The echocardiogram after pericardiectomy. Many factors may affect the interventricular septal motion. This study measures the effect of pericardiectomy on septal motion in 9 patients who were evaluated 1 week to 58 months after pericardiectomy. Echocardiography was performed with the patient in recumbent position with the special care to record motion of the muscular septum and not that of the aorta. No patient had left bundle branch block, angina, myocardial infarction, pericardial effusion or right ventricular volume overload. Septal motion was paradoxical in 7, normal in 1 and could not be evaluated 1 patient. The mean value of the right ventricular internal dimension was normal. Two of 9 patients had technically satisfactory echocardiograms preoperatively. Septal motion was normal in both, and both developed paradoxical septal motion postoperatively. We conclude that paradoxical septal motion pericardiectomy, but in contrast with other causes of this finding right ventricular internal dimension remains normal.


Surface potential distribution on the human thoracic surface in left bundle branch block. The sequences of myocardial excitation in the cases of human LBBB have been studied by the surface mapping technique. Analysis of the surface map patterns of 12 subjects has enabled 4 different types to be described. It is suggested that Type I represents a complete LBBB in the presence of an intact right bundle branch, while Types II and III show different degrees of conduction defect in the right bundle branch, too. The left ventricular activation of these 3 types has a similar pathway in phases II and III which is determined by orientation of the main subepicardial muscle layer coursing through the apex and terminating in the anterobasal region. The terminal anterobasal activation in the cases of LBBB has not only theoretical, but clinical significance, since in the presence of anteroseptal myocardial infarction the signs of necrosis must be hidden not in the early, but in the terminal parts of the QRS complex of conventional ECG. The lack of terminal anterior positivity of surface maps in the case of LBBB may be indicative of chronic anterior myocardial infarction.


Inhibition of constrictor responses of dog coronary artery by atropine. A possible effectiveness of atropine on variant form of angina pectoris. A possible effectiveness of atropine on variant form of angina pectoris was investigated using the left circumflex coronary arterial strips of dogs. Acetylcholine 10(-5)--10(-3) Gm/ml dose-dependently constricted the isolated arterial strips during potassium-contracture in 6 cases, and repetitive applications of acetylcholine could produce the similar contractions to the control. In 18 strips atropine 10(-6) Gm/ml significantly depressed the contractions of coronary arteries induced by acetylcholine 10(-5)--10(-3) Gm/ml. In 5 arterial strips atropine 10(-6) Gm/ml significantly inhibited norepinephrine-induced responses of these arteries, and by 10(-5) Gm/ml further suppression of the responses was obtained. The results suggest that atropine may suppress the contractile responses of the coronary artery induce by acetylcholine and nonrepinephrine through a muscarinic-receptor blocking action and simultaneously partly through an adrenergic alpha-receptor blocking action.


Noninvasive diagnosis of pseudoaneurysm of the left ventricle. The echocardiographic, scintigraphic, angiocardiographic and autopsy correlations in a patient with left ventricular pseudoaneurysm are presented. Interruption of the echo of the left ventricular wall and radioisotope image of pseudoaneurysm and its communication channel are demonstrated for the first time. The striking similarity of the radioisotope image to the angiographic image is noted. This study suggests that echocardiography has capability to visualize left ventricular wall defects, such as the perforation seen in this case and radioisotope ventriculography is equivalent to the invasive contrast technique. Both of the methods seem to be safe and specific for the diagnosis of left ventricular pseudoaneurysm.


Cross-sectional and M-mode echocardiographic study on ventricular septal defect. One hundred and eight patients with ventricular septal defect (VSD) including 20 operated patients were studied with real time cross-sectional echocardiography combined with M-mode echocardiography. The subjects were divided into 3 groups according to the cross-sectional echocardiographic findings. Group 1 included 34 patients in whom the defect area of interventricular septum (IVS) was demonstrated and they were diagnosed as VSD solely with this method. The majority of the patients in this group showed marked pulmonary hypertension and severe cardiac symptoms. Group 2 consisted of 13 patients who showed abruptly posterior movement of IVS toward the left ventricular cavity at early diastole and were suspected of VSD. Group 3 consisted of 41 patients with VSD showing normal cross-sectional echocardiograms without echo discontinuity of IVS. This group had a small defect of IVS with near normal pulmonary artery pressure. The analysis of cross-sectional echocardiogram combined with M-mode echocardiogram and the data of other cardiac examinations revealed that group 1 showed a larger left-to-right shunt at the ventricular level, severer pulmonary hypertension and more marked heart enlargement than groups 2 and 3. The patients with visualized defect of IVS had severe cardiac signs and symptoms and were indicated for the cardiac surgery. In the postoperative patients, the patch echo was clearly recognized as a linear strong echo. Real time cross-sectional echocardiography is available to visualize directly the defect of IVS in the majority of the patients with VSD and to estimate the condition of patients with this lesion.


Change in plasma renin substrate level after the intravenous furosemide administration. Plasma renin substrate (PRS) was determined immediately before and 30 min after the intravenous administration of 40 mg of furosemide in 26 hypertensive subjects. PRS level after the administration of furosemide was found elevated by 30.5 +/- 4.7% which was statistically significant.


Electrophysiologic study and prognosis of chronic bifascicular block. Thirty patients (22 males and 8 females, aged 64 to 89 years) with chronic bifascicular block were studied electrophysiologically and prognosis was assessed. Three had RBBB with LPH, 17 had RBBB with LAH, and 10 had LBBB. AH interval was prolonged in 12 (43%) of 28 patients and HV interval was prolonged in 11 (37%) of 30 patients. Of 16 patients with first or second degree AV block, 11 (69%) had prolonged AH interval and 8 (50%) had prolonged HV interval. Effective refractory period of the right atrium was prolonged in 8 (50%) of 16 patients and that of atrioventricular node was prolonged in 9 (64%) of 14 patients. Second degree AV block was observed at lower rates of atrial pacing (130 beats/min or less) in 14 (74%) of 19 patients. Sinus node dysfunction was present in 16 (62%) of 26 patients. During the follow-up period (37.1 +/- 6.1 months), advanced or complete AV block developed in 2 of 27 patients (2.4% per year) and a patient died of acute myocardial infarction (1.1% per year). The present study showed that prolongation of AH interval was observed more frequently than that of HV interval, and the presence of widespread lesions in the conduction system was suggested in chronic bifascicular block, and in spite of these facts prognosis was not so unfavorable as reported previously.


A clinicopathological study on 25 cases of complete left bundle branch block. A total of 25 cases (12 men, 13 women) of complete left bundle branch block (LBBB) were found among 1,400 consecutive autopsy in the aged. Their ages ranged from 70 to 86 years (average 78.9). ECG was analyzed as for the occurrence of LBBB and myocardial infarction (MI). Pathological examinations included observations of the conduction system by serial sections. They were divided into group A with MI and group B without MI. Duration of LBBB was 1 to 3 days in 4 cases, more than 1 month in 7, and more than 1 year in 14. From the temporal sequence of LBBB and MI in group A, cases were classified into (1) MI preceding LBBB in 5, (2) both coexistent in 5, and (3) LBBB preceding MI in 1. There were 8 cases of normal electrical axis, 17 left axis deviation, 7 first degree A-V block, and 2 atrial fibrillation. Various heart diseases were underlying in 21 cases, including hypertension, MI, mitral and aortic regurgitation, and primary myocardial disease, and there were 4 cases with no cardiac diseases. Cause of death was cardiac in 12; MI, congestive heart failure, and sudden death. Heart weight was 410 Gm on the average (240 to 550 Gm). MI was found in 11, with stenotic index of 12/15, while it was 9/15 in group B. Lesions of the conduction system were slight to moderate (1.5 to 2.4) except left bundle branch, which showed marked changes in posterior (4.9) and anterior (4.8) fascicles. Site of interruption of the left bundle branch was the junction between the branching portion of the A-V bundle and the left bundle branch (Junctional type) in 17, and peripheral portion of the left bundle branch about 10 mm or more below the junction in 8 (Peripheral type). In conclusion, 2/3 of cases of LBBB belonged to the junctional type and most of them were not related to MI, but to the lesions caused by mechanical injuries at the septal summit. One third of the cases were as peripheral type, which was mainly related to the various types of lesions including septal ischemia (necrosis and fibrosis).


The effects of angiotensin II and indomethacin on the pulmonary arterial prostaglandin E levels and pulmonary circulation in dogs. We studied whether pulmonary arterial levels of plasma prostaglandin E rose following pressor effects of angiotensin II in the intact dogs. Furthermore, the modulation by indomethacin of the effect of angiotensin II, PGF2 alpha, and PGE1 on pulmonary circulation was evaluated. Pulmonary arterial plasma PGE levels rose significantly from 0.52 +/- 0.10 (SE) ng/ml to 0.85 +/- 0.07 by the infusion of angiotensin II. This increase was not observed when indomethacin was given. The rise in pulmonary arterial pressure and total pulmonary resistance by angiotensin II was augmented significantly with pretreatment of indomethacin. These results showed that there was an augmentation of the pulmonary vasoconstrictor action of angiotensin II as indomethacin blocked an increase of pulmonary arterial PGE level. Thus, it was suggested that prostaglandins (especially PGE) modulated the pulmonary vasoconstrictor effects of angiotensin II.


Absence of acute cardiac effect of triiodothyronine in isolated, blood-perfused canine atrium. Effects of triiodothyronine (T3) on SA node pacemaker activity, atrial contractility and on chronotropic and inotropic responses to norepinephrine were investigated, using 9 isolated, blood-perfused dog atrium preparations. T3 (0.001 pg--0.1 microgram) did not cause a significant direct action injected into the cannulated sinus node artery. When T3 (10 pg/min, 40 pg/min, 0.1 microgram/min, or 0.4 microgram/min) was continuously infused into the sinus node artery, both positive chronotropic and inotropic actions of norepinephrine (0.03 microgram--0.3 microgram) were not influenced. From these results, it is concluded that T3 has neither acutely direct chronotropic nor inotropic effects, and also T3 does not have an acute effect on responses to norepinephrine in the isolated, blood-perfused canine atrium.


The effect of phenoxybenzamine on the pulmonary vascular bed in surgically corrected ventricular septal defect associated with pulmonary hypertension. From 1971 to 1977, a total of 43 cases with ventricular septal defect associated with pulmonary hypertension (VSD + PH), ranging from 3 months to 6 years of age, underwent VSD closure using cardiopulmonary bypass with a prophylactic dose of phenoxybenzamine (POB) 1 mg/Kg. Twenty of these cases are included in the present study of the effect of POB on pulmonary hypertension. The ratios of pulmonary to systemic arterial pressures (Pp/Ps) and vascular resistances (Rp/Rs) were measured before, immediately after and 1 month after VSD closure. In all cases, the Pp/Ps before VSD closure was larger than 0.75. Both Pp/Ps and Rp/Rs markedly decreased immediately after VSD closure but rose again 1 month thereafter. These results suggest the possibility of pulmonary vasodilating effect of POB, which could be potentially useful in relieving the right ventricular load in the early postoperative period. The over all mortality was 3 out of 43 cases including 2 late deaths.


Two cases of rubella infection with cardiac involvement. During the prevalence of rubella infection in Japan in 1975, we experienced 2 cases complicated with cardiac involvement: a 40-year-old housewife and a 52-year-old man. These 2 cases showed enlarged cardiac silhouettes and bilateral pleural effusion on the chest X-ray films. Pericardial effusion was demonstrated by echocardiogram and cardiac RI pool scintigram. A myocardial biopsy specimen showed slight cell infiltration in Case 1. The anti-rubella antibody titer rose from 128x to 4096x in Case 1 and from 265x to 1024x in Case 2. From these findings Case 1 was diagnosed as rubella pancarditis and Case 2 as pleuropericarditis. Only 4 cases with the cardiac involvement of rubella was reported in the past.


An analysis of water movement between myocardial tissue and capillary blood during reactive hyperemia. The colloid osmotic pressure (COP) of blood from the great cardiac vein was continuously measured by means of a membrane colloid osmometer during the reactive hyperemia following temporary occlusion of the anterior descending branch of the left coronary artery in anesthetized open-chest dogs. The COP increased sharply after releasing the occlusion, then decreased below the preocclusion level before gradually returning to it. These findings indicate that a measurable amount of water moved from the capillary blood into the myocardial tissues and then flowed back slowly into the capillary blood. To analyse the factors affecting this water movement, a method is proposed in which the Starling mechanism is combined with the interstitial volume elasticity and a steady-state solution of a Navier-Stokes equation. The pressure observed with a catheter wedged into a branch of the great cardiac vein was used as a measure of capillary perfusion pressure. During the coronary arterial occlusion, the filtration constant increased while the volume elasticity of the myocardial interstitial spaces decreased rapidly. The filtration constant and volume elasticity of the interstitial space under normal conditions were approximately estimated to be 2.4 X 10(-11) cm/(sec.dyn.cm-2) and 1.1 X 10(7) dyn.cm-2, respectively.


Postsynaptic potentials in the hypoglossal motoneurons set up by hypoglossal nerve stimulation. In nembutalized cats intracellular potentials were recorded from hypoglossal motoneurons innervating either protruder or retractor muscles of the tonge (protruder and retractor motoneurons: P-Mns and R-Mns). Responses to stimulation of the hypoglossal nerve were explored and found to consist of an antidromic spike followed by an afterhyperpolarization (AHP) and a postsynaptic potential (PSP). When hypoglossal nerve stimulation was made with an intensity three times as large as the threshold for the hypoglossal motor fibers, the PSPs became evident under blockage of soma-dendritic invasion of the antidromic spike. In most of P-Mns or R-Mns, the PSPs were IPSPs, independent of the side of peripheral stimulation. The latencies were about 12 msec. Even when the cell membrane was hyperpolarized by injecting a hyperpolarizing current of up to 16 nA, the reversal point of the IPSP was difficult to find. In a small fraction of hypoglossal motoneurons the PSPs to hypoglossal nerve stimulation were EPSPs with latencies of 10 to 12 msec.


Effect of SCN on potassium contracture in twitch muscle fibers of the frog. The effect of SCN on potassium contracture, especially the time course and the mechanical inactivation of the contracture, was investigated using frog twitch muscle fibers. SCN increased the magnitude and the rate of rise of the potassium contracture tension and prolonged its time course. These effects of SCN depended on the concentration of K+ in the external medium and on the duration of pretreatment of the fibers with SCN-Ringer solution. The potentiating effect of SCN on the potassium contracture tension was pronounced at lower and moderate concentrations of K+ and this effect attained a maximum within 1 min after the pretreatment. In the contracture induced by exposure of the fibers to K-SCN-solution without the pretreatment, the time course of the contracture, especially the retardation of the spontaneous relaxation, was marked at higher concentrations of K+. This retarding effect of SCN attained a maximum at more than 10 min after the pretreatment with SCN-Ringer solution. SCN shifted the mechanical inactivation curve of potassium contracture toward lower concentrations of K+, as in the case of the activation curve, and markedly increased the rate of the inactivation induced by conditioning with 15 mM K+. In addition, SCN delayed the recovery of potassium contracture from the mechanical inactivation induced by preceding K-SCN-contracture. On the basis of these results, the sites and the mechanism of action of SCN on potassium contracture are discussed.


Intracellular distribution of calcium in cardiac muscles studied by electron microscope autoradiography. The intracellular distribution of calcium was investigated by 45Ca electron microscope autoradiography in the frog or rat ventricular muscle and guinea pig papillary muscle. The muscle was incubated for 30 min in 45Ca-Ringer's solution or high Ca solution in which 1/10--1/20 of Ca was replaced with 45Ca. The distribution of developed silver grains sensitized by the 45Ca (45Ca grains) was found to be 38% in the mitochondria, 43% in the myofibrils and 19% in the other regions (8% in the cytoplasma and 11% in the various membranous structures) in the frog muscle cell incubated in the 45Ca-Ringer's solution. After electrical stimulation (10 Hz, 5 min), the distribution was 22% in the mitochondria, 53% in the myofibrils and 25% in other regions. Similar results were obtained after high K stimulation in the frog ventricular muscles and after electrical stimulation in high Ca solution in guinea pig papillary muscles. Following the addition of 1 X 10(-6) g/ml adrenaline into the incubating solution, the grain distribution in guinea pig papillary muscles did not show significant change but the distribution in myofibril decreased after electrical stimulation, while it increased in the mitochondria. Longitudinal localization of 45Ca grains along the myofibril was also examined and it was a general tendency throughout all animals examined that the grain density at the A band and near the Z band decreased after electrical stimulation, while it increased at the I band and, especially, at the A-I junction.


The dynamics of contraction in the guinea pig taenia coli. Tension-length, load-velocity and tension-extension relations were studied in the taenia coli muscle of the guinea pig weighing 0.25--0.5 kg at 36--37 degrees C. The muscle was relaxed by 10(-6) g/ml adrenaline and stimulated by a strong AC field. The tension-length diagram was far wider than that of the skeletal muscle and sufficient tension was generated at longer lengths than 1.8 Lm, where Lm is the optimal length at which the maximum tension, Fm, is generated. The developed force per unit cross-sectional area was almost unchanged between 1.2--2.0 Lm. Average of the maximum forces was 2.2 kg/cm2. Load-velocity curves obtained at various isometric forces at Lm coincided with each other, if the velocity was plotted against the relative force. All curves can be expressed by a single force-load-velocity equation, (P+A)(v+b)=b(F+A), A=(F/Fm)a, where P is the load, F the isometric force, v the velocity, a and b are constants. The maximum velocity per unit muscle length was constant, irrespective of the muscle length. The compliance of the series elastic component, that is, the slope of the tension-extension curve, did not depend on the isometric force but decreased with decreasing muscle length. The internal lengthening of the series elastic component by the full isometric tension was about 3% of the muscle length at Lm.


Action of ammonium ions on the resting membrane of crayfish stretch receptor neuron. In the crayfish stretch receptor neuron, extracellularly applied NH4+ acted on the nonsynaptic membrane and produced not only a depolarizing shift of EIPSP but also depolarization and conductance increase. Under certain conditions these actions may become the main cause of the disinhibitory effect of NH4+ on the inhibitory synapse.


Z shaped primary colorectal anastomosis using the GIA autosuture for Hirschsprung's disease. The Duhamel operation for Hirschsprung's disease has won wide acceptance throughout the world. However, this procedure is not without difficulties, and the usual technique of employing various crushing clamps for division of the colo-rectal septum is inelegant, inconvenient and uncertain. This paper presents an operative technique with particular reference to the use of the GIA autosuture surgical stapling instrument in the Z shaped primary colorectal side-to-side anastomosis for Hirschsprung's disease advocated by Ikeda. This is a single and primary procedure, and makes the postoperative care easier and more comfortable for the patients. Experiences with twenty-five patients are reported.


Immunoreactive carcinoembryonic antigen [CEA] levels in feces from colorectal cancer patients. Immunoreactive CEA (IR-CEA) in feces or sera from 20 volunteers and 20 patients with colorectal cancer were measured before and at various intervals after surgery by a radioimmunoassay utilizing a "one step sandwich method."  Elevated fecal IR-CEA level was observed in 17 of 20 patients with colorectal cancer; elevated serum CEA levels were observed in only 7 of all patients. There could not be found any correlation between fecal IR-CEA levels and Dukes' classification; there was but a little correlation between serum and fecal IR-CEA levels. In 8 of 14 patients treated by surgery, fecal IR-CEA levels obviously dropped, but in 2 patients with hepatic metastasis they were found rising in spite of colon tumor removal. It was speculated from these data that high values of fecal CEA depend on mass production of CEA by cancer cells. From these observations, it appears that fecal IR-CEA level presents a more ideal diagnostic competency in colorectal cancer than serum CEA level.


An experimental study of the preparation of a substitute stomach following total gastrectomy in the rat. In 38 rats, a substitute stomach was prepared through transplantation of the ileocaecal intestinal portion following total gastrectomy. 47% of rats tolerated the operation. The survival rate of the tolerated rats for 360 days after the surgery was 16%. Their body weight corresponded to 77% of that in the untreated control rats on the 360th day after the operation. Compared to other conventional methods of total gastrectomy and reconstruction, this method is quite outstanding. From this experimental fact, the preparation of a substitute stomach through transplantation of the ileocaecal intestinal segment seems possible to supplement a part of the defects in the agastric syndrome accompanying total gastrectomy for a prolonged period.


A resected case of pulmonary multiple fibro-leiomyomatous hamartoma--light and electron microscopic study. A light and electron microscopic study of a case of multiple pulmonary fibro-leiomyomatous hamartoma is described. Like the previous reports, the patient was an old woman with no complaint. The histologic features were characterized by mingling with rich fibroblasts and mesenchymal cells. The definite diagnosis was made by the features which were detected ultrastructurally. In this case, we considered that the fibrous component was more predominant than the leiomyomatous component.


Expanded polytetrafluoroethylene grafts for small artery replacement. Twenty vascular grafts of expanded polytetrafluoroethylene with a 1.5 mm. internal diameter and a 4.0 cm. length, were placed in the femoral arteries of dogs. The animals, divided into two groups, with and without pluronic F 68, were sacrificed two weeks after surgery. The patency rate was 33.3% (2/6) and 21.5% (3/14), which was not statistically significant. One factor contributing to the occlusion of the grafts were excessive proliferation of granulation tissue due to early formation of the thrombus. Histological findings showed that the pseudointima was almost complete, although it was only about 0.114 mm. thick at the anastomotic line.


Follow-up of 514 consecutive patients with cardiopulmonary arrest outside the hospital. During the years 1974 of 1976, 514 patients with prehospital cardiopulmonary arrest were brought to the Hennepin County Medical Center (HCMC) Emergency Department. Of these, 344 patients (67%) were either dead on arrival or died in the emergency department despite efforts at resuscitation. The remaining 170 patients were admitted to the coronary care unit. Eighty-seven patients (51%) died in the coronary care unit, primarily from uncontrolled rhythm disturbances and/or cardiogenic shock. The remaining 83 patients (16% of the total group, 49% of those admitted to the hospital) were discharged alive from HCMC. In this group, 49 patients of the 83 long-term survivors were ambulatory with full mental function when discharged. The remaining 34 patients were trnasferred to chronic care facilities for medical treatment of on-going problems. Of the 49 ambulatory patients, satisfactory data for follow-up was obtained on 47. Their mortality rate was 15% in the first year and 50% in the second, primarily from sudden death syndrome.


Prophylactic lidocaine in suspected acute myocardial infarction. The incidence of serious ventricular arrhythmias following acute myocardial infarction is highest during the first few hours after injury, and thereafter declines. Several investigations into the prophylactic use of lidocaine to prevent the development of arrhythmias have shown that lidocaine, given in therapeutic doses, is effective in preventing ventricular fibrillation and in reducing early mortality. Lidocaine was found to be effective when given either by the intravenous or by the intramuscular routes. The recommended dosage is 100 mg given as an intravenous bolus followed by 2 to 4 mg/min as an infusion, which should be given by infusion pump. Another recommendation is to use two 100 mg boluses 20 minutes apart, along with the same infusion. We recommend that lidocaine be started as soon as possible in all patients suspected of having suffered acute myocardial infarction.


Traumatic injuries in the parotid region. The facial nerve, parotid duct, and external ear canal are at risk from penetrating injuries in the parotid region. The areas of the face supplied by the major branches of the facial nerve should be checked in the emergency department so that repair of a cut nerve can be performed while the distal end is able to be stimulated electronically. The parotid duct can be probed and lacerations repaired. The external ear canal should be repaired and stented to prevent stenosis.


Intravenous glucagon in the management of esophageal food obstruction. The use of intravenous glucagon in patients with obstructing esophageal food impaction of at least 24-hours duration has recently been described. Two cases of acute esophageal obstruction were relieved within ten minutes by intravenous infusion of 1 mg of glucagon. Esophagram performed both before and after glucagon administration confirmed the original obstruction and the passage of the food bolus. Therapy for bolus obstruction of the esophagus has classically included proteolytic enzyme digestion, as well as esophagoscopy with manual extraction. Each entails risk of esophageal perforation and mediastinitis. Also, the dose of proteolytic enzymes, such as papain, may take several hours to administer while endoscopic examination is generally not feasible as an outpatient emergency procedure. Intravenous glucagon can dissolve food other than meat and has the further advantage of safety in the patient in which anticholinergics, another occasionally employed therapy, are contraindicated. A protocol for management of these patients is included.


Posttraumatic aneurysms of the hand.

Posttraumatic aneurysms of the hand. Aneurysms should be suspected in patients with a mass in the hand following either open or closed trauma. Posttraumatic aneurysms are classified as true or false. False aneurysms usually result from penetrating trauma and can occur in any disrupted vessel. In contrast, true aneurysms usually occur in either the thenar or hypothenar eminence a few weeks following closed hand injuries. Pulsations may be evident. Symptoms are coolness or paresthesia of the digits and dull pain aggravated by exercise. A positive Allen's test is a helpful confirmatory sign in diagnosis. Treatment is surgical with resection of the aneurysm and primary anastomosis or vein graft when possible.


Spontaneous hemothorax.

Spontaneous hemothorax. A 31-year-old man presented to the emergency department with dyspnea and pleuritic chest pain resulting from a spontaneous hemothorax. A tube thoracostomy was performed on the left side and 700 cc of blood removed. Another 1800 cc of blood oozed from the chest tube. Open thoracotomy was performed in the operating room. There were approximately 1 to 2 liters of blood and clot in the chest cavity. Multiple bleeding points in the apex were ligated and wedge resection was done. Spontaneous hemothorax may represent a form of spontaneous hemopneumothorax or it may be a complication of a variety of situations. Open thoracotomy may be necessary for definitive diagnosis and treatment.


Iron toxicity screening.

Iron toxicity screening. Fischer's method for rapid detection of acute iron toxicity is modified to suit pediatric cases. TPTZ (2,4,6-tripyridyl-s-triazine) is the chromogen of choice since in a small volume of serum slight to moderate hemolysis can cause a false positive result bathophenanthroline. Ordinary labware is amenable to this simplified procedure.


Shock and resuscitation. III. Accurate refractometric COP determinations in hypovolemia treated with HALFD. In 38 critically burned patients with symptomatic hypovolemia being treated by intravenous fluids, the accuracy of colloid oncotic pressure (COP) calculated from the refractometrically-determined serum total protein (TPRI) was compared with COP values determined by a commercially-available clinical oncometer. Sera were obtained randomly from seven patients receiving Ringer's lactate solution, five receiving a hypertonic solution (240 mOsm Na+) and 26 receiving a hypertonic solution containing albumin (12.5 gm/liter, HALFD method). There was poor correlation between COP measure and that calculated from RI in patients receiving colloid-free fluid, but high correlation (r = 0.925) in patients receiving HALFD. There was high correlation (r = 0.951) between measured COP and values calculated from TPRI in patients receiving hypertonic fluid, colloid containing hypertonic fluid, or no fluid:COP = 4.08 (TPRI)--4.61.


Handling of nonsevere head injuries.

Handling of nonsevere head injuries. In emergency patients with nonsevere head injuries, there are conflicting opinions over which patients should be admitted for observation, but little data directly useful to the emergency physician in making this decision. The literature was reviewed and records of 182 patients presenting for head injury were examined. Although many factors must be considered, by far the most helpful element in predicting outcome is the mental status of the patient as observed in the emergency department. Features suggesting depressed skull fracture or possible foreign bodies require radiographic examination. Most patients can be observed in the emergency department mainly for changes in level of consciousness and discharged with instructions for further observation at home.


Activated charcoal updated.

Activated charcoal updated. Activated charcoal, commonly recommended for treatment of chemical ingestions, is the residue from destructive distillation of various organic materials treated to increase its adsorptive power. Since there are no known side effects, the dose should be sufficiently large for optimum adsorption. In the literature, the recommended doses range from 30 gm to 120 gm, or in a charcoal-drug ratio of 10:1. For maximum effect, activated charcoal should be administered within 30 minutes of ingestion. It can be given while its effectiveness for a particular toxic substance is verified.


Pressure gun injection injuries of the hand. In the growing number of pressure gun injuries with injection of materials into the hand, the degree of toxicity of the material, the amount injected and early adequate treatment are the three most important factors in determining the final result. Paint is the most toxic agent and causes an extreme amount of tissue inflammation. Early debridement of the injected material gives the best functional result. In spite of early surgical debridement, some of these injuries, most commonly with highly toxic agents, progress to eventual amputation.


Acute nontraumatic cardiac tamponade.

Acute nontraumatic cardiac tamponade. A 33-year-old man presented with acute nontraumatic cardiac tamponade as a result of pneumococcal pericarditis in association with pneumococcal pneumonia. Hypotension, tachycardia and pulsus paradoxicus, 50 mm Hg, were present. Echocardiographic findings were compatible with cardiac tamponade. Pericardiocentesis was performed. Acute nontraumatic pericardial tamponade in the emergency department presents special problems of diagnosis and management. Diagnosis is based on correlation of data from the history, physical examination, electrocardiogram, chest x-ray films, and a high index of suspicion. Echocardiography to confirm the diagnosis of tamponade and aid in correct placement of the needle in pericardiocentesis is especially helpful.


The amobarbital interview.

The amobarbital interview. In two apparently disoriented patients, the emergency physician's use of amobarbital quickly eliminated diagnoses of an organic etiology. Although thousands of amobarbital interviews have had no complications, the use of amobarbital should follow a thorough evaluation. The amobarbital interview is a safe and simple technique to discriminate functional from organic illness, thus avoiding unnecessary medical and surgical treatment, neglected illness, and inappropriate disposition.


Acute hypokalemia as a possible cause of death in a patient with advanced muscular dystrophy. A patient with advanced muscular dystrophy of the Duchenne type developed severe hypokalemia thought to be secondary to moderate gastro-intestinal losses in association with reduced intracellular potassium stores. With correction of the hypokalemia, the cardiac rhythm became more normal. In patients with advanced dystrophy, hypokalemia may be functionally significant.


Fetal Monitoring during cardiopulmonary bypass for removal of a left atrial myxoma during pregnancy. A 26-year-old woman was discovered to have a left atrial myxoma during the second trimester of pregnancy. Because of concern about potential complications from the cardiac tumor, it was elected to operate on this patient using cardiopulmonary bypass and careful fetal heart rate monitoring. Excision of the myxoma was carried out uneventfully and a healthy male infant was born at full term 16 weeks later. Problems associated with maternal extracorporeal circulation during pregnancy are discussed. This case illustrates the feasibility and safety of performing open-heart surgery during pregnancy, utilizing a simple external fetal monitoring technique.


Complications of percutaneous central venous catheterization: a report of two cases and review of the literature. Percutaneous catheterization of the central venous system is a valuable and commonly employed procedure, but it is not without risk. Two cases are reported which illustrate complications of both internal jugular and subclavian vein cannulation: a fatal cerebrovascular accident; and hemo- and pneumothorax. Literature review indicates that pneumothorax and air embolus are major complications of both routes of catheter insertion. Additionally each route has untoward effects related to the proximity of easily compromised structures (pleura, lungs, arteries, nerves). Awareness of potential complications and use of precautionary measures may reduce the risk of these procedures.


Intussusception of the excluded segment following jejuno-ileal bypass. Intussusception of the defunctionalized intestinal segment following jejuno-ileal bypass for obesity has rarely been reported. Persistent crampy abdominal pain (often accompanied by nausea and vomiting) and normal radiologic evaluation are suggestive of this entity. The routine use of silver clips, although helpful in some instances, cannot exclude this diagnosis. A high index of suspicion and the use of sonography may prove that intussusception of the defunctionalized segment is more common than has been previously reported.


Thrombin and fibrin-induced growth of fibroblasts: role in wound repair and thrombus organization. Skin fibroblast cultures were treated with various components of the blood clotting system (thrombin, fibrinogen and fibrin) during the logarithmic growth phase. Fibrin as well as thrombin showed dose-dependent growth promoting activities as revealed by cell counting and 3H-thymidine uptake. No effect was seen with fibrinogen. After entrapping in polymerizing fibrin enriched by complete culture medium the cells elongated, multiplied and formed net-like interconnecting cell strands throughout the clots. Nutritional deprivation appeared as a limiting factor for eventual growth cessation. The results demonstrate active growth of fibroblasts in fibrin clots such as present in healing wounds and thrombi. The production of thrombin by the coagulation cascade does not only result in the conversion of fibrinogen to fibrin but has also a long-lasting hormone-like effect on fibroblast proliferation which is of essential importance in wound healing, thrombus organization and progression of chronic atherosclerotic lesions.


[Molecular weight analysis of physiological proteinuria in newborn infants (author's transl)]. The physiological protien and glycoprotein excretions in the urine samples of a larger group of newborn infants were separated according to the molecular weights by SDS polyacrylamide gel electrophoresis and compared with the protein excretions of older children. We found higher proportions of albumin, of high molecular weight (MW = molecular weight greater than or equal to 150 000 dt) and of lower molecular weight (MW less than albumin 6800 dt) proteins in the first 24-h urine samples after birth. One week after birth the low molecular weight proteins predominated because there was a substantial decrease in the excretion of albumin and of high molecular weight proteins (MW greater than or equal to 150 000 dt). We compared the patterns of protein excretion of the newborn infants with those of children aged from 2 1/2 to 15 years. These urines samples showed a typical pattern of protein excretion not correlated to the age. These findings express a transitory immaturity of the glomerular filter and of the tubular protein reabsorbing system of the newborn kidney. Apparently, the tubular protein handling normalizes later than the glomerular filtration of proteins.


[Chronic mercury poisoning following topical application of skin bleachers (author's transl)]. In two female patients chronic mercurialism following topical application of skin bleachers for the treatment of freckles was diagnosed. Over 20 to 25 years 3 to 10% mercurial ointments were applied twice daily. Recurrent attacks of headache, dyspnoea and abdominal colic-like cramps had lead repeatedly to emergency hospitalisations, multiple medical check-ups and surgical exploratory procedures. The diagnosis of mercurialism was made clinically because of a slate-grayish skin hyperpigmentation in the presence of freckles, and the drug-history. Metallic deposits in facial biopsies were demonstrated by electron microscopy. On admission 15.4 microgram% and 5.0 microgram % total Hg respectively were found in the two patients (normal values up to 2.0 microgram %). Following D-penicillamine treatment the mercury excretion via the urine could be elevated up to 25 microgram %. Neither the slate-gray facial discoloration nor the neurasthenic complaints were affected by this therapeutic trial. In one patient, a maculo-papular drug-induced skin rash to D-penicillamine developed. Persistent unsolved neurological complaints and cramp-like abdominal pains should remind that percutaneous mercury intoxication through intact skin following skin bleachers is still possible today.


DNA of free and complexed origin in human plasma: concentration and length distribution. The DNA content in plasma of five healthy human individuals has been estimated. Structures ascertained by electron microscopy have been identified as double-stranded DNA. Depending on the isolation procedure applied the DNA molecules found may originate from free and/or complexed forms of DNA. The lengths range from less than 0.2 microns up to about 13 microns. DNA concentration is in the range of 3 to 11 ng/ml.


Age- and sex-related differences in plasma aldosterone in essential hypertension. Relationship to plasma renin activity. In essential hypertension mean basal (supine) and stimulated plasma renin activity (2 h upright posture + 40 mg furosemide intraveneously) decreased progressively with age. No significant differences were observed in renin levels between male and female patients. With increasing age mean basal (supine) plasma aldosterone remained almost unchanged in females, whereas in males a slight increase was found. However, in the comparable age-groups no significant sex-related differences were obtained. In female patients changes in mean stimulated plasma aldosterone with increasing age paralleled those of plasma renin activity, whereas in males this relationship was less obvious: only a slight age-related decline in stimulated aldosterone levels was observed and significantly lower plasma aldosterone concentrations in male than in female hypertensives of the younger age-groups (less than 40 years) were found. The results indicate that in essential hypertension with increasing age dissociation between plasma aldosterone and plasma renin activity occurred. Furthermore, the described alterations in adrenal aldosterone release are more pronounced in male than in female patients.


Evaluation of autonomic neuropathy in diabetes mellitus. Comparison of clinical, functional and biochemical parameters. Quantitative assessment of signs or symptoms of neuropathy, and the beat-to-beat variation, valsalva, orthostasis, handgrip and cold pressor tests, and measurements of plasma renin and catecholamine excretion rate were performed in 23 diabetic patients and 10 age-matched normal subjects. Significant inverse correlations were found between the clinical score and the beat-to-beat variation (a test of efferent vagus function) (r=-0.55, -0.72, P less than 0.0005) or the pressor response to handgrip (possible test of efferent sympathetic integrity (r=p less than 0.005) or the values of both tests combined (r=-0.79, P less than 0.0005); but not with the other measured parameters. Beat-to-beat variation was abnormal in all 9 diabetics with increased and in 9 of 14 with normal clinical score, whereas only seven and one patient from these subgroups, respectively, had an abnormal Valsalva ratio. The pressor response to handgrip was only slightly reduced in the diabetic patients, with greater tendency in those with abnormal clinical score. Additional possible indices of adrenergic dysfunction such as the pressor response to cold stimulus, plasma renin levels and noradrenaline or adrenaline excretion rates did not differ significantly between normal subjects and diabetics. These finding demonstrate a greater prevalence of parasympathetic as compared to sympathetic impairment in diabetic autonomic neuropathy; the beat-to-beat variation was the most sensitive among the tests used. An assessment of clinical evidence combined with non-invasive functional procedures such as the beat-to-beat variation and handgrip tests provide a valuable and easy to perform tool in the evaluation of diabetic neuropathy.


[Combined action of space flight and radiation factors on the skeletal musculature of rats]. A prolonged irradiation of rats at a dose of 800 rad on their 10th day of flight aboard the biosatellite Cosmos-690 aggravated the severity of weightlessness- and hypokinesia-induced atrophic and dystrophic processes in the soleus muscle and the atrophic process in the gastrocnemius muscle. These space flight factors did not influence the muscles (biceps brachii, extensor digitorum longus), in which no flight-associated pathologies occurred. Radiation exposure altered the pattern of reparation in the areas of the soleus muscle that developed pathological changes, and delayed resorption which occurred during the pathological process of the connective tissue, which resulted in an inhibition of the reparation process.


[Action on water-salt metabolism as a prophylactic method in orthostatic intolerance in crew members of the 2d expedition of the Saliut-1 station]. The water-salt supplement developed in ground-based experiments in order to increase human tolerance to LBNP and orthostatic tests was recommended to be given to the crewmembers at the final stage of the second expedition of Salyut-4. On the 53rd flight day, concomitantly with an intake of 4.0 g sodium chloride and 900-1200 ml water, an LBNP test was carried out to assess the effectiveness of this supplement, to select its optimal doses and to clarify individual responses. After the intake both cosmonauts showed a better tolerance of the LBNP test. They also displayed individual variations in their responses, viz. the commander in arterial circulation, and the flightengineer in venous circulation. As suggested by the ground-based experiments and the inflight provocative test, both cosmonauts were requested to take 9.0 g sodium chloride and 1000--1200 ml water on the last flight day. The postflight examinations demonstrated that the countermeasures applied (physical exercises, LBNP) in combination with the direct action on the fluid-electrolyte metabolism gave a pronounced positive effect.


Peripheral neuropathy in the diabetic mutant mouse. An ultrastructural study. Structural changes in peripheral nerves were studied sequentially in mutant diabetic mice. Axonal changes were found in both myelinated and unmyelinated fibers, the outstanding early change being the development of honeycombed Schwann cell-axon networks followed by axonal atrophy in both myelinated and unmyelinated fibers. In the late stages of the diabetic syndrome, this axonopathy was accompanied by secondary corrugated myelin breakdown. The changes, indicative of a primary axonal degeneration, are comparable to findings in human diabetic neuropathy for which this seems a suitable experimental model.


The "wavefront phenomenon" of myocardial ischemic cell death. II. Transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. The present study was done to quantitate the evolution of myocardial ischemic cell death within the framework of (1) the anatomical boundaries of the ischemic bed at risk and (2) the magnitude and transmural distribution of collateral blood flow. Myocardial ischemia was produced by proximal circumflex (LCC) occlusions in open chest dogs. Infarcts reperfused at 40 minutes, 3 hours, or 6 hours were compared with permanent infarcts. All dogs were sacrificed at 4 days. Regional myocardial blood flow was measured with 9-micrometer tracer microspheres before, and 20 minutes after, LCC occlusion. The location and size of the ischemic LCC bed at risk was determined by a dye injection technique. Infarct size was quantitated from multiple histologic sections. Necrosis involved 28 per cent, 70 per cent, and 72 per cent of the ischemic bed at risk in infarcts reperfused at 40 minutes, 3 hours, and 6 hours versus 79 per cent following permanent LCC ligation. Viable and potentially salvageable subepicardial muscle persisted for at least 3 hours after the onset of ischemia. Most of the salvageable myocardium was in the subepicardial region. In all groups, the lateral margins of necrosis were sharp in the subendocardial zone and were determined by the anatomical boundaries of the ischemic LCC bed at risk. LCC bed size ranged from 29 to 48 per cent of the left ventricle and thus contributed to variation in infarct size. However, infarct size, as a percentage of bed size, was determined by the transmural extent of necrosis within that bed (r = -0.97). This transmural extent of necrosis was related to subepicardial collateral flow after 3 hours (r = 0.92) and 6 or 96 hours (r = -0.85) but not after 40 minutes (r = -0.26) of ischemia. Thus, irreversible injury of ischemic myocardium developed as a transmural wavefront, occurring first in the subendocardial myocardium but ultimately becoming nearly transmural. Eventual transmural necrosis, and therefore over-all infarct size was determined by, and can be predicted from flow measurements obtained shortly after coronary occlusion.


[Possibilities of preventing the adverse reactions in modeling the acute period of adaptation to weightlessness]. It has been shown that during head-down tilting at an angle of -30 degrees occlusion of the four limbs by 70 mm Hg relieved unpleasant symptoms. According to rheoencephalography, cerebral blood flow decreased to the level normally seen in the supine position. During a prolonged head-down tilting at an angle of -15 degrees intermittent occlusion of only lower limbs by 60--30 mm Hg proved more effective.


[Skeletal muscle mixed fiber tissue metabolism in rats after a flight on the Kosmos-690 biosatellite]. On the R+O day the quadriceps muscle of rats showed a decrease in the content of T protein and an inhibition of LDH activity of sacroplasmatic proteins. These changes resulted from the combined affect of space flight factors and gamma-irradiation, and may be considered as a decline of compensatory synthetic processes responsible for the recovery of muscle proteins in weightlessness. Inhibition of the age-associated shift of the M:H ratio of LDH found on the R+25 day can be attributed to the inhibitory effect of gamma-irradiation. No change in the content of glycogen in the gastrocnemius muscle of flight rats was noted.


Morphologic effects following massive exchange transfusions with a stroma-free hemoglobin solution. II. Kidney. The effects on renal morphology of exchange transfusion with stroma-free hemoglobin solutions (SFHS) were compared in rats to the results obtained using an asanguineous resuscitative fluid containing albumin. Animals underwent 75 per cent blood volume replacement, and tissue collected at intervals after the exchange transfusion was examined by light and electron microscopy. Urine volumes, osmolarity, and pH also were determined, and serum creatinine and blood urea nitrogen were measured both before and after exchange transfusion. Hemoglobin was filtered through the renal glomerular basement membrane, and a portion was reabsorbed into the proximal tubular cells in the form of absorption droplets. Unabsorbed hemoglobin was excreted in the urine. Despite a distention of proximal and distal tubules 5 hours after exchange transfusion with SFHS, there was no ultrastructural evidence of renal parenchymal damage. Proximal tubular cells of albumin-exchanged animals contained fewer protein absorption droplets and no intraluminal material. The apparent higher rate of glomerular filtration of hemoglobin over albumin probably reflected the dissociation of hemoglobin into dimers, resulting in a diuresis. Urine volumes were 3 times greater in SFHS-exchanged animals than in albumin-treated rats, and the urine was relatively hypoosmolar in the former. The greater urine volumes in SFHS-treated animals also were associated with a large reduction in intravascular fluid volume. There was no alteration of serum creatinine or blood urea nitrogen after exchange transfusion with albumin and only a mild elevation in blood urea nitrogen in SFHS-treated rats. The latter most likely was a result of prerenal hypovolemia. SFHS, even when exchange-transfused in massive quantities, does not appear to affect renal function or ultrastructural morphology adversely. However, the rapid disappearance of hemoglobin from the intravascular space, the consequent loss of intravascular fluid volume, and the diuresis induced by its administration are complications which must be overcome before the product can be a useful adjunct in the treatment of hemorrhagic shock.


Immune receptors (IgG-Fc and complement receptors) in normal human organs. The presence of immune receptors (IgG-Fc and complement receptors) was examined in normal human tissues from various organs. Sheep erythrocytes sensitized with rabbit IgG antibody (IgG-EA) or with rabbit IgM antibody and human complement (IgM-EAC) were used for the detection of IgG-Fc receptors and complement receptors, respectively. IgG-Fc receptors were detected on sinuses of the lymph node, splenic red pulps, hepatic lobules, renal glomeruli, alveolar wall of the lung, intestinal villi, superifical layer of the synovium, and subcutaneous tissue. The presence of complement receptors was demonstrated in the follicles and the sinuses of lymph nodes, white pulp of the spleen, renal glomeruli, alveolar wall of the lung, and lamina propria of the intestine. The specific binding of IgG-EA was consistently inhibited by heat-aggregated human IgG or by a high concentration of native human IgG. The detection of immune receptors in these various tissues might be helpful for understanding why the immune complexes are often detected when immunologically mediated disease processes involve these tissues.


[Animal tolerance to exposure to repeated impact acceleration]. The harmful effect of repeated impact accelerations on the animal body was studied. The dogs were exposed to accelerations one, three, five or ten times. The experiments showed a cumulative effect of repeated exposures which included a consistent increase of changes in the physiological and morphological parameters. Tolerance to repeated accelerations increased due to better restraint of the animals.


[Effect of acute hypoxia on the indices of kidney excretory function and renal hemodynamics]. Diuresis, glomerular filtration, tubular reabsorption (endogenous creatinine clearance), renal blood and plasma flow, total resistance of renal vessels, and filtration fraction were measured in 59 patients with mechanical (strangulation) asphyxia. Asphyxia and resulting hypoxia induced a substantial increase of diuresis, glomerular filtration and a decrease of tubular reabsorption. Disorders of renal hemodynamics which involved a decrease of renal plasma and blood flow and an increase of total resistance of renal vessels contributed significantly to the mechanism of changes of the renal excretory function. As shown by vasographic and morphological examinations, the state of intrarenal hemodynamics plays the major role in changes of the renal function.


[Oxygen toxicity in a mixture with helium]. A 3-day exposure of mice to a 20%--80% He-O2 environment at 28--30 degrees C led to an earlier decrease of gas exchange, a faster development of pulmonary inflammatory changes, and an earlier death of the animals as compared with an exposure to similar N2-O2 and He-O2 atmospheres at room temperature. The possible role of the indifferent gas in the toxic effect of oxygen on the animal body is discussed.


[Evaluation of the antiorthostatic reactions of the cerebral circulation]. On the basis of experiments on 122 healthy male test subjects the norms of reactions of cerebral circulation to antiorthostatic exposures, basic principles and evaluations of its antiorthostatic tolerance (AOT) were established. The level of AOT was found to increase in acrobats in the course of their training, in test subjects after 30-day head-down tilting, and in space crewmen postflight. This increase can be regarded as an adaptive reaction of cerebral circulation to the excess blood rush to the head both on the Earth and in weightlessness. The similarity of regulatory hemodynamic changes in the above groups shows the possibility and indicates approaches to the ground-based training of cerebral circulation aimed at facilitating and accelerating its adaptation to weightlessness.


[Blood albumin-globulin makeup in the crew of the Saliut-3 orbital station]. Postflight changes in the blood protein composition involving albumin and globulin fractions with the predominant increase of most globulin fractions and an increase of total protein were noted. These changes were adaptive. The content of gamma-globulin fractions returned to the normal within a comparatively short period of time (four days post-flight). A complete recovery of the changes in the protein composition of blood required a longer period of time.


Ultrastructure of pulmonary mast cells in patients with fibrotic lung disorders. The topographic distribution, population density, and ultrastructural features of metachromatic cells (mast cells and basophilic leukocytes) were studied in lung biopsies from five control patients and 17 patients with fibrotic lung disorders. The great majority of metachromatic cells were mast cells. The average number of metachromatic cells per square millimeter of tissue section was much larger in patients with fibrotic lung disorders (45.8 +/- 6.5) than in control patients (2.6 +/- 1.6). In control patients, mast cells were most frequently seen in subpleural and perivascular connective tissue. In contrast, the vast majority of mast cells in patients with fibrotic lung disorders was present in thickened, fibrous alveolar septa; mast cells also were found within the alveolar epithelial layer and alveolar lumina. The quantitative distribution of different types of mast cell granules differed in the two groups of patients: granules composed of scrolls were more frequent in control patients, and granules of the combined type (containing mixtures of different components within the same granule) were more frequent in patients with fibrotic lung disorders. Mast cells in the latter patients appeared to migrate through defects in the basement membrane into the epithelial layer and alveolar lumina; mast cells in these areas often showed reduced numbers of granules and disorganized granule content. These changes suggest that pulmonary parenchymal mast cells in fibrotic lung disorders undergo a chronic process of partial degranulation which differs from that found in anaphylaxis; this chronic release of mast cell products may contribute to the continuing alveolar injury and the ventilation-perfusion inequalities observed in the fibrotic lung disorders.


Alterations in the relative abundance of specific messenger ribonucleoproteins associated with compensatory renal hypertrophy. A possible role of messenger RNA (mRNA)-associated proteins during compensatory renal hypertrophy in modulation of mRNA biogenesis has been examined in this investigation. Renal cytoplasmic free messenger ribonucleoprotein (CF mRNP) and polysomal mRNP (PA mRNP) have been isolated from kidney following 48 hours of compensatory renal hypertrophy, and the relative amounts of proteins associated with CF mRNP and PA mRNP in control and hypertrophying mouse kidney are compared. (CF mRNP refers to nonpolysomal messenger ribonucleoprotein found in the subribosomal region of sucrose gradients. PA mRNP or polysome-associated mRNP refers to mRNP released from polysomes.) CF mRNP has a buoyant density of 1.3 to 1.44 gm. per ml., contains RNA that sediments at 5 to 22 Svedberg units, and has a protein moiety comprising at least 15 polypeptides as revealed by sodium dodecyl sulfate polyacrylamide gels. PA mRNP contains three major polypeptides (molecular weights, 77,000, 52,000 and 17,000). Following 48 hours of compensatory renal hypertrophy, the relative amounts of proteins are changed: a 44,000- and 52,000- molecular weight polypeptide in CF mRNP is increased, a 52,000-molecular weight polypeptide in PA mRNP is reduced, and a 17,000-molecular weight polypeptide in PA mRNP is increased.


[Effect of short-term antiorthostatic hypokinesia on the pressure in various parts of the healthy human cardiovascular system]. Before and after 5-day head-down tilting (-4.5 degrees) blood pressure was measured in different cardiovascular compartments by the technique of selective catheterization: the upper bulb of the internal jugular vein, superior and inferior venae cavae, hepatic, renal and iliac veins, right atrium and right ventricle, coronary sinus, pulmonary and radial arteries. After exposure the pressure in extrathoracic vessels increased by 1.4 mm Hg on the average: in the internal jugular vein it rose by 1.7 mm Hg whereas in the iliac vein by 1.0 mm Hg. The blood pressure in the intrathoracic vessels of the systemic circulation increased, as a rule, by no more than 0.5--0.8 mm Hg. This elevation was characteristic of diastolic regions of the pressure curve (x- and y-collapse). The pressure in pulmonary vessels--pulmonary artery and left atrium--showed a trend for a decrease of 1.3 mm Hg. The factors that may be responsible for the dissimilar changes of pressure in different cardiovascular compartments under the influence of short-term simulated weightlessness are discussed.


5'-Nucleotidase levels in normal and virus-transformed cells: implications for cellular aging in vitro. 5'-Nucleotidase activity in the postnuclear supernatant of normal and SV-40 virus-transformed human embryonic lung, chick embryo, and mouse embryo fibroblasts, WI-38, IMR-90, VA-13, CEF, 3T3, and SV3T3 cells was measured. In IMR-90 and CEF cells, both of which have a limited lifespan in vitro, 5'-nucleotidase activity increased 6- and 20-fold, respectively, with increasing population doublings. However, VA-13 cells, a permanent cell line, showed no increase in this enzyme activity with progressive population doublings. 5'-Nucleotidase activity was not detectable in two other permanent cell lines, 3T3 and SV3T3 cells. Of the six cell lines tested, the conspicuous enhancement in 5'-nucleotidase activity with increasing population doublings was observed only in normal cell lines and was absent in transformed cell lines. These observations suggest a molecular mechanism which may play a role in aging of normal cells in vitro and which may involve catabolism of nucleic acids.


Post-traumatic tuberculoid leprosy. (A case report). Inoculation Tuberculoid Leprosy has been described by various leprologists off and on and this mode of onset has been established. A case of tuberculoid leprosy over thumb, appearing after trauma in an Army recruit is described with the review of the literature.


Immunological assessment of sera of leprosy patients. IgG levels were significantly high in sera of all types of leprosy. House-hold contacts of lepromatous leprosy (LL) cases also showed significantly higher values for IgG when compared to that of control. Except polar tuberculoid (TT) cases and house-hold contacts other types of leprosy revealed a significant rise in IgA levels in their sera. IgM was only raised in borderline tuberculoid (BT) cases. C-reactive protein (CRP) was present in the sera of all types of leprosy. Highest positivity (97%) was shown by sera from erythema nodosum leprosum (ENL) cases. Rose-Waaler antibody (RA) was noted in BT, borderline leprosy (BL), LL and ENL cases. Significance of these findings is discussed.


In vivo response of mast cells to lepromatous serum. Adult healthly mice of pure line Institute strain were given, into the foot pad, an intradermal injection of normal human serum in group A and lepromatous serum in group B. In both groups, the animals were killed at varying time intervals. Serial paraffin sections of the foot pad skin 5--7 mu thick, were cut and stained with haematoxylin and eosin, toludine blue, acridine orange and para-bromaniline. On comparing the two groups, in group B the response of mast cells was more prompt, pronounced and persistant. The increase in the number of cells was accompanied by explosive degranulation around nerves, blood vessels and muscles. This response became less by 15 days but did not disappear completely. There were still few intact cells in the dermis. Histamine, heparin and 5-Ht showed a corresponding rise. The importance of the findings is discussed.


Influence of rifampicin on D.D.S. excretion in urine. The plasma half-lives and urinary excretion levels of DDS were compared before and during concurrent administration of Rifampicin in 23 cases of active lepromatous leprosy. The plasma half-life of DDS was found to be slightly less during Rifampicin administration. The urinary excretion of DDS was found to be consistently enhanced in all the cases, particularly duotal duration of Rifampicin therapy. The findings are discussed.


Squamous cell carcinoma arising from trophic ulcers. This study presents two cases of Squamous Cell Carcinomas arising from trophic ulcers of leprosy attending Leprosy Department, Government General Hospital, Madras. The aim of this presentation is to analyse these cases in the light of the earlier reports and to draw attention to certain significant features of them.


The association of leprosy and pulmonary tuberculosis. The association of leprosy with pulmonary tuberculosis was seen in 20 cases during January 1972 to October 1977. Of these 20 cases, 15 were of lepromatous, 3 of dimorphous and 2 of tuberculoid leprosy. Maximum number of cases were from 3rd decade of life with male to female ratio of 3 : 1. Patients were suffering from the disease for a very long time (8 cases of lepromatous leprosy with duration of illness 10-15 years). The symptoms of leprosy seemed to have preceded to the symptoms of pulmonary tuberculosis. Duration of tuberculosis in most of them was within 6 months (55%). The predominent presenting symptom was cough with expectoration (100%) and fever (80%). Anaemia (75%) and crepitations (60%) were the presenting physical sign mainly. Radiologically bilateral extensive pulmonary lessons were seen in 14 cases (70%). Sputum for acid fast bacilli was positive in 80% of cases. The general condition and nutritional status was poor and death was resulted in 4 cases (3 of lepromatous and 1 of dimorphous leprosy).


Study of non-lepromatous leprosy among Indian Armed Forces personnel. Clinico-histopathological study of 50 cases of Non-lepromatous leprosy among Indian Armed Forces personnel is presented. Maximum cases were of Tuberculoid (TT) type. Thirty four individuals were having single lesions. Posterior aspect of elbow and medial aspect of forearm were the favourite sites. Both Indian and Ridley and Jopling classification was studied while classifying the lesions. The individuals belonged to almost all the states of India. All of them denied the history of contact with a known case of leprosy. The highest prevalent age group was between 20 to 30 years. Two cases of Tuberculoid and 3 of Maculo-anaesthetic leprosy were without involvement of nerves.


Comparison of the reaction to Dharmendra antigen in the normal skin and in the lesion of leprosy patients. In this study 0.1 ml of Dharmendra antigen was injected intradermally into the normal skin and lesions of 35 leprosy patients. The response was measured at 24 hrs., 48 hrs. and 21 days. It was found that the maximum response to Dharmendra antigen occurred at the end of 24 hrs. and started wanning by 48 hrs. In tuberculoid leprosy, there was significantly greater response in the lesion as compared with the nearby normal skin. It has been suggested that this could reflect an increased immunological activity at the site of the lesion. In the borderline tuberculoid cases with annular lesions, Dharmendra antigen was injected into the peripheral infiltrated area and into the apparently normal centre of the lesion, and a greater response was found at the centre. This might be the site of a previous lesion. The late reaction at the end of 21 days did not show much significant difference.


Some observations on default among leprosy patients. The problem of default or irregularity in taking the medicine is a great hinderance to the eradication of the disease. An attempt has been made here to judge this problem from various angles and to pin point the factors leading to default. A cohort of 253 patients have been comprehensively interviewed and the results have been analysed statistically.


Employee alcoholism policies in New York state hospitals. Of 179 hospitals responding to a questionnaire survey of 301 nonfederal short-term general hospitals in New York State, only 15 had a written policy concerning employee alcoholism.


Ethanol-inhibited platelet prostaglandin synthesis in vitro. Inhibition of human platelet malonyldialdehyde (an indicator of platelet prostaglandin synthesis) in platelet-rich plasma, not found after 100 mg of ethanol per 100 ml in vitro, was dose-related at 200, 400 and 750 mg per 100 ml.


MAC scale scores of three samples of men under conditions of conventional versus independent scale administration. When the MAC scale was administered both independently and in the context of the complete Minnesota Multiphasic Personality Inventory to three samples of men, only negligible differences were found between the scores obtained under the two conditions of administration.


Hepatotoxicity in disulfiram-treated patients. Thirty-five alcoholics receiving disulfiram for 3 weeks showed no dose-related hepatotoxicity compared with controls, but 9 did exhibit non-dose-related subclinical hepatotoxicity.


Reliability of an alcohol self-report instrument. According to testing and retesting of alcoholics admitted to a detoxication center, the reliability of the Alcohol History Form is comparable to that of most other psychometric instruments.


Augmentation of alcohol consumption by caffeine in malnourished rats. The alcohol consumption of malnourished rats increased substantially when caffeine, but not isohedonic quinine, was added to their available fluids. The effect was not observed in rats receiving an adequate diet. Conversely, food restriction raised alcohol consumption substantially in adequately fed but not in malnourished rats.


Relationship of socioeconomic status, psychiatric diagnosis and sex to outcome of alcoholism treatment. At 2 1/2 to 5 years after treatment at a psychiatric hospital, 68 of the 100 patients followed up were considered improved: 60% were of upper socioeconomic status, 64% were men, and 72% had received diagnoses of psychoneuroses or personality disorders.


A follow-up study of male halfway-house residents and matched nonresident controls. Men in a halfway-house sample had more detoxication readmissions but fewer drunkenness arrests in a 3-month follow-up period than did their matched controls; the total number of documented drunkenness episodes did not differ in the two groups.


Driving records of persons convicted of driving under the influence of alcohol. The average interval between convictions of driving under the influence decreases from 2 years between first and second convictions to 17, 11 and 8 months, respectively, between the second and third, the third and fourth and the fourth and fifth convictions.


Family characteristics and the outcome of treatment for alcoholism. Families in which the alcoholic patient showed better treatment outcome were higher than the other in cohesion, active-recreational orientation and organization, and lower in conflict and control; they also experienced more positive and fewer negative life events, and reported fewer physical and emotional symptoms and disagreements.


An experimental treatment program for alcoholic couples. An experimental treatment program for alcoholic couples, which included a period of conjoint hospitalization during which drinking was allowed, is described.


Marital conflict resolution of alcoholic and nonalcoholic couples during drinking and nondrinking sessions. The marital interactions of alcoholics and their wives did not differ significantly from those of nonalcoholic maritally distressed couples, but both differed from the interactions of nonalcoholic, nondistressed couples.


The detoxication alternative to the handling of public inebriates. The Ontario experience. A review of the Ontario experience in the development of a public health alternative to the handling of public inebriates has revealed some difficulties inherent in this approach to reform.


Clients' characteristics and the expectations of staff in halfway houses for alcoholics. In 23 halfway houses in Florida, the percentage of men residents, the percentage of residents who were employed and the mean weekly earnings of patients were positively related to the average staff member's expectations that residents would behave independently.


EEG alpha correlates of alcohol consumption in smokers and nonsmokers. Effects of smoking and smoking deprivation. Tobacco smoking either prior to or during alcohol consumption or both counteracted the alcohol-induced slowing of alpha frequency which was evident in both nonsmokers and deprived smokers.


An application of the multidimensional model of alcoholism. Differentiation of alcoholics by mode analysis. Cluster analysis of the responses of 563 alcoholics on the Human Services Scale revealed 5 homogeneous groups.


The Adolescent Alcohol Involvement Scale. An instrument for measuring adolescents' use and misuse of alcohol. The reliability of the scale was measured by the test-retest scores of adolescent alcoholics and adolescents who drink infrequently; its validity was assessed by psychiatrists' and others' ratings of the items, the scores of adolescents reporting alcohol misuse and the factor-analyzed scores of a large population of high-school studnets.


Reported effects of alcohol on the sexual feelings and behavior of women alcoholics and nonalcoholics. Women alcoholics were more likely than nonalcoholics to report that they desire, engage in and enjoy sexual intercourse more after drinking. Reproductive dysfunction was more typical of women having various types of psychopathology (including alcoholism) than of normal women.


Alcohol consumption and the incidence of violent crime. The incidence of violent crime in an industrialized area of Ontario was positively correlated with sales of alcoholic beverages to establishments licensed to serve them on premises and negatively correlated with mean income and percentage of owner-occupied dwellings.


In-home support for recovering alcoholic mothers and their families; the family rehabilitation coordinator project. A program is described for training paraprofessional workers to aid recovering alcoholic mothers and their families to improve household organization and communication and to use community services.


Effect of preoperative intralesional BCG and postoperative 5-FU chemotherapy in three adenocarcinoma lines in rats. In No. 13762 mammary adenocarcinoma, it has been shown that the combination of tumor infiltration with BCG and of subsequent surgery is more curative than either treatment modality alone. And the administration of postoperative systemic 5-fluorouracil (D-FU) is equally effective in eliminating the visceral metastasis and prolonging the host survival. In the experiments reported here, two other spontaneously metastasizing adenocarcinoma lines were similarly treated. Postoperative 5-FU chemotherapy, but not intralesional BCG, significantly improved survival duration of rats with SMT-2A mammary adenocarcinoma, but neither chemotherapy nor BCG immunotherapy was effective in the new colonic adenocarcinoma line.


Relationship of race to functional status among breast cancer patients after curative surgery. Analysis of functional status of 197 breast cancer patients three years after curative radical mastectomy indicated a cumulative probability of disability of 25%, whereas the probability of death regardless of prior disability was 40.5%. Analysis of functional status by patient characteristics indicated that nonwhites were three times more likely than whites to experience disability (P less than 0.01) as defined in terms of their ability to carry on normal activities without assistance. Although whites and nonwhites were diagnosed at similar stages of disease, nonwhites were, on average, eight years younger than whites. They younger age may reflect a larger proportion of premenopausal breast cancer cases among nonwhites, which if associated with more rapidly progressing disease could account for their poorer prognosis. Alternatively there may exist factors in the nonwhites' social or economic environment that limited the ability of the family to care for the patient at home. These data reaffirm the need to monitor closely breast cancer patients to diagnose acute complications, and they indicate that most patients can resume normal activities shortly after curative surgery.


Visceral neoplasia presenting at the umbilicus. An umbilical mass as the presenting and only symptom of an underlying visceral carcinoma is an infrequent occurrence. The implications of such a finding are illustrated by four examples, with primary tumors in pancreas, colon, and ovary. Adenocarcinoma in the umbilicus represents a metastatic deposit until proved otherwise. Further diagnostic evaluation to localize the primary tumor should be based upon therapeutic implications. The need for abdominal exploration must be individualized.


Septic arthritis: a complication of BCG immunotherapy. A new complication of cutaneous vaccination for immune therapy is reported: non-acid-fast bacteremia with metastatic septic arthritis. Systemic antibiotics should be administered prophylactically in patients with signs and symptoms of local infection, particularly in the presence of orthopedic prostheses or valvular heart disease.


Comparison of intraoperative nitroprusside unloading in mitral and aortic regurgitation. To compare the hemodynamic effect of vasodilator therapy on different regurgitant lesions, we infused sodium nitroprusside intraooperatively in 12 patients with mitral regurgitation and 15 with aortic regurgitation. During the critical period preceding establishment of cardiopulmonary bypass, both groups had developed intense vasoconstriction and cardiac decompensation. All demonstrated improved cardiac function with vasodilator therapy; however, the degree of improvement with nitroprusside differed in the two groups. Stroke volume increased 10 ml. per beat per meter squared in those patients with aortic regurgitation and only 6 ml. per beat per meter squared in those with mitral regurgitation (p less than 0.05). The percent increase in stoke volume induced by nitroprusside was inversely correlated to the preoperative left ventricular ejection fraction (r = 0.44, p less than 0.02). Patients with aortic regurgitation had lower preoperative left ventricular ejection fractions than those with mitral regurgitation (0.53 versus 0.63, p less than 0.02). Therefore, we conclude that patients with aortic regurgitation derived greater intraoperative hemodynamic benefit from unloading with nitroprusside, because they came to surgery with greater impairment of left ventricular contractility. Although nitroprusside improved cardiac function in both groups, only the patients with aortic regurgitation achieved normal pulmonary artery pressure (17 torr) and pulmonary vascular resistance (2.1 units) as a result of unloading. Those with mitral regurgitation continued to have pulmonary hypertension (28 torr) and increased pulmonary vascular resistance (3.9 units) despite vasodilator therapy. Thus the data suggest that patients with mitral regurgitation derived less hemodynamic benefit from intraoperative nitroprusside therapy because they were also limited by right ventricular dysfunction and a less responsive pulmonary vasculature.


Ventricular tachycardia secondary to aneurysm of sinus of Valsalva. A patient with unruptured aneurysm of the sinus of Valsalva presented because of ventricular tachycardia refractory to medical therapy. The underlying problem was not suspected until cardiac catheterization. Once the aneurysm was repaired, the tachycardia was abolished; the patient required no antiarrhythmic drugs. Two points are emphasized: First, cardiac catheterization is often indicated early in cases of ventricular tachycardia without obvious cause. Second, recurrent ventricular tachycardia is a hitherto unreported but important complication of sinus of Valsalva aneurysm.


Compression of superior vena cava associated with aneurysmal dilatation of left atrium. A patient with rheumatic mitral valve disease and persistently elevated jugular venous pressure (JVP) is described. Angiography revealed a valve-like structure in the superior vena cava (SVC) at the site where a pressure gradient was recorded. At operation, this previously unreported anomaly proved to have been caused by aneurysmal dilatation of the left atrium which exerted traction on the pericardial insertion to the SVC. Disinsertion of the pericardial attachment to the vena cava at the time of mitral valve replacement released the compression. Postoperatively, the JVP became normal.


Anomalous origin of left coronary artery from pulmonary artery in association with intracardiac lesions. Report of two cases. Two cases are presented to illustrate the diagnostic and therapeutic dilemma when an anomalous origin of the left coronary artery from the pulmonary artery occurs with a hemodynamically significant intracardiac lesion. Hemodynamic alterations resulting from the associated intracardiac lesion may obscure the clinical features of the coronary arterial abnormality, and the appearance of normal coronary arterial distribution with left ventricular or aortic root angiography may create a false impression of a normal origin of the coronary arterial supply. A high index of suspicion may be the only lead to the detection of an anomalous origin of the left coronary artery from the pulmonary artery in association with an intracardiac lesion. In addition to the intracardiac lesion known to be associated with coronary arterial abnormalities, the question of anomalous coronary supply should be raised by the finding of poor left ventricular function or mitral insufficiency after operation (unexplainable by other causes), by the development of poor myocardial function during cardiac catheterization or anesthesia, or by the significant enlargement of a coronary artery seen during left ventriculography or supravalvular aortography.


Acute mitral valvular obstruction from infective endocarditis: echocardiographic diagnosis and report of the second successfully treated case. Severe mitral stenosis of rapid onset and progression was observed in a patient with infective endocarditis superimposed upon mild rheumatic mitral valvular stenosis. This severe stenosis resulted from large vegetations impinging upon the mitral valve orifice. Preoperative studies indicating mitral stenosis with vegetations and pulmonary edema were followed by emergency mitral valve replacement, which was sucessful.


Survival following fracture of strut from mitral prosthesis with disc translocation. Mechanical complications of prosthetic valves are increasingly rare. The acute, catastrophic nature of the symptoms associated with massive transvalvular regurgitation preclude survival except with immediate operation. In the patient described herein, two weld fractures of a Björk-Shiley mitral prosthetic strut led to displacement of the valve occluder into the left atrium. The patient survived reoperation, following which the strut was detected radiologically in the left ventricular free wall. A slow, limited recovery resulted from his 5 preoperative hours of deep shock and coma. No complication attributable to the retained ventricular foreign body has been identified.


Intra-aortic balloon pumping: two-year experience. Experience with 29 patients who underwent intra-aortic counterpulsation between January, 1975, and December, 1977, was reviewed to determine (1) if the results of this method of treatment were similar at the community hospital and university hospital levels and (2) if earlier institution of counterpulsation made possible by easy availability of equipment resulted in improved survival. The balloon was successfully inserted in 27 patients. Arterial blood pressure was below 80 mm. Hg in all patients prior to institution of either pharmacologic or balloon therapy. Pulmonary capillary wedge pressure was greater than 12 mm. Hg in the 22 patients in whom it was measured. In 15 patients counterpulsation was instituted less than 12 hours after infarction (Group A), and in the 14 elapsed time was greater than 12 hours (Group B). There was no difference in precounterpulsation hemodynamic measurements between Group A and Group B. Ten patients in Group A were weaned and survived hospitalization. Seven (54 percent) are long-term survivors (6 months to 2 years). Four are in New York Heart Association Class I, two are in Class II, and one is in Class III. Ten patients in Group B were weaned, seven survived hospitalization, and five are long-term survivors (35 percent). Two are in N.Y.H.A. Class I, two are in Class II, and one is in Class III. These results indicate that counterpulsation is possible at the local hospital level and that early institution of the intra-aortic balloon pumping may improve long-term results.


Intra-aortic balloon counterpulsation for cardiac support during noncardiac operations. Major noncardiac surgery is a serious hazard to patients with advanced coronary disease. Perioperative infarction is common, and preliminary coronary bypass is often unwarranted. We suggest that the use of the intra-aortic balloon pump (IABP) for perioperative support of such patients makes perioperative infarction unlikely and permits otherwise hazardous operations. Three patients with advanced coronary disease (unstable angina in two) had major thoracotomies for lung masses without cardiac complications. This management plan has wider implications for other noncardiac surgical problems in such patients, particularly for mandatory operations wuch as relieving intestinal obstructions.


Six-month survival of a calf with an artificial heart. A pneumatically powered artificial heart, constructed primarily from a polyurethane, was implanted in the chest of a calf and supported the calf for more than 6 months. The heart, which was designed to fit in the chest of a 90 kilogram calf, was able to suppor the animal when it weighed 180 kilograms. During the first 105 days the calf remained strong and healthy. The animal grew progressively weaker after day 106, and by day 160 right heart failure became apparent. The principal cause of the right heart failure was an obstructive growth between the right atrium and the right ventricle. An attempt to correct the problem on day 184 with an artificial heart resulted in the animal's death.


The spectrum of anomalies of aortopulmonary septation. Embryologically related defects resulting from abnormal septation of the aortopulmonary trunk in 13 patients were reviewed and grouped according to a new classification system. Seven patients (54 percent) had typical aortopulmonary septal defects or windows (Type I), three (23 percent) had a more cephalad defect between the ascending aorta and the origin of the right pulmonary artery (Type II), and three (23 percent) had anomalous origin of the right pulmonary artery from the ascending aorta (Type III). Type I defects are caused by incomplete septation of the aortopulmonary trunk; Type II and III defects result from unequal partitioning of the aortopulmonary trunk by the conotruncal ridges. Three of six patients survived correction of Type I defects; both patients having correlation of Type II defects and all three patients with Type III defects survived and remain well 2 to 216 months (mean 61 months) postoperatively. The recommended technique for Type I and II defects is transaortic closure of the defect by prosthetic patch with the aid of cardiopulmonary bypass, supplemented by profound hypothermia (20 degrees C.), and circulatory arrest for improved exposure in selected cases. For Type III defects, division of the anomalous connection plus direct implantation of the right pulmonary artery into the main pulmonary artery is the preferred approach.


Esophageal perforation during attempted endotracheal intubation. Perforation of the cervical esophagus in the course of attempted intubation of the trachea is a very rare accident, or at least rarely reported. Over the past 11 years, 12 patients ranging in age from 44 to 72 years were treated in our unit. If suspected, esophageal perforation is easy to diagnose when intubation has been difficult or when the patient complains of dysphagia and neck pain. Subcutaneous cervical emphysema appears early. All the patients who were operated upon early made an uneventful and prompt recovery. In those subjected to delayed operation (more than 12 hours) or nonoperative treatment, the mortality rate was 56 percent and recovery was achieved only after long and difficult treatment.


Surgical treatment of aneurysms of the inferior left ventricular wall. Experience with surgical treatment of 10 patients with aneurysms of the inferior wall of the left ventricle is presented. Six of the 10 aneurysms were false (pseudoaneurysms), and four were classified as true aneurysms. All except one resulted from myocardial infarction. Combined procedures, performed at the time of aneurysm resection, included mitral valve replacement (five patients), coronary artery bypass grafting (four patients), and closure of an interventricular septal defect (one patient). Three of four patients with true inferior aneurysms had mitral valve dysfunction, whereas only two of six patients with false aneurysms required mitral valve replacement (one because of infective endocarditis). Nine of the 10 patients survived operation, and all are functionally improved except one. On the basis of this and previously reported experience, it is concluded that a substantial proportion of inferior left ventricular aneurysms exhibit the pathological features of false aneurysms. Because of the associated propensity toward rupture of such lesions, an aggressive surgical approach is recommended.


New surgical method for repair of anomalous left coronary artery from pulmonary artery. A new surgical method for repair of anomalous origin of the left coronary artery from the pulmonary trunk is described. The principle of the proposed technique is to transmit the oxygenated blood to the anomalous left coronary artery through surgically created aortopulmonary window and the internal tunnel created in the main pulmonary trunk. A 2-year-old boy in whom this anomaly was associated with mitral regurgitation caused by papillary muscle dysfunction was successfully treated by this new surgical method, and the deformed mitral valve was concomitantly replaced by a Hancock porcine xenograft.


Aneurysm of left ventricle secondary to bacterial endocarditis. Three cases are described of aneurysms of the area of fibrous continuity between the aortic and mitral valves, each associated with infective endocarditis of the aortic valve. In two cases surgical treatment was successful, one of these having been diagnosed by angiography prior to operation. The other case was discovered only at autopsy, but the histologic findings showed the lesion to be a true aneurysm. Although some cases have been successfully managed by operation, most have proved fata. These cases and the previous successes illustrate the potential value of urgent operation.


Predictive value of preoperative in vitro and in vivo studies for correct individual heparinization in cardiac surgery. Heparin administration for operations with extracorporeal circulation (ECC) usually is performed following prefixed, standardized protocols. These regimens secure an adequate level of anticoagulation, but they often involve prolonged periods of overheparinization associated with an undue risk of hemorrhage. The predictive value of preoperative studies in the anticoagulant effect of heparin was investigated in 10 patients. The study was performed both in vitro and in vivo using the Xa inhibitor assay as an index of the anticoagulation induced by heparin. Adding variable amounts of heparin in vitro to patient's plasma resulted in straight (at least up to 7 U. per milliliter) and parallel, but not coincident, dose/response curves, so confirming a different individual sensitivity to heparin. Disappearance curves of the anticoagulant effect in plasma following intravenous administration of a single standard dose of heparin in the same patients showed an even greater patient-to-patient variability, with "half-life" times ranging from 30 to 150 minutes. No relationship was found between the parameters (in vitro sensitivity to heparin and clearance rate from plasma in vivo). Moreover, neither of them could be correlated with the response to heparin, subsequently observed during ECC in the same patients. Preoperative investigations with the methods presently available are not adequate to choose individual heparin administration regimens for cardiac operations.


Heparin administration during extracorporeal circulation: heparin rebound and postoperative bleeding. The individual variations in heparin dose response and heparin activity decay have indicated limitations of the protocols based on body surface area and weight of the patients. In the present study the heparin levels and simpler clotting tests were monitored in a consecutive series of 71 patients undergoing standard cardiac operations. The clotting tests used were the Celite activated clotting time (Celite ACT) and the whole blood activated recalcification time (BART). Forty-four patients received a loading dose of heparin, 3 mg. per kilogram, a maintenance dose of heparin, 1.5 mg. per kilogram per hour, and 6 mg. of protamine sulfate per kilogram at the termination of extracorporeal circulation (ECC) (Protocol I). Twenty-seven patients received a similar initial dose, but the maintenance dose of heparin and the dosage of protamine sulfate were administered according to the measured heparin levels (Protocol II). A significant difference was seen in the measured heparin levels (p less than 0.01, Celite ACT (p less than 0.01), and BART (p less than 0.01) in patients on Protocols I and II. Ten of the 24 patients on Protocol I and none on Protocol II showed heparin rebound phenomenon, and blood loss in patients on Protocol I was significantly greater than that in patients on Protocol II. The study clearly demonstrates that our protocol of heparin administration and control with simpler tests ensures safe hypocoagulation during ECC and efficient reversal at the end, with minimal postoperative blood loss.


Observations on hepatic superficial lymph flow. Hepatic superficial lymph flow was studied by injecting patent blue V solution into the liver under peritoneoscopy. This procedure enabled detailed observations of the direction of hepatic lymph flow in superificial lymphatic vessels and migration of lymph from these lymphatic vessels to lymphatic vessels of the gallbladder. Increase in this flow was observed in patients with increased liver fibrosis and lobular distortion.


Morphological studies on liver lymphatics. Form, distribution and structure of liver lymphatics were studied in pig, calf, kid, dog, rabbit and human using both light and electron microscopes. The relation of the lymphatics to both blood vessel and connective tissue was the same throughout the material. The lymphatic capillaries were supported by a lattice of the coarse bundles, composed of collagenous fibers. The endothelial cells of the lymphatic capillaries lying in the meshes of the lattice showed a marked change in the volume and a phagocytotic activity. The results were discussed in relation to the function.


Structure of lymphatics in the aorta and the periaortic tissues, and vascular lesions caused by disturbance of the lymphatics. In the cases of obstruction of the lymphatics alone, vascular lesions were slighter compared with those of obstruction of the arterial vasa vasorum (5). However, in the cases of severe disturbances of flow from the vascular wall with marked increase of the connective tissues, vascular lesions such as wide intimal thickening progressed. So, disturbance of lymphatics in the aorta and the periaortic tissue seemed to give an influence on the microcirculation in the vascular wall and vascular lesions.


Lymph flow in human leg.

Lymph flow in human leg. A little bit of RISA (0.01--0.02 ML) was injected into a lymphatic at the back of a human foot in supine and/or sitting position, and the radioactivity curves were obtained at the inguinal and/or at the middle of the thigh. Radioactivity curves at the inguinal region showed stepwise rise with the frequency of about 1/min. in subjects without edema and steep rise without staircase in patients with cardiac edema. Radioactivity curves at the middle of the thigh showed many spiky waves with the frequency of about 1/min. in supine subjects without edema, which were increased in frequency, duration and/or height in sitting subjects without edema and also in supine and sitting patients with cardiac edema. Therefore, it may be said that there are rhythmic lymph flows in lower leg of subjects without edema and of patients with cardiac edema not only in supine but also in sitting position, and also that lymphatic contractility plays some role in propelling lymph in human leg.


Lymphographic classification of malignant lymphoma. In an attempt to raise the diagnostic accuracy of lymphography in malignant lymphoma, especially in early stages, the disease were radiographically classified into 3 groups such as atypical, typical and advanced group mainly based on the lymphographic findings. The findings showed characteristic features corresponding to the stages of the disease. Atypical group showed the following findings: small filling defects, increased number of lymph node and visualization of the marginal sinus. The findings were regarded as those of early stages of malignant lymphoma.