicates that outcome does not differ significantly from that of residential treatment, but that costs are markedly lower.


Community mental health ideology: a problematic model for rural areas. The prevailing model for mental health services is found to be inappropriate with respect to many of the needs of rural communities. Special problems of rural areas are identified, and suggestions are offered for revision of mental health concepts and practice that might result in a better fit between professional ideology and rural reality.


The interpersonal relationship between parents and caregivers in day care settings. A structured interview measuring communicative behaviors and attitudes was used to determine the nature of parent-caregiver relationships. While frequent parent-caregiver communication was found, the data suggest minimal attempts to coordinate day care children's socialization processes. Implications for day care practice, policies, and research are discussed.


Reexamining barriers to women's career development. This paper reviews recent literature concerned with beliefs and values relevant to women's careers. Changes in sex-role stereotyping, potential problems relating to affirmative action programs, and the conflict between "counter-culture" values and values of the women's liberation movement are discussed.


"Irreconcilable differences" between parent and child: a case report of interactional pathology. Certain parents use their child as a representative of their own unacceptable impulses, perceiving the youngster as evil and seeking experts to confirm their opinion. They come to mental health clinics for diagnoses but not treatment; evidence that contradicts their view is ignored out of a need to protect their own precarious psychological balance. The child, in spite of good early adjustment, tends to conform to the parents' preferred perception. Legal and ethical implications for professionals working with such cases are discussed.


Diagnostic classification of learning problems: some data. Despite the large body of literature on diagnoses related to learning problems, little systematic information has been gathered on the specific labels assigned by professionals and the bases for their determination. In this study of children enrolled in a clinical school program, only one diagnosis out of fifteen resulted from a consistent pattern of test findings, while over half the diagnoses were based primarily on observation, and a third were arrived at despite contradictory evidence. Implications for current clinical and research practices are considered.


Perinatal mortality: assisting parental affirmation. The health professional's role does not cease with perinatal death, but shifts towards the prevention of postmortem psychiatric sequelae in the parents. A multidisciplinary bereavement service has found that an increased awareness of the final processes of "viewing" and "burial" diminishes the production of fearful speculations both by parents and staff, and allows them to cooperate more fully in dealing with the tragedy.


The psychodynamics and developmental psychology of the borderline patient: a review of the literature. The author reviews the psychodynamics and developmental psychology of the borderline patient as described in the literature on intensive therapy, early mother-child interaction, and family interaction. Focusing on the borderline patient's characteristic difficulties in intimate relationships, he describes the patient's use of splitting and projective identification as seen in the characteristic transference-countertransference interaction in intensive therapy. These primitive defensive mechanisms, which are also utilized by family members, appear to contribute to a failure of empathic responses both during the child's early development and in the family interactions during his adolescence. The author concludes that conceptual attempts to relate adult and child phenomena, although highly speculative, create new and useful perspectives for the treatment of the borderline patient.


Bilateral and unilateral ECT: effects on verbal and nonverbal memory. The memory loss associated with bilateral and nondominant unilateral ECT was assessed with verbal memory tests known to be sensitive to left temporal lobe dysfunction and with nonverbal memory tests known to be sensitive to right temporal lobe dysfunction. Bilateral ECT markedly impaired delayed retention of verbal and nonverbal material. Right unilateral ECT impaired delayed retention of nonverbal material without measurably affecting retention of verbal material. Nonverbal memory was affected less by right unilateral ECT than by bilateral ECT. These findings, taken together with a consideration of the clinical efficacy of the two types of treatment, make what appears to be a conclusive case for unilateral over bilateral ECT.


Tricyclic antidepressants: plasma levels and clinical findings in overdose. Following amitriptyline or imipramine overdose by 30 patients, total plasma concentrations ranged from 29 to 1732 ng/ml but did not correlate well with physical findings or most electrocardiographic changes. Only those patients with a QRS interval greater than 0.1 second had significantly elevated plasma levels. However, a plasma level ratio of the parent drug (amitriptyline, imipramine) to its respective N-desmethyl metabolite (nortriptyline, desmethylimipramine) greater than or equal to 2.0 was associated with an acute overdose. This ratio was more useful than total plasma levels in differentiating an overdose from a therapeutic dose with associated toxicity and an elevated steady-state plasma level.


Paradoxical reaction to L-dopa in schizophrenic patients. The authors administered 6 g of L-dopa to 8 schizophrenic patients and 750 mg of chlorpromazine to 7 schizophrenic patients. Chlorpromazine showed only a modest advantage over L-dopa and only on some Brief Psychiatric Rating Scale factor scores, and at maximum dosage the thought disturbance factor score in the L-dopa-treated group was not worse than at baseline. The results suggest that L-dopa is associated more with toxic than with schizophreniform symptoms and that there is adaptation to its effects. The authors discuss implications of these findings for the dopamine hypothesis of schizophrenia.


Coping styles of 34 adolescents with cerebral palsy. The author presents a follow-up study of 34 children with cerebral palsy. Eight years previously 23 of these children were attending a special school for handicapped children, and 11 were attending regular schools. The author evaluated the children and their families through formal and informal interviews and by administering parent and teacher rating scales of the children's behavior. He found that the development of these children between the ages of 10 and 14 was highlighted by their increased awareness and their parents' awareness of the permanence of their handicap and their consequent search for personal and, ultimately, occupational identity and their parents' emotional withdrawal.


The future for mental health in primary health care programs. Our largely separate mental health system has developed in relationship to a health care system oriented toward specialization and solo practice. Now the health care system is moving in the direction of primary care and group and organizational practice. New forms of mental health delivery are needed to maximize the potential of these new health care programs for mental health services. The author describes these new integrated programs which bring mental health providers into the primary health care programs for direct services as well as consultation. Issues discussed include mutual roles, changes in services, the referral process, and provider relationships. The advantages of such integrated programs include decreased stigma, increased prevention through earlier detection and referral, increased family orientation, greater coordination of care, and less duplication.


The future of state mental health programs for the chronic psychiatric patient in the community. The author explores the problems facing the chronic psychiatric patient in the community and discussed the response of federal and state governments to these problems. Errors of the past and present are delineated and corrective actions are suggested for the future. Finally, it is argued that if society is able to meet the challenge posed by the chronic psychiatric patient in the community it will simultaneously have set up mechanisms to solve the problems of other disabled and disadvantaged groups of people as well.


Private practice of psychiatry: future roles. Psychiatrists in private practice have contributed more to treating the mentally ill in America than is generally known. The private practice sector may be viewed as a massive national outpatient and inpatient service for the mentally ill. The impact of national health insurance on the future character of the private practice of psychiatry and the thorny problems to be resolved are discussed and compared with the experiences of England, the Soviet Union, and China. Future trends will most likely include increased emphasis on adjuvant techniques, greater emphasis on resident training in general psychiatry, briefer forms of therapy, and psychiatry's return to the medical model.


Will community mental health survive in the 1980s? There are now 675 funded community mental health centers (CMHCs), covering almost half the country. Many of these programs were funded in the social optimism of the 1960s and now face a crisis of purpose and funding. Additional requirements imposed by the 1975 amendments to the CMHC act are not matched by additional fiscal resources. Programs are graduating from the federal grant to find that other sources of funds, especially third-party insurance funds, are not replacing the lost federal dollars. There is evidence that CMHCs are changing from clinical/medical programs to social programs; the numbers of persons seeking care who have diagnosable mental illness and of psychiatrists and nurses relative to other staff are decreasing. The issue is whether CMHCs as a national program are headed for extinction or whether there will be new vitality for this program into the 1980s.


A comparison of depression and physical illness in men and women. A limited self-rating depression scale given to male and female factory workers indicated that subclinical depressive symptoms were correlated with visits to the factory health service for females and with absenteeism from work for males. In general, the females acknowledged more depression symptoms.


Blind ratings of mother-infant interaction in home movies of prepsychotic and normal infants. Home movies of infants later diagnosed as having early childhood psychoses were compared with movies of normal control infants. A scale of attachment indicators measured mother-infant dyadic avoidance and reciprocity in the first 6 months of the infant's life. Three judges blind to diagnosis saw a general trend to dampened interaction for prepsychotic infants and their mothers. Prepsychotic and normal infants were not significantly different in touching and eye gaze behaviors, whereas mothers of prepsychotic infants exhibited less adequate eye gaze and touching than mothers of normal infants.


Psychological factors in susceptibility to drug-induced extrapyramidal symptoms. In an effort to identify nonneurobiologic factors in the susceptibility to neuroleptic-induced extrapyramidal symptoms (EPS), the EPS response in 20 patients was correlated with field dependence, self-object differentiation, and premorbid social competence. Only the last proved to be a good predictor, which suggests that psychosocial factors play a role in a patient's EPS response.


Psychological observations of bank robbery. Bank robbery has been only partially examined in the psychiatric literature. It has been publicly considered an act of men of strong will to obtain money. According to the author's observations in a federal penitentiary, bank robbery more often is a symptomatic act with psychological meaning. The author describes several of the unconscious motives and defense aspects of bank robbery in the hope that this will assist in demythologizing the bank robber.


A look at psychiatric decision making.

A look at psychiatric decision making. The author reviews the efforts of medicine and psychiatry to understand their decision-making processes and notes the lack of psychiatric literature in this area. The decision table, a sophisticated form of algorithm, is introduced as a structure to help explain the decision-making process. This tool is applied to the evaluation and biological treatment of depression. Decision tables can be used as an educational tool, a method to facilitate the delivery of mental health care, a method to monitor the quality of treatment, and as a research tool.