Duodenal contraction wave patterns in patients with and without ulcer. To determine whether differences in frequency of specific wave sequences and types existed in the four parts of the duodenum in ulcer subjects and controls an analysis of contraction waves in 14 controls and 10 duodenal ulcer patients of similar age was done by a statistical analysis of differences between the two groups. A water-perfused tube system was used. Differences in motor activity, namely, decreased frequency of waves in the proximal duodenum and increased frequency of waves in the distal duodenum in ulcer subjects as compared to controls was demonstrated. This involved a statistically significant decrease in numbers of mixing (or basic rhythm) waves in the proximal duodenum. Increased numbers of isolated waves were found in ulcer patients in the distal duodenum. The predominant types of contraction waves in both ulcer and control subjects were isolated and simultaneous waves, with peristaltic waves were less common in the fasting state. These findings suggest that differences exist in the types of contraction waves in duodenal ulcer subjects compared to controls.


Current thoughts on the surgical treatment of rectal cancer. From August, 1971 to May, 1974, 52 cases of rectal cancer belonging to different groups, according to Mason's classification, were seen at the First Surgical Department, University of Athens Medical School. In the majority of the cases the tumor was removed by combined abdominoperineal resection; the variety of other surgical methods in the treatment of rectal cancer are discussed. Emphasis is focused on certain important technical aspects in the surgery of rectal cancer: 1. the need for thorough preoperative preparation of the bowel; 2. the ligation of the inferior mesenteric artery at its origin from the aorta; 3. the intraluminal infusion of cytotoxic agents into the tumor-bearing segment after ligation of the inferior mesenteric vein; 4. the idea of the intra-arterial regional chemotherapy, during the operation; 5. the demarcation of the area with radiopaque clips for acute postoperative radiation,when residual tumor is  left behind. The authors consider adherence to the above technical details critical in achieving good surgical results.


Crohn's disease of the appendix presenting as acute appendicitis. A patient is reported who initially presented with findings simulating acute appendicitis and who was subsequently found to have Crohn's disease isolated to the appendix. Although the hazard of appendectomy in Crohn's disease is well known, it is interesting that none of the known patients with isolated appendiceal Crohn's disease has developed a fistula. Three of the 15 reported cases of Crohn's disease solely involving the appendix developed granulomatous changes involving other regions of the bowel as long as four years following the initial diagnosis. Because of the rarity of this condition, however, specific conclusions regarding the likehood of future recurrence cannot be drawn. We stress increased physician awareness of this entity in order to emphasize long-term follow-up for such patients.


Pseudomembraneous colitis associated with antibiotics. Radiographic manifestations of the colon on barium enema examination in two cases of antibiotic-induced pseudomembraneous colitis are presented. The radiographic findings are ulcerations, shaggy edematous mucosa and excessive mucus secretion. Although these roentgenorgraphic findings could not be differentiated from other inflammatory bowel disease, the antibiotic-induced enterocolitis must be included in the differential diagnosis whenever there is a clinical history of recent antibiotic therapy.


Primary sclerosing cholangitis. A report of nine cases and clinical review. Nine cases of primary sclerosing cholangitis were reviewed as to methods of diagnosis, association with other disease states and clinical course of the patients. There were four cases of primary sclerosing cholangitis occurring alone, four cases associated with inflammatory bowel disease (three with chronic ulcerative colitis and one case with proctosigmoiditis) and one case associated with porphyria cutanea tarda. All cases of primary sclerosing cholangitis occurring alone, progressed to secondary biliary cirrhosis, however, none of the cases associated with chronic ulcerative colitis progressed to secondary biliary cirrhosis. In all cases, the diagnosis was established by operative findings and biopsy results. The mode of clinical presentation was similar in all cases and was characterized by slowly progressive  jaundice. Intravenous and oral cholangiography were not useful in establishing a diagnosis but endoscopic retrograde cholangiography offers preoperative diagnostic hope and use for follow-up evaluation. One case with ulcerative colitis had a Strongyloides infection and the organism was found in the fibrotic duct and pericholedochal lymph nodes. The etiological considerations are reviewed and the classification of sclerosing cholangitis associated with ulcerative colitis, as primary, is discussed. Therapeutic modalities are discussed, though therapy is mainly empirical at present.


Precipitous rise and fall of SGOT.

Precipitous rise and fall of SGOT. Three patients are reported whose studies showed a transient but marked elevation of serum transaminase levels with a rapid return toward normal. In two patients this phenomenon was associated with transient episode of hypotension; in the third case this was an incidental finding discovered fortuitously on a routine test. Hepatic ischemia and parenchymal injury may cause transient elevations of serum transaminase levels.


Liver tests, HB-Ag and HB-Ab in asymptomatic drug addicts. One hundred eighty-eight asymptomatic addicts were studied to determine the frequency of a history of hepatitis (previous episodes of jaundice), abnormalities of liver tests (serum bilirubin, alkaline phosphatase, serum albumin, serum glutamic oxalacetic transaminase) and incidence of HB-Ag and HB-Ab. Seventy-four were white and 114 were nonwhite. A history of hepatitis was obtained in only 38%. One hundred and fifty-two of the 188 addicts (81%) had one or more abnormal liver tests. The bilirubin was abnormal in 5%, akkaline phosphatase in 28% and serum glutamic oxalacetic transaminase in 55%. HB-Ag was positive in 2.6% using radioimmunoassay and HB-Ab was found in 66%. There was a higher incidence of elevated serum glutamic oxalacetic transaminase, HB-Ab and history of hepatitis among white, compared to nonwhite addicts.


Hepatitis B-antigen subtypes in Australia as detected by radioimmunoassay. The distribution of the major subtypes of hepatitis B surface antigen (HBsAg) was examined in asymptomatic white Australian blood donors and patients with liver disease to attempt ot assess the biological significance of these subtypes in this relatively homogeneous Caucasian population. Since previous studies have shown a very low prevalence of HBsAg in white Australians, a highly sensitive solid phase radioimmunoassay (RIA) was developed and used to subtype the antigen. A total of 46 samples of hepatitis B-antigen positive sera, obtained from 21 asymptomatic volunteer blood donors and 25 patients with liver disease, were tested. Sixteen of these 21 asymptomatic carriers were shown to have subtype "ad" whereas only seven of the patients with liver disease had this subtype. This difference was significant (P less than 0.005) and supports the view that subtype "ad" is associated with a carrier state and subtype "ay" with liver disease in Australia.


Clinical observations on the biliary system in cystic fibrosis. The biliary tree of 66 patients with cystic fibrosis was examined by conventional roentgenographic methods. Forty-five per cent of the oral cholecystograms were judged abnormal by our criteria. A study was considered abnormal if there was no visualization or if there was visualization of a microgallbladder or structural abnormality including marginal irregularities, septate gallbladder or cholelithiasis. Intravenous cholangiography was used to further study the 22 patients who did not visualize on the oral study. Again, anatomic abnormalities were prevalent but six patients in this group had normal appearing gallbladders. Abdominal pain, a frequent symptom in cystic fibrosis, was not associated with roentgenographic abnormality. No correlation was seen between the external biliary tree abnormalities and multifocal biliary cirrhosis which was present in 40% of these patients. Further, no correlation was seen between serum gamma glutamyl transpeptidase levels and either of these lesions.


Relation of exocrine pancreatic function to the diameter of the pancreatic and common bile ducts. One hundred and thirty-nine patients were examined for possible chronic pancreatitis by means of both pancreozymin-secretin test and endoscopic pancreatography of pancreatocholangiography. Pancreatic function as assessed by the pancreozymin-secretin test was impaired in 89 (64%) of the entire group. No significant relationship was demonstrated between pancreatic secretion of fluid, bicarbonate and amylase and the diameter of main pancreatic duct in both the entire group of the subgroup of patients with pancreatic dysfunction. On pancreatogram no gross morphological abnormalities were found in a high proportion of patients whose pancreatic function was impaired in minimal to moderate degree. There was a significant linear correlation between the diameters of the main pancreatic duct and common bile duct. These data question the value of endoscopic pancreatography in the diagnosis of low to moderate grade chronic pancreatitis.


Liver actinomycosis: a case report.

Liver actinomycosis: a case report. A case of liver actinomycosis successfully treated with high doses of penicillin for a long period after surgery is reported. The unusual location of the disease and early detection difficulties delayed the diagnosis and establishment of proper treatment, causing additional liver damage. Serum globulin levels, alkaline phosphatase and turbidity tests were of diagnostic significance. Adequate drainage of the lesion and long-term antibiotic treatment with penicillin proved therapeutically satisfactory.


Pruritus of pregnancy and jaundice induced by oral contraceptives. This article presents a young girl who developed jaundice while on oral contraceptives. A most significant feature in this particular patient's history was the severe pruritus she developed during a previous gestation. This combination of events should alert physicians to the possible diagnosis. Oral contraceptives should be prescribed to such a patient with great caution.


The jejunal mucosa in two cases of A-beta-lipoproteinemia. The jejunal biopsy appearances in two cases of a-beta-lipoproteinemia are described and compared with those of previous cases recorded in the literature. No significant differences were noted in one of the cases in the appearances of a biopsy taken before and another taken after 10 months of treatment.


Polyposis coli associated with fibrosis of mesentery, mesocolon and retroperitoneal tissues: a rare variant of Gardner's syndrome. The association of polyposis coli, osseous and dental abnormalities with fibrosis of mesentery, mesocolon and retroperitoneal tissues is described in a black male. The prognostic significance of this association, rendering colectomy impossible, is stressed.


Cholecystoenteric fistulas:s ignificance and radiographic diagnosis. Cholecystoenteric fistulas, not associated with gallstone ileus syndrome, are relatively common complications occurring during the natural history of cholelithiasis and cholecystitis. The etiology, pathogenesis as well as common and uncommon forms of gallbladder fistulas are presented and discussed. The roentgenographic findings are reviewed and a simple classification into two major groups is offered. The majority are acute, transitory, short-lived fistulas, which are self-limiting and relatively common events that usually remain undiagnosed. A minority fail to heal, become chronic and permanent fistulas and are associated with obstruction of the common duct.


Estrogen use and stroke risk in postmenopausal women. Among postmenopausal women (58-98 years of age) in a retirement community use of oral estrogens was not significantly associated with overall risk of stroke. Estrogen use was significantly associated with blood-pressure status. An observed association between estrogen use and nonembolic cerebral infarction in women aged 70-79 may be secondary to an interaction between hypertension and estrogen usage.


Aggregation of blood pressure in infants and their siblings. Sibling aggregation of blood pressure has been shown in children 2 to 14 years of age. To determine the earliest age at which this finding is detectable, blood pressures were evaluated in 98 siblings from 43 black families with newborns. Variances of blood pressure scores were significantly greater among families than within families for systolic (p less than .025) but not diastolic pressures. Sib-sib intraclass correlation coefficients were .26 (95% two-sided confidence limits .05 to .47) for systolic and .16 (-.06 to .38) for diastolic pressures. When 1-month-old infant pressures were added, significant aggregation was present for systolic (p less than .01) and diastolic (p less than .025) pressures. The intraclass correlation coefficients were .21 (.02 to .38) and .17 (.03 to .34), respectively. When newborn scores were substituted, aggregation was not demonstrable. These data demonstrate a familial influence on blood pressure in infancy by 1 month of age.


Changing risks in tuberculosis.

Changing risks in tuberculosis. Past and present experience with tuberculosis in New York State exclusive of New York City is presented. TB has been on the decline since the turn of the century and reached an all-time low in 1974 with only 844 new active cases and 137 deaths reported. Although incidence rates are highest among the poor, the bulk of cases come from middle and upper socioeconomic levels. Cohort analysis shows an individual's risk of developing pulmonary or miliary TB is greatest at age 20-24, whereas the greatest risk of dying from TB is before age 5. Projections based on past experience indicate a male born in 1970-74 will have a lifetime risk of developing pulmonary or miliary TB of 80/100,000 and of dying from TB of 4/100,000. For females the respective risks are 40/100,000 and 6/100,000.


Effect of a mass screening program on the risk of cervical cancer. In Finland, the organized mass screening program for the early detection of cervical cancer covers, with few exceptions, all women between the ages of 30 and 55 every fifth year. On the basis of material originating from the Finnish Cancer Registry it was estimated that the probability for a woman aged 30-59 to experience frankly invasive cervical cancer was 0.010 before the screening program, and 0.002 after the first screening. The corresponding probability estimate was 0.022 for pre-invasive lesions subjected to operative treatment. On the assumption that the same relationship applies beyond this age group it was estimated that from 28-39% of the pre-invasive cases progress to invasive cervical cancer, and that 21% of the frankly invasive cases are preceded by a pre-invasive stage of shorter duration than the time period between the screenings, or have no preclinical stage.


Limitations of compounding diazepam suspensions from tablets. The concentration of diazepam in two types of suspension vehicles, as prepared from 10-mg tablets was tested over a 14-day period. The suspensions (1 mg/ml) were stored at room temperature in amber glass bottles. In one suspension, consisting of eight triturated tablets, 4.0 ml ethanol, 24.0 ml propylene glycol, 20.0 ml Syrup, USP, and 32.0 ml chocolate syrup, 90% of the diazepam was dissolved. This suspension demonstrated consistently acceptable concentrations of diazepam. In the other suspension, consisting of triturated tablets and Syrup, USP, only 25% of the diazepam was dissolved, and less consistent, subpotent concentrations of diazepam were found. The variation of diazepam concentrations between the suspensions was unrelated to the chemical stability of the drug.


Operations analysis applied to a drug distribution system. The application of operations analysis to a hospital drug distribution system is discussed. The existing system in a 360-bed community hospital was reviewed to identify areas for improvement; alternate approaches to achieve the identified benefits were explored. Improved manual procedures, which integrated pharmacy and nursing operations to a greater extent and resulted in fewer lost charges, were developed. Potential savings through computerization of 10 functions were identified. A rating system was developed to evaluate eight vendors of computerized pharmacy systems. The hospital as a whole undertook the following steps designed to assure the success of new systems: (1) determine the overall hospital benefits desired in order to prevent fragmentation by individual efforts; (2) establish a planning process; (3) establish a process for reviewing projects; (4) develop a plan for systems improvement; and (5) monitor the performance of the systems improvement program. The steps for successful operations analysis are summarized.


Computerized pharmacy services in a large community hospital. A computerized pharmacy system dealing with drug distribution, clinical services and administrative services is described. Present systems, implemented for 50% of the institution's beds, are discussed fully. Future applications of the system are outlined.


Current federal legislation.

Current federal legislation. Current legislative proposals before Congress that will affect the practice of pharmacy are discussed. Revisions to the Medicare and Medicaid programs and amendment of the HMO Act of 1974 are being considered. Major legislation includes a bill that will regulate the activities of clinical laboratories and a bill that establishes a Presidential commission to oversee biomedical and behavioral research. Also proposed is a reorganization of the FDA which would create a new agency to assume responsibility for scientific and enforcement duties related to drugs and devices. Regulation of vitamins, health manpower and drug utilization improvement are also discussed.


Tardive dyskinesia.

Tardive dyskinesia. The etiology, pharmacology, treatment and possible prevention of tardive dyskinesia (TD) are discussed. This neurological disorder, characterized by involuntary movements of the lips, jaws and tongue, can occur as a result of short-term antipsychotic drug therapy, but usually occurs after long-term treatment. Phenothiazines, the thioxanthines, butyrophenones, dibenzoxazepines and dihydroindolines also posess the potential for inducing TD. Methods of treatment of TD with dopamine-depleting agents, dopamine-blocking agents and cholinomimetics are discussed. Despite the apparent effectiveness of some drugs in the treatment of TD, it should be kept in mind that most of the studies demonstrating drug effectiveness involved a small number of patients.


Management of insulin allergy and resistance. The pathophysiologic basis and therapy of insulin insensitivity and insulin allergy are discussed. Topics covered include primary and secondary causes of insulin insensitivity, management of insulin resistance (elimination of diabetogenic factors; use of less antigenic insulin, oral hypoglycemic agents, immunosuppression, or nonmammalian insulin), and insulin allergy and its treatment. A pharmacist's knowledge of insulin products and the pharmacologic activity of the oral hypoglycemic and immunosuppressive agents may aid in the care of patients who are allergic or resistant to insulin.


Intropin (dopamine hydrochloride) intravenous admixture compatibility. Part 2: stability with some commonly used antibiotics in 5% dextrose injection. The stability of dopamine hydrochloride (Intropin) and several commonly used antibiotics was studied as admixtures in 5% Dextrose Injection USP. The antibiotic-dopamine-dextrose 5% admixtures were assayed for dopamine by colorimetric and chromatographic procedures. The antibiotics were assayed by standard microbiological methods. Kanamycin sulfate, tetracycline hydrochloride, carbenicillin disodium and chloramphenicol sodium succinate were stable in the Intropin-5% dextrose admixture for a period of 24 hours at room temperature in fluorescent and natural (western exposure) light. Gentamicin sulfate, penicillin G potassium and cephalothin sodium were stable in Intropin-5% dextrose admixture for six hours. Ampicillin sodium was stable in the Intropin admixture for only one hour. Amphotericin B was physically unstable in the Intropin-dextrose 5% solution upon admixture. The potency of dopamine hydrochloride remained substantially unchanged in the presence of the above antibiotics. It is recommended that dopamine not be added to amphotericin B or ampicillin sodium admixtures. Further, in order to avoid a fixed combination of potent drugs, it is recommended that a "piggyback" administration set or administration into a second injection site be employed when another drug is to be administered with dopamine hydrochloride.


Particulate matter assessment of a clinical investigation on filtration and infusion phlebitis. Particulate contamination levels of a base intravenous solution and five admixtures were assessed in a double-blind study conducted to determine the effect of inline i.v. filtration on infusion phlebitis. Only a qualitative evaluation on actual patient filters was possible due to deformation of the filter membrane after 72 hours; simulation of i.v. therapy in the laboratory gave more reliable information about particle counts and distribution. The base solution was dextrose 5% in 0.2% sodium chloride injection; the admixtures contained this base solution and the following additives (per liter): (1) 20 mEq potassium chloride, (2) 20 mEq potassium chloride and 2 ml vitamin B complex, (3) 20 mEq potassium chloride and 5 million units of potassium penicillin G, (4) 20 mEq potassium chloride and 1 g cephalothin sodium (delivered in a 100-ml volume from a medication chamber), and (5) 30 mEq potassium chloride and 3 million units of penicillin G (delivered every four hours from a medication chamber) and 80 mg of gentamicin sulfate (delivered every eight hours from a medication chamber). None of the six i.v. infusion schedules simulated exceeded the standards for particulate matter prescribed by the USP XIX. As expected, however, the particle counts increased as a function of the additives used in the simulation, particularly with the antibiotics.


Compliance with USP osmolarity labeling requirements. In view of the USP requirement that the label of certain parenteral products contain the osmolarity of the solution, actual and theoretical osmolarity values for six preparations were determined, and the extent of any deviation was noted. Osmolarity values were determined experimentally by osmometry and converted to osmolarity values for six products: Calcium Chloride Injection USP, Dextrose Injection USP, Mannitol Injection USP, Potassium Chloride Injection USP, Sodium Bicarbonate Injection USP, and Sodium Chloride Injection USP. Theoretical values were calculated according to a standard equation based on the mass of the substance per liter of solution. The most substantial deviations between actual and theoretical osmolarity values occurred with the calcium chloride, sodium bicarbonate, potassium chloride and dextrose solutions. It is proposed that the technology for making osmotic measurements which exists in the industrial setting should be used to provide clinical practitioners with accurate and actual values. It is also urged that the USP specify a procedure for measuring osmolality and calculating actual osmolarity.


ABC inventory analysis and economic order quantity concept in hospital pharmacy purchasing. ABC inventory analysis and the economic order quantity (EOQ) concept were studied as alternatives to the cyclical ordering system used by the pharmacy in a 558-bed general hospital. The inventory was divided into A, B or C groups according to the annual dollar value of the items. Two samples were selected to be studied (the first consisting of 10% of the total inventory and the second consisting of 10% of the A, or high cost, items). For each item in both samples the EOQ was calculated to estimate the proposed annual inventory cost as compared to the actual cost as determined from past inventory records. In the first sample, there was a statistically significant mean annual savings of $4.13 +/- $0.36 (S.E.) using the proposed annual cost. In the second sample there was a mean savings of $2.42 +/- $0.60 (S.E.) using the proposed method, which was not statistically significant. Most of the savings with the proposed ABC-EOQ system would occur with the low dollar value items (B and C items) which were being purchased too frequently.


Alpha-methyldopa interference with the phosphotungstate uric acid test. The effect of alpha-methyldopa on the phosphotungstate method of uric acid analysis was tested using a group of 17 hypertensive patients being treated with only this drug for their elevated blood pressure. The uric acid values of these patients tested by the phosphotungstate method showed no significant difference from the uricase test values, when compared to a control population of 32 normotensive patients tested in the same manner. The proposed interference was further tested by in vitro studies. Both uricase and phosphotungstate analysis of uric acid was performed on serum containing various dilutions of alpha-methyldopa. The concentration of alpha-methyldopa required to clinically affect the uric acid level, whereby a false positive result occurred, was 60 mug/ml. The mean plasma aplha-methyldopa concentration in the study group, however, was found to be only 2.03 mug/ml. The postulated interference of therapeutic levels of alpha-methyldopa on the phosphotungstate uric acid method was invalid.


Portland Retail Druggists Association vs Abbott Laboratories et al, part 1. The findings of the U.S. Supreme Court, in its March 24, 1976, decision in the case of Portland Retail Druggists vs Abbott Laboratories et al, are presented. The case deals with price differentials offered to nonprofit hospitals by pharmaceutical manufacturers. Historical background leading to the case, and early rulings of a federal district court and a court of appeals, are discussed. The Supreme Court decision appears to reflect favorably on current hospital policies and procedures for drug purchasing and ambulatory care. Issues that require further clarification will be discussed in Part 2.


Pharmacotherapy of cardiopulmonary arrest. The assessment and treatment of patients requiring cardiopulmonary resuscitation (CPR) is discussed. Cardiovascular pharmacotherapy is discussed as suppressive therapy, stimulant therapy and treatment of hypotension. Special situations covered include hyperkalemia, anaphylaxis and drug overdosages. It is concluded that the likelihood of success of CPR depends on the rapid initiation of ventilation and restoration of circulation, and is inversely dependent on the severity of the underlying disease or injury.


Potassium iodide and iododerma.

Potassium iodide and iododerma. The development of iododerma in a 75-year-old male following administration of potassium iodide is described. Recovery from the allergic manifestation of iododerma occurred after discontinuation of potassium iodide. The adverse effects of potassium iodide and the general signs of acute and chronic iodine toxicity are reviewed.


Nationwide epidemic of septicemia caused by contaminated intravenous products. I. Epidemiologic and clinical features. Between mid-1970 and April 1, 1971, Enterobacter cloacae or E. agglomerans septicemia developed in 378 patients in 25 American hospitals while they were receiving intravenous products manufactured by one company. Each of the hospitals noted a marked increase in the incidence of such septicemia during this period. Enterobacter agglomerans (formerly designated Erwinia, herbicola-lathyri group) was better known as a plant pathogen and had been a human blood pathogen only rarely in the past. Septicemia caused by E. cloacae had also been uncommon.


Selective immunoglobulin M (IgM) deficiency in two immunodeficient adults with recurrent staphylococcal pyoderma. Two adult men with recurrent pyoderma due to Staphylococcus aureus and a selective deficiency of immunoglobulin M (IgM) antibody synthesis are described. An analysis of each patient's polymorphonuclear leukocyte chemotaxis, phagocytosis and killing of Staph. aureus, serum opsonizaiton of Staph. aureus, and serum and lymphocyte-mediated responses to antigenic stimulation was performed. Family studies revealed a possible autosomal dominant inheritance pattern with heterogenetic expression of various dysgammaglobulinemic states in each patient's first degree relatives. In vivo studies of delayed hypersensitivity and in vitro studies of polymorphonuclear leukocyte and lymphocyte function were normal. A defect in IgM, but not in IgG (immunoglobulin G), antibody synthesis to a number of antigens, and a mild decrease in serum opsonic activity to Staph. aureus correctable by heat inactivated normal human serum were found in each patient. In these patients, the recurrent staphulococcal pyoderma prompted an investigation of host defense mechanisms and revealed low to absent IgM levels and a defect in IgM antibody synthesis.


Staphylococcus aureus bacteremia. Current clinical patterns. One hundred and five cases of bacteremia due to Staphylococcus aureus were reviewed to assess the current clinical spectrum of serious staphylococcal disease. Mortality was 21 percent, lower than previously reported. Patients could be separated into two groups according to the presence of identifiable primary staphylococcal infections; 63 bacteremic patients had such lesions, the remaining 42 lacked them. The latter group contained 24 of 26 cases of endocarditis. Illnesses in that group were marked by the presence (in 38 of 42 patients) of staphylococcal foci occurring secondary to bacteremia. Such foci were responsible for five of seven instances of relapse or treatment failure encountered in that group. Secondary staphylococcal foci occurred in only five of 63 patients with primary infections, and the response of this group to conventional therapy for bacteremia was satisfactory. This study suggests that endocarditis has become an unusual complication of identifiable primary staphylococcal infection. A clinical classification based on the presence of such lesions therefore separates bacteremic patients likely to be cured by conventional antibiotic therapy (those with primary infections but no secondary foci) from others (those with secondary foci, suggesting endocarditis) who should receive a more prolonged course of antibiotics.


Salmonella heidelberg enteritis and bacteremia. An epidemic on two pediatric wards. Symptomatic infection with Salmonella heidelberg developed in 55 children after their admission to the pediatric wards of two adjacent hospiatls in San Juan, Puerto Rico. Many of these children had been hospitalized for the treatment of diarrhea of unidentified etiology. In 25 of these patients, Salmonella bacteremia was documented. Five had clinically unsuspected and untreated bacteremia with no evidence of complications during the follow-up period of four and a half months. The remaining 30 had "standard" symptomatic infection due to S. heidelberg. Eight children died; four of these proved to be bacteremic. The index patient, who also introduced the infection into one of the hospitals, was identified. Person to person spread perpetuated the outbreak within and between the two hospitals for nearly four months. Although neonates with salmonellosis had a higher rate of bacteremia than other children, no other specific predisposing factors for Salmonella bacteremia were identified. Laboratory studies of the epidemic strain revealed neither invasive nor enterotoxic properties of the organisms, nor enhanced virulence in laboratory mice. Cohort nursing and isolation of patients with positive cultures halted the epidemic. Nontyphoid Salmonella bacteremia, sometimes clinically unsuspected and self-limited, should be recognized as a frequent accompaniment of Salmonella enteritis in young hospitalized children.


Further observations on tuberculin reactions in active tuberculosis. One hundred patients with active tuberculosis were tested for tuberculin reactivity within 24 hours of their admission to the hospital. Commercial intermediate tuberculin, Tween stabilized intermediate tuberculin and the Tine test as well as a mumps antigen were applied simultaneously. False negative reactions were obtained in 28 per cent with Tine testing and in 21 per cent with Tween stabilized as well as plain tuberculin. These nonreactors were clinically identifiable as seriously ill with manifestations primarily attributable to protein depletion as a result of their illness. This is not specifically related to the effects of tuberculosis itself, but can be demonstrated in patients suffering the same sequelae of other debilitating illness. After two weeks of protein supplementation via a high calorie, high protein, hospital diet, skin reactivity was restored in the vast majority of these nonreactors. It is concluded that the lack of tuberculin reactivity on hospital admission probably results from impaired lymphocyte function in patients suffering serious protein depletion as a result of their illness; it is not attributable to deficiencies in the tuberculin test itself.


Clinical usefulness of 67gallium scanning in the malignant lymphomas. To determine the clinical usefulness of 67 gallium (Ga) scanning in the evaluation of patients with lymphomas, we reviewed 142 total body Ga scans performed on 44 patients with Hodgkin's disease and 53 patients with non-Hodgkin's lymphoma. Fifty-two per cent (123 of 236) of known disease sites were detected on scan. The false-positive rate was less than 5 per cent. The accuracy of detecting lymphoma varied in individual anatomic areas from 33 per cent in the axilla to 73 per cent in the thorax. In eight patients with bone involvement, all bone lesions were detected on scan. The size of the lesion appeared to influence accuracy, since tumors greater than 3 cm in diameter were more often positive.


Multifocal eosinophilic granuloma ("Hand-Schuller-Christian disease"). Report illustrating H-S-C chronicity and diagnostic challenge. We have described an unusual case of multifocal eosinophilic granuloma ("Hand-Schueller-Christian disease") in a middle-aged woman. The case underscores the varied and subtle nature of the disease presentation and the extent to which many organ systems may become involved. Unusual features of her case include atypical bone roentgenograms, cutaneous anergy, panhypopituitarism and evidence of diffuse central nervous system dysfunction. Several features of multifocal eosinophilic granuloma present in the older age group are different from those presenting in children and young adults. Finally, multifocal eosinophilic granuloma may present all the clinical and laboratory features of a progressive, chronic disease.


Cogan's syndrome: a systemic vasculitis. Nonsyphilitic interstitial keratitis with vestibuloauditory dysfunction (Cogan's syndrome) is a rare clinical entity. We have reviewed 53 cases (including one of our own) of this disease. In 72 per cent of the affected patients there was an underlying systemic process, often a vasculitis. Ten per cent had fatal or near fatal aortic valvular disease, which has been shown to be amenable to surgical intervention. Other systemic manifestations have included congestive heart failure, gastrointestinal hemorrhage, adenopathy, splenomegaly, hypertension, musculoskeletal involvement and eosinophilia. The clinical course is extremely variable, ranging from months to over 15 years with a minimal five year survival of 28 per cent. Medical therapy with corticosteroids has been beneficial but has only limited effect on symptoms of vestibuloauditory dysfunction. Cogan's syndrome appears to be a manifestation of a systemic disorder which is often apparent only after long-term follow-up.


Bronchoconstriction and pulmonary hypertension during abortion induced by 15-methyl-prostaglandin F2alpha. Patients have experienced severe breathlessness during second trimester abortion initiated by the intramuscular injection of 15-methyl-prostaglandin F2alpha (15-me-PGF2alpha). In four healthy women given 400 mug of 15-me-PGF2alpha to induce abortion, pulmonary function tests showed reductions in arterial oxygen tension, maximum expired air flow and vital capacity. Residual lung volume and the slope of phase III of the closing volume curves increased.


Chronic thromboembolic occlusion of main pulmonary artery or primary branches. Case report and review of the literature. Chronic thromboembolic occlusion of the left pulmonary artery in a 36 year old woman is described, and similar cases reported in the past 15 years are discussed. On review, this disease remains a rare entity. In the majority of cases, the etiology is thrombophlebitis and acute pulmonary embolism. Associated cardiopulmonary disease is uncommon. The most common presenting symptom is unexplained dyspnea, and the majority of patients have past histories of hemoptysis. Acute cardiovascular collapse is distinctly rare. Most physical signs and laboratory tests are normal or nonspecific. The perfusion lung scan, although nonspecific, is the best screening test. Antemortem diagnosis, with rare exception, is established by pulmonary angiography. Eleven patients have been operated on: thromboembolectomy in nine, saphenous vein graft in one and pneumonectomy in one. Operative mortality was 36 per cent (four of 11), definite improvement was seen in 46 per cent (five of 11), and 18 per cent (two of 11) survived the operation with no improvement. The role of medical therapy in this disease is considered.


Endocarditis due to accidental penetrating foreign bodies. A 15 year old boy had an eight month history of recurrent fever, malaise and poor appetite. Chest roentgenogram revealed a foreign object overlying the right ventricle. Multiple blood cultures grew Enterobacter cloacae. The patients condition improved and blood cultures became negative following gentamicin and carbenicillin therapy. E. cloacae was isolated from the foreign body (a finishing nail) at surgery. Antimicrobial therapy was continued for a total of 30 days, and the patient made an uneventful recovery.


Arizona hinshawii osteomyelitis with antecedent enteric fever and sepsis. A case report with a review of the literature. A case of Arizona osteomyelitis of the spine which occurred 11 months after an episode of gastroenteritis and enteric fever is presented. As close biochemical and antigenic relative of Salmonella, Arizona infection produces a similar clinical course with gastrointestinal manifestations frequently preceding localized infections by several months. The boney lesion in the present case and in three of the four other cases of Arizona osteomyelitis described in the literature was a chronic inflammation which may have a xanthomatous component. The bone destruction caused by Arizona infection is less severe than that of tuberculosis or pyogenic osteomyelitis. Proposed treatment of Arizona osteomyelitis consists of debridement of the localized infection and long term antimicrobial therapy.


Carpal tunnel syndrome as the initial manifestation of tuberculosis. Two patients presenting with carpal tunnel syndrome as the initial manifestations of tuberculosis were seen during a recent four month period at a larg city-county hospital. Although the clinical picture of the carpal tunnel syndrome was typical, a definite diagnosis could not be made until the time of surgery because of the many other causes of the carpal tunnel syndrome. A review of the experience with musculoskeletal tuberculosis and carpal tunnel syndrome at our hospital indicates that although this combination is not common, it is one of the treatable causes of the carpal tunnel syndrome. A review of the literature substantiates this impression.


Candida arthritis. A manifestation of disseminated candidiasis. Fungal infections infrequently involve the joints. Review of the literature reveals that Candida arthritis is rare, that it is usually a complication of disseminated candidiasis and that it occurs as a primary joint infection without spread from adjacent osteomyelitis. In the patient we describe Candida arthritis and bursitis of separate joints developed as a late manifestation of disseminated infection following "transient" C. tropicalis fungemia. Treatment consisting of aspiration and parenteral amphotericin B eradicated the joint infection without the need for surgery. Bursectomy, however, was required to eradicate the bursal infection. Awareness of this as well as other late complications of candidemia which signify disseminated infection is important. Optimal therapy will be determined only by further clinical experience with this unusual manifestation of Candida infection.


Job analysis in the clinical laboratory. Questionnaires were sent to 111 hospitals located within a 100-mile radius of Morgantown, West Virginia. In the 55 responding hospitals, 1,532 laboratory workers were employed; of this total, 399 were MT(ASCP), 55 were MLT(ASCP), 262 were CLA(ASCP), and 816 were not certified by the Board of Registry of the American Society of Clinical Pathologists (ASCP). Participating hospital laboratory directors were asked to distribute task inventories to medical technologists and to individuals not certified as MT(ASCP). One hundred sixty-five task inventories were completed and returned for analysis. Using the chi square test, comparison was made between the tasks performed by ASCP-certified medical technologists and ASCP-certified laboratory assistants. Both performed essentially the same tasks in the clinical laboratories included in this study. In the final analysis, teaching and supervision were performed more frequently by MTs than by CLAs.


The cloak of competence: years later.

The cloak of competence: years later. A sample of the persons in Edgerton's 1960-1961 study, The Cloak of Competence, was revisited in 1972-1973. The life circumstances of many of these persons had improved, but predictions of the direction and nature of community adjustment in a number of cases proved to be inaccurate. We discussed the issue of diversity in these cases and factors which make prediction problematic, such as environmental variables (as opposed to personal ones) and the effects of time on individual adaptation. Caution was suggested in looking at short-term adaptation without considering these factors. The importance of recognizing the individual's own definition of success was also stressed.


Transfer as a result of synthetic and analytic reading instruction. Fifty EMR children and an equal number of nonretarded children were paired on the basis of WISC vocabulary scores. Pairs were then randomly assigned to one of two conditions (synthetic or analytic). Children in the analytic condition learned to read words printed in a contrived alphabet by a whole-word method, and children in the synthetic condition learned the same words by a parts-to-whole method. At the end of each of three learning sessions, children identified transfer words, including some which were consistent with those taught in phoneme-grapheme relationships and some that were inconsistent. The synthetic method promoted identification of both consistent and inconsistent transfer words for both retarded and nonretarded children.


Teaching styles of mothers and the match-to-sample performance of their retarded preschool-age- children. Twenty-one mothers and their preschool-age retarded children were observed during three structured teaching sessions. Each session was rated for various forms of maternal preresponse and postresponse activity as well as performance of the children. The results indicated that the most frequent forms of maternal behavior were preresponse verbal directions and instructions; however, the best predictor of children's correct performance was postresponse positive feedback. Patterns of intercorrelations among maternal measures were generally consistent with those reported by Hess and Shipman (1965). The hypothesis was advanced that maternal postresponse feedback may occur as the result of correct responding which, in turn, is more directly affected by other aspects of teaching style.


Comparison of two procedures for fostering the development of the object construct. To determine the extent to which training can effect acquisition and retention of the object construct, we exposed 21 severely mentally retarded individuals to training or control conditions for about 10 minutes per day on 8 days. There were two training procedures: one that seemed typical of previous efforts to foster the object construct and a second that differed primarily in the size of the steps in the systematic chain of tasks required of the subjects. Both procedures affected acquisition significantly and equally but neither appeared to result in long-term retention.


Acquisition and retention of a mediational strategy for PA learning in EMR children. The ability of EMR children to acquire and retain a mediational strategy for PA learning was demonstrated by a training procedure which consisted of the sequencing of consecutive lists under varying degrees of mediational facilitation. The components of the training procedure included training interval, overt verbalization, and verbal context combined with imagery instruction. Forty-five EMR children (mean CA = 11.26; mean IQ = 63.33) were randomly assigned to one of three groups: mediation, standard, and control. Analyses of data showed significantly superior performance of the mediation group in acquisition and retention of the mediational strategy. The pedagogical implications of the study were discussed.


Interpersonal interactions between institutionalized retarded children and their attendants. An observational method was devised to enable detailed analysis of the behavioral and situational components of aide-resident interpersonal interactions in an institutional ward for retarded children. With this device we measured mode of communication, interpersonal affect, response to the initiator of an encounter, the context within which the interaction occurs, and a mand/tact dimension. In this article, the development and validation of the scale, including data on its reliablity, utiliy, and communicability in training novice observers, was reported. Interrater agreement in each dimension exceeded 80 percent, averaging 89 percent over all categories. Observations over a 7-week period indicated that the dormitory was consistently characterized by child-care and ward-management activities and a neutral affective atmosphere in which aides initiated most of the interactions. The observational method appears appropriate for evaluating interventions designed to improve the quality of residential treatment.


Factor structure and correlates of adaptive behavior in noninstitutionalized retarded adults. Forty mentally retarded adults working at a vocational training center were rated by their counselors on the 10 behavior domains of the Adaptive Behavior Scale. A factor analysis yielded the following factors: 1, personal independence; 2, personal responsibility; 3, productivity; and 4, social responsibility. A regression analysis of the four factors on the variables of age, sex, verbal IQ, performance IQ, and maternal trust showed that the predictors together accounted for 75 percent of the variance in Factor 1 and very little of the variance in the other factors. Theoretical and practical implications of the results were discussed.


Comparison of three procedures in reducing self-injurious behavior. In the present study the effects of withdrawal of food, withdrawal of attention, and the simultaneous withdrawal of food and attention on the rate of self-injurious behavior of three profoundly retarded girls during mealtime were investigated. The two treatments that prevented eating led to a marked reduction of self-injurious behavior. Application of the method allowing continuation of eating (withdrawal of attention) resulted in an increased rate of two subjects' self-injurious behavior and had little effect on the rate of self-injurious behavior of the third. An analysis of the data suggests that contingent interruption of meal consumption can reduce the behavior and that rates of self-injurious behavior vary as a result of reinforcement.


Establishing conditional discriminations without direct training: stimulus classes and labels. An attempt was made to expand the paradigm published by Spradlin, Cotter, and Baxley (1973). Spradlin et al. conditioned subjects to select a choice stimulus in response to two different sample stimuli and then conditioned them to select a new choice stimulus in response to one sample stimulus. The remaining sample stimulus then controlled the second choice stimulus. In the current investigation, two subjects were taught two classes of four symbols each through visual match-to-sample training. When auditory symbols were conditioned to control some members of these two classes, the reamining members came under auditory control without direct training.


Experimental preadmission program to encourgage home care for severely and profoundly retarded children. An experimental treatment program was designed to reduce institutionalization of severely and profoundly retarded children under 6 years of age. Subjects were randomly assigned to experimental and control groups. Results showed that counseling with the mother alone tends to result in increased marital conflict as well as a decision to keep the child at home, particularly for parents who are uncertain about their plans and hopes for the child. Since this conflict could defeat the real purpose of fostering the welfare of the child, family counseling should be used and consensus within the family should be sought. Instructing the mother in child-training procedures tends to reduce the number of instances of objectionable child behavior, as well as to induce a decision to keep the child at home, particularly for parents who are uncertain about their hopes and plans for the child.


An association between the Dalkon Shield and complicated pregnancies among women hospitalized for intrauterine contraceptive device--related disorders. A nationwide mail survey of virtually all physicians likely to be involved with intrauterine contraception resulted in 3,502 unduplicated reports of intrauterine contraceptive device (IUD)--related hospitalizations during the first six months of 1973. Dalkon Shield use was significantly more frequent among women hospitalized for a complicated pregnancy than those hospitalized for a non-pregnancy-related disorder. Although the observed association was not substantially altered by stratifications of the mail survey reports by the patient's age, race, or geographical region, the association did not apply to those women whose IUD's were explicitly reported to be of the nulliparous size. Interviews conducted with a probability sample of physicians who had not responded to the survey confirmed that the association between the Dalkon Shield and complicated pregnancy also existed in their experience. An association between the standard Dalkon Shield and complicated pregnancies might reflect an increased rate of pregnancy with this device, an increased rate of complications occurring after zygotic implantation, or perhaps both. Whatever the explanation, the observed association is sufficiently widespread to require further investigations.


Relation of obstetric parameters to the concentrations of four pregnancy-associated plasma proteins at term in normal gestation. The relations between normal obstetric parameters and the maternal levels of four pregnancy-associated plasma proteins (PAPP) were studied, with the use of plasma samples taken from 187 normal pregnant women within seven days before delivery. PAPP-A levels were correlated with placental and newborn weights. The levels of this pregnancy protein was higher in primigravid women and in groups with higher diastolic blood pressure than in other groups. Women with extremely high PAPP-A concentrations were likely to have extremely large placental weight was not necessarily associated with a high PAPP-A level. PAPP-C was not correlated with placental or newborn weight. The relationship between PAPP-C and maternal age, as well as maternal weight, was significant by one but not in the other three statistical analyses employed. The pregnancy zone protein was found to be correlated with parity. In primigravid women, this protein additionally showed an inverse correlation with the placental weight. Human chorionic somatomammotropin was significantly related to placental weight and inversely related to maternal weight. Its relationship with newborn weight was best seen in primigravid subjects. Other parameters (systolic blood pressure, one- and five-minute Apgar scores, weeks of gestation, days before delivery, newborn sex, and newborn bilirubin level) were not related to any of these pregnancy proteins.


A simple assessment of the risk of low birth weight to select women for nutritional intervention. There is growing evidence that the high prevalence of low-birth-weight (LBW) babies, a characteristic of many poor societies, can be significantly reduced through nutritional intervention programs. In order to increase the efficiency of these programs, pregnant women at risk of delivering LBW babies must be identified. Several risk scales have been extensively used in urban populations of developed countries. However, these indicators are of little use in poor communities, since most of them require expensive laboratory techniques, a long interview, at least two visits to a health center, and a precise estimation of gestational age. The present paper proposes several risk indicators of LBW, appropriate for use in areas with inadequate health resources. In a four-year longitudinal study of pregnant women from poor rural villages in Guatemala, mothers of LBW babies were found to be typically small in stature and head circumference. In addition, their houses tended to be of relatively poor quality. The proportion of LBW babies found among women at risk, as defined by these indicators, was significantly lower among women with similar characteristics receiving adequate food supplementation during pregnancy. Categories of high risk were based on maternal height, head circumference, and house quality. It is concluded that use of these categories will increase the efficiency of these programs without decreasing significantly their effectiveness.


Immunobiological function of the syncytiotrophoblast: a new theory. The main purpose of this paper is to present our hypothesis concerning the antigen-antibody complex formation and the resolution system inside the syncytiotrophoblast to explain immunologic fetomaternal relationships. This hypothesis, derived from the results of our experiments, might be an answer to why the fetus is not rejected by the mother, in contradistinction to other allografts. We also believe that this hypothesis makes important contributions to the explanation of the immunologic processes of cells, i.e., those processes which work against antigens inside a living body.


A rapid, flow-through column radioimmunoassay for human chorionic somatomammotropin. A rapid, flow-through, column, nonequilibrium radioimmunoassay for human chorionic somatomammotropin (HCS) is described. The total incubation time is about 1 hour, and no centrifugation is needed. Reproducibility, sensitivity, specificity, recovery, and parallelism are adequate for clinical utility. Hormone levels in a variety of pregnancy sera assayed by this column method are closely related to results from another more conventional radioimmunoassay method.


Extraperitoneal cesarean section: a new need for old skills. A preliminary report. Preliminary results of the effect of extraperitoneal cesarean section on operative and postoperative morbidity are presented. The extraperitoneal technique did not prolong delivery time or operative time, as compared to transperitoneal cesarean section. Postoperative febrile morbidity seemed to be less in the patients who had extraperitoneal cesarean section, even when compared to randomly selected transperitoneal cases. Further data will be necessary to conclude that renewed interest in this technique is warranted.


Fetal growth retardation in relation to maternal smoking and weight gain in pregnancy. Two types of fetal growth retardation were recognized in term infants. One type was characterized by an abnormally low ponderal index (defined as birth weight in grams X 100 divided by crown-heel length in cubic centimeters.) The other type of growth-retarded infants had abnormally short crown-heel lengths for fetal age. Both types were observed under all conditions studied. However, mothers who smoked cigarettes during pregnancy were more likely to have infants with short body lengths for dates, whereas mothers who had low weight gain in pregnancy were more likely to have infants with low ponderal indices. Social group, prepregnancy weight, parity, marital status, and fetal sex were found to be less determinant of fetal growth than were maternal weight gain and smoking habits.


Fetal scalp abscess secondary to intrauterine monitoring. Thirty-one cases of fetal scalp abscess secondary to internal fetal monitoring over a 32 month period were reviewed. The over-all incidence was 1:230 monitored labors, or 0.4 per cent. Twenty-nine infants were cultured, with no growth in 10, Staphylococcus epidermidis in 11, and pathogenic organisms in the remainder. Gram stains of the exudates generally supported the culture results. All cases responded to drainage, local care, and systemic antibiotics, with no deaths. One case of osteomyelitis of the skull was confirmed roentgenographically. A strong correlation between prolonged rupture of the membranes and scalp abscess was observed, but no definite infectious origin was confirmed. The etiology of scalp abscess secondary to monitoring remains obscure.


Absolute neonatal insulin levels in children of insulin-requiring diabetic patients. This report describes the relationship between cord plasma insulin and neonatal blood glucose in nine children of diabetic patients treated during pregnancy with monocomponent insulins. Plasma insulin in cord blood was similar to that found in patients with gestational diabetes and was not related to either neonatal blood glucose or maternal diabetic control.


Incidence of infections associated with the intrauterine contraceptive device in an isolated community. In an attempt to estimate more precisely the frequency of infections associated with the intrauterine contraceptive device (IUD), all gynecologic morbidity resulting from infection and occurring during a two-year period in an isolated community was reviewed. Ten septic abortions occurred, and all but one were associated with IUD use. In 26 gynecologic inpatients (41 per cent of all admissions for acute pelvic inflammatory disease), pelvic infection was associated with IUD use. In contradistinction to the septic abortion data, implicating only the Dalkon Shield, the gynecologic infections were associated with various types of devices.


Microinvasive carcinoma of the cervix.

Microinvasive carcinoma of the cervix. The depth and pattern of invasion were compared in 115 cases of microinvasive carcinoma. The 71 invading 1 mm. or less were focal (96 per cent) rather than confluent (4 per cent) and were cured by simple hysterectomy(one vaginal vault recurrence). The 44 invading 2 to 5 mm. showed a confluent pattern in 39 per cent; a need for treating pelvic lymphatics was demonstrated by one with a positive hypogastric lymph node and by two pelvic recurrences. An additional 26 cases assessed as beyond microinvasive (6 to 10 mm. in depth) included five of 16 without radical treatment who died from cancer, while all treated radically survived, including five with lymphatic involvement.


Scalene node biopsy in the pretreatment staging of carcinoma of the cervix uteri. This study reports the experience at the Ellis Fischel State Cancer Hospital with the use of scalene node biopsy for the pretreatment evaluation of patients with carcinoma of the cervix uter. The study was stimulated by a report from the National Cancer Institutes which stated that impalpable scalene nodes contained metastatic cancer in 13 per cent of a series of 84 cases. By a meticulous biopsy technique, we were unable to confirm this high incidence, In a series of 73 cases, no impalpable lymph nodes were found to contain metastatic cancer regardless of the clinical stage of the cancer. Consequently, we have terminated the use of scalene lymph node biopsies in the staging of cervical cancer for primary treatment. The study is still in progress to evaluate patients with recurrent cervical cancer who may possibly require pelvic exenteration. Also, the procedure will be continued in patients referred for further treatment in whom carcinoma was first diagnosed as an unsuspected finding in a hysterectomy specimen.


Endometrial aspiration in fertility control. A report of 500 cases. Outpatient endometrial aspiration was offered to patients who suspected that they were pregnant, but were within 5 to 21 days after failure of expected menstruation and had a uterus of normal size on pelvic examination. This is a report of 500 consecutive cases treated between September, 1973, and April, 1975. Histologic examination of the aspirated tissue was obtained on all 500 cases (100 per cent). Follow-up examination and urine pregnancy was obtained on 407 patients (81.4 per cent). Histologic evidence of pregnancy was obtained in 323 patients (64.6 per cent). Complications were limited to five infections (1 per cent), only one of which led to hospitalization of the patient, and failure to completely evacuate the pregnant uterus in 39 patients (12.1 per cetn of the 323 pregnant). Thirty-four of these had the uterus emptied by a second outpatient procedure and five patients were hospitalized to complete their abortion.


Clinical significance of fetal heart rate patterns during labor. I. Baseline patterns. From a population of 2,774 high-risk patients monitored during labor, 1,304 single pregnancies in cephalic presentation and with direct monitoring for at least 1 hour before completion or cesarean-section were studied. The maternal and fetal clinical data and the tracings were hand reviewed, coded, and programmed for computer analysis. In the record were studied baseline, its changes (tachycardia, fixed, saltatory), the accelerations, and the decelerations (early, variable, late). Fifty-four per cent had some type of FHR deceleration. Accelerations were recorded in over 12 per cent of all cases and were associated with cord problems in 41 per cent. Subgrouping the patients by age of gestation (less than or equal to 36 weeks, 37 to 41 weeks, and greater than or equal to 42 weeks) revealed a 10 per cent prolonged gestation rate and only 6.8 per cent premature; these had a lower 5 minute Apgar score. Fetal weight and age were positively correlated with Apgar score. Baseline changes were much frequent among pre- and postmature infants, particularly tachycardia in the latter (40 per cent). The premature infants had a 25 per cent incidence of fetal distress and the postmature infants had 20 per cent. Neonatal morbidity and mortality rates were very high among premature infants and a mortality rate of 2.3 per cent was found among postmature infants. Saltatory pattern and particularly fixed baseline seem characteristic of prolonged gestation and placental insufficiency. With tachycardia, they constitute subtle symptoms of fetal distress.


Induction of labor with oral prostaglandin E2. Prostaglandin E (PGE2) was administered orally for induction of labor to 100 patients. Active labor and progression occurred in 92 per cent of these cases. The dosage regimen used was 0.5 to 1.5 mg. hourly. Amniotomy was performed in most cases once active labor and progression were noted. There were 83 vaginal deliveries and 12 cesarean sections. There were eight failure of induction, one patient left the study, and one was not delivered at that admission. Fetal distress occurred in 10 patients but this was related to cord and placental problems and not to PGE2 per se. Side effects were minimal, the most prominent being nausea and vomiting. Total labor in hours compares to normal labor. Over-all, labor in primigravidas averaged 10.15 hours and 6.5 hours in multiparas. There was a direct relationship of the Bishop score to the start of active labor and progression. PGE2 appears safe and efficacious for inductions of labor at terms.


Carcinoma of the cervix in oral contraceptive steroid and IUD users and nonusers. A total of 40,211 cytologic examinations and subsequent diagnostic procedures resulted in the diagnosis of carcinoma of the cervix in 76 patients. The 76 patients did not demonstrate any variations in use of oral contraceptive steroids or intrauterine devices when compared to 780 randomly selected control patients. This study is in agreement with our earlier report demonstrating no increased risk of carcinoma of the cervix in oral contraceptive steroid users compared to nonusers.


The Pereyra procedure. Favorable experience with 200 operations. This communication documents experience with 200 Pereyra operations performed for stress urinary incontinence over a 9 year period. The majority of patients were 35 to 55 years of age, were obese, and had varying degrees of uterovaginal prolapse. More than one fourth also had excessive bleeding and all were best managed by vaginal surgery. Important points in surgical technique are emphasized. Of 188 patients followed, 82 per cent had complete symptomatic relief and another 10.5 per cent were improved. There was a 7.5 per cent failure rate and morbidity was minimal. We conclude that the Pereyra procedure should be considered for stress urinary incontinence whenever vaginal surgery is indicated.


Doctors and patients in obstetrics and gynecology: the next 15 years. The major impact on the development of obstetrics-gynecology during the next 15 years will come from the substantially increased number of of practicing physicians in the specialty and less rapidly increasing patient population they will serve. Even at present record low fertility rates, the annual number of births in the United States will increase slowly to a level near 4 million by the early 1980's; children already born will contribute to a 16 per cent increase in the female population 15 to 44 years of age between now and 1990. Over the same time interval, the number of practicing  specialists will increase dramatically, based on rising numbers of medical school graduates and more Ob-Gyn residents; there will be a 52 per cent increase in certified specialists per unit population over the next 15 years.


The cytologic diagnosis of endometrial adenocarcinoma. An outpatient diagnositc technique comparable to the Papanicolaou smear for carcinoma of the cervix is needed to permit early recognition of adenocarcinoma of the endometrium. Five different techniques of sampling the endometrial cavity were carried out on 1, 742 patients at the University of Michigan Medical Center. A total of 2,553 specimens were correlated with operating room curettings to assess the accuracy of each sampling technique. The methods of saline irrigation with an antrum cannula, endometrial brush sampling, high-vacuum aspiration, and the Gravlee jet washer proved not to be accurate enough to be used as a routine screeening test. There was excellent correlation (96 per cent) between endometrial biopsies and curettings. In our experience, endometrial biopsy with a suction or basket curette was the diagnostic technique short of curettage which permitted accurate diagnosis.


Maternal deaths due to spontaneous subarachnoid hemorrhage. Spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriovenous malformation accounted for 4.4 per cent of all maternal deaths in the State of Minnesota from 1950 to 1973. This catastrophic entiity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. An analysis of the 37 deaths among 1,763,824 live births is presented. These 37 patients had delivered 96 infants and had 10 spontaneous abortions prior to current pregnancy. This suggest that pregnancy per se has no appreciable effect upon the occurrence of the hemorrhage. Five of these died in association with labor and delivery, or during a 1 day period-three during labor, one during vaginal delivery, and one only 1 hour postpartum. This is equivalent to 35 per week. On the other hand, 15 occurred during pregnancy (underlivered) (0.4 per week) and 17 during the first 3 months post partum (1.4 per week). These data seem to indicate that labor and delivery increase the risk of spontaneous subarachnoid hemorrhage. The neurologic state of these 37 patients was bad from the very onset of the hemorrhage. Rapid irreversible coma occurred in 34 (76 per cent). Of these 34, 24 (74 per cent) were dead within the first 24 hours and 32 (94 per cent) were dead within the first 4 days following the onset of the hemorrhage.


Maternal deaths in California from 1967 to 1971. A demonstration of the need for mortality review. An evaluation of maternal mortality statistics in California from 1967-1971 has been performed. There has been a fall in the maternal mortality rate following the institution of a therapeutic abortion act. However, analysis of the data reveals that there was an increase in the deaths due to hemorrhage and sepsis. At this same time the maternal mortality study committee was discontinued. It is strongly felt that the data demonstrate the need for a continuing review of maternal deaths. A proposal is made to redesign the maternal mortality study committee so that it can fully meet the needs of the medical profession and the patient.


Treatment of ovarian stromal tumors.

Treatment of ovarian stromal tumors. Fifty-one patients with granulosa-cell tumors and nine patients with Sertoli-Leydig-cell tumors have been treated at the M. D. Anderson Hospital. The most important prognostic finding was the stage of the tumor when first seen. Conservative surgery was utilized in young patients with lesions confined to one ovary. More advanced tumors were treated with maximal tumor resection and postoperative treatment with either irradiation or chemotherapy. Postoperative radiation was given when the tumor capsule had ruptured or residual tumor less than 2 cm. in diameter was present after surgery. Single-agent chemotherapy was ineffective in ovarian stromal tumors, but combination chemotherapy was found to be effective in advanced or recurrent stromal tumors. Actinomycin-D, 5-fluorouracil, and cyclophosphamide were effective in granulosa-cell tumors. Vincristine, actinomycin-D, and cyclophosphamide were effective in Sertoli-Leydig--cell tumors.


Endometriosis and anovulation: a coexisting problem in the infertile female. Over an 8 year period, 350 cases of endometriosis (77 per cent confirmed histologically) from the Department of Obstetrics and Gynecology, Baylor College of Medicine, were reviewed. Of these cases, 58 (17 per cent) exhibited significant anovulation as measured by a scoring system. Endometriosis and anovulation can coexist contrary to classic concepts of these diseases. Both infertility factors required treatment to achieve pregnancy. A 43 per cent pregnancy rate reflects the dual infertility problem.


Immunologic aspects of pre-eclampsia.

Immunologic aspects of pre-eclampsia. It has been suggested by a number of investigators that immune reactions of the mother against antigens of her conceptus contribute to the development of pre-eclampsia. Evidence for and against this hypothesis is reviewed and the possible clinical implications are discussed.


Pars plana vitrectomy for the management of sever diabetic retinopathy. In 100 severely diseased diabetic eyes we performed pars plana vitrectomy. After a median follow-up time of seven months, major visual improvement was achieved in 49% of the eyes. An additional four eyes maintained a preoperatively good visual acuity resulting in an overall success rate of 53%. Eyes with only vitreous hemorrhages did better (71%) than eyes with posterior retinal detachments (31%). We did not observe new tissue proliferation in any of the operated eyes.


Pars plana vitrectomy for removal of intravitreous Cysticercus. Pars plana was used for the removal of an intravitreous cysticercus, with minimal postoperative inflammation and an excellent visual result. This approach avoids lens removal and the visualization provided by the operating microscope allows removal of all vitreous humor particles and debris. The aspirated specimens allowed identification of the Taenia solium cysticercus.


Occlusive retinal arteriolitis with neovascularization. A 34-year-old white woman who had used oral contraceptives for six years showed an occlusive bilateral retinal arteriolitis that resulted in a branch arteriolar occlusion in the right eye and retinal neovascularization. Three years later, we observed active arteriolitis in the left eye with successive occlusion of several branch arterioles. The disease has shown spontaneous remissions and exacerbations. An extensive medical evaluation revealed only old pulmonary granulomatous disease and an elevated sedimentation rate in association with exacerbations of the arteriolitis.


Idiopathic focal subretinal neovascularization. In 20 patients idiopathic focal subretinal neovascularization was characterized by a solitary focus of subretinal neovascularization at or near the fovea, associated with serous or hemorrhagic detachment of the overlying and adjacent sensory retina, or both. Although the lesions resembled the neovascular membrane seen in the presumed ocular histoplasmosis syndrome, none of the other associated characteristic ophthalmoscopic findings, considered essential to make the latter diagnosis, were apparent. In this group of patients, the incidence of positive histoplasmin skin tests was no greater than in the general population. Of the 20 patients, two had bilateral disease. In no case were there any other lesions of any kind in the afflicted or the opposite eye. The disease is self-limited over a variable period of time, but may result in extensive scarring with loss of central vision.


Myelinated nerve fibers and severe myopia. Two 4-year-old boys, one white and one black, had unilateral extensive myelinization of retinal nerve fibers associated with severe myopia, esotropia, and amblyopia. The finding of unilateral extensive myelinization of the nerve head and retinal fibers in a child may indicate a potentially remediable anisometropic amblyopia.


Rapid resolution of venous stasis retinopathy after carotid endarterectomy. A 60-year-old woman with ocular hypertension developed unilateral venous stasis retinopathy and neovascularization of the optic disk as the first signs of carotid occlusive disease. The retinopathy and the neovascularization disappeared rapidly and dramatically after carotid endarterectomy. Neovascularization in venous stasis retinopathy must be maintained by hypoxia or hypoperfusion, possibly through some intermediate substance such as a vasoproliferative factor.


Severe proliferative retinopathy as the only sign of sickle cell hemoglobin C disease. A 48-year-old black woman developed severe bilateral hypoxic proliferative retinopathy without other clinical manifestations. The hemoglobin level was 10.6 to 11.5 g/100 ml, reticulocyte level was 2.2%, targeted and sickled red blood cells were seen on blood smears, and hemoglobins S and C were demonstrated by electrophoresis. Glucose tolerance test was normal. The development of neovascular proliferation, vitreous hemorrhage, and retinal detachment unassociated with other clinical symptoms is unusual in sickle cell hemoglobin C disease.


Cystoid macular edema in the first week after cataract extraction. Fluorescein angiography was safely performed in 100 consecutive cases of cataract extraction during the first postoperative week. Seventy-five percent of the 100 eyes had good quality fluorescein angiograms. Four eyes demonstrated cystoid macular edema. Therefore, the incidence of cystoid macular edema in the first week after cataract surgery was low when compared to the reported incidence (40%) four to six weeks postoperatively.


Central corneal abscess.

Central corneal abscess. Central corneal abscess developed in the experimental animal after inoculation of biologically active staphylococcal strains in a paracentral epithelial lesion of the cornea. These abscesses did not ulcerate, developed only with high inocula, occurred more frequently in immunized rabbits. A serpiginous type of ulceration did not develop at the site of the initial epithelial lesion nor at any other place in the cornea. Histologically, the lesions consisted of densely packed polymorphonuclear leukocytes between the corneal lamellae.


Urinary calculus during methazolamide therapy. A 68-year-old white man with Paget's disease and open-angle glaucoma was treated with methazolamide, 50 to 100 mg three times daily. Ten months after the medication was initiated he developed ureteral colic and a calcium oxalate stone was surgically removed. Three months after the drug was reinstituted the patient passed three calcium phosphate stones. This suggested a casual relationship between methazolamide and stone formation, although renal calculi also complicate Paget's disease and acetazolamide had been administered briefly.


Peripheral chorioretinal lesions and axial length of the myopic eye. A study of the retinal periphery of 1,437 predominantly myopic eyes revealed a statistically significant association of four types of peripheral chorioretinal degenerations with increased axial length of the eye. These were white without pressure, pigmentary degeneration, pavingstone degeneration, and lattice degeneration. There was a tendency for both white without pressure and lattice degeneration jointly to affect eyes of individuals 19 years of age and younger. Increasing age was a significant factor in the incidence of pigmentary and pavingstone degenerations, whereas aging significantly reduced the prevalence of white without pressure.


Vidarabine therapy of complicated herpes simplex keratitis. Patients with active herpetic epithelial keratitis who had toxic reactions or were resistant to idoxuridine received vidarabine. Only one of 35 cases of herpetic epithelial keratitis without stromal disease failed to heal. Of 21 patients with active epithelial keratitis complicating stromal keratitis or uveitis. 11 had complete reepithelialization by day 14. Two patients were removed from the trial as treatment failures. The remaining cases healed in 21 to 48 days. In most instances the stromal keratitis was inactivated when the epithelial ulcer healed. In our patients treated with vidarabine, healing of herpes simplex epithelial ulcers was biphasic: Stage 1, progression from an active to an inactive viral ulcer, and Stage 2, complete reepithelialization.


Cyst of the intraorbital optic nerve sheaths. A 43-year-old woman had a history of gradual unilateral visual acuity loss and proptosis. A 2.5-cm cystic dilatation of the intraorbital dura mater was removed. Microscopic examination revealed a vascular proliferation within the leptomeninges. We inadvertently injected the lesion during orbitography, providing us with an unusual radiographic appearance.


Spheno-orbital meningioma with optociliary veins. A 40-year-old white woman had slowly progressive unilateral loss of visual acuity and increasing proptosis during an eight-year period. Ophthalmoscopy and fluorescein angiography revealed chronic disk edema and optociliary shunt vessels in the right eye. Polytomography showed an enlarged right optic canal. Cerebral arteriography demonstrated a dumbbell-shaped tumor blush in the right juxtasellar region and a diffuse tumor blush in the right orbit. Right frontal craniotomy and orbital exploration showed a cranio-orbital junction (spheno-orbital) meningioma that invaded the sclera and peripapillary choroid. Anomalous optociliary veins were demonstrated histologically at the optic disk.


Safety glasses as protection against shotgun pellets. I designed this experiment to determine if spectacle lenses would protect against a No. 6 shot fired from a 12-gauge shotgun over progressively longer testing distances, and compared plastics, heat-tempered glass, and chemical-tempered glass lenses of standard and industrial thicknesses. The likelihood of a spectacle lens being hit by a well-centered shot pattern at 40, 50, and 60 yards was approximately 66%, 25%, and 20%, respectively. Virtually all lenses were destroyed at a testing distance of 30 yards. At 40 yards, standard-thickness plastic and heat-tempered lenses were destroyed but the chemical-tempered lenses offered some protection. At 40 yards, all types of industrial-thickness lenses provided protection but the most protection was provided by the chemical-tempered lenses. At 50 yards, chemical-tempered lenses offered more protection than either plastic or heat-tempered lenses. Throughout the experiment, plastic lenses performed no better than heat-tempered lenses.


A comparison of four projection perimeters. Identical specifications for size and luminance of the target and dome on four projection perimeters-Goldmann, Marco, Topcon, and Rodenstock- seemed to indicate that similar visual fields should be plottable with each instrument. We subjected 30 eyes to perimetry with all four machines. The Rodenstock perimeter was usually unable to map the central field with the I2e target and to identify the presence of most visual field defects. The Goldmann was most capable of demonstrating the presence of existing scotomata and was also able to plot them with the greatest definition. The Topcon was next most sensitive followed closely by the Marco. Analysis of the actual target size and luminance on each machine showed that significant variation existed and was probably responsible for the visual field differences that we found.


A foot-pedal controlled valve for intraocular irrigation. A solely mechanical foot-pedal operated valve for control of intraocular irrigation provided independence from an assistant and allowed accurate adjustment of flow. It was particularly useful during cataract aspiration, vitreous cutting, and intraocular lens implantation.


A self-retaining contact lens for slit-lamp examination of the fundus and for photocoagulation treatment. A self-retaining contact lens for slit-lamp examination and photocoagulation treatment of the posterior fundus afforded a wide-angle view of the retina and allowed freedom of both hands of the examiner.


Ultrastructure of sarcoplasmic reticulum in atrial myocardium of patients with mitral valvular disease. Alterations observed in the sarcoplasmic reticulum of muscle cells in left and right atrial myocardium from 10 patients with mitral valvular disease consisted of: a) proliferation of rough-surfaced endoplasmic reticulum, which formed large cisterns in perinuclear areas of hypertrophied cells and was considered indicative of increased protein synthesis; b) proliferation of free sarcoplasmic reticulum, a change that occurred in degenerated cells and appeared to be related to loss of contractile elements; c) two types of aggregates of tubules of free SR--one type was associated wtih abnormal Z-band material and was found only in cells showing loss of myofibrils and proliferation of free SR, whereas the other was not associated with either of these changes and occurred in less severely altered cells; and d) proliferation and enlargement of cisterns of extended junctional sarcoplasmic reticulum, which formed two distinct types of complexes: the first of these consisted of large, convoluted (Type A) cisterns that were wide (550 to 650 A in thickness) and did not have a central dense lamina; the second was composed of stacks of concentric or parallel (Type B) cisterns that were narrower (220 to 300 A in thickness), had a central dense lamina, and were separated from one another by layers of glycogen granules. The formation of these complexes of cisterns was regarded as an extreme form of overdevelopment of extended junctional sarcoplasmic reticulum in atrial muscle cells.


The alveolar macrophage delivery system. Kinetic studies in cultured explants of murine lung. The production of alveolar macrophages in a blood-free organ culture system has been studied to determine whether free macrophages undergo mitosis or whether their ongoing production is dependent upon continuing division of interstitial cells. Explants of murine long were attached to cellophane or glass; after 6 days of culture, a population of cells identified morphologically and functionally as macrophages appeared around the central tissue. These cells did not divide, and they disappeared 4 days after removal of the central lung explant. 3H-thymidine labeling of these peripheral macrophages was observed only when the central tissue was present and when the thymidine pulse was 24 hours in duration. Actual cell division was observed only in the interstitial cells of the explant. It is concluded that the interstitial cell population provides a continuing pool of precursor cells that divide and migrate outwards, creating a "steady state" system in which macrophage loss at the periphery is balanced by cell production at the center.


Adrenal medullary hyperplasia. A morphometric analysis in patients with familial medullary thyroid carcinoma. The syndrome of familial medullary thyroid carcinoma (MTC), pheochromocytoma, and parathyroid hyperplasia is inherited as an autosomal dominant trait, and is characterized by development of bilateral and multicentric thyroidal and adrenal medullary tumors. One of the earliest manifestations of adrenal medullary hyperfunction in patients with this syndrome is an increased ratio of epinephrine to norepinephrine in urine. In order to define the morphologic correlates of these early catecholamine abnormalities in a large kindred with familial MTC, a morphometric analysis based on a point-counting system to asses adrenal medullary volume was undertaken. These studies clearly revealed adrenal medullary hyperplasia as reflected by a two- to three-fold increase in medullary volume and weight as compared to age- and sex-matched controls. The increase in total medullary mass resulted from diffuse and multifocal modular proliferations of adrenal medullary cells primarily within the head and body regions of the glands. These results support the hypothesis that the pheochromocytomas in patients with familial MTC may, in fact, represent extreme degrees of nodular hyperplasia of the medulla.


Lipid accumulation in human aortic smooth muscle cell lysosomes. Lipid deposition is a central feature of the human atherosclerotic lesion. Deficient lysosomal lipolytic activity has been implicated as a pathogenetic factor in atheroma formation. Cytochemical and ultrastructural examination of the abdominal aortas of 2 normal young males, ages 11 and 23, demonstrates lipid accumulation with lysosomes of intact mural smooth muscle cells. This appears to be an early stage in the process which eventually results in an overloading of lysosomes and the formation of lipid-laden foam cells.


Endocytosis by vascular smooth muscle cells in vivo and in vitro. Roles or vesicles and lysosomes. Overloading of lysosomes of smooth muscle cells with excess substrate may be a key event in the development of hypertensive and atherosclerotic vascular disease. Cellular uptake of materials and its relation to lysosomal function were studied by ultrastructural cytochemistry in aortic smooth muscle cells grown in vitro and in the intact animal. Injection of horseradish peroxidase (HRP) into hypertensive rats resulted in rapid insudation of the material into the environs of medial smooth muscle cells, entrance into surface pinocytic vesicles, and transport via vesicles into the cell interior where material was seen to accumulate within lysosomes. In vitro exposure of calf aortic cells to HRP in the medium resulted in a similar sequence of events. Pinocytic vesicles, seen both in vitro and in vivo, ranged in diameter from 650-1000 A. These dimensions are adequate to permit incorporation of intact lipoproteins of all classes, except the larger chylomicrons.


Sodium balance and the natriuresis of hypertonic saline infusion in dogs. Recently, a paradoxical effect of dietary salt intake on the natriuresis following hypertonic saline infusion was observed in rats. In these experiments the effects of alterations in dietary sodium on the natriuretic response to a hypertonic saline load was studied in dogs. Dogs maintained on a high-sodium diet did not have a significantly different natriuresis than those on a low-sodium diet. When differences in sodium balance were amplified by the use of deoxycorticosterone, furosemide, and manipulation of dietary sodium, dogs in positive sodium balance showed a significantly enhanced initial excretion of sodium followed by a reversal of the pattern. Consequently, the cumulative sodium excretion was not different between low- and high-sodium groups. Since the cumulative natriuretic response to isotonic saline infusion was larger in dogs in positive sodium balance compared to those in negative sodium balance, the failure to detect a difference following hypertonic saline infusion was probably because of the increased plasma sodium concentration.


Thyroid function in a hibernator, Spermophilus tridecemlineatus. Thyroid hormone secretion (assessed as thyroid 125I release rate) was monitored in Spermophilus tridecemlineatus from summer to winter (July-December) in 1973. The average release rate in July was 2.3% per day, but in August this rate decreased significantly and remained at an average 0.52% per day until December. This low rate (being similar to that of hypophysectomized rats), and the absence of any change in oxygen consumption following thyroidectomy, suggested hormone secretion was "turned off" during this period. During the period August-December, four S. tridecemlineatus showed normal thermoregulatory responses to anterior hypothalamic cooling but no thyroidal response whether restrained, unrestrained, or anesthetized. Thyroid 125I uptake (and presumably hormone manufacture) continued during the period August-December and 24-h uptake averaged 27.0% in December. Possible reasons for "turning off" thyroid hormone secretion are discussed, and it is concluded this is to allow the membrane fatty acids to revert to a less-saturated condition in preparation for low body temperatures during hibernation.


Compensatory adaptation of sodium and bicarbonate excretion: effect of diuretics. Complete clamping of the contralateral kidney results in a rapid and significant increase in the fractional excretion of Na, K, and bicarbonate by the remaining kidney during bicarbonate loading. Similar studies were performed in dogs after administration of diuretics with different major sites of action to localize the adaptive excretory response to acute reduction in renal mass. Volume expansion was carefully avoided. In experiments with the loop inhibitor, furosemide, contralateral kidney clamping rapidly and significantly increased fractional excretion of Na and bicarbonate. A more delayed and smaller response was observed in dogs given hydrochlorothiazide. Acetazolamide, a potent inhibitor of proximal Na bicarbonate reabsorption, completely blocked the excretory response to contralateral kidney clamping. The enhanced response with furosemide and its blockade with acetazolamide indicates a proximal site of adaptation to acute contralateral kidney exclusion. The overall natriuretic response depends on the level of inhibition of loop reabsorption.


Electrolyte transport in remnant kidney of the dog: effect of furosemide. Micropuncture studies were performed in 26 dogs with a unilateral remnant kidney to examine its response to modest extracellular volume expansion and furosemide administration in the presence (Stage II) and absence (Stage III) of an intact contralateral kidney. During hydropenia in 15 Stage II dogs, proximal and distal transport of sodium and potassium was comparable to that of normal dogs (Stage I). Following 3% volume expansion, fractional proximal reabsorption was reduced similarly in Stages I and II. Although a slightly greater reduction in fractional loop reabsorption of sodium in Stage II after volume expansion was not significant, it was significantly greater with furosemide administration. In 11 Stage III dogs, proximal fractional reabsorption was depressed during hydropenia, and the loop sodium response to both volume expansion and furosemide administration was exaggerated. In contrast, greater increase in distal potassium secretion was demonstrated mainly in Stage III but not in Stage II remnant kidneys both before and after the diuretic maneuvers. The observations of exaggerated sodium response to furosemide by the remnant kidney in both Stages II and III but greater potassium response only in Stage III suggest that independent factors are responsible for these adaptations when functioning renal mass is reduced.


Neuromuscular function at hyperbaric pressures: pressure-anesthetic interactions. Hydrostatic pressure and anesthetic agents exert mutually antagonistic effects, including pressure reversal of anesthesia and anesthetic amelioration of the high-pressure nervous syndrome. To clarify the cellular basis for these phenomena, twitch tension and electromyogram (EMG) were monitored in the indirectly stimulated isolated rat diaphragm. Compression to 137 atm increased twitch tension without changing EMG amplitude. Partial phrenic nerve block accompanied EMG depression induced by methoxyflurane and chloroform; pressure antagonized these effects. To examine subthreshold pressure effects, calcium concentration was decreased from 2.5 to 0.5 mM. Compression to 137 atm then reversibly decreased EMG amplitude, while enhancing twitch tension. In 0.5 mM calcium, methoxyflurane and chloroform depressed EMG amplitude before blocking phrenic nerve conduction; pressure to 137 atm produced additional depression. These results suggest that pressure enhances twitch tension by acting on excitation-contraction coupling or on the contractile mechanism. They also indicate that pressure may inhibit transmission at the neuromuscular junction, and they do not support synaptic transmission as a site of pressure-anesthetic antagonism.


Evidence for active chloride transport in dogfish rectal gland. To evaluate the characteristics of the transport process for Na and C1 by the rectal gland of the dogfish shark, experiments were performed with an in vitro perfused model. Changes in glandular secretion rate and net electrical potential difference (PD) were measured during independent alterations of the Na and C1 concentrations of the perfusate solution. The rate of net secretion was enhanced by increasing the concentration of either Na or Cl in the perfusate, demonstrating a substratedependent process. When tetramethyl-ammonium was substituted for Na, the rate of secretion fell in association with a rise in net PD from -8 mV to -17 mV (lumen negative). When SO4 was substituted for Cl, secretion rate also fell, but in association with a fall in net PD. Despite almost complete replacement of Cl with SO4, net PD was not reversed. Although the mechanism responsible for Na secretion remains unclear, these data suggest that chloride is transported by an active process in the dogfish rectal gland.


Intestinal calcium absorption: differences in transport between duodenum and ileum. The interaction of calcium with sugar, sodium, and water absorption was studied in rats fed laboratory chow and in vitamin D-deficient and -repleted rats with the use of intestinal loops in vivo. Calcium absorption in the duodenum was enhanced by D-glucose only in the vitamin D-deficient state. In both vitamin D-deficient and -repleted ileum, calcium absorption decreased when NaCl was replaced by mannitol; however, it remained unchanged when NaCl was replaced by choline chloride or urea. Calcium absorption was enhanced by actively transported sugars and by increasing net water flow generated by differences in osmotic pressure and urea. Under all experimental conditions there was a strong association between net water and calcium absorption in the ileum. These findings suggest that calcium absorption is enhanced by solvent drag, although the role of sodium cannot be excluded entirely.


Effects of anoxia and glucose depletion on isolated veins of the dog. Canine vein strips were mounted for isometric tension recording. Anoxia did not affect basal tension of saphenous and pulmonary strips mounted in standard Krebs-Ringer solution or after 30 min of incubation in glucose-free solution. Anoxia depressed the strength of spontaneous contractions of mesenteric veins; in glucose-free solution (30 min), anoxia relaxed the strips. Veins placed in glucose-free solution for more than 60 min contracted with anoxia; this contraction was not inhibited by iproveratril. When the vein strips were contracted by norepinephrine or KCl, anoxia depressed the contractions, most in mesenteric and least in saphenous preparations; this depression was greater in the absence of glucose. When oxygen was present, the absence of glucose had little effect on the response to vasoactive agents. Contractions with acetylcholine were depressed by anoxia in mesenteric and pulmonary strips but were augmented in saphenous veins; the latter potentiation was inhibited by iproveratril and by incubation in glucose-free solution. Thus, especially in the saphenous vein, anaerobic glycolysis can provide most of the energy requirements, and intracellular substrates are available for oxidative metabolism.