55 degrees oblique hilar tomography.

55 degrees oblique hilar tomography. Fifty-five-degree oblique hilar tomography is an accurate and simple means of evaluating hilar anatomy and pathology. It is of most value in proving the hilum to be normal in cases in which plain chest roentgenograms suggest a hilar lesion. It is accurate in differentiating hilar adenopathy from hilar masses and in both of these it is helpful in determining the extent and bilaterality of the disease process. Unfortunately, granulomatous infiltrates within the hilum cannot be differentiated from tumor. The procedure is of limited value in the presence of diffuse perihilar pulmonary fibrosis, and at this time caution must be advised in the interpretation of small, unilateral, ill-defined hilar densities as tumors.


Parasystole and its variants.

Parasystole and its variants. Various mechanisms that cause deviations from the classical manifestations of a parasystolic rhythm are reviewed and illustrated by selected clinical electrocardiograms. They consist of: (1) Transient or continued fixed coupling of the ectopic beats, due to (a) synchronization of basic and parasystolic rhythms; (b) reversed coupling of the basic to the ectopic rhythm (unidirectional protection); (c) the operation of supernormal phase of excitability; and (d) intermittent parasystole, due to gap in the protection of the parasystolic center. (2) Irregularities in response to a regular parasystolic discharge may be caused by a second degree exit block, usually of Mobitz type II, rarely of type I. An electrophysiologic basis for the emergence and maintenance of parasystolic rhythms appears to be abnormal states of spontaneous diastolic (phase 4) depolarization in otherwise latent subsidiary cardiac pacemakers.


Interstitial lung disease in polymyositis and dermatomyositis: analysis of six cases and review of the literature. Interstitial pneumonitis may be the presenting manifestation of polymyositis-dermatomyositis, or may occur later in the evolution of the disease. The clinical picture is characterized by non-productive cough, dyspnea and hypoxemia. The chest radiograph demonstrates interstitial infiltrates with predilection for the lung bases, often with an alveolar pattern in addition. The histopathologic features are those of organizing and interstitial pneumonitis and pleuritis, with variable fibrosis. In the present series, the patients with mixed alveolar and interstitial infiltrates on chest radiograph and organizing pneumonia and bronchiolitis obliterans in addition to interstitial pneumonitis. In one patient evolution from pulmonary inflammation to interstitial fibrosis was demonstrated. The etiology of primary lung disease in PM-DM is not known, but cell-mediated autoimmunity to an unidentified component of lung tissue is suggested. Including the present series, 50 percent of patients have responded favorably to corticosteroids with decreased dyspnea, clearing of the chest radiograph and improved pulmonary function tests.


Lactate dehydrogenase and isoenzyme changes in rats with experimental thiamine deficiency. Heat and liver lactate dehydrogenase (LDH) and isoenzyme distributions were studied in rats with experimental thiamine deficiency. No change in total heart LDH activity was observed on days 24 and 40 of a thiamine deficient diet. At the time of symptoms (average 53 days on diet), total heart muscle LDH was slightly decreased in thiamine deficient rats (248 +/- 12 U/g tissue, Mn +/- SE) compared to ad lib fed controls (293 +/- 12, p less than 0.05), but did not differ from pair fed controls (273 +/- 15). Heart muscle LDH isoenzyme distribution showed a relative increase in the H4 band and a decrease in the H2M2 and HM3 bands in thiamine deficiency on day 24. This pattern became more promient by day 40. Calculated total M-LDH activity of heart muscle in thiamine deficient rats was significantly decreased at day 40 (44 +/- 3) compared to pair fed controls (57 +/- 5, p less than 0.05) and ad lib fed controls (85 +/- 7 p less than 0.001). Further changes were not observed in the symptomatic stage. Total H-LDH in heart muscle did not change during the period of study, while total liver LDH activity was reduced in thiamine deficient rats at the symptomatic stage (137 +/- 15) compared with pair fed controls (193 +/- 12, p less than 0.05) and ad lib fed controls (407 +/- 50, p less than 0.01). Liver isoenzyme electrophoresis showed an almost 100% distribution to the M4 band. The present investigation demonstrates a decrease in cardiac muscle M-LDH in experimental thiamine deficiency. Differences in LDH isoenzyme distribution in chronic hypoxia and thiamine deficiency are discussed.


Effect of contraceptive steroids on arginine- stimulated glucagon and insulin secretion in women. II. Carbohydrate and lipid physiology in insulin-dependent diabetics. The effect of contraceptive steroids on aminogenic glucagon secretion was studied in six insulin-dependent diabetic women. After 2 wk treatment with combined mestranol (80 mug) plus norethindrone (1 mg) daily, the mean peak plasma glucagon response to arginine infusion was suppressed to one-fourth of control levels. This was associated with a small but significant decrease in mean basal plasma cholesterol concentrations. There were no changes in basal plasma triglyceride, free fatty acid, glucose, insulin, or alpha-amino nitrogen concentrations or in daily insulin requirements during mestranol plus norethindrone treatment. These results confirm previous reports of no consistent changes in the insulin requirements of insulin-dependent diabetic women using contraceptive steroids and suggest that these women may not experience dramatic changes in their lipid metabolism during contraceptive therapy.


Stimulation of insulin secretion in man by oral glycerol administration. The effects of an orally administered glycerol load (1 g/Kg body weight) on blood glucose, plasma FFA, and plasma insulin levels have been determined in eight normal fasting or glucose loaded (1 g/Kg body weight) volunteers. Blood glucose levels were not affected by glycerol loading while glicemia followed the same pattern of a glucose tolerance test in the group treated with glucose plus glycerol. Plasma FFA were significantly lowered only 90 min after glycerol loading while they had markedly and persistently decreased by glycerol plus glucose per os. Finally, though glicemia did not change, insulinemia was markedly increased by glycereol, 90 min after loading; moreover, plasma IRI was significantly higher in the group treated with glycerol plus glucose than in the group treated with glucose alone. These data suggest that the release of insulin may be stimulated by a very small increment of blood glucose, which derives from glycerol.


Dietary protein, fat, and minerals in nephrocalcinosis in female rats. Young female rats fed semipurified diets containing casein or a soy protein isolate had extensive nephrocalcinosis at the junction between the outer and inner stripe of the outer medullary zone after 5 wk on the diets, whereas rats fed a diet containing a lactalbumin concentrate did not. Although the percentages of actual protein and of total ash were similar in all three diets, the concentrations of individual minerals were not, owing to methods used in isolating the proteins. Comparison of the individual mineral contents of these diets with those in other laboratories as compiled from the literature suggested that factors other than minerals, including protein, are also implicated. Dietary fat appeared to be another such factor in a series of experiments in which saturated medium-chain triglycerides and corn oil were included in diets containing soy protein isolate. Although these diets had identical mineral compositions, the rats fed medium-chain triglycerides had less severe lesions.


Starvation-induced alterations of circulating thyroid hormone concentrations in man. Serum concentrations of triiodothyronine (T3), thyroxine (T4), and TSH were examined in seven men and seven women of normal weight during a 60-hr fast. Similar studies were conducted in two women who received daily for 1 mo before and during a similar fast, 0.4 mg and 0.5 mg of 1-thyroxine. The serum concentrations of T3 decreased in each of the untreated normal subjects (sign test of significance, P less than 0.001). The mean control concentration of T3 in women was 152 +/- 9 ng/100 ml (X +/- SEM); after 24 hr of fasting, 131 +/- 31 ng/100 ml; and at the termination of the fast, 90 +/- 15 ng/100 ml. The latter value differed from the control value with a p value of less than 0.01. Similar changes of T3 concentration occurred in men (mean basal T = 160 +/- 11 ng/100 ml; mean at termination of fast = 87 +/- 16 ng/100 ml). The range of decrease for T3 in all subjects varied from 24% to 55%. The mean T4 concentration at the beginning of the fast was 6.9 +/- 0.9, and at the termination of the fast, 7.5 +/- 0.6 (p = NS). TSH concentrations remained unchanged (Control, 3.8 +/- 0.45 muU/ml; at 60 hr, 4.0 +/- 0.26 muU/ml, p = NS). Studies in two women who received, before and during a fast, T4, indicate that a decreased peripheral conversion of T4 to T3 is the most likely mechanism responsible for this change.


Changes in body chemical composition with age measured by total-body neutron activation. Total-body levels of calcium and phosphorus (reflecting skeletal mass) and total-body levels of potassium (reflecting muscle mass) were measured by neutron activation analysis in 39 men and 40 women ages 30-90 yr. In order to intercompare the total body calcium (TBCa) values in a heterogeneous population, such as this, it was necessary to normalize the data for skeletal size. The normalization consisted of dividing the absolute calcium level by the predicted calcium level for each individual matched to a set of critical parameters. The parameter used in the computation of normal values were age, sex, muscle mass, i.e., total body potassium (TBK) and height. For the calcium data of the women, it was necessary to add an age correction factor after the age of 55 yr. The calcium ratio(mean ratio of the predicted to measured TBCa) in men was 1.000 +/- 7.8% and in women 0.996 +/- 7.1%. The TBCa of normal males and females can thus be predicted to +/- 13% (at the 90% confidence level). An exception to this was found in males (70-90 yr) who exhibited a mean calcium ratio greater than 1.13. The derivative of TBCa with time was determined for this population of men and women by taking into account the dependency of calcium on three time dependent variables, height, TBK, and an explicit age correction factor in the case of the women. The mean rate of loss of TBCa in women was 0.37% and 1.1% per year before and after menopause (50 yr). In the males, the average rate of loss of TBCa was 0.7% per year after 50 yr of age. The pattern of total body phosphorus (TBP) loss with age paralleled that of TBCa as the ratio of TBP/TBCa was rather constant with age. The constancy of the ratio suggests that the mineral composition of bone does not change significantly with age. The rate of loss of TBK with age was also related directly to that of TBCa. The mean ratio of TBK/TBCa was 9.9 in females and 8.0 in males and this ratio remained relatively constant from 30-70 yr. Thus, the mechanism responsible for the loss of bone with age, whether nutritional deficiency or decreased gonadal function and physical activity may also be responsible for the loss of muscle mass with age.


Effect of intravenous glucose and insulin on plasma tryptophan and tyrosine concentrations in normal subjects and patients with carcinoid tumors. We evaluated the effect of intravenous (i.v.) glucose on the plasma tryptophan (TRP) and tyrosine (TYR) concentration of 12 normal subjects, six patients with carcinoid tumors and the carcinoid syndrome (carcinoid syndrome), and five patients with carcinoid tumors without the carcinoid syndrome (tumor.) Following i.v. glucose administration, the plasma Trp concentration of the normal subjects and the tumor patients incresed, while the plasma Trp concentration of the carcinoid syndrome patients decreased. Following i.v. glucose administration, the plasma Tyr concentration of the normal subjects and the tumor patients decreased, while the plasma Tyr concentration of the carcinoid syndrome patients did not change. The response to i.v. insulin differed in some respects from the response to i.v. glucose: the plasma Trp of normal subjects did not change while the plasma Trp of carcinoid syndrome patients decreased; the plasma Tyr of the normal subjects increased while the plasma Tyr concentration of the carcinoid syndrome patients did not change. The carcinoid syndrome patients had high serum serotonin concentrations and impaired glucose tolerance and insulin secretion as compared to both normal subjects and tumor patients. We conclude that under appropriate experimental conditions, glucose administration can increase the plasma Trp concentration of normal human subjects.


[Effects of low doses of lynestrenol on endometrium and nidation (author's transl)]. In 10 women taking 0.5 mg lynestrenol for oral contraception endometrium biopsies were carried out in several consecutive cycles between the 21st and 25th day of each cycle. In addition pregnandiol excretion in the urine was measured in one of the last three treatment cycles always on the 10th and 21st day of cycle. During treatment of a characteristic, monomorphic microscopical endometrium picture was observed with hardly distinct endometrium glands and only slight decidualike transformation of cellular elements of the stroma. From these histological pictures it is concluded that oral application of 0,5 mg lynestrenol produces endometrium changes characterized by insufficient transformation so that nidation of a blastocyte becomes impossible.


[The influence of pregnancy on the venous return from the lower extremities (author's transl)]. Determination of intravenous pressure in the lower extremities revealed in 77 pregnant women a marked insufficiency of the venous drainage. In the last third of pregnancy the capacity of the venous drainage is reduced by approximately 30 per cent. Determination two to five days post partum showed a significant improvement but not yet complete normalization. The causes of the insufficiency of the venous drainage are hormonal influences, dilating the vessels, which are still active post partum. The insufficient venous return is a major factor in the genesis of varicosity during pregnancy. The disturbance of venous return by the large uterus will result in an increase of static venous pressure on the average of 10 mm Hg. In the upright position this is a qualitatively as well as quantitatively individually variable phenomenon. There ist no relation between the increase in static venous pressure and the occurrence of varicosity.


[Feto-maternal microtranfusion after amniocentesis in the 2nd trimenon (author's transl)]. 120 healthy patients 16 to 34 years of age were studied. All patients were admitted to the clinic for legal abortion and were admitted to the clinic for legal abortion and were between 16 and 20 weeks pregnant. Amniocentesis were performed for intraamniotic application of prostaglandins. The incidence of microtransfusion of fetal red blood cells in these patients were studied. Blood samples were taken before and one hour after amniocentesis. 104 patients (86.7 p.c.) did not show any fetal erythrocytes in the peripheral blood neither before nore after amniocentesis. In ten patients (8.4 p.c.) less than 0.055 ml transfused fetal blood were determined as well before as after the puncture of the amniotic sac without any increasing tendency. In six patients (4.9 p.c.) signs of an induced fetal-maternal-microtransfusion could be proved. All six patients had no fetal cells in the circulation before treatment. Four of these had a microtransfusion of less than 0.05 ml, two patients between 0.05 and 0.10 ml. The localisation of the placenta by ultrasonic technic as an absolutely demand before amniocentesis is strongly recommended, especially in cases of prenatal diagnostic purpose.


[Deliveries in foreign women (author's transl)]. The question is to be answered whether the delivery in foreign women has in any case to be valued as riskful birth. The development of deliveries in 1941 foreign women from 1968-1973 is therefore analysed and compared with 9009 deliveries in German women. The share of deliveries in foreign women increased from 3% in 1968 to 32% in 1973. Wifes from Turkey and Jugoslavia are prevailing (68,1% and 19,5%). A significant moving of parity to a higher number of children can be noticed in foreign women. The incidence of operative deliveries in foreign women amounting to 12,5% was 5% lower than in German women. The incidence of sectio amounted to 9.4% in German women and to 7.5% in foreign women. The rate of premature births in foreign women figured up to 9,5% surpassed the rate of premature births in German women by 1%. The comparison of uncleared as well as of cleared perinatal mortality did not show any statistically significant difference. Merely the mortality of sectio-children amounting to 6.9% was significantly higher in foreign women than in German women with 3.7% - owing to the accumulation of vital indications in caesarean sections. Authors come to the conclusion that based on their material examined deliveries in foreign women cannot be juged as riskful births. Particularities in foreign deliveries are specially indicated.


The treatment of salmonellosis in Equidae. Among 23 Equidae in which various treatment or management regimens for salmonellosis were observed and evaluated, 9 horses were infected with Salmonella typhimurium and 8 with S anatum; an aged mule harbored S newport, and 1 isolant was not identified. Four dual sero-type infections occurred: 3 typhimurium/anatum and 1 anatum/newington. The results obtained with various antimicrobials in therapy of peracute, acute, and chronic infections were discouraging or questionable with regard to efficacy against salmonellae per se. The antimicrobial resistance patterns of the salmonellae and coliforms from the same fecal sample of the patient were determined. Salmonellae cultured from feces prior to, during, and following treatment with a variety of drugs were often sensitive to the antimicrobial administered during these periods. Drug sensitivity or resistance appeared to have little, if any, bearing on eliminating salmonellae from the feces or organs of infected Equidae.


[Neuraminidase induced hemolytic anemia. Experimental and clinical observations (author's transl)]. Recently, increasing attention has been focussed on the in vivo action of neuraminidase as possible pathogenetical factor of hemolytic anemia and even hemolytic-uremic syndrome. Neuraminidase action in red cell membranes results in the release of neuraminic acid, and thereby the uncovering of previously hidden receptors, socalled cryptantigens. With special reference to the phythemagglutinin Anti-TAh from the peanut (Arachis hypogae) and the agglutinin Anti-AHP from the albumin gland of the small Helix pomatia we describe some new methods for the detection of these cryptantigens. In addition to the screebubg genagglutination test with Anti-TAh we developed an "Anti-T-consumption test" for quantitative detection of neuraminidase action on red cells. With the purified reagents we developed an indirect fluorescnet antibody method on blood smears for the detection of cryptantigens on single cells. By animal experiments we could show that not only the membranes of red cells but the intima of renal capillaries as well are damaged by neuraminidase. With these new methods we observed 14 patients suffering from hemolytic anemia due to bacterial or viral neuraminidase. Some of these patients developed a hemolytic-uremic syndrome. We believe that the positive reaction with Anti-T Ah should lead to prophylactic heparinization to prevent dissiminated intravascular coagulation. Neuraminidase is the first identified toxin which directly acts on the membranes of red cells and the intima of renal capillaries as well, and thereby in some patients may induce hemolytic-uremic syndrome. Possibly, these results may stimulate the development of further testsystems for the detection of still unknown toxins which are not tested with our reagents, but may equally be involved in the damage of cell membranes.


[Advantages of breast feeding (author's transl)]. The advantages of breast feeding are due to numerous factors i.e. the favourable composition of basic nutritives, the content of nucleotides, polyamines, rare fatty acids and rare oligo- and polysaccharides in human milk, its high content of immunologically active substances like immunoglobulins, fats, glycoproteins, lysozyme and lactoferrin, and the psychologically important opportunity for close sensual contact between mother and infant. Involution of the uterus is greatly accelerated by breast feeding. In case the mother has to take certain drugs her breast feeding can be disadvantageous for the infant. At present, we do not see any reason to recommend discontinuation of breast feeding because of the relatively high DDT content found in human milk, since the concentration observed has shown no toxic effects. Furthermore a decrease of DDT concentration in human milk has been observed recently.


[Induction of acrodynia by grain preservative (author's transl)]. A five year old boy suffered from acrodynia induced by the ingestion of the mercury containing compound Ceresan-Morkit. Mercury was traced in blood and urine. Since the excretion of the 17-Ketosteroids was augmented, we treated the patient with cortison, cuasing a prompt improvement of the condition.


[X-Ray diagnosis of hepatic rupture in a newborn (author's transl)]. Presumably due to trauma during birth newborn infant had a hepatic rupture and intraabdominal haematoma, which was diagnosed by injection of contrast solution into the umbilical vein catheter. Radiographically the haematoma was seen in the left upper abdomen (perhaps in the omental bursa). Besides additional birth injuries the infant suffered from fetopathia diabetica, asphyxia, meconium aspiration syndrome, mediastinal emphysema and pneumoperitoneum.


Deficient sympathetic nervous response in familial dysautonomia. Norepinephrine concentration and dopamine-beta-hydroxylase activity were measured in the plasma of 10 dysautonomic patients and 10 normal subjects while they were reclining, standing and exercising. While reclining, dysautonomic patients had normal norepinephrine concentrations and blood pressure, but after standing they did not have a normal increase in their levels of norepinephrine (P less than 0.005), dopamine-beta-hydroxylase (P less than 0.05) or plasma protein concentration (P less than 0.01); they became hypotensive. In reclining dysautonomic patients there appeared to be a correlation between blood pressure and plasma norepinephrine concentration. These data support the view that hypertension and hypotension in dysautonomia are related to the rate of norepinephrine release.


Coffee drinking and death due to coronary heart disease. For a series of 649 patients who died of coronary heart disease within 24 hours of onset of symptoms, and an equal number of neighborhood controls, information was obtained on a large number of variables, including coffee consumption. An analysis using multivariate risk scores to control for all available variables yields a maximum likelihood estimate of the risk ratio associated with coffee drinking of 1.1 (95 per cent two-sided confidence limits, 0.8 to 1.6). The estimate of the risk ratio depends somewhat on the number and nature of variables controlled for in the analysis. Overall, our findings, limited to low-risk and middle-risk patients, suggest that the risk, if any, of death from coronary heart disease associated with coffee drinking is small.


Idiopathic hirsutism--an ovarian abnormality. We investigated increased production of testosterone and androstenedione in 44 women with unexplained adult-onset hirsutism, 41 of whom had normal-sized ovaries. Twenty women in this group had at least 50 per cent suppression of plasma testosterone and androstenedione after four to five days of dexamethasone. Testosterone and androstenedione values in ovarian-vein effluents were higher than those of their adrenal veins. We calculated adrenal secretion rates of both androgens in each patient by relating the adrenal gradients to those of cortisol. In 42 of the hirsute women, including those whose androgens were suppressed after dexamethasone, the ovaries were the predominant source of androgen production. The women with dexamethasone suppression had milder degrees of virilism and lower production rates of testosterone and androstenedione. We conclude that the ovaries are the source of excessive androgens in most women with unexplained hirsutism, and that corticoid-suppressible patients have milder forms of ovarian hyperandrogenism.


Delivery of primary health care--union style. A critical review of the Robert F. Kennedy plan for the United Farm Workers of America. The primary health-care program developed by the United Farm Workers of America, an example of a consumer-controlled system, provides quality health care at locations and time convenient to patients and employs bilingual clinic personnel from the same worker background to bridge the cultural gap between provider and consumer. By combining health-care delivery with union activities, it has been possible to finance the system through grower contribution by contract and to alter unhealthy working and living conditions on the farms. However, the lack of decision-making power by the health workers has resulted in poor working conditions and a high turnover of personnel. Complete consumer control has built into it the same hazards as complete professional control, and some balance of power is clearly necessary if the needs of both are to be adequately met.


Suicide attempts by hospitalized medical and surgical patients. To characterize siucidal behavior among hospitalized medical and surgical patients, all suicide attempts in the Peter Bent Brigham Hospital were surveyed for seven years. Seventeen attempts occurred, non of them fatal. Only four patients were seriously ill, two with neoplasia. All the attempts were impulsive and were associated with stress and disturbances of impulse control. Anger, not depression, was the effect most often seen before the attempts. In all cases the precipitating stress was loss of emotional support. However, patient vulnerability to suicide seemed to be the key determinant. Fifteen patients had mental disorders, including eight with personality disorders, three with schizophrenia, three with organic brain syndromes, and one with manic depressive psychosis. Seven were psychotic, and six had made prior suicide attempts. These findings suggest that the characteristics of impulsive suicide should be considered when a suicide prevention program is being developed for a general hospital.


Normal serum ferritin concentrations in precirrhotic hemochromatosis. We investigated 33 of 58 members of two families with latent or precirrhotic hemochromatosis to determine its pattern of inheritance and to evaluate the serum ferritin levels as an index of iron stores. In both families, the pattern of inheritance was as an autosomal dominant trait with incomplete expressivity. Mean serum ferritin values in the affected family members were 88.5 ng per milliliter (range, 28.0 to 201.9) for males and 65.2 ng per milliter (range 23.7 to 97.0) for females, which were no different from controls (P is less than 0.5). Furthermore, the serum ferritin values did not correlate with or reflect mobilizable iron stores, and there were no relations between the serum iron, iron-binding capacity and transferrin saturation (P is less than 0.2). Thus, serum ferritin concentrations in precirrhotic familial hemochromatosis appear to underestimate iron stores. Serum ferritin levels do not help to identify such patients with increased iron stores for therapeutic phlebotomy.


Association between maternal diabetes and the respiratory-distress syndrome in the newborn. Perinatal data on 805 infants of diabetic mothers and 10,152 infants of nondiabetic mothers were examined for a relation between maternal diabetes and respiratory-distress syndrome of the newborn. The syndrome occurred in 23.4 per cent of the diabetic vs. 1.3 per cent of the nondiabetic group. The risk of the syndrome in an infant of a diabetic mother was 23.7 times greater than that for an infant of a nondiabetic mother (P less than 0.00001). Further analysis to control for features associated with diabetes but also in themselves risk factors, such as gestational age and route of delivery, showed that respiratory-distress syndrome in infants of diabetic mothers was 5.6 times as likely to develop as in infants of nondiabetic mothers (P less than 0.00001). Thus, maternal diabetes mellitus per se predisposes to newborn respiratory-distress syndrome.


Radiologic detection of breast cancer. Review and recommendations. In response to recent public demand for mammographic examination after the discovery of breast cancer in two women of national prominence, the Ad Hoc Committee on Mammography of the Massachusetts Radiological Society reviewed the present indications, benefits, and risks of radiologic technics used in the detection of neoplastic breast disease. Either low-dose film mammography or xeromammography can provide diagnostic information with minimal radiation hazard, and thermography is a sensitive though nonspecific technic for interim follow-up observations and for screening of large groups of well patients. Mammographic examination should be performed before contemplated breast operations and in women at high risk for the development of breast cancer, especially those who have had previous neoplastic breast disease. Routine mammographic studies on well women may be initiated after the age of 35 years, the frequency of periodic re-examination being determined by clinical and mammographic findings.


Combination chemotherapy as an adjuvant treatment in operable breast cancer. Prolonged cyclic combination chemotherapy with cyclophosphamide, methotrexate and fluorouracil was evaluated as adjuvant treatment to radical mastectomy in primary breast cancer with positive axillary lymph nodes. After 27 months of study, treatment occurred in 24 per cent of 179 control patients and in 5.3 per cent of 207 women given combination chemotherapy (P less than 10(-6)), the advantage appearing statistically significant in all subgroups of patients. Patients with four or more positive axillary nodes had a higher per cent of relapses than those with fewer nodes. The initial new clinical manifestations occurred in distant sites in 81.5 per cent of relapsed patients. Long-term chemotherapy produced an acceptable toxicity, thus allowing the administration of a high percentage of drug dosage. These results should be considered with caution, since, at present, the effect of this therapy on survival and possible long-term side effects remain unknown.


Location of aldosterone-producing adenomas with 131I-19-iodocholesterol. We used 131I-19-iodocholesterol as an adrenal-imaging agent in 27 hypertensive patients who had biochemical evidence of abnormalities in the renin-angiotensin-aldosterone system. In 10 of 12 patients in whom the biochemical findings suggested the presence of an aldosterone-producing adenoma the adrenal uptake was asymmetric. The adenoma was subsequently confirmed in all eight patients in this group who underwent operation. In contrast, the adrenal uptake was asymmetric in only one of 13 patients with biochemical evidence of iodopathic hyperaldosteronism or low-renin essential hypertension. Two patients with adrenal carcinoma causing primary aldosteronism did not concentrate the isotope in their tumors. When metabolic studies suggest an aldosterone-producing adenoma, adrenal imaging with 131I-19-iodocholesterol may locate the tumor before operation.


Oral contraceptives and reduced risk of benign breast diseases. In 1970 a questionnaire on oral-contraceptive use was mailed to 97,254 married women 25 to 49 years of age in Greater Boston. Sixty-nine per cent responded. During the subsequent 30 months, 1072 of the women were hospitalized for breast diseases. Hospitalization rates for fibrocystic disease were similar for non-users of oral contraceptives and users of one to 12 months' duration. However, users for 13 months to 24 months and 25 or more months had rates only 70 and 35 per cent, respectively, of those of non-users. Detailed analysis of these results, and their similarity to findings in previous studies, suggest that the association is causal--use of oral contraceptives appears to lower risk of fibrocystic breast disease. A similar association was seen for fibroadenoma. Rates of breast cancer were lower for users than for non-users, but this finding was neither related to duration of use nor statistically significant.


Hyperglucagonemia and blood glucose regulation in normal, obese and diabetic subjects. Glucagon was infused to maintain plasma concentrations three to six times the basal level (300 to 600 pg per milliliter) into 16 normal and seven non-diabetic obese subjects. Hyperglucagonemia caused only a transient rise of 5 to 10 mg per 100 ml in basal glucose levels and had no effect on oral glucose tolerance or plasma insulin. In three patients with adult and two with juvenile-onset diabetes on maintenance insulin, hyperglucagonemia maintained for two to four days caused no change in plasma glucose of ketone concentration. In contrast, in nine insulin-withdrawn patients the glycemic response to hyperglucagonemia was five to 15 times greater (P less then 0.05) than in normal controls. Hyperglucagonemia does not cause glucose intolerance in normal subjects or bring about deterioration of diabetic control when insulin is available. Glucagon in the insulin-deprived patient can worsen the diabetic state. These findings suggest the primary role of insulin deficiency in the diabetogenic action of glucagon.


The complement abnormalities of lipodystrophy. Investigation of the serum complement system in 25 patients with various forms of lipodystrophy showed no abnormality in three patients with total lipodystrophy; a single patient with limb lipodystrophy had evidence of activation of the classical complement pathway. However, of the 21 patients with partial lipodystrophy, 17 had low serum C3, with normal C4 and C2, concentrations, accompanied in 14 by a serum C3 splitting factor indistinguishable from nephritic factor, suggesting activation of the alternative pathway. These abnormalities occurred in 10 patients without clinically overt renal disease. Seven patients had overt nephritis; renal biopsies obtained in six showed mesangiocapillary (membranoproliferative) nephritis in all. Thus, the majority of patients with partial lipodystrophy have hypocomplementemia. Although nephritis may not invariably develop, the high rate of mesangiocapillary nephritis in these patients suggests that complement activation via the alternative pathway predisposes to the development of this form of glomerular disease.


Presence of gene for beta globin in homozygous beta0 thalassaemia. In one southern Italian and one Pakistani patient with homozygous beta0 thalassaemia in which no detectable beta-globin synthesis occurs and no beta-globin messenger RNA is found, the gene for beta globin has been shown to be present using complementary DNA. This demonstrates that for these patients the imbalance in chain synthesis is not attributable to a gene deletion.


The next twenty-five years.

The next twenty-five years. The next 25 years have been reviewed from the general standpoint of people and economy and from the specific focus of the health care needs of women. Special problems in patient care which will require our immediate attention have been identified. The strengths and weaknesses of the College have been presented. A proposal for reinforcement of organization within the discipline to help us pull together as a team is the creation of 1) A Coordinating Council For Obstetrics and Gynecology; and 2) A Board of Trustees for the American College. These steps I believe are essential to the health growth of our College and the advancement of quality education and improved patient care.


Treatment of adenocarcinoma of the endometrium at Memorial-James Ewing Hospitals, 1949-1965. This retrospective study of patients receiving initial therapy for endometrial adenocarcinoma at Memorial-James Ewing Hospitals from 1949-1965 confirmed that the most important factor related to survival was extent of disease at presentation. Those patients with spread beyond the corpus had a much poorer prognosis regardless of method of therapy. Within Stage I, histologic grade and depth of myometrial penetration were of much greater prognostic significance than uterine size. Advanced age was associated with a higher incidence of poorly differentiated tumors. Apparently for Stage I, simple hysterectomy alone was not as effective as simple hysterectomy combined with preoperative radium or radical hysterectomy with or without node dissection. There was a 6% incidence of positive nodes when node dissection was performed in Stage I patients who had no spread of disease to the cervix confirmed at operation. Pure vaginal recurrence rate was low for all methods of therapy in Stage I. Eradication of recurrences by any means was relatively ineffective.


Progestational potency of oral contraceptives. The induction of glycogen deposition as subnuclear vacuoles was found to be a better method in estimating progestational potency of individual progestins than the delay of menses assay. Norgestrel was the most potent progestin in all assays. The progestational potency of oral contraceptives was estimated by multiply potency of individual progestins by their dose. Combination oral contraceptives containing norgestrel were in the mid range of progestational potency because of the relatively higher potency of their progestin. The progestational potency of the norethindrone "mini" pill was compared with that of the norethindrone low-progestogen combination pill and the sequential pill over a 28-day cycle, and no appreciable difference was found.


An ultrasound aspiration transducer for diagnostic amniocenteses. The many benefits of ultrasonography in the management of pregnancy are briefly reviewed. The use of a B-mode ultrasound aspiration transducer in the performance of diagnostic amniocentesis is described. This new tool was of considerable assistance in the management of 3 patients.


Amenorrhea: a review of forty cases.

Amenorrhea: a review of forty cases. A retrospective analysis of the clinical data from 40 patients with amenorrhea has enabled us to reach useful generalizations applicable to the management of this problem. Chromosome studies when puberty is delayed and a thorough pelvic examination when menarche fails to appear at the proper time relative to the sequence of other pubertal events will lead to an early definitive diagnosis in most cases of primary amenorrhea. A schema for the functional categorization of patients with secondary amenorrhea is presented to obviate the necessity of obtaining a needlessly expensive battery of laboratory tests which often yield misleading or uninterpretable data.


Pregnancy after removal of abdominal aortic aneurysm. A case of pregnancy complicated by an abdominal aortic aneurysm was treated by abdominal hysterotomy and resection of the aneurysm. The patient had a subsequent pregnancy without complication. To our knowledge, this is the first reported case of pregnancy following abdominal aortic aneurysmectomy.


Fetal heart deceleration patterns in relation to asphyxia and weight-gestational age percentile of the fetus. The relation between fetal heart rate deceleration patterns and fetal asphyxia and the weight-gestational age percentile characteristics of the fetus has been reviewed from data obtained from 533 patients monitored during the intrapartum period. There is a significant relation between the frequency of total and late decelerations and fetal asphyxia, again confirming this as a useful criterion in the identification of fetal asphyxia. There is a significant relation between decreasing weight-gestational age percentile of the fetus and increasing frequency of total and late decelerations, identifying this fetal characteristic as another variable which will influence fetal heart rate deceleration patterns. The appreciation of the effect of this variable is useful in the interpretation of the fetal heart rate record during the intrapartum period.


Hereditary spherocytosis with hemolytic crisis during pregnancy. Treatment by splenectomy. Hemolytic anemia was detected in 2 young women in the second trimester of pregnancy. The diagnosis of hereditary spherocytosis was made, and the patients underwent uneventful splenectomy. Five similar cases from the literature are reviewed.


The natural history of an hematosalpinx. A patient who had experienced an actopic pregnancy and subsequent salpingectomy was found to have an ectopic pregnancy, presenting as an hematosalpinx, in the remaining fallopian tube. The diagnosis was made at the time of laparoscopy, and the patient refused definitive surgery. Fourteen months later she achieved an intrauterine pregnancy, and repeat laparoscopic examination revealed an essentially normal pelvis and fallopian tube. This is evidently the first case report of a pregnancy occurring through a fallopian tube that had had a previous ectopic gestation and in which no surgical procedure was performed on the affected tube.


Acute puerperal inversion of the uterus in a primipara. A rare case of uterine inversion immediately following delivery is reported. The uterus was successfully repositioned by a combined abdominal and vaginal approach.


Antenatal diagnosis and management of the small-for-gestational-age fetus. The small-for-gestational-age fetus continues to account for a large proportion of fetal demise in late pregnancy. Delivery at 37 to 38 weeks' gestation to preempt this is our recommended mode of management. Prenatal diagnosis was made in only 33% of cases in this study. The course of 101 growth-retarded pregnancies has been critically evaluated towards improving the rate of prenatal diagnosis.


Recovery after prolonged anuria following septic abortion. After a criminal abortion, a 21-year-old woman developed clostridial sepsis, massive hemolysis, shock, and protracted renal failure. Anuria was present for 3 weeks and hemodialysis was required for 35 days. Because of the prolonged anuria, the patient was thought to have irreversible renal cortical necrosis. A renal biopsy demonstrated tubular necrosis only. Shortly after the biopsy procedure, urinary volumes began to increase, and renal function gradually returned to normal levels. This case demonstrates that a protracted course of renal failure following clostridial infection is not necessarily due to cortical necrosis but may result from tubular necrosis, and renal function may return to normal.


Pregnancy associated with renal glucosuria. On reviewing 17,647 pregnancies over a 6-year period, 291 of 17,229 singleton pregnancies were noted to be associated with renal glucosuria. On analyzing these 291 pregnancies in 277 women, renal glucosuria was more frequently observed in those women with blood group types A and B and less in those with blood group type O. The incidence of renal glucosuria in nulliparous women, 2.8%, was significantly higher than that in parous women, 1.1%. A significantly high incidence of prematurity, 25.0%, was noted in women who persistently spilled a large amount of glucose.


Maternal and fetal plasma cortisol levels at parturition. Fetal adrenal function during pregnancy has a probable role in parturition. Ninety-five mothers and fetuses were evaluated to ascertain maternal or fetal plasma cortisol interrelationships under various clinical situations. When mode of delivery was evaluated, maternal cortisol levels showed no differences. However, the fetuses from vaginal delivery (mean, 43.7 mug/100 ml) had higher levels than those from cesarean section (mean, 34.7 mug/100 ml). Induction of labor showed a rise in maternal cortisol from preinduction levels (mean, 40.2 mug/100 ml) to delivery (mean, 49.6 mug/100 ml), probably reflecting the maternal stress of labor. The fetal cortisol level after induced labor (mean, 35.2 mug/ml) supporting the adrenal contribution to the initiation of labor. Gestational age of the fetus was significant in the fetal cortisol levels: 36 weeks or less (mean, 34.1 mug/100 ml); 37 weeks or more (mean, 44.5 mug/100 ml). This again supports the development of adrenal maturity. Fetal weight, postdatism, acute and chronic fetal distress, hypertensive disease in pregnancy, and race were evaluated without revealing any significant intergroup differences. Two anencephalic pregnancies were also studied.


Gorlin's syndrome: ovarian fibromas at adolescence. An adolescent with bilateral ovarian fibromas associated with Gorlin's or the multiple nevoid basal cell carcinoma syndrome is described. The syndrome should be considered and looked for when bilateral solid ovarian masses are found in young women.


Failure of triiodothyronine to prevent propylthiouracil-induced hypothyroidism and goiter in fetal sheep. Administration of propylthiouracil (PTU) to pregnant, third trimester sheep led to decreasing serum thyroxine and increasing serum thyroid-stimulating hormone in both mothers and fetuses. Hypothyroidism appeared more pronounced in the fetuses than in the ewes, and goiter formation was observed in all fetuses exposed to PTU. Concomitant administration of triiodothyronine failed to protect the fetuses from the effects of PTU.


Ovarian pregnancy with delivery of a live baby. A case of a primary ovarian pregnancy culminating in abdominal delivery of a live baby is presented. The absolute necessity of endometrial tissue for development of the fertilized ovum is discussed. Although in advanced ovarian pregnancy there is no profound difference from normal intrauterine gestation, it may mask the presence of an abruptio placentae.


Fibroepithelial polyp of the vagina. A report of five cases. Fibroepithelial polyp of the vagina is a rare lesion. Although benign, it can be confused with malignant connective tissue lesions because of its bizarre histology. Treatment is simple local excision. Recurrence is extremely uncommon. Five cases are reported.


The clinical syndrome of triploidy.

The clinical syndrome of triploidy. The clinical syndrome associated with triploidy is quite typical but is rarely reported in near-term stillborns and newborns. The occurrence of a large placenta with areas of hydatidiform changes in combination with an edematous fetus with macroglossia, facial clefts, eye defects, dysplastic cranial bones, omphalocele, meningomyelocele, syndactyly, and, in males, genital maldevelopment is suggestive of a triploid chromosomal constitution.


Prenatal diagnosis of trisomy 13 with decision not to terminate pregnancy. We report the antenatal diagnosis of trisomy 13 syndrome using cultured amniotic fluid cells. Our patient, in contrast to previous patients, elected to continue the pregnancy to term. A description of the fetus is given, and a rationale for management is discussed.


Androgenic function of a granulosa cell tumor. Virilizing granulosa cell tumors are uncommon and have not been well studied hormonally. A hirsute woman with a cystic granulosa cell tumor of the ovary is presented. Plasma hormone levles obtained before and after surgery indicate testosterone production by the tumor with LH and FSH suppression. Plasma testosterone (T) and T-index returned to normal after tumor removal, and ovulation resumed.


Massive edema of the ovary. A case report and a review of the literature. A patient with massive ovarian edema is described. This represents the eighth such case in the literature and the largest tumor reported. The literature on massive ovarian edema is reviewed and summarized.


An evaluation of the significance of positive oxytocin challenge test. Sixty-six of 390 patients studied at LAC/USC Women's Hospital between 1970 and 1973 had positive oxytocin challenge tests (OCT). Twenty-four percent of patients who were allowed direct monitored labor after a positive OCT showed no late deceleration and must be assumed to have had false-positive tests. Patients with positive OCT's had significantly increased incidences of perinatal mord late deceleration in labor when compared to patients with no positive OCT. The combination of a positive OCT and abnormal 24-hour urinary estriol excretion should be considered ominous.


Unilateral streaked ovary syndrome. Slotnick-Goldfarbs syndrome. A case of unilateral streaked ovary (Slotnick-Goldfarb's syndrome) is reported and documented with hormonal, chromosomal, laparoscopic, and histologic studied. It is postulated that viral oophoritis associated with mumps might explain the coexistence of a streaked ovary of a congenital origin with a hypoplastic ovary, tbat would be the expression of a factor acting in postnatal life.


Primary ovarian pregnancy and the intrauterine device. Two new cases of ovarian pregnancy are reported in relation to use of the intrauterine device, bringing the total number of reported cases to 18. Theories concerning the failure of the IUD to reduce the number of ovarian pregnancies are discussed.


Postmenopausal tuboovarian abscess.

Postmenopausal tuboovarian abscess. Twelve postmenopausal women with tuboovarian abscess were manages at the Los Angeles County-University of Southern California Medical Center in the period 1970 to 1975. Post-menopausal uterine bleeding and a palpable pelvic mass were the most common findings. On admission however, presenting signs and symptoms were generally not helpful in making a correct descriptive diagnosis. Four of the patients had a ruptured tuboovarian abscess at the time of surgery, and additional pathologic findings were common. The total hospital course was prolonged, with significant postoperative complications in 7 patients. Three patients developed gastrointestinal fistulas and 5 patients required further surgery. Possible etiologies of these adnexal abscesses and suggested patient management including appropriate antibiotic therapy is discussed.


Carcinoembryoinc antigen in cervical and vulvar cancer patients. Serum levels and disease progress. Serial carcinoembryonic antigen (CEA) assays were performed on 10 patients with primary invasive squamous cell carcinoma of the cervix, 7 patients with recurrent squamous cell carcinoma of the cervix, and 5 patients with invasive squamous carcinoma of the vulva. Plasma CEA determinations were accomplished by radioimmunoassay, using a modification of Hanson's method. In 8 of the 10 patients with invasive squamous cell carcinoma of the cervix, positive CEA values dropped to normal ranges during the course of radiotherapy, usually in the first 4 weeks of treatment. A similar decrease in patients' serum values was seen after surgical extirpation of recurrent squamous cell carcinoma of the cervix by pelvic exenteration. Serum values also dropped to within normal limits in a limited number of patients with squamous cell carcinoma of the vulva after complete removal of all gross disease. Persistence of disease was associated with all gross disease. Persistence of disease was associated with chronically elevated values. A suggestion is made that patients with elevated CEA values may be followed with serial determinations to substantiate complete eradication of their disease.


Radiology of the normal maxillary sinus and related structures. The radiographic anatomy of the maxillary sinus and related structures as shown in the Waters, lateral, submentovertical, and Caldwell views has been presented. A number of structures, which are of clinical importance but infrequently emphasized, are discussed. Careful study of these four standard sinus projections should provide an excellent knowledge of the radiographic anatomy of the maxillary sinus and its normal variants.


Glycoproteins from mature human milk whey. Two milk-specific glycoprotein fractions and serum orosomucoid were isolated from mature human milk. One of the milk-specific glycoproteins was homogeneous and was termed glycoprotein A. Its sedimentation and diffusion constants were 2.6 S and 6.3 F, respectively, giving a molecular weight of 29,5000. It contained some 70% carbohydrate consisting of sialic acid, galactose, fucose, glucosamine, and galactosamine. It was not immunologically related to serum orosomucoid. The other glycoprotein, called glycoprotein B, was heterogeneous with an average molecular weight of near 4,000, and carbohydrate comprised some 75% of its weight. Both glycoprotein fractions supported the growth of Lactobacillus bifidus var. Penn. Removal of sialic acid enhanced the growth-promoting activity of glycoprotein B but not of A.


Behavioral and biochemical correlates of diet change in phenylketonuria. The investigation was designed to explore the use of tests tapping reversible aspects of behavior and performance and to find out whether these data can be correlated with concurrent metabolic changes in different dietary phases. The four subjects had classic phenylketonuria, diagnosed on the basis of a high level of serum phenylalanine on a regular diet, and severe mental retardation. Three types of diet were used: the general institutional diet, a low phenylalanine diet, and a low phenylalanine diet with added L-phenylalanine. A position discrimination and reversal task was used. Blood samples were taken every week on the day before psychological testing, and one 24-hr urine sample was collected during each dietary phase. In subjects I and II performance deteriorated upon elevation of the serum phenylalanine level, but these changes were transient only, thus showing an adaptation to the effects of the high serum phenylalanine level. Subject III showed increased response latencies (slower test responses) during high phenylalanine diet phases and faster responses while on a low phenylalanine diet. The correlation between response time and phenylalanine level is highly significant (r = 0.86, P less than 0.001). On the low phenylalanine diet subject IV's responses were fast and her performance was very stable, which contrasted with erratic performance during the high phenylalanine phases. Calculations show a significant association with phenylalanine level, both for response time (r = 0.47, P less than 0.05) and for variability in response time within each session (r = 0.46, P less than 0.05). Biochemical variability was observed in metabolic responses to phenylalanine loading, especially in the excretion of tryptophan metabolites.


Therapeutic effects of glycine in isovaleric acidemia. The effect of glycine administration on acute leucine loading (125 mg/kg) was tested in a patient with isovaleric acidemia. Serum isovaleric acid at 1-3/4 hr after the leucine loading alone was elevated to 5.60 mg/100 ml and urinary isovaleryglycine excretion was 9.90 mg/mg creatine/24 hr. Whe the same amount of leucine was given with glycine (250 mg/kg) serum isovaleric acid was only 0.93 mg/200 ml. Unfortunately, urine was collected for only 12 hr after the leucine-glycine loading. However, the amount of urinary isovaleryglycine was 26.2 mg/mg creatine in this period. In the following experiments in which a meal containing 80 mg leucine/kg was given, serum isovaleric acid was elevated to 1.14 and 1.01 mg/100 ml at 3 hr and 6 hr after the loading, respectively. How-ever, serum isovaleric acid was only 0.53 and 0.79 mg/100 ml at 3 and 6 hr, respectively, when the identical mean was given with 2 g glycine. The effect of long term glycine administration (250 mg/kg/24 hr) was also tested. It did not prevent two ketotic episodes which were caused by infections. However, the duration of clinical symptoms such as vomiting and a large anion gap in the acute episodes were much shorter with rectal glycine administration. The patient's linear growth and weight gain durin glycine administration was much better than that in the pretreatment period.


Micropuncture study of fluid transfer in aminonucleoside nephrosis in the rat. The relationship between glomerular filtration rate and proximal tubular fluid reabsorption was evaluated in control rats and in rats 96 and 144 hr after the injection of an aminonucleoside of puromycin. Urine volume and sodium excretion were decreased in the rats injected with aminonucleoside. Proteinuria increased progressively. Total kidney glomerular filtration rate (GFR) was diminished less than surface nephron GFR at 96 hr and greater than single nephron GFR at 144 hr after injection when a large proportion of nephrons are nonfunctional. Clearance of p-aminohippurate was unchanged initially and depressed subsequently after aminonucleoside injection. Absolute reabsorption to the end of the proximal convolution was unaltered despite a decrease in total kidney filtration fraction. This decrease in GFR coupled with unchanged absolute reabsorption and hence increased fractional proximal reabsorption leads to decreased delivery of sodium and fluid to the more distal portions of the nephron.


Transfer across perfused human placenta. IV. Effect of protein binding on free fatty acids. The effect of protein binding on the rate of placental transfer of hexanoic (C 6) and decanoic (C 10) acids was investigated in an in vitro perfusion system of human placenta. As much as 30% of transferred C 6 was converted to more polar compounds, so that the observations related to the combined effects on transfer and metabolism. Less than 10% of C 10 was similarly metabolized. Both fatty acids are soluble in buffered salt solutions at the concentrations used (40 muM) and both are bound to serum albumin, C-10 having higher association constants (K' for C 6, 1.48 X 10(4); for C 10, 1.03 X 10(5). When the placenta is perfused with buffered salt solution, the transfer of C 6 is 22% more rapid than that of C 10. It is suggested that binding within the placenta retards C 10 more than C 6. The addition of 1 g/100 ml bovine serum albumin to the maternal perfusate reduces the transfer rate of C 10 by 80%, whereas 2 g/100 ml serum albumin has a more moderate effect on C 6 (a reduction of 50%). The addition of 1 g/100 ml serum albumin to the fetal perfusate increases transfer rate of both free fatty acids (FFA), C 6 by 25% and C 10 by about 250%. With equivalent concentrations of serum albumin in maternal and fetal perfusates, the transfer rate of C 10 was reduced by 65%, whereas there was no detectable effect on transfer of C 6 in two of three experiments. The transfer rate of FFA increase logarithmically with progressive shortening of the carbon chain from C 16 to C 8 when maternal and fetal perfusates contain serum albumin. Protein binding is apparently the determining factor. The rate of transfer falls off at C 6 and C 4, 4ven though protein-binding continues to decrease. The determining factor may be the hydrophilic nature of these molecules.


Hereditary sever combined immunodeficiency and adenosine deaminase deficiency. A retrospective study aiming at detection of heterozygous carriers of blood adenosine deaminase (ADA) deficiency was carried out in nine families known to us because children had died of combined immunodeficiency (SCID). The trait was found in 3 of 9 parent couples, and in 14 other relatives. In two families one homozygous patient was identified. A total of 54 family members and 60 healthy control subjects were tested. Clinically, the patients were all characterized by marked lymphopenia, nearly normal immunoglobulin levels, and inability to produce antibodies. One homozygous patient recovered after transplantation of fetal liver and thymus and is immunologically normal 1.5 years afterwards.


Cell-mediated immunity to respiratory syncytial virus induced by inactivated vaccine or by infection. Transformation and increased mitotic activity in donor lymphocytes exposed to specific antigens is considered by many to be a manifestation of cell-mediated immunity. In attempts to understand the apparent "sensitization" of individuals to respiratory syncytial virus (RSV) as a result of receiving inactivated RSV vaccine, in vitro lymphocyte transformation studies were carried out on infants who had received inactivated RSV vaccine and on infants who had received a similarly prepared inactivated African green monkey kidney (AGMK) cell-grown parainfluenza type 1 virus vaccine or a trivalent parainfluenza vaccine prepared in hen's eggs. Each group included some infants who had, and others who had not, undergone natural RSV infection under our observation before the lymphocyte studies. Lymphocytes were studied from 21 infants and young children who had received the inactivated RSV vaccine, 14 who had received a similarly prepared inactivated parainfluenza 1 vaccine, and 5 who received a trivalent parainfluenza vaccine. Twelve of the RSV vaccinees and 14 of the parainfluenza vaccinees had been naturally infected with RSV as indicated by virus recovery and/or antibody rise between the time of vaccination and the lymphocyte studies. In comparing the arithmetic mean for RSV-specific transformation and mitotic activity there was a significant difference between RSV vaccinees and parainfluenza vaccinees whether one compared those who had undergone natural RSV infection or those who had not undergone natural infection. The difference between RSV vaccinees who had not undergone natural RSV infection and RSV-infected parainfluenza vaccinees also was significant. There was a greater level of transformation and mitotic activity in those who had experienced natural infection than those who had not among both RSV vaccinees and parainfluenza vaccinees, but these differences were not significant statistically.


Brain glucose utilization in undernourished rats. The in vivo incorporation of radioactivity from [U-14C]glucose was reduced in undernourished rat pups at ages 6, 10, and 17 days for brain lipids, and at age 10 days for brain amino acids. Brain glucose concentrations were lower at age 20 days (controls 1.58 +/- 0.26 vs. test 1.14 +/- 0.07 mumol/g) but other alterations in brain glucose, glycogen, ATP, or phosphocreatine concentrations were not found. Brain mitochondrial glutamate dehydrogenase activity was 21% and 30% lower in undernourished animals at ages 10 and 20 days, respectively. Brain mitochondrial and supernatant isocitrate dehydrogenase activities and pyruvate kinase activity were similar for undernourished and control animals. Brain glycogen levels were 2-4 times higher in late fetal and newborn control animals (13.6 and 15.3 mumol/g) than in older animals (4.2-5.7 mumol/g). Brain glucose, ATP, and phosphocreatine levels increased from the 15-day fetus to the newborn, but thereafter showed no further increase.


A longitudinal study of total body potassium in normal breastfed and bottle-fed infants. In a previous publication we predicted that growth as measured by 40K is best described by comparison of the semilog function of total body potassium (TBK) vs. length with a slope that differs in infants from that of children aged 3-18 years. Data for 84 infants having three or more measurements during the first year of life attest to this hypothesis, with a regression line for TBK and length: loge K, g = -0.265 + 0.04112 length in centimeters.


The postnatal hypotransferrinemia of early preterm newborn infants. Preterm newborns were found to be markedly hypotransferrinemic when compared with normal term infants. At birth the concentration of transferrin in sera from preterm infants of gestational age equal to or less than 32 weeks is 45% of that found in normal term infant sera. The preterm infant transferrin levels slowly rise so that 7-8 weeks after birth they are 78% of the level found in the sera of normal term infants. We also found that the serum transferrin concentrations at birth correlate with gestational age. Therefore, the transferrin levels postnatally in early preterm infants reflect postconceptional rather than postnatal age.


The influence of age on cardiac refractory periods in man. As age is a determinant of cardiac refractory periods, this communication describes changes of refractory periods in an age continuum of infants, children and adults, 7 months through 77 years. Seventy patients with evidence of normal A-V conduction on scalar electrocardiogram were included. The patients were divided into six age groups: less than 2 years, 3-5 years, 6-10 years, 11-15 years, 16-30 years, and greater than 30 years. Extrastimulus technique was used to determine refractory periods in sinus rhythm or at longest cycle length assuring atrial capture, then at shorter cycle lengths. Cycle lengths (CL) for each age group were divided into ranges: CL1, 1,000-600 msec; CL2, 599-460 msec; CL3, less than 459 msec. Refractory periods at the three CL's within each age group were determined. Full recovery times of the A-V node within groups of children were determined. Statistical significance of the data was found by analysis of variance. The younger group tended to have shorter values than the older groups (F less than 0.05-0.001).


High speed cinemicrographic studies on rabbit tracheal (ciliated) epithelia: determination of the beat pattern of tracheal cilia. High speed cinemicrographs reveal that the ciliary configuration and beat pattern of rabbit tracheal cilia differ significantly from classid descriptions, although the basic forward and return pattern is still observed. The tracheal cilia are short and stout (about 6 mum in length) and are of a slightly bent original configuration bent original configuration. At the start of the forward stroke, the cilia bear about 75-90 degrees to the epithelial surface in the direction of the forward stroke. The forward stroke is planar and consists of a simple "bowing" movement, without showing any progressive bending and without changing the original ciliary configuration. The complete forward stroke sweeps through an arc of about 35-40 degrees, with the tips of the cilia penetrating the bottom of the mucous layer through an arc of about 5-8 degrees at the start of each forward stroke. The return stroke starts from close to the epithelial surface and returns to the starting position of the forward stroke by reversing the planer forward pathway at a reduced speed. The stout nature of the cilia, the original bent ciliary configuration, the near vertical starting position of the forward stroke, the extent of the angular sweeps of the strokes, the peculiar "bowing" forward stroke movement, and the nature of the return stroke all serve to enhance efficiency in moving fluid forward. It has been documented that each forward stroke of the tracheal cilia caused and maintains a swift forward movement of the intermediate serous (liquid) layer of the mucociliary system. This movement, in turn, reacts hydrodynamically with the top mucous layer, and together with the clawing action of the tips of the cilia at the start of the forward stroke, causes the mucous layer to move cephalad in the manner of a conveyor belt.


High speed cinemicrographic studies on rabbit tracheal (ciliated) epithelia: cytolytic effect of cystic fibrosis serum on tracheal epithelial cells. High speed cinemicrographs are made on the ciliary activity of rabbit tracheal cilia with the aid of Nomarski optics. The detailed nature of the ciliary beat pattern is determined from slow motion analysis of the high speed cinemicrographs (1-3). Such documented forms of ciliary beat pattern and the physiologic state of the tracheal epithelia are utilized as basic reference controls to investigate the physiologic effects of cystic fibrosis serum on ciliated epithelia and the cystic fibrosis tracheal mucus stagnation phenomenon. Careful analyses of the high speed cinemicrographs reveal that cystic fibrosis serum has no effect on the rhythm and beat pattern of rabbit tracheal cilia. However, it is shown in controlled procedures that cystic fibrosis serum has a cytolytic effect on the tracheal epithelial cells and also at the cell junctions. Ciliary dyskinesis, as described in previous reports (6-9), is actually a secondary effect of cytolysis and cell destruction.


Spontaneous rupture of the stomach in the newborn: clinical and experimental evaluation. Our study presents an experimental model for studying gastric rupture in the newborn. We showed that gastric rupture could be produced in eight newborn rodents and in three puppies less than 10 days old after injection of 120 ml air at 100 mm Hg pressure in the rodents and 175 ml air at 240 mm Hg pressure in the puppies. Gastric rupture occurred with animals supine and with approximately 20 ml barium injected into the stomach. Positioning of the animal in the supine position permitted the barium to pool in the antral-pyloric region of the stomach.


Lysine malabsorption syndrome: a new type of transport defect. A 21-month-old girl with physical and mental retardation is described. She excreted an increased amount of lysine in urine but no excessive quantities of arginine, ornithine, or cystine. Serum level of lysine was found to be low but the levels of the other amino acids were within normal limits. The endogenous renal clearance rates of amino acids showed a marked high value of lysine and normal values of the other dibasic amino acids. Oral loading test of amino acids revealed an imparied absorption of lysine and normal absorption of arginine, ornithine, and cystine in the intestine. These results indicate a specific defect in transport of lysine in the intestine as well as in the renal tubule.


Diagnosis of Meckel's diverticulum by radioisotope scanning. The clinical illness observed in a 5-month-old infant with Meckel's diverticulum is described. A sodium pertechnetate radioisotope scan was employed to confirm the clinical impression. The technical procedure, evaluation, and importance of the radioisotope study is discussed.


Etiology of respiratory tract infections in children in Cali, Colombia. One hundred eighty children hospitalized for acute respiratory disease were studied in Cali, Colombia. In the majority of patients, pneumonia was the reason for hospitalization and remained the final diagnosis. Fifty-one cases of pneumonia of indeterminate etiology comprised the largest single diagnostic category, followed by 38 cases of pneumonia associated with measles, and 22 cases assocaited with serologic evidence of infection with other viral agents or Mycoplasma pneumoniae. Etiologic diagnosis could be assigned with a reasonable degree of confidence in 116 of the 180 patients (64%). The laboratory procedure found most likely to provide the etiologic diagnosis in this series was paired sera specimens for demonstration of rise in antibody titer against the  common viral respiratory pathogens. Those most frequently implicated serologically as etiologic agents in the cases studied were, in order of decreasing frequency, measles, influenza, parainfluenza, and adenoviruses.


Hepatic hemangioendothelioma: hemodynamic observations and treatment. The clinical course of five infants with heptic hemangioendothelioma is reviewed. Hemodynamic abnormalities observed at cardiac catheterization included an increased cardiac output (range, 9.2 to 10.5 liters/min/sq m) with over 50% of this output being shunted through the arteriovenous malformation, an elevated right and left end diastolic pressure (8 to 10 mm Hg and 9 to 15 mm Hg respectively), a small systolic pressure gradient across the pulmonary outflow tract (4 to 6 mm Hg), and mild elevation of pulmonary artery pressure (range, 35/16 to 37/12 mm Hg). All four patients treated with prednisone improved while on therapy; three are well one to three years after cessation of therapy. One patient died from unrecognized congestive heart failure following discontinuation of prednisone and another before prednisone was started. We conclude that prednisone in high doses (2 to 4 mg/kg/day) with the addition of digitalis and diuretics for control of congestive heart failure is an effective treatment regimen for infants with hepatic hemangioendothelioma.


Rapid diagnosis of iron deficiency by measurement of free erythrocyte porphyrins and hemoglobin: the FEP/hemoglobin ratio. The concentration of free erythrocyte prophyrins (FEP) and of hemoglobin can be measured on blood samples spotted on filter paper. The FEP/hemoglobin ratio in iron deficiency increases exponentially with a decrease of both transferrin saturation and hemoglobin level. The FEP/hemoglobin is an indicator of imparied heme synthesis. In small children an elevation of the FEP/hemoglobin ratio is a better indicator of iron-deficiency anemia than low transferrin saturation. The FEP/hemoglobin ratio is normal in thalassemia trait and renal anemia but it may be elevated in sickle-cell anemia. Measurement of FEP and hemoglobin on filter paper provides a useful diagnostic tool for the diagnosis of iron deficiency, of anemia, and (in populations at risk) of leas intoxication.


Exaggerated natural measles following attenuated virus immunization. An adolescent girl, devoid of a detectable humoral immunity to measles virus despite two inoculations of live, attenuated vaccine, developed an exaggerated atypical rubeola illness following exposure to wild virus. This observation suggests that attenuated virus may be capable of immunologically sensitizing some individuals as has been described with killed virus vaccine.


Acute epiglottitis in children-treatment with nasotracheal intubation: report of 14 consecutive cases. Fourteen consecutive cases of acute epiglottitis were treated by nasotracheal intubation during a ten-month period. The duration of intubation averaged 47.2 hours. No mortality or morbidity occurred. Mean hospitalization was 4.6 days. This study demonstrates the ease of maintaining an assured airway by nasotracheal intubation in cases of acute epiglottitis.


Cyanosis, cough, and hypotension following intravenous administration of paraldehyde. Clinical and roentgenorgraphic evidence of pulmonary edema developed following the intravenous administration of paraldehyde to a child. Experimental and clinical evidence indicate that administration of undiluted paraldehyde intravenously is hazardous.


The spectrum of growing skull fracture in children. The genesis and complications of the growing skull fracture in children is discussed. Four patients are presented to illustrate the common and uncommon features of growing skull fractures. The need for complete radiological evaluation as well as the timing of follow-up examinations is stressed.


Hyperkinetic behaviors and learning disabilities followed over seven years. A seven-year follow-up study of 500 children was conducted by teacher questionnaire in the second, fourth, and fifth grades for the presence of behavior problems and learning disabilities. These children represent all the second-graders in a number of rural school districts. The three scores on each child were summed. The 20% of children with the highest scores (i.e., most symptoms or disabilities) showed a rate of behavioral or academic maladjustment in ninth grade of 35%. The 30% of children with the lowest scores (i.e., fewest symptoms or disabilities) did not have a single member functioning poorly in ninth grade. Of the group between the 30th and 70th percentile, 5% were adapting poorly and most of their scores placed them in the upper range. Consistent correlations are also shown when the group is divided according to IQ, grade point average, and school systems.


Oxygen toxicity in the newborn lung: reversal of inhibition of DNA synthesis in the mouse. Continuous exposure to 100% oxygen at atmospheric pressure for two weeks causes significant alterations in the growth of the lung and the body of newborn mice. These changes can be divided into three phases. The initial phase, which lasts 96 hours, is characterized by inhibition of lung DNA synthesis, diminished total lung DNA, and a decrease in the ratio of lung DNA to body weight. The intermediate phase from 96 to 144 hours is characterized by a sharp increase in mortality, a plateau in body weight, and a minimal lung DNA/body weight ratio. During this period, however, surviving animals show a reversal of the inhibition  of DNA synthesis and thus an increase in total lung DNA. The third phase, occurring after 144 hours, is characterized by a continued increase in DNA synthesis and total lung DNA, a gain in body weight, a return of the lung DNA/body weight ratio to control levels, and a sharp decline in mortality. The survival rate of 54% in newborn mice over two weeks contrasts with the near total mortality reported for adult experimental animals similarly exposed. The reversal of the inhibition of lung DNA synthesis in surviving mice suggests either that some newborn animals are inherently resistant to pulmonary oxygen toxicity or that they develop, during a critical exposure period, an adaptive process necessary for their survival.


Longitudinal observations of the relationship between free erythrocyte porphyrins and whole blood lead. Short- and long-term comparison of the variations with time of whole blood lead and free erythrocyte porphyrins (FEP) suggests that changes in FEP are slow and predictable whereas blood lead changes are quite unpredictable. However, when FEP suggests a different clinical category from blood lead, the blood lead is likely to change in the direction predicted by the FEP. Comparison of FEP to blood lead at first contact in 349 children with mild elevation of blood lead reliably predicted which children would still have elevated blood lead six weeks later and which would fall or be normal. The observation of long-term follow-up in four groups of children with various combinations of FEP and blood lead indicated that the follow-up blood lead could be predicted to change in the direction indicated by the FEP measurement. The implications for screening for lead poisoning are discussed.


Cardiovascular malformations associated with tracheoesophageal fistula and esophageal atresia. Cardiovascular malformations were present in 48 of 326 (14.7%) patients with tracheoesophageal fistula. The most common cardiac lesion was ventricular septal defect. When tracheoesophageal fistula or esophageal atresia was associated with other gastrointestinal anomalies, tetralogy of Fallot and atrial septal defect were very frequent; when skeletal anomalies were present, the cardiac malformations were usually complex. The hospital mortality in infants with tracheoesophageal fistula and cardiovascular malformations is 79% in contrast to 23% for infants without cardiac abnormalities.


Cardiovascular abnormalities associated with congenital diaphragmatic hernia. Cardiovascular abnormalities were present in 11 of 48 (23%) patients with congeital diaphragmatic hernia. Cardiac abnormalities included congenital heart disease, compression of a major vascular structure, cardiac malposition, and abnormalities in pulmonary circulation. The differential diagnosis between isolated congenital diaphragmatic hernia and coexisting cardiac abnormality may be difficult and may require echocardiographic or invasive studies. Mortality in infants with diaphragmatic hernia and cardiovascular abnormalities is 73% in contrast to 27% in those without cardiac abnormalities.


Generalized lymphadenopathy and nephrotic syndrome as a manifestation of mephenytoin (mesantoin) toxicity. This report describes a patient who developed marked generalized adenopathy and nephrotic syndrome while receiving mephenytoin (mesantoin) for a seizure disorder. Renal biopsy showed a diffuse proliferative glomerulonephritis. Lymph node histopathology revealed replacement of parenchyma with lymphocytes, eosinophils, and reticuloendothelial cells. A hypersensitivity reaction is postulated as the etiology of both these processes.


[Education in public health sciences at the faculty of medicine at Tampere]. A large public health institute - one of the three at Tampere - handles the instruction in subjects related to behaviour and community medicine. The students meet patients already in the first term during the group instruction, take part in educational visits, and work for several different periods with the health and sick-care services. In the third year, 30 hours are devoted to a course on the doctor-patient relationship.


[Education in medical psychology--goals, contents and means]. Education in medical psychology is now being extended to include 56 hours at the Faculty of Medicine at Copenhagen University. 26 hours are devoted to lectures during the first term, and a one-week intensive course comprising 30 hours is given during the sixth term. The training concentrates on problem solving, and studies comprise, among other things, TV-instruction, case histories, and group and panel debates.


[Education in medical psychology and community medicine at Karolinska Institutet]. In connection with experiments for the first three years of study the instruction in medical psychology and community medicine has been widened to comprise a total of seven weeks, three during the first term (lectures on basic principles, days devoted to field work, group work), three at the end of the fifth term, and a total of one week's instruction at various times during the sixth term, when the students are given more direct preparation for contacts with patients.


[Eduction in community medicine in Iceland]. Instruction at health centres and in the home environment, which are important features of the psychological and social sections of medical education, has been neglected. Students are prepared for good relations with the patient only by means of a few isolated lectures and through the example provided by organ-centred hospital specialists.


[Behavioural sciences in basic medical education]. In Oslo, instruction in medical psychology and sociology is to be widened to include approximately one term's training during the first year of study, in other words about 200 hours in all. An institute for medical behavioural sciences is to be established. Group training is being planned, and attempts will be made to create clinical relevance by linking up the instruction with everyday situtations met by the doctor.


[Community medicine at the faculty of medicine at Tromsø]. About 17 per cent of the whole period of the medical study at Tromsø is devoted to training in community medicine, which is combined with the other medical courses and spread out over the whole period. Courses include medical sociology, general and social medicine, psychiatry-psychology, epidemiology-statistics and preventive medicine. The students meet patients undergoing care at an early stage in the training, and work in groups with individual patients.


How does leukemia invade the central nervous system? Prolongation of survival of children with acute leukemia by systemic therapy has brought a marded increase in incidence of CNS leukemia. In mice inoculated with leukemia cells, CNS i nfiltrates are rare unless life is prolonged by chemotherapy. Available evidence seems to indicate that leukemic cells in the CNS in most cases originate in bone marrow or lymph nodes.


Symposium: Controlling diabetes mellitus with diet therapy. The effectiveness of caloric restriction and weight reduction in lowering the blood sugar level in obese diabetics has been rediscovered. The twin goals of attaining and maintaining ideal body weight and normoglycemia can be achieved through diet therapy in about 80% of patients who are intensively educated and continuously monitored by a well informed, highly motivated team of physician, dietitian, and nurse. It appears that chronic insulin therapy should be reserved for hyperglycemic individuals who are pregnant or who are at or below ideal body weight, for persons with juvenile onset diabetes who are obviously insulin-dependent, and for acutely decompensated diabetics.


Managing insulin-dependent diabetic patients. About 95% of insulin-dependent diabetics can be managed satisfactorily with one or a combination of the follwoing insulin preparations: single-peak U-100 beef-pork NPH, Lente, and Regular. Complications of insulin therapy are commonly attributable to poor regulation of insulin dosage, irregular or excessive food intake, or unusual physical activity. One form of hyperglycemia is induced by insulin. Generalized allergic reactions to insulin sometimes require desensitization. Insulin-resistant patients are treated with a glucocorticoid.


Use of oral agents in treating diabetes mellitus a perspective. A comprehensive study by the University Group Diabetes Program compared the effects of therapy with oral antidiabetic agents, insulin, and placebo in patients with adult-onset diabetes mellitus. Results showed an increased number of deaths, particularly due to cardiovascular diseases, among patients receiving oral agents. In spite of these findings, therapeutic recommendations have changed only slightly. An FDA proposal recommends moderate labeling changes. When possible, control of diabetes with diet alone should be attempted. If this is unsuccessful, an oral sulfonylurea should be added to the regimen. If glucose and lipid levels remain high after six months of such therapy, insulin should be used.


Neuropathic and vascular complications occurring in diabetes. Vascular and neuropathic complications of diabetes are a significant cause of morbidity and mortality. Symmetric polyneuropathy is the most common diabetic neuropathy. Treatment of the mononeuropathies consists of pain control and physical therapy to maintain muscle tone. Prognosis for recovery is excellent. Renal and retinal microangiopathy produce most of the clinically significant mortality and morbidity in diabetes. Recent advances in chronic hemodialysis and renal transplantation have improved the outlook for diabetics with end-stage nephropathy. The poor prognosis for retention of vision in diabetic malignant retinopathy has led to exploration of various forms of palliative therapy, including pituitary ablation, xenon arc coagulation, and laser treatment. Cardiovascular disease is more prevalent among diabetics than among the general population, according to a recent study, and mortality from this cause is three times higher. Animal studies linking aortic wall metabolism and atherosclerotic changes with hyperglycemia suggest that poor control of diabetes may play a role in the development of vascular lesions.


Gaseous indigestion reviewing the record. Patients who complain of gaseous indigestion may be more sensitive to an underlying intestinal motor abnormality than are others with similar dysfunction. Modifications in living and eating habits are basic steps that can be taken to relieve the problem; drugs that alter intestinal activity or responses may be effective.


The expanding classroom trends and issues in postgraduate medicine. Why self-assessment? Self-assessment can provide more than a direction for independent study and credit toward recertification. It can also provide an effective learning experience if the instruments are designed to serve an instructional purpose as well as the more traditional measurement function. Based on existing research, the characteristics of self-assessment instruments--questioning, controlling attention, elucidating objectives, evoking performance, and assessing outcomes--can enhance the learning and retention of new material.


Eye disorders. Retinopathy. What to expect in the diabetic patient. Two forms of diabetic retinopathy are recognized clinically--nonproliferative and proliferative. Nonproliferative diabetic retinopathy is characterized by microaneurysms, hemorrhages, hard exudates, retinal edema, cotton-wool spots, and intraretinal microvascular abnormalities. The general outlook is optimistic, and most people with nonproliferative diabetic retinopathy will maintain useful vision for a long time. Proliferative diabetic retinopathy is characterized by formation of neovascular tissue on the surface of the retina or optic disk. Aspirin, photocoagulation, or vitrectomy may be used in treatment, depending on the type of retinopathy and its stage of progression.


Office gynecology. Relieving dyspareunia. Effective treatment of dyspareunia can be a simple matter of reassuring the patient or conferring with her sexual partner. Or it may require vaginal dilation, use of lubricant or estrogenic cream, or surgery. Psychogenic dyspareunia is relatively uncommon.


Surgery. Cornstarch peritonitis following the trail of the surgeon's gloves. Granulomatous inflammation of the peritoneal surfaces resulting from exposure to cornstarch granules from surgical gloves produces a syndrome of abdominal pair, adynamic ileus, fever, peritonitis, variable white blood cell count, and inflammatory ascites. Symptoms develop three to four weeks after a routine abdominal surgical procedure. Recognition of this entity by nonsurgical means is necessary to avoid reoperation. Paracentesis with examination of fluid by polarized light offers the best method of non-surgical diagnosis. Treatment is with steroids or indomethacin or conservative measures. To prevent the disease, gloves must be washed effectively before operation.


Viral hepatitis--a primer. 2. Prevention and control. The clinical differentiation of hepatitis A from hepatitis B is often impossible, and only a finding of hepatitis B surface antigen in blood allows the presence of hepatitis B to be definitely diagnosed. Heaptitis A is most easily contracted via the fecal-oral route, while hepatitis B is usually transmitted percutaneously, especially by inoculation with contaminated instruments. Because viral hepatitis has a long incubation period, controlling its spread is difficult. Prevention and control have traditionally depended on general public health measures, and for hepatitis A, passive immunization with immune serum globulin. Promising research is now being conducted to develop vaccines for both active and passive immunization against hepatitis B.


Venous disease. Advances in objective diagnosis. A number of newer noninvasive or minimally invasive diagnostic techniques overcome the inaccuracies of clinical diagnosis of venous disease. Among these are Doppler ultrasound; plethysmography, especially the strain-gauge technique; the 125I fibrinogen uptake test; and radionuclide phlebography. Contrast phlebography is still the procedure of choice when diagnostic controversy remains or when facilities for the other techniques are not available.


Listening in the helping relationship.

Listening in the helping relationship. Physical therapists have been reported to spend nearly one-quarter of their time with patients in listening or talking. Listening is an important tool for observation and a valuable information gathering medium. Interference with effective listening occurs when 1) the listener is unwilling to listen, 2) the listener attends only to what he wishes to hear, 3) the listener's thoughts wander, and 4) a language difference exists. Guidelines are provided for control of these problems within the context of physical therapy.


Interacting with computer personnel in performing clinical rehabilitation research. Computer usage by physical therapists performing clinical research is becoming a reality. In this article, the basic computer operations are discussed with emphasis placed upon the way in which the physical therapist may interact with knowledgeable computer personnel during the formulation and execution of a hypothetical research problem. Some essential points concerning the therapist's expectations from computer analysis of research data are provided.


Hyperextension complicating total knee replacement. An elderly man with bilateral total knee replacements had an unusual hyperextension probelm complicating one knee prosthesis. A new type of orthosis which was fitted to the patient corrected the hyperextension. The management of the patient is described. The goal of treatment was to help this man become ambulatory and independent in activities of daily living. He progressed sufficiently to return to his own apartment in the city where he lives alone.


Fluid secretion in the nephron: Relation to renal failure. It had been generally accepted that glomerular filtration and tubular reabsorption were the basic modes of fluid transport in mammalian nephrons. Recently, evidence was obtained to indicate that net fluid secretion may occur in mammalian nephrons as well. In the pars recta portion of proximal tubules of rabbit kidney net fluid secretion was observed in vitro in response to PAH  and other aryl acids in the peritubular bathing medium. Net fluid secretion appeared to be coupled to the transcellular transport of aryl acid from bath to lumen. Serum from uremic subjects stimulated net fluid secretion in the pars recta in a manner similar to PAH. The accumulation of high levels of endogenous aryl acids may contribute to the general organ dysfunction that is a part of the uremic syndrome of advanced renal insufficiency. Futhermore, there is evidence to suggest that the fluid-secretion phenomenon in association with aryl acids may significantly affect renal excretion and morphology in slow-flow states, in patients with cystic kidney disease, and in obstructive nephropathy.


Spoken words in dreams a critique of the views of Otto Isakower. In 1974 Baudry confirmed Isakower's original and important concept that the spoken word in dreams may be a manifestation of the superego, but found that this is not always true and that there may be important contributions from drive and defense, according to the principle of multiple function. The particular type of dream speech most emphasized by Isakower--that characterized by a portentous, threatening, awe-inspiring, oracular tone--is extremely rare in dreams but may be observed in certain waking phenomena, e.g., psychotic delusions of self-observation or situations of life-threatening stress.


Lessons from Watergate. A derivative for psychoanalysis. Periods of social upheaval, by revealing aspects of behavior ordinarily repressed, provide an opportunity for deepening out insights into the nature of man. The searing experience of Watergate is viewed not as the psychopathology of a man, or the group psychology of forty men under the ex-President, but as reflecting psychic processes at the base of the population pyramid. The people supported Nixon for a quarter century during which his character traits were known, and were in collusion with the cover-up to the end during the two and half years of Watergate. The theory is advanced that this was due to an identification with Nixon based on the universal wish to triumph over the superego. Ego-superego conflicts are as ubiquitous and ongoing in mental life as the struggle between ego and id. The latter results in neuroses, the former in compromises of integrity. The 'syndrome of the compromise of integrity' is on a par with neurosis in human affairs.


Notes on shamelessness.

Notes on shamelessness. The effect of the decline of the sense of shame on the individual and on society is discussed. It is postulated that when the element of shame is changed in relation to instinctual drives, the later power of shame in preserving social cohesion is weakened, and a regression in some important functions of the ego results.


Who needs darkrooms?

Who needs darkrooms? With the advent of recent developments in film manufacturing and experience with photographic filters, the possibility that the traditional x-ray darkroom may no longer be necessary, has been raised. The authors present their experiments using various light filters and film and suggest that with the use of various combinations of lights, films and small tabletop film processors now on the market the darkroom is indeed no longer necessary. Consequently, the elimination of the expense and space for planning darkrooms in new facilities, or replacing them in existing facilities, is a feasible possibility at this time.


How patients view the efficient use of diagnostic radiation. Patients who are subjected to diagnostic x rays sometimes feel victimized by their dependence on large and very complex medical-care systems which treat them with over-all indifference. Some of these individuals are confronted with physicians and dentists who seem to order radiographs without giving reasons, as well as with employers and hospitals who require radiographs without seeming to "need" them. Other patients feel that they are acting as guinea pigs in training programs to technologists who appear to require retakes because they are working in a rapid and slapdash manner. When questioned by patients, personnel who are responsible for ordering or conducting x-ray examinations often inform them that someone else in the system is responsible for any unnecessary radiation exposure. Patients, dentists, physicians, radiologists, technologists, health physicists, and radiation control officers all bear responsibility for the efficient use of diagnostic radiation. People working in these capacities should cooperate more closely in the mutual sharing of responsibility for the well-being of patients.


Guidelines for the establishment of written agreements between colleges and clinical affiliates. If a program in radiologic technology is to consist of a sponsoring institution with one or more clinical affiliates, it is necessary that each party understand and be willing to cooperate in this endeavor. However, understanding and cooperation are dependent upon the degree of involvement each has had in the decision-making process. Once responsibilities are decided upon, each party must agree to abide by the terms. It is with this in mind that we present some guidelines and a suggested format for written agreements.


A disposable barium and air rectal tip.

A disposable barium and air rectal tip. To prevent leakage during the barium enemas the retention balloon is maintained in close apposition to the anorectal junction. This has been accomplished by using the counterpressure produced by simply allowing barium to flow into a small bag on the rectal tip adjacent to the anus.


Medical-legal implications of angiography. Since no member of the health-care team is immune to malpractice suits, technologists must be aware of their individual responsibilities and carry them out with utmost care. The increasing sophistication of equipment and radiologic techniques, such as are utilized in angiography, makes it even more imperative that technologists be alert to the legal implications and the standards of practice that all members of the team should follow to minimize the risks to the patient and to the team in terms of malpractice suits.