Binding properties of radiolabeled basic protein of myelin: reassessment in relation to diagnostic immunoassays. The binding of radioiodinated basic protein of myelin ([125I]BPM) to a sheep lymphocyte cell pellet, sheep erythrocytes, and cell-free tubes used in the assay was investigated as a possible diagnostic procedure in multiple sclerosis. [125I]BPM apparently bound to 5 x 10(6) sheep lymphocytes incrementally with no plateau, up to 300 ng, and also to sheep erythrocytes; when cells were transferred to fresh tubes, over 90% of the radioactivity remained on the original tube, regardless of the tube surface. Various substances, including BPM and unrelated basic proteins, competitively inhibited the binding of basic protein of myelin to sheep cells and assay tubes. Binding was inhibited by sera from patients with multiple sclerosis, but equally so by normal sera. The large capacity of BPM to bind nonspecifically could limit its use in the above type of binding assay and would need to be allowed for in conventional radioimmunoassays.


Active surgical management of primary vesicoureteral reflux in adults. Of 27 adults with primary vesicoureteral reflux, 23 were treated surgically. These patients had suffered from chronic urinary-tract infections with poor response to conservative therapy. Urography revealed inflammatory changes in one or both kidneys in 18 patients, as well as other renal or ureteral deformities. Micturition cystography showed reflux reaching the renal pelvis and dilatation of the pelvis and ureter in 18 patients (28 ureters). An antireflux operation was performed on 32 ureters and in all cases was followed by disappearance of the reflux. No ureteral stricture developed postoperatively. During an observation period averaging more than three years only three patients had postoperative urinary-tract infections. These occurred when a short period of medication was terminated. On the basis of present experience we consider that antireflux surgery is indicated for all adults with vesicoureteral reflux and urinary-tract infections or progressive dilatation of the upper urinary tract.


Vein patch grafting for repair of short ureteric strictures. The generally accepted treatment for short and medium-length strictures of the ureter has been to split the stricture and splint the ureter for a month or more. A new method is here described in which the ureteric stricture is split and the opening is covered with a vein patch-graft. The length of hospital stay is considerably reduced by this operation. Four successfully treated cases with follow-up periods of six months to ten years are presented.


Total replacement of ureter with a segment of ileum. Replacement of ureter with a segment of ileum was successfully performed in two patients. One had ureteral cancer and the other recurrent calculi due to cystinuria. The first patient had only one kidney. In the second both ureters were replaced with ileum. Formation of a papilla at the distal end of the ileal segment in the bladder may reduce the risk of vesico-ileal reflux.


Delimitation of plasma creatinine concentration values for assessment of relative renal function in adult patients. Plasma creatinine concentrations and glomerular filtration rates (GFR) were determined simultaneously in 200 females and 180 males of various ages (20-79 years) covering all degrees of relative renal function: normal (greater than 75%); moderately impaired (75-52%); considerably impaired (51-28%); and severely impaired (greater than 28%). The percentages express GFR relative to corresponding age--and sex-dependent normal means. This relative parameter evaluates whether--and to what extent--the combined function of the two kidneys is affected by nephro-urological disorders. For practical purposes plasma creatinine was found to be independent of age in all function groups for both sexes. The data were used to delimit plasma creatinine concentrations for the assessment of relative renal function. For females the limits of plasma creatinine (mumol per litre) were: "normal" (less than 115); "moderately elevated" (115-150); "considerably elevated" (151-250); and "profoundly elevated" (greater than 250). The corresponding figures for males were: less than 128; 128-170; 171-270; and greater than 270.


Preoperative irradiation in the treatment of renal adenocarcinoma. The effect of preoperative irradiation on the survival of patients with renal adenocarcinoma was studied in a clinical trial. 88 patients with verified renal carcinoma entered the trial during 1968-1972, of whom 38, selected in a randomized fashion, received preoperative irradiation to a total dose of 3 300 rads in 3 weeks, followed by extrafascial nephrectomy after a 3 week interval; in the remainder an extrafascial nephrectomy was performed immediately. Actuarial 5-year survival was 47% in the "preoperative irradiation" group and 63% in the "nephrectomy-only" group, i.e. preoperative irradiation did not improve the 5-year prognosis. Survival was also studied in P-categories of the U.I.C.C. as well as in high and low grade malignancies. In none of these groups could we find a clear tendency to a more favourable prognosis with preoperative irradiation; no statistically significant differences were found. Because no improvement in prognosis after preoperative irradiation was found in our series or any of the sub-groups, we consider preoperative irradiation not routinely indicated as an adjuvant therapy. It may be useful in some selected cases, but selecting these cases will be difficult.


Surface structure of unused and used catheters. A scanning electron microscopic study. The surface structure of different catheter materials was investigated by scanning electron microscopy. Two catheter types were also examined after long-term use in three patients with chronic urinary tract infection. It was found that the amount of salt encrustation was more pronounced the higher the degree of catheter surface roughness.


Advanced cancer of the prostate combined with hypercalcaemia. Despite the high frequency of skeletal metastases from cancer of the prostate, hypercalcaemia is extremely uncommon in this condition. In two patients with advanced, poorly differentiated metastasizing cancer a fairly uniform clinical picture developed, with anaemia, leukocytosis, increased serum creatinine, thrombocytopenia, elevated alkaline and acid phosphatase levels and symptoms secondary to hypercalcaemia. The development of more effective agents against cancer of the prostate will probably afford longer palliation, but evidently at a risk of severe metabolic disturbances in the preterminal state.


Repair of renal pelvic defects with a capsular flap. In a case of recurrent renal pelvic tumour a renal capsular flap was successfully used to repair the defect after excision of the tumour. This technique is recommended in difficult clinical situations when sacrifice of renal parenchyma is the only other alternative.


Self-inflicted haematuria and the syndrome of hospital addiction. Self-inflicted haematuria may occur as part of the so-called Münchhausen syndrome or, better, the syndrome of hospital addiction. This rare but important differential diagnosis must be kept in mind in the investigation of obscure urological cases with long-standing and polysymptomatic histories. Two patients with factitious haematuria and hospital addiction are described. Some practical viewpoints on aetiology, diagnosis and management are given. An early recognition of the syndrome is important in order to avoid unnecessary and expensive investigations.


Psychotic symptoms in schizophrenia after the acute phase. Sixty schizophrenic and 34 nonschizophrenic patients were assessed 3 years after discharge on 17 types of psychotic symptoms. Schizophrenics were significantly higher than nonschizophrenic patients on the overall index of psychotic features (p less than .01) and on the index of delusions (p less than .01). Using a weighted estimate, 38.5 percent of the nonparanoid schiziphrenics showed clear evidence of psychotic features, and another 20.5 percent showed some evidence of psychotic features which were weak or sporadic or which the patients seemed able to bring into perspective. Schizophrenic subdiagnosis did not predict later psychotic sysmptoms, although there was a trend for more psychotic features in paranoid and in chronic schizophrenics. The belief that psychotic symptoms in schiziphrenia are not just temporary states was supported. However, conceptions about psychotic symptoms persisting in all schizophrenics were not affirmed.


Oxygen uptake and cardiac output in graded arm exercise in paraplegics with low level spinal lesions. Oxygen uptake (V32), heart rate (fH) and cardiac output (Q, CO2-rebreathing method) were measured in 8 paraplegics with complete low level (Th6-Th12) lesions and in 1 paraplegic with a Th2 lesion during graded exercise performed on an arm ergometer. The submaximal work rates taxed about 50, 70 and 90% of the estimated functional capacity of the subjects. A linear relationship between the work rate and VO2 were assessed in the three tests. The increase of Q with increasing VO2 was accomplished by a considerable increase in fH accompanied by a slight increase in stroke volume (SV, calculated). Markedly low values of Q were found in 6 of the 9 subjects. The resulting high arterial-mixed venous blood oxygen content differences (calculated) as well as the high blood lactate concentrations (3.5-4.5 mM/l at 20-30 W and 8-11 mM/l after maximal exertion) indicate that the blood flow in the arm muscles was not adequate.


The grip pattern of the healthy hand during eating. Thirty subjects with healthy hands have been studied in standardized meal experiments comprising serving, eating and drinking. The activities were filmed and the grips classified by means of a descriptive code system and analysed by automatic data processing. The investigation has resulted in new information about the grip pattern of the normal hand as well as detailed data on fingers and parts of fingers used. The study demonstrates the value of analysing hand function with reference to integrated activities.


Grip function of the healthy hand in a standardized hand function test. A study of the Rancho Los Amigos test. In an experimental study 30  healthy subjects performed the tests of prehensile function in the Rancho Los Amigos test. The subjects were allowed a free choice of grip instead of those prescribed when the test is used for clinical purposes. The hand-grips were filmed and registered by means of a descriptive code system and the results were subjected to automatic data processing. The results showed that healthy subjects performing the RLA test used a stereo-typed grip pattern as a consequence of the uniform purpose of the hand-grips. Comparison with the results from a standardized meal study in the same subjects showed that functional assessment of a patient with a test of this type is not directly applicable to integrated daily activities, as several of the hand-grips most frequent in daily activities were rarely used. Comparison with types of grip prescribed for clinical use of the test showed that normal subjects often did not spontaneously handle the objects in the manner intended by the test.


Voluminometric estimation of the degree of lymphedema and its therapy by pneumatic compression. The degree of lymphedema of an arm after surgical treatment of breast cancer is usually estimated by the measurement of arm circumference. In this study, the calculation was based on the volume of the arm in order to improve the estimation. The method of measuring the arm volume adopted for these experiments has been tested for precision. Measurements have been made of the decrease of volume due to treatment by lymph pulsator in edematic and healthy arms. A comparison taken between these experiments has allowed for better estimation of the efficiency of lymph pulsator treatment.


Standardization of kinematic gait measurements and automatic pathological gait pattern diagnostics. The estimation of patients gait in the field of rehabilitation is the starting point for an appropirate therapy decision and convenient prosthesis or orthosis choice. The measurement and estimation of human locomotion is increasingly being transferred to every day clinical use. In recent times many systems are intended for kinematic gait parameters measurements: stroboscopic photography, movie camera, TV picture analysis, TV signal analysis, chronocyclographical measurement, polarised light goniometer, the "Selspot" system, parallelgram goniometers, exoskeleton goniometers. In the paper the role of the computer in gait measurements is also determined. The problems of the choice of parameters to be measured, unique reference coordinate systems and normal gait pattern are encountered in this work. Finally two versions of pathological gait pattern estimation are described: clinical gait analysis and mathematical quantitative gait analysis. A combination of both methods provides an efficient, compact automatic pathological gait pattern diagnostics.


Homonymous hemianopsia and rehabilitation in fifteen cases of C.C.I. Fifteen cases of severe cranio-cerebral injuries (C.C.I.) with hemianopsia and rehabilitation problems are presented. The correlation between the side of the hemianopsia, dexterity, visual motor organization, intellectual functions and rehabilitation outcome are discussed.


Sensory feedback therapy in patients with brain insult. Brain insults, regardless of etiology, may disrupt the CNS servosystems concerned with patterned voluntary movements and result in disorders of such movement. To aid functional recovery, we applied in these patients oscilloscopic display of digitally integrated EMG, monitored from malfunctioning primary movers, during attempted execution of movement (sensory feedback therapy). Such display provided the patient with an immediate and continuous visual feedback loop reflecting the events underlying the movement and occuring in the monitored muscle (force, displacement and rate). This information is essential for motor control of patterned voluntary movement. Coupled with auditory reward for optimal performance, such feedback also assumed reinforcing qualities and motivated the patient to execute voluntary movements with progressive improvement. Sixty patients with longstanding CNS insult, resulting in motor impairment, were treated and followed for periods of four months to four years. One half of these patients learned and retained voluntary movements that significantly improved their functional capabilities. Temporary substitution of feedback information about fundamental events in dysfunctional muscles can apparently be of lasting value in treatment of some patients with brain insult.


FGP assessment of postural disorders during the process of rehabilitation. Application of the newly developed footground pressure pattern (F.G.P.) method to a number of cranio-cerebral injured patients (C.C.I.) as well as to hemiplegics and normal subjects is made. The postural disorders in standing are assessed through modifications of the F.G.P. and different stages of the rehabilitation process may be followed up. Special parameters of the standing posture, which characterize its disorders, are presented; a diagonal pressure pattern is described. The visual qualitative analysis of the pressure pattern may also be directly useful in the physiotherapy treatment.


The effects of message speed on auditory comprehension in patients with cerebral cranial injury. A brief preliminary report is presented on the effects of varying the speed of a spoken message on the performance of motor tasks by patients with cerebral cranial injury. The token test for aphasia was recorded at three different speech time compression/expansion ratios, then presented under sound field (loudspeaker) conditions to three groups of subjects, one of normal young adults as a control, the second of patients with cerebral cranial injury without evidence of aphasia, and the third containing CCI patients with aphasia. Results are reported for speech speed increases (compression) of 25% and 50% and for a speed decrease (expansion) of 35%.


Tests of auditory perception in the assessment and management of patients with cerebral cranial injury. Special listening tests have been applied to patients with cerebral cranial injury to determine whether such tests of auditory performance will provide functional evidence of lesions which are difficult to examine physically. There have been many reports in the literature on the apparent relationship between lesions affecting portions of the central auditory nervous system and results on tests of auditory perception for speech which is either distorted in some way or presented in competing arrangements to the two ears. The premise is that these tests require integrative function of the brain while reducing the effects of conditions of the peripheral organ of hearing and of basic language functions such as symbolization and memorization. Much of the previous literature has been concerned with infiltrative lesions, such as tumors. Our rehabilitation facility serves a number of patients whose lesions are the result of injuries rather than growths or vascular accidents. The present study was undertaken, therefore, to explore the contribution of information derived from such test procedures to diagnosis and to the planning of individual programs of rehabilitation. Preliminary findings are presented for a series of patients with cerebral cranial injury.


Teflon paste injection into the paralytic vocal fold. A simple procedure to improve disturbed cough function. Teflon paste injection into the paralytic vocal fold is a simple method for the relief of difficulties with insufficient expectoration and for the prevention of aspiration caused by laryngeal paralysis. The laryngeal valve and voice functions in three patients with unilateral laryngeal paralysis were studied before and after teflon paste injection. Aerodynamic registrations comprised subglottal and supraglottal air pressure and oral air flow during cough and phonation. The aerodynamic records, as well as the patients' own reports, all showed improved laryngeal valve function as a result of the treatment and these improvements were not accompanied by any deterioration in respiratory function as revealed by pre- and postoperative spirometry.


Outpatient sputum cytology in the diagnosis of lung cancer. The objective of the present survey was to show whether outpatient sputum examination for malignant cells gives sufficient material suitable for diagnostic purposes. The results of 1031 sputum cytological examinations carried out in 767 patients over a 30-month period are presented. Three hundred and two (29.3%) specimens were unsuitable. Initial examinations revealed 17 with clearly malignant changes in 15 patients, and 23 with suspected malignancy in 14 patients. Examination of new specimens in these 14 patients revealed a further four tumors. Of the 19 patients diagnosed as having lung carcinoma five were operated upon. Three of these five were diagnosed cytologically although they had normal chest X-ray pictures.


Undiagnosed active tuberculosis in a medicolegal autopsy material. A review of a mediocolegal autopsy material comprising 6,283 cases revealed a very low incidence of unrecognized active tuberculosis, namely 0.05%. The incidence appears to be lower than among non-forensic autopsies. The three cases showed uniform characteristics, being middle-aged men who could be classified as destitute.


The function of drug company representatives. The drug industry has a major influence on drug prescribing habits through their medical representatives. We therefore set out to see whether their work was more concerned with providing information or with selling, more with demand or with supply, and how much it cost in Finland. We interviewed currently employed and former representatives and contact persons in health institutions, and analysed advertisements for vacancies for medical representatives. It seems that companies regard detailing more as a sales activity than as public relations and that this trend towards selling has gained in importance in recent years. The number of representatives engaged in the pharmaceutical industry exceeds the demand for their services. The drug companies allotted in 1975 detailing at least 5 000 Fmk (+1 300) per physician per year. Our conclusion is that drug detailing is neither necessary nor beneficial for the health services.


Drug poisoning mortality trends in the Scandinavian countries 1961--1973. Poisoning mortality rates have increased considerably in Denmark and Sweden, slightly in Norway, and remained essentially the same in Finland, during the period 1961 to 1973. In the present study, fatal poisoning included cases of intoxication by solid or liquid substances classified as suicidal, accidental (alcohol poisonings excepted) or of undetermined intent. From 1961 to 1973 poisoning mortality rates increased in Sweden by about 200%, in Denmark by about 100%, and in Norway by about 50%. In males, the age-standardized mortality rates were: in Denmark and Sweden, about 130; in Finland, about 70, and in Norway, about 30 cases per one million of population in1972. The corresponding figures for females were 125, 75, 40 and 20. Despite this overall rise, rates of suicidal poisoning mortality and mortality from accidental poisoning have decreased in Sweden since 1969. From this year onwards, the classification category "undetermined poisoning" has been used and the decreases in other categories are compensated by an increase in this group. On the basis of the scanty data available, the substances most frequently responsible for fatal poisoning are drugs (in particular barbiturates), other soporifics, and tranquilizers. There is some evidence that poisoning mortality is correlated with the prevalence of drug use and could consequently be reduced by drug control.


Phenytoin, phenobarbitone and serum cholesterol. Epileptics receiving phenytoin and/or phenobarbitone medication are observed to have an exceedingly low incidence of myocardial infarction. Serum cholesterol samples from 96 epileptics treated with these anticonvulsant drugs have been measured and found not to deviate from values found in a mass screening carried out in the same geographical area. Since medication with phenytoin/phenobarbitone reduces vitamin D levels in serum and intake of this vitamin is positively correlated to myocardial infarction, we suggest that vitamin D might be a factor to be considered.


Smoking habits among Norwegian doctors 1974. In the spring of 1974 a representative sample (N = 1200) of all doctors in Norway (6 000) received a mailed questionnaire regarding past and present smoking habits. Close to 95% responded. Among late responders there was a disproportionately high number of smokers. As compared with the general population, both male and female doctors constitute a small proportion of daily smokers and a large proportion of exsmokers. The greatest contrasts are observed in the younger age groups. The percentage of daily smokers in this crossectional study on the medical profession is approximately 50% lower than that found in the 1952--53 study on Norwegian doctors. There is also a shift away from cigarette smoking toward the use of pipe and cigars, which is not found in the general population. Answers to questions regarding reasons for quitting as well as certain attitudinal indicators show that the doctors' reduction in smoking is related to their professional involvement and high level of knowledge concerning the health consequences of smoking.


Effects of a health screening on mortality and causes of death in middle-aged men. A prospective study from 1970 to 1974 of mean in Malmö, born 1914. All men born in even-numbered months in 1914 and domiciled in Malmö were invited in 1969 to participate in an investigation regarding risk factors for cardiovascular disease. Individuals with a blood pressure of 165/110 and over were treated and a sub-sample of heavy smokers were later invited to take part in a quit-smoking project. During the following five year period total and cause-specific mortality in the examined group was compared with corresponding data for men born in uneven months in 1914. Mortality in the examined cohort was lower than among controls and differed significantly from that in the control group with regard to cardiovascular mortality.


Utilization of coronary care units in Sweden. Coronary care unit usage has expanded rapidly in all high income countries with little attention to effectivity or cost. A study of six randomly chosen Swedish units showed that larger units in teaching hospitals had significantly lower age-adjusted mortality rates, higher proportions of myocardial infarction patients, and greater productivity and efficiency. Comparisons with a study from the United States showed better results in the Swedish hospital units according to all variables measured. Although proof of effectiveness of CCU's is lacking, their continued use is assured. A less than optimal solution is a rational distribution of units based upon epidemiologically determined need, while stressing good organization and efficiency.


Results five to seven years after aortic valve replacement with the original Delrin disc model Björk-Shiley prosthesis. Isolated aortic valve replacement with the original Delrin disc model Björk-Shiley prosthesis was performed in 128 patients at the Thoracic Surgical Clinic, Karolinska Sjukhuset, Stockholm, Sweden, during the period 1969--71. No patient was lost at follow-up 5--7 years after surgery. The early mortality rate was 5% (6/128) and the actuarial late death rate at 5 years was 13% (16/122). This late survival rate represents a significant improvement over the natural history of symptomatic aortic valvular disease. Age at operation and the particular size of prosthetic valve inserted had no bearing on late mortality, while large heart size and aortic incompetence were associated with a higher incidence of late deaths. There was only one death due to thromboembolism and no case of mechanical prosthetic valve dysfunction. The incidence of thrombo-embolism was 0.7 per 100 patient years with continuous anticoagulation therapy during sinus rhythm, but increased during atrial fibrillation and after discontinuation of anticoagulation. Survival without complications was 75% at 5 years among the 122 patients discharged from hospital.


Central haemodynamics in the immediate postoperative period after aortic valve replacement. Twelve patients with aortic valve lesions were studied haemodynamically before operation and on the three consecutive days after uncomplicated aortic valve replacement with a Björk-Shiley tilting disc valve prosthesis. Five patients had pure aortic stenosis, 4 aortic insufficiency and 3 had combined lesions. Cardiac output at rest, which was within normal limits before operation, was unchanged on the first postoperative day, but showed a tendency to increase on the two following days. Heart rate was markedly increased postoperatively with a corresponding decrease in stroke volume. Arteriovenous oxygen difference was slightly higher postoperatively, indicating a more hypokinetic circulation after surgery. Right atrial mean pressure, which was normal preoperatively, increased in average 3 mmHg postoperatively, whereas left atrial mean pressure, which was pathologically elevated in most patients before operation, showed a marked decrease after operation with a corresponding decrease in pulmonary artery pressure. No significant change in radial artery pressure was observed. Pulmonary and systemic vascular resistance did not change significantly after surgery. The causes of tachycardia, decreased left atrial pressure and hypokinetic circulation after operation are discussed. It is suggested that, in spite of a positive fluid and blood balance, a relative hypovolaemia exists with insufficient blood volume in the left atrium, leading to diminished filling of the low-compliant left ventricle.


Thrombolytic treatment for thrombotic complication of valve prosthesis after tricuspid valve replacement. A case report. The report of a case, in which thrombolytic treatment with streptokinase was twice used successfully in a 14-year-old girl, 23 and 27 months after tricuspid valve replacement with a Björk-Shiley tilting disc valve prosthesis, is presented. The patient had earlier undergone a thrombectomy.


Aneurysms of the ascending aorta with aortic valve incompetence. Twelve out of 14 patients with aneurysm of the proximal ascending aorta (AA) combined with aortic valve incompetence (AI) were operated upon by replacement of both the aneurysm and valves by prostheses. Eight of the patients operated on (67%) survived and are living free of symptoms 3 months to 3 years after operation. The operative technique and complications are discussed.


Parasternal mediastinotomy for implantation of a myocardial electrode. Experience of 71 patients. The clinical experience of a pacemaker material of 71 petients in whom myocardial electrodes were implanted through left parasternal mediastinotomy is presented. The indication for implantation of a myocardial electrode was a complication of the transvenous electrode in 93% of the cases. Minor pulmonary/pleural complications with insignificant sequelae occurred in 18%. Wound infections accompanied by fistulisation as a late complication occurred in 4.2%. There was one (1.4%) postoperative death in hospital. Two patients died later at the end of the first postoperative month of causes not directly associated with surgery. These three patients were over 75 years of age. The material was followed up for an average of 21.5 months. The incidence of fistulisation during the follow-up period was 5.5%/patient-year. One case of breaking of the tip of the myocardial electrode was encountered during the follow-up. The mortality rate for the series was 7%/patient-year.


Arterio-intestinal fistula as a complication following insertion of an aorto-iliac bifurcation graft. A case report. A patient who had been treated with insertion of an aorto-iliac bifurcation dacron prosthesis for atherosclerosis 6 years previously, developed a fistulous communication between a false aneurysm at the distal anastomosis to the left iliac artery and an ileal loop. Intestinal haemorrhage and signs of infection were the main symptoms. Successful surgical treatment consisted of suturing the intestinal defect, removal of the left limb of the graft and vascular reconstruction by means of a subcutaneous femorofemoral vein bypass.


Peroperative vasopressin infusion during portocaval shunt surgery. Intravenous infusion of vasopressin decreased mesenteric arterial- and portal venous flow in dogs. In 4 of 5 high-risk patients, in whom acu te portosystemic shunting was performed, the peroperative intravenous infusion of vasopressin facilitated the surgical procedure by reducing portal pressure and peroperative bleeding from venous collaterals. In 1 patient with reversed portal flow, the portal pressure and flow were not affected by the vasopressin infusion. No undesirable effects of vasopressin were encountered and all patients survived surgery and the early postoperative period.


Popliteal aneurysms.

Popliteal aneurysms. Four typical cases of popliteal aneurysms are reported and the recent literature is briefly reviewed. The aneurysm should be operated upon once the diagnosis is made, whether symptomatic or not. The treatment of choice is proximal and distal exclusion of the aneurysm and a vein bypass, using the medial approach.


Spontaneous pneumothorax.

Spontaneous pneumothorax. A ten-year clinical series of 219 patients with spontaneous pneumothorax is presented with an average follow-up of 9 years. The vast majority of the patients were young men with a ruptured subpleural bleb. A slight increase in the incidence was noted in the older age groups with tuberculosis and chronic bronchitis as compared with the earlier series from the same hospital. The primary treatment was conservative in 197 and surgical in 22 cases. Recurrence of the pneumothorax occurred in 55 cases (25%). Primary conservative treatment failed in 41 cases, yielding 118 patients to operative approach. None of the patients treated by operation (plication or resection and suture of the bleb) had a later recurrence. Five re-operations were necessary: four because of a prolonged air leak after the first operation and one for bleeding. Two patients died on account of their pneumothorax, which gave a mortality of 1%. On the basis of the experience obtained, intercostal tube drainage is recommended as primary treatment; if it fails, thoracotomy seems to offer a good permanent result.


Intrapleural streptokinase in the treatment of haemothorax and empyema. Thirty-eight patients with haemothorax or empyema, in whom conventional drainage treatment had proved ineffective were treated with streptokinase instillations. An increased yield of fluid was noted in all cases, up to 1300 ml after one instillation. Re-expansion of the lung was observed radiologically in 30 cases. No serious complications occurred. The method seems very useful and is recommended.


Intrabronchial polypoid hamartome. A case report. A case of intrabronchial hamartoma is reported. These are very rare tumours, generally accepted as being of developmental origin. Signs and symptoms may strikingly suggest bronchogenic carcinoma. Malignant changes in intrabronchial hamartomas have not been proven and treatment is surgical removal, if possible, with preservation of lung tissue distal to the tumour.


Mediastinoscopy in cancer of the oesophagus or cardia. Fifty consecutive patients with verified squamous cell carcinoma in the oesophagus or adenocarcinoma had mediastinal metastases. One of 21 patients scopy. Seven of 29 patients with squamous cell carcinoma and mediastinal metastases. One of 21 patients with adenocarcinoma had this finding. It is concluded that patients with squamous cell carcinoma of the oesophagus should be mediastinoscopied and that it is also a worthwhile method in patients with adenocarcinoma.


Surgical treatment of carcinoma of the oesophagus and cardia. A clinical series of 216 patients with carcinoma of the oesophagus or cardia, who underwent surgical resection of the oesophagus, is presented. There were 104 patients with oesophageal carcinoma and 112 patients with carcinoma of the cardia. Histologically, there were 102 squamous cell carcinomas, 98 adenocarcinomas, 11 anaplastic carcinomas and 7 non-differentiated carcinomas. Oesophago-gastrotomy was the procedure mostly used; colon interposition was done in only 13 cases. The hospital mortality was 21%. The 5-year survival rate for the whole series after oesophageal resection was 23%. The duration of symptoms, location of the tumour, age and sex of the patients, pre- or postoperative radiotherapy and the histological type of the tumour had only a minor bearing on survival. The two most important prognostic factors were the spread of the tumour at time of operation and a preceding lye stricture. The 5-year survival rate was 34% for the patients with a local tumour at operation and 44% for those in whom the carcinoma developed at the site of a previous lye stricture. The variance of the results in the literature is discussed. Surgical approach to the carcinoma of the oesophagus and cardia is recommended in all the cases in which the patient and tumour seem to be eligible for resection.


Trace-element concentrations in blood samples from welders of stainless steel or aluminium and a reference group. The concentrations of 17 trace elements (e.g., copper, cobalt, iron, manganese, chromium, silicon and magnesium) were determined in whole blood samples of 81 persons working with different welding methods on stainless steel or aluminium and 68 nonwelders. Inorganic spark source mass spectrometry was used for the chemical analyses. The data were analyzed by the SIMCA method for pattern recognition (discriminant analysis). No differences were found between the five groups, either in the average levels of the trace elements or in the correlation structures between the trace elements. Thus no blood concentration data on the analyzed elements and collected from a single person contained any information with respect to exposure to the welding fumes investigated.


Urinary chromium as an indicator of the exposure of welders to chromium. Five welders working with high alloy Cr-Ni steel and one working with mild steel were followed during one work week. The chromium concentration in air was measured concomitantly with urinary chromium determinations. The water-soluble chromium concentrations in air exceeded 0.05 mg/m3 during welding with coated electrodes, but metal inert-gas (MIG) welding produced much lower concentrations. The proportion of water-soluble hexavalent chromium in the air was usually more than 50% of the total chromium concentration during welding with coated electrodes, whereas less than 10% of the chromium produced during MIG welding was in a water-soluble. Since water-soluble chromium (hexavalent) is the more important biologically, the determination of both water-soluble and water-insoluble chromium concentrations is emphasized instead of the measurement of the total concentration. The urinary chromium concentration proved to be a good indicator of short-term exposure to water-soluble chromium when exposure was above the current threshold limit value of 0.05 mg/m3, concentrations of more than 30 microgram/g of creatinine representing an exposure level higher than the threshold limit value.


Central nervous defects in two children of mothers exposed to chemicals in the reinforced plastics industry. Chance or a causal relation? With the use of a specially designed questionnaire, with the emphasis on occupational exposure to chemical agents at work, a case-referent study was started on 1 June 1976. The series comprised mothers of all children with central nervous defects notified to the Finnish Register of Congenital Malformations and their matched-pair referents. Information was gained by personal interview. By 1 March 1977 information had been gathered from 43 cases and their referents. Two case mothers had been employed in the reinforced plastics industry and had been exposed at work to a combination of styrene, polyester resin, organic peroxides, and acetone. When the number of fertile women in this industry is considered (some 250), along with the low rate of anencephaly and hydrochephalus in the general population--diagnoses made of the children of these case mothers (0.5/1,000 live births in Finland)--this occupational group is strongly overrepresented in the material. The paper is a more-detailed report regarding the two cases. Moreover a third case is mentioned in which the pregnant mother, a juvenile diabetic, had been exposed at home to styrene, polyester resin, and organic peroxides.


Exposure to methylene chloride. Content in subcutaneous adipose tissue. The fat content of the body was calculated in 12 healthy male subjects aged 21 to 35 years by means of hydrostatic weighing and anthropometric estimation of skeletal weight. The subjects were exposed to a concentration of 2,600 mg of methylene chloride per cubic meter of inspired air (750 ppm) for 1 h while performing work at an intensity of 50 W on a bicycle ergometer. The uptake in the organism was measured continuously with the Douglas bag technique. The amount of methylene chloride absorbed correlated highly with degree of obesity and body weight. Needle biopsy specimens of subcutaneous adipose tissue were taken from the buttocks before exposure and 0, 1, 2, 3 and 4 h after exposure. The mean yield of tissue from the 72 biopsies was 25 mg. The concentration of methylene chloride in the adipose tissue was determined by gas chromatography, using a headspace method. The mean concentration was 10.2 mg/kg 1 h after exposure and 8.4 mg/kg after 4 h. There was a wide distribution around the mean values. In the six slim subjects the concentration in the adipose tissue during the 4 h after exposure was on an average twice that of the six more obese subjects. On the other hand, in spite of lower concentrations, the obese subjects had a greater calculated amount of methylene chloride in the total fat depots of the body. Two subjects were studied about 22 h after exposure, the concentration in subcutaneous adipose tissue being 1.6 and 1.7 mg/kg, respectively, at that time.


Age and sex as determinants of the relative aerobic strain of nonmotorized mail delivery. The relative aerobic strain (RAS) of nonmotorized mail delivery was assessed in 54 Finnish mail carriers who represented both sexes, the entire workage range and both downtown and suburban delivery districts. The mean RAS of the entire delivery time was 55% of the maximal oxygen uptake (ml/kg-min). It was higher for women than for men, and higher for suburban than for downtown delivery. The RAS tended to increase systematically with age after the age of 50. The work strain of mail carriers of over 50 years of age, especially of older women carriers in suburban areas, was concluded to be high enough to lead to possible excessive strain on the workers.


[Kearns syndrome. Progressive external ophthalmoplegia, retinal pigment degeneration and heart conduction disorders]. Two patients aged 17 and 25 years with Kearns syndrome are described. This condition is characterized by the triad of chronic progressive external ophthalmoplegia, pigmentary degeneration of of the retina and cardiac conduction defects. A review of the literature reveals frequent association with other symptoms, mainly cerebellar ataxia, neurosensory hearing loss, small stature, muscle weakness, mental retardation or dementia and endocrine disturbances. In skeletal and extraocular muscle biopsies, abnormalities of mitochondria, at present of unknown significance, have been found. CSF protein is almost always increased. The etiology of this multisystem disorder remains obscure. The 58 published cases have been sporadic, with no evidence of hereditary transmission. The prognosis seems mainly to depend on the progressive cardiac conduction defects, since several patients have already died in the second or third decade due to heart block. Patients with progressive external ophthalmoplegia should be investigated for Kearns syndrome. If appropriate, implantation of a cardiac pacemaker should be considered.


[Brick and concrete driller's silicosis]. Two unusual observations on silicosis in workers specialized in brick and concrete drilling prompted the authors to draw attention to this hitherto little recognized silicogenic hazard. Drilling specialists are employed in new construction and reconstruction firms for the purpose of drilling apertures in completed walls. During the processes of drilling, chiselling and milling in concrete and in brick walls, silicogenic dust is produced, often in concentrations clearly exceeding the maximal concentration values (MAC). In the interests of disease prevention this economy-motivated but health-threatening technique of drilling apertures in walls after they have been completed should be abandoned.


[The importance of house dust mites and stored food mites as house dust allergens in the rural population]. House dust samples from rural districts contain more mite species (in particular stored food mites) than samples from urban areas, and the total number of mites is also approximately three times greater. 77 patients from rural districts, 48 of whom allergic to their own house dust, and 29 controls, were tested with mite extracts from Dermatophagoides pteronyssimus, D. farinae, Chortoglyphus arcuatus, Acarus siro, Glycyphagus destructor and Tyrophagus putrescentiae, and a house dust extract. Out of 32 patients who showed positive scratch tests to one or more mite extracts, 29 (90,6 percent) reacted positively to D. pteronyssimus, 25 (78.1 percent) to D. farinae and from 7 to 12 (20-40 percent) to the stored food mites. Out of the 48 patients allergic to their own house dust, 27 (56.2 percent showed positive reactions to D. pteronyssinus, 24 (50.0 percent) to the house dust extract and 21 (43.7 percent) to D. farinae. Only 5 (17.2 percent) out of the 29 controls reacted positively to one or more of the solutions tested. The stored food mites showed 2.5 to 4.5 times more positive reactions in the rural patients compared with the results obtained in urban patients. The importance of these mites in the sensitization of patients from rural districts is discussed.


[The epidemiology of drug, cigarette and alcohol consumption in young men]. In view of the recent rise in drug consumption, a 3-year longitudinal study of 19-year-old men was conducted to investigate development of consumption behavior. Consumption of cigarettes and alcohol was also considered. The aim was to obtain information about the development of consumption by 19-year-old men (increase, decrease, etc). The follow-up sample consisted of 841 men in the Canton of Zurich who had been selected from a complete survey of men born in 1952. They answered a questionnaire at the age of 19 and again three years later. The results show that drug, cigarette and alcohol show a different development of consumption in the ages between 19 and 22 years. The percentage of drug consumers had decreased from 23.3 percent to 14.8 percent. In approximately 4 percent there is a high risk of dependence in addition to absence of social integration. The percentage of cigarette smokers did not change (approximately 53 percent), but the number of cigarettes smoked per day increased. For alcohol there is a general increase in consumption. For all three substances, heavy consumption at the age of 19 increases the risk of heavy consumption at the age of 22.


[Consequeces of the elimination of a combination drug. Transition from combination antisacer: attention]. Antisacer compositum, a commonly prescribed speciality which associated phenobarbitone and phenytoin in a dose ratio of 1:4, was withdrawn after demonstration of a negative interaction of this formula. A retrospective analysis is presented of phenytoin plasma levels during bitherapy and after passage to monotherapy, in 13 adult epileptics followed as outpatients. Phenytoin plasma levels increased over twofold in 12 cases, of whom 5 continued to take the same doses, while 7 received higher doses on, and in one case two weeks after, the withdrawal of phenobarbitone. Plasma level decreased slightly in the thirteenth in spite of increased doses. Five phenytoin intoxications occurred after this change of prescription: one amongst the 5 cases with identical doses, and 4 amongst the 7 cases with increased doses. The initially high levels of phenytoin tend to decrease after several months. Physicians required to change the prescription should be aware of the risk of initial intoxication and later underdosage.


Grossly bloody urine of runners.

Grossly bloody urine of runners. A study of 13 men with grossly bloody urine induced by running incriminated the urinary bladder neck or posterior urethra as the site of blood loss. Our evidence also showed that diet lacking in animal protein can play a causative role. The ailment seems to have no long-term sequelae and may not affect female runners. Although we recommend medical evaluation for any runner with gross hematuria, the extent of diagnostic work-up and any modification of the victim's training problem program will depend on the circumstances in each case.


Influence of dosage and duration of therapy on the rate of response to methyclothiazide in essential hypertension. One hundred twenty patients with essential hypertension were studied to determine whether patients who had not responded to the usual dose of a thiazide (methyclothiazide, 5 mg daily during a six-week drug trial) would respond to a higher dose (10 mg daily). The 14-week study was divided into three periods: (1) a two-week placebo period; (2) a six-week single-blind trial; and (3) a six-week period for double-blind dose comparison. Among the 77.3 percent of patients who responded to the drug, diastolic blood pressure was reduced to 90 mm Hg or lower. Two types of thiazide responders were identified-early and late. The early responders (50 percent of study patients), showed a significant reduction in diastolic blood pressure within four weeks; the late responders (27.3 percent) showed a modest reduction in diastolic blood pressure during the first four weeks of therapy, followed by a plateau lasting about two weeks, then a further significant reduction in blood pressure during the ensuing six weeks. Hypokalemia was more common in early responders. There were no significant differences in late response among patients who continued on the usual dose of methyclothiazide compared to those whose dosage was doubled, suggesting that the late response was not due to increasing the dose of the drug.


Surgical treatment of urethral stricture. We reviewed 59 cases of urethral stricture diseases treated at Charity Hospital of Louisiana in New Orleans from 1965 to 1975 to determine whether surgery was a feasible alternative to repeated urethral dilatations. Five different surgical procedures were done: internal urethrotomy, Johanson-Leadbetter, patch-graft, Turner-Warwich, and dismembered technics. Results of internal urethrotomy were poor, but the other procedures had an overall success of 72 percent.


Reconsideration of orchiectomy in the treatment of advanced prostatic carcinoma. The results of a large randomized prospective clinical trial conducted by the Veterans Administration Co-operative Urological Research Group (VACURG) in 1968 are updated and reevaluated. In this study, placebo, diethylstilbestrol (DES, 5 mg/day), orchiectomy plus placebo, and orchiectomy plus DES were compared in patients whose conditions were initially diagnosed as stage III and IV carcinoma of the prostate. Results showed that orchiectomy alone or in combination with estrogen did not improve overall survival rates in stage III and IV carcinoma of the prostate. In the two treatment groups receiving estrogen, however, there were fewer deaths due to cancer of the prostate, but this effect tended to be offset by an increased number of deaths due to cardiovascular causes. Deaths from other causes showed no particular pattern with respect to treatment. These studies showed that estrogen is more effective than orchiectomy in preventing deaths from cancer and that the addition of orchiectomy to estrogen does not offer any clear-cut advantage over estrogen therapy alone. If cancer symptoms necessitate treatment, initial therapy with estrogen is preferred. Orchiectomy should be reserved for those circumstances in which a patient is not reliable, cannot tolerate estrogens, or has severe cardiovascular disease.


Bilateral synchronous transitional ureteral carcinoma: two additional cases. Bilateral synchronous transitional ureteral carcinoma has previously been reported only 11 times. Herein, two additional cases are reported. Analysis shows these tumors to be of relatively low grade and low stage. It is necessary to fully evaluate the opposite side in a patient presenting with unilateral ureteral tumor. If bilateral disease is present, a conservative surgical procedure should be done.


Hemangiomas of the striated muscle.

Hemangiomas of the striated muscle. Presented are three cases of hemangiomas of skeletal muscle in which the presenting symptom was pain. Examination revealed almost spot tenderness at the site of the tumor, but no masses were palpable. Treatment was exicision. Results of surgery usually are good, although local recurrence can follow incomplete resection, as it did in one of our cases.


Interpretation of the diagnostic biochemical profile. Interpretation of the diagnostic biochemical profile has been assisted in some laboratories by simply listing on the chart paper the most common conditions causing increased and decreased concentrations of the substances measured, or by computer print-outs of a list of the most likely conditions causing the observed patterm. These are not always available, and in their absence the pathologist or the clinician or both must attempt interpretation on their own. We have prepared four algorithms (decision trees) as an aid to interpretion of the 12-test profile provided at Charity Hospital (which differs from the more usual ones by the inclusion of both creatinine and urea nitrogen and omission of cholesterol). The algorithms are still in the process of revision and development and thus should be regarded as tentative.


Diagnostic implications of markedly elevated erythrocyte sedimentation rate: a reevaluation. To reevaluate the diagnostic significance of a markedly elevated erythrocyte sedimentation rate (ESR), the clinical diagnosis associated with an ESR of 100 mm/hr or greater was retrospectively analyzed in 200 patients at the Massachusetts General Hospital. In contrast to previously reported experiences in the the American literature suggesting a high frequency (58 percent) of malignant disease in such patients, the present study found infections to be the most frequently associated diseases (35 percent), while malignant disease accounted for only 15 percent of the patients. Review of the foreign literature similarly suggested infection rather than malignancy as a major association with markedly elevated ESRs. It is concluded that an ESR greater than or equal to 100 mm/hr has little diagnostic specificity and should not of itself dictate evaluation for occult malignancy in most patients.


Failure of single-session dietary counseling to reduce salt intake in hypertensive patients. Twelve ambulatory, stable, hypertensive patients were studied to determine the effect of a single, structured session of dietary counseling on daily sodium intake. The patients understood the material presented to them, as measured by testing six weeks after the original session, and they perceived themselves as having substantially reduced their daily salt intake (p less than 0.005); objective assessment of dietry sodium from measurement of 24-hour urinary sodium excretion, however, showed no significant decrease in this patient group. We conclude that single-session dietary counseling in hypertensive patients is unlikely to result in significant reductions in daily salt intake.


Salvage of bovine graft arteriovenous fistula for hemodialysis. This report describes three patients with complications of bovine graft implanted for chronic dialysis. The three complications were surgically corrected so that each graft could be used again for hemodialysis access.


Plasma osmotic changes during major abdominal surgery. Fluid balance across the capillary membrane is maintained normally by a balance of hydrostatic and colloid osmotic pressures (COP). In 12 patients having major intra-abdominal procedures, the COP was followed during the operative and immediate postoperative periods. The patients' intraoperative fluid management consisted of replacing shed blood with blood and following Shires' concept of crystalloid replacement. Significant decreases in COP to approximately two thirds of the initial value occurred in patients having intra-abdominal procedures versus only a 10 percent decrease in those having peripheral procedures (greater than .001). As a result of this decrease in COP, the balance between hydrostatic and colloid osmotic pressures is lost and risk of pulmonary intersitial edema is increased.


Vessel tortuosity as a cause of posterior fossa cranial nerve syndromes. Neurologic syndromes may be caused by mechanical vascular compression of cranial nerves in the posterior fossa. The clinical expression is variable and can be divided into two main groups. Isolated cranial nerve involvement is most frequently associated with tortuous, elongated vertebral and basilar arteries as well as redundant loops of the anteroinferior cerebellar artery. Pseudotumoral manifestations of cranial nerve involvement at the level of the cerebellopontine angle are more frequently related to aneurysms of the vertebral and basilar arteries.


Renal medulla: an endocrine organ involved in blood pressure regulation. The renal medulla is not often considered an endocrine organ, but recent evidence suggests that this part of the kidney may have important antihypertensive, endocrine functions. The antihypertensive factor(s) of the medulla have been localized to the interstitial cells and characterized as neutral and acidic lipids. The acidic lipids, or protstaglandins, have been the more extensively investigated. Animal and human studies indicate that prostaglandins may influence systemic arterial pressure directly or indirectly by promoting excretion of salt and water. Recent evidence suggests that prostaglandins may be mediators of the renin-angiotensin-aldosterone system, thus influencing blood pressure via this system that plays such a key role in blood pressure control.


Metastatic metaplastic carcinoma from a pseudosarcoma (Lane tumor) of the mouth. A case of polypoid metaplastic carcinoma (Lane tumor) of the mouth is presented. There are well defined zones of transition between the squamous epithelium of the polyp and the stroma. Metastases in the right neck and paratracheal lymph nodes contain areas of cartilaginous and osseous metaplasia as well as squamous epithelial pearls.


Malignant chondromyxoid fibroma of the scapula. A rare case of malignant chondromyxoid fibroma developed in the scapula of a woman who was treated with interscapulothoracic resection. When a biopsy specimen was submitted for study, difficulty was encountered in establishing the histologic diagnosis. A large dose of radiation was given before surgery, based on an original biopsy diagnosis of osteosarcoma; in retrospect, preoperative irradiation probably was contraindicated. Two years and four months after surgery, the patient was working with no evidence of recurrence or metastasis.


Pancreatic pseudocyst with massive ascites. The autopsy finding on a patient with pancreatic ascites are discussed in relation to the cause of the ascites. The findings are consistent with the theory that the ascites is due to peritoneal irritation caused by leaking pancreatic secretions.


Pancreatic pleuropericardial effusions presenting as tumor of the lung. A 45-year-old man presented with what was thought to be a mass in the left upper lung and a pericardial friction rub. He was subsequently discovered to have a loculated pleural effusion and pericardial effusion associated with chronic pancreatitis. This is the first instance we were able to find of pancreatitis mimicking bronchogenic carcinoma with pericardial metastasis.


Anterior segment ischemia in temporal arteritis. Anterior segment ischemia is perhaps the most rare ocular manifestation of temporal arteritis. We described a 73-year-old woman with anterior segment ischemia in the course of temporal arteritis. Early recognition of the syndrome and treatment with high doses of steroids led to visual recovery in the involved eye.


Immunodepression, ascites tumour and lactate dehydrogenase virus. The delayed hypersensitivity (DH) response to picryl chloride was studied in Ehrlich ascites tumour-bearing and normal control mice. A significant depression of the DH response was found in the tumour-bearing mice, which was associated with a marked elevation of serum lactate dehydrogenase (LDH). Depression of DH was also observed in mice receiving cell-free ascitic fluid. These mice also showed an elevated serum LDH which is assumed to be associated with the lactate dehydrogenase virus. A method for assaying DH in vivo is described.


SSI recipients in domiciliary care facilities: federally administered optional supplementation, March 1976. Under the supplemental security income program, federally administered payments amounting to $24.7 million were made in March 1976 to 107,000 persons who were residing in domiciliary care facilities and under other supervised living arrangements. These persons were unable to function under totally independent living arrangements but did not require medical or nursing care on a regular basis. Of the total, $9.5 million was represented in Federal SSI payments and $15.2 million came from optional State supplements--with California paying $6.2 million and New York $4.6 million. The average payment to the residents of these facilities was $232 a month. Comparable data for four States show greater caseload growth for persons in domiciliary care facilities and under other supervised living arrangements than for the total SSI population. Nearly two-thirds of the States are adding funds to Federal SSI payments for persons under such care. Data are available, however, only from Social Security Administration program records for those States that have elected Federal administration of their optional programs.


Questionnaire survey of reported early congenital syphilis: problems in diagnosis, prevention, and treatment. A retrospective questionnaire survey of a sample of 173 of the 360 cases of early congenital syphilis reported in 1972 revealed serious problems with diagnostic certainty, prevention, and treatment of congenital syphilis. Only 24 (13.9%) of the reported cases could be categorized as probably or definite cases based on criteria developed from a literature review. Forty percent of the mothers received no prenatal care and an additional 19% received no prenatal care until the third trimester. Initial and followup serologic testing was inadequate in those who received care. Eighty-three different penicillin treatment schedules were used in the treatment of 128 infants. Carefully reasoned diagnostic and therapeutic decision making about the management of congenital syphilis appears to be lacking.


Effect of vocational rehabilitation on employment and earnings of the disabled: state variations. Analysis of followup data in linked records of the Social Security Administration and the Rehabilitation Services Administration shows wide variation by State in 1972 employment and earnings of rehabilitants compared with those for other disabled persons whose cases were closed by State vocational rehabilitation agencies in fiscal year 1971. These State differences in the effect of rehahabilitation occur for both men and women. When the States are ranked by the magnitude of the rehabilitation effect, a reasonable consistency is found among the rankings under the various measures of effect. Under the most valid measure used--employment percentage difference between rehabilitated and not-rehabilitated clients--two patterns emerge: (1) The effect of rehabilitation among the States increases proportionally in South-to-North and West-to-East directions and (2) the relative effect favors women in more States than it does men and in more States than under the other measures.


Chlamydial pharyngitis?

Chlamydial pharyngitis? Among 118 women who were sexual contacts of men with nongonococcal urethritis, the practice of fellatio correlated with symptoms of a sore throat. Oropharyngeal cultures for Chlamydia trachomatis were negative in all women, including 11 women who practiced fellatio and whose partners were known to have nongonococcal urethritis due to C. trachomatis. The study does not support a major role for C. trachomatis as a cause of sore throat in women who practice fellatio.


The establishment of a therapeutic alliance with parents of psychiatrically hospitalized children. In response to the increased use of family therapy as an adjunct to the treatment of emotionally disturbed children, hospital-based social workers are impelled to explore the initial barriers to effective parental involvement. The stresses facing parents at the time of a child's admission include feelings of inadequacy and guilt, as well as fear of separation and loss. The consequences of this traumatic threat to family homeostasis may appear as hostile resistance to cooperation with staff members who potentially represent competitive, more adequate parent surrogates. The social worker, using support, interpretation, and education, bridges the gap between two powerful systems--the family and the hospital. As the preconditions for successful, family-oriented treatment are examined, the chances for creative and skillful social work are maximized.


An educational and counseling program for phenylketonuric adolescent girls and their parents. Since adolescent girls with phenylketonuria are in need of informed counseling, parents and their phenylketonuric daughters were invited to five successive group meetings at Children's Hospital Medical Center in Boston. During these sessions the staff reviewed general aspects of the disorder, dealt with particular problems of adolescence, and focused primarily on the complexities relating to maternal phenylketonuria. Subsequent lively discussions allowed the participants to express their feelings and concerns relative to these issues. The information conveyed will assist parents and their daughters in realistic planning for the future.


Application of knowledge about prevention in social work education and practice. The status of preventive social work in the United States is reviewed, as are the three knowledge sources used in the teaching and practice of prevention: public health, mental health, and social work. The integration of concepts of prevention in social work curricula and practice are discussed, and new directions for its use are projected.


Early detection and treatment: social worker and pediatricians in private practice. A social worker in the private group practice of pediatricians provides multiple and varied services to children and families. Findings from the first six months of a demonstration project suggest that service is rapidly provided and is utilized by referred patients. Professional issues of practice and education are identified and discussed.


How reliable is the morphological diagnosis of penile ulcerations? Material from 100 consecutive men who presented with penile ulcerations was tested for a variety of microorganisms. Fifty-one patients had microorganisms identified that were considered primary pathogens. The laboratory data were compared with the clinical diagnoses and the diagnostic accuracy and index of suspicion calculated. The diagnostic accuracy for lesions due to Treponema pallidum was 77.8%, Herpesvirus hominis 62.9% and Haemophilis ducreyi 33.3%, whereas the indexes of suspicion were 88.2%, 67.7% and 300% respecitively. These data show that the clinical diagnosis of genital ulcers is oftern inaccurate and that definitive diagnosis requires laboratory tests.


Attitudes toward social work in family medicine: a before and after survey. An initial survey of attitudes among Family Medical Center staff rated social work as highly consistent with the values of family medicine, capable of competently addressing difficult problems, and contributing valuably to a team approach to continuous and comprehensive family medical care. After integration of a social worker into the practice, a repeat survey documented significant attitude changes, rating social work as more competent, passive, and difficult, and lowering the estimate of patients potentially helped by a social worker from 38 percent to 31 percent. Such attitudes may influence the evolution of the social worker's role in the family medicine patient care team.


An ecological perspective on social work practice in health care. The ecological perspective conceptualizes the social work "case" as the patient and relevant features of his life space, including the health organization itself. The perspective requires a dual and simultaneous focus on the coping tasks of patient and family and on the coping supports that must be provided by the health organization. Four prescriptions for humanizing health care are suggested, and their congruence with social work purpose, roles, and practice domain is developed.


Emotional reactions of patient, family, and staff in acute-care period of spinal cord injury: part 2. Part 1 of this paper, published in the last issue, dealt with the sequence of emotional reactions of patients in the Spinal Cord Injury Center at New York University Hospital. Part 2, presented here, considers the reactions of family members and staff through these same stages of shock, denial, anger, and depression, and further discusses implications for treatment.


Attitudes toward mental illness in the working class. By reviewing both the anecdotal and experimental data on attitudes toward mental illness and assessing the popularized cultural portrayal of this affliction, the authors have shown that the working class, per se, maintains a unique and characteristic response to such illness as differentiated from the middle class. Working-class people are likely to be authoritarian, less accepting of and more exclusionary toward those diagnosed as "psychologically sick," and subsequently less amenable to psychotherapeutic intervention than their more affluent counterparts. It is suggested that clinicians be sensitized to this empirical socioeconomic differential in attitude and as such monitor their service delivery approach accordingly.


The establishment of social worker participation in rural primary health care. This paper analyses four attempts to establish programs involving social worker participation in rural primary health care agencies. Successful programs are likely to be those in which the host physicians have been involved in program design and have specifically invited participation by social workers. The successful solicitation of such invitations will require the development of multilevel advocacy programs and effective communication strategies.


Monitoring in critically ill patients.

Monitoring in critically ill patients. Although monitoring of critically ill patients has made giant steps forward in the past 15 years, such monitoring techniques must be viewed as a calculated risk, since a small but finite proportion of patients who are monitored by invasive techniques will suffer untoward and, occasionally, catastrophic consequences. Minimizing the risk involves careful general evaluation of the patient, adherence to strict indications for use of invasive techniques, and care coupled with experience in the actual manipulation. The specific procedure or procedures to be undertaken must be felt to be essential to the successful outcome of the care of the patient. The treatment of all critically ill patients must be individualized, and the monitoring techniques employed should be similarly individualized. With such a judicious approach, a great deal of valuable information can be obtained, and an effective and intelligent therapeutic regimen outlines so as to assure a successful outcome in as many patients as possible.


Dissecting intracranial aneurysms.

Dissecting intracranial aneurysms. The clinical, operative and pathological characteristics of a dissecting aneurysm of the vertebral artery are presented. A review of the literature suggests that this type of intracranial aneurysm is being recognized with increasing frequency and can be characterized by its symptomatology and radiological patterns. A set of guidelines for the management of dissecting intracranial aneurysms is proposed.


Schistosomiasis of the spinal cord.

Schistosomiasis of the spinal cord. Involvement of the central nervous system is a rare complication of schistosomiasis. A case is reported which manifested as a granulomatous, transverse myelitis in a 13-month-old child. Removal of the granuloma resulted in return of motor function.


Effects of procainamide and chloramphenicol on acute vasospasm. The basilar artery of the dog was exposed through the clivus and made spastic by puncture or by topical application of 5% barium chloride. Injections of procainamide or chloramphenicol into the vertebral artery or into a peripheral vein had no discernable effect on the acute vasospasm. Topical application of 0.1% to 10% concentrations of either of these drugs effected definite vasodilation, with the extent and rapidity of vasodilation increasing with increasing concentrations. Lesser concentrations were ineffective.


Glossopharyngeal and vagal neuralgia secondary to vascular compression of the nerves. Glossopharyngeal and vagal neuralgia secondary to neurovascular compression of the 9th and 10th cranial nerves is reported. Microsurgical decompression of the nerves provided relief from the symptoms.


The diagnosis of diastematomyelia by computed tomography. CT scanning has proven efficacy for the demonstration of normal and altered anatomy of the soft tissues of the head, providing information not available with any other modality. The introduction of total body CT has enabled us to study the entire spine and its contents. This new modality is extremely useful in diagnosing a variety of abnormalities of the spine, including diastematomyelia. A case is presented and the application of CT scanning to the spine is discussed.


Complementary role of computed tomography and other neuroradiologic procedures. Although a probable initial diagnosis may be suggested by computed cranial tomography, the diagnostic accuracy is often increased by the complementary use of other neuroradiologic studies. The use of CT scanning is conjunction with other more invasive neuroradiological studies results in improved diagnosis and patient management in almost the entire spectrum of neurosurgical diseases-- subarachnoid hemorrhage due to aneurysm, stroke, trauma, normal pressure hydrocephalus, and especially neoplasms.


Progressive multifocal leukoencephalopathy presenting as focal mass lesion in the brain. Progressive multifocal leukoencephalopathy is a rapidly progressive patchy, demyelinating process seen in patients with a long standing reticuloendothelial disorder. The first instance of abnormal angiographic features of this entity simulating a neoplasm is presented.


CT cisternography with intracranial arachnoidal cysts. Four patients with an intracranial arachnoidal cyst studied by computed tomography are reported. On the routine CT scan, arachnoid cysts are well defined lesions with the same density as cerebrospinal fluid and are not enhanced with contrast. Metrizamide CT cisternography further provides precise anatomic and physiologic information which may be difficult to obtain by angiography or air encephalography.


Continuous lumbar drainage of cerebrospinal fluid in neurosurgical patients. Continuous spinal drainage of cerebrospinal fluid was used in 50 patients with CSF fistulas both traumatic and postoperative. The method seemed to be helpful in the healing of leaks, thereby rendering surgery unnecessary. It also helped the surgical sealing of long standing tears.


Spinal cord abscess: a review.

Spinal cord abscess: a review. The literature on abscesses in the spinal cord has been reviewed. A total of 54 cases was reported. A digest is made of information on the subject including the diagnosis, pathology, treatment and the results to be expected. The best results have been achieved by operation plus antibiotic therapy. It is essential that the abscess be drained after aspiration. A case of ours showing the salient features and management of a subacute cervical spinal cord abscess is also reported.


Ocular histoplasmosis: clinicopathologic correlation of 3 cases. The eyes of three patients followed clinically for many years with a diagnosis of macular disciform scarring, secondary to ocular histoplasmosis, were studied histopathologically. A fibrovascular scar interposed between the choroid and retina was observed in all cases. Vessels passing from the choroid through defects in Bruch's membrane into the nodule were demonstrated. Theories of the pathogenesis of the lesion are discussed.


Prescribing cylinders: the problem of distortion. Astigmatic spectacle corrections produce distortion of retinal images. Under binocular conditions, small amounts of monocular distortion may significantly alter the sense of spatial localization, producing symptomatic binocular distortion. From examination of the nature and sources of monocular distortion, a rational basis may be developed for methods to minimize distortion when necessary. Adaptation to distortion occurs both by interpretive and physiological mechanisms, with the physiological mechanism appearing to be a type of rotational anomalous retinal correspondence. Through better knowledge of distortion and adaptive mechanisms, a revised set of practical guidelines for prescribing cylinders is presented.


Arsenate-induced renal agenesis in rats. The developmental origin of arsenate-induced renal agenesis was investigated. Pregnant Wistar rats were each injected once ip with 45 mg/kg sodium arsenate at day 10 (sperm day = day 0). Pregnancy was terminated at various times following injection and the embryos recovered and serially sectioned. Renal agenesis resulted when the mesonephric duct failded to give rise to a ureteric bud with subsequent failure of induction of the metanephric blastema. The underlying defect was retardation in growth of the mesonephric duct, first observed 48 hours after arsenate injection. A shortened mesonephric duct also resulted in a failure of the mesonephros to attain normal size and in the male resulted in absence of the ductus deferens, seminal vesicle a variable portion of the epididymis. Due to the intimate association of the mesonephric and growing paramesonephric ducts, a shortened mesonephric duct resulted in a shortened paramesonephric duct with resultant lack of a uterine horn.


Holoprosencephaly in human embryos: epidemiologic studies of 150 cases. One hundred fifty embryos with holoprosencephaly were found among the total of 36,380 conceptuses obtained through induced abortion in the period from 1962 to 1974, giving an overall incidence of 0.4 percent. The occurrence was period from 1962 to 1974, giving an overall incidence of 0.4 percent. The occurrence was largely at random through time, and no "epidemic" was noted in particular years or months, but there appeared more cases derived from conceptions in winter than in summer months. The mean maternal age did not differ significantly from that of the general embryonic population, indicating that, although none of our cases were karyotyped, chromosome aberrations such as trisomies 13 and 18 that are closely associated with maternal age may not constitute a major part as causes of holoprosencephaly in human embryos. Materal age did not differ by the presence or absence of associated external anomalies. No association was found with paternal age, parental consanguinity nor with maternal medical history, including irregularity of menstrual cycles, and smoking and drinking habits. There was an indication that the mothers were prone to have repeated miscarriages, supporting the view that some kind of maternal predisposition is responsible for the causation of holoprosencephaly. Argument was made that, apart from various chromosome aberrations well documented as causes of this malformation, polygenic mechanism probably accounts for the majority of the cases with normal karyotype.


Differential susceptibility of the embryo to inorganic lead during periimplantation in the mouse. The effect of intravenously administered inorganic lead on periimplantation period of embryonic development in the mouse was investigated with light microscopy. Three developmental stages were studied: the attachment of the blastocyst, the invasion of the trophoblast and the formation of the primitive streak. All three stages were affected, but the stage of invasion was found to be the most susceptible to lead as determined by decrease in frequency of animals with normal embryos.


Incidence rates for cleft lip and palate in British Columbia 1952-71 for North American Indian, Japanese, Chinese and total populations: secular trends over twenty years. The incidence of cleft lip and/or cleft palate was examined for the 1952-71 period for the Province of British Columbia. Although there were some fluctuations, some of which were significant, there was no general trend which indicated that the rates were either increasing or decreasing. These rates are important for a background calculation when investigating new invironment teratogens. The total rate of 1.97 per 1,000 live birth is comparable with other Caucasian populations where there is good ascertainment and adequate follow-up period. This study also confirmed the previously reported high rate for North American Indians in British Columbia (3.74 per 1,000 live births) and established rates for the Japanese (3.36 per 1,000 live births) and Chinese (1.76 per 1,000 live births) of British Columbia. Since these three sub-populations are relatively small in relation to the total population, they do not influence the overall total rate to any great extent.


The effect on fetal development and utero-placental blood flow of ligating a uterine artery in the rat near term. The uterine artery of one horn of 13 rats was ligated on day 18 of gestation; the remaining horn was used as a control. The effect, four days later, on blood flow to the reproductive tract, was measured with radioactive microspheres and compared to the effect on fetal and placental weights. Fetal survival in the ligated horns, 41 percent, was significantly lower (P less than 0.05) than that in the control horns, 98 percent. Fetal and placental weights of the survivors in the ligated horns, 3.159 +/- 0.133 g (SE) and 450 +/- 18 mg respectively, were similarly lower than those in the control horns, 3.814 +/- 0.111 g and 529 +/- 27 mg respectively. Maternal placental blood flow closely reflected the weight of tissue being supplied and was similar in the ligated and control horns, 129 +/- 21 and 130 +/- 18 ml.min(-1). 100g(-1), respectively. Myometrial blood flow was again similar in the ligated and control horns, 34 +/- 5 and 37 +/- 4 ml.min(-1). 100 g(-1), respectively, and in the ovarian, middle and cervical sections of each horn. These results are compatible with the view that ligation causes only a temporary reduction in uterine blood flow which permanently checks placental and fetal, or placental thus fetal, growth. Blood flow then returns to normal levels compatible with the reduced weights of tissues being supplied.


Non-confirmation of thalidomide induced teratogenesis in rats and mice. It has been reported that thalidomide, dissolved in a 1:3 mixture of Tween 20 and physiological saline and administered intraperitoneally to pregnant mice and rats induces a variety of malformations, including limb deformaties, characteristic of the primate syndrome. The studies reported herein attempted to confirm these findings without success although the rodent strains used were not the same. A low level of non-specific malformations was observed in the fetuses of both species at dose levels reported to cause a 47 percent and 92 percent rate of malformation in mice and rats respectively. One possible source of difference was Tween 20 which was toxic to the point of lethality in these studies at dose levels reported to be non-toxic in the earlier studies.


A lethal neonatal dwarfing condition with short ribs, polysyndactyly, cranial synostosis, cleft palate cardiovascular and urogenital anomalies and severe ossification defect. A case of severe lethal neonatal dwarfism is reported. It appears to be a new variety of short rib-polydactyly dwarfism. It is characterized by severe lack of ossification of all bones except the clavicle and the presence of cleft palate, as well as genitourinary, central nervous system and cardiovascular anomalies. Electronmicroscopy revealed accumulations of granular material in the chondrocytes.


Revival of the Senning operation in the treatment of transposition of the great arteries. Preliminary report on recent experience. This preliminary report presents recent experience with the Senning operation for transposition of the great arteries. Reasons are given why the traditional Mustard procedure was abandoned in favour of the Senning operation. Technical details are presented and the advantages and disadvantages of the procedure are discussed.


Cerebral protection during open-heart surgery. To reduce the incidence of cerebral damage after open-heart surgery measures were undertaken based on physiological principles and consideration of the possible injury caused by microemboli. Intellectual function was measured by psychometric tests before and after operation. The results were compared with those of an earlier series. There was a striking reduction in the incidence of neurolocial complications. There was also a considerable reduction in the degree of impairment of intellectual function previously shown to develop after open-heart surgery. However, there are still signs that cardiopulmonary bypass brings about subclinical cerebral injuriies. The measures taken and their rationale are discussed. Psychometric testing is a useful method for evaluating the quality of cardiopulmonary bypass as it allows a quantitative assessment of postoperative cerebral function.


Significance of changes in cerebral electrical activity at onset of cardiopulmonary bypass. A study of 100 patients requiring open-heart surgery has been undertaken to ascertain whether prophylactic measures designed to minimise cerebral damage have influenced the incidence or severity of changes in cerebral electrical activity recorded at the onset of cardiopulmonary bypass. The incidence of change in cerebral electrical activity remains high but the severity of the disturbances has diminished as compared with a series investigated before prophylactic measures were introduced. Changes suggestive of cerebral depression were particularly notable in children under 10 years of age. The significance of these findings is discussed in the context of factors which might influence cerebral electrical activity at the onset of bypass.


Diagnostic fibreoptic bronchoscopy in the immunocompromised host with pulmonary infiltrates. Nineteen immunocompromised patients with pulmonary infiltrates underwent diagnostic fibreoptic bronchoscopy with transbronchial forceps and brush biopsy. A specific diagnosis was obtained in 21/25 procedures (10/11 focal lesions and 11/14 diffuse legions). The most common diagnosis was infection, and organisms isolated included bacteria, fungi, Pneumocystis carinii, and herpes simplex. A pneumothroax requiring tube drainage occurred in two cases and mild lung parenchymal bleeding was noted in two others. It is concluded that fibreoptic bronchoscopy with forceps and brush biopsy can be performed safely with an excellent diagnostic yield in immunocompromised hosts with lung lesions. Supplemental oxygen should be administered during fibreoptic procedures in these patients and platelet transfusions should be given when thrombocytopenia is present.


Transbronchial lung biopsy: A review of 85 cases. Transbronchial lung biopsy using the fibreoptic bronchoscope was carried out in 85 patients. There were no serious complications; two patients had a 10% pneumothorax and 17 had slight haemoptysis lasting less than 24 hours. The problems of interpreting small biopsy specimens are considered. Satisfactory specimens were obtained without fluoroscopic guidance, particularly in diffuse and lobar lesions. A histological diagnosis was made in 62% of diffuse lesions and compatible histology was found in a further 22%. In a further case Pneumocytis carinii infection was diagnosed. Blind biopsy of discrete periheral lesions was less successful with only one positive diagnosis in 12 patients.


Thoracoscopy in the diagnosis of pleural effusion. The technique, indications, and complications of diagnostic thoracoscopy are described. Two hundred and eight explorations have been performed in our service in the last seven years. From 137 pleural malignancies we have obtained an unequivocal positive biopsy in 129 (94%) with a minimum number of complications and no mortality. From our experience we conclude that thoracoscopy, when porperly performed, is diagnostic in most pleural conditions.


Intravenous or inhaled salbutamol in severe acute asthma? Ten patients with life-threatening attacks of asthma (status asthmatiucus') were treated with salbutamol inhaled by intermittent positive pressure breathing, and their response in terms of rise in peak flow rate was measured. They were then given intravenous salbutamol and any further increment in peak flow was measured. Hydrocortisone treatment was started simultaneously and the responses to salbutamol were re-measured on each of the next three days. Only two patients initially responded to the aerosol, whereas all save one responded to the intravenous drug. The two who responded initially to the aerosol were the two who were able to produce sputum at the time of admission. All patients subsequently responded to the aerosol, and the onset of this response correlated closely with the beginning of sputum production. Sympathominetics should be given parenterally to patients in severe asthma if the response to inhaled drug is reduced or absent.


Metabolic effects of intravenous salbutamol in the course of acute severe asthma. Peak expiratory flow rate and plasma free fatty acids, potassium, insulin, and glucose were measured in 10 patients admitted with acute severe asthma before and at frequent intervals for one hour after an infusion of salbutamol, 4 microgram/kg over 10 minutes. These studies were repeated during the recovery phase and again before discharge. Effective bronchodilatation seen after the infusion  was similar in the acute and recovery phases. Baseline plasma free fatty acids were elevated but rose significantly after the infusion. There was also a significant fall in plasma potassium. These changes occurred in all individuals. There were no significant differences in mean baseline or peak changes of plasma free fatty acids, potassium or insulin on any of the study days. There was no evidence of beta receptor blockade in the acute phase in any patient.


Extrinsic allergic alveolitis: a disease commoner in non-smokers. The smoking habits of 18 patients with extrinsic allergic alveolitis, 22 with cryptogenic fibrosing alveolitis, and 75 patients with sarcoidosis were compared with the smoking habits of the normal population of the Prairie Region for 1973. The patients were diagnosed at the same two hospitals over the four-year period November 1971--75 and were of comparable age. Non-smoking was significantly associated with allergic alveolitis in men and the three cases in women were all non-smokers. For the other two diseases, smoking habits were similar to those of the local population.


Cardiac surgery relative to population: pattern of cardiac surgery in South Australia, 1949--75. The total work load of the sole cardiac surgery unit in South Australia has been analysed by means of a computer-based data retrieval system. The review covers the period 1949--75 inclusive. This study analyses the case-loads year by year, in total, and in different diagnostic categories, and has allowed conclusions to be drawn about surgical needs relative to population figures. From these figures future trends in requirements for cardiac surgical facilities have been deduced. There are many lessons to be learnt by maintaining an easily recoverable set of data for all the surgery performed in any cardiac surgery unit. This type of analysis makes it possible to maintain surveillance of demands on resources and of the results of the surgery performed. Because of the structure and situation of the community of South Australia and the fact that it is served by a single open heart unit, the pattern of this series may truly represent the optimum cardiac surgery case-load for any modern westernised community of comparable size.


A kinetic study of lung DNA-synthesis during simulated chronic high altitude hypoxia. Rats were exposed to crhonic hypobaric hypoxia at a simulated altitude of 4250 m for 3, 6, 9, 12, 20, and 35 days. The in-vitro incorporation of 3H-thymidine into the DNA of lung tissue was measured and compared with that of normoxic controls: the obtained time course study showed a maximum increase of 345% on the ninth day of hypoxia, indicating a marked stimulation of cellular proliferation. Between the 12th and 20th day of hypoxia, the lung DNA-synthesis reached control values. No significant change in the DNA-concentration of the lungs was registered. The response to hypoxia was less impressive in rat livers used as controls.


Roôle of carcinoembryonic antigen in bronchial carcinoma. It has been reported that lung cancer patients often have raised carcinoembryonic antigen (CEA) levels but the significance of this in diagnosis and follow-up has yet to be established. The results of 256 preoperative investigations in patients with lung cancer are reported. Sequential values after radical surgery and chemotherapy and immunotherapy have been performed in 57 patients during treatment and outpatient follow-up. Ninety-nine per cent of preoperative values were more than 5 ng/ml and 41% greater than 15 ng/ml. Only 6% reached diagnostic levels for malignancy (greater than 52ng/ml) and adenocarcinomas formed 47% (7 out of 15) of these. Sequential estimation in patients during and after treatment showed fluctuations which were related to disease status in 7 (32%) of 22 who have developed secondary disease. In three patients levels of greater than 50 ng/ml preceded clinical evidence of recurrence, and two patients have developed very high levels but have not yet developed other evidence of recurrent disease. It is concluded that raised CEA levels in lung cancer are infrequent, but in those patients who have or develop raised levels sequential investigation may be of value in monitoring response to treatment and clinical coourse.


Effect of intravenous terbutaline on arterial blood gas tensions, ventilation, and pulmonary circulation in patients with chronic bronchitis and cor pulmonale. Terbutaline sulphate was given intravenously to 10 patients with pulmonary vascular disease secondary to chronic hypoxia. The resting cardiac index increased after terbutaline in all the patients between 5 and 74% above the control level. The greatest change was seen in patients who had received the largest total dose. The rise in cardiac index was associated with a fall in pulmonary vascular resistance although mean pulmonary artery pressure remained unaltered. There was a significant increase in the venous admixture but this did not adversely affect the arterial oxygen tension. The peak expiratory flow rate did not change significantly but there was an increase in ventilation from a mean value of 4.36 1/min/m2 to 4.67 1/min/m2. The results show that terbutaline has little adverse effect on the pulmonary circulation or gas exchange in patients with irreversible airways disease who are in a stable state.


Pulmonary calcinosis.

Pulmonary calcinosis. The clinical and pathological features are described of a case of pulmonary calcinosis complicating cystic disease of the renal medulla. A histopathological study of the lung revealed calcification in the alveolar walls and in the blood vessels, predominantly in the pulmonary veins and venules. The calcified deposits were also studied by electron microscopy, and appearances suggestive of active growth of the deposits were recognised. Chemical analysis of the lung revealed a calcium content some 55 times greater than that of a normal lung. There was a five-fold increase in magnesium content. Reference is made to the literature demonstrating that the chemical composition of metastic calcification differs according to whether it is visceral or non-visceral in type.


Pulmonary dirofilariasis: report of a human case. Dirofilaria immitis (dog heartworm) principally infests canine hosts. However, human pulmonary dirofilariasis is being reported with increasing frequency, and the following case illustrates essential features of the disease. It typically presents as a solitary pulmonary nodule without symptoms and invariably requires pulmonary resection to differentiate it from primary or secondary malignancy.


Rupture of the normal aortic valve after blunt chest trauma. Rupture of the normal aortic valve after blunt trauma to the chest is seen infrequently. With the ever-increasing incidence of car and motorcycle accidents, this injury should be considered during the initial examination of an accident victim. Any patient without a history of heart disease presenting with heart murmurs after severe blunt trauma to the chest should give rise to the suspicion of aortic valve damage. When the diagnosis is proved, aortic valve expoloration is necessary. Review of the published cases establishes that valve replacement is the treatment of choice.


Thrombotic superior vena caval obstruction after repair of tetralogy of Fallot. A case of tetralogy of Fallot is described, in which thrombotic obstruction of the superior vena cava developed after total correction. Partial thrombolysis was achieved with streptokinase therapy.


Lung carcinoma after radiotherapy and chemotherapy for Hodgkin's disease. Two patients, aged 29 and 40, with nodular sclerosing Hodgkin's disease, in complete remission for four and six years respectively after intensive radiotherapy and combination chemotherapy, developed carcinoma of the lung in the previous radiation port. Although radiotherapy and chemotherapy can eradicate Hodgkin's disease involving the thorax, this treatment may be associated with the development of a secondary pulmonary malignancy, particularly in a previous radiation port, and several years may elapse before the new tumour becomes evident.


Pulmonary metastases from basal-cell carcinoma of skin. Although rodent ulcers are a relatively common malignant condition of the skin, pulmonary metastases arising from them are extremely rare. There have so far been only 29 authenticated reports of this condition. A further case is described of a man who, at the age of 35, developed a rodent ulcer (typical basal-cell carcinoma) on the forehead. Despite local excisions, skin grafting, and radiotherapy, the ulcer continued to recur, although there was no spread to regional lymph nodes. When he was aged 52, he developed widespread bilateral pulmonary lesions and a right pleural effusion. Thoracotomy provided a lung biopsy which showed the typical histological appearance of basal-cell carcinoma. He died aged 54, 19 years after the onset of the rodent ulcer, and necropsy confirmed that the pulmonary lesions were bloodborne metastases of basal-cell carcinoma.