Sanguineous cerebrospinal fluid in recanalized cerebral infarction. To clarify the causal relationship between spontaneous recanalization of the occluded cerebral artery and development of hemorrhagic infarction, 15 patients with internal carotid or middle cerebral arterial axis occlusion were submitted to consecutive lumbar punctures and follow-up cerebral angiography. Consequently, six of seven recanalized patients had sanguineous cerebrospinal fluid (CSF) on the second or third day after ictus, while only one of eight non-recanalized patients had bloody CSF. It was strongly suggested that recanalization might have an initimate relationship with the development of hemorrhagic infarction.


Action of vasodilators on regional cerebral blood flow in subacute or chronic cerebral ischemia. Regional cerebral blood flow (bicompartmental and stochastic method) was measured in a series of 20 patients with unilateral brain softening. Measurements were repeated during the administration of a vasodilator. A deterimental effect on the perfusion of the disease area was observed in the majority of cases. It has been shown that the chances for a vasodilator to decrease the perfusion in the diseased area were greater when the angiogram showed obstruction of an intracranial artery.


Granulomatous angiitis. An unusual etiology of stroke. A 43-year-old man, who died five months after the onset of left-sided sensory deficit, had angiographical and pathological evidence of an angiitis confined largely to the distribution of the right middle cerebral artery. Histological examination identified this process to be intracranial noninfectious granulomatous angiitis. Although certain clinical and pathological features of this disorder overlap with other vasculitides which effect the central nervous system, the disease nevertheless retains sufficient individuality to warrant status as an entity, and should be considered in the differential diagnosis in adults with lesions which produce focal neurological deficits and signs of increased intracranial pressure. The definitive answer regarding an infectious etiology will come only from detailed culture studies of the affected vessels.


Reassessment of cerebral capillary changes in acute global ischemia and their relationship to the "no-reflow phenomenon". Electron and light microscopic studies were performed on rabbit brain to re-examine the structural changes of endothelial cells and perivascular glia following ischemia. Although swelling of perivascular glia occurred, earlier findings of extreme perivascular glial swelling and bleb formation leading to luminal collapse and plugging could not be confirmed. Ischemic brains, however, had a higher proportion of small-diameter capillaries than controls. It is felt that structural changes in ischemic capillary walls in themselves are not sufficient to explain failed cerebral reperfusion, or the no-reflow phenomenon.


Radionuclide cerebral blood flow and carotid angiogram. Correlation in internal carotid artery disease. Radionuclide cerebral blood flow (CBF) examinations of 48 patients with atherosclerosis, 18 with occlusion and 30 with stenosis of the internal carotid artery (ICA) were correlated with their respective cerebral angiograms. The following results were obtained. Flow was visually unilaterally diminished in 29 (60%) of 48 patients, including 14 (78%) with occlusion and 15 (50%) with stenosis. Sixty-two percent of the subjects with severe stenoses and 46% of the patients with mild stenoses had a positive flow study. Diminished flow was evident in the neck in 80% of the patients, intracranially in 20%. Positive radionuclide angiograms always pointed to the side with occlusion or the greater degree of stenosis even though bilateral interanl carotid disease was frequently found (54%). The data leading to the differentiation between major and minor ICA stenosis are not sufficient to justify any conclusion.


Cation activities in reversible ischemia of the cat brain. In normothermic anesthetized cats cerebral blood flow was interrupted completely for one hour by arterial clamping and induced hypotension. The effect of ischemia on the ionic gradients of the cerebral cortex was assayed by determining total cortical electrolytes and by recording the activities of extracellular potassium ([K+i1e) and subarachnoid sodium ions ([Na+])s) with ion-sensitive electrodes. During ischemia [K+]e increased from 3.3+/-0.3 to 56+/-5.4 mEq per liter (means+/-SE) and [Na+]s decreased from 133+/-3.8 to 53+/-5.8 mEq per liter. When the brains were recirculated with blood after one hour's ischemia, [K+]e and [Na+]a gradually returned to normal within 45 minutes. The calculated intracellular uptake of sodium during ischemia amounted to 139 mEq per kilogram dry weight, whereas the intracellular release of potassium was only 64 mEq per kilogram. The increase in intracellular cation was accompanied by a movement of water from the extracellular into the intracellular compartment, causing a reversible shrinkage of the extracellular space from 18.9 to 8.5 vol %. The changes in ionic gradients were related to the development and resolution of ischemic brain swelling, and to the elctrophysiological events during and after ischemia.


Detection of porcine-specific canine antibodies by a radioimmunological technique. A sensitive radioimmunological technique is described in which the primary interaction of 125I porcine membrane antigens with naturally occurring canine antibodies is measured by precipittion with 20% polyethylene glycol. Porcine membrane antigens were isolated, radiolabeled, and found to be maximally soluble in 20% polyethylene glycol solution. Binding of canine antisera to porcine antigens could be reduced by absorption with porcine lymphocytes. An eluate was obtained from a porcine kidney that was perfused in vivo for 330 min with oxygenated canine plasma and was identified as canine IgG by immunoelectrophoresis. When added to normal dog serum, the eluate markedly augmented the binding titer. Samples of dog serum taken after extracorporeal perfusion showed a significant decline in binding with no significant changes in lymphocytoxicity titer. These results suggest that this primary binding assay is a more sensitive indicator of the presence of graft-specific humoral antibodies and may be of value in evaluating prospective heterograft donors as well as in following the course of therapy.


Frequency and course of pure motor hemiparesis: a clinical study. A review of 850 acute unselected stroke cases at Harlem Hospital found only 25 (3%) who met a clinical definition of pure motor hemiparesis. Compared to other cerebral infarction survivors, the 23 pure motor syndrome survivors were slightly younger, not much more often hypertensive and did not make a faster recovery. The degree of motor deficit a year later was nearly the same in both groups. Brain scans were positive in one-third of the pure motor patients, which suggests that this clinical picture may be associated with larger brain lesions than had been suspected before, as well as with lacunar infarction.


Site dependency of TA3 Ha allotransplantability. An ascites tumor line, TA3 Ha, is allotransplantable i.p. while a sister line, TA3 St, has retained its strain specificity. This study shows that the allotransplantability of TA3 Ha, with very few exceptions, is restricted to the peritoneal cavity and is not operative s.c. or i.v.


Adrenergic innervation of large cerebral blood vessels of the rabbit studied by fluorescence microscopy. Absence of features that might contribute to non-uniform change in cerebral blood flow. The literature provides evidence for non-uniform regional changes in cerebral blood flow under a variety of circumstances. Possible causes of such changes were sought in the larger cerebral arteries of the rabbit prepared according to the glyoxylic acid fluorescence histochemical technique. The adrenergic innervation of the circle of Willis, the basilar artery and their main branches, although showing small differences, is essentially of uniform density. There is no evidence for collars of adrenergic nerves around the origin of small branches nor for cushions at their orifices. Innervation density appears to diminish as the pial vessels get smaller and all vessels seem to be innervated. Thus non-uniform alterations of cerebral blood flow cannot be accounted for by these factors.


Maintenance of the functional state of isolated rat liver by hypothermic perfusion with an erythrocyte-free medium. Isolated rat liver was studied before, during, and after hypothermic perfusion at 5 C for 24, 48, or 72 hr with an acellular perfusate consisting of 7% bovine serum albumin in Kreb-Ringer buffer containing glucose, penicillin, and streptomycin. Bile production ceased at 5 C but resumed when the temperature was raised to 35 C. The rate of flow and the total amount produced was unaffected by 24 hr of hypothermia but decreased when the cooling period was extended to 48 and 72 hr. The data of other workers was used to show a correlation between bile flow and oxygen consumption by the liver. Cooling also caused the release of potassium into the perfusate but it was quickly reaccumulated after rewarming; however, the extent and rate of reaccumulation decreased as the cooling period increased, as did the ability of the livers to retain the ion. Urea synthesis did not cease after cooling and after rewarming, the rate of synthesis increased as the period of hypothermia was lengthened. The maximum concentration of urea in the perfusate was found when rewarmed livers had produced 200 mumol of urea but at this point, control livers had produced 280 mumol. The concentration of glucose in the perfusate of livers maintained at 35 C  showed peaks at 2 and 9 to 10 hr after the start of perfusion. After cooling for 24 hr these peaks arose at 2 and 7 hr after rewarming, but with 48 hr of hypothermia, these peaks were higher and appeared at 2 and 4 hr. When the cooling period was extended to 72 hr, only a single peak was seen 2 hr after rewarming. These results suggest that rat liver can be cooled to 5 C for 24 hr with little effect on its functional characteristics but a marked decline becomes apparent when the cooling period is extended beyond 24 hr. None of the livers studied was transplanted after perfusion and it remains to be seen how the functional tests conducted in vitro correlate with the ability of the livers to support life.


133Xenon inhalation method. Analysis of reproducibility: some of its physiological implications. Regional cerebral blood flow (rCBF) was simultaneously measured at seven locations in each hemisphere by the Obrist 133Xenon inhalation method. In each of 35 healthy right-handed subjects two rest measurements were performed on consecutive days. The data analysis comprises the two-compartmentally derived parameters for flow (f1), relative tissue weight (w1), and fractional flow (FF1) respectively of the first compartment, and in addition the initial slope index (ISI). At each detector location the coefficient of variation (C.V.) of the change from first to second measurement was on average 10.4% (ISI), 14.2% (f1), 7.2% (w1), and 2.9% (FF1) respectively. However, when each regional measurement was expressed as a percentage of its hemispheric mean, the C.V. of the intermeasurement change was on average 4.4% (ISI), 7.0% (f1), 7.7% (w1), and 1.9% (FF1) respectively; that of the hemispheric means of ISI, f1, and FF1 was found to be distinctly larger, whereas that of w1 was about equal in size. The interhemispheric coefficient of variation for the change of the hemispheric means from first to second measurement was only 2.3% (ISI), 4.4% (f1), 1.6% (w1), and 1.1% (FF1) respectively. The findings suggest that (1) the variability of rCBF from subject to subject and in consecutive measurements in the same subject is to a substantial degree of physiological origin, and that (2) there are two determinants of rCBF which may operate independently: a determinant of the hemispheric mean level, probably a single determinant for both hemispheres, and a set of determinants for each separate regions superimposed on the hemispheric mean level.


Allograft rejection in larval and adult Xenopus following early thymectomy. The effect of thymectomy (performed on 7- to 8-day old larvae) on the development of alloimmunity in the clawed toad is examined. Rejection of first-set skin grafts applied in larval life (30 days of age) and at intervals following metamorphosis (70 to 370 days of age) was always impaired following thymectomy. However, most of the thymectomized animals, even those grafted as larvae and blocked in the larval state by thiourea treatment, were able to destroy the transplants, albeit with prolonged rejection times. The pattern of graft rejection in thymectomized larvae was similar to that seen in adults. After thymectomy, these seemed to be no improvement or impairment of the alloimmune response with the passage of time. Experiments with second-set grafts applied subsequent to first-set destruction demonstrated the existence of an alloimmune memory component throughout ontogeny in both control and thymectomized animals. The results indicate that a population of cells involved in graft rejection develops early in ontogeny, independent of the thymus and the emergency of bone marrow at metamorphosis.


Effect of cerebrospinal fluid removal on cerebral blood flow and metabolism in patients with Alzheimer's disease versus recent stroke. Cerebral hemispheric blood flow (HBF) and metabolism were measured before and after withdrawal of 20 to 30 ml of cerebrospinal fluid (CSF) over a 10-minute interval in eight patients with recent cerebral infarction and in four patients with Alzheimer's disease (AD). Immediately after CSF removal HBF decreased significantly in the AD group (-14%) but showed no significant change in the stroke group (-5%). There was rapid reduction in cerebral venous O2 content and some increase in cerebral venous PCO2 appearing within 60 seconds of CSF withdrawal, interpreted as a rapid reduction of cerebral blood flow (CBF) as judged by cerebral A-VO2 differences. The reduction in CBF was confirmed by the hydrogen clearance method. Reduction of CBF in response to lowering CSF pressure is presumably of neurogenic origin since it was rapid and occurred without changes in PaCO2 or MABP. Furthermore, measurement of HBF demonstrated that cerebral metabolism constant after CSF removal. It is postulated that in AD, reduction of HBF following CSF withdrawal is mediated by a disordered neurogenic veno-arterial vasoconstriction reflex which is stimulated by rapid reduction in CSF pressure (CSFP). In patients with stroke, when cerebral perfusion pressure is increased by lowering CSFP, CBF is maintained constant most likely by a physiological cerebral veno-arterial vasoconstrictive reflex. Apparently, this vasocontrictive reflex becomes excessive in Alzheimer's disease, possibly due to cerebral neurogenic imbalance.


Genetic aspects of umbilical hernia incidence in cats and dogs. The incidence of umbilical hernia in a family of Cornish rex cats approximated monogenic proportions. The genetic and developmental basis for umbilical hernia may be similar in cats and dogs. The defect is probably a polygenic threshold character, possibly involving a major gene whose expression is mediated by the genetic (breed) background.


Control of headfly on sheep.

Control of headfly on sheep. Headfly caused irritation to sheep in Northumberland from late June of each year 1973 to 1975. Numbers of headflies caught in sweep nets declined sharply from early August 1973 and 1975 but remained fairly high in 1974 until mid September. Attacks on sheep followed a similar pattern. The effectiveness of a number of fly repellent applications was examined. Headcaps gave good and sometimes complete protection.


Biochemical indicators of liver injury in calves with experimental fascioliasis. Twenty calves were infected with 1000 metacercariae of Fasciola hepatica, the activities of 10 enzymes in plasma or serum were assayed and concentrations in serum of proteins, urea and bilirubin were determined. These values were compared with control data obtained from 14 uninfected calves. Aspartate aminotransferase, lactate dehydrogenase, sorbitol dehydrogenase, glutamate dehydrogenase, ornithine carbamoyl transferase and gamma-glutamyl transpeptidase activities increased in infected calves. Total serum protein increased, albumin decreased, globulin increased and the albumin/globulin ratio was decreased in infected calves. Plasma alanine aminotransferase, leucine aminopeptidase, alkaline phosphatase and cholinesterase activities and serum concentration of urea and bilirubin were unaffected. It was concluded that glutamate dehydrogenase and gamma-glutamyl transpeptidase were the most sensitive indicators of liver cell damage in fascioliasis.


Cloprostenol as a treatment for no visible oestrus and cystic ovarian disease in dairy cows. A total of 253 cows was treated using 500mug cloprostenol intramuscularly. Of those, 129 cows were treated for failure to exhibit an observed oestrus, 124 for being negative at pregnancy diagnosis examination; all possessed a corpus luteum as detected by rectal palpation. One hundred and sixty nine (66.8 per cent) were detected in oestrus within eight days, and of these 159 were served. Eight-seven (54.7 per cent) of them conceived. Sixteen cases of luteinised ovarian cysts were also treated with a resultant 14 conceptions occurring at a mean interval of 19-4 days. It is condisered that the time of the induced oestrus is not predictable enough to warrant "fixed time" insemination. The success of treatment will be related to: (1) The efficiency of oestrus detection on the farm (2) The normal conception rate on the farm (3) The accuracy of the rectal palpations.


[Stress-induced blood protein and blood lipid changes and their dependence on learning and conditioning]. Rats were subjected to two kinds of stress and consequent changes in blood protein and lipids were investigated. Furthermore, an attempt was made to ascertain whether or not increases or decreases in these blood parameters were reproducible by conditioning. In the first experiment animals were subjected to stress in a modified running wheel (Noble Collip drum). A series of 10 conditional stimuli (light-sound combined) was delivered together with the stress-producing stimulus. After the first exposure to stress a relative alpha1-globulin increase was observed. After  10 stress exposures the hitherto neutral stimulus alone produced a conditioned increase in the alpha1-globulin fraction. The gamma-globulin values were decreased after the first exposure to stress, but increased after 10 stress exposures. This increase could also be conditioned. In the second experiment "white noise" stress was used (110 dB). The conditional stimulus was light. After short exposure to the stress-inducing stimulus, the gamma-globulins showed a slight drop and remained thus during the whole experiment. The analysis of blood lipids showed increased stress values for alpha-lipoprotiens and reduced values for beta-fractions. Cholesterol and triglycerides reacted like the beta-lipoproteins. The total blood lipid content was, however, increased. The conditioned increase in alpha-lipoproteins and total lipids was statisticallysignigicant. It is noteworthy that the conditioned alpha-lipoprotein levels shoeed significant differences between experimental and control groups. The conditioned stress increased the levels of cholesterol and triglycerides, whereas under real stress conditions decreases were found. Research on "conditioned stress" could beof improtance in regard to clinical aspects of coronary heart disease.


[Acute intermittent porphyria. A  case report and family study]. The course of acute intermittent porphyria is described in a patient who died during an acute exacerbation of the disease. An analysis of the urinary porphyrin precursors (delta-aminolaevulinic acid and porphobilinogen), the determination of toal porphyrin excretion and the separation of haem precursors in the urine according to the number of carboxylic groups demonstrate different degrees of biochemical severity in the individual consanuinious members of this patient's family. The detection of latent carriers is of particular importance since the avoidance of porphyrogenic substances is the most important prophylactic measure to be undertaken in all latent clinical cases. According to our experience, however, prophylactic measures must also be extended to young consanguineous family members with negative excretion patterns in view of the difference in age at which the disease manifests itself.


[Morphometric studies on epithelial cells of the rat stomach under chronic effect of alcohol]. In studying the effect of ethanol on the size of parietal cells 60 Wistar rats received 15% ethanol ad libitum and were killed after 8 days, 2, 4, 8, and 12 weeks. For the control group 24 untreated animals were used. The parietal cells were stained with Kongo-red for the histological preparations and with a Papanicolaou modification for the cytological smear. With two measuring-methods -- the Integration-disc and the Mikrovideomat -- the cell and nucleus surface were determined and the nucleus-plasma-relation was calculated. After 8 days of alcohol administration a significant increase of parietal cell surface appeared in the histological and cytological preparation. The cytoplasma surface area increased continuously until the 8th week. With further application of alcohol until the 12th week the zytoplasma surface area decreased again but remained above the starting size. The calculation of the cell surface areas produced nonuniform results. Further the sizes of parietal cells (cytoplasma and nucleus surface areas) in the cytological smear and after being embedded in the histological preparation were compared. In the applied measuring methods a comparison was also made.


[Toxic dilatation of the colon].

[Toxic dilatation of the colon]. Twelve patients (8 males and 4 females) with toxic dilatation of the colon in acute ulcerative colitis were reviewed, who required surgery between 1962 and 1974 at the Department of Surgery, University Kiel. This complication always occured during a relapsing exacerbation of known colitis. Nine patients died. This high operative mortality (75%) was related to faecel sepsis because of praeoperative perforations, operative disruptions of walled-off perforations and to a delaying conservative approach of more than ten days. These results with the onestage coloproctectomy or colectomy with later excision of the rectum urge an early surgical intervention before perforation took place. The diverting ileostomy and decompression colostomy may additionally lead to a better prognosis.


[Morphologic, animal experimental study on the question of sex specific liver lesions due to chenodesoxycholic acid]. Male Wistar rats were fed orally 20 mg, female rats were fed 20, 50 and 90 mg CDC/kg body weight. The animals were killed on the 5th, 14th, 20th, 30th and 60th day, female animals were killed in addition 14 days after end of treatment, their liver was examined by means of light- and electron microscopy. No pathological changes were to be seen in the light microscope. In the electron microscope we observed in male and female animals dilated bile capillaries and intracytoplasmic vacuoles, in female animals more over alterations of mitochondria and an increase of peribiliary lysosomes. Sex-linked differences were not to be detected. In female animals the findings were quantitatively better discernible. Even a tetrafold increase of dosage in female rats produced no change in findings. 14 days after end of therapy no alterations were visible any more. It is being assumed that CDCA or its metabolite lithocholic acid exert some influence upon the bile secretory apparatus of the liver cell.


[Hyperoxaluria in intestinal and liver diseases]. Excretion of oxalic acid in urine was measured in 28 healthy and 97 patients with gastrointestinal diseases. We found significantly higher values in the following groups: patients after resection of parts of the small intestine, patients with sprue and other diseases with malabsorption, patients with M. Crohn of the small intestine, colitis ulcerosa and granulomatosa, patients with chronical diseases of the pancreas gland and patients with cirrhosis of the liver. In 4 patients after resection of parts of the small intestine or pancreas urolithiasis could be verified. Reduction of fat and food without ballast reduced the excretion of oxalic acid in urine. Hyperoxaluria correlied significantly with the following parameters: excretion of fat in feces, exhalation of 14CO2 in the glykocholate breath test, resorption of vit. B12 and the length of resected small intestine. This form of hyperoxaluria is caused by hyperresorption of oxalic acid from food. The mechanism of this hyperresorption is not clarified yet, an important factor seems to be ill resorption of fat.


[The significance of coronary artery calcification seen by roentgenoscopy (author's transl)]. The detection of coronary artery calcification by roentgenoscopy is an important hint at possible ischemic heart disease. By the advent of image intensification and magnification, this examination can easily be performed. If no calcifications are visible, an ischemic heart disease must not be excluded. The presence of calcification in the coronary arteries however strongly favours the diagnosis of arteriosclerotic heart disease. The roentgenoscopical search of coronary calcification is considered to be a valuable procedure since it is inexpensive, noninvasive and widely applicable.


[Early mobilisation after myocardial infarction. A prospective and controlled study (author's transl)]. Early mobilisation after acute myocardial infarction is said to increase the risk of ventricular aneurysm and -rupture, reinfarction, sudden death, and heart failure. In order to evaluate these possible negative effects, we run a prospective and controlled study: 2 X 100 consecutive patients with acute myocardial infarction were mobilized conventionally (A) and according to an early mobilisation programme (B) respectively-the two groups were comparable according to age, sex, CHD-history, infarction transmural/non transmural and coronary prognostic index (Norris). There was a significant reduction in the average hospital stay from 31.4 days in group A to 25.8 in group B. The patients were followed up for 32 (A) and 46 days (B) respectively. In the early mobilized group we found no increased risk for heart failure, reinfarction, or sudden death. On the other side, early mobilisation has many psychological, oeconomic and social advantages for patients and hospital.


[Long term results after operation of patent ductus arteriosus or ventricular septal defect and pulmonary hypertension (author's transl)]. The behaviour of pulmonary hypertension and elevated pulmonary vascular resistance was followed up to 12 years postoperatively in 29 patients with patent ductus arteriosus (DAA) and 34 patients with ventricular septal defect (VSD). 8 of 11 patients with VSD and rest defect underwent a second operation. All patients had preoperatively pulmonary hypertension due to elevated pulmonary vascular resistance (RPA) and elevated pulmonary blood flow. Pulmonary arterial mean pressure (PPA) was usually reduced immediately after operation corresponding to the reduced pulmonary blood flow. In the later postoperative period PPA and RPA were either reduced to normal values, reduced but not normalized or increased progressively. In patients with moderate elevation of RPA before operation (200-800 dyn - sec cm-5) 34 % showed normalisation of RPA, 11 % increase of RPA in the follow-up period. In patients with severe elevation of RPA before operation (greater than 800 dyn - sec - cm-5) 11 % showed normalisation, 30 % an increase of RPA in the follow-up period. There was no correlation between age at operation and the late postoperative results. Exercise test were useful to confirm normalisation of the pulmonary vascular changes. The results in patients with VSD and rest defect demonstrate that apparently small left-t0-right shunts are able to stop the involution of organic changes in the pulmonary arteries. Prognosis of follow-up cannot be established from the hemodynamic results obtained early after operation. Therefore repeated hemodynamic investigations have to be performed in the later follow-up period.


[Transposition of the great arteries: natural history and indications for surgery after balloon-atrioseptostomy (author's transl)]. The natural history of 162 children with transposition of the great arteries is referred, whose first heart catheterization fell between 1967 and June 1975. In 149 of them balloon atrial septostomy (BAS) was performed, with a mean increase in arterial oxygen saturation of 21 %. In 11 cases BAS was repeated after inadequate first BAS, but again without success. In 19 patients an atrial septectomy (Blalock-Hanlon) was performed later on, with 20% mortality. 3 children died during or immediately after BAS. The early mortality after BAS was 13% and the late mortality 17%. These values include the mortality of palliative operations which were necessary to bridge over the time until "corrective" operations could be performed. The operative mortality of Mustard operations was 10% for the simple TGA and 16% for all TGA cases operated on. On the basis of the mortality values of the BAS, of atrioseptectomy (Blalock-Hanlon) and of the Mustard procedure the proceeding after BAS and the indication for operations is thoroughly discussed.


[Rhabdomyomatosis of the heart and ventricular septal defect (author's transl)]. An unusual case of cardiac rhabdomyomatosis associated with a ventricular septal defect without signs of tuberous sclerosis is described. On 3 different angiocardiographies the region of the tumor seemed to be a right ventricular aneurysm. The tumor was identified as such only on operation and its nature defined histologically. Subtotal excision of the tumor and closure of the large ventriccular septal defect and debanding (pulmonary banding at the age of 8 month) was successfully undertaken at the age of 10 years.


[Right atrial fibroma simulating cyanotic cardiac vitium in a newborn (author's transl)]. The clinical picture in a cyanotic newborn suggests pulmonary atresia or tricuspid atresia. Angiocardiography shows a right atrial tumor, at necropsy a ping-pong-ball sized fibroma is found. Hypoxia and congestive heart failure occurred and the baby died on his eleventh day of life. Uncertain cardiac symptomatology should always raise the suspicion of a cardiac tumor. Cardiac tumors with predominant intramural growth can show pure cardiomegaly- and/or cardiac arrhythmias, congestive failure, while intracavitary growth may lead to various kinds of in- and outflow obstruction and/or embolisations.


[About some rare complications caused by transvenous pacemaker electrodes. Morphological and clinical findings (author's transl)]. Early and late dislocation of electrodes incl. perforation of myocardium and infections of pacemaker systems are the most frequent complications during endocardial pacing. Next functional disorders caused by a risen threshold for stimulation and sensing problems as well as pure technical defects have to be mentioned. The following rare complications were observed in three autopsies: 1. Electrode located in the vena cordis media. 2. Bipolar pacemaker electrode in unstable position near the atrioventricular boundary. 3. Infected transvenous pacemaker electrode migrated into the right vena iliaca externa. Letal thromboemboli sm of the pulmonary arteries. 4. Electrode fragment causing chronic cervical fistula. Consecutive death of the patient by bacterial endocarditis of the mitral valves. Some morphological and clinical aspects of these complications are discussed, the literature is reviewed. Special sight is kept on "trapped" electrodes and coincident infection. It is considered how to avoid those accidents.


[Accelerated idioventricular rhythm with second degree v.a.-block and reentry (author's transl)]. A case of acute myocardial infarction is presented with accelerated idioventricular rhythm and parasystolic character of the center, complicated by a retrograde v.a. block of 2nd degree with Wenckebach and reentry phenomena. It is supposed that a previous i.v. digitalis medication has contributed to the complicated arrhythmia.


[Determination of 1,2- and 3,4-benzpyrene besides other polycyclic aromatic hydrocarbons in smoked meat products by mass fragmentography (author's transl)]. In comparison with conventional gas chromatographic methods the combined gas chromatography--mass spectrometry with monitoring of two characteristic ions (mass fragmentography) allows a considerable shortening of analysis length and an increase in sensitivity in the determination of the polycyclic aromatic hydrocarbons benzfluoranthene, 1,2- and 3,4-benzpyrene. Analytical experiences in testing of smoked meat products are reported.


[A gas-chromatographic method for the determination of volatile nitrosamines in plant material and soil (author's transl)]. A method is described which enables low molecular nitrosamines to be determined in plant material and mineral soils. The principle of this method is based on the steam volatility of these nitrosamines by means of which they can be isolated. Their detection and quantiative determination is then carried out by gas chromatography. The limit of detection in this method is 4 to 8 ppb fresh plant material or soil, the possible sample weigth in each case being decisive. The various species of plants or soils have no influence.


The influence of heat on the aroma of cloudberries (rubus Chamaemorus l.). The qualitative and quantitative differences between the volatiles of fresh and heated cloudberries have been evaluated and the significance of the differences calculated. 14 new cloudberry volatiles have been identified, including vanillin, methyl vanillate, acetovanillone and 3,5-dihydroxy-2-methyl-4H-pyran-4-one. During the heating procedure two additional compounds, 3-hydroxypyran-2-one and 2-pyrrolaldehyde, were formed. Comparison of the quantitative data for the heated and unheated samples revealed 21 compounds having significant differences in concentration at or below the 10% level. The concentration of 4-vinylphenol, 2-methoxy-5-vinylphenol, furfural, 5-hydroxymethylfurfural and 3,5-dihydroxy-2-methyl-4H-pyran-4-one increased very markedly on heating. The concentrations of 81 compounds in the unheated press juice of cloudberries are given.


[Inhibitors for trypsin and chymotrypsin in seeds of the broad bean (Vicia faba) (author's transl)]. Several inhibitors for trypsin and chymotrypsin were detected in seeds of Vicia faba by isoelectric focussing. Their isoelectric points are at pH 8.5 (main peak with shoulder), at pH 9.1 (minor peak with shoulder) and in the range of pH 9.1-6.4 (several minor peaks with significant lower activities). From the mixture of inhibitors obtained by affinity chromatography on carrier bound trypsin, three inhibitors were isolated by preparative electrophoresis in polyacrylamide gel. On electrophoresis these inhibitors behaved uniformly at pH 9.2 and at pH 4.0. Their molecular weights are about 6000 daltons. The amount of basic amino acids is high, while methionine and isoleucine are absent. Beside of trypsin and chymotrypsin some serine proteinases of microbiol origin are inhibited. The thermal stability is quite high. The Vicia inhibitors therefore differ significantly from the Phaseolus inhibitors in several properties.


[Degradation of aflatoxin b1 by various microorganisms (author's transl)]. The degradation of aflatoxin B1 by various representatives of bacteria, yeasts and moulds in growing and resting cultures was investigated. We found that growing cultures of Corynebacterium rubrum degraded the added aflatoxin nearly quantitatively. -- Growing cultures of anascosporogenous yeasts degraded most of aflatoxin B1 while no degradation of this substance by ascosporogenous yeasts could be stated. Moulds degraded aflatoxin B1 to a high extent. -- With regard to the course of degradation three types can be distinguished. -- In the cultures of moulds two blue fluorescing compounds were found beside aflatoxin B1.


[Breakdown of linoleic and linolenic acid hydroperoxides in the presence of ascorbic acid analysis of the volatile aldehydes (author's transl)]. Hydroperoxide emulsions with 10(-3) mol ascorbic acid were stored for 19 h at 22 degrees C. Volatile aldehydes were formed in the presence of oxygen and traces of metals. The main compounds were identified as follows (mol-%): 2-pentenal [51] and 2-hexenal [22] from 13-hydroperoxioctadeca-9,11,15-trienoic acid; propanol [38] and 2-hexenal [25] from 9-hydroperoxioctadeca-10,12,15-trienoic acid; hexanal [82] respectively [66] from 13-hydroperoxioctadeca-9,11-respectively 9-hydroperoxioctadeca-10,12-dienoic acid. C9 and C10 aldehydes were only detected in very low concentrations as fragments of the 9-hydroperoxides.


[Quantitative determination of nitrogen oxide in cigarette smoke by means of chemiluminescence (author's transl)]. A measuring method with a chemiluminescence-analyzer is developed for determining the content of nitrogen oxide in cigarette smoke. This method is suitable for puff/puff analysis. It could be demonstrated that a determination of fresh smoke is necessary as nitrogen oxides react very quickly with other constituents of the vapor phase. Measured values have to be corrected for a quench factor in analogy to the CO2 concentration, as carbon dioxide shows an influence on the measuring sensitivity of the chemiluminescence-analyzer.


Automated determination of the density of liquids adoption of the kratky density meter in the continuous-flow system. For the determination of the density of liquids, the density meter according to Kratky [1] has been adopted in the continuous flow system of the Technicon AutoAnalyzer. The result is that 50-60 density measurements can be carried out in one hour. The precision is superior as compared with those of the conventional methods.


Glial and neuronal alterations in the corpus striatum of rats with CCl4-induced liver disease. A quantitative morphological study using an electronic image analyzer. The density and size of astrocyte-, oligodendrocyte- and neurone nuclei in corpus striatum were determined in rats with CCl4-induced liver encephalopathy by means of an electronic image analyzer. After 8 weeks of CCl4-administration, the astrocyte number had nearly doubled, and astrocytes with increased nuclear size appeared. After 20 weeks, a reduction (appr. 25%) was found in the number of nerve cells and oligodendrocytes. The total number of glial cells, however, was unchanged during the experiment; this demonstrates the need of performing differential counts when evaluating gliosis. Probably, a part of the increase in the number of astrocytes was due to a transformation from precursor cells, usually classified as oligodendrocytes. The increased number and size of astrocyte nuclei are probably connected with an enhanced astrocyte metabolic capacity due to alterations in the ammonia and amino acid metabolism.


The effects of cholesterol/fat feeding on lipid levels and morphological structures in liver, kidney and spleen in guinea pigs. Guinea pigs were fed a semisynthetic diet containing 10 per cent (by weight) cottonseed oil with or without 1 per cent cholesterol. In the animals fed fat, the lipid levels and the morphology remained normal in all tissues studied. Concomitantly with a marked accumulation of cholesteryl ester (CE) in the liver, however, many microscopical changes occurred in guinea pigs fed cholesterol/fat. A prominent deposition of lipids in vacuoles, mostly without delimitating membranes, where observed at centrilobular sites. Multivacuolated, secondary lysosomes, membrane bound lipid vacuoles (lipolysosomes) and myelin figures were found both in hepatocytes and Kupffer cells. Myelin figures and crystalline clefts were observed more often in Kupffer cells than in hepatocytes. The granular endoplasmic reticulum in the Kupffer cells was grossly dilated and filled with an amorphous material. Both the biochemical and the morphological findings in hepatocytes and Kupffer cells are very similar to those observed in cholesteryl ester storage disease and in Wolman's disease. These two lipid storage diseases are both related to deficiency of an acid lipase in the liver. Measurement of the acid liver CE hydrolase in guinea pigs fed fat and in those fed cholesterol/fat showed similar activity. A relative deficiency of this enzyme activity could be the reason for the development of the enormous CE storage in guinea pig livers. These findings suggest that guinea pigs fed cholesterol/fat, in some respects, can be used as a model for Wolman's disease and cholesteryl ester storage disease. We did not find any microscopical changes in the kidneys from animals fed cholesterol/fat, thus indicating that the experimental condition it not useful as a model for studies of the kidney changes in lecithin:cholesterol acyltransferase (LCAT) deficiency.


Demonstration of hormonal sensitivity in gynaecomastic tissue by thymidine incorporation in vitro. Gynaecomastic tissue from six patients were tested for oestrogen and testosterone sensitivity as measured by thymidine incorporation in tissue fragments in vitro. The DNA synthesis of the cultures was increased in tissue from five out of the six patients under the influence of oestrogen, whereas it was increased in tissue from only one patient under the influence of testosterone. The results are discussed in relation to the medical histories of the patients and hormonal excretion studies done by others.


Intimal pits of aorta in rabbits: Imprints of vortices of blood flow? Scanning electron microscopy of rabbit aorta showed that the intimal folds had a regular, linear pattern in areas of expected laminar flow. In areas of expected vortex formation, however, there was deviation of the fold pattern with the formation of rounded depressions or pits in the intimal surface. Platelet depositions were found in connection with some of the pits. In sections for light microscopy the pits corresponded to small areas of flattened folds of the innermost elastic membranes. It is concluded that the intimal pits probably reflect imprints of vortices of the whirling blood.


Observations by scanning electron microscopy of normal and pathological human gall bladder epithelium. Thirteen gall bladders presenting normal findings, cholesterolosis, chronic cholecystitis, mucosal hyperplasia and adenomyomatosis were studied by scanning and light microscopy. In the bladder of patients with cholesterolosis the mucosal folds were clearly dilated, but the individual epithelial cells had preserved their normal hexagonal structure. In the gall bladder of one patient with cholesterolosis, goblet-like cells were seen in the epithelium. The greatest changes were seen in material from patients with chronic cholecystitis, in which the mucosal folds were clearly flattened and the cell boundaries indistinct and small polypoid structures were seen on the surface of the epithelium. No special changes were seen in material obtained from patients with adenomyomatosis or mucosal hyperplasia.


Secretion of calcitonin and gastrin in rats with transplanted medullary thyroid carcinoma. Rats transplanted with medullary thyroid carcinoma (MCT) were followed with radio-immuno assay of serum calcitonin (iCT) using antisera to human CT and I125 labelled calcitonin-M. From the 4th month after transplantation, serum from the tumour rats contained iCT in concentrations 8-10 fold higher than serum from the control rats. The tumour cells had retained their ability to react on pentagastrin and calcium injections with increased CT release. It was further shown that the tumour bearing rats had elevated basal gastrin concentratkons in serum. While calcium injection lead to a rise in the serum gastrin concentration in the control group, the adverse effect was seen in the tumour bearing rats. The morphological features and the responsiveness of the rat tumour cells to physiological secretagogues make this tumour a suitable animal model for the study of interactions between CT and gastro-intestinal factors. It is suggested that the gastrin response to calcium might be of interest also in the diagnosis of human MCT.


Light microscopical and ultrastructural observations on the effect of vinblastine on ameloblasts of rat incisors in vivo. I. Short-term effect on secretory ameloblasts. The highly polarized secretory ameloblasts in the incisors of rats fixed by perfusion with glutaraldehyde two or three hours after intravenous administration of vinblastine sulfate at a dosage of 5 mg per 100 g body weight were studied in the light microscope and the electron microscope. The following effects were observed: 1. All cytoplasmic microtubules in the ameloblasts had vanished. This was not accompanied by the appearance of paracrystals of microtubular protein or macrotubules. 2. The ameloblasts preserved their external features of polarized cells but lost their ability to maintain normal orderly segregation of the cell constituents; i.e. their normal internal compartmentalization and polarity had vanished. 3. The ameloblasts lost their capability of directional translocation of the secretory granules towards the cell apex. 4. Secretory granules already translocated to the cell apex regurgitated in the cell and a probably delayed discharge of secretory material had started in abnormal site at the surface. 5. The normal arrangement of ribosomes into polyribosomes on the membranes of the rough endoplasmic reticulum was no longer present; the ribosomes were apparently distributed at random. 6. New secretion was inhibited or brought to a standstill but secretory material already present in the Golgi complex appeared to be transported normally. 7. The centriole had started to develop into a cilium in many of the cells. 8. The number of autophagic vacuoles had increased.


Electron microscopy of lymph nodes of hamsters experimentally infected with Treponema pertenue. The morphology of lymph node tissue from normal hamsters and from hamsters experimentally infected with Treponema pertenue Gauthier was compared by means of light and electron microscopy. The capsules of the lymph nodes from infected hamsters showed an increased thickness in comparison with those of the non-infected animals. The infected lymph nodes differed from normal lymph nodes by small accumulations of neutrophilic leucocytes in the cortical areas. In addition, the amount of intercellular collagenous matrix present between large elongated cells was greatly increased in lymph nodes from infected animals. Electron microscopy of thin sections of infected lymph nodes showed intercellularly located treponemes in the leucocyte infiltration areas. These regions also showed the increased amounts of the collagenous matrix. Treponemes were occasionally found intracellularly in macrophages. These treponemes did not show their typically helical shape, but were present as spherical forms or cysts.


Right atrial monophasic action potential in patients with paroxysmal supraventricular tachyarrhythmias. Thirteen patients with paroxysmal atrial tachyaarhthmias (six atrial supraventricular tachycardia, six atrial fibrillation, and one atrial flutter) have been investigated by recording of monophasic action potentials (MAP) during a period free from arrhythmias. None of the patients differed from healthy individuals with respect to any of the MAP variables. Occasional recordings showed values not found in healthy individuals, such as prolonged duration of the MAP or slow phase 4 depolarization. The atrial effective refractory period (AERP) was determined in two patients. One AERP was short compared with values found in healthy individuals. Thus some MAP recordings gave a possible explanation for the mechanism behind the arrhythmias, while other recordings showed no differences from results in healthy individuals.


Human atrial conduction with reference to heart rate and refractory periods. Atrial conduction time (ACT) between a stimulating pacemaker electrode and an "impulse-detecting" monophasic action potential (MAP) electrode has been determined in 20 healthy males. A small increase in ACT was found with increasing paced heart rates. Using the extra stimulus technique, ACT was found to increase when the early ectopics approached the atrial effective refractory period (AERP). The degree of ACT prolongation was similar at long and short basic ACTs, indicating that the slowing of impulse propagation probably occurred near the simulating electrode and presumably within 1/2-1 cm from that electrode. The increase in ACT close to the AERP was of importance when determining the atrioventricular refractory period. In three recordings a supernormal phase of conduction was found. The small errors of the MAP recordings in detecting the time of excitation make the method sensitive enough to detect small differences in ACT.


Ventricular arrhythmias in acute myocardial infarction. A comparative study on some tests for ventricular arrhythmias. A continuous ECG recording has been made in 31 myocardial infarction patients during the first 24 hours after admission to hospital. The number and severity of ventricular arrhythmias were recorded in great detail. Before discharge from hospital the patients were submitted to 20 hours of ECG tape recording, an exercise test on a bicycle ergometer and a static work test (handgrip). Another exercise test was performed one month after discharge. During the first day in the Coronary Care Unit (CCU) all 31 patients had ventricular arrhythmias and in 27 of them the arrhythmia was classified as major (calling for treatment according to Lown's criteria). At the exercise tests 23 patients showed ventricular arrhythmias, 12 of them considered as major. No antiarrhythmic therapy was given during the investigation. No correlation was found between the degree of arrhythmia during the first day in the CCU and during the exercise tests. Tape-recorded ECG's appeared to be inferior to dynamic exercise tests in the ability to disclose a latent tendency to ventricular arrhythmia. Static work did not provoke any ventricular arrhythmias. At a 2-year follow-up 5 patients had died, 4 of them suddenly. Examination of additional material on 11 patients with ventricular tachycardia or ventricular fibrillation during the CCU stay, showed that 2 had died, but only one suddenly. Frequency and severity of arrhythmias during the first day after the infarction seemed to correlate poorly to a persistent tendency to arrhythmias during the first day after the infarction seemed to correlate poorly to a persistent tendency to arrhythmias or to the risk of sudden death during the following 2 years. A dynamic exercise test performed before discharge would appear to be more effective in selecting patients in need of long-term prophylaxis. However, very few patients seem to need such a specific antiarrhythmic prophylaxis.


Regional coffee consumption and mortality from ischemic heart disease in Finland. In Finland the mortality from ischemic heart disease is highest in North Karelia and lowest in Southwest Finland. In this study the consumption of coffee has been measured from the total sales in the different areas of Finland to see if it correlates with the mortality from heart disease. North Karelia had higher coffee sales per inhabitant than Southwest Finland. This finding reinforces the view that carefully controlled dietary studies are needed to establish the role of coffee in the mortality from ischemic heart disease.


Aetiology of febrile mucocutaneous syndromes with special reference to the provocative role of infections and drugs. The survey covers 266 patients with febrile mucocutaneous syndromes. A brief account of the highly varied clinical picture is given. The syndromes constitute an allergic reaction which in most drug-provoked cases appeared as a late immunological reaction of serum disease type; for the rest sensitization had probably often taken place. An allergic disposition could be traced in 34% of the cases. Infections and drugs were the causative factor 235 cases (88.3%). Infections accounted for 25.2% drugs for 36.1% and both together for 27.1%. An account is given of the provocative bacterial and viral infections and of the role of drugs in cases with and without infection. Among the remaining 31 cases an infection and/or drug may have been the provocative agent in 16 (6 %) whereas 15 (5.6%) may have been due to alimentary and other factors.


Pleuroperimyocarditis caused by immunization with anticatarrh vaccine. A case report. A case of pleuroperimyocarditis caused by immunization with anticatarrh vaccine is described. During the most acute phase, circulating immune complexes were demonstrated in the patient's serum. The possibility that these complexes represent a pathogenic mechanism in the illness and the value of anticatarrh vaccination are discussed.


Pyoderma gangrenosum associated with regional enteritis. Improvement in defective granulocyte function and healing of skin lesions during administration of clofazimine. A defective uptake of oxygen by peripheral blood granulocytes during phagocytosis, indicating a subnormal phagocytic capacity, has been found in a patient with regional enteritis complicated by pyoderma gangrenosum (PG). During administration of clofazimine and granulocyte function normalized and the skin lesions healed. It is possible that a defective granulocyte function may sometimes be involved in the pathogenesis of PG and that a clofazimine-induced improvement in the function will favour healing of the lesions. The result of treatment in our patient and in other cases recently published indicates that the drug may be worth trying in PG.


Effects of total energy withdrawal (fasting) on thelevels of growth hormone, thyrotropin, cortisol, adrenaline, noradrenaline, T4, T3, and rT3 in healthy males. Ten days of total energy deprivation evoked the following endocrine changes in 12 healthy, normal-weight males: early and marked reductions and increments in the blood levels of T3 and reverse T3, respectively, with rapid returns to pre-starvation levels after refeeding; a slight and late decrease in the blood levels of T4; a minute reduction of the blood levels of TSH; a pronounced increase in the blood levels of growth hormone, but a return towards pre-exposure levels even before discontinuation of starving; a minor and gradual enhancement of the blood levels of cortisol, and an increase in nocturnal urinary adrenaline excretion. It is assumed that these changes reflect a complex regulatory mechanism, the purpose of which is to secure adequate energy supply to vital organs.


Calcium, phosphate and albumin in serum. A population study with special reference to renal stone formers and the prevalence of hyperparathyroidism in middle-aged men. Serum valuse for calcium, phosphate and albumin have been determined in a population study of 2322 49-50-year-old men participating in a health examination survey. Calcium and albumin were significantly correlated (r = 0.34) but adjustment for albumin only caused minor effects on the distribution of calcium. No inverse relationship was found between calcium and phosphate. Seasonal variations over the three years of the health survey could not be established for either calcium or phosphate, whereas there was a slight tendency for albumin to decline during summer. The prevalence of hyperparathyroidism (HPT) in this population of men up to the age of 50 was 0.3% and among those with recurrent renal stones 5.3%. All subjects with verified HPT had a history of recurrent renal stones. One man on thiazide treatment had a slight elevation of calcium which returned to normal after cessation of the drug. No other case of hypercalcemia besides those caused by HPT was found. Mean values and frequency distributions for calcium, phosphate and albumin were almost identical in renal stone formers and matched controls. Hence it seems likely that other factors than those which markedly affect serum levels of calcium and phosphate are of major importance in common renal stone formation.


1alpha-hydroxycholecalciferol in the treatment of hypoparathyroidism. In two patients (father and daughter) with idiopathic hypoparathyroidism, one of whom was resistant to the action of vitamin D2 and AT-10, 1alpha-hydroxycholecalciferol (1alpha-(OH)D3) in doses of 2-5 mug/day restored the serum calcium concentration to the normal range. The calcemic effect of 1alpha (OH)D3 was in both patients due to an increased intestinal calcium absorption and increased calcium mobilization from bone. In one of the patients 1alpha-(OH)D3 also increased the renal tubular calcium reabsorption; in the other it did not have this effect, resulting in hypercalciuria as serum calcium rose. The lack of effect on tubular calcium reabsorption probably accounts for the relative resistance to the action of 1alpha-(OH)C3 in this patient compared with other.


Serum and erythrocyte magnesium in normal elderly danish people. Relationship to blood pressure and serum lipids. Serum lipids, blood pressure, and magnesium levels in serum and erythrocytes have been measured in 73 men and women, aged 60. The purpose was to evaluate the relationship between the serum and erythrocyte magnesium and indicators of ischaemic heart disease. The results showed significant inverse correlations between serum magnesium levels and PB, and positive significant correlation between erythrocyte magnesium and serum cholesterol.


Bioavailability of propylthiouracil: Interindividual variation and influence of food intake. The bioavailability of 6-propylthiouracil (PTU) has been examined in eight healthy volunteers, with respect to interindividual variation and influence of food intake. PTU was given as a single oral dose, both in a fasting state and together with a standardized breakfast. Numerous venous blood samples were taken during 5 hours after PTU ingestion, and the concentration of unmetabolized PTU in serum was determined by a specific gas-chromatographic technique. The observations indicate that the amount of PTU absorbed is subject to a large interindividual variation, and that concomitant food intake may exert a minor and non-systematic influence on PTU absorption. Hence, the major issue in PTU therapy is the individualization of the size and interval of dosage. Testing of single-dose PTU kinetics in patients would apparently be helpful.


Counter regulation of basal insulin secretion during alcohol hypoglycemia in hypercalcemic and  normocalcemic man. In seven normocalcemic subjects, fasted for 48 hours, alcohol hypoglycemia has been accompanied by a significant decline in basal insulin secretion. In another six healthy subjects, fasted for two days, infusion of calcium also induced a significant fall in basal secretion of insulin. However, when six healthy volunteers, fasted for two days, were infused with calcium and given alcohol simultaneously, no significant fall in insulin was recorded, even though the hypoglycemia, following this combined load, was of the same magnitude as in the subjects given alcohol alone. The implications of these findings are discussed.


Accumulation of myoinositol in plasma and red cells of diabetic patients. The concentration of myoinositol in plasma, cerebrospinal fluid and red cells and its elimination by the kidneys have been studied in 51 diabetic patients with normal or impaired kidney function, 16 non-diabetic patients with renal failure and 37 healthy controls. All diabetic patients who had a glomerular filtration rate considerably below normal, was the plasma concentration of myoinositol higher than in controls. The findings show that the rise in plasma concentration of myoinositol most probably results from a decreased glomerular filtration rate. In diabetic patients, urinary excretion of myoinositol correlated with an exponential increase in glucose excretion. That myoinositol accumulates in red cells of diabetic patients may be the result of its retention within these cells caused primarily by a transient, abnormal increase in the plasma concentration of myoinositol after an average meal.


Tubular reabsorption and urinary excretion of acetoacetate and 3-hydroxybutyrate in normal subjects and juvenile diabetics. The renal handling of acetoacetate (AA) and 3-hydroxybutyrate (3-HB) has been examined in 8 normal subjects and 7 insulin-treated juvenile diabetics before and after i.v. infusion of sodium DL-3-hydroxybutyrate. In both normals and diabetics and ketone bodies were reabsorbed. At low filtration rates of AA and 3-HB the reabsorption was nearly complete. With increasing filtration rate both the tubular reabsorption rate and the urinary excretion rate of AA and 3-HB increased linearly. A maximal tubular reabsorption rate could not be demonstrated. In spite of higher filtration rates of AA and 3-HB in the diabetics, the mean reabsorption percentage of either ketone body did not differ from that found in the normals.


Immunoglobulin levels and autoantibodies in epileptics on long-term anticonvulsant therapy. Serum immunoglobulin (Ig) levels and various autoantibodies have been determined in 53 epileptics treated with anticonvulsant drugs for more than 10 years and in 53 controls matched for age and sex. Aberrations in both IgG, IgA and IgM values were demonstrated. The mean IgG concentration was significantly lower in epileptics (1217 mg/100 ml) than in controls (1364 mg/100 ml) p less than 0.05). The mean IgA value was 161 mg/100 ml in both patients and controls (F-test, p less than 0.01), but abnormally low IgA values were found in 17%, and abnormally high values in 11% of the epileptics. The mean IgM concentration was 157 mg/100 ml in epileptics and 117 mg/100 ml in controls (F-test, p less than 0.01). Autoantibodies were found significantly more often in epileptics (26.4%) than in controls (3.8%) (2p less than 0.002). The occurrence of autoantibodies could not be related to alterations in the Ig levels. Neither was it possible to correlate the occurrence of mitochondrial antibodies, smooth muscle antibodies and antinuclear antibodies to the slightly abnormal biochemical liver parameters found in these patients. Thus, the abnormalities in Ig levels and the autoimmune phenomena observed in epileptics on long-term anticonvulsant therapy are not intimately related.


Determination of effective orifice area in mitral stenosis from non-invasive ultrasound Doppler data and mitral flow rate. Ten patients with mitral stenosis, but without mitral insufficiency, have been studied during cardiac catheterization. The mitral orifice blood velocities, the mitral pressure gradient, and the mitral flow rate were determined with ultrasound, manometry, and the direct Fick method, respectively. The effective orifice area was calculated from the ultrasound data and the mitral flow rate. The geometric orifice area was calculated from the pressure gradient and the mitral flow rate, using a revised Gorlin formula. A comparison of the two methods showed a correlation coefficient of 0.975. The investigation demonstrated that the ultrasound method represents an alternative to the conventional catheterization methods used for the quantification of mitral flow obstruction.


Restricted lignocaine prophylaxis in acute myocardial infarction. In a consecutive series of 274 AMI cases ventricular tachycardia (VT), defined as three or more ventricular premature beats (VPBs) in succession but not VPBs, has been used as the indication for ventricular fibrillation (VF) prophylaxis. No primary VF occurred, and this fits with the hypothesis of VT as a sufficient indication for prophylaxis against primary VF. Six patients developed complicating VF (preceded by rales or hypotension but not frank pulmonary edema or shock). Four of the six patients (67%) had VT (0-1.5 hours) before VF, while the mean VT incidence of the six corresponding monitoring periods in 247 non-VF patients was 5%. Three of the four VT patients were on lignocaine/procainamide when VF developed. Thus, VT is acceptable as the only warning arrhythmia even in complicating VF but antiarrhythmic drugs do not seem to have the same prophylactic efficacy in complicating VF as in primary VF. Another 21 patients developed VF during shock, frank pulmonary edema or manipulating a pacemaker catheter within the heart.


Energy deprivation in man--methodological problems and possibilities. Various approaches to the study of physiological and behavioural effects of energy deprivation are presented and discussed. An experimental, total energy deprivation in 20 healthy human volunteers during an 11-day period, preceded and followed by 4-day control periods, is described. Potentially pathogenic reactions which occurred in spite of precautions are analysed. It is concluded that the present controlled real-life model with acute total energy deprivation serves the purpose of studying hypotheses concerning potentially pathogenic mechanisms occurring in deprivational situations under conditions of natural and man-made catastrophes.


Haemodynamic effects of four months' mefruside therapy in hypertensive patients. The haemodynamic changes after 4 months' mefruside therapy in 13 patients with essential hypertension have been studied. Intraarterial BP was significantly reduced both at rest supine and during standardized leg exercise in sitting position. The reduction was caused mainly by a decrease in cardiac output in about half of the patients and mainly by a decrease in total peripheral vascular resistance in the remainder. Thus, for the total material there was no significant change in either cardiac output or total peripheral vascular resistance. At rest, however, there was a significant decrease in storke volume (p less than 0.05) and an increase in heart rate (p less than 0.05). On changing from supine to sitting position, the average systolic and diastolic pressures increased before and decreased after therapy, the differences being significant. The results indicate that the hypotensive effect of long-term saluretic therapy is accomplished by a decrease in cardiac output and/or peripheral vascular resistance, with large interindividual variations.


Haemodynamic effects of saluretic treatment and beta-receptor blockade in patients with essential hypertension. The long-term haemodynamic effects of treatment with mefruside alone or in combination with alprenolol have been studied in nine patients with essential hypertension. After four months of mefruside therapy alone there was a significant decrease in intraarterial BP both at rest and during standardized leg exercise. Cardiac output and calculated total peripheral vascular resistance (TPVR) showed only minor mean decreases which were not statistically significant. Stroke volume tended to decrease and heart rate to increase. After another four months' treatment with addition of alprenolol there was a further significant decrease in intraarterial BP, related mainly to a further mean decrease in cardiac output which was not statistically significant. Heart rate decreased significantly, stroke volume was not significantly changed. Compared with the pretreatment levels, combination therapy induced a substantial decrease in intraarterial BP and a significant decrease in cardiac output both at rest in supine position and during standardized leg exercise. TPVR decreased slightly both at rest and during exercise but the change was not statistically significant. The results suggest that the decrease in BP after combined therapy with mefruside and alprenolol is mainly related to a decrease in cardiac output, the changes in TPVR being not significant. The additive hypotensive effect of alprenolol seems to be related in part to blocking of the increase in sympathetic activity that was found after treatment with mefruside alone.


Priorities and indications of computed tomography in clinical practice. Because of its technical capabilities, its rapidity and its non-invasive nature, computed tomography (CT) has given a new scope to neurological diagnosis and to the understanding of various aspects of neurological science. The availability of this test is determined by the patient load. If precise clinical indications are not considered, patients requiring CT the most may be denied immediate examination because less urgent cases may be occupying valuable diagnostic time. Moreover, the test is relatively expensive for the individual patient and for the community; this presents another facet of its use that should be taken into account. The technical limitations and clinical priorities to be considered when a physician is entertaining this test for a patient have been outlined. The indications have been divided into absolute and relative, according to the degree of clinical urgency. As a result, a priority guideline for diagnostic CT has been provided.


Epidural haematoma following a shunt revision. A case of epidural haematoma developing after shunt revision is presented. Change from the prone to the standing position was thought to be the causative factor.


Dural haemangioma with extracranial component. A rare case of dural haemangioma with extracranial component is described. A subcutaneous frontal tumour was thought before operation to have originated in the skull. Angiography showed drainage into the superior sagittal sinus via a cortical vein. Dural haemangioma is thought to be a clinical rarity. Also, an arteriovenous malformation draining into the superior sagittal sinus is rarely encountered.


Morphological changes in anaplastic gliomas treated with radiation and chemotherapy. The effects of antineoplastic treatment on gliomas are related to tumour cell cycle and proliferation kinetics, glioma tissue architecture, and the surrounding environment. Morphological changes induced by radiation and chemotherapy are characterized by cell necrosis and severe alterations in cell and nuclear morphology caused by changes in the cell kinetic parameters which, however, may also occur spontaneously in untreated anaplastic gliomas. Comparative studies of cytological imprints and routine histological preparations of biopsy and autopsy specimens were performed in four groups of anaplastic astrocytomas and glioblastomas (78 cases) with postsurgical irradiation, combination chemotherapy, and CCNU treatment, and without specific postsurgical treatment (control group). Following radiation and chemotherapy, in addition to increased necrosis and vascular response, a variety of characteristic but nonspecific changes were observed in cell and nuclear morphology with prominent formation of multinucleated giant and monstrous cells, irregular and hyperchromatic nuclei, and severe cytoplasmic degeneration indicating both inhibition of cell division and cell damage. Statistically significant findings were a posttreatment increase in the number of multinucleated giant and monstrous cells and a decrease in the number of mitoses. These changes were more pronounced after chemotherapy than after radiation, while no significant dissimilarities were found between combination chemotherapy and CCNU. The implications of these changes on the mechanisms of antitumour treatment in anaplastic gliomas are discussed.


[Stablization of destructive processes in the cervical spine by means of acrylic prostheses (author's transl)]. Stabilization of destructive processes in the cervical spine by means of acrylic prostheses has hitherto been carried out either by an anterior approach or by a posterior approach. With progressively destructive lesions the stability achieved by either of these methods is unsure, and therefore the author has employed a combination of both approaches. The first two patients treated with this new technique have now been followed up for two years. The position and stability of the prosthesis in each case has remained excellent.


Long-term results in 62 cases of post-traumatic complete apallic syndrome. After the transition state of decerebrate coma, at least four different kinds of the so-called apallic status can be identified: 1. Complete apallic syndrome: coma vigil, alertness without any awareness, mass movements only, impairment of sleep rhythm, absence of any emotional responses, postural abnormalities, some primitive motor responses, tetraplegia, and alteration of muscle tone. 2. Incomplete apallic syndrome: some of the features of the complete apallic syndrome are lacking, and the patient shows emotional reactions with appropriate grimacing and some appropriate motor responses. 3. False apallic syndrome: most signs of complete apallic syndrome are present, but the patient is in touch with the environment. This condition is somewhat similar to the so-called locked-in syndrome. 4. Functional apallic syndrome: full clinical picture of the complete apallic syndrome but full recovery within a few days. Long-term results in 62 patients, aged between 4 and 62, affected by a post-traumatic complete apallic syndrome are reported. Thirty two patients were operated upon and 30 were not operated upon. Out of these cases, 38 died after weeks or months; 3 patients entered a chronic apallic status; 2 patients are improving; 10 recovered with severe neurological or psychic sequels or both; 4 recovered with minimal sequels, and 5 without sequels; no patients in these two last groups were aged more than 20.


Radiosensitivity of meningioma--analysis of five cases of highly vascular meningioma treated by preoperative irradiation. Preoperative 60Co-irradiation was given in five cases of highly vascular meningioma. Radiation doses ranged from 3,000 to 6,000 rads and were delivered over periods from 17 to 45 days. In one case of tentorial meningioma preoperative irradiation produced a marked reduction in the size and the vascularity of the tumour, as seen on the angiograms, and of the hot area in the brain scan. Papilloedema and abducens palsy also improved. After irradiation the tumour was totally removed. Histopathologically the tumour was a meningioma resembling a haemangiopericytoma. Coagulation necrosis of the parenchyma of the tumour was prominent. In the other four cases (three of meningothelioma type and one of haemangioblastoma type) the preoperative irradiation caused little or no change in the angiograms or in the brain scans. A mild clinical improvement occurred in one case, but deterioration took place in other cases. It may be concluded that preoperative irradiation gives little or no beneficial effect on meningiomas other than those of certain types, such as those resembling haemangiopericytomas, or malignant meningiomas. The clinical and radiological differential diagnosis between the usual types of meningioma and those which are either malignant or resemble haemangiopericytomas is discussed.


Lactate dehydrogenase (LD), hydroxybutyrate dehydrogenase (HBD), and LD-isoenzymes in brain tissue. The total activities of lactate dehydrogenase (LD) and hydroxybutyrate dehydrogenase (HBD), and the LD isoenzyme distribution were determined in tissue samples taken in vivo from different parts of the rabbit brain, and in cortical grey, subcortical white, and cerebellar tissue from man. The total LD and HBD activities were found to be higher in the brain stem than in the cerebral hemisphere, basal ganglia, and cerebellum of the rabbit brain. The isoenzyme distribution in the brain stem and the cerebellum showed an anodal shift, i.e., significantly higher activities of LD1 compared with the cerebral hemisphere and the basal ganglia. In man the total LD activity was found to be lower in white than in grey matter, although the isoenzyme patterns did not differ. The implications of these findings in relation to the LD isoenzyme pattern in serum after traumatic brain injury are discussed.


Changes in lactate dehydrogenase isoenzyme patterns in patients with tumours of the central nervous system.? The total activities of lactate dehydrogenase (LD) and the LD isoenzyme distribution were determined on homogenates from 61 benign and malignant intracranial tumours, and in serum and cerebrospinal fluid from 45 and 28 of the tumour patients respectively. The LD activity and the LD isoenzyme distribution in serum were not changed in patients with intracranial tumours. The LD activity in the cerebrospinal fluid was raised in about 50% of the tumour patients, but without any significant differences between patients with benign and malignant tumours. Except for very low activities in acoustic schwannomas and in pituitary adenomas, the tumour tissue did not differ significantly from normal brain in total LD activity. The LD isoenzyme distribution showed a pronounced cathodal shift in the grade 3-4 astrocytomas and the metastatic carcinomas, but an anodal shift in the grade 1-2 astrocytomas and the oligodendrogliomas. The meningiomas and the ocoustic schwannomas showed a midzone isoenzyme pattern with a dominant LD3 fraction. Knowledge of the LD isoenyme distribution can thus sometimes be a complement to the histological examination in the classification of brain tumours.


[New aspects of cerebrospinal fluid dynamics in man revealed by sequential camera scintigraphy and analysis with the digital computer. Part 1: method and physiologic patterns]. 1. The use of rapid sequential gamma camera scintigraphy in conjunction with computer aided storage and evaluation of data has been shown to be a promising method for the analysis of CSF dynamics in man. 2. Using this method rapid flow of CSF in the basal cisterns can be studied. The further course of tracer activity in different CSF compartments can be followed, and slow currents may be demonstrated. 3. Using this technique the patterns of varying regional CSF dynamics and reabsorption states can be examined. Intracranial activity after 24 hours is 40 to 45% anar behaviour of CSF circulation patterns in the basal cisterns, cisterna magna, and upper cervical area leads us to suggest that this complex of spaces forms a functional unity which may be called "The distribution center of CSF". Further movements of tracer substance seem to start from this complex. 5. In the well recognised CSF pathways over the cerebral convexities some characteristic patterns of fluid flow are demonstrated. The flow times at different situations over the convexities are given. 6. Analysis of spinal CSF flow shows that there are considerable variations in spinal CSF dynamics. 7. Finally, the different uses of this method in various situations are indicated.


Neurocutaneous melanosis. Report of a case and review of the literature. A case of neurocutaneous melanosis in a 15 year old male is described. A primary malignant meningeal melanoma caused the death of the patient in six months. The skin lesions were benign. The literature is reviewed, and the nature of the disease and its relationship with other phakomatoses is discussed.


Diagnostic possibilities of the uncorrected orthogonal ECG Trethewie system in ventricular overload. The possibilities of the uncorrected orthogonal ECG system (Trethewie) in assessment of the ventricular overload have been studied. The uncorrected orthogonal ECG system detects the left ventricular overload better than conventional ECG system. The simultaneous application of both uncorrected orthogonal ECG and conventional ECG increases the diagnostic possibilities of the ECG method.


Medical sculpture: a valuable aid to patient rehabilitation. Silicone rubber is the most satisfactory material for cosmetic prostheses. It has a soft, lifelike texture, is easily worked and easily colored and is strong enough to withstand frequent application and removal. Examples of patients referred to the medical sculptor include those with congenital defects of one or both ears, loss of the nose or an eye and orbit due to cancer surgery, loss or absence of fingers or parts of the hand and those who have had radical breast surgery.


False-positive epidemic infectious mononucleosis. Investigation of four alleged infectious mononucleosis (IM) epidemics revealed that each resulted from either misuse or misinterpretation of mononucleosis slide tests. Even though such tests are a valuable, rapid adjunct to the diagnosis of IM, they must be carefully done with fresh reagents, using both positive and negative controls, and must be interpreted in the light of clinical findings and blood cell morphology.


Unsuspected pulmonary emboli in well persons: the incomplete pulmonary infarction syndrome. Pulmonary embolization from occult venous thrombosis in the lower extremities occurs in previously well individuals of all ages. Incomplete or hemorrhagic pulmonary infarction may result. The incomplete pulmonary infarction syndrome (IPIS) is characterized by sudden onset of pain in the lower chest, knife-like and stabbing in quality and accentuated by breathing, with pathognomonic abnormalities on chest x-rays. The physician should hospitalize the patient, begin heparinization and confirm the diagnosis with daily chest x-rays in multiple views. Failure to promptly diagnose and treat IPIS may lead to catastrophic, massive pulmonary embolism and death, or to recurrent embolism with pulmonary hypertension and chronic cor pulmonale, resulting in incapacitating dyspnea on exertion, and disability.


Destructive cultism.

Destructive cultism. Bizarre cults harmful to the physical and emotional health of adolescents, young adults and their families have been increasing in our society. Destructive cultism is a distinct syndrome. It includes behavioral and personality changes, loss of personal identity, cessation of scholastic activities, estrangement from family, disinterest in society and pronounced mental control and enslavement by cult leaders. Management of this sociopathic problem requires confrontation, rehabilitation, sociologic, psychotherapeutic and general medical measures.


The ambulatory patient with ectopic beats and episodic tachyarrhythmias. Ventricular ectopic activity in a young person with an otherwise normal heart usually requires no treatment. In older patients, 10 or more ectopic beats per minute, multiform beats and ectopy occurring close to the preceding beat are indications for drug control. Exercise-induced ectopic beats may respond to physical training. Three or more consecutive ventricular ectopic beats constitute ventricular tachycardia, which requires prevention. Supraventricular tachyarrhythmias, when paroxysmal, may be aborted by maneuvers to enhance vagal tone. When they are frequent, treatment is required.


Programmed left ventricular contrast injection. A method to minimize left ventricular irritability during angiography. Left ventricular angiography frequently produces one or more premature atrial or ventricular contractions which may make quantitative volume analysis unreliable. Three hundred left ventricular power injections were analyzed and found to produce premature ventricular contractions (PVC's) in 28 per cent of injections and PAC's in 6 per cent. Forty-four per cent of injections starting near the end of the T wave were associated with PVC's, whereas those starting near the end of diastole during the P wave produced PVC's in only 11 per cent. Injections through a Gensini catheter were associated with PVC's in 24 per cent compared to 37 per cent when a pigtail catheter was used (p less than 0.05). The introduction of an 0.6 second delay in the development of peak injection pressures and ECG triggering to start the injection in the last half of the cardiac cycle did not alter the incidence of PVC's. The use of timed diastolic injections with pressure rate-rise delay is of little value in reducing injection induced arrhythmias.


Left ventricular contractile function in aortic stenosis evaluated by isovolumic and ejection phase indexes. This study is to reappraise the usefulness of isovolumic as compared to ejection phase indexes for detecting abnormal left ventricular contractile function patients with a common hemodynamic abnormality, namely, chronic left ventricular pressure overload. In 41 subjects with pure or predominant aortic stenosis left ventricular pressure measurements were performed by micromanometry. Single-plane left ventricular cineangiograms were carried out in the right anterior oblique (RAO) and the A-P position. The isovolumic contractile indexes we used in this study were peak measured velocity of shortening of the contractile elements (Vpm) and Vmax obtained from linear extrapolation of total pressure-velocity curves. The end-diastolic and end-systolic RAO cineventriculograms served for the calculation of the ejection phase parameters mean velocity of circumferential fiber shortening (VCF) and mean normalized systolic ejection rate (MNSER). Of the 41 patients, Vpm was depressed in 16 (39 per cent), Vmax in 17 (42 per cent), VCF in 12 (29 per cent), and MNSER in 14 (34 per cent). When the isovolumic and the ejection phase parameters were combined, 24 patients (59 per cent) were found to have at least one of the four contractile indexes below normal. In 26 of the 41 patients the isovolumic and the ejection phase indexes provided the same conclusions as to normality of left ventricular function. In contrast, 15 patients showed discordant isovolumic and ejection phase indexes. An increased left ventricular end-diastolic pressure was only inconsistently related to an abnormal left ventricular function because in 7 of 28 patients with an end-diastolic pressure above 14 mm. Hg all contractile indexes were normal. Furthermore, a normal end-diastolic pressure was present in three of 24 patients with depressed myocardial function. It is concluded that in chronic left ventricular pressure overload from aortic stenosis neither the isovolumic nor the ejection phase indexes are superior in sensitivity for assessing contractile function. In this clinical setting the combination of both types of indexes appears to be the most reliable way for identifying patients with depressed contractile function of theleft ventricle in the basal state.


Left ventricular posterior wall motion in patients with the Wolff-Parkinson-White syndrome. Echocardiography appears to be a sensitive technique for detecting disturbances in left ventricular posterior wall motion in subjects with WPW type A. The characteristic abnormality consists of premature anterior displacement of the LVPW shortly after the inscription of the delta wave. The ability to detect abnormal wall motion is influenced by the size of the segment of myocardium undergoing pre-excitation, the site of insertion of the anomalous pathway, and its accessibility to echocardiographic study. The results of this study support the concept that WPW type A represents premature excitation of the posterior left ventricular wall in some patients. Moreover, such pre-excitation may be associated with an altered pattern of left ventricular contraction. A similar pattern of LVPW motion was not observed in a large group of randomly selected clinical echocardiograms including a variety of intraventricular conduction disturbances.


Hemodynamic alterations during septal or right ventricular ischemia in dogs. This study indicates that in dogs, ischemic injury to just the ventricular septum has little effect on left ventricular function. The data demonstrate that ischemic injury to either the right ventricular free wall or the ventricular septum alters right ventricular function and/or compliance, suggesting that both regions play a role in maintaining right ventricular performance. That septal contraction supports right ventricular function may explain why in earlier studies, right ventricular pressure development and output were little affected by severe injury to the free wall.


The effect of propranolol on hemolysis in patients with an aortic prosthetic valve. Propranolol was given to five patients with severe hemolytic anemia from arotic prostheses. Red cell survival, lactic dehydrogenase, serum hemoglobin, and 24 hour urine iron values were used to evaluate the severity of hemolysis with and without propranolol treatment. Three patients had a clear decrease in the level of hemolysis with propranolol therapy. One patient developed congestive failure after 6 months on propranolol. The decrease in hemolysis is most likely related to a slower heart rate.


A depressed response of left ventricular contractile force to isoproterenol and norepinephrine in dogs with congestive heart failure. The inotropic response of the left ventricle to intravenous administration of norepinephrine (NE) and isoproterenol (I) was studied in dogs with congestive heart failure (CHF) resulting from aortocaval fistula. Left ventricular contractile force (CF) was recorded at the peak of the length-tension curve with a modified Walton-Brodie strain gauge arch in five dogs with CHF and five control animals. Arterial blood pressure (ABP) and heart rate (HR) were also monitored. Graded dose-response curves (0.0125 to 1.6 mug per kilogram) were obtained to NE and I. The response of CF was significantly depressed at all dose levels to both NE and I ni dogs with CHF. For example, at the dose of 0.8 mug per kilogram the CF response to I in the control dogs was 201 +/- 32 per cent above control level, whereas in CHF dogs the response was 92 +/- 31.5 per cent. Similarly, NE at this dose level produced a 168.6 +/- 14.7 per cent increase in CF in control dogs and 71 +/- 21.3 per cent in CHF dogs. I was approximately four times as potent as NE and this ratio was not altered in CHF dogs. The response of HR and diastolic ABP to drug administration was not altered by CHF. These data clearly suggest a depressed inotropic response to beta-adrenergic stimulation in this CHF model and a separation of the inotropic and chronotropic response.


Cardiac arrhythmias on swallowing.

Cardiac arrhythmias on swallowing. A middle-aged male patient with cardiac arrhythmias on swallowing due to incoordinate peristaltic activity of the esophagus is reported. Medical treatment with propranolol and quinidine sulfate made the symptoms manageable initially but recurrence of symptoms made surgical treatment desirable. Barium sulfate with apple produced the incoordinate peristalsis with resultant arrhthmias as soon as it arrived at the junction between the middle and lower third of the esophagus. This was followed by a normal peristaltic wave which cleared the esophagus and brought the cardiac rhythm back to normal again. Balloon distension of the esophagus located the afferent stimuli as arising from the lower third of the esophagus. A circular esophageal myotomy at the junction of the middle and the lower third, although not completely abolishing the reflex, has made the symptoms less severe. However, this procedure has produced considerable ballooning of the mucosa at the myotomy site, and has resulted in some difficulty in swallowing.


Clinical evaluation of the enhancement of vagal tone in acute myocardial infarction by edrophonium hydrochloride: effects on ventricular arrhythmias, His bundle electrography, and left ventricular function. Enhanced electrical stability of acutely ischemic myocardium with vagal stimulation and acetylcholinesterase inhibition has been demonstrated experimentally. To extend these findings clinically, within 24 hours of acute myocardial infarction, 11 patients underwent continuous 10 hour Holter monitoring: 2.5 hour control before and after 5 hour constant edrophonium infusion (0.25 to 2.00 mg./minute). Continuous infusion of the agent lowered heart rate 92 to 78 b.p.m. (p less than 0.01). Although mean total ventricular extrasystoles (PVC's) per 5 hours per patient (131) and PVC's per 1,000 beats (4.7) were unchanged (p greater than 0.05), potentially lethal tachyarrhythmias (malignant PVC's: multifocal, R on T, paried, greater than 5 per minute or ventricular tachycardia) were terminated in six of 10 patients by edrophonium. However, serious ventricular arrhythmias continued in three patients and appeared in four despite the agent. Ventricular fibrillation did not occur during the 10 hour period of study. In addition, the patients were evaluated hemodynamically and by His bundle electrograms before and after a 10 mg. bolus of edrophonium prior to the 10 hour constant infusion: heart rate declined (88 to 72 b.p.m., p less than 0.01), while mean arterial pressure (98 mm. Hg), left ventricular filling pressure (14 mm. Hg), cardiac index (2.4 L. per minute per square meter), and stroke work index (36 Gm.m./M.2) were unchanged (p greater than 0.05). The edrophonium bolus prolonged the A-H interval (117 to 135 msec., p less than 0.01) while the H-Q interval was unaltered (48 msec; p greater than 0.05). It is concluded that increased vagal tone with edrophonium did not reduce the over-all presence of premature ventricular contractions in the entire study group; however, the malignant nature of PVCs and ventricular tachycardia appeared to be lessened by the parasympathomimetic agent in certain patients. In addition, no adverse hemodynamic or intraventricular conduction effects were produced by edrophonium administration.


Clinical implications of differences in pharmacodynamic action of polar and nonpolar cardiac glycosides. The principal effects of cardiac glycosides probably can be classified as parasympathomimetic or sympathomimetic. Data from animals and from man suggest that polar cardiac glycosides, such as ouabain and digoxin, possess greater parasympathomimetic (vagal) cardiac effect for a given amount of sympathomimetic (positive inotropic) cardiac effect than do less polar cardiac glycosides, such as digitoxin. Polar glycosides therefore offer some advantage in uncomplicated paroxysmal atrial tachycardia and in uncomplicated atrial flutter and atrial fibrillation when the principal desired effect is reduction in the number of atrial impulses reaching the ventricles or conversion to normal sinus rhythm. Non-polar glycosides offer an advantage when positive inotropicity is desired but when there is some degree of atrioventricular block or when inappropriate sinus bradycardia or anorexia, nausea, or vomiting are present. Ecotopic impulse formation when due to cardiac glycosides is a toxic manifestation of excessive sympathomimetic effect, but is aggravated by vagal-induced sinus bradycardia, so that both parasympathomimetic and sympathomimetic capability of cardiac glycosides must be considered when dealing with myocardial electrical instability.


Correlative classification of clinical and hemodynamic function after acute myocardial infarction. To characterize the relation between clinical and hemodynamic state in acute myocardial infarction, 200 patients with acute infarction were evaluated with clinical and hemodynamic criteria. Patients were classified clinically on the basis of peripheral hypoperfusion (hypotension, tachycardia, confusion, cyanosis, oliguria) and pulmonary congestion (rales, abnormal chest roentgenogram). Four clinical subsets were defined that correlated with cardiac index (Cl, liters/min per m2) and pulmonary capillary pressure (PCP, mm Hg): (see article). Parallel hemodynamic subsets were developed independently on the basis of depressed cardiac index (2.2 liters/min per m2 or less) and elevated pulmonary capillary pressure (greater than 18 mm Hg). The rate of accuracy of clinical examination in predicting hemodynamic abnormalities was 83 percent. Mortality rates were similar in the clinical and hemodynamic subset calssifications, averaging 2.2 percent in subset I, 10.1 percent in subset II, 22.4 percent in subset III and 55.5 percent in subset IV. Drug interventions in the course of hospitalization resulted in a 38 percent increase in depressed cardiac index and 34 percent decrease in elevated pulmonary capillary pressure. Resolution of clinical abnormalities paralleled this hemodynamic improvement in 70 percent of patients. These data suggest that clinical performance and both clinical and hemodynamic subsets are directly relevant to establishing prognosis and the selection of therapy in patients with acute myocardial infarction.


Continuing disease process of calcific aortic stenosis. Role of microthrombi and turbulent flow. Microthrombi with evidence of organization were observed in 10 of 19 calcified and stenotic aortic valves (53 percent). The organization that results from such thrombi may contribute to the deformity of the valve. Repetitive deposits of microthrombi, followed by organization and calcification, would explain the continuous process of stenosis in previously deformed aortic valves. The formation of such thrombi may be initiated by turbulent flow and other fluid dynamic factors.


Congenital bicuspid aortic valve after age 20. The bicuspid aortic valve is recognized as a frequent cause of aortic stenosis in adults. Aortic stenosis has been reported to occur in as many as 72 percent of adults with a congenital bicuspid aortic valve, with peak incidence occurring in the 5th and 6th decades of life. Review of the clinical records of 152 patients aged 20 years and older found to have a bicuspid aortic valve at autopsy revealed aortic stenosis in only 28 percent. The incidence of aortic stenosis increased progressively with age; 46 percent of patients over age 50 years and 73 percent over age 70 years had some degree of stenosis. The stenotic valves were obstructed by nodular, calcareous masses but commissural fusion was present in only eight cases. The largest group of patients in the series (40 percent) died of infective endocarditis; 77 percent of these were under age 50 years. Primary aortic regurgitation without infective endocarditis was uncommon. Thirty-two percent of the patients in this series had an apparently normally functioning aortic valve, and this rate remained relatively constant with increasing age; 37 percent of patients over age 50 years and 27 percent over age 70 years had an apparently normal valve. The bicuspid aortic valve in patients over age 20 does not invariably become stenotic or insufficient.