Alcohol consumption, cardiovascular risk factors, and mortality in two Chicago epidemiologic studies. Multivariate analysis of the association at baseline between problem drinking and cardiovascular risk factors among 1,233 white male employees of the Chicago Peoples Gas Company age 40-59 showed the 38 problem drinkers with significantly higher blood pressures and cigarette consumption and significantly lower relative weights than the others. Similar analysis among 1,899 white male employees of the Hawthorne Works of the Western Electric Company in Chicago age 40-55 showed the 117 men consuming 5 or more drinks per day with significantly higher blood pressures and cigarette use than the others. No significant differences were recorded between heavy drinkers and the others in serum cholesterol level. The gas company problem drinkers had significantly higher 15-year mortality rates from all causes, cardiovascular diseases, coronary heart disease, and sudden death. These differences could not be entirely explained by their blood pressure, smoking, and relative weight status. The Western Electric heavy drinkers had increased 10-year mortality rates both for all causes and noncardiovascular causes.


Axial cineangiography in congenital heart disease. Section I. Concept, technical and anatomic considerations. Cineangiographic axial techniques were designed to overcome the limitations of conventional angiography in the diagnosis of congenital heart disease. Two basic patient (or equipment) maneuvers are involved; 1) long axis of the heart is aligned perpendicular to the X-ray beam, and 2) rotation of patient results in the heart being radiographically sectioned at 30 degree angles. To accomplish this with fixed vertical and horizontal X-ray tubes, three positions were developed: 1) "hepato-clavicular," "4 chamber," 2) "long axial oblique," 3) "anterior-posterior axial." A fourth, the "sitting-up" projection is discussed. The hepato-clavicular position profiles the posterior ventricular septum and atrial septum, separates the A-V valves, places the four cardiac chambers en face, and clarifies mitral valve-semilunar valve and outflow tract relationships. The long axial oblique profiles the anterior ventricular septum, left ventricular outflow tract, aortic valve-anterior mitral valve leaflet. The sitting-up view visualizes the bifurcation of the pulmonary trunk and separates true pulmonary arteries from systemic collaterals.


De subitaneis mortibus. XXVII. Histological abnormalities in the sinus node, atrioventricular node and His bundle associated with coarctation of the aorta. A twenty-year-old carpenter died suddenly and unexpectedly nine years after surgical treatment of coarctation of the aorta. Both before and after surgery he had paroxysmal atrial fibrillation, T wave inversions in the ECG and persisting cardiac hypertrophy. At postmortem examination there was focal fibromuscular dysplasia narrowing the sinus node artery, but other small coronary arteries were normal and there was no focal fibrosis of the ventricular myocardium. Within the sinus node there were several small glomera surrounding branches of the sinus node artery. Pericardial fibrosis was present over much of the heart, including margins of the sinus node. The central fibrous body was thickened, particularly on the left, and the His bundle was smaller than normal in cross section. The His bundle appeared displaced toward the right. The artioventricular (A-V) node was split into an upper and lower half tenuously connected through the central fibrous body which divided it. In its lower half the A-V node was directly continuous with ordinary myocardial cells of the interventricular septum. Possible developmental relationships between these unusual anatomical findings in the conduction system and coarctation of the aorta are discussed. How these findings might relate to the known electrophysiological disturbances and some causes for his sudden death are considered.


Familial congenital complete heart block and maternal systemic lupus erythematosis. A family is reported in which two siblings had congenital complete heart block with resultant congestive heart failure, the father and paternal grandfather show adult-onset conduction defects, and the mother has systemic lupus erythematosis. The interaction of heredity and environment is discussed in this context. A review of the literature on familial complete heart block suggests that so-called pure congenital-onset familial heart block, originally felt to be genetic, may in fact have an important enivronmental component, specifically related to ongoing maternal factors such as systemic lupus erythematosis.


Truncus arteriosus communis. Unusual case associated with transposition. A child with truncus arteriosus communis, characterized by the posterior origin of an individualized pulmonary trunk is presented. This relationship between the great arteries is unusual in truncus arteriosus communis and the spatial orientation resembles that seen in transposition of the great vessels. A brief discussion is proposed about a proper terminology in this type of complex anomaly.


Improved outcome for prehospital cardiopulmonary collapse with resuscitation by bystanders. Despite the development of trained mobile rescue squads, cardiopulmonary collapse outside the hospital continues to carry a poor prognosis. We examined retrospectively the clinical courses of 19 consecutive coronary unit patients who had experienced prehospital cardiopulmonary resuscitation. Seven patients received basic life support from bystanders within five minutes. Cardiopulmonary resuscitation in the other 12 patients was delayed beyond five minutes pending the arrival of rescue personnel. Six of seven early-resuscitated patients survived compared with six of 12 late-resuscitated patients (P less than 0.01). The early-resuscitated patients were more alert on admission and had lower pulmonary pressures and higher cardiac outputs compared to the late-resuscitated patients. The early-resuscitated patients also had less residual central nervous system and myocardial damage on discharge than the late-resuscitated patients. On follow-up, three early-resuscitated patients had returned to full-time work compared with none in the late group. Training laymen to initiate early basic life support can benefit the cardiopulmonary collapse victim.


Estimation of stroke volume changes by ultrasonic doppler. The purpose of this study was to conduct a controlled evaluation of the continuous-wave Doppler technique for the estimation of stroke volume changes. Six anesthetized dogs were studied. Aortic blood velocity was recorded from the suprasternal notch by a special continuous-wave Doppler unit. Cardiac output was varied by fluid infusion and exsanguination, and over 300 simultaneous records of aortic blood velocity and thermodilution cardiac output were taken. Average stroke volume and average systolic velocity integral (SVI), the area under the Doppler velocity curve were calculated. The relationship of SVI to stroke volume was evaluated for each animal using linear regression. Average results were: correlation coefficient 0.95 +/- 0.04 SD; y-intercept 0.38 +/- 0.14 cm(SD); standare error of fit 0.29 +/- 0.03 cm (SD). These data show that the systolic integral of aortic blood velocity was essentially directly proportional to stroke volume, even over a six-fold range. Thus, this technique will provide an accurate non-invasive estimate of changes in stroke volume.


Comparative responses to dobutamine and nitroprusside in patients with chronic low output cardiac failure. The acute hemodynamic effects of dobutamine and nitroprusside were compared in 19 patients with low output cardiac failure. At dosage levels yielding similar increases in cardiac index (12 patients), nitroprusside resulted in significantly lower arterial systolic and wedge pressures and did not increase heart rate suggesting advantages over dobutamine when reduction in myocardial oxygen requirement or pulmonary congestion is a major goal. Systemic arterial mean and diastolic pressures were minimally changed with dobutamine, but fell significantly with nitroprusside suggesting advantages of dobutamine over nitroprusside in patients where hypotension could limit coronary blood flow or perfusion of other vital organs. Reduction in pulmonary arteriolar resistance occurred only with nitroprusside. Arterial hypoxemia developed in three patients during nitroprusside infusion suggesting the possibility of increased right-to-left intrapulmonary shunting resulting from a direct vasodilating effect of nitroprusside on pulmonary arteriole smooth muscle. Although both inotropic and vasodilator drugs can result in hemodynamic improvement when administered to patients with chronic low output cardiac failure, significant differences of potential clinical importance exist between these two modes of therapy.


Occult constrictive pericardial disease. Diagnosis by rapid volume expansion and correction by pericardiectomy. Significant pericardial disease can exist without overt manifestations. Occult constrictive pericardial disease (OCPD) is identified by normal baseline hemodynamics and normal left ventricular systolic function with a characteristic response to rapid volume infusion. Following the intravenous administration of 1000 ml of normal saline over six to eight minutes, striking elevations of filling pressures are seen; however, diagnosis depends specifically upon a) the development of typical pressure pulse morphology of constriction, b) loss or reversal or respiratory variation of right atrial pressure, and c) precise diastolic equilibration of intracardiac pressures. Nineteen patients with OCPD have been identified in a five year period. Unexplained fatigue, dyspnea and chest pain was the uniform pattern of presentation. Eleven have undergone pericardiectomy resulting in a dramatic symptomatic improvement in all. Each demonstrated gross and/or microscopic evidence of pericardial disease. Recatheterization with volume infusion in five patients following pericardiectomy has revealed return to normal or near normal hemodynamics. This study describes the method for diagnosis of OCPD and recommends pericardiectomy for the management of disabling symptoms.


Cardiovascular function during early recovery from acute myocardial infarction. Fifty patients with acute myocardial infarction were studied serially to evaluate the extent and nature of functional cardiovascular impairment and the time course of recovery. Reinfarction or death occurred in six patients. Peak workload during bicycle exercise in a subgroup of 25 patients with maximal initial test and complete follow-up increased from 334 to 409 kpm/min (P less than 0.01) bwtween three and six weeks. There was further significant (P less than 0.01) improvement between three and six months from 438 to 488 kpm/min. The incidence of ischemia at a constant workload decreased between three and six weeks without any significant changes in heart rate or blood pressure. Mean cardiac output during exercise at three months was 6.5 and at six months 7.8 L/min (P less than 0.05). Corresponding values for stroke volume were 61 and 72 ml (P less than 0.05). The data suggest that in clinically stable patients there is an early improvement of the relation between myocardial oxygen supply and demand and a late improvement of functional capacity associated with increased stroke volume and cardiac output.


Left ventricular function before and following aortic valve replacement. Twenty-four patients with aortic valve disease were studied before and 19+/-12 months following valve replacement with a well functioning prosthesis. Biplane left ventricular angiography and pressures were utilized to determine end-diastolic volume/m2 (EDV), end-systolic volume/m2 (ESV), ejection fraction (EF), left ventricular mass/m2 (LVM) and stroke work (SW). There were nine patients with aortic stenosis (AS), ten patients with combined stenosis and regurgitation (AS-AR), and five patients with aortic regurgitation (AR). Following surgery, patients with regurgitation preoperatively showed marked regression in EDV and ESV. All groups demonstrated regression in LVM. Fifteen patients with a normal EF preoperatively (65+/-11%) had no change after surgery; the nine patients with a low EF before surgery (38+/-8%) had a normal EF after surgery (60+/-16%). We conclude that left ventricular dilatation, hypertrophy, and reduced left ventricular pump function are largely reversible after successful aortic valve replacement.


Echocardiographic study of cardiac tamponade. We studied 14 patients with cardiac tamponade and pulsus paradoxus; 11 were studied after relief of tamponade by pericardiocentesis. Right ventricle diastolic diameter increased during inspiration in each of 12 patients; left ventricle diastolic diameter decreased during inspiration in each of 13. Mitral valve DE amplitude decreased with inspiration in 13 of 14 patients. Mitral valve E-F slope could be measured in eight patients, and was rounded and not measurable in six. Six of the eight showed inspiratory decrease in mitral E-F slope. Similar changes were observed in two other patients with pulsus paradoxus who had chronic obstructive airway disease. Twenty patients with large pericardial effusions and no tamponade did not show these changes. These results suggest inspiratory augmentation of right ventricular filling and inspiratory diminution of left ventricular filling, not only in cardiac tamponade, but in obstructive airway disease associated with pulsus paradoxus.


The utility of contrast echocardiographic techniques in the care of critically ill infants with cardiac and pulmonary disease. In order to assess the utility of contrast M-mode echocardiography in an intensive care nursery population of critically ill newborns with cardiac and pulmonary disease and to validate contrast echo methods, we performed 200 serial contrast echoes on 40 infants via umbilical arterial or venous catheters which had been placed into these infants for clinical indications. The resulting contrast echoes recorded from the precordium or the suprasternal notch allowed the delineation of intra- and extracardiac right-to-left and left-to-right shunting patterns. Patterns identified and validated by cardiac catheterization (in cardiac patients) were: right-to-left atrial shunts, right-to-left ventricular shunts, and left-to-right patent ductus arteriosus shunts. The studies were without complication. Serial application of these echocardiographic techniques was extremely important in assessing changing physiology in these neonates. Contrast echocardiography adds physiologic flow information to the anatomical information available from M-mode echoes and is quite important in the diagnosis and sometimes in the management of critically ill newborns.


A mathematical model of parasystole and its application to clinical arrhythmias. A ventricular parasystolic focus capable of generating manifest ectopic beats should not be totally insulated from the electrical events that accompany depolarization in the surrounding tissue; the intrinsic cycle length of the ectopic discharge may be modulated by electrotonic influences transmitted across the zone of "protection." To study the nature of the interaction, response patterns were examined in a mathematical model programmed to simulate an ectopic pacemaker protected, but not divorced from ventricular responses to the normal pacemaker. Computer runs covered a wide range of heart rates, and a wide range of magnitudes of the simulated electrotonic influence. Application of the results obtained in the model to published examples of complex arrhythmias revealed a remarkably close fit to many clinical examples. This findings suggests that many patterns attributed to a re-entrant "extrasystolic" rhythm may, in fact, represent the modulated activity of a parasystolic focus.


Suppression of ventricular ectopic depolarizations by tocainide. In a previous clinical study we demonstrated that tocainide is effective in the suppression of ventricular ectopic depolarizations (VEDs) after single oral doses. This information provided the basis for evaluating this drug's antiarrhythmic efficacy after multiple dose administration according to a loading-maintenance regimen. Twelve patients with stable VEDs were given loading doses of tocainide (400-600 mg) with maintenance doses every 12 hours. Every 48 hours the dose was increased until either arrhythmia suppression to less than 25% of VED frequency during placebo administration or side effects occurred. Computer analysis of 12-hr telemetric ECGs taken 24-36 hr after each dosage increment documented effective suppression (76-95%) in 8 of 12 patients. Those subjects demonstrating suppression were randomly assigned to a cross-over study of placebo or active drug at the dosage found effective in the dose-ranging phase. Dosages for the cross-over stage ranged from 400 to 1100 mg every 12 hours. Comparison of the two five-day periods documented suppression in these patients (mean +/- SE = 83.3 +/- 4%). No serious side effects or undue drug accumulation occurred during the study. The data indicate that tocainide can effectively suppress VEDs for 8-12 hours in many patients and that continuous suppression could be possible on an 8-12 hr dosage regimen.


Predictive implications of ventricular premature contractions associated with treadmill stress testing. Follow-up data on future coronary events was collected on 6,500 patients who had undergone stress testing; 1,327 of these exhibited ventricular premature contractions (VPCs) associated with one or more phases of treadmill stress testing (TSTs). Eighty-three percent of all patients tested had known or suspected cardiovascular disease. The annual incidence of new coronary events (myocardial infarction, angina, cardiac death) during a five year follow-up was 1.7% among 1,067 patients without VPCs or ischemic ST changes, 6.4% in 758 patients with VPCs alone, 9.5% among 609 patients with ischemic ST changes alone and 11.4% in 569 patients with VPCs plus ischemic ST changes. The significance of VPCs associated with the TSTs rests largely upon the clinical status of the persons tested. VPCs observed among patients referred for TSTs for the evaluation of known or suspected cardiovascular disease, with or without ischemic ST abnormalities, represent a definite risk factor for future coronary events.


The influence of constitutional variables on orthogonal electrocardiograms of normal women. Correlations between 276 orthogonal electrocardiographic measurements and constitutional variables were made in 450 normal women, aged 18 to 90 years. Advancing age led to decreases in amplitudes, left QRS axis shift, rightward and superior displacement of the ST segment, and anterior shift of the T wave. QZ was absent in 1% of normal women over age 40. In the oldest subjects, Ry amplitude was 71% and RZ amplitude was 80% of the respective values in the youngest group. Whereas QRS amplitude decreases with age leveled off at the sixth decade of life, they continued to old age for ST-T measurements. Men revealed steeper age trends than women. Blacks had larger QRS amplitudes and smaller Q/R ratios than whites. Stratification of electrocardiographic criteria according to age, sex, and race appears essential for routine interpretations and for epidemiological studies where new events, such as myocardial infarcts, need to be differentiated from normal age trends.


A method for serum octanoate in hepatic cirrhosis and hepatic encephalopathy. We describe a new, more efficient, and more reproducible method for determination of octanoate in serum. This method involves ethanol extraction, followed immediately by alkali addition before concentration of the extract. The concentrate is made acidic only before it is to be steam distilled (in a special all-glass apparatus with an alkali trap). The material is acidified again just before separation by gas-liquid chromatography. The yield is 89-107%. When assayed by mass spectrometry, only octanoate was found in the fraction from chromatography. Previous methods yielded only 30-55% of the expected octanoate value and the recovered materials showed impurities by mass spectrometry. Octanoate concentrations were determined in the serum of 24 fasting controls and that of 85 fasting cirrhotic patients, of whom 50 had encephalopathy. Concentrations in arterial and venous blood were significantly higher in cirrhotic patients in coma than in those not in coma, and arterial concentrations were statistically higher than venous concentrations in the cirrhotic patients.


High-performance liquid-chromatographic assay for nitrofurantoin in plasma and urine. The high-performance liquid-chromatographic method described here for the quantitative analysis for nitrofurantoin in urine and plasma involves direct analysis of urine samples and analysis of plasma samples after protein precipitation by methanol. The assay, which requires only 0.2 ml of biological fluid and shows a linear relationship in the range 0.02 to 200 mg/liter, can be performed in 9 min and is reproducible (CV less than 2%). Results for nitrofurantoin so obtained correlate well with those obtained by the Hyamine 10-X spectrophotometric method (CV = 2%), but the present method is more sensitive. With no modification, the present procedure can also be used for nitrofurazone. The sensitivity, accuracy, and convenience of the method make it suitable for clinical monitoring and pharmacokinetic/bioavailability studies with 5-nitrofuran derivatives.


Evaluation of Ames' "Clini-Tek".

Evaluation of Ames' "Clini-Tek". Reproducibility of reading "N-Multistix" dipsticks by a semi-automated urinalysis instrument (Ames' "Clini-Tek") has been described for artifically prepared samples. Glucose, ketone, urobilinogen, and nitrite showed high reproducibility (greater than 90%) for reading multiple samples at predetermined analyte concentrations. Determination of proteinuria showed the lowest proportion of false positives (2-3%) and false negatives (0%). Determination of hemoglobinuria and bilirubinuria by dipsticks were the least reproducible. Urobilinogen showed no interference from bilirubin in concentrations up to 32 mg/liter. Precision was high for results for quality-control capsules provided by the manufacturer.


Semi-automated vs. visual reading of urinalysis dipsticks. Semi-automated reflectance readings of urinalysis dipsticks showed better precision than visual readings in the case of artificially prepared urine samples containing glucose, ketone, and protein. Actual pathological specimens containing glucose, protein, and nitrite also showed that instrumental readings were better than visual. Results of repeated visual readings spread over three different color blocks for certain concentrations of glucose, ketone, and protein, whereas repeated instrumental readings were never spread greater than two color blocks. Subjectivity can be reduced by semi-automated dipstick urinalysis.


Urinary 3-methoxy-4-hydroxyphenylacetic (homovanillic) and 3-methoxy-4-hydroxymandelic (vanillylmandelic) acids: gas-liquid chromatographic methods and experience with 13 cases of neuroblastoma. We present a quantitative gas-chromatographic method for determining urinary 3-methoxy-4-hydroxymandelic acid (vanillylmandelic acid) and 3-methoxy-4-hydroxyphenylacetic acid (homovanillic acid). In this rapid technique an internal standard is used and the procedure involves ether extraction and silyl ether formation. Analytical recovery of vanillylmandelic acid averages 87.5% (CV, 0.95%), of homovanillic acid 102.3% (CV, 9.95%). Our data on 34 samples from 13 neuroblastoma patients show that homovanillic acid is more consistently elevated than is vanillylmandelic acid.


Microdetermination of plasma ATP and creatine phosphate concentrations with a luminescence biometer. We optimized conditions for determination of adenosine-5'-triphosphate (ATP) and creatine phosphate from plasma extracted with ethanol/water (96/4 by vol). The procedures utilize the firefly luciferin/luciferase reaction, the bioluminescence being measured with a Du Pont Biometer. ATP is quantitated directly and creatine phosphate is quantitated by reaction with creatine kinase and ADP, after plasma ATP is removed by incubation with the enzyme apyrase. The method is applied to plasma from humans, rabbits, and rats, and possible clinical applications are discussed.


Measurement of free-circulating cis-dichlorodiammineplatinum(II) in plasma. Dichlorodiammineplatinum(II) is an anti-neoplastic agent that is currently undergoing clinical evaluation. We describe an analytical method for monitoring the free drug (or its breakdown products) in plasma. The method is able to distinguish between free and protein-bound drug. Plasma samples are deproteinized by centrifugal ultrafiltration. The platinum in the ultrafiltrate is converted to a cationic species by reaction with ethylenediamine and then collected on paper impregnated with cation-exchange resin. This process concentrates the samples, increases the stability of the platinum compounds (by removing the compound from solution), and places the sample in a uniform matrix of minimum thickness, which maximizes detection capabilities. Platinum was measured directly on the ion-exchange disks by X-ray fluorescence. The detection limit for free drug is 240 microgram/liter of plasma at the 3s level and fluorescence intensity is linearly related to drug concentration in the range from 570 to 5700 microgram/liter.


Influence of oleic acid on serum lipoprotein-X in vitro. Lipoprotein-X is no longer detectable in serum by either the agar gel-electrophoresis/polyanion precipitation technique or immunoelectrophoresis with specific antiserum after in vitro addition of oleic acid. Evidence is presented which indicates that this ostensible loss is due not to its destruction, but rather to altered electrophoretic mobility. The findings suggest an explanation for the well known post-heparin "disappearance" of lipoprotein-X, and indicate that caution may be needed in the interpretation of such lipoprotein-X testing of sera from subjects with increased concentrations of lysolipids in their blood.


Use of gel filtration to examine the distribution of calcium among serum proteins. Gel filtration of serum by use of dextran bisacrylamide beads ("Sephacryl S-200," fractionation range: 5000-250 000 daltons), separates the serum proteins into three distinct peaks. We used an eluent containing (per liter) 140 mmol of sodium, 1.10 mmol of calcium, 0.50 mmol of magnesium, and 10 mmol of 2-([2-hydroxy-1, 1-bis(hydroxymethyl)ethyl]amino)ethanesulfonate buffer (pH 7.43 at 37 degrees C) to provide the physiological conditions necessary to maintain the equilibrium of bound calcium in serum. We examined the calcium binding by each of the three protein groups. Calculating the calcium bound per gram of protein in each peak, we found that proteins in the first peak (alpha2-macroglobulin, IgM, haptoglobins) bind about the same amount of calcium per gram as does albumin. The proteins of the second peak (largely IgG and IgA) bind less calcium than does albumin, which is the protein accounting for 90% or more of the third peak. We also were able to calculate intrinsic association constants for calcium/albumin under physiological conditions.


Inhibition by concanavalin A as the basis for a specific assay of serum 5'-nucleotidase activity. Concanavalin A inhibits serum 5'-nucleotidase activity, without causing significant inhibition of alkaline phosphatase activity. This observation serves as the basis for a new method for assaying the 5'-nucleotidase activity in serum, which depends upon the difference between the enzymic hydrolysis of adenosine-5'-monophosphate in the presence and absence of concanavalin A. A denosine released by the 5'-nucleotidase reaction is deaminated by a coupled reaction with adenosine deaminase to liberate inosine and ammonia, and ammonia is measured colorimetrically by the Berthelot reaction. In sera from 40 healthy adult persons, 5'-nucleotidase activity averaged 6.4 U/liter (SD, +/-2.0; range, 3-12). In sera from 100 patients, measurements of 5'-nucleotidase activity by the new assay averaged 8% lower than by a generally accepted method in which phenyl phosphate is used to suppress hydrolysis of adenosine-5'-monophosphate by alkaline phosphatase activity. The clinical validy of the new assay was tested by measuring serum 5'-nucleotidase activities in rats with bile duct ligation and in rats treated with thioacetamide to induce hepatocellular injury.


Radioimmunoassay for normalized thyroxine with use of Sephadex columns. We describe a reproducible radioimmunoassay, with use of Sephadex columns, for measuring normalized thyroxine. In comparison with a competitive protein-binding procedure, the present method is more specific because antibody rather than thyroxine-binding globulin is responsible for the competition between endogeneous and tracer thyroxine. In barbital buffer, various concentrations of thyroxine binding pre-albumin and albumin had no influence on the results. Values obtained by the present method correlated well with those by the free thyroxine index and a generally accepted thyroxine normalized method.


Some aspects of sodium nitroprusside reaction with human erythrocytes. Sodium nitroprusside is an excellent agent for lowering blood pressure in hypertensive emergencies, for producing controlled hypotension during anesthesia, and for treating acute myocardial infarction and chronic heart failure. Toxic effects of this drug have been reported and above-normal cyanide and thiocyanate concentrations have been observed in the blood of a small proportion of subjects receiving nitroprusside. Nitrite, syanide, and thiocyanate are major decomposition products of nitroprusside, resulting from an in vitro reaction with human blood. On the basis of the conversion mechanism, we suggest that, in the cyanide/thiocyanate cycle, only cyanide is directly responsible for any acute toxicity attributed to sodium nitroprusside. In this work, the extent of cyanide production by erythrocytes in vitro was studied. The rate of detoxification of cyanide by human liver in vitro was experimentally determined and data from a search for a possible inhibitor of the nitroprusside/hemoglobin reaction are presented. Also, the possible mechanism of the nitroprusside/hemoglobin reaction is discussed.


Urinalysis by use of multi-test reagent strips: two dipsticks compared. We compared Ames' "N-Multistix" with Boehringer's "Combur-8" ("Chemstrip-8") multi-test urine reagent strips by analysis of contrived urine specimens, testing accuracy, precision, specificity, and limits of detection of both products. Relative cost and ease of use were also examined. Each brand of urinary dipstick had specific advantages but it is unlikely that patient care would be adversely affected by preferential use of either product.


Diminished cap formation in lymphocytes from patients and carriers of Duchenne muscular dystrophy. Currently, the most useful clinical laboratory aid in establishing the carrier state of Duchenne muscular dystrophy is to determine creatine kinase (EC 2.7.3.2) activity in the plasma. The considerable overlap between plasma creatine kinase activities of controls and of carriers at the childbearing age contributes appreciable difficulty to genetic counseling of potential carriers. The consistent failure of lymphocyte cap formation in Duchenne muscular dystrophy patients and carriers in this study suggests a valuable tool for the confirmation of the carrier state.


Effect of glucocorticoids on liver and blood cholinesterases. The effects of oral prednisone on plasma and red blood cell cholinesterases have been studied in human volunteers. While the activity of plasma pseudocholinesterase is depressed by glucocorticoid administration, the activity of red blood cell true cholinesterase is not affected. Cortisol administration to rats, intraperitoneal or subcutaneous, inhibited liver pseudocholinesterase activity, indicating a possible depression of the enzyme protein synthesis.


Serum lipids and lipoproteins in healthy Africans. Using a simple precipitation technique we observed that the serum concentrations of low density lipoproteins in healthy Africans were less than half the serum concentrations in healthy Europeans. Serum concentrations of lipids and the lipoproteins varied according to the social class of Africans. Serum triglyceride concentrations did not rise with adult age but serum cholesterol concentrations did. Contrary to the findings in Europeans, the proportion of alpha lipoprotein fraction on serum electrophoresis in the Africans was relatively higher than that of beta lipoprotein fraction.


Selective protamine sulphate inactivation of lipoprotein lipase and hepatic lipase in human post-heparin plasma: specific lipase levels in normals and in type I hyperlipoproteinaemia. The rate of inactivation of triglyceride hydrolase activity by protamine sulphate was determined in pooled, normal, post-heparin plasma. Two distinct first-order rates of inactivation were obtained and the derived constants used to calculate the lipoprotein lipase and hepatic lipase contributions to the total post-heparin triglyceride hydrolase activity in normal controls and in patients with familial hyperchylomicronaemia. The lipoprotein lipase was reduced in the patients whereas the hepatic lipase was normal. There was however a marked age-related increase in the hepatic enzyme activity in normal subjects. Post-heparin lipolytic activity, assayed in vitro against lipoproteins of d less than 1.006 derived from the patients, was markedly reduced in our hyperchylomicronaemic subjects. This assay correlated well with the lipoprotein lipase activity determined by selective protamine sulphate inactivation.


A rapid assay for urinary porphyrins by dual-wavelength spectrophotometry. A procedure has been developed for the separation and quantitative assay of urinary porphyrins. Urine was directly diluted to a final concentration of 1 MHCl and the amount of porphyrins was determined from the peak-to-trough height deflection of the first derivatives of the absorption spectrum in the region of the Soret band. The ratio uro-/coproporphyrin was determined from the wavelength at which the spectrum intercepted the baseline. The specificity (as shown by a correlation coefficient of 0.99 compared to the method of Doss and Schmidt (1971) Z. Klin. Chem. Klin. Biochem. 9, 415-418), precision (coefficient of variation 5.2 percent) and sensitivity (lower detection limit approx. 0.01 mumol/l) of the present method were highly sufficient to estimate total and different porphyrins in the routine laboratory.


Spontaneous shedding of plasma membrane fragments by human cells in vivo and in vitro. Human duodenal fluid, secretion fluid of a villous adenoma of the rectum, urine and culture medium of HeLa cells contain plasma membrane fragments which can be revealed by electrophoresis in different media, gel filtration on Sepharose 4-B, electron microscopy and cytochemistry. They carry plasma membrane enzymes (alkaline phosphatase EC 3.1.3.1, leucine aminopeptidase EC 3.4.1.1, 5'-nucleotidase EC 3.1.3.5, maltase EC 3.2.1.20) in the same ratio as the membranes of the cells of origin. Equilibrium density centrifugation results in recovery of these plasma membrane fragments at density 1.190 (g/ml) in CsCl, 1.165 (g/ml) in sucrose, and 1.135 (g/ml) in metrizamide. Similar plasma membrane fragments were decribed previously in the serum of certain liver patients. These observations give evidence that shedding of whole plasma membrane fragments (koinozymic shedding) is a widespread feature of viable cells.


Human serum amine oxidase. Enzyme activity in severely burnt patients and in patients with cancer. During a study of serum amine oxidase (SAO) levels in patients with fibrotic disease processes, 127 patients (100 adults and 27 children) with moderate to severe burns were investigated. Of these, 55 adults and 20 children, classified as severe, had enzyme levels of 2.7 +/- 0.3 and 4.6 +/- 0.9 McEwen Units (McE.U) (mean +/- S.E.) respectively, which, compared with those for normal healthy adults (18.3 +/- 0.6 McE.U), gave a difference of striking significance (t=21.05 for 130 d.f., and t=10.33 for 95 d.f., respectively). Subsequently, 125 patients with proven cancer were studied. 52 percent of the untreated and 41 percent of the treated showed remarkably low enzyme activity. The mean of the group of untreated patients was 9.6 +/- 1.1 McE.U, that of the treated 11.6 +/- 1.0 McE.U, and that of the entire group 10.7 +/- 0.7 McE.U. The difference between these values and normal activity is highly significant (p less than 10(-6)). Sequential SAO estimations on severly burnt patients and those with cancer established the time course of enzyme activity in these patients. Our observations suggest that estimation of SAO activity may be useful not only for the classification, monitoring and prognosis of severe burns, but also in the diagnosis of cancer and the evaluation of its treatment.


Serum levels of proline imino-peptidase in normal adults and children. Serum proline imino-peptidase activities in 98 normal individuals aged 1 month to 75 years are examined. Mean enzyme activity in sera of individuals ages less than 1 year is 66.6 U; 2 to 6 years; 46.2 U; 7 to 11 years, 52.8 U; 12 to 16 years, 48.8 U; 17 to 19 years, 34.1 U; 20 to 29 years, 28.8 U; 30 to 39 years, 30.5 U; 40 to 59 years, 35.6 U; and more than 60 years, 31.6 U. Serum enzyme activities were markedly elevated in infants aged less than 1 year, then decreased with age up to 20 years. Serum proline imino-peptidase activity in 44 normal adults aged 20 to 59 years ranged from 19.9 to 43.1 U and averaged 31.5 +/- 5.8 U. There is no statistical difference in serum activities in normal adults between males and females.


Serum aspirin esterase activity in women with habitual aspirin intake. A method for the determination of aspirin esterase activity in serum is described. Sera from 59 pregnant women who were habitual aspirin users were found to have a mean enzyme activity value statistically lower than those of 68 non-pregnant women controls or of 12 pregnant women controls who were either occasional users of the drug or were non-users. The distribution of enzyme activity in the experimental group was also significantly different from that of the control group. It is postulated that the low enzyme activity may further aggravate the injurious effects of high intake of aspirin.


Inorganic phosphorus measurement: an improved method. An improved micromethod for the determination of inorganic phosphorus in serum and urine is outlined. The procedure requires no deproteinization and yields a stable colour. The new formulation proposed avoids the pitfalls of other techniques. The method is both accurate (recovery 99-100.4 percent) and precise (C.V. 2.19 percent).


A simple slide-rule method for the assessment of renal tubular reaborption of phosphate in man. The activity of renal tubular reabsorption of phosphate in man is best expressed as the ratio of the maximum rate or reabsorption to the glomerular filtration rate (TmP/GFR). A slide-rule method based on existing data is described for the derivation of TmP/GFR from values of phosphate and creatinine concentrations in single samples of plasma and urine. This is a simple method which is suitable both for research and for clinical purposes.


[Influence of oral contraceptive agents on the concentration of amino acids in leukocytes of supposedly healthy women (author's transl)]. The concentration of amino acids has been measured in leukocytes of women taking oral contraceptive agents and also in controls. These assays were made by means of ion exchange chromatography. The amino acid pool in leukocytes was found to be smaller in those patients taking the "pill". Each amino acid concentration decreased except for taurine and glutamine. Taurine represented 64.1 percent of the pool in treated women and only 23.5 percent in controls. Glutamine represented 9.5 percent of the pool in patients and 3.7 percent in controls.


Levels of immunoglobulin E (IgE) in paired examinations of serum and synovial fluid in rheumatoid arthritis and reactive synovitis of local origin. Levels of IgE were examined in pairs of serum and synovial fluid of the knee joint in a series of 78 patients with rheumatoid arthritis (RA), reactive synovitis during osteoarthrosis, and after injury. The IgE levels in synovial fluid were significantly lower (p less than 0.05) in all groups; in RA, they were in significant correlation (r=0.6208, p less than 0.0001) and in direct linear regression to the levels in serum. In 5 patients of the whole series, however, the IgE levels in serum were lower by one order of magnitude as compared with synovial fluid. Serum levels of IgE in RA were in significant correlation and in direct linear regression to the titres of rheumatoid factors according to the latex-fixation test (r=0.3688, p=0.0249) and the haemagglutination test with sheep red cells (r=0.3721, p=0.0235).


Comparative determinations of aminotransferase activities in serum with so-called "optimised" methods. Comparative determinations of aspartate aminotransferase and alanine aminotransferase activities were made with so-called "optimised" methods introduced in the G.D.R., G.F.R. and Scandinavia. By means of the paired t-test significant differences could be established. These differences are partly due to different reaction conditions. For practical clinical aspects these differences should be of little relevance. In comparison with above-mentioned activites determined at 37 degrees C, aspartate aminotransferase activities measured with the IFCC reference method are lower by about 30 percent.


Evidence for a dopaminergic activity of methysergide in humans. The acute administration of 2 mg of methysergide significantly reduced plasma prolactin levels in nine normal subjects and in seven hyperprolactinaemic patients. The prolactin lowering effect of this drug was abolished by sulpiride. Morever methysergide lowered plasma GH levels in four out of nine acromegalic patients, who were also responsive to a dopaminergic drug such as bromocriptine. Although methysergide did not significantly blunt the TRH-induced prolactin release, our data suggest that this drug may affect GH and prolactin release through a dopaminergic mechanism of action. This effect should be taken into account when methysergide is employed as antiserotoninergic drug in neuroendocrinological studies.


Is the growth-hormone response to insulin due to hypoglycaemia, hyperinsulinaemia or a fall in plasma free fatty acids? Seven normal male volunteers were given a 2 h intravenous infusion of insulin (2 mu kg-1 min-1). During the first hour, in which nomoglycaemia was maintained by glucose infusion, no detectable increase in growth hormone (GH) secretion occurred. When controlled symptomatic hypoglycaemia was produced during the second hour of the insulin infusion a brisk rise in plasma GH concentration was observed in all the subjects studied. Since it was possible that the falls in the concentration of plasma free fatty acids (FFA) occurring during infusion of insulin also acted as a stimulus to GH release the study was repeated in four subjects but normoglycaemia was maintained throughout the entire 2 h period of insulin infusion. In these experiments there was no rise in plasma GH concentration although a similar fall in plasma FFA was produced. These results clearly indicate that hypoglycaemia per se was the important stimulus to GH secretion and not hyperinsulinaemia or a lowering of plasma FFA. Furthermore there appeared to be a threshold hypoglycaemic stimulus to GH secretion. In no subject was a rise in plasma GH seen without a fall in plasma glucose greater than 1.4 mmol/l. Prolonged mild hypoglycaemia did not stimulate GH secretion.


Comparison between the plasma insulin and glucose responses to five different insulin regimes in diabetic patients. Diurnal plasma insulin and glucose concentrations were studied in six diabetic patients, each treated with five different insulin regimes. Subcutaneous soluble insulin was too slow and long acting for physiological replacement of the normal insulin response to meals, but the peak insulin levels were higher than the postprandial levels of normal subjects. Intramuscular insulin, though absorbed more quickly than subcutaneous insulin, was not clinically advantageous. Three rather than two injections of soluble insulin gave improved blood glucose control but two combined injections of short and medium acting insulins gave nearly as good results. A long acting insulin was needed to prevent raised plasma glucose levels overnight.


The characterization of growth hormone release inhibiting hormone-like immunoreactivity in normal urine. Using a previously described radioimmunoassay for growth hormone release inhibiting hormone (GH-RIH), the presence of GH-RIH-like immunoreactivity in urine has been characterized by demonstrating mobility identical to synthetic GH-RIH standard on two sephadex gel chromatographic systems, and parallelism of dilutions of the sephadex fractions with synthetic GH-RIH. Furthermore, 74% of the sephadex fraction cross-reacting in the immunoassay bound to antibody conjugated to sepharose and could be eluted by 1 M acetic acid. This immunospecific eluate showed identity with synthetic GH-RIH on both ion exchange and thin layer chromatography. Thus GH-RIH-like immunoreactivity is present in normal urine; this may have potential relevance in the search for a physiological role for this peptide.


Undifferentiated carcinoma of the nasopharynx: a light and electron microscopical study. Light microscopical study of 29 cases of undifferentiated carcinoma of the nasopharynx showed evidence or origin of the tumour cells from overlying epithelium in 10 cases. In all cases the tumour cells had a distinctive cellular appearance of 'empty' chromatin deficient nuclei, prominent nucleoli and indefinite cytoplasmic margins. Electron microscopy indicated desmosomes and poorly defined tonofilaments in addition to the above cytoplasmic features. Undifferentiated carcinoma of the nasopharynx shows characteristic light and electron microscopic features which indicate that the tumour cells take origin from squamous epithelium, but are of an extreme degree of dedifferentiation.


Transcranial approach for cancer of the antroethmoidal area. An improvement in the treatment results of antroethmoidal cancers may be achieved through the use of a transcranial approach, which makes an en bloc excision of the ethmoid labyrinths possible. This exposure allows dural involvement to be assessed, excised and repaired under direct vision. The technique used in the management of 9 patients is described. Eight of these patients presented with recurrent disease after previous radiotherapy and surgery. There were no deaths in the immediate postoperative period. Two patients are dead: one with disease in the frontal lobe; the other 18 months after operation, apparently free of disease. Facial deformity in patients who have undergone this operation is no greater than that associated with other operations in this area, and may be less, as a superior approach may allow the posterior ethmoidal and sphenoid area to be excised without orbital exenteration.


Pulmonary complications of methotrexate therapy. Diffuse interstitial pulmonary infiltration was first reported in 1969, occurring during intermittent methotrexate therapy and it is suggested that it represents an adverse reaction to this drug. Despite the severity of the clinical and radiological changes, the disease is usually self-limiting. An additional case is presented and the previous 28 reported cases of this syndrome are summarized. Since intermittent methotrexate therapy is becoming more widely used, the importance of recognizing this respiratory illness as a possible complicating reaction to the drug is stressed.


A two-part obturator prosthesis for use following maxillectomy in edentulous patients. Some problems of conventional prostheses after maxillectomy are discussed. A two-part appliance which incorporates a removable, flexible obturator is described. It is simple to construct and comfortable to wear.


A study of serum IgA levels in children undergoing tonsillectomy. Earlier work has suggested that up to 25% of children undergoing tonsillectomy because of recurrent sore throats are relatively deficient in IgA immunoglobulin and that they do less well after the operation than 'normal' children. Measurements of serum immunoglobulin levels were carried out in 96 children undergoing tonsillectomy for recurrent sore throats. Levels of IgA, IgM and IgG were found to be similar to those in healthy children, 7-29% of those studied had 'low' IgA serum levels. There was a significant relationship between serum IgA levels and the age of the child. No relationship could be established between IgA levels and pre- or postoperative clinicaal state of the children. Low IgA serum levels are probably the result of delayed immunological maturation rather than a true immunodeficient state. IgA estimations, therefore, have no bearing on selection for operation or the prognosis after operation.


Squamous carcinoma of the oropharynx.

Squamous carcinoma of the oropharynx. One hundred and ten patients with an oropharyngeal carcinoma seen in the period 1961--1971 at the Antoni van Leeuwenhoek Hospital in Amsterdam are analysed. Approximately 75% of the patients were older than 60 years. About 60% of the patients had a cervical lymph node metastasis at the time of admission. Virtually all patients were treated exclusively by radiotherapy. Of the total group, the absolute survival was 26%, for tumours of the tonsil 35%, and for the base of the tongue 17%. There was no significant correlation between the histological degree of differentiation and the survival. The possibility of improving the results of selected patients is discussed.


Propranolol serum levels during twenty-four hours. Propranolol serum levels during a 24-hr period were determined every 2 hr in 9 hospitalized patients with angina pectoris after oral administration of 40 mg of propranolol 3 times a day. After the first, second, and third tablets the mean maximum serum propranolol concentrations averaged 118 +/- 71 ng/ml, 134 +/- 97 ng/ml, and 118 +/- 94 ng/ml and the mean minimum concentrations averaged 21 +/- 18 ng/ml, 45 +/- 25 ng/ml, and 54 +/- 34 ng/ml (+/-SD), respectively. These data show a very wide inter- and intraindividual variation in serum propranolol levels. No relationship was found between serum level and blood pressure or dose (related to body weight).


Propranolol-induced increments in total and free serum thyroxine in patients with essential hypertension. The effect of propranolol on serum levels of total and free thyroxine, total and free triiodothyronine, and thyroid-stimulating hormone (TSH) was investigated in 15 clinical euthyroid patients with essential hypertension. Oral propranolol in dosages from 80 to 480 mg/day for a 30-day period induced an average increase in total serum thyroxine of 15.5 +/- 2.2% (mean +/- SEM, 2 p = 0.00002) and in free thyroxine of 17.7 +/- 3.5% (2 p = 0.00009). The oral dose of propranolol correlated positively with serum propranolol (r = 0.70, 2 p = 0.007). No significant correlation between serum propranolol and changes in serum thyroxine could be demonstrated. Total and free triiodothyronine, as well as TSH, remained unchanged during propranolol treatment. The most likely explanation is a propranolol-induced decreased degradation of thyroxine. A practical consequence is that in patients with an uncertain clinical picture and slightly elevated serum thyroxine, propranolol intake should be considered.


Bioavailability and first-pass metabolism of oral pentazocine in man. The bioavailability of oral pentazocine was studied in 5 healthy volunteers. Plasma concentrations were determined from 30 min up to 6 hr following oral administration (two 50-mg tablets) and, at other occasions, after intravenous injection of 30 mg pentazocine. The average bioavailability was found to be 18.4 +/- 7.8% (SD, n = 5). It is shown that this low bioavailability depend almost entirely on the first-pass metabolism of pentazocine following oral administration by application of intravenous clearance concepts. The average beta-phase half-life was about the same following intravenous administration, 203 +/- 71 (SD, n = 5) min as following oral administration, 177 +/- 34 (SD, n = 5) min, with a total volume of distribution of 5.56 +/- 1.63 (SD, n = 5) L/kg. It is suggested that the variations in bioavailability of orally administered pentazocine have the potential to contribute to variations in pharmacologic effects in patients.


Amitriptyline plasma levels and clinical response in primary depression. Sixteen patients with primary depression were treated for 4 wk with amitriptyline. After clinical diagnoses were determined, patients entered a double-blind protocol (amitriptyline or placebo) and their clinical status was determined with the Hamilton Depression Rating Scale by raters blind to the drug type, its dosage and plasma levels. Amitriptyline (AT) and nortriptyline (NT) plasma levels were assayed twice weekly by gas chromatography-mass spectrometry. In the 16 patients, a negative correlation between the Hamilton Score and the mean total tricyclic level (p less than 0.01), as well as with individual plasma levels, was found at the end of the treatment period. When the group was divided into clinical responders and nonresponders, the mean total tricyclic (AT + NT) levels discriminated the two groups by day 12 (p less than 0.001) as well as at the end of the protocol (day 26, 88% of the patients were classified correctly if an arbitrary level of 200 ng/ml total tricyclic plasma level was chosen). These results strongly suggest the presence of a positive correlation between plasma levels and clinical improvement in patients with primary depression.


Effectiveness of prednisolone during phenytoin therapy. The effects of diphenylhydantoin (DPH) on the clearance of prednisolone from plasma, its bioavailability, and its biologic effectiveness were studied in 5 persons before and after daily DPH therapy for more than 3 wek. DPH decreased the mean half-time of disappearance of prednisolone from plasma by 45% and increased its metabolic clearance rate by an average of 77%. The gastrointestinal absorption of prednisolone and its first-pass clearance through splanchnic tissues were not significantly altered by DPH. The mean oral midnight dose of prednisolone required to suppress the 8 A.M. plasma level of cortisol to 5 microgram/dl was doubled following treatment of DPH. The increment in dose of prednisolone varied from 58% to 260% in the five individuals.


Diabetes mellitus in pregnancy.

Diabetes mellitus in pregnancy. Physiologic changes that occur during pregnancy are diabetogenic. If diabetes does not exist before pregnancy, it may become evident, and if diabetes pre-exists, it becomes aggravated. The changing insulin requirements and propensity for ketoacidosis require weekly visits and careful urine testing on a daily basis by the mother. In addition, microvascular complications of diabetes must be carefully monitored. Delivery is planned progressively early in the pregnancy according to diabetic class. Hospitalization is necessary one week before anticipated delivery. Urinary estriol tests, OCT, amniocentesis, and ultrasound are all helpful in managing the pregnancy. Delivery of the fetus and placenta results in a profound fall in the insulin requirement. The neonate should be carefully observed during the first few days of life because of the increased frequency of complications.


Diagnosis and surgical treatment of pituitary lesions. The primary care physician has a critical role in the recognition and early screening of pituitary lesions. Often the symptoms are nonspecific--headache, fatigue, and weakness. With menstrual irregularity, visual field loss, growth abnormality, or changes in body habitus or appearance, however, further investigation is needed. A single lateral skull X-ray may be enough to indicate pathology and warrant endocrine referral. If doubt exists even with a normal skull film, endocrine evaluation is worth undertaking. With increasing selectivity and safety of neurosurgical procedures, and with the help of physicians and radiotherapists, the neurosurgeon is able to offer the patient with a pituitary tumor a good chance of cure with minimal morbidity. However, the surgeon must often depend on the primary care physician to discover new visual field loss or endocrine changes that may signal recurrence, as well as to suspect the diagnosis of a pituitary lesion. The diagnosis, treatment, and follow-up of these lesions is best handled by an interdisciplinary team of physicians.


Respiratory abnormalities in hypothyroidism. While the respiratory and oxygen transport systems are complex, they are orderly, so that they can be studied logically and systematically. There are many interactions and potential abnormalities at various levels that may combine to give the ultimate defect of inadequate oxygen supply at the tissue level. An understanding of these many factors using hypothyroidism as a model should enable the clinician to approach the problem rationally and manage if effectively.


[Freedom and voluntary death: suicide as ideology]. Voices have been increasing in the last years, demanding the right of men to choose time and way of ending his life, thus asking consequently the liberty for mankind of killing themselves. The most important of these ideas are explained in connection with their philosophical, psychological and sociological background and confronted with the results of modern suicide research. The outcome of this review gives, however, no reason for changes in the previous and successful ways of suicide prevention.


[Information and evocation. Materials toward a sociopsychologically oriented psychopathology]. Psychopathology is always science of interaction, because mental illness is recognizable only in interaction. It will be useful for psychopathology to have a critical look on ideas and models of modern linguistic science. This is especially true for those tendencies which are interested in the concept of a theory of speaking and acting and work out the social implications of communicational processes beyond the formal examination of language structure. From this point of view new basic knowledge of psychopathology may accumulate. Tendencies going in that direction are examined in detail, especially the meaning of evocation, which was introduced by Lacan and which might prove to be a key conception of psychiatry.


Nonverbal dialogue with the brain-damaged elderly. In a population of twelve 63- to 89-year-old residents of a nursing home, rank-ordered scores of copying errors on the revised Benton visual retention test were found to be significantly correlated with the rotational shifts in the Minnesota percepto-diagnostic test. Residents on both ends of the continuum of brain damage could paint interesting, expressive and/or original pictures, in spite of the fact that the first eight residents were on psychotropic medication and the last four were occasionally handicapped by constructional apraxia. Ten adjudicators ranked pairs of figure drawings for each resident in decreasing order of 'aesthetic pleasingness' and 'originality'. Degree of brain damage was found unrelated to both measures. Interadjudicator agreement was stronger on 'originality' than on 'aesthetic pleasingness'. Some of the beneficial and provocative results of art therapy with the elderly are elaborated ans a plea made for accepting their observed creative performance as part of the realm of legitimate art.


[Disturbances in time perception in relation to changes in experiencing music in experimental psychosis]. Music is a structure ('Gestalt') in time. The recognition of disturbances of the perception of music enhances the knowledge of disorders of perception of time. Disturbances of perception of music and time in experimental psychoses (psilocybine) are discussed in relation to the studies by Piaget on the development of the notion of time in childhood. The results allow a new interpretation of the disturbances of the perception of time in diencephalic disorders as described in the literature.


Changes in sympatho-adrenal and kallikrein-kinin systems in the terminal stage of extensive myocardial infarction. Fifty patients with acute extensive myocardial infarction, with unfavourable course, were continuously survelled from the beginning of the disease till the terminal stage with the aim to study the interdependences between changes in the sympatho-adrenal and kallikrein-kinin systems in blood. The blood levels of adrenaline and noradrenaline were determined fluorometrically. The activity of the kallikrein-kinin system was estimated on the basis of three components: spontaneous esterase activity, prekallikrein activity, and kallikrein inhibitor activity in blood. Within the first six hours all patients had significantly elevated adrenaline and increased activity of the kallikrein-kinin system in blood. At 24h before death and during the terminal stage, in patients with acute heart failure and those with cardiogenic shock the adrenaline level gradually rose, and in patients with myocardial rupture the noradrenaline level increased. The activity of the kallikrein-kinin system remained elevated throughout the follow-up period. The application of findings as diagnostic and prognostic criteria in myocardial infarction is suggested.


Obliterative arteriosclerosis of extremities in patients with coronary heart disease. In a group of 314 patients after past myocardial infarction or an episode of acute coronary insufficiency, angiological examination, repeated after a one-year interval, was performed. In the first examination, signs of obliterative arteriosclerosis in the lower extremities were found in 18.8% of the patients. It was noteworthy that 34% of patients with peripheral obliterative arteriosclerosis had no complaints connected with an impairment of circulation in the limbs. On the basis of the second examination, performed after a one-year interval, it was found that the annual incidence of obliterative arteriosclerosis in the lower extremities was 7.4%. In 66% of patients showing signs of obliterative arteriosclerosis at the first examination, objective impairment of peripheral circulation was observed after a one-year interval. In none of the patients did the investigators find signs of obliterative arteriosclerosis in the upper extremities.


Venous tone in essential hypertension.

Venous tone in essential hypertension. Peripheral venous tone was measured in 124 patients with essential hypertension and in 20 healthy persons by digital electroplethysmography according to B. E. Votchal. In patients with hypertension stage II, the venous tone significantly decreased with increasing arterial tone; in patients in stage I this tendency was statistically not significant. In orthostasis the increase in venous tone was much lesser than that in arterial tone. The close positive correlation between venous capacity and the degree of decrease in systolic and pulse pressure make it possible to assess the systemic venous pressure on the basis of findings obtained from occlusion plethysmographic measurements. In patients with hypertensive disease in stage IIA, treated with reserpine, the arterial tone and pressure decreased, whereas the venous tone significantly increased (normalized).


Abnormalities of cardiac conduction in sinus node disease. Correlation with clinical findings. His bundle recordings, sinus recovery time and the response to atropine were studied in 28 patients with symptomatic sinus node disease. The electrophysiological data were correlated with the clinical picture and the course of the disease. The marked prolongation of sinus recovery time and a decidedly diminished responsiveness to atropine may increase the accuracy of clinical assessment of the disease but negative results of these tests do not exclude even serious dysfunction of the node. The His bundle electrogram provides a more thorough evaluation of AV conduction and should be taken into account when permanent electrotherapy is being considered.


The limitation of mitral echocardiography in combined mitral lesions. In combined mitral stenosis and incompetence, the mitral echocardiogram is able to estimate the degree of mitral stenosis (i. e. mitral valve area) without being able to detect or quantify mitral incompetence. A diastolic closure rate of 20 mm/sec or less does not exclude significant mitral incompetence as claimed by others. Cardiac catheterization is still necessary in mitral stenosis, where concominant mitral incompetence is suspected clinically, to confirm its presence and quantify its degree.


Case report of congenital tricuspid insufficiency. This is a report of a 16 years old male with moderate mitral disease, probably rheumatic, and with severe tricuspid insufficiency which at surgery appeared to be a congenital malformation of the tricuspid valve (absence of the anterior leaflet). A tricuspid heterograft was successfully inserted. The symptoms of congenital tricuspid insufficiency are discussed and this affection is differentiated from other causes of tricuspid insufficiency.


Involution of changes in lesser circulation after closure of prolonged aortopulmonary anastomosis. Possibilities of involution of changes in lesser circulation after closure of experimental aortopulmonary anastomosis were studied. 37 observations at various intervals after closure of anastomosis (several minutes to 13.5 months) in 25 dogs were analyzed. Before closure the anastomosis had functioned for 1-7 months. The results of histological examinations of lungs, pressure measurements in lesser circulation, heart weight, electrocardiographic and spirographic examinations were analyzed. It was found that complete involution of changes in lesser circulation was possible only in first month of existence of anastomosis, in this case with changes of both "early" and "late" types. "Late"-type changes after four months function of anastomosis had both reversible and irreversible character, whereas "early"-type changes became irreversible already after three-month duration of anastomosis. With the "late"-type changes, the operation itself (closure of anastomosis) was accompanied by symptoms of pulmonary vasomotor paresis and heart failure, whereas in the presence of "early"-type changes the operation elicited no morphological or functional changes.


Prevention of ventricular fibrillation in experimental myocardial infarction. The fall in the ventricular fibrillation threshold during the first half an hour following ligation of the descending branch of the left coronary artery in dog was not influenced by the i.v. injection of trimecain (Mesokain Spofa). On the other hand, an i.v. injection of methypranol (Trimepranol Spofa) given prior to ligation increased the level of ventricular fibrillation threshold 3 to 4 times compared to control value before occlusion in all 10 studied dogs. Depression of the beta-blocking adrenergic activity may thus prevent the occurrence of ventricular fibrillation in acute myocardial ischaemia.


The development of myocardial changes during intermittent high altitude hypoxia in rats. The initial phase and the development of myocardial focal necroses were studied in 50 rats adapted successively to intermittent high altitude. The altitude hypoxia was produced in a low pressure chamber (7000 m, five days a week, four hours daily). First-minute myocardial changes detected by histochemical methods were found after 4 exposures at a level of 3000 m and distinct ones after 8 exposures at a level of 4500 m. Histologically, acute focal necroses were found after 11 exposures at a level of 6000 m. Hypoxia and stress are suggested to account for these myocardial focal changes. During further adaptation no further acute focal necroses were observed.


Sensitivity to musical denotation and connotation in organic patients. Musical segments convey at least two kinds of meaning: The "real-world" events referred to by lyrics and by occasions of performance constitute musical denotation: the formal expressive patterns suggested by such constituents as pitch, timbre, and intensity constitute musical connotation. To ascertain sensitivity to these musical facets among brain-injured patients, tests assessing appreciation of musical denotation and connotation were administered to unilaterally brain-injured subjects in the United States and Italy. On the musical denotation test, right hemisphere patients excelled on items where knowledge of lyrics was required; in contrast, anterior aphasics surpassed both posterior aphasics and right hemisphere patients on items where acquaintance with lyrics was unnecessary. On the musical connotation test, right hemisphere patients performed relatively better in matching sound patterns to temporally-sequenced designs than to gestalten; these patients also performed better than left hemisphere patients on a number of other dimensions. The relatively high performance of posterior aphasics on the connotation test, along with the lack of correlation between connotative and denotative scores received by aphasic patients, suggest a behavioral and neurological dissociation between the two forms of musical sensitivity.


Further studies of tactile perception and motor coordination in agenesis of the corpus callosum. A 12-year-old female with total agenesis of the corpus callosum has been tested on several tasks involving tactile perception and motor coordination. Her performance has been compared with a group of normals of the same age and sex and a group of subjects matched for age, sex and I.Q. On 3 of the bimanual motor coordination tasks the acallosal's performance was not clearly distinguishable from the control's. She was, however, slower than the controls on the pegboard task. On a transfer of training task (formboard) the acallosal was slower than normals and did not manifest transfer. However, transfer of training was shown on a maze-learning task. No deficit was found in the ability to tactually cross-identify objects, but a deficit in tactile cross-localization was evidenced.


The effect of auditory signals on the control of the rapidity of arm movements. An experimental study of the effect of auditory signals on the rapidity of arm movements was undertaken in 32 right-handed subjects. The task (a printed tapping test) was performed with the presence of metronome clicks intended to act as pacemakers of the subject's tapping movements. The effect of preferred hand, direction of movement (i.e. left-right and right-left) and mode of acoustic presentation (monoaural or binaural) was investigated. Results indicate that the presence of acoustic signals increases (without a concomitant decrease in accuracy) the rapidity of movements, but there is not differential increase whether the signals are delivered to the right or left ear or binaurally. Repetitive movements of the right arm are faster than those of the left; and the direction in which the movements are made influences the rapidity of performance for both arms, left-right movements being faster than those made in the right-left direction. Some theoretical intrepretations of the findings are discussed.


Classification of reading problems by the Q-technique of factor analysis. The Q-technique of factor analysis was used to define subtypes of reading problems in terms of performance on 31 tests of rapid reading skills. Subjects included a group of 34 children with learning problems, language problems, and mental retardation. Three subgroups were identified within each group by the statistical classification procedure. For the reading group, one subgroup was characterized by slow oral word reading, a second by slow auditory-visual letter association, and a third by slow auditory-visual association of words and syllables. The first and second subgroups for the mixed group were essentially the same as the second and third subgroups for the reading group, and the third subgroup was characterized by slow visual matching. These results were compared with those of previous investigators, none of whom used multivariate correlational procedures for classifying reading disabilities. It was concluded that the use of statistical classification techniques would greatly facilitate the achievement of a consensus regarding the number and the types of developmental reading disabilities.


Ability to transcribe music and ear superiority for tone sequences. Trained musicians able to transcribe music make fewer erros in recognition of conventional melodies when the melodies are presented in the right ear, but show more right ear than left ear errors in the recognition of random note sequences. Other subjects, even though able to read music and play instruments, make more errors across all types of stimuli when stimuli are presented in the right ear. The ability to transcribe music, but not the ability to read music or to play instruments is associated with a sharp reduction in errors for stimuli presented in either ear.


Hemispheric superiority in reaction time to faces: a sex difference. In males but not females, reaction time to faces is faster when stimuli are presented to the right hemisphere than when presented to the left hemisphere. The complete lack of a hemispheric difference in females suggests that with brief exposure and immediate judgement, a lateralized mechanism specialized for faces can be activated only in males.


The reliability of reaction time determinations. The reliability of simple and two-choice reaction time (RT) as a function of number of trials and measure of central tendency was examined. It was found that, within the particular conditions of the study, 18 trials were sufficient to obtain a highl reliable determination of simple RT but 30 trials were required for a highly reliable determination of two-choice RT. The selection of measure of central tendency was not related to degree of reliability.


Functional relationship between forward and backward digit repetition and a non-verbal analogue. It has been suggested that the forward digit span employs a verbal representation of sequences of digits, whereas the backward digit span employs a spatial representation. This was tested by comparing the two digit spans with a non-verbal analogue of the forward digit span. The latter did not explain any of the variation in the backward digit span when the forward digit span was stastically controlled. It is concluded that the two digit spans employ a common verbal representation.


Failure to confirm a spatial ability impairment in persons with evidence of right hemisphere speech capability. Levy hypothesized that persons lacking strict left hemispheric dominance for language processing should be impaired in spatial processing ability. This leads to the expectation that left-handers, because they are more often not strictly left hemisphere dominant for language, would, as a group, be impaired in spatial ability relative to right-handers. Evidence regarding this hypothesis has been inconsistent. The present study systematically examined the effects of handedness, sex, and hemispheric language dominance on verbal and spatial ability in 80 right-handed and 71 left-handed university students. Males were found to be superior to females in all handedness-hemispheric language dominance groups on the spatial ability measure. No effects of handedness or hemispheric lanaguage dominance nor interactions of these factors obtained for either verbal or spatial ability measures. It was concluded that the hypothesis of verbal-spatial processing incompatibility within the same hemisphere was not supported.


Self-correctional strategies in the conversational speech of aphasic and nonaphasic brain damaged adults. Self-correctional strategies in the conversational speech of aphasic and non-aphasic brain-damaged adults were analyzed for frequency of occurrence and percentage of success. Similar strategies were used by groups resulting in the same rank order of most to least successful for delay, association, description and generalization. Further analysis of self-correctional strategies among aphasic subgroups indicated that frequency and success of strategies were not significantly related to type of aphasia. Severity level and success of a particular strategy appeared to depend on the amount of information about the target word which was available to the subject at the time of error.


Experience of treatment in the Amanita phalloides poisoning (clinical and experimental observations). Intensive care was applied in 13 patients with acute liver insufficiency and different degrees of metabolic encephalopathy due to the ingestion of Amanita phalloides. Twelve of them were subjected to hepatic assist with E.T., in three cases this measure was repeated. Ten recoveries were obtained, which denote, on the basis of the necrosis enzymes and the hepatic histo-pathological aspects from bioptic samplings, the use of the E.T. method, when applied within the first 72 hours. In pigs poisoned with Amanita phalloides, the clinico-biochemical pattern and the histopathological findings are comparable to the observations in man. Electron microscopy demonstrates peculiar lesion in the cytoplasm. The anatomo-pathological findings in the three dead patients show a liver necrosis over the 90% and the presence of cerebral edema.


Effects of dibenzothioline and silymarin on the dry weight of isolated hepatocytes of rats acutely poisoned with phalloidin and alpha-amanitin. The protective action of dibenzothioline and silymarin in the acute intoxication by phalloidin and alpha-amanitin has been studied on the basis of their ability to attenuate changes in dry mass distribution and class-pattern of the hepatocytes, as evaluated by microinterferometry. Protective agents were given to male rats 30 min before toxin, and the animals were sacrificed 3.0 h later. Both dibenzothioline and silymarin markedly counteract the toxic action of phalloidin and alpha-amanitin on the hepatocyte population, as revealed by a substantial prevention (a) of the striking displacement of hepatocytes in the intervals among the classes as regards phalloidin poisoning, and (b) of the number decrease of hepatocyte classes due to disappearance of the heaviest ones, of the shift of hepatocytes to the lighter classes, of the appearance of very light cells, of the displacement of hepatocytes into the class intervals and of the decrease in nuclear dry mass as regards alpha-amanitin. It is suggested that dibenzothioline and silymarin exert their protective action by a non-specific stabilization of the cell membrane.


Diagnosis and treatment of aortic valve stenosis. The present review has attempted to summarize the classic symptoms and signs of aortic valve stenosis, especially in an adult. It is emphasized that all the classic signs rarely are present and their absence may mislead an unwary clinician. The diagnostic help provided by noninvasive tests, including echocardiography and phonocardiography, has been emphasized. A need for cardiac catheterization and angiography in most patients prior to corrective surgery is stressed. The natural history of the disease without operative intervention is dim and a significant risk of sudden death exists. The current surgical approach with immediate and long-term results is summarized. Finally, attention has been drawn to the special clinical circumstances when the aortic valve stenosis provides a strinkingly different clinical picture. We cannot find a better way to end this review than by quoting a warning note given by Thomas Lewis in 1920: "It is the faint cry of an anguished and fast failing muscle, which, when it comes, all should strain to hear, for it is not long repeated. A few months, a few years at most, and the end comes."


Papulosquamous eruptions: usefulness of biopsy in establishing diagnosis. Papulosquamous dermatoses are caused by a variety of etiologic agents. T. rubrum in particular can produce clinicopathologic changes which mimic a spectrum of disorders. Of these, some are papulosquamos in character. Whenever patients are seen with atypical papulosquamous dermatoses, the clinical differential diagnosis should always include dermatophytosis caused by T. rubrum. If skin scrapings for direct microscopic examination and culture studies are negative, a biopsy should be seriously considered as the best procedure to aid in making the correct diagnosis. Periodically, tissue diagnoses of fungal disease are made by dermatopathologists when the problem has not even been suspected by the clinician. Clinicians and pathologists should maintain a high index of suspicion for the disease spectrum which T. rubrum can cause in the human host. T. rubrum represents a great mimicker of cutaneous diseases similar to eruptions caused by Treponema pallidum and drugs. Information T. rubrum and methods have been reported.


How useful is a biopsy in a case of suspected fungal infection? In suspected cases of superficial fungal infections, biopsies are not routinely performed. This paper has analyzed some diagnostic features of histopathologic examination in dermatomycosis that are not usually emphasized. The usefulness of light microscopic observation of PAS-stained and plastic-embedded specimens has also been shown.


Case of suspected connective tissue disease presenting as chronic edema or swelling of face, neck, and upper trunk. An adequate biopsy that includes the subcutaneous tissue is very helpful in the evaluation of patients with suspected connective tissue disease. However, the histologic features must often be correlated with the clinical features and other laboratory tests for a definitive diagnosis. An objective histologic diagnosis can usually be made in scleroderma, lupus erythematosus panniculitis, amyloidosis, and angioedema, and in diseases such as lepromatous leprosy and mycosis fungoids (which are sometimes confused with connective tissue diseases). Correlation with clinical features and, sometimes, other laboratory tests is often required to establish a diagnosis of scleredema, dermatomyositis, myxedema, and lichen myxedematosus. The features in cheilitis granulomatosa usually are not specific, but a biopsy is helpful to rule out other diseases.


Multidisciplinary treatment of chronic pulmonary insufficiency. 3. The effect of physical training on cardiopulmonary performance in patients with chronic obstructive pulmonary disease. We examined the effect of physical training on cardiopulmonary function in 21 patients with chronic obstructive pulmonary disease and compared the results with similar observations in eight untrained patients. The training consisted of daily walking on a treadmill at increasing speeds and grades and other graded physical exercises. Evaluation of pulmonary function, including spirometric studies, lung volumes, and arterial blood gas levels, showed no significant change after training. Hemodynamic functions, including heart rate, cardiac index, stroke index, pulmonary vascular resistance, and arteriovenous oxygen content difference, were similarly unchanged at comparable submaximal loads. Pulmonary arterial wedge pressure increased after training in the treated group at rest and during exercise, but this may be related to changes in respiratory mechanics. Consumption of oxygen and minute ventilation decreased in the treated group during treadmill exercise, suggesting improved neuromuscular coordination and efficiency of walking on the treadmill. Total work performed on the treadmill increased significantly in the trained group. This increase was unexplained by physiologic observations but was thought to be due in part to increased efficiency of walking and increased motivation. We conclude that improvement in the capacity for exercise following physical training for four weeks is not associated with improvement in cardiopulmonary function at submaximal exercise.


Multidisciplinary treatment of chronic pulmonary insufficiency. 4. The influence of intrathoracic pressure variations on increases in pulmonary vascular pressure during exercise in patients with chronic obstructive pulmonary disease. In the present era of direct monitoring of pressure in patients with chronic obstructive pulmonary disease (COPD), an appreciation of all factors that may influence the observed pulmonary vascular pressures is essential. Our study examines the impact of respiratory variations in intrathoracic pressure on the recorded pulmonary vascular pressures in 28 patients with COPD. Althouth pulmonary hypertension was present in only nine subjects at rest, all had an abnormal increase in the mean pulmonary arterial pressure during supine exercise. In 15 subjects, this abnormal response was, in part, related to an increase in pulmonary arterial wedge pressure to 15 mm Hg or more. The increase in pulmonary arterial wedge pressure was directly related to the amplitude of the peak-to-peak respiratory variation of such wedge pressure. This variation correlated with the specific airway resistance but was not related to the arterial oxygen pressure or pulmonary vascular resistance. These findings indicate the important influence of exaggerated respiratory effort on the measurement of pulmonary arterial wedge pressure and mean pulmonary arterial pressure in patients with chronic obstructive pulmonary disease.


Colloid osmotic pressure as a prognostic indicator of pulmonary edema and mortality in the critically ill. The relationship of colloid osmotic pressure (COP) to pulmonary edema and mortality in 128 critically ill patients was investigated in our critical care unit, and confirms previously reported observations. The COP in the 86 survivors was 22.0 (+/- 0.4 SEM) mm Hg versus 17.2 (+/- 0.6 SEM) mm Hg in the 42 who died (P less than 0.001). The patients were divided into three groups: 71 with no pulmonary edema, COP of 21.5 (+/- 0.5 SEM) mm Hg; 40 with cardiogenic pulmonary edema, COP of 21.4 (+/- 0.4 SEM) mm Hg; and 17 with noncardiogenic pulmonary edema, COP OF 13.6 (+/- 0.8 SEM) mm Hg. Colloid osmotic pressure was significantly lower in patients with noncardiogenic pulmonary edema (P less than 0.001). In 36 patients in whom pulmonary artery wedge pressures (PWP) were available, a COP-PWP gradient of 4.0 mm Hg or less was always associated with pulmonary edema, while a COP-PWP gradient greater than 4.0 mm Hg was never associated with pulmonary edema. Colloid osmotic pressure is a useful prognostic indicator of pulmonary edema and mortality in the critically ill.


Effects of digitalis on the exercise electrocardiogram in normal adult subjects. Controversy continues regarding the effects of administration of digitalis upon the exercise electrocardiogram. Thus, maximal treadmill exercise tests were performed before and two weeks after administration of 0.25 mg of digoxin daily in 15 normal subjects (documented by cardiac catheterization and coronary arteriographic studies). Administration of digitalis induced abnormal findings on exercise tests in all 14 subjects with serum levels of digoxin greater than or equal to 0.5 ng/ml; however, at workloads greater than 75 to 90 percent of maximal predicted heart rate, the changes in the ST segment reverted to a normal configuration in all subjects, thereby providing differentiation of digitalis-induced ST-segment alterations from those due to myocardial ischemia at maximal treadmill stress.


Left ventricular performance in diabetic patients without clinical heart disease. Evaluation by systolic time intervals and echocardiography. To examine left ventricular performance in diabetic patients without clinical evidence of cardiac involvement, systolic time intervals (pre-ejection period, left ventricular ejection time index and ratio of pre-ejection period to left ventricular ejection time) and echocardiographic measures (percentage changes in minor axis diameter, end-diastolic and end-systolic diameter, end- diastolic volume and end-systolic volumes, stroke volume and ejection fraction), were obtained. There were 89 diabetic patients and 93 control subjects evaluated for systolic time intervals, and 40 diabetic patients and 20 control subjects evaluated by echocardiogram. The diabetic group demonstrated significant (P less than 0.001) differences from the normal control group in each of the noninvasive measures of systolic time intervals. Pre-ejection period/left ventricular ejection time ration was increased by 25 percent and the pre-ejection period was increased by 12 percent in the diabetic patients. Among 40 diabetic patients studied by echocardiography, abnormal percentage change in minor axis diameter, (less than 30 percent) occurred in six individuals. Ejection fraction was decreased by 20 percent as compared to the control group, whereas end-diastolic pressure was not significantly different in the groups.


Mitral valve prolapse in rheumatic mitral stenosis. Four adult women with histories of rheumatic fever and clinical findings of mitral stenosis and regurgitation had echocardiograms demonstrating moderately severe mitral stenosis (EF slope less than 20 mm/sec, mean left atrial size 3.0 cm/m2, mean anterior mitral leaflet excursion 25 mm) as well as typical mitral valve prolapse. Three patients  underwent cardiac catheterization which confirmed the presence of mitral stenosis, as well as systolic prolapse and excessive scalloping of the mitral valve with no visible mitral calcium and no coronary artery disease. One patient had associated mild aortic stenosis and regurgitation. Two patients underwent mitral valve surgery which revealed anterior and posterior commissural fusion consistent with rheumatic disease and intact chordal apparatus. Both leaflets were large and the anterior leaflets were redundant. There were no vegetations. Pathology revealed myxomatous degeneration of the valve leaflets. In the absence of heavy calcification and thickening, the presence of mitral stenosis with commisural fusion does not exclude the possibility of a redundant mitral valve. When these entities coexist, systolic clicks may be absent.


Primary dissecting aneurysm of the right coronary artery. Coronary arterial dissection is extremely rare. Such dissections have been reported to occur secondary to atherosclerosis, trauma, the postpartum state, and cystic medial necrosis and to be iatrogenically induced during catheterization. The clinical picture of coronary arterial dissection is usually sudded death. A review of the literature reveals that our case is the second in which a spontaneous coronary arterial dissection has been diagnosed during life and documented by coronary arteriographic studies. This report describes a 31-year-old man who presented with an acute inferior myocardial infarction. Coronary arteriographic studies demonstrated a dissection of the right coronary artery.


Retropharyngeal abscess following endotracheal intubation. Retropharyngeal abscess is an unusual complication of endotracheal intubation. We present a case in which such a lesion developed following traumatic intubation in an emergency situation.


Iatrogenic false-positive findings on cardiac scans. Two patients subjected to cardiopulmonary resuscitation with chest massage and direct-current cardioversion had positive activity on myocardial scintiscans using radioactive 99mtechnetium pyrophosphate. Possible explanations are offered, and recent reports of false-positive findings on scans due to organic disease, as well as iatrogenic causes, are discussed briefly.


Desquamative interstitial pneumonia associated with granulomatous lymphadenopathy. A unique association between desquamative interstitial pneumonia and granulomatous lymphadenopathy in a six-year-old black girl is presented. Although clinical and laboratory improvement followed corticosteroid therapy, fairly severe restrictive pulmonary disease persisted.


Mediastinal compression due to tension hydrothorax. We describe a patient in whom a malignant pleural effusion accumulated with sufficient pressure to cause mediastinal compression resulting in acute respiratory distress, dysphagia, and massive edema of the lower extremities. Emergency thoracocentesis produced immediate relief to respiratory symptoms and dysphagia, with gradual disappearance of the edema and a weight loss of 6.8 kg (15 lb) without adjunctive medications. It is suggested that thoracocentesis is a life-saving measure in this circumstance and should be done immediately in patients with similar initial clinical findings, as further diagnostic evaluation or other therapy directed to the mediastinum will not releive the tension and will only delay removal of the fluid.


Cardiac toxicity of clonidine.

Cardiac toxicity of clonidine. A 22-year-old woman with systemic lupus erythematosus complicated by mild renal insufficiency and severe systemic hypertension inadvertently received an excessive amount of clonidine hydrochloride. In association with a presumed toxic level of clonidine in the serum, the patient developed abnormalities of cardiac conduction, including 2:1 atrioventricular block, complete heart block, 3:2 Wenckebach block, and first-degree atrioventricular block. The transient nature of these abnormalities, with the return of normal conduction upon the cessation of therapy with clonidine, implicates this drug as being capable of producing high-grade atrioventricular block at toxic levels.


Ball variance in a Harken mitral prosthesis. Echocardiographic and phonocardiographic features. A case of ball variance in a caged-ball prosthetic valve is presented, illustrating the echocardiographic and phonocardiographic features. The swollen silicone ball was observed on echocardiographic studies to have diminished motion and to incompletely open within its cage. On phonocardiographic studies, the Q-S1 interval was prolonged, and no opening sound could be recorded. These noninvasive techniques may be helpful in predicting the need for replacement of prosthetic valves that have silicone rubber balls.


An unusual lethal complication associated with Starr-Edwards prosthetic aortic valve holder. This is the first report of an unusual fatal complication associated with the Starr-Edwards prosthetic aortic valve holder. The patient died 51 days after replacement of his aortic valve with a Starr-Edwards prosthetic aortic valve. The cause of death was coronary arterial embolus caused by a fragment broken off of the prosthetic aortic valve holder.


Echocardiographic recognition of silent aortic root dilatation in Marfan's syndrome. Echocardiography has proven a useful and sensitive means to determine noninvasively the cardiac dimensions. This report describes the echocardiographic detection of progressive dilatation of the aortic root over an 18-month period, which led to death in a 33-year-old man with Marfan's syndrome; however, at no time was the aortic dilatation evident on chest x-ray films. This patient illustrates the sensitivity of the echocardiogram in detecting and assessing the severity of disease of the aortic root not readily assessed by other noninvasive techniques and the value of serial measurements of aortic dimensions in patients with proven or suspected dilatation of the aortic root.


Pseudomyxoma peritonei. Report of a case with extraperitoneal metastasis and invasion of the spleen. The findings in a patient with pseudomyxoma peritonei, probably of appendicular origin, are reported. As a rule, pseudomyxoma peritonei remains limited to the peritoneal cavity, but in this case, dissemination occurred to the right pleural cavity and to the pericardium. In addition, invasion of the spleen (to our knowledge, nor previously described) was noted.


Endocarditis due to Pseudomonas aeruginosa in a heroin addict. Successful treatment with trimethoprim-Sulfamethoxazole mixture plus colistin. Endocarditis of the tricuspid valve due to Pseudomonas aeruginosa in a heroin addict failed to respond to therapy with gentamicin, carbenicillin, and amikacin. Clinical and bacteriologic cure was achieved with oral administration of a trimethoprim-sulfamethoxazole mixture plus parenteral therapy with colistin. In vitro synergism was demonstrated for the three drugs at concentrations achievable in the serum. Therapy for endocarditis due to Pseudomonas continues to be a major problem; however, the successful treatment of this patient warrants consideration for instituting therapy with a trimethoprim-sulfamethoxazole misture plus colistin in individuals with this infection who fail to respond to standard therapeutic regimens for severe infections with Pseudomonas.


Putrid pulmonary abscess and empyema with inappropriate secretion of antidiuretic hormone. The syndrome of inappropriate secretion of antidiuretic hormone has been associated with many pulmonary inflammatory diseases. The origin of the hormone in these cases is the neurohypophysis, although the afferent stimulus has not been adequately characterized. A previously unreported association of this syndrome with putrid pulmonary abscess and empyema is documented.


Elimination of para-aminosalicylic acid in patients with liver disease and renal insufficiency. The elimination of para-aminosalicylic acid (PAS) after the intravenous injection of 20 mg PAS sodium/kg was estimated in patients with liver disease, in uremic patients and in volunteers without damage of the liver or kidneys. The drug was estimated with a colorimetric and fluorometric method. In the volunteers, the half-lives obtained with the fluorometric method were significantly longer than those estimated with the colorimetric method. This is caused by the estimation of more PAS metabolites by the used fluorometric method. In the patients with renal insufficiency (dialysis patients) the elimination rate of unchanged PAS--estimated with the colorimetric method--was not altered, whereas the elimination of PAS and its metabolites extractable by ethyl acetate was markedly slowed in comparison with the results obtained with the volunteers. The clearance of the unchanged PAS was even increased in the uremic patients. The serum protein binding of PAS was lowered significantly in the serum of uremic patients. In patients with liver cirrhosis, acute virus hepatitis and cholangitis the elimination rate of the drug was not altered in comparison with the volunteers. The results show that the dose of PAS in patients with renal insufficiency may not be reduced. The therapeutic level of the drug cannot otherwise be reached in these patients.