Determination of the lower esophageal sphincter pressure in patients having a Nissen or Belsey fundoplication. Thirty patients were studied prospectively in evaluating the Nissen (28) and Belsey (2) fundoplication manometrically using the Kronsberg probe and Honeywell recorder. Twenty-eight patients in the Nissen fundoplication group had abnormally low LESP preoperatively and normal postoperative for one year with an average increase of 9 mm. Hg. They became asymptomatic and their esophageal mucosa became normal and remained normal endoscopically for three years. The only failures were two patients treated with the Belsey fundoplication. The gas bloat syndrome occurred in two patients and was relieved by esophageal dilatation. The Nissen fundoplication should be highly recommended as the surgical procedure of choice in the treatment of reflux esophagitis not responding to medical program.


Hepatitis B antigen and antibody in heroin users. Hepatitis B surface antigen (HBsAg) and antibody (anti-HBsAg) were determined on 442 asymptomatic heroin users and 246 controls. Of the drug-taking group, 124 used heroin intravenously and 318 nonintravenously (smoking, sniffing). Twenty-three (5.2%) heroin users were HBsAg positive and 118 (26.7%) anti-HBsAg positive, compared to three (1.2%) HBsAg positive and 28 (11.4%) anti-HBsAg positive controls, both statistically significant. HBsAg was positive in eight (6.5%) intravenous heroin users and statistically identical to 15 (4.7%) HBsAg positive nonintravenous users. Positive anti-HBsAg in 55 (44.4%) intravenous heroin users compared to 63 (19.8%) nonintravenous users, however, is statistically significicant.


Ultrasound in the diagnosis of cholestatic jaundice. A total of 70 cases of cholestatic jaundice have been studied by gray scale ultrasonography in order to evaluate how this technic may be used to differentiate between intra- and extrahepatic cholestasis. In 37 out of 42 patients (88.1%) with jaundice of extrahepatic origin, dilatation of the biliary tree was demonstrated, whereas in all the 28 patients with intrahepatic cholestasis biliary dilatation was clearly excluded. In addition, gallstones in the biliary ducts were detected in 12 out of 20 cases and enlargement of the head of the pancreas (due to carcinoma or chronic pancreatitis) was often correctly diagnosed (nine out of 13 cases). These results suggest that ultrasonography should represent the first step in the diagnostic approach to cholestasis. Information gained from this noninvasive technic should make it possible to correctly plan the more complex investigations (endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography).


Idiopathic calcific pancreatitis, CRST syndrome and progressive systemic sclerosis. A 43-year old man with CRST syndrome (calcinosis, Raynaud's phenomenon, sclerodactyly and telangiectasia) and progressive systemic sclerosis presented with a four-year history of relapsing abdominal pain, the result of chronic pancreatitis, not associated with alcoholism, biliary disease, or any of the known causes of pancreatitis. He had a good response to retrograde pancreatic duct drainage but exhibited management problems and complications that may be peculiar to the systemic sclerosis patient with pancreatitis. A cause and effect relationship between progressive systemic sclerosis and pancreatic disease is not proven but we believe there is evidence to suggest such a relationship.


Pancreatic polypeptide (PP) responses to oral and intravenous glucose in man. Serum human pancreatic polypeptide (hPP) responses to 50 gm. of oral glucose and a 25 gm. intravenous bolus of glucose were measured in 10 healthy human volunteers. Oral glucose caused a 50% rise, whereas I.V. glucose caused a 35% fall in hPP concentration. There was no relationship between the absolute glucose concentration or the change in glucose level and the PP concentration. It is suggested that oral and I.V. glucose affect PP by indirect mechanisms and that PP may be involved in carbohydrate metabolism in man.


Pancreatic Ascites.

Pancreatic Ascites. Ascites occurring in patients with a history of alcoholism is usually due to cirrhosis but clinically significant ascites also occurs in association with pancreatic disease. We reviewed 265 cases of pancreatitis over a five-year period. There were 129 blacks and 136 Caucasians. Ages ranged from 19-86 years with a mean of 46.2 years. Eight of these cases (3%) were found to have pancreatic ascites. The initial serum and urinary amylase had no prognostic value regarding the subsequent development of pancreatic ascites. The mean ascitic fluid amylase was 14,426 Somogyi units (range 1,279-67,774). The mean ascitic fluid protein was 4.6 gm./100ml. (range 1.4-7.2). High enzyme and protein concentration in the ascitic fluid are characteristic of pancreatic ascites. Out of eight cases, two were associated with a pseudocyst, three with hemorrhagic pancreatitis and three with acute edematous pancreatitis. Four of these eight (50%) died. Pancreatic ascites is a distinct clinical entity which should be differentiated from cirrhotic, tuberculous or malignant ascites.


Acute cholecystitis secondary to unusual gallstones. Gallstone formation around metallic foreign bodies is an unusual cause of acute cholecystitis. Two cases of penetrating abdominal trauma are described in which metallic fragments served as the nidus for calculus formation and later precipitated an acute abdominal problem.


Pernicious anemia caused by Crohn's disease of the stomach. A patient with granulomatous gastritis is described. Two years after the presentation of his gastric disease he developed pernicious anemia. Lack of intrinsic factor production secondary to Crohn's disease of the stomach is felt to be the cause of his Vitamin B12 malabsorption.


Fulminant disseminated intravascular coagulation in advanced gastric carcinoma. A case of fulminant disseminated intravascular coagulation (DIC) in a 51-year old man, presenting with bleeding gastric adenocarcinoma, is reported. In spite of initial hematologic improvement by replacement therapy the patient died on the fifth day after admission. The rare association of DIC with adenocarcinoma of the stomach is discussed.


Peliosis hepatis due to oxymetholone--a clinically benign disorder. Peliosis hepatis is a rare hepatic disorder mainly diagnosed at surgery or autopsy. Clinical outcome is thus frequently poor. We report a patient in whom the diagnosis was established by percutaneous needly biopsy. Withdrawal of the steroid medication was followed by a prompt clinical improvement. Although histologic proof of regression is not available, this experience suggests a more favorable prognosis than previously thought possible.


Absorption of orally administered digoxin after massive resection of the small bowel. Digoxin absorption was studied in a patient after massive small bowel resection (with only 15 cm. of jejunum left) after mesenteric thrombosis. Oral administration of 0.25 mg. digoxin tablets resulted in therapeutic blood levels between 0.7 and 2.2 ng./ml. Measurement of the urinary excretion of the drug in steady state revealed more than 80% of the maintenance dose. Renal digoxin clearance was 125 ml./min. This resulted in slowing of the heart rate from 120 to 80/min. with no side-effects. It is thus concluded that total absorption of digoxin might be normal in a patient with only 15 cm. of jejunum and that usual dogs of digoxin were sufficient for a therapeutic effect and "therapeutic" blood levels


Colonic intussusception in uremia.

Colonic intussusception in uremia. Colonic intussusception is a condition primarily found in infants and young children. In adults, it is usually associated with a colonic neoplasm. The following report illustrates a case of colonic intussusception in an adult uremic patient in whom postmortem examination showed evidence only of intramural colonic hemorrhage.


Risk of suicide among cancer patients.

Risk of suicide among cancer patients. Of the 28,857 cancer cases registered by the Finnish Cancer Registry in 1955, 1960 and 1965, 63 patients had committed suicide by the end of 1970. The suicide rate among males was 1.3 times higher (p less than 0.01) and among females 1.9 times higher (p less than 0.05) than the rate in the general population. The highest suicide risk (relative risk 2.5, p less than 0.001) was associated with gastrointestinal cancer. Patients with a non-localized tumor at diagnosis had a two-fold risk of suicide and the rate was higher among patients undergoing no treatment, or treatment with chemotherapy or hormones only. It was estimated that 23% of all suicides among male cancer patients and 46% among female cancer patients was associated with the patients having cancer.


The UCLA population studies of chronic obstructive respiratory disease. I. Methodology and comparison of lung function in areas of high and low pollution. The prevalence of symptoms of chronic obstructive respiratory disease and of functional respiratory impairment was determined in 3465 residents (70 per cent of enumerated) of an area historically exposed to photochemical/oxidant pollutants and 4509 residents (79 per cent of enumerated) of an area exposed to low levels of chemical pollutants. Tests administered included the NHLI questionnaire, electronic volume spirometry, whole body plethysmography, and the single-breath nitrogen test (deltaN2750-1250 and closing volume). Cough and cough with sputum were more frequently reported in the low-pollution area. Lung function was better among residents of the low-pollution area according to FEV1, FVC, maximal expiratory flow rates, closing volume fraction, thoracic gas volume, and airway resistance. Maximal mid-expiratory flow rate, considered to be a sensitive spirometric test for detection of small airways disease, was similar in residents of both areas. Mean deltaN2750-1250 was slightly worse among residents of the low-pollution area. Findings suggest that adverse effects of long-term exposure to photochemical/oxidant pollutants may occur primarily in the larger airways both among smokers and never smokers. The greatest differences between areas were observed in residents 18-59 years of age, suggesting that long-term exposure may be required to cause measurable impairment and that these differnces may be obliterated by such factors as smoking, differential out-migration and differential survival.


Vibrio parahaemolyticus gastroenteritis outbreaks aboard two cruise ships. Outbreaks of Vibrio parahaemolyticus gastrointestinal illness occurred on two Caribbean cruise ships in late 1974 and early 1975. In all, 697 passengers and 27 crew were affected. Epidemiologic evidence incriminated seafoods served on the ships as the vehicles of transmission. The seafoods were probably contaminated by V. parahaemolyticus after cooking in seawater from the ships' internal seawater distribution systems. Use of seawater in foodhandling areas was discontinued, and no further outbreaks occurred.


Anencephalus, drinking water, geomagnetism and cosmic radiation. The mortality rates from anencephalus from 1950-1969 in Canadian cities are shown to be strongly correlated with city growth rate and with horizontal geomagnetic flux, which is directly related to the intensity of cosmic radiation. They are also shown to have some association with the magnesium content of drinking water. Prior work with these data which showed associations with magnesium in drinking water, mean income, latitude and longitude was found to be inadequate because it dismissed the observed geographic associations as having little biological meaning, and because the important variables of geomagnetism and city growth rate were overlooked.


Inversion duplication of chromosome 6 with trisomic codominant expression of HLA antigens. Trisomic codominant expression of the HLA antigens was observed in an infant with duplication of a part of 6p occurring as a result of crossing over within a paternally transmitted pericentric inversion. The HLA-A and B loci were linked absolutely with the inversion chromosome in a four generation pedigree.


Population genetic studies of the Philippine Negritos. II. gm and km allotypes of three population groups. Serum samples of the three tribal Negrito populations in the Philippine Islands (127 from Zambales, 87 from Bataan, and 93 from Agusan) were tested for Glm(1,2,3 and 17), and G3m(5,6,11,13,14,15,16, and 21), and Km(1). The GMpatterm of the Negritos is characterized by three haplotypes, Gm1,17;21, Gm1,2,17;21, and Gm1,3;5,11,13,14, which is also characteristic of Mongoloid-related populations, especially with high incidence of the latter haplotype. They also have the haplotype, Gm1,17;5,13,14, prevalent in Africa, New Guinea, and northern Australia, suggesting an ancient link between the Negritos and the New Guinean-Australian group. Two unusual samples of G3m(15) positive without G3m(16) observed in Zambales Negritos suggest the presence of Gm1,17;5,11,13,14,15 haplotype in the population. This appears to be unique to Zambales Negritos and the first such samples to be found.


Preliminary communication: prenatal detection of the Fanconi Anemia gene by cytogenetic methods. We have studied the pattern of chromosome instability in cultured fibroblasts and fetal membrane cells from a fetus aborted by an individual with a history of a previous child affected with Fanconi anemia (FA). These cells exhibited a low level of spontaneous chromosome instability. Upon treatment with diepoxybutane (DEB), chromosome breakage increased to a level comparable to that reported earlier in DEB-treated FA heterozygous cells. Cultured cells derived from chromosomally normal fetuses which served as controls did not show DEB-induced chromosome breakage. This observation suggests that the fetus studied is heterozygous for the FA gene. The ability to distinguish readily between the three genotypes (homozygous FA, heterozygous FA, and normal) in an in vitro stress system that measures the response of the cells to a clastogenic agent makes available a test for the prenatal and postnatal detection of the FA gene.


Compounding times and contamination rates associated with the preparation of intravenous admixtures in three types of plastic containers. The compounding times and contamination rates associated with the preparation of admixtures in three different plastic i.v. containers of dextrose 5% in water were compared. The time required for a technician to prepare, in a laminar air flow hood by the needle and syringe technique, 120 admixtures in each of three different plastic i.v. containers was measured and recorded by two investigators. The 360 admixtures were tested within one hour of preparation for sterility using an enriched brain heart infusion broth. The total time required to compound the i.v. admixtures varied significantly with container design (p less than 0.01), preparation being fastest with the Accumed container, followed by the LifeCare then the Viaflex containers. The major contributing factors to increased compounding time were (1) removal of outer wrap, (2) swabbing of LifeCare and Viaflex medication ports with isopropyl alcohol pads and (3) freeing of the hangar flap from the Viaflex container. Sterility tests revealed no detectable contamination of any of the admixtures. Container design of plastic i.v. containers did influence the preparation time for admixtures but did not influence admixture sterility.


Prognosis in rheumatoid arthritis. A longitudinal study of newly diagnosed younger adult patients. The course of rheumatoid arthritis was analyzed in 50 newly-diagnosed adults followed prospectively for an average of over five years. Eighteen patients had no swelling and no erosion (outcome 1), 22 patients had swelling without erosion (outcome 2) and 10 patients had erosion (outcome 3). Computer-assisted data screening and multivariate analytic technics were employed to derive a simple index from entry data which correlated closely with the patients' subsequent articular course. The index included six entry items: positive rhematoid factor; two or more swollen upper extremity joints on examination (2 points each); history of Raynaud's-like symptoms; malaise or weakness at the onset of arthritis; white race and female sex (1 point each). This index was 80 per cent accurate over-all in classifying patients into the three mutually exclusive articular outcome categories. Zero to 2 points on entry predicted no swelling, 3 to 5 points swelling without erosion and 6 to 8 points the development of bony erosion. Although results must be qualified to this patient population in the early stages of disease, the analytic approaches developed promise to assist with a broad range of clinical research and medical care delivery problems.


Pericardial disease in rheumatoid arthritis. Six patients with rheumatoid constrictive pericarditis, five seen in a two and one half year period, are described. All patients were male, all had rheumatoid factor, and all had active arthritis. Diagnosis was suspected from careful physical examination and confirmed in five patients by cardiac catheterization. Pericardiectomy was successful in all five patients on whom it was performed. Rheumatoid constrictive pericarditis should be suspected in any patient with rheumatoid arthritis and unexplained signs of right heart failure.


Propranolol therapy in thyrotoxicosis. A review of 84 patients undergoing surgery. The effect of propranolol on the surgical course of 84 thyrotoxic patients undergoing partial thyroidectomy or extrathyroidal surgery was evaluated. Seventy-two patients (group 1) underwent surgery with propranolol as their sole preparatory medication, whereas in 12 (group 2) surgery was carried out after a rather prolonged period of thionamide preparation with the addition of propranolol preoperatively as an adjunctive therapeutic agent. Preoperative pulse rate and systolic blood pressure levels fell in both groups, and the clinical features of thyrotoxicosis were rapidly ameliorated with an average dose of propranolol of 330 mg (range 40 to 1,280 mg) daily. Maximal clinical response occurred within 48 to 72 hours of starting propranolol therapy. In 14 patients in group 1, paired serum calcium levels were reduced by the administration of propranolol preoperatively; serum thyroxine levels were unchanged. Serum thyroxine decay, evaluated postoperatively in the patients in group 1, was decreased. The half life of thyroxine was inversely related to the initial thyroxine levels. Analysis of these data indicates that the administration of propranolol alone provides rapid, safe and effective preparation of thyrotoxic patients for emergency or for elective thyroidal or extrathyroidal surgical procedures.


Selective jejunal hyperabsorption of calcium in absorptive hypercalciuria. Calcium absorption in the jejunum and ileum of patients with absorptive hypercalciuria was studied by in vivo intestinal perfusion. Net calcium absorption in the jejunum was markedly increased at four luminal calcium concentrations (1 to 20 mM) in the patients with absorptive hypercalciuria when compared to that in normal subjects. In the ileum, net calcium absorption was only slightly increased in the patients with absorptive hypercalciuria. Experiments with radioactive calcium (47Ca) revealed increased unidirectional flux out of the jejunal lumen in the patients but no difference in the unidirectional flux into the lumen, when compared to that in normal control subjects. Net magnesium absorption was normal in the patients. These results suggest that hyperabsorption of calcium in patients with absorptive hypercalciuria is mainly due to enhanced calcium transport in the jejunum and that the defect is specific for calcium since magnesium is absorbed normally.


Nonalcoholic liver disease. Overlooked causes of liver injury in patients with heavy alcohol consumption. Alcoholic subjects with abnormal liver chemistry studies are often assumed to have alcoholic liver disease, even though the diagnosis is not established by liver biopsy. To determine the magnitude of nonalcoholic liver disease in patients with heavy alcohol consumption, the data on 145 consecutive patients judged to consume at least 80 g of alcohol daily for prolonged periods, and who underwent liver biopsy at the University of Chicago, were reviewed. Nonalcoholic liver disease was suspected clinically and confirmed by liver biopsy in 40 (28 per cent), whereas alcoholic liver disease was suspected in 105 but confirmed in only 83 (80 per cent). The remaining 22 patients had liver disorders, including cholangitis or pericholangitis, acute hepatitis or some form of chronic hepatitis, for which they required appropriate therapy. Neither clinical features, hepatitis B surface antigen (HBsAg), anti-HBsAg nor serum glutamic oxaloacetic transaminase to serum glutamic pyruvic transaminase (SGOT:SGPT) ratios distinguished these 22 patients from those with alcoholic liver disease. Thus, liver biopsy is necessary for the identification of nonalcoholic liver disease in patients suspected of harboring alcoholic liver disease, since other clinical features do not allow identification of these patients.


Central nervous system complications of non-Hodgkin's lymphoma. The potential role for prophylactic therapy. In 38 patients with non-Hodgkin's lymphoma, involvement of the central nervous system (CNS) by malignant lymphoma developed during an eight year period. All patients had lymphomatous meningitis; clinical involvement of the spinal nerves or cranial nerves suggested the diagnosis. Spinal fluid was abnormal in 97 per cent of the patients although a positive cytology could be documented in only 67 per cent by lumbar puncture. The histology in 82 per cent of the patients was diffuse. Involvement of the CNS in nodular lymphoma was uncommon (3 per cent), and the histology in virtually all of these patients had converted to diffuse. At the time of diagnosis of CNS disease, 95 per cent of the patients had other evidence of advanced disease; 66 per cent had bone marrow involvement. In only 18 per cent of the patients did CNS disease develop while they were in clinical remission. Eighty-five per cent of the patients treated with whole brain irradiation and intrathecal chemotherapy had a good clinical response. Knowledge of these risk factors permits definition of a group of patients who may benefit from CNS prophylaxis.


Infections due to group C streptococci in man. Although a common cause of infection in animals, group C streptococci are rarely noted to be pathogenic in man. A total of 150,000 blood cultures obtained at the Mayo Clinic from 1968 to 1977 revealed group C streptococci in only eight patients. Acute bacterial endocarditis, meningitis, pheumonia, cellulitis and bacteremia due to group C streptococci are described in a host who had undergone immunosuppression (immunosuppressed host), and the relatively few cases previously reported are reviewed. Although severe, these infections may respond favorably to penicillin therapy. Endocarditis caused by group D streptococci is acute and destructive, and associated with early cardiac decompensation. The manifestations of cellulitis and pneumonia are similar to those when group A streptococci are causative organisms. Meningitis due to group C streptococci is acute and severe, and responds slowly to antimicrobial therapy. Colonization also occurs.


Occult dental infection as a cause of fever of obscure origin. Three patients with prolonged unexplained fevers were ultimately found to have deep-seated dental infection. After initial examination failed to elicit symptoms or signs of dental infection, and extensive in-hospital evaluation was nonproductive, dental consultation with roentgenograms provided the diagnosis. All three patients underwent dental extractions with periapical or peridontal debridement; following a brief postoperative febrile period, all three responded with defervescence, without subsequent recurrence of fever. These cases emphasize the importance of periapical and peridontal infection as causes of fever of obscure origin. The pathogenesis, characteristics and bacteriology of periapical abscess are discussed.


Recent advances in programmable pacemakers. Consideration of advantages, longevity and future expectations. The important electrical characteristics of conventional ventricular demand pacemakers currently widely employed are unable to be altered by noninvasive means after their implantation. However, a number of domestic pacemaker manufacturers have started to introduce a new modality for atraumatic modulation of these devices, the fully programmable pacemaker system, whereby the several variables regulating pacemaker operation may be optimized on an individual basis according to need. Such programmable pacemaker functions which can be varied include rate, energy output, refractory period and sensing threshold. The indications, significance and mechanisms for control of the various function programming are delineated for physician understanding at the present time.


Wide splitting of the first heart sound secondary to tricuspid valve endocarditis. A phonocardiographic-echocardiographic study. A patient is described with tricuspid valve endocarditis in whom the vegetation interfered with valve closure resulting in marked wide splitting of the first heart sound. M-mode and two-dimensional echocardiographic studies detected the presence of a vegetation. Simultaneous phonocardiographic and echocardiographic studies documented the marked delay in tricuspid valve closure and differentiated wide splitting of the first heart sound from other causes of early and mid-systolic sounds. Following pulmonary embolization, the first heart sound returned to normal. Echocardiographic disappearance of the vegetation of the tricuspid valve was also noted. Regrowth of the vegetation again produced the abnormal phonocardiographic and echocardiographic findings.


Renal artery dysplasia in a patient with membranoproliferative glomerulonephritis. A 27 year old man with nephrotic syndrome due to membranoproliferative glomerulonephritis had multifocal stenoses of the renal and intestinal arteries. The arterial lesions demonstrated by angiograhy closely resembled those of medial fibromuscular dysplasia. The dysplasia progressed over a five year period to involve both renal arteries from their extrarenal segments through their interlobar branches. Low serum levels of complement components C3 and C4, focal reduplication of the glomerular basement membrane on light microscopy, and the patterns of glomerular localization of IgG and C3 by immunofluorescence were characteristic of type I membranoproliferative glomerulonephritis. The development of the arterial dysplasia in a patient with chronic glomerulonephritis suggests a common immunologic pathogenesis of both disorders.


Haemophilus parainfluenzae mitral valve vegetation without hemodynamic abnormality. Demonstration by angiography and serial echocardiography. The occurrence of Haemophilus parainfluenzae endocarditis on a previously normal mitral valve of a drug addict is described. A large mitral valve vegetation was demonstrated by serial echocardiography and cineangiography. The vegetation did not produce hemodynamic abnormalities preventing detection by physical examination. Multiple septic emboli to various organs, including brain, resulted in death. The role of serial echocardiography and the levophase of right heart cineangiography in detecting mitral valve vegetation in a patient suspected of having infective endocarditis is emphasized.


Disordered breathing and oxygen desaturation during sleep in patients with chronic obstructive lung disease (COLD). Seven patients with chronic obstructive lung disease (COLD) were monitored during their overnight sleep to determine the occurrence of disordered breathing and oxygen desaturation. Nasal and oral airflows were sensed by thermistor probes, chest wall movement by impedance pneumography and arterial oxygen saturation by ear oximetry. These variables were correlated with electroencephalographic and electrooculographic tracings. The subjects had a mean base line oxygen saturation of 89.2 per cent and slept an average of 218 minutes. Six of these seven subjects had one to 30 episodes of oxygen desaturation (decrease more than 4 per cent), 4 seconds to 30 minutes in duration, with declines in saturation as great as 36 per cent. In two subjects, saturation dropped to less than 50 per cent. Breathing was disordered in five of the seven subjects and included apnea and hypopnea. Subjects experienced from nine to 37 episodes of disordered breathing. Disordered breathing caused 42 per cent of the episodes of desaturation, all of which were less than 1 minute in duration. The mean maximum decline in saturation was 7.6 per cent. All episodes of desaturation lasting longer than 5 minutes occurred in rapid eye movement (REM) sleep and were not caused by disordered breathing. The mean maximal decrease in saturation was 22 per cent. This study reveals that disordered breathing is common in subjects with COLD and often causes desaturation but that it cannot explain all episodes of sleep desaturation.


The usefulness of fiberoptic bronchoscopy in evaluating new pulmonary lesions in the compromised host. Thirty-four fiberoptic bronchoscopies employing various bronchoscopic technics were carried out in 33 immune-compromised patients for the evaluation of new pulmonary lesions. Transbronchial biopsy was performed only with fluoroscopic guidance and was omitted in patients with a bleeding tendency. Bronchial brushing and bronchial washing were successfully carried out despite the presence of contraindications to biopsy. Brushing and washing were diagnostically useful in 66 and 74 per cent of the cases, respectively, compared to 71 per cent for forceps biopsy. The combined over-all yield was 88 per cent, with no serious complications encountered. The most common etiology of new infiltrates was opportunistic infection. Among bacterial infections, gram-negative organisms were the most common, and among fungal etiologies, Coccidioides immitis was the predominant pathogen in this series from Tucson, Arizona. Although the roentgenographic pattern was not helpful in predicting the etiology of the new infiltrates, diffuse lesions were more frequently evaluated correctly by fiberoptic bronchoscopy than localized lesions. The low incidence of complications and the high over-all yield indicate that fiberoptic bronchoscopy, employing bronchial brushing and washing as supplements to transbronchial biopsy (and as a replacement to biopsy in patients with a bleeding diathesis), can be very useful in evaluating new pulmonary lesions in the immune-compromised patient. When used together, these technics significantly increase the diagnostic yield and eliminate the risks associated with performing more invasive diagnostic procedures in the compromised host.


Ectopic production of lipotropin by cancer. Lipotropin (LPH) has been evaluated as a potential tumor marker using a sensitive beta melanocyte-stimulating hormone (beta MSH) radioimmunoassay. All 79 acetic acid extracts of carcinomas of lung, colon, stomach, esophagus and breast contained LPH in concentrations greater than blood; 61 of 79 extracts contained LPH in larger amounts than control tissues from patients without cancer. In a blind prospective study, plasma LPH was quantified in 107 patients admitted for work-up because of an abnormality on a chest roentgenogram. Thirty-one of 33 patients subsequently diagnosed as having benign lesions had plasma LPH within the 95 per cent confidence limits of normal subjects whereas 28 (36 per cent) of the 74 patients subsequently diagnosed histologically as having primary lung carcinoma had elevated levels. In control studies, 13 of 100 patients with chronic obstructive pulmonary disease had elevated plasma LPH levels; three of the 13 with elevated levels and four with normal levels have been diagnosed, during the two years of follow-up, as having lung carcinoma. In control studies of 23 patients with granulomatous lung disease, 22 had normal levels of LPH. In those with carcinoma of the colon elevated plasma LPH levels were observed in two of 21 untreated patients and in 11 of 61 patients receiving noncurative chemotherapy. Elevated plasma LPH levels were also observed in 10 of 59 patients with breast cancer, eight of 28 with pancreatic cancer, eight of 22 with gastric or esophageal cancer, six of 16 with renal cancer, four of eight with prostatic cancer, one of seven with cervical cancer and one of six with ovarian cancer. We conclude, an elevated LPH level is frequently observed in blood and tumor tissue from patients with various types of carcinoma.


Myasthenia gravis, thymectomy and serum thymic hormone activity. Serum thymic hormone activity was measured in 36 patients with myasthenia gravis and in 10 control subjects from each age decade. In all 25 patients under 50 years of age results were within, or close to, the normal range. Activity at levels considered normal for juveniles was detected in 10 of the 11 older patients whereas levels normally decline in older subjects. One week after thymectomy, 13 of 17 patients (76 per cent) had no demonstrable serum thymic hormone activity. However, 10 months or longer after thymectomy only five patients (30 per cent) lacked thymic hormone activity in the serum. There was a significant correlation between clinial improvement and sustained lowering of serum thymic hormone activity after thymectomy.


Prophylaxis of attacks of hereditary angioedema. Danazol, an attentuated androgen, has been suggested as an effective agent for the prophylaxis of attacks of hereditary angioedema. Four patients, with a clinical history of hereditary angioedema and a demonstrated depression of the serum inhibitor of the first component of complement (C1 INH) and the fourth component of complement (C4), were entered into a study to determine the minimum effective dose of this agent. All four of the patients had been experiencing attacks at least monthly, but they had only six attacks during a total of 60 patient months of Danazol therapy. The minimum effective dose varied from 100 to 400 mg/day. The drug appeared to work by increasing the level of serum C1 INH which reached the normal range in two of four patients. Side effects were only the anticipated menstrual irregularities in the female patients. Danazol appears to be an efficacious drug for prophylaxis of hereditary angioedema.


Plasmapheresis in the treatment of acute renal failure in multiple myeloma. Three patients with multiple myeloma and severe acute renal failure were treated by repeated plasmapheresis. Recovery of renal function was observed in all. The pathogenetic role of light chains and the possible mechanisms responsible for renal damage are discussed. It is suggested that the removal of light chains by plasmapheresis may be of therapeutic value in this condition.


Treatment of Goodpasture's syndrome with plasmapheresis. A case report and review of the literature. A case is reported of antiglomerular basement membrane antibody-induced Goodpasture's syndrome in which the patient required hemodialysis and was treated with immunosuppressive agents and plasmapheresis. A severe (80 per cent) cresentic lesion was reversed, and creatinine was stabilized at 2.5 mg/dl at one year follow-up. Earlier reports of therapy without plasmapheresis showed that 88 per cent of the patients would either die or require long-term hemodialysis. Fifteen other reported cases of Goodpasture's syndrome in which the patients were treated with plasmapheresis are reviewed. When reported, short-term follow-up showed that nine of these patients were alive without need of dialysis, five wee receiving dialysis, and only two had died. This suggests that plasmaheresis and immunosuppressive therapy may reverse the renal lesion in some patients with Goodpasture's syndrome.


Regression of pituitary tumors, a possible effect of bromergocryptine. With the advent of the prolactin radioimmunoassay and more sensitive methods of roentgenologic examination, prolactin-secreting pituitary tumors are now being diagnosed with much greater frequency. Definitive treatment has been considered to involve transphenoidal hypophysectomy. The symptoms of hyperprolactinemia including amenorrhea, galactorrhea and infertility can usually be controlled without difficulty by bromergocryptine therapy, but little is known regarding continued tumor growth. Bromergocryptine and other ergot alkaloids have been shown to decrease the production of prolactin and to inhibit the rate of pituitary tumor growth in animal studies. In man, evidence for a similar effect is not as clear. The present study demonstrates tumor regression associated with bromergocryptine therapy in two patients.


Severe mycoplasma pneumonia with pleural effusions in a patient with sickle cell-hemoglobin C(SC) disease. Case report and review of the literature. We describe a patient with sickle cell hemoglobin C(SC) disease in whom severe pneumonia developed complicated by large bilateral pleural effusions and respiratory failure. Mycoplasma infection was not initially suspected but was subsequently proved serologically. The course of the illness was unusually long. A review of the literature showed occurrence of large pleural effusions to be infrequent for pulmonary infection with Mycoplasma in adults, with only eight such cases previously reported. The possibility of Mycoplasma pneumonia should not be dismissed merely because of the severity of the illness or the presence of pleural effusions.


The treatment of the hemolytic-uremic syndrome with inhibitors of platelet function. In four patients with clinical and laboratory manifestations of the hemolytic-uremic syndrome, the administration of aspirin and dipyridamole was associated with a dramatic and rapid increase in the platelet count. In three of the four patients there was also improvement in neurologic or renal function. No subject experienced bleeding or other untoward effects. We conclude that a trial of aspirin and dipyridamole therapy is warranted early in the course of the hemolytic-uremic syndrome.


Evaluation of SICKLEQUIK, a differential solubility test for hemoglobin S. Researchers evaluated a differential tube solubility test's ability to detect Hemoglobin S (Hb S) in sickle cell conditions. Six hundred twenty-nine blood samples, including 190 S hemoglobinopathies, were used to assess test performance. Alkaline cellulose acetate electrophoresis was used to confirm all results. The test correctly indicated the presence of Hb S in every case in which Hb S was found on electrophoresis. Six of the 198 specimens containing Hb S incorrectly differentiated the heterozygous from the homozygous state (two with Hb AS, three with Hb SF, and one with Hb SC). Electrophoresis later showed four of these samples to be inappropriate for solubility testing. Three of these specimens contained Hb SF and the other specimen contained Hb SC. One specimen from a patient with polycythemia gave a false positive result. Results were compared using different methods of centrifugation. This solubility test was found to be dependable as a screening method provided the manufacturer's directions are followed and all positive results are confirmed by electrophoresis.


Experience in the laboratory detection of the carrier state of classic hemophilia. The predictive odds for suspected carriers of hemophilia have been calculated using data derived from normal and known carrier populations. For each individual, the concentration of Factor VIII-related antigen and Factor VIII biological (procoagulant) activity was measured and the data were studied by linear discriminant analysis. Forty-five suspected carriers were evaluated, with 31 percent (14/45) classified as carriers. Using Factor VIII procoagulant activity alone, 18 percent (8/45) appeared as carriers, while the ratio method of activity level to antigen level showed 44 percent (20/45).


An unexpected albumin-bilirubin band in cellulose acetate electrophoresis for alkaline phosphatase isoenzymes. In 4 out of 202 consecutive electrophoretic patterns for serum alkaline phosphatase isoenzymes, an extra band was observed in the albumin zone. Subsequent heat inactivation tests and comparison studies with an albumin-based bilirubin standard indicated that the band was due to staining of an albumin-bilirubin complex. The band should not be mistaken for an isoenzyme of alkaline phosphatase.


Follow-up of intrauterine transfused surviving children. The long-term effects of intrauterine transfusion (IUT) are still being assessed since the procedure was first reported in 1963. Therefore, we undertook a follow-up study on the survivors of 57 infants who received IUT's between 1966 and 1975. Forty-two infants were born alive, but 15 died in the neonatal period. Overall survival was 27/57 (48%). An extensive follow-up examination was carried out at age 22 months to 10 years in 21/27 survivors. Height was below the third percentile in one child and head circumference above the mean and 2 SD in another. Of 21 children, 19 had normal vision, one was slightly myopic, and one had hyperopia. One child had unilateral high-frequency hearing loss. All had normal EEG's and none have mental retardation but 2/21 have "major" and 6/21 have "minor" neurologic signs. No evidence of passive antibody transfer was found, but minor disturbances of immunoglobulin levels were present.


Human fetal breathing activity during electively induced labor at term. Human fetal breathing movements were measured during the first stage of electively induced labor in 20 healthy term pregnancies. Fetuses made breathing movements 25.6% of the time during a 1 hour control period and breathing decreased significantly to 8.3% during latent-phase labor and further decreased to 0.8% during active labor (P less than 0.001). Patterns of increased fetal breathing activity accompanied by increased gross fetal body movements and increased fetal heart rate variability for periods of 20 to 60 minutes out of every 1.0 to 1.5 hours were observed, and the intermittent patterns of increased body movement and heart rate variability continued throughout the first stage of labor despite the decrease in fetal breathing activity during latent- and active-phase labor. It will be important to account for rest activity patterns when interpreting variability of heart rate during labor. The absence of fetal breathing activity during electively induced labor at term is not a clinical indicator of fetal ill health.


Effect of danazol on estradiol-17beta and progesterone secretion by porcine ovarian cells in vitro. The effect of danazol on progesterone (P4) and estradiol-17 beta (E2) secretion by cultured porcine granulosa cells was studied. Danazol markedly inhibited both basal and luteinizing hormone (LH)-stimulated P4 secretion by both granulosa and luteal cells in a dose-dependent manner during 24 hour culture periods. E2 secretion by granulosa cells was low (less than 3 ng/mg of protein) when cultured in the absence of an exogenous aromatizable substrate but was markedly increased when testosterone (T) was added to the media. Danazol inhibited E2 secretion by granulosa cells only when cultured in the presence of testosterone. E2 secretion by luteal cells was low even in the presence of testosterone and was not affected by danazol. These findings support the hypothesis that danazol can directly inhibit ovarian steroidogenesis independently of its inhibitory action on gonadotropin secretion.


Experience in treating two hundred and eighty-eight patients with endometrial carcinoma from 1968 to 1972. The results in treatment of 288 patients with endometrial carcinoma (1968 to 1972) were compared to results achieved in a similar series of 236 patients (1962 to 1967) at The University of Alberta, Edmonton, Alberta, Canada. The overall 5 year survival rate for the 524 patients was 76.1% (75.4% when Stage 0 is excluded), with generally better results in the more recent series except in treating Stage II disease. The overall 5 year survival rate for Stage I disease in the more recent series was 89.1%. Parameters for assessing a prognosis and management plan are indicated, with emphasis on the identification of high-risk Stage I cases.


Overt diabetes in pregnancy.

Overt diabetes in pregnancy. Of 45 diabetic pregnancies, 80% were Class C, D, or R. The perinatal mortality rate was 4.4% (corrected 2.2%); however, neonatal morbidity was high. Of the infants, 28% developed respiratory distress syndrome (RDS); 18%, asphyxia; and 42%, hypoglycemia. Thus, the woman with overt diabetes needs delivery in an institution where neonatal expertise and modern neonatal facilities exist. Of the mother 28% had a family history that was negative for diabetes mellitus. Four neonates developed RDS despite mature lecithin/sphingomyelin ratios.


The clinical prediction of intrauterine growth retardation. From a total study group of 8,030 deliveries, 2,788 patients with risk factors and 292 representative patients from the 5,242 patients without risk factors were selected for detailed analysis of predictors of intrauterine growth retardation (IUGR). Two thirds of the IUGR infants came from the population with risk factors and a weighting was assigned to individual risk factors. One third of the IUGR infants came from the population without risk factors, and their mothers demonstrated significantly differing maternal characteristics from those with a normally grown infant. The perinatal mortality rate was higher in the IUGR group and particularly in the population with risk factors.


Natural history of placenta previa ascertained by diagnostic ultrasound. Placental localization by diagnostic ultrasound was performed at 16 to 18 weeks' gestation in 1,098 patients prior to amniocentesis for genetic indications. Placenta previa was diagnosed in 58 patients, 47 of whom went on to delivery uncomplicated by placenta previa. There were five patients with placenta previa at delivery, four of whom had third-trimester bleeding. One patient was diagnosed as having a normal placental implantation at midtrimester but placenta previa was demonstrated at delivery. The incidence of placenta previa at 16 to 18 weeks' was 5.3% and fell to 0.58% at delivery, indicating a 90% conversion rate. Thus the vast majority of cases of asymptomatic placenta previa remain so and convert before delivery. These patients should be observed with serial ultrasound at 6 to 8 week intervals until delivery or unequivocal conversion. No restriction in activity seems indicated unless the placenta previa persists beyond 30 weeks or becomes clinically manifest.


Marlex gauze hammock sling operation with Cooper's ligament attachment in the management of recurrent urinary stress incontinence. In 1970 Morgan described an operation designed to meet the problem created by scarring and fibrosis resulting from previous operative procedures to the urethra and bladder neck. In the method, a 2 cm wide polypropylene (Marlex) mesh is placed as a broad hammock to elevate and support the urethrovesical junction with lateral attachment at Cooper's ligament. Sixty-nine women operated upon by Morgan's technique have been followed up for 6 months to 8 years. In those with unmixed stress incontinence, 90% were dry at follow-up, whereas in those with a mixture of stress incontinence and symptoms of detrusor disturbance, only 50% were benefited.


Amniotic fluid lecithin/sphingomyelin ratio, palmitic acid, palmitic acid/stearic acid ratio, total cortisol, creatinine, and percentage of lipid-positive cells in assessment of fetal maturity and fetal pulmonary maturity: a comparison. Lecithin/sphingomyelin (L/S) ratio, creatinine, percentage of lipid-positive cells, palmitic acid, palmitic acid/stearic acid (P/S) ratio, and total cortisol were analyzed as tests for fetal maturity and fetal pulmonary maturity in 164 samples of amniotic fluid from 121 patients. Fifty samples were taken within 72 hours of delivery. The best tests for fetal maturity (37 weeks) with differential percentages were L/S ratio, palmitic acid, and P/S ratio. In the assessment of fetal pulmonary maturity, we studied an additional 174 samples in which only L/S ratio, creatinine, and lipid-positive cells were analyzed. All tests showed a high predictive value of an immature (positive) result was much less for all six parameters; the three best tests were total cortisol (33%), lipid-positive cells (26%) and L/S ratio (14%).


Ultrastructural basis for maintenance and termination of pregnancy. Myometrial tissues from guinea pigs, sheep, and human subjects at various stages of gestation and postpartum were quantitatively examined in the electron microscope for the presence of gap junctions between muscle cells. Gap junctions were found in tissues from guinea pigs and sheep which were being delivered or ready to be delivered and in tissues taken immediately post partum. Gap junctions were also present in 19 tissues obtained from 69 women undergoing elective or emergency cesarean section for a variety of reasons. The frequency of their occurrence varies in relation to the presence or absence of labor and other conditions. We propose that gap junctions are required for effective muscle contractions leading to termination of pregnancy in all animals, including human beings. The absence of gap junctions throughout gestation may be necessary for maintenance of pregnancy and the premature appearance of the cell contacts may lead to premature labor.


Plasma prolactin, human chorionic gonadotropin, estradiol, testosterone, and progesterone in the ovarian hyperstimulation syndrome. Plasma prolactin, estradiol, progesterone, and testosterone, but not HCG-beta levels, were higher in a patient who developed the ovarian hyperstimulation syndrome while undergoing ovulation induction with human gonadotropins than in two other women who also became pregnant after similar treatment without complications. These results suggest that hyperprolactinema, in association with elevated ovarian steroid levels, may be factors in the pathogenesis of this disorder.


Sterilization and contraceptive services in Catholic hospitals. Sterilization and contraceptive practices in United States Catholic hospitals were surveyed by anonymous mail questionnaires, obtaining a 57% response rate (340 of 598). Twenty per cent of the hospitals permitted medically indicated sterilization operations. Forty-seven per cent of those hospitals not allowing sterilization procedures reported that their medical staffs were interested in performing medically indicated sterilizations. The types of contraceptive services offered varied widely. The rhythm method was most frequently available, with oral contraceptives in second place; many hospitals did not provide any family-planning services; 13% utilized all types of contraception. The thesis is advanced that improvement in availability of sterilization and contraceptive services is a duty of hospital medical staffs.


The obstetrician, fetal asphyxia, and cerebral palsy. In the current legal climate, the recognition of cerebral palsy or other major brain dysfunction in a child is likely to lead to a malpractice action against the obstetrician who delivered the child. Perinatal asphyxia is usually considered the most likely cause of the brain damage, and the obstetrician is presumed by the lawyer either to have failed to recognize the fetal asphyxia or to have ignored it. In this essay, the illogic in this reasoning is discussed. While fetal asphyxia clearly can cause fetal brain damage, the infrequency of this relationship is stressed. The dilemma faced by the obstetrician as a result of modern perinatal care is discussed.


Postoperative bladder training.

Postoperative bladder training. A group of 87 women who had either a retropubic suspension or anterior colporraphy with or without hysterectomy were studied to determine an optimal method of postoperative bladder training to facilitate recovery of normal bladder function. All patients received suprapubic catheters but 43 women had their catheters on constant open drainage while the remaining 44 patients were placed on an intermittent clamping regimen which was begun on the first postoperative day. The method of catheter management was selected randomly. Subgroups based on the operative procedure performed, patient age, and the presence or absence of postoperative infection were examined. In all groups of patients studied, those undergoing early intermittent clamping resumed normal micturition earlier than those who did not. It is recommended that this technique be utilized routinely in this group of patients to shorten the interval of time during which bladder drainage is required.


Carbon dioxide versus electronic urethrocystometry for the detection of detrusor dyssynergia. The reliability of rapid-fill carbon dioxide urethrocystometry in detecting detrusor dyssynergia was compared with the more physiologic method of electronic urethrocystometry. Fifty female patients who had urinary incontinence were studied. All patients with abnormal electronic studies had abnormal studies with carbon dioxide. Ten patients with normal electronic studies had an abnormal response to carbon dioxide and 40 per cent of these patients responded well to anticholinergic agents, indicating that carbon dioxide may be more sensitive in detecting mild forms of detrusor dysfunction that are medically treatable. Complete urodynamic assessment is recommended in conjunction with carbon dioxide urethrocystometry.


Preoperative hot conization of the cervix: a possible method to reduce postoperative febrile morbidity following vaginal hysterectomy. Laboratory results indicate that the endocervix may be a source of bacterial contamination when vaginal hysterectomy is performed. In a series of 160 consecutive vaginal hysterectomies in premenopausal women, hot conization of the cervix was performed prior to the scrub with an iodophore. No preoperative antibiotics were used in this series. The postoperative febrile morbidity rate was 4.3 per cent and the average stay was 4.5 days. These results are compared with those of three other groups: (1) patients who received a three-dose parenteral prophylactic antibiotic course with the first dose two hours prior to surgery had a febrile morbidity rate of 8.6 per cent. (2) In patients who had prophylactic antibiotics for five days with the first dose given intraoperatively, the febrile morbidity rate was 10.1 per cent. (3) The febrile morbidity rate in the group with no antibiotic prophylaxis or hot conization was 49.1 per cent. Laboratory and clinical data suggest that preoperative conization may be effective in the reduction of postoperative febrile morbidity.


Remission of uterine leiomyosarcomas treated with vincristine, Adriamycin, and dimethyl-triazeno-imidazole carboximide. Six patients with metastatic uterine leiomyosarcoma have been treated with the combination of vincristine, Adriamycin, and DTIC. Complete remissions were obtained in three patients and a partial remission in a fourth. The average duration of response was 15.6 months and one patient is free of disease at 24 months. Severe nausea and vomiting caused discontinuance of chemotherapy in two patients.


A reassessment of the fractional postcoital test. The present investigation was designed to reassess the fractional postcoital test (PCT). Specifically, the study addressed the question of whether the internal cervical mucus sperm count is significantly different from the sperm counts at other cervical levels. By means of standardized methodology, 25 normal postcoital tests were perfoemed on 22 couples. Cervical mucus from three different levels within the endocervical canal was examined for total count, motility, and sperm morphology. No significant difference could be found in these three parameters among any of the cervical levels (p greater than 0.05). Significantly fewer abnormal sperm were found in the cervical mucus when compared to the total abnormal forms in the semen (p less than 0.001). Therefore, while the fractional PCT is a reflection of cervical sperm, this study indicates that the three different cervical levels in the fractional PCT (internal-mid-external) are equally effective in the interpretation of the postcoital test.


A blocking factor in amniotic fluid causing leukocyte migration enhancement. Amniotic fluid was found to cause significant leukocyte migration enhancement during the second and third trimester of pregnancy and in the early postpartum period when compared to the migration area obtained with an ovarian tumor homogenate antigen (p less than 0.01), choriocarcinoma spent medium (p less than 0.01), and placental pool homogenate (p less than 0.01). Only borderline significance (p less than 0.1) was obtained when migration enhancement with AF was compared between pregnant and nonpregnant female control patients, indicating minimal unspecific activity of AF. Migration enhancement with autologous amniotic fluid was slightly larger than with homologous amniotic fluid, but the difference did not reach significance (p less than 0.4). None of the control antigens caused migration enhancement; placental pool homogenate in concentrations above 4 mg. per cent caused migration inhibition but did not in lower concentrations. The enhancing effect of AF could be abolished by dilution but not by addition of excessive antibody to estrogen of HCG. It is suggested that a blocking factor is present in AF preventing recognition of fetoplacental antigen by the maternal immune system. Thus in vitro leukocyte migration enhancement may correlate to in vivo graft enhancement.


Cesarean section in California--1960 through 1975. The cesarean section rate has been rising in California since 1965. In this article, we describe the trend in cesarean section rates in California from 1960 to 1975 in relation to maternal and infant variables. Approximately proportionate increases in cesarean section rates by infant birth weight and maternal race were found. Cesarean section rates for women under 20 years of age and for those of first parity have risen proportionately more than rates for other age and parity groups. We also found that cesarean section rates for births at gestational age's exceeding 42 weeks have risen proportionately more than rates for births at other gestational ages. Maternal mortality ratios associated with cesarean section were twice those associated with noncesarean births for the years 1973, 1974, and 1975. Possible explanations of the current cesarean section rate include an increase in indications for the procedure, use of the fetal monitor, and the current medical-legal climate. The potential problems that cesarean section may create for the mother and infant are higher rates of iatrogenic prematurity and respiratory distress and of maternal morbidity and mortality.


Sudden collapse and death of women obtaining abortions induced with prostaglandin F2alpha. Two recent cases of sudden collapse and eventual death of the woman after induction of abortion with prostaglandin F2alpha (PGF2alpha) have been reported to the Center for Disease Control as part of the epidemiologic surveillance of deaths due to abortion. We present these cases in order to document this event associated with the use of PGF2alpha. The etiology of the sudden collapse is still unknown. Nonetheless, the deaths of these two healthy young women undergoing induced abortions with PGF2alpha should heighten clinicians' awareness of some possible risks associated with these new abortifacients.


Analysis for amniotic fluid crystallization in second-trimester amniocentesis. A potential complication of second-trimester amniocentesis for genetic indications is inadvertent needle insertion into the maternal bladder, resulting in aspiration of urine rather than amniotic fluid. Amniotic fluid forms a characteristic crystalline arborization pattern when allowed to air dry. We utilized this property of amniotic fluid to distinguish amniotic fluid from maternal urine. In 24 of 25 cases studied in a randomized blind fashion the crystalline arborization test correctly identified amniotic fluid, whereas none of the 25 urine samples showed this pattern. Our study indicates that the crystalline arborization test is reliable in distinguishing amniotic fluid from maternal urine during the second trimester of pregnancy.


Perinatal listeriosis--a review of twelve patients. From July, 1974 to February, 1978, we managed 12 infants with listeriosis. This infection presented in two distinct forms: an early-onset type (nine patients), often representing a congenital infection following maternal illness, and a late-onset type in which the patient presented with meningitis (three patients). Of our nine infants with early-onset disease, three died, three developed permanent sequelae, and only three were normal at follow-up. Appropriate early management in the perinatal period may improve the outlook in this condition. Affected infants were often premature and had pneumonia, rash, and hepatosplenomegaly at birth. Prenatal clues to the diagnosis included maternal fever, abdominal pains, and leukocytosis with meconium staining of the preterm amniotic fluid. Examination of gastric aspirate at birth showed gram-positive coccobacilli. Antibiotic therapy should be started prenatally and continue for three weeks after birth to prevent recurrences of the late-onset type. This late-onset disease presented as meningitis after the second week of life and responded well to antibiotics. Our three patients recovered without sequelae.


Evaluation of a new rapid slide test for pregnancy. A new latex-inhibition slide test for pregnancy, Gest female State, with the use of polystyrene latex particles to which human chorionic gonadotropin (hCG) has been bound, is described. The sensitivity of this test was found to be 2 to 4 1.U. of hCG per milliliter of urine. Clinical trials with the Gest female State in urine samples from 328 patients (203 positive, 125 negative) showed one false negative and no false positive results. Urine containing drugs or high concentrations of various ingredients and abnormal urine did not result in interference with expected test results. The new test was comparable with or superior to other commercially available rapid slide tests for pregnancy.


Abnormal antepartum fetal heart rate tracings, failure to intervene, and fetal death: review of five cases reveals potential pitfalls of antepartum monitoring programs. The goal of antepartum fetal heart rate monitoring is to identify which infants among high-risk obstetric patients are at risk for intrauterine death and which are not. Effective programs, by appropriately selecting cases for intervention and nonintervention, should contribute to lowering of perinatal morbidity and mortality rates. A review of five fetal deaths preceded by abnormal antepartum FHR tracings suggests effective programs require strict control. Individuals performing the testing should be experienced and knowledgeable in regard to instrumentation characteristics and recognition of normal and abnormal fetal heart rates. Dual responsibility of antepartum testing and providing primary patient care to labor and delivery patients is undesirable. Test interpretation should be based on strict criteria.


The preterm small-for-gestational age infant: a two-year follow-up study. Previous investigators have reported unfavorable neurologic and developmental outcome of small-for-gestational age (SGA) infants (birth weight less than 1,500 grams born at term or at less than 30 weeks. of gestation. Since obstetrical considerations for the delivery of a SGA fetus often arise between 30 and 38 weeks, the outcome of these survivors becomes a relevant issue. In 1975 and 1976, twenty-eight of 47 such infants survived and 21 were followed sequentially during the first two years. Their birth weight was 1,220 +/- 195 grams (mean +/- S.D.) and the gestation 33.4 +/- 2 weeks. Each SGA infant was paired with a birth weight-matched appropriate-for-gestation (AGA) infant whose birth weight was 1,195 +/- 190 grams and gestation 29 +/- 2 weeks. The weight, length, and head circumference of the SGA infants attained the tenth percentile by 6 to 8 months and were similar to the AGA group. Quarterly neurologic examinations showed similar findings during the first year in the two groups. At 2 years, two SGA (diplegia) and one AGA (hemiplegia) infants were abnormal. The quarterly Bayley scores of the SGA infants were lower during the first 18 months but at 24 months, the two groups had similar scores. The favorable outcome in preterm SGA infants weighing less than 1,500 grams may serve as useful information in making clinical decisions for the management of mothers with suspected intrauterine growth retardation.


Oral contraception and twinning: an epidemiologic study. Among 4,428 women studied at five large hospitals in Connecticut, those conceiving within two months of cessation of oral contraceptive use had a twofold increased rate of delivering twins. This increase was found in both black and white women. Analysis of unlike and like sex twins indicates that this effect seems to clearly depend on an increased rate of dizygous twinning.


Further evidence for the role of prolactin on human fetoplacental osmoregulation. The addition of ovine prolactin (oPRL) to the fetal side of human term amnion in vitro is associated with a decrease in membrane permeability to tritiated water (THO). As the concentration of oPRL is increased from 2.5 to 20.0 micrograms per milliliter, permeability is progressively impaired. The addition of a specific prolactin receptor antibody completely abolished the effect of oPRL. Also, the addition of Ouabain abolished the effect of oPRL. When an osmolic gradient was created using Dextran-10 on the maternal side of the amnion, the bulk flow of water in control and 3PRL-treated membranes was not significantly different. These findings suggest that PRL acts predominantly on the diffusional flow rather than the bulk flow of water across amnion and that it is a transcellular transport. These studies also represent indirect evidence for the existence of prolactin receptor sites at the level of the amnion.


Free metanephrine in human amniotic fluid as an index of fetal sympathetic nervous system maturation. Free metanephrine, a major metabolite of catecholamines, was measured in the amniotic fluid of 113 pregnant patients at various gestational ages. The results indicate that prior to 30 weeks the levels of free metanephrine are below the level of assay sensitivity. After 30 weeks' gestation there is a positive correlation of free metanephrine concentrations in amniotic fluid with gestational age. In addition there is a further increase in free metanephrine levels in amniotic fluid with labor.


In-training examinations for residents in obstetrics and gynecology, 1975 to 1978. In the four years from 1975 to 1978, 12,712 in-training examinations were administered to residents by the Council on Resident Education in Obstetrics and Gynecology. Whereas the first four tests (1970 to 1974) consisted entirely of multiple choice items (MCQs), these examinations were approximately equally divided between MCQs and patient management problems (PMPs). Discrimination, difficulty, and reliability indices for the total examination have remained relatively constant. The MCQ subtest scores have decreased in validity due mainly to the decrease in the number of items necessary to accommodate the PMPs. However, the overall test performance remains satisfactory to meet its educational objective. Accomplishment of this objective was enhanced by the unique "key word feedback" instituted in 1975. The tests have continued to show a progressive score increase from the first to the fourth years of training. These and other data are presented by year, and the future directions for the examination are discussed.


Mechanism of failed labor after fetal death and its treatment with prostaglandin E2. Pregnancy was terminated with prostaglandin E2 in 65 women harboring a dead fetus for 3 days to 8 weeks. The study was designed to: (1) elucidate the mechanism of failed onset of labor in the presence of fetal death, (2) determine appropriate dose-response relationships, and (3) evaluate safety and efficacy of this new method of intervention. Results indicate that plasma progesterone levels from 12 to 40 weeks' gestation are in the lower normal statistical range as compared to those seen in pregnancy with a living fetus. Uterine size as estimated from fetal birth weight is also in the low normal range compared to that seen in a viable pregnancy. Hence the uterine volume-progesterone ratio is equal to or greater than that in normal pregnancy and thereby partially explanatory for the failed initiation of labor. The dosage required to produce delivery declined in each month's grouping from a mean of 56 +/- 26 (SD) mg at 12 to 15 weeks to 22 +/- 8.4 mg at 38 to 40 weeks. Dose-delivery response did not correlate with age, parity, or progesterone levels but did correlate with oxytocin response. Three unusual and serious complications occured.


Intrapartum fetal heart rate monitoring. I. Classification and prognosis of fetal heart rate patterns. A total of 1,996 direct fetal heart rate (FHR) tracings in labor were analyzed using the first and last 30 minutes of monitoring in order to evaluate individual FHR characteristics as to their ability to predict the fetal status. Comparisons were made between individual FHR characteristics occurring alone ("uncomplicated") and those occurring in association with others ("complicated") in predicting fetal status as judged by 1 and 5 minute Apgar scores. These comparisons were made separately for the first 30 minutes and the last 30 minutes of monitoring.


Calcium metabolism in normal pregnancy: a longitudinal study. Total and ionic calcium, magnesium, phosphorus, albumin, and immunoreactive parathyroid hormone (iPTH) and calcitonin (iCT) were measured in serum or plasma from 30 women throughout pregnancy (beginning before 12 weeks' gestation) and the puerperium. Total calcium levels declined during gestation, paralleling a progressive fall in albumin concentration, whereas ionic calcium values declined only very slightly. Although iPTH levels in early pregnancy were lower than postpartum values (suggesting that iPTH may decline initially following conception), the major portion of gestation was characterized by progressively increasing concentrations which at term averaged 53% above early pregnancy levels and 33% above puerperal values. Thus, the principal adjustment during pregnancy is "physiologic hyperparathyroidism" which acts to preserve maternal homeostasis by maintaining the concentration of calcium ions in extracellular fluid in the presence of expanding fluid volume, increased renal function, and placental transfer. iCT levels were not affected consistently by pregnancy and exhibited highly variable patterns; half of the subjects demonstrated an increase during the first and second trimesters and then a decline in the third trimester and the remaining half was equally divided between those with no change and those with progressively falling levels.


The evolution of a treatment program for adenocarcinoma of the endometrium. Previous studies at the University of Minnesota suggest that overall survival rates after treatment for adenocarcinoma of the endometrium are related to increased surgical applicability, that vaginal recurrence is frequently related to cervical involvement, and that virtually all women can safely undergo abdominal hysterectomy and radical irradiation therapy. In this program a simple abdominal hysterectomy was applied to as many women with this disease as possible. High-risk patients also received preoprative or postoperative irradiation. This program increased the survival rate for all stages from 58% to 69.7%. The survival rate among women with Stage I high-risk disease treated with supplementary irradiation was significantly lower when compared to that among women with low-risk disease who were treated by surgery alone. No vaginal recurrences were observed in either group and 98.4% were operated upon. The survival rate of women with Stage II disease treated with irradiation and surgery improved significantly. The rate of vaginal recurrence was 2.2%.


Extrapelvic lymph node metastases in cervical carcinoma. One hundred and fifty patients with invasive cervical carcinoma underwent preradiation therapy celiotomy and para-aortic node excision. The incidence of histologically documented metastases in these nodes was 33% (34/102) in Stage IIIB. The last 23 patients with positive para-aortic nodes had left sclanene node excision; nodes were positive in eight patients (34.8%). Sixteen patients had visceral metastases including 11 with small and large bowel metastases, two with liver metastases, and one with metastases to the liver and intestine. Pretreatment celiotomy with para-aortic lymph node excision and, where positive, followed by scalene lymph node excision is valuable in treatment planning in advanced cervical carcinoma limited to the pelvis.


An alternate approach to early cancer of the vulva. Early invasive squamous cell carcinoma of the vulva has emerged as a controversial issue in recent literature. Reports illustrating metastatic disease in the inguinal lymph nodes have conflicted with other reports suggesting local treatment only. The morbidity produced by radical vulvectomy to both body image and sexual function make this issue worthy of serious consideration. This report deals with an alternate approach to this disease entity which attempts to preserve vulvar tissue without sacrificing curability where possible metastatic disease exists. The concept is proposed of utilizing the superficial inguinal nodes as sentinel nodes in the treatment planning. The results of 20 patients treated in this manner are presented.


A simplified surgical technique for the treatment of the vault in vaginal hysterectomy. The surgical steps in the various techniques to remove the uterus by vaginal hysterectomy are quite uniform; however, the handling of the vaginal cuff differs with each and all techniques reviewed. The technique here described is a simplified method that secures hemostasis, establishes drainage of the anterior vaginal wall, and creates a vaginal canal adequate for sexual function. Emphasis is placed on the inclination of the vagina, a step that brings the vaginal axis almost perpendicular to the body axis, obviating the constant bearing-down effect on the intra-abdominal pressure on the apex of the vagina. Prevention of subsequent enterocele formation is achieved by the occlusion of the weak spot between the ulterosacral ligaments, the site of the hernial sac formation.


Changing obstetric practices and amelioration of perinatal outcome in a university hospital. A 40 year review of obstetric statistics revealed that the perinatal outcome has improved significantly following the introduction of biophysical and biochemical fetal surveillance systems. A simultaneous increase in the cesarean section rate is noted; however, this increase in the cesarean section rate is not related to an increase in the diagnosis of fetal distress. Other factors which may influence an improved perinatal outcome have been examined. It is concluded that biochemical and biophysical fetal surveillance has played a decisive role in the improvement of perinatal results.


Proliferation kinetics of human endometrium during the normal menstrual cycle. A radioautographic analysis of the number and distribution of labeled nuclei after in vitro incorporation of radiothymidine was carried out in human endometrium during the normal menstrual cycle. The highest rates of proliferation were recorded on cycle days 8 to 10 in the upper one third of the functionalis layer. Coinciding with intraglandular secretory activity on cycle day 19, the rate of proliferation of gland cells decreased near zero levels and remained unchanged thereafter. Midsecretory phase arteriolar coiling and stromal predecidualization were associated with increased isotope incorporation. DNA synthesis in premenstrual endometrium was limited to the surface epithelium, predecidua, and vascular endothelium. The endometrium of the isthmus and cornual regions and of the basalis zone demonstrated relatively constant and comparatively lower rates of proliferation throughout the cycle. Regional and cellular variations in nucleic acid synthesis in cyclic endometrium are likely to reflect differences in physiologic functions in target cells in response to cyclic hormonal stimuli.


Psychological development of children who received intrauterine transfusions. The intellectual, visual-motor, and social development of 15 children, 3 to 10 years of age, who received IUT for eythroblastosis fetalis was compared with that of 15 children of similar age who had required only exchange transfusions for the treatment of the same disorder. No over-all differences were found between the two groups or between the groups and the normal population. In comparison with normal population, recipients of IUT have above average IQ's and normal development in visual-motor integration and adaptive behavior.


Alterations in activity of enzyme catechol-O-methyltransferase in central and peripheral regions of the rat and rabbit during pregnancy, parturition, and the postpartum period. Natural variations in the activity of the enzyme catechol-O-methyltransferase in central and peripheral regions of the rat and rabbit during pregnancy and parturition were observed. All of the organs of the rat showed a decrease in enzyme activity up to the twenty-first day of pregnancy. Rabbit tissues also demonstrated a decrease in catechol-O-methyltransferase activity during Days 24 to 30 after coitus. Increases in activity of the rat ovary, brain, and hypothalamus took place from during Day 21 after coitus to the onset of parturition. The enzyme activity in the rat hypothalamus reached its maximum level at four hours post partum from the Day 21 value, but the rabbit hypothalamus showed the maximum activity at 0 hour parturition. During post partum hours, rat brain catechol-O-methyltransferase activity was very high but the rabbit brain showed a very low level of activity. Rabbit uterine activity reached its minimum value at Day 31 after coitus, but at the comparable intervals the situation was inversed in the rat. Results show an important modification of monoamine degradation by 3-O-methylation during midgestation in the central and peripheral regions. These modifications may be attributed to the natural variations in endocrine activity taking place during pregnancy.


Prostaglandin F2 alpha metabolite levels in plasma, amniotic fluid, and urine during pregnancy and labor. Levels of 13, 14-dihydro 15-keto-prostaglandin F2alpha (dhk PGF2alpha) in the plasma of 30 patients as well as in the amniotic fluid of 17 patients, and 5alpha,7alpha-dihydroxy 11-keto tetranor-prostane 1,16-dioic acid (the main urinary metabolite of PGF2alpha [PGF2alpha MUM]) levels in the urine of 30 patients were measured by radioimmunoassay during pregnancy, labor, and the puerperium. During pregnancy, no increase in dhk PGF2alpha (ng/ml) in plasma was detected as the time of delivery approached. The levels of dhk PGF2alpha during the second stage (0.64 +/- 0.15) and also at delivery (0.88 +/- 0.27) were significantly elevated over those in the first stage (0.38 +/- 0.29) (P less than 0.025 and P less than 0.005, respectively). Its level 2 hours after delivery was reduced to predelivery levels. Its levels in umbilical arterial and venous blood were 0.71 +/- 0.26 and 0.67 +/- 0.26, respectively. A significant elevation (P less than 0.01) of dhk PGF2alpha from 0.89 +/- 0.21 before labor to 6.16 +/- 2.40 at delivery was found in amniotic fluid. The hourly excretion of PGF2alpha MUM (microgram/hour) increased significantly from pregnancy levels to 1.06 +/- 0.45 in the first stage (P less than 0.01), to 7.67 +/- 4.31 (P less than 0.005) for the first 2 hours after delivery, and 2.37 +/- 1.08 from 2 to 12 hours after delivery (P less than 0.01). The excretion of PGF2alpha MUM decreased to pregnancy levels 12 hours post partum. These data indicate that during labor the production of PGF2alpha is remarkably increased.


Prolonging paracervical block anesthesia: addition of dextran to 2-chloroprocaine. Forty parturient women received paracervical block (PCB) anesthetics during labor with 2-chloroprocaine (2-CP) and epinephrine in either normal saline or dextran. Thirty-six patients were though to have adequate anesthesia. Nineteen patients who recived 2-CP in saline had a mean duration of anesthesia lasting 55.4 min; one fetus developed post-PCB bradycardia. Seventeen patients who received 2-CP in dextran had a mean duration of anesthesia lasting 72.7 min; no fetal bradycardia was observed following PCB. Neonatal depression, expressed by 1 and 5 min Apgar scores below seven, was not observed in either group. The addition of dextran to 2-CP significantly prolongs the duration of PCB anesthesia and does not appear to compromise the fetus. The pain relief provided by a single PCB with 2-CP in dextran is still relatively short and would not persist throughout the active phase of labor in most parturient women.


Meperidine and normeperidine levels following meperidine administration during labor. I. Mother. Because of the unavailability of sensitive analytic techniques, the pharmacokinetics of meperidine have not been clearly delineated in obstetric patients during labor. Moreover, the production of the active meperidine metabolite--normeperidine--has not been investigated. By means of gas chromatographic and mass spectrometric techniques, these characteristics of meperidine metabolism were evaluated in 23 pregnant patients in the present study. The data show that the disappearance curve and pharmacokinetic constants for meperidine are similar to those previously reported for nonpregnant subjects. In regard to normeperidine, the data indicate that it is produced within ten minutes after meperidine injection, increases rapidly for the next 20 minutes, and then slowly increases throughout labor. The results enumerate the pharmacokinetic constants of meperidine in obstetric patients and describe the appearance of normeperidine, the active meperidine metabolite, following meperidine administration during labor.


Meperidine and normeperidine levels following meperidine administration during labor. II. Fetus and neonate. The time interval between the administration of meperidine to laboring patients and delivery may affect neonatal status, but sophisticated analytic techniques have not been used to determine the exposure of the fetus to meperidine at various drug-delivery intervals. By means of gas chromatography and mass spectrometry, the concentrations of meperidine and normeperidine (the principle metabolite of meperidine) were quantitated in the umbilical cord venous and arterial plasma at delivery and in the urine of the neonate for three days postpartum. Following 50 mg. of meperidine administered intravenously during labor, fetal exposure to meperidine was highest two to three hours after maternal medication while fetal exposure to normeperidine was highest four hours or more after medication. We conclude from this study that there is a definite but nonlinear relationship between the drug-delivery interval and the amount of meperidine and normeperidine an infant receives; and that the drug-delivery intervals resulting in maximum fetal exposure reported here correspond with those resulting in maximum neonatal depression reported by others.


The ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity. A practical classification of placental maturity changes has been developed based on a review of multiple ultrasound evaluations of placental texture over a 4 year period. This classification grades placentas from 0 to 3 according to specific ultrasonic findings at the basal and chorionic plates as well as within the substance of the organ itself. The placentas of 129 patients were graded according to this system at the time of ultrasound evaluation. Eighty-six patients had placentas classified as Grade 1 or greater and all of these had lecithin-sphingomyelin (L/S) ratio determinations performed. Mature L/S ratios (2.0) were found in 68% of Grade I (21/31), 88% of Grade II (28/32), and 100% of Grade III placentas (23/23). These results suggest a correlation between maturational changes of the placenta as seen by ultrasound and fetal pulmonic maturity as indicated by L/S ratio.


Water-borne contamination of intrauterine pressure transducers. Internal intrapartum fetal monitoring has been implicated as a source of maternal and fetal sepsis. We report water-borne contamination of a component of the intrauterine pressure transducer and suggest that this may be a potential source of nosocomial infection.


Allergic granulomatous nodules of the eyelid and conjunctiva. The XXXV Edward Jackson Memorial Lecture. We studied the clinical and pathologic features of 22 cases of granulomas of the conjunctiva or eyelids. All cases showed the histologic features of the Splendore-Hoeppli phenomenon, that is, a giant cell and eosinophil granulomatous reaction to an antigen-antibody precipitate originally described in relation to parasites or fungi. In four of seven typical cases selected for detailed description unidentified nematodes were found to be the cause of the condition. In light of these findings together with a review of similar "allergic granulomas" reported both in ocular tissues and elsewhere in the body, we considered the cause in the remaining cases. All 22 cases may have been caused by nematodes, as seems, probable in 14 of them, or the causative antigens may have been of widely different kinds. Although in our cases all ocular granulomas had an identical histology, this study did not resolve the problem of those cases where no causative agent was found. Thorough investigation of such cases in the future and the demonstration of their cause may elucidate the wider problem of nonocular allergic granulomas.


Congenital retino-pigment epithelial malformation, previously described as hamartoma. Six patients with a congenital malformation of the retina and pigment epithelium had a slightly elevated greenish-blue or gray lesion in the macular area or fundus periphery composed of a flat, outer pigmented portion consisting of a layer of hyperpigmented, presumably hypertrophied retinal pigment epithelium and a prominent, unpigmented inner portion consisting of malformed thickened retina. Marked tortuosity of the retinal vessels was explained by an intraretinal disturbance of the retinal layering and the presence of preretinal membranes. Angiography revealed blockage of the background fluorescence caused by the abnormal retinal pigment epithelium and leakage from dilated, abnormal capillaries. Typically, the lesion was unilateral and was found in children or young adults who had monocular strabismus, reduced visual acuity, and often hyperopia. Most of the patients were males, and their cases were frequently misdiagnosed as tumors.


The diagnosis and treatment of secondary glaucoma after hyphema in sickle cell patients. Four patients with sickle cell hemoglobinopathies (one sickle cell hemoglobin C disease (SC); three sickle cell trait (AS)) and hyphemas had a higher percentage of erythrocytes sickled in their anterior chambers than in their circulating venous blood. Intraocular pressure (IOP) was severely increased, despite relatively small amounts of intracameral blood. Systemic hypotensive agents were not always successful in reducing IOP, and in patients with sickle cell hemoglobinopathy, are probably contraindicated in high or repeated dose regimens. Moderate increase of IOP in sickle cell hemoglobinopathy patients may produced rapid deterioration of visual function, because of a greater than usual effect on vascular perfusion in the central retinal artery and optic nerve. Early anterior chamber paracentesis may be the best treatment for this type of hyphema-induced secondary glaucoma.


Transcorneal flux of topical pilocarpine to the human aqueous. Aqueous fluid was withdrawn from eyes of patients undergoing cataract extraction at various intervals after administration of two drops of 2% pilocarpine HCl in a standard manner. Determination of aqueous pilocarpine concentration was made both by spectroscopy of a ferric hydroxylamine complex and by gas-liquid chromatography. Results of both methods were consistent in indicating that concentration does not rise at any time following such topical instillation beyond 5 microgram/ml, with an average of 1.67 microgram/ml, representing a flux efficiency of 0.03%. These findings correlate well with previous investigations of transcorneal flux of pilocarpine for the rabbit in a transport chamber system, in which comparable low flux efficiency was found after simulated drop administration. This serves in some measure to validate an extrapolation of other findings in chamber experiments to the living human eye.


Delayed absorption of subretinal fluid after scleral buckling procedures. Delayed absorption of subretinal fluid beyond six weeks after surgical repair for rhegmatogenous retinal detachment was recognized in 39 of 575 consecutive cases of scleral buckling. The most common preoperative condition was large clumps of cells on the undersurface of the detached retina (subretinal precipitates). Approximately one in four patients in whom precipitates are seen preoperatively will have fluid persisting beyond six weeks from surgical repair to complete absorption. A second relatively common condition associated with delayed fluid absorption that could be recognized before operation was long-standing peripheral (usually inferior) retinal detachment, which typically spared the macula, was associated with demarcation lines, and was caused by round atrophic holes with or without associated lattice degeneration. An analysis of subretinal fluid protein concentrations in 39 cases showed a positive relationship between protein concentration and duration of detachment. Pigment-laden macrophages in the subretinal space, possibly originating from the retinal epithelium, were common.


Neonatal retinal hemorrhages and influence of perinatal factors. We studied fundus oculi in 234 newborns, divided into two groups of mothers and neonates with or without disease. The overall frequency or retinal hemorrhages was 30.3% (71 neonates). In each group, we studied the association between retinal hemorrhage and several variables of labor and the newborn infant. Statistically significant differences were found in the incidence of hemorrhage in one (2.6%) neonate born by cesarean section, as compared with 61 (38%) spontaneous or 9 (25%) forceps delivery.


Exacerbation of senile macular degeneration following cataract extraction. Six eyes in four patients had hemorrhagic detachment of the retinal pigment epithelium following cataract extraction. All eyes had evidence of nonexudative senile macular degeneration preoperatively as manifested by drusen or alterations in the retinal pigment epithelium, or both. Postoperatively, all eyes had evidence of a subretinal neovascular membrane manifested by the presence of subretinal hemorrhage or by evidence on fluorescein anglography. We believe cataract extraction may cause changes in the choroidal hemodynamics that allow pre-existing new blood vessels to leak or bleed, or induces the formation of choroidal neovascularization in a predisposed eye.


The use of strontium-90 in the treatment of carcinoma in situ of the conjunctiva. Four patients with carcinoma in situ were treated with strontium-90 beta ray application. The dose used was 4,500 rads after surgical removal or with small recurrent tumor and 7,000 rads for primary treatment. All patients were disease-free at follow-up periods of 48 to 320 months after treatment. One patient required superficial x-ray treatment for recurrent disease. No serious complications developed with the treatment and no progressive cataracts have occurred.


Monocular vertical nystagmus as an initial sign of chiasmal glioma. A 5-year-old boy with monocular vertical nystagmus, initially believed to have spasmus nutans, subsequently developed optic atrophy and visual loss. Neuroradiologic investigation indicated probable chiasmal glioma. The case of this patient re-emphasizes the necessity of careful clinical and radiologic assessment before assuming acquired monocular nystagmus to be a benign and self-limited disorder.


Opticociliary veins in a primary optic nerve sheath meningioma. A 59-year-old man developed painless visual loss in his left eye over a one-year period, with rapid progression to blindness over three months. Ocular examination of the left eye revealed proptosis, marked optic disk pallor, dilated retinal veins, and congeries of vessels at the disk margin (opticociliary veins). His right eye was unremarkable. Fluorescein angiography and histopathologic examination confirmed the presence of opticociliary veins communicating between branches of the central retinal vein and the adjacent choroidal vasculature. Primary orbital optic nerve meningioma associated with opticociliary veins was diagnosed.


Hemorrhage into retinoschisis diagnosed as malignant melanoma. A 55-year-old man had organized hemorrhage into retinoschisis that simulated malignant melanoma both clinically and with ultrasonography. The correct diagnosis was made histopathologically after enucleation.


Learning scleral depression with binocular indirect ophthalmoscopy. Scleral depression with binocular indirect ophthalmoscopy will be easier to learn if the examiner observes the patient's pupillary reflex through the ophthalmoscope without looking through the hand-held condensing lens. When the tip of the scleral depressor is properly positioned the pupillary reflex will darken slightly. If the condensing lens is then moved into position the actual scleral depression will be visible.


Fixation of cadaver eyes for surgical practice. Cadaver eyes for surgical practice may be prepared by melting No. 7 dental wax in a 1-ounce medicine glass and fixing the globe with melted dental wax. The preparation is then placed in a styrofoam wig stand with openings prepared for the medicine glass.


Lens implantation, miosis, and glaucoma. In a series of 1,079 patients, average age 76.3 years, 48 eyes required an iridoplasty for chronic miosis and, of these, visual acuity was 6/12 (20/40) or better postoperatively in 89.6% (43). In those patients with glaucoma, the control of intraocular pressure was the same or better than post-operative levels in 83.3% (15) of patients. Lens implantation was not contraindicated in the miotic patient if adequate iris surgery was performed before both cataract extraction and implant insertion. When there was concomitant glaucoma, lens implantation was likewise not contraindicated if the glaucoma was well controlled.


Cataract extraction in glaucoma.

Cataract extraction in glaucoma. Cyclodialysis lens extraction or cyclodialysis canalicular trabeculectomy lens extraction in one eye and cataract extraction in the fellow eye were performed in 24 glaucoma patients. The combined procedure follow-up was from five to 12 years in the first group, two to four years in the second group, and from three to ten years in the control group. The 50% success rate of cyclodialysis lens extraction can be enhanced with no significant increase in surgical morbidity or postoperative complications by performing a cyclodialysis canalicular trabeculectomy where the disinsertion of the scleral spur is carried out under direct visualization.


The clinical course of serpiginous choroidopathy. We closely observed nine patients (17 eyes) with serpiginous choroidopathy for time periods ranging from two to ten years. There were seven men and two women with ages ranging from 22 to 58 years, average age was 46 years. Eight patients were bilaterally affected; one patient had only one eye. The clinical course of the disease was characterized by multiple recurrences. The recurrences and progression of the disease often were not noticed by patients if the macular area was not involved. Serial fundus photographs proved to be invaluable in establishing progression. Although the disease usually progresses in a centrifugal manner from the disk toward the periphery, three patients demonstrated centripetal progression and one of these three permanently lost central acuity. Visual acuity was affected only when the foveal or parafoveal areas became involved, but in nine of the 17 eyes, visual acuity returned to a variable degree. None of the patients had any general systemic illness. However, five of the patients reported chronic exposure to an unusual variety of chemicals.


Lysozyme content of tears in patients with Sjögren's syndrome and rheumatoid arthritis. In 37 patients and 143 control patients we estimated tear fluid lysozyme content by the Micrococcus lysodeikticus agar diffusion assay. We found no correlation between the titer of lysozyme in tear fluid and the rate of tear flow. Decrease in lysozyme production was found to be a sensitive indicator of the involvement of the lacrimal system in Sjögren's syndrome.


Familial exudative vitreoretinopathy.

Familial exudative vitreoretinopathy. At age 26 years a woman who had been blind in the left eye from birth had visual acuity of R.E.: 6/18 (20/60); L.E.: 6/120 (20/400), with 40 prism diopters of left exotropia. The left eye showed a decreased anteroposterior diameter of the globe and a complete retinal detachment behind a cataractous lens. The right eye had a posterior subcapsular lens opacity severe vitreous fibrosis, dragging of the optic disk, and intraretinal and subretinal exudation with a fibrovascular mass in the temporal retina. The patient's 3-year-old daughter had 45 to 50 prism diopters of exotropia, a pendular nystagmus with intraretinal and subretinal dragging of each disk, and early degeneration and band formation in the periphery of each fundus.