Psychopathology, feelings of confinement and helplessness in the dental chair, and relationship to the dentist in patients with disproportionate dental anxiety (DDA). Nineteen individuals with inordinate fear of dental treatment are presented and discussed with respect to their psychopathology and those aspects of their fear involving feelings of confinement and helplessness in the dental chair, and a negative relationship with the dentist. This material is part of a comprehensive investigation previously reported by the authors into the components and factors contributing to this kind of fear, and the personality and emotional reactions of the individuals suffering from it. The data presented are based on single structured interviews of each patient. Analysis of the patient population suggests division into four major categories: those in whom fear of dental treatment was associated with feelings of inferiority in bodily appearance or function (the largest category); those in whom the fear was associated with neurotic disturbances in which disturbance in body image is not apparent; those in whom the  fear was a reflection of a schizophrenic or schizoid process; and those in whom no overt psychopathology was found. The patients in the first category were those who tended most to be afraid of dental treatment due to feelings of confinement or helplessness in the dental chair, or due to a negative relationship with the dentist.


An analysis of homicide by young persons in England and Wales. An analysis of 11 children (one girl, 10 boys) convicted of homicide indicates a maternal over-dominant relationship in eight of the males studied. The murderers were found to have more cooperative personalities than other children found guilty of non-capital offences and showed both normal intelligence and personality factors. Despite a history of "blackouts" in several cases, all were found on investigation to be free from both major and minor epilepsy. Difficulty was experienced in determining the presence or absence of parental alcoholism, promiscuity, and criminal convictions. All of the children came from normal homes and apart from minor offences none had been involved previously in serious antisocial behaviour. Future research is indicated on two aspects: (a) Role of the working mother with particular reference to maternal dominance and (b) The "Cycle of Deprivation" theory.


Effect of flupenthixol on depression with special reference to combination use with tricyclic antidepressants. An uncontrolled pilot study with 45 patients. In an open, uncontrolled trial flupenthixol was administered to 45 patients with endogenous depression. The drug was markedly effective in eight patients, effective in nine patients, fairly effective in 12 patients, and ineffective or aggravating in 16 patients. Four patients showed transient manic symptoms. Dosage was 1-3 mg daily. In 36 patients flupenthixol was used in combination with previously administered tricyclic antidepressants, and in nine patients it was used alone. Clinical effect was quickly apparent. It appeared within 1 week in 63% and within 2 weeks in 93% of subjects. Side-effects were observed in 13 patients: insomnia, five patients; slight extrapyramidal symptoms, nine patients. Sedative-hypnogenic effects were rarely seen. In 71% of 17 patients in whom the drug was found to be markedly effective or effective, flupenthixol's influence on psychomotor retardation was particularly striking. Other clear benefits were relief of depressive mood, psychic anxiety, and agitation. It is recommended that flupenthixol is given, as supplementary medication, to patients (1) whose depressive symptoms other than psychomotor retardation have already improved with current tricyclic antidepressants, and (2) in whom, before antidepressant medication, psychomotor retardation is a principal feature.


L-alpha-hydroxycholecalciferol treatment of adults with chronic renal failure. Five adult patients with chronic renal failure and associated renal osteodystrophy have been treated for 6 months with 1-alpha-hydroxycholecalciferol (1 alpha-OH-D3), a synthetic vitamin D analogue. All 5 patients had severe metabolic bone changes as estimated by bone scintigraphy. Three patients were hypocalcemic, 4 had elevated serum alkaline phosphatases, 5 had elevated serum immunoreactive parathyroid hormone (i-PTH) concentration and 3 had bone pains. During treatment serum calcium increased in all patients (mean 11.4%) and 3 originally hypocalcemic patients became normocalcemic. Serum alkaline phosphatases decreased (mean 27.3%) and became normal in 4 patients, who initially had elevated values. A pronounced decline in the serum concentration of i-PTH (mean 53%) was seen in all patients and 1 patient obtained normal i-PTH levels after 4 months of treatment. The intestinal calcium absorption, which was low initially, even when calcium intake was considered, rose almost threefold (mean 273%) and reached normal values in all cases. The bone mineral content increased in all patients, but the changes were small (mean 4.9%) and insignificant. Finally, bone pain disappeared in 2 patients and improved in 1 of 3 patients exhibiting this symptom. A linear correlation (r = 0.48, p less than 0.001) was found between the dose of 1 alpha-OH-D3 and serum calcium. But in spite of this and the frequent control, all patients developed one episode of hypercalcemia. This disappeared within 48 hours after discontinuing the drug. It is concluded that treatment with 1 alpha-OH-D3 appears to be of therapeutic value in metabolic bone disease associated with chronic renal failure, but frequent control of blood biochemistry seems mandatory.


Three-year follow-up of middle-aged men with low blood pressure. The blood pressure (BP) development in 142 middle-aged men with BP within the lower region of the BP distribution (supine BP less than or equal to 120/70 mmHg) has been studied. Over a 3-year period there was a moderate but significant rise in supine systolic BP but not in supine diastolic BP. However, no subject developed hypertension defined as supine BP greater than or equal to 175/105 mmHg. These findings support the assumption that among middle-aged men the hypertensives are recruited from the upper part of the BP distribution. Subjects with low BP may be rescreened at longer intervals, if at all.


Attempted diagnosis of ventricular mural thrombi in acute mycardial infarction using 125I-labelled fibrinogen. In an attempt to diagnose ventricular mural thrombi complicating acute myocardial infarction (AMI), 80 patients have been given 100 muCi 125I-labelled fibrinogen after admission to a CCU. Precordial radioactivity was recorded for the following 6 days over four sites corresponding to chest leads CR1-CR4. A sustained rise in radioactivity of at least 15% of initial recordings was classed as type A pattern, a minor rise or flattened response as type B pattern and a rapid decrease as type C pattern; 28% showed a type A, 19% a type B and 54% a type C pattern. There was no significant difference between the groups in incidence of pericardial friction rub but when patients with suspected pericarditis (as evidenced by characteristic pains) were added, pericarditis was significantly overrepresented in the type A group. Smaller infarctions (SGOT less than 100 U/1) were significantly more common in patients with a type C decay pattern. No differences were noted between the groups as regards type and site of the infarction. A sustained rise in precordial radioactivity after an AMI may be an indication of mural thrombosis but the influence of other factors secondary to an infarction, e.g. pericarditis, cannot be determined at present.


Prevalence of hypercalcaemia in a health screening in Stockholm. A free health check, offered to 21417 20-63-year-old employees of the Stockholm City and County Council in 1971-73, was accepted by 15903 persons. The examination included a multichannel chemical analysis of a single blood sample. Serum calcium levels greater than or equal to 11.0 mg/100 ml (2.75 mmol/l) and greater than or equal to 11.1 mg/100 ml (2.78 mmol/l) were encountered in 3.9% and 1.1% of the population, respectively. Among subjects below 50 years of age, the calcium concentration was significantly higher in males than in females. This difference disappeared in older subjects, essentially because the calcium level decreased with advancing age in the men. To a further investigation were invited 178 subjects with a single serum calcium registration greater than or equal to 11.1 mg/100 ml (2.78 mmol/l). Of this group, 95 persons (53.4%) exhibited hypercalcaemia (HC) on repeated testing. Twelve had been operated on prior to the actural follow-up and found to have parathyroid adenomata. Twenty subjects were on continuous treatment with diuretics of the thiazide type and seven had diseases that might induce HC (two had hyperthyroidism, two hypothyroidism, one sarcoidosis, one hypernephroma and one mammary carcinoma). In 56 patients the laboratory and physical examinations did not reveal any obvious cause for the HC except possible hyperparathyoidism (HPT). Eighty (84.2%) of the 95 HC subjects were women, mostly over 50 years. The 95 persons constituted 6% of the total number of health-screened persons. The highest prevalence, 13%, was recorded for women aged 60-63. The prevalence of HPT in the total material was 3.6%, which is higher than that found in several other studies. This is based on surgical findings to date.


Extensive nodular infiltration of extra-osseous tissues in human myelomatosis. A case report. The autopsy findings of a woman with myelomatosis diagnosed half a year before her death are described. She had an IgG-lambda myeloma which initially responded to treatment. However, subsequently she developed a condition characterized by massive soft tissue involvement with increased number of plasma cells in peripheral blood. Rounded hard myeloma infiltrates were disseminated through the body, only sparing the adrenal glands and intracranial structures.


Prolonged symptoms of brain dysfunction--adverse effect of levodopa. Symptoms of brain dysfunction occurred in a 67-year-old woman with idiopathic parkinsonism on treatment with levodopa. The adverse effect reappeared in a more severe and prolonged form when she was treated one year later with levodopa in combination with the peripheral decarboxylase inhibitor Ro-4-4602. The symptoms were associated with a markedly altered level of HMPG (a noradrenaline metabolite) in the cerebrospinal fluid.


Studies on subclinical hypothyroidism with special reference to the serum lipid pattern. Subclinical hypothyroidism is an example of the impact of technology on the concept of a disease. It denotes a condition in which laboratory findings, at least including a raised serum thyrotropin (s-TSH), indicate hypothyroidism in the absence of clinical signs or symptoms of this disease. One reason for attention to cases of subclinical hypothyroidism is the publication of reports, from the time before introduction of the s-TSH assay, that hypercholesterolaemia precedes other evidence of thyroid failure with attendant risks of ischaemic heart disease and other atherosclerotic manifestations. The present investigation, which concerned the lipid pattern in sublinical hypothyroiism, offered no support for such a concept of hypercholesterolaemia as a premonitory sign of hypothyroidism. Furthermore, no significant differences were found between the serum levels of cholesterol and triglycerides before and after the administration of a thyroxine dose, necessary to suppress the s-TSH into a normal range, in cases of sublinical hypothyroidism. Nor were there any changes during this therapy in body weight, ECG, or Hb levels, which represent important parameters often found to be abnormal in overt hypothyroidism. From a practical point of view, subclinical hypothyroidism probably can be regarded as a state in which reduction of thyroid activity has been compensated by an increased s-TSH secretion to maintain a clinically euthyroid state. When no goitre is found, the rationale of treatment of this condition remains to be proved.


The composition of food consumed by Greenland Eskimos. Food specimens have been collected, by means of the double-portion technique, from Greenland Eskimo hunters and their wives, in all seven persons, on seven consecutive days. Their food was found to contain more protein and less carbohydrates than average Danish food and an almost equal amount of fat. Compared with Danish food, the fatty acid pattern of the consumed lipids--essentially of mammalian marine origin--showed a higher content of long chain polyunsaturated fatty acids (especially C20:5) and lower contents of linoleic and linolenic acids. However, the sum of the polyunsaturated fatty acids was smaller than in Danish food. Using Keys' formula, describing the serum cholesterol level as a function of the nutritional fatty acids, the essentially lower serum choelsterol level found in Greenland Eskimos was not explained by our findings. It is suggested instead to be a special metabolic effect of the long chain polyunsaturated fatty acids from marine mammals. There might be a similar effect on the plasma triglyceride and very low density lipoprotein concentrations, explaining the much lower plasma concentrations of these components in Eskimos than in Western populations. Our findings might have an essential bearing on the difference in morbidity from coronary atherosclerotic disease between these populations.


Reduction of isoniazid bioavailability in normal men by concomitant intake of food. The influence of food intake on the bioavailability of isoniazid (INH) has been examined in nine healthy male volunteers. INH was administered as a single oral dose, both in fasting state and together with a standardized breakfast. Numerous venous blood samples were obtained 5 min-6 hours after the INH ingestion, and the concentrations of unmetabolized INH in serum were assessed by spectrophotometry. The observations indicate that both the peak concentration and the total amount of INH absorbed are greatly reduced when the drug is ingested together with food. Hence it is recommended that, in the treatment of tuberculosis with INH, the drug should be given on an empty stomach. The data may also have some bearing on the use of INH for assessing acetylation rates and estimating dosages of hydralazine and related drugs.


Lactate production during fructose infusion with or without amino acids. Lactate production from the liver during fructose infusion was decreased when an amino acid infusion was given simultaneously. The most pronounced decrease was observed when the amino acid infusion was started before the simultaneous administration of fructose and amino acids. The explanation of the phenomenon is thought to be a stimulation of gluconeogenesis by amino acids.


On the nature of brain stem disorders in severe head injured patients. In head injured patients changes were found in the CSF levels of metabolites of the dopaminergic and the serotonergic neurotransmission (HVA and 5-HIAA). After the fifth day following trauma a significant decrease of the HVA levels in the lumbar CSF after probenecid treatment was found. The intensity of this decrease was found to be related to the severity of the trauma (period of unconsciousness), but not to the state of consciousness. Also the probenecid-induced 5-HIAA levels in conscious patients were decreased after the fifth post-traumatic day. In unconscious patients, the period of unconsciousness, particularly in the period of 5-20 days after trauma. Between 21 and 60 days after trauma the 5-HIAA concentrations in unconscious patients decreased remarkably, but they were still significantly higher than in the conscious patients. It can be concluded that during unconsciousness serotonergic neurons have a high rate of turnover, but that both neurotransmitter systems are damaged by the direct or indirect consequences of the injury.


Diagnosis of pinealoblastomas by positive response to cobalt-therapy. Surgical excision of pineoblastomas is considered dangerous, and relief of raised intracranial pressure by shunting followed by cobalt therapy is the preferred treatment. Demonstration by pneumoencephalography of tumour shrinkage after therapy confirms the diagnosis of pineoblastoma. Failure of the tumour to become smaller indicates a different pathology which calls for a surgical approach, except in the case of a brain stem tumour.


Diagnosis and treatment of tumours in the pineal region. In a series of 3.072 cases of intracranial neoplasms up to the end of 1973 there were 82 tumours in the pineal region (2.7%), excluding meningiomas of the falx and tentorium. More than half (forty seven) were pinealomas (two cell pattern type tumours, and pineoblastomas), twelve were teratomas, eight were ependymomas, three were epidermoids, and the remainder were gliomas. In addition to ventriculography, millipore filter-cell culture of cerebrospinal fluid, and fibre ventriculoscopy were found useful for diagnosis. Most of the patients were treated by surgery followed by radiotherapy. Results with the pinealomas were fairly good, the one year, five year, and ten year survival rates being 87.5%, 71.4%, and 33.3% in those below the age of 15 years, and 80.0%, 46.2%, and 12.5% in those above that age. The radiosensitivity of pinealomas and the beneficial effect of reduction of tumour bulk by direct surgery may both be important factors in the achievement of good results.


Surgical management of tumours of the pineal region. Tumours of the pineal region and posterior part of the third ventricle are rare in European and American series (0.5 to 1% of space-occupying lesions). Personal experience is usually limited and thus cooperative studies or critical reviews of reported cases are necessary to establish therapeutic criteria. We have studied 50 cases from our own material of more than 5,000 brain tumours and intracranial space-occupying lesions operated on during the last 30 years. Another 6 verified cases from Dr. F. Isamat, and more than 200 verified tumours from the literature are added. Histological distribution shows that 24% of the tumours in this locality are benign. The different surgical techniques fro reaching the pineal region are reviewed. The results of palliative operations, or partial removals together with radiotherapy, and total removals are presented in 200 verified cases (Table 1), as well as the results obtained by the different surgical approaches (Table 2). Finally, some conclusions are reached regarding the surgical management of these tumours. More than two thirds are radiosensitive, and in about 50 to 70% good results may be obtained with palliative operations and radiotherapy. The remainder of the pineal tumours (about 20%) should be treated by a direct surgical approach. Recent technical improvements and the use of the surgical microscope have reduced the mortality of pineal surgery and allow verification of the histological nature of the tumour in order to establish more rational treatment.


Quantitative study of muscle fibre atrophy and restitution after nerve grafts. Our comparative experimental studies on rabbits using clinical, electromyographical, and quantitative histological examinations of long autologous and homologous nerve grafts in 35 rabbits, paying special attention to quantitative histological changes in the gastrocnemius muscles, allow the statement that, compared to the short holografts, the long homografts showed worse results. Moreover, it became obvious that the regeneration rate of autografts was not influenced by increasing the lengths of the grafts. The answer to the question of how far even longer grafts may influence the quality of regeneration will need further investigations.


Experience with allografts in the surgery of peripheral nerves (experimental study). Peroneal nerve allografts four to seven cm in length were transplanted in 36 tissue typed beagle dogs, using a standard microsurgical technique. The influence of tissue typing on nerve regeneration through these grafts was studied with the help of electromyography and histology seven to nine months after nerve implantation. Better regeneration was found through the grafts with compatible than with noncompatible typing. The favourable effect of tissue compatibility became more evident when the length of the graft was longer than four cm. Tissue rejection reaction was much more marked and evident with longer grafts in noncompatible than in compatible groups. Radiation, with tissue typing, did not seem to confer any additional beneficial effect. Compatible tissue typed nerve allografts probably behave more like autografts.


Regeneration of the spinal ventral roots. An experimental study in cats. From a clinical standpoint recovery of spinal nerve roots is less likely than that of peripheral nerves, despite their identical structures. This may be due to several factors including the length of gap to be bridged, changes in the proximal stump or neuroma, and chromatolysis. In this paper we discuss the roles of some of these factors in relation to the neuronal depopulation in the spinal cord anterior horn area following section of the anterior root. The lack of growth or the successful growth of the axon through the gap in the root influences the degree of depopulation in the anterior horn area.


Radial nerve lesions and their treatment. Out of 332 patients with peripheral nerve injuries operated upon in our Department from the beginning of 1972 to the end of 1974, in only 30 were different types of radial nerve injury observed. In most cases radial nerve palsy was seen to be a secondary occurrence following fracture of the humerus or other types of injuries. Operation revealed 16 cases of fibrosis of the radial nerve and 14 of radial nerve defect. The longest defect was 20 cm long. In the first group of patients funiculolysis was performed, and in the second group funiculorrhaphy was performed using sural nerve grafts. With the exception of one case in the first group, good reinnervation of the previously denervated muscles was achieved, as well as the restoration of sensitivity in the affected skin areas.


Precise selective alcoholic Gasserian injection for tic douloureux. Recent advances in technic and results. The Ecker-Perl method of alcoholic trigeminal rhizolysis has proved to be a safe and effective method of treating tic douloureux in a consecutive series of 324 patients over a period of 21 years.


Is angiographic spasm real spasm?

Is angiographic spasm real spasm? Systematic morphological study of the cerebral arteries was made in six autopsy cases of ruptured aneurysms. The time course of the arterial luminal narrowing was observed by repeated angiograms, and segments of the narrowed arteries were studied histologically. Various histological changes were found consistent with the angiographic findings. We have devided these into three stages according to the duration of the disease. In the acute stage (less than one day) the contraction of the medial smooth muscle cells may be the main cause of the luminal narrowing. In the subacute stage, arteries showed a reduction in lumen size with medial thickening, marked corrugation of the internal elastic lamina, and thrombus formation attached to the endothelial surface. If vasoconstriction remained localized to the same segment for several days, the intimal or medial thickening and thrombus might produce the luminal narrowing consistent with the angiographic narrowing. In the chronic stage (more than two weeks), most cases showed dilatation of the arterial lumen on angiography. These arteries showed frank necrosis of the smooth muscle cells histologically. In a case which demonstrated progressive luminal narrowing on angiograms over 2 weeks, the arterial wall showed luminal narrowing with cellulofibrous thickening of the intima and organization of the thrombus. The presence of these structural changes in the narrowed arteries seen at angiography seems to be very important for proper understanding and treatment of vasospasm.


Cerebral blood flow changes in acute experimental haemorrhagic vasospasm. Subarachnoid haemorrhage was produced in 26 dogs by injecting fresh homogenous blood into the cysterna chiasmatica. Two types of vasospasm were observed, firstly segmental arterial spasm closely related to the bleeding point and secondly generalized arterial vasospasm not directly related to the bleeding point and often occurring some way from the bleeding point. Reduction in CBF occurred in 61% of cases and was always accompanied by radiological vasospasm. However, in about one quarter of the cases with vasospasm there was no alteration in CBF.


Dynamics of the blood pressure changes in sodium nitroprusside induced controlled arterial hypotension in neurosurgery. Dynamics of the arterial blood pressure changes under the influence of intravenous infusion of sodium nitroprusside (SN) were studied in 12 patients operated on for intracranial aneurysms. Adequate measures were undertaken to avoid blood pressure (BP) changes due to the anaesthetic procedure itself. It was found that the speed of BP lowering corresponded to the rate of infusion, and could easily reach 10 mm Hg/min. After stopping the infusion, the BP recovery rate averaged a mean speed of 8.5 mm Hg/min, varying from 3.8 to 12 mm Hg/min. High speeds of BP lowering and recovery achieved with the use of SN are the main advantages of this hypotensive agent in neurosurgical procedures.


The effect of increased intracranial pressure on pressure in the superior sagittal sinus. It is difficult to explain why rises in ICP provoke different types of response in superior sagittal sinus pressure. In most of our experimental animals there was close correlation between rises in ICP and SSSP. In the remainder, SSSP showed little increase when ICP rose. The animals with marked increase in SSSP showed a greater capacity for compensation for increased amounts of intracranial fluid.


Rheographic assessment of cerebral blood volume and correlations with changes in intracranial pressure. The authors present a four electrode rheographic technique for simiquantitative continuous measurement of CBV, by examining changes in cerebral tissue impedance induced by changes in blood content of the brain parenchyma. Correlation between the data obtained and ICP measurements permits conclusions regarding the behaviour of the cerebral blood bed. pCO2 regulates CBV, and the phenomenon is reversible according to a hystereris shaped time course in acute experiments. The rebound of ICP after sudden injections of CSF into the cisterna magna is of a vasogenic nature. Changes in CSF volume induce contrary changes in CBV. Pharmacological effects can be studied. The validity of the method is discussed.


Dynamic changes in cerebrospinal fluid pressure during neurosurgical operations. The effects of hyperventilation, osmotic and diuretic agents (urea, frusemide), thiopentone and succinylcholine chloride on the intracranial pressure were studied in neurosurgical patients with brain tumours. We have shown that hyperventilation together with osmotic and diuretic agents is very useful for reducing increased intracranial pressure.


Continuous peroperative supraoccipital cisternal drainage. 1. The technique of continuous peroperative supraoccipital cisternal drainage for intracranial decompression by means of a slow and progressive removal of CSF from the ventricles and the basal cisterns is described. 2. This procedure was used in eight patients with good results, considerable decompression being obtained with no untoward effects. 3. In four cases of intracranial aneurysm marked intracranial hypotension was obtained, greatly facilitating treatment of the lesions. 4. In four cases of brain tumour, the reduction of intracranial hypertension was not so great, and was complemented with general antihypertensive treatment. 5. Supraoccipital cisternal drainage removes intracranial CSF, but not the fluid in the spinal theca. The tonsils of the cerebellum are thus kept floating, and this, in our experience, has prevented them from impacting in the foramen magnum and compressing the medulla,


Assessment and prognosis of coma after head injury. The Glasgow Coma Scale, based upon eye opening, verbal and motor responses has proved a practical and consistent means of monitoring the state of head injured patients. Observations made in the early stages after injury define the depth and duration of coma and, when combined with clinical features such as a patient's age and brain stem function, have been used to predict outcome. Series of cases in comparable depths of coma in Glasgow and the Netherlands showed remarkably similar outcomes at 3 months. Based upon observations made in the first 24 hours of coma after injury, data from 255 previous cases reliably predicted outcome in the majority of 92 new patients. The exceptions were patients with potential to recover who later developed complications: no patient did significantly better than predicted.


Classification of coma.

Classification of coma. By order of the Head Injuries Committee of the W.F.N.S. the author and his coworkers give definitions of consciousness, clouding of consciouness and unconciousness or coma. Furthermore, they suggest a definition of the termination of unconsciousness, with particular reference to the transition into a stage of clouding of consciousness. Any statistical evaluation and comparison of different materials depend on the use of identical definitions. As an example, it has been shown that the duration of aa uninterrupted coma, which can be survived, becomes relatively short if in accordance with the proposed definitions the various stages of clouding of consciousness are excluded from "coma".


Assessment of the psychosocial outcome of severe head injury. Increasing numbers of those concerned with the primary treatment and later care of individuals who sustain head injuries are becoming interested in the development of methods for assessing the outcome of severe brain damage. In the past such methods seldom involved balanced consideration of the physical, mental and social sequelae of injury. Moreover rehabilitation, which should involve restoration of patients to their fullest physical, mental and social capability, is often biased towards the improvement of physical disability alone. The long lasting and chronically disabling mental changes which occur so frequently, and which tend to cause the greatest difficulties for patients in terms of their  reintegration into society, usually receive scant attention. Assessment of outcome necessitates evaluation of the contribution of both physiogenic and psychogenic factors to the patient's mental state, and thus their respective contributions to the degree of social integration achieved. With these points in mind a pilot study was designed to evaluate three simple indices of outcome--namely neurophysical, mental and social assessment scales. The relation of each scale to the severity of brain damage, assessed in terms of post-traumatic amnesia, was examined. The relation of the scales to each other and to measures of cognitive function (the Wechsler Adult Intelligence Scale) were also considered, Results from 56 severely brain injured patients reveals a clear cut relation between the duration of post-traumatic amnesia and the measures of disability devised. Further, social disability was related to the level of physical and mental handicap, but it was the latter which caused the most severe problems. The level of intellectual recovery was related to all scales of disability and to the duration of post-traumatic amnesia, although the latter proved to be a less accurate predictor of the ultimate degree of intellectual recovery than was expected.


The blink reflex in coma and after recovery from coma. Comparative studies of the blink reflex in a series of head injuries through the stages of coma and recovery from coma in a series of miscellaneous hemispheral lesions, and in a normal series, reveals that, although the principal centre for the R1 component of the blink reflex seems to be localised in the upper pons, the seat of the R2 late component is in the reticular system. The reappearance of this late component of the blink reflex in our cases of coma although seeming to depend on the integrity of the mesencephalic formation, correlates with the recovery of the patient's alertness. On the other hand, habituation of this reflex depends on the integrity of global cognitive function, rather than on any localised centre. The roles of the cortex, selective attention, and emotional factors, are discussed. The recovery of the normal habituation of the blink reflex obtained by glabellar tapping was found to be a useful sign in the follow up of patients recovering from concussion and other lesions, such as subdural haematomas and brain tumours, with global mental impairment.


Initial state, outcome, and autopsy findings in a series of 200 consecutive traumatic comas. A computerised analysis. Based on 200 nonselected consecutive cases of primary traumatic coma a preliminary mathematical model--computed, multiple linear regression analysis--has been developed, which seems to be suitable for calculating the prognosis from some initial anamnestic and clinical data. It is to be expected that the analysis of greater material will help to establish an even better model, e.g. by a more detailed age subdivision and choice of more or other factors. It is the aim of this report to encourage further work in this field.


Intracranial circulatory insufficiency. Surgery of carotid atheroma. Clinical and radiological studies are presented from 81 cases of intracranial circulatory insufficiency due to extracranial atherosclerosis, and the results of surgical treatment are given.


New approach to brain tumour chemoradiotherapy with cellular synchronization by colcemid. Cellular synchronization using Colcemid as pretreatment for combined chemoradiotherapy was investigated. C6 rat brain tumour was cultured in RPMI medium containing 10(-5)-10(-7) Mol. of Colcemid for 24 hours. The basic cell kinetics were analysed with a Pulse Cytophotometer, which facilitated the analysis of tumour cell cycle phase distribution according to the DNA content. The effect of Colcemid depended on the concentration, and the minimal concentration showing continuous blocking during 48 hours after removal of the drug was 10(-6) Mol. G1 fraction of 2 C DNA content was reduced from 74% to 36%. G2-M phase of 4 C DNA content increased from 9% to 28%. S phase cells increased from 17% to 31%. Polyploid cells in the Tetraploid cell cycle could be recognized. The remaining 36% of cells within the GO + G1 peak of 2 C DNA content were considered to be diploid GO cells.


Mathematical analysis (fast Fourier transform) of the ultrasonic echo pulsation curve in brain diseases. The ultrasonic pulsation curve can be analysed by the computer. This technique has been useful for measuring haemodynamics. We detected prodromal signs of rebleeding from an intracranial aneurysm.


Recovery from experimental paraplegia after levodopa administration. In decompression sickness and during some surgical procedures, air emboli that form sometimes cause serious damage if the gas bubbles find their way to the vital organs. Paralysis of the spinal cord is one of the most serious manifestations induced by air emboli. Exposure to compression chambers is effective in air emboli treatment, but availability of chambers is inadequate and the treatment is lengthy. Until now there has been no fully effective injectable agent that can remedy the damage caused by air embolization. In this work levodopa was chosen as an injectable drug that might help to improve recovery from experimental paraplegia because of the reported effects of levodopa on muscle tone, spasticity and locomotion. To induce air emboli, the descending aorta of rats was chronically cannulated. Two weeks later, after full recovery from surgery, air was injected through the chronically implanted cannula into unanesthetized rats (0.35 ml of air per 100 g, during 4 sec). The paraplegia (paralysis of both hind legs) was manifested 2-10 minutes later. Only animals that had total paraplegia, without any sensation, were used in the experiments. Levodopa was administered 2 minutes after paraplegia was established. The levodopa treatment was repeated each day during one week. After six days, ten levodopa treated (intra-arterially) animals in a group of twelve and six levodopa treated (intraperitoneally) animals in a group of eight recovered completely from paraplegia. In control groups only three from thirteen (untreated), or two from twelve (solvent administration) animals recovered from paraplegia.


Molecular evidence for a viral etiology of human CNS tumors. The newer methods of molecular virology, including molecular hybridization and the "simultaneous detection test," were used to examine human brain tumors for evidence of RNA tumor viruses. It was found that they contained 70S RNA and RNA-directed DNA polymerase, both encapsulated in a particle possessing a density of 1.17 g/ml. These particles therefore satisfy the three diagnostic features that characterize the animal RNA tumor viruses. Of 26 of the most malignant (glioblastoma and medullo blastoma) brain tumors examined, 24 (92%) contained these virus-like entities. The possible usefulness of these particles as aids in diagnosis and monitoring therapy is briefly discussed.


Monoamine acid metabolites in ventricular CSF of patients with brain tumours. Homovanillic acid (HVA) and 5-hydroxyindolacetic acid (5-HIAA) in ventricular CSF were determined in 19 patients (12 female 7 male) with brain tumours. No relationship was found between ventricular fluid pressure (VFP) and levels of HVA and 5-HIAA. A relationship was observed between ventricular CSF, HVA concentrations and tumour induced alterations in CSF dynamics. HVA concentrations were very high in patients whose tumours involved the third ventricle, the aqueduct, or the fourth ventricle, producing marked alterations in CSF flow. HVA concentrations significantly lower than in controls were observed in cases where tumours involved the lateral ventricles. Concentrations of acid metabolites in patients with little or no alteration in CSF dynamics corresponded with those in patients with other neurosurgical disorders.


Microsurgical lumbosacral ganglionectomy, anatomic rationale, and surgical results. Recent anatomic and physiologic work suggests that there may be substantial numbers of unmyelinated sensory axons in the ventral roots. The cell bodies of origin for these unmyelinated axons would presumably be located in the dorsal ganglion. We have performed 18 microsurgical lumbosacral ganglionectomies over the past two years for chronic lumbosacral pain syndromes. In spite of preoperative nerve block trials, good results were obtained in only 10 of 18 patients. Four patients obtained some pain relief, and four patients no pain relief whatsoever. Microganglionectomy in the lumbosacral area is probably easier technically than the more traditional intradural rhizotomy, but may not yield any better results.


Changes in serum and cerebrospinal fluid enzyme activity after head injury. We studied simultaneously in serum (S) and CSF (L) the enzyme activities of GOT, GPT, LDH, ICDH, MDH, ALD, and CPK in 28 patients with head injuries divided into three groups according to the severity of the trauma. We found a correlation between severity of brain lesion and enzyme activity. The best correlation was found for SGOT, SCPK, LGOT, LLDH, LMDH and LCPK. We do not believe that enzyme activity is of prognostic value. We think that further studies should be made of the specific isoenzymes of the Central Nervous System.


Cytotoxic antibodies in preoperative glioma patients: a diagnostic assay. The use of a microcytotoxicity test for complement-dependent serum antibodies cytotoxic to cultured astrocytoma cells has been explored as an aid in the diagnosis of brain tumors. Fourteen of 21 randomly selected preoperative glioma patients (67%) had antibodies detectable by this assay in contrast to 4 of 21 normal blood donors (19%). Five of the glioma patients (24%) were strongly positive (cytotoxic index greater than 80-80) while none of the controls was in this range. Although positive responses were seen in patients with tumors of every grade, only 6 of 11 patients with astrocytomas of Grades I-III were positive as compared to 8 of 9 patients with Grade IV astrocytomas. The microcytotoxicity test used is simple, inexpensive and capable of being performed on an outpatient basis. It is concluded that this assay has usefulness both as a screening technique and as a diagnostic adjunct for patients suspected of having brain tumors.


Heterologous antibodies in human and rat's glioblastoma. IgG from immunized rabbits was labelled with Fluorescein Isothiocyanate, and conjugated in vitro with human and with rat glioblastoma. After absorption of the antisera with normal brain and liver, a heavy concentration of antibody was found in the rat tumour cells. A great amount of antibody was also found in the human neoplastic cells. The incorporation of this antibody in glioma cells of different rats developing new tumours indicates that transplantation antigens of the H-2 type are not the only ones capable of inducing specific antibody attachment.


Change of local spinal cord blood flow in acute ischaemia. The local blood flow of the spinal cord was recorded by the hydrogen polarographic method with platinum electrodes. The blood flow and its changes were measured during acute ischaemia caused by compression of the thoracic aorta, and also after release of compression. Ten cats were included in these experiments, and more than 100 measurements were made in the lumbar region of the spinal cord. In the grey matter a high flow was observed in every case, resembling that in the cerebral cortex. Reduction of the lumen of the thoracic aorta by one half resulted in a 23%, and by three quarters in a 60-70% decrease in blood flow. With total occlusion there was practically entire cessation of flow. Rapid restitution of blood supply in the grey matter of the spinal cord caused a 65%, and in the white matter a 170% increase in blood flow due to reactive hyperaemia. Normal flow rates returned within 2-2.5 minutes.


A long term observation of local cerebral blood flow using the hydrogen gas clearance technique. Local blood flow was estimated in the cerebral hemispheres of conscious goats using implanted platinum electrodes and the hydrogen gas clearance technique over periods of several weeks. During the first days of the experiments the blood flow rate was either below 27 ml/100 g/min. or above 40 ml/100 g/min. A gradual decrease in flow was observed over five weeks. The final flow values were between 20 ml/100 g/min. and 30 ml/100 g/min. Carotid injections of serotonin, noradrenalin, or metaoxamine, and inhalation of 5% carbon dioxide produced only insignificant changes in local blood flow. The cause of the slow decrease of flow and the change from a biexponential to a monoexponential curve may be explained by local tissue changes during the observation periods.


Ultrastructural findings after microsurgical interventions on the carotid artery of the rat. For 10 years, it has been known that operations on vessels 1 mm in diameter are possible. The application of microvascular techniques to neurosurgery demands microscopic and ultrastructural examinations of the effects of such interventions on small vessels. Histological examinations can help to provide answers to questions concerning operating technique, ultrastructural examinations give information on the indications for operation. Since these questions have not been studied previously, preliminary examinations on easily accessible vessels are necessary. For this purpose, the common carotid artery of the rat was chosen. Histological and ultrastructural examinations were carried out on end-to-end anastomoses of these vessels. The ultrastructural findings are described and compared with anatomical findings in normal and abnormal vessels in the rat.


Experimental middle cerebral artery microsurgical embolectomy. The canine middle cerebral has been embolized using the method of Molinari. Microsurgical embolectomies were done at two hours and six hours post-embolism. Animals done at two hours remained virtually intact neurologically, and hence fared better than control dogs whose embolus remained in place. Animals done six hours post embolism had increased neurologic morbidity and mortality as compared to the controls. Pathologic study revealed hemorrhagic infarctions in 50% of the animals done six hours post embolism.


Some observations on the microneurosurgical treatment of intracranial aneurysms. This paper reports a retrospective study of the microneurosurgical management of intracranial aneurysm in 133 patients. Good or fair results were obtained in 76%, 12% of patients had a poor result and the mortality was 12%. Major factors which were found to influence the outcome of surgery were: pre-operatively, the Botterell grade of the patient, pre-existing systemic hypertension and the time interval between the last subarachnoid haemorrhage and surgery. Post-operatively, the development of cerebral vasospasm was associated with a poor outcome from surgery. Better results might be obtained from the surgery of intracranial aneurysm by delaying operation to the second week after subarachnoid haemorrhage and by better management of hypertensive patients pre-operatively and patients who develop cerebral vasospasm post-operatively.


The role of cytochrome P-450 in the regulation of steroid biosynthesis. A cytochrome P-450 from bovine adrenocortical mitochondria has been purified to near homogeneity. The protein catalyzes side-chain cleavage of cholesterol (cholesterol leads to pregnenolone) but neither 11beta- nor 18-hydroxylation. It consists of 16 subunits of two species (MW 52,000) and contains 8 heme groups. The enzyme has been used to determine the stoichiometry of side-chain cleavage with the following results: (TPNH and O2 consumed/mole of cleavage), cholesterol 3:3:1, 20S-hydroxycholesterol 2:2:1 and 20S,22R-dihydroxycholesterol 1:1:1. These findings support the occurrence of the proposed pathway for the side-chain cleavage of cholesterol. Cleavage of the diol is inhibited by CO and shows a characteristic P-450 photochemical action spectrum. Evidently the diol is cleaved in a typical monoxygenase reaction. The active form of the enzyme contains 16 subunits (protein 16); forms consisting of 8 (protein 8) and 4 (protein 4) subunits can be isolated and are enzymatically active only by prior conversion to protein 16.


Contractile effects of histamine in large and small respiratory airways. The described technique allows recording of circular smooth muscle activity in isolated airways approx. 1 mm in diameter (bronchioles). It also allows recording of graded contractile and relaxant responses to drugs. Bronchiolar preparations and spirally cut airways (diameters 3-6 mm) were obtained from cat, dog, guinea-pig and man. Histamine is shown to contract cat bronchioles, large airways in cat being unaffected. The contraction is blocked by brompheniramine, but not by atropine. Other contractile agents, cholinoceptor-stimulants, prostaglandin F2alpha'5-hydroxy-tryptamine, and potassium contract the isolated cat airways irrespective of their size. In preparations from dog, guinea-pig and man,histamine was shown to contract both small and large respiratory airways. The effect was blocked by brompheniramine, which did not change the effect of acetylcholine or pilocarpine. Both large and small airways contracted to cholinoceptor stimulation Within species, small and large airways were similarly sensitive to the contractile agents, except for histamine in cat airways. The present findings show a size-and species dependent effect of histamine in respiratory airways. The effect of histamine in isolated cat airways might partly explain the pulmonary effect of histamine in vivo. The importance of including both small and large airways in studies of contractile and relaxant effects is emphasized.


An investigation of the therapeutic value of the 'copper bracelet'-dermal assimilation of copper in arthritic/rheumatoid conditions. From over 300 arthritis sufferers, half of whom previously wore 'copper bracelets', three treatment-group-subjects were randomly allocated for a psychological study. This involved wearing 'copper bracelets' and placebo bracelets (amodised aluminum resembling copper) alternately. These groups, as also a control group, answered questionnaires. The copper bracelets were weighed before and after use. Preliminary results show that, to a significant number of subjects, the wearing of the 'copper bracelet' appeared to have some therapeutic value. A study of the components of sweat and the solubility of copper in sweat was carried out. In five sweat samples, the copper concentration was of the order 2 x 10(-5) M and after equilibrating with copper turnings at room temperature for 24 hours the samples turned blue in colour and contained approximately 2 x 10(-3) M copper. The permeability of skin to copper containing solutions has also been discussed. It has also been shown that the wearing of a 'copper bracelet' results in a weight loss in excess of the body's total burden of copper (100-150 mg). A pair of copper bracelets lost 80 mg in 50 days when worn around the ankles and a copper bracelet worn around the wrist also lost about 90 mg in that time.


Protection by phalloidin against lethal doses of phalloidin. Tolerated doses of phalloidin, a toxin from the mushroom Amanita phalloides, protect mice against lethal doses of phalloidin. Resistance is conferred by the 1/10 LD95 of phalloidin and sets in at about 8 hours after the pretreatment.


Inactivation of bradykinin the plumonary circulation. Bradykinin is very efficiently inactivated on passage through the pulmonary circulation by enzymes on the vascular walls. Several different cleavages of the bradykinin molecule have been observed; one appears to be due to angiotensin converting enzyme. Several types of inhibitors have been useful in the study of these pulmonary peptidases and have helped increase understanding of the functioning of the angiotensin and plasma kinin systems.


The emotional aftermath of adoption.

The emotional aftermath of adoption. Adopted children are emotionally vulnerable. Adoptive parents must cope with more complex problems than biologic parents. The family physician can provide valuable counseling. Preadoption counseling focuses on motivation and ambivalence. After adoption, however, serious, sometimes predictable, issues arise, such as: how and when to tell the child he is adopted; the child's search for knowledge; the problem of subsequent divorce; the birth of a natural sibling, and the involvement of other family members. New concepts include "open adoption" and "single parent adoption."


Influenza: current concepts.

Influenza: current concepts. Changes in surface antigens make preparation of an effective vaccine against the influenza virus a difficult job. When the changes are small (antigenic drift), a vaccine can be expected to be of some value; when larger changes occur (antigenic shift), its effectiveness is greatly curtailed. Improvements in the purification process for the vaccine have greatly lessened the incidence and severity of reactions. Although the current vaccines are still imperfect, they represent the best available control.


Management of ocular foreign bodies.

Management of ocular foreign bodies. Fluorescein staining is helpful in diagnosis. Many conjunctival foreign bodies can be removed by swab or irrigation, without anesthesia. Cycloplegics can prevent painful ciliary spasm. A surgical opening may be required for deeply embedded objects. Topical anesthesia is required for corneal foreign body removal. Caution: x-rays must be made to rule out intraocular foreign bodies in cases of flying metal. Rust rings must be removed. Mydriatics or cycloplegics can precipitate glaucoma. Corneal abrasions are easily infected. Secondary iritis may follow deeply embedded foreign bodies.


Diabetic osteopathy of the foot and ankle. Neuropathic osteopathy of the foot and ankle is almost always due to underlying diabetes mellitus. The "Charcot joint," or destructive type, affects the ankle or tarsal area, and the "bone absorption," or mutilating type, usually affects the forefoot. If both types are present in the feet, it is almost certain that the patient is a diabetic. While these findings are usually seen in patients with long-standing, poorly controlled diabetes, they may be the first indication of diabetes.


Caring for the hypochondriac.

Caring for the hypochondriac. The patient's manner and the content of his complaints offer early diagnostic leads. The hypochondriac clings to his symptoms. Rather than relief, his goal is forming a relationship with the doctor that provides care and understanding. The physician's goal must be the provision of this care in such manner as to reassure, treat sparingly and convert this potentially fatal illness to a chronic disorder with which the patient can function to the limits of his capabilities.


Viral coronary arteritis and myocardial infarction. Two young male patients are described in whom a viral type of upper respiratory tract infection was followed by myocardial infarction. Based upon previously reported experimental studies in mice and monkeys in which Coxsackie B4 virus produced extensive coronary arterial and capillary injury, and upon the clinical data in these two patients, it is suggested that the myocardial infarcts in our two patients were the result of viral coronary arteritis.


A comparative study of 48 host valve and 24 prosthetic valve endocarditis cases. Forty-eight cases of host valve endocarditis and 24 cases of prosthetic valve endocarditis occurring during a concurrent period of time were analyzed to assess differences between the two groups. The over-all incidence of prosthetic valve endocarditis during this 40 month period was 4.4%. The symptoms and signs in both groups were similar, except that PVE patients had more frequent occurrences of changing heart murmurs and splenic and cerebral emboli. Spleen scans may be helpful in the diagnosis of selected cases of culture-negative prosthetic valve endocarditis. There was no significant difference between the two groups for the various infecting microorganisms. However, the culture-negative prosthetic valve group had a mortality rate of 77.7% compared to 46.2% for the host valve group. In the HVE patients the oral cavity or urinary tract was the probable source of infection in 50.0% of the patients. In about one third of HVE cases, there was strong evidence that the infection was related to a therapeutic procedure, whereas nearly half of the PVE patients had clinical evidence of an extracardiac infection at the time of open-heart surgery. We emphasize the need for good pre- and postoperative surveillance to eliminate possible predisposing infections and appropriate antibiotic prophylaxis in all patients with valvular disease at times of risk. The survival rate in patients with prosthetic valve endocarditis was highest in those patients who received "appropriate" antibiotics and, if significant congestive heart failure was present, surgical intervention was necessary.


A comparative analysis of four protocols for maximal treadmill stress testing. The purpose of this investigation was to compare the results from four commonly used maximal treadmill stress tests: Balke, Bruce, Ellestad, and a continuous multistage running protocol. The results compared serial and maximal heart rate, metabolic demands, and ECG determinations. Fifty-one healthy men, 35 to 55 years of age, volunteered for this study and were dichotomized into trained and untrained subjects. Regression analyses showed all the tests to correlate highly. No significant differences were found between tests at maximum for V02, heart rate, and blood pressure, except for V02 for the Balke as compared to the running protocol (39 vs. 41 ml./Kg-min). The Balke protocol showed lower values at maximum in VE and RP than the other three tests as well as the most gradual rate of progression in MET cost (0.5 METS per minute). The increase for the Bruce and Ellestad tests was from 1 to 1.5 METS per minute, and a rapid initial increase (9 METS in the first 3 minutes) made the running test undesirable as a screening method. Although serial plots of heart rate and MET costs were similar to those previously reported for different population samples, the present data further refined these values. Finally, a nomograph comparing treadmill time and V02, max. for the Balke, Bruce, and Ellestad tests was developed from these data.


The effects of increased blood viscosity on pulmonary vascular resistance. The isolated left lower lobes of 15 dogs' lungs were perfused by means of a roller pump with blood at hematocrit values ranging from 31 to 80 per cent. Pressure-flow curves were constructed at blood flow rates from one half to three times the normal flow for the left lower lobe at each hematocrit level. The perfusion pressure was normalized with reference to the normal hematocrit(38 to 48 per cent) and normal blood flow for the left lower lobe (20 ml. per kilogram per minute). From these normalized pressure-flow curves, normalized resistance-flow curves were constructed at different mean hematocrit levels. Regression lines were drawn relating normalized pulmonary vascular resistance to hematocrit at different rates of pulmonary blood flow which might be found in patients with congenital heart disease. It was found that pulmonary vascular resistance rose in an exponential fashion as the hematocrit was increased, and that the blood viscosity determined both the shape of the resistance-flow curve and magnitude of the increase in resistance to pulmonary blood flow, especially when the pulmonary blood flow was less than normal and the hematocrit was greater than 54 per cent. The family of regression lines relating pulmonary vascular resistance to hematocrit at different flow rates may be used clinically in patients with congenital heart disease and polycythemia to determine if an elevated pulmonary vascular resistance is due to increased blood viscosity or obstructive pulmonary vascular disease. It is concluded that an increased blood viscosity due to polycythemia significantly alters the pulmonary hemodynamics of patients with congenital heart disease with either increased or decreased pulmonary blood flow. Increased blood viscosity may play an important part in the early initiation and development of pulmonary arteriosclerosis in patients with transposition of the great arteries.


Comparison of left atrial size and pulmonary capillary pressure with P wave of electrocardiogram. The amplitude and duration of P waves in Leads II (P II), P terminal force in V1, (PV1) and the sums of P II and PV1 were compared in 37 subjects with left atrial size obtained by echocardiographic technique in 36 instances and with hemodynamic estimates of pulmonary capillary wedge pressures in 16 cases. The 22 females and 15 males were subdivided into the following groups. Group I, four normal subjects, Group II, 11 patients with predominant aortic insufficiency (two of whom had a mild mitral insufficiency); Group III, 14 patients with mitral valve disease, seven of whom had mitral insufficiency (two with minimal aortic insufficiency) Group IIIa) and seven had mitral stenosis (Group IIIb); Group IV, eight patients with miscellaneous disorders, i.e., coronary artery disease (5), hypertension (2), and idiopathic hypertrophic subaortic stenosis (1). Good correlations were obtained between left atrial size and P in Lead II (P II) (r = 0.74; p less than 0.001) and between P terminal force in V1 (PV1) and left atrial size (r = -0.69; p less than 0.001). In Group IV good correlation between PV1 and atrial size was noted. Some correlation between the sum of P II and PV1 and left atrial size (r = 0.51; p less than 0.02) was noted, but a better correlation was obtained in the patients with aortic insufficiency (r = 0.80; p less than 0.01). Pulmonary capillary wedge pressures were not reflected in changes in P II or PV1, except for the group with mitral stenosis (Group IIIb). Adding P II to PV1 improved the correlation with wedge pressure for the entire group.


Rupture of interventricular septum in acute myocardial infarction. Three cases of rupture of the interventricular septum occurring coincident with acute inferior myocardial infarction are reported and the relevant literature is reviewed. One patient under-went successful surgical repair and, in addition, had an aneurysmectomy. Clues and pitfalls in diagnosis as well as the possible confusion with ruptured papillary muscle are discussed. Due to a dual blood supply to the interventricular septum, rupture occurs most often in the setting of advanced, diffuse coronary artery disease. Hypertension or other factors may be of lesser importance. Early surgical approach is advocated and may of necessity include infarctectomy, aneurysmectomy, and coronary artery by-pass surgery in addition ot repair of the ruptured interventricular septum. Use of an intraaortic balloon counterpulsator may prove to be of considerable help in the preoperative and postoperative management of these patients.


Effect of beta-adrenergic blockade with alprenolol on ST-segment depression and circulatory dynamics during exercise in patients with effort angina. 1. Nine subjects with severe coronary artery disease were studied during graded "sprint" and "steady-state" exercise before and after intravenous administration of the beta-receptor antagonist alprenolol. During "sprint" workload was increased every minute until maximum work capacity (Wmax) was reached. "Steady-state" exercise was performed at work rates of 0.250, 0.50, and 0.75 of each subject's sprint Wmax. Variables measured included ST-segment depression, changes in heart rate, blood pressure, respiratory gas exchange, and arterial blood composition. Cardiac output (indirect Fick) was measured during "steady-state" exercise. 2. Alprenolol did not alter Wmax during "sprint" but reduced the incidence of angina in both types of exercise. After the drug work capacity was limited by symptoms and signs suggestive of mild left ventricular failure. 3. The relationship between workload (normalized in terms of Wmax) and ST-segment depression was curvilinear. Under control conditions a given rate of work during "steady-state" exercise was assocaited with more marked ST-segment depression than during "sprint". Alprenolol displaced the work-ST-depression curve to the right in each type of exercise; now a given rate of work produced similar ST-depressing during "steady-state" and "sprint" exercise. 4. Alprenolol attentuated the exercise tachycardia during both types of exercise. Cardiac output was lower in "steady-state" exercise after the drug than under control conditions. Metabolic effects included significant reduction in body oxygen consumption after alpreprenolol at 0.25 Wmax and diminished arterial lactate at 0.75 Wmax. The beneficial effects of the drug thus appeared to involve not only cardiac but peripheral effects on beta receptors. 5. Before alprenolol cardiac output was relatively fixed at all workloads, but after the drug there was a work-related rise in output in five out of nine subjects. Comparison with data in normal subjects suggested that in anginal subjects cardiac output at low "steady-state" workloads was inappropriately high.


Incidence and morphology of carotid shudders in aortic valve disease. The incidence and morphology of shudders in carotid arterial pulse tracings were examined in 73 patients with aortic valve disease documented by cardiac catheterization. Two forms of carotid shudder were recorded: coarse and fine. Shudders were present in 67 per cent of patients with aortic stenosis, 48 per cent of patients with aortic insufficiency, and 57 per cent of patients with mixed aortic stenosis and insufficiency. No significant difference existed among these three groups of patients with respect to the over-all incidence of carotid shudders or with respect to the incidence of coarse or fine shudders. In patients with aortic insufficiency, stroke volume index (Fick) and phonocardiographic systolic ejection murmur amplitude were significantly greater (p less than 0.01, p less than 0.001, respectively) in those with coarse carotid shudders compared with those manifesting fine or absent shudders. Loud, flow-related, systolic ejection murmurs of aortic insufficiency are capable of producing radial vibrations in the aortic wall which are recorded as carotid shudders. The finding of a carotid shudder in a patient with aortic valve disease does not enable the physician to distinguish between stenosis, insufficiency, or mixed stenosis and insufficiency.


Comparison of the effects of atrial and ventricular stimulation on sinus node function in man. Although sinus node function has been evaluated during premature atrial stimulation, no study of retrograde ventriculoatrial sinus node activation following premature ventricular stimuli has been reported. The purpose of this study was to investigate the production of compensatory and noncompensatory pauses by premature ventricular contractions through a comparison of the effects of atrial and ventricular stimulation on sinus node function. Eleven patients in sinus rhythm were studied with programmed introduction of premature atrial and ventricular stimuli outside the ventricular vulnerable period. The onset of sinus node reset, duration of return sinus cycle (A2-A3) during reset, and estimated sinoatrial conduction times were recorded. Sinus node function during premature ventricular stimulation was approximated by utilizing the interval between the last sinus beat and onset of retrograde atrial depolarization (A1-A2 interval). The return cycle length (A2-A3) during sinus reset compared at equal A1-A2 intervals was significantly less with ventriculoatrial conduction (1,145 +/- 52 msec. atrial vs. 1,076 +/- 52 msec ventriculoatrial; P less than 0.01 by paired t test) and the estimated sinoatrial conduction time was significantly less with ventriculoatrial conduction (71 +/- 7 msec. atrial vs. 25 +/- 7 msec. ventriculoatrial; P less than 0.01 by paired t test). Ventriculoatrial sinus reset occurred later in the sinus cycle than atrial reset in three of seven patients with sinus reset produced by both atrial and ventricular prematures. This study shows that the effects of ventriculoatrial conduction on sinus node function are significantly different from those of atrial stimulation alone. The return sinus cycle length during reset and estimated sinoatrial conduction time are significantly reduced with ventriculoatrial conduction. Although the zones of sinus reset with atrial and ventricular stimulation are approximately equal, ventriculoatrial depolarization may produce sinus reset later in the sinus cycle in some cases.


ECG and VCG changes in experimental hemiblock and bifascicular block. ECG and VCG changes in QRS configuration before and after left anterior subdivision block (LASB), isolated and combined with right bundle branch block (LASB combined with RBBB), were studied in canine hearts. In another series left posterior subdivision block (LPSB), isolated and combined with right bundle branch block (LPSB combined with RBBB), were also performed. With LASB, the A QRS axis deviated superiorly to the left and the QRS duration showed no significant prolongation. Additional RBBB to the existing LASB, moreover, rotated the A QRS axis counterclockwise, and prolonged the QRS duration significantly. With LPSB, the axis was deviated inferiorly to the right and the QRS duration showed no significant prolongation. Additional RBBB to the existing LPSB rotated the A QRS axis clockwise. The QRS duration showed significant prolongation. Vectorcardiographically, the initial part of the QRS loop did not show any essential changes with either LASB or LPSB. The main and terminal parts of the QRS loop, however, were deviated superiorly and to the left with LASB and inferiorly and to the right with LPSB. No changes were observed in the direction of rotation of QRS loop with either subdivision block. From these results it appears that the changes in the terminal forces are more of importance than the initial forces in the diagnosis of hemiblock.


Propranolol in experimental myocardial ischemia: dissociation of effects on contraction and epicardial ST segments. Recent studies have suggested that propranolol decreases the extent of myocardial injury in acute ischemia. Although other studies have shown that global myocardial performance is depressed, zonal effects of propranolol in this setting are unknown. Therefore, the effect of propranolol (1.0 mg. per kilogram) was investigated in nine dogs with the use of Walton-Brodie strain gauge arches and local epicardial electrograms (10 to 12 sites). The heart rate effects of propranolol were controlled by atrial pacing. After coronary occlusion, heart rate increased slightly without a significant change in blood pressure. Following the infusion of propranolol, heart rate decreased significantly from 165.0 +/- 3.5 to 126.2 +/- 4.7 beats per minute (p less than 0.001) while both the systolic and diastolic blood pressures showed insignificant changes. After coronary occlusion, nonischemic zone tension showed no significant changes; however, propranolol decreased total tension from 105.2 +/- 2.5 per cent to 66.8 +/- 4.7 (p less than 0.001). Similarly, propranolol further decreased total tension in the border zone from 84.4 +/- 6.7 per cent (p less than .02) to 50.6 +/- 5.1 (p less than 0.01). Ischemic zone tension also fell further (p less than 0.025) after propranolol. Restoration of prepropranolol heart rate had no significant effect on tension development. Following coronary occlusion, sigmaST increased from 5.7 +/- 2.2 to 72.9 +/- 20.1 mv. (p less than 0.001). Coincident with the decrease in heart rate and tension development induced by propranolol, sigmaST decreased to 60.8 +/- 18.8 mv. (p less than 0.05). When the heart rate was restored to prepropranolol level, sigmaST again rose to 73.2 +/- 16.9 mv. (p less than .005). Thus, propranolol does effect an improvement in ischemic injury which is related, at least in part, to the induced decrease in heart rate. A concomitant substantial decrease in local tension development also occurs, however. The latter observations may limit the potential usefulness of propranolol in this setting.


Cardiovascular effects of ajmaline.

Cardiovascular effects of ajmaline. Ajmaline, a rauwolfia derivative, has been found to possess potent antiarrhythmic effects. The present study has been designed to define the cardiovascular effects of this drug. Hemodynamic studies performed in anesthetized and conscious dogs demonstrated no significant changes in measured hemodynamic parameters at doses equal to or less than 2 mg. per kilogram. Studies in isolated papillary muscle demonstrated no negative inotropic effects until concentrations of 1 X 10(-4). Disparate results were obtained with regard to heart rate reflecting the state of autonomic tone. Electrophysiologic studies in both anesthetized and conscious dogs demonstrated a significant depression of intraventricular conduction with no significant effect on AV nodal conduction; ventricular automaticity was not affected. Ajmaline did not alter digitalis-induced AV nodal conduction prolongation. However, ajmaline dramatically altered or abolished ventricular arrhythmias secondary to acute ischemia. In conclusion, these studies demonstrate that ajmaline specifically depresses intraventricular conduction, suggesting that this drug would be particularly effective in the treatment of re-entrant ventricular arrhythmias.


Intraventricular trifascicular block verified by His bundle electrocardiography. A patient with the combination of right bundle branch block and intermittent left anterior and left posterior hemiblock is presented. His bundle recordings proved that this type of intraventricular conduction defect appeared when the two left fascicles were damaged partially, and to a varying degree. The recordings also revealed a Grade 2 A-V block distal to the A-V node. The mechanism is discussed.


Acute coronary occlusion following blunt injury to the chest in the absence of coronary atherosclerosis. A 35-year-old man suffered transmural diaphragmatic wall infarction immediately after receiving a nonpenetrating trauma to his chest. During subsequent months crippling angina pectoris developed and coronary arteriography was performed. A complete obstruction of the left circumflex coronary artery was demonstrated 2 cm. distal to its origin. In contrast to most cases previously published, in this case no signs of atherosclerosis were observed in the other coronary arteries. It must be assumed, therefore, that blunt trauma can induce complete coronary occlusion with infarction, even in subjects with normal coronary arteries.


Occupational Health/Safety Program Accreditation Commission. This presents a brief history of programs for accrediting occupational health activities with discussion of weaknesses and strengths. The relatively short life of the Occupational Health/Safety Program Accreditation Commission is reviewed with emphasis on its charge, goals and accomplishments. The mechanisms for accreditating Occupational Health and Safety Programs is described and some reasons for seeking accreditation are given.


Variation in trash composition in raw cottons. Raw cotton from 4 machine picked varieties and 2 machine stripped varieties is examined by stereomicroscope and bright-field microscopy for presence of plant trash(bract, leaf, stem, seed, boll, and weed fragments-size range 841-2000mum) that gives rise to cotton dust during yarn manufacturing operations. Bract was found to be the major trash component in all raw cottons examined. Cotton leaf and non-cotton weed materials were also major trash components in most raw cottons.


Plant trash in linters and willowed picker: materials used in the cotton garnetting industry. First cut linters and willowed picker, used in cotton garnetting, were examined for content of cotton bract an other plant trash. Bract was found to be a minimal contaminant of the trash of first cut linters. A significant amount of bract (about 9% of the trash) was present in willowed picker. Cotton seed hulls, a valuable oil mill by product, contained an insignificant amount of bract trash.


A rapid method for the determination of arsenic concentrations in urine at field locations. A colorimetric method for arsenic in urine utilizing a portable hood and requiring minimal laboratory facilities is described. Urine samples are combusted in a hot plate-oven with MgO and Mg(No3)2. Arsine is generated from the ashed product and passed into silver diethyldithio-carbamate in pyridine. Inorganic and organic arsenicals in urine at 0.03 ppm with 6% variation is detectable.


The pregnant woman in industry.

The pregnant woman in industry. The intent of this paper is to relate current thought in proper perspective to the mounting concern for the pregnant woman in industry. Embryo toxicology may demonstrate a need for lowered standards of exposure for the woman worker during a pregnancy. Lastly, a plan is offered to obtain data for comparison of female work populations which may or may not be exposed to certain, primarily airborn, contaminants.


The retention of large particles (greater than 2mum) in fibrous filters. A simple method of testing fibrous filters to obtain the grade efficiency curve in the particle size range 2-22 mum is described. Dust collected by the method has been used to measure the retention efficency of model filters and it is shown that there is a maximun in the grade efficency curve. The influence of relative humidity on filter behaviour has been investigated. It is shown that the efficiency of filtration in high particle inertia systems increases with increasing relative humidity. It is considered that the reason for this is an increase in particle-fiber adhesion force.


An evaluation of fluorescent light sources for use in phototherapy of neonatal jaundice. An evaluation of fluorescent lamps for use in the phototherapy of neonatal jaundice was undertaken by making spectral irradiance measurements of each lamp. Conclusions are drawn on the usefulness of current methods of measuring exposure dose to radiation from the lamps. UV hazards from the lamps are evaluated.


Echocardiogram of the porcine aortic bioprosthesis in the mitral position. Echocardiography was performed in 10 consecutive patients who had a clinically normally functioning porcine aortic bioprosthesis in the mitral position. Strong well defined echoes were recorded from the anterior and posterior aspects of the xenograft stent. The maximal separation of the anterior and posterior stent echoes approximated the diameter of the stent at its base. The maximal excursion of the anterior stent was 5 to 10 mm (mean 7.5) with a mean systolic slope of 15 to 35 mm/sec (mean 22.2) and diastolic slope of 11 to 59 mm/sec (mean 21.5). In all 10 patients it was possible to record an anterior xenograft leaflet with anterior movement at the onset of diastole and posterior movement at the onset of systole and with appropriately steep (more than 200 mm/sec) slopes. The diastolic (E-F) slope of the anterior leaflet in 9 of the 10 patients ranged from 9 to 38 mm/sec (mean 19). In 6 of the 10 patients a posterior xenograft leaflet with a movement pattern symmetric with that of the anterior leaflet was recorded. In two patients, the central aortic leaflet was recorded with little diastolic displacement. These two patients also had mild aortic regurgitation, which was associated with diastolic shudder of the xenograft leaflets. Echocardiography was also performed in one patient who was later shown to have a 10 cm3 thrombus on the ventricular surface of a xenograft valve. The echocardiogram in this patient revealed the following abnormalities: (1) excessive anterior stent movement and systolic slope suggesting paravalvular leak in the presence of abnormal cinefluoroscopic valve tilt, and (2) multiple dense nonhomogeneous echoes between the anterior and posterior aspects of the valve stent, with an early diastolic clear space behind the anterior stent and abnormal echoes behind the posterior stent during systole. Echocardiography therefore appears to be useful in evaluating the porcine aortic bioprosthesis in the mitral position.


Myocardial infarction in young women.

Myocardial infarction in young women. This study of 24 women under age 40 years with myocardial infarction demonstrates that even in young women myocardial infarction is most commonly due to coronary atherosclerotic heart disease. Other causes of coronary occlusion were documented in 17% of these patients, indicating that these lesser causes of myocardial infarction are more common in young women than in older persons or in young men. In those patients with coronary atherosclerosis one or more significant risk factors could usually, but not always, be documented. The clinical manifestation of the coronary occlusion in the study group was not unlike its manifestation in groups of different ages or sex, or both.


Effect of glucose-insulin-potassium infusions on arteriovenous differences of glucose of free fatty acids and on tissue metabolic changes in dogs with developing myocardial infarction. Glucose-insulin-potassium infusions were given to dogs for 6 hours, starting 30 minutes after ligation of the left anterior descending coronary artery. Effects on substrate arteriovenous differences, indexes of ischemic damage and other tissue metabolic changes were compared with changes in dogs with comparable ligations but no infusions. Glucose-insulin-potassium increased the arteriovenous difference of glucose, decreased that of free fatty acid and decreased the arterial free fatty acid/albumin molar ratio. Glucose-insulin-potassium accelerated the rate of fall of the epicardial S-T segment in the infarct zone and prevented the small rise in S-T segment found in the perlinfarct and nonischemic zones. Glucose-insulin-potassium increased the tissue content of glycogen in peripheral infarct, periinfarct and nonischemic zones; increased tissue potassium ion/sodium ion ratios in epicardial infarct zones and in the periinfarct zone; increased adenosine triphosphate in the endocardial infarct zone; decreased inorganic phosphate in the periinfarct and nonischemic zones and in the endocardial infarct zone; and increased lactate in the central infarct and nonischemic zones. The phosphate potential increased in the periinfarct and nonischemic zones. Thus, many glucose-insulin-potassium effects were greater in the peripheral infarct and especially the periinfarct zones. Although increased anaerobic metabolism with lactate production could not be excluded as a mode of action of glucose-insulin-potassium, estimated rates of anaerobic glycolysis were very low, suggesting that other effects such as increased aerobic glycolysis decreased extraction of free fatty acid by the heart, increased tissue glycogen or a "membrane" effect might be of major importance.


Control of cardiac output in essential hypertension. Cardiac and renal hemodynamics and cardiopulmonary and total blood volume were determined in 202 men, 101 with normotension and 101 of the same age with chronic essential hypertension, normal renal function and balanced sodium intake and urinary output. Cardiac output was identical in the two groups, whereas blood pressure and total peripheral resistance were significantly different. The two groups exhibited strong differences in the correlation study: (1) Correlations of blood pressure with, respectively, heart rate, cardiopulmonary blood volume and total blood volume were significant in the normotensive group but not in the hypertensive group. (2) Correlations of cardiac output with, respectively, heart rate, cardiopulmonary blood volume and total blood volume were significant in both groups. (3) Correlations of renal blood flow with, respectively, cardiac output, blood pressure and total blood volume were significant in the hypertensive group but not in the normotensive group. This study provides evidence that: (1) the volume and neural control of blood pressure are disrupted in hypertension whereas control of cardiac output is maintained; and (2) adaptive mechanisms involving renal function are necessary to the maintenance of normal cardiac output in patients with essential hypertension.


Echocardiographic sepctrum of the hypoplastic left heart syndrome: a clinicopathologic correlation in 19 newborns. Ultrasonic studies were performed in 19 neonates with the hypoplastic left heart syndrome whose diagnosis was confirmed at angiography or autopsy, or both. The patients were classified in two echocardiographic groups: Group I, 10 infants whose ventricular septum could be recorded, and Group II, 9 infants whose septum could not be recorded. The findings in these groups were compared with those in 60 neonates without congenital heart disease also studied with ultrasound. Two additional neonates who presented with signs of shock were also studied. The diagnostic echocardiographic features of hypoplastic left heart syndrome were: (1)a left ventricular end-diastolic dimension of less than 9 mm; (2)an aortic root diameter of less than 6 mm; (3)a ratio of left ventricular end-diastolic to right ventricular end-diastolic dimension of less than 0.6; and (4)a mitral valve echo that is absent or greatly distorted and of small amplitude. These echocardiographic criteria differed significantly from findings in the normal group (P less than 0.01). Echocardiography proved valuable in neonates with shock. It is a safe, reliable technique that can be used to delineate the intracardiac anatomy in sick neonates with the hypoplastic left heart syndrome.


Surgical correction in complete levotransposition of the great arteries with an unusual subaortic ventricular septal defect. Six children with an uncommon variant of complete (that is, physiologically uncorrected) transposition of the great arteries are described. In this malformation, levoposition of the aorta is coincident with situs solitus and concordant atrioventricular relations. All patients underwent successful surgical correction. Four had a ventricular septal defect; in three, the defect was subaortic and because of its unusual anatomic features, a right ventriculotomy was required for repair. Interatrial transposition of venous return was carried out in all cases by insertion of a baffle, as in complete dextrotransposition of the great arteries. The surgical verification of the arterial positions in these cases illustrated the fallibility of the so-called loop rule. The significance of the cases in relation to terminology, classification and morphogenesis of this variant is discussed.


Asymmetric distribution of the pulmonary blood flow between the right and left lungs in d-transposition of the great arteries. Pulmonary angiograms, radionuclide lung images and chest roentgenograms were evaluated regarding the incidence, magnitude and natural evolution of maldistribution of the pulmonary blood flow between the lungs in 63 patients with dextrotransposition of the great arteries. Approximately half of these patients had some degree of greater perfusion of the right relative to the left lung. A significant correlation was demonstrated between the incidence of this maldistribution of blood flow and the angulation between the main and the right pulmonary arteries. For any given angulation between these vessels, additional pulmonary stenosis increased the incidence of disparity in perfusion. Our observations suggest the following developmental mechanisms: The maldistribution in flow results from the abnormal rightward inclination of the main pulmonary artery in the transposition malformation which straightens the flow axis from the main to the right pulmonary artery. Under these circumstances the momentum of the blood in the main pulmonary artery carries the blood preferentially into the right pulmonary artery. This momentum is increased when there is stenosis of the left ventricular outflow tract. Consequent differences in the mechanical properties of the two pulmonary vascular beds can increase this maldistribution. The disparity in perfusion between the lungs is not present in newborns with d-transposition, appears to be progressive in severity and in time may result in almost complete cessation of effective perfusion of the left lung. The effect of the Mustard operation on this abnormality of flow is discussed.


Congenitally corrected transposition of the great vessels: localization of the site of complete atrioventricular block using his bundle electrograms. Complete atrioventricular block proximal to the bundle of His in a patient with congenitally corrected transposition of the great vessels was documented using His bundle electrograms. The spontaneous rhythnm probably originated from the bundle of His and was responsive to carotid sinus massage, atropine and isometric and treadmill exercise. These electrophysiologic observations are consistent with recent anatomic studies of congenitally corrected transposition of the great vessels.


Pathologic correlations in a case of complete heart block with split His potentials resulting from a stab wound of the heart. A 23 year old previously healthy man was stabbed in the anterior chest. This resulted in a ventricular septal defect and complete atrioventricular (A-V) block. The electrocardiogram revealed complete A-V block with a QRS pattern of right bundle branch block. His bundle recordings 26 days later revealed A-V dissociation with split His potentials (P-H1 interval of 100 msec and H2-V interval of 40 msec). During the study the escape QRS shifted from right to left bundle branch block with H2 potentials still preceding each QRS interval with H2-V intervals of 40 msec. A permanent pacemaker was implanted because of persistent congestive heart failure and bradycardia due to A-V block. The patient subsequently became asymptomatic. He died suddenly 3 1/2 years later. Pathologically there were sizable openings in both the tricuspid and mitral valve substance and a ventricular septal defect involving the pars membranacea and part of the adjacent muscular septum. Serial sections of the conduction system revealed total destruction and fibrous replacement of the bifurcation and beginning of the right and left bundle branches and subtotal fibrous replacement of the branching bundle. Thus, the bifurcation of the bundle of His was totally absent at autopsy despite apparent electrophysiologic evidence of its existence 26 days after the stab wound. A possible explanation for this discrepancy is the subsequent fibrosis of the bifurcation produced by hemodynamic changes at the lower margin of the ventricular septal defect.


Nutritional status measures as predictors of nutritional risk in preschool children. Data from 19 dietary and biochemical indices of nutritional status for 419 participants in the Preschool Nutrition Survey were analyzed to determined the smallest number of variables that could be used to identify all children with any of measure below a criterion of adequacy. Serum transferrin iron and dietary iron intake identified 74% of those at nutritional risk. Additional information on dietary calories, calcium, ascorbic acid, thiamin, and vitamin A identified all subjects at risk.


Growth and development of three Yugoslav populations in different ecological settings. The role of genetical and ecological factors in the physical growth and development was studied in three Yugoslav populations living in different ecological settings. Anthropometric measurements of 6,908 children and young adolescents ages 1 to 18 years were taken and the results were compared in regard to ethnic and ecological characteristics. The evidence is presented that significant improvement in physical characteristics follows the improvement in environmental factors including nutrition. In addition to an increase in body height, changes were also noted in the build of the bony frame of the population living under improved environmental conditions. There was a change in the shape of the skeleton from the squatty appearance of the short population to the more lanky shape of the tall population. It is concluded that systematic periodic collection of the information on child growth could serve as a useful monitoring system for the surveillance of ecological and nutritional trends of a country.


Effect of oral contraceptives and vitamin B6 supplements on alanine and glycine metabolism. Plasma alanine or glycine concentrations and blood pyruvate were studied before and after oral administration of the two amino acids to women using estrogen-containing oral contraceptives and to a control group of women. Thirty oral contraceptive users and 14 controls received alanine loads (200 mg/kg of body weight). The two groups had similar fasting plasma alanine levels, but the fasting blood pyruvate was elevated in the contraceptive steroid-treated women. After alanine ingestion, the increases in plasma alanine were significantly lower in the oral contraceptive users. Both groups showed a rise in blood pyruvate; there were no differences in the increments above fasting values. Treatment with pyridoxine hydrochloride, 25 mg for 4 weeks, had not effect on the responses of 11 oral contraceptive users to alanine loading. Twenty-four oral contraceptive users and 14 controls were studied before and after a glycine load (140 mg/kg of body weight). The fasting plasma glycine levels were similar, but lesser increases after ingestion of the amino acid occurred in the oral contraceptive-treated group. Blood pyruvate concentrations in both oral contraceptive users and controls were unaffected by oral glycine loads.


Postprandial glucose, insulin, free fatty acid and growth hormone responses in children consuming all the day's protein in one meal. BLOOD GLUCOSE, INSULIN (IRI), growth hormone, and plasma free fatty acids (FFA) were determined in six children consuming a diet of uneven distribution of protein relative to energy (study period). Preprandial and postprandial samples surrounding the 8 AM protein-free feeding and the 3 PM feeding containing all the day's protein were compared with values obtained in the same children similarly sampled while consuming an isonitrogenous isoenergetic diet of even protein distribution (control period). After the 8 AM feeding during the study period there was a mean maximal rise of blood glucose at 30 min of 51 mg/dl compared with a rise of 16 mg/dl during the control period. Glucose remained significantly elevated above fasting values at 120 min during the study but not the control period. IRI response after the 8 AM feeding was significantly greater and suppression of FFA was more marked during the study than during the control period. Glucose concentration 30 min after the 3 PM feeding was significantly lower during the study period than during the control period. A peak value occurred at 60 min during the study period which was equal to the 30 min peak control value. Despite the slower elevation of blood glucose during the study period, IRI rose at 30 min, possibly related to a larger influx of amino acids from the protein-containing meal. FFA rose at 30 and 60 min and were then suppressed by the slowly rising blood glucose. Growth hormone after both meals while consuming both diets was variable but considered normal. The qualitative changes in glucose-IRI-FFA responses were for the most part attributable to differences in the test meals and suggested little long-term adaptation to the uneven protein distribution diet.


Anti-platelet antibody determination by platelet factor 3 assay. Anti-platelet antibody determinations by a recently introduced platelet factor 3 assay (Pf-3 assay) were evaluated in 159 specimens from 95 patients who had low platelet counts. As a standard procedure, the 51Cr lysis test (51Cr test) was used. The 51Cr test and Pf-3 assay had an excellent correlation (results agreed for 80.5% of 159 specimens tested). Overall positive results for the 159 specimens were 27.7% by the 51Cr test and 22.0% by the Pf-3 assay. A significantly high incidence of anti-platelet antibodies (71.4%) was found in patients who had received more than 10 units of blood transfusions, in contrast to a non-transfused group, which had an incidence of 6.3%. The difference between transfused and non-transfused groups was significant (x2 = 11.854, p less than 0.001). The Pf-3 assay is easy to perform in most laboratories and yet sensitive enough to detect anti-platelet antibodies that were detectable by the 51Cr test.


The effect of increased contact activation time on the activated partial thromboplastin time. With the kaolin-cephalin activated partial thromboplastin time technic, the plasmas of persons who have Fletcher factor deficiency have shown considerable shortening of clotting times when contact activation has been lengthened from 3 (PTT-3) to 10 minutes (PTT-10). The authors demonstrate that in plasma of most normal individuals, and in coagulopathies of other sorts, only slight shortening usually occurs. Abnormal shortening occurs in plasmas of a few otherwise normal people, the "slow activators," and patients receiving coumarin drugs, who have greatly prolonged prothrombin times. Longer activation may produce greatly prolonged PTT's in plasmas containing heparin in relatively high concentrations. The authors discuss the significance of these findings.


Transfusion reaction with pulmonary infiltration associated with HL-A-specific leukocyte antibodies. A case of a non-hemolytic transfusion reaction with pulmonary infiltration secondary to leukocyte antibodies is described, and previously reported cases are reviewed. This type of reaction can be diagnosed at the bedside when a patient develops fever, hypotension and dyspnea within a few hours following transfusion of whole blood or a plasma product. The roentgenogram of the chest shows pulmonary infiltrates with a normal cardiac silhouette constituting non-cardiac pulmonary edema. To provide laboratory confirmation of this reaction, it is essential to search for leukocyte antibodies by both leukoagglutinin and cytotoxic technics, as well as to determine HL-A phenotypes of both donor and recipient. As the plasma products involved usually come from multiparous women, donor parity should be a routine question in the donor interview in transfusion services. To prevent this reaction, which may prove fatal, blood donated by women who have two or more children should be used for packed cells only.


Electronic platelet counts with the Coulter counter. Reassessment of a correction factor. Platelet counts are determined on the Coulter electronic counter by counting the diluted platelet-rich plasma obtained by sedimentation or centrifugation of whole blood. In calculating the whole-blood platelet count, an empirical correction factor for platelet-free plasma trapped by sedimented erythrocytes has been recommended, and a widely-distributed circular slide rule calculator incorporates the correction factor. In this study, visual and electronic platelet counts were compared in 100 specimens with counts ranging from 10 to 1,100 X 10(3) per mul and hematocrits ranging from 17.5 to 48.5%. Platelet-rich plasma samples prepared by a centrifugation method (Plateletfuge) gave machine counts in close agreement with those of samples prepared by sedimentation. Whole-blood platelet counts determined with the circular calculator were consistently lower than visual counts, with an average difference of -17%. The electronic counts were recalculated after elimination of the correction factor, and agreement then improved to an average difference of only +1.6%. The correction factor for trapped platelet-free plasma leads to erroneously low values and should not be used.