Satisfactions, dissatisfactions, and causes of stress in medical practice. Careers of physicians who graduated from Case Western Reserve School of Medicine have been examined in several longitudinal career studies. Physicians have been interviewed in their own offices, have filled out short-answer questionnaires, and have taken four tests. Emphasis has been placed on factors that have made their medical careers particularly satisfying or dissatisfying. Physicians report many satisfactions that evolve around helping patients, solving problems, and developing relationships with patients and their families. A major dissatisfaction relates to time pressures. In the current interviews with graduates, several sources of stress (malpractice suits, having to give up certain aspects of medical work, threats of physical harm, and certain features of peer review) are being expressed that were infrequently mentioned in previous studies.


Depression in cancer patients. An approach to differential diagnosis and treatment. Despite recent attention to death and dying, many questions remain about the diagnosis and treatment of depression in cancer patients. To provide a framework for effective treatment, this article distinguishes the following types of depression: (1) transient stress reactions, (2) major psychiatric disturbances requiring prompt attention, and (3) other depressive reactions. Depressions in the third general category, comprising the majority, are often mismanaged because of characterological, interpersonal, and organic factors receive insufficient attention. Understanding of such factors provides a basis for rational intervention with both patients and their families.


Where did I see that article?

Where did I see that article? Searching through stacks of unbound journals is an inefficient method of information retrieval. I have developed an inexpensive and easily used filing system. This filing system provides an excellent medical-information retrieval system.


Medullary sponge kidney and renal-leak hypercalciuria. A link to the development of parathyroid adenoma? The pathogenesis of the association of medullary sponge kidney and hyperparathyroidism from parathyroid adenoma remains obscure. This unusual case of medullary sponge kidney and secondary hyperparathyroidism due to renal-leak hypercalciuria gives insight into a possible mechanism for the occurrence of medullary sponge kidney with parathyroid adenoma. Suppressible hyperparathyroidism due to renal calcium wasting could represent an intermediate stage in the development of unsuppressible parathyroid hormone secretion. Thus, parathyroid adenoma occurring with medullary sponge kidney may represent a consequence of disordered renal calcium excretion rather than a primary abnormality.


Blood coagulation following vasectomy.

Blood coagulation following vasectomy. Concern that men may have an increased risk of the development of thrombophlebitis following vasectomy prompted the study of 58 vasectomized men and 37 age-matched controls. Eight patients undergoing total hip replacement also were studied, since they are known to have an increased risk of thrombotic complications. There were no changes in coagulation suggestive of a thrombotic tendency in the vasectomized population, though an increase in fibrinogen concentration was present preoperatively, and transient increases in factor V concentration, prothrombin time, and fibrinogen concentration were seen postoperatively in some cases. None of the vasectomized patients had clinical evidence suggestive of thrombosis.


Oxygen concentration from room air. A new source for oxygen therapy in the home. Most oxygen concentrators use molecular sieves that selectively adsorb molecules according to their size and polarity. Their present rental cost is about half that of the traditional oxygen tanks or liquid-oxygen systems. Two concentrators have been tested. They are able to produce both high oxygen concentrations (95% oxygen at 2 L/min) and high flow rates (10 L/min with 40% oxygen), which remained stable for one week. After 24 hours of continuous use, neither machine concentrated toxic gases from room air in a city. Both were suitable for use with 24% and 28% Venturi masks.


Patients' reactions to psychiatric consultation. Physicians are often concerned that patients will resent a request for psychiatric consultation. To investigate this problem, 60 patients undergoing psychiatric consultation in a general hospital were inverviewed 24 hours after the consultation. Nearly two thirds of these patients believed that the consultation was beneficial. Patients' attitudes were independent of their demographic characteristics, reason for referral, and hospital service involved. Patients with long-term illnesses more often had positive attitudes than patients with short-term illnesses. Patients who were initially hostile or ambivalent usually had positive attitudes 24 hours later. Substance abusers and patients who denied clearly recognizable psychiatric disorders often did not value the consultation. Even so, their physicians frequently believed that the consultation was useful. We attribute the positive attitudes of patients in our study largely to the referring physicians' preparing them for psychiatric consultation.


Prenatal diagnosis of homozygous alpha-thalassemia. A Vietnamese couple were both carriers of alpha-thalessemia-1. The woman had a first pregnancy terminated in the delivery of a hydropic fetus due to homozygous alpha-thalassemia. The couple requested prenatal diagnosis for the second pregnancy. The DNA obtained from cultured amniotic fluid cells was studied pregnancy. The DNA obtained from cultured amniotic fluid cells was studied by hybridization with globin cDNA in solution and on filters (Southern technique). Both analyses demonstrated no alpha-globin structural genes were present. Following termination of the pregnancy, the diagnosis was established by the presence of only hemoglobins Barts (gamma 4) and Portland (zeta 2 gamma 2) in the fetal blood.


Cryoprecipitate as a reliable source of fibrinogen replacement. The recent withdrawal of commercial fibrinogen from the market makes alternate sources most important. Although it has been previously reported that single-donor cryoprecipitate contains appreciable amounts of fibrinogen, most clinicians need to be reminded of the reliability of cryoprecipitate for replacement of both fibrinogen and factor VIII. We assayed fibrinogen from 88 bags of cryoprecipitate prepared by five different blood banks in California and Oregon; we found that the average bag of cryoprecipitate contains at least 250 mg of fibrinogen depending on the volume of plasma processed. Cryoprecipitate was found to be a poor source of factors II, V, IX, X, XI, and XII.


Rebound insomnia. A potential hazard following withdrawal of certain benzodiazepines. Five benzodiazepine drugs (diazepam, flunitrazepam, flurazepam hydrochloride, nitrazepam, and triazolam) were evaluated separately in 15 sleep laboratory studies. Rebound insomnia, a worsening of sleep compared with baseline, occurred following withdrawal of triazolam, nitrazepam, and flunitrazepam after they had been given in only single, nightly doses for short periods. The rebound insomnia was attributed to the short and intermediate half-lives of these drugs. Diazepam and flurazepam, which have longer half-lives, did not cause rebound insomnia on withdrawal. Rebound insomnia may play a role in the development of hypnotic drug dependence with shorter-acting benzodiazepine drugs.


Pruritic urticarial papules and plaques of pregnancy. We report an intensely pruritic cutaneous eruption that occurs in the third trimester of pregnancy. The clinical manifestations include erythematous urticarial papules and plaques that begin on the abdomen and spread to involve the thighs and occasionally the buttocks and arms. This dermatosis appears to be clinically distinct from previously described pruritic eruptions occurring in pregnancy. Biopsy specimens of the lesions show two histological patterns. We propose that this entity be termed "pruritic urticarial papules and plaques of pregnancy (PUPPP)".


Health education for hypertensive patients. Three educational interventions for the control of essential hypertension in ambulatory patients were based on analyses of the educational needs of patients and providers. The educational program increased reported compliance with medication, improved the proportion of patients losing weight, and improved appointment keeping. Most important, there was a favorable effect on blood pressure (BP) control. The proportion of patients with BP under control in the group assigned to all three interventions increased by 28% (from 38% to 66%), while the proportion in the control group receiving standard medical therapy with no educational interventions remained unchanged at 42%.


Streptococcal endocarditis (nonenterococcal, non-group A): single vs combination therapy. A 14-year experience with streptococcal endocarditis was reviewed. The effect of single vs combination antibiotic therapy on the relapse rate was found to be comparable. Of 68 patients treated, four patients died during therapy. Two of 46 patients receiving single-agent and none of 18 patients receiving combination therapy experienced a relapse. Duration of symptoms before diagnosis was the main risk factor predisposing to relapse, which occurred in two of 13 patients with symptoms for longer than three months and in none of 51 patients with symptoms for three months or less before diagnosis. Combination therapy offered no advantage over a single agent in the latter group. Optimal therapy for patients with symptoms for longer than three months could not be determined in this study. However, no relapses were observed in this high-risk group when a single agent was given for longer than 21 days.


Hemodialysis and pregnancy.

Hemodialysis and pregnancy. When severe renal failure requiring hemodialysis complicates pregnancy, there is hesitation to continue the pregnancy. However, successful hemodialysis in pregnancy is being reported with growing frequency. Fetal survival and even conception is possible in patients undergoing dialysis.


Hyperthermia potentiates doxorubicin-related cardiotoxic effects. The intercurrent administration of doxorubicin hydrochloride to a patient undergoing whole-body hyperthermia for the treatment of metastatic cancer repeatedly produced ventricular irritability and cardiac dysfunction. Individually, doxorubicin and hyperthermia were tolerated by the patient without incident. Catecholamine determinations showed that the administration of doxorubicin under hyperthermic conditions increased the liberation of both epinephrine and norepinephrine. The acute synergistic cardiotoxic effects occurred with doxorubicin dosages that were severalfold less than those associated with only mild and transient ECG disturbances under normothermic conditions.


Marital status, health, and use of health services. An old relationship revisited. Historical data indicate that married persons live longer on the average than unmarried persons and that they generally make less use of health care services. These facts are increasingly important in view of the growing proportion of "singles" in the US population. The complex cause-and-effect relationship between marriage and better health has long been recognized, but there is now some indication that the relationship is less strong than before. Despite lack of precise knowledge on many aspects of this issue, two facts are clear: perceptions of health, illness, and "need" for health care are constantly changing and as the family's role in health has declined, there has been a concurrent rise in the "need" for, and cost of, the external health care system. The future of these trends depends, in part, on the future of the American family.


Mobile intensive care units. An evaluation of effectiveness. Implementation of mobile intensive care units in four suburban communities permitted a retrospective evaluation of their impact on patient outcome. Data on 1,796 cases of myocardial infarction were obtained from medical reords and death certificates of patients arriving at four hospitals during a 65-month period. There were statistically significant reductions in mortality rates in two communities (41.1% to 23.9% and 37.6% to 27.0%) after the service began. A reduction in one community (34.5% to 22.0%) was not statistically significant, and the fourth community showed an increase in the mortality rate (31.1% to 44.0%). Analysis of plausible rival hypotheses permitted most of these to be ruled out as causes for the observed reduction in mortality.


Effectiveness of advanced paramedics in a mobile coronary care system. The mobilized coronary care system in Columbus, Ohio, began with operation of a single vehicle with a physician in attendance. Currently, advanced emergency medical technician-paramedics work without direct physician supervision. When both experiences are compared, the results indicate that advanced emergency medical technician-paramedics working independently perform as well as physician counterparts.


Cardiac resuscitation in the community. Importance of rapid provision and implications for program planning. Several time-related variables involving resuscitation from out-of-hospital cardiac arrest were studied. Short time intervals from collapse to initiation of cardiopulmonary resuscitation (CPR) and to provision of definitive care were significantly associated with survival from cardiac arrest. The two times were jointly related, and one short time without the other was unlikely to result in survival. If CPR was initiated within four minutes and if definitive care was provided within eight minutes, 43% of patients survived. If either time was exceeded, the changes of survival fell dramatically. The time to initiation of CPR and definitive care are factors directly influenced by emergency medical service program decisions. A realistic option to improve time to initiation of CPR is widespread citizen CPR training. A possible option to improve the time to definitive care is the training of emergency medical technicians in defibrillation.


Evidence of dietary copper and zinc deficiencies. The mean daily amounts of copper and zinc found in hospital diets by atomic absorption spectrometry were 0.76 and 9.4 mg, respectively. Comparison of these diets with published data showed median daily amounts of copper and zinc to be 0.78 and 12.0 mg, respectively, for 20 diets made from conventional foods. These amounts of copper and zinc are less than the 2 mg of copper and 13 mg of zinc thought to be required daily by adults. Hospital diets and perhaps diets in general seem to be low in copper and zinc; the amounts of copper are lower than those of zinc in comparison with respective requirements. Common dietary amounts of these elements may cause health problems.


Education for self-treatment by adult asthmatics. A prospective experimental design evaluated the ability of a series of educational and motivational interventions to enhance self-treatment by adult asthmatics and to reduce use of emergency department services for asthma attacks. After treatment for an asthma attack, subjects were randomly assigned to the following sequential interventions: (1) reinforcement by interpersonal similarity at the time of the emergency visit, (2) recepit of positive written appeals, and (3) follow-up telephone reinforcement. The asthmatic nurse educator was generally more effective in achieving short-term reduction of emergency department visits. Although the usefulness of the positive written appeal increased when employed by the asthmatic nurse, there were no substantive independent effects of the written message on emergency department use.


The congestive heart failure model of schizophrenia. Many primary care physicians wish to address the psychiatric aspects of their medically ill patients but are impatient with the abstract terminology used in psychiatry's past psychoanalytical period. Modern psychiatry is a more integrated field and considers the biological and social as well as the analytical contributors to disease. Using these newer concepts, we present a teaching model in which schizophrenia is viewed as a syndrome and is compared with the well-known medical syndrome of congestive heart failure. This approach facilitates the conceptualization of a complex psychiatric illness and makes it more appealing to primary care physicians by demonstrating common gound between medicine and psychiatry.


Acute myocardial infarction. Prognosis complicated by ventricular fibrillation or cardiac arrest. A community-wide study was conducted in metropolitan Baltimore in which the prognosis of 330 patients hospitalized with an acute myocardial infarction (MI) complicated by ventricular fibrillation or cardiac arrest (VFib/CA) was compared with that of 1,071 patients hospitalized with acute MI not complicated by VFib/CA. As expected, the in-hospital case-fatality rate among patients with MI complicated by VFib/CA was significantly higher than that in patients without VFib/CA. However, for patients discharged alive from the hospital, no significant differences in long-term survival were found between patients with MI with or without VFib/CA. These results suggest that attempts at preventing subsequent mortality should be diligently pursued in patients with MI who are discharged alive from the hospital regardless of the occurrence of VFib/CA in the acute phase.


Intramuscular hemorrhage in hemophiliacs with inhibitors. A medical emergency. Any hemorrhage in a hemophilic patient must be regarded as a serious problem. A small percentage of hemophiliacs have an inhibitor that will destroy factor VIII or IX clotting activity, thus making control even more difficult. This occurrence predisposes these patients to joint contractures and deformities secondary to repeated, uncontrolled hemorrhages into muscle compartments and joints. Patients with an inhibitor must, therefore, be recognized, and any bleeding should be treated as an emergency. A combined treatment protocol has been developed by the hematology and orthopedic departments in a effort to achieve early hemorrhage control and prevent subsequent deformity.


Noninvasive testing vs clinical evaluation of arterial disease. A prospective study. In a prospective clinical study involving 458 diabetic patients, the results of noninvasive testing procedures were compared with the findings obtained by clinical evaluation. The results of the study showed that nearly one third of the patients who gave no history of intermittent claudication were found to have arterial disease when tested. One fifth of the patients with what were considered normal physical examination results had abnormal results by noninvasive testing. When history and physical examination prove ineffective for obtaining a diagnosis of arterial disease, the use of noninvasive devices effectively rules out or confirms the presence of hemodynamically significant arterial obstruction. Not only can simple, noninvasive testing methods greatly increase the accuracy of clinical diagnosis for the presence of arterial disease, but the baseline data obtained can serve as objective indexes to follow the natural history of the disease.


Diabetes and cardiovascular disease. The Framingham study. Based on 20 years of surveillance of the Framingham cohort relating subsequent cardiovascular events to prior evidence of diabetes, a twofold to threefold increased risk of clinical atherosclerotic disease was reported. The relative impact was greatest for intermittent claudication (IC) and congestive heart failure (CHF) and least for coronary heart disease (CHD), which was, nevertheless, on an absolute scale the chief sequela. The relative impact was substantially greater for women than for men. For each of the cardiovascular diseases (CVD), morbidity and mortality were higher for diabetic women than for nondiabetic men. After adjustment for other associated risk factors, the relative impact of diabetes on CHD, IC, or stroke incidence was the same for women as for men; for CVD death and CHF, it was greater for women. Cardiovascular mortality was actually about as great for diabetic women as for diabetic men.


Enzymatic fluorometry for estimating serum total bile acid concentration. Fasting serum total bile acid (SBA) levels were estimated by enzymatic fluorometry (EF) in 36 subjects without liver disease, 28 with hepatic lesions and impaired hepatic function, and 79 with hepatic lesions and normal function. Fasting and postprandial EF-SBA levels were compared in nine normal subjects and nine patients with cholestasis, and SBA assays by EF and gas-liquid chromatography (GLC) were compared in 28 patients with hepatic lesions and impaired function. Levels of SBA were below 9 mumole/L in all but two of the 36 subjects without liver disease, and above that level in all 28 with impaired hepatic function and 17 (24%) of the 70 with hepatic lesions and normal liver function. In most subjects, EF detected notable postprandial rises in SBA. Enzymatic fluorometric and GLC-SBA values were closely correlated (coefficient of correlation, 0.869).


Heart disease risk factors and hormone use in postmenopausal women. A population of 1,496 women aged 55 to 74 years was studied for the distribution of heart disease risk factors in the presence or absence of postmenopausal estrogens. Current hormone use was reported by 39%. Hormone users were significantly slimmer than nonusers at all ages. After adjustment for the effect of obesity, hormone users had significantly lower mean levels of plasma cholesterol and higher mean levels of plasma triglycerides than nonusers. Blood pressure and fasting plasma glucose concentration tended to be lower among hormone users, although the differences were not statistically significant in all age groups. This article discusses the theoretical implications of these observations for cardiovascular disease mortality and contrasts them with the cancer risk of postmenopausal estrogen use.


Occupational exposure to hexachlorocyclopentadiene. How safe is sewage? In March 1977, a large volume of the industrial chemical hexachlorocyclopentadiene (HCCPD) was dumped into a municipal sewage system in Kentucky. We evaluated the health effects of exposure to HCCPD in 145 sewage treatment plant workers. We found that 85 (59%) had noted eye irritation, 65 (45%) had headaches, and 39 (27%) had throat irritation. Symptoms occurred throughout the plant; however, highest attack rates occurred in primary sewage treatment areas. Medical examination of 41 employees three days after the plant was closed showed proteinuria and elevation of serum lactic dehydrogenase levels; these findings were not present three weeks later. This episode demonstrates the toxicity of HCCPD and emphasizes the vulnerability of sewage workers to chemical toxins in wastewater systems.


A national study of medical and surgical specialties. III. An empirical approach to the classification of patient care. A major feature of a national survey of medical and surgical specialties is the development and application of an algorithm for classifying patient care services provided by physicians. The care classification reflects much of prevailing opinion regarding what constitutes primary and nonprimary care. The classification system provides a powerful tool for the analysis of patient care services, since it is based on conditions of access to care, the physician's role in providing the care, measures associated with continuity of care, and a proxy measure of comprehensiveness of care. Furthermore, it is based on the recordings by physicians of actual patient-encounter characteristics and is not operationally dependent on physician characteristics or propensities.


Genital and abdominal self-surgery. A case report. In two separate procedures, a psychiatric patient first performed a bilateral orchiectomy on himself and then later attempted to denervate his adrenal glands. This case suggests that physicians should be alerted to the possibility of self-surgery occurring in patients who have sought elective surgery and have been rejected.


Hyperpyrexia (temperature greater than 40 C) in children. A total of 516 charts of children who presented to the Oklahoma Children's Memorial Hospital Emergency Department or Walk-In Clinic with a temperature of 40 C(104 F) or more were reviewed. The findings were consistent with the concept that high fever in children is most often associated with common illnesses such as upper respiratory tract infections, otitis media, pneumonia, acute gastroenteritis, urinary tract infection, etc. There were only 22 (4%) admissions from the entire group and one death, actually due to delay in seeking medical help. The incidence and recurrence of febrile seizures (24 cases) was related to the use and compliance with anticonvulsant drugs rather than antipyretic measures. Appropriate laboratory work, x-rays and cultures should be done only when consistent with clinical findings. Follow-up can be done without hospitalization or antibiotics, as most children have a benign illness. The need for treatment of the underlying cause of the fever should, of course, remain the paramount goal. With proper parental guidance and education, the use of traditional methods of lowering fever can be discouraged.


Epidemiologic and clinical aspects of animal bite injuries. During 1975, 332 animal bite injuries accounted for 1.2% of all surgical problems treated at the UCLA Hospital Emergency Department. Data on 307 bite injuries were available and analyzed for environmental, animal, human, interaction, and clinical factors. More than half of the dog bites and almost three fourths of the cat bites-scratches happened at or near the victims' homes. Dog bites were almost twice as common among men, while cat bites-scratches were twice as common among women. Of the incidents in which ownership information was available, 85% of dog bites and 80% of cat bites-scratches were from an animal belonging to the victim, his family or friends, or another known person. Forty-three percent of dog bites, and 52% of cat bites-scratches were provoked, that is, happened while the victim was interacting with the animal. Of bites of the head and/or neck, 38% injured the upper lip; 17% of dog bites injured the eye or adjacent tissues; 48% were in children less than ten-years-old. On fifth of cat bites-scratches involved the head and/or neck, 60% of these injured orbital or periorbital tissues. Over 2% of patients were hospitalized. Five percent of dog bite victims and 29% of cat bite-scratch victims returned with complications, mostly cellulitis or lymphangitis. Pasteurella multocida was the most common pathogen cultured, as evidenced by the 50% and 80% culture-positive rates for dog and cat bite-scratches respectively in this series.


Prospective vs retrospective data for evaluating emergency care: a research methodology. Emergency department records and patient charts do not provide enough or sufficiently detailed data for audit of quality of care in a high volume emergency department. As a solution, at the Department of Emergency Medicine, University of Southern California School of Medicine, three emergency medical technicians--hospital-based paramedics--were trained as observers of patient process and treatment. In addition to basic identification information, the form completed by observers listed 21 procedural steps and process data such as sequence, time for completion, type of personnel performing, necessary equipment and supplies, and space for comments. Direct observation of patient process was carried out in 442 patients, a total of 3,882 procedures was observed and recorded. The direct observation is perhaps the most accurate method of data collection for auditing purposes because it reflects actual events. This data was used by the Research Peer Review Committee to help rate the quality of patient treatment process.


A characterization of emergency medicine. A Medical Specialty Preference Inventory (MSPI) containing 199 items relating to the practice of medicine was developed through ratings by a national sample of over 1,000 board certified physicians in internal medicine, obstetrics-gynecology, pediatrics, psychiatry, surgery, and family practice. Sixty-one emergency physicians completed the MSPI for emergency medicine. Scores on the emergency medicine characterization were compared with those of the six specialties. Results showed emergency medicine most similar to surgery and least similar to psychiatry, although the similarity to surgery was two standard deviations below the mean overall surgery score. A more extensive and systematic effort to characterize emergency medicine using the MSPI rating system could create a national representative factorial characterization of emergency medicine to be used by medical students and physicians when choosing a specialty.


Isolated transection of the common duct. A patient with complete transection of the common bile duct after blunt trauma from a steering wheel presented with severe right-sided lower chest pain. Based on results of physical examination, blood and urine analysis and chest x-ray films, he was discharged after suture of a lip laceration. Five days later upon his return for suture removal, the appearance of jaundice and mild symptoms of abdominal distention prompted hospitalization and exploratory surgery. At surgery, avulsion of the common bile duct was the only injury. In the few previously reported cases of this injury, jaundice and mild symptoms of abdominal distention appeared three to four days after injury. The minimal findings of a potentially fatal lesion emphasize the need for securing appropriate follow-up medical care for patients with a history of blunt trauma to the chest and/or abdomen.


Time trends in prognosis of patients with myocardial infarction: a population-based study. A population-based study was conducted in metropolitan Baltimore, in which the prognosis of 504 patients hospitalized with acute myocardial infarction (MI) from July 1966 through June 1967 was compared with that of 803 patients hospitalized from January through December 1971. For patients admitted to coronary care units (CCUs), the in-hospital case-fatality rate (CFR) in 1971 (20%) was found to be significantly lower than that in 1966/67 (27.5%) (p less than .025), after simultaneous adjustment for 16 variables which may affect prognosis. No such significant difference was detected for patients not admitted to CCUs when the two time periods were compared. As a result of these time trends, CFRs were not significantly different between CCU and non-CCU patients in 1966/67, but in 1971 a significant advantage was shown for CCU patients (p less than .005). These results suggest that effectiveness of CCUs in prevention of in-hospital deaths increased between 1966/67 and 1971. For hospital survivors, regardless of admission to a CCU, no significant differences in long-term prognosis were found between patients discharged in 1971 and those discharged in 1966/67. This finding may reflect the lack of major therapeutic advances between the two study periods, aimed at reducing the progression of coronary atherosclerosis and/or the extent of the infarcted area.


Individual temperament as a predictor of health or premature disease. Two studies of temperament as a possible predictor of continuing good health or premature disease are reported. In earlier work to determine youthful precursors of premature disease, a number of separate characteristics distinguishing medical students who remain healthy from those with premature disorders have been identified. Characterization by temperament, an expression of innate biological endowment, provides a more global portrayal of an organism that can an aggregate of separate characteristics alone. Criteria for designating three temperament types, termed Alpha, Beta and Gamma, are presented. In 1948, 45 subjects were assigned to one of these types on the basis of youthful characteristics. The subjects in the three temperament groups had different health outcomes 30 years later, significant at the p less than 0.01 level. Gamma type had the most disorders and deaths, Beta type the fewest. A cross-validation study on 127 subjects had similar results at the p less than 0.05 level. Temperament appears to be a variable of predictive potential of individual stamina, or of vulnerability to premature disease and death.


Aspergillus flavus as a cause of thyroiditis in an immunosuppressed host. Disseminated aspergillosis is a major complication in immunosuprressed patients. Infiltration of the thyroid with Aspergillus organisms occurs in approximately 20% of autopsies in patients dying with disseminated disease. The present report describes Aspergillus thyroiditis, Hashimoto's thyroiditis, and possible hypothyroidism in a patient with disseminated aspergillosis.


[Testosterone content in the blood plasma in acute myocardial infarct]. The testosterone content was studied in 50 male patients, who sustained myocardial infarction, on the 1,3--5,10 and 20th day of the disease. Forty seven patients with ischemic heart disease served as controls. The results obtained were analysed in relation to the patients age and the course type of the disease. The testosterone concentration on the 1st day of myocardial infarction was not different from that in the ischemic heart disease patients. Elevation of the testosterone level was observed in the myocardial infarction patients during the acute period of the disease, but its dynamics depended on the course type of the disease. No relationship was revealed between the testosterone level increase and the patients age.


[Importance of hormones and free fatty acids in the pathogenesis of carbohydrate metabolic disorders in myocardial infarct]. The increase in the content of the somatotropic hormone and cortisol in blood plasma as well as the increase in the content of free fatty acids in serum in the acute period of myocardial infarction are more marked in patients with impaired tolerance than in those with normal tolerance. The authors believe that free fatty acids are of utmost importance among the factors causing the development of insulin resistance in patients with acute myocardial infarction. Their increased concentration is due to hypersecretion of catecholamines, somatotropic hormone, and cortisole.


[Characteristics of the course of ischemic heart disease in thyroid hypofunction]. The peculiarities of lipid metabolism and hyperlipoproteinemia, blood coagulation and myocardial contractility in normal and reduced thyroid function were studied in 162 patients with ischemic heart disease. It was shown that hyperlipoproteinemia, hypercoagulation, and myocardial hypodynamia are revealed more frequently and at earlier periods in hypofunction.


[Adaptive and compensatory mechanisms in chronic circulatory insufficiency in ischemic heart disease]. Activation of some neuroendocrine systems is one of the compensatory-adaptation mechanisms in circulatory insufficiency in patients with ischemic heart disease. Evidence of this is that patients with stage I--IIA of the disease are marked by an increase in the activity of the sympatheticoadrenal system (increase in the excretion of free catecholamines) and the renin-angiotensin-aldosterone system, in the glucocorticoid function of the adrenal cortex, in the functional condition of the epiphysis cerebri, and in the blood plasma antidiuretic activity. Participation of these systems in the adaptation processes maintains an adequate level of venous blood return to the heart and inotropic myocardial function.


[State of the kallikrein-kinin system in chronic circulatory insufficiency]. The condition of the kallikrein-kinin system was studied in 93 patients with chronic circulatory insufficiency. In 25 of them it was studied in dynamics--before and after treatment with cardiac glycosides. Marked activation of the kinin system was found in all patients; this was manifested by a decreased level of plasma prekallikrein and phase changes in the content of the kallikrein inhibitor. Improvement in the clinical picture and values of central hemodynamics during treatment was attended by normalization of the main indices of the kinin system. In tolerance of patients to treatment with cardiac glycosides, restoration of the content of the main components of the kinin system was not encountered.


[Renin-angiotensin-aldosterone system in acute embologenic arterial obstruction]. Examination of patients with acute embologenic arterial occlusion yielded data testifying to activation of the renin-angiotensin-aldosterone system both in the ischemic and in the postischemic periods. Direct dependence of the activation of the renin-angiotensin-aldosterone system on the degree of tissue ischemia and duration of the ischemic period of up to 2 days was revealed. The development of secondary hyperaldosteronism in patients with embolism of the major vessels stipulated the expediency of using aldosterone antagonists in patients with most marked ischemic changes in the tissues as well as when the ischemic period lasted more than 6 hours.


[Extracellular fluid and total potassium content in obesity patients]. The content of extracellular fluid and total potassium was studied by total-body radiometry with 82Br and according to 40K in 162 females aged 41 to 55 years suffering from obesity. It was established that in patients with obesity the volume of extracellular tissue, in per cent, and the amount of total potassium, in gramms and millieequivalent per unit of actual body mass, were reduced. An increase in the content of extracellular fluid and a decrease in the level of total potassium in obese patients with circulatory insufficiency may be revealed only when the real content of extracellular fluid and the total potassium are stimated in relation to the unit of body surface. In obese patients with no signs of circulatory insufficiency these relative values hardly differ from the control values.


[Determination of excess body mass in epidemiological studies of cardiovascular diseases]. In epidemiological studies of cardiovascular diseases, in order to determine excessive body weight and its significance in the spread and development of ischemic heart disease among different populations it is necessary to use the best index characterizing the height-weight relationships and meeting such requirements as independence of growth and high correlation with weight. Analysis showed that the index weight/height2 may be used to determine excessive weight in 40--59-year-old males living in one of the Moscow districts. A 30.0 kg/m2 or higher value of this index is evidence of excessive increase in body mass.


[Calcium and the permissive effect of glucocorticoids: the role of glucocorticoids in an adrenaline-induced increase in the rate of calcium absorption by the ventricular tissue of the rat heart]. It was demonstrated in rat experiments that the ability of the myocardial ventricles to increase 45Ca absorption after the injection of adrenaline was disturbed on the 3rd--5th day following adrenalectomy. The decrease in sensitivity to adrenaline occurred in two phases and was delayed essentially after a fall in the concentration of glucocorticoids in circulation. Chronic in vivo injection of hydrocortisone (2.5 mg per rat) into these animals for 3--5 days restored the effect of catecholamine to a great extent. The restorative effect was weaker when the rats were given a single intravenous hydrocortisone infusion 6 hours before being killed. Increase of the single intravenous dose of the hormone to 5 and 7.5 mg per rat reduced its effect. The authors assume that the described permissive effect of glucocorticoids is determined not by their direct interaction with the cytoplasmic membrane but by hormone induced intracellular synthesis of proteins capable of participating in the regulation of permeability to ions.


[Surgery on the eye under anticoagulative therapy (author's transl)]. Surgery on the eye of patients on long term anticoagulation therapy is possible. To avoid bleeding suprarenin solution 1:1000, coagulation of conjunctival and scleral blood vessels, incision into the cornea when removing cataracts and iridectomy under the operating microscope are recommended. Local anaesthesia is advisable, has however the risk of a retrobulbar hematoma. Thromboplastin time (Quick) under 15% of the norm should be avoided, and only raised in cooperation with the responsible internist.


[The circulatory disturbance of the optic nerve with special reference to the side distribution and other dispositional factors (author's transl)]. We examined 38 patients with disturbed blood supply to the optic nerve. The observations suggest: 1. men are more frequently affected than women. 2. the first attack of apoplexia nervi optici occurs most often in the left eye. 3. diabetes mellitus and most probably arterial hypertension are risk factors.


[Changes of refraction following operations with episcleral plugs and encircling procedures in cases of retinal detachment (author's transl)]. Episcleral plugs reduce the circumference of the globe and cause an egg-shaped deformation; immediately after the operation the deformation seems to be more important than the circumference reduction. Out of 46 eyes operated on with episcleral silastic sponges or submitted to encircling procedures 3 developed hypermetropisation, and 35 myopisation; in 8 cases the refraction did not change.


[The application of highly hydrophilic contact lenses in the Fuchs-Steven-Johnson syndrome (author's transl)]. In 3 patients with status after Fuchs-Steven-Johnson syndrome highly hydrophilic contact lenses (72% H2O-up take) were adapted and worn permanently. 2 patients had worn already for a long time usual HEMA-lenses. The lenses showed themselves to be favorable against mechanical irritation from cilia and accessory eyelashes and from scarring conjunctival conditions, and they affected favorably the signs of dessication of the cornea. Corneal defects healed, and the patients had subjectively no complaints. It is sometimes necessary to replace the tears. An increase in the corneal vascularisation already present could not be observed during the 18 months observation time.


[Spontaneous hyphaema in the senium (author's transl)]. Two case reports are given of "spontaneous" hyphaema in the anterior chamber of eye of two elderly women-patients. Haemorrhages as well per diapedesin as per rhexin, possibly by biotropic influence of weather, or possibly also a reflux into Schlemm's canal, too, are discussed for aetiology. There are no pathological laboratory findings.


[Massive subretinal fat and lipoid deposits (author's transl)]. Both in exsudative retinitis (Coats disease 4 cases [presumed angioma of the chorioid in 1 case]), and in the exsudative form of senile macular degeneration (1 case), massive subretinal fat and lipoid deposits were observed. These form a yellowish central disc approximately between the upper and lower lateral retinal vessels. The centre of the subretinal depositis, and therefore the highest point of retinal detachment (3 dioptres), appears white.


[Coating of artificial lens with methylcellulose (author's transl)]. The corneal haze which in the past often followed lens implantation was clearly decreased by applying one drop of a 1% solution of methylcellulose into the lens immediately prior to its insertion. It is surmised that by coating the lens in this way injury to the corneal endothelium is prevented. Methylcellulose caused little if any rise of intraocular pressure postoperatively.--The preparation of a sterile solution of methylcellulose is described in detail. Finally, it is important to stress that--in addition to applying methylcellulose--one should always attempt to work under an air bubble.


[On the peripheral refraction of the human eye (author's transl)]. As the measurements of the peripheral refraction of the living human eye published till now point out a confusing abundance of variants but no clear results, the peripheral refraction of fictitious model eyes is computed to find out which components influence the refraction and how they do it. Then for some special selected representative eyes the peripheral refraction and the astigmatism are computed and the results analyzed. The result consists in three typical refractioncurves which can be reduced to simple rules. This paper intends to stimulate future experiments on exactly defined conditions.


[The polaroid SX 70 camera for photodocumentation in ophthalmologist practice (author's transl)]. The polaroid SX 70-camera with slight modifications is being described as an instrument for photographic representation of skin and lid diseases. It may also be used for photography of anterior eye diseases, however it cannot replace slit-light-photography. The possibilities of the camera are demonstrated by a series of photographs.


[Patients on dialysis--late fundus controls (author's transl)]. In 102 patients on dialysis for renal failure late fundus controls have been done to studie the response of retinal vessels to blood pressure reduction. In 52 patients follow up studies were possible. Only 4 patients showed reversible changes of the vessels, in 4 other patients changes increased. In the majority of the patients hypertensive vascular changes (stage I or II) remained unchanged. Young age and deep diastolic pressure seems to be necessary for normalization of the fundus vessels. Vessel changes did not improve if the diastolic pressure was 90--100 mmHg and more.


[Adie's syndrome from a neurological standpoint (author's transl)]. The findings in 22 examinations of tonic pupils, 15 of which presented Adie's syndrome, are described. The neurological and chemical as well as liquor analyses are normal except for the well known tendon reflex anomalies. Neurophysiologically, in 7 of 10 examinations mild disruptions in the sensory nerve conduction velocity were observed. The literature of the last 10 years, where it is of interest from a neurological standpoint and where it relates to the site of damage or to the origin of the tendon reflex abnormalities in Adie's syndrome, is discussed. Adie's syndrome is interpreted as damage to the peripheral nervous system in a polyneuropathic form.


[Contribution to the epithelial tumors of the ciliary body (clinical, histopathological and electronmicroscopical observation) (author's transl)]. An adenoma of the non pigmented epithelium of the ciliary body was supposed to be an irisciliary body melanoma (32P-test positive) and was treated by irido-cyclectomy. Vision acuity remained 0,4 one year after operation. The tumor formed adenoid tubes lined with a cubical or cylindrical epithelium. The cytoplasm of all tumorcells was threaded with compactly arranged tonofilaments. The histopathological examination showed unequivocal the benignant character of this tumor. Nevertheless the tumorcells were infiltrating the deep scleral layer in one place. Also the lens was deformed by the tumor and developed a local opacity in the periphery. It is refered to the difficulty of a clear histopathological distinction between adenomas, adenocarcinomas and pseudo-adenomatous hyperplasia of the ciliary body (Fuchs adenoma).


[Strabogenesis in case of low hypermetropia, in addition a simple comparison test to detect aniseikonia (author's transl)]. Author attempts to explain the rise of infantile convergent squint, when the hypermetropia is less than 3,5 diopter. In such cases the low hypermetropia is relative in the sense of Donders, because a sometimes isometropic aniseikonia prevents the fusion. To examine the aniseikonia he recommands a very simple procedure, the comparison test, carried out joined to the cover test.


[A comparative study of the reflective and apperceptive refractions (author's transl)]. Reflective (objective) refraction differs basically from apperceptive (subjective) refraction in that it excludes conscious seeing from the measuring procedure. As a result limits can be established for the subjective acceptability of refraction values with automatic or manual refractometers. In a comparative study of 50 cases the correction values obtained with the manual refractometer PR 50 (Rodenstock) and the automatic refractometers Dioptron (Coherent Radiation) and Auto-refractor 6600 (Acuity Systems) were compared with the results of conventional subjective refraction. Criterion for this comparison was the visual acuity achieved with the correction values. In 55% of the cases the same, in some cases even better visual acuity was achieved than with subjective refraction. In the other 45% a direct comparison of the reflective and the subjective refraction values shows which component (sphere, cylinder) of the refractometer correction value leads to a lower visual acuity.


[Indications and results of the tenotomy of the superior oblique (author's transl)]. The tenotomy or tenectomy of an overactive superior oblique produces a similar effect as an elongation of the tendon. Its efficiency cannot be compared with the tenotomy or myotomy of an overactive inferior oblique or rectus muscle. No discernible underaction or complete paralysis of the superior oblique are to be feared, if the surgical indication and technique are correct. We prefer the tenotomizing of the overactive superior oblique to the recession of its insertion. Commonly, but still not always, the overaction of the superior obliques is associated with an A syndrome. Besides, the tenotomy and tenectomy of the superior oblique may be useful in true Brown's syndrome and as an additional procedure in cases of paralysis of the two elevators of one eye, During the past four years this operation was done 32 times on 24 patients. In none of these cases an insufficiency of the superior oblique was produced.


[Operative treatment of Duane's syndrome associated with extreme vertical divergence (author's transl)]. In following an operative treatment of Daune's-Syndrome associated with extreme vertical divergence is described. During operation the external rectus muscle is recessed and inserted lower due to anatomical anomalies. This is performed by a little known method described by A. B. Scott. Our results are very satisfactory. Psychical alterations associated with these disorders also could be sucessfully managed.


[Recurring pterygium. Modifying the operation with conjunctivo plasty to guard against recurrence (author's transl)]. Simple conjunctivoplasty is recommended as a good modification of the pterygium operation. With this modification only a small number of recurrences were seen in a large number of operated cases.


[The determination of IgE in human aqueous humor in a case of intraocular parasitosis (ophthalmomviasis interna) (author's transl)]. A case of intraocular myasis is here reported, as well as the difficulties of diagnosis--mostly too late--of this disease, which is rare in Europe and the northern hemisphere and which leads, almost invariably, to functional or even anatomical loss of the eye.--The determination of IgE in human aqueous humor (ah) and corresponding serum (s) by means of the ultrasensitive and quite simple PRIST method could represent a possibility of timely diagnosis, and this theoretically too in the case of other, much more frequent oculoparasitosis cases.--A retrospective study of the preoperative aqueous humor of the ophthalmomyiasis case presented here revealed an IgE concentration of 113 U/ml in the aqueous humor, with only 3 U/ml (1 U congruent to 2 ng) in the corresponding serum. A simple serum-IgES-determination would not have permitted the diagnosis--at least not in the case examined--just as little as numeration of eosinophilic granulocytes in blood and/or aqueous humor.


[HEMA-contact lens and HEMA-dressing lens-damage to the eye (author's transl)]. 3 cases in which HEMA-contact lens, and 2 cases in which HEMA-dressing lens caused corneal damage were analyzed with regard to symptomatology, etiology and sequence of events. Hyperemia of the limbus is the main symptom. Avoidable causes are exaggerated tightness, overwearing, storing up of proteins, rough surface, and incompatibility of soft-lens solutions. Irreversible and largely resistant to therapy is, damage resulting from the synthetic itself.


[Aqueous outflow following seton operations (author's transl)]. In 6 rabbits which had been submitted to a seton operation 2--6 months previously, the mode of aqueous outflow has been documented photographically after injection of fluorescein into the anterior chamber. In all 6 cases the catheter allowed direct passage of aqueous humour through its lumen into the subconjunctival space; further sources of diffuse aqueous egress were provable at the site of the corneo-slceral wound, either next to the catheter or aside from it. Additional drainage via preformed channels occurred through lymphatic vessels as well as through secondary aqueous veins.


[On the clinical picture of Asteroid hyalitis (author's transl)]. The clinical data of 98 cases (104 eyes) of Asteroid hyalitis are reported and found to be similar to those of previous publications. As to etiology no certain evidence for an underlying general disease is available from the literature. The disease is found to be very rare in myopic eyes, which supports the occurrence of a local determinating factor.


[Diagnostic value of muscle biopsy findings in myotonic dystrophy (Curschmann-Steinert) (author's transl)]. By histological, enzyme histochemical, histometrical and ultrastructural studies of 15 muscle biopsies from patients with myotonic dystrophy the typical morphological picture of a myopathy with multiple internal nuclei, sarcoplasmic masses and ring fibers can be shown only in 7 cases with very severe or prolonged clinical course. There is fiber degeneration under the sarcolemma which corresponds to findings in myopathies caused by hypothyroidism. Type-I-fiber-atrophy, which is thought to be an early morphological sign of the disease. can be demonstrated in our material only in proximal muscle groups, especially biceps muscle, whereas tibialis anterior muscle shows a slight focal atrophy of both mean fiber types, which is not helpful for differential diagnosis. Therefore in early cases of myotonic dystrophy which are not clarified by clinical and electromyographic investigation, a biopsy of biceps muscle should be done. Advanced cases as a rule can be confirmed by EMG without muscle biopsy. The morphological differential diagnosis of type-I-fiber-atrophy and the similarities of fiber degeneration under the sarcolemma in myotonic dystrophy as well as in myopathy caused by hypothyroidism are discussed.


[Radioimmunoassay for human myoglobin: methodology and diagnostic significance in myocardial infarction (author's transl)]. A radioimmunoassay was developed to determine serum myoglobin (SMb). 50 healthy persons showed values between 0 and 90 ng/ml. Serial tests of 10 patients following acute myocardial infarction or during angina pectoris (AP) indicated that SMb reached pathological values before CK and CK-MB (average 250 +/- 95 ng/ml at the time of hospitalisation which corresponds to 3.3 +/- 1.4 h after beginning of angina pectoris). At hospitalisation the simultaneously determined CK was within normal limits and reached pathological values only 6.2 +/- 1.9 h after the onset of angina. Maximum of SMb was 506 +/- 194 ng/ml occurring 8.8 +/- 2.8 h after beginning of AP, maximum of CK was 905 +/- 475 mU/ml occurring 20.0 +/- 7.8 h after AP. CK-MB and CK differed only slightly in their time course. One patient with severe AP had pathologically increased SMb values whilst all other enzymes were completely normal. Methodical and clinical results are discussed.


Kinetics of elimination of thiocyanate in 7 healthy subjects and in 8 subjects with renal failure. The concentration of thiocyanate in the serum of eight test subjects with renal failure and seven healthy control subjects was measured, as it declined with time, after oral doses of thiocyanate or i.v. injections of nitroprusside had been administered. Additional measurements were taken, on the healthy subjects only, of the concentrations of thiocyanate in the urine, and also of the influence of an increased chloride intake on the rate of elimination of thiocyanate. For the healthy subjects an elimination half-life of between one and five days (mean c. 3 days) was found. Increasing the chloride elimination rate to approximately twice normal did not significantly speed up the rate of thiocyanate elimination. The amounts of thiocyanate which had been administered as doses reappeared almost exclusively in the urine. For the subjects with renal failure, the elimination half-life had a mean value of approximately nine days. The elimination constants were found to be proportional to the creatinine-clearance rates. The ke value at a creatinine-clearance of zero ml/min was approximately 15% of the ke value at a creatinine-clearance rate of 120 ml/min. The distribution volumes for thiocyanate were greater for the patients with renal failure than for the healthy subjects. The conclusions for therapies using nitroprusside are discussed.


C-cell hyperplasia and medullary thyroid carcinoma in the rat. An immunohistochemical and ultrastructural analysis. Medullary thyroid carcinoma (MTC) is a distinctive neoplasm which is derived from the calcitonin-producing intrathyroidal C-cell system and which develops commonly in untreated rats of various strains. Thyroid glands of Long-Evans rats ranging in age from 3 months to 3 years showed a spectrum of C-cell proliferative abnormalities. As compared to 3-month-old control rats, thyroids from 9- to 12-month-old animals exhibited mild diffuse C-cell hyperplasia (CCH). Thyroids from animals ranging from 1 to 3 years of age exhibited progressively more severe C-cell abnormalities including severe diffuse CCH, nodular CCH, and/or MTC. In contrast to the normal basal serum calcitonin levels in controls and in animals with mild diffuse CCH, animals with severe diffuse CCH, nodular CCH, or MTC had elevated basal serum calcitonin values. Nodular CCH was characterized by the replacement and enlargement of individual follicles by C-cells. Larger foci of nodular CCH were characterized by similar changes in multiple adjacent follicles or by an irregular expansion of individual follicles. MTC was characterized by penetration of the follicular basal lamina by C-cells with extension into the adjacent thyroid stroma. In addition to the high incidence of thyroidal C-cell abnormalities, diffuse and/or nodular parathyroid hyperplasia was commonly found. There was no evidence of chronic renal failure in these animals, and the serum calcium levels were within normal limits. Although the stimulus for the initial C-cell proliferation remains unknown, the appearance of MTC is preceded by relatively prolonged phases of CCH. These findings are essentially identical with those noted in human familial MTC and indicate that the rat provides a useful model system for studying the regulation of C-cell proliferation during the processes of neoplastic development and progression.


Dissolution of human cholesterol gallstones in vitro with bile salts. A scanning and stereoscanning electron microscopic study. This report deals with the in vitro dissolution of cholesterol gallstones by bile salts, as observed with the scanning electron microscope. Scanning electron microscopic techniques permit excellent visualization of the substructure of these stones and hence allow insight into the structural basis of gallstone dissolution. The small faceted, mixed cholesterol gallstone was used since this is the most common type clinically. Scanning electron microscopy revealed that the gallstone has four structurally different zones; an outer surface, a cortex of compactly layered cholesterol plates, an inner layer of cholesterol mixed with other components, and a center or nidus. The cortex is of particular importance in terms of gallstone dissolution with bile salts, since the interior of the stone remains unaffected until this zone is removed. The speed and completeness of dissolution of the stone depends mainly upon the thickness of the cortex and in part upon the content of noncholesterol components in the interior of the stone. Chenodeoxycholate and cholate behave similarly in terms of the dissolution process as observed by scanning electron microscopy. The solubilization process is very similar to that observed in vitro with solvents such as ether and ethanol. Stones treated with 400 mM cholate were completely solubilized in 3 weeks. The process described in this paper is probably similar to that which occurs in vivo in spontaneous gallstone dissolution in man and in patients treated with bile salts for gallstone dissolution.


Endocardial alterations in myocardial infarction. Transmural infarcts of the ventrolateral wall of canine left ventricle were produced by ligation of the ventral interventricular (anterior descending) branch of the left coronary artery. Endocardium from these infarcted hearts was sampled at sites corresponding to the infarct center and periphery, and to uninfarcted (normal) area at 24 and 48 hours after ligation, and examined by correlative scanning and transmission electron microscopy and by light microscopy. Endocardial samples from sham-ligated hearts were included as a further control. Striking alterations were observed in the endocardium that lined infarcted myocardium. There was endothelial desquamation coextensive with leukocytic invasion. Leukocytes appeared to initiate sloughing by separating the endothelial cells from their basal lamina and partially from one another. The latter cells desquamated in sheets, leaving behind a denuded basal lamina. Although altered in form, the individual endothelial cells seemed to remain largely intact. Denuded subendothelial surfaces only rarely contained thrombi. In areas where the cardiac endothelium was altered, the subjacent subendocardium, myocardium, and usually the remainder of the endocardium also showed leukocytic exudate. Samples from uninfarcted regions showed an intact, leukocyte-free endocardium, as did the sham-ligated controls. The appearance of abnormal endocardium was qualitatively similar wherever found, whether in different areas of the same heart or from one heart to another, and regardless of age of infarct. In 48-hour infarcts, almost all of the central and most of the peripheral samples exhibited the changes described. The data suggested a similar pattern for hearts with 24-hour infarcts. By locating biopsy sites in frozen cardiac sections processed for histologic staining and 201-thallium autoradiography, the electron microscopy results were shown to correlate with the intramural histopathologic topography of the infarcts. The alterations described here represent the endocardial manifestation of the inflammatory stage of transmural infarcts, known to be well developed in 1- and 2-day-old lesions.


Platelet interaction with damaged rabbit aorta. We have quantified the accumulation of 51Cr-labeled washed rabbit platelets on the subendothelium of rabbit aortae following injury with a balloon catheter. The amount of radioactivity that became associated with the damaged wall within 10 minutes of the injury did not change appreciably during the following 24 hours, indicating that there was little turnover of platelets on the injured vessel wall. In addition, by injecting 51Cr-labeled platelets into rabbits at different times after injury, it was possible to estimate the reactivity of the exposed surface to newly injected platelets. Scanning electron microscopy showed that a monolayer of platelets initially formed on the injured surface; the number of platelets associated with the surface decreased over the 7-day observation period. The amount of 51Cr associated with the injured vessel wall also diminished during this period. The ability of the damaged surface to attract fresh platelets gradually decreased during the 7 days following injury. Platelet survival in rabbits was not significantly reduced following the removal of the aortic endothelium (balloon catheter injury 66.3 +/- 12.2 hours, sham operated 72.1 +/- 7.2 hours, untreated controls 76.2 +/- 3.8 hours). Thus, in rabbits, it cannot be assumed that platelet survival provides an estimate of endothelial injury in all circumstances.


Abnormal collagen fibril structure in the gravis form (type I) of Ehlers-Danlos syndrome. The Ehlers-Danlos syndrome (EDS) is a clinically, genetically, and biochemically heterogeneous group of disorders characterized by generalized connective tissue abnormalities. We studied collagen fibrils by electron microscopy in the dermis of nine individuals with clinical findings consistent with type I Ehlers-Danlos syndrome. In all patients the collagen fibrils had an increased mean diameter (13 to 40%) and showed a higher degree of variability in width and shape than collagen fibrils from controls. Approximately 5% of the fibrils were much wider (up to 500 nm. versus 90 nm.), had a highly irregular outline when viewed in cross-section, and were spiraled and fragmented in longitudinal view. The periodicity of banding was normal. The mode of inheritance was dominant in five patients, probably recessive in two, and could not be determined in the remaining two. Despite genetic heterogeneity among these patients with type I Ehlers-Danlos syndrome, the ultrastructural findings are indistinguishable and do not allow discrimination in sporadic cases between the recessive and the more common dominant form. We conclude that abnormalities of fibrillogenesis are heterogeneous in origin; some might be due to primary defects in collagen whereas others may result from alterations of noncollagenous extracellular matrix components that influence collagen fibril formation.


The localization of catalase in the pulmonary alveolar macrophage. A combined biochemical and cytochemical study of catalase was performed on alveolar macrophages lavaged from the lungs of adult male rats. Biochemically, catalase activity was present in both a high-speed granule fraction and in the supernatant. The granule-associated activity exhibited latency. Two methods of cell breakage, sonication and homogenization, yielded similar levels and distributions of catalase activity. Catalase activity in whole cells was identified cytochemically by the alkaline diaminobenzidine method and was localized within membrane-lined cytoplasmic granules similar in size to microperoxisomes and associated with cisternae of smooth endoplasmic reticulum. Localization of the reaction product was inhibited by 0.04 M aminotriazole, by cyanide, and by boiling prior to incubation. The cytochemical reaction continued in the absence of exogenous peroxide, but could be prevented by addition of catalase or pyruvate to the peroxide-free medium. Enzyme activity was also localized within a portion of the membrane-bound granules present in the cell fractions used for the biochemical assays.


Glomerular fibrinolytic activity during nephrotoxic nephritis. The glomerular fibrinolytic activity (GFA) was measured during the development of glomerulonephritis induced by the intravenous injection of horse or rabbit antiglomerular basement membrane antibodies in rats either untreated or preimmunized with horse or rabbit Ig. A variety of nephritides was produced ranging from proteinuria with no or mild changes in glomerular architecture to severe diffuse proliferative glomerulonephritis with close to 100% crescent formation. GFA was measured on preparations of isolated glomeruli using a radioassay based on lysis of 125I fibrin adsorbed on a solid phase. In some experiments a fibrin plaque technique was also used. Both methods clearly demonstrated a marked increase in GFA with a good correlation between the two sets of results when the glomerular architecture is preserved. The increase in GFA is related both to the severity of the nephritis estimated by the percentage of glomeruli showing crescent formation and to the extent of the fibrin deposits. The results therefore indicate that the persistence of fibrin in the glomeruli and particularly in crescents is not due to a loss of GFA.


Experimental allergic neuritis. Ultrastructure of serum-induced myelin aberrations in peripheral nervous system cultures. Mature myelinated cultures of mouse dorsal root ganglia (sometimes grown in combination with spinal cord tissue) have been exposed to unheated and heated (complement-inactivated) serum from rabbits with experimental allergic neuritis (EAN). Experimental cultures were examined for periods ranging from several hours to approximately 2 weeks of exposure. Some cultures were exposed to EAN serum for approximately 1 week then returned to normal medium for examination of the reversibility of the lesions. Unheated EAN serum induced demyelination of peripheral nervous system fibers within 96 hours of exposure. Following removal of the EAN serum, affected fibers remyelinated. Heated EAN serum produced a type of myelin swelling identical with that described previously in spinal cord explants exposed to serum from rabbits with experimental allergic encephalomyelitis. The lamellar spacing of the peripheral nervous system meylin was increased to approximately 23 nm. and the normal bifilar intraperiod line was increased to four leaflets. Some hypermyelination was seen. The swelling was incompletely reversible following removal of the heated serum. These findings are discussed in terms of their relevance to immunemediated demyelination and peripheral neuropathy associated with the hypergammaglobulinemic states.


Evaluation of a procedure for systematic semiquantitative analysis of glomerular ultrastructure in human renal biopsies. A method is described for systematic semiquantitative investigation of glomerular ultrastructure in renal biopsies from patients with glomerulonephritis. Three glomeruli per biopsy were studied by electron microscopy. Ten systematically recorded micrographs at x12,000 and a montage covering the whole glomerular cross-section at x3,000 were analyzed from each glomerulus. The severity of each of 34 different ultrastructural lesions was semiquantitatively evaluated on a 4-degree scale, 0 to +++. The usefulness of the method was evaluated by calculating different parameters for the reproducibility of semiquantitative scoring, representativeness of micrographs, and representativeness of glomeruli. The reliability of the method was considered good or acceptable with respect to 17 of the lesions. Ten lesions obtained a high reproducibility of scoring but the usefulness of the scores was limited due to a segmental and/or focal distribution of these lesions. The evaluation of these lesions can be improved by analyzing a larger number of micrographs, or glomeruli, or both. Seven lesions were so rare in the present biopsies that no statistical evaluation was possible. When applied to a large number of biopsies, this practical and useful method allows a reproducible comparison of the patterns of ultrastructural lesions in various types of glomerulonephritis.


Differential pathology of nasal polyps in cystic fibrosis and atopy. Nineteen nasal polyps from 13 patients were examined histologically. Nine polyps from seven cystic fibrosis (CF) patients could be positively identified by a triad of observations: delicate, barely visible basement membrane of surface epithelium without submucosal hyalinization, lack of extensive infiltration of eosinophils (Giemsa stains), and a preponderance of acid mucin in glands and cysts of the polyp and in its surface mucous blanket (Alcian Blue-periodic acid-Schiff stains). Two polyps from two patients with CF and atopy showed the characteristic findings of CF without modification. Eight polyps from four atopic patients without CF were identified by the reverse triad of changes: extensive thickening of the epithelial basement membrane and its extension into the submucosa as an irregular hyaline membrane, high stromal eosinophil count, and mainly neutral mucin in mucous glands, cysts, and mucous blanket. Hyperplastic mucous glands, mucous cysts of variable sizes, focal metaplasia of surface epithelium, and acid mucin in goblet cells were considered nonspecific lesions.


Uptake of iron aerosols by mouse airway epithelium. Spontaneously breathing mice were exposed to an aerosol of iron oxide for 3 hours. Participation of the tracheal and bronchial epithelium in the uptake of iron oxide was noted immediately following the exposure and at 1 day, 4 days, and 7 days postexposure. Observations with the electron microscope revealed that iron oxide was pinocytosed and converted to ferritin and hemosiderin in all epithelial cell types except mucous cells. Iron content increased over time and approximately 50% of the nonmucous cells contained hemosiderin by 4 days postexposure. Ferritin and hemosiderin, but not iron oxide, were noted in connective tissue cells in the submucosa beneath the airway epithelium. Soluble iron and/or ferritin produced in the airway epithelial layer was transported to the submucosa, but normal epithelium prevented the penetration of deposited iron oxide particles to the connective tissue compartment.


Primary myocardial disease in the diabetic mouse. An ultrastructural study. The hearts from C57BL/KsJ db+/db+ mice and controls were examined by light and electron microscopy at intervals during 5 to 28 weeks of age. C57BL/6J ob/ob mice and their lean littermates served as other controls. The percentage of increase in body and heart weights of the diabetic animals was 150% and 64% greater, respectively, than that of the controls. Over the period of observation there was progressive damage to the ventricular myocytes and intramural small arteries and arterioles of the diabetic animals. Initially, the cardiac muscle cells of both ventricles contained large numbers of lipid droplets. Subsequently, there was shrinkage and increased electron density of mitochondria that were enveloped by single limiting membranes that in turn gave rise to large residual bodies. This was followed by loss of myofilaments and atrophy of myocytes. Similar changes occurred in the smooth muscle cells of intramural arteries and arterioles but not in those of epicardial arteries. Reduplicated layers of basal laminae were seen around interstitial capillaries. Degenerative changes also occurred in perivascular nerve endings. These changes are discussed in relation to the altered metabolism of the diabetic state. It is concluded that the pathologic lesions in the cardiac muscle cells and intramural arterial vessels and capillaries constitute a primary myocardial disease in the genetically diabetic mouse.


Alterations in hepatic pericanalicular cytoplasm during enhanced bile secretory activity. In an attempt to demonstrate the morphology of the bile secretory apparatus, male rats were restrained and maintained on an isocaloric diet with (experimental) and without (control) taurocholate, which was continuously infused via a duodenal cannula. This method of taurocholate administration promotes a 2-fold increase in the bile acid pool size and bile secretory rate and increases the transport maximum of taurocholate by approximately 50%. After 48 hours, the livers from both the control and experimental animals were perfusion-fixed and whole hepatocytes as well as pericanalicular cytoplasm (defined as a 1-micron. wide zone of cytoplasm adjacent to the bile canaliculus) in both centrolobular and periportal cells were subjected to a stereologic analysis. Although taurocholate infusion produced relatively few changes in the amounts of organelles or inclusionswithin hepatocytes, it caused highly significant increases in the amount ofGolgi-rich area, Golgi membranes, and the number of vesicles with diameters greater than 1000 A in the pericanalicular area of cytoplasm. In addition to these changes, which occurred in both central and periportal zones, decreases in the volume of lysosomes and the surface area of smooth surfaced endoplasmic reticulum were observed. These data provide new evidence that the "bile secretory apparatus" may encompass several hepatocellular components which include the Golgi complex and a vesicular transport system.


The value of preoperative screening procedures in stage I and II malignant melanoma. Fifty patients with melanoma (30 with clinical Stage I disease and 20 with clinical Stage II disease) were analyzed retrospectively along with the screening test done prior to surgery. While the value of the chest X ray is unquestioned in preoperative screening, the same cannot be said of liver, brain, and bone scans. The bone marrow biopsy, however, done with a Janshidi needle was of value in detecting one patient with bone-marrow metastases who on examination had clinical Stage II disease and precluded surgery in this same individual. Therefore, we feel that in the preoperative scanning of patients with Stage I or Stage II human malignant melanoma, and especially in the latter, the bone-marrow biopsy should be done routinely in addition to a hematological profile, liver profile, and chest X ray.


Recall skin-test antigens and the prognosis of stage I melanoma. Thirty-one patients with Stage I melanoma were studied with regard to their response to common skin antigens. Patients were divided into two groups, those who had surgery alone, and those who had surgery and BCG. The results were comparable. It was found that the disease-free interval was longer and the recurrence rate lower in patients who demonstrated cutaneous hypersensitivity to common antigens than in those who did not. Patients who had Clark's levels I and II lesions were more likely to be immunocompetent. The addition of BCG in the study did not appear to decrease the rate of recurrence, which seems to be related to the basic immunological status of the individual.


Carcinoma of the bronchus with atypical presentation: report of a case. A 64-year-old man presented with dysphagia due to obstruction of lower third of the esophagus. Esophagoscopy showed narrowing of the esophagus with normal mucosa. Chest X rays were normal, but on lung scan there was no perfusion of the left lung. That patient died of aspiration and on post mortem a carcinoma of the bronchus with abscess formation and perforation into the esophagus was found.


Recurrent breast cancer: factors influencing survival, including treatment. Factors influencing survival were reviewed in 464 patients with recurrent breast cancer. Site of first recurrence and rate of tumor progression governed prognosis more than choice of initial therapy. Overall median survival was 22--26 months for bone/soft-tissue disease, 10--12 months for pleura/lung, and 4--6 months for liver/brain recurrence. Patients with slow rates of tumor progression at each site had longer survival terms than did rapid progressors. About 50% of patients with bone or soft-tissue recurrence had slow progression and long survival, regardless of whether initial treatment was local or systemic. In visceral recurrence, the number of patients with slow progression was doubled with systemic therapy in comparison to local treatment (from 16--20% for the latter to 37--38% for the former). In addition, long-term survival in patients with similar progression rates was best using initial systemic therapy.


Tumor cell karyotypes in malignant melanoma. Fifteen malignant melanomas were subjected to chromosomal analysis, in order to determine whether the number of chromosomes in a tumor cell could be correlated to a clinical prognosis. The protocol involved a direct technique which utilized a Colcemid blockade of spindle formation in mitosis to allow study of metaphase chromosomes. The direct method was chosen to reveal chromosome changes in the tumor cell in situ rather than changes in the cultured cell. Two tumors yielded chromosome spreads which could be counted and correlated with a clinical prognosis. Failure to obtain other adequate chromosome spreads were accounted for by the presence of tissue necrosis and the absence of viable tumor cells.


Effect of infusion chemotherapy and hepatic artery ligation on normal liver: experimental study in the cat. The effects of arterial infusion with chemotherapy alone or in combination with hepatic artery ligation on the normal liver of the cat were studied. Early in the course of treatment cats receiving chemotherapy infusion only appeared sicker than animals in other groups. Yet only 1 of 5 cats was dead at 12 weeks. In contrast, 4 of 6 animals that had hepatic artery ligation and chemotherapy infusion, and 3 of 6 that had ligation of the hepatic artery only, died during the same period of follow-up. Progressive liver damage after dearterialization accounted for the high mortality rate. Histologic examination of liver biopsies taken from animals in these latter groups revealed marked destruction of the parenchyma. These changes were more extensive in animals treated by a combination of hepatic artery ligation and chemotherapy infusion. To avoid the injurious effects of permanent interruption of the hepatic arterial flow on normal liver tissue an alternative method of hepatic dearterialization is currently under investigation.


Immunotherapeutic effect of tumor necrosis after cryosurgery, electrocoagulation, and ligation. Tumor necrosis in situ by cryosurgery, electrocoagulation, or ligation generally induces or augments some increase in tumor-specific transplantation immunity (TSTI) as compared with excision. Excision of the tumor 24 hours after it has been rendered ischemic by either ligation or cryosurgery seems to produce TSTI that is significantly greater than that after excision of viable tumor without prior ligation or cryosurgery; the degree of this immunity is similar to that seen after the tumor is left in situ indefinitely after treatment. These data suggest that most of the immunization following tumor necrosis in situ occurs within 24 hours of treatment. The experimental findings support the clinical reports of putative immunologic potentiation after tumor necrosis in situ.


The effect of age and postsplenectomy interval on the susceptibility of the asplenic adult rat to pneumococcal challenge. The response to intravenous challenge with pneumococcus was examined in asplenic and sham-operated adult Sprague-Dawley rats eighteen weeks following surgery. The LD50 was over 2,0000 fold greater in the sham-operated animals than in the asplenic animals. These results suggest that the age of an asplenic host, the length of time following splenectomy, and the presence of a normal immune system other than the asplenic state do not in themselves confer immunity.


Reduction of metastatic rate by immunotherapy: a comparison of the immunogenic properties of metastasizing tumor cells versus tumor cells in the primary mass. The vasculature of a poorly immunogenic, highly metastatic transplantable fibrosarcoma (T-241) maintained in the femoral muscle of C57BL/6J mice was perfused. This permitted collection of tumor cells which had invaded into the tumor vascular channels (ie, metastasizing tumor cells). Also collected as a separate population were tumor cells from the primary tumor mass. Immunization was carried out with these cell populations in conjunction with BCG and the effect on the growth of primary tumor and metastatic rate was evaluated following rechallenge with unfractionated tumor cells. The rate of tumor growth at the primary site was not affected by any of the immunization schedules. However, immunization with venous effluent cells (metastasizing tumor cells) and BCG was two times more effective in reducing the number of pulmonary metastases than immunization using tumor cells isolated from the primary tumor mass. Passively transferred spleen cells from donors immunized with the cell populations listed above had exactly the same effect, that is, no effect on the growth of the primary tumor, but a dramatic reduction in the metastatic rate when effluent tumor cells were used to immunize cell donors. The data point to an antigenic heterogeneity with this particular transplantable tumor.


Multiple carcinomas following therapy for Hodgkin disease. A 52-year-old man developed synchronous squamous-cell carcinoma of the larynx and middle one-third of the esophagus following treatment of Hodgkin disease. This patient fell into the subgroup of patients treated by intensive radiation therapy followed by intensive chemotherapy. The link between the therapy and subsequent carcinoma is suggestive. Long-term follow-up care of patients with Hodgkin disease demands continuing evaluation of this possible complication.


Experimental evaluation of hypothermic intermittent coronary perfusion. The recovery of the myocardial contractility of blood-perfused papillary muscle from the rabbit hearts was used to determine if hypothermia would minimize the myocardial injury associated with intermittent aortic cross-clamping (IACC). Continuous normothermic coronary perfusion for 2 hours with either cross circulation or a membrane oxygenator had only minimal adverse effects on contractility. None of the hearts tolerated normothermic IACC (45 minutes of anoxia and 10 minutes of reperfusion, repeated twice), When the myocardial temperature was reduced to 32 degrees C., the recovery following IACC was 41.25 +/- 11.21 percent (n=8). With hypothermia of 28 degrees C., it was 70.43 +/- 13.03 percent (cross circulation group, n=7) or 68.36 +/- 13.11 percent (membrane oxygenator group, n=7). If the hearts were cooled to 24 degrees C., the recovery of the myocardial contractility following IACC was 90.95 +/- 5.42 percent (n=11). The improvement of the degree of recovery by hypothermia was statistically highly significant (p less than 0.005). Creatine phosphokinase (CPK) and isoenzymes (CPK-MB) were also measured in some groups, but the results warrrant further studies before they can be correlated with the myocardial function.


Ischemic injury to the conducting system of the heart. Involvement of myocardial lysosomes. The conducting system was studied in an in situ perfused swine heart preparation with reduced coronary flow (ischemia) using perfusate containing high and low levels of glucose (26.6 versus 8.6mM) with and without insulin. Coronary flow was maintained at normal levels for 60 minutes in control hearts. In ischemic hearts flow was reduced to about 50 percent of control levels for 30 minutes. Ultrastructural studies documented only subtle modifications of Purkinje fibers in ischemic hearts. Glycogen depletion and disruption of cell junctions were observed in some fibers. One consistent finding was the activation of the lysosomal system. The outer membranes of primary lysosomes appeared herniated and in some cases disrupted, and small vesicles containing hydrolytic enzymes were seen in association with the Golgi apparatus and larger primary lysosomes. Specimens prepared for the demonstration of acid phosphatase indicated a redistribution of hydrolytic enzymes in Purkinje fibers with a depostion of acid hydrolases in smaller lysosomal vesicles, the transverse and side-to-side junctions between cells, and occasionally in the sarcoplasmic reticulum. Enriched perfusate containing high levels of glucose with insulin appeared to have no therapeutic effects in terms of the structure of the Purkinje fibers. The results suggest that alterations in the lysosomal system may be one of the earliest structural changes which occur in oxygen-deficient hearts.


Optimization of coronary perfusion rate during cardiac surgery in man. Myocardial oxygen consumption (Vo2) and lactate flux were measured in 12 patients with aortic valve disease and left ventricular hypertrophy during cardiac surgery with hypothermic cardiopulmonary bypass and artificial coronary perfusion. Coronary flow was varied from "standard" flow-defined as giving a "line pressure" of 110 mm. Hg-to 25 or 50 percent higher than standard flow. Lactate flux was not significant at any flow. Vo2 was higher at +25 percent flow that at standard flow, but no significant further increase in Vo2 occurred at +50 percent. Myocardial Q10 and coronary vascular resistance also approached optimal values at a flow of +25 percent, corresponding with a mean coronary flow of 203 ml. times min -1. The difficulties are discussed of standardizing coronary perfusion in useful practical terms.


Palliative Mustard or Rastelli operation in complete transposition of the great arteries. Option decided by lung biopsy. A case history is reported of a patient with complete transposition of the great arteries and a ventricular septal defect in whom pulmonary hypertension developed, with a pulmonary resistence of 10 units M.2. Because of the possibility that the pulmonary vascular obstructive disease might have been of recent onset and that a high hematocrit value of 82 percent may have interfered with the precise determination of pulmonary resistance, an open lung biopsy was performed. The histologic findings suggested that the vascular disease was as yet reversible. Because of these findings and the aforementioned considerations, a Rastelli operation was performed instead of a palliative Mustard procedure. At present, 6 months postoperatively, the patient is asymptomatic.


Evaluation of right atrial-pulmonary artery conduits for tricuspid atresia. Experimental study. Blood flow through right atrial-pulmonary artery (RA-PA) conduits was investigated. Experiments were designed to evaluate the pumping function of the right atrium, effects of the atrial versus ventricular pacing site, the necessity of a valve within the conduit, and the effect of positive-pressure ventilation on conduit flow. Twenty foxhounds were subjected to silicone patch closure of 90 percent of the tricuspid valve orifices to create stenosis. Ten dogs successfully underwent RA-PA shunting with a conduit with paralled limbs, one containing a prosthetic valve. The proximal main pulmonary artery was ligated to ensure total diversion of blood via the conduit. Valved and nonvalved conduit flow was significantly correlated with right atrial pressure (RAP): r = 0.95, p less than 0.05; r = 0.98, p less than 0.01, respectively. There was no significant effect of increasing heart rate (p = 0.19), atrial versus ventricular rhythm (p = 0.28), or the presence of a valve (p = 0.63). Increasing tidal volume resulted in increasing tidal conduit flow (expiration-inspiration) (r = 1.0, p less than 0.01), but mean flow was unaffected. Therefore, RAP is the most important factor influencing conduit flow. The absence of a valve, ventricular rhythm, and tachycardia did not significantly alter flow in this acute experimental model.


Conducting tissues in univentricular heart of right ventricular type with double or common inlet. Four specimens of univentricular hearts of the right ventricular type, three with two atrioventricular valves and one with a common valve, have been examined histologically to identify the atrioventricular conduction system. Three of the specimens were initially thought to have only one chamber within the ventricular mass, a chamber which had a right ventricular trabecular pattern. On detailed examination and with removal of blocks of tissue for histologic study, a second, rudimentary chamber was found in the posterior ventricular wall. This chamber had a trabecular zone of the left ventricular type and was connected with the main chamber only via a small defect in the septum which separated the two chambers. In all four cases the connecting atrioventricular node was dound in normal relationship to atrial markers and the penetrating bundle descended onto the posterior wall of the main chamber. In three cases it ran along the crest of the septum between the main chamber and rudimentary chamber, in relation to the septal defect. In two cases left bundle branch tissue was identified running into the rudimentary chamber. This pattern of conducting system is different from that previously identified in other varieties of univentricular heart and again underlines the importance of intraoperative mapping of the conduction system during surgery of the univentricular heart.


Correction of anomalous origin of the left coronary artery. Successful surgical treatment for anomalous origin of the left coronary artery from the pulmonary artery was performed in one patient by left coronary artery-subclavian anastomosis and in two patients by direct implantation of the left coronary artery into the aorta. The excellent early and late results obtained with these methods and the suboptimal results reported with saphenous vein grafting for this lesion make these other alternatives more attractive. Direct implantation of the left coronary artery into the aorta utilizing cardiopulmonary bypass and hypothermic (4 degrees C.) potassium-induced (20 mEq. per liter) cardioplegia is now our preferred approach for most patients with this lesion.


Postoperative evaluation of patients with tetralogy of Fallot repaired in infancy. Including criteria for use of outflow patching and radiologic assessment of pulmonary regurgitation. The late hemodynamic and radiologic findings were good or excellent in 96 percent of 23 infants in whom tetralogy of Fallot was repaired with the use of profound hypothermia. These results encourage continuation of the policy of early repair rather than palliation in tetralogy of Fallot. The preoperative cineangiocardiographic assessment of the type and severity of the pulmonary stenosis accurately predicted the findings at operation and the type of repair required. In infants between 1 and 21 months of age and 3 and 10 kilograms in weight, a main pulmonary artery (MPA) diameter of less than 7 mm. was the cineangiocardiographic measurement most accurately predicting the necessity for an outflow patch across the pulmonary ring. Postoperative studies showed significant increases in the MPA and pulmonary ring diameters. A Method of cineangiocardiographic assessment of pulmonary incompetence is presented. Severe mechanical pulmonary incompetence in some patients produced mild hemodynamic effects by radiologic criteria.


Lung pathology in infants with severe pulmonary hypertension and cardiac disease. Lung biopsy specimens were taken from 39 infants younger than 12 months of age with congenital heart disease and severe pulmonary hypertension (Pp/Ps greater than or equal to 0.75) accompanied by respiratory distress. The pathological change in lung specimens and clinical courses were compared. These 39 infants underwent surgical treatment of patent ductus arteriosus (PDA), seven patients; ventricular septal defect (VSD), 13 patients; and complex heart anomaly, 19 patients. The common pathological findings of the lung specimens taken from these infants were lymphoid cellular infiltration and thickening of the alveolar septum, which we have called "septitis" in the present study. In most cases pulmonary vascular obstructive change was within Grade 2 of the Health-Edwards criteria. Septitis was classified into three categories: mild, moderate, and severe. Only three of the 19 infants with severe septitis survived postoperatively, whereas 10 of the 12 infants with moderate septitis and all eight with mild septitis could be successfully weaned. The cause of septitis remains unidentified. We have found the patient's age and pulmonary hypertension to be closely related to the grade of septitis in this study. Septitis plays a much more important role than pulmonary vascular obstructive change in the prognosis of pulmonary hypertensive heart disease in early infancy.


Mitral atresis with normal-sized ventricles, ventricular septal defect, and dextro-transposition of the great arteries. A case is described of mitral atresia, patent foramen ovale, subcristal ventricular septal defects (VSD), and dextro-transposition of the great arteries (d-TGA), coexisting with a normal-sized left ventricle and normal-sized great arteries in a 6 8/12-year old girl. The discussion is related to anatomic, embryologic, and surgical aspects of this particular condition, which, to our knowledge, has never been documented before.


False aneurysm of right pulmonary artery. New complication of aorta-right pulmonary artery anastomosis. The case history of an infant with tetralogy of Fallot who had a Waterston anastomosis performed at the age of 1 year is presented. Subsequent chest roentgenograms revealed a ringlike calcification which was shown at angiography and operation to be due to a false aneurysm of the right pulmonary artery at the site of the Waterston anastomosis. The aneurysm also produced unidirectional obstruction of the right pulmonary artery. A review of the literature suggested that a false aneurysm of the right pulmonary artery after a Waterson anatomosis had not been reported previously.


Tricuspid valvular incompetence and rupture of the ventricular septum caused by nonpenetrating trauma. A young adult involved in an automobile accident had tricuspid valvular incompetence and rupture of the ventricular septum owing to blunt trauma. He had a successful repair of the ventricular septal defect and replacement of the tricuspid valve. Tricuspid valvular incompetence owing to nonpenetrating trauma is uncommon. Blunt trauma resulting in rupture of the ventricular septum is rare. Rupture of the membranous portion of the ventricular spetum is extremely rare. This is the first report of a patient having a combination of these lesions.


Postoperative chylous pseudocyst.

Postoperative chylous pseudocyst. A 59-year-old man underwent resection of aneurysm of the descending thoracic aorta with graft replacement. A postoperative chylothorax was managed by nonsurgical means and subsided. Subsequently, an expansile mass appeared in the left side of the chest and was surgically removed. This was found to be a chylous pseudocyst. Management of chylothorax and the details of this unique case are described.


Familial cardiac myxoma: emphasis on unusual clinical manifestations. This report describes familial cardiac myxoma involving parent and child. The familial occurrence of this condition, previously reported in four other families, underscores the necessity of screening all direct members of the family by echocardiography once the diagnosis of cardiac myxoma is made. Each patient presented with unusual clinical manifestations. The father, who had a right atrial myxoma associated with an atrial septal defect and mitral valve prolapse, presented with findings highly suggestive of paradoxical embolism. The daughter, who had an infected right ventricular myxoma, was initially treated for valvular subacute bacterial endocarditis before the diagnosis was made.