Anxiety associated with exposure to organophosphate compounds. Acute organophosphate poisoning is known to result in substantial behavioral abnormalities. We assessed psychiatric manifestations of exposure in workers less substantially exposed to organophosphate compounds and showing no obvious signs of toxicity. Commercial pesticide sprayers and farmers recently exposed to organophosphate agents were compared to control subjects on personality tests, a structured interview, and cholinesterase level. The commercial sprayers but not the exposed farmers showed elevated of anxiety and lower plasma cholinesterase than control subjects. Assessment of other behavioral manifestations and red blood cell cholinesterase failed to disclose other group differences. These findings are viewed as tentative until confirmed by additional study, but they point to the possibility that organophosphate compounds may produce subtle defects in workers who are not obviously toxic. The findings do not justify public alarm but do suggest an area warranting more systematic and definitive investigation.


Self-enucleation and psychosis. Report of two cases and discussion. We report two cases of self-enucleation and the case histories of the two schizophrenic men who carried out this drastic form of self-mutilation. In a review of the literature and consideration of the case material, it is concluded that castration fears, failure to resolve oedipal conflicts, repressed homosexual impulses, severe guilt, and self-punishment are ubiquitous phenomena in such cases. However, we conclude that psychosis, most probably schizophrenia, with a severe disturbance in body image, are necessary variables in the act of self-enucleation.


Analogical reasoning and postoperative outcome. Predictions for patients scheduled for open heart surgery. We investigated whether postoperative outcome of open heart surgery is related to preoperative cognitive dysfunction. Patients ill enough to require open heart surgery frequently have gravely compromised circulation and, hence, possible brain damage. The Conceptual Level Analogy Test (CLAT), a new, rigorously constructed analogy test, was used to measure cognitive dysfunction. The results indicated that the CLAT, aministered preoperatively to open heart surgery patients, differentiated between patients having different types of postoperative outcome. A significant relationship between type of surgical procedure and poor postoperative outcome was also found; cardiac valvular surgery patients had significantly worse outcome than coronary bypass surgery patients. The incidence of good outcome (survival with no psychiatric complications) was 28% for cardiac valvular surgery patients with extremely poor preoperative CLAT scores, but 74% for valvular surgery patients with higher preoperative CLAT scores.


The psychiatrist in the surgical intensive care unit. I. Postoperative delirium. Delirium has been defined as a condition of cerebral insufficiency consisting of impairment of cognitive processes, with a characteristic slowing of the electroencephalographic pattern. Present also is a global "clouding" of consciousness, resulting from a potentially reversible impairment of ability to maintain attention. In these states there is usually a simultaneous diminution of the ability to think, perceive, and remember. Although drowsiness may be a part of this state, patients can be awake and yet delirious, with diminished consciousness of their surroundings. Postoperative delirium is seen more often in patients over 50 years of age, in those who are "vigilant" or overalert, and in those undergoing more complex surgery. Adverse influences in the postoperative period are certain drugs and the psychological stresses engendered by the ICU environment. Appropriate management obtains from attention to the impact of the strange enviornment on the patient.


Further hazards of heparin therapy in vascular surgery. Three consecutive patients were treated with heparin sodium administered intravenously for phlebitis and pulmonary embolism following abdominal aortic surgery. After the institution of heparin, hemorrhage in these patients occurred from the suture line 14 days, 18 days, and 31 days after surgery, respectively. the diagnosis was correctly made and control of the bleeding was achieved in each case. The first two patients required exploratory surgery and the third patient was treated successfully without surgical intervention. We propose that the integrity of the clot at the suture line is in dynamic balance. There is a continuous lysis and resorption of old thrombus and replacement with new clot formation until the suture line is sealed by regeneration of the new "intima". If the blood is anticoagulated by heparin, this balance is disrupted and hemorrhage may result.


Septic nonsuppurative thrombophlebitis.

Septic nonsuppurative thrombophlebitis. Nonsuppurative peripheral thrombophlebitis is a frequently recognized source of sepsis. Eleven patients cared for on general medical and surgical services had Gram-negative bacillary sepsis on this basis. Ten had isolation of organisms of the Klebsiella-Enterobacter group from the involved peripheral vein. All failed to respond to organism-sensitive antibiotics until the involved vein was excised. After local vein excision, all patients were afebrile within 48 hours and recovered. In seven of the 11 patients, the septic phlebitis source was associated with a standard intravenous needle, and none had cutdown procedures. It is strongly emphasized that this condition is a source of life-threatening sepsis that can be treated by vein excision at the bedside. The treatment in our patients resulted in no morbidity. A high index of suspicion is necessary to diagnose this occult  source of sepsis because of the minimal local physical signs.


Early age of onset in familial breast cancer. Genetic and cancer control implications. Although breast carcinoma is the most frequently occurring cancer in American women and has been the subject of extensive epidemiologic investigation, little attention has been devoted to use of risk-factor information in its control. Six of our 52 breast-cancer-prone families have at least one woman who has manifested breast cancer at age 30 or earlier. One such family had two women with breast cancer before age 30, and at least ten others affected by age 50. Transmission of this lesion was consistent with autosomal-dominant mode of inheritance. Ages of onset indicated a notably early peak, in contrast with the expected pre- and post-menopausal peaks in findings of the New York State Tumor Resistry and others. Genetic and epidemiologic information should be utilized to control breast cancer in certain families.


Nosocomial infections in surgical patients. Observations on effects of prophylactic antibiotics. In a "spot survey" to determine prevalence of nosocomial infections in the Surgical Services of Boston City Hospital in January 1972, the use of antibiotics prophylactically did not significantly affect the occurrence of infections either in patients who had undergone surgery or in those who had not at the time of the survey. Among both groups, whether they had acquired infections or not, the use of antibiotics for prophylaxis did not affect the duration of hospitalization up to the time of the survey. In another study (August through October 1971) of the incidence of infections among patients admitted to the Orthopedic Service of the same hospital, the incidence of infections was the same in patients who received antibiotics prophylactically and in those who did not receive any during their period of hospitalization.


Splenic injury during abdominal surgery. Of 237 splenectomies performed over a six-year period, 39 were necessitated by intraoperative injury. Capsular and hilar tears were predominant. All injuries were recognized at the time they occurred. The incidence of pulmonary complications and wound infections exceeded those for other categories of splenectomy and for these other abdominal operations without splenectomy. Although these complications were not fatal and the mortality was not increased, measures for avoidance of intraoperative splenic injury are indicated. These include knowledge of anatomic relationships and exercising cautious traction in operations on the upper part of the stomach and the splenic flexure of the colon, in reoperation in elderly people, or where there is suspicion of intrinsic splenic abnormality.


Repair of abdominal and thoracic wall defects by bovine fascia (ox fascia). Sheets of heterologous fascia (bovine fascia) were used to close large defects of the thoracic and abdominal wall in four patients with malignant neoplasms. The material was well tolerated by the body and provided adequate protection and support to the underlying viscera. Although the fascial graft was not covered by skin flaps in two patients with abdominal wall defects, it became readily incorporated into granulation tissue that was receptive to split thickness skin grafts. The fascia was used successfully in a contaminated field and control of active infection was possible without removing the graft. These findings demonstrate that heterologous fascia is particularly useful under conditions that are not suitable for the use of synthetic materials.


The influence of venous occlusion on xenon 133 muscle clearance. Progressive degrees of venous occlusion in the canine hind limb were employed to evaluate the influence of venous disease on the xenon 133 muscle washout test. Increasing degrees of venous occlusion, from superficial venous occlusion alone to total occlusion induced with intravenously administered thrombin, decreased both resting muscle blood flow and maximal muscle blood flow stimulated with intra-arterially administered papaverine hydrochloride. This alteration lasted for varying lengths of time with all but the group with total venous occlusion eventually returning to a normal flow. The status of the venous circulation must be considered in order to accurately interpret the results of the 133Xe clearance test when used to evaluate arterial occlusive disease. The 133Xe washout test may be an accurate indicator of venous occlusion in a limb with normal arterial supply.


Energy metabolism following thermal burns. Partitional calorimetry was performed on burned rats with and without excision of the adrenal medullae; animals were housed at ambient temperatures of 20 and 28 C. Rates of excretion of urinary nitrogen were determined for the 12 hours before calorimetry runs. Covering the burn wound with polyethylene returned the evaporative heat loss to normal and resulted in a corresponding decrease in the rate of heat production. Excision of the adrenal medullae resulted in chronic hypothermia of burned rats housed at 20 C. The highest rate of excretion of urinary nitrogen occurred in burned rats with intact adrenal medullae housed at 20 C; this excretion rate was significantly reduced when similar animals were housed at 28 C. The net effect of preventing evaporative heat loss from the wounds of burned rats is the same as that of reducing dry heat loss by elevation of the ambient temperature. Both result in a reduction in the rate of heat production.


Enhancement of flow through arteriovenous fistula. Hydrostatic dilation and moist heat applied postoperatively are methods that enhance blood flow in side-to-end radial artery to cephalic vein arteriovenous fistula. This improves early patency of the fistula with marginal sized outflow.


Repair of cholecystocholedochal fistulas using gallbladder patching. Spontaneous cholecystocholedochal fistulas are a rare but serious complication of calculous biliary tract disease. An effective repair technique that has good long-term results is to close the defect in the common duct wall by utilizing the proximal part of the gallbladder as a pedicled graft. A T-tube drain inserted into the common duct should be maintained postoperatively until there is firm evidence of free passage of bile into the duodenum.


Small-bowel obstruction due to congenital anomaly of the falciform ligament. A patient who initially had a small-bowel obstruction was found, at laparotomy, to have an internal hernia through a defect of the falciform ligament. Simple resection of the round ligament was curative. The defect is presumed to have been congenital in origin. No previous report could be found in our review of the literature.


Membrane filters. Additional safety for intra-arterial infusions. The addition of a 0.45mu in-line membrane-filter to the delivery system for intra-arterial infusion therapy is a simple and inexpensive means of providing additional safety. The filter decreases particulate and microorganism infusion by removing all measurable particles and most bacterial and fungal organisms. Since air will not pass through the filter, air embolism is prevented. In addition, in the event of set disruption, the filter will prevent bleeding via red blood cells clogging the membrane.


Arterial occlusion secondary to methylmethacrylate use. We are reporting a new complication of the use of methylmethacrylate, namely occlusion of the iliac artery with embolization. We believe that the occlusion is related to trauma to the intima by the heat of polymerization created by methylmethacrylate, with resultant thrombosis. In view of the initial failure of embolectomy alone, we suggest direct attack on the involved artery with prosthetic replacement, and management of the distal embolus by embolectomy with Fogarty catheters.


[Experience with the use of horseradish peroxidase for light and electron microscope studies of interneuronal connections]. By the method based on a retrograde axonal transport of exogenous horseradish peroxidase (HRP), the origins of afferentation of the motor cortex of adult cats, kittens and albino rats were studied. HRP-positive neurons were found by light and electron microscopy in the somatosensory cortex (C1) of the ipsilateral hemisphere and in the portions of the cortex of the contralateral hemisphere which were symmetrical to the site of injection of HRP. The disposition of neurons, marked by HRP, in the Vth layer of the motor cortex suggest that these neurons may send their axons into the bundles of comissural fibres going to the motor cortex of the opposite hemisphere. This method considerably expands possibilities of revealing the origins of afferentation of the investigated portion of the nervous system and allows more complete and reliable investigation of interneuronal connections.


[Ultrastructural changes in the connective tissue of skeletal muscles following denervation]. The ultrastructural changes found in the endomysium of rats after denervation of the diaphragm and m. plantaris were studied. Within the first week after crossing the peripheral nerve in the nedomysium there appeared an increased amount of neutrophils and monocytes as well as phagocytic material in the cytoplasm of histocytes. Activization of the cytoplasm of fibroblasts which manifested itself in the appearance of numerous vesicles and multiple free and bound ribosomes was detected by the end of the second and the beginning of the third weeks after denervation. At the same period eosinophils invaded the endomysium and became closely surrounded by numerous collagenic fibres. After reparation of neuromuscular synapses these changes disappeared. On the basis of these results and others founded in previous studies of denervated and reinnervated skeletal muscles the authors consider these changes in the endomysium appearing under the above experimental conditions to be manifestations of metabolic interrelations between the endomysium connective tissue and muscle fibres.


[Histochemical studies of several "K"-cell enzymes in guinea pig thyroid glands]. The thyroid gland of guinea pigs were studied morphologically. Histochemical methods were used for detection of lactate dehydrogenase, succinic dehydrogenase, cholinesterase, alkaline phosphatase and acid phosphatase. The distribution of "C"-cells in normal thyroid glands was proved to be uneven. In the center of the gland they were more numerous. For statistical investigations the method of silver impregnation of "C"-cells is more practicable, since they can not be obviously distinguished from acinar cells on the basis of glycerophosphate dehydrogenase only. The activity of cholinestarase in "C"-cells and in some other cells of folliculi epithelium is very high. A supposition is made that there exist two kinds of the follicular lining thyrocytes, having different histochemical properties and histogenesis as well.


[Histogenesis of chicken aorta endothelium]. The formation of tissue properties of the aorta endothelium of two-week chicken embryos, and one day chickens has been followed. The morphological characteristics of the aorta endothelial lining in adult chickens are given. The endothelium was studied in tangential sections and flat film preparations. Histological certain histochemical and biometrical methods were used. At the end of the second week the signs of a heteromorphous state of the endothelium were already seen most distinctly, which appeared as early as the end of the first week of embryogenesis. Later these signs accumulated and became stronger. The aorta endothelial lining of adult chickens is polymorphous. Certain regularities in the regional distribution of cells of a definite shape and area were observed in it. Throughout embryogenesis the endothelium behaved like a tissue having its oun cambium. The mitotic index drops in the course of embryogenesis. No mitoses have been found in the endothelial lining of adult chickens.


[A quantitative electron microscopic study of the respiratory parts of the lungs. II. The capillary network and septal spaces of the interalveolar septa]. A parallel histological and electron microscopic study of the capillary network of interalveolar septa has shown that in this microstructure there is only one two-dimensional capillary network, common for adjacent alveoles. In septal spaces of interalveolar septa the collagenic fibrils form an even thin network and additional collagenic bundles. The latter are mainly found in intercapillary septal spaces. The elastic fibres in interalveolar septa are found rarely, no interstitial cells being found at all.


[Cholin- and adrenergic components of the vegetative innervation of the dura mater]. Cholin- and adrenergic nerves in the fornix and base of the dura mater of rats, cats and dogs have been studied by methods of Kelle, Falck and Glenner. It has been established that the dura mater has a developed cholin- and adrenergic nervous apparatus innervating arteries, veins and the connective tissue of the mater. The concentration of nerve fibres is always greater on a meningea media and its daughter branches. The statistical processing of the data obtained has shown that the maximum quantity of nerve fibres is in cats, less in dogs and still less in rats. It has been established that in the dura fornix of cats and dogs there are more cholinergic nerve fibres than in the base. In rats there is no such difference. The amount of fibres with monoaminoxidase approximately corresponds to the amount of conductors with noradrenaline.


[The effect of gravitational stress in the pelvis--head direction on the blood vessels of the sympathetic trunk]. The experiment was carried out in 15 rabbits. Three of them were control. The stress of the pelvis--head direction was obtained in a centrifuge of 1 m radius. Six animals were rotated for 1 min., the other six--til death, which came within 3--4,5 min. of the experiment. By methods of injection, clearing and measuring it was found that in the vessels of the sympathetic trunk congestion phenomena were first and foremost under effects of stresses of the caudo-cranial direction. Their intensity is in direct dependence on the duration of stress. In the 1st series (1 min.) a considerable congestion of venous blood in the cranial sympathetic ganglion was observed in 1 case, while in the 2nd series (3--4,5 min.) very drastic congestion phenomena, with an enlarged diameter, vein deformity and so on, were constantly noted. A support is given to literature data that such "negative" stresses are less endurable for animals, death comes soon, since the phase of relative compensation under given conditions is promptly changed for the phase of decompensation.


[Age and the succinate dehydrogenase activity of human cardiac neurons]. Under study was the SDG activity in human heart neurons in postnatal ontogensis. Succinic dehydrogenase was revealed with nitrablue tetrazole after Nachlas, quantitative measurements in preparations were made in a cytospectrophotometer. A regular developmental increase in the SDG activity in human heart neurons was established to have certain fluctuations in different age periods. The most intensive growth of the enzyme activity was found in early childhood, youth and senile age which is related to physiological state of the organism and the cardio-vascular activity.


[So-called muscular "bridges" and their interrelationship with blood vessels]. Fifty hearts of corpses of humans of different age groups were studied by means of macro-microscopical anatomical dissection of muscle fibres and cardiac blood vessels. The muscle bridges were found over the coronary arteries in all preparations of the heart. They were most frequently met on the anterior interventricular branch of the left coronary artery. The topography of muscle bridges is described and the miocardium muscle bundles participating in their formation are revealed. The character of the course of fibres in the muscle bridge is related to the course of the fibres of the muscle bundle forming it.


[Hormonal stimulation of the reparative process in the skin or fats with vitamin A deficiency]. The effect of thyroid hormone on the regeneration of skin of A-deficient rats was studied. It was established that the reparative process in such animals was considerably retarded due to disturbances of the intensity and the character of the reaction. Under these conditions the succession of main stages of the regenerative process was maintained but there occurred a number of important qualitative and quantitative morphological disorders which substantially changed the course of healing of skin wounds. An additional injection of the thyroid hormone against this background had a favourable effect upon the skin regeneration but failed to produce a typical stimulating effect, characteristic of the hormonal agent in normality.


[Changes in rat testis glandulocytes under deep hypothermia]. White mongrel rats weighing 180-220 g were daily cooled in water at 4-5 degrees C up to 21-23 degrees C in the rectum. The animals were killed on the 1, 5, 10, 15, 20 and 25th days of experiment. The total amount of glandulocytes counted per a cross section of the tubule did not change throughout the experiment. The total weight of pictures of 100 glandulocytes (taken randomly), obtained through a drawing apparatus on a standard paper was  reliably decreased by 28%. By the end of the observation period the amount of degenerating glandulocytes increased 2 times and that of slightly active in a functional respect so-called "small" glandulocytes increased 4 times, while the number of active ("large") glandulocytes diminished approximately 1,5 times. The activity of SDG and ICDG in interstitial cells dropped by 26% and 18%. The activity of LDG was 52% greater. The G-6-PhDG activity was 40% greater while the activity of clue enzyme steroidgenase--3beta-OSD under hypothermia was inhibited by 36%.


[Age and variability in the inguinal lymph nodes of adult humans]. Lymphatic nodes on the anterior surface of the femur, in the region of the femoral triangle were studied in 56 corpses of humans of either sex from 31 to 82 years of age, dead of accidental causes or of diseases not related to lymphatic nodes. The investigation was carried on by the method of interstitial and direct injection of the Gerota's mass to some regions of foot skin, external genitalia and the skin of the anterior wall of the abdomen. It has been established that the size of inguinal lymphatic nodes (both superficial and profound) in humans of either sex, are in direct dependence on the age of the person. The amount of inguinal lymphatic nodes in young people prevails over that in old people. The external diameter of the afferent and efferent vessels in elderly humans is greater than in young ones. The amount of afferent lymphatic vessels to inguinal lymphatic nodes in most cases prevails over the amount of efferent ones, independent of age and sex. The external diameter of the former is greater than that of the latter.


[Changes in the innervational connections of the urinary bladder upon experimental stimulation of the hypothalamus]. The innervation of the urinary bladder was studied in 40 rabbits, 5 of which were control and in 35 animals the posterior and anterior nuclei of the hypothalamus were stimulated by electric current through bipolar electrodes. The efferent innervation connections in whose terminal plexuses there occurred absorption of catecholamines were shown histochemically and neurohistologically to be involved in the pathological process. Reactive and degenerative changes were found to take place in receptory nerve terminations, and first of all in free ones. Then the bodies of pseudounipolar neurons of spinal ganglia were changed. Changes were also found in the connections of sensory neurons with the cells of Goll's and Burdach's nuclei.


Hemiplegic amyotrophy. Muscle and motor point biopsy study. Thirty hemiplegic patients had simple muscle atrophy with reduced mean muscle cross sectional areas (predominantly type II fiber atrophy) and complex, multiple, or enlarged subneural apparatuses, many of which resembled subhuman endplates. Ultrastructural observations in a few patients revealed nonspecific responses of damage to sarcolemma and myofibrils. There was no correlation between structural changes and alteration of tone, sensory impairment, or site of lesion. We propose that hemiplegic amyotrophy results from a combination of disuse, loss of central "trophic" influence, and transsynaptic degeneration.


Hypomyelination in copper-deficient rats. Prenatal and postnatal copper replacement. Copper deficiency induced by a low copper diet in three generations of rats was associated with substantial reductions in the yield of myelin (56%), brain weight (11%), and body weight (43%) in F2 generation rat pups nursed by their own copper-deficient mothers. The composition of the purified myelin was not different from that of controls in the content of individual proteins, lipids, 2',3'-cyclic nucleotide 3'-phosphohydrolase (CNP) activity, or GM1 ganglioside. The major myelin-associated glycoprotein (mGP) was consistently shifted slightly toward higher apparent molecular weight in the copper-deficient animals. Postnatal copper replacement by a foster mother produced a normal yield of myelin per gram of brain tissue, but failed to reverse the deficiency of brain and body growth. After copper replacement in a copper-deficient mother's diet prior to conception, a subsequent litter showed correction of all abnormalities found in her previous litters. The results suggest that copper is essential for myelin formation and general growth during critical periods in development.


Modification of the actions of some neuroactive drugs by growth hormone. The flat serum growth hormone (GH) patterns of untreated parkinsonian patients develop diurnal rises during treatment with levodopa. This chronic exposure to excesses of GH might lead to the eventual emergence of the "on-off" phenomenon, which would indicate a need for animal experiments. Pretreatment of mice with GH increased (1) cerebral dopa and dopamine concentrations in levodopa-treated mice, (2) cerebral accumulation of injected tritiated apomorphine and tritiated thymidine, and (3) behavioral responses to levodopa, L-m-tyrosine, apomorphine hydrochloride, and oxotremorine.


Erythrocyte surface membrane alterations. Electrophoretic mobility measurements were made of red blood cells obtained from patients with Duchenne and myotonic muscular dystrophy, from dystrophic mice and chickens, and from corresponding controls. Alterations in the erythrocyte surface electrokinetic properties were found in dystrophic mice and chickens and in many, but not all, patients with muscular dystrophy. The results are consistent with the concept of muscular dystrophy as a systemic membrane disease not limited to muscle.


Reaction times in Parkinson disease.

Reaction times in Parkinson disease. Ten hypokinetic parkinsonian patients and ten age- and sex-matched controls were tested, using reaction times with and without a warning signal. The time difference between each was used as a measure of phasic arousal. Both groups' reaction times improved with a warning signal, but there were no differences in reaction-time reduction between the parkinsonian and control groups. These results suggest either that hypokinesia in parkinsonism is not caused by an arousal defect or it is caused by a defect in the "autoevoked" arousal system.


Disulfiram-induced encephalopathy.

Disulfiram-induced encephalopathy. Two patients with disulfiram-(Antabuse-)induced encephalopathy exhibited paranoid ideas, disorientation, impaired memory, ataxia, dysarthria, snout and grasp reflexes, and abnormal electroencephalograms. The first patient developed symptoms on two occasions, each time after disulfiram administration. The second patient experienced a generalized seizure followed by fulminant psychosis three weeks after starting disulfiram therapy. Spinal fluid examination in the latter patient revealed a low homovanillic acid (HVA) level. Since disulfiram inhibits dopamine oxidation, disulfiram-induced encephalopathy may be related to excess dopaminergic activity in the central nervous system.


The role of extracellular potassium in hippocampal epilepsy. It has been proposed that the notable capacity for epileptogenesis in the hippocampus may be related to potassium accumulation in extracellular spaces. To investigate this hypothesis more directly, we measured changes in extracellular potassium concentration ([K+]o) during focal hippocampal epilepsy using potassium-sensitive microelectrodes. Interictal and ictal electroencephalographic events were accompanied by increases in [K+]o that varied systematically with depth from the ependymal surface and lateral distance from the focus. Maximal [K+]o changes during interictal and ictal discharges occurred in the stratum pyramidale. Initiation of ictal activity did not correlate with a particular "threshold" [K+]o. Comparing these results with similar data from neocortex, we observed that interictal K+ responses in hippocampus lasted longer and had slower rise times, and that peak interictal and ictal [K+]o values were consistently lower. Increases in [K+]o cannot be the sole explanation for regional variations in seizure susceptibility, interictal-ictal transitions, or termination of ictal episodes.


Amelioration of brain damage after 12 minutes' cardiac arrest in dogs. To determine the efficacy of cerebral microcirculation promoting therapy in postischemic brain failure, 11 dogs awakening from methohexital sodium anesthesia were subjected to 12 minutes of reversible circulatory arrest by ventricular fibrillation. Physiological variables were controlled for six hours after resuscitation, and the dogs were observed for seven days. Six dogs without the special postresuscitative therapy did not awaken, and either died within 36 hours or remained comatose for seven days. In five dogs, a combination of the following measures was applied: (1) mean arterial pressure was raised to 150 to 180 mm Hg with norepinephrine for six hours; (2) heparinization; (3) rapid intra-aortic injection of dextran 40 (10 ml/kg body weight); and (4) normovelemic hemodilution with dextran 40 to a hematocrit reading of 25% to 30%. All five treated dogs awakened within 24 hours and appeared normal on the seventh day. Therapy enhanced constriction of pupils and normalization of the electroencephalogram (P less than .05). Postischemic neurological deficit is at least partially due to impaired reperfusion and can be ameliorated or prevented by blood flowing-promoting therapy.


Concurrence of iris aneurysms and cerebral hemorrhage in hypertensive rabbits. The development of miliary aneurysms of the iris is associated with the high risk of cerebral hemorrhage in rabbits with renal hypertension. The high-risk group of hypertensive rabbits in this series was characterized by the formation of iris aneurysms, and this group developed a striking proportion of hemorrhagic strokes (42.5%). In the low-risk group of hypertensive rabbits that did not develop aneurysms of the iris, only a low proportion of cerebral hemorrhages were found (11%). The development of iris aneurysms in rabbits was directly proportional to increments in level of blood pressure, and their rate of formation was very rapid. The formation of miliary aneurysms of the circular artery of the iris in hypertensive rabbits is likely related to the common embryologic origin and the morphologic similarity between perforating arteries of the brain and the principal arterial vessel of the iris.


Sequelae of carbon monoxide-induced hypoxia in the rat. Rats were exposed to carbon monoxide, and conduction velocity of ventral caudal nerve (VCN), visual cortical evoked potential (VEP), electroencephalogram, and vital functions were determined in relation to the degree of CO-induced hypoxia. The conduction velocity of VCN and VEP (latency of P2 [second positive deflection of the visual evoked response]) were unaffected until carboxyhemoglobin (COHb) levels reached between 60% and 70%. These levels were maintained for approximately one hour before decreased conduction velocity or increased latency of P2 occurred. Decrease in mean arterial blood pressure resulted in impaired neurological function. Recovery of conduction velocity was discontinuous. Conduction was lost and recovered again within a three-hour period after exposure. It decreased again 9 to 13 days later, recovering in approximately four days. Data on P2 latency after exposure were fragmentary, but suggest that later increases might occur. Similar effects of CO-induced hypoxia on peripheral and central nervous systems were found. Decrease of mean arterial blood pressure was consistently associated with impaired nervous system function.


Carbon monoxide-induced neuropathy in the rat. Ultrastructural changes. The peroneal and ventral caudal nerves of rats exposed to 2,500 ppm CO until loss of nerve conduction occurred were studied by electron microscopy. Loss of normal axonal and Schwann cell structure was seen at the node of Ranvier. This loss was more prominent in large myelinated fibers, but was also seen in small myelinated fibers at seven and ten days postexposure. At this time, ventral caudal nerve conduction velocity decreased following a transient period of recovery lasting 9 to 13 days. Repair of the node began at 14 to 21 days postexposure, when maximal nerve conduction velocity had returned to normal. Complete normalization of node structure was not seen even 60 days after exposure, in many instances.


Painful diabetic neuropathy. A morphometric study. We investigated three diabetic patients whose neuropathy was characterized by pain, hypesthesia, and autonomic dysfunction, with preservation of epicritic sensation and muscle-stretch reflexes. Two sural nerves were studied qualitatively and quantitatively, using teased fiber, light, and electron microscopical techniques. The most striking alterations were encountered in unmyelinated and small myelinated fibers. Unmyelinated nerve fiber sprouting was evident. The clinical features, which suggested small-fiber involvement, correlated with the pathological findings in biopsied cutaneous nerve. The balance of evidence indicates that the painful small-fiber neuropathy of diabetes is an axonal disorder.


Pathophysiologic aspects of human botulism. Physiologic studies were carried out in six patients with botulism. Abnormalities were those of a defect of acetylcholine release. Although the most consistent findings were small, evoked muscle action potentials (MAP) and posttetanic facilitation similar to the Eaton-Lambert syndrome, there were differences. In botulism as opposed to the Eaton-Lambert syndrome, the following were true: (1) posttetanic facilitation of the amplitude of the evoked MAP was considerably less and did not approach the normal value when the block was severe; (2) posttetanic facilitation persisted at least several minutes during the postactivation cycle; (3) posttetanic depression did not occur; (4) significant tetanic facilitation of the amplitude of the MAP occurred in less than half the patients and, even then, did not approach normal (on the other hand, a decremental response, as in myasthenia gravis, is not seen); and (5) no decremental response of the MAP occurred during slow rates (two per second) of nerve stimulation. Evidence of transient physiologic denervation occurred as in experimental animals affected by botulinum toxin. All physiologic abnormalities revert to normal in association with clinical recovery.


Desmosterol in human and experimental brain tumors in tissue culture. Desmosterol, a possible chemical indicator of brain tumors, was detected in cells of neurogenic, nitrosourea-induced rat tumors (neurinomas and gliomas, C6 cell line) and in human astrocytomas grown in lipid-poor media. A further increase in the amount of cell desmosterol was obtained when triparanol was added to media containing delipidized serum. Cholesterol was replaced almost completely by desmosterol in tumor cells grown in media containing nontoxic levels of 20,25-diazacholesterol. Desmosterol did not accumulate when these inhibitors of desmosterol-reductase were added to culture media containing cholesterol and other lipids (whole fetal calf serum). The results demonstrate that tumors of the nervous system grown in tissue culture are capable of sterol synthesis, and indicate that a central mechanism of cholesterol synthesis is operative in these cells, which may be related to the availability of exogenous cholesterol. It is concluded that these findings are relevant to clinical studies on the use of cholesterol inhibitors as tools for the detection of brain tumor activity.


Experimental allergic encephalomyelitis. Passive transfer by the intraocular injection of sensitized cells. Experimental allergic encephalomyelitis is a disease of cell-mediated immunity and can be transferred passively to virgin recipients by lymphoid cells from sensitized donors. The rabbit eye contains myelinated medullary rays that can be visualized ophthalmoscopically. Intraocular injection of autologous lymph node cells from myelin basic protein (BP)-immunized rabbits into the vitreous leads to readily visualized optic neuritis while injection of cells from adjuvant immunized control rabbits does not. Microscopical study confirmed the presence of myelin destruction in recipients of cells from BP-sensitized donors. This eye chamber technique provides a simple model for the study of demyelination in vivo under direct observation.


Infantile diffuse cerebral degeneration with hepatic cirrhosis. Four children had progressive degeneration of the cerebral cortex, with hepatic cirrhosis. They and four previously described ones, are representative of a distinct form of hepatocerebral degeneration. Onset of the neurological disorder is between ages 1 and 3 years, at times with mild developmental delay. Explosive onset of intractable convulsions, leaving the child in a stuporous and demented state, is characteristic. Generalized hypotonia or hemiparesis were observed in several affected children. Clinical evidences of hepatic disease, including ascites and jaundice, occurred late, if at all. The illness ended fatally within ten months of onset of convulsions. Pathological findings in the brain are neuronal loss and gliosis, in a pattern that is indistinguishable from that in degeneration of the cerebral gray matter in infancy (Alpers disease). The hepatic lesions consist of cirrhosis or of subacute hepatitis, with superimposed fatty infiltration of hepatocytes. The disorder is genetically determined, with recessive inheritance.


Delayed encephalopathy after strangling. An 11-year-old boy who had been the victim of a strangling attempt was asymptomatic for one week whereupon involuntary movements involving the trunk and limbs developed, along with repetitive episodes of opisthotonos and autonomic dysfunction. Meanwhile, he remained alert and appeared to be mentally intact. An electroencephalogram was normal. He died 13 weeks after the onset of the neurological disorder. The neuropathological examination showed cavitating lesions in the caudate nucleus, putamen, and globus pallidus bilaterally, with sparing of the white matter. The delayed onset of a progressively evolving neurological disorder has been noted in various forms of hypoxicischemic insult, including previously reported cases of strangling, but its occurrence cannot be predicted from the preceding clinical state or course. In the cases in which abnormal movements have been predominant, the pathological findings have been similar despite diversity in the preceding circumstances. We suggest the underlying metabolic disorder common to these cases may be lactic acidosis, and that they should be studied for evidence of a biochemical defect.


Electroencephalographic findings in phencyclidine intoxication. The first report of electroencephalographic findings in clinically encountered phencyclidine intoxication is presented. When first seen, the patient was in a coma, initially distinguished only by nystagmus, waxy rigidity of the extremities, and an EEG with a widespread, sinusoidal theta rhythm interrupted every few seconds by periodic slow-wave complexes. The similarity of the EEG to that of deep ketamine anesthesia suggested intoxication with a ketamine-related (phenylcyclohexylamine) drug. Phencyclidine, the prototype of the phenylcyclohexylamine compounds and a widely abused hallucinogen, was subsequently identified in the urine and blood.


Urinary excretion of carnitine in Duchenne muscular dystrophy. The urinary excretion of carnitine by boys with Duchenne dystrophy did not differ significantly from age-matched controls. Since serum and muscle concentrations of carnitine are also normal in Duchenne dystrophy, it cannot be proved that this small molecule leaks from muscle in Duchenne dystrophy. If the muscle surface membrane is abnormally leaky in Duchenne dystrophy, different molecules seem to be affected in different ways.


Computerized axial tomography of intracerebral hematoma. A clinical and neuropathological study. Excellent correlation between computerized axial tomographic (CT) scans and the location and extent of pathologically verified intracerebral hematomas was demonstrated in eight patients. Superficial and intraventricular extension, hydrocephalus, and mass effect were easily identified; CT scanning was superior to angiography and radionuclide brain scanning in diagnosing hematoma and in determining its extent and associated ventricular size. Angiography was superior to CT scanning in demonstrating aneurysms and arteriovenous malformations as a cause of intracerebral hematoma. Computerized axial tomographic scanning is also useful in following the resolution of hematomas and in guiding surgical intervention.


Presumed ocular histoplasmosis syndrome. The fellow eye. The fundus photographs of 308 patients with presumed ocular histoplasmosis syndrome (POHS) were examined. Bilateral macular involvement was found in 20% of the cases. The incidence of maculopathy, peripapillary lesions, and peripheral "punched-out" lesions in one fundus and only peeipapillary changes in the fellow eye was 12%. The incidence of these features in one fundus and clinically inactive, atrophic scars in the posterior pole of the fellow eye was 23%. Twenty-five patients with atrophic lesions in the macular area of the fellow eye were followed for an average of 24 months. Six patients (24%) demonstrated activation of eight previously documented atrophic lesions resulting in macular involvement. One patient also demonstrated activation from a pre-existing juxtapapillary lesion. None of the remaining 18 patients exhibited any evidence of serous or hemorrhagic retinal sequelae in the fellow eye.


Contusion angle deformity in prizefighters. Ophthalmic examinations of 55 retired boxers showed nine eyes with contusion angle deformities and no cases of secondary glaucoma due to the trauma, despite an average duration of 33 years since injury. The subjects with chamber angle recessions had more proptotic eyes (average, 19.7 mm) than those without recessions (average, 17.9 mm). The difference between the means was not significant (P less than .05).


The electro-oculogram in diffuse (familial) drusen. Twelve patients with diffuse drusen of Bruch membrane had their condition evaluated by electro-oculography (EOG). All had normal EOG light-peak/dark-trough ratios, which suggests that the disease does not involve a diffuse functional abnormality of the retinal pigment epithelium. This finding is in contrast to the abnormal EOG ratios reported in patients with fundus flavimaculatus. Categorizing these two diseases along with fundus albipunctatus as flecked retina syndrome should be continued on the basis of the somewhat similar morphologic appearance of the lesions, rather than because of similar results on functional testing.


Visually evoked response. Use in neurologic evaluation of posttraumatic subjective visual complaints. Evaluation of subjective visual complaints unassociated with objective signs is a frequent problem in neurologic and ophthalmic practice. The visually evoked response (VER) is an important tool for separating the functional from the organic in patients claiming visual disturbance. In visual complaints associated with late posttraumatic epileptic activity, the VER can demonstrate an abnormality even in asymptomatic intervals. In complaints due to concussion, it demonstrates disorganized evoked responses initially and later a return of the normal resonse. It shows an abnormality in the occipital lobes during and after transient compression of the vertebral artery. A normal VER excludes all but trivial involvement of the visual system, symptomatic claims of the patient notwithstanding.


Sarcoidosis of the paranasal sinuses with orbital extension. A 21-year-old black man with unilateral proptosis and decreased visual acuity was shown to have sarcoidosis of the paranasal sinuses with secondary invasion of the orbit, as demonstrated by contact B-scan ultrasonography, sinus tomography, surgical exploration, and biopsy.


Ocular toxoplasmosis in an adult receiving long-term corticosteroid therapy. Sudden death of a 58-year-old woman who developed ocular toxoplasmosis while receiving long-term systemic corticosteroid therapy permitted correlation of early histopathologic lesions with their clinical counterpart recorded on fundus photographs. A wide-spread, paravascular, whitish, retinal opacification dominated the initial clinical picture. These lesions were represented histologically by focal zones of inner retinal necrosis located adjacent to arteries and veins. No associated inflammatory cell infiltrate was present, and numerous viable free Toxoplasma organisms were consistently present at the interface between necrotic and healthy retina. Electron microscopy of formaldehyde-fixed tissue provided a useful technique for confirming the identity of the infecting organism in the absence of serologic or culture data.


The effect of rectus muscle union.

The effect of rectus muscle union. It is shown that the rectus muscle union of Jensen allows the lateral half of the superior rectus and the lateral half of the inferior rectus to provide active abduction.


Aphakic bullous keratopathy treated with prosthokeratoplasty. An analysis of 34 consecutive cases. Thirty-four eyes with advanced aphakic bullous keratopathy were treated with the Cardona keratoprosthesis as a primary procedure. There were three extrusions (9%), two of which were associated with infections; two other conditions were worsened (6%) as a result of a late permanent vitreous hemorrhage or possibly an infection. Twenty-eight eyes (82%) showed a notable improvement during follow-up periods that ranged from 6 to 72 months. The advantages and limitations of this technique are compared to those of penetrating keratoplasty.


Repair of nasocanthal malignant neoplasms. Combined laissez-faire and chemosurgery techniques. A simplified method for management of nasocanthal malignant neoplasms combines the laissez-fiare technique first reported by this author with the Mohs technique of microscopic control of cancer cell eradication. Basically, with a little surgical help, the wound is allowed to granulate in spontaneously.


A teaching pointer for indirect ophthalmoscopy. A simple teaching pointer has been devised for use with the indirect ophthalmoscope. A bristle is attached to a thimble that is placed on the thumb of the hand not holding the indirect lens. It can be used with or without scleral depression to define specific retinal lesions.


De novo subretinal neovascularization in the histoplasmosis syndrome. A 22-year-old man was seen with the ocular histoplasmosis syndrome. This case demonstrates that spontaneous or "de novo" neovascularization without prior pigmentary changes can occasionally, although rarely, give rise to the disciform macular disease process and the potential for loss of central vision. The lesion initially responded favorably to treatment with heavy argon laser photocoagulation in the parafoveal area, including the papillomacular area, but subsequent areas of neovascularization proved intractable to laser therapy.


Human whole-nerve response to clicks of various frequency. The averaged VIIIth nerve response to third-octave clicks at 500, 2000 and 8000 Hz was recorded from the promontory of 4 normal-hearing young adults. As click frequency is lowered, the N, latency increases in a manner consistent with the changes in velocity of the cochlear traveling wave. This finding suggests that clicks of different spectral content stimulate different regions of the basilar membrane. N amplitude shows a general increase with frequency; this observation appears related to the increased synchrony of neural firing that results from the higher velocity of the traveling wave in the more basal portions of the cochlea.


Early tone-evoked responses in normal and hearing-impaired subjects. Early evoked responses to 500-Hz tone bursts were recorded from normal and hearing-impaired children and adults. The threshold values of the early evoked responses provide useful estimates of auditory functioning, even among difficult-to-test populations, such as deaf-blind children. Latency measures indicate that the early response is generated at the brain stem. Latency measures from hearing-impaired subjects show that the response can identify recruitment. Several subjects having a history of nonspecific communication disorders, e.g., dyslexia, exhibited aberrant early evoked response waveforms. The early-evoked response measures, therefore, amy be useful in detecting and assessing communication disorders which are believed to be of cortical origin, but now should be considered to have a basis in brain stem dysfunction.


Tympanomety from 200 to 2000 Hz probe tone. Previous investigations have shown that the probe tone frequency is the main factor in determing the shape of the tympanogram. These had, however, been limited up to 800 Hz. In the present paper, a multifrequency investigation (from 200 to 2000 Hz) has been performed on 72 ears with different pathophysiological conditions of the middle ear. From the analysis of the result some new critical aspects of tympanometry emerge. The multifrequency tympanometric investigation proves to be, according to our experience, a far more sensitive method for checking small changes in the transmission characteristics of the tympano-ossicular system than the monofrequency traditional analysis. In this connection, the technique seems to furnish a simple and reliable method for discriminating between stiffness versus mass-controlled systems.


Electrophysiological studies of the auditory system. Electrophysiological measures of cochlear function can be obtained using the techniques of transtympanic electrode and surface electrocochleography. These provide measures of the basic parameters of the cochlear microphonic, cochlear nerve and auditory brainstem nuclei action potentials, which enable the functional mechanisms of the cochlea and auditory pathway to be defined for normally hearing subjects and, by comparison, give diagnostic information about the pathologies involved in auditory disorders. Data are presented on the values and variability of the responses obtained from normally hearing subjects. The comparative values of each technique in estimating auditory threshold, cochlear function and in evaluating neurological conditions are discussed using data from clinical patients.


Two-component versus admittance tympanometry. The probe tone frequency of electro-acoustic bridges has a direct effect on the shape of the tympanograms obtained. At higher frequencies (800 Hz) typical patterns are generated for eardrum abnormalities and ossicular discontinuities. The 625- and 660-Hz frequencies sometimes prove to be not quite high enough to obtain the expected 'W' or undulating admittance tympanograms. Our investigation proves that much more certainty is given even at 660-Hz probe tone when components B and G are both recorded. The same information for ossicular disruption is found in an admittance (Y) together with a new kind of tympanogram, namely the phase tympanogram.


Evoked cerebral potential audiometry and hearing threshold. Audiometric testing by means of the nonspecific evoked cerebral potential (NECP) was performed in 20 children (11 with normal hearing, 6 with conductive and 3 with sensorineural hearing loss). The threshold as determined by this method was 20-30 dB higher than the threshold of the subjective tonal audiograms in the majority of the cases. Only in two cases the difference was up to 70 dB. There were no significant differences between the results of the methods in the three groups of children. The possible reasons for the described discrepancy between the thresholds of the ECP audiometry and the subjective tonal audiometry are discussed. It is pointed out that either of the two methods explores one of two different functional systems: the nonspecific activating system of the brain stem and the auditory pathway. It is suggested that the observed discrepancy between the results of the two methods may mainly be due to different thresholds of the two systems. To avoid false negative results of the ECP audiometry in subjects with 'constitutionally' low amplitude of the NECP it is proposed to routinely determine the amplitude of the NECP produced by somatosensory stimuli. Careful evaluation of the recorded data can improve the diagnostic value of ECP audiometry.


Influence of test tone duration on auditory masking patterns. Temporal integration functions of tone bursts masked by critical band noises become shallower with increasing test tone frequency. This holds for tone bursts in the centre as well as at the slopes of the masking pattern of critical band maskers. When shortening the tone bursts, the horizontal masking pattern of uniform masking noise changes into a pattern with decreasing slope for increasing frequency. The shape of the masking pattern of critical band  maskers remains rather independent of test tone duration.


Directional hearing, temporal order and auditory pattern in peripheral and brain stem lesions. Tests have been applied to the following subjects: (1) 25 normal individuals; (2) the same individuals during temporary impairement of the brain stem by barbiturate (3 mg/kg); (3) 32 patients affected by acute nucleo-reticular vestibular syndrome; (4) 7 patients affected by unilateral Menière's disease, and (5) 1 patient affected by acoustic neuroma with well preserved hearing. Directional hearing was tested by changing the delta i and delta t of two pure tones 400 and 600 Hz) presented through earphones or two fixed loudspeakers placed at +/- 30 degrees from the azimuth and with balanced intensity: temporal order and auditory patterns were tested with the same frequencies by changing the delta t or the order of presentation of the stimuli at fixed intensity. On the basis of the results obtained in the normal subjects, a distinction can be made between the patients affected by brain stem impairment and those affected by Menière's disease. In these patients it was very difficult to obtain reliable discriminations due to the failure of the affected cochlea, especially during an acute phase of the disease, to perform adequate time, intensity and frequency analysis. In brain stem patients, spontaneous or pharmacological, the directional hearing judgments were impaired whereas temporal order and auditory pattern discrimination were normal. It is suggested, therefore, that these various central-hearing tests do not investigate analogous performances, but on the contrary different ones. This difference can be attributed to different structures, or to different performance along the same pathways but also to an identical structure of different sensitivity to the noxious agents.


Possibilities of improving the diagnosis of noise-induced hearing damage by means of directional audiometry, the dichotic speech discrimination test, and the EEG1. Several audiometric tests were made of 85 noise workers exposed to an intensive impulse noise during pressing and punching. These tests aimed at finding out noise-induced central hearing damages (directional audiometry, dichotic speech discrimination test according to Feldmann and checking of the induction of the impedance jump). In addition, a clinical EEG was taken from each subject. Having obtained the necessary norms with series of tests in subjects with normal hearing abilities for their respective ages, the following results have been obtained: (1) directional hearing has hardly been affected by noise-induced hearing damage. It behaves like age changes in the group compared with it; (2) the dichotic speech discrimination test shows increasingly pathological values with progressive noise-induced hearing damage; this was already obvious in the age group 41-50. The impedance jump is less and less produced with progressive noise-induced hearing damage and finally disappears at a noise intensity of up to 110 dB. Because of these findings a progressive degeneration of the spiral ganglion and hearing  nerve in noise-induced hearing damage is discussed as a cause of a deteriorated speech discrimination and the absence of the impedance jump. The EEG findings show changes in the alpha-rhythm in about 50% of the cases at an exposure time of 10 years onwards which may be possibly due to damage to the reticular formation, once increasing noise-induced hearing damage no longer exists.


[Auditory-evoked responses to a monaural or a binaural click, recorded from the vertex, as in two temporal derivations; effect of interaural time differences (author's transl)]. The auditory-evoked responses have been recorded on 5 subject by vertex, right temporal and left temporal electrodes simultaneously. 30 dB sensation level clicks were used as stimuli; one click was presented only to the right ear, or one click only to the left ear, or one click to the right ear and another click to the left ear with a variable interaural time difference in this latter case (0-150 ms). The N-P amplitude variations and the N and P latency variations have been studied and compared to those observed in the perceived lateralizations of the sound source.


Binaural and monaural speech discrimination under reverberation. This study investigated the effects of reverberation upon the speech discrimination performance of 30 normally hearing subjects and 30 persons with bilateral sensorineural hearing loss. Following preliminary tests, the Modified Rhyme Test was administered monaurally and binaurally at reverberation times of 0, 1, 2 and 3 sec. All stimuli were administered under earphones. The lists and conditions were appropriately randomized and counterbalanced so that each subject heard a test list at each reverberation time (RT) monaurally and binaurally. The expected gain due to binaural summation of loudness was simulated in order to test the possibility that any binaural enhancement of intelligibility might be due to binaural loudness summation. For all conditions, the normally hearing subjects performed significantly better than the hearing-impaired group. However, in relative terms, the two groups were remarkably similar. Binaural scores were significantly higher than monaural scores at each RT for both groups (in spite of homophasic conditions). For both groups, monaural and binaural scores decreased with increasing RT. Monaural scores decreased at a significantly faster rate with RT than did the binaural scores (the binaural advantage, however, was larger for the normal group). Increasing the monaural presentation levels to simulate the binaural loudness gain did not result in higher scores. It was concluded that speech discrimination under reverberation is better binaurally than monaurally for both normally hearing and hearing-impaired persons. This is due, at least partly, to the ability of the binaural auditory system to squelch the effects of reverberation. A tentative model is suggested for the binaural squelch of reverberation. The current findings are compared with existing data; and suggestions are offered for clinical application.


Hearing aid fitting by prescription.

Hearing aid fitting by prescription. A procedure for the specification of hearing aid response characteristics is described. Thresholds of discomfort and most comfortable levels for narrow bands of noise centered at 0.25, 0.5, 1, 2, 3 and 4 kHz are determined. The thresholds of discomfort relate to the maximum power output of the hearing aid and the most comfortable levels determine the gain and frequency response that will be required. The data derived from these measurements are given to the hearing aid dispenser who provides a hearing aid that matches the prescribed response characteristics. This technique requires less time than the conventional hearing aid evaluation procedure, and it provides the audiologist with measures of auditory function that can be directly related to hearing aid parameters.


Studies in infant behavioural audiometry. I. Neonates. The behaviour of 93 clinically normal neonates was video-recorded while they were presented with sequences of sound stimuli which varied in sound pressure level, bandwidth and rise time and which included two voice signals and a no-sound (control) trial. Video records were made both for the whole body aspect and for a 3 1/2 X "close-up" of the head. Later, the video records were shown to 6 observers who were allowed to see the babies for 10 sec at each trial. The first 5 sec was a pre-stimulus observation period, and the second 5 sec usually contained a sound stimulus. Between the trials, the observers were given 20 sec in which to record (1) pre-stimulus activity, (2) confidence in response, and (3) movement details (data for (3) not reported here). For the whole-body aspect, observers were allowed to see (1) the whole body, (2) the head, arms and trunk, (3) the arms, trunk and legs, (4) the head only, (5) the arms and trunk only, or (6) the legs only, during different viewing sessions. For the head aspect, they could see (7) the whole head, (8) the head above the upper lip, or (9) the head below the upper lip. This segmentation was achieved by masking parts of the television screen with shutters. The response confidence ratings were analysed using aspects of signal detection theory to show differences amongst various body segments (p less than 0.001), sound pressure levels (p less than 0.001), bandwidths (p less than 0.001), and rise times (p less than 0.01). There were significant interactions between sound pressure level X bandwidth (p less than 0.001), sound pressure level X rise time (p less than 0.01), and bandwidth X rise time (p less than 0.001). A 90-dB broad-spectrum noiseband was by far the most effective stimulus. The response to different sound stimuli was differentially affected by pre-stimulus activity state. The results are discussed in relation to recent work on clinical screening techniques.


Intracardial bubbles during decompression to altitude in relation to decompression sickness in man. Doppler ultrasound was used in five subjects to detect intracardial gas bubbles during decompressions to altitude. At a simulated altitude of 8,000 m, neither intracardial bubbles nor symptoms of decompression sickness occurred. At 9,000 m, bubbles were registered in two subjects, one of which had questionable bends. At 11,500 m, bubbles were registered in all but one subject and two had bends. The three subjects who had not gotten bends were exposed to an air-breathing period of 30 min or, in one case, even 45 min at 2 ATA, for extra nitrogen loading, followed by decompression to 11,500 m. These subjects had heavy showers of bubbles followed by bends. In all cases with decompression sickness during the decompressions to altitude, intracardial bubbles were registered prior to the appearance of symptoms. The technique may be used in studies of decompression sickness without provoking actual symptoms, thus making the studies safer.


Effect of physical activity of airline flight attendants on their time of useful consciousness in a rapid decompression. To determine the effect of physical activity on the "time of useful consciousness" (TUC) of airline flight attendants in a rapid, severe decompression, 10 male and 10 female subjects were exposed to a decompression profile while at rest and performing light-to-moderate work. Decompression from 6,500 to 34,000 ft (2,000 to 10,400 m) was followed by descent at 5,000 ft/min (1,500 m/min). The average TUC for the males decreased from 54 s (omega 7.1) at rest to 34 s (omega 4.4) while performing work. The average TUC for the females decreased from 54 s (omega 8.1) at rest to 32 s (omega 4.0) while performing work. Supplemental oxygen had a marked paradoxical effect when the subjects were performing work.


Simulated flying performance after marihuana intoxication. Ten pilots smoked, in counterbalanced order on a double blind basis, a social dose of marihuana (.09 mg/kg delta-9-tetrahydrocannabinol) and a matched placebo after being trained to fly a specific flight sequence on an ATC-510 flight simulator. In contrast to placebo, marihuana caused a gross decrement in flying performance, with increased prevalence of major errors, minor errors, altitude deviations, heading deviations, and radio navigation errors. These effects of active marihuana persisted for at least 2 hr and generally had disappeared by 4 to 6 hr after marihuana administration.


Circulatory response to acute hypobaric hypoxia in conscious dogs. Hemodynamics were studied in seven conscious dogs during acute hypobaric stress at 14,000 ft simulated altitude. Silastic catheters were chronically implanted in the pulmonary artery, left atrium, and aorta. Pulmonary and central aortic pressures, cardiac output, and pulmonary blood volume were determined under conditions of normoxia and acute hypoxia in a hypobaric chamber maintained at 446 mm Hg pressure (14,000 ft). Altitude resulted in significant increases in heart rate, cardiac output, pulmonary blood volume, and pulmonary artery pressure. Left atrial pressure and calculated systemic vascular resistance decreased during hypobaric hypoxia while stroke volume, stroke work index, arterial pressure and pulmonary vascular resistance remained unchanged. Arterial blood PO2 decreased markedly at altitude, and all animals hyperventilated with resultant systemic hypocarbic alkalosis. The combination of elevated pulmonary arterial pressure and increased pulmonary blood volume may by an etiologic factor in the development of high-altitude pulmonary edema.


Alpha index and personality traits of pilots. This investigation was instituted to provide information regarding the relationship between individuals with radically different alpha indices (low vs. high) and personality traits of the subjects. EEG recordings were obtained and acceptable diagnostic personality testing techniques administered. The results indicate that the group with low alpha index revealed a significantly higher level of anxiety and neuroticism.


Some behavioral effects of pesticides: The interaction of mevinphos and atropine in pigeons. The interaction of the organophosphate mevinphos and atropine was examined in two pigeons performing in a variable interval schedule of reinforcement. When administered separately, both atropine and mevinphos produced a dose-related decrement in responding. The combined exposure to these drugs produced a performance decrement greater than that caused by exposure to each component drug alone. These findings suggest that prophylactic use of atropine may increase the detrimental behavioral effects of organophosphate exposure and that the atropine exposure alone may produce serious behavioral deficits.


Effect of a reduction in arterial oxygen content (carbon monoxide) on coronary flow. Mongrel dogs were chronically instrumented for ventricular pacing, to measure left circumflex coronary flow (CF), left ventricular and arterial pressure, and to obtain blood samples from the left atrium and coronary sinus. Following a 3- to 4-week recovery period, the animals were subjected to a 30% reduction in arterial oxygen saturation by exposure to low levels of carbon monoxide. Three types of experiments were performed: 1) control, 2) pacing at 150 bpm, and 3) double blockade with propranolol and atropine. Reduction in arterial oxygen saturation in the three conditions studied resulted in a significant increase in CF and no change in myocardial oxygen consumption. The relationship between CF and arterial saturation demonstrated that double blockade produced a difference in the magnitude of the CF response. These results indicate a neurogenic mechanism to regulate coronary flow that may aid in maintaining oxygen availability during stressful conditions.


Effect of dietary "antioxidant" supplementation on the susceptibility to oxygen toxicity in mice. This study was undertaken to test chronic feeding of some normal dietary constituents on susceptibility to oxygen toxicity. Eight-week-old male CD-1 mice were fed a semi-purified diet simulating that of the average American male and supplemented with either vitamin E, vitamin K3, selenium, or the sulfur amino acids methionine and cystine. After 2, 4, 8, or 16 weeks, groups of mice were exposed to oxygen at 1, 4, or 8 ATA and times to respiratory distress, convulsion, and death recorded. Vitamin E and amino acid supplementation had no effect whereas vitamin K and selenium supplements increased time to death at 1 ATA. Only the effect of selenium was statistically significant. All diets significantly increased the time of onset of the measured parameters beginning after 4 weeks, suggesting that one or more constituents of the basal diet afforded some protection against oxygen toxicity.


Changes in blood constituents in rats administered morphine and subjected to He-O2 at 11 ATA. Changes in blood constituents in rats exposed to He-O2 at 1 ATA and 11 ATA after administration of morphine (100 mg/kg) are reported. Injected animals are compared with controls (non-injected) in ambient air and animals subjected to He-O2 at 1 ATA and 11 ATA. Temperature of the chamber was controlled and O2 partial pressure and CO2 levels were maintained at standard conditions. After morphine injection the rats were pressurized and maintained for 4 h before decompression, at which time additional blood samples were obtained. Morphine-injected animals in ambient air showed significant decreases in hematocrit, MCV, glucose, and protein in the blood while showing an increase in the leukocyte count and blood potassium. Non-injected animals maintained in He-O2 at 1 ATA and 11 ATA showed no deviation from ambient air control animals. Injected animals in He-O2 at 1 ATA showed no changes from those in ambient air, but animals injected and exposed to 11 ATA did not have a decreased serum protein level or an increase in potassium.


Evaluating the ability of aircrew personnel to hear speech in their operational environments. High-quality tape recordings were constructed of single, double, and triple word test items from the six monosyllabic work lists of the Modified Rhyme Test (MRT), a multiple-choice intelligibility test. The test workd were incorporated in a carrier phrase somewhat analogous to typical aircraft radio messages. The recorded lists were mixed with shaped noise and played back to a group of listeners at three speech-to-noise ratios. The regular closed-response format of the MRT was utilized for all three types of test items. There was little difference in overall listener performance for the single, double, and triple word test items. Because of their more representative message length and decreased testing time, the triple word test items will be utilized in subsequent data-gathering studies directed toward the development of an efficient reliable test for assessing the ability of aircrew personnel to hear speech in their operational environments.


Effects of acute heat stress on tissue carbohydrate in fasted rats. Exposure of starved female rats to 45 degrees C db, 26 degrees C wb for 0.25-2 h tended to lower blood glucose levels, and increase blood lactate levels, compared with controls at 24 degrees C db, 14 degrees C wb. There was a sustained liver glycogenolysis, but no detectable change in muscle glycogen level. Despite the severity of the stress, the effect of a high environmental temperature on carbohydrate metabolism cannot be satisfactorily interpreted in terms of increased adrenal medullary activity. It is suggested that increased respiratory muscle activity may explain the changes observed.


Pulmonary function evaluation during the Skylab and Apollo-Soyuz missions. Previous experience during Apollo postflight exercise testing indicated no major changes in pulmonary function. Pulmonary function has been studied in detail following exposure to hypoxic and hyperoxic normal gravity environments, but no previous study has reported on men exposed to an environment that was both normoxic at 258 torr total pressure and at null gravity as encountered in Skylab. Forced vital capacity (FVC) was measured during the preflight and postflight periods of the Skylab 2 mission. Inflight measurements of vital capacity (VC) were obtained during the last 2 weeks of the second manned mission (Skylab 3). More detailed pulmonary function screening was accomplished during the Skylab 4 mission. The primary measurements made during Skylab 4 testing included residual volume determination (RV), closing volume (CV), VC, FVC and its derivatives. In addition, VC was measured in flight at regular intervals during the Skylab 4 mission. Vital capacity was decreased slightly (-10%) in flight in all Skylab 4 crewmen. No major preflight-to-postflight changes were observed. The Apollo-Soyuz Test Project (ASTP) crewmen were studied using equipment and procedures similar to those employed during Skylab 4. Postflight evaluation of the ASTP crewmen was complicated by their inadvertent exposure to nitrogen tetroxide gas fumes upon reentry.


Associations between psychological factors and pulmonary toxicity during intermittent oxygen breathing at 2 ATA. Associations between the psychological and pulmonary effects of breathing intermittent oxygen at 2 ATA were examined among four experienced divers. A fifth diver, who served as a control, breathed only normoxic nitrogen. Psychological tests included digit span, short-term memory for easy and difficult word associations, simple and complex psychomotor performance, and reported moods. The criterion of oxygen toxicity was the total hours of intermittent oxygen exposure tolerated before developing a 10% reduction in vital capacity. Short-term memory for difficult word associations and self-reported moods of Activity, Depression, Fatigue, and Happiness were found to be significantly correlated with this criterion of oxygen toxicity. Part of the impairment found on these measures, however, was probably related to the absence of adequate sleep and rest as evidenced by the worsened performance of the control diver over the 15-h testing period. The results replicated the findings of earlier research on the psychological effects of continuous oxygen breathing under hyperbaric conditions and at 1 ATA, and may indicate that oxygen intesifies the effects of other stressors such as fatigue. In addition, the results showed that reported moods may be important indicators of impending pulmonary toxicity during intermittent oxygen exposure.


Cross-validation study of the personality aspects of involvement in pilot-error accidents. Pilot-error accidents have dominated accident statistics consistently from the 1940s to the present. Sanders and Hofmann (3) found that three factors from Cattell's Sixteen Personality Factor Questionnaire (16 PF) significant differences (p less than 0.05) between pilot-error accident groups and were used to correctly classify 86% of the aviators tested as to their previous pilot-error accident involvement. There were 66 aviators given the 16 PF in the present study in an attempt to cross-validate the findings reported in the original study. The results indicate that the personality factors did not significantly discriminate between the pilot-error accident groups. The primary personality differences between the present sample and the original sample were due to variations in the pilot-error accident-free groups. The findings indicate that individual differences in personality characterstics of the aviators prevent consistent identification of traits associated with pilot-error groups.


Preemployment and periodic physical examination of airline pilots at the Mayo clinic, 1939-1974. A descriptive study of medical disqualifications and deaths in an airline pilot population revealed that, of 2,751 pilot applicants, 145 (5.3%) were rejected by the preemployment company medical examination. Of the 145, 117 were rejected because of a primary disqualifying "laboratory" abnormality. During the lifetime of the airline, 103 pilots have retired because of medical reasons, primarily cardiovascular, and 120 have died, the majority in aircraft accidents. The rate of medical disqualification is minimal before the age of 45 years, but it increases rapidly thereafter. By use of the actuarial survivorship method, it was determined that the chance of a pilot reaching retirement age in this airline company was less than 50%, although his chance of not reaching retirement age because of medical reasons was only 20%. Based on the results of this study, a departure from the "traditional" periodic company medical examination program is suggested.


Paroxysmal and chronic atrial fibrillation in airman certification. Of the 757,693 airmen with valid FAA medical certificates on Oct. 31, 1974, 125 (all males but one) had a history of paroxysmal atrial fibrillation. Episodes of paroxysmal atrial fibrillation occurred once in 91, twice in 14, and more than twice in 20 airmen, and were attributed to one or more of 23 factors in 72 of the medical records studied. Associated symptoms reported in 27 records were considered serious enough to produce pilot incapacitation. Chronic atrial fibrillation was idiopathic in all but one airman, who developed this arrhythmia following atrial septal defect repair. Medical records report no associated symptoms, and heart rates, resting and in response to exercise, were reported as within normal limits.


Care of patients after cardiac catheterization. In an effort to provide more definitive diagnosis for Air Force flyers referred to the USAF School of Aerospace Medicine, cardiac catherization has been performed, as indicated, on over 425 flyers since 1971. Since they are an apparently healthy and asymptomatic population, their recovery after cardiac catheterization is usually uneventful. However, the nurse must be able to recognize and interpret significant potential and/or existing post-catheterization complications. Nursing care of the patient after this procedure is essential to the successful completion of the test. Since any invasive procedure can lead to complications, quick and accurate nursing assessment and action are essential. The possible complications of cardiac catheterization which the nurse may encounter have been divided into possible causes, and a suggested plan of action. Reference tables are provided for each of the two main classifications, in an effort to provide quick guidance for the nurse responsible for care of the patients after catheterization.


On detection of the Staphylococcal enterotoxin A by aggregate-hemagglutination technique and electron-microscopic data on this toxin. Recently, great success has been attained in studies on agents responsible for food intoxication. The modern stage of research on food intoxication of bacterial etiology is qualitatively different from previous ones, since many investigators ignored the determination of food toxic agents and instituted direct investigation of biologically active substances produced by microorganisms which could cause food intoxications, i.e., enterotoxins. The data presented in this work concern the problem of Staphylococcus aureus enterotoxin, which was identified by Casman in 1960 (2). Our interest in enterotoxins of this kind originates from statistics on staphylococcal intoxication, since 49% of the latter is caused by St. aureus stamms, producing enterotoxin A.


Motivational and personality trait relationships in mate selection. This article discusses the question of homogamy and/or heterogamy in human mate selection with particular emphasis on Winch's principles of type I and type II complementarity. The experiment was performed on 82 married couples, at least one spouse of which was a graduate student at the University of Illinois. All were given the 16PF, the Motivational Analysis Test (MAT), and the Marriage Role Questionnaire. The authors found that except for fear and pugnacity all husband-wife trait correlations were positive, in contrast to Winch's principle of type I complementarity. They also found that their data did not support Winch's principle of type II complementarity.


Genetic and environmental correlations between brain weight and maze learning in inbred strains of mice and their F1 hybrids. The relationships among body weight, cerebellum weight, cerebrum weight, maze-learning ability in a double T-maze, and discrimination learning in a Y-maze were studied in six inbred strains of mice and some of their F1 hybrids. The subjects were 131 male albino mice from 14 genotypic groups: five inbred groups and nine groups of crossbred offspring. Intra- and intergroup correlations were computed between all possible pairs of the anatomical and behavioral traits. A significant difference between the intragroup and intergroup correlations for any pair of variables was taken to indicate the presence of a genetic correlation between the two variables. On this basis, positive genetic correlations were indicated between T-maze learning ability and Y-maze learning ability, between body weight and T-maze learning ability, and possibility between body weight and both cerebellum and cerebrum weight and between cerebrum weight and T-maze learning ability. Negative genetic correlations were indicated between cerebellum weight and running time in both mazes and between total number of successes in the Y-maze and Y-maze running time.


Effects of floor textures on open-field behavior in selected lines of mice. Mice representing the twenty-second generation of selection for high and low open-field activity were tested on four different floor textures: soil, bedding, metal, and astroturf. Members of both groups were most active on soil and least active on the metal floor surface. Although floor texture significantly affected activity level, rank order of the high and low selected groups was maintained. In general, defecation scores were negatively correlated with activity.


Coexistence of ankylosing spondylitis and rheumatoid arthritis. Ankylosing spondylitis and rheumatoid arthritis share many common features. However the presence of rheumatoid factor, histologically classic rheumatoid nodules, and the histocompatibility cell wall antigen (HLA-B27) helps distinguish one from the other. Two cases are reported in which these features established the coexisting diagnoses of ankylosing spondylitis and rheumatoid arthritis.


Correlations between transaminase concentrations and serum salicylate concentration in juvenile rheumatoid arthritis. Simultaneous measurements of serum salicylate, SGPT, and SGOT concentrations were made on 92 children receiving salicylates for arthritis during a 13-month period. Statistical correlations were found between salicylate and transaminase concentrations in patients with juvenile rheumatoid arthritis when in active stages. However elevated transaminase levels occurred with low salicylate levels and during inactive stages, and were inconstant in individual patients. Marked transaminase abnormalities were transient and appeared unpredictably in individual patients. Some factor in addition to salicylate concentration must be involved in raising serum transaminase levels. No evidence of chronic hepatotoxicity was noted.


Perforation of nasal septum in rheumatic diseases. Perforation of the nasal septum was noted in 12 patients with rheumatic disease, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), systemic lupus erythematosus (SLE), progressive systemic sclerosis (PSS), and mixed connective tissue disease (MCTD). Biopsies were taken from the rim of the perforation in 7 of the 12 and revealed no vasculitis, immunoglobulin deposition, or consistent abnormality. Nasal septal perforation is an occasional finding in rheumatic disease and the cause is unknown.


Specific detection and semiquantitation of microorganisms in tissue by nucleic acid hybridization. II. Investigation of synovia from pigs with chronic Erysipelothrix arthritis. Synovial tissues from animals with chronic Erysipelothrix arthritis were examined by a technique based on RNA-DNA hybridization in an attempt to detect the inducing organism, Erysipelothrix insidiosa (EI). Twelve synovial specimens from 5 animals whose joints lacked culturable EI also lacked EI detectable by this technique. Because the technique is capable of detecting approximately one organism per 50 mammalian cells, it is concluded that no more than this number were present in the involved tissue. Implications of these results for proposed pathogenetic mechanisms in this disorder and in human rheumatoid arthritis are discussed.


Experimental hemarthrosis in the knee of the mature canine. The knee joints of 14 skeletally mature mongrel dogs were subjected to a continuous hemarthrosis. Minimal morphologic changes of the articular cartilage did not occur until after 16 weeks. As early as 4 weeks, biochemical analyses showed a significant decrease in glycosaminoglycans (GAG) that became progressively more severe with time, whereas total collagen was not significantly altered until after 12 and 16 weeks. Bioengineering measurements of the experimental cartilage surfaces showed that the tissue becomes more deformable as well as less resistive to shear than the control at 8 weeks. These differences increased as the duration of hemarthrosis increased.


Reduction of phagocytosis and lysosomal enzyme release from human leukocytes by serum from patients with systemic lupus erythematosus. Serums from 22 of 30 (73.3%) patients with systemic lupus erythematosus (SLE) interfered significantly with particle (zymosan) uptake and subsequent release from normal human neutrophils of lysosomal enzymes. SLE serums with low as well as those with normal functional hemolytic complement activity (CH50) suppressed phagocytosis and enzyme release despite the presence of normal serum in cell suspensions. The defect did not appear to be caused by anticomplementary activity of serum. Serums from patients whose clinical activity of disease varied from none to severe and whose treatment varied from none to high doses of prednisone were capable of suppressing phagocytosis and enzyme release. The severity of clinical SLE activity did not affect the degree of suppression. Serums from patients treated with corticosteroids were more inhibitory than serums from patients not so treated. The nature of the inhibitor is unknown.


Dermatoglyphic study of systemic lupus erythematosus. Dermatoglyphic patterns were analyzed from two races of patients with SLE: a Mexican-American series of 27 females with SLE and 28 matched controls, and a Caucasian series of 28 females with SLE and 26 matched controls. Eighty-five measurements and 23 indices were analyzed. From these data, eleven parameters were statistically significant, four separating the Mexican-American SLE group from their controls and seven separating the Caucasian SLE group from their controls (P values less than 0.002 to less than 0.05). Only two parameters were significantly different between the two normal series, but nine parameters differentiated the Mexican-American SLE from the Caucasian SLE groups. A multiple linear discriminant function was computed using the most significant parameters. A misclassification rate of 25-30% was observed between patients and matched controls. Dermatoglyphic patterns have been shown to be genetically controlled. These data suggest a genetic abnormality associated with SLE.


Hemarthrosis associated with sodium warfarin therapy. Three patients with hemarthrosis of the knee joint complicating sodium warfarin oral anticoagulation therapy are described. In all 3 the prothrombin time was at least 2.4 times the control value at the time of hemarthrosis. After initial bleeding was controlled, 2 patients had recurrences at times when their prothrombin times were again more than 2.5 times greater than those of the normal control subject. Joint symptoms persisted in all patients until the warfarin dose was substantially decreased or discontinued. Underlying joint disease was present in 1 individual and may have predisposed him to the occurrence of hemarthrosis. No long-term joint damage was recognized as resulting from the hemarthrosis at followup 1 to 2 years later. The authors conclude that hemathrosis associated with oral anticoagulant therapy occurs when the prothrombin time is excessively prolonged any may remain symptomatic until anticoagulation is reduced or discontinued. Management includes careful diagnostic aspiration, despite the prolonged prothrombin time, and discontinuation of anticoagulation.


A new model for human bioassay of topical corticosteroids. The aiblity of topical corticosteroids to reduce the size of weals induced with histamine on human skin was used as a human bioassay model to assess their relative efficacy. Histamine was introduced by the pinprick method and various topical corticosteroids were assessed. It is a simple, easy and reliable procedure which can be used on both white and dark people. Even though it is a non-clinical assay, it possesses close similarity to processes involved in the development of clinical dermatoses.


Effect of environmental temperatures on oxygen consumption in infants with congenital disease of the heart. The effect of changes in environmental temperature on the oxygen consumption in babies with congenital disease of the heart has been studied and it has been shown that an inverse relation exists between those two variables. The significance of these findings on the practice of calculating systemic and pulmonary blood flow from predicted values of oxygen consumption is discussed.


Spasm of left main coronary artery.

Spasm of left main coronary artery. A 46-year-old male patient with atypical angina pectoris appeared to have an important elongated stenosis of the left main coronary artery on coronary arteriography, and slight irregularities in the left anterior descending, circumflex, and right coronary arteries. A saphenous vein bypass graft to the left anterior descending artery was performed, and this relieved the patient's symptoms. Postoperative coronary arteriography demonstrated a widely patent left main coronary artery and graft. The original narrowing of the left main coronary artery was probably caused by spasm and the source of the patient's anginal symptom.


Cor triatriatum dexter with imperforate Ebstein's anomaly. A case of cor triatriatum dexter is described in which the anomalous right atrial partition is identified as the right venous valve; there is an associated anomaly of the right atrioventricular valve which combines features of Ebstein's anomaly, and an atypical, imperforate, tricuspid atresia.


Granulomatous mitral valve obstruction.

Granulomatous mitral valve obstruction. Acquired non-rheumatic valvular mitral valve obstruction is extremely rare. A case of mitral valve obstruction is described which resulted from a granulomatous mass replacing the valve cusps. The problems in diagnosis and probable aetiology are discussed.


Assessment of left ventricular function by indices derived from aortic flow velocity. The velocity and acceleration of aortic blood flow were measured by means of a catheter velocity probe in 40 patients during routine diagnostic cardiac catheterization. Ten different variables were derived from the aortic velocity measurements, and their ability to discriminate between good and bad left ventricular (LV) function was tested. By means of eight conventional indices of LV function derived from pressure, mean flow, and quantitative cineangiography, the patients were divided into 3 groups: group 1, good LV function; group 2, moderate LV function; group 3, poor LV function. Aortic peak velocity and maximal acceleration correlated well with stroke volume and were thus indices of LV pump function. Aortic peak velocity also showed a significant correlation with LV stroke work. Both aortic peak velocity and maximal acceleration failed to discriminate between the three groups of patients, and correlated poorly with conventional indices of LV function. The mean values of stroke volume differed significantly between groups 1 and 2, and between groups 1 and 3, and also correlated better with the conventional functional indices. The best discrimination between normal and abnormal LV function was provided by dividing stroke volume by maximal acceleration, but stroke volume divided by peak velocity discriminated better than stroke volume alone. Stroke volume divided by maximal acceleration also gave more significant individual correlations with the conventional functional indices than did any other variable derived from aortic velocity.


Congenital heart disease in Down's syndrome. Eighty cases of Down's syndrome were found among 1504 children with congenital heart disease under the age of 15 years. The most common cardiac anomaly, ventricular septal defect, was found in 49 per cent of the 80 cases studied, while the second most frequently encountered anomaly, common atrioventricular canal, was found in 15%. Haemodynamic investigations of 24 cases of ventricular septal defect showed Eisenmenger's syndrome to be present in 10 cases; this seemed to appear at an earlier age in mongoloid children than in other children with ventricular septal defect. Right-to-left shunt was found in 5 out of 9 cases of common atrioventricular canal. Pulmonary hypertension was found in all of 24 cases of ventricular septal defect and in 7 of 9 cases of common atrioventricular canal. The cumulative survival up to 10 years was 64% for girls and 49% for boys. Death was most commonly the result of pulmonary complications which occurred in 22 out of the 34 patients who died.


Constancy of pressure-rate product in pacing-induced angina pectoris. The pressure-rate product during anginal pain produced by right atrial pacing was studied in 12 patients before, during, and after an angiotensin infusion sufficient to produce a significant rise in blood pressure. During the infusion the pain occurred at a significantly lower heart rate (P less than 0.001). However, the pressure-rate product was similar during anginal pain before and during the angiotensin-induced hypertension and after it wore off. Our studies support the concept that in each individual there is a constant level of myocardial oxygen consumption, as expressed by the pressure-rate product, at which anginal pain occurs.


Usefulness of systolic time intervals in differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy. Systolic time intervals in 15 patients with constrictive pericarditis and seven patients with restrictive cardiomyopathy were compared in order to assess their value in the differential diagnosis of the two disorders. Clinical examination had failed to make the distinction. Right heart catheterization was helpful in diagnosing restriction but failed to differentiate patients with constrictive pericarditis from those with restrictive cardiomyopathy. The systolic time intervals clearly separated the two groups. The PEP/LVET was normal in all patients with constrictive pericarditis (0.34 +/- 0.01) and abnormal in all patients with restrictive cardiomyopathy (0.70 +/- 0.09, P less than 0.001). In 13 patients (five with restrictive cardiomyopathy and eight with constrictive pericarditis) the results of quantitative left ventricular angiocardiography were available. A high correlation (r=-0.90, P less than 0.01) between the PEP/LVET and the ejection fraction confirmed the validity of the PEP/LVET as a measure of left ventricular performance in these patients. Thus the systolic time intervals clearly distinguished between constrictive pericarditis and restrictive cardiomyopathy and are a reliable non-invasive technique for making the difficult differential diagnosis.