[Comparative ultrastructural study of the epithelial stromal junction in the prostatic gland]. In this paper, the authors carry out a comparative study of the structures adjacent to the alveolar periphery of the prostate-glands of men, dogs and bulls. In the three cases an E.S.J. (Epithelial-Stromal-Junction) similar to that described in the mammary gland and characterized in the first two cases by the existence of four, ultrastruct strata, consisting of the basal lamina, the somas of the adjacent fibroblasts and their cytoplasmic expansions as well as the arrangement of the intercellular, collagen microfibrils, was found to exist in this gland. In the case of the bovine prostate gland, the structural organization of the E.S.J. was basically characterized by the structural arrangement of the collagen microfibrils. The structures described constitute models on which to base future research on the hyperplastic and neoplastic processes of the prostate gland.


Primary osteoathrosis of the hip and Heberden's nodes. One hundred patients with primary osteoarthrosis of the hip were examined for evidence of generalised arthrosis associated with Heberden's nodes, and in addition their hips were graded by the radiographic pattern of loss of joint space. Twenty-nine patients had bilateral concentric loss of joint space, and 18 in this group had Heberden's nodes. None of the 17 patients with bilateral upper pole changes had Heberden's nodes, and only 7 of the 31 patients with unilateral upper pole changes had Heberden's nodes. None of the 6 patients with medial loss of joint space had Heberden's nodes. This study has shown an association between Heberden's nodes had primary osteoarthrosis of the hip where this is characterised by concentric loss of joint space. The association is most marked where hip changes are bilateral, suggesting that hip involvement in generalised osteoarthrosis is part of a generalised disorder with possible genetic or biochemical abnormalities.


Sacroiliitis detected by bone scintiscanning: a clinical, radiological, and scintigraphic follow-up study. Twenty-four patients had abnormal sacroiliac joints detected by quantitative sacroiliac scintigraphy but no radiological evidence of sacroiliitis on original investigation. We studied them again after intervals of 12 to 36 months. Four patients developed radiological change. Two young, HLA B27-positive men had undoubted ankylosing spondylitis, and a young woman had possible ankylosing spondylitis. A middle-aged man had changes that could be attributed to post-traumatic osteoarthrosis. Of the remaining 20 cases 15 had symptoms and signs suggestive of inflammatory disease of the axial skeleton (and peripheral arthropathy in 5 cases). The sexes were affected equally (8 females, 7 males), and only 2 of the 15 were B27-positive. The response to anti-inflammatory medication was generally good to excellent, and scintiscans tended to improve. Of the remaining 5 patients, 3 had mechanical or traumatic problems, and in 2 there was no explanation for the abnormal sacroiliac scintiscan. We conclude that quantitative sacroiliac scintigraphy may detect ankylosing spondylitis prior to the develpment of radiological change and that it can identify an organic basis for backache in patients with a spondylitis-like syndrome. The clinical circumstances must be taken into account, as scintigraphic abnormalities are not diagnostic of any specific disease entity.


Behçet's syndrome: a family study and the elucidation of a genetic role. A family with features of the mucocutaneous ocular syndrome is described. A 4-generation study reveals that the condition has been inherited as an autosomal dominant trait with variable expressivity. Psychiatric symptoms and myalgia have been prominent features peculiar to our patients.


[Testicular teratoma in infancy].

[Testicular teratoma in infancy]. The authors describe a case of testicle-based teratoma, in a 20-month old boy. Due to the characteristics of the palpation and its eventual transillumination, it may be confused with a hydrocele. They stress its rarity and on the basis of a review of the literature, they explain its histological peculiarities and refer to its prognosis, usually benign, when it is diagnosed at about 2 years of age, providing that a very careful examination of the histological sections rules out the presence of anaplastic cells. Finally there is a short discussion on the possibilities of complementary therapy when there are metastases.


An evaluation of repeat intra-articular injections of yttrium-90 colloids in persistent synovitis of the knee. The effectiveness of a second intra-articular injection of yttrium-90 colloid was studied in 30 patients with persistent synovitis of the knee. All had responded poorly to a first injection of yttrium-90 yet seemed likely to benefit from this therapy. With a minimum review period of 6 months complete remission of synovitis was obtained in 20%, while 63% gained symptomatic relief, with some reduction of synovitis. No improvement occurred in 17%, and in this group generalised disease activity was more apparent.


[Ureteral triplication with one blind branch]. We present a case of a double left ureter, one of which branched with one blind branch, which has not been described in the literature.


IgA rheumatoid factor in the sera and saliva of patients with rheumatoid arthritis and Sjögren's syndrome. With a sensitive radioimmunoassay we have found elevated IgA rheumatoid factor (IgA-RF) levels in the sera of patients with rheumatoid arthritis, Sjögren's syndrome, and systemic lupus erythematosus. The IgA--RF showed a pattern of reaction with human IgG subclasses and animal gammaglobulins similar to that of IgM-RF from the same patients. Rheumatoid factors of both classes were shown to be present in saliva of patients with rheumatoid arthritis and Sjögren's syndrome.


[Rupture of a single renal cyst in the excretory ducts]. After observing one case, the authors review the contemporary literature on ruptures of single kidney cysts in the pyelo-calicial cavity. They comment upon the pathogenesis of this entity which is produced by an increase in the intracystic pressure, an increase in the pressure inside the pyelo-calicial cavity or a decrease in the resistence of the wall separating the cyst from the intrarenal cavities. They review all the possible etiological causes (intracystic haemorrhaging, infection, traumatism, idiopathic disorder in the dynamics of the cystic fluid, obstructions in the excretory ducts, previously pathological stones, etc.). They enumerate the principles for the radiological diagnosis issued by McLaughlin and Pfister, to which the authors of this paper add, as a matter of interest, the retraction of the cortical at the level of the renal cavity.


Synthesis of sulphated proteoglycans by rheumatoid and normal synovial tissue in culture. Synthesis of sulphated proteoglycans by cell lines derived from explants of 7 rheumatoid and 9 normal specimens of synovial tissue, as well as by 7 lines of skin fibroblasts from non-rheumatoid patients, was examined. Cells of all 3 types were cultured as monolayers. They were then disaggregated and their capacity to synthesise proteoglycan estimated in cell suspensions by the incorporation of [35S]-sulphate into CPC-precipitable material during 2 hours of incubation. Cell suspensions incorporated somewhat more [35S]-sulphate than corresponding duplicate monolayers. Synovial cells from rheumatoid patients incorporated 2 to 3 times as much [35S]-sulphate as synovial cells from normals. Skin fibroblasts, however, incorporated less [35S]-sulphate than rheumatoid or normal synovial cells up to the fifth passage. Thereafter their incorporation gradually increased to overtake that of synovial cells. About one-half to one-third of the total [35S]-sulphate labelled material was closely associated with cells from synovial tissues and fibroblasts respectively.


[The role of C reactive protein in urological neoplasms]. The authors make a study of 46 urological patients (16 control and 30 neoplasia persons) determining the R.C.P. before and after the operations. The positive results obtained (77%) should lead to the said test becoming routine in uro-genital neoplasias.


Acetylator phenotype in spontaneous SLE and rheumatoid arthritis. Acetylator phenotype was determined in 22 patients with spontaneous systemic lupus erythematosus and the proportion of 'slow' acetylators compared with that obtained in a group of patients with rheumatoid arthritis and a group of healthy controls. 73% of the SLE group were designated 'slow' compared with 72% of the rheumatoid group and 64% of the control group. These differences were not significant.


[A case of urethrocele (radiographic image)]. The authors present a case of male urethrocele situated at the base of the free portion of the penis, on the inferior side and containing 240 g. of dirty and fetid urine. The urethra is free from any stenosis, obstacle or stone. They mention the case of Gausa Raspall in Barcelona, presented in 1949 along with the clinical picture of the male urethrocele. They also include a retrograde urethrocystograph with antero-posterior and oblique anterior left projections.


Serum copper and its relationship to clinical symptoms in rheumatoid arthritis. Total serum copper and ultrafilterable copper levels in patients with rheumatoid arthritis were determined and related to articular index, erythrocyte sedimentation rate (ESR), and serum iron concentration. Relationships were found between serum copper and ESR, and between ultrafilterable copper and articular index. The relationship between serum copper and serum iron was found to be a drug-dependent.


Rapidly progressive scleroderma associated with carcinoma of the oesophagus. A patient with scleroderma of recent onset was found to have a carcinoma of the oesophagus. The rapid progression of the scleroderma suggested the possibility that it represented a systemic manifestation of malignancy.


Hypercholesterolaemic arthropathy in primary biliary cirrhosis. A new cause of severe transient fitting polyarthritis is described in a patient with primary biliary cirrhosis. Hypercholesterolaemia is thought to provoke acute inflammatory periarthritis and peritendinitis. The clinical features are sudden onset of peripheral joint pain and effusion, with redness of the overlying skin, often precipitated by unusual exercise. Cholestyramine may help to prevent this form of arthritis.


Attitudes of the public to arthritis.

Attitudes of the public to arthritis. A survey of the public's attitude to arthritis was commissioned by the Arthritis and Rheumatism Council (ARC) in 1974. The survey was carried out by National Opinion Polls (NOP) Market Research Ltd. The ARC were interested to find out whether people underestimated arthritis and what they thought about the consequences. Respondents were asked to rank a number of illnesses in terms of their seriousness and the loss of work to which they give rise. They were also shown a series of statements about arthritis and rheumatism in order to elicit the extent of their agreement with the views these represented. The public appear to have fairly realistic ideas about the magnitude of the problem and of its nature and associations. However, although the pain of arthritis and rheumatism was appreciated, their possible impact in terms of disturbance of the normal pattern of daily life tended to be underestimated. The findings reflect the climate of opinion from which present and potential arthritis sufferers come and may therefore reveal part of their attitudes to their disease.


Traumatic injuries of the portal vein. The role of acute ligation. Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a "second look" operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel.


Surgical treatment of pancreatic pseudocysts. Analysis of 119 cases. A review was made of the hospital records of 119 patients with pancreatic pseudocysts. Alcoholism, biliary disease and abdominal trauma were the most common antecedent conditions. Abdominal pain was the most frequent symptom, and abdominal tenderness or mass were the most common physical findings. Abdominal echography and contrast study of the upper gastrointestinal tract were diagnostic in 90% of the patients examined. X-rays of the chest, colon, and biliary tract revealed pathology in 30--40% of the patients. Compared to patients with uncomplicated pseudocyst, patients who were acutely ill at the time of external drainage had twice the incidence of postoperative complications. Each subgroup experienced similar, high rates of postoperative death and pseudocyst recurrence. Both groups of patients treated by internal drainage had lower rates of postoperative morbidity, mortality, and pseudocyst recurrence than patients with uncomplicated pseudocysts undergoing external drainage. External drainage should be used in all patients with immature pseudocysts and in critically ill patients with mature pseudocysts not juxtaposed to a portion of the upper gastrointestinal tract. Internal drainage is a safer and more effective procedure in most other patients with mature pseudocysts, irrespective of the clinical status of the patient.


Antibiotic penetration into normal and inflamed tissues as reflected by peripheral lymph. The concentration of antibiotic in peripheral lymph reflects the tissue levels. Following microsurgical cannulation of the right lymphatic duct in 28 healthy rabbits, either penicillin-G, nafcillin, erythromycin, or cefazolin was given intramuscularly, and lymph and serum samples obtained at frequent intervals. Penicillin or nafcillin was administered to 14 additional rabbits with cellulitis of the right upper extremity. A serum sample drawn between one and two hours after an intramuscular injection, in general, reflects the peak lymph antibiotic concentration and hence the peak tissue concentration of the drug. After two hours the lymph level remains equal to or greater than the simultaneous serum level. The presence of inflammation did not alter the peak antibiotic levels. However, nafcillin required longer for equilibration in the inflamed state than in the uninflamed state, whereas penicillin-G equilibrated more rapidly in the presence of inflammation.


Prognosis after treatment of villous adenomas of the colon and rectum. With the existing evidence of neoplastic polyps of the colon and rectum as precursors of most or all colonic cancer, information of the short- and long-term course after treatment is a prerequisite of using the knowledge of the polyp-cancer sequence in an effective cancer prophylaxis. One hundred seventy-four patients treated for villous adenomas of the colon and rectum during the years 1960-1975 were re-examined. Survival and cure rates were estimated by actuarial analysis. The death rate of colonic cancer among patients treated for a benign villous adenoma was significantly higher than in an age and sex matched normal population, resulting in a significantly reduced crude survival rate among these patients. Almost all recurrences after treatment of benign villous adenomas occurred within the first four to five years recurrence rate of roughly 30%, indicating that five years seem to be an adequate total control period following treatment.


False aneurysm of the left ventricle. Report of four cases and review of surgical management. False aneurysms of the left ventricle were repaired in four patients (average age, 61 years). The etiology was myocardial infarction in three patients and disruption of an apical left ventricular cannulation site in the fourth. The interval from initiating event to surgery averaged 11 months. One patient was in cardiogenic shock and succumbed in the operating room from myocardial failure. The other three patients, in functional class III at the time of surgery, survived and are currently asymptomatic. The literature records 43 patients who have undergone surgical repair of a false aneurysm of the left ventricle. The causes were myocardial infarction (12 patients), operative injury (13 patients), penetrating trauma (11 patients), and blunt trauma (seven patients). Twenty-seven (63%) were under the age of 50 years. In those who were limited by symptoms, congestive heart failure predominated. Forty seven per cent of the patients were operated upon in the first five months following the initiating event; 61% within the first year. Only four patients underwent surgery more than 48 months after the myocardial insult. Thrombus was present in 28% of the aneurysms. Morbidity was recorded in nine patients, and six patients (14%) died. This study documents the necessity for early surgical repair and the relatively low operative mortality obtained with this lethal lesion.


Heparin induced alterations in clearance and distribution of blood-borne microparticles following operative trauma. The influence of systemic heparin administration on the vascular clearance and tissue distribution of blood-borne microparticles was evaluated in normal rats and rats after operation (laparotomy plus intestinal manipulation) utilizing an (131)I- colloid which is phagocytized by the reticuloendothelial system (RES). Intravenous heparin administration (100 USP/100g body weight) into normal animals three minutes prior to colloid injection (50 mg/lOOg) induced a significant increase in pulmonary localization of the microparticles as compared to nonheparinized control rats, while hepatic and splenic uptake were decreased. Surgical trauma decreased hepatic RE uptake and increased pulmonary localization of the microparticles when injected systemically at 60 minutes postsurgery. Heparin administration 60 minutes after surgery and three minutes prior to colloid injection, magnified the increased pulmonary localization response with an associated further depression of the RES. The ability of heparin to alter both RE clearance function and lung localization of microparticles was dose dependent and a function of the interval between heparin administration and systemic particulate infusion. Thus, low dose heparin administration was capable of stimulating RE activity while heparin in doses of excess of 50 USP units/lOOg body weight decreased RE function. These findings suggest that the functional state of the hepatic RE system can be greatly affected in a dose-dependent manner by systemic heparin administration which may influence distribution of blood-borne microparticles.


The effect of vasopressin on oxygen availability. Vasopressin has been used with increasing frequency to control gastrointestinal bleeding, the beneficial effect being attributed to marked splanchnic vasoconstriction. Because vasopressin may result in impaired cardiac function and because other potent vasoconstrictive substances have been shown to increase the pulmonary shunt and decrease arterial oxygenation, this study was undertaken to determind the effect of vasopressin on oxygen availability. Ten healthy anesthetized mechanically ventilated dogs received a five hour intravenous vasopressin infusion, 0.005 U/kg/min. The heart rate decreased moderately and briefly. The mean systemic arterial pressure increased and then decreased, both minimally. The pulmonary shunt and the arterial oxygen content decreased slightly. The total systemic resistance increased and the stroke volume decreased, both substantially. The pulmonary artery wedge pressure gradually increased. The oxygen availability decreased markedly. This study demonstrated that a vasopressin infusion causes a marked decrease in oxygen availability due primarily to a decreased stroke volume and, to a lesser extent during the first hour, to a decreased heart rate. The pulmonary shunt did not increase. Increased systemic resistance followed by a gradual increase in the pulmonary wedge pressure suggests that the decreased stroke volume resulted, at least in part, from an increased afterload and left ventricular failure. It is suggested that until the effect of vasopressin on the cardiopulmonary systems and hence oxygen availability is fully studied in critically ill patients, that it be used with caution and with appropriate hemodynamic monitoring.


Causes for 340 reoperations on the extrahepatic bile ducts. Three hundred forty of 5,086 patients undergoing operations on the extrahepatic biliary trees at the Swedish and University of Washington Hospitals in Seattle between 1956 and 1970 required reoperation on this system. This figure for reoperations did not include procedures for subhepatic or subphrenic abscess and/or wound complications. The most common cause for reoperation was an attempt to retrieve a residual or recurrent common duct stone (26.8% of the cases). The second most common cause for re-exploration was a tumor obstructing the common bile duct (18.9%). Less frequent causes for secondary surgery were stenosis of the ampulla of Vater (10.3%), bile duct injury (12.1%), pancreatitis (10.3%), inflammatory stricture (1.5%), cystic duct remnant (5%), and many other less important problems. Thus 4.7% or almost one in 20 of all our biliary operations were secondary. We feel that operative cholangiograms supplemented by manometry are the useful adjunct towards finding otherwise undetectable biliary pathology, whether on the basis of stones, tumors, or structures. We also feel that placement of T-tubes with a large arm going to the surface will allow the removal of most stones left behind after common bile duct explorations with the assistance of directable stone baskets.


Changes in the costs of elective cholecystectomies, 1955-1965-1975. The costs for elective cholecystectomies were measured 1955, 1965 and 1975. The average length of stay decreased by 25% between 1955 and 1965 and with the same amount between 1965 and 1975. In spite of these marked reductions in the average length of stay there was only a significant decrease in costs between 1955 and 1965 but not between 1965 and 1975.


Non-operative differentiation between pancreatic cancer and chronic pancreatitis. Eighty-five of 186 patients investigated for suspected pancreatic cancer had an unequivocal final diagnosis of either pancreatic cancer (58 patients) or chronic pancreatitis (27 patients). They had been studied prospectively using ultrasonography, computerized tomography, radionuclide scanning, endoscopic retrograde cholangiopancreatography (ERCP), selective celiac and superior mesenteric angiography, duodenal drainage studies, cytologic studies, serum carcinoembryonic antigen assay, and pancreatic oncofetal antigen assay, The results were compared to determine which test would most frequently and reliably differentiate between pancreatic cancer and pancreatitis in a patient believed to have one or other disease. Criteria for interpreting results, first for highest rate of correct diagnoses, and second for highest accuracy were derived. Applying these criteria, ultrasonography achieved the highest rate of correct diagnoses (97% of patients diagnosed with 84% accuracy). ERCP, duodenal drainage studies, and cytology were the most accurate tests ((86% accuracy each test) but, with this accuracy, ERCP most frequently gave a diagnosis (diagnosis rate: ERCP--70%, duodenal drainage--32%, cytology--35%). The results suggest that ultrasonography is the best noninvasive test, and that a combination of ERCP, pancreatic juice assay and cytology in a single procedure may prove to be the best discriminating investigation.


Rectal obstruction secondary to carcinoma of the prostate. The records of 13 patients with symptomatic rectal obstruction secondary to prostatic carcinoma have been critically reviewed to provide criteria for identifying this atypical presentation. The site of obstruction varied from the anal verge to 17 cm by sigmoidoscopy. Significant clinical findings were ureteral obstruction on excretory urography in 12 of the patients, elevated acid phosphatase in eight, intact mucosa over the obstructing mass in seven and osteoblastic bone metastasis in six. Primary diagnosis was generally established by comparing histopathologically the prostate and the obstructing lesion. Colostomy was necessary in nine cases. In three patients colostomy was obviated in partially obstructing lesions by intravenous diethylstilbestrol diphosphate therapy. One patient had an inappropriate low anterior resection. Rectal obstruction is most commonly due to primary adenocarcinoma. Occasionally the obstruction is secondary to prostatic carcinoma masquerading as an intrinsic rectal cancer. Identification of the true nature of the illness is essential for proper treatment.


Pseudomembranous enterocolitis in adults. Twenty-one patients with pseudomembranous enterocolitis were seen over a 17 year period. Major inciting factors appeared to be an antecedent operation or a serious medical illness. The most common symptoms were fever, diarrhea and abdominal pain. The most commonly involved organ was the colon. The diagnosis was missed in the majority of patients. Neither conservative treatment or surgical treatment were successful. Awareness of the disease and its course will lead to earlier diagnosis and hopefully to a higher cure rate.


The clinical correlation of an autopsy study of recurrent colorectal cancer. The complete autopsies of 145 patients dying of colorectal cancer are reviewed. Isolated local or distant metastases are infrequent, compared to disseminated disease. Solitary local recurrences are most common after resection of rectal tumors. Right colon tumors spread to local and distant sites in 90% of autopsies, and to distant sites alone in 10%. Rectal tumors spread locally only in 25% of cases, to distant site alone in 25%, and to both in 50%. Regardless of the origin of the primary tumor, the liver is the most common site of metastasis, followed by the regional lymph nodes and the lungs. Two-thirds of the patients with right colon lesions died of liver metastases, and three-quarters of those with rectal tumors succumbed to disseminated disease. The current curative and palliative treatment of recurrent colorectal cancer in clinical medicine by surgery, radiotherapy, and chemotherapy is reviewed. It is suggested that an understanding of the anatomic patterns of cancer recurrence will increase in importance as advances in the modalities of treatment are made,


Ileal resection potentiates 1,2-dimethylhydrazine-induced colonic carcinogenesis. The effect of colonic hyperplasia produced by resection of the distal third of the small bowel (DSBR) on the development of chemical carcinogenesis of the colon by dimethylhydrazine (DMH) was tested in rats. For the most part the amounts of RNA and DNA in the small bowel were the same with the combined treatments as with either one alone; quantities of nucleic acids tended to increase only in transverse and distal colon. After 37 weeks the number of neoplasms per rat was increased six-fold by combining DSBR with DMH. Neoplasms were spread throughout the colon after combined treatment as opposed to the ascending colong after DMH alone. Postresectional hyperplasia appears to increase the incidence and distribution of colon tumors.


Respiratory failure in acute pancreatitis: a possible role for triglycerides. Respiratory failure is a frequent complication of acute pancreatitis. Two clinical studies of this association have demonstrated a high incidence of concomitant hypertriglyceridemia. Experimental studies were carried out using an ex vivo, isolated, perfused, ventilated, canine pulmonary lobe to evaluate the effects of triglyceride elevations on pulmonary mechanics and gas exchange. Control lobes perfused for a four hour period remained stable. When 5g and 10g of triglyceride were added to the perfusate, the lobes became grossly edematous and hemorrhagic. Intrapulmonary shunting developed (23 and 46%), weight gain occurred (130 and 189g), effective compliance decreased, and the pressure-volume deflation curves became abnormal. Free fatty acid (FFA) levels increased markedly during the perfusion periods. When small quantities of FFA were infused directly into the pulmonary artery, similar changes, but less severe, occurred. These studies demonstrate that triglyceride elevations are capable of adversely affecting pulmonary gas exchange and mechanics. Such changes probably occur secondary to FFA release. These data thus add support to the concept that the respiratory insufficiency that is seen in acute pancreatitis could be mediated through triglyceride elevations.


A comparison of modified radical mastectomy to radical mastectomy in the treatment of operable breast cancer. This study compares the results of modified radical mastectomy (144 cases) to radical mastectomy (188 cases) in the treatment of operable breast cancer. Two hundred five patients had Stage I breast cancer, 60 had Stage II disease and 67 had Stage III disease (TNM System). There was no statistically significant difference in five year survival when the results of a radical mastectomy were compared to a modified radical mastectomy at any stage of disease. There was no statistically significant difference in the incidence of local recurrence in patients with Stage I and Stage II disease when the results of a radical mastectomy were compared to modified radical mastectomy. Those patients with Stage III disease who were treated by a modified radical mastectomy had a statistically significant higher incidence of local recurrence (chest wall and axilla) in comparison to patients treated by radical mastectomy. We have concluded that a modified radical mastectomy is the treatment of choice in patients with Stage I and Stage II diseases. In patients with Stage III disease, a radical mastectomy provides a better chance of local control of the disease but offers no increased chance of survival.


KMA-Greenfield filter placement for chronic pulmonary hypertension. Over a period of four years, 23 patients had the diagnosis of chronic pulmonary hypertension made on the basis of elevated resting pulmonary arterial pressures above 30 mmHg mean. Clinical features included dyspnea (100%), previous thromboembolism (43%), congestive failure (39%), venous thrombosis (35%), syncope (30%), lung disease (22%), recent trauma (22%), hemoptysis (17%) and precordial pain (17%). Pulmonary angiograms showed embolic occlusion in all but four patients, who were considered to have primary pulmonary hypertension. KimRay-Greenfield((R)) vena caval filters were inserted in 18 patients. Three of them were in refractory shock at the time, and only the one who had successful intraluminal catheter embolectomy survived. These patients have been followed an average of 23 months with two embolic deaths, one from the right atrium and one bypassing a filter misplaced in the right iliac vein (overall mortality 22%). There has been no other known recurrent embolism, but one patient developed hematuria from the filter. The five patients who did not receive a filter have all died after intervals up to 18 months. Recurrent thromboembolism was documented in three and suspected in one patient with known embolic disease who died suddenly. Regardless of etiologic factors, pulmonary hypertension with cor pulmonale is associated with a high incidence of fatal thromboembolism. In our experience, maximal protection is afforded by long-term anticoagulation therapy and the placement of a venacaval filter.


Carotid sinus syndrome: treatment by carotid sinus denervation. Hypersensitive carotid sinus is a rare cause of spontaneous syncopal attacks. It must be differentiated from the other more common causes, such as intrinsic cardiac disease, vasovagal responses, postural hypotension and cerebrovascular insufficiency, although it may accompany these conditions. The definition of carotid sinus syncope is syncope elicited by stimulation of a hypersensitive carotid sinus. Nineteen patients with carotid sinus syncope were treated by carotid sinus denervation. Ages ranged from 48 to 83 with a mean of 65.5 years. Symptoms of marked dizziness or syncope were reproduced by gentle compression over the carotid bifurcation, while ECG monitoring revealed bradycardia or transient asystole. Seventeen patients had carotid arteriograms, eleven of which were normal. One patient had stenosis of the external carotid artery, while five had stenosis of the internal carotid. The right carotid sinus was involved in ten patients, the left in three and both sides in six. All patients underwent unilateral or bilateral carotid sinus denervation. Five patients with internal carotid stenosis had concomitant carotid endarterectomy. Complete relief of symptoms or marked improvement was noted in all but one patient. Postoperative follow-up ranged up to 15 years. Carotid sinus denervation is a simple, effective method of treating this disorder.


New techniques of gastrointestinal anastomoses with the EEA stapler. A new instrument for accomplishing inverted stapled anastomoses in the gastrointestinal tract is described. Side-to-side, end-to-side and end-to-end anastomoses can be performed. Techniques developed for utilization of the instrument in virtually all gastrointestinal anastomoses are described. In most instances a proximal or distal enterotomy is required. Experience with 57 anastomoses in 42 patients is reported. One leak occurred; no other complications not recognized intraoperatively were observed. Anastomoses completed included gastroduodenostomy, gastrojejunostomy, cholecystojejunostomy, colocolostomy and ileocolostomy. Hazards and complications associated with the use of the instrument are described. It should be used only after the surgeon has acquired the skills to operate the instrument properly. The instrument saves time, creates better anastomoses than can be obtained by hand sewing and is extremely versatile. It may permit safer anastomoses in adverse conditions, such as in obstruction and peritonitis. The instrument opens new horizons in gastrointestinal surgery.


Intubation injuries of the trachea in children. Management and prevention. The problem of intubation injuries of the trachea in children has been summarized. Preventive measures designed to protect the trachea from injury have been outlined. In spite of these measures, acute intubation injuries have occurred in 15 children. An aggressive approach combining bronchoscopic evaluation, intratracheal injection of steroids, tracheal stenting with an endotracheal tube and systemic steroids has been employed in the treatment of these injuries. We feel that this therapy has prevented the development of cicatrical stenosis in many of the cases and has allowed permanent decannulation of the trachea.


Surgical experience with neonatal necrotizing enterocolitis (NNE). Neonatal necrotizing enterocolitis, a highly lethal disorder of premature infants, is a common occurrence in newborn care units. This report details operative experience with 33 infants over the past seven years. During this time many more infants with NNE have recovered with supportive therapy. All patients are treated on a standard protocol of therapy and monitoring designed to select those with signs of continuing clinical deterioration. Therefore, those coming to operation had additional complications, such as perforation, intestinal gangrene or stenosis. This protocol is described. The 33 infants, averaging less than 4 lbs., developed NNE within five days of birth. Perforation and signs of continued clinical deterioration were the indications for operation; severe sepsis and clotting abnormalities were the rule. The overall mortality was 40% but included six infants with total bowel necrosis who had laparotomy alone. Five patients had intestinal or colonic resection with primary anastomosis, with two leaks leading to death. Twenty-one patients had staged resection with delayed anastomosis and only four deaths. Thus 27 determinative cases had a 26% mortality, and the recent group with staged resection had a 19% mortality. The essentials of pre-, intra- and postoperative management are detailed, as well as pathology and bacteriologic data. Most infants had temporary malabsorption requiring parenteral nutrition and special diets. Long-term results are gratifying.


Zollinger-Ellison syndrome. Spontaneous regression of advanced intra-abdominal metastases with 20 year survival. A 35-year-old man with the Zollinger-Ellison syndrome who is alive and well 20 years following diagnosis at age 15, is represented. At the initial operation for a bleeding duodenal ulcer a ZE tumor of the pancreas also was excised. After two additional ineffective ulcer operations, total gastrectomy was performed. At that time, retroperitoneal and peripancreatic metastases were noted, and several were removed. Three years later at laparotomy, extensive hepatic metastases were biopsied as well. Spontaneous remission occurred and when re-explored at age 34, after 14 years, no metastases were identifiable in any area. The serum gastrin level has remained elevated, casting doubt upon its value as a criterion for evaluation of tumor recurrence or activity. Other additional interesting aspects are discussed. The importance of elimination of the acid-secreting cells by total gastrectomy is emphasized. The patient remains well.


Selective treatment of duodenal ulcer with perforation. Selective treatment of duodenal ulcer with perforation has been based on several premises: 1) The natural history of the ulcer following closure of a perforation is generally favorable with an acute and unfavorable with a chronic ulcer. 2) An upper gastrointestinal series with water soluble contrast media can reliably document a spontaneously sealed perforation. 3) With a spontaneous seal, nonsurgical therapy is an acceptable option and is preferable for an acute ulcer or a chronic ulcer with poor surgical risk. 4) The treatment of choice for an unsealed perforation of an acute ulcer is simple surgical closure. 5) The treatment of choice of perforation of a chronic ulcer with acceptable surgical risk is an ulcer definitive operation. Sixty cases of perforation of duodenal ulcer have been treated. Nonsurgical therapy was employed without complication in eight cases with radiologically documented spontaneous seal. Truncal vagotomy and pyloroplasty in 36 cases and truncal vagotomy and antrectomy in two cases were each without mortality. Four fatalities occurred among 13 cases of closure and omental patch, each a case with severe associated disease. The mortality was 6.7% among the 60 cases; 2.4% for chronic ulcer and 16% for acute ulcer.


An interim report on parietal cell vagotomy versus selective vagotomy and antrectomy for treatment of duodenal ulcer. This is an interim report of a prospective, randomized study involving 194 consecutive patients who underwent elective operation for treatment of duodenal ulcer. The results of parietal cell vagotomy without drainage (PCV) and selective vagotomy-antrectomy and Billroth I anastomosis (SV-A-B I) were compared. There was no mortality. Postoperatively patients were examined at two, six, 12 months and every 12 months thereafter. The two operations showed no statistical difference in the frequency of diarrhea. Dumping was less (p < .01) after PCV than after SV-A-B I. Weight loss was less (p < .01) after PCV than after SV-A-B I. There were no recurrent ulcers after SV-A-B I and five after PCV. In each instance but one the recurrent ulcer healed on withdrawal of an ulcerogenic drug. One patient required reoperation. Reoperations in the PCV group consisted of one for recurrent ulcer, one for gastric outlet obstruction and three for intestinal obstruction. The reoperations after SV-A-B I consisted of four for gastric outlet obstruction, three for intestinal obstruction, one for ruptured spleen and two for incisional hernia. PCV was technically feasible and practical to perform except in the occasional patient with severe pyloric stenosis. Obesity was never a deterrent. After PCV it is reasonable to assume that a recurrent ulcer rate in the range of 5-10% can be expected by surgeons who have been properly trained. This recurrence rate is higher than that after SV-A-B I but no higher than that encountered with TV-P. The recurrence rate is acceptable and is a fair exchange for the avoidance of dumping and weight loss that accompany SV-A-B I with significantly greater frequency and which on occasion can produce gastric crippling, although this did not occur in this study. All recurrent ulcers after PCV do not require reoperation but when operative treatment is required the patient has all the options that he had prior to PCV.


The timing of biliary surgery in acute pancreatitis. The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed nonoperatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 "mild" episodes (1.8% mortality) and 23 "severe" episodes (17% mortality). Early (day 0-7) definitive biliary surgery was undertaken in 11 patients with "mild" pancreatitis, with one death (9%), and in six patients with "severe" pancreatitis, with four deaths (67%). In three recent patients with "severe" pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with "mild" acute pancreatitis, early definitive surgery is hazardous in "severe" pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.


Surgery for chronic pancreatitis. Drainage versus resection. A retrospective study of 49 patients with chronic obstructive and chronic calcific pancreatitis is presented. All patients were operated upon and underwent either a partial pancreatectomy or internal drainage of the ductal system into a Roux-en-Y loop of jejunum. The criteria for selection of operation are discussed, and the follow-up of the two operative groups is given. In patients selected as described, internal drainage provided better relief of pain and was accomplished with a lower operative mortality and morbidity and with less postoperative pancreatic insufficiency.


Functional anatomy of haploid and diploid rabbit spermatozoa. Ultrastructural studies of surface replicas of haploid and diploid rabbit spermatozoa after treatment with various chemical media have shown that the various structural components of the diploid sperm head possess the same stabilities and labilities as those of the haploid. Therefore, at least in terms of functional anatomy, diploid rabbit spermatozoa should be capable of penetrating the egg investments and undergoing syngamy.


Ethanol and sulfamethoxazole for functional evaluation of male accessory glands. The secretory function of male accessory glands was tested with two chemical markers, ethanol and sulfamethoxazole (SMZ). Fifty-eight men ingested 70 ml of 40% ethanol; ethanol reached a peak in the blood and prostatic fluid within 0.5 hr, which was sustained for 2 hr. Twenty-one men ingested 1.6 g of SMZ; SMZ reached a peak in serum and semen 4 hr after ingestion and was sustained in semen for 24 hr. Ethanol and SMZ were excreted equally by the prostate and seminal vesicle. Pathologies of the prostate were not correlated with either ethanol or SMZ secretion.


Relationship of seminal plasma testosterone and dihydrotestosterone to sperm count and motility in man. A radioimmunoassay previously described for serum T and DHT was adapted for use in the measurement of these hormones in seminal plasma. The seminal plasmas of 273 semen specimens were assayed for T and DHT concentration. Mean levels of these hormones for various sperm count and sperm motility categories were determined. We found that: (1) the DHT level of the azoospermic group was significantly lower than all other groups; (2) the T level of the group whose mean sperm count exceeded 40 x 10(6)/ml was higher than that of all other groups; (3) the DHT level of the group with absent sperm motility was lower than the level of all other groups; and (4) changes in sperm motility were not accompanied by changes in T levels. We concluded that idiopathic male subfertility as evidenced by oligospermia, azoospermia, and decreased sperm motility may be related to insufficient androgen production due to a primary intratesticular defect.


Endocrine correlates of meiosis in the male rat. Changes in the proportion of cells within various DNA classes of dispersed testicular cells from the developing rat were monitored by microflow fluorometry and correlated with changes in the function of the pituitary (FSH), of the Leydig cells (androgens) and Sertoli cells (androgen-binding proteins, ABP). Peaks of androgens and of FSH appeared simultaneously and coincided with an accumulation of tetraploid cells and with the first appearance of haploid cells in the testis and ABP in the epididymis. Estrogen treatment (5 micrograms/day) of developing rats from day 7 completely prevented the appearance of haploid cells in the testis as well as ABP in the epididymis. In these animals the wave of tetraploid cells started and progressed normally, indicating that transformation and progression of germinal cells to the stage of the primary spermatocytes were taking place. A combined treatment with FSH and dihydrotestosterone propionate (DHTP) resulted in a premature start of Sertoli cell secretion of ABP into the epididymis, but in a normal appearance of haploid and tetraploid cells. The time correlation between peaks in FSH/androgens, the start of Sertoli cell secretion, and the occurrence of haploid cells in the testis stresses the importance of these two hormones for normal Sertoli cell function and the importance of a functional Sertoli cell for the completion of meiosis.


Lifetime changes in aspartate carbamyltransferase of reproductive tissue of male rats. Aspartate carbamyltransferase (ACTase) of the testis, epididymis, and prostate gland was determined throughout the lifetime of rats. Testicular ACTase concentration (nmoles carbamyl aspartate formed per microgram protein) peaked at about 45 g body weight, then declined.  Epididymal concentration increased up to 100 g body weight and around 155 g plateaued in the caput and declined slightly in the cauda. A lifetime decline followed the maximal prostatic concentration found in the youngest test rats. Maximal total testicular activity, which occurred at 350 g, was undiminished in the oldest rats, while maximal epididymal activity occurred in the latter group. Total prostatic activity peaked at about 450 g body weight. Castration and testosterone replacement showed prostatic ACTase levels to be hormone dependent.


Pregnancy rate after homologous insemination. Homologous insemination (AIH) was performed in 151 patients. The pregnancy rate was 27% in 143 patients treated with the cervical cap method. In cases of large ejaculate volume the split-ejaculate technique was applied to several types of sperm quality, resulting in a pregnancy rate of 43%. Of 36 women with diminished fertility, five (14%) became pregnant. The motility of the spermatozoa was correlated with the success rate, with 30% good progressive motility thought necessary to consider insemination.


A second look at Steinach's second procedure: testiculoepididymal occlusion in man and dog. After advocating vas occlusion as a biological method for rejuvenating aging males, Steinach had suggested that the effect might be more pronounced if the obstruction were placed proximal to the epididymis. This Steinach II procedure has now been studied in 15 dogs and five men. Occlusion was performed at the level of the vasa efferentia, avoiding any vascular trauma. Radiological visualization confirmed a perfect block. There were no untoward reactions, such as orchitis or hydrocele. In dogs, widespread degeneration in the seminiferous tubules was evident, and the total Leydig cell volume showed an increase from 0.7 to 1.0 ml/testis. The changes, however, were not significantly different from conventional vasectomy. In men, there were considerable preexisting senile changes, and the total Leydig cell volume was already as high as 2.8 ml/testis. These changes obscured any possible effect of Steinach II operation.


Derivation and determination of a human prostatic epithelial index. The approximate percentage of epithelium (Iepith) in a sample of human prostate tissue can be estimated by assaying the specific activity of epithelial marker enzymes, beta-glucuronidase or arginase. There is a good correlation between epithelial density and beta-glucuronidase activity per unit of tissue protein.


[Vectorcardiogram in experimental infarct of the right posterior ventricular wall]. In 20 dogs a chemical necrosis was produced by infiltration of 80% phenol solution within the posterior right ventricular wall and the neighboring interventricular septum. Vectorcardiographic loops were obtained by the cube system in vertical and horizontal heart positions under control conditions, 90 minutes after the necrosis was produced and also after RBB was severed. In 15 dogs the RBB was injured after the necrosis was produced and in 5 previously. In all dogs direct unipolar leads (epicardial and intraventricular), thoracic and abdominal unipolar leads (MD, ME, MI) as well as standard leads were also obtained following the experimental protocol outlined above. Analysis of the changes caused by necrosis in the location rotation and voltage of the initial, intermediate and preterminal portions of the vectorcardiographic curve in the three planes (F, H and left S) permits the formulation of the following conclusions: 1) The most significant alterations were observed in the frontal and sagital planes, particularly in RF and RS loops. In most of the cases, RF and RS loops were displaced upwardly, to the left on the frontal view and slightly anterior on the sagital. The rotation changed to counterclockwise direction on the frontal view and to clockwise on the sagittal one. In a few cases, the clockwise rotation of RF loop was conserved but it was displaced above the mean value of RF curl in horizontal hearts (+ 3 degrees 30'). 2. RH loop shifted posteriorly in both vertical and horizontal heart positions. The area enclosed by centripetal anterior branch RH loop was reduced and its apex was frequently delayed by 3 msec. 3) In presence of RBBB, the alterations described above on the frontal and sagittal views were conserved in both heart positions. The only distinct behaviour was observed in the horizontal loop, in which RH loop is posteriorly located with counterclockwise rotation in the vertical hearts and anteriorly in the horizontal one. Nevertheless, the voltage of R loops increased in both positions when the necrosis was produced after the RBBB. 4) In spite of differences in thickness of the right ventricular wall between dog and man (it is thicker in the dog), we propose that alterations of RF and RS loops could be extrapolated to the human V.C.G. in order to evaluate the involvement of the right ventricle by myocardial necrosis. 5) Similar alterations of RF and RS loops were observed in the presence of necrosis of the left posterior ventricular wall. The only clue to establish a differential diagnosis is based on the characteristics of RH loop, which is more anteriorly displaced with an "8" aspect or clockwise rotation in the presence of left side necrosis. Both VCG and ECG appear to be helpful on the topographic diagnosis and evaluation of injured myocardium in the right ventricle.


[About vectorcardiographic examination]. The clinical importance of the spatial exploration of the cardiac electrical phenomenon (vectorcardiography), which is a very useful integration of the analytical and limited electrical exploration (electrocardiography), is outlined here. Reasons inducing the mexican school to prefer the Grishman's cube method for the vectorcardiographic recordings of other more elaborate and complex systems, are explained. The former reflects in a more reliable way the sequence of myocardial depolarization and repolarization. Morphological and chronological aspects characteristic of the normal vectorcardiogram in the frontal, horizontal and sagittal planes, are described. Additionally some typical examples corresponding to the three main electrical heart positions are presented. The vertical position is frequent in children and longilineal persons, the intermediate position is common in adults and the horizontal one is observed in age people and brevilineal persons. Some vectorcardiographic aspects typical of myocardial necrosis, injury and ischemia are discussed, underlining the importance of the complementary elements given by vectorcardiography.


[Role of the autonomic nervous system in early arrhythmias in acute myocardial infarct in the rabbit]. In order to evaluate the influence of the autonomic nervous system in the incidence and characteristics of the early arrhytmias that follows myocardial infarction, we have developed an experimental myocardial infarction in rabbits by acute occlusion of the left ventricular artery. The influence of adrenergic and cholinergic suppression over rhythm disorders and hemodynamics changes after experimental infarction in the rabbit was also studied. We found that after the acute experimental infarction in the rabbit heart, arose an early stage of rhythm disorders in 60% of the animals. In a group of animals that were injected with Practolol before coronary occlusion, the incidence of arrhythmias was 25% and in a group of animals with vagotomy prior to occlussion none of them developed rhythm disorders. It was concluded that the model is highly steemed for the study of early arrhytmias and that automatic nervous system has an important role in the incidence of such arrhythmias.


[Congenital intrapericardial parietal aneurysm of the left atrium. The electrocardiogram and echocardiogram as methods of diagnostic value]. A case of congenital intrapericardial aneurysm of the left atrium associated with functional mitral insufficiency is described; it was resected successfully. Clinical, radiographic, vecto-electrocardiographic, ecocardiographic and angiocardiographic findings are shown. Those are compared with those of other nine similar cases. The finding of qR or QS complexes in L-I and a VL in the electrocardiogram as a sign of left atrial enlargement and eco-fre space posterior to the left ventricular endocardium in the ecocardiogram is mentioned as useful data in the diagnosis of left atrial aneurysmal dilatation not previously reported. Considering that the surgical result is always good, it is concluded that the congenital intrapericardial aneurysm of the left atrium is a rare malformation which needs to be resected irregardless of the presence or absence of arrhythmias, embolisms or heart failure.


[Exertion test in patients with previous myocardial infarct]. Seventy-six survivors of a prior myocardial infarction were subjected to maximal treadmill stress testing. At least two months had elapsed between the acute episode and the inclusion of the patients in the study. In 39% of the cases the infarction was located to the inferior wall of the left ventricle, in 42% it was anterior and in 18% it was both anterior and inferior. The stress test was positive in 51% and negative in 46% of the cases, while it was non-diagnostic in 3%. The high percentage of negative tests may be explained by the fact that, in these patients, the coronary obstructive lesions are limited to the vessels supplying infarcted myocardium, while the remaining muscle has an adequate coronary perfusion. The percentage of positive tests was higher in patients with anterior (59%) than in those with inferior wall infarctions (43%). In the group of patients with anteroapical aneurysms the incidence of ischemic responses to exercise was 73%. In two of these cases, there was an exercise induced elevation of the ST segment. 75% of the patients who had post-infarction angina had positive tests. Ventricular premature beats developed in 17% of the subjects during or immediately after the period of exercise. The great majority of patients showed an impaired functional aerobic capacity. In patients with coronary artery disease, the left ventricle has a diminished capacity to augment its stroke volume. In order to increase cardiac output during effort, these patients depend on early elevations of heart rate. A positive exercise stress test, in patients with prior myocardial infarction, appears to be a valuable means of identifying the existence of residual myocardial ischemia resulting from coronary lesions in other vessels. It may be a prognostic tool helping to detect the high risk subjects and it may also be used to precisely determine the effort capacity in individual subjects.


[Phonomechanocardiography of 141 healthy patients]. When studying 141 normal persons of both sexes we checked acoustic phenomena and measured the sistolic intervals. We discuss here the presence of blowing anorganic phenomena and sounds III and IV among the general public. We develop equations of regression to correct the electromechanic sistole (QIIA) and the left ventricular ejection time (LVET) the registered values being different from those published by other researchers. Last of all we analyse semiology and the interpretation of the sistolic phases of the cardiac cycle using them in a routinary way and stressing its value and limitations, specially when used to get a better knowledge of the state of the myocardial functions.


[Pulmonary eosinophilia and pulmonary arterial hypertension]. Pulmonary artery hypertension is a rare feature in the eosinophilic pulmonary syndrome, it had been observed only in some cases of tropical pulmonary eosinophilia. A case of prolonged pulmonary eosinophilia with reversible pulmonary hypertension is presented.


[Penicillin allergy. Immunological bases in the diagnosis and prevention of acute reactions]. Drug alergy is always a risk in Therapeutics. Penicillin allergy although less frequent than usually though, is very important because sometimes is life threatening. Penicillin allergy is an immunological phenomenon, it is possible to use in vitro and in vivo procedures able to demonstrate individual ability to develop allergical reaction, in particular to predict such severe reactions like anaphilaxis. This paper review current concepts regarding immune mechanisms for Penicillin allergy and immunological testing useful in its study.


[Chronometric cardiovascular examination. A clinical method to determine the duration of various circulatory processes]. In 127 cases (70 with cardiopathy, 41 with arteriopathy and 16 normals) a "chronomethryc clinical exploration" was performed. This procedure consists in obtaining an electrocardiogram at the same time a clinical examination is performed and in the very moment of the occurrence of a physical or oscilometric phenomenon the standardization marker of the electrocardiogram is actioned to register a mark indicating a Q-phenomenon interval. 3 of this intervals are measured for each clinical phenomenon and the two closest values are averaged. This method is based in the fact that the time of human reaction varies relatively little when 2 successive similar phenomena are appreciated (for ej.: 0.158 sec. +/- 0.036 (SD) and 0.154 sec. +/- 0.042 (SD), n = 32, P = non significant for the first and 2nd. auscultated cardiac sounds). In this way the following intervals were estimated: acustyc systole (n = 52), 2nd. sound-opening mitral snap interval (n = 17), duration of systolic cardiac murmur (n = 22), mechanic systole (n = 14), left ventricular eyection time (n = 15), and IIa-O interval (n = 17) and compared with their respectives phonographyc or apicography values with correlations coefficients of 0.58, 0.83, 0.73, 0.58, 0.70, and 0.70, respectively. The sistolic murmurs were classified in proto, meso or telesystolic and a good correlation was found with the phonography (method in 91.0% of cases). This procedure also identified correctly a left IV sound (n = 8) even in cases in which this sign formed a complex with the first heart sound.


High-dose corticosteroids: their use in treating idiopathic rapidly progressive glomerulonephritis. To evaluate the response of patients with idiopathic rapidly progressive glomerulonephritis (RPGN) to high-dose corticosteroids, we have studied ten consecutive patients with this disorder. All were given 1 g of methylprednisolone intravenously each day for one week and then placed on a high-dose orally administered prednisone regimen. Four of the ten patients with idiopathic RPGN responded with a sustained reduction in the serum creatinine level of at least 50%. The patients who responded were characterized by a symptomatic illness of short duration and normal blood pressure. Renal biopsies in the responding patients showed minimal glomerular and crescentic sclerosis with mild interstitial fibrosis. The nonresponders had a long symptomatic illness with elevated initial blood pressures. The renal tissue in this group had considerable fibrosis of the crescents, glomeruli, and interstitium. The results suggest that a certain group of patients with idiopathic RPGN will improve with high-dose corticosteroid therapy.


Enhanced cardiac effect of digoxin during quinidine treatment. Quinidine causes an increase in the serum digoxin concentration. Three patients were studied to determine if the increase in serum concentration is paralleled by an increase in the cardiac effect of digoxin. Each patient's clinical condition and serum digoxin concentration were stable when quinidine administration was begun. In all three patients, serum digoxin concentrations increased significantly after beginning quinidine, and decreased when quinidine was discontinued. While taking quinidine, all three patients had ECG findings that suggested enhanced digitalis effect and one patient had clinical evidence of an increased hemodynamic effect. These effects paralleled the increases in serum digoxin concentration. Our findings suggest that the increase in serum digoxin concentration, which occurs after beginning quinidine, is associated with an increase in the effect of digoxin on the heart.


[Evaluation of the experience of the observer in the interpretation of myocardial scintillography with radioactive phosphates]. Two-hundred-and five myocardial scans with radioactive phosphates, performed in 185 patients interned at the Coronary Care Unit due to acute chest pain (147 myocardial infarcts: 58 coronary heart disease), were independently interpreted by six observers with different degrees of experience on the lectures of these kind of images (two nuclear physicians, two cardiologists, and two fellows of the Nuclear Medicine Unit). A series of six different grades of myocardial concentration of the radioactive phosphates, related to its osseous concentration were followed. Each observer reported the grade of concentration he found in each image. The fraction of myocardial infarcts and of coronary heart disease found by each observer in every grade of concentration were calculated. With these data, it was determined the optimal criterion level of each observer by which he attained the minor incidence of false negative and false positive results. Four observers found their optimal criterion level on 2F, where grades 0-2D are considered as negative, and grades 2F-4 are considered as positive. One observer found his optimal level at 2D (0-1: -; 2D-4: +) and other at 1 (0: -; 1-4: +. By using a decision matrix which relates results of the test with a binary outcome (normal, abnormal) to the actual diagnosis, also with a binary outcome (infarct, no infarct), the ratios for "sensitivity", "specificity" and "accuracy" were derived for each observer performing at his particular optimal criterion level. Our results suggests that the observer performance depends on his particular degree of experience in interpreting nuclear medical images and on his visual perception. It was concluded that it is necessary to periodically evaluate the individual optimal criterion level of the physicians in charge of the lectures of the myocardial images with radioactive phosphates, liable to shift with time in relation to the experience of the observer. The need of a more objective procedure to quantitate myocardial concentration of the radioactive phosphates is also implied.


Large bronchial casts.

Large bronchial casts. Unusually large bronchial casts developed in four patients. In two, the casts were associated with pneumonia. In one, a large RBC cast resulted from a complication of fiberoptic bronchoscopy. Bronchial casts developed in an additional patient as a manifestation of plastic bronchitis. Although unusual, bronchial cast formation may complicate a number of hypersecretory pulmonary diseases. Therapy ordinarily includes specific measures to treat the underlying disease state and maneuvers designed to remove or facilitate the expectoration of bronchial casts.


Rapid blood pressure control with minoxidil: acute and chronic effects on blood pressure, sodium excretion, and the renin-aldosterone system. Changes in blood pressure, heart rate, electrolyte excretion, and the renin-angiotensin-aldosterone system were monitored before and after minoxidil was added to a regimen of a diuretic and propranolol hydrochloride in 12 severely hypertensive patients. None required more than 40 mg of minoxidil daily for control. On a constant intake, urinary sodium excretion decreased, while urinary potassium excretion remained stable. Heart rate, body weight, and plasma volume increased, while creatinine clearance did not change. Although plasma renin activity increased fourfold, the plasma aldosterone concentration did not increase. Six subjects were restudied after two months of minoxidil treatment. Although blood pressure control continued to be excellent in these subjects, plasma renin values and plasma volume had returned to pretreatment levels. These studies suggest that minoxidil rapidly and effectively lowers blood pressure. Although sodium retention accompanies minoxidil administration acutely, the effect is independent of aldosterone and may be transient.


[Isolated mitral valve substitution with Beall prosthesis. Long term results]. During a three-year period (1970 to 1973) the Beall mitral prosthesis (103, 104 & 105 series) was used in 97 patients for isolated mitral valve replacement. The early surgical mortality rate within the first 30 days of operation was 11.34%. Among the 86 survivors, 7 developed thromboembolic complications (8.14 per cent), and there were 20 late deaths. Incidence of other complications such as prosthetic malfunction and significant intravascular hemolysis are commented. The 92.42 per cent of the late survivors are in Class I or II of the N.Y.H.A. functional classification.


Chronic progressive coccidioidal pneumonitis. Report of six cases with clinical, roentgenographic, serologic, and therapeutic features. Chronic progressive coccidioidal pneumonitis (CPCP) is an uncommon sequela of acute pulmonary coccidiodomycosis. Six recent patients with CPCP are described, most of whom were previously healthy. The clinical presentation was indolent, resulting in long diagnostic delays. Serial chest roentgenograms showed progressive pulmonary infiltration and sputum cultures were persistently positive for Coccidioides immitis. Serum complement fixation (CF) antibody titers were high, with five of six patients having titers greater than or equal to 1:16. No patients had evidence of extrapulmonary coccidioidal spread at time of diagnosis of CPCP, although hematogenous dissemination occurred later in one patient. Five patients received amphotericin B intravenously (greater than or equal to 30 mg/kg total), resulting in rapid clinical and mycologic cure, decline in CF titers, and roentgenographic improvement or stabilization. However, two of these five patients suffered permanent physiologic impairment. One patient refused therapy and remains clinically symptomatic, with chronic positivity of sputum cultures for C immitis and high CF titers.


Hypertension continuation adherence: natural history and role as an indicator condition. We analyzed a random sample of general medicine clinic patients to determine the natural history of newly treated hypertensive (NH) patients: discontinuation patterns, critical intervention periods, and hypertension's (HBP) utility as an indicator condition. The NH patients exhibited a 48% dropout rate in the first year and better continuation adherence than new nonhypertensive (NNH) patients. Patients with HBP and other chronic diseases had better continuation adherence than those with HBP alone, although no predictive patterns emerged. New patients displayed rapid early discontinuation, with further linear decline by four months for NNH and by eight months for NH patients. All patients showed similar subsequent falloff: linear annual decline at 13% to 36%. We conclude that discontinuation rates are unacceptably high, that interventions must be continued throughout treatment, and that HBP has limited utility as an indicator chronic disease.


Rhinocerebral mucormycosis: premortem diagnosis and therapy. The diagnosis of rhinocerebral mucormycosis is most often made at autopsy. We report a series of nine patients in whom the diagnosis was established premortem. Six of the patients had underlying diabetes mellitus and three had acute leukemia. Facial or ocular pain was the complaint found in all patients, and frequently was the initial symptom. The diagnosis was established by examination and culture of infected tissue obtained by biopsy. In seven patients, identification of hyphal elements in smears of biopsy material allowed the immediate institution of amphotericin B therapy. Four of the seven patients treated with amphotericin B survived. All surviving patients had underlying diabetes mellitus and had undergone surgical debridement. Early diagnosis leading to immediate institution of appropriate therapy is most important for survival of patients with mucormycosis.


St Louis encephalitis in Ohio, September 1975: clinical and EEG studies in 16 cases. In 1975, during the largest epidemic of St Louis encephalitis (SLE) in the United States, 416 cases were diagnosed in Ohio. Persons who were admitted to two Columbus (Ohio) hospitals with suspected acute viral CNS infection were prospectively studied to define the virologic and clinical aspects of SLE. Sixteen cases of SLE were diagnosed serologically. Fifteen patients had signs of encephalitis and one had aseptic meningitis. Six patients had the syndrome of inappropriate antidiuretic hormone secretion. Other frequent findings included moderate peripheral leukocytosis and CSF pleocytosis, with mild elevation of CSF protein levels but normal glucose levels. Severe neurologic sequelae were infrequent. The EEG proved valuable in diagnosis and prognosis. Results of brain scans were normal. Virus in CSF or urine was not demonstrated, nor was viral antigen in CSF or urine sediments. Specific antibody was found in the sera and CSF of all patients who were tested, but interferon was not detected.


Bacteremia and meningitis following fiberoptic bronchoscopy. Bacteremia and meningitis due to Streptococcus pneumoniae developed in a 52-year-old man 28 hours after an otherwise uncomplicated fiberoptic bronchoscopy. The patient responded to antimicrobial therapy and supportive care and later underwent pneumonectomy for carcinoma. This report reinforces previous observations that bacteremia may occasionally be associated with the performance of fiberoptic bronchoscopy.


Recovery from aplastic anemia after treatment with antilymphocyte globulin. A 16-year-old boy with aplastic anemia that was resistant to treatment with androgens and prednisone and that had a high transfusion requirement was treated with antilymphocyte globulin. A complete normalization of the hematologic values was obtained. The result supports the theory of immune pathogenesis in some cases of aplastic anemia.


Detection of adrenal tumors by computerized tomographic scan in endocrine hypertension. Localization of adrenal lesions in various adrenal disorders can be difficult. An attempt to identify the adrenal tumors in ten patients with pheochromocytoma, Cushing's syndrome, or primary aldosteronism was made using computerized tomographic (CT) scans. The adrenal tumor was visualized in eight patients. The CT scan appears to be a promising noninvasive technique for localization of adrenal tumors.


Aspergillus flavipes group osteomyelitis. Lumbar vertebral osteomyelitis caused by Aspergillus Flavipes group organisms developed in a nonchronically immunosuppressed patient. Diagnosis was confirmed morphologically and culturally from both closed needle biopsy of the vertebrae and subsequent lumbar laminectomy. The patient was treated with 3 g of amphotericin B with apparent eradication of the organism.


Cryofibrinogenemia in Henoch-Schönlein purpura: report of a case. A patient with Henoch-Schönlein purpura (HSP) had exacerbations of disease that correlated closely with the presence of cryofibrinogenemia. Cryofibrinogen was absent consistently during asymptomatic intervals. To our knowledge, such a pattern has not been described previously in typical HSP. We suggest that all patients with HSP be screened for cryofibrinogenemia during the active phase of disease to determine the incidence of this abnormality.


Histoplasmosis and Lennert's lymphoma.

Histoplasmosis and Lennert's lymphoma. Histoplasma capsulatum was cultured from splenic tissue obtained at diagnostic laparotomy in a patient with "Lennert's lymphoma." The patient had no clinical features suggesting histoplasmosis, and the organism was not seen on histologic specimens. It is suggested that mycologic cultures as well as histopathological examinations of surgical specimens be performed routinely in immunologically compromised individuals.


Transient thyrotoxicosis associated with painless thyroiditis and low radioactive iodine uptake. We describe a patient with transient thyrotoxicosis and low radioactive iodine uptake by the thyroid. Although the clinical course in this patient was compatible with subacute thyroiditis, she did not experience pain or tenderness in the neck. The use of thyroid hormones or iodine was excluded. The substantial level of thyroid antibody in serum was present during the entire phase of the disease. Histological findings on thyroid biopsy were characteristic of chronic lymphocytic thyroiditis. Furthermore, it was remarkable that the histological abnormalities improved spontaneously during the course of several months, with the spontaneous recovery of clinical signs and biochemical abnormalities.


Extent and severity of coronary heart disease. Determinations by thallous chloride Tl 201 myocardial perfusion scanning and comparison with stress electrocardiography. Rest and exercise ECGs are the most widely used "noninvasive" tests for detecting coronary heart disease, but their sensitivity and specificity are suboptimal. Therefore, the diagnostic value of myocardial perfusion scanning using thallous chloride Tl 201 during rest and stress electrocardiography was examined in 95 patients with a chest discomfort syndrome. Overall, thallous chloride Tl 201 perfusion scanning had a sensitivity of 75% and a specificity of 91% for coronary heart disease compared with 56% sensitivity and 86% specificity with exercise-induced ST segment depression on the ECG. Combining rest and stress ECGs resulted in a sensitivity of 71%. In patients with coronary heart disease, perfusion scanning had a sensitivity of 93% for asynergy compared with 58% for exercise-induced ECG ST depression. Rest and stress myocardial perfusion scanning with thallous chloride Tl 201 provides improved sensitivity with good specificity in the diagnosis of coronary heart disease compared with exercise electrocardiography alone.


Measurement of medication compliance in a clinical setting. Comparison of three methods in patients prescribed digoxin. Medication compliance is an important medical process, and useful methods are needed to measure compliance in clinical practice. Interview, pill count, and serum digoxin concentration (SDC) were compared in 173 patients prescribed digoxin to determine (1) feasibility, ease, timeliness; (2) reasons for noncompliance; and (3) validity of interview and pill count compared with SDC. All patients were interviewed; among 33 (19%) not taking their medication correctly, nine (5%) did not know how. Pill counts were possible for 68 patients (39%). One patient had a correct pill count. Steady-state SDCs were obtained for 143 patients (83%), but were not available during patients' visits. The SDCs for 25 patients were less than 0.50 ng/mL. Interviews correlated with SDCs, pill counts did not. Pill counts and SDCs required telephoning patients before appointments. In clinical practice, interview may be the most useful methof of measuring medication compliance.


Reduction in exertional myoglobinemia after physical conditioning. The development of a sensitive radioimmunoassay for the measurement of myoglobin now permits the accurate determination and detection of even small concentrations of serum myoglobin. To determine the effect of exercise and physical conditioning on serum myoglobin levels, 16 male Army recruits (ages 18 to 28 years) underwent treadmill exercise and strenuous physical evaluation tests (PETs) that consisted of sit-ups, push-ups, horizontal ladder, obstacle course, and 3.2-km run. These tests and exercise were performed before and after 12 weeks of physical conditioning performed in conjunction with basic military training. Serum myoglobin levels did not rise after treadmill exercise, but they were increased greatly six hours after PET. After physical conditioning, serum myoglobin concentrations measured after the treadmill exercise remained normal and values after PET showed a significant decrease (P less than 0.001) as compared with those measured before physical conditioning (mean +/- SD, 160 +/- 81 ng/mL after initial PET vs 76 +/- 60 ng/mL after physical conditioning). These results demonstrate that physical training reduces the degree of myoglobinemia occurring after strenuous exercise, possibly by modifying skeletal muscle alterations that allow myoglobin release in this setting.


Thyrotoxicosis, hypercalcemia, and secondary hyperparathyroidism. Two patients with hypercalcemia and hyperthyroidism had elevated levels of parathyroid hormone (PTH). When the patients were made euthyroid with appropriate medical therapy, both the levels of PTH and calcium returned to normal. Since thyroid hormone can increase tissue responsiveness to catecholamines, and since catecholamines can stimulate PTH secretion, we postulate that the elevated levels of PTH were secondary to thyrotoxicosis. In patients with coexisting hyperthyroidism and hyperparathyroidism, primary hyperparathyroidism should only be diagnosed when the patient is eumetabolic.


Sampling variability on percutaneous liver biopsy. Sampling variability of liver biopsy was determined in three consecutive biopsy specimens obtained from each of 118 patients immediately prior to autopsy. No sampling variability was found for fatty liver, alcoholic hepatitis, nonspecific hepatitis, fulminant hepatitis, leukemic infiltrate, and venous congestion. Cirrhosis was diagnosed in 80% of cases at the first biopsy but in all cases after three biopsies. Chronic aggressive and chronic persistent hepatitis were diagnosed correctly in two of three cases each at the first biopsy, and in all cases after three biopsies. Metastatic carcinoma was detected in 46% of cases at the first biopsy and in 69% after three biopsies. Granulomas were missed once on the first biopsy, but found on a subsequent biopsy. The amounts of fat and fibrosis in the biopsy specimens often were not representative of the amounts present at autopsy.


Vacuolization of the neutrophil in bacteremia. We evaluated cytoplasmic vacuolization in the neutrophil as a marker of bacterial infection. We sought this phenomenon in 96 septic and nonseptic subjects. No significant differences in the extent of vacuolization were found among control patients, toxic patients without bacterial infections, and patients with bacterial infections in the absence of documented bacteremia. The extent of vacuolization was significantly greater in bacteremic patients when compared with all other groups, including patients with bacterial infection without bacteremia. However, extensive vacuolization in the neutrophils of some patients in toxic states not apparently caused by bacterial infection was noted. The phenomenon seems useful as a diagnostic test to identify bacteremia, although it may be less specific than previously thought.


Clinical resistance to vasopressin. Detection of antibody by hemagglutination. We describe a patient with hypothalamic diabetes insipidus who after 20 years became refractory to the effect of commercial vasopressin injection. Vasopressin antibodies were measured using a sensitive hemagglutination technique. Resistance was associated with a high titer of antibodies that disappeared once vasopressin therapy was withdrawn and the diabetes insipidus was controlled with chlorpropamide. Antibodies were also measured in four additional patients with diabetes insipidus while they were or were not receiving vasopressin. A patient who had received the drug for only two years already had a substantial titer of antibodies to vasopressin, but in this case the response to the hormone was not impaired.


Trace element composition of ascitic fluid. The relationship between trace elements in the serum and ascites of the cirrhotic patient was investigated because there is an interchange of protein, particularly albumin, between serum and ascitic fluid. To study this relationship, serum and ascitic fluid were obtained from 13 patients with biopsy-proved Laennec's cirrhosis. The trace element content of the ascitic fluid studied was less (22% to 73%) than that in serum. Protein fractions were all decreased in ascitic fluid compared with serum. Levels of zinc, calcium, copper, selenium in ascitic fluid correlated well with the ascitic fluid protein fractions. Thus, the trace element composition of ascitic fluid differed appreciably from that of serum, and seemed to correlate with the protein composition of the ascitic fluid in the case of zinc, copper, calcium, and selenium.


Polycythemia vera and mesenteric arterial thrombosis. A disease association resulting from decreased platelet sensitivity to aspirin. Recurrent mesenteric arterial thrombosis developed in a 56-year-old man with polycythemia vera (PV) despite therapy with heparin sodium, warfarin sodium, and standard doses of aspirin and dipyridamole. Platelet aggregation studies disclosed a normal response to aggregating agents in the presence of blood levels of aspirin that usually inhibit in vitro platelet aggregation. Increasing the in vivo dose of aspirin was associated with inhibition of in vitro platelet aggregation and, thereafter, arterial thrombosis did not recur. This case demonstrates that some patients with PV and arterial thrombosis may be refractory to standard doses of anticoagulants and platelet antiaggregating agents.


Acute hepatitis with bridging necrosis due to hydralazine intake. Report of a case. A 59-year-old woman was admitted to the hospital for evaluation of her hypertension. She was treated with hydralazine; two days later a severe acute hepatitis supervened. On discontinuation of the agent, the liver damage disappeared, relapsed during inadvertent rechallenge, and healed following permanent withdrawal from the drug. Histologic study of the liver showed severe acute hepatitis with bridging necrosis (so-called subacute hepatitis). Six months after discontinuation of hydralazine, a second liver biopsy specimen showed a complete remission of the disease. This hydralazine-induced hepatitis appears to be fully reversible and to differ both on clinical and histological grounds from two previous reports documenting a granulomatous liver disease.


Histoplasmosis. Association with circulating immune complexes, eosinophilia, and mesangiopathic glomerulonephritis. A patient with disseminated histoplasmosis, eosinophilia, and transient mesangiopathic glomerulonephritis stimulated a search for the presence of circulating immune complexes. Serum samples obtained on the fifth and 11th hospital days were strongly positive for ciculating immune complexes by both the Raji cell radioassay and the C1q solid phase assay. During the course of complete clinical recovery without therapy, both assays were weakly positive for circulating immune complexes on day 33. On day 56 they were negative. Using this case as a prototype, possible mechanisms for the renal immunopathology and the eosinophilic response are discussed with reference to the immunological perturbations thay may be observed in systemic mycotic infection.


Recurrent meningococcal meningitis with occult CSF leak. Recurrent meningococcal meningitis was associated with a slow CSF leak in a 24-year-old man. Unique features of the case included isolation of meningococcal group 29E. We speculate that an association exists between subclinical CSF leaks and sporadic cases of meningitis.


Hepatic encephalopathy precipitated by fecal impaction. Two episodes of hepatic encephalopathy developed in a 64-year-old man with cirrhosis during the course of hospitalization. The first event was precipitated by spontaneous bacterial peritonitis; the second occurred four weeks later and was associated with a massive fecal impaction, an unreported precipitant. No other potential causes were demonstrated. Symptoms promptly resolved following disimpaction.


Pulmonary lymphangitic carcinomatosis from the cervix. Diagnosis by transbronchial biopsy. A diagnosis of pulmonary lymphangitic spread of cervical cancer was established by transbronchial biopsy in a 58-year-old woman requiring mechanical ventilation. Confirmation of the clinical diagnosis allowed supportive therapy in this terminal stage of cancer. To our knowledge, this report is the first to describe this result from cervical carcinoma and to establish the diagnosis of lymphangitic carcinomatosis by transbronchial biopsy.


Characterization of the cytoplasmic fibrils of Treponema refringens (Nichols). The cytoplasmic fibrils of Treponema refringens were studied in situ by electron microscopy of thin sectioned and negatively stained cells. From 5 to 21 parallel fibrils ran through the cell in a band adjacent to the inner side of the cytoplasmic membrane, on the inner sides of the curves of the spirochete. The nuclear areas of cells were adjacent to the fibrils. Cross sections of fibrils isolated from cells which had been lysed were polygonal and not uniformly electron dense. Polyacrylamide gel electrophoresis of partially purified fibril preparations indicated their main component to be a protein with a molecular weight of 97,000. Fibrils were solubilized by 1% trypsin, 1% pronase, 6 M urea, 1 N HCl, 0.005 N NaOH or 1.3% sodium dodecyl sulfate. By electron microscopy of negatively stained isolated fibrils, each fibril was found to be a complex arrangement of strands rather than a single tubule.


Branched chain amino acid aminotransferase isoenzymes of Pseudomonas cepacia. Pseudomonas cepacia grew rapidly using a mixture of all three branched chain amino acids as carbon source, but failed to use individual branched chain amino acids as sole carbon source. Extracts of bacteria grown on branched chain amino acids had between 2- and 3-fold higher levels of alpha-ketoglutarate-dependent branched chain amino acid aminotransferase activity than extracts of glucose-grown bacteria. The increase in enzyme activity was due to the presence of a second aminotransferase not detected in extracts of glucose-grown bacteria. The enzyme, which presumably plays a role in branched chain amino acid degradation, had an apparent molecular weight (mol.wt.) of 75,000. The other aminotransferase was formed constitutively and apparently functions in synthesis of branched chain amino acids. It was more stable than the 75,000 mol.wt. enzyme, and was purified to homogeneity and found to be a 180,000 mol.wt. oligomer containing 6 subunits of approximately 30,000 mol.wt. Antiserum prepared against the purified enzyme inhibited its activity but failed to influence the activity of the 75,000 mol.wt. aminotransferase, suggesting that the two isoenzymes are encoded by different genes.


DNA-DNA homology studies among strains of Arthrobacter and Brevibacterium. Sixteen named strains of Arthrobacter and two strains of Brevibacterium were investigated by nucleic acid hybridisation. The Arthrobacter strains show homology values ranging between 11 and 55% to the type strain A. globiformis DSM 20124 (ATCC 8010), indicating only a low to moderate relationship. Two strains of A. globiformis, DSM 20124 and DSM 20125, exhibit only poor relationship to one another (30%). Among all the Arthrobacter strains the homology data range between 10 to 70% demonstrating separate status of almost all species. Only A. polychromogenes DSM 20136 was found to be a subspecies of A. oxydans DSM 20119. The type strain of A. citreus, DSM 20133 shows a remarkable lack of homology to four other strains of A. citreus, deposited as ATCC 15170, ATCC 17775, ATCC 21040 and ATCC 21348 (11--13%) which themselves can be separated into two groups according to the homology data (24--31%). Each of the two strains of Brevibacterium share high genetic relatedness with one of these A. citreus groups (71 and 73%, respectively). According to the DNA-DNA homology data, most of the species of Arthrobacter can actually be ranged taxonomically as species.


Interfamilial transfer of amber suppressor gene for the isolation of amber mutants of Mycobacteriophage I3. A suppressor-containing strain of Mycobacterium smegmatis SN2 was isolated by transferring an amber suppressor carried on the plasmid of Pseudomonas pseudoalcaligenes ERA through transformation. Amber mutants of mycobacteriophage I3 were isolated.


[Abnormalities associated with extrahepatic bile duct atresia]. In 19 cases of extrahepatic biliary atresia there were other malformations, 9 of which could be included in the polysplenia syndrome. The importance of these associated with malformations for the early diagnosis of extrahepatic biliary atresia and for eventual surgery for secondary portal hypertension is emphasized. The histological findings of the fibrous remnants of the biliary system are similar in those with and without associated malformations. Thus, these abnormalities do not contribute of the understanding of the pathophysiology of extrahepatic biliary atresia but they do suggest that the initial insult may occur early in pregnancy.


[Therapeutic embolization of a congenital vertebral arteriovenous fistula]. An arterio-venous fistula in the neck arising from the right vertebral artery is described. Selective angiography showed a single communication. A Fogarty catheter, introduced by the occipital artery and left in situ was used as a means of embolisation. This procedure was simple and effective.


[Diet regimen and long-term prognosis in juvenile diabetes]. Two groups of diabetics who were diagnosed before the age of 15 years and followed by the same doctors of 20-25 years were compared. The frequency of complications was significantly different in France compared to that in the United States. The differences may be dietary in origin because in France the diet is high in carbohydrate and low in fat but in the United States the diet is high in fat and low in carbohydrate.


[Hemineurine: an always present hazard in children]. Chlormethiazole, a hypnotic and sedative drug that selectively inhibits the cerebral cortex is occasionally used in status epilepticus in children. A child aged 18 months is described who developed toxic side effects. This drug, given as an alcoholic solution is highly toxic if used inappropriately.


[Coumarin-induced fetal abnormalities and stippled epiphyses]. The ability of most anticoagulants (except heparin) to cross the placenta and the consequent hemorrhage in the fetus has been recognized for some time (3). A teratogenic effect specifically attributed to warfarin sodium is a more recent finding (7, 9, 10). The following is a case report of a newborn with clinical and roentgenographic features similar to the cases reported previously.


[Fibrous dysplasia of long bones with remission. Apropos of 3 cases]. Three cases of fibrous dysplasia of bone, affecting the long bones of the leg are described. This condition is a clearly defined radiological and clinical entity. The tibial lesion is reminiscent of a congenital pseudarthrosis but the involvement of the fibula is a useful diagnostic clue. The most important feature of the condition is that it heals spontaneously.


[Aortic arch interruption and cutaneous PO2]. In three neonates with cardiac failure and coarctation the cutaneous PO2 (cPO2) has been measured during the administration of a high concentration of oxygen. One sensor was fitted to the skin just below the right clavicle (preductal) and the other on one of the legs (postductal). The difference in the cPO2 provided evidence for a large right to left shunt through the duct. This finding in conjunction with the clinical syndrome of co-arctation is characteristic, in our view, of atresia of the aortic arch. The results of the test, with clinical and echocardiographic details enable more accurate decisions to be made before catheterisation and surgery.


[Acute polyradiculoneuritis in children. Clinical and developmental aspects. Prognostic factors apropos of 100 cases]. The main clinical features of acute infectious polyneuritis are described from a study of 100 cases. The distinction between Guillain-Barré syndrome and the atypical forms of the condition is arbitrary. In particular, the atypical features (pleocytosis, normal C.S.F. protein, relapses) had no influence on the final prognosis. In contrast, the severity of the distal neurological deficit, the duration of the acute illness, a late dissociation between the cells and proteins C.S.F., the age and sex were all statistically significant prognostic factors.


[A 45 X/46 X dic (Yq) puberal male without genital ambiguity. Critical study of the peculiarities of his phenotype]. A boy with a chromosomal mosaic 45 X/46 X dic Yq is described. The unusual features were a Turner phenotype with normal genitalia and he was in puberty. It is apparent that it is not possible to blame alterations in the Y chromosome when this mosaic is associated with ambiguous genitalia or the stigmata of Turner's syndrome.


[Acute necrosis of the thoracic esophagus and ileum complicating rheumatoid purpura]. A child is described who developed acute ischaemic necrosis of the oesophagus complicating an otherwise typical case of anaphylactoid purpura. This episode was preceded by a necrotising ileitis requiring intestinal resection and ileostomy. The histological similarities of the lesions in the oesophagus and the ileum suggest a common cause connected with the anaphylactoid purpura.


[Severity factors of poisoning in children admitted to intensive care units]. From 1964 to 1976, 854 children were admitted with poisoning to three intensive care units in Paris. The severity of the condition has been assessed in terms of the patients received: 1. observation only (67%). 2. routine intensive care (27%). 3. very seriously ill (6%). At the time of discharge, 92% of children were normal, 3% had minor sequelae, 3% had major sequelae; 2% died. The outcome was closely related to the severity of the illness. The main factors affecting the severity were: 1. The nature of the ingested substance. Poisoning with Amanita phalloides was the most serious with a high mortality. Poisoning with domestic agricultural and industrial products were more often responsible for major sequelae, particularly affecting the oesophagus, than drugs. 2. The type of poisoning. This was related to the age of the child. Iatrogenic poisoning of infants and self poisoning by adolescents were more serious than accidental poisoning in toddlers. 3. The toxicity of the ingested dose. 4. The interval between ingestion and effective treatment. Although all the factors are interrelated, each factor has its own prognostic value.