Spontaneous abortion after midtrimester amniocentesis. Of 371 consecutive patients who underwent midtrimester diagnostic amniocentesis, 8 subsequently aborted spontaneously (2.2%), and 1 had a stillbirth at 24 weeks of gestation (0.17%). In 3 of the 9 patients who suffered fetal loss, infection appears to have played a significant role. Whereas midtrimester diagnostic amniocentesis is widely considered to be a safe and accurate procedure, the possibility of hazard to the patient and her fetus remains and should be considered during the preliminary counseling session.


The effects of oxytocin on fetal scalp temperature. During a study of fetal temperature, it was found that there was a significantly higher temperature among infants whose mothers received oxytocin than among a comparable control group. These data indicate that normal-appearing oxytocin-induced contractions may reduce uterine blood flow and thereby raise the intrauterine fetal temperature.


Choriocarcinoma following term pregnancy. Two hundred and sixty-five patients with malignant trophoblastic disease were admitted to the Southeastern Trophoblastic Disease Center at Duke University Medical Center between July 1966 and June 1976. Of these 165 patients, 20 had choriocarcinoma following a term gestation with a survival rate of 60% as compared to 95% survival rate for the remaining 245 patients. Previously described risk factors of initial human chorionic gonadotropin (hCG) titer of greater than 100,000 IU/24 hr urine, duration of symptoms for more than 4 months, significant prior unsuccessful chemotherapy or cerebral or hepatic metastases identified the "poor prognosis" group. Post-term gestation "poor prognosis" patients had a significantly lower cure rate (47%), than other patients with "poor prognosis" for gestational trophoblastic disease (75%; P less than 0.05). Post-term gestation choriocarcinoma has a propensity for more extensive metastatic spread and would appear to be less responsive to conventional chemotherapy, which may be due to an altered immune response in these patients. This suggests that an antecedent term pregnancy should be added to the previously described high-risk factors for patients with malignant trophoblastic disease.


Smooth muscle tumors of the vulva.

Smooth muscle tumors of the vulva. The clinical and pathologic features of 32 smooth muscle tumors of the vulva were studied to determine the pathologic characteristics that best relate to the clinical behavior and to define criteria for separating leiomyomas from leiomyosarcomas. The length of follow-up ranged from 16 months to 20 years, with a median of 9 years. None of the tumors metastasized. Of the 4 neoplasms that recurred, the 2 with infiltrating margins recurred within 1 year and of these 2, the one with more than 5 mitotic figures in 10 high-power fields (HPF) recurred 5 times within a 2-year period. Neoplasms were discovered during pregnancy in 7 patients; these were characterized by extensive myxoid change, but none of the tumors that occurred during pregnancy showed significant cellular atypism or mitotic activity. Local excision is recommended as initial therapy and also for recurrences.


Primary invasive squamous carcinoma of the vagina. Forty-three cases of primary vaginal squamous cell cancer were treated at the University of Wisconsin Hospital between 1956 and 1971. These cases comprised 1.2% of patients admitted to the University Hospital with female genital tract cancer. Evidence is presented to support a modification of the currently accepted FIGO staging system for vaginal carcinoma (Stage II disease). Radiation therapy using both external beam and brachyradium equivalents or interstitial implantation of suitable isotopes was an effective method for the treatment of patients having early and locally advanced invasive vaginal cancer. The 5-year absolute survival rate for the entire series was 37.2%. Absolute survival rate by modified FIGO clinical staging was 66% for Stages I and IIA, 31% for Stage IIB, 25% for Stage III, and 0% for Stage IV.


Living cytology--revisited. In vitro demonstration of intraabdominal adenocarcinomatosis. An in vitro culture technique, "living cytology", was used in a single-blind study to study 36 paracentesis and 7 intracystic fluid specimens for possible adenocarcinomatosis. Islets of epithelial cells were demonstrated only in the 20 patients who were ultimately shown to have intraabdominal adenocarcinomatosis. Ten patients with nonmalignant conditions and 6 patients with nonmetastatic malignancies did not exhibit a comparable pattern. One of the 7 intracystic fluid specimens grew out epithelial islets similar to those observed in patients with intraabdominal adenocarcinomatosis.


Hemodynamic effects of head-down lithotomy position in patients with coronary artery disease. The hemodynamic effect of the head-down lithotomy (HDL) position was studied in 12 anesthetized patients with documented coronary artery disease. Data were collected in patients in supine position and then 10 minutes after placement in a 10-degree HDL position. Systolic arterial pressure (SP), mean arterial pressure (AP), mean right atrial pressure (RAP), mean pulmonary artery pressure (PAP), mean pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and heart rate-systolic pressure product (HRSP) increased significantly. Heart rate (HR), systemic vascular resistance (SVR), and pulmonary vascular resistance (PVR) were unchanged. In 2 patients with very low ejection fractions (EF), CO was decreased. The increase in HRSPP and PCWP suggests that all patients had increased myocardial oxygen demand. This increased demand may not be met because of impaired coronary circulation, potentially causing myocardial ischemia. This study suggests that patients with significant coronary artery disease should not be placed in the HDL position for extended periods without appropriate monitoring.


Oral contraceptive use and secondary amenorrhea. Among 1099 patients seen over an 8-year period for amenorrhea or oligomenorrhea, 115 (10.5%) had developed amenorrhea after ceasing oral contraception. These patients were the subject of a special study. Those who were treated received either clomiphene alone, hMG/hCG therapy, or both. There was no correlation between the incidence of either spontaneous or treatment-induced ovulation and menstruation and the duration of use of oral contraception, previous parity, or the nature of prior menstrual cycles. The incidence of treatment-induced resumption of menses was essentially the same as that for spontaneous resumption. An average duration of 30 months of oral contraceptive use did not significantly affect urinary excretion levels of estrogens and gonadotropins.


Artifactual fetal heart rate recording secondary to 60-Hz power-line interference. The presence of excessive 60-Hz power-line interference may produce fetal heart rate (FHR) monitor records that do not reflect the true fetal condition. A case in presented where improper leg-plate grounding resulted in an artifactual tracing that could have easily been misinterpreted. Careful examination of the monitor oscillographic display is urged whenever a tracing appears to have no variability and/or a rigidly fixed baseline rate.


The gravity suit: a major advance in management of gynecologic blood loss. We have used the gravity suit (G-suit) to stabilize patients in shock as a result of ruptured ectopic pregnancies. Four patients presenting in shock were carefully studied with serial vital signs, fluid replacement, and blood loss before and after application of the G-suit. These studies were continued through surgery and the removal of the G-suit. The G-suit improved vital signs, increased peripheral organ and limb perfusion, and decreased blood loss in all cases.


A dose-response study with Monistat cream. A randomized multiregimen clinical study was undertaken using Monistat Cream for the treatment of vulvovaginal candidiasis. The objective of the study was to find if there is a shorter regimen comparable in effectiveness to the currently marketed 14-day regimen. The results indicate that there is no significant difference between the cure rate obtained for 7 days of therapy and for 14 days of therapy.


The Swan-Ganz catheter and management of patients undergoing pelvic exenteration. A Swan-Ganz catheter has been used in 10 consecutive patients undergoing pelvic exenteration and has made the intraoperative and postoperative management of these patients a much easier task. Use of this catheter eliminates the guesswork involved in managing fluid and volume status by providing an accurate assessment of left ventricular end diastolic pressure. The complication rate is reported as 5% and consists mostly of ruptured balloons, infection, coiling of the catheter, and cardiac irritability. There have been no complications in the 10 patients in whom we have used the catheter. We believe that the use of the Swan-Ganz catheter in these difficult-to-manage patients is justified because of its low complication rate, easy use, and the accurate valuable information obtained.


Painless abruptio placentae.

Painless abruptio placentae. Three cases of abruption of a posteriorly inserted fundal placenta are described. This condition is characterized by vaginal bleeding associated with backache, a nontender uterus, and if unrecognized, high fetal mortality. Ultrasonography permits early recognition and definitive diagnosis. Fetal survival is ensured by closely supervised monitoring and early recourse to cesarean section.


Vasa previa: a major complication and its management. Vasa previa is an extremely rare condition. Consequently it is not often considered in the differential diagnosis of antepartum or intrapartum hemorrhage. Rupture of a fetal vessel may lead to sudden fetal death from exsanguination; therefore, this condition should be suspected in any antepartum or intrapartum hemorrhage. The blood that is lost should be tested for the presence of fetal hemoglobin. Other diagnostic tests to assess the degree of fetal distress are described. Four patients showing unusual presentations of vasa previa are reported. These cases demonstrate that fetal vessel rupture may occur independently of membrane rupture.


[Oligosymptomatic manifestation of congenital hypothyroidism (author's transl)]. A 4-year-old girl with congenital dysgenesis of the thyroid gland is reported. The girl's appearance was that of hypothyroidism in childhood but the classical symptoms of constipation and cerebral retardation were missing. Thus it is assumed that relative insufficiency of the ectopic thyroid at the base of the tongue produced manifestations only a short time before diagnosis, having had no influence on cerebral maturity.


[Polycystic disease of early infancy in two sisters (author's transl)]. Polycystic disease of early infancy is a heritable disorder diffusely involving both kidneys with no other evidence of renal parenchymal malformation. After discussing the typical histological data of two sisters with normal family history a short survey about classification and differential diagnosis of similar heritable renal cysts is given. With regard to the few other cases with familiar occurrence an autosomal recessive transmission is the most likely form of inheritance, delayed manifestation has not been observed until now.


[The psychodynamics of violence against children (author's transl)]. It was attempted to describe some important aspects of the complicated psychodynamics of violence against children. The empirical research has still the task to solve many essential problems concerning this subject. Nevertheless we can conclude from our knowledge we gained up to now, that great attention has to be paid to the psychodynamics in all therapeutic, preventive and legislative initiatives, which concern the problem of battered child syndrom and physical punishment. This is necessary in order to focus on a symptom only, that is the flogging of children, but to influence the psychodynamic conditions as well.


[Pathogenesis of ketotic hypoglycemia (author's transl)]. 4 children with ketotic hypoglycemia (KH) showed during a fasting period over 24 hours significant higher decreases of serum alanine levels than normal controls. Insulin induced hypoglycemia was followed by only minimal increase of urine epinephrine secretion, while all controls showed more than 6 times higher increases. 2-desoxy-glucose-tests were pathological in all cases with KH. One can speculate, that there is a connection between the reduced availability of alanine and the adrenal medullary hyporesponsiveness. Epinephrine stimulates glycogenolysis in muscle cells. Lack of epinephrine reduces pyruvate production and subsequently alanine synthesis. Alanine however is essential for gluconeogenesis in liver cells especially during starvation. After some days administration of diazoxide the 2-desoxy-glucose-test was normalised in all patients. This observation could probably be of some interest in therapy of KH.


[Additional comments on the differential diagnosis of rare bone diseases (author's transl)]. We report about two seldom types of diseases of bones. Both came to our hospital with the diagnosis Osteomyelitis. The first case, the Mafucci-Syndrome, is presented--a systemic Chondrodysplasia with Angiomatosis. This disease is not hereditary. There are found multiple Enchondromas mostly in the longer bones. In 20% the cases of the Mafucci-Syndrome get malignant. The second case shows the Conradi-Hünermann-Syndrome a Chondrodysplasia calcificans congenita, which seems to be hereditary. The characteristic sign is the minor growth of the bones, caused by early deposition of lime in the regions of ossification. Malignity is not described.


[Winter sport injuries in childhood (author's transl)]. 3374 accidents occurring on the field of sport during the years 1975--1977 accounted for 19% of all accidents dealt with at the Institute of Kinderchirurgie in Graz. 51% of the accidents were caused by the typical winter sports: skiing, tobogganing, ice-skating and ski-jumping with skiing accounting for 75% of the accidents. The fracture localization typical of the different kinds of winter sport is dealt with in detail. The correct size and safety of the equipment were found to be particularly important in the prevention of such accidents in childhood.


[Enteritis regionalis (Crohn's disease) in two twelve-year-old sisters (author's transl)]. It is reported of two sisters with Crohn's disease manifesting in both cases at the age of twelve years but in a temporal distance of eight years. The outbreak of disease at the same age and its similar development emphasize the importance of constitutional and/or genetic factors.


Monoamine oxidase in adult Hymenolepis diminuta (Cestoda). A membrane-bound monoamine oxidase (EC 1.4.3.4) was demonstrated in homogenates of Hymenolepis diminuta. The enzyme oxidized a variety of biologically active amines (in decreasing order: dopamine,  adrenaline, noradrenaline, tryptamine, tyramine, octopamine), there was, however, no activity with 5-hydroxytryptamine or benzylamine. No diamine oxidase (EC 1.4.3.6.) could be detected in H. diminuta (using histamine, cadaverine or putrescine as substrates). The monoamine oxidase from H. diminuta was not inhibited by azide, hydroxylamine or semicarbazide, but was inhibited by cupferron, alpha-alpha dipyridyl and iodoacetamide, and by the specific monoamine oxidase inhibitors pargyline, nialamide and iproniazid. Several anthelmintics were also found to be inhibitors of monoamine oxidase. The possible roles of monoamine oxidase in H. diminuta are discussed.


Efficacy and cross-resistance studies on N, N'-bis (3,4 ditrifluoromethylphenyl) methylmalonamide, a novel anticoccidial agent. N,N'-bis (3,4 ditrifluoromethylphenyl) methylmalonamide (Sch 18545) completely controlled a mild Eimeria necatrix infection at 50, 40 or 30 p.p.m. in the diet, and controlled E. tenella infections at 50 and 40 p.p.m. Slight oocyst passage was observed at each E. tenella treatment level with a marked increase at the 30 p.p.m. treatment level. Fifty p.p.m. were necessary to control E. acervulina infections; levels of 40 p.p.m. reduced E. acervulina oocyst production while 30 p.p.m. were ineffective. Evaluations of Sch 18545 using a mixed infection (Coccivac D) further suggested that activity with this compound was weakest against E. acervulina. Weight gains decreased with increasing concentration of drug in the diet of treated, infected birds and thus the compound showed an insufficient safety margin to be of practical value. Such 18545 administered at 35 p.p.m. in the diet was effective against amprolium, zoalene, aklomide or nicarbazin-resistant strains of E. tenella.


Studies on Eimeria dispersa Tyzzer 1929 in turkeys. Eimeria dispersa was isolated from young, intensively housed turkeys in Britain. The parasite has morphological features in common with those of the original description. At least two generations of schizonts occur before gametogony and one or two more schizont generations are concurrent with gametogony. Four generations of schizonts are needed to account for the observed reproduction index of 2.08 x 10(6)/oocyst inoculated. The first oocysts were discharged by 105 h and these sporulated within 30 h at 30 degree C. A single dose of between 1 x 10(2) and 1 x 10(6) oocysts depressed body weight gain of 3-week-old poults and 2 poults died 6 and 12 days after receiving 1 x 10(4) or 1 x 10(6) oocysts. A single dose of oocysts protected against a challenge inoculation given 14 days later. Poults immunized against E. dispersa were resistant to challenge with a strain of E. dispera obtained from the United States. Electrophoretic examination of 2 enzymes from both strains of E. dispersa showed that they had similar mobilities. Attempts to infect chickens, guinea-fowl and Japanese quail with E. dispersa were unsuccessful. The strain of E. dispersa isolated here is best referred to as E. dispersa (Briston).


The possible role of the frontal and sub-parietal gland systems of the pentastomid Reighardia sternae (Diesing, 1864) in the evasion of the host immune response. The frontal and sub-parietal glands of the pentastomid Reighardia sternae elaborate lamellate secretion which is poured on to the cuticle. The entire surface of the cuticle, including the mouth, hook pits and reproductive apertures, is coated with secretion. Electron microscope studies indicate that the glands are continuously active, which implies a turnover of surface membranes. The postulated function of these membranes is to protect certain vital areas of the host--parasite interface, notably the pores of ion-transporting cells, from the host immune response. The available evidence suggests that pentastomids do evoke a strong immune response but since most are long-lived they must circumvent it. We believe the surface membrane system to be instrumental in this. Studies on another pentastomid, Porocephalus crotali in rats have shown that an immune response stimulated by a primary infection will kill subsequent infections and that the surface membranes are strongly immunogenic. Obvious parallels between this situation and that of schistosome infections in mammals are discussed. An alternative explantation of concomitant immunity is proposed.


Phosphoglucomutase polymorphism in the tick Ixodes ricinus. Ten variants of phosphoglucomutase were detected by starch-gel electrophoresis in extracts of the tick Ixodes ricinus. Agreement of phenotype frequencies with those predicted by the Hardy-Weinberg model indicated that the enzyme is coded by a single gene locus (Pgm) at which 10 alleles are segregating. Allelic proportions in 5 Irish tick samples indicated that both spatial and temporal genetic differentiation exist. It is suggested that this polymorphism may be of use as a marker for studying the relationships of I. ricinus populations in Europe, as well as in taxonomic studies. A hypothesis is advanced which offers a possible adaptive explanation of the very high Pgm heterozygosity in tick populations. It is suggested that if kinetic differences exist between the various enzyme variants, the polymorphism may act to maintain an array of individuals in each population with varying developmental rates and longevities. Such a genetic strategy could be one factor which determines that the host-infesting seasons are spread over several months, thus ensuring maximum feeding and reproductive rates in each population.


Heparin and warfarin therapy. Recommendations concerning efficacy and safety. Heparin and warfarin are antithrombotic agents effective against venous thrombosis as well as pulmonic and systemic emboli. They can exert a favorable effect on mortality and morbidity in a diverse group of illnesses associated with thrombosis. Proper use of these agents will increase their efficacy and diminish the risk of serious hemorrhage.


Recurrent urinary tract infections. Therapeutic considerations. Urinary tract infections can recur because of bacterial persistence after chemotherapy or because of reinfection. Treatment of bacterial persistence varies with the cause. Chemoprophylaxis has helped to reduce the incidence of reinfection.


Chronic diarrhea in children.

Chronic diarrhea in children. Among the many causes of chronic diarrhea in children are food, the most common; inflammation; enzyme deficiencies; metabolic, anatomic, and physiologic abnormalities; and endocrine disorders. The first step in management is to estimate fluid losses and treat dehydration greater than 5%. Workup should include a careful diet history, physical examination, examination of stools and urine, and usually a sweat test. Treatment should be directed to the underlying disease.


Syndrome delineation. 2. Inborn errors of metabolism, deformities, and variant familial developmental patterns. Classification of genetic disorders and birth defects into the following five categories aids in efficient patient evaluation, prognostic counseling, and therapy: malformations, dysplasias, inborn errors of metabolism, deformities, and variant familial developmental patterns. These categories highlight different pathogenetic aspects of disease processes. Mixed disorders with manifestations from the different categories may be of special significance.


Primary Pseudomonas maltophilia infection of the lung. To our knowledge, this is the first reported case of primary Pseudomonas maltophilia pneumonia. Presenting symptoms were fever and chills of two days' duration and a density in the right upper lobe. Sputum culture showed normal flora, and multiple blood cultures were negative. Antibiotic therapy initially with penicillin and then with carbenicillin was unsuccessful. Selective bronchial aspiration yielded pure cultures of P maltophilia. When an appropriate antibiotic, chloramphenicol, was given, a prompt therapeutic response followed.


Vasospastic disorders.

Vasospastic disorders. Acute digital ischemia not due to thromboembolism may be the result of either a primary vasospastic disorder (Raynaud's disease, acrocyanosis, livedo reticularis) or vasospasm associated with a systemic, regional, or traumatic disorder (Raynaud's syndrome, cold injury). Raynaud's disease versus syndrome is distinguishable up to 95% of the time from clinical criteria.


Glucose-insulin-potassium infusion in acute myocardial infarction. Review of clinical experience. A solution of 300 gm of glucose, 50 units of regular insulin, and 80 mEq of potassium chloride in 1,000 ml of sterile water infused at a rate of 1.5 ml/kg of body weight per hour can alter the availability of glucose and free fatty acids to the myocardium. Clinical studies of patients receiving this infusion less than 15 hours after the onset of symptoms of acute myocardial infarction suggest a reduction in mortality, an improvement in left ventricular mechanical performance, and a reduction in cardiac irritability as beneficial effects. Swan-Ganz catheterization for hemodynamic, electrophysiologic, and metabolic monitoring is recommended. Diabetics who require insulin and patients with impaired renal function are not candidates for the infusion. Further clinical studies are required before conclusions can be reached regarding the efficacy of glucose-insulin-potassium infusion in attempts to salvage damaged myocardium.


Systemic lupus erythematosus as seen in primary care. Systemic lupus erythematosus does not wholly deserve its bad reputation. At the Kaiser-Permanente Medical Center in San Francisco, the ten-year survival rate among patients with the disease has been about 90%. Many clinicians no longer hold renal biopsy to be mandatory in cases of the disease, even if there is clinical evidence of renal involvement. Clinically significant renal involvement occurs in fewer than 10% of patients. Initiation of corticosteroid therapy when deterioration of renal function is demonstrable is recommended. Cytotoxic agents are seldom indicated.


The myth of senility. Diagnosing nonspecific major illness in the elderly. In the elderly, physical and mental concemitants of chronic and explainable ill health are often masked by the diagnosis of senility. The presentation of major illness in the elderly is commonly nonspecific, and a full physical examination and tests with special attention to infections and to the signs of endocrine and metabolic disorders should be carried out. Symptoms such as confusion and memory loss, hostile or difficult behavior, and dementia point to different probable causes, and the physician should carefully search for the underlying pathology.


Anticonvulsant therapy. Approaches to some common clinical problems. The anticonvulsants generally preferred for initial therapy of most seizure disorders are phenytoin for adults and phenobarbital for children. If seizures continue despite a high serum level of drug or the patient has symptoms of toxicity, another anticonvulsant may be added. A patient who is taking three or four drugs but still having seizures may benefit from adjustments in dosage, or if an epileptogenic focus is present, from surgical excision. Anticonvulsant therapy is usually continued indefinitely because of the continued risk of seizures. Newer drugs are becoming available, but none is free from side effects. Increasing attention is being given to the effect of anticonvulsants on the fetus.


Acute splenic sequestration crisis in an adolescent with S-C hemoglobinopathy. Acute splenic sequestration crisis occurs rarely as a complication of sickle hemoglobinopathy. It is a medical emergency requiring immediate restoration of intravascular volume with transfusions of fresh packed RBCs. If the blood of the patient under discussion had not contained strong irregular antibodies, the delay in blood transfusion and the subsequent fatal outcome might have been avoided. Whether young children with sickle hemoglobinopathies should be checked periodically for the presence of irregular antibodies is an unanswered question. Monitoring might be important in view of the small but definite risk during childhood of the development of acute splenic sequestration crisis.


Patient compliance to antibiotic regimens. A simple method of evaluation. Clinicians are often perplexed by patients with bacterial infection who are not responding to oral antibiotic therapy. Since most of the commonly used antibiotics are excreted in the urine, inhibitory activity of urine against susceptible organisms can be used as a measure of patient compliance. To assess the reliability of this technique, we studied 42 hospitalized patients documented to be receiving oral antibiotics. All urine samples from patients receiving oral antibiotics inhibited bacterial growth at a dilution of greater than or equal to 1:32, while none of the specimens from control patients inhibited growth. Subsequent experience in the outpatient clinic has corroborated the reliability and simplicity of this test as a measure of compliance in patients who are receiving antibiotics either for prophylaxis or for therapy of acute infection.


Cervical cytologic evaluation. And what to do when findings are abnormal. Detection and treatment of cervical carcinoma in the preinvasive stage have increased substantially as a result of the widespread cytologic screening made possible by development of the Papanicolaou test. The numerical system of reporting has been abandoned, and reports are now descriptive and more specific than formerly. Outpatient evaluation of the patient with abnormal cytologic findings has been improved by the use of colposcopy and directed biopsies. Cold cone biopsy is used less frequently than in the past but still has specific indications. Therapy depends on histologic diagnosis and cannot be based on cytologic or colposcopic findings alone.


Investigation of nonpoikilocytic normochromic normocytic anemia. When the mean corpuscular volume is normal in an anemic patient, examination of a blood smear becomes of paramount importance. When the RBCs are normochronic, normocytic, and nonpoikilocytic, the reticulocyte count determines the line of investigation. When the count is increased, either hemorrhage or hemolysis is present. When the count is not increased (ie, normal or low), the differential diagnosis includes anemias due to iron deficiency, chronic disease, renal disease, hemodilution, marrow infiltration, and marrow failure (aplastic anemia). Some morphologic clues to cause other than those pertaining to RBC morphology are discussed and illustrated. A working approach to the investigation of nonpoikilocytic normochromic normocytic anemia is suggested.


Prenatal diagnosis of genetic defects.

Prenatal diagnosis of genetic defects. A wide discrepancy exists between the number of amniocenteses performed for prenatal diagnosis of genetic abnormalities and the size of the population at risk of having offspring with these abnormalities. A small percentage of the women at risk are being offered amniocentesis. The optimal time for amniocentesis is 14 to 16 weeks of pregnancy. Preliminary ultrasonography is indicated in all instances. Highly specialized biochemical tests may be necessary and should be done at special centralized laboratories. The risk of complications of amniocentesis is 0.5% to 1%.


Osteoarthritis. Changing concepts in pathogenesis and treatment. The clinical features of osteoarthritis provide little support for the traditional view of the disease as a wear-and-tear phenomenon of aging. In many cases osteoarthritis consists of a polyarthritis with mildly inflammatory features, such as stiffness, effusions, and hot Heberden's nodes. The finding of biochemical abnormalities of cartilage throws new light on this enormously important disease and suggests the possibility of more effective therapy.


[Clinical uses of electrostimulation anaesthesia (author's transl)]. Since 1972 electrostimulation anaesthesia (ESA) has been employed in an attempt to reduce the amount of anaesthetic agents needed. In the beginning the Chinese combination of acupuncture points was used; at a later stage Benzer et al. inserted the needles paravertebrally and Abdulla replaced the needles by contact electrodes for ophthalmic operations. At the Department of Anaesthetics, Hamburg, the same course was followed, i.e. the classic acupuncture points were used originally, then the acupuncture points were used originally, then the technique was changed to paravertebral insertion of the needles and now only paravertebrally placed contact electrodes are being employed for inducing ESA for various surgical operations. All three techniques of ESA have proved satisfactory; but ESA with contact electrodes is considered the method of choice on account of both practical considerations and success rate.


[Characteristics of electrostimulation with the multi-purpose therapy apparatus 71-3 for electroacupuncture analgesia]. The stimulating impulses employed in electroacupuncture analgesia are of widely differing character and strength. Experiences with the Chinese impulse generator MPTA 71-3 clearly show the necessity to determine the performance of the generator and to measure and record the strength, configuration and frequency of the electrical impulses employed. A simple equipment for measuring these factors is described. The apparatus makes it possible to record the character and type of the stimuli and to compare different techniques of stimulation.


[Haemodynamic alterations after epidural anaesthesia in geriatric patients (author's transl)]. In 22 elderly patients haemodynamic alterations after epidural anaesthesia with Carticain 2% (Ultracain) with epinephrine (1:200 000) were compared to those after Lidocaine 2% with epinephrine. There were no differences to be found in these agents, and a less pronounced depressing effect of Carticain on circulation could not be confirmed. Unlike young people elderly patients only develop slight and short rises of heart rate and cardiac output after epidural anaesthesia, which are not sufficient to compensate for the distinct fall of mean arterial pressure up to the 15th minute. In our study mean arterial pressure decreased to critical values which might lead to cerebral and coronary ischemia in these patients. Adequate prophylactic and therapeutic measures are discussed.


[Haemodynamics of the systemic and pulmonary circulation during surgery of hip fractures in spinal anaesthesia in elderly persons (author's transl)]. The haemodynamics of the pulmonary and systemic circulation during anaesthesia and surgical treatment of a hip fracture were investigated in 26 patients (mean age 73 +/-  4.5 years). After induction of spinal anaesthesia the mean arterial pressure, right atrial pressure, pulmonary capillary wedge pressure and systemic vascular resistance were significantly reduced. The cardiac index remained constant due to mild tachycardia. During the operation no significant variations of the haemodynamic parameters were observed. Implantation of methylmethacrylate in 10 patients was followed by a significant increase of the mean pulmonary pressure and pulmonary vascular resistance. The PaO2 DECREASED. 15 minutes after implantation the original values were again reached.


[Problems of nerve block during prolonged surgery on the upper extremities (author's transl)]. Regional anaesthesia secured by injecting the supraclavicular plexus was used for 34 reconstructive surgical operations on the fingers and hands. The operations lasted for 5 1/2-19 hours. The advantages and disadvantages of the technique are reviewed. In 5 cases other anaesthetic techniques had to be substituted because the patients, despite sedation, could not tolerate the forced position any longer. Motivation, intensive psychic support during the operation, optimum positioning and the use of suitable sedatives are pre-conditions for the success of nerve block for prolonged surgery.


Long duration subarachnoid anaesthesia with continuous epidural block. A method of spinal anaesthesia with Dixidextracaine-70 (a mixture of xylocaine 40.0 mg + percaine, 10.0 mg+ Dextran-70, 60,0 mg+ distiled water ad 2.0 ml) with continuous epidural block has been tested in 150 patients. The advantages of this association are: the possibility of obtaining a high quality conduction anaesthesia, virtually unlimited in time, the ability to extend over several anatomical regions the surgical field, minimal toxicity, the absence of postoperative pulmonary complications, and the economy. Drawbacks are: the need for two vertebral punctures, the longer induction time of anaesthesia and some difficulty in finding the subarachnoid space after catheterisation of the epidural space. The indications of the method include subdiaphragmatic surgery, interventions on more than one anatomical region, surgery in aging patients, patients with full stomach, and those with anaesthetic and surgical risk, as well as socioeconomic factors which may prevent application of a differentiated and safe narcosis. those of subarachnoid and epidural block. The incidents and accidents are minimal and specific to both techniques. The fear of producing total subarachnoid anaesthesia by injection of the anaesthetic solution in the epidural space after puncture of the subarachnoid space is virtually unfounded.


[Anaesthesia for peripheral angiographies (author's transl)]. The anaesthetic requirements for peripheral angiographies in geriatric or poor risk patients are temporary sedation, analgesia and sufficient immobilisation. Neither general anaesthesia using muscle relaxants and assisted ventilation nor regional methods warrant satisfactory results in all cases, especially if multiple arteriographies are to be performed at the same session. Therefore a few new anaesthetic techniques were studied, having combined benzodiazepines with ultrashort acting intravenous narcotics. Premedication with Pethidin 1mg/kg, the administration of Flunitrazepam 0,017 mg/kg with regard to sedative, analgesic and relaxant effects and Methohexital 0.67 mg/kg as anaesthetic given prior to injection of contrast medium would seem more useful than other techniques.


[Electrostimulation anaesthesia for surgery of the limbs (author's transl)]. In Germany electrostimulation anaesthesia (ESA) has, so far, not been considered suitable for surgical operations on the extremities. An attempt was made to develop a combination of acupuncture points that would allow the use of ESA for this type of surgery. Based on the experience gained with ESA in abdominal surgery the suitability of paravertebral contact electrodes for operations on the limb was studied. Because of its simplicity and efficacy this technique of ESA is highly recommended.


[Gonadotropic regulation of ovarian function in patients with polycystic ovaries]. The authors studied the LH-125I binding by the interstitial tissue of 12 polycystic ovaries obtained after wedge resection of the ovaries in 6 patients. Prior to the operation the patients were differentiated by the LH, FSH, prolactin, and testosterone level. Disturbances of LH125I binding were revealed in the interstitial tissue of polycystic ovaries. The peripheral blood LH level did not correlate with disturbances of the LH125I binding.


[Changes in the myocardium during the early stages of dithizone diabetes development]. Sorption capacity, the content of catecholamines, cytochrome C, the activity of cytochromoxidase, of some tricarbonic acids cycle enzymes were studied in the myocardium of rabbits with dithizone diabetes of moderate severity. The detected electrocardiographic changes, hypoxia, disturbances of the hormone-mediator-enzymatic metabolism an increased affinity to the myocardial cell stain at the early periods of diabetes mellitus development permitted to regard cardiovascular affections in diabetes mellitus as a manifestation, not as a complication of the disease.


[Dynamics of cellular and humoral immunologic reactions following insulin administration to guinea pigs]. Prolonged daily insulin administration to guinea pigs induced humoral and cellular immunological reactions to insulin; the earliest phenomena were reactions of lymphocyte blast-cell transformation and delayed skin hypersensitivity. Inhibition of macrophage migration and immediate skin hypersensitivity, as well as circulating insulin antibodies appeared later. Following prolonged 3--6 month insulin administration the blast-cell transformation reaction to insulin becomes negative; as to other immunological reactions under study--they displayed sensitization to insulin.


[Morphologic studies of the placenta in alloxan diabetes]. Experiments were conducted on the placentae of 18 female Wistar rats. Alloxan diabetes was induced in prepubertal rats; in some of the animals diabetes was compensated by sulphanilamides before pregnancy. Histological examination of the placentae demonstrated that prematurity signs (the presence of cytotrophoblastic and giant cells in the labyrinth) and vascular affection were determined in the manifest alloxan diabetes. These changes were less pronounced in rats with compensated diabetes. It was demonstrated with the aid of contact microscope that, in comparison with the treated rats and control animals, rats with alloxan diabetes displayed in vivo a significant (p less than 0.001) increase of the number of vessels in the field of vision; it was also noted that in rats with alloxan diabetes and treated rats the vessels were tortuous.


[Antiandrogenic effects of 4-nitro-3-trifluoromethylisobutyrylanilide (niftolide) in prepubertal male rats during stimulation with exogenous gonadotropins]. Nonsteroid antiandrogen 4-nitro-3-trifluoromethylisobutyranilide (10 mg/kg per os from the 26th to the 37th day after birth) decreased the weight of the accessory sex organs, and levator ani muscle. DNA, RNA, and protein content in the ventral prostate and the seminal vesicles, the thickness of the secretory cell epithelium of the ventral prostate under conditions of stimulation of prepubertal male rat gonads with human gonadotropin (100 Units/kg subcutaneously from the 21st to the 37th day after birth). The mentioned effects were observed against the background of hyperplasia and hypertrophy of Leidig's cells and increase of the activity of steroid-delta5-3beta-ol-dehydrogenase of the testes activity. A conclusion was made that niftolide was capable of preventing or delaying the development of some signs of premature sexual maturation.


[Adenylate cyclase activity in human embryo adrenals]. Adenylate cyclase activity was studied histochemically in the human embryo adrenal glands by means of Reik's et al method modified for light microscopy. A negative or very weak reaction to adenylate cyclase in 7--8 week embryos was sharply intensified in 9-week-old embryos, and persisted up to 12 weeks. The reaction was the most intense along sinus capillaries of the provision zone where the enzyme apparently localized in the endothelium and the adjacent cytomembranes of adrenocorticocytes. The latter displayed activity in the areas which had no contact with the endothelium. Manifestation of high adenylate cyclase activity is regarded important for glandular cells differentiation in the adrenal glands.


[Incorporation of 3H-estradiol into elements of the tanycytic and ciliated ependyma of the 3d cerebral ventricle in experiments in vitro]. The label incorporation into the arcuate nucleus neurons, the tanicytic and ciliary ependyma of the mediobasal hypotahalamus, and also into the underlying nerve tissue after in vitro incubation of male Wistar rats hypothalamic tissue in the presence of 3H-estradiol was studied autoradiographically. After incubation at 37 degrees C, along with the nuclear localization of the label in the neutrons of the arcuate nucleus, characteristic of estradiol, high radioactivity was revealed in tanicytes; the label incorporation into beta-tanicytes was always higher than into the alpha2-tanicytes. Subsequent incubation of the tissue with nonlabeled estradiol led to reduction of beta-tanicytes radioactivity; as to ciliary ependyma and alpha2-tanicytes radioactivity--it rose. Reduction of incubation temperature to 22 degrees C failed to alter the character of the label incorporation into tanicytes. The data obtained confirmed the possibility of participation of the mediobasal hypothalamus tanicytes in the realization of the estradiol action of the hypothalamus.


[11-azasteroids. V. Hormonal properties of 11-azaestranes]. Experiments were conducted on sexually-immature female rats, ovariectomized mice and castrated male rats. Hormonal properties of some 11-azaestran were studied. As shown, introduction of azafunction into the position of the 11 molecule of the steroid sharply reduced the hormonal activity, irrespective of other functions in the molecule determining the reference of the steroid to the estron, estradiol, or 19-nortestosterone series.


[Progestagen and contraceptive activity of a 16alpha-methylene derivative of progesterone]. Data of experimental character reflecting the pharmacological activity of 16alpha-methylene derivative of progesterone--melengesterol acetate--are presented. A high progestagenic activity of the preparation was revealed in a series of tests, namely, the appearance of secretory changes in the uterine endometrium of infantile female rabbits and persistence of pregnancy in ovariectomized rabbits. A high contraceptive activity not accompanied by suppression of ovulation was found in administration of the preparation in low doses combined with mestranol.


[Cytochemical and histoautoradiographic analysis of changes in the epithelium of the submandibular gland of white rats following ovariectomy]. The author considers the dependence of the changes in the submaxillary gland epithelium in albino rats on the female sex hormone balance. Histochemical peculiarities of the secretory cells of the gland following ovariectomy were studied. The intensity of RNA and protein synthesis was studied by means of histautoradiography. The change of the nuclear and cytoplasmic area of the acinar cells, reduction of the RNA synthesis in all the gland parts after ovariectomy were demonstrated. The secretion synthesis intensity was disturbed; also the histochemical composition of the product secreted was altered. There occurs "masculinization" of the submaxillary gland epithelium in female rats, and secretion characteristic of males of these animals appears.


Effect of coadministration of procainamide and isoniazid on each other's acetylation pathway. The effect of isoniazid (INH) and procainamide (PA) on each other's acetylation pathway was studied in 7 normal subjects (3 rapid acetylators, 3 slow acetylators, 1 of indeterminate phenotype). Oral PA (6 mg/kg) was administered every 4 h for a total of seven doses. Following the final dose subjects received a single 300-mg oral dose of INH. Analysis of the parent drugs and their acetylated metabolites in plasma and urine revealed no effect on the acetylation of either drug. In 2 subjects (1 rapid, 1 slow acetylator) increasing doses of PA were given and the effect on INH (300 mg) acetylation measured. High mean circulating levels of PA (7.1 microgram/ml) appeared to inhibit acetylation of INH in the rapid acetylator whereas a mean PA plasma level of 8.6 microgram/ml had no effect on INH acetylation in the slow acetylator. However, the results from this study suggest that alterations of INH acetylation by PA are unlikely to be of clinical significance.


Effect of epinephrine and alprenolol on ethanol metabolism, liver cell respiration and mitochondrial function. Chronic administration of epinephrine to adult male rats resulted in a significant increase in the rate of ethanol elimination, when given alone or together with the beta-adrenergic blocker alprenolol. This effect was observed concomitantly with an increased hepatic oxygen utilization and no changes in mitochondrial respiratory functions. Epinephrine given acutely did not modify the rate of ethanol metabolism. Blood glucose levels were enhanced in these conditions, but were unaffected in rats treated with epinephrine plus alprenolol. These results suggest that chronic epinephrine treatment induces an increased oxidative capacity in the liver characterized by enhanced rates of oxygen uptake and ethanol metabolism, which is not related to its beta-adrenergic actions.


Sex-related differences in biotransformation of aniline hydroxylase in Sprague-Dawley rats. A significant difference was found in the rate of aromatic hydroxylation of the type II substrate, aniline, between male and female rats of the Sprague-Dawley strain. In addition, microsomal cytochrome P-450 levels were significantly lower in female rats and aniline-induced spectral binding was significantly greater in microsomes isolated from male rats. Castration caused a significant reduction in aniline metabolism in male rats and testosterone treatment elevated this metabolism toward control level. Treatment of male rats with 17beta-estradiol significantly reduced aniline hydroxylase activity and female rats receiving testosterone for 1 month exhibited significantly increased rates of aniline metabolism over control females. Enzyme activities measured in immature male and in mature and immature female rats were all significantly lower than in mature male rats. These results suggest that the metabolism of aniline in Sprague-Dawley derived rats is controlled by androgen and, thus, is sex-dependent.


Development of a classification rule for four clinical therapeutic psychotropic drug classes with EEG power-spectrum variables of human volunteers. An objective rule for the classification of psychotropic substances has been developed. Classification is based on data from five basic studies simultaneously designed and performed and involving 75 healthy volunteers who ingested 20 different psychotropic drugs and 5 placebos in single oral dosages. Each volunteer took one psychostimulant, one antidepressant, one neuroleptic, one minor tranquilizer and one placebo in a double-blind Latin square cross-over design. The variables were 6 frequency bands, based on power spectrum estimates and determined by factor analysis, plus total power in the 1.5-30.0 Hz range. An objective classification rule was established by multi-group (5 groups) linear discriminant analysis. Reclassification of the substances by the new rule yielded correct results for 17 out of 20 psychotropic drugs and 4 out of 5 placebos. Of placebos from various studies not used for the establishment of the classification rule, 7/9 were classified correctly. The validity of the rule for other classes of substances will have to be verified in independent studies.


HZI systems for EEG parametrization and classification of psychotropic drugs. The EEG effects of twenty, clinically most frequently used psychotropic drugs and five placebos were studied in 75 male volunteers in five simultaneously designed basic studies. In each of the five studies single oral dosages of five drugs (well known representatives of neuroleptics, antidepressants, anxiolytics and psychostimulants, as well as placebos) were investigated in 15 subjects in a double-blind latin-square research design using the methods of the Quantitative Pharmaco-EEG. The results demonstrated that the therapeutically equivalent effective compounds also have similar effects on human EEG. With a classification rule, based on discriminant function 20, and with a classification rule, based on correlation statistics 19 of 25 compounds could be reclassified into correct clinical-therapeutic psychotropic drug groups. It is suggested that CEEG is an important tool in predicting and describing psychotropic properties of compounds, and should routinely be used in psychotropic drug development.


Evaluation of pharmacodynamic properties of psychotropic drugs: quanitative EEG, psychometric and blood level investigations in normals and patients. Quantitative EEG analyses in combination with certain statistical procedures may be utilized in order to classify psychotropic drugs and to determine their cerebral bioavailability. Psychometric tests including evaluation of attention, concentration, psychomotor activity, critical flicker frequency, reaction time, Archimedean spiral, mood and affectivity, may add valuable information about a drug's psychotropic and pharmacodynamic properties. As was seen in studies involving a new pyridodiazepine, short-term drug effects in the EEG of normals are predictive of EEG and clinical effects in patients. Pharmaco-EEG profiles of lopirazepam were found similar in normals and alcoholic patients with an anxiety syndrom as far as the type of changes was concerned, although some quantitative differences were observed. As previously described, quantitative EEG changes during treatment were correlated with clinical improvement or deterioration. Moreover, there is some evidence that single dose effects in the EEG of patients may eventually be utilized to predict therapeutic outcome with a certain drug. Finally, relationships between blood level, quantitative EEG and psychometric changes after administration of phentermine and oxazepam are described and discussed.


Is a man, a man, a man? (or: is an EEG, an EEG, an EEG?) some remarks on the homogeneity of "normal subjects". Many studies involving computerized EEG analyses are based on the assumption that normal subjects constitute a homogeneous population, so that under specified conditions across-subject averaging is justified. Quite often EEG signals are processed with little or no concern for the state of the particular person from whom they are obtained. It is the purpose of this discussion to draw attention to the fact that only can normals have different EEG's one from another, but also that the same ones can display markedly different EEGs from recording session to recording session. A consequence of this situation is that there is always a large between-subject variability, and that the source of the signals needs to be carefully documented before generalizations can be made.


Orthopedic manual therapy--an overview. Part II: the spine. The focus of this article is orthopedic manual therapy for the spine: 1) precautions and contraindications for manual methods of treatment; 2) definitions of general terms for therapeutic techniques of mobilization and traction; and 3) the general concepts and the evaluation, treatment, and aftertreatment procedures of James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geoffrey Maitland, MAPA, FCSP; and John McM. Mennell, MD.


Contract learning.

Contract learning. The learning contract format can be used to provide a learning situation that encourages individuality, flexibility, and mutuality. General components of the learning contract are formats, roles, climate setting, goal setting, resources, timing, and evaluation. Suggestions are made for applying the learning contract to self-directed continuing education for physical therapist educators, clinical physical therapists, and individual physical therapists.


Effect of pelvic-femoral position on vertebral separation produced by lumbar traction. The purpose of this study was to determine the relationship between hip position and the amount of vertebral separation produced by intermittent lumbar traction. Ten subjects received intermittent lumbar traction at a force of 31.8 kg (70 lb) for 15 minutes in each of three positions of hip flexion (supine): 0 degrees, 45 degrees, and 90 degrees. Vertebral separation was measured on lateral roentgenograms by outlining and marking the vertebral bodies and measuring interspaces with fine-point calipers. Except for the T12-L1 interspace, traction produced greater posterior interspace separation as the angle of hip flexion increased from 0 to 90 degrees. These differences were statistically significant at interspaces L4-5 and L5-S1. We found no systematic changes in anterior interspace distance. To produce maximal posterior vertebral interspace separation, pelvic traction should be applied with the hip flexed 90 degrees.


Toward understanding the terminology of exercise mechanics. The purpose of this paper is to reduce the confusion and misunderstanding of exercise mechanics terminology by giving simplified definitions of the most important physical quantities and terms. Isometric, isotonic, and isokinetic exercises are discussed and related to the appropriate physical quantities. The correct use of the most confusing and frequently misused terms is discussed.


The Cyrano nose: a clinical review of hemangiomas of the nasal tip. It is always difficult to establish one preferred management program for all patients with any lesion, but serious consideration must be given to "no-touch" management of cavernous or capillary-cavernous hemangiomas of the nasal tip. This requires frequent consultations with the parents to furnish psychological support. If extreme pressure from the parents makes surgery inevitable, the operation should be limited to the immediate confines of the nasal tip.


Predicting the course of a congenital hemangioma. We report a series of 10 congenital hemangiomas which have been followed by serial examinations with the Doppler apparatus, to determine persistence of and increase in A--V fistulae, or a decrease in same. We believe the data on the A--V fistulae correlate inversely with the likelihood of spontaneous regression and involution.


Cornifying Darier's disease.

Cornifying Darier's disease. Five patients with cornifying Darier's disease were treated successfully by partial-thickness resection of the skin and dermabrasion down through the papillary dermis into the reticular dermis. Healing was quick and the complication rate was low. Although some lesions recurred, all of these 5 patients have been able to return to full work and are now employed. The histology and genetics of the disease are discussed.


Rhytidectomies in office operating rooms. We report our experiences in 100 consecutive face lifts done in a well-equipped office operating room, and we believe the results answer the question about the safety of face lifts being done in this manner in a carefully screened population. With the application of our preoperative criteria for patient selection, the complication rate in these outpatients compares favorably with the reported rates in inpatient series of face lifts. Patient satisfaction has been higher, we feel.


Use of pectoralis major muscle flaps to repair defects of anterior chest wall. We closed defects of the anterior chest wall in 6 patients, using either unilateral or bilateral pectoralis major muscle flap transpositions. In 4 of these patients the defect was stabilized with autogenous rib grafts, and none of these had a flail chest. All of the transposed muscle flaps remained viable and innervated. The deformities and the functional disturbances resulting from the transpositions were minimal.


Review of long-term results in supportive treatment of facial paralysis. We have reviewed approximately 150 patients who were treated with supportive measures for facial paralysis. We found that in the patient's view an adequate result requires establishment of a proper lip sphincter--either by restoring muscular tone, or by creating an anatomical framework to which can be added either a motor unit or stabilization to aid the opposite intact muscle. We also found lasting value from dampening contralateral spasticity, and from the use of such ancillary procedures as the face lift, the brow lift, and the creation of a nasolabial fold. It is important for the physician to help the patient acquire a tranquil face during speech and emotion by persevering in mirror training and mimetic gymnastics.


Clinical experiences with Proplast as an implant. We report our experiences with 38 Proplast implants to the face, with 33 results which we classified as good. The material seems to be biocompatible, and because it is porous there is rapid tissue ingrowth into it.


Reduction mammaplasty with a single superiorly-based pedicle. We have reduced 68 breasts in 34 women, transposing the nipple-areolar complex on a single superiorly-based pedicle. The complication rate was 4.4 percent. The method appears to be safe, and it produces better shaped breasts than we obtained by operations using double pedicles.


Management of radiation necrosis and advanced cancer of the chest wall in patients with breast malignancy. Aggressive resection, with individualized reconstruction by several methods, is of value in many patients with radiation necrosis and/or advanced breast cancer of the chest wall. Although this does not always significantly lengthen survival, it can improve the quality of life markedly in many instances. Remarkably large defects can be reconstructed with single-stage procedures.


Experimental evaluation of microarterial grafts in rats and rabbits: long-term histological studies. This experimental study was done to compare the fate of microarterial grafts versus microvenous grafts. Based on morphological aspects, patency rates, and histological features, the arterial grafts gave better long-term results than the venous grafts--due mainly to an absence of subintimal fibrotic changes in the microarterial grafts.


A complication of a transareolar augmentation mammaplasty. A case of sudden development of a small tender mass in the breast, one year after an augmentation mammaplasty, is presented. This mass was found to be a herniation of the implant in the region of the previous incision.


Pulmonary embolism associated with hemolymphangioma of lower extremity. We present a case of major pulmonary embolization from a hemolymphangiomatous malformation of the loin and lower extremity. Treatment was with a low-dose infusion of urokinase for a short period directly into the pulmonary artery, and dramatic clinical improvement was noted. Prolonged maintenance therapy was with a low dose of heparin.


Outpatient breast surgery under intercostal block anesthesia. During the past 3 years, we have performed various breast operations in 320 patients under local anesthesia, using intercostal nerve block. The amount of local anesthetic solution required has been about 20 ml 1% lidocaine for blocking both sides, and an additional 24 ml of 0.5% lidocaine during the surgery. This dosage is well within safe limits. We have found that various breast operations, ranging from augmentation mammaplasty to a staged reconstruction after mastectomy, can be done with this method of anesthesia. The complications attributable to the nerve block were nil in our series.


Facial bone changes with vascular tumors in children. Deformities of the adjacent facial bones are common with large vascular tumors. Most hemangiomas will resolve spontaneously, but the incidence of resolution appears to be quite low when the adjacent bones are affected. In these, we have used high dosage corticosteroid therapy in the early cases, particularly those involving the orbit. Surgical excision has been used in most of the other cases, with reasonable improvement.


Concentric circle operation for massive gynecomastia to excise the redundant skin. A technique is described for excising the excess skin in gynecomastia operations, using a concentric "circle" design to remove a calculated amount in the vertical in the horizontal directions. The sole residual scar is a circular one around the periphery of the areola.


A cost analysis of office plastic surgery. A cost analysis of doing surgery in an office operating suite is presented, and other possible benefits to patients and physicians of this type of practice are commented upon.


Use of a muscle flap in lower blepharoplasty. An adjunctive technique for lower lid blepharoplasty is presented. This operative procedure uses the principle of anchoring the upper margin of the lower lid by suturing a triangular muscle flap from it to the lateral-superior part of the orbital rim. This more effective support for the lower lid margin permits one to excise more redundant tissue without getting an ectropion.


Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. With the increasing popularity of platysmal face lifts, the anatomy of the cervical branch of the facial nerve should be noted. The postoperative appearance of lack of ability to retrude the corner of the mouth, in someone who had a "full denture" smile preoperatively, could possibly be due to severance or stretching of the rami of the cervical branch of the facial nerve--rather than an injury of the facial nerve of the marginal mandibular branch.


Transfer of a large, single temporo-occipital flap for treatment of baldness. A technique is described to correct male pattern baldness by transferring a large, single, temporo-occipital flap after one delay.


Ear cartilage grafts to the nose.

Ear cartilage grafts to the nose. We present our experience in the treatment of secondary nasal deformities caused by excessive resection of the nasal dorsum. We have used ear cartilage autografts, with good results and (on the whole) little or no resorption (some have been followed for 10 years). We consider it essential to correctly shape the transplant and to hold it firmly in the proper position for a period of not less than one week.


Experimental studies on the effects of tension on intraneural microcirculation in sutured peripheral nerves. Tension on an end-to-end nerve suture causes injury to the intraneural vessels. Impairment of the transverse anastomoses occurs first, followed by degeneration of the intrafascicular vessels. The the transverse anastomoses undergo complete degeneration, and the extrafascicular vessels also sustain severe damage. This series of circulatory disturbances is an important factor to consider when determining the advisability of an end-to-end nerve suture.


Epigenetic regulation of the shape and position of the auricle in the rat. We hypothesized that epigenetic (non-genomic) factors, related to muscular function, significantly regulate the shape and position of the auricular cartilage. We tested this experimentally by doing unilateral partial and total facial neurectomies, auricular myectomies, and ear rotations with skin excisions in rats. The neurectomies produced muscle atrophy, abolished the horizontal scaphoid ridging, and produced characteristic changes in the auricular shape. The myectomies of extrinsic auricular musculature alone were followed routinely by complete muscle regeneration and no changes in shape. The auricular rotations, with skin excision, produced an antihelix-like complex analogous to the human ear--a configuration that was permanent and was accompanied by muscle relocation. The findings are believed to support our hypothesis.


Elastic cartilage choristoma of the neck. Two cases of elastic cartilage choristoma in the skin and subcutaneous tissues of the lower midline of the neck are reported.


[The value of a systemic method for radiologic examination of the stomach (author's transl)]. A method for systematical examination of stomach is described. The exporation is done with different technics (double-contrast, full-filling, compression). Films are taken in 13 positions. The purpose of the method is, to get an exact documentation of all parts of the stomach and to raise the number of detected lesions. Further, the training of young radiologists will be easy and more effectiv.


[Radiologic findings on crohn's disease of the adult (author's transl)]. Roentgen signs of 42 patients with Crohn's disease are reported. Characteristic features are stenosis [30], fistulas (30), cobble-stone formation (14), asymetry of lesions (12), and thickening of the mucosal wall (10). Main locations are the ileum, predominantly its terminal part (32). The frequency of colon involvement has increased compared with earlier publications. 1 fistula between colon and urinary bladder is described as a rare type of tract formation. In comparison with a study of Hanke et al. (1978) in children there is no significant change in frequency distribution reported.


[The significance of x-ray-examination in early diagnosis of colon carcinoma compared with colonoscopy (author's transl)]. The medical literature and our own observations show the importance of x-ray examinations to diagnose colon carcinoma. The conventional barium enema examination without double contrast is not suitable for a general medical check-up. In contrast to the diagnostic value of the conventional procedure, the diagnostic accuracy of double contrast examination is comparable to that of the colonoscopy. In 1108 patients, endoscopically proven polyps smaller than 1 cm were detected in 61%, whereas the percentage for polyps bigger than 1 cm was 87. These results are achieved only in patients with a sufficient preparation. Two of 25 colorectal carcinomas were detected neither by endoscopy nor by the double contrast method.


[Duplication of the gallbladder. A rare anomaly, more often a diagnostic error (author's transl)]. A case of true duplication of the gallbladder and three cases with roentgen signs simulating duplication are reported. In true duplication the diagnosis was made by routine cholecystography which showed a double gallbladder with ductular shape. In three cases the cause for an incorrect diagnosis by cholecystography were an ampullary right renal pelvis visualized by heterotopic renal excretion of the contrast medium, a short loop of the first and second part of the duodenum and a diverticulum at the outer border of the duodenum.


[Analysis and differential diagnosis of gastric impressions (author's transl)]. Based on the vector principle conceived by Whalen pertaining to the spreading of intra abdominal space occupying lesions, the attempt was made to analyse impression effects of the gastric wall and to demonstrate their relevance for differential diagnosis. An examination technique (hypotensive double contrast technique), suitable for adequate assessment, applicable also to minor alterations, is being described.


[Cinedensitometric documentation of a catheter-induced spasm in the carotid siphon (author's transl)]. During a transfemoral cerebral angiography spasm of the carotid siphon was to be observed. This circulatory disturbance has been recorded by angiocinematography and evaluated by cinedensitometry. The analysis of the catheter-induced spasm is intended as a contribution to the etiology and the pathophysiology of vasospasm in man.


[Thibièrge- and Weissenbach-syndrome (author's transl)]. Subcutaneous and periarticular calcium deposits in progressive systemic sclerosis usually appear due to prolonged disease. One case with 40 years' duration is demonstrated which developed extensive subcutaneous and periarticular calcium deposits as well as soft tissue calcifications around old fractures.


[Radiological reporting systems. The viewpoint of the central radiodiagnostic department in an university hospital (author's transl)]. The use of automatic Roentgen diagnostic reporting systems is limited. Therefore, the capabilities of these systems should be expanded, and should include an integral patient identification as well as relevant data regarding the clinical patient information. By this way, appropriate data considering payments and statistics can be collected. In addition, there is selective access to the data from previous investigations. Thus, the evaluation of the entire information about a patient, including a verification of previous diagnosis is possible. Based on the radiology reporting system of Wheeler (Sirep, Siemens Ltd.) and of Vadraux-Vernier (Sacre, CGR, Ltd.), an additional set of input and output parameter is described as well as their use in a system comprising a small central processor and large external storage unit.


Management of dementias.

Management of dementias. Our best hope of helping patients who appear to be demented lies in the painstaking diagnostic evaluation of each such patient whom the physician encounters. The first step is to separate out those patients who appear to have organic dementias but in fact do not. These pseudodemented patients, i.e., patients with functional psychiatric disorders mimicking dementia, often have an excellent prognosis. Next, in those patients with diffuse organic dysfunction, a diligent search must be made for those disorders that are amenable to specific therapy. Good evidence is available to demonstrate that thorough diagnostic evaluation pays off in the identification of a significant proportion of treatable disease. Even when no treatable disease can be identified, treatment of coexisting medical and physical problems, environmental manipulation, and pharmacologic therapy can do much to alleviate the patient's plight.


Gas exchange in the parabronchial lung of birds: experiments in unidirectionally ventilated ducks. Pulmonary exchange of O2 and CO2 was measured in unidirectionally ventilated ducks in an attempt to determine lung O2 diffusing capacity, DO2. Perfusion shunt (= venous admixture) was estimated from O2 exchange in hyperoxia, and the ventilation shunt (ventilation of non-perfused parallel lung units) was estimated from exchange of the highly soluble inert gas, chloroform. Differences in the ventilation/perfusion ratio of parallel lung units were assessed from measurement of CO2 exchange using a parallel two-compartment model. DO2 values were calculated accounting for ventilation shunt, perfusion shunt, and inhomogeneity. Perfusion shunt averaged 2.7% and ventilation shunt, 9.4%. The ventilation/perfusion ratio in the two compartments differed on the average by a factor of 2.6. The uncorrected values of DO2, not accounting for lung inhomogeneities, progressively declined with increasing inspired PO2, but this dependence was less pronounced after correcting for lung inhomogeneities. The corrected value of DO2 averaged 100 mumol . min-1 . torr-1 for ducks of 1.8 kg mean body weight. DO2 did not differ when nitrogen was replaced by helium in the ventilatory gas indicating that diffusion within the air capillaries did not contribute a significant resistance to O2 uptake. The results suggest that neither functional inhomogeneities nor diffusion between lung gas and blood limit O2 uptake of the resting duck. Under conditions of elevated metabolism, however, these parameters may become rate-limiting for O2 supply.


Involvement of thoracic nerve afferents in the respiratory response to chest compression. Chest compression elicits extravagal neural reflexes which can alter the respiratory pattern. Experiments were conducted to determine the source of the afferents responsible for the respiratory response to chest compression (CC). The effects of CC on VT, f, TI, TE, blood gases, end-tidal CO2, and blood pressure were studied in anesthetized, vagotomized dogs and cats. In dogs, thoracic wall afferents were eliminated by thoracic dorsal rhizotomies (TDR) and/or spinal blocks (SB). There were two different respiratory responses to CC. In one (I), Tt decreased and TE increased, resulting in a decreased f. The second (II) resulted in a decreased TI and TE. The I response was still present, but weaker, in animals after TDR (1--4), TDR (5--9), TDR (1--9, T5 or T10 SB and absent in those with T1SB. The II response was still present after TDR ()--4), TDR (5--9), TDR (1--9), or T10SB and absent after T5SB. The results indicate that: (1) afferents responsible for the I response to CC arise from the upper, middle and lower thoracic wall, (2) afferents responsible for the II response arise from the middle and lower thoracic wall, and (3) the responses are not due to changes in chemical drive, blood pressure or lung receptors.


[On the pathogenesis of unilateral kerley-b lines (author's transl)]. Histological and roentgenological synopsis on the importance of lymphangiosis carcinomatosa for the occurrence of unilateral Kerley-B lines.


[The unilateral pulmonary oedema (author's transl)]. 6 cases of unilateral pulmonary oedema give rise to discuss the causes of the atypical distribution of pulmonary oedema by means of the literature on hand as well as to consider differential diagnosis in view of pulmonary infiltrates of other origin. Knowledge of the possible unilateral manifestation of pulmonary oedema is necessary to introduce early effective therapy.


[The value of scintigraphy and osteoscintimetry for the early detection of legg-calvé-perthes disease (author's transl)]. Scintigraphy and the stimultaneously effected osteoscintimetry of the pelvis and of both hip joints offers the possibility of a safe early diagnosis of Perthes' disease directly after manifestation of the clinical symptoms, two months before the roentgenologically identifiable, discrete changes of stage I have occurred, or four months before the clear roentgenological visualisation of the disease (stage II). Moreover, scintigraphy enables detection of the time at which restitution or revascularisation of the necrotic bone of the epiphysis of the head of the femur sets in, and to draw further conclusions from the scintigraphic and scintimetric pattern of results, on the prognosis and further course (with time) of Perthes' disease.


[Arthrographic proof of loosening of the acetabulum following total endoprosthesis of the hip joint (author's transl)]. Arthrography is a useful method to prove the loosening of the cup after total hip replacement. Contrast medium seeping between the bone and acrylic is an unequivocal sign of loosening. False positive diagnoses are unknown. Because of the risk of infection, arthrography is only indicated, if plain films and push-pull-roentgenograms are not significant. Possible errors and complications are discussed.


[Dose and time-saving fluoroscopy by means of immediate reproduction of a high-quality stored image (author's transl)]. A report is given on a special unit for use with an X-ray television chain, which permits the immediate reproduction of views stored during fluoroscopy, and thus speeds up the establishment of a reliable diagnosis. The stored images are also available during the examination. They clearly show whether the phases of functional processes needed for assessment purposes are actually represented. The result is that additional radiography is avoided, the patient subjected to less exposure the examination procedure shortened. A comparison with the corresponding 100 mm image intensifier views in clinical examples shows that the quality of the stored image is completely adequate for the establishment of the diagnosis.


[The efficacy of chemotherapy in the treatment of cancer of the breast (author's transl)]. The article reports on two female patients with cancer of the breast who had primarily not been treated by surgery or exposure to radiation, but only with cytostatics. Complete remission of the tumour occurred in both patients in the course of several years of treatment. These two examples show that in patients with cancer of the breast in stages which appear refractory and hopeless, a treatment course with cytostatics should be attempted.


[Which arguments favour radiation therapy in induratio penis plastica? (author's transl)]. Vitamin E and percutaneous irradiation are the most common treatment regimens of Peyronie's disease. This report presents the results of 49 patients irradiated with 137Cs gamma rays. 28 of them had also received Vitamin E. An objective improvement was achieved in 37 patients (75%). Vitamin E did not show any additional benefit. In spite of the fact that these results do not permit an objective evaluation of both treatment regimens, the following advantages of radiotherapy should be considered: a) short treatment time b) low costs c) no serious side effects.


Evidence that soluble products released by PHA-stimulated human lymphoid cells activate immunosuppressive monocytes. Soluble mediators, lymphokines, released by stimulated lymphoid cells can modify immunological responses in several ways. In this investigation we have examined whether the supernatants of phytohaemagglutinin (PHA)-activated human lymphocytes (active SUPs) contain factors that can suppress proliferative responses of lymphocytes in vitro. The results have shown that crude preparations of peripheral lymphoid cells incubated for 24 h in active SUPs can suppress the responses of cocultured autologous lymphocytes to PPD tuberculin in vitro. Their suppressive activity was not abolished by mitomycin treatment. Some reduction of phytomitogen responses was also noted. Maximal suppressive activity was obtained within 24 h of incubation in active SUPs and it could not be induced in cell preparations depleted of monocytes-macrophages. Similar results were obtained by treating lymphoid cells with lipopolysaccharide from Escherichia coli, which is a known activator of monocytes. These results thus show that lymphokines released by stimulated lymphoid cells can activate monocytes-macrophages in such a way that they become immunosuppressive.


Incompatibility between complement components C3 and C5 of guinea-pig and man, an indication of their interaction in C5 activation by classical and alternative C5 convertases. The use of heterologous combinations of guinea-pig and human complement components for titration of C5 with convertases of the alternative and classical pathway has been investigated. In addition to the known unfavourable combination of C2hu with C4gp partial incompatibilities were detected between heterologous C3 and C5 as well as between CZhu and C5gp. The incompatibility between heterologous C3 and C5 is of special interest since it indicates an interaction of these two non-enzymic components. Concomitant binding studies have demonstrated that a reduced efficiency of C5 convertases correlates with decreased binding affinity of surface-fixed C3b for C5 when heterologous components are offered. Hence, the present studies give further evidence that surface-bound C3b has the function of a co-factor which binds C5; this interaction is required for C5 activation via the classical as well as the alternative pathway, i.e. by the C3/C5 convertases C42 and C3bB.


Bacterial endocarditis. II. A prospective study with clinical, laboratory and therapeutic observations. In a prospective study 31 cases of proved and 10 of highly suspected bacterial endocarditis were analysed. Valve incompetence was the usual consequence but stenosis occurred in 3 cases, all fatal. Congestive heart failure developed in two-thirds. Secondary manifestations were common and as often caused by alpha-streptococci as by other bacteria. Initial antibiotic treatment was mainly applied according to a fixed schedule, generally with continuous intravenous infusion, followed by oral therapy. In 10 patients, the infection was still active after 6 weeks of therapy. Therefore, we now use intermittent injections or infusions for at least 4--6 weeks. Within a year, 9 patients died from uncontrolled infection together with congestive heart failure, and 1 from heart failure and active chronic endocarditis. In 4, myocardial abscesses or inflammations were found. All 10 had underlying factors or advanced stages of the disease. Of 18 patients with alpha-streptococci or enterococci none died from endocarditis, as against 10 of 23 with other or unknown bacteria. Follow-up yielded valuable information on one-third of the patients. The mortality during the initial hospital stay was 22%, after 1 year 24% and after 5 years 39%.


Pseudomonas cepacia in 16 non-fatal cases of postoperative bacteremia derived from intrinsic contamination of the anaesthetic fentanyl. Clinical and epidemiological observations in Denmark and Holland. From Nov. 15 to Dec. 17, 1977, Pseudomonas cepacia was isolated from the blood of 16 patients in Odense, Denmark, and Nijmegen, Holland, 2--5 days after an operation with general anaesthesia. The fever started 14--70 h after operation and lasted 2--4 days. All patients recovered. 14/15 patients examined 7--51 days later had agglutinating antibody titres of 400-3,200 against the epidemic strain. Ps. cepacia with identical biochemical characters and sensitivity pattern was isolated from unbroken vials containing the anaesthetic fentanyl, which had been given to all 16 patients. Two batches were contaminated, one heavily so (10(4)--10(5) cfu/0.1 ml). Seven other batches examined yielded no growth. The preservative added to the vials was a mixture of methyl- and propyl-p-hydroxybenzoates which not only allowed growth of the Ps. cepacia strain but could also serve as a carbon source as did citric and malonic acids. The concentration of preservative was not reduced in contaminated vials. The vials had not been sterilized after closure; too much reliance had been placed on an aseptic technique and insufficient preservatives.


Correlations between clinical and postmortem findings in listeriosis. Clinical data were correlated with postmortem findings in 14 cases of fatal listeriosis in adults and 23 cases of listeriosis during pregnancy and the neonatal period. Most children born with congenital listeriosis showed the typical morphological picture of granulomatosis infantiseptica. Occasionally no pathological changes were demonstrable. In adult patients the morphological lesions were those of non-specific purulent meningoencephalitis or septicemia. Sometimes encephalitis with abscesses in the brain was found.


Epidemiology of listeriosis in Sweden  1958--1974. In 1958--1974 altogether 110 cases of listeriosis were diagnosed in Sweden by culture. 64 cases were seen in children and adults. Of these, 52 had manifestations of meningoencephalitis and 10 of septicemia. Another 46 cases were seen in pregnant women and/or their neonates. Pregnancy ended in abortions in 8 cases and in stillborns in 3. Out of 37 neonates born alive, 22 had "early disease", mostly granulomatosis infantiseptica, and 8 had "late disease" with meningoencephalitis. The reported frequency of listeriosis in humans showed no correlation with that in animals. With the exception of pregnant women the incidence and mortality showed no difference with sex. Serotypes 1 and 4b prevailed and were equally common. The serotype did not vary with the clinical diagnosis or the outcome. There was no seasonal variation. Cases of all serotypes were uniformly distributed over the country in proportion to the density of its population. Occupational contact with animals was less common. Only in a few cases was there reason to suspect infection from animals. Co-existing disorders predisposed for the disease and often determined its outcome. Neonates with early onset of disease were infected by their mothers, while neonates with late onset of disease were infected from other and often nosocomial sources.


Lysozyme activity and immunoglobulins in middle ear effusion fluid in acute purulent otitis media and in otitis media with effusion. 147 samples of punctured middle ear effusion fluid from cases of otitis media with effusion and 150 samples from patients with acute purulent otitis media were tested for lysozyme activity. In otitis media with effusion the concentration was 182.0 U/ml, in acute otitis 433.8 U/ml. The lysozyme concentration in otitis media with effusion depended upon the nature of the effusion. Serous fluid showed an activity of 124.8 U/ml and mucoid 311.6 U/ml, respectively. In culture-positive cases of acute otitis media the lysozyme level was 423.4 U/ml. Culture-negative cases showed about the same concentration, 438.3 U/ml. The possible role of lysozyme in defence systems of the middle ear is discussed.


Treatment of anaerobic infections with metronidazole. Metronidazole (Flagl), a compound widely used in man with minimal side-effects, has been used in the treatment of anaerobic infections caused by Bacteroides fragilis and other Bacteroides species. Seven patients were treated and all were restored to full health. Four of them did not respond to lincomycin or clindamycin which so far have been the drugs of choice against anaerobic infections. The reasons for the good results during metronidazole therapy such as the good penetration through the blood/brain barrier and into abscess cavities are discussed.


Clinical pharmacology of tobramycin in infants. Tobramycin was used in the treatment of severe infections in infants, mostly newborns and prematures. Serum half-life of the drug was 3.5 h in infants older than one week and above 2,500 g, and 8.0 h in infants below one week and less than 2,500 g. Apparent volume of distribution was similar in both groups, 0.24 l/kg. Intravenous infusions of the drug gave considerably higher plasma levels than intramuscular infections. Particularly in the newborn and premature group intramuscular injections gave fairly unpredictable plasma concentrations.


Congenital rubella after maternal reinfection. This report concerns a boy with congenital rubella virus infection. The diagnosis was confirmed by virus isolation, demonstration of rubella-specific serum IgM and by persistence of serum antibody at the age of 9 months. In 2 sera from the mother sampled 2 weeks apart 20 months before the birth of the boy, low titers of rubella antibody were demonstrated by hemagglutination-inhibition, hemolysis-in-gel and complement fixation tests, but not by neutralization. Significant rises in titer were demonstrable by all serologic reactions--including neutralization--at the time of birth of the infected child. The mother was not aware of any rubella-like illness or exposure to such disease during pregnancy. The case is discussed against findings of neutralizing activity in sera from natural immunes and rubella vaccinees.


Acute tubulointerstitial nephritis in a patient with Mycoplasma pneumoniae infection. A 26-year-old man developed pneumonia, hepatitis and biopsy-verified acute tubulointerstitial nephritis coinciding with a rise and fall of complement-fixing antibodies to Mycoplasma pneumoniae. M. pneumoniae antigenic material and complement (C3) in the renal interstitium were shown by immunohistochemical techniques. A causal relationship between M. pneumoniae infection and the renal lesion is suggested.


Fatal group G streptococcal sepsis in a neonate. A full-term infant became ill at 16--24 h of age following an uncomplicated pregnancy, labor, and delivery. The clinical course (absence of prenatal warning, rapidly progressive respiratory distress, apnea, shock, and coagulopathy) terminated fatally and resembled that seen in neonatal 'early onset' group B streptococcal sepsis. Previous cases of neonatal group G streptococcal disease are briefly reviewed.


Acute Corynebacterium endocarditis causing aortic valve destruction. Successful treatment with antibiotics and valve replacement. A case of acute infective endocarditis caused by diphtheroids in a healthy young male is described. The pathogenic role of the diphtheroids was verified by recognition of the same bacterium in 6 consecutive blood cultures and simultaneous rise of specific antibody titers. The infection was effectively controlled by antibiotic treatment, but destruction of the aortic valve led to progressive heart failure irresponsive to medical treatment. The affected valve was successfully replaced by a prosthetic valve, and the patient made a complete recovery. Neither congenital or acquired cardiac defects, nor signs of immunological deficiency could be detected.


Priapism: surgical or medical treatment? Two cases of priapism treated with fibrinolysin (streptokinase) are presented. Comparisons are made between medical and surgical treatment in the literature. It is concluded that fibrinolysin may be useful in some cases of early priapism, but should be chosen only after serious consideration of the circumstance that its use precludes early surgery.


Familial renal agenesis and urogenital malformations. Seminal vesicle cyst and vaginal cyst with bicornuate uterus in siblings. A seminal vesicle cyst was found in a 30-year-old man with ipsilateral renal agenesis. His sister had embryologically analogous malformations--Gartner duct cyst, bicornuate uterus and renal agenesis. This seems to be the first reported familial occurrence of these combined malformations. The embryogenesis is reviewed and the diagnostic procedure and treatment are discussed.


Cyst of seminal vesicle associated with ipsilateral renal agenesis. A report on four cases. Four cases of seminal vesicle cyst associated with agenesis of the ipsilateral kidney are presented. The literature and the embryologic development of this rare anomaly are briefly surveyed.


Carcinosarcoma of the urinary bladder in an adult male. Carcinosarcoma of the urinary bladder in a 64-year-old man is described. Total cystectomy with bilateral ureteroileostomy was performed. The patient is in good health 12 months after the operation. Histologically the main bulk of the tumour tissue was rhabdomyosarcomatous, but in some areas atypical glands were intermingled with the rhabdomyoblasts. This histologic pattern has not previously been described. The histologic features, clinical manifestations and treatment of these rare bladder tumours are discussed in relation to the literature.


Right ureteral occlusion due to isolated Crohn's disease of the appendix. A case of Crohn's disease limited to the vermiform appendix is described. The patient was initially thought to have an appendiceal abscess. The condition was complicated with right ureteral occlusion. Urinary stasis completely ceased after removal of the appendix. Our patient is apparently the first reported case of obstructive uropathy due to isolated Crohn's disease of the appendix.


Traumatic haematuria in supernumerary hydronephrotic kidney. A case report. A 27-year-old man had macroscopic haematuria following a blow to the right side of the abdomen. Intravenous pyelography showed narrowing and lateralisation of the right renal pelvis and suggested rupture and fragmentation of the right kidney. Surgical exploration, however, revealed massive hydronephrosis in a supernumerary kidney. The haemorrhage had been caused by rupture of the pelvis. Diagnostic considerations are discussed and the surgical procedure is described. Correct pre-operative evaluation was exceedingly difficult in this case. Only two similar cases were found in the literature.


Epiermoid cyst in the kidney.

Epiermoid cyst in the kidney. Epidermoid cyst of the kidney is a rare entity. In the case here presented, epidermoid cyst was an incidental finding at urography performed in a 67-year-old man in connexion with splenectomy for polycythaemia. The cyst was interpreted as an old tuberculous focus. Two years later partial nephrectomy was performed because of repeated attacks of renal colic and signs of recurrent pyelonephritis. The diagnosis of epidermoid cyst was not made preoperatively in this case, or in the cases described in the literature.


Prostatitis in the rat.

Prostatitis in the rat. A high incidence of spontaneous, non-acute, age-dependent prostatitis was observed in the lateral prostate of Copenhagen rats and Wistar rats. The lumen of infected acini was filled with polymorphonuclear leucocytes, shed epithelial cells and cell residues. Epithelial cells lining such acini showed degenerative changes. Lymphocytes and macrophages were seen in the stroma. A histochemically observed increase in acid phosphatase and beta-glucuronidase activity in affected epithelial cells may indicate an increased lysosomal activity. Some bacteriological cultures of infected lateral prostates were positive for Proteus vulgaris and diphtheroids. It is suggested that this spontaneous rat prostatitis may be a useful model for the study of the pathogenesis and treatment of human non-acute prostatitis.


Surface characteristics of malignant human urinary bladder epithelium studied with scanning electron microscopy. Biopsies were obtained from 28 male and seven female patients with cystoscopically and histologically confirmed urinary bladder carcionoma. Tissue specimens for light microscopy and scanning electron microscopy (SEM) were obtained from the tumours as well as from cystoscopically tumour-free mucosa of the dome, the lateral walls and the trigone of the urinary bladder and also from the proximal urethra. Certain surface structural changes, which seem to represent malignancy, present in different regions of the urinary bladder were detected by SEM, although not visible by light microscopy.


Epodyl treatment of bladder tumours.

Epodyl treatment of bladder tumours. Multiple, non-invasive bladder papillomas were treated with intravesical instillation of Epodyl in 44 patients. Irritative cystitis occurred in 16 per cent of the series, and in these cases Epodyl treatment had to be stopped. Total or partial disappearance of the papillomas was seen after 16 months of treatment in 43% of the total series. This was the minimum success rate, since all the patients who left the study were counted as failures. When the treatment could be carried through, total or partial disappearance of papillomas occurred in 19 of 29 patients (66%). Epodyl has a place in the treatment of vesical papillomas when other methods have failed.


Observations on the effect of metoclopramide (Primperan) on the human ureter. A preliminary communication. Metoclopramide, a procainamide derivative with a documented effect on the gastro-intestinal motility, was given to four patients with hydroureter. It induced strong peristalsis in the ureter, manifested clinically as relief of pain and fluoroscopically as emptying of the ureter and the renal pelvis.


Disc pressure measurements in para- and tetraplegic patients. A study of of mobilization and exercise in para- and tetraplegic patients. The intradiscal lumbar pressure was measured in 10 patients with para- or tetraplegia and in one normal subject. The pressure was registered both in the horizontal position and during tilting on a table, during the performance of a standardized exercise program for the upper extremities, as well as during cough, during abdominal strain and while the subjects were being turned from the supine to the lateral position. The increase in pressure during the tilting to an angle of +30 degrees, and mostly to +50 degrees was less than the maximum pressure change during the exercises to which an immobilized patient with acute unstable fracture of the spine, was exposed daily, such as being turned, performing respiratory exercises and muscular training for the upper extremities. Provided fixation was secured with a belt, patients with unstable fractures of the thoracic and lumbar spine maybe treated with a "more active immobilization" tilting them in the bed even during the acute stage. Forward flexion exercises in the shoulder joints with hand weights produced a greater increase of the intradiscal pressure than did abduction exercises with the corresponding load. Spasticity produced a considerable increase in intradiscal pressure.


Movements in the lumbar spine during exercises of the upper extremities. A roentgenologic study in para- and tetraplegic patients. Strengthening exercises during treatment of patients with unstable lumbar fractures produce a kyphotic or lordotic sagittal movement in the lumbar spine. These movements have been measured roentgenologically. Forward flexion exercises in the shoulder joints to 45 degrees produced a kyphotic movement, while forward flexion to 110 degrees and abduction exercises to 90 degrees produced a lordotic movement. Flexion of hips and knees to 45 degrees produced a kyphotic movement adding to the movements caused by the shoulder exercises. Increasing the load on the upper extremities produced an increase of all movements.