Serum bile acids after a test meal in Crohn's disease. The serum levels of conjugated cholic and chenodeoxycholic acid have been studied before and during a 4 h period after the intake of a liquid test meal in seven control subjects and in fourteen patients with Crohn's disease. The concentrations of serum bile acids were determined by radioimmunoassay. The control group showed a postprandial increase of both conjugates with a return to the fasting level for cholic acid within 4 h. The chenodeoxycholic acid conjugate did not return to the fasting level within the test period. The serum bile acid concentration in Crohn's disease divided the patients in two groups; one group with decreased or normal fasting levels and low postprandial increase and another group with elevated fasting levels and a postprandial increase without return to the fasting levels within the test period.


The relationship between the erythrocyte sedimentation rate (ESR) and plasma proteins in clinical materials and models. The relationship between the erythrocyte sedimentation rate (ESR) and plasma proteins was studied within homogenous clinical material and in vitro models. In acute phase reactions, fibrinogen was the likely cause of the ESR-elevation, but there were significant associations between the ESR and the concentrations of alpha 1-antitrypsin, C3, haptoglobin and albumin. In chronic diseases, the ESR-elevation was probably caused by fibrinogen, mono- or polyclonal increase of IgG, IgA, IgM alone or in combinations. In multiple myeloma of the IgG and IgA subtypes, significant correlations were found between the ESR and the monoclonal proteins or between the ESR and the percentage of plasma cells in bone marrow. Model studies showed that the ESR increased linearly with the concentrations of fibrinogen or gammaglobulin (IgG) when these exceeded normal thresholds. The ESR was slightly decreased by increasing concentrations of albumin. Albumin had a synergistic effect on the ESR together with gamma-globulin, but not together with fibrinogen.


Rapid and sensitive radioimmunoassays for human myoglobin. A radioimmunoassay for quantitation of serum myoglobin in healthy individuals and patients with different diseases is described. Purified myoglobin was labelled by an 125I-labelled ester (N-succinimidyl 3-(-4 hydroxy, 5-[125I]iodophenyl) propionate), a commercially available antiserum was used, and the antigen-antibody complex was precipitated with polyethylene glycol 6000. The rapid assay can be performed within 1 h at 37 degrees C with a detection limit of 45 micrograms/l. Prolonged incubation at 4 degrees C for 18 or 72 h gives a detection limit of 6 and 2 micrograms/l, respectively. The mean coefficient of variation of the routine assay was 11%. In healthy human subjects a significant difference in mean serum myoglobin concentration was found between 43 women (34 +/- 17 micrograms/l) and 51 mean 47 +/- 15 micrograms/l). In twenty patients admitted to hospital with the clinical diagnosis acute myocardial infarction, the serum myoglobin concentration profiles were in close agreement with the final diagnosis. In three patients with myocardial infarction serum samples were taken every 2 h after the acute episode, and serum myoglobin levels were compared with the levels of creatine kinase, lactate dehydrogenase, aspartate aminotransferase and creatine kinase isoenzyme-MB.


Effect of myocardial ischaemia and antilipolytic agents on lipolysis and fatty acid metabolism in the in situ dog heart. Myocardial metabolism was studied in open-chest dogs before and during induction of myocardial ischaemia by coronary artery occlusion. Blood was sampled from a local coronary vein draining ischaemic tissue and from coronary sinus draining predominantly nonischaemic tissue. In the basal state, induction of myocardial ischaemia stimulated myocardial lipolysis as shown by release of glycerol from the ischaemic zone. During isoprenaline infusion, free fatty acids (FFA) extraction across the ischaemic myocardium was substantially increased, but no glycerol release occurred. Pretreatment with nicotinic acid or sodium salicylate markedly depressed FFA extraction across ischaemic myocardium, both during basal and isoprenaline stimulated lipolysis and nicotinic acid most likely inhibited lipolysis in the ischaemic zone. Thus, reduced severity of acute ischaemic injury by antilipolytic treatment might be due to a combination of inhibited myocardial lipolysis and reduced FFA extraction.


Measurements of cardiac stroke volume in various body positions in pregnancy and during Caesarean section: a comparison between thermodilution and impedance cardiography. A total of 220 simultaneous pairs of measurements of cardiac stroke volume were made in twelve women before and during Caesarean section in order to compare impedance cardiography with the thermodilution method. A significantly higher coefficient of correlation was found before (r = 0.77) than during anaesthesia (r = 0.55). Further, there was a significant difference in the slope of the regression lines: before anaesthesia the slope was 1.07 and during anaesthesia with thiopentone, nitrous oxide, oxygen and suxamethonium it was 0.45. Significant changes in the intercept on the Y-axis were found before (-13.9 ml) and during anaesthesia (33.4 ml). When the uterus was displaced upwards and to the left from the 15 degrees tilt position the stroke volume and the cardiac output were increased when measured by both methods to nearly the same values as in the left lateral position. It is concluded that the impedance method is reliable for measuring cardiac stroke volume in late pregnancy under physiological conditions in the conscious patient, but that it cannot replace the thermodilution method in pharmacological studies.


Metabolism in hypothermically perfused human kidney carcinoma: incorporation rate of leucine into proteins. Protein synthesis in tumour-involved human kidneys was studied before, during and after hypothermic perfusion. Before and after perfusion the incorporation rate of leucine into tumour and kidney cortex proteins was determined by incubation of tissue slices at 37 degrees C. During perfusion the incorporation of leucine from the perfusate into tumour and kidney cortex proteins was determined. Before hypothermic perfusion the incorporation rate of leucine into proteins at 37 degrees C was almost the same in kidney cortex and tumour. Leucine was incorporated linearly with time into kidney cortex and tumour proteins during hypothermic perfusion but the incorporation rate was 3-4 times higher into kidney cortex proteins than into tumour proteins. After 6 days of hypothermic perfusion the leucine incorporation rate into proteins at 37 degrees C was depressed by 50% in kidney cortex and by 90% in tumour tissue. The specific activity of leucine in the perfusate decreased during the perfusion period indicating a release of leucine from degradation of proteins. It is concluded that the effect of hypothermic perfusion on protein synthesis was more pronounced in the tumour than in the normal renal parenchyma.


Creatine kinase isoenzyme MB assay by electrophoresis. A method for determination of the creatine kinase isoenzyme MB (CK-MB) is reported: separation of the isoenzymes was done by electrophoresis and the activity of the isoenzyme bands quantitated by scanning fluorometry. Total CK activity was used for calculation of CK-MB level. The precision of the method was satisfactory: coefficient of variation 5-10%. Its accuracy good: CK-MB was consistently found in high concentrations in tissue extracts of myocardium, but was virtually absent in skeletal muscle and could not be demonstrated in serum from patients with skeletal muscle damage. The sensitivity of the method fitted its clinical use: CK-MB was undetectable (less than 5 U/l) in normal sera, below 30 U/l in seventy-six out of seventy-seven patients in whom the diagnosis of acute myocardial infarction (AMI) was disproved, and above 30 U/l in all seventy-two patients with AMI according to WHO criteria. The CK-MB concentration in serum rises to a maximum about 20 h after onset of clinical symptoms of AMI and reaches baseline levels 20-30 h later. The electrophoretic CK-MB method is easy, fast and reliable and is considered as an important diagnostic test for AMI.


Interlaboratory variation of leukocyte differential counts: results from the Finnish proficiency testing programme in haematological morphology, 1974-1977. The interlaboratory variation of leukocyte differential counts in the Finnish proficiency testing programme in haematological morphology is presented. During 1974-1977 altogether twenty-four different blood smears with neither leukocytosis nor abnormal leukocytes were examined by the participants. During this period 206 laboratories participated in the voluntary programme. The interlaboratory variation of leukocyte differential counts was analyzed for band neutrophils, segmented neutrophils, eosinophils, basophils, lymphocytes and monocytes. Except for band neutrophils and monocytes the observed variations were found to closely match the known random sampling variation which is inherent in the method for estimating the proportions of the various leukocytes of peripheral blood. It is suggested that the results point to variations in the definitions to differentiate band vs. segmented neutrophils and monocytes vs. lymphocytes. Interlaboratory proficiency testing is considered to offer an effective means to investigate the quality of morphologic analyses as practised on a day to day basis in the participating laboratories.


Renal metabolic rate during changes in bicarbonate-dependent sodium reabsorption in the proximal tubules. Previous studies indicate that water and at least 2 mol NaCl are reabsorbed in the proximal tubules for each mol NaHCO3 reabsorbed. To examine the effect on cortical energy metabolism of variations in this bicarbonate-dependent sodium reabsorption, the cortical metabolic rate was examined in anaesthetized dogs by the heat production technique during continuous infusion of saline and ethacrynic acid. Sodium reabsorption was altered either by intravenous infusion of a large dose of acetazolamide (500 mg/kg body wt) or by changing plasma Pco2 during metabolic alkalosis. Acetazolamide reduced bicarbonate reabsorption by 71 +/- 2%, sodium reabsorption by 54 +/- 2% and cortical heat production by 21 +/- 3%. A rise in Pco2 to 16.4 +/- 1.3 kPa during metabolic alkalosis increased sodium reabsorption by 25 +/- 3% and cortical heat production by 14 +/- 2%. A similar elevation of plasma Pco2 during metabolic acidosis had no effect on electrolyte reabsorption or the cortical metabolic rate. A reduction in Pco2 to 2.3 +/- 0.3 kPa reduced sodium reabsorption by 40 +/- 3% and cortical heat production by 19 +/- 2%. We conclude that a rise in proximal tubular reabsorption requires energy. However, the changes in energy requirement are small, accounting for previous failures to observe significant changes in cortical energy metabolism during less extensive changes of sodium reabsorption in the proximal tubules.


Histamine metabolism in severe obesity before and after jejuno-ileostomy. Histamine metabolism was studied in three patients during histamine-reduced diet before and at intervals after jejuno-ileostomy by analyses of the urinary excretion of non-labelled and 14C-labelled histamine and its metabolites. Labelled histamine was administered intravenously and orally. The preoperative excretion of free histamine and its endogenously formed metabolites was essentially the same as in controls. After intestinal bypass the inactivation of [14C]histamine by both routes of administration was not impaired. Pronounced increases in the excretion of non-labelled conjugated histamine (acetylhistamine) and methylimidazoleacetic acid were found at different intervals postoperatively. This was probably due to histamine synthesis by intestinal bacteria since the diet only contained minute quantities of histamine. It is concluded that the increased urinary excretion of conjugated histamine after intestinal bypass indicated an abnormal bacterial activity in the intestine.


A rapid polyethylene glycol assay for gastric intrinsic factor. The use of polyethylene glycol (mol. wt 4000) in a rapid radioassay for intrinsic factor is reported. The assay is based on the observation that polyethylene glycol precipitates the intrinsic factor-vitamin B12 complex in the presence of serum from patients with pernicious anaemia having auto-antibodies against intrinsic factor. The assay was found highly reproducible (CV 1.8%) and well correlated to the classical method using coated charcoal in the separation step.


Intrarenal venous and cortical catheter pressures in the dog kidney. To examine the validity of intrarenal venous pressure (IRVP) as a measure of peritubular capillary pressure when obtained with a method applicable in man, IRVP was measured with a 0.9 mm o.d. catheter introduced retrograde into interlobar veins of anesthetized dogs and was compared with a modified needle pressure (cortical catheter pressure = RCCP) measured simultaneously in the same kidneys. In twelve dogs with a mean experimental kidney control sodium excretion of 91 +/- 15 (SEM) micronmol/min IRVP averaged 16.0 +/- 1.1 mmHg and was significantly lower than the average RCCP of 22.6 +/- 1.1 mmHg (P less than 0.001). These pressures compare well with the reported micropuncture pressures in the peritubular capillaries and proximal tubules, respectively, at comparable levels of sodium excretion. IRVP fell significantly during reduction of renal perfusion pressure within the range of autoregulation of renal blood flow and increased during elevation of renal pelvic pressure (PP). At at PP of 60 mmHg, when urine flow had stopped, the PP-IRVP gradient was 22.7 +/- 3.1 and increased to 36.7 +/- 3.8 (P less than 0.001) at a PP of 80. Acute renal vein constriction always increased IRVP before renal vein pressure reached the preceeding control level of IRVP. Increased urine flow during saline volume expansion and furosemid infusion was associated with increased IRVP. The results when compared with micropuncture data indicate that IRVP is a satisfactory expression of peritubular capillary pressure in the experimental conditions included in the study.


Postglomerular vascular hydrostatic and oncotic pressures during acute saline volume expansion in normotensive man. The importance of the peritubular physical factors as mediators of the natriuretic response to saline volume expansion was examined in twenty normotensive, hydropenic indivduals. Intrarenal venous pressure (IRVP), used as a measure of peritubular capillary hydrostatic pressure, and efferent arteriolar colloid osmotic pressure, calculated from arterial colloid osmotic pressure and the filtration fraction, were measured before and during sustained volume expansion with 0.9% NaCl, increasing the body weight by 3% and plasma volume about 20%. During expansion there was a significant increase in urine flow from 1.1 +/0 0.1 to 3.1 +/- 0.4 ml/min and sodium excretion from 161 +/- 12 to 551 +/- 61 microEq/min. Efferent colloid osmotic pressure fell from 31.9 +/- 0.6 to 23.6 +/- 0.5 mmHg (P less than 0.001) while IRVP changed from 24.8 +/- 0.8 to 25.1 +/- 0.9 mmHg (P greater than 0.10). In eight individuals IRVP increased during saline loading but later fell during sustained expansion. Glomerular filtration rate and renal blood flow did not change significantly. It is concluded that increase in peritubular capillary hydrostatic pressure is not necessary either to induce or to maintain the natriuresis of a moderate saline volume expansion. Although the fall in postglomerular vascular colloid osmotic pressure is a possible mediator of the natriuretic response, the change in peritubular transcapillary net driving force produced by a modest saline volume expansion is probably small.


Balance of net base in the rat: adaptation to and recovery from sustained hypercapnia. Net base and mineral balances were evaluated in a group of male 350 g Wistar rats exposed to 10% carbon dioxide in air for 10 days with a view to identifying the source of net base subject to retention during renal compensation of sustained respiratory acidosis. In response to hypercapnia, the rate of renal net acid excretion rose but insignificantly. However, a rise in whole body net base concentration from about 215 mmol/kg to about 250 mmol/kg came about by ongoing gastrointestinal absorption in the weight-losing animal, absorbed net base being distributed to extracellular and non-extracellular compartments of the body, presumably including bone. During an 8-day recovery period, a small decrement in whole body net base concentration was observed.


In vivo haemodynamic evaluation of the Hall-Kaster central flow prosthetic heart valve. The first in vivo haemodynamic observations of the recently developed Hall-Kaster central flow prosthetic heart valve are reported. Haemodynamic evaluation of valve function was performed both in acute and chronic experiments following implantation of the Hall-Kaster prosthesis in the mitral position in dogs. These studies showed a low transvalvular pressure gradient, an effective opening angle of about 70 degrees and good diastolic flow through both the large and small orifices of the prosthesis. A slow rotational movement was depicted by the disc during opening and closure.


Fatty acid metabolism during hypothermic perfusion of the isolated dog kidney. Perfusion of isolated dog kidneys was performed at 8--12 degrees C using an albumin solution containing caprylic acid (about 6 mmol/l) and long-chain fatty acids (about 0.5 mmol/l). During 48 h the amounts of caprylic acid in the perfusate fell by about 3 mmol, whereas long-chain FFA increased by 0.2--0.3 mmol and small amounts of arachidonic acid appeared. [14C]palmitate or [14C]linoleate--when added--decreased by about 10% in the perfusate. The decrease was mainly due to exchange with kidney phospholipid fatty acids. Only about 0.4% was recovered as [14C]CO2. The amounts of total phospholipids in kidney tissue decreased by up to 10% during the perfusion (when 10% kidney weight gain was taken into account), whereas lysophospholipids, cholesterol, triglycerides and free fatty acids remained essentially unchanged. The distribution of fatty acids in the total phospholipid fraction was strikingly altered. The relative amounts of arachidonic acid increased, whereas all other major fatty acids decreased. Synthesis of arachidonic acid by chain elongation of perfusate [14C]linoleic acid could not be demonstrated, and no evidence was found for a significant increase of the total amounts of arachidonic acid. The possibility that arachidonic acid-containing phospholipids in the kidney are preferentially preserved during the hypothermic conditions is discussed.


Gastric flow measured with hydrogen clearance technique. Regional gastric flow could be measured by hydrogen clearance technique. This method permitted the simultaneous measurement of flow in the mucosa, submucosa, and muscularis of both the antrum and corpus in anesthetized dogs. The main advantage of this method compared with other techniques used for gastric microcirculatory studies is that it offers the opportunity of repeated flow determinations in an anatomically identical area under various experimental conditions.


The effect of cholestyramine on bile acid kinetics in healthy controls. Serum lipids and the kinetics of the two primary bile acids, cholic acid (C) and chenodeoxycholic acid (CD), were studied in six normolipidaemic subjects before and during treatment with cholestyramine (12 g/day). After therapy, total serum and low-density lipoprotein cholesterol decreased by about 15%. These changes were accompanied by significant increases in the pool size, synthesis, and fractional turnover rate (FTR) of C and in the synthesis and FTR of CD. In spite of the enhanced formation of CD, the CD pool size decreased in all subjects, on average by more than 50%. The combined pool size of C and CD remained constant, but the mean total bile acid formation increased by a factor of 2.9. It is suggested that the different responses of C and CD, with an augmented contribution of C to the total amounts of bile acid produced, reflect an enhanced hepatic cholesterogenesis and, possibly, that C and CD to some extent originate from different cholesterol precursor pools.


Ampicillin concentrations in pancreatic fluid bile obtained at endoscopic retrograde cholangiopancreatography (ERCP). To investigate the distribution of ampicillin to the pancreas, ampicillin concentrations in pancreatic fluid obtained at endoscopic retrograde cholangiopancreatography (ERCP) were determined. Alternatively, ampicillin concentrations in bile obtained via ERCP were determined. Ten subjects with non-acute biliary-tract or pancreatic disease received a single dose of ampicillin (250 or 500 mg) parentally before ERCP. Timed simultaneous specimens of blood and pancreatic fluid or bile were obtained. Serum concentrations of ampicillin were measured in all subjects. In six of seven subjects no ampicillin was detectable in pancreatic fluid; in the seventh less than 1 microgram/ml was found. Pancreatic duct anatomy did not appear to correlate with pancreatic fluid concentrations. Failure to detect ampicillin in pancreatic fluid may account for results of clinical studies in which no clinical benefit from ampicillin has been found. Low or undetectable concentrations of ampicillin were found in bile; these concentrations in bile obtained at ERCP are similar to those found previously in bile recovered at biliary-tract surgery.


Microvasculature of the human pancreas. A microangiographic study. The microvasculature of six human pancreases was studied immediately after resection. Three of the pancreases were histologically normal, two were fibrotic, and one was inflamed. Immediately after resection a 10% Micropaque (Nicholas) solution was infused into the lienal artery for 1 h, and the tissue was studied by microangiography. The microvasculature of the normal human pancreas is very similar to the pancreatic microvasculature of the rat. Changes produced by inflammation in human pancreas seem to be similar to changes in the rat pancreas with experimental pancreatitis. Remarkable histologic changes of the pancreas cause only small changes in the anatomic arrangement of the arteries and arterioles, and slightly more changes in the acinar capillaries, which may explain the diagnostic difficulties associated with angiography of pancreatic disease.


The effect of experimental pancreatitis and diabetes on the microvasculature of the rat pancreas. Experimental diabetes was produced in 59 rats by intravenous injection of streptozotocin, and the rats were studied from 9 days to 4 months later. Experimental pancreatitis was produced in 28 rats by injecting sodium taurocholate, 3% or 6% solution in saline, into the pancreatic duct. These rats were studied with microangiography from 2 h to 4 days later. Experimental diabetes caused atrophy of the islets of Langerhans but did not cause any changes in the vessels of the exocrine pancreas, liver, or kidney up to 4 months. Capillary filling of the young, long-term diabetic rats was poor in all the examined organs, and the muscle arterioles showed variation of caliber. A 3% sodium taurocholate solution produced mild pancreatitis and little or no changes in the vasculature, whereas a 6% solution caused severe hemorrhagic pancreatitis with local extravasations and poor capillary filling. It is concluded that diagnostically useful vascular changes appear in the pancreas only if severe pancreatitis is present.


Gastric and colorectal cancer in Greenland. Diagnostic basis and minimum incidence. Forty-three gastric cancers, 38 colon cancers, and 26 cancers of the rectum were diagnosed among indigenous Greenlanders in the 20-year period 1955--1974. When cases based on clinical evidence only were excluded, a comparison with Danes showed significant deficits for male gastric cancers for 1960--1964 and female rectal cancers for 1970--1974. For the 20 years as a whole, gastric cancers in females were significantly lower than expected. Eleven clinical gastric cancers, 5 clinical colon cancers, and an additional 34 malignancies suspected of being primary gastrointestinal cancers had not been exhaustively investigated, mainly owing to metastatic spread and old age at the time of diagnosis. It seems reasonable to assume that the incidences of gastric cancer and of colorectal cancer in Greenland did not differ greatly from the incidences in Denmark during the study period in spite of dietary differences. A more regular use of rather simple examinations in the diagnostic routine is necessary for future epidemiological studies.


Liver copper content in patients with inflammatory bowel disease and associated liver disorders. In 45 patients with inflammatory bowel disease (9 with Crohn's disease and 36 with ulcerative colitis) and associated liver disorders, increased liver copper content (above 100 microgram/g dry weight) was found in 14 (31%). These patients represented about 50% of the patients with either biliary cirrhosis or pericholangitis. Four of the patients had levels regarded as compatible with hepatolenticular degeneration (greater than 250 microgram/g dry weight). In patients with chronic active hepatitis or non-specific changes in liver tissue, normal levels were found. The patients with Crohn's disease also had normal levels. Plasma ceruloplasmin was normal or increased in all. Determination of urinary copper output gave little diagnostic information. Alkaline phosphatases were markedly increased in most of the patients with increased liver copper concentration. In patients with ulcerative colitis and enhanced alkaline phosphatases, elevated liver copper content should be suspected and chelation therapy should be considered.


Endoscopic duodenal biopsies in coeliac disease and duodenitis. Endoscopic duodenal biopsies were taken from 27 patients with suspected coeliac disease and compared with intubation capsule jejunal biopsies. The specimens were reported without knowledge of the patients' names or symptoms. In 24 patients (89%), coeliac disease could either be diagnosed or excluded with 100% accuracy, despite the inability to orientate the biopsies correctly. Six biopsies were considered technically unsatisfactory, but only in three (11%) was it impossible to exclude coeliac disease. Duodenal biopsies were also taken from 118 consecutive patients attending for routine upper gastrointestinal endoscopy, and 1 patient with coeliac disease was discovered. We conclude that endoscopic duodenal biopsies are a reliable and worthwhile screening test for coeliac disease in certain patients attending for routine upper gastrointestinal endoscopy.


Mortality and autopsy rate for gastrointestinal diseases in Finland in 1955--1973. Gastrointestinal diseases accounted for about 10% of all natural deaths in Finland in 1955--1973. Total mortality for these diseases decreased slightly amongst young and middle-aged people in 1955--1973. This was mainly because mortality for ulcerative diseases of the stomach and the small intestine decreased continuously in practically all are groups, and also because the death rates of men and women from malignant neoplasms of the stomach decreased slightly but linearly at all ages. The autopsy rates increased highly significantly in all major categories of deaths between 1963 and 1973. In 1973 the autopsy rate for diseases of the digestive system (the ninth ICD main group) was 67%. This rate exceeded highly significantly the mean autopsy rate recorded for all (38%) and all natural deaths (33%). The autopsy rate for gastrointestinal malignancies was 26%, which in turn was highly significantly lower than the average rate for all and all natural deaths. The highest single autopsy rates in 1973 were recorded for ulcer of the duodenum (87%), diseases of the pancreas (78%), cholelithiasis (77%), and chronic enteritis and ulcerative colitis (76%). The present results suggest that the mortality statistics of Finland are obviously more reliable for the gastrointestinal diseases as a cause of death than in most other major categories of diseases.


Atopy in inflammatory bowel disease.

Atopy in inflammatory bowel disease. Thirty-nine patients with ulcerative colitis and 35 with Crohn's disease have been investigated for evidence of reaginic hypersensitivity and compared with control subjects. There was no difference in the frequency of a personal or family history of atopy or in serum IgE levels. Similarly, no overall difference was noted in prick test responses to 21 allergens. However, further analysis of prick test responses showed that patients with inflammatory bowel disease responded more frequently to food allergens. This was highly significant when compared with healthy controls (p less than 0.001). The relevance of this finding to the aetiology of inflammatory bowel disease is discussed.


Pressure profiles in ileal pouch outlets. Water-perfused open-tip catheters were used to measure the pressure profiles in the nipple valve of the continent ileostomy. In in vitro studies the conditions required to measure the yield pressure in collapsed vessels like the nipple valve were determined. Flow rates below 4--5 ml/min should not be used when measuring the pressure with open-tip catheters size Ch 8. At lower flow rates the yield pressure was underestimated. When appropriate flow rates were used, a moderate increase of the perfusional flow rate did not increase the measured pressure notably. Measurements were performed in 31 patients with continent or incontinent ileostomy reservoirs. Nineteen patients had outlets with a nipple valve, and 12 patients outlets without such a valve. In most cases it was possible to distinguish a pressure zone in the outlet. The length of the pressure zone was fairly constant in consecutive measurements, whereas the pressure varied, presumably owing to contractile activity, in the outlet. In continent patients with nipple valve outlets the pressure was significantly higher than in patients who were incontinent owing to nipple valve sliding. In patients who were incontinent owing to fistula formation the pressure was of the same order of magnitude as in continent patients.


Intestinal villous atrophy in chronic active hepatitis. Three out of 16 patients with chronic active hepatitis (CAH) had total or subtotal villous atrophy in a suction biopsy taken from the upper jejunum. One of the three patients had a history of intestinal dysfunction. The patients with abnormal intestinal mucosa had lower levels of serum albumin and higher levels of IgG than patients without intestinal mucosal changes. The occurrence of intestinal villous atrophy in CAH may be due to a genetically determined disposition to CAH and coeliac disease associated with HLA-B8, which was carried by all three patients. The present findings have led to trials with gluten-free diet in CAH associated with intestinal villous atrophy.


Blood flow distribution in the stomach of cats with acute gastric ulcer. An ulcer was induced in the anterior wall of the antrum of cats by local injection of acetic acid solution. Carbonized microspheres, 15 +/- 5 microns in diameter, labelled with 141Ce, were used to measure blood flow in different regions and layers of the stomach wall. The radioactivity of a blod reference sample and of tissue samples was determined, and the blood flow was calculated for each tissue sample. The gastric tissue samples were examined microscopically, and the level of gastrin in serum was determined. Two groups of anaesthetized animals were used: in one group of animals blood flow was determined 24 h after ulcer induction and in a group of control animals 24 h after laparotomy. In the ulcer animals the gastric blood flow as increased both in the mucosa and in the muscularis in a zone around the ulcer. Microscopic examination revealed tissue necrosis corresponding to the floor of the ulcer and acute inflammatory changes in the gastric wall around the necrotic area. The serum gastrin concentration tended to increase after ulcer induction.


Effect of indomethacin on blood flow distribution in the stomach of cats with acute gastric ulcer. An ulcer was induced in the anterior wall of the antrum of cats by local injection of acetic acid solution. Carbonized microspheres, 15 +/- microns in diameter, labelled with 141Ce, 46Sc, and 85Sr, were used to measure blood flow in different regions and layers of the stomach wall. The radioactivity of a blood reference sample and of tissue samples was determined, and the blood flow was calculated for each tissue sample. The blood flow distribution was determined before, 1/2 h, and 1 h after an intravenous infusion of indomethacin in a dose of 3 mg/kg. Two groups of anaesthetized animals were used: animals with a 24-h gastric ulcer and control animals 24 h after laparotomy. In the control animals indomethacin caused a mean reduction in gastric mucosal blood flow of approximately 50%. The flow reduction was about the same in different regions of the stomach. In the muscularis there was no change in blood flow after indomethacin. The blood flow was reduced in the duodenum and jejunum but not in the other intestinal organs studied. The blood pressure and cardiac output remained unchanged. In the ulcer group indomethacin caused about the same reduction in mucosal blood flow. However, the blood flow was reduced less in the ulcer region and tended to increase in the mucosa around the ulcer 1 h after indomethacin infusion.


The value of the 14C breath test in the assessment of fat absorption. The absorption of oral 14C-glyceryl tripalmitate was tested in 77 subjects by hourly interval sampling of breath 14CO2 for up to 6 h. A highly significant correlation was obtained between maximum breath 14CO2 activity and faecal fat excretion. The test was very effective in differentiating between patients with and without steatorrhoea. Repetition of this examination with oral 14C-palmitic acid demonstrated normal absorption in pancreatic steatorrhoea but impaired absorption in intestinal steatorrhoea, thus enabling these conditions to be distinguished. The 14C breath tests are most useful as simple and inexpensive outpatient screening tests for steatorrhoea.


Effect of metoclopramide on oesophageal peristalsis and gastro-oesophageal sphincter pressure. A study in normal subjects. The aim of the present study was to measure the amplitude, the duration, and the velocity of the peristaltic pressure wave in the lower part of the oesophagus in the basal state and at different time intervals after oral intake of 10 and 20 mg metoclopramide. In addition, gastro-oesophageal sphincter pressure was measured in the basal state and 90 min after the intake of metoclopramide. The pressure studies were carried out in eight healthy subjects, using a pressure probe consisting of two open-tip polyethylene catheters that were fed by a capillary tubular system and connected to external pressure transducers. Sphincter pressure was measured (intermittent withdrawal), and the probe was positioned with the distal opening 5 cm orally to the sphincter. Dry and wet (bolus, 5 ml of water) swallows were made in randomized order in the basal state and at the time intervals after the intake of metoclopramide. Finally, the sphincter pressure measurement was repeated. No differences were seen with regard to the peristaltic activity: amplitude, duration, or velocity. Sphincter pressure rose from 12 to 19 mmHg after 10 mg (p less than 0.05) and from 13 to 20 mmHg after 20 mg metoclopramide (p less than 0.05). There were no significant differences between basal values and the response to 10 or 20 mg metoclopramide.


The effect of a test meal on plasma vasoactive intestinal polypeptide (VIP), gastric inhibitory polypeptide (GIP), and secretin in man. In six fasting healthy young male students a 15-min test meal consisting of 160 ml milk, 200 ml coffee, 70 g bread, 3.5 g butter, 35 g cheese, and 30 g ham (45 g carbohydrates, 30 g proteins, and 25 g fat) caused a late but significant elevation in plasma vasoactive intestinal polypeptide (VIP), an early and sustained significant rise in plasma gastric inhibitory polypeptide (GIP), but no significant change in plasma secretin.


Hepatic handling of a gamma-emitting bile salt derivative, 123I-cholylglycylhistamine, in the dog. The hepatic handling of the bile salt derivative 123I-cholylglycylhistamine has been compared with that of the physiologic bile salt taurocholate in boxer dogs equipped with a Thomas duodenal cannula. After intravenous injection of trace amounts, 123I-cholylglycylhistamine and 14C-taurocholate disappeared from plasma with nearly identical disappearance rate constants. Excellent scintiscans of the liver were obtained with the Anger camera after injection of 3 mCi of 123I-cholylglycylhistamine. Monitoring of radioactivity over a hepatic region of interest revealed rapid uptake of 123I-cholylglycylhistamine by the liver, which reached a maximum 5.7 +/- 0.4 min after injection. The biliary excretion rates of the compounds closely paralleled each other, reaching their maximum within 15 min after injection. Cumulative biliary excretion within 45 min was 58.5 +/- 2.9% and 61.4 +/- 5.0% of the dose for 123I-cholylglycylhistamine and 14C-taurocholate, respectively. Modification of the side chain and gamma-labelling of bile salts may provide scintigraphic agents for the study of the biliary system, which in the behaviour closely resemble the physiologic parent compounds.


Gastric bile acids before and after Roux-en-Y transposition for bile reflux gastritis and in asymptomatic controls. Eight patients with severe postgastrectomy syndromes for predominantly bile reflux gastritis were examined by quantification of bile acids in the gastric remnant before and after a standardized liquid meal. Gastroscopy with biopsy and determination of gastric acid secretion and gastric emptying were performed. Six of the patients were also studied 3 months after Roux-en-Y transposition. Controls consisted of six completely asymptomatic partially gastrectomized patients studied 4--11 years postoperatively and six healthy students without any history of gastrointestinal disease. The healthy subjects had virtually no reflux of bile acids in the fasting state or after a meal. Both the symptomatic and asymptomatic patients had reflux in the fasting state and postprandially. The reflux of bile acids was, however, significantly greater late in the fasting period and early in the postprandial period in the symptomatic patients than in those without symptoms. The Roux-en-Y transposition eliminated the bile acid reflux and the symptoms of bile reflux gastritis but did not change the gastric emptying pattern. In patients with reflux gastritis the acid disappearance in the gastric remnant was moderate and the maximal acid output was unchanged after Roux-en-Y transposition.


Cimetidine treatment of recurrent ulcer. Twenty-one consecutive patients with endoscopically proven recurrent ulcer were treated continuously with cimetidine, 1 g daily for 8 weeks. After 4 weeks' treatment 18 (86%) of the patients were free of symptoms, and the ulcers had healed in 17 (81%). At the 8th-week examination symptoms had disappeared, and ulcers were healed in 19 patients (91%). Within 6 weeks after withdrawal of cimetidine six patients (28%) presented recurrence of ulcers and symptoms. This study demonstrates that recurrent ulcer patients respond to cimetidine with regard to healing of ulcers and disappearance of symptoms, as do unoperated duodenal ulcer patients. Because operation for recurrent ulcer carries an increased mortality, we suggest that cimetidine should be attempted in the treatment.


Measurement of duodeno-gastric reflux in dogs. For the elaboration of a formula estimating the reflux volume of duodenal secretion into the stomach, gastric and duodenal secretion have been studied during pentagastrin and secretin stimulation. In the stimulated gastric secretion the concentration of sodium varied with the secretion rate, whereas the concentration of chloride was nearly constant. The concentration of sodium in duodenal juice was constant, but the chloride concentration dropped significantly during secretin stimulation. Secretin induces duodenal reflux. When duodenal reflux occurs, a substantial amount of the sodium in gastric juice is attributable to intruding duodenal juice. The formula gives the duodenal reflux volume in 15-min samples on the basis of the sodium in gastric secretion and in the duodenal juice. A concentration of sodium in samples of gastric juice twice exceeding the concentration of sodium in maximally stimulated gastric secretion (8 +/- 2 mmol/l, mean +/- S.D.) may suggest 'contamination' of the samples with duodenal juice. The present formula allows for quantitative determination of this 'contamination.'


Hepatic sinusoidal dilatation in Crohn's disease. In a prospective study of liver function in 19 patients with Crohn's disease, examination of liver biopsies showed a sinusoidal dilatation in 16 patients. This dilatation was moderate in 5 cases and pronounced in 6 cases and was associated with a closely parallel dilatation of the centrilobular vein. There was no correlation between these diffuse vascular changes and the site of the bowel disease, the clinical presentation, and the course of the disease. The pathogenesis of this sinusoidal dilatation is unknown.


The diagnostic accuracy of gray-scale ultrasonography compared with ERP and arteriography in the detection of pancreatic carcinoma. Forty patients who underwent ultrasound, endoscopic retrograde pancreatography (ERP), and selective arteriography examinations and who had a finding of or were suspected of having pancreatic carcinoma in one or several of these examinations form the basis of the study. Nineteen pancreatic carcinomas were verified at operation. Eighteen of these could be detected with ERP, 18 with arteriography, and 15 with sonography. ERP had no, arteriography one and sonography one false-negative finding. All methods had difficulties in distinguishing carcinoma from other pancreatic diseases, and therefore there were many false-positive findings.


Penetration of cephradine and cefazolin into ulcers of patients suffering from peripheral arterial circulatory insufficiency. 11 patients with peripheral arterial circulatory insufficiency with ulcers on the big toe or on the heel were given 1 g of cephradine intravenously (i.v.) and later 1 g of cefazolin i.v., two cephalosporins with different degrees of protein binding. Antibiotic concentrations were followed in serum and wound secretions after the injections. The peripheral circulatory state of the patients and the degree of protein binding of the cephalosporins used seemed to be of minor importance for the concentrations of the antibiotics in the ulcers, i.e. the infectious focus, compared to local factors such as the bacterial flora of the ulcers. In-vitro studies with bacterial strains isolated from the ulcers of 2 of the patients indicated that beta-lactamases from gram-negative bacteria might be at least part of the explanation for the low concentrations in wound secretion of one or other of the agents used in 4 out of the 11 patients.


Granulocyte function during prophylaxis with doxycycline. The influence of doxycycline on granulocyte migration was investigated on patients undergoing fracture surgery. The granulocyte migration of the patients was depressed when doxycycline was administered. Scanning electron microscopy demonstrated a decreased granulocyte adherence to glass as well as a decrease in number of filopods per cell in the presence of doxycycline.


Local and Gastrointestinal reactions to intravenously administered cefoxitin and cefuroxime. Side effects of cefoxitin and cefuroxime were noted in 2 different studies during intravenous treatment for at least 14 days. In the cefoxitin group of 33 patients thrombophlebitis was observed in 3 cases and diarrhoea in 4 cases. In the cefuroxime group of 31 patients 1 case of thrombophlebitis was noted and 5 cases of diarrhoea occurred. Most patients with diarrhoea had decreased renal function or received higher dosage of the antibodies than the other patients.


Experience of the Rieser operation for chronic female urethritis. A follow-up study of 42 cases. Forty-two women with chronic urethritis of 2 to 30 (mean 10.7) years' duration underwent the Charles Rieser operation. The symptoms in all cases were severe and therapy-resistant. The follow-up time was 2 to 27 (mean 12.8) months. Two patients were almost asymptomatic, 6 had only minor persistent symptoms, 8 were somewhat improved but still had symptoms requiring therapy, and 25 had not benefited by the Rieser operation. Two patients had more severe symptoms postoperatively than preoperatively. Initial improvement, lasting 0.5 to 13 (mean 3.9) months had occurred in 28 patients, but was often followed by deterioration. Stress incontinence, present preoperatively in 11 women, was improved in 4 cases and unchanged in 7 after the operation. Sacro-iliitis was associated with the chronic urethritis is 5 patients. It was not improved by the operation. The procedure's mode of action and the complications are discussed.


A morphological study on the effect of cyproterone acetate on human prostatic carcinoma. Sixteen patients with prostatic carcinoma were treated with 200 mg of Cyproterone acetate daily. No other kind of hormonal treatment was given. Transrectal biopsies of the prostate were taken before the treatment was started, and at regular intervals afterwards. The treatment period lasted from 3 to 16 months, with an average of 9 months. A thorough examination of multiple sections from all specimens revealed no convincing signs of cellular involution. The study has demonstrated no specific or significant atrophic changes following Cyproterone acetate therapy. Some possible explanations regarding the effect of Cyproterone acetate on human malignant prostatic tissue are discussed.


Malignant testis tumors. Survival in 53 patients with minimum 5 years observation time. Survival rate of 53 patients with malignant testis tumors treated during the years 1956-1971 is reported. The observation time is from 5 to 20 years. Thirty-three patients are still alive. Eighteen out of 20 patients with pure seminoma stage A-B are alive, and 1 out of 3 in stage C. Of the 30 patients with non-seminomatous tumors all 8 patients in stage A are alive, while only 1 out of 9 in stage B, and 1 out of 9 patients in stage C have survived. Four patients (including 3 children) which could not be classified according to stage are all alive. All the patients who did not survive died within 5 years after the diagnosis. A new treatment protocol for testicular malignancies is described.


Tumours of the renal pelvis and ureter. Symptomatology, diagnosis, treatment and prognosis. Forty-two cases of tumour of the renal pelvis and/or ureter are presented. The primary tumour was in the renal pelvis in 25 cases and in the ureter in nine. A co-existent tumour elsewhere in the uroepithelium was found in 16 of these 34 patients. In the remaining eight patients, tumour of the urinary bladder was the initial diagnosis, but tumours of the upper urinary tract subsequently appeared. The principal symptom (38 of 42 cases) was haematuria, but flank pain and a mass in the kidney region also occurred. In most cases the diagnosis was indicated by the urograms and was confirmed by retrograde pyelography. Nephro-ureterectomy was done in most of the patients. The possibility that local tumour resection may be sufficient is briefly discussed. The tumours were classified as papillary in 24 patients and as solid in nine. There was no histologic classification in nine cases. The mean observation time was 29 months. Since new growths tend to arise at other sites in the uro-epithelium, follow-up examination should always include cystoscopy and urography. The prognosis was particularly poor in solid tumours: two-thirds of these patients died in the first postoperative year. Survival was clearly dependent on the tumour differentiation. High-grade tumours carried a poor prognosis.


Antithrombin III in uremia.

Antithrombin III in uremia. Antithrombin III (AT-III) was measured immunologically in 20 uremic patients on maintenance hemodialysis and in 10 non-dialysed uremic patients. The dialysed patients had slightly elevated AT-III levels. The non-dialysed patients had significantly elevated AT-III levels. A negative correlation was found between AT-III and serum creatinine and between AT-III and serum albumin. AT-III did not correlate to the heparin amount required for hemodialysis. A negative correlation was found between the heparin requirement and serum albumin. It is suggested, that serum albumin might facilitate the action of AT-III and heparin. It is also suggested, that AT-III levels may be high in active renal disease, decreasing as uremia advances.


Urological septicemia. A retrospective study. In order to investigate the clinical course and outcome of septicemia in urological patients, data were collected retrospectively from all patients admitted to a specialized urological department, in whom positive blood cultures were drawn. During a 5-year period 91 patients were registered with urosepsis corresponding to an incidence of 1.2%. In non-iatrogenic urosepsis due to ureteral obstruction women dominated over men, however, in iatrogenic disease--after investigative manoeuvres as well as after surgery--men by large dominated the material. Gram-negative bacteria were responsible for almost 75% of the septicemias and for 99% of the cases where septic shock was present. Where a urinary infection was demonstrated prior to septicemia (45%- identical bacteria were subsequently found in the blood, whether the focus had been successfully treated or not. Septic shock developed in 20 of the patients of whom 3 died. This overall mortality of 3% occurred only in patients with comcomitant serious disease. In general the course of septicemia was benign and the complication rate low. It is concluded that in urological patients septicemia is a less serious problem than in gastroenterological patients. The possible explanation for this is discussed in relation to the more discrete diagnostic and therapeutical procedures in the urological clinic.


Blood pressure measurements in the conscious rat. An improved photoelectric, sphygmomanometric device. A photoelectric device for repeated, noninvasive registration of blood pressure in the tail of the rat was built, mainly using available materials and components. A description of the measuring system is given. Comparison between blood pressure measurements performed simultaneously in the tail of the rat and intravascularly in the aorta are in good agreement.


Urinary bladder tumours in children. Case report of inverted papilloma. A short review is given of tumours of the urinary bladder in children, and the first case of an inverted papilloma in a child is reported. The tumour was situated in the trigone of the bladder and was successfully extirpated, with no recurrence at follow-up 9 months later. It was histologically typical of these tumours. The 105 patients described in the literature had an average age of 55 years, whereas the present case is the first to be described arising during the first two decades of life. The most frequent symptoms of such tumours are haematuria and urinary obstruction. It is suggested that the treatment of choice is transurethral excision. The term Brunnian adenoma is recommended for use with this tumour, in order to avoid the impression given by the name papilloma of the bladder, that the tumour is malignant.


Renal adenomatosis. Report of an autopsy case. An incidental finding at autopsy of a 72-year-old man was that both kidneys contained more than a hundred small (diameter 1-7 mm) white tumours, which could be classified as benign adenomas both histologically and at electron microscopy. The relationship between renal adenoma and renal adenocarcinoma is discussed, and it is concluded that this case represents a benign condition. The appropriate designation for this new entity is renal adenomatosis.


Principles of treatment in chiropractic. An attempt has here been made to summarize some views on chiropractic methods of examination and treatment as well as some theories on the origin of the disturbances. The general and mechanical examination has been described and examples given of adjustments of the cervical, thoracic, and lumbar spines. A chiropractic adjustment has been defined and the mechanisms of an adjustment of a diarthrodial joint discussed. Functional disturbances in the intervertebral joints, the intervertebral discs, and the foramina intervetebralia are also considered.


Principles of examination and treatment in manual medicine. Manual medicine is a diagnostic and therapeutic technique, comprising the use of the hands. It is a complement to general medical diagnosis and therapy of the locomotor system, underlining the value of the information which can be obtained by manual contact with the patient. Particularly the physician's work within manual medicine will be discussed. Some general medical principles are looked upon as obvious: The physician's general responsibility, the necessity of a correct diagnosis, prescription of correct medication or surgery, organization of rehabilitation and evaluation of work capacity.


Immunoprofile studies in patients with pulmonary tuberculosis. III. Study of haemolytic complement in serum and phagocytic activity of blood neutrophils. The total level of haemolytic complement in serum, and the phagocytic activity of blood neutrophils were found to be significantly increased in patients with active pulmonary tuberculosis prior to treatment. A relationship could not, however, be demonstrated between the elevation in the two studied values and the extent of tuberculous changes in the lungs of the patients.


Serological diagnosis of tuberculosis. Evaluation of two years' experience. Two years' experience of a simple serological test for the diagnosis of tuberculosis has been evaluated. This test fails to distinguish clearly between tuberculous and non-tuberculous patients. There is an unacceptably high incidence of false positive and false negative results, although the latter would be reduced by taking the highest titre values of several samples from one patient. Modification of the test to eliminate IgM agglutination produced a marked fall in false positive results. These preliminary results suggest that this modified test is more useful, in that a positive test is a strong indication of tuberculosis. The use of a Coombs' test to agglutinate incomplete complexes did not improve results.


Lung cancer. Symptoms, signs and diagnostic criteria. A consecutive hospital series of 1 053 patients treated for lung cancer during the period 1962 through 1971 has been studied. Clinical symptoms were present more often in men than in women and in 42% symptoms had been noted more than 6 months prior to the diagnosis. Peripheral tumours gave less symptoms than central ones. Although in 22% of the patients the tumour was discovered on a chest film in the absence of relevant symptoms, 12% only had been detected by regular mass X-ray screening. More than 40% of the peripherally located tumours were clinically silent. Squamous cell and anaplastic small cell cancers were predominantly centrally located (80 and 90%, respectively) against 65% and 74% for adenocarcinomas and undifferentiated large cell tumours.


Lung cancer. Treatment and early results. Of 1053 patients with primary cancer of the lung, 549 (52%) underwent thoracotomy and 40% a presumably radical resection. Lobectomies were performed in 227 patients (41% of those operated), pneumonectomy in 160 (29%). Early mortality (death within 30 days) was 5.5% with the highest figure (11%) after pneumonectomy, 5% after explorative thoracotomy and 3% after lobectomy. Cardiorespiratory failure and myocardial infarction occurred in 19 (3.5%) of the operated cases and were responsible for 14 early deaths. Bronchopleural fistula developed in 11 patients. Of 874 morphologically classified tumours, squamous cell composed 45%, undifferentiated large cell 17%, small cell anaplastic 14%, adenocarcinoma 19%, carcinoid 2% and others 3%. Of 21 tumours typed as small cell anasplastic prior to therapy, six were differently classified at the later (postoperative/postmortal) stage.


Treatment of recurrent pleural effusion by pleurodesis with quinacrine. Comparison between instillation by repeated thoracenteses and by tube drainage. A total of 121 pleurodeses using instillations of quinacrine (mepacrine) in patients with recurrent pleural effusion were performed. All but three patients suffered from pleural malignancy. A comparison was made between the results achieved by repeated thoracenteses (73 cases) and by simultaneous tube drainage (48 cases). Tube drainage shortened the treatment and lowered the number of painful interventions. There was no difference in the quality of pleurodesis achieved by the two methods. The treatment failed in 12% of patients treated by repeated thoracenteses and in 14% of those treated by tube drainage. Patients with pleurodeses survive longer than non-treated subjects and have a considerably better quality of life.


Corticosteroid therapy of pulmonary sarcoidosis. A prospective evaluation of alternate day and daily dosage in stage II disease. Thirty-nine sarcoidosis patients with pulmonary infiltrations (stage II) of less than 5 years duration and not treated earlier with corticosteroids were randomly allocated for treatment with methylprednisolone for 7 months or for observation without therapy. Every other treated patient was given the drugs daily and every other followed an alternate-day regimen. After 7 months the chest radiographic finding, the forced vital capacity and the diffusion capacity for carbon monoxide were superior in the treated group. There was no difference between the two drug regimens. After 24 and 48 months no statistically significant differences between the untreated and the treated groups were found.


[Local reactions after repeated tetanus vaccinations]. Subjects who had exhibited a strong local reaction after vaccination with tetanus toxoid showed a high serum antitoxin titer. This observation confirms earlier findings published in the United States. Since the falloff rate in tetanus antitoxin, year by year, is no more than 30%, such patients should not receive a new booster injection in the following 10 years unless the risk of tetanus is considered great. When boostering these persons, the dose of tetanus toxoid can be reduced to 1-2 Lf.


[Isoelectric focusing and agar electrophoresis of the cerebrospinal fluid in neurologic patients]. Both isoelectric focusing and routine agar gel electrophoresis have been carried out on the CSF, and in some cases also on the corresponding serum, from 452 control subjects and patients with neurological diseases among whom cases with multiple sclerosis (MS) predominated. Comparison of the results confirms the superiority of electrofocusing over gel electrophoresis for the evaluation of oligoclonal immune reactions of the CNS. Over 90% of the MS patients showed discontinuous subfractionation of the gamma-globulins, mostly confined to the CSF, whereas with agar gel electrophoresis an identical effect could be seen only in about 60% of the same patients. Of special interest is the fact that by isoelectric focusing an additional 20% of MS patients whose gamma-globulin content, cell count and plasma cell findings in the CSF are within normal limits show oligoclonal CSF immune reactions. Thus, after appropriate screening by routine electrophoresis to reduce the number of analyses, the relatively laborious method of isoelectric focusing is an effective addition to the usual CSF investigations.


[Elements of the prognosis of invasive epidermoid carcinoma of the cervix. Study in terms of the clinical stage and histologic criteria]. The prognosis in 143 cases of squamous cell carcinoma of the uterine cervix was studied in terms of clinical stage and various histological parameters. The results were compared with those in the world literature. In our series the clinical stage proved to be the most decisive element in the prognosis: the survival rates of stages I to IV were 77.1%, 58.3%, 28.6% and 0% at five years and 65.7%, 51.7%, 20.0% and 0% at ten years. The majority of deaths due to cancer occurred in the first five years after treatment. The prognosis was less favorable when the carcinoma occurred on the cervical stump after subtotal hysterectomy. The authors found Wentz and Reagan's histological classification adopted by the WHO to be difficult if not impossible to apply uniformly without error, due to numerous mixed forms. In addition, it has no statistically significant prognostic value. Among the other parameters considered in this study, only the type of stroma appeared to have some prognostic value. The prognosis was less favorable in tumors with a stroma of the fibrous type.


[Rubella infection during pregnancy. Results of serologic diagnosis 1975-1978]. The sera of 663 pregnant women with unknown immune status were tested for HI rubella antibodies between 1975 and 1978 because of exposure to rubella or presence of clinical symptoms. The majority of sera were from women in the first three months of pregnancy. Comparison of the distribution of antibody titers with those in a control group of 670 nonpregnant women of the same age showed no significant difference. The percentage of seronegative subjects was 8.6 in pregnant and 10.5 in nonpregnant women. Eighteen women (2.7%) became infected with rubella virus during pregnancy. Ten of these were devoid of rubella antibodies, representing 17.5% of the seronegatives. Diagnosis was confirmed by seroconversion and rise in antibody titer. The remaining 8 women had antibodies in the first blood specimen. Diagnosis was established by a fourfold or greater increase in titer or by the demonstration of rubella specific IgM-antibodies in a single specimen. It is of interest that almost all the pregnant women with rubella infection had clinical symptoms such as fever or exanthem. The results of this study show that the aim of complete rubella prophylaxis in women of childbearing age has not yet been achieved. It is therefore necessary to increase the uptake of rubella vaccine by schoolgirls and reduce the percentage of seronegative adult women by single vaccination and vaccination in the postpartum period.


[Various aspects of respiratory emergencies in non-hospital practice]. Classical symptoms and signs common to most pulmonary diseases, such as dyspnea, cough, chest pain and cyanosis, are reviewed to assess their significance for diagnosis and evaluation of the degree of impairment in acute respiratory failure. While frequently useful for diagnosis, they are often inadequate to determine the degree of emergency. In each particular etiology other information is needed to obtain an objective and quantitative assessment. Two examples selected for their frequency are considered: barbiturate intoxication and severe exacerbations of asthma. The severity of barbiturate poisoning can be assessed clinically in the light of the degree of central nervous depression. Classical signs and wheezing are poorly correlated with the intensity of acute asthmatic attacks, but high-risk patients can be identified by seeking neglected physical findings such as pulsus paradoxus and sternomastoid muscle contraction. In many other pulmonary emergencies further studies are required to assess the usefulness of various clinical signs as objective indices of the severity of respiratory impairment.


[Respiratory failure and surgery].

[Respiratory failure and surgery]. The question whether a patient may be amenable to surgery involving anesthesia depends on many different factors and can only be answered by the anesthetist-surgeon team. The internist, on the other hand, will determine the degree of functional impairment of particular organ systems and cooperate in preoperative preparation of the patient. Patients with obstructive pulmonary disease are particularly at risk, especially during the postoperative period. The search for pulmonary symptoms is therefore extremly important. The limiting values given in medical literature are not absolute. Through preoperative therapy, the choice of suitable anesthetic methods and optimal postoperative care in an efficient intensive care unit, the risk of perioperative mortality and morbidity for this "poor risk patient" can be reduced almost to the level of the average surgical patient.


[Clinical value of human thyroglobulin measurement]. A direct radioimmunoassay for human serum thyroglobulin (TG) has been developed. The lower limit of detection of the assay was 7.5 ng/ml. The serum values in normal subjects were between 0 and 44 ng/ml (n = 34, 21 female subjects, 13 male subjects). In 22 of the 34 subjects, TG was not detectable. The mean value of TG in a group of 19 subjects with multinodular goiter was 115.8 +/- 62.7 ng/ml (mean +/- SD). A group of 16 thyrotoxic individuals also had an elevated TG concentration (107 +/- 71 ng/ml). The serum TG levels in 6 patients with differentiated thyroid carcinoma with metastases were much more elevated than in any other clinical situation (3430 +/- 1100 ng/ml). In patients with thyroid cancer in clinical remission (n = 9), the TG levels were normal. In 2 patients with non-differentiated thyroid tumors, TG was not detectable. The major methodological problem in TG determination is the presence of anti-TG autoantibodies which may interfere with the radioimmunoassay.


[Electrocardiographic manifestations of myocardial ischemia]. The ECG is an indirect and non-specific test of myocardial ischemia, which means that the limits in respect to sensitivity and specificity must be evaluated. The dynamic Holter ECG is a useful method, particularly if pain appears during the recording time. The exercise test as an example of additional stress is of great general interest, especially in man; stress-testing is particularly useful in explaining the origin of atypical anginal pain. Hence the interpretation criteria must be closely followed rather than enlarged as long as the indication for diagnostic coronary-angiography is limited by the result of exercise testing. When other non-invasive methods are not readily available it should be possible to broaden the diagnostic criteria to increase sensitivity; by the same token, the number of false positive tests will be controlled by these complementary non-invasive methods.


[The diagnosis of coronary disease and of myocardial ischemia by means of echocardiography]. An attempt is made to define the respective roles of one- and two-dimensional echocardiography in the evaluation of coronary heart disease and myocardial ischemia. The two methods have their advantages and drawbacks and are complementary. Echocardiography provides information on the motion of the various ventricular segments; when the technical quality of the recording is good, it shows excellent correlation with left ventriculography. Echocardiographic diagnosis of myocardial ischemia usually implies provocative manoeuvres which are difficult to perform. Finally, echocardiography is an excellent method for the evaluation and follow-up of patients with acute myocardial infarction.


[Determinants of left ventricular function in aortic stenosis. Analysis based on pre and postoperative hemodynamic studies]. In 11 preoperative patients with aortic stenosis the isovolumic contractile indices Vpm and Vmax were normal (group N). In 8 patients with aortic stenosis these indices were depressed (group D). Peak systolic circumferential wall stress (afterload) did not differ in the two groups and showed a similar decrease after successful valve replacement. Left ventricular ejection fraction increased significantly in group D from 48 to 71% and remained unchanged in group N (70 and 75%). It is concluded that the significant improvement in ejection performance in group D at similar afterload conditions as in group N is indicative for an impaired preoperative myocardial contractile state.


[Radionuclide determination of the left ventricular ejection fraction under stress: comparison with angiocardiography]. Left ventricular ejection fraction (LVEF) determined by first pass radionuclide (Nucl.) and biplane contrast angiocardiography (Angio.) was compared in 62 patients with suspected coronary artery disease under resting conditions and in 32/62 patients during bicycle ergometry at identical work load. At rest both methods correlated with r = 0.81 with similar heart rates in both determinations. The mean value of LVEF (Nucl.) was lower than the mean value of LVEF (Angio.), at 50 +/- 2 (SE) % and 58 +/- 2% respectively (p less than 0.001). During exercise a significant correlation between the two methods was again found (r = 0.76). This time no difference was detected between the mean values for LVEF (50 +/- 3% [Nucl.] vs 48 +/- 2% [Angio.], n.s.), which may be explained by the higher heart rates during the invasive study (123 +/- 5/min [Angio.] vs. 108 +/- 4/min [Nucl.], p less than 0.001), resulting in a higher degree of ischemia and hence a lower LVEF. The interobserver variability did not differ between the two methods.


[Muscle fiber hypertrophy and myocardial function of the left ventricle in patients with chronic volume stress and cardiomyopathy]. Left ventricular angiography and endomyocardial biopsy were performed in 10 patients with aortic insufficiency and in 10 patients with congestive cardiomyopathy. Muscle fibre diameter and interstitial fibrosis were determined. In aortic insufficiency the diameter of muscle fibres is highest in the endstage, while in congestive cardiomyopathy it is highest in the earliest stage.


[The effect of slight to moderate stenoses on the coronary reserve and hemodynamics]. The effect of slight to moderate stenosis (less than or equal to 50% of external diameter) on the coronary reserve and coronary hemodynamics has been studied in 8 pigs. The coronary reserve was measured by the technique of reactive hyperemia, which consists of brief total occlusion of the artery concerned and sudden relaxation. The decrease in coronary reserve is directly proportional to the degree of stenosis. At 73% of stenosis the coronary reserve is completely abolished and the zone perfused by the stenosed artery is unable to increase its flow when needed. Slight to moderate stenosis soon causes the appearance of pressure gradients through the stenosis. The gradient increases simultaneously and proportionately to the increase of flow and is directly proportional to the degree of stenosis. These gradients decrease the perfusion pressure, and this induces an unhomogeneous distribution of myocardiac perfusion.


[Plasma myoglobin level as a course criterium in patients with acute myocardial infarct]. Myoglobin and the enzymatic activity of creatine phosphokinase CK), MB-isoenzyme of CK (CK-MB), aspartate aminotransferase (GOT), alanine aminotransferase (GPT) and lactic acid dehydrogenase (LDH) were serially determined in 10 patients with acute myocardial infarction. Additionally the same parameters were assessed in 5 patients with angina pectoris for 24 hours after bicycle ergometry. 10 in-patients served as controls. Myoglobin was determined by radioimmunoassay and the other enzyme activities according to the current kinetic methods. Comparison of myoglobin with the enzymatic parameters showed that the myoglobin peak occurs 5.6 hours after the beginning of the sampling period, i.e. 7.3 hours earlier than CK and CK-MB and 11.6 hours earlier than GOT. In analogy to this finding the descending limb of the myoglobin curve was significantly earlier at a level of one third of the peak value, i.e. 8.2 hours earlier than CK-MB, 18.8 hours earlier than CK and 27.3 hours earlier than GOT. No signs of myocardial necrosis in terms of myoglobin or enzymatic activity could be detected after bicycle ergometry. It is concluded that myoglobin is a more sensitive parameter for assessment of the acute phase in patients with myocardial infarction than the usualy enzymatic parameters.


[Hemodynamic consequences of the furosemide treatment of cardiac insufficiency in recent myocardial infarct]. Furosemide was administered intravenously to 11 patients with cardiac failure after acute myocardial infarction. After an initial loading dose furosemide was given four-hourly if the pulmonary capillary wedge pressure (PCW) was not normalized, i.e. less than or equal to 15 mm Hg. The comparison of the hemodynamic results with the results of a previous study with nitrates was as follows: like the nitrates furosemide lowered the PCW early, i.e. within 15 minutes from 22 +/- 3 to 18 +/- 5 mm Hg, but the therapeutic objective (PCW less than or equal to 15 mm Hg) was reached later than with nitrates. During the 24-hour observation period PCW and total peripheral resistance decreased steadily. The decrease of cardiac index to critical low values in some patients after a mean of 7.5 hours of therapy, and of the mean arterial pressure from 100 +/- 13 to 91 +/- 14 mm Hg, may limit the use of furosemide alone in these patients. During nitrate therapy PCW started to rise again after 12 hours in some patients, necessitating higher doses of nitrates with a corresponding decrease of diuresis. A combination of both forms of therapy may be of value and needs further investigation.


[Tetralogy of Fallot: results of 77 hemodynamic controls after complete correction]. 77 patients (representing 91% of all survivors) underwent catheterization within 5 months of surgical repair of tetralogy of Fallot. The data show that residual pulmonary gradient is significantly higher in patients with infundibular and valvular stenoses than in patients with infundibular stenoses only, whereas the method of intracardiac repair (patch) had no influence on residual gradient. Significant pulmonary insufficiency was found almost exclusively when a patch was extended through the pulmonary annulus. Hemodynamic results were excellent in 37% of cases, good in 51%, satisfactory in 3% and unsatisfactory in 9%. Finally, primary intracardiac repair in children below 4 years of age yielded excellent or good results in all cases: this suggests that toal correction should be performed without previous aorto-pulmonary anastomoses in this youngest group of patients.


[Medical education].

[Medical education]. There can be no doubt about the need for more comprehensive medical education. Increasing pressure has been brought to bear from outside on health care, calling for humanization and extension into hitherto neglected areas such as health disorders due to psychological, professional, familial and environmental problems. A new education and re-education programme must include an ethical basis, communication and cooperation with patients and exchange of the biomedical model for a biopsychosocial model of disease.


[Massive heroin intoxication. Hemodynamic studies]. Acute hemodynamic changes during heroin overdose have not been frequently reported. We observed 2 male patients aged 24 and 21 years admitted in coma and shock and presenting severe mixed acidosis, with, respectively, pH 6.80, PaCO2 72 mm Hg, PaO2 70 mm Hg, BE -18 mEq/l, lactic acid 16.5 mmol/l, and pH 6.86, PaCO2 94 mm Hg, PaO2 46 mm Hg, BE -16 mEq/l, lactic acid 5.45 mmol/l. The hemodynamic data of the first patient showed a low output failure state associated with high filling pressures, suggesting biventricular heart failure. In the second case, clinically and radiologically marked pulmonary edema was associated with a hyperdynamic state and moderately elevated pulmonary artery pressure, but normal pulmonary capillary pressure. The possible pathophysiological mechanisms of those different, hemodynamic patterns are discussed.


[Atenolol in the treatment of angina pectoris]. 18 patients with angina pectoris participated in a double blind trial with atenolol (100 mg and 200 mg once daily, or 100 mg twice daily) and propranolol (80 mg twice daily). The number of anginal attacks (NAP), the number of days free of pain (NAFT), consumption of sublingual nitroglycerin (NNT) and bicycle ergometry data (EFE) were recorded. Atenolol given in a dose of 100 g twice daily significantly reduced NAP and NNT as compared with the other dose schedules for atenolol and propranolol. There was, however, no difference between NAFT and EFE under any of the treatment schedules mentioned above. Only with 100 mg atenolol twice daily was it possible to reduce heart rate at rest and immediately after exercise testing, and also diastolic blood pressure (at rest, upright and after stress testing). In spite of the long plasma T 1/2 (= 24 hours) reported by others, atenolol given twice daily seems to be the most effective schedule. It is concluded that atenolol (100 mg twice daily) has a more potent anti-anginal effect than propranolol (80 mg twice daily). In addition, atenolol has the advantage of being cardioselective.


[Hyperventilation and airway resistance. Bronchial spasms after hyperventilation]. Airway resistance, FEV1.0 and lung volume were measured by body plethysmography before and after voluntary hyperventilation. In normal subjects, resistance increased to 130--140% of the initial value measured before hyperventilation. The same increase was observed in silicosis patients without chronic obstructive bronchitis. Asthmatic patients in an asymptomatic phase showed a rise in airway resistance to an average of 255% of the nearly normal initial values, and also a reduction in FEV1.0. In normal subjects and asthmatic patients, the administration of bronchodilators inhibits the rise in airway resistance induced by hyperventilation. The hyperventilation test can be used to identify increased susceptibility to bronchoconstriction.


[Minoxidil in treatment resistant hypertension]. 22 patients (4 female, 18 male, mean age 47 +/- 10.7 years) with severe essential hypertension (n = 21) and renovascular hypertension (n = 1) were treated with a mean daily dosage of 16.3 +/- 5.1 mg minoxidil for up to 42 weeks. In addition, all patients received a diuretic (hydrochlorothiazide or furosemide) and a beta-blocker (pindolol or propranolol). 8 patients were treated simultaneously with alpha-methyl-dopa. Within one week minoxidil led to a significant reduction in both systolic and diastolic supine blood pressure (p less than or equal to 0.005) from 201.3 +/- 29.0/125.4 +/- 19.2 mm Hg to 172.8 +/- 28.3/106.0 +/- 19.9 mm Hg. The maximum initial blood pressure response was observed after 3 weeks with a mean daily dosage of 12.2 +/- 9.4 mg of minoxidil (160.5 +/- 20.7/99.4 +/- 13.8 MM Hg, p less than or equal to 0.001). Throughout the remaining period a constant and significant reduction in supine systolic and diastolic and upright diastolic blood pressure was achieved (p less than 0.005-less than 0.001) whereas at times systolic blood pressure values could not be lowered significantly. Body weight and pulse rate showed no significant changes throughout the study. In some cases furosemide had to be added by up to 500 mg/day to counteract minoxidil induced water and salt retention. Only moderate doses of beta-blockers were required to prevent a drug induced rise in pulse rate. In these patients a significant change in renal function was not observed. The results show that minoxidil is a potent drug in the treatment of severe essential hypertension.


[Continuous ambulatory peritoneal dialysis, a turning point in dialysis treatment?]. Clinical experience with continuous ambulatory peritoneal dialysis (CAPD) is described in 12 patients. A survey over 8 months shows satisfactory results. Besides the numerous advantages of this treatment, peritonitis represents the main problem. Technical developments in the future will aim at a reduction of this risk.


[Effect of 1,25-dihydroxycholecalciferol in renal osteopathy]. 9 patients with advanced renal failure and renal osteodystrophy documented by iliac crest biopsy were treated with 1,25-dihydroxycholecalciferol (average dose 0.53 micrograms per day) for 6 months. Under 1,25-DHCC there was a statistically significant increase in serum calcium and decrease in serum alkaline phosphatase and immune parathyroid hormone. Histomorphometric evaluation of posttreatment bone biopsies showed reduction of osteoclastic resorption and endosteal fibrosis. Osteoid volume decreased in most cases. In 3 patients with predominant fibroosteoclasia, bone turnover practically normalized. Bone mineral content of the radius (photoabsorptiometry) did not change with treatment. Transient hypercalcemia occurred in 5 patients and was easily corrected by adjustment of 1,25-DHCC dosage.


[is there an osteomalacia component in femur neck fractures?]. In 29 patients with fractures of the femoral neck (group A) and 22 patients operated on for osteoarthritis of the hip (group) B), plasma levels of 25-hydroxycholecalciferol (25-OH-D3) were compared with the results of histological bone tests. A third group of 19 patients at the Geriatric hospital served as a control in this age group for 25-OH-D3 values (group C). The average level of 25-OH-D3 was 9.64 +/- 5.8 micrograms/l in group A and 13.25 +/- 7.6 micrograms/l in group B. This difference is not significant. On the other hand, the difference between groups B and C (9.31 +/- 4.04) is significant (2 p less than 0.05). Evaluation of the histological sections did not reveal evidence of osteomalacia. Generally speaking, the levels of plasma 25-OH-D3 in these patients were low, but without signs of osteomalacia on histological evaluation.


[Diagnosis of primary hyperparathyroidism and differential diagnosis of hypercalcemia]. The leading symptom in patients with primary hyperparathyroidism (pHPT) is renal lithiasis and not osteopathy. The most abundant circulating forms of parathyroid hormone in pHPT represent COOH-terminal fragments with molecular weights ranging from 4000 to 7000. Radioimmunnoassays making use of antibodies directed to CCOH-terminal parts of human parathyroid hormone are therefore suitable in distinguishing patients with pHPT from control subjects and patients with hypercalcemia unrelated to hyperfunctioning parathyroid glands.


[Fibrinogen metabolism and plasma fibrinopeptide A in disseminated neoplasms]. FPA immunoreactivity was elevated in 14 out of 15 patients with disseminated neoplasia. Two of the patients showed signs of DIC, two had clinically evident thrombosis and one a positive 125I-fibrinogen uptake test suggesting thrombosis. Infusion of heparin produced a prompt fall in FPA levels. FPA immunoreactivity correlated well with the turnover of intravasal 125I-fibrinogen. The results confirm that the RIA of FPA provides a specific and quantitative index of the conversion of fibrinogen into fibrin and indirectly of the thrombin action in vivo.


Instrumentation and data processing in cardiovascular nuclear medicine: evaluation of ventricular function. Cardiovascular nuclear medicine encompasses a variety of clinical procedures. Some of these procedures place demands on the imaging and data processing equipment that far exceeds those associated with other nuclear medicine procedures. This paper is devoted to an evaluation of the imaging and data processing requirements for two of the more demanding studies in cardiovascular nuclear medicine--first transit and gated equilibrium measurement of ventricular function. Imaging instrumentation and collimation, computer system hardware, and computer acquisition and analysis software are each treated as they apply to these procedures.


First-pass radionuclide assessment of right and left ventricular performance in patients with cardiac and pulmonary disease. First-pass radionuclide angiocardiography allows noninvasive determination of right and left ventricular performance from a single study. Analysis is made from the high frequency components of the regional radionuclide time-activity curves. Both regional and global ventricular performance can be assessed at rest and during exercise. Sequential studies can be performed to evaluate therapeutic interventions. This technique has been applied in a broad spectrum of patients with cardiac and pulmonary disease and has been shown to have major clinical impact.


Radionuclide evaluation of left ventricular function with nonimaging probes. Portable nonimaging probes have been developed that can evaluate left ventricular function using radionuclide techniques. Two modes of data acquisition are possible with these probe systems, first-pass and gated. Precordial radiocardiograms obtained after a bolus injection can be used to determine cardiac output, pulmonary transit time, pulmonary blood volume, left ventricle ejection fraction, and left-to-right shunts. Gated techniques can be used to determine left ventricular ejection fraction and sytolic time intervals. Probe-determined indices of left ventricular function agree excellently with comparable measurements determined by conventional camera-computer methods as well as by invasive techniques. These have begun to be used in a preliminary manner in a variety of clinical problems associated with left ventricular dysfunction. This review discusses the types of probe systems available, the methods used in positioning them, and details the specifics of their data acquisition and processing capacity. The major criticisms of probe methods are that they are nonimaging and that they measure global rather than regional left ventricular function. In spite of these criticisms, probe systems, because of their portability, high sensitivity, and relatively low cost are useful supplements to conventional camera-computer systems for the measurement of parameters of left ventricular performance using radionuclide techniques.


Of linens and laces--the eighth anniversary of the gated blood pool scan. Evaluation of ventricular performance is essential in the diagnosis and long-term management of patients with heart disease. This can be most easily performed clinically using simple tools. When more definitive objective assessment of cardiac function is indicated, the equilibrium gated blood pool study provides reliable angiographic evaluation of the heart. It will continue as a mainstay in the armamentarium of cardiology.


Radiology of postnatal skeletal development. II. The manubrium and sternum. Thirty-six manubriosternal composites from skeletally immature cadavers were examined morphologically and radiographically. Sternebral ossification followed certain patterns. The manubrium (first sternebra) usually had one primary ossification center and one or two smaller centers. These usually were caudad to the major center (longitudinally bifid). The second sternebra invariably had only one ossification center. The third and fourth sternebrae had latitudinal (right-left) bifid ossification centers, undoubtedly a result of the original formation of the sternum from two longitudinal mesenchymal anlagen. Occasionally the fourth sternebra exhibited longitudinally bifid ossification. The usual pattern was ossification of four sternebrae, although a fifth was intermittently present. The xiphisternum (not a true sternebra) was infrequently ossified.


Radiology of postnatal skeletal development. III. The clavicle. Thirty-one pairs of clavicles obtained from human cadavers ranging in age from full-term stillborn to fourteen years were studied morphologically and radiographically. Specimen roentgenography using air/cartilage interfacing demonstrated the osseous and cartilaginous portions of the epiphyses. Overall longitudinal growth appeared to occur to a greater degree in the sternal end, which also developed a secondary ossification center. No comparable ossification was seen in the acromion. The curve patterns differed in the acromial and sternal ends. The sternoclavicular joint has a meniscus throughout postnatal development. This was demonstrated by air arthrography. Finally, the sternoclavicular joint was dislocated anteriorly and posteriorly to duplicate trauma to this region. Roentgenographic aspects of development are discussed and illustrated to provide a reference index.


Multiple loose bodies in rheumatoid arthritis. Intra-articular loose bodies are usually secondary to osteochondral fractures, osteochondritis dissecans, synovial osteochondromatosis, and degenerative arthritis. The authors report four patients with longstanding rheumatoid arthritis and multiple loose bodies in a variety of joints. All patients have remained active despite their disease, suggesting that the loose body production was secondary to trauma of continued activity superimposed on joints containing pannus and eroded cartilage.


Osteopathia striata and focal dermal hypoplasia. A 43-year old female, presenting with pain in the left knee, attributed to a stress fracture of the tibia, was found to have osteopathia striata and numerous other congenital anomalies, not only of the skeleton, but also of other tissue systems. Of the latter the most important was the presence of focal dermal hypoplasia, a disorder of the skin. Review of the radiological and dermatological literature has shown this to be the fourteenth case in which these excessively rare entities have been associated. Such an association is considered to be more than a coincidence. A radiological diagnosis of osteopathia striata, therefore, should be followed by a careful dermatological examination for focal dermal hypoplasia. Conversely, diagnosis of this rare dermatological disease should indicate the necessity for radiological survey of the skeleton.


Mechanical evaluation of the Dwyer screw-cable attachment. A critical portion of the Dwyer technique is the crimping of the screw head to prevent the cable from slipping. Initally, Dwyer designed a hydraulic mechanism to crimp the screw head. However, this instrument was cumbersome to use and presented potential sterility problems. Today the Simmons crimper is used by the majority of orthopaedic surgeons. It is the purpose of this paper to report the studies conducted on 1) different materials used for the fabrication of the screws, and 2) the significance of the variations in the jaw opening using the Simmons mechanical crimper.


Anterior and posterior spinal fusion for paralytic scoliosis. Twenty-three patients with paralytic scoliosis were treated with a combination of anterior and posterior spinal instrumentation and fusion. The sequence was anterior surgery first in 19 patients and posterior surgery first in 4. The average age was 14.4 years. Preoperative correction with a halo-hoop apparatus was performed in 12 patients. The average preoperative curve for the group measured 100 degrees, and the average postoperative curve at a mean follow-up time of 21 months was 37 degrees. The mean loss of correction was 8 degrees. Although superior hook dislodgment occurred in 5 patients, no pseudarthrosis or beinding of the fusion mass was documented.


Intercostal nerve transfer to lumbar nerve roots. Part I: development of an animal model and cadaver studies. This is a description of the development of an animal model for intercostal nerve transfer and saphenous nerve grafting to lumbar nerve roots in the dog. Further, the technical feasibility of intercostal nerve transfer and autogenous sural nerve grafting to the lumbar and sacral nerve roots in the adult and infant human cadaaver is demonstrated graphically.


Intercostal nerve transfer to lumbar nerve roots. Part II: Neuropathologic findings in the animal model. These are the neuropathologic findings in dogs 8-11 months after a unilateral intercostal nerve transfer and anastomosis to a lumbar nerve root were performed. This is a follow-up study of a procedure that was initially carried out in the adult and infant human cadaver and subsequently in an animal model by Malik and Buhr, as reported in this issue of Spine. At the time of sacrifice, the animals in this study had lost the limp that they had postoperatively. The results demonstrate the viability of the intercostal nerve transfer and its anastomosis to the lumbar motor root. There was supplied by a lumbar nerve root that had been operated upon, but the basis of this was not definitely established.


Treatment of severe spondylolisthesis. A combined approach for reduction and stabilization. A technique for combined posterior and anterior reduction of spondylolisthesis is presented. Preliminary results suggest that this is a valid technique for obtaining satisfactory reduction of the deformity and stabilization in severe cases of spondylolisthesis (greater than 50%). The indications for this approach and possible complications are described in detail.


Reduction of severe spondylolisthesis. A preliminary report. This report describes the development of a technique for reduction and fusion of spondylolisthesis that includes posterior mobilization with alartransverse fusion, halo-femoral traction with the patient in some extension, and finally, anterior interbody fusion of the lumbosacral joint. The report emphasizes the technique, which has been employed in the care of 8 patients thus far.


Needle placement of myelography.

Needle placement of myelography. Proper placement of the entire bevel of the spinal needle within the subarachnoid space at myelography is necessary to prevent partial extra-arachnoid deposition of the contrast medium. A Cuatico aspiration cannula passed through the spinal needle at the time of spinal puncture serves to indicate the depth of the needle tip within the subarachnoid space.


A comparison of radiographic findings in fusion and nonfusion patients ten or more years following lumbar disc surgery. Ninety-six patients who had undergone disc excision and midline spinal fusion and 36 patients who had had simple disc excision had spinal radiographs made 10 or more years postoperatively. Claw spurs were found most commonly at the L2-3 and L3-4 levels in fusion patients, particularly male laborers. Traction spurs with segmental hypermobility were found more commonly at the L4-5 level in patients whose spines were not fused, particularly women. Total lumbar flexion-extension was greater in nonfusion than in fusion patients, but the L1-3 mobility was greater in those who had undergone fusion, suggesting a compensatory increase in the range of lumbar motion. Segmental mobility at levels of surgery in nonfusion patients was similar in those with good and those with poor clinical results. Disc space narrowing was common at levels of operation, but did not correspond to the clinical result. Pseudarthrosis was demonstrated in 26% of fusion patients, but was of no clinical significance. Although complex radiographic changes follow lumbar disc surgery, with or without failure, it is concluded that the plane radiograph is of little aid in determining the source of postoperative pain. The sole exception is that of acquired spondylolysis, which was found in 2.5% of this group of fusion patients, and was clearly associated with a poor clinical outcome. Symptomatic degenerative disc disease at levels above lumbar spinal fusions appears to be an uncommon clinical problem.


A study of Tinea capitis in Libya (Benghazi). Tinea capitis formed 20% of all superficial mycotic infections, which in turn represented 12% of all skin disease diagnosed at the skin outpatient department of Al-Jamaheria hospital in Benghazi. The majority (94%) of tinea capitis occurred in children. A sample of 200 cases cultured revealed Trichophyton schoenleinii to be the most prevalent species of dermatophyte (69.5%) followed by Microsporum audouinii. (23.8%).


Prototheca stagnora, an encapsulated organism. The type species of Prototheca stagnora, SEC-L-1690 (ATCC 16528) (2) was found to have a large capsule surrounding the cells, in India ink preparations. Cryptococcus neoformans and P. stagnora are very similar organisms in their morphology and they should be differentiated by their reproduction process or by their biochemical and physiological characteristics.


Wangiella dermatitidis isolated from bats in Manaus Brazil. Wangiella dermatitidis was isolated for the first time from the macroscopically asymptomatic internal organs of 2 Phyllostomus discolor, 1 Molossus molossus, 1 Sturnira lilium and 1 Myotis albescens among bats captured in the region of Manaus, Brazil. The dermatiaceous fungi isolated exhibited polymorphism at 25 and 37 degrees C, showing toruloid hyphae, integrated and terminal phialides without collarettes and yeast-like cells. The fungi did not hydrolyze gelatin, casein or starch. Some ecological aspects of bats in relationship to the epidemiology of phaeohyphomycosis are discussed.


Association of ABO blood group and outcome of coccidioidal infection. Dissemination of fungal infection due to Coccidioides immitis has been previously shown to be related to hereditary factors. Two associations reported to date are race (e.g., Filipino and black ancestry) and HLA histocompatibility type (HLA-19). In the present study of 105 patients a significant association of blood group B and dissemination is demonstrated. C. immitis is known to possess antigens with blood group A activity. Previous epidemiologic studies have also shown HLA-A9 and blood group B are both more common in persons of black and Filipino ancestry. Further studies are needed to define whether these are independent variables, and may define subgroups at particularly high risk following coccidioidal infection.


Electron microscopic studies of saprobic and parasitic forms of Coccidioides immitis. During studies of both saprobic and parasitic cycles of Coccidioides immitis, we found that the hyphae contained septa with simple pores, Woronin bodies, pinocytotic vesicles and/or lomasomes. The alternating thallic arthroconidia were released by fracturing of the adjacent sterile cells. The endospores were formed by progressive cleavage of the spherules. The taxonomic classification of C. immitis still remains obscure.


Use of morpho-physiological characteristics for differentiation of the species of Prototheca. Fifty-two cultures of Prototheca spp. isolated from water and 7 isolates received from a culture collection were tested for their ability to assimilate carbon and nitrogen sources. Based upon these findings and on micromorphological features of the isolates a rapid method allowing differentiation of Prototheca spp. in culture is presented.