Reconciling Quinlan and Saikewicz: decision making for the terminally ill incompetent. One of the most perplexing problems in the medicolegal field concerns the criteria on which decisions not to treat terminally ill incompetent patients should be made. These decisions traditionally have been made by physicians in hospitals--sometimes with the assistance of the patient's family--on the basis of their perceptions of the patient's "best interests." Recently, two state supreme courts have ruled on this question. The New Jersey Supreme Court, in the Quinlan case, developed a medical prognosis criterion, and permitted the patient's guardian, family, and physicians to apply it with the concurrence of a hospital "ethics committee." The Massachusetts Supreme Judicial Court, in the Saikewicz case, adopted, on different facts, the test of "substituted judgment" to be applied by a probate court after an adjudicatory hearing. The two cases have been interpreted by many in the medical profession as representing conflicting viewpoints--one supportive of traditional medical decision making and the other distrustful of it. It is the thesis of this Article that Quinlan and Saikewicz are in fundamental agreement and can be reconciled by the next state supreme court that rules on this question. Both courts enunciate a constitutional right to refuse life-sustaining treatment, based on the right to privacy. They agree that incompetents should be afforded the opportunity to exercise this right, and that certain state interests can overcome it. They agree also that physicians should be permitted to make medical judgments, and that societal judgments belong in the courts. The differences in how the opinions are perceived result from the interplay of several factors: the differences in the facts of the cases; the inarticulate use of the term "ethics committee" by the Quinlan court; the literal interpretation of the role of such a committee by the Saikewicz court; a desire for 100 percent immunity on the part of physicians and hospital administrators in Massachusetts; and advice from their counsel on how such immunity can be guaranteed. It is the author's hope that this Article will help to dispel much of the misinformation surrounding these two cases, and to refocus the debate on how decisions should be made for the terminally ill incompetent patient on the real issues regarding criteria and the decision-making process that remain to be resolved.


Patient Compensation Funds: legislative responses to the medical malpractice crisis. Fifteen states have created Patient Compensation Funds in response to the increased cost and reduced availability of medical malpractice insurance associated with the so-called "medical malpractice crisis." Patient Compensation Fund statutes limit health care providers' liability to a specified amount, and establish state-administered funds to compensate victorious malpractice plaintiffs for damage awards in excess of that amount. This Note examines the Patient Compensation Fund mechanism, evaluates its effectiveness as a compensation system for malpractice victims, and recommends particular provisions that might enhance its effectiveness. The Note concludes that the Patient Compensation Fund mechanism is an effective means of increasing the availability and of reducing the cost of medical malpractice insurance, and should be adopted by other states experiencing a "medical malpractice crisis."


Medical paternalism or legal imperialism: not the only alternatives for handling Saikewicz-type cases. In 1977, the Supreme Judicial Court of Massachusetts held in the Saikewicz case that the probate court is the proper tribunal for making decisions whether to give or withhold "life-prolonging treatment" for terminally ill incompetent patients. This ruling provoked debate in the medical and legal communities. Dr. Arnold Relman, Editor of The New England Journal of Medicine, argues that Saikewicz encroaches on existing sound medical practice and requires decision-making machinery that is impractical and inhumane. Relman contends that treatment decision for terminally ill incompetents in Saikewicz-type cases should be made by the physician in consultation with the patient's family. Law professor Charles Baron, in contrast, defends Saikewicz's judicialization approach, arguing that such decision must bemade in an adversary framework that approximates the ideal of the rule of law. In the present Article, Professor Buchanan argues that Relman's criticism of Saikewicz rests on a defective, medical paternalist view of the physician-patient relationship, and that Baron's support of Saikewicz is based on an unjustifiable, legal imperalist view of decision making for incompetents. In Buchanan's view, Relman's approach fails to distinguish appropriately between the making of medical judgments and the making of moral judgments and wrongly assumes that the patient's family typically cannot understand the elements of the decision, while Baron's approach unjustifiably extends the sphere of the legal process by ignoring the special moral relationship that usually exists between the family and its incompetent member. Buchanan proposes an alternative decision-making approach that he believes incorporates the merits, while remedying the defects, of both Baron's and Relman's approaches. The alternative is based on three propositions. (1) The proper presumption in Saikewicz-type cases is that the family of an incompetent is to make decisions concerning treatment. (2) This presumption of the family's dominant role in decision making is defeasible: protection of the patient's rights requires that decisions be made within a framework that allows vigorous discussion and accoutability through impartial review and that provides for legal intervention when necessary. (3) The institutional framework for implementing the features listed in the preceding proposition will rely heavily upon an ethics committee that is neither an all-medical prognosis committee nor an administrative agency of the hospital. Besides evaluating and responding to the Relman and Baron approaches, Buchanan examines the contribution to the Saikewicz debate made by law-and-medicine professor George Annas. In essence, Buchanan rejects Annas's argument that, taken together, the Saikewicz opinion and the Quinlan opinion of the Supreme Court of New Jersey delineate a proper division of medical and legal decision-making responsibility concerning terminally ill incompetents. Buchanan concludes that, contrary to Annas's view, those two cases are not reconcilable.


Relationship of inappropriate drug prescribing to increased length of hospital stay. The relationship of inappropriate drug prescribing to increased length of hospital stay was studied. The medical records of 77 cases of pyelonephritis were reviewed retrospectively. Appropriateness of antimicrobial drug therapy was judged by three types of explicit screening criteria: drug-specific, patient-specific, and match of drug to infecting organism. Patients whose therapy passed all the criteria were hospitalized, on the average, two days less than those whose therapy failed one or more of the criteria. This was a significant difference (p less than 0.05). Age, seriousness of the pyelonephritis, or method of payment appeared to have no significant moderating effect on this result. However, the increased length of stay may not have been associated with only inappropriate prescribing, because the inappropriately prescribing physicians kept their patients hospitalized longer beyond the point of symptom remission than did the appropriately prescribing physicians. The study suggest that successful interventions for improving drug therapy could result in large cost savings.


Administrative approach to disaster preparedness in the pharmacy. Disaster planning for a hospital pharmacy department is discussed. During a crisis, the type of behavior exhibited by hospital personnel and the community can be used to predict the situation's severity and to prepare a response. During disasters, it is important to focus on accomplishing tasks by defining employees' roles, establishing chains of communication, delegating authority to competent persons, limiting decision-making by persons other than those in command and defining the boundaries of pharmacy's involvement in the disaster. A case study of pharmacy operations during a crisis is presented, with guidelines for assessing the situation, establishing priorities, identifying resources and executing a response. Hospital pharmacy administrators must display a high degree of creativeness and responsibility during disasters, but training in the principles of disaster management can be helpful.


Pharmacy practice in an operating room complex. The steps involved in establishing a comprehensive pharmaceutical service in an operating and recovery room complex is described. Objectives of the operating room pharmaceutical satellite were to: (1) improve control of distribution, storage and charging for all drugs, especially Schedule II controlled substances; (2) reduce inventory costs and loss of revenue; (3) improve compliance with the drug formulary; and (4) establish patient-oriented pharmaceutical services. The pharmacy satellite improved inventory control and patient charging, assured continual access to all drugs and appropriate security for controlled substances, and expanded the pharmacy department's clinical, drug information and research activities.


Developing drug-use profiles from drug-charge records. The potential for developing a drug-use profile from drug-charge records was studied at an 830-bed community hospital. Patient drug charges were reviewed retrospectively for one year (1975) to identify: (1) which key drugs accounted for a high percentage of cost and usage; (2) where key drugs were used within the hospital; (3) how they were used; and (4) who were the chief prescribers. Of the drugs used, 8% accounted for 80% of total drug product costs. Seven drug groups (10% of the total drug groups) appeared in the top 10 of both drug cost and quantity categories. Six individual drugs also appeared in the top 10 of both categories. According to cost, cephalosporin antibiotics were ranked first among drug groups but were sixth according to quantity. Analgesics-antipyretics were ranked first among drug groups by quantity and second by cost. Cephalothin was ranked first among individual drugs by cost and was not in the top 10 in quantity. Diazepam was ranked first among individual drugs by quantity and third by cost. Patients' drug-charge records can be used effectively to generate drug-use profiles for ongoing drug use review, quality assurance and cost containment programs.


Predicting warfarin maintenance dosage based on initial response. The relationship between initial response to warfarin sodium, as measured by prothrombin time, and warfarin maintenance dose was studied. Hospital patients received 10 mg of warfarin sodium daily until the prothrombin ratio (patient's prothrombin time/control) was 1.5 to 2.5. Patients subsequently were maintained at that warfarin dosage which maintained prothrombin ratios within this range. Twenty-two patients completed the study. A correlation was found between maintenance dose and the logarithm of the prothrombin ratio on the third day after initiating warfarin therapy (p less than 0.01, r = -0.74). There was no relationship between maintenance dose and the number of days needed to reach therapeutic response. Patients with baseline prothrombin ratios of less than one took significantly longer to reach therapeutic response than did patients with baselines of greater than one (p less than 0.01y. A simple yet scientific approach to determining warfarin maintenance dosage would seem to be feasible. The correlation found between maintenance dose and prothrombin ratio in this study would have to be applied cautiously and only after further validation.


Effect of filtration on complications of postoperative intravenous therapy. The incidence of intravenous complications (phlebitis) and the length of hospital stay in postoperative patients whose infusions were filtered through inline final filters were compared with those in patients whose infusions were not filtered. Identical i.v. solutions were administered to 150 postoperative orthopedic patients randomly assigned to three study groups: control (no filter), 5-micrometers membrane filter and 0.45-micrometers membrane filter. An i.v. therapy team of seven nurses inspected patients for phlebitis. The phlebitis rate of the control group (27%) was significantly greater (p less than 0.05) than that of the 0.45-micrometers filter group (6%) but not significantly different (p less than 0.9) from that of the 5-micrometers filter group (22%). In a subgroup of 104 patients undergoing total hip replacement, the mean reduction in length of postoperative hospital stay compared with the control group (13.6 days) was: 5-micrometers filter group--3.4 days (p less than 0.01); and 0.45-micrometer filter group--3.3 days (p less than 0.01). The results suggest that final filters can be used to reduce the incidence of phlebitis-related i.v. complications and thereby reduce the length of hospital stay.


Deterioration of stannous ion in radiopharmaceutical kits during storage. The deterioration of stannous ion (Sn++) in inhouse-prepared and commercial radiopharmaceutical kits was studied. Sn++ content of three types of nonlyophilized, deoxygenated, aqueous inhouse-prepared kits [diethylenetriamine pentaacetic acid (DTPA), pyrophosphate and glucoheptonate] and of three commercially prepared kits (two lyophilized pyrophosphate kits and one diphosphonate in sealed glass ampul kit) was measured by differential pulse polarography. Inhouse-prepared kits were assayed initially and after storage for 6, 12, 24 and 48 days at 24, 5 and -18 C. Commercial kits were assayed initially and after storage for 12, 24 and 48 days at 5 and 24 C. Of the inhouse-prepared kits, Sn++ stability when stored for 48 days at 5 and 24 C. Freezer storage should be used, when possible, to insure maximum stability of Sn++ in inhouse-prepared, nonlyophilized ratiopharmaceutical kits. The commercial procedures of lyophilization and of sealing the reagent in a sealed glass ampul prolong Sn++ stability.


ASHP Midyear Clinical Meeting papers: 1967--1978. Trends in the types of topics of papers presented at the American Society of Hospital Pharmacists' Midyear Clinical Meetings from 1967 to 1978 are reviewed. A total of 1,210 abstracts of papers presented at the 12 meetings were reviewed. Twenty-three subject categories were identified. Papers were subdivided into four different study types--review, case report, report, and study. Topics such as general hospital pharmacy, management and administration, and drug distribution were emphasized more during the early years of the meeting. Papers on role evaluation, adverse drug reactions and drug use review were presented more frequently in the early 1970s. Therapeutics and general clinical pharmacy were topics consistently emphasized. Case reports increased from 0% in 1967, to 2% in 1972, to 6% in 1978. Review papers decreased from 72% in 1967, to 11% in 1972, to 3% in 1978. Studies increased from 4% in 1967, to 28% in 1972, to 43% in 1978. Concentration on increasing the number of studies presented at the meeting will advance hospital pharmacy and thus improve patient care.


Infections caused by aterial catheters used for hemodynamic monitoring. Utilizing a semiquantitative technique for culturing vascular catheters, we prospectively studied the risk and profile of infection caused by arterial catheters used for hemodynamic monitoring in 95 patients with a high risk of nosocomial infection. Of 130 catheters, 23 (18 per cent) produced local infection (larger than or equal to 15 colonies on semi-quantitative culture) and five septicemia (4 per cent). Sixteen of the 23 local infections and all septicemias occurred with catheter placements exceeding four days (p less than 0.001). Other factors associated with an increased risk of infection included insertion by surgical cut-down rather than percutaneously (ninefold increased rate of bacteremia, p = 0.008) and the presence of local inflammation (12-fold increase, p = 0.009). Systemic antimicrobial therapy (given to 80 per cent of the entire group and to four of the five with septicemia) did not protect against catheter-related infection but may account for the predominance of enterococci, Candida and gram-negative bacilli in these infections. Twelve per cent of all nosocomial bacteremias occurring in this critical care unit population originated from an arterial catheter. Indwelling arterial catheters pose a significant risk of bacteremic infection to ctirically ill patients. The percutaneous mode of placement is preferred; when prolonged arterial cannulation is required, the site should be rotated every four days. Local pain or inflammation, or clinical signs of sepsis without an obvious source should prompt removal and culture of the catheter.


Mezlocillin in the therapy of serious infections. Mezlocillin, a new semisynthetic penicillin chemically related to ampicillin which is more active than carbenicillin against Ps. aeruginosa, B. fragilis and Strep. faecalis and which inhibits many Klebsiella, was evaluated in the therapy of 34 episodes of infection in 26 patients. Infection sites included pulmonary, urinary tract and tissue infections, including peritonitis. Seven patients had bacteremia. Clinical cures were achieved in 83 per cent and bacteria cures in 76 per cent of infections. Cure was achieved with mezlocillin in patients with infections caused by carbenicillin-resistant species. Adverse effects of therapy were minimal, one rash and one episode of reversible neutropenia. Serum and body flevels of susceptible organisms.uid levels were easily maintained above the inhibitory levels of susceptible organisms. Mezlocillin was a safe, well tolerated and effective antibiotic in the treatment of infections due to susceptible organisms.


Renal function in gout. V. Factors influencing the renal hemodynamics. Renal hemodynamics as measured by inulin clearance (Cinulin) and para-aminohippurate clearance (CPAH) was evaluated in 149 patients with primary gout over intervals of two to 22 years. In over 30 per cent of the patients plasma urate was greater than 10 mg/dl and urinary uric acid greater than 800 mg/min. A linear trend in decreasing frequency of hyperuricemia and excessive uricosuria is significantly related to the patient's age at the onset of gout. Group I consisted of 84 patients with uncomplicated gout in both clearance studies. Cinulin and CPAH were somewhat lower in patients larger than or equal to 50 years of age with longer duration of gout. Further reduction in clearances was minimal at the second clearance study in intervals of approximately 10 years. Group II included 27 patients who had no associated disease at the time of the first clearance study but in whom associated disease had developed by the time of the second clearance study. A striking reduction in Cinulin and CPAH was noted, especially in those 50 years old or above. There were 38 patients in group III with associated diseases at the time of both clearance studies. They had lower Cinulin and CPAH at the time of the first study, particularly the older patients. Further reduction during the second study was less striking than that in group II. Analyses of variance suggest that various coexisting vascular diseases with associated nephropathy have the most significant impact on the status of renal function in gout, with aging the second most important and duration of gout, the third.


The pathogenesis of hyperadrenergic postural hypotension in diabetic patients. Patients with diabetes generally exhibit normal plasma catecholamine responses to standing. Some have blunted norepinephrine responses and postural hypotension-hypoadrenergic postural hypotension due to classic diabetic adrenergic neuropathy. Others, including some with postural hypotension, have exaggerated norepinephrine responses to standing. In order to clarify the pathogenesis of this hyperadrenergic state which occurs in a subset of diabetic patients, we studied aldosterone secretion, vascular and metabolic responsiveness to the administration of norepinephrine, and intravascular volumes in four diabetic patients who were selected for their exaggerated plasma norepinephrine responses to standing. Three of the four patients also exhibited (hyperadrenergic) postural hypotension. None of the hyperadrenergic diabetic patients had evidence of hypoaldosteronism or vascular resistance to norepinephrine, but all four patients had subnormal red blood cell masses and the mean (+/-SE) red blood cell mass (13.1 +/- 1.0 ml/kg) was approximately half of that of age- and sex-matched diabetic controls (26.5 +/- 2.7 ml/kg, p less than 0.01). Thus, intravascular volume contraction, specifically a reduction in the red blood cell mass, may play an important role in the pathogenesis of hyperadrenergic state observed in a subset of diabetic patients and in the pathogenesis of hyperadrenergic postural hypotension in affected diabetic patients.


Transient S-T segment elevation in unstable angina: prognostic significance. The clinical and prognostic significance of the direction of the S-T segment shift on the 12-lead electrocardiogram was evaluated in medically treated patients with unstable angina pectoris. Long-term mortality and morbidity of 11 patients with transient S-T segment elevation (group I) were compared to that of 21 patients with transient S-T segment depression (group II). The average follow-up duration was 62 months. There was no significant difference between groups I and II with respect to survival or nonfatal myocardial infarction over a five-year period. Mortality was related to the extent of coronary artery disease and left venticular ejection fraction rather than to the direction of the S-T segment shift.


Severe methanol poisoning. Application of a pharmacokinetic model for ethanol therapy and hemodialysis. Two patients with extremely high blood methanol concentrations (260 and 282 mg/dl) were successfully treated using pharmacokinetic dosing of ethanol, hemodialysis and supportive measures. Both patients recovered completely without residual ophthalmologic deficits. Early hemodialysis and inhibition of methanol metabolism with effective ethanol concentrations were attributed to the patients' full recovery. Methanol elimination was enhanced by hemodialysis as evidenced by a decrease in half-life from eight to two and a half hours. Methanol dialysance was 98 ml/min. A dosage regimen for ethanol was devised, utilizing dose-dependent pharmacokinetic parameters and the ethanol dialysance (100 to 120 ml/min) from these two patients. An ethanol loading dose of 0.6 g/kg should be administered to an adult with an acute methanol ingestion. This dose will produce a blood ethanol concentration of approximately 100 mg/dl which can be maintained by an ethanol infusion of 66 mg/kg/hour for nondrinkers to 154 mg/kg/hour for chronic ethanol drinkers. Hemodialysis should be initiated if the blood methanol concentration is greater than 50 mg/dl. If hemodialysis is initiated, the ethanol infusion should be increased by 7.2 g/hour.


A follow-up study of 48 patients with Reiter's syndrome. A follow-up study of 48 patients with Reiter's syndrome was carried out in an attempt to clarify the clinical course of the disease. The mean age at the onset of Reiter's syndrome was 27.1 years (range 15 to 52 years) and when seen at follow-up 32.5 years (range 19 to 58 years). The average time from the onset of the first attack of peripheral arthritis to the time of follow-up was six and a half years (range 0.5 to 27 years). Only three patients had diarrhea prior to the onset of Reiter's syndrome. At follow-up 22 per cent of the patients were asymptomatic, 24 per cent had recurrent minor symptoms, 24 per cent had recurrent moderate symptoms, and 30 per cent had recurrent major symptoms. However, even in the last group, all patients were in functional classes 1 or 2 between the flares of disease. No patients in the series were in functional class 3 or 4, and 30 per cent were in class 1.


Fatty liver hepatitis and cirrhosis in obese patients. Liver function and liver biopsy findings were studied in a selected group of 29 overweight patients. Fatty liver, fatty hepatitis, fatty fibrosis and fatty cirrhosis were seen with equal frequency. Diabetes was also present with an equal incidence in each of these four pathologic groups. Lipoprotein abnormalities, particularly type IV hyperlipoproteinemia, were found mostly in the two groups with the lesions with less fibrosis (fatty liver and fatty hepatitis). The pathologic picture resembled that of alcohol and postjejunoileal bypass-induced liver diseases suggesting a common denominator in these three conditions.


Echocardiographic assessment of cardiac anatomy and function in acromegalic patients. Echocardiography was used to evaluate cardiac anatomy and function in 25 patients with accromegaly. Eighty per cent of the patients (20 of 25) had abnormal echocardiograms including 13 patients without other signs or symptoms of cardiac involvement. The most common abnormality was increased left ventricular mass with concentric left ventricular wall thickening, which was found in 64 per cent (16 of 25) of the patients. Increased left ventricular transverse dimension at end diastole was found in 36 per cent (nine of 25) of the patients. Other echocardiographic abnormalities found included left atrial or aortic root enlargement (three patients), disproportionate septal thickening (one patient) and depressed left ventricular ejection fraction (three patients). Since five of the patients with increased left ventricular mass had no history of hypertension or hyperthyroidism, the increased mass cannot be ascribed solely to these conditions commonly associated with acromegaly. Furthermore, the degree of cardiac hypertrophy showed no significant correlation with pre- or post-treatment growth hormone levels, or with known duration of acromegaly prior to treatment. Thus, although the pathophysiology and significance of cardiac abnormalities in acromegalic patients is not yeat fully understood, echocardiography does provide a sensitive tool for detecting such abnormalities before they are otherwise apparent.


Altered collagen composition in a prolapsing mitral valve with ruptured chordae tendineae. A patient presented with mitral valve prolapse, ruptured chordae tendineae, severe mitral regurgitation and congestive heart failure. Pathologic studies demonstrated myxomatous changes of both mitral leaflets. Collagen analysis of the valve and of the chordae tendineae revealed the presence of type I collagen in normal quantities and a striking absence of type III and AB collagens. The altered collagen in this patient's mitral valve probably contributed to the development of his mitral valve disorder.


Long-term survival with diffuse interstitial pulmonary amyloidosis. A 51 year old man presenting with amyloidosis involving the lungs, the testes, the skin and the stomach has been followed for eight years. Serial pulmonary function tests revealed slowly progressive physiologic deterioration. The various clinical features and the lengths of survival in the previously reported cases of diffuse interstitial pulmonary amyloidosis are reviewed. The unusually long survival of this patient and its implications are discussed.


Disseminated granulomatous acanthamoeba infection presenting as an unusual skin lesion. A fatal case of disseminated granulomatous infection with a skin lesion and focal encephalitis due to Acanthamoeba astronyxis is reported. Indirect fluorescent antibody tests of both tissue and serum from the patient established the diagnosis. The administration of amphotericin B is ineffective in vitro and has not been effective in vivo. It is recommended that corticosteroid therapy be avoided because it may aggravate the disease. Physicians caring for diseases caused by free-living ameba may call the CDC Parasitic Drug Service.


Severe mixed metabolic acidosis secondary to rhabdomyolysis. A patient with severe metabolic acidosis in association with rhabdomyolysis and nonoliguric acute renal failure is presented. Evaluation of his acidosis indicated a large excess of unmeasured anions as well as evidence of a renal acidifying defect. We conclude that the metabolic acidosis seen with myoglobinuric acute renal failure may represent a mixed acid-base disturbance.


Eosinophilia, elevated immunoglobulin E level and chronic enteritis due to intestinal helminthiasis. Recurrent urticaria, abdominal pain, peripheral eosinophilia, hyperimmunoglobulin E and small bowel abnormalities on roentgenograms prompted evaluation of a 36 year old man for intestinal parasitism. Evidence for helminthiasis as the cause of his symptoms included changing antibody titers to helminth antigens and a dramatic response to therapy. Helminth larvae or eggs were not recovered. Diagnosis of strongyloidiasis, the most likely cause of the illness, is discussed.


An evaluation of the self-study process. Results of an evaluation of the self-study process in clinical laboratory sciences education accreditation are presented. The evaluation included questionnaires for program officials and site surveyors, follow-up personal interviews, and comparisons of time required to critique and prepare analytical reports for self-studies. The primary goals of the study were to determine the usefulness and validity of the self-study process. The results indicate generally positive trends and identify components in need of further refinement.


Effect of prostaglandin A1 on renal hemodynamics in pregnancy toxemia. PGA1 was infused at a constant rate for 2 hours in 35 pregnant women in the third trimester. Twenty-five patients had clinical manifestations of pregnancy toxemia and 10 served as control subjects. Two dose levels (0.5 to 1.0 mug/kg/min) were investigated and obstetric aspects as well as renal hemodynamics were evaluated. At the high-dose level, the drug induced labor in half the subjects (toxemia patients and control subjects) and elicited a hypotensive response only in hypertensive cases. A marked increase in GFR and RPF was achieved at both dose levels in all cases. Plasma electrolytes, osmolality, and urea levels were unaltered. Also, the infusions did not induce any appreciable diuresis or natriuresis. Tph mechanisms of the induced changes and possible etiologic involvement of PGA1 in toxemia are discussed.


Hemodynamic changes during pregnancy in the rabbit. Blood volume (BV), plasma volume (PV), red cell volume (RCV), cardiac output (CO), and organ blood flows were measured in nonpregnant (Group I), 10 to 19 days' pregnant (Group II), and 20 to 30 days' pregnant (Group III) rabbits. BV, PV, and RCV increased throughout pregnancy, with maximum increase during the second third of gestation. CO peaked during the second third of gestation and then decreased. Mean arterial pressure and systemic vascular resistance decreased. Total reproductive blood flow increased throughout pregnancy but when calculated per unit of weight it did not change. Redistribution of blood flow within the reproductive organs occurred, with ovarian and placental flow per unit of weight increasing and myometrial flow/unit of weight decreasing. Splenic flow decreased significantly; liver flow decreased. The flow to the lungs and kidneys remained unchanged. The data suggested that major hemodynamic changes occur during the first two thirds of gestation and this period appears to test the competency of the maternal organism to adapt to the needs of pregnancy. The last one third of gestation is characterized by the fetoplacental unit interaction.


Oxytocin challenge test for antepartum fetal assessment. Report of a clinical experience. OCT's were performed 1,209 times on 533 fetuses at risk for UPI. OCT interpretation was negative for 72% of tests, and there were were no fetal deaths within a week following a negative test. Our data thus support the concept that the use of the OCT for fetal surveillance most frequently justifies a course of nonintervention. Of 69 fetuses with positive test, 47 were subjected to the stresses of labor with maternal hyperoxygenation and lateral poisoning. Twenty of these 47 (43%) tolerated labor without biophysical evidence of distress. Reactivity of the FHR, when present during a positive test, significantly increased the likelihood that a fetus would tolerate labor. The fetal and perinatal mortality rates in the patients identified as a risk for UPI and studied with OCT's were no greater than in a comparable group of pregnancies without identifiable risk for UPI and not studied with OCT's.


Fetal baseline heart rate variability estimation. I. Comparison of clinical and stochastic quantification techniques. Baseline fetal heart rate variability is an important parameter in the evaluation of fetal status during the intrapartum period. Prior descriptions of variability have largely been either visual-subjective or stochastic in nature. Unfortunately, correlation between the two has not been substantiated. Sample heart rate tracings were evaluated for variability by a panel of nine experts. Interobserver agreement in the evaluation of variability was high; correlation between visual subjective and stochastic methods was low. The implications are discussed.


Blood flow to fetal organs as a function of arterial oxygen content. In a sheep preparation the blood flow to fetal organs was studied 3 to 10 days after surgery by means of the microsphere technique over a range of fetal arterial O2 content from 6 to 1 mM. Blood flows to neural tissues (cerebrum, cerebellum, brain stem), heart, and the adrenals increased in inverse relation to arterial O2 content. As a result the arterial supply of O2 to these organs tended to remain constant over the O2 range studied. Blood flow to the fetal lungs decreased progressively with hypoxia. The blood flow to kidneys, digestive tract, pancreas, and carcass had a tendency to remain constant or increase gradually in the transition from high to moderately low levels of arterial O2 content and then to decrease abruptly in more severe hypoxia. Umbilical blood flow did not change systematically in relation to arterial O2 content.


A comparison of medroxyprogesterone serum concentrations by the oral or intramuscular route in patients with persistent or recurrent endometrial carcinoma. A randomized study, comparing serum medroxyprogesterone concentrations by the oral and intramuscular routes, was performed on 22 patients with persistent or recurrent endometrial adenocarcinoma by six institutions of the Gynecologic Oncology Group. The oral group (11 patients) received cutaneous Provera (medroxyprogesterone), 50 mg three times a day, and the intramuscular group (11 patients) received 300 mg of Depo-Provera (medroxyprogesterone) weekly for at least 2 months. Serum levels were evaluated at 0, 2, 4, 6, 8, 10, and 12 hours after administration and every day for the first week and weekly thereafter for 8 weeks. The mean serum levels (nanograms per milliliter) of medroxyprogesterone in the oral group were consistently higher than the corresponding mean levels of the intramuscular group. In addition, from the first through eighth weeks, the measurements (medians) for the oral group were statistically higher than those for the intramuscular group. Although the study indicates a significant increase in serum levels achieved by the oral route, the follow-up period of patients under study is too early to evaluate its clinical effectiveness as compared to the intramuscular route.


Corpus luteum surgery.

Corpus luteum surgery. The corpus luteum is responsible for a substantial number of emergency operations, some of which prove to be unnecessary and others which are unnecessarily complex. The routine utilization of culdocentesis and pregnancy testing will identify the large majority of those patients who can safely be treated by expectant observation or who should first be investigated by a diagnostic operative technique, such as laparoscopy, before an exploratory laparotomy is performed. When a laparotomy is performed, the ovary should be conserved whenever possible. An analysis of two hundred consecutive emergency operations for ruptured corpus luteum or corpus luteum cyst support these observations.


Pelvic colonization with Actinomyces in women using intrauterine contraceptive devices. Recent reports suggest a relationship between intrauterine contraceptive device (IUD) use and colonization or infection of the genital tract with Actinomyces species. This prospective, case-controlled study was designed to determine the incidence of colonization or infection with Actinomyces in IUD users. None of 50 control patients and four of 50 study patients (8%) had Actinomyces identified. None of the patients with positive results had symptomatic pelvic infection. Cervical cytology was effective in detecting each of the four study patients with positive results. It appears that the presence of any type of IUD is a major predisposing factor to colonization with Actinomyces.


The results of treatment of microinvasive carcinoma (stage iA) of the uterine cervix by means of simple and extended hysterectomy. At the Department of Obstetrics and Gynecology of Tohoku University, radical hysterectomy with pelvic lymphadenectomy had been performed on patients with microinvasive carcinoma of the uterine cervix before 1966. Investigation of lymph nodes of 90 patients treated in this manner has shown no lymph node metastasis of tumor cells in any of them. Since 1967, microinvasive carcinoma has been treated as a matter of principle by extended hysterectomy without lymphadenectomy. From that time until 1974, 119 cases of microinvasive carcinoma have been treated by extended hysterectomy and 69 such cases by simple hysterectomy. The 5-year relative survival rate was 0.989 for extended hysterectomy patients and 1.008 for simple hysterectomy patients. Together, a 5-year relative survival rate of 0.992 was obtained.


Immediate effect of amniocentesis on fetal breathing and gross body movements. The incidence of fetal breathing movements (FBMs) has been observed to be significantly reduced at 24 and 48 hours after amniocentesis. The cause is unknown. We studied the immediate effects of amniocentesis on two fetal variables, FBMs and gross body movements (FMs). No effect was observed in the incidence of FBMs but an immediate increase in FMs occurred.


Appraisal of "rigid" blood glucose control during pregnancy in the overtly diabetic woman. The degree of maternal glucose control achieved during the third trimester of pregnancy was evaluated for 120 overtly diabetic women hospitalized on a high-risk pregnancy ward. "Rigid" blood glucose control, defined as a mean preprandial plasma glucose concentration less than 115 mg/dl was achieved in only 14% of these women. Although mean preprandial plasmal glucose concentrations ranged between 115 and 172 mg/dl in 66% of women and exceeded 172 mg/dl in 20%, the perinatal salvage rate was greater than 95%. Pregnancies of those women whose mean plasma glucose levels exceeded 172 mg/dl required earlier intervention for signs of fetal jeopardy, but the degree of glucose control was not significantly related to either perinatal death or neonatal morbidity. These results suggest that maternal hyperglycemia exceeding a mean preprandial glucose concentration of 172 mg/dl is to be avoided, whereas, at the other extreme, mean glucose levels less than 115 mg/dl or "rigid" control is unnecessary for a successful perinatal outcome.


Carbohydrate tolerance in gonadal dysgenesis. Among 42 patients with GD, one had clinical diabetes and 10 had chemical diabetes (26%) when tested by OGTT. The insulinogenic index was lower in patients with chemical diabetes than in patients with normal OGTT. Among 19 patients with isolated hypogonadotropic hypogonadism, similarly tested, three had chemical diabetes (15%). In a prospective study of 29 patients with GD tested repeatedly, the incidence of diabetic OGTT increased significantly with age. As glucose tolerance deteriorated, the plasma insulin response was delayed and the insulinogenic index decreased. The carbohydrate tolerance was unrelated to weight, estrogen replacement therapy, chromosomal pattern, and GH response. In six GD cases studied at a 6 year interval, the tolerance to oral glucose decreased with time whereas glucose utilization following its intravenous injection or tolbutamide administration was only slightly diminished; the plasma insulin was reduced by approximately 50% in response to each of these stimulations. These studies suggest that carbohydrate intolerance is frequently associated with GD and is due to a diminished beta-cell function.


Epidemiologic aspects and factors related to survival in 384 Registry cases of clear cell adenocarcinoma of the vagina and cervix. Three hundred and eight-four cases of clear cell adenocarcinoma of the vagina and cervix accessioned in the Registry as of December 31, 1978, have been analyzed. The annual incidence of these tumors has been found to correspond closely to the estimated usage of diethylstilbestrol (DES) for pregnancy support in the United States. The annual incidence of the DES-associated cases appears to have dropped in the United States in the past 2 years in comparison to 1973 to 1975. The risk of tumor development appears to be higher in young women exposed to DES early in intrauterine life than in those exposed later. The carcinomas are rare before the age of 14 years and an irregular peak in the age-incidence curve appears between 17 and 21 years followed by a decline. The 5-year survival rate is better for women over the age of 19 years than for younger patients, and a higher frequency oral contraceptive usage did not appear to influence the behavior of the tumor and the improved survival in those using this medication appears to be related to greater medical surveillance.


Changes in amniotic fluid glucose, beta-hydroxy-butyrate, glycerol, and lactate concentration in diabetic pregnancy. Amniotic fluid glucose, beta OH butyrate, glycerol, and lactate concentrations were measured in 75 samples collected in the third trimester of pregnancy from 50 diabetic patients, all but four of whom required insulin. Increases in maternal fasting plasma sugar were accompanied by corresponding increases in amniotic fluid glucose and on occasion increases in amniotic fluid beta OH butyrate. These data correspond to previous reports of placental glucose transfer and in addition, provide statistically significant evidence of placental betaOH butyrate transfer since the hyperglycemic, hyperinsulinemic fetus of a diabetic mother would be a poor primary source for ketogenesis. Relatively poor correlation of elevated fluid levels of these solutes to fetal outcome probably reflects a low incidence of maternal hyperglycemia, ketogenesis. Relatively poor correlation of elevated fluid levels of these solutes to fetal outcome probably reflects a low incidence of maternal hyperglycemia, ketoacidosis, and over-all reduced neonatal morbidity-mortality rates in this group of metabolically well-controlled, predominantly insulin-requiring diabetic patients managed in a regional high-risk perinatal center.


Oxytocin challenge test results compared with simultaneously studied serum human placental lactogen and free estriol levels in high-risk pregnant women. Three perinatal health indicators (serum human placental lactogen [hPL] levels, serum free estriol [E3] levels, and OCT) were simultaneously completed in 149 high-risk women who were more than 34 weeks pregnant. There was a significant correlation between the hPL and E3 results (r = 0.28, p less than 0.01). There was a 15.4% positive OCT result rate and the blood hormone values for the negative and positive OCT groups were compared. There was a significantly lower hPL value in the positive OCT group (4.7 +/- S.E.M. 0.4 vs. 6.2 +/- S.E.M. 0.2 micrograms/ml for positive and negative groups, respectively), whereas the free E3 levels were not different in these two OCT groups (14.8 +/- S.E.M. 1.5 vs. 16.3 +/- S.E.M. 0.7 ng/ml for positive and negative groups, respectively). The free E3 value did not help in predicting the OCT result as the low free E3 subgroup had the same frequency of positive OCT result as did the over-all group. There was a highly significant increase in the positive OCT results (42.9%) in women with a low hPL value (p less than 0.01). In those women with an hPL value of 6.0 microgram/ml or more there were only 8% positive OCT's. It is concluded that on hPL test at about 34 weeks of gestation could be used to screen pregnant women, and if the value were low (less than 4.0 microgram/ml) an OCT evaluation test would be indicated, for there is a very high frequency of positive results in that subgroup of women.


Effects of dietary lead and zinc on pregnancy. In order to further understand the effects of ingested Pb on pregnancy and the possible interaction of the trace element Zn with Pb, groups of dated pregnant rats were fed 10, 50, 100, 200, or 500 mg/L of Pb in water throughout pregnancy. A control group with no Pb, but diet ad lib, and a pair-fed control group with no Pb were also studied. Maternal average daily food consumption was significantly reduced at 50 mg/L of Pb and up. Total and net maternal weights were significantly reduced at 50 mg/L of Pb and up. Pair feeding at the 200 mg/L level improved maternal weight gain but not to control levels. Zn, 200 mg/L, supplement at the 200 mg/L of Pb level caused no improvement nor did ad lib diet with Pb removed after 16 days. Fetal weight decreased progressively as Pb levels were increased. Pair feeding at the 200 mg/L Pb of level and Zn, 200 mg/L, supplement with 200 mg/L of Pb significantly increased fetal weight but not to control levels. Placental weight was unchanged throughout. The results indicate that Pb-induced fetal growth retardation is due to reduced maternal food and energy intake, as well as to direct effect on the fetus. Excess dietary Zn improves fetal growth, probably by increasing maternal food consumption.


The precursors of endometrial carcinoma. For many years, a variety of abnormal endometrial lesions have been linked to endometrial cancer but have been designated as hyperplasia and classified by modifying adjectives such as cystic, adenomatous, atypical, moderate, and severe. Though descriptively distinctive, there are enough consistent histologic transitions between them to designate the entire group as belonging to a continuous spectrum from benign to malignant. Furthermore, because these epithelial lesions demonstrate not just hyperplasia but significant disorderly growth patterns, it has been suggested that they be referred to as dysplasias. In order to evaluate the association of these types of dysplasia to cancer, two groups of patients were studied. In one group, the histologic states of the endometrium of patients with endometrial cancer were retrospectively analyzed. In the second group of patients, who were selected for study because the endometria were diagnosed as belonging to the dysplastic groups, the subsequent endometrial histology was prospectively studied. The findings suggest that there is a recognizable group of endometrial lesions with an association to endometrial cancer strong enought to label and treat them as neoplastic.


Uterine metabolism of gonadal steroids during the menstrual cycle. The metabolic clearance rate and uterine extraction of (3H)progesterone, (3H)estradiol, and (14C)estrone were studied at the time of hysterectomy in six women on or before day 12 of the menstrual cycle, in three women after day 12, and in one postmenopausal woman. The metabolic clearance rates of progesterone, estradiol, and estrone were in the same range as for normal women as previously reported by us. The uterine extraction for progesterone ranged between 12% and 37% on or before day 12 and 0% to 5% after day 12, and was 7.4% in the postmenopausal woman. The uterine extraction of estradiol was 0% to 25% on or before day 12, and 0%, 4%, and 22% after day 12 and was 18% in the postmenopausal woman. The uterine extraction of estrone was 7% to 24.5% on or before day 12 and 0% after day 12 and was 18% in the postmenopausal woman. The across-uterine interconversion of estradiol to estrone was 0% to 2.7% and of estrone to estradiol 0% to 2.6%. Both conversions appeared to be independent of the day of the menstrual cycle. The results suggest that the uterine metabolism of progesterone and estrone and perhaps estradiol is lower in the luteal phase of the cycle as compared to the follicular phase and that the conversion of estradiol to estrone may not be a major reaction of estradiol metabolism in the human uterus.


Breech delivery: evaluation of the method of delivery on perinatal results and maternal morbidity. A retrospective study of 460 single-gestation infants in breech position was conducted at the University of Colorado Medical Center to assess the impact of a policy for the selection of cases for vaginal delivery. Among infants weighing more than 2,500 grams, there was an increase in the cesarean section rate from 13% to 54%, with an associated increase in maternal morbidity from 7% to 15%. This occurred with no significant reduction in adverse perinatal outcome. However, a case-by-case review suggests that more frequent and timely cesarean sections would have further reduced perinatal morbidity and deaths among term infants. Among the infants weighing 2,500 grams or less there was an increase in cesarean births from 5% to 55% following the introduction of the strict criteria for vaginal delivery. Among the infants weighing 1,501 to 2,500 grams there was no significant difference in survival between the cesarean and vaginally delivered patients. Although infants weighing 501 to 1,500 grams delivered by cesarean section survived more frequently than did those delivered vaginally, the differences in perinatal deaths may have been due to a higher birth weight in the cesarean-delivered infants or an over-all improvement in neonatal intensive care for infants of very low birth weight.


Rewiew of ovarian cancer at the University of Texas Systems Cancer Center, M.D. Anderson Hospital and Tumor Institute. The records of 2,115 patients with ovarian cancer who were treated at the M.D. Anderson Hospital and Tumor Institute in Houston, Texas, during the 30 year period from 1944 to 1973 were reviewed. Ninety percent of the patients had an epithelial cancer of the ovary. The important prognostic factors include stage and grade of tumor and the presence or absence of ascites. Probably the most important prognostic factor, however, was the size of the largest tumor mass that remained after initial surgery. The patient's age and socioeconomic level were also influencing factors in the survival rate in this series of patients. Most of the patients had advanced disease when first examined and received some type of adjunctive postoperative treatment. The survival of patients who received postoperative irradiation, when compared by stage and size of the largest residual tumor mass, was improved over those who received chemotherapy.


Prophylactic transfusions of normal red blood cells during pregnancies complicated by sickle cell hemoglobinopathies. Prophylactic transfusions of normal donor red cells were administered during 37 pregnancies to women with sickle cell anemia, sickle cell-hemoglobin C disease, or sickle cell-beta thalassemia disease. Once the diagnosis was confirmed, the transfusions were administered intermittently throughout the rest of the pregnancy in such amounts and at such frequencies that no more than 60% of the circulating red cells contained hemoglobin S and the hematocrit was above 25. The maternal mortality rate was zero and maternal morbidity as the consequence of the sickle cell hemoglobinopathy was minimal. The perinatal mortality rate was appreciably reduced when compared to that previously observed without prophylactic transfusions but perinatal morbidity was still excessive. Evidence that the intrauterine environment was compromised, in spite of the transfusions consisted of an increased frequency of growth-retarded fetuses, of meconium staining of amnionic fluid, and of ominous decelerations of fetal heart rate. Morbidity from the transfusions was troublesome. Nonetheless, it is concluded tentatively that both the mother with a sickle cell hemoglobinopathy and her fetus are likely to benefit from prophylactic transfusions of normal donor red cells administered during one pregnancy according to the protocol employed in this study.


The incidence of fundus lesions in septicemia. Ophthalmoscopic examination in a series of septicemic patients with positive blood cultures revealed a significant number of patients with fundus lesions. Review of the medical diagnoses and laboratory data did not show any consistent abnormalities differentiating between septic patients with or without fundus lesions. Septicemia should be considered in the differential diagnosis of cotton wool lesions, hemorrhages, or white-centered hemorrhages in the retina.


Sudden occlusion of the retinal and posterior choroidal circulations in a youth. A 14-year-old boy was stabbed above the left eye and had subsequent loss of both retinal and choroidal perfusion to the posterior segment. Ophthalmoscopic examination ten days after the injury disclosed intense nerve fiber layer edema, most prominent in the posterior pole, and absence of a cherry-red spot. Intravenous fluorescein angiography showed no filling of retinal vessels and only patchy, segmental, peripapillary choroidal filling, probably secondary to collateral circulation developing from the episcleral arterial plexus. Leakage of dye from the peripapillary choroid into the overlying retina was caused by ischemic necrosis of the retinal pigment epithelium. Follow-up examination 11 days later revealed marked sclerosis of the smaller arterioles, optic pallor, atrophic retinal pigment epithelial changes, and loss of retinal substance, most marked in the posterior pole.


Radiation retinopathy after irradiation of intracranial lesions. Six patients developed a mild retinopathy after radiation therapy for intracranial lesions. The retinopathy, consisting of capillary microaneurysms, cotton-wool patches, and telangiectasis, developed after a latent period that varied between nine months and three years. The visual acuity remained within normal limits. The severity of the retinopathy is related to the retinal or optic nerve dose of radiation.


Foveal cone electroretinograms in retinitis pigmentosa and juvenile maular degeneration. Foveal cone electroretinograms were elicited with a hand-held stimulator-ophthalmoscope from 16 patients with retinitis pigmentosa and 17 patients with juvenile macular degeneration. Among 11 patients with retinitis pigmentosa and visual acuities of 6/9 (20/30) or better, eight had foveal cone ERGs that were normal in amplitude and b-wave implicit time; all five patients tested with visual acuities of 6/12 (20/40) to 6/18 (20/60) had foveal cone ERGs that were reduced in amplitude and normal in implicit time. All patients with juvenile macular degeneration and visual acuities of 6/15 (20/50) or worse showed subnormal amplitudes with normal or delayed implicit times, or responses indistinguishable from noise. Amplitudes tended to be smaller and delays greater among patients with juvenile macular degeneration and visual acuities of 6/60 (20/200) or worse.


Ophthalmology and the carotid artery.

Ophthalmology and the carotid artery. During the last three decades, carotid artery occlusive disease has changed from an obscure and rarely diagnosed condition to a clearly understood and frequently seen neurologic disorder. Its medical management and its surgical treatment are constantly improving. Ophthalmologists, together with neurologists, have contributed greatly to the understanding of the ocular signs and symptoms of carotid artery disease. Using his knowledge of these signs and symptoms, the ophthalmologist may make a significant contribution in the diagnosis and treatment of carotid artery occlusive disease.


Uveal malignant melanoma in three generations of the same family. Three patients in three successive generations from the same family had choroidal malignant melanoma. The third generation patient had multiple primary malignancies; his siblings also had multiple malignancies. Chromosome studies of the third generation patient revealed no abnormality. To the best of our knowledge, this is the second such pedigree reported.


Mapping the representation of the visual field by electrical stimulation of human visual cortex. Electrical stimulation of human visual cortex produces punctuate phosphenes in the visual field. This phenomenon, which is being explored as the basis for a visual prosthesis for the blind, also provides the first electrophysiological information about the retinocortical map in man. Stimulation of points clustered on the surface of the visual cortex produces phosphenes clustered in visual space. However, adjacent surface electrodes located on opposite sides of a sulcus can produce widely separated phosphenes, because the intervening cortex is buried and inaccessible to stimulation. Such electrodes can also produce multiple phosphenes by simultaneously stimulating both banks of the sulcus. Electrodes which are widely spaced on the brain can produce phosphenes close together in visual space providing they stimulate cortex corresponding to overlapping maps in areas 17 and 18. Analysis of the phosphene map indicates that successive stimulation of points further from the tip of the occipital pole produces phosphenes progressively more distant from the fixation point. Successive stimulation of points along the orthogonal dorsoventral dimension produces a progressive change in phosphene bearing. These results confirm the general view of cortical organization derived from field defect studies in man, and from anatomical and electrophysiological studies in monkeys, and provide a new tool for more detailed study of retinotopic projections in man.


Adverse effects experienced by patients taking timolol. Adverse effects involving one or more organ systems occurred in 38 of 165 patients with various types of glaucoma when timolol was added to their glaucoma therapy. It was necessary to discontinue timolol because of these side effects in 15 (9%) of the patients. Double-masked studies will be necessary to clarify the relationship of these adverse effects to the use of timolol.


Corneal anesthesia after timolol maleate therapy. Symptomatic superficial punctate keratitis associated with complete corneal anesthesia occurred in three patients after they had been taking timolol maleate for glaucoma. After discontinuation of the timolol maleate and substitution of conventional antiglaucomatous collyria, the keratitis gradually cleared with restoration of normal corneal sensitivity. Corneal sensitivity, measured in 25 additional patients taking timolol maleate, was markedly diminished in four patients, all of whom were elderly and had been using the drug for a minimum of three months. Timolol maleate does appear to have some local anesthetic properties in human cornea after chronic use by susceptible individuals.


Recurrent herpetic angular blepharitis in an adult. A 36-year-old man had several episodes of left angular blepharoconjunctivitis associated with upper respiratory infections, herpes labialis, or emotional stress. The clinical diagnosis had always been a blepharitis of bacterial origin. During the last attack, cytologic examination of a scraping obtained from an eyelid pustule vesicle revealed multinucleated keratinocytes, diagnostic of a herpetic infection. Virologic studies proved that herpes simplex virus type 1 was the causal agent.


Schirmer test and break-up time of tear film in normal subjects. We examined the precorneal film, the Schirmer test No. 1, and the break-up time tests in 440 healthy young students. There were no statistically significant differences (1) between men and women from the same origin who were brought up in the same environment, (2) between students from different ethnic origins who were brought up in the same environment, and (3) between students of the same origin who were brought up in different environments. Gradual seasonal changes in climatic factors, such as temperature, humidity, visibility, and barometric pressure, seem to have no appreciable effect on the Schirmer test No. 1 or break-up time test.


A mirror for hemianopia.

A mirror for hemianopia. I devised a small mirror for hemianopia that is mounted on a clip placed over the spectacle frames on the nasal side. The mirror is adjustable so that the peripheral retina is stimulated by any motion reflected in the mirror when the eye is gazing straight ahead.


Optic disk edema in sarcoidosis.

Optic disk edema in sarcoidosis. A 24-year-old woman had bilateral optic disk edema. A granulomatous uveitis and macular edema subsequently ensued. Histologic examination of a biopsy specimen taken from an area of marked hilar adenopathy revealed noncaseating epithelioid cell tubercles. No other associated systemic findings were noted, and after a course of topical and systemic corticosteroid therapy, the ocular manifestations disappeared.


New suspension of operating microscope and chair. We developed a new operating microscope system consisting of magnetically locked suspension for the microscope, an operating chair that makes synchronous coaxial rotation with the microscopy, and has a cryostat and electric coagulator built into its back, and a slit lamp with brighter illumination. The new operating microscope system, which permits a wider range of motion and a clearer view of the operative field than conventional microscopes, has proved useful in such surgical procedures as the running suture in corneal transplantation, loop fixation in intraocular lens implantation, preparation of an intrascleral pocket in detachment surgery, open sky vitrectomy, and decompression of the optic canal.


Adjustable length infusion needle for Ocutome vitrectomy. We devised an adjustable length infusion needle for Ocutome vitrectomy. Visualization of the tip of the infusion terminal is not necessary and the risk of infusion into the uvea is eliminated.


Limbal extraction of posterior segment foreign bodies. In aphakic patients, we devised a technique for forceps removal of posterior segment intraocular foreign bodies through the corneoscleral limbus. Enlargement of the pars plana incision was not necessary.


The changing scene of intraocular implant lens surgery. A review of lens implant surgery using different implant styles and both methods of cataract extraction revealed that there is little difference in the final visual acuity regardless of which implant or cataract technique is used. There appears to be a higher rate of cystoid macular edema with the intracapsular technique and a higher rate of corneal edema with the extracapsular technique. A modern attitude toward this technologic explosion insists more than ever on conventional points of view regarding patients' needs.


A critical analysis of the long-term results of trabeculectomy. We analyzed the long-term results of trabeculectomy in a homogeneous group of 90 eyes (75 patients) followed up one to five years after surgery. The effect on intraocular pressure was considered stable after one year; complete success was achieved in 69 (71%) of cases with a further in 8 (9%) partial success in eight (9%). The pressure-lowering effect was closely related to the presence of a filtering bleb. The main complication was the late appearance of lens opacities, although these seemed less frequent than after other antiglaucoma operations. Lens opacities were particularly frequent in hypotonic eyes and may depend upon the process of aqueous humor filtration itself.


Continuous wave argon laser iridectomy in angle-closure glaucoma. By using a continuous wave argon laser in a multiburn fashion, successful iridectomies were achieved in 42 out of 45 phakic eyes with either acute or chronic angle-closure glaucoma. Five of the successful procedures required multiple sittings on different days or abandonment of the primary treatment site in favor of an alternate site, or both, to attain patency. Within the immediate postoperative period, ten eyes needed retreatment to eliminate moderate pigment proliferation at the perforation site. The procedure was performed on an outpatient basis under topical anesthesia, usually required less than one-half hour for completion, and resulted in only minimal complications. Therefore, continuous wave argon laser iridectomy appears to present a viable alternative to surgical iridectomy for the definitive treatment of angle-closure glaucoma, although long-term evaluation of this modality of therapy is presently unavailable.


Efficacy and patient acceptance of pilocarpine gel. Fifteen patients with symmetrically increased intraocular pressure (IOP) participated in a single-masked random 30-day clinical trial comparing 4% pilocarpine hydrochloride gel applied at bedtime to one eye with 4% pilocarpine hydrochloride drops instilled four times daily in the fellow eye. Both forms of pilocarpine reduced IOP significantly at 8 A.M., 12 noon, and 4 P.M. (P less than .01). At these times there was no significant difference in effect between the two forms of pilocarpine (P greater than .05). The mean IOP of eyes treated with gel showed no significant difference from the pretreatment value at 10 P.M. (P = .37), whereas at this time eyes treated with drops did maintain a significant IOP reduction (P = .02). At 10 P.M. pilocarpine drops reduced IOP significantly more than did pilocarpine gel (P = .002). Pupil diameter was affected by the gel and drops in a similar pattern to that of IOP. Patients tolerated the gel with few side effects and were pleased by the convenience of administration once daily.


An analysis of visual acuity, visual fields, and disk cupping in childhood glaucoma. We analyzed the long-term functional results in 102 eyes of 59 patients with childhood glaucoma with specific reference to the pattern of optic nerve damage. Optic disk photography and quantitative perimetry were used to judge the degree of damage that had been sustained. There was a predilection for initial visual field damage in the arcuate area, followed by further arcuate and nasal field loss, similar to the pattern of visual field loss seen in adult glaucoma. In children, as in adults, neural tissue appeared to be lost preferentially at the vertical disk poles. The selective pattern of glaucomatous optic nerve damage seemed not to depend upon the age of the optic nerve structures. In contrast to adult eyes, the scleral canal in children apparently enlarges with high IOP. Thus, disk cup size increase in children could occur from neural tissue loss, from scleral canal enlargement, or from a combination of the two processes.


Comparison of photographic techniques and films used in stereophotogrammetry of the optic disk. We compared photogrammetric measurements of optic cup volume, area, and depth made from two types of stereophotography and two types of film to determine their effect on the precision of the measurements. We found that measurements from simultaneous stereophotography (Donaldson stereoscopic fundus camera) had a smaller range of values and a smaller mean percent error than measurements from consecutive stereophotography (Zeiss Fundus Flash II camera). However, a Student's t-test for related measures showed no significant difference. The measurements from Kodachrome 25 film and Kodak Photomicrography film varied in range and mean percent error without a pattern. The Student's t-test for related measures showed no significant difference.


Hereditary progressive arthro-ophthalmopathy of Stickler. The ocular histopathologic findings in three patients with the Stickler syndrome from two families included the following: total retinal detachment with marked folding, disorganization of the retina, and a preretinal membrane. The progression of the fundus lesions was followed up in two patients during the course of 30 and 24 years. Many cases variously reported as Wagner's disease, familial retinal detachment, hyaloideoretinopathy with cleft palate, and the Pierre Robin syndrome probably were the Stickler syndrome.


Ocular manifestations and treatment of hemifacial atrophy. Enophthalmos, flattening of the maxilla that may progress to inferior orbital rim and floor defects, eyelid atrophy, and slight relative hypotony occurred in patients with hemifacial atrophy. Less common manifestations included pupillary and iris abnormalities, vertical muscle imbalances, and retinal changes. The prognosis for vision was good. Fluid silicone injection was the major modality in treatment and the results were generally excellent.


Acute posterior multifocal placoid pigment epitheliopathy associated with cerebral vasculitis and homonymous hemianopia. An 18-year-old man developed acute posterior multifocal placoid pigment epitheliopathy and homonymous hemianopia. Cerebral angiography showed cerebral vasculitis probably with occipital infarction. To the best of our knowledge, this is the first reported case with such concomitant visual defects. Other published reports suggest that such cerebral vasculitis may not be unusual in acute posterior multifocal placoid pigment epitheliopathy.


Surgical management of macular pucker after retinal reattachment surgery. We used vitrectomy techniques to remove epiretinal membranes that caused reduced visual acuity in 13 consecutive eyes with macular pucker after otherwise successful retinal reattachment surgery. A technically successful result with visual improvement was achieved in each case. An iatrogenic retinal tear (successfully repaired) occurred in one eye, and recurrent retinal detachment requiring an additional operation occurred postoperatively in two eyes. Despite such risks, and that the best postoperative visual acuity achieved was 6/9 (20/30), the use of vitrectomy methods in removal of epiretinal membranes in selected cases of macular pucker can provide significant improvement in vision.


The role of vitrectomy instrumentation in the treatment of severe traumatic hyphema. Eight patients with severe traumatic hyphemas underwent clot evacuation with vitrectomy instrumentation. The patients were followed up for periods of one to four years. No significant intraoperative complications were noted, but one eye developed a postoperative flat anterior chamber and another developed multiple staphylomas with uncontrolled glaucoma, leading to the eventual enucleation. Seven of the eight operated eyes achieved intraocular pressure control in the early postoperative period, and this control was sustained throughout the course of follow-up without antiglaucomatous medication. These same seven eyes had final visual acuities of 6/12 (20/40) or better.


Extraction of magnetic foreign bodies from the clear lens. In 20 patients with magnetic foreign bodies in the clear lens, I closed the apperture in the anterior lens capsule by a fibrin cover after extraction of the foreign body. The lens remained clear in 17 patients; total cataract was formed in three. Two of these three patients had had a foreign body in the lens for a longer period of time, and at the time of the extraction the signs of lens siderosis were marked. The cause of the cataract progression in the third subject was not clear. There were no complications of operation or in the postoperative period.


Automatic diaphragm control for television camera used in microsurgery. We developed an automated diaphragm control to achieve constant good exposure during televised microsurgery by using a commercially available diaphragm control for a movie camera and modifying slightly the television camera.


Streaks (schlieren) as a sign of rhegmatogenous detachment in vitreous surgery. Schlieren or streaks can be observed as light passes through incompletely mixed fluids having different refractive indices. During vitreous surgery, the vitreous humor is replaced by an aqueous solution whose density and refractive index differ from those of subretinal fluid. The observation of schlieren during vitrectomy therefore suggests the presence of subretinal fluid and a retinal hole. After observing this sign, a careful search should be made for the retinal break if it has not been previously diagnosed.


The effect of unsuspected carotid-cavernous fistula in enucleation. An 18-year-old man with an unsuspected carotid-cavernous fistula underwent enucleation as the result of a severe localized perforating ocular trauma. Potentially lethal bleeding occurred that was difficult to control. Auscultation of the orbit should be performed in all cases before eye enucleation to avoid the possibility of overlooking a carotid cavernous fistula.


Independence of convergence and divergence: norms, age trends, and potentiation in mechanized prism vergence tests. Motor-driven prism stereoscope vergence tests, base in break, base in recovery, base out break, and base out recovery, repeated three times (BIB, BIR, BOB, BOR X 3) were given to three separate groups. Two instruments with different speeds were used. Repeated testing shows a slight trend to convergence in slower machines. The results from both machines are still comparable. Means are similar to previously published norms from hand-turned instruments, but the variance of scores is about twice as large and there is an eso trend at near. The motor drive aids discrimination, since Ss who are capable can now follow with smooth vergences over a wider range. In general, there is no substantial trend with age between 3 and 25 years other than those which may be due to decreasing response times. Vergence scores can be adequately reduced to two independent factors, loading on convergence and divergence, respectively, which suggests that there are two processes varying independently in maturation and therapy as well as assessment.


Contrast thresholds vs border enhancement: sensitivity to retinal defocus. The two visual responses, contrast threshold and border enhancement, are both affected by retinal image quality. Thus, with increasing defocus of the retinal image contrast thresholds with sinusoidal line gratings increase, and the enhanced region near a border becomes wider. These two visual responses were compared to determine their suitability as gauges of retinal image quality. Border enhancement was found to be more sensitive to deterioration of the retinal image in the form of defocus than contrast thresholds throughout the greater portion of the grating frequency spectrum. However, the contrast threshold increases in sensitivity toward cutoff frequency, and beyond a certain high frequency it surpasses border enhancement in that respect. At the same time, for these optimum frequencies, the contrast range is exhausted within a relatively small defocus range. Therefore, a limitation is imposed on the usefulness of the contrast threshold as an index of retinal image quality.


Knowledge and use of eye care services by college and health professional students: implications for the profession. A questionnaire survey of 1277 students in colleges of liberal arts, medicine, pharmacy, nursing, dentistry, and podiatry was undertaken in an effort to determine their knowledge and use of vision care services. Students were asked to define the differences among optometrists, ophthalmologists, and opticians. Utilization, type of practitioner used, and site of examination are reported. About 56% had had an examination within the past year. Optometrists provided at least 40% of the examinations, but the confusion in the minds of the students is revealed by the fact that some said they were examined by opticians, some by the Department of Motor Vehicles, and some by a person they were not able to identify. Clearly, optometry and the related disciplines have a responsibility to clarify the public confusion.


Strabismic amblyopia in infants.

Strabismic amblyopia in infants. Monocular acuities, in two infants with nonaccommodative comitant esotropia, were measured before and during occlusion therapy. The results indicate that strabismic amblyopia is present within the first year of life and that the infant visual system is remarkably sensitive to short periods of monocular occlusion during this time period.


Ischemic myocardial cell injury. Prevention by chlorpromazine of an accelerated phospholipid degradation and associated membrane dysfunction. Ligation of the left coronary artery of an adult rat heart results in the reproducible ischemic cell death of the entire free wall of the left ventricular myocardium. The time course of the development of the cellular changes is biphasic. The subendocardial and subepicardial cells die within the first few hours. The main mass of free-wall myocardium reacts more slowly, with morphologic evidence of irreversible cell injury developing after 12 hours. Measurement of the increases in total free wall Ca++ reflected this biphasic pattern. There was a rapid 3-fold rise in total Ca++ during the first 4 hours. Between 4 and 12 hours the Ca++ was constant. Between 12 and 30 hours there was a second increase that reached a level some 8-10 times the control value. Treatment with chlorpromazine before and subsequent to surgery prevented the appearance of ischemic cell death in the main portion of the free-wall myocardium for at least 24 hours without affecting the reaction of the subepicardial and subendocardial cells. Chlorpromazine also inhibited the second phase of Ca++ accumulation. An accelerated degradation of phospholipids was observed with a 33% decrease in total phospholipids by 12 hours. Phosphatidylethanolamine was reduced by 50% and phosphatidylcholine by 25% without increases in the corresponding lysophospholipids. Chlorpromazine prevented the accelerated degradation and consequent loss of phospholipid. Isolated sarcoplasmic reticulum showed a time-dependent loss of phospholipid with a parallel loss of active Ca++ uptake that reach 60% with a total lipid depletion from these membranes of 33% by 12 hours. Twelve-hour ischemic sarcoplasmic reticulum exhibited a 6--7-fold increase in passive permeability to Ca++. Chlorpromazine protected against the loss of phospholipids, the inhibition of Ca++ uptake, and the increased Ca++ permeability of the sarcoplasmic reticulum. These observations indicate that rat myocardial cells react to lethal doses of ischemia in a manner similar to the reaction of liver cells described previously. In both cases the evidence implies that a disturbance in phospholipid metabolism and its associated membrane dysfunction is the critical alteration that produces irreversible cell injury in ischemia.


Hypophyseal adenoma--a case report follow-up. A patient with bitemporal hemianopia due to a pituitary tumor was followed postsurgically for 4 years. Visual fields and acuities were assessed at regular intervals under the same lighting conditions and with the same instrumentation. The changes in the visual field were both striking and unusual, as they did not correlate with those reported in the literature in other patients with pituitary tumors.


Diverse cardiovascular responses to aortic constriction in normotensive Sprague-Dawley versus spontaneously hypertensive rats. Normotensive, Sprague-Dawley (S-D) and spontaneously hypertensive (SH) rats were subjected to aortic ligature. The systolic blood pressure of S-D rats was increased by +/- 80 mm Hg, whereas the blood pressure of SH rats with pre-existent hypertension increased only slightly, +/- 9 mm Hg. The S-D rats developed myocardial and renal infarcts as well as polyarteritis nodosa; the SH rats developed testicular and microadrenocortical infarcts only. Aortic-ligated S-D rats had elevated creatine phosphokinase, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and lactic hydrogenase levels and manifested hyperglycemia, hypercholesterolemia, and elevated blood urea nitrogen (BUN) levels. Corticosterone levels increased in aortic-ligated S-D rats but decreased in SH rats. Collateralization about the site of aortic ligature appeared to be the same in both strains. It is suggested that the acutely induced hypertension in S-D rats rather than SH rats and differences in adrenal steroidogenesis between the two strains would best account for the dichotomous cardiovascular response to aortic constriction.


Chemically induced bidirectional differentiation of embryonal carcinoma cells in vitro. N,N-dimethylacetamide, hexamethylene bisacetamide, and Polybrene induced rapid and extensive differentiation in vitro in an otherwise slowly differentiating subline of embryonal carcinoma cells. The type of differentiated cell induced was dependent on the spatial organization of the stem cells during drug treatment. In monalayer culture "epithelial" cells were produced exclusively. However, treatment of aggregated suspension cultures yielded predominantly "fibroblast-like" cells. The undifferentiated embryonal carcinoma cells and the two differentiated cell types were morphologically distinct when examined by light microscopy, scanning electron microscopy, and transmission electron microscopy; and they had differences in cell surface antigens. Both differential cell types  produced large amounts of fibronectin, whereas the embryonal carcinoma cells produced only minimal amounts. This system provides a convenient way to induce relatively synchronous differentiation of embryonal carcinoma cells into specific differentiated cell types.


The selection and characterization of an invasive variant of the B16 melanoma. Several in vitro properties of two variant cell lines of the B16 melanoma (B16-F10 and B16-BL6) with markedly different spontaneous metastatic behavior were examined. The two cell lines were compared with regard to their in vitro growth rate, ability to migrate, ability to adhere to a variety of substrata, detachment rates, production of plasminogen activator, and cell surface proteins as determined by lactoperoxidase-catalyzed iodination. Growth rates in vitro, attachment rates, and qualitative patterns of cell surface proteins were almost identical. B16-F10 cells (the less spontaneously metastatic line) produced greater amounts of plasminogen activator, were more motile in vitro, and detached more readily from plastic than the more invasive B16-BL6 cells. The study of tumor cell variants, selected for different biologic behavior, is a valuable approach to the elucidation of those mechanisms responsible for their malignant activity.


Immunologic studies of membrane mutants of a highly metastatic murine tumor. MDAY-D2 is a highly tumorigenic and anaplastic DBA/2 strain murine transplantable tumor capable of rapid and widespread spontaneous metastatic growth. It was therefore chosen as an ideal murine tumor model for the study of factors affecting metastatic growth. Two approaches were taken in an effort to obtain stable qualitative and quantitative low-metastatic variants of MDAY-D2, namely, cloning of multiple sublines and derivation of lectin-resistant (LecR) mutants. In the first method, 20 clones were isolated, and of these, three initially showed a marked reducstion in ability to metastasize from a subcutaneous site. However, these clones proved to be unstable both in vivo and in vitro. In the LecR selection experiments, 18 independent variants were obtained using chemical mutagenesis followed by treatment with wheat germ agglutinin (WGA), phytohemagglutinin (PHA), or concanavalin A (Con A). All of the variants proved to be highly metastatic except two WGAR variants, designated MDWI and MDW3. They proved to be nontumorigenic in normal DBA/2 hosts even when as many as 5 X 10(6) cells were injected, and this was found to be a stable change. Despite this fact, the nontumorigens an unchanged expression of H-2d and Ly-6.2 alloantigens and Fc receptors. The variants were, however, tumorigenic and metastatic in severely immunosuppressed (nude) mice, but not in moderately immunosuppressed 250-R-irradiated DBA/2 hosts. The results demonstrate that 1) stable membrane mutant sublines possessing radically altered growth properties in vivo can occasionally be obtained by selection of LecR variants, and 2) their growth and metastatic properties can be greatly affected by the immunologic status of the host. The possibility that the chemical mutagen treatment itself induced, or was responsible for, MDW1 and MDW3 variant formation is also discussed.


Some characteristics of metastasis in man. The studies of experimental cancer metastasis are only truly meaningful to the degree that knowledge applicable to the therapeutic problem of cancer metastasis in man ensues from them. The salient features of cancer metastasis in man, therefore, are important to the laboratory researcher, for they provide a framework for which the relevance of an experimental model system must be judged. This brief discussion of some of the clinical characteristics of metastasis in man demonstrates the wide spectrum of biologic behavior and the complex multifaceted nature of this problem. It must be concluded that a complex interaction between tumor cells and host mechanisms eventually governs whether or not metastasis occurs in man.


Properties of metastatic and nonmetastatic cloned subpopulations of an ultraviolet-light-induced murine fibrosarcoma of recent origin. The present studies were designed to evaluate whether tumor cell properties such as growth rate, chromosome number, anchorage-independent growth, susceptibility to lymphocyte- or macrophage-mediated lysis in vitro, and antigenicity in vivo correlated with metastatic potential. A murine fibrosarcoma of recent origin induced in a C3H- mouse by chronic irradiation with ultraviolet light was used. Cells from the parent tumor and its clones were grown in culture. No single property of tumor cells that was measured in vitro or in vivo predicted or correlated with their metastatic potential. In order for metastasis to occur, all steps of the process must be completed. Therefore, interruption of the sequence at any stage can prevent the production of visible metastasis. It was concluded that the search for a single property common to all metastatic cells in a large variety of neoplasms is likely to be unproductive.


Psychiatric education at the crossroads: issues and future directions. Psychiatric education is currently facing many critical issues. Their resolution will determine the future availability of psychiatrists and is dependent on the development of new strategies that will require a reorientation in several aspects of current psychiatric education. This may be necessary if the vitality of psychiatry as a specialized branch of medicine is to be maintained and the relevance of psychiatric training and practice to service needs and research objectives is to be increased.


The sequelae and nonsequelae of conjugal bereavement. The author reviews prospective studies of bereavement, which show that widows and widowers suffer from significant depressive symptoms in the first year. Young widows and widowers may have more physical distress and take more drugs. There are few changes among older men and women in physical health, visits to physicians, and hospitalizations. Psychiatric consultation and hospitalization are rare and tend to occur early in a bereavement rather than later. There is probably an increase in mortality only among older widowers in the first year. The death of one's spouse is a psychologically stressful event; however, during the first year men and women cope with the loss with minimal morbidity and mortality.


Families of manic-depressive patients: effect of treatment. The authors studied the families of 12 patients with bipolar manic-depressive illness. They measured family stability using a life events scale for a 2-year period before lithium treatment and for 2 years during lithium treatment. The patients responded well to treatment; they were able to resume normal roles within the family. The life events scores decreased substantially during treatment in comparison with before treatment. The most severe impact of the illness was found in the children: 45% (N = 10) were moderately ill or symptomatic. The authors discuss the effect of manic-depressive illness on the family system as a whole and emphasize the need to combine psychosocial treatment with lithium treatment.


Joint custody: solution or illusion?

Joint custody: solution or illusion? Although the phrase "joint custody" is in popular use, the concept lacks standard definitin; parents who express interest in this form of disposition have widely differing objectives and expectations. The authors discuss the need for determining the primary objectives of the parties involved and for exploring the potential for achieving these through joint custody as well as through other alternatives. They examine the benefits of joint custody as well as the risks engendered by this type of arrangement and make a number of specific recommendations. They conclude that joint custody should be considered and explored, together with other available alternatives, and awarded only in appropriate cases.


The invested partner in sexual disorders: a profile. To determine the relevant psychosexual characteristics of invested partners of patients with sexual disorders, the authors administered the Derogatis Sexual Functioning Inventory (DSFI) to 51 invested partners and 200 normal volunteers. Female invested partners (N = 18) participated in a significantly more constricted range of specific sexual activities and revealed significantly lower sexual drive than the normal women. Tbey also had significantly lower scores on the femininity component of the gender role definition subtest. Male invested partners (N = 33) also showed significantly lower femininity scores and had somewhat lower scores on endorsement of specific sexual experiences. Degree of sexual satisfaction in the invested partners was comparable to that of their sexually dysfunctional partners.


Effect of clozapine on human serum prolactin levels. The authors determined serum prolactin levels in 13 patients receiving clozapine, an antipsychotic drug that does not produce extrapyramidal side effects. Morning serum prolactin levels, 11 hours after the last dose, were not elevated during chronic treatment with clozapine in any subject despite its therapeutic effects. Serum prolactin levels were moderately increased between 90 minutes and 4 hours after administration of very high doses of oral clozapine in 4 patients but were smaller than those produced by chlorpromazine in other subjects. The authors suggest that clozapine in other subjects. The authors suggest that clozapine may achieve its antipsychotic effect differently than do classical neuroleptics and that sustained prolactin increases are not essential for antipsychotic action.


Intrapsychic structural effects of psychiatric research. The authors observed that many psychotic patients on a clinical/research ward incorporated various aspects of research organization into their own evolving intrapsychic structures. This process had either beneficial or deleterious clinical effects, depending on the attributes of the research and the specific mental functions to which these attributes became attached. The observations resulted in the development of a set of recommendations for maximizing the therapeutic usefulness of this phenomenon and minimizing its countertherapeutic drawbacks.


Ethnic density and psychiatric hospitalization: hazards of minority status. The relationship between ethnic density (the relative size of a given ethnic group in a multi-ethnic neighborhood) and risk for psychiatric hospitalization was explored for black, white, and Puerto Rican residents of New York City's 338 health areas. The author found that the smaller the ethnic group, the higher its hospitalization rate in comparison to both the rate of other residents in the same area and that of members of the same ethnic group living in areas where they constituted a numerical majority. Analysis of sociodemographic variables showed that the effect of ethnic density on risk for psychiatric hospitalization cannot be accounted for by differences in poverty, family cohesiveness, or population mobility.


The evolution of modern psychiatric care in Nigeria. The author discussed the development of modern psychiatric care in Nigeria. There are two primary conceptual orientations among mental health workers in the country--the "non-culture bound" and the "culture-bound" approaches to mental health care. The effectiveness of modern psychiatric care in this society might well depend on the extent to which commonly accepted notions of mental illness are accommodated by professional care agents.


Common mistakes in psychotherapy.

Common mistakes in psychotherapy. To better monitor the psychotherapy training of psychiatric residents and to understand therapist factors involved in a negative outcome to psychotherapy, the authors surveyed 20 supervisors on the frequency of mistakes made by resident therapists. Among the mistakes most commonly made were wanting to be liked by patients, premature interpretations, overuse of intellectualization, inability to tolerate patients' aggression, and avoidance of fee setting. The authors conclude that the mitigation of the most common errors requires open discussion of countertransference issues.


Violence associated with phencyclidine abuse. Violence associated with chronic phencyclidine (PCP) abuse was investigated by administering a structured interview to 16 chronic PCP abusers. A more intensive study was done of another individual who committed murder and self-mutilation under the influence of PCP. The results suggest that there is no consistent association between PCP-related violence and a history of violence not related to drug or alcohol abuse. The author defines four types of violence associated with chronic PCP abuse.


Colleagues' responses to the pregnant psychiatric resident. A number of researchers have suggested that the pregnant psychiatrist has many intrapsychic conflicts, as a result of the pregnancy, which influence her interactions with colleagues. In contrast, the authors suggest that colleagues' reactions to the pregnancy may be based on their intrapsychic conflicts, which create internal conflicts for the pregnant psychiatrist and affect her relationships with her colleagues. The authors present case reports involving psychiatric residents that illustrate their thesis.


Identification and evaluation of competencies of public health nutritionists. The Delphi Technique was used to elicit a number of essential competencies expected of the "entry-level" public health nutritionist from members of Graduate Faculties of Programs in Public Health Nutrition. Questionnaires composed of "competency statements" were constructed from these responses and sent to practitioners in public health nutrition. The questionnaire requested evaluation of the "necessity" of each competency. Responses served as the basis for "factor analysis" procedures, employed to obtain clusters of competency functions expected of the nutritionist. From the 109 competency items originally identified, 17 competency scales were derived from the factor analysis. A ranking from both faculties and practitioners revealed that both groups highly rated competencies to communicate, to counsel and deal with clients/patients, and to interpret scientific data in "lay language." Less important in the ranking were competencies which dealt with administrative abilities, program planning, legislative activism, and consumer advocacy. These findings have cimplications for the practitioner in public health nutrition as well as for academic groups who must plan and evaluate curricula in public health nutrition and in other fields of public health.


A student community dental experience with migrant farmworker families and the rural poor. For the past six years, 78 dental students have worked with 25 rural dentists to provide over 31,000 dental health services to migrant patients for all of Colorado's agricultural communities. In 1977, each of 19 dental students averaged over $538 per week in value of comprehensive dental services, including preventive and peridontal services (36 per cent, N=3,006); restorative services (46 per cent, N = 3,904); surgical services (8 per cent, N = 705); services in pulp therapy (5 per cent, N = 413); and an additional 5 per cent (N = 412) in miscellaneous services. A unique combination of federal resources from the Departments of Labor, and of Health, Education and Welfare, were combined through the Colorado State Health Department and the University of Colorado Medical Censtrated by: 1) a relatively low extraction to restoration ratio (1 to 5) when compared to reported studies (1 to 2); 2) a relatively low extract to root canal therapy (10  to 1) when compared to reported studies (400 to 1); 3) no statistical difference between students and rural practitioners in the quality of services as determined by peer review study. This dental program is an integrated component of a comprehensive program combining student and professional services in medicine, nursing, nutrition, and health education.


A survey of mental health service coverage within health maintenance organizations. This 1978 national survey of all operating Health Maintenance Organizations (HMOs) provided information on the current status of mental health services utilization and service coverage within HMOs. It achieved a 68 per cent response rate. Approximately 90 per cent (108) of the HMOs offered mental health services through basic or supplemental coverage plans; HMO organization characteristics reflected relative heterogeneity; the mean monthly costs for basic health plan coverage (physical and mental health services) were $33.85 (for individuals) and $95.15 (for families); HMOs reported lower physical and mental health hospital utilization and higher ambulatory utilization when compared to more traditional forms of health insurance coverage. The present coverage and uitlization of mental health services within HMOs reflect greater variability of benefits and utilization within HMOs. There is need for further studies of mental health utilization in relation to organizational structure and delivery pattern relationships within HMOs.