Dystocia in late labor: determining fetal position by clinical and ultrasonic techniques

A failure of adequate progression during late labor occurs often and may prohibit an accurate determination of the fetal head position from scalp edema or caput formation. This investigation was undertaken to determine whether ultrasonic evaluation could confirm or correct the digital examination impressions of the fetal head position. Eighty-six attempted vaginal deliveries had recent evidence for arrested cervical dilation after 7 cm or more. An occiput transverse position in 24 (28%) cases was diagnosed accurately, with the need for additional ultrasonic information only in the presence of scalp edema. Distinguishing between a persistent occiput posterior (15 cases, 17%) or anterior (47 cases, 55%) position was often inexact by palpation alone. Combined clinical and ultrasonic impressions allowed for a significantly more precise diagnosis. Ultrasonic imaging allowed for more security while waiting, more confidence with midforceps application, or a prompter decision for cesarean section, depending on the head position.

Evaluation of furcation region response to periodontal therapy

Five hundred fifty-eight molars were treated with one of four types of periodontal therapy: coronal scaling (CS); root planing (RP); modified Widman surgery (MW); or flap with osseous resectional surgery (FO). This report presents the probing depth and probing attachment changes in the furcation region following therapy and two years of maintenance follow-up. All types of therapy were effective in reducing probing depths. FO was the most effective in reducing probing depth followed by MW, RP, and CS. Reduction in probing depth was primarily due to gingival recession. FO resulted in a loss of probing attachment in both a vertical and horizontal direction following therapy. Following two years of maintenance care, sites treated with FO continued to exhibit a mean net loss of vertical probing attachment. A mean net loss of horizontal probing attachment was present after two years of maintenance care, regardless of the treatment modality employed. Many more sites were initially removed during osseous resectional surgery to achieve treatment criteria than were initially removed from the other groups. FO treated teeth demonstrated a lesser percentage of furcation sites demonstrating clinically significant breakdown during the two years of maintenance care.

Evaluation of four modalities of periodontal therapy. Mean probing depth, probing attachment level and recession changes

Eighty-two periodontally involved patients were treated in a split mouth design such that one quadrant received coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resection surgery (FO). The therapy was performed in three phases: Phase I: the teeth previously designated to receive RP, MW, and FO were thoroughly root planed and the teeth designated to receive CS were scaled with no subgingival instrumentation, plaque control was initiated and reinforced for the entire mouth; Phase II: the designated teeth received MW or FO surgery; and Phase III: maintenance therapy every three months. The CS teeth received coronal scaling and polishing during maintenance appointments, while RP, MW, and FO teeth received supragingival instrumentation, subgingival instrumentation and polishing. Clinical measurements were taken initially, four weeks post-Phase I, 10 weeks post-Phase II, and after each of two years of maintenance care. All therapy modalities resulted in a decrease of mean probing depth with the FO producing the greatest decrease followed by MW, RP, and CS. The deeper the initial probing depth, the greater was the mean reduction of probing depth. FO created a loss of mean probing attachment in the 1 to 4 mm category. RP and MW produced the greatest gain of mean probing attachment in the 5 to 6 mm category. RP, MW, and FO produced similar gains in the greater than or equal to 7 mm category. FO created the most gingival recession followed by MW, RP, and CS.

Blood histamine and solid malignant tumors

A clinical study was performed to determine whether patients with a newly diagnosed solid malignant tumor manifest an alteration in whole-blood histamine levels. Our results indicate that such patients have blood histamine nearly three times greater than either normal, healthy individuals or noncancerous disease controls. Following surgical removal of the tumor, blood histamine levels remained high for 2 months and then dropped close to the normal range 3 months after surgery. Basophil counts did not change significantly in the presence of a malignant tumor. Patients receiving either chemotherapy or radiation therapy, and terminal cancer patients who were no longer receiving any therapy except for pain control had blood histamine within or below the normal range. By analogy with animals studies, we suggest that nascent histamine synthesis is increased in the presence of a developing tumor. The clinical usefullness of this observation remains to be determined.

Patient-controlled analgesia for post-cesarean section pain

Recent reports have suggested that patient-controlled analgesia is an effective means of narcotic administration in postoperative patients. This prospective investigation was undertaken to determine the efficacy and safety of patient-controlled anesthesia infusion after cesarean section. During a recent ten-month period, 130 patients were assigned randomly to receive meperidine by pump or intramuscular injection. Meperidine consumption using the device varied widely to meet individual needs. Overdosage and drug dependence were not encountered with the prescribed drug concentrations. The patient-controlled analgesia method provided less sedation and more immediate pain relief without the need for painful injections. The additional cost of renting the infuser device was offset by combined patient and nursing satisfaction. We conclude that patient-controlled infusion of meperidine is safe and effective in satisfying individual patient needs after cesarean section.

Aortic rupture and aortic smooth muscle tumors in mice. Induction by p-hydrazinobenzoic acid hydrochloride of the cultivated mushroom Agaricus bisporus

p-Hydrazinobenzoic acid (HBA), an ingredient of the cultivated mushroom Agaricus bisporus, was given in hydrochloride form at a dosage of 0.125% in drinking water for life to randomly bred Swiss mice. Previous studies had demonstrated that either synthetic or naturally occurring hydrazines are carcinogenic in mice with the main tumors so-induced being peripheral angiomas and angiosarcomas. As a result of HBA treatment in the present experiments, smooth muscle cell tumors of the aorta and large arteries were induced in 14% of females and 42% of males, whereas the corresponding frequency of tumors in untreated female and male controls was 0 and 4%, respectively. Tumors were observed as early as at 17 weeks of age. Numerous experimental animals (32% of females and 50% of males) died of aortic rupture. Histopathologically, two major changes were observed to explain both the ruptures and tumors. First, the intimal and inner medial aspect of the aortic walls had undergone effacement with widespread fibrinoid necrosis, accompanied by medial elastinolysis. Second, a proliferation of cells arising in the media, benign in some aortae and frankly malignant in others, was strikingly positive by immunohistochemistry for cytoplasmic actin and myosin, moderately positive for desmin, weakly positive for vimentin, and negative for factor VIII-related antigen. When malignant, the tumors extended into the periaortic adventitial connective tissue. The tumors were classifiable as leiomyomas and leiomyosarcomas. Thus, HBA is an additional carcinogenic ingredient of the widely consumed mushroom, A. bisporus. A continuum from toxic tissue injury to cellular hyperplasia, dysplasia, and ultimate neoplasia is well-illustrated by HBA.

The seasonal risk of pediatric/juvenile acute lymphocytic leukemia in the United States

Acute lymphocytic leukemia (ALL) occurring in pediatric and juvenile patients of nine U.S.A. locations during 1973 through 1980 was investigated by epidemiologic methodology. Time series periodic regression analysis of the monthly cumulative risk for ages 0-19 years revealed evidence of trimodal periodicity at seven of the nine locations tested. Combined analyses revealed a significant effect of latitude in causing asynchrony of the trimodal patterns observed. The average risk maxima occurred in April, August, and December for U.S.A. locations with latitude above 40 degrees (Seattle, Nebraska, Iowa, Detroit, and Connecticut), and in February, July, and October for other locations (San Francisco, Utah, New Mexico, and Atlanta). Because periodic regression analysis is a complex method, independent validation tests were performed to supplement the original results. Here, the best symmetric trimodal sine curve model of each location was utilized to predict the average pattern among the remaining locations of similar latitude. These validation tests supported the existence of similar trimodal patterns for all of the southern locations, and all of the northern locations except Connecticut. The observed peaks in monthly ALL risk coincide with seasonal elevations in the rates of allergenic and infectious diseases, elements of which are capable of promoting lymphocytic proliferation and transformation. Annual disease rates were significantly lower in populations with a high proportion of Blacks or American Indians compared to predominantly Caucasian populations. The possibility that seasonal factors (environmental allergens and/or infectious agents) promote leukomogenesis via indirect mechanisms is briefly discussed.

Comparison of manual and pressure-controlled periodontal probing

Over 25,000 sites around natural teeth in three stages of periodontal therapy (prior to instrumentation, following closed subgingival instrumentation and following surgical therapy) were independently probed by two examiners. Examiner A used a conventional periodontal probe with uncontrolled pressure. Examiner B used an identical probe tip mounted in a handle which controlled vertical probing force at 50 g. The pressure-controlled technique produced significantly deeper clinical probing measurements on the direct facial and lingual aspects of teeth regardless of the stage of periodontal therapy that had been completed. Manual probing obtained deeper measurements on the distal-lingual aspects of teeth in the posterior regions which had not received surgical therapy. The percentage match between probing depths obtained by the two methods declined as the probing depths increased. Control of vertical force during probing may provide a more objective method of monitoring periodontal status during longitudinal trials.

How physicians use clinical information in diagnosing pulmonary embolism: an application of conjoint analysis

To investigate what diagnostic strategies physicians adopt when the literature is unclear about the best use of diagnostic information, the authors examined how physicians weighted eight items of clinical information in diagnosing pulmonary embolism. Thirteen faculty members, 23 house officers, and 19 students estimated the likelihood of pulmonary embolism and predicted whether they would begin treatment in 27 simulated cases. The vignettes were constructed using a fractional factorial design and analyzed using conjoint analysis. Overall the lung scan results (34.7%) and leg examination (19.0%) were weighted most heavily in making the diagnosis, whereas the leg examination (35.7%) was given the greatest weight when deciding about therapy. Weights given by groups at different levels of training were similar, but there was considerable variation within groups. Heterogeneity of diagnostic strategies did not appear to decrease in groups with more training and experience. Multivariate analysis of predictors of pulmonary embolism in 102 actual cases showed that although lung scan results were important in both actual and simulated cases, heart rate accounted for the most variance in the actual cases but was hardly used in the physicians' strategies. There is considerable variation among physicians in how clinical information is used in diagnosing pulmonary embolism, and the variation may not decrease with increased experience.

Preoperative cardiac screening before peripheral vascular operations

Myocardial infarction continues to be a major cause of morbidity and mortality after peripheral vascular operations. In this study, radionuclide angiography (RNA) of the heart was used to delineate the cardiac risk. In 78 patients, there were 53 abnormal RNA studies. Twenty-seven patients with abnormal RNA underwent coronary angiography. Six aortocoronary bypasses were performed prior to or in conjunction with the vascular operation without complications. Ninety major operations were carried out in these 78 patients. There was no myocardial infarction in patients with normal RNA. There were two postoperative fatal myocardial infarctions in patients with abnormal RNA giving a procedure mortality of 2.2 per cent. In 11 patients, the proposed operation was changed. Thirteen patients with abnormal RNA had no cardiac symptoms. Three patients in this subgroup underwent aortocoronary bypass. It was concluded that RNA can effectively identify the cardiac risk in patients undergoing peripheral vascular operations. Routine coronary angiography may be unnecessary as patients with normal RNA have minimal risk of myocardial infarction.

The Hemasite-incorporated graft. Operative technique and early results

A new device (the Hemasite-incorporated graft), has been available to provide access for hemodialysis. Herein, we have described the technique to insert the device and reviewed our early experience. Sixteen Hemasite-incorporated grafts were inserted in 11 patients over a 16 month period. Cumulative functional patency at the end of 1 year was 70 percent. The major complication rate was 0.15 per dialysis month. Patient comfort was considerably increased compared with what was achieved with other grafts. The need for temporary blood access methods is also decreased. More patients may be able to receive hemodialysis at home.

Sputum changes associated with the use of ipratropium bromide

Long-term effects of ipratropium bromide (IB) were evaluated using a double-blind cross-over design in 23 adult chronic bronchitic participants. Two 20-micrograms doses of either IB or placebo were administered as an inhalant four times a day for a period of seven weeks. Sputum volume expectorated during a 24-hour period decreased significantly (p less than 0.05) over the entire length of the study, but sputum viscosity or its dry weight were not affected. Although total number of inflammatory cells in sputum was decreased by the use of IB (p less than 0.05), macrophages increased slightly. Subjects coughed less while receiving IB, and their cough was less severe (p less than 0.05). Ipratropium bromide caused a significant improvement (p less than 0.05) in the mechanics of breathing primarily in the subjects between 46 to 55 years of age. No major adverse reaction to IB was recorded.

Thrombectomy of a Hemasite graft

Hemasite is a new device incorporated in a graft that is used for hemodialysis. A technique of thrombectomizing this device incorporated graft is described.

Three-year survival rates of pulmonary rehabilitation patients with chronic obstructive pulmonary disease

A retrospective study analyzed medical and psychosocial factors associated with the three-year survival rates of clinically stable chronic obstructive pulmonary disease patients enrolled in a pulmonary rehabilitation program. The 69 percent three-year survival rate was similar to rates reported in previous studies. Neither continued cigarette smoking nor psychological variables were significantly associated with patient longevity. Discriminant analysis revealed that the combination of arterial O(2) and CO(2) tensions or its simple approximation (PaO(2) - PaCO(2)) was the best predictor of patient survival at three years.

The growth of primary subcutaneous fibrosarcoma and its pulmonary metastases in normal and athymic Swiss mice

The growth of primary subcutaneous fibrosarcomas and their pulmonary metastases was studied in normal and athymic Swiss mice. The metastases tended to develop more rapidly than did the primary tumors. However, when growth rates of tumors of small volumes (up to 1 cm3) were compared, the tumor and metastases exhibited similar rates of development in both strains indicating the growth rate of pulmonary metastases was related to that of the tumor of origin. Modified immune reactivity, as in athymic mice, influenced the growth of the same tumor in that the subcutaneous fibrosarcoma exhibited a faster rate of development, while the growth rate of pulmonary metastases decreased, when compared with growth in Swiss mice. Therefore, it appears that growth characteristics of the primary tumor from which metastases originated and the reactivity of the host must be included among the factors determining metastatic growth rates.

Cancer induction in mice with acetaldehyde methylformylhydrazone of the false morel mushroom

Acetaldehyde methylformylhydrazone (AMFH), which occurs up to 0.3% in one of the edible false morel mushrooms, Gyromitra esculenta, was administered to noninbred Swiss mice in propylene glycol in 52 weekly intragastric instillations as 100 micrograms/g body weight. The treatment induced tumors of the lungs, preputial glands, forestomach, and clitoral glands. The tumor incidences in these four tissues in treated females were 70, 0, 16, and 12%, respectively, whereas in the treated males they were 40, 90, 0, and 0%. The corresponding tumor incidences in the solvent control females were 26, 0, 0, and 0%, whereas in the solvent control males they were 22, 0, 0, and 0%, respectively. Histopathologically, the neoplasms were classified as adenomas and adenocarcinomas of the lungs; squamous cell papillomas and carcinomas, adenocarcinomas, undifferentiated carcinomas, angiosarcomas, and fibrosarcomas of the preputial glands; squamous cell papillomas and carcinomas of the forestomach; and squamous cell papillomas and carcinomas and keratoacanthomas of the clitoral glands. The study thus proves for the first time the tumorigenicity of AMFH. In view of these and earlier findings, the human population should abstain from consumption of Gyromitra esculenta.

Chart reminders in the diagnosis of anemia

We hypothesized that chart reminders would decrease the number of cases in which a low admission hemoglobin level was missed or ignored. Additionally, we compared the cost of generating the chart reminders by hand with the estimated cost of modifying the university hospital information system for this function. For three months, two medical students reviewed all abnormal hemoglobin results and assigned those more than 1 g below normal limits to a control or study group. A questionnaire, placed in all study group charts, requested an explanation for the low hemoglobin level. Eleven of 141 study cases and 16 of 150 control cases failed the audit criteria (differences not significant). The cost was $308 compared with $3,000 for altering the hospital information system. We conclude that chart reminders did not improve the detection of anemia and that it cost less to test this intervention by manually simulating the computer function.

Personality traits affecting vocational rehabilitation success in patients with chronic obstructive pulmonary disease

Item analysis of the Minnesota Multiphasic Personality Inventory responses of 147 patients with chronic obstructive pulmonary disease produced 48 items associated with three levels of post-hospital vocational adjustment, and with death. A subgroup of vocational rehabilitation candidates provided insights to the psychological processes underlying successful outcome. Those who worked more than six months following hospitalization were more gregarious and used more denial than other patients. Those who did not work at all were more anxious and had lower self-confidence. Patients who died within a year had shown a charitable philosophical orientation'.

Beclomethasone dipropionate aerosol in the treatment of steroid-dependent asthmatic patients. An assessment of 18 months of therapy

Twenty-nine of 33 steroid-dependent asthmatic patients received 18 months of therapy with beclomethasone dipropionate. Only four of 29 subjects required concurrent oral therapy with steroids. Twenty-six of 29 patients noted a marked improvement in their asthma; three of 29 described an indeterminate response. A statistically significant improvement in many of the symptoms, the plasma cortisol level, the first-second forced expiratory volume, and the forced expiratory flow at 50 percent of the observed forced vital capacity was present only at the end of three months of therapy with beclomethasone dipropionate. Steroid-withdrawal symptoms, particularly those related to the nose and sinuses, were initially troublesome but decreased with the passage of time. No oropharyngeal fungal infections were observed. At a dose below the hypothalamic-pituitary-adrenal suppressive level, therapy with beclomethasone dipropionate appears to be safe and effective for treating patients with steroid-dependent asthma.

Unidirectional inhibition and activation of "malic' enzyme of Solanum tuberosum by meso-tartrate

A kinetic study of "malic' enzyme (EC 1.1.1.40) from potato suggests that the mechanism is Ordered Bi Ter with NADP+ binding before malate, and NADPH binding before pyruvate and HCO3-. The analysis is complicated by the non-linearity that occurs in some of the plots. meso-Tartrate is shown to inhibit the oxidative decarboxylation of malate but to activate the reductive carboxylation of pyruvate. To explain these unidirectional effects it is suggested that the control site of "malic' enzyme binds organic acids (including meso-tartrate) which activate the enzyme. meso-Tartrate, however, competes with malate for the active site and thus inhibits the oxidative decarboxylation of malate. Because meso-tartrate does not compete effectively with pyruvate for enzyme-NADPH, its binding at the control site leads to a stimulation of the carboxylation of pyruvate. A similar explanation is advanced for the observation that malic acid stimulates its own synthesis.

Correlation of psychophysiologic variables with vocational rehabilitation outcome in patients with chronic obstructive pulmonary disease

Despite the magnitude of the public health problem presented by respiratory diseases, there have been few studies concerned with vocational rehabilitation (VR) potential of patients with chronic obstructive pulmonary disease (COPD). Certain physiologic variables which show a high degree of relationship to VR success are identified. The three independent variables which most highly correlate with the VR potential of patients with COPD are the percentages predicted for the first-second forced expiratory volume (FEV(1.0)), forced expiratory flow between 25 and 75 percent of the forced vital capacity (FEF(25-75 percent)), and maximum voluntary ventilation (MVV). The mean "cutting" percentages for inclusion in VR programs were 50, 27, and 40, respectively. The emotional variables studied do not differentiate potential VR success or failure as clearly as the physiologic factors. The criteria set forth not only can be used by rehabilitation workers but could serve as a basis for future demonstration studies.

The control of NAD specific malic enzyme from cauliflower bud mitochondria by metabolites

NAD malic enzyme (EC. 1.1.1.39) has been purified from cauliflower (Brassica oleracea. var. botrytis) bud mitochondria. The enzyme exhibits complex regulatory properties being activated by a variety of metabolites including glycolytic intermediates, CoA, sulphate and Krebs cycle acids-the tricarboxylic acids with the exception of citrate being more effective than dicarboxylic acids. Fructose diphosphate which is a positive effector of the enzyme increases the affinity of the enzyme for L-malate.The enzyme is inhibited by glutamate, aspartate, phosphate and ATP, in the latter case the inhibition is largely due to chelation of Mg(2+). The plot of rate versus malate concentration is sigmoid at pH 7.0 with Mg(2+) but normal Michaelis-Menten kinetics are observed with Mn(2+). The molecular weight of the enzyme as measured by gel filtration is ca. 400000. The physiological significance of the responses to metabolites is discussed.

Regulation of 'malic' enzyme of Solanum tuberosum by metabolites

A purification of ;malic' enzyme from potato is described. The purified enzyme is specific for NADP and requires a bivalent cation for activity. At pH values below 7 the plot of rate versus malate concentration approximates to normal Michaelis-Menten kinetics. At pH values above 7 the plot of rate versus malate concentration is sigmoid. A number of dicarboxylic acids activate the enzyme and remove the sigmoidicity. The enzyme is inhibited by phosphate, triose phosphates and AMP. In general, effectors of the oxidative decarboxylation of malate behave in the same manner in the reductive carboxylation of pyruvate. The response of the enzyme to energy charge is reported and the physiological significance of the response to metabolites is discussed in relation to the proposed role of the enzyme in the control of pH.

Control of CO(2) Fixation by Cell-free Extracts of Chlamydomonas reinhardtii

Contrary to earlier reports, CO(2) fixation by extracts of Chlamydomonas is inhibited by glutamate and aspartate. These amino acids and some organic acids are shown to be inhibitors of phosphoenolpyruvate carboxylase. Inorganic phosphate is shown to activate CO(2) fixation, but there is a time lag before inorganic phosphate exerts its full activating effect.

Thermographic localization of incompetent perforating veins in the leg

Incompetent perforating veins in the leg were localized separately by clinical and thermographic methods. Clinically, the methods used were a multiple tourniquet test and palpation for fascial defects. Thermographically, the diagnosis of an incompetent perforator was made by finding rapid and localized heat flow to the skin in a cooled limb with occlusion of circulation in the superficial veins distally and proximally. Exploration of all the sites marked clinically or thermographically showed that the clinical method detected 60%, missed 40%, and gave false-positive results in 40%, while thermography detected 94.5%, missed 5.5%, and contributed 13% false-positive results. All these findings show a highly significant difference (P<0.0005) in favour of the thermographic technique as against the clinical method.